CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
CHILDHOOD ASTHMA PSYCHOMAINTENANCE:
A CASE STUDY OF MEDICAL NONCOMPLIANCE
A thesis submitted in partial satisfaction of the
requirements for the degree of Master of Arts in
Educational Psychology, Counseling and Guidance
by
Craig Andrew Zacuto
May, 1983
The Thesis of Craig Andrew Zacuto is approved:
- Marg~et TMmpso.6, Ed. D
~n i llermo Mendo"iaJ jll. D.
Luis A. Rubalcava, Ph.D., Chair
California State University, Northridge
ii
TABLE OF CONTENTS
THESIS APPROVAL .
ii
ABSTRACT
v
CHAPTER
I
II
III
IV
V
VI
VII
Introduction
1
Family Structure and Personal
History . . . .
. . . . .
7
Identifying Data . . .
. ..
Family Structure and History . .
Summary
10
17
Medical Data
19
Classification of Illness Severity .
Medical Noncompliance
. . .
Summary . . . . .
. . . .
19
21
33
Educational Data .
35
Absenteeism
. . . . . . . . . .
Academic Achievement . . . . . . . . . .
Summary
35
Psychometric Data
41
The Battery of Asthma Illness
Behavior (BAIB)
. . .
Tennessee Self-Concept Scale
Summary . . . . . .
. • . .
41
47
. . . . . . . .
Psychotherapy . . . . . . . . .
Summary . . . . . . . . . .
. . . .
Case Study Summary . .
. . .
Psychomaintenance
. . .
Intervention . . .
. . .
Psychological Data
.
iii
7
38
39
50
52
52
60
62
62
65
VIII
Thesis Conclusion
67
Interfacing Medicine and
Psychology . .
Future Research
67
69
LIST OF TABLES . . . .
REFERENCES .
. .
.
. . . .
. .
. . .
. . . . .
. .
72
73
Published References . . . .
Special References . . .
APPENDICES
A
B
. .
Classification of Medications
Chronology of Prescribed
Medications
iv
73
77
ABSTRACT
CHILDHOOD ASTHMA PSYCHOMAINTENANCE:
A CASE STUDY OF MEDICAL NONCOMPLIANCE
by
Craig Andrew Zacuto
Master of Arts in Educational Psychology,
Counseling and Guidance
May, 1983
This case study has the purpose of investigating the
causal factors of childhood psychomaintenance (the perpetuation of chronic illness) .
The subject of this case
study is a black, asthmatic boy who participated in
psychotherapy sessions aimed at discovering his own motivations for being medically noncompliant.
Information for this case study was gathered from
personal interviews, tape-recorded therapy sessions,
medical records, educational records, and psychometric
evaluations.
The information that has been collected for
this case study was presented under the following headings:
(1) family structure and personal history,
v
(2) medical
data,
(3) educational data,
(4) psychometric data, and
(5) psychological data.
This data has been compiled and organized to outline
the important characteristics of psychomaintenance.
The
author has discovered that three factors appear to be
highly related to one another and are causative agents of
psychomaintenance:
self-concept.
family structure, secondary gains, and
These results were supported by findings in
the existing literature.
This thesis is also an exercise in interfacing
psychology with medicine, with the goal of maximizing
behavioral health care potentials.
The conclusions are that psychomaintenance must then
be evaluated on an individual basis for a useful assessment.
This means that psychologists and physicians must
share knowledge, and methods which cover the whole person
for the benefit of that patient.
Finally, then, the field of research and pragmatic
implementation of knowledge within the sphere of psychomaintenance can be demonstrated through this case study
as a possible example.
vi
CHAPTER I
Introduction
The purpose of this thesis is to demonstrate the
significance of psychological factors in the medical
treatment of childhood asthma.
In many cases an adequate
psychological assessment is necessary to augment conventional medical treatment.
A common complication, powerful
enough to defeat an adequate medical program, is omitting
to take medicine that potentially can control the illness.
This factor of medical noncompliance is a form of psychomaintenance.
Psychomaintenance as defined by Kinsman,
Dirks, and Jones (1982) refers to the psychologic and
behavioral perpetuation and exacerbation of physical illness.
The perpetuation of acute asthmatic attacks leading
to emergency hospital room visits resulting from medical
noncompliance, is the focus of this thesis.
What are the
psychological and familial influences in this form of
psychomaintenance?
The goal of psychological assessment is based upon
specific assumptions as to the nature of asthma.
Chai
(1975) defines asthma as an intermittent, variable, and
reversible airway obstruction.
Asthma is a difficult
disease to predict and hence to manage.
However, even the
most severe cases are controllable through a variety of
medications.
The exact physiological basis of asthma is
1
2
yet poorly understood (Matus, 1981) despite the potential
for pharmacological control.
Furthermore, Matus (1981) has
clearly outlined how psychological assessment fits into the
context of treating the disease of asthma.
"It is assumed
that asthma results from a physiological defect involving
pulmonary mechanics, the immunological system, and other
processes that regulate respiration."
"The psychological
aspects of asthma, while undoubtedly important in many
cases, are not viewed as primary or causative."
Although
the psychological factors are not causal in the physiology of asthma, they are causal in setting off a chain of
events leading to this physiological process:
medical
noncompliance.
It is then assumed that asthma (mild, moderate or
severe) is potentially a controllable disease through
medications.
However, the prevalence of psychomaintenance
is still proportionally very high.
Specifically, medica-
tion noncompliance of asthma patients has been reported to
be 54% (Kleiger & Dirks, 1979), 67%
(Kinsman, Dirks, &
Dahlem, in 1980a), even as high as 88% (Envey & Goldstein,
1976).
This data points to the importance of psycho-
logical factors in the health care of asthma patients.
It
is possible that the medical psychologist may offer an
evaluation of these psychological characteristics which
inhibit pharmacological maintenance of asthma.
The author
of this thesis contends that such an evaluation should
include an assessment of the asthma patient at the person-
3
ality level and at the systems level.
The medical psychol-
ogist is best able to assess psychomaintenance behaviors
within the context of the patient as a whole person.
Through this approach the most productive intervention may
be offered to meet the patient's individual needs.
At the personality level, Jones, Dirks & Kinsman
(1981} have taken a psychometric approach by constructing
The Battery of Asthma Illness Behavior (BAIB).
This test
measures the salient personality factors and illnessspecific attitudes which effect psychomaintenance.
This
battery was designed with the purpose of illustrating the
features of asthma and patients' experiences in coping with
the disease.
The BAIB is an extremely useful tool in
assessing the behavior patterns of the patient discussed in
this case study of medical noncompliance.
Through a series of taped psychotherapy sessions,
with the patient in this study, the issue of self-esteem
was examined.
Consequently a second psychometric device
was implemented to measure self-concept--The Tennessee
Self-Concept Scale.
This score is an objective measurement
to support and contrast the author's subjective impressions.
These psychotherapy sessions have been a vehicle for
the patient to work through his personal issues related to
his psychomaintenance and provide insights at both the
personality level and the systems level of evaluation.
These sessions occurred weekly at the residential treatment
home for asthmatic children where he lived at the time this
4
study was conducted.
It is also of great value to investigate in context
how the asthma patient relates to others in his environment.
By viewing medical noncompliance as a secondary gain
(Matus, 1981), it is possible to understand how a patient
would become and remain out of control with his asthma.
Minuchin, Rosman, & Baker (1982) have been successful in
treating the intractable asthma (asthma out of control
even though appropriate levels of medications have been
prescribed) patient as a member of a poorly functioning
family system.
The family system as it relates to psycho-
maintenance is an important dimension in this complete
evaluation.
Data was gathered on family history and
relationships through psychotherapy sessions with the
patient, interviews with the patient's mother, and with
the social worker at the home for asthmatic children.
This
system's perspective was further expanded to include the
patient's peer relationships at the residential treatment
home and observations by this author during therapy sessions.
The various methods of data collection include:
interviews, tests, school records, medical records, and
psychotherapy observations.
It is then possible to blend
the analysis of the personality level and systems level to
assess psychomaintenance.
It is in this author's opinion
that only after considering both these dimensions of the
asthma patient can there be a complete assessment of
5
psychomaintenance.
This balanced approach draws from
distinctly (perhaps needlessly) separate spheres of
psychology and psychotherapy.
The result of this synthesis
is a more congruent appraisal of a whole person who
happens to have a chronic illness.
The case study method of research was chosen for this
thesis as to demonstrate how such an assessment requires an
in-depth view of each individual patient.
There is sup-
port, Cattell (1950), Shontz (1965) and Rothney (1968)
that this model of inquiry is most useful in organizing
and presenting personal psychological data.
The exact
format of this case study has been tailored to capture the
unique assessment characteristics of psychomaintenance.
The significance of illustrating the typical behaviors
and psychological mechanisms of medical noncompliance is
valuable to both psychology and medicine.
When working
with asthma patients, psychomaintenance becomes an important issue for physicians during the course of treatment.
The medical psychologist then is able to offer strategies
of intervention based on a formal assessment.
This team
approach to treating asthma opens the doors toward more
effective health care, education, behavior modification,
counseling, psychotherapy, family therapy, and family
environment interventions.
This thesis is an example of
the expanding area of medical psychology.
The interfacing
of medicine and psychology is a natural merging, as is
demonstrated here in the treatment of asthma patients in
6
the outpatient clinic, or residential treatment facility.
Therefore, this thesis is an example of how various
traditions within psychology can be joined to evaluate
psychomaintenance and point to a new direction for both
medicine and psychology.
CHAPTER II
Family Structure and Personal History
Numerous special sources of information were used for
this study and are referred to as special references.
are identified by number, type and date, i.e.,
They
(s.r. #2,
personal communication, 2/10/83), and are listed separately
in the special reference section following the regular
references.
In all cases, actual names of sources are
omitted, but their relationship to the subject is stated.
Identifying Data
The subject of this case study is a twelve-year-old
black boy, Cory
s.,
residing in a large western city.
He
is above average in height, and extremely thin, almost
bony in appearance.
At the time this study was conducted, Cory was living
temporarily in a residential treatment home for asthmatic
children.
This move from his home to this facility was in
response to the medical advice (s.r. #3, personal communication* 3/20/83) of Drs. E. and M.
These physicians
believed that prolonged medicine noncompliance could be
fatal.
Cory, as an outpatient in a university pediatric
asthma clinic, had not taken medications frequently over
the course of six months.
Hence, Cory moved to the asthma
* Hereafter referred to as p.c.
7
8
treatment home where medications were dispensed.
He began
psychotherapy at this time, with the author, to examine
and more fully understand the dynamics of his psychomaintenance (s.r. #1, psychotherapy sessions** 10/10/82 4/5/83).
Cory is a very friendly extrovert, as exhibited
through is verbose demeanor and often flamboyant interpersonal style.
He is often very entertaining with
engaging stories and jokes.
His verbal ability is a
valuable tool, enabling him to express feelings with great
clarity, often using clever and descriptive metaphors.
Along with being very outgoing, Cory is also a very
sensitive boy.
He is eager to please others and is cau-
tious not to hurt the feelings of others.
This quality
often clashes with living among a peer group inclined to
tease and play practical jokes on one another.
He is very
capable of teasing back, hence he experiences "cognitive
dissonance"; conflict between his thoughts and actions.
Cory is in the 7th grade, attending the local junior
high school adjacent to the asthma treatment home.
He
enjoys school and, when motivated, he excels in academic
work.
is
-
His academic profile, as it relates to his asthma,
exam~ned
further in chapter five (s.r. #1, p.s. 10/10/82
4/5/83).
Like boys his age, Cory is an avid sports enthusiast;
both in participation and as a loyal fan.
** Hereafter referred to as p.s.
He enjoys playing
9
sports with such vigor that this exercise, under minimal
medication requirements, triggers acute asthma attacks.
This complication is one of the dimensions of his psychomaintenance--deliberate physical exertion without adequate
medicines.
Cory is able to compensate for such low doses of
medication through a pattern of shallow breathing, practices of which he is often unaware of occurring.
The
masking of his tight breathing is so deceiving that
observers are unable to hear any traces of wheezing.
Therefore, only by using objective measurements--peak flow
meters, or spiro meters -- is his airway obstruction detectable; physician and patient reports are inaccurate.
This pattern of neglecting to take daily medications
is often not purposeful.
However, when trying to cope with
family conflicts, he has often resorted to consciously
not taking medications with the goal of being temporarily
hospitalized to escape the family environment.
This author has discovered how complex these forms of
psychomaintenance are through this investigation.
In
weekly sessions, Cory is very open to, and, in fact, eager
to discuss his frustrations, leading him to be medically
noncompliant.
This quality of talking to adults about his
feeling is noticeable to the staff at the treatment home,
consequently Cory is thought of as "being special" in this
way (s.r. #8, p.c. 3/20/83)
(s.r. #6, p.c. 2/10/83).
10
Family Structure and History
Cory's nuclear family consists of his mother, Mrs. A.,
half-brother, Curtis A., and uncle, Mr. J.
They live
together in a two-bedroom apartment in a low socioeconomic neighborhood.
Mrs. A. is an attractive woman in her mid-thirties,
who dresses quite fashionably despite her limited income.
She was born and raised in a large east coast city, and
moved to the west coast in 1971.
She is the second young-
est member of her family, having two older brothers, one
older sister, and a younger brother.
She claims to have
been the most difficult child for her mother to raise (her
mother raised all the children alone, as she and her
husband were separated when this child was only 3)
(s.r.
#2, p.c. 12/21/82).
Mrs. A. is a high school graduate, and, like Cory, is
especially articulate verbally.
She does appear to be
disorganized and overwhelmed with the responsibilities
associated with raising two boys.
She was very candid
about how difficult it has been for her being married and
divorced twice; consequently Cory and Curtis have separate
fathers
(s.r. #2, p.c. 12/21/82).
Mrs. A. married Mr.
school.
s.
upon graduating from high
She describes Mr. S. as a "quiet and gentle man,
who changed drastically after his tour in Vietnam."
subsequently divorced Mr.
s.
She
while still pregnant with
Cory (s.r. #2, p.c. 12/21/82).
11
Cory was born in 1970 and diagnosed as asthmatic at 9
months.
Mrs. A. describes this diagnosis as a "difficult
thing to accept at first."
Having a first child be
afflicted with a chronic illness was very stressful for
her.
Consequently, she would often phone her ex-husband,
Mr. S., from the hospital requesting him to come and be
with her during these early emergency room visits.
She
also relied heavily upon her mother (Mrs. J.) for support
during this period (s.r. #2, p.c. 12/21/82).
Mrs. A. moved to the west coast in 1971, leaving Cory
with her mother, who joined her three months later.
When
Cory was a year old, Mrs. A. met Mr. A., "who is on the
wild side," and were married a year later.
Their marriage
lasted three years, ending in 1975 when Curtis was born.
Although Mr. A. was not Cory's father, he was the only
father figure Cory had during this time.
Mr. A. never
struck Cory, according to Mrs. A., but he did have a bad
temper and often displayed this verbal violence in arguments, and in reprimands to Cory.
Upon their divorce, Mr.
A. moved to a large city in the southwest, and would frequently be visited by both boys together (s.r. #2, p.c.
12/21/82).
Mrs. A. describes Curtis as "a difficult child to
handle."
Curtis, now 8, is a very active child, often
teasing other children, and is physically aggressive.
This
attribute of being verbally and physically challenging has
been a source of conflict between Mrs. A. and Curtis, as
12
well as between both boys.
It should be noted here also
that upon interviewing Mrs. A., this author observed Mrs.
A.'s inability to effectively set consistent disciplinary
limits upon Curtis.
This observation is congruent with
Mrs. A.'s own report of her difficulties in successfully
"handling" Curtis (s.r. #2, p.c. 12/21/82).
Mrs. A.'s younger brother, Mr. J., has lived with
this family intermittantly over the course of the past
five years.
Mrs. A. did not offer much detail as to what
his role has been in raising Cory and Curtis, except
that he does break up fights between them when she is not
available (s.r. #2, p.c. 12/21/82).
Cory has mentioned
that his uncle and mother do quarrel often.
Cory does
report different impressions of his uncle, varying from
feelings of warmth and respect, to abandonment and disappointment (s.r. #1, p.s. 10/10/82 - 4/5/83).
This author
has concluded from Cory's most common references to Mr. J.
that he has inconsistently displayed the male concern he
most naturally needs.
This is an important element in
Cory's background, as it relates to his psychomaintenance
of his asthma--his need for a male role model.
This point
is further discussed in chapter six.
Up until the age of ten, Cory's asthma was well under
control, as exemplified by very few emergency room visits.
However, in the next two years, leading up to the present,
Cory's condition became increasingly more severe.
It is
this author's opinion that the events of these two years
14
from his grandmother, but also did not have his younger
brother to contend with for the attention of his mother
(s.r. #1, p.s. 10/10/82 - 4/5/83).
When talking about that summer, Cory's affect seems
exceptionally warm and happy.
home on the west coast.
He doesn't feel as much at
Cory has revealed that perhaps
the most central issue for him in his psychomaintenance
is the desire to return to the east coast to live.
This is
to say that he was not aware of it at the time, but that
his medical noncompliance was his way of saying he wishes
to live on the east coast.
This realization for Cory, at
the time, was very strong and profound to him (s.r. #1,
p.s. 10/10/82 - 4/5/83).
Not long after Cory returned home from his visit to
the east coast, Mrs. A. suffered an injury which restricted
her to being in bed a great deal of the time.
This put
great pressures upon Cory to help his mother with the
needed parenting of his younger brother.
These extra
responsibilities included his making breakfast for the two
of them, as well as getting to school on time.
This was a
heavy chore indeed as Curtis fought the idea of being taken
care of by Cory.
So Cory, age 10, is not only taking care
of himself, but is also responsible for his younger,
rebellious brother.
This time was most difficult for Cory
as he both literally and figuratively cried over the
thought of not being able to escape Curtis, as they were
together before and after school, as well as sleeping in
15
the same room.
They were two very energetic boys with
similar needs, clashing constantly.
Cory's sense of dire
helplessness at trying to cope with this responsibility
contributed greatly to his psychomaintenance.
This tension
only mounted until it was, in fact, a greater secondary
gain (Matus, 1980) to be ill, than to strive for health-medical noncompliance (s.r. #2, p.c. 12/21/82)
(s.r. #1,
p.s. 10/10/82 - 4/5/83).
The result economically on the family of Mrs. A.'s
inability to work was having to resort to living on welfare
and food stamps.
This economic burden intensified an
already explosive situation.
The sibling rivalry between
Cory and Curtis subsequently increased.
A contributing
factor to this strife between the boys was Mrs. A.'s
ineffective and inconsistent disciplinary practices,
especially with Curtis.
Mrs. A.'s coping skills varied
from being very punitive with Curtis, to allowing him
privileges after his acting out behavior.
Through this
time, Mrs. A. also continued to ask Cory to accept certain
household responsibilities which he felt burdening, while
desperately trying to live up to his own unrealistic expectation of carrying out adult responsibilities at his age
of 11 (s.r. #2, p.c. 12/21/82)
(s.r. #1, p.s. 10/10/82 -
4/5/83).
In January of 1982, Mrs. A. found the sibling rivalry
to be completely draining.
She admits that, for the most
part, Curtis appeared to be the culprit, and consequently
16
she sided in with Cory in most disputes.
Curtis was then
considered to be the trouble-maker, or more the cause of
the fights between the boys in Mrs. A.'s opinion.
At the
request of Curtis' school teacher, Mrs. A. took him to be
tested in search of some answers to his acting out behavior.
The results indicated to Mrs. A. that perhaps Curtis is not
"that bad" after all.
She, in fact, saw much of herself
in Curtis, and believed that they were more alike than she
had ever noticed before.
Mrs. A. then thought that "maybe
Cory is not so good, and Curtis is not as bad" as previously assumed.
Cory has a tendency to not tell the com-
plete truth, and hence was not as trustworthy as she had
once thought.
She evaluated many subsequent conflicts, and
began to see that Cory can be "a little sneak" and often
the cause of conflict between the boys.
Mrs. A. then
began to give Curtis more praise and attention.
She felt
Cory may have perceived himself as the "bad guy" by this
change.
This shift of coalitions from mostly Mrs. A. and
Cory, to Mrs. A. and Curtis, appears to be very significant in regards to Cory's psychomaintenance.
He became
sick more often at this time with frequent emergency room
visits, and absence from school.
He began to not take
medications and often lied about doing so.
Cory began at
this time to go regularly to the university pediatric
outpatient clinic for treatment.
He had been so upset,
angry and scared about this shift of alliances that, upon
the second meeting with this author, he confessed to not
17
taking medications purposefully, with the intention of
becoming ill enough to be hospitalized.
After confiding
these feelings, he referred often to his sense of powerlessness and frustrations.
The only way out, he believed,
was to be sick and even hospitalized.
He thought it was
worth it to him to escape, if only briefly, through the
consequences of not taking his medications (s.r. #1, p.s.
10/10/82 - 4/5/83).
Summary
Cory's early childhood consisted of living in a
constant state of change, especially with regard to having
available, consistent male role models.
This desire and
need for a closer relationship with his own father has
played an important role in Cory's medical noncompliance.
He openly expresses the desire to return to the east coast,
referring to it as "home," even though he has spent only
three summers there.
However, these summers represent,
for him, many of the healthy, familial qualities required
for any child's development.
He also spent this summer-
time away from Curtis, and did not have to experience the
frustrations of having such a powerful sibling rival (s.r.
#1, p.s. 10/10/82 - 4/5/83)
(s.r. #2, p.c. 12/21/82).
The events leading up to Cory actually lying and
often purposefully not taking medications, reveal the consequences of an inadequate familial environment.
The
change of the family power structure of Cory being a
18
position of strength, to one of weakness, may have been
the final stress factor, setting off his pattern of
psychomaintenance.
et al.
It has been reported by Minuchin,
(1982) that such feelings of powerlessness can sig-
nificantly affect one's striving for health.
Therefore, it can be said that Cory's medical noncompliance served a dual purpose at the systems level.
Both of these purposes are secondary gains (Matus, 1981)
which, for many asthmatic children, may outweigh the benefits of being healthy.
The first purpose is his escape from the family
structure through hospitalization, residential treatment
home relocation, and moving to the east coast.
The result-
';ing secondary gain is being reunited with his grandmother
;and living closer to his father.
Secondly, he is attempting to change the power structure of the family by being hospitalized.
During an emer-
]gency room visit, all attention is drawn to the asthmatic,
:and this attention continues during his hospital stay, the
i
!
!result being a realignment with his mother, and reinstating
ithe previous power structure.
I
!structure in asthmatic families
This is a common power
(Leibman, R., Minuchin,
'
i
iS. ,
I
&
Baker, L. , 19 7 4) .
Both of these patterns would offerJ at the systems
I
llevel, an explanation for Cory's medical noncompliance.
CHAPTER III
Medical Data
Classification of Illness Severity
There are several important criteria that are used in
the classification of illness severity in asthma patients.
The strength of the medications, frequency and duration of
hospitalization, and the intermittency of attacks, are
significant factors in making a diagnosis of asthma
severity.
Bernstein (1978) has presented a classification
of illness severity based upon the above-mentioned variables.
Patients were assessed, then divided into the
following categories:
1.
Minimal.
Patients showed a good response to
occasional use of medications.
2.
Moderate.
Patients showed a good response
dependent on chronic administration of nonsteroid drugs.
3.
Severe.
Patients showed a good clinical
response to chronic administration of
corticosteroids.
4.
Severe (refractory).
Patients showed a poor
response to all treatment, necessitating
acute hospitalization or long-term hospitalization and rehabilitation.
Cory was diagnosed as to having asthma at the age of
19
20
nine months (s.r. #2, p.c. 12/21/82).
He was taking medi-
cations on an "as needed" basis from this time up until the
age of ten (upon entering the university hospital outpatient clinic) .
He essentially then was considered to be
a minimal asthmatic with few emergency room visits (s.r.
#2, p.c. 12/21/82).
It is very difficult to explain
medically what caused his illness severity to increase
toward a moderate/severe category (s.r. #3, p.c. 3/20/83).
However, by February of 1982, Cory's first outpatient visit
to the university, his condition required daily doses of
medications* (s.r. #5, university hospital records).
This university clinic specializes in working with
such children who are out of control with their asthma.
The common procedure is to use a rigorous medicine combination, steroids if needed, and slowly cut back on these
medicines.
The goal is to maximize a patient's breathing
capacity with the least intervention.
However, this takes
some cooperation by both physician and patient--trust.
The final goal being complete independence by the patient
for self-management.
The physician/patient contact may be
reduced to phone conversations and occasional clinic
visits to review the patient's condition (s.r. #3, p.c.
3/20/83).
This relationship between physician and patient
is a contract with both parties carrying certain responsibilities to achieve a successful health care program.
When
* See appendix for exact medications, doses, dates prescribed.
**Hereafter referred to as u.h.r.
21
patients are not taking their medications as prescribed,
then the physician is unable to detect exactly how severe
a patient's asthma happens to be.
This "medicine non-
compliance" may be accidental, or perhaps the behavioral
manifestation of a patient's asthma psychomaintenance.
When Cory entered the university hospital outpatient
clinic, the physicials were unable to determine his level
.of asthma severity (diagnosis).
Because of Cory's medicine
noncompliance, it was difficult to assess him medically-what are the minimal medicines necessary for bronchodila'tion?
Cory continued to be out of control (emergency room
visits and hospitalizations); therefore, he appeared to be
more of a severe asthmatic than moderate to the physicians
(s.r. #3, p.c. 3/20/83).
Because of this cycle of non-
compliance by Cory, he remained on steroids (measure of
severity) until he was relocated to the residential treat-
1
ment home.
He was taken off steroids at this facility
only after demonstrating a physical capacity to breathe
optimally without them (see table 2.2 and appendices A & B)
(s.r. #8, p.c. 2/10/83).
Cory may be considered medically,
i
!then, to be more moderate than severe with his illness when
I
!medically compliant (s.r. #3, p.c. 3/20/83).
I
!Medical Noncompliance
I
'I
Because of the nature of asthma, it is an intermittent
condition, there are periods when the patient would be
!
!~asymptomatic,
Mathews & Hingson (1977) have reported that
,medication compliance is generally poor when the patient
22
is asymptomatic.
Because of this, patients often skip
medications during these asthma-free periods.
A further complication is the feeling of hopelessness
in controlling the illness, and loss of faith in the
physician to help the patient (s.r. #3, p.c. 3/20/83).
Consequently, repeated emergency room visits and hospitalizations may only weaken a patient's belief that he can
control the asthma, not vice-versa.
This experience, of
course, can greatly debilitate a patient's motivation to
comply with a physician's suggested health care plan.
Both of these patterns emerge when investigating
Cory's psychomaintenance.
He has not taken adequate levels
(sometimes none at all) of medicine when asymptomatic, and
even following a hospitalization or emergency room visit.
But of the two of these patterns, the latter apparently is
a much more potent force in his noncompliant behavior
(s.r. #1, p.s. 10/10/82 - 4/5/83)
(s.r. #5, u.h.r. 2/5/82 - 10/8/82)
(s.r. #2, p.c. 12/21/82)
(s.r. #8, p.c. 2/10/82).
Along with not taking prescribed oral medications,
Cory was also over-using his pressurized aerosol nebulizer
containing a quick relief medication (s.r. #1, p.s.
10/1/82 - 4/5/83)
3/28/83)
(s.r. #2, p.c. 12/21/82)
(s.r. #3, p.c.
(s.r. #5, u.h.r. 2/5/82 - 10/8/82).
very lethal form of medical noncompliance.
This is a
The following
studies, British Commonwealth countries (Hyposensitization
in Childhood Asthma, 1968), Inman & Adelstein (1969),
Stolley (1972) and Physician's Desk Reference (1980),
23
indicate that prolonged abuse of the aerosol nebulizer has
been the cause of death to those asthma patients.
The
combination of not taking the medications orally, which
continually maintain open bronchial airways, and the
asthmatic (Cory)
taking numerous whiffs off the aerosol
nebulizer for relief, may kill that patient.
On a more
personal note for Cory, there was a young man abusing his
aerosol nebulizer in the above fashion, who died and who
happened to have been an acquaintance of Cory's.
There are several different measurements which may be
employed to detect a patient's medical compliance.
It is
possible through blood tests to examine the amounts of
medications in a patient, and contrast this level with an
expected level.
There is also the peak flow meter, which
is a simple instrument used to measure the amount of
expiratory air blown in an initial 0:1 second.
These
scores indicate the degree of airway obstruction and, consequently, when matched with predicted values (based on
height and age) medicine compliances may be assessed.
These values also may show how well a patient responds
to inhalation therapy in the clinic or inpatient hospital.
Inhalation therapy is when the patient receives medications
in a vaporized form through a breathing device which is
called a nebulizer.
This is a common procedure in both
outpatient clinics and inpatient hospitals.
Hospital
records provide the above information and compliance
behaviors of patients after official visits, and physi-
24
cians' recommendations.
In table 3.1 is a summary of Cory's peak flow measurements and improvement scores upon receiving inhalation
therapy.
It is important to note the inconsistency of
dates entered here.
The gap between 2/5/82 and 4/2/82 indi-
cates two missed appointments and consequently two hospitalizations.
Cory (4/2/82 hospital records) missed at
least one dose (or all doses) of oral medication prior to
the clinic visit.
The next entry is taken on 6/11/82 where
Cory also missed two appointments to the clinic.
The
6/11/82 measurements were recorded as an inpatient in the
university hospital.
Prior to hospitalization on this
date, Cory's medication level was again near zero.
This
means there were at least two medications that were not
taken within a 24-hour period.
Cory was also using his
aerosol nebulizer at least ten times
a
day, while pre-
scribed at only twice a day, to compensate for lack of
i
adequate prophylactic medications.
When he left the
hospital, his medication level was adequate.
However, upon
returning the next day (no peak flow was recorded), his
medication level was once again far below optimum values.
On 7/9/82, he entered the outpatient clinic after missing
two previous clinic appointments, and consequently, between
those appointments, he was again hospitalized twice.
The
next clinic visit was on 7/23/82, and once more, Cory's
oral medications were below prescribed levels.
It was only
after Cory's physician called his home did he appear again
25
at the clinic on 8/30/82.
Lastly, on 10/8/82 (as all other
entries), Cory's peak flow of 180 is considerably lower
than his predicted value of 380.
This data clearly shows
the manifestations physically on Cory's ability to breathe
when he was medically noncompliant.
This danger, as pre-
viously outlined as personally experienced through the
death of an acquaintance, still did not affect Cory's
medical compliance.
This fact was continually echoed in
attempts to educate Cory of these dangers by his physicians.
It is important to note at this point that Cory's physicians were extraordinary health care practitioners, as
evidenced by continuous phone calls, verbal reminders, and
in demonstrating concern for Cory's health.
Unfortunately,
rather than affecting his medical noncompliance positively,
these physicians served other secondary gain motives for
Cory--adult male models.
Therefore, this continuous atten-
tion from the adult male physicians may have served as a
reinforcement for Cory's medical noncompliant behavior
(s.r. #3, p.c. 3/20/83)
(s.r. #5, u.h.r. 2/5/82 - 10/8/82).
26
Table 3.1 Inhalation Therapy
(s.r. #5, u.h.r. 2/5/82 - 10/8/82)
Date
Peak Flow Post Treatment Peak Flow
2/5/82
155
3/26/82
120
4/2/82
250
260
6/11/82*
80
200
6/13/82
300
7/9/82
160
7/23/82
260
8/30/82
100-160
10/8/82
180
255
310
200
The consequences of not following a daily regimen of
medications are frequent emergency room visits and hospitalization (for one to three days).
In June of 1982, Cory
went to the emergency room three times:
6/8, 6/9 and 6/18.
During this time, not only was Cory not taking the needed
prophylactic drugs, but he was missing outpatient clinic
appointments on a regular basis.
These emergency room vis-
its were only temporary reliefs of acute asthma attacks.
Each of these emergency room visits led to a hospitalization.
Cory was hospitalized three times between February and
October of 1982:
2/27, 6/11 and 6/18.
These hospitaliza-
tions occurred between 6:00 p.m. and 12:00 a.m., a common time
for asthmatics to feel airway obstruction.
Although asthma
* Peak flow recorded as inpatient in university hospital.
27
may be a seasonal phenomena, medicine noncompliance
greatly outweighs this variable to explain the frequency of
emergency room visits and hospitalizations (s.r. #3, p.c.
3/20/83)
(s.r. #5, u.h.r. 2/5/82 - 10/8/82).
The above data outline the numerous ways Cory has been
medically noncompliant:
not taking medications, missing
appointments, and over-use of nebulized aerosol.
It is
important to also notice in table l how quickly Cory is
able to respond to inhalation therapy.
This phenomena
may only serve as a reinforcer; however bad his condition
may be, it is easily reversible.
This effect then may
reduce the fear of dying from abusing medicines and not
strictly adhering to daily prophylactic drugs.
This
behavior also parallels a psychological mechanism discovered in Cory's therapy sessions--issues of omnipotence.
This sense of grandiosity and power is validated by his
ability to physiologically respond to the above-mentioned
therapy.
Therefore, this behavior undermines an adequate
self-management health care plan.
This point will be
further discussed in chapter four (s.r. #1, p.s. 10/10/82 4/5/83).
Another factor which is important when discussing
Cory's medical noncompliant behavior is the absence of
wheezing when Cory is below breathing capacity.
Wheezing
is a whistling sound caused by mucous plugs in the bronchial airways.
Cory may
not wheeze even when he is
breathing only at 21% lung capacity (peak flow value of 80).
28
This is possible through short, shallow breaths.
Wheezing
only occurs when an asthmatic takes a deep breath in, and
tries to exhale through obstructed airways.
It is possible
that Cory has adapted himself to taking shallow breaths as
a result of being "tight"
tional response.
(obstructed airways)--a condi-
However, by not being aware of how
blocked his airways are, and not taking medications, Cory
easily does slip into a crisis state--emergency room treatment or hospitalization.
This ability to mask his tight-
ness has been noticed by his mother, physician, pulmonary
nurse (residential treatment home), and this author.
This
ability is quite remarkable to observe because he is able
to talk, and even walk, without a trace of his airway
obstruction and consequently adds to his medical noncompliance.
This behavior is consistent with the aforemen-
tioned psychological issue of omnipotence and power (s.r.
#1, p.s. 10/10/82 - 4/5/83)
(s.r. #2, p.c. 12/21/82)
(s.r. #3, p.c. 3/20/83)
(s.r. #5, u.h.r. 2/5/82 - 10/8/82)
(s.r. #8, p.c. 2/10/83)
(s.r. #9, residential treatment
home medical record* 10/8/82 - 2/16/83).
In table 3.2 there is a listing of Cory's peak flow
scores during his stay at the residential treatment home.
It is vital to compare here how well Cory is able to
breathe when he is taking adequate medicine levels.
His
peak flow predicted is 380 and it is possible that people
with asthma may vary between 50 and 100 points due to
* Hereafter referred to as r.m.r.
29
environmental allergic irritants.
This data also adds to
the earlier question of Cory's actual severity of illness;
moderate or severe?
The values in table 3.2 (mean consecu-
tive measurements) indicate after 2/10/83 Cory's capacity tD
breathe without steroids--moderate asthma (s.r. #9, r.m.r.
10/8/82 - 2/16/83)
Table 3.2 Daily Paak Flo~ Values
(s.r. #5, u.h.r. 2/5/8~ - 10/8/82)
Date
Mean Peak Flow
10/19/82
309
10/26/82
200
11/1/82
266
11/8/82
343
11/7/82
271
11/22/82
291
11/30/82
290
12/7/82
265
12/15/82
312
12/22/82
299
12/30/82
287
1/5/83
288
1/10/83
317
1/20/83
209
1/26/83
292
2/1/83
327
2/10/83*
322
2/16/83
310
* Cory was taken off all steroid medications.
30
However, even when Cory is taking medications (in a
highly controlled environment), he still demonstrates
medical noncompliant behavior.
He was constantly one of
the last children in line to take medications.
On several
occasions the nurse of the dorm would have to look for him
and bring him to the nurses' station to take his medications.
This resistance continued in varying degrees until
one month before discharge from this facility.
Cory also
had medication blood levels near zero twice consecutively
upon returning from weekend home visits.
These measures of
medical noncompliance run parallel with those previously
mentioned in this chapter.
Cory's behavior in the resi-
dential treatment home continued to be resistant to medical
treatment.
His attitude (feelings, thoughts and behaviors)
iri regard to taking medications with the rest of the residents,
an~
at home, changed slowly as his personal themes
in therapy were addressed, and his home environment
changed.
Upon negotiating Cory's future residence with
his mother and grandmother, a drastic change in his attitude of medication compliance ensued.
He returned from
home visits with adequate medication levels as indicated
from blood tests.
Also, he began to be either one of the
first, or in the middle of the line of children to take
medications at the treatment home.
This was not only an
advancement in medication compliance, but also an important
psychological adjustment (s.r. #1, p.s. 10/10/82 - 4/5/83)
(s.r. #6, p.c. 2/10/83)
(s.r. #8, p.c. 2/10/83)
(s.r. #9,
31
r.m.r. 10/8/82 - 2/16/83).
When examining the whole picture of Cory's medical
noncompliant behavior, the focus turns to psychomaintenance.
The behaviors of not taking medications, being last
in line to take medications, led to painful consequences.
On his own admission, Cory does not like going to the
emergency room late at night, or sitting in a hospital room
with a catheter in his arm.
He has often complained about
living in the residential treatment home (s.r. #1, p.s.
10/10/82 - 4/5/83).
These are all painful, frightening
and frustrating events to experience.
Matus (1981) has
labeled this phenomena "striving toward health," and
addresses it in the following:
-"The child whose striving
toward health is weak would be expected to experience illness to its fullest impact, to be highly incapacitated by
it, and to minimize the chances for treatment success."
What can account for a patient's low striving toward
health?
Matus (1981) has offered several insights into
the subject, secondary gains being one of the most appropriate to mention in this chapter.
Basically, the concept
of secondary gain indicates that it may be more advantageous
for a patient to be, or appear to be, sick instead of well.
If Cory does not comply with taking medications, many
adults will show concern, although negatively, and offer
attention.
This fulfills an important need of his.
It is
a sure and predictable way to receive male adult attention;
physicians and therapist.
Another secondary gain (further
32
discussed in chapter two) is the control over the family
,dynamics, especially in competing with his younger brother.
Lastly, a negative secondary gain may be self-punishment to
'reaffirm a low self-concept.
Through setting very high
goals and expectations (in areas outside asthma), Cory
fails and feels sad and helpless.
By setting excessively
'high goals and conquering this illness, which at best can
only be controlled, he feels hopeless and responsible for
poor health care management, but then, not motivated
toward change.
This behavior of setting himself up for
failure serves the purpose of validating a low self-concept ..
This is another psychological mechanism working in harmony
',with Cory's medical noncompliant behavior.
:further explored in chapter five.
This point is
All of these secondary
:gains may be interrelated, or oftentimes independent of one
another.
They do point toward a rationale, from Cory's
point of view, as for his low striving toward health.
This must be only examined within the context of these
secondary gains.
What may appear at first glance to not make logical
!sense, not following medical recommendations, does in
I
[effect follow consistently with Cory's experience within.
IBis behavior is both purposeful and
lor not.
~aningful,
intentional
The important goal of both the practitioner of
!medicine and the researcher is to understand how a
!Patient's medical noncompliance is a consistent and mean1
[ingful behavior.
I
Therefore, appropriate psychological and
33
medical interventions may be taken to achieve a patient's
successful independent health care program.
Summary
The classification of illness severity is a difficult
medical procedure due to the nature of asthma.
Because of
its intermittent occurrence, asthma is difficult to assess.
Combine this fact with a patient's medical noncompliance
(especially net taking medications), this task is further
complicated.
Because of these factors, Cory's illness
status was not fully determined until months after being
relocated to the asthma residential treatment home.
It is
safe to assume that along the moderate/severe continuum, he
is closer to the moderate end when taking appropriate
medications daily.
Cory's medical noncompliant behavior may be measured
by several approaches:
blood tests, peak flow values,
appointment dates missed and distance between, attitudes
in taking medications, and following prescribed aerosol
nebulizer doses.
These behaviors, although they sabotage
effective control over asthma, do serve the function of fulfilling less observable psychological needs.
The personal
themes of omnipotence, excessively high self-expectations,
and consequent low self-concept feelings serve to consistently motivate medical non-compliance.
These factors
plus environmental deficits, lack of appropriate male role
model, also promote medical noncompliance.
The issue of
34
family dynamics also is causitive in Cory's medical noncompliance--sibling rivalry.
The above-mentioned secondary
gains are less observable than the simple act of not taking
medications, but may explain Cory's low striving toward
health.
CHAPTER IV
Educational Data
Absenteeism
Asthma can be very restrictive for children, especially
in regard to school attendance.
The disease accounts for
one-fourth of days lost from school because of chronic
illness (Schiffer & Hunt, 1963) .
There has been a more
recent study by Bharani & Hyde (1976) which reaffirms that
asthma remains to be a leading contributor to school
absenteeism.
According to school records (s.r. #4, public school
records* 9/15/80 - 2/20/83), Cory's rate of absenteeism
rose significantly from 1981 to 1982.
In the academic year
of the 6th grade (9/15/80 - 6/19/81), Cory was absent from
school only seven times.
However, in his 7th grade year
(9/14/81- 6/18/82), Cory missed 29 days from school.
The
·school records do not indicate specifically the cause of
these absences, but upon verbal reports from Cory's mother
(s.r. #2, p.c. 12/21/82), these days missed from school
were brief (one or two days), largely due to asthma
attacks.
This is a dramatic increase over a single year
and does indicate how debilitating asthma can be.
It is very possible to feel very tight (unable to
breathe) in the morning and not be able to go to school.
Then by noon perhaps (warmer, less damp air), the asthmatic
* Hereafter referred to as p.s.r.
35
36
feels better, thus able to go to school.
This begins a
pattern of frequent short absences and consequently few
prolonged absences.
This is still a sign that the asthma
is out of control.
ALthough the above dates were prior to
Cory's first visit to the university outpatient clinic,
this was the beginning of his trouble with asthma maintenance.
The medicines taken on an as-needed basis were
insufficient to control his airway obstructions.
In September, 1981 (s.r. #2, p.c. 12/21/82), Cory's
mother suffered a back injury which restricted her
mobility to being bedridden.
She recalls asking Cory to
help her with many of the daily chores.
This included
making breakfast for himself, as well as for his younger
brother, Curtis.
He was also responsible for getting them
both to school in the morning.
He resented (s.r. #1,
p.s. 10/10/82 - 4/5/83) this responsibility greatly.
He
felt overburdened and frustrated.
No specific information was found to link Cory's
resentment, and the onset of an asthma attack, or days
missed from school, due to his frustrations.
However,
because of the sequence of events happening at this time,
shifting of responsibilities, the beginning of family
structure changes {coalitions), and a huge increase in days
missed from school, a correlation appears to be likely.
Perhaps all of these events, coupled with Cory's existing
predisposition to asthma, may account for this increase in
days missed from school.
37
These days lost in school represent a significant
point in time for Cory.
This was when he felt most iso-
lated from his friends, heightened his aggression towards
Curtis, and resulted in continuous family conflict.
This
conflict was aggravated even more when Mrs. A. asked Cory
to come straight home from school to take care of Curtis.
Then Cory's friends teased him by calling him names, such
as "home boy"
(s.r. #1, p.s. 10/10/82 - 4/5/83).
Cory was
getting angrier with Curtis because of his taunting him,
which led to physical violence.
Because Cory is the older
boy, he would be subsequently punished for the fistfights.
It was at this time that Mrs. A. had Curtis evaluated
psychologically and then discovered that perhaps Cory is
more the cause of friction between the boys.
This led to
a change in family coalitions, leaving Cory to feel triangulated; feelings of "ganged-up" upon.
Thus this was
the beginning of a significant change in the family structure which may have affected Cory's rate of absenteeism
through psychomaintenance of his asthma.
Therefore, these days in school that were lost had an
impact (or represent an impact) upon his peer relationships, self-concept, family environment, and his psychomaintenance.
He was experiencing a great deal of pressure
at home (s.r. #1, p.s. 10/10/82 - 4/5/83) and was out of
control with his asthma.
Cory's academic growth was then affected by these days
lost from being in school (s.r. #4, p.s.r. 9/15/80 -
38
2/20/83).
Academic Achievement
Although the number of days missed is important, it is
the pattern of absenteeism which is also of major significance.
Douglas & Ross (1965) have shown that frequent,
brief absences from school were more harmful to the academic progress of a youngster than were the occasional long
absences.
Creer & Yoches (1971) have found that asthmatic
children follow the former pattern of days missed from
school.
Because asthma is an intermittent condition that
is reversible, then a day missed of school may be followed
by several days of being present.
This pattern breaks down
the needed continuity for growth in education.
In terms of overall performance, Cory did very well
in his 7th grade year.
He received B's in science, health,
and the oral expression of language.
He also earned C's
in mathematics, social studies, fine arts, and creative
writing.
These grades are recorded quarterly to track student
progress.
Cory dropped in two subject areas, mathematics
and social studies, from B's to C's.
His work and study
habit grades declined in the third and fourth quarters.
He went from satisfactory marks in the following subjects:
completes work on time and uses time wisely, to needs to
improve marks.
His motivation to learn may have been
affected by the number and pattern of his absences.
teacher's fourth quarter comments support the above-
Cory's
39
mentioned conclusion, "Cory has had excessive absences
that have hampered his growth in all areas"
(s.r. #3,
p.s.r. 9/15/80 - 2/20/83).
Cory's achievement motivation is a strong indicator
of his performance.
In his 10-week progress report at his
new school (relocated to the residential treatment home),
Cory's grades indicate his low achievement motivation.
His grade in history was a D, and unsatisfactory in work
habits with five out of eight assignments missing.
absent three times from history class.
He was
He received a D in
English with an unsatisfactory mark in work habits, and was
missing three assignments out of seven.
Cory earned an A in mathematics, and a B in foods.
In these classes he had zero absences and received excellent marks in work habits.
When he did go to classes and
worked hard, his grades reflected his efforts.
His move to the residential treatment home reduced his
asthma-related absences, but his motivations to achieve
varied accordingly depending upon the specific subject
area.
Cory's grades and achievement motivation dropped,
perhaps due to the vast increase in absence from school.
These absences were often asthma-related and reduced his
desire considerably to excel in school.
Summary
The literature on children with asthma indicates a
40
pattern of frequent, brief absences from school (due to
the nature of asthma), which, as a consequence, impedes the
youngster's academic progress.
Cory does follow this
pattern as demonstrated by the decline of his grades in
the third and fourth quarters of his 7th grade year, when
he was absent 29 times.
During this time, Cory was experiencing a great deal
of change at home, coalition changes, and new responsibilities that had an effect upon peer relations, and possibly
his achievement motivation.
These factors may have
exacerbated his existing predisposition to asthma and
contributed to his psychomaintenance.
This would then
account for Cory's huge increase in his rate of absenteeism
at this crucial time.
CHAPTER V
Psychometric Data
The Battery of Asthma Illness Behavior (BAIB)
If a patient is to be assessed from the point of view
of psychomaintenance, then it is assumed that the patient
brings to the illness a personal style that may either
defeat, have no effect, or facilitate medical management.
The focus here is on how personality factors and more
illness-specific attitudes and symptom reports are linked
together in the assessment of that patient's psychomaintenance.
These linkages reveal, at the individual level, how
a person is apt to regard asthma, experience it, and behave
during its treatment.
This approach has been put to use
psychometrically through the development of the Battery of
Asthma Illness Behavior (Jones, et al., 1980).
The Battery of Asthma Illness Behavior (BAIB), as
summarized in table 5.1, contains three separate psychometric instruments (Jones, et al., 1980).
At the most general level, the Minnesota Multiphasic
Personality Inventory (MMPI) is used to assess the
patient's personality on the characteristic of Panic-Fear,
with high, moderate and low categories.
This is a very
stable instrument as reported by Dirks, Kinsman, Jones &
Fross (1978).
41
42
Table 5.1
Battery of Asthma Illness Behavior (BAIB)
(Kinsman, et al., 1982)
Assessment Level
Assessment Locus
Psychometric Instr.
l.
General
Patient personality
Minnesota Multiphasic Personality
Inventory (MMPI)
2.
Intermediate
Attitudes toward
illness and
treatment
Respiratory Illness
Opinion Survey
(RIOS)
3.
Illness-Specific
Asthma subjective
symptom reports
Asthma Symptom
Checklist (ASC)
The Asthma Symptom Checklist (ASC) is an illnessspecific level of assessment of subjective symptom reports
(high, moderate, and low Panic-Fear symptomology) that
forms an index of a patient's attention level to asthmatic
symptoms (Dirks, Kinsman, Staudenmayer & Kleiger, 1979).
The development and psychometric characteristics of the
ASC have been described by Kinsman, Luparello, O'Banion &
Spector (1973).
The interaction of these two distinct levels of psychologic functioning, the ASC and the MMPI, are represented by nine asthmatic patient subtypes.
Each of these
subtypes outlines specific and stable personality styles
of asthmatic patients (Kinsman, et al., 1982).
The intermediate level of assessment is the Respiratory Illness Opinion Survey (RIOS)--an expression of various patient attitudes toward being ill, being in treatment,
43
Table 5.2
Respiratory Illness Opinion Survey (RIOS)
(Kinsman, et al., 1982)
Attitude Category Description
Attitude Category
1.
Optimism (0)
Professed ability to cope
with and master the asthma.
2.
Negative Staff Regard
(NSR)
Dissatisfaction about treatment and toward medical caregivers.
3.
Specific Internal
Awareness (SIA)
Patient awareness reports of
the early bodily signals of
asthmatic attacks.
4.
External Control (EC)
Degree that a patient regards
treatment in the hands of
others.
5.
Psychological Stigma
(PS)
Extent to which asthma is
garded as a psychological
flaw.
and regard toward physicians
(Kinsman, et al., 1982).
re~
This
measurement reflects a patient's most immediate opinions
and functions.
The statements within the RIOS organize
empirically into five reliable clusters, as is shown in
table 5.2 above.
These attitude categories may be
examined separately or together in assessing a patient's
psychomaintenance.
This is a powerful tool because it
yields a different measurement from the above patient subtypes.
When comparing and contrasting RIOS with the nine
patient subtypes, i t is possible to determine psychomaintenance in terms of personality (stability) or immediacy
(environmentally influenced).
The RIOS described (Kinsman,
Jones, Matus & Schum, 1976; Staudenmayer, Kinsman & Jones,
1978).
44
Each category of these three psychometric instruments
(MMPI, ASC and RIOS) comprising the BAIB yields a T-score
with a mean of 50 and a standard deviation of 10 (Kinsman,
et al., 1982).
Therefore, it is possible to apply part, or all, of
the BAIB in assessing psychomaintenance potentials among
chronic asthmatic patients on a clinical basis.
It has
been suggested (Kinsman, et al., 1982) that the nine
patient styles provide a starting point for assessment
application with the BAIB.
Cory was given the BAIB after being relocated to the
asthma treatment home, following a tw0-month adjustment
period (s.r. #1, p.s. 10/10/82 - 4/5/83).
He expressed
empirically his attitudes towards health care practitioners
as they existed for him during his stay at the residential
facility.
Beginning with Cory's score on the patient style
patterns, he is categorized as a generally adaptive personality (MMPI Panic-Fear), and is vigilant in responding
to symptoms (ASC Panic-Fear Symptoms) .
In this combina-
tion, he is expected to exhibit compliant behavior in
taking medications and not abusing prescribed as-needed
medications.
These patients are low on frequency of hos-
pitalizations, moderate on length of hospitalizations, and
moderate on the intensity of prescribed medications.
Their
typical attitude towards asthma (RIOS) is appropriately
high on optimism.
The concluding long-term medical conclu-
45
sion (Kinsman, et al., 1982) is good.
This is a pattern
which is more descriptive of Cory prior to 1981, marking
the beginning of his asthma being out of control (s.r. #1,
p.s. 10/10/82- 4/5/83)
(s.r. #2, p.c. 12/21/82)
(s.r. #7,
p.c. 2/11/83).
However, the above data does not explain Cory's medical
noncompliant behavior post-1981--marked hospitalizations,
vast increases in daily medications, and abuses of prescribed as-needed medications (s.r. #5, u.h.r. 2/5/82 10/8/82).
Upon close examination of Cory's RIOS score, an
explanation of the above discrepancies is revealed.
The
RIOS measurement reflects current behavior that is environmentally influenced, less stable than personality styles.
On the RIOS, Cory scored low on optimism (mastering
asthma) that indicates current feelings of helplessness
over the illness.
He is at this point in time not living
at home (where he felt "ganged-up" upon) and following
several months of battling with his asthma.
He was very
high on Negative Staff Regard and External Control, which
indicates that medical care is dictated by others at the
residential facility, and he feels powerless; this conclusion is supported by clinical evidence (s.r. #1, p.s.
10/10/82- 4/5/83).
His score on Psychological Stigma was
also very high, along with being very low on Specific
Internal Awareness; perhaps a denial of his asthma (further
supported by self-concept measures reported in the final
46
section of this chapter).
This data does describe Cory in
relation to his asthma when taken in context with his
environment and recent family history--uncovering his
psychomaintenance patterns.
He is relating to his feelings
of helplessness with his asthma in the residential treatment facility and as proposed in this thesis, his unsuccessful attempt to use his asthma as a vehicle of coalition
change in the family (mother/Cory as before), hence a
secondary gain motive for being medically noncompliant.
If this conclusion is true (unfortunately there is
not a RIOS measurement prior to his asthma being out of
control), it would explain the differences between measurements of the BAIB and his medical noncompliance.
His con-
dition medically has already been demonstrated in chapter
two as being closer to moderate rather than severe, as
predicted by his personality style score.
Given an envir-
onment where he feels safe, love, and a reasonable amount
of power and influence, he would be medically compliant.
According to his personality style, he is able to control
his asthma and from psychotherapy sessions, he has admitted
to purposefully sabotaging his medical care for secondary
gains (s.r. #1, p.s. 10/10/82 - 4/5/83).
Therefore, the personality style demonstrates how Cory
is able to behave without secondary gain motives.
The RIOS
scores indicate how Cory currently feels toward his
asthma, which was once serving as a secondary gain and now
is a source of frustration itself.
If Cory was to leave
47
the environment which stimulated his secondary gain motives
(entering one with nurturance and flexibility), psychomaintenance would predictably discontinue based upon his
personality style
(~1MPI
Panic-Fear, ASC Panid-Fear Symp-
toms) .
The BAIB was useful in assessing Cory in terms of
psychomaintenance; capabilities and current attitudes for
asthma health maintenance.
These results point to a direc-
tion of intervention requiring a more stable, warm and
supportive environment which would foster Cory's vigilant
and adaptive personality, and not threaten his fears that
initially triggered his psychomaintenance.
Tennessee Self-Concept Scale
The Tennessee Self-Concept Scale was chosen by this
author to identify the relevant features of Cory's selfconcept that may be significant contributory agents to his
psychomaintenance.
This instrument measures how the
individual perceives himself in the following areas:
physical self, moral-ethical self, personal self, family
self, and social self.
on three levels:
Each of these ''selves" is examined
identity, self-satisfaction, and behavior.
This tool also provides for an item analysis which indicates
how the subject scores question by question in important
areas of the self.
These are normalized T-scores based on
the normative sample, having a mean of 50 and a standard
deviation of 10.
This is a useful instrument and has been
48
thoroughly reviewed by Bentler, Suinn & Crites (Seventh
Mental Measurements Yearbook 7).
Cory's results follow a predictable pattern based
upon what is already known andestablished about his psychomaintenance pattern of behavior.
He scored at least one
standard deviation below the mean on the following:
satisfaction, behavior, moral-ethical self, family
selfself~
These measurements individually fall into the context of
how Cory views himself in his home environment.
His self-
satisfaction is very low as verbally reported (s.r. #1,
p.s. 10/10/82 - 4/5/83) by Cory on several occasions.
This
lack of self-satisfaction is oftentimes related to his
asthma and frequently is not.
Specifically he oftentimes
feels frustrated with sibling rivalry, being teased by his
peers, and his inadequate feelings that result.
His
behavior score follows the self-satisfaction measurement
as would be expected.
Given the above-mentioned stresses,
he admits (s.r. #1, p.s. 10/10/82 - 4/5/83) that oftentimes
he does not know how to react and make effective changes
upon others and his environment.
His moral-ethical self
may very well be related to his personal feelings of complete responsibility for all trouble in his environment;
family history and current strife in the dormitory at the
residential treatment home (s.r. #2, p.c. 12/21/82)
#8, p.c. 2/10/83)
(s.r. #6, p.c. 2/10/83).
(s.r.
Therefore,
feeling a sense of low self-concept, as Cory would say,
"I'm just a bad guy," as indexed by the moral-ethical
49
measurement.
Finally, his family self measurement is, in
fact, the lowest at one and one-half standard deviations
below the mean.
This is perhaps the single most descrip-
tive psychometric measurement of this study.
It does
indicate that the given hypothesis that Cory's psychomaintenance is a reaction to family conflict and, at the
personal level, his perception and fears of not being adequately nurtured by his mother.
This existing feeling of
low self-concept points to the dynamics at the systems
level whereby Cory was experiencing a sense of triangulation.
Therefore, as a means of regaining power in the
family structure, Cory consciously (s.r. #1, p.c. 10/10/82 4/5/83) chose to be medically noncompliant from the interaction of his inner fears and inconsistent family environment.
These factors relating to low self-concept may be
contrasted with his surprising measurement of physical self.
This value landed precisely upon the mean, in fact.
Perhaps, then, this is a denial of seeing his asthma as
part of his physical self.
Because it has been already
stated in this chapter that he experiences a great deal of
psychological stigma in relation to his asthma (see RIOS
measurement of psychological stigma) .
In evaluating Cory's self-concept that has been viewed
as being low in significant areas (specifically family
self), these results support the stated hypothesis.
In a
very complicated way, his family environment has affected
50
his psychomaintenance, along with his inner feelings of
low self-concept.
There is data to support this conclusion
for asthmatic children; Panides & Ziller (1980) have found
that severe asthmatic children (especially those with
enuresis) appear to be a higher risk for low self-concept
than mild asthmatics.
Bedell, Giodan, Amour, Tavormina
& Boll (1977) discovered that chronically ill children
from high stress environments appeared to have poorer selfconcepts than chronically ill children from low-stress
environments.
Summary
The BAIB and the Tennessee Self-Concept Scale psychometrically describe some of the salient features of Cory's
personality and attitudes at the personal level of analysis.
This data supports the claims of the author that
Cory's psychomaintenance behaviors are more transitory
in nature, rather than an indication of more permanent
personality dimensions.
Specifically, the two measure-
ments within the BAIB do not combine into an expected profile.
Instead, they are inconsistent with each other, one
instrument conclusion (MMPI Panic-Fear, ASC Panic-Fear
Sumptoms) points to a medically compliant, vigilant, highly
optimistic patient, while the other (RIOS) describes a
fearful, highly stigmatized, frequently noncompliant
patient.
By virtue of the fact that the RIOS points toward
the individual reacting currently to environmental factors,
51
leads the analysis toward the family.
Within the Tennessee
Self-Concept Scale there were several significant low
measurements of self, the lowest being the factor of family
self.
It does make sense in lieu of significant family
coalition changes (see chapter two) that this would be an
expected result, thus linking the RIOS with the Tennessee
Self-Concept Scale.
In conclusion, the above-mentioned psychometric instruments outline how Cory at the individual level would react
to his environment with psychomaintenance behaviors-secondary gain of winning over his brother in sibling
rivalry for mother's attention.
This pattern then follows
the systems analysis of triangulation affecting Cory at the
psychological level with his medical noncompliant behaviors.
CHAPTER VI
Psychological Data
Psychotherapy
Cory began weekly therapy sessions with this author
when he moved from his home to the residential treatment
facility (s.r. #1, p.s. 10/10/82 - 4/5/83).
These sessions
continued until Cory was discharged from this facility.
The purpose of these sessions was to examine the emotional issues that are either directly, or indirectly,
related to Cory's psychomaintenance of his asthma.
Through
the combined efforts of this author, and Cory, the goal was
to break down the self-defeating behavior of his psychomaintenance.
The therapy aims included not just dialoguing
about his personal themes, which are tied into his psychomeintenance, but actively (behaviorally) pursuing achievable goals and rehearsing these changes in the session.
This process included a two-way communication, mutual and
appropriate (Rogers, 1961), fostering significant lifestyle changes.
This atmosphere of honest, human communica-
tion allowed Cory to express his strongest fears and work
toward overcoming these fears with dignity.
The author's personal biases toward the nature of this
therapeutic relationship are also of importance in this
inquiry.
Specifically, it is of the utmost importance to
treat the asthmatic (child or adult) as a psychologically
52
54
feelings of anger, pain and sadness openly in the sessions.
He could verbally articulate his pain and when guided to
focus on these hurt feelings, able to cry (s.r. #1, p.s.
10/10/82 - 4/5/83).
This trust manifested itself with Cory primarily when
he was experiencing a great deal of pain and frustration.
However, if he was not feeling an emotion (except happiness) in any acute volume, then Cory was reluctant to talk
about himself.
He would say the following:
"I'm fine
today and I don't have any problems; let's talk about you
today, Craig!"
This was partially a matter for Cory to
learn more about how to focus on himself and those events,
situations, actions and people that were specific cues for
his painful feelings.
This process may be a difficult one
for a 12-year-old to exercise because the above-mentioned
events may not be occurring immediately.
This was taken
into account as part of the learning process of tying
together existing personal themes, and how they interact
with others in the environment--therapeutic process (s.r.
#1, p.s. 10/10/82 - 4/5/83).
However, even for his age,
Cory was able to utilize the talk therapy format with great
precision.
He possesses the extraordinary gift to express
himself verbally (in comparison with other asthmatic
children his age).
This gives him the advantage of des-
cribing with clarity his past, and present, feelings that
may be accentuated and punctuated with vivid examples.
This tool, however, oftentimes led him directly into exper-
55
iences from the past into the present.
This helped him to
gain new confidences in the process of defining and understanding himself better.
He was able to utilize these
insights and would proudly report his new efforts toward
change (s.r. #1, p.s. 10/10/82 - 4/5/83).
Cory often used his verbal abilities toward a positive
movement in the psychological discovery of how he affects
his world, and vice-versa.
He did often use his verbal
capacities also to re-direct attention away from himself,
and his concrete choices.
This pattern was most pronounced
at the start of therapy.
He would oftentimes approach painful personal themes
and would respond with safer, and even profound, abstractions.
He often did this in a flamboyant and funny manner,
or in a very sad and withdrawn affect that appeared unreachable from the outside.
As his therapist, I responded to him
in a variety of ways, depending upon the context, the theme,
and the stage of the therapeutic relationship.
In the beginning, while still developing trust, I sim:ply reflected back his abstractions with an attempt to focusi
I
1upon the masked potent feelings behind them.
After the
I
I
ltrust was more clearly established, I would confront his
!evasive strategies more directly.
This confrontation poin-
lted out to him his own elusive pattern.
1
!sages resulted:
Two important mes-
one, the setting of very consistent and
I
!concrete limits, and the other, a statement of knowledge
!about his inner world (empathy)
I
(s.r. #1, p.s. 10/10/82-
55
iences from the past into the present.
This helped him to
gain new confidences in the process of defining and understanding himself better.
He was able to utilize these
insights and would proudly report his new efforts toward
change (s .r. #1, p. s. 10/10/82 - 4/5/83).
Cory often used his verbal abilities toward a positive
movement in the psychological discovery of how he affects
his world, and vice-versa.
He did often use his verbal
capacities also to re-direct attention away from himself,
and his concrete choices.
at the start of therapy.
This pattern was most pronounced
He would oftentimes approach
painful personal themes and would respond with safer, and
even profound, abstractions.
He often did this in a flam-
boyant and funny manner, or in a very sad and withdrawn
affect that appeared unreachable from the outside.
As his
therapist, I responded to him in a variety of ways,
depending upon the context, the theme, and the stage of
the therapeutic relationship.
In the beginning, while
still developing trust, I simply reflected back his abstractions with an attempt to focus upon the mass potent feelings
behind them.
After the trust was more clearly established,
I would confront his evasive strategies more directly.
This
confrontation served the purpose of pointing out to him his
own elusive pattern.
messages:
This gave Cory two very important
one being the setting of very consistent and
concrete limits, and the other a statement of knowledge
about his inner world (empathy)
(s.r. #1, p.s. 10/10/82 -
56
4/5/83)
(s.r. #6, p.c. 2/10/83)
(s.r. #10, p.c. 9/10/82 -
4/12/83).
Cory is a very sensitive boy who is quite able to show
his own empathy for others.
He has demonstrated on several
occasions the ability to take the role of the other when
describing non-threatening situations, or responding to
painful self-disclosures by others.
This was a strength
that was utilized often in the therapy sessions.
If,
perhaps, Cory should recoil emotionally and say, "You don't
understand, you do not have asthma," a very effective
response included a focus on the feelings of hopelessness
and helplessness, that are behind the above statement.
The
goal is to demonstrate the universality of pain and the
individual differences in its experience.
He was able to
allow this kind of response to be meaningful perhaps
because of his own ability to emphathize with the author
after hearing painful self-disclosing comments.
This
bridged the two of us, giving him a new perspective on
his situation and reduced the volume of his helplessness
(s.r. #1, p.s. 10/10/82- 4/5/83)
(s.r. #10, p.c. 9/10/82 -
4/12/83).
Because of Cory's flamboyant, and oftentimes theatrical, interpersonal style, he was more open to actionoriented therapeutic techniques.
These included using the
empty-chair technique (Passons, 1975).
He was able to
monoplay each of any two warring aspects of himself and
see the differences, and decide how to act in his own best
57
interest.
In terms of his own psychomaintenance, he was
able to identify separate roles that are in conflict.
These included the "stupid Cory," and the "smart Cory."
The "stupid Cory" does things that he identified as being
self-destructive, such as not taking his medications and
setting himself up for obvious trouble with his brother in
family conflicts.
This "stupid Cory" is consequently for-
ever in trouble and responsible for all that goes wrong in
his immediate environment.
This is, of course, an expres-
sion of sensitive feelings of low self-concept.
In con-
trast, however, the "smart Cory" is the sensible, fun and
likeable boy he often identifies with.
He further categor-
izes the "stupid Cory" as being the "bad boy"
(as such
labeled by his mother after the significant family coalition change) .
The "smart boy" he also calls the "good
Cory," the one who enjoys sports, and achieves high grades,
and is sensitive to others.
He was most able to see how
these two entities are in fact separate parts of himself.
He was less likely to slip into evasive patterns when
physically active in the session,
because
he was able to
relate to these unproductive and self-destructive behaviors,
not only in the past, but also within the session hour.
The psychodrama technique of role reversal (Blatner, 1973)
was one more way which these psychological themes came to
life for Cory in the therapy sessions.
He would switch
chairs with me and play the role of the therapist and I
would enact his behavior.
This changing of roles worked
58
well because after we would switch back, he would respond
to his own facilitating comments as the therapist.
Conse-
quently, he experienced his own ineffective behavior both
as self and observer.
These awarenesses needed no special
prodding, once roles were reversed back.
He was then able
to draw his own conclusions and often did so with great
animation.
Therefore, the techniques offered not only
vehicles toward insight, but also validated his own preexisting verbal strength (s.r. #1, p.s. 10/10/82 - 4/5/83)
(s.r. #10, p.c. 9/10/82 - 4/12/83).
Because of Cory's willingness to experiment with
these action-oriented therapy approaches, he was also
inclined to be open for setting achievable goals outside
of the sessions to compare, and contrast, his insights.
This sometimes was a difficult task because he had the
tendency to search for goals that were not appropriate for
his age and social role.
The sessions opened for Cory new
possibilities in behaving in directions that can maximize
his strengths and point out his painful patterns (s.r. #1,
p.s. 10/10/82 - 4/5/83).
The ongoing process of therapy for Cory outlined his
personal themes and issues both related to, and not, with
his psychomaintenance.
For this thesis, the issues that
affected his medical noncompliance are of interest.
One
of these themes has already been alluded to, this being his
tendency to try and accept complete responsibility for all
trouble that is in his immediate environment--"bad Cory."
59
This theme was most clear at home when his mother would
place great burdens of responsibility onto him, such as
having to take care of Curtis after school.
More directly
than this, Mrs. A. verbally admits (s.r. #2, p.c. 12/21/82)
that perhaps Cory is more responsible for the conflicts
that occur between the two boys.
This feeling of taking
responsibility spills over into his experiences with the
children in his dormitory at the residential treatment horne.
As Cory would say, "Trouble follows me everywhere."
These
feelings of doom lead him to experience himself as powerless
and unable to change his fate
(in regards to his asthma
specifically se chapter five) , and consequently feels
( s. r. #6, p.c.
depressed ( s. r. #1, p. s. 10/10/82 - 4/5/83)
2/10/83)
( s. r. #10' p.c. 9/10/82 - 4/12/83).
The above theme is closely linked to his feelings of
omnipotence and power.
He believes that through his
behavior alone, all of his problems and the ones that he
feels follow him may be solved.
He then consequently
sets unreasonably high goals for himself.
This is demon-
strated through such boasting as "I will be the first from
now on to take my medications here at the treatment horne."
Another like example is when he expects himself to never
again "respond with anger to his brother's taunting."
The obvious consequence is that when he does fail, as may
be expected, he feels helpless, hence a low self-concept
(as empirically demonstrated in chapter five)
p.s. 10/10/82 - 4/5/83).
(s.r. #1,
60
These issues were examined as they arose in the
sessions.
Cory learned to distinguish between his role
in conflict, and taking complete responsibility for all the
trouble in a given situation--an important adjustment.
He
is now more sensitive to circumstances where his behavior
is able to produce a reasonable impact upon a situation
and identify those which are beyond his powers; challenging
his issue of omnipotence.
Therefore, because of these
insights, he is behaviorally seeking more acceptable
middle-of-the-ground goals and thus not trapping himself
with excessive expectations.
He was actually scored on
his attendance placement in the medications line at the
residential treatment home.
The goal here was for him not
to be last, and at least, not to always be first--seeking
a reasonable compromise (s.r. #1, p.s. 10/10/82 - 4/5/83).
All of these issues are related to Cory's motivation
to strive toward health instead of secondary gains.
These
secondary gains serve the purpose of fulfilling those needs
of Cory's which are left unsatisfied.
Each of these issues
are based upon true elements of Cory's experience of himself and his environment.
However, they are over-emphasized
(omnipotence, taking on complete responsibilities), and
therefore overshadow his striving for health--psychomaintenance.
Summary
Psychotherapy for Cory was a means toward understanding
61
how he developed a poor health care response to a very
simple and manageable chronic disease.
He was able, due
to his temperament, to gain the most valuable lessons of
therapy in the action-oriented approach, which also reinforced his skill with words.
It is then expected that
after discovering what his themes are, he is now able to,
at least indirectly, make important strides at changing his
environment--requesting not to live at home.
Prior to
this therapeutic experience, he may have continued only to
unsuccessfully change the coalitions at home at the expense
of his own health.
At the individual level of assessment, it is possible
to see how Cory's psychomaintenance developed overtime, and
was challenged in the sessions.
CHAPTER VII
Case. Study Summary
Psychomaintenance
According to Creer (1979), one of the major goals of
a behavioral health care system is that the individual
accept responsibility for his, or her, health by engaging
in behaviors that promote his, or her, welfare.
This goal
is, by definition, undermined by psychomaintenance-perpetuation of chronic illness.
One of the aims in this case study is to diagram how
psychomaintenance may develop and emerge in the form of
medical noncompliance.
Through examining the details of
a single asthmatic boy, it is possible to see how destructive psychomaintenance can be; family, peer relationships,
self-concept, achievement motivation, and lowered optimism
toward coping with asthma all can be highly affected.
These are unfortunate consequences because it has been
demonstrated (Matus, 1981) that asthma is a chronic disease
which can be regulated, regardless of its severity.
There
are existing medications (if properly prescribed) that may
help the asthmatic lead healthy and successful lives (s.r.
#3, p.c. 3/20/83).
Because this is true, then the results
of this study not only are of value academically, but are
also pragmatic.
The question then is raised, under what conditions
62
63
does psychomaintenance occur?
What are also some of the
salient features of psychomaintenance as it occurs through
medical noncompliance?
This inquiry has uncovered some
important answers to these questions through examining
closely Cory's history, family, personality, medical and
educational records, and the supportive literature on
asthmatics.
This author has organized this data to be assessed at
two separate levels of analysis:
individual and systems.
Each person experiences the world through their own perceptions and individualized mechanisms which filter all
external events.
However, human beings do not exist in a
world void of order and interdependency; hence systems are
significant for the individual's development and sustenance.
It is for these reasons that Cory's psychomaintenance is
viewed from both levels of analysis.
It was proposed in chapter one of this thesis that
the factors of family structure, secondary gains, and selfconcept are important causal agents of psychomaintenance.
These three factors are so tightly bound that it is difficult to determine a linear causality.
At the systems level, it is clear to see how psychomaintenance may result.
Cory's family history includes
transient male role models, or highly inconsistent ones
when present.
The male, or father, figure is vital for
healthy development, as evidenced by Freud (1964), Parsons
& Bales (1955), Erikson (1958), Lederer (1964), Fromm
64
(1971), Mitscherlich (1970), Bandura & Walters (1963),
Biller (1968), Bonfenbrenner (1960), Lynn (1969), Mowrer
(1950), and Sears, Rau & Alpert
various theoretical positions.
(1~65),
representing
Cory openly admits (s.r.
#1, p.s. 10/10/82 - 4/5/83) that he misses his father and
wants very much to be closer with him, even at the cost of
his own health.
He has said directly in therapy sessions
that he also loves his mother, but she does not seem to be
fair or consistent with her love or attention.
Cory con-
fesses to feelings of being shut out, due to shifts in
family coalitions, or triangulation (Minuchin, 1982).
His feelings of frustrations toward his fighting with his
younger brother, Curtis, may be summed up with the following:
"It was better being sick in the hospital than being
home with him"
(s.r. #1, p.s. 10/10/82 - 4/5/83).
Cory's home is one lacking an adequate male role model,
a mother whose attention is often difficult to gain or
simply diffuse (Cory or social activities), and a brother
he frequently feels powerless against.
Cory's medical
noncompliance was often in direct response to his own
frustrations with this family structure.
His psychomain-
tenance was, at various times, aimed at challenging this
structure in an attempt to change it, and ultimately a
vehicle to leaving altogether.
Just prior to leaving the
residential treatment facility, he realized that his
medical noncompliance was his signal to others that he
wanted to leave that environment {s.r. #1, p.s. 10/10/82 -
65
4/5/83).
Because of Cory's dissatisfactions with living at
home, he had several strong secondary gains from being
medically noncompliant.
He was. able to get the attention
of male adults (physicians, psychotherapist) and that of
his mother (temporarily), which was rewarding for him.
He was able to influence his environment--move to the
residential treatment home, and finally live with his
grandmother.
Lastly, his self-concept being low in areas directly
related to his family and his asthma (see chapter five)
affected his striving toward health.
Through a series of
failures with asthma maintenance and setting unreasonably
high expectations for himself, he felt unable to control
his illness.
This cycle would be repeated because he was
able to respond quickly to medications and treatments
only to boost feelings of omnipotence which challenged
daily health care.
Then he would crash physically and
emotionally--psychomaintenance (s.r. #1, p.s. 10/10/82 4/5/83).
It is then possible to see, phenomenologically, how
these variables, family structure, secondary gains, and
self-concept combine to motivate Cory's medical noncompliance.
Intervention
Cory's medical noncompliant behaviors eventually
66
caught the attention of his physicians who were instrumental in the initial steps of intervention--relocating him
to the residential treatment home (s.r. #3, p.c. 3/20/83)
(s.r. #5, u.m.r. 2/5/82 - 10/8/82).
Once living at this facility, he received very strict
asthma health care guidance and education.
psychotherapy with this author.
He also began
In collaboration with a
clinical psychologist, his family, various health care
providers, and Cory himself, the assessment of his psychomaintenance was systematically examined (s.r. #1, p.s.
10/10/82 - 4/5/83)
p.c. 3/20/83)
2/10/83)
(s.r. #2, p.c. 12/21/82)
(s.r. #6, p.c. 2/10/83)
(s.r. #3,
(s.r. #8, p.c.
(s.r. #10, p.c. 9/10/82 - 2/16/83).
The final intervention, being Cory's wish to live
with his grandmother on the east coast, was put into
action.
Upon leaving the residential treatment home, he
moved in with his grandmother (very stable, consistent
and nurturing woman), who lives only blocks away from
other supportive adult relatives.
He is also not far from
his father, who is taking an active interest in Cory's
physical and emotional well-being.
He left showing a
strong desire to get along well with his grandmother
(s.r. #1, p.s. 10/10/82 - 4/5/83) and satisfied with the
change.
CHAPTER VIII
Thesis Conclusion
Interfacing Medicine and Psychology
The fields of psychology and medicine have most
recently been combined to work in the team approach in
meeting the needs of patients in beahvioral health care.
For psychology, this has
mean~
a bridging and symbiosis of
the laboratory and the clinic as described by Miller
(1983).
There is also the trend of psychologists working, not
only in hospital settings, but in private practices of
physicians.
Specifically it has been reported by Routh,
Schroeder & Koocher (1983) that clinical psychologists have
worked with pediatricians in private practice settings in
the service as primary health care providers for children.
It has been the experience of this author that the
merging of these disciplines is a highly valuable consolidation of professional expertise.
It becomes educational for
physicians and psychologists in attempting to work in concert with one another.
The unspoken assumptions within
fields of study are oftentimes not challenged, or even
examined; however, when working in unison, these assumptions are identified and open to compromise.
This author
has worked as a counseling trainee in a major university
hospital, and observed psychologists and physicians working
67
68
together and defining their separate roles.
This has
occurred in the function of direct health care services
(in hospital clinics), in seminars for developing patient
support groups, attending patient support groups, and in
community-based non-profit agencies in a consulting capacity.
The psychologist, as a team member, may be very
effective in the role of consultant, therapist, educator,
because of the wide spectrum of knowledge and skills
available through psychology.
This thesis was an attempt
to demonstrate how some of the most diverse areas of
psychology, and specifically counseling, can be united for
making assessments.
The literature from family therapy,
personality (self-concept), and even illness-specific
psychometric devices were utilized to draw out salient
features of psychomaintenance.
The observations and taped
interviews also were invaluable data sources used to enter
Cory's world to best understand his motives for being
medically noncompliant.
This is only a very narrow application of psychology
within a very specific division of pediatric medicine.
The
future expansion into other areas of medicine are as
possible as the professionals are willing to frontier
them.
The prerequisite for beginning more innovative, and
creative, applications of separate knowledge (medicine and
psychology), are that all professionals must demonstrate a
mutuality of respect for such a union to be achieved.
69
The therapist specifically must be very open to
shifting from traditional settings of conducting therapy,
to more pragmatic settings (outpatient clinic and residential treatment facility).
In many cases, consultations with
physicians and patients are more appropriate than therpay.
This is an important flexibility to have.
Oftentimes
there is not the availability of resources, or even time,
to make systematic assessments; therefore, the therapist
must utilize his own trained capacities for observation in
the formation of a presentable opinion to offer immediate
insights about patients for physicians, that may be
followed up more systematically later.
The final goal
being that the therapist, as a practitioner of knowledge,
needs to be open to using both psychometric devices and
clinical experiences and observations, to work as a wellrounded and complete professional.
The exciting possibilities of working as a therapist
in servicing patients who are chronically ill, is challenging and highly motivating.
This study and field has
generated my interest as both a therapist and researcher.
Future Research
Miller (1983) has surveyed the field of behavioral
medicine and pointed to a variety of possible inquiry
areas.
The psychologist is able to bring from the labora-
tory knowledge and methods that can expand both medicine
and psychology.
70
It has been interesting to observe how physicians
interact with patients in the outpatient clinic.
The family
system is definitely affected by the medical interventions
that permeate into the daily lives of each family member,
as presented in this case study.
How the physicial affects
family systems is an empirical question.
The results
could modify behavioral health care practices by physicians.
Another area of inquiry might be to investigate the
long-term effects upon asthmatic children who have lived
in a relocation treatment facility (hospitals, treatment
homes), their asthma, family relationships, and psychological development.
This also is an important area
because the intervention of relocating a child from his,
or her, home may be quite dramatic and the effects not
immediately observable.
At the individual level, the asthmatic child may be
trained to use mini-peak flow meters at home for selfmonitoring.
What are the benefits of becoming more
internally aware of airway obstructions?
It may enhance
the independence of these patients in taking medications
to prevent asthma attacks.
The ramifications, psycholo-
gically, of feeling more in control of the asthma (optimism
and locus of control) are indeed measurable, using the BAIB.
These are all researchable questions that could be helpful
for both psychologists and physicians in medical care and
education.
71
These areas mentioned in regard to asthma may be
expanded into other chronic illnesses.
Chronic illnesses,
in general, affect the daily functions of people living in
environments that may not promote maximum health care.
Therefore, chronic patients are constantly adjusting (or
not adjusting) themselves to adapt their lifestyles because
of their illnesses.
The research then on psychomainten-
ance may include many other chronic illnesses and how they
affect that individual psychologically, and the systems
which they are interdependent upon.
There are perhaps countless theses and dissertations
that may be conducted to broaden the knowledge in the study
of psychomaintenance.
This author wishes to continue
studying the effects of psychomaintenance at a broader
academic level.
LIST OF TABLES
Table
3.1
Inhalation Therapy
3.2
Daily Peak Flow Values
5.1
Battery of Asthma Illness Behavior (BAIB)
5.2
Respiratory Illness Opinion Survey (RIOS)
72
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BANDURA, A. and R. H. WALTERS. Social Learning and
Personality Development. New York: Holt, Rinehart
& Winston, 1963.
BEDELL, J. R., B. GIORDANO, J. L. AMOUR, J. TAVORMINA and
T. BOLL, "Life stress and the psychological and
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BERNSTEIN, I. L., "Asthma in adults," in E. Middleton, Jr.,
c. E. Reed and E. F. Ellis (Eds.), Allergy: Principles and Practice, St. Louis: c. V. Mosby, 1978.
BHARANI, s. N. and J. s. HYDE, "Chronic asthma and the
school," Journal of School Health, 1976, 46, 24-30.
BILLER, H. B., "A note on father absence and masculine
development in lower class negro and white boys,"
Child Development, 1969, 40, 539-546(a).
BLATNER, H. A. Acting in: Practical Applications of
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Psychodramatic
Method. New York: Springer, 1973.
BRONFENBRENNER, U., "Freudian theories of identification
and three derivatives," Child Development, 1960, 31,
15-40.
CATTELL, R. B. Personality: A Systematic, Theoretical and
Factual Study. New York: McGraw-Hill Book Co., 1950.
CHAI, H., "Management of severe chronic perennial asthma
in children," Advances in Asthma and Allergy, 1975,
2, 1-12.
CREER, T. L. Asthma Therapy: A Behavioral Health Care
System for Resporatory Disorders. New York: Springer
Publishing Company, 1979.
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CREER, T. L. and c. YOCHES, "The medication of an inappropriate behavioral pattern in asthmatic children,"
Journal of Chronic Diseases, 1971, 24, 507-513.
DIRKS, J. F., R. A. KINSMAN, N. F. and K. H. FROSS, "New
developments in panic-fear research in asthma:
validity and stability of the MMPI :}?anid-Fear Scale,"
British Journal of Medical Psychology, 1978, 51, 119126.
DOUGLAS, J. W. B. and J. M. ROSS, "The effects of absence
on primary school performance," British Journal of
Educational Psychology, 1965, 35, 28-40.
ENVEY, R. D. and E. 0. GOLDSTEIN, "Compliance of chronic
asthmatics with oral administration of theophylline
as measured by serum and salivary levels," Pediatrics,
1976, 57, 513-517.
ERIKSON, E. H.
Young Man Luther.
New York:
Norton, 1958.
FREUD, SIGMUND. New Introductory Lectures in Psychoanalysis. New York: Norton, 1964.
FROMME, E., "Mother," Psychology Today, March 1971, 4(10),
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Journal, 1968, 2, 478-479.
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mortality rate in England and Wales in relation to use
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SPECIAL REFERENCES
1.
Cory's psychotherapy sessions, 10/10/82 - 4/5/83.
2.
Mrs. A. (Cory's mother)
12/21/82.
3.
Dr. M. (University hospital)
3/20/83.
4.
Educational data (grammar school and junior high
school records) 2/10/83.
5.
University hospital records 2/5/82 - 10/8/82.
6.
Ms. B. MSW (clinical director of residential treatment
home)
Personal communication 2/10/83.
7.
Mrs. J. (Cory's grandmother)
2/11/83.
8.
Mrs. C. RN nurse (pulmonary functions nurse of
residential treatment home) 2/10/83.
9.
Residential treatment home medical records 10/8/82 2/16/83.
10.
Dr. P. (University hospital clinical psychologist)
Personal communication 9/10/82 - 4/12/83.
Personal communication
77
Personal communication
Personal communication
APPENDICES
Appendix A
Classification of Medications
(Spector, 1983}
1.
Oral Theophylline: Oral theophylline is quickly and
consistently absorbed, opening bronchial airways and
preventing constriction at serum therapeutic levels.
There are several sustained released products that
provide for long dosage intervals with little variation
in serum concentration.
A. Theo-Dur
B. Slobid
2.
Aerosolized Beta Agonist: Aerosolized bronchodilators
are dispensed in metered dose inhalers providing rapid
onset. Metaproterenol is favored by physicians because
of its long duration with minimal cardiovascular
effects. Therefore, the aerosolized bronchodilators
provide rapid relief for patients.
A.
Alupent
3.
Cromolyn Sodium: Cromolyn works mainly to block nonimmunological stimulation of mediator release from
mast cells. This agent then is used only prophylactically and does not provide quick relief of symptoms.
Cromolyn should not be used during acute attacks; it
may in fact irritate the lungs.
4.
Corticosteroids: Dispensed in oral and aerosol forms,
this treatment is the most potent antiasthmatic agent.
When patients are unresponsive to the usual bronchodilators, it is added to reverse airway obstruction.
Steroids are the last line of medications used and the
first removed from treatment programs due to potential
side effects and because they :are poorly understood.
Patients should be cautioned about potential side
effects before steroids are prescribed at safe levels.
A.
B.
Prednisone (oral}
Vanceril Aerosol (effect prophylactically like
Cromolyn}
Reference
Spector, Sheldon. Oral and inhaled drugs in asthma: A
current reappraisal.
Immunology & Allergy Practice,
1983, March, Vol. v, 3, 17-24.
Appendix B
Chronology of Prescribed Medications
(University Hospital Records)
Date
Medication
Dosage
2/5/82
Theo-Dur
Alupent
Cromolyn
300 mg. ql2h
2 whiffs q6h
1 whiff po. q.i.d.
2/27/82*
Theo-Dur
Alupent
Cromolyn
3/26/82
Theo-Dur
Alupent
Cromolyn
4/2/82
Theo-Dur
Alupent
Cromolyn
6/11/82
Theo-Dur
Alupent
Cromolyn
6/13/82*
Theo-Dur
Alupent (oral)
Prednisone
200 mg. po. t.i.d.
2 whiffs q6h
20 mg. 1 whiff po.
q.i.d.
400 mg. ql2h
2 whiffs q6h
20 mg. 1 whiff po.
q.i.d.
300 mg. ql2h
2 whiffs q6h
20 mg. 1 whiff po.
q.i.d.
300 mg. q8h
Max q4
20 mg. 1 whiff po.
q.i.d.
450 mg.
20 mg. po. b.i.d.
30 mg. po. b.i.d.
6/20/82*
Theo-Dur
Alupent
Prednisone
300 mg.
20 mg. po. b.i.d.
30 mg. po. b.i.d.
7/9/82
Theo-Dur
Alupent
Prednisone
300 mg.
2 whiffs q6h
5 mg. po. q.i.d.
7/23/82
Theo-Dur
Alupent
Vanceril
300 mg. po. b.i.d.
2 whiffs
2 whiffs
8/30/82
Theo-Dur
Theophylline
Alupent
Prednisone
300 mg. po. b.i.d.
180 mg. (acutely)
2 whiffs
10 mg. po. b.i.d.
10/8/82
Slobid
Alupent
Prednisone
300 mg. po. b.i.d.
2 whiffs p.r.n.
10 mg. po. b.i.d.
5/10/83**
Theo-Dur
Alupent
Vanceril
400 mg.
3 whiffs
3 whiffs
* Hospitalization discharge
** Asthma treatment home