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Home health care and national health policy
Book reviews impede access to care for growing numbers of publicly assisted patients. The book does, however, need a more critical analysis of the geriatric ‘levels of care’ system. (Under this system, long-term care facilities are classified according to the intensity of services provided, with skilled nursing facility (SNF) care the highest level provided for patients in need of daily treatments and observation by a licensed nurse; intermediate care facility (ICF) care for patients in need of less intense nursing; and residential care for the elderly in need only of some supervision and assistance.) Dunlop does point out some flaws in the system, particularly as it relates to Medicaid patients. He asserts that “hardly ever is a patient, once admitted to a nursing home, later denied coverage because his condition is judged not to require a further nursing home stay”. One paradoxical feature of the level of care system is the quite restrictive policy of Medicare reimbursement as distinct from Medicaid’s laxity. Medicare’s restrictive policy on eligibility for SNF care (and resultant retroactive denial of payment to providers) has led to significant withdrawal of facilities from the Medicare program, while virtually any elderly patient can qualify as needing ICF care under Medicaid. Dunlop links these operational problems of the level of care system with bed shortage. He notes the tendency of clinical personnel to ‘stretch’ level of care definitions for Medicaid patients: “ICF guidelines are too broad and alternative living arrangements too narrow once a person has entered a nursing home to result in his or her being denied coverage at some level”. The concluding chapter cites the need for public officials to develop more alternatives to nursing home care for the elderly, and contends that “increase in the number of supportive residential facilities is the single most pressing need in long term care”. Regrettably, Dunlop does not elaborate this concept--especially, how these facilities will differ from the ‘residential groups settings’ earlier identified as having been supplanted by nursing homes. What are these ‘sup portive’ residential facilities? What services will they offer to render them an attractive alternative to nursing home care? Finally, the questions Dunlop raises about home care as an alternative are insightful, particularly the role of ‘informal care’ provided by family members and whether, in the absence of informal supports, the elderly could make use of formal home care. Dunlop cites the need for further research on these questions before home care can become a realistic alternative to institutionalization for the elderly.
345
and the Older Americans Act. Between these four there is no consensus as to what constitutes “home health care”, how it should be funded, who should be eligible for it, which services should be provided for how long, what records should be kept. and by what parameters it should be measured. This fragmentation and inherent incoordination creates bureaucratic barriers separating impaired Americans from the services they need to avoid institutionalization, to preserve fUnCtiOnal status, to obtain early intervention for acute medical problems, to maintain a reasonable quality of life and to provide respite for their frequently over-extended family networks. In a nine page concluding chapter, she then outlines her proposals to streamline and provide uniformity to the various programs. She favors expansion to a massive network of home services with broad eligibility, hopefully funded under a new national health plan with universal entitlement. While I substantially agree with both her assessment of the current problems in home services and her proposed solutions, I nevertheless must raise several issues. First, she makes no mention of the role of the physician in home care, although inadequate levels of reimbursement under the federal program are one of the major constraints to physician home visiting. The physician is nowhere acknowledged as a member of the home care team, although he is sometimes the key-decision-maker. The “social services model” and the “medical model” of service needs are artificial separations that should be transcended in a comprehensive review. Second, there is insufficient attention to placing the problem of home services in perspective. The reader is disoriented through most of the first chapter, trying to understand why home care is important, who would use it, what the alternatives might be, and why coordination of services is a critical issue. The problem is complicated by the book’s lack of an index and by a compressed table of contents at the bottom of the title page, where it can easily be missed. Most importantly, this treatise suffers from tunnel vision. Trager perceptively analyzes the failures of the current programs and outlines acceptable bureaucratic solutions, but fails to consider the data base needed to expand home services. Before any expansion is undertaken (assuming such an enterprise is possible in the emerging austerity of federal policy-makers), we need to know much more about the costs of home care, the differential utilization of services, the effectiveness and efficiency of selected services, the proper place of home care in the health services delivery spectrum and the mechanisms of integration of home services into the present institution-based system. How KATHLEENCONNELLY should the informal family support network be aided? Can Policy Analysis and Eualuation home care services allow earlier hospital discharge followMassachusetts Department of ing an acute illness? When should respite care be offered? Public Health What factors determine whether an impaired individual Boston, MA. U.S.A. will do better at home or in a long-term facility? HOW should home services differ among ethnic groups, socioeconomic levels and geographical regions? Moreover, we need further discussion of the fundamental policy issues: Home Health Care and National Health Policy, by BRAHNA how much of the GNP can we afford for health care? If home services were not cost effective and did not prevent TRAGER.Haworth Press. New York. 1980. 103 pp. 812.95 institutionalization, but contributed to preservation of This monograph, by a veteran social policy analyst, is mental status, alleviated family stress and enhanced the actuallv a soecial issue of the fledgling Home Health Care quality of life for the impaired person, would that be sufficient justification? What if they did nothing except butSewice; Quwrerlp (Vol. I. No. 2: Spring 1980). It catatress the family? A number of researchers are attempting to logues the failures of federal home health care programs find answers to these questions, but we are far from reachand proposes the creation of a re-structured, coordinated. ing a consensus. In the absence of convincing data, it is and easily accessible nationwide home care service patunwise to move too rapidly into a major new venture. terned after the European model. however intuitively appealing it may be. Trager devotes the bulk of her effort to an indictment of Finally, the style of this book is turgid and soporific. the present quagmire of home care services. She begins by Also. there are tables following Chapters 3, 4 and 5 which listing the programs under which such services are proare set in type different from the rest of the book. are vided. which include Title 18 of the Social Security Act visually complicated and are inexplicably not referred to (Medicare). Title 19 (Medicaid). Title 20 (Social Services).
346
Book reviews
anywhere in the text. Trager has something worthwhile to say, which makes the writing style doubly unfortunate. The best part of her book is Trager’s assessment of the current federal programs, which are an undeniable mess. I agree with her perception of the problems of home services and with her proposed remedies, but would build a stronger data base before any major policy shifts. Although unlikely to attract a broad readership, this book will be useful to health planners and to those concerned with home health policy. Department of Medicine Massachusetts General Hospital Chelsea Health Centre Boston, MA, U.S.A.
FRED H. RLJBIN
Masochism and the Emergent Ego: Selected Papers of Esther Menaker, edited by LEILA LERNER.Human Sciences,
New York, 1979. 384 pp. $19.95 This book consists of twenty-two selected papers of Esther Menaker and covers a period of over forty years. The material is divided into five parts: 1. Prologue: Psychoanalysis in Perspective; 2. Aspects of Masochism; 3. Identification and the Social Process; 4. Creativity: and 5. Epilogue, Indications for the Future. The editor’s introductions to Aspects of Masochism, Identification, the Social Process and Creativity highlights the history and development of each topic. Of the six papers on the Aspects of Masochism, the first cites the masochistic aspects of submission in Thomas Mann’s story of “Mario and the Magician”, when the submission of hypnosis is broken, agression takes over and the magician is killed. Dr Menaker thereafter clarifies the elements of masochism in papers that deal with separation from the mother, the evolution of masochism as a self concept of the ego in an early phase of the mother/child interaction, and the sense of child’s weakness as an imprint of the mother’s image of the child. Masochism becomes a way of relating and avoiding separation. The passive role in the analytic process may hide the patient’s devalued sense of self in relationship to the analyst, a reaction that is counter-therapeutic. The analyst’s behavior in displaying a friendly interest toward the patient is deemed important; in this way, the patient’s ego is liberated so that the patient is able to relate to the analyst as a person rather than an authoritarian parent. From the work of ethologists on animal behavior, Menaker reports masochistic behavior of animals similar to the human pattern, e.g. the young timber wolfs submissive reaction to a more powerful wolf. By baring his jugular vein and placing himself in a submissive position, he placates the more powerful wolf and survives. Masochism is part of the evolutionary process of survival in both animal and man. For treatment, Menaker strongly emphasizes the concept of will as a function of the ego in contrast to Freudian analysts who view will as a definition of ego strength or weakness. In borderline states, character disorders and masochistic patients, insight as a therapeutic tool fails. Consequently, Dr Menaker supports the ego as will the ability to actualize goals and choices. This capacity of will depends on the ego development in the mother/child relationship and on the inherited abilities of the individual. Dr Menaker suggests that the early masochistic reaction prevents independent action or will, so that one must undo and redo the experiences of childhood. This reconstruction can only be accomplished in actual relationship with the therapist. In that relationship, the Patient can exercise his will and rupture the masochistic
bond to mother with its attendant anxiety. This process could be designated as a new identification. In her paper. The Issues of Symbiosis and Ego: Autonomy in the Treatment ofMasochism, Menaker again advises the therapist to
minimize the transference neurosis by behaving as a helping person rather than a distant, neutral professional, and by analyzing the patient’s reality distortions in relationships with others. a process which allows the patient to establish new identifications. Identification with the analyst is primary, establishing a basis for new identifications with still others. The second section, Identification and the Social Process. is a series of eight papers, dealing with social processes as the basis of analogy of the genetic code as transmitter of biological evolution; identification, similarly, is the transmitter of social evolution. Basic to this concept is the mother/child bonding which leads to the separation/individuation process. In the paper, Possible Forerunners of the Indentijication Process in the Animal World, Menaker writes of Elsa, the baby lioness raised from her first few days by Joy Adamson, so that Adamson became the mother through imprinting or bonding. On the other hand, Elsa’s cubs were six weeks old before they met Adamson so that their reaction was one of distrust and caution. In the paper on The Injkence ofChangingVa/alues,Menaker stresses that because of massive social changes, value systems may be disrupted for succeeding generations due to the lack of solid identifications, increased narcissism and lack of genuine ego autonomy. The last section is devoted to the concepts of creativity, concepts derived from Otto Rank, which are compatible with Menaker’s view of differentiation and individuation. Creativity is a form of individuation based on unconscious functions-on the ego-ideal, the sense of self and the relationship to contemporary life. I would highly recommend the book and its exceptional combination of excellent case material, understanding of personality, and concepts of treatment. Department of Psychiatry Massachusetts General Hospital Boston. MA, U.S.A.
JEROMEL. WEINBERGER
ANDREW M. GREELEY, WILLIAM C. MCCREADY, and GARY THEISEN.Praeger, New
Ethnic Drinking Subcultures, by York, 1980. 138 pp. IE15.95
This thin volume reports the findings of an investigation into differences in drinking problems and their genesis among five American national-descent groups (English, Irish, Italian, Jewish, and Swedish) sampled in four cities (Boston, Chicago, Minneapolis, and New York) during 1978. Data were collected by means of self-administered questionnaires filled out by one parent and one adolescent child in each of the 980 families studied. The study was designed to test a general multivariate model, derived for the most part from previous research by the senior author into the socialization of political values among ethnic groups. Essentially, the model postulates that drinking behavior (with particular emphasis on drinking problems) is determined by cultural norms (defined as parental approval+iisapproval of drinking), parental drinking behavior, relationship between parents, family drinking customs, family structure (i.e. power, or the locus of parental decision making, and support, or perceived closeness to parents), and personality factors (i.e. efficacy, or sense of competency; attitude towards authority; and achievement orientation). The model was tested by path analysis. With regard to findings. the investigators expected and
345
and the Older Americans Act. Between these four there is no consensus as to what constitutes “home health care”, how it should be funded, who should be eligible for it, which services should be provided for how long, what records should be kept. and by what parameters it should be measured. This fragmentation and inherent incoordination creates bureaucratic barriers separating impaired Americans from the services they need to avoid institutionalization, to preserve fUnCtiOnal status, to obtain early intervention for acute medical problems, to maintain a reasonable quality of life and to provide respite for their frequently over-extended family networks. In a nine page concluding chapter, she then outlines her proposals to streamline and provide uniformity to the various programs. She favors expansion to a massive network of home services with broad eligibility, hopefully funded under a new national health plan with universal entitlement. While I substantially agree with both her assessment of the current problems in home services and her proposed solutions, I nevertheless must raise several issues. First, she makes no mention of the role of the physician in home care, although inadequate levels of reimbursement under the federal program are one of the major constraints to physician home visiting. The physician is nowhere acknowledged as a member of the home care team, although he is sometimes the key-decision-maker. The “social services model” and the “medical model” of service needs are artificial separations that should be transcended in a comprehensive review. Second, there is insufficient attention to placing the problem of home services in perspective. The reader is disoriented through most of the first chapter, trying to understand why home care is important, who would use it, what the alternatives might be, and why coordination of services is a critical issue. The problem is complicated by the book’s lack of an index and by a compressed table of contents at the bottom of the title page, where it can easily be missed. Most importantly, this treatise suffers from tunnel vision. Trager perceptively analyzes the failures of the current programs and outlines acceptable bureaucratic solutions, but fails to consider the data base needed to expand home services. Before any expansion is undertaken (assuming such an enterprise is possible in the emerging austerity of federal policy-makers), we need to know much more about the costs of home care, the differential utilization of services, the effectiveness and efficiency of selected services, the proper place of home care in the health services delivery spectrum and the mechanisms of integration of home services into the present institution-based system. How KATHLEENCONNELLY should the informal family support network be aided? Can Policy Analysis and Eualuation home care services allow earlier hospital discharge followMassachusetts Department of ing an acute illness? When should respite care be offered? Public Health What factors determine whether an impaired individual Boston, MA. U.S.A. will do better at home or in a long-term facility? HOW should home services differ among ethnic groups, socioeconomic levels and geographical regions? Moreover, we need further discussion of the fundamental policy issues: Home Health Care and National Health Policy, by BRAHNA how much of the GNP can we afford for health care? If home services were not cost effective and did not prevent TRAGER.Haworth Press. New York. 1980. 103 pp. 812.95 institutionalization, but contributed to preservation of This monograph, by a veteran social policy analyst, is mental status, alleviated family stress and enhanced the actuallv a soecial issue of the fledgling Home Health Care quality of life for the impaired person, would that be sufficient justification? What if they did nothing except butSewice; Quwrerlp (Vol. I. No. 2: Spring 1980). It catatress the family? A number of researchers are attempting to logues the failures of federal home health care programs find answers to these questions, but we are far from reachand proposes the creation of a re-structured, coordinated. ing a consensus. In the absence of convincing data, it is and easily accessible nationwide home care service patunwise to move too rapidly into a major new venture. terned after the European model. however intuitively appealing it may be. Trager devotes the bulk of her effort to an indictment of Finally, the style of this book is turgid and soporific. the present quagmire of home care services. She begins by Also. there are tables following Chapters 3, 4 and 5 which listing the programs under which such services are proare set in type different from the rest of the book. are vided. which include Title 18 of the Social Security Act visually complicated and are inexplicably not referred to (Medicare). Title 19 (Medicaid). Title 20 (Social Services).
346
Book reviews
anywhere in the text. Trager has something worthwhile to say, which makes the writing style doubly unfortunate. The best part of her book is Trager’s assessment of the current federal programs, which are an undeniable mess. I agree with her perception of the problems of home services and with her proposed remedies, but would build a stronger data base before any major policy shifts. Although unlikely to attract a broad readership, this book will be useful to health planners and to those concerned with home health policy. Department of Medicine Massachusetts General Hospital Chelsea Health Centre Boston, MA, U.S.A.
FRED H. RLJBIN
Masochism and the Emergent Ego: Selected Papers of Esther Menaker, edited by LEILA LERNER.Human Sciences,
New York, 1979. 384 pp. $19.95 This book consists of twenty-two selected papers of Esther Menaker and covers a period of over forty years. The material is divided into five parts: 1. Prologue: Psychoanalysis in Perspective; 2. Aspects of Masochism; 3. Identification and the Social Process; 4. Creativity: and 5. Epilogue, Indications for the Future. The editor’s introductions to Aspects of Masochism, Identification, the Social Process and Creativity highlights the history and development of each topic. Of the six papers on the Aspects of Masochism, the first cites the masochistic aspects of submission in Thomas Mann’s story of “Mario and the Magician”, when the submission of hypnosis is broken, agression takes over and the magician is killed. Dr Menaker thereafter clarifies the elements of masochism in papers that deal with separation from the mother, the evolution of masochism as a self concept of the ego in an early phase of the mother/child interaction, and the sense of child’s weakness as an imprint of the mother’s image of the child. Masochism becomes a way of relating and avoiding separation. The passive role in the analytic process may hide the patient’s devalued sense of self in relationship to the analyst, a reaction that is counter-therapeutic. The analyst’s behavior in displaying a friendly interest toward the patient is deemed important; in this way, the patient’s ego is liberated so that the patient is able to relate to the analyst as a person rather than an authoritarian parent. From the work of ethologists on animal behavior, Menaker reports masochistic behavior of animals similar to the human pattern, e.g. the young timber wolfs submissive reaction to a more powerful wolf. By baring his jugular vein and placing himself in a submissive position, he placates the more powerful wolf and survives. Masochism is part of the evolutionary process of survival in both animal and man. For treatment, Menaker strongly emphasizes the concept of will as a function of the ego in contrast to Freudian analysts who view will as a definition of ego strength or weakness. In borderline states, character disorders and masochistic patients, insight as a therapeutic tool fails. Consequently, Dr Menaker supports the ego as will the ability to actualize goals and choices. This capacity of will depends on the ego development in the mother/child relationship and on the inherited abilities of the individual. Dr Menaker suggests that the early masochistic reaction prevents independent action or will, so that one must undo and redo the experiences of childhood. This reconstruction can only be accomplished in actual relationship with the therapist. In that relationship, the Patient can exercise his will and rupture the masochistic
bond to mother with its attendant anxiety. This process could be designated as a new identification. In her paper. The Issues of Symbiosis and Ego: Autonomy in the Treatment ofMasochism, Menaker again advises the therapist to
minimize the transference neurosis by behaving as a helping person rather than a distant, neutral professional, and by analyzing the patient’s reality distortions in relationships with others. a process which allows the patient to establish new identifications. Identification with the analyst is primary, establishing a basis for new identifications with still others. The second section, Identification and the Social Process. is a series of eight papers, dealing with social processes as the basis of analogy of the genetic code as transmitter of biological evolution; identification, similarly, is the transmitter of social evolution. Basic to this concept is the mother/child bonding which leads to the separation/individuation process. In the paper, Possible Forerunners of the Indentijication Process in the Animal World, Menaker writes of Elsa, the baby lioness raised from her first few days by Joy Adamson, so that Adamson became the mother through imprinting or bonding. On the other hand, Elsa’s cubs were six weeks old before they met Adamson so that their reaction was one of distrust and caution. In the paper on The Injkence ofChangingVa/alues,Menaker stresses that because of massive social changes, value systems may be disrupted for succeeding generations due to the lack of solid identifications, increased narcissism and lack of genuine ego autonomy. The last section is devoted to the concepts of creativity, concepts derived from Otto Rank, which are compatible with Menaker’s view of differentiation and individuation. Creativity is a form of individuation based on unconscious functions-on the ego-ideal, the sense of self and the relationship to contemporary life. I would highly recommend the book and its exceptional combination of excellent case material, understanding of personality, and concepts of treatment. Department of Psychiatry Massachusetts General Hospital Boston. MA, U.S.A.
JEROMEL. WEINBERGER
ANDREW M. GREELEY, WILLIAM C. MCCREADY, and GARY THEISEN.Praeger, New
Ethnic Drinking Subcultures, by York, 1980. 138 pp. IE15.95
This thin volume reports the findings of an investigation into differences in drinking problems and their genesis among five American national-descent groups (English, Irish, Italian, Jewish, and Swedish) sampled in four cities (Boston, Chicago, Minneapolis, and New York) during 1978. Data were collected by means of self-administered questionnaires filled out by one parent and one adolescent child in each of the 980 families studied. The study was designed to test a general multivariate model, derived for the most part from previous research by the senior author into the socialization of political values among ethnic groups. Essentially, the model postulates that drinking behavior (with particular emphasis on drinking problems) is determined by cultural norms (defined as parental approval+iisapproval of drinking), parental drinking behavior, relationship between parents, family drinking customs, family structure (i.e. power, or the locus of parental decision making, and support, or perceived closeness to parents), and personality factors (i.e. efficacy, or sense of competency; attitude towards authority; and achievement orientation). The model was tested by path analysis. With regard to findings. the investigators expected and