© the author
International Journal of Therapeutic Communities 12:2 and 3 (1991),
REFLECTIONS ON AN INCIDENT AT DINGLETON
Max had set up our chairs and table
outside in the sun, as he had each morning since I arrived. The birds were
waiting, singing loudly in the trees. But Max was nowhere to be seen. I found
him in his study, papers and books piled on his desk and strewn about the
Max: I've been foraging around
in my papers - you know I can never throw away anything. Well, I found
something that might be of interest. It might help clarify some of the issues
we were talking about yesterday.
You asked me to write this up for you one time:
Memo for: Dennie BRIGGS
From: Maxwell JONES
On Thursday, 21st November, I was
called away from the review of the Admissions Ward because I was told that Eden
Ward had a crisis and wanted me. When I got to Eden, a young patient was
sitting in the middle of the floor and people were pleading with him to control
himself. The ward seemed to be in a quite disturbed state. I thought it
expedient to bring the charge nurse with me from the review because he was
technically still attached to that ward, although in the process of
transferring to the admissions ward. The new charge nurse had the day off and
Dennie and a young nurse seemed to be the leaders on the ward. The former
charge nurse seemed to have largely opted out of his role and, if anything,
seemed to be sulking. He did, however, take the disturbed patient in hand and
moved him into the sitting room in order that the ward could return to some
sort of calm.
In the group discussion, the younger
element of the ward seemed to be saying what a good fellow Dennie was, implying
that there were staff who were against him. The doctor on the ward seemed to
have opted out as he was preparing to leave and return to his own country. It
seemed that there was a crisis of leadership on the ward and no real
clarification as far as I could see.
The patients assumed that Dennie was
the popular leader on the ward who was going to give them all kinds of good
times. It seemed that he had ideas about the staff eating with the patients and
had already begun to do so in the dining room. I felt it necessary to tell the
patients that Dennie was a charismatic leader, although of course I didn't use
such words, and that he tended to identify with the underprivileged, in this
case, the patients, which might put the staff against him. This splitting was a
danger to the stability of the ward. I thought it proper to say how impressed
the whole hospital had been by the developments in Eden, particularly in the
field of rehabilitation, and the plans for the male hostel. Four of the Eden
female patients were going to look after the men there, do their cooking, and
so on, as a prelude to going outside and looking after themselves in their own
cottage. I felt that there was a tremendous difference between a rehabilitation
programme for psychopaths and one for schizophrenics and that perhaps they were
putting too much responsibility on the patients too quickly.
I was impressed by Dennie's
willingness to have his performance discussed without becoming defensive. He is
undoubtedly having a profound effect on the ward and arousing a tremendous
amount of enthusiasm and optimism amongst patients. The danger is, I think,
that Dennie does tend to become the good internalised object and I think he
should try to make himself more familiar with the concepts like object
relationships. He offers himself to schizophrenic patients as the gratifying,
internalised father. By activating this excitatory part of the individual
schizophrenic ego, he forces the staff to appear as being destructive and
punitive-if one wants to use psychoanalytic jargon.
Dennie: To be honest, Max, I'd
totally forgotten about that incident.
Max: I thought it pertinent,
because of the importance of what part leadership plays in bringing about
change. That's a complex issue because there are so many expectations of the
leader which are often at odds. And of course, the setting itself adds
Dennie: For example ...
Max: If we're using a hospital
ward or a medical centre as our point of reference, then the doctor or the
nurse has been cast into a familiar, authoritarian role and the patient
complies-even unconsciously. Add to that the formality of uniforms and titles,
and so on. All of which reinforces the way the patient or client will react,
and thereby shapes or inhibits what takes place.
Max: Now if we yield to that
temptation, we may never be able to examine the nature of conflict and explore
potentials. I realise that's stating the issue too simply. Let's say at least
the opportunities are limited.
Dennie: But this is true of
Max: To some degree. In
psychoanalysis-in the more classical sense-you have a similarly contained
situation. You have time, however, and hopefully through the skill of the
analyst, a temporary relationship is formed, which may last for as long as five
years . But in so doing, a different construction can emerge, which may allow
the person to lead a more satisfying life.
Dennie: That's the tacit
Max: But this analogy bothers
me a bit because you know I'm not convinced it works quite that smoothly or
always in that manner. In analysis you have a controlled situation where the
analyst is fully in command-and is usually very authoritarian. And as the
analysis proceeds, the analysand eventually takes on more and more
responsibility until they terminate the procedure.
Be that as it may, there are
differences in the therapeutic community. Leadership has to be examined
constantly. It's not only continually emerging, but evolving as well, and the
interplay of psychodynamic forces is where the potential for growth or change
Dennie: In the therapeutic
community, you don't have the time you have in analysis to work out an
intensive relationship and then resolve it.
Max: Not that kind, no. But
intensive relationships are formed nevertheless-not one but many and from so
many different perspectives.
Now, if I may return to the real
psychodrama in which you found yourself that day on Eden Ward-had you allowed
yourself the liberties you did practising individual therapy, you might have
been in grave trouble.
Dennie: I'm not clear what
you're referring to.
Max: Merely that you would have
been running the risk of aiding and abetting the patients' conditions, which
might not have been helpful. It could have prevented them from exploring their
own conflicts and defenses. This would be especially true if you were dealing
with people who had psychopathic characteristics- like your prisoners in
California. Presumably awareness of one's own dynamics from, say a personal
analysis, would prevent one from entering into the treatment situation to the
extent that the patient's exploration of his own situation would be blocked. Do
you get what I'm driving at?
Dennie: I think so. But do
Max: Well, I don't want to get
into a discourse on psychoanalysis or make too many comparisons. What I'm
leading up to is that, in a therapeutic community, you have a complex situation
whereby you are trying to establish an environment-be it in a hospital ward, a
prison, or a classroom-that is also selfcontained more or less. It has a
periphery within which it is relatively safe to let one's guard down, to be
one's true self within the limits of that special se tting. Do you
Max: This incidentally, is a
rare event in most people's lives today. There aren't many places where it can
occur-even in marriages or families. As people rely less on the usual means of
social control, they begin to "act out" the ways they handle tension
relating to others. So the advantage of a therapeutic community is that in this
atmosphere, changes can be made to accommodate to the needs of the people who
are involved. It's not a static environment dominated by any one person-no
matter how wise or altruistic he or she may appear. I found myself constantly
shifting my views both at Henderson and at Dingleton, in response to the
relevance of social forces.
If I may continue, getting back to
this memo about Eden Ward which involved you. I've seen you in enough different
situations to know that you appeal to the healthier or positive side of
people's personalities. You have the ability to bring out enthusiasm and
dedication in the people you work with. And that includes chaps like me! You
know I always considered it a high point and made considerable effort to see
you when I made my annual consulting visits to America. I learnt so much from
what you were doing.
Dennie: It's always been
Max: People rally round you,
get involved, try new things and there's always this aura of excitement about
the projects you undertake. This is good; we need more of this. Yet you must
realise that, in the excitement you generate, there can be negative factors.
Especially as you operate in a team with other people who do not completely
share your views or your enthusiasm.
I've found from even more experience
tha n you've had, that many people just aren't suited to working openly as one
has to in a therapeutic community. Among doctors, I dare say, only one in four
or five can make the transition.
But just let me say in brief that a
leader has many roles to play depending on the circumstances: however, by
seeking to please too much the leader may block the process of change or growth
in the group. A leader must at times risk being disliked or being unpopular,
knowing that growth is often a painful process.
Dennie: But crises like this
aren't all bad, are they?
Max: Not at all, they're
terribly important for learning and growth. Now, if you wouldn't mind being the
subject for a moment, take that memo that I dug up this morning. It had some
Let me review that situation at Din
gleton as I saw it. Correct me if I'm wrong or leave out things you think
I responded to your request to come to
the ward as you had a crisis on your hands.(fn1) No one knew how to handle the young patient who was on the
floor having some kind of episode. His condition was further complicated due to
epilepsy, making it difficult to know if his episodes were psychotic or
physical in nature and also he was on various medications. Patients and staff
alike were afraid of his violence from previous episodes. Is this a fair
picture so far?
Dennie: As I remember.
Max: The staff on the ward was
in a transition phase. The doctor hadn't been a particularly strong leader and
had used medications freely. At the patient's outburst he had panicked and
wanted him restrained. The previous charge nurse on the ward had been
transferred to another recently, and the new one had the day off. The male
nurse who was most familiar to the patients was also off for the day. That left
you and the ward nurse. And quite naturally the group had turned to the two of
you for leadership. Is that fair?
Dennie: Yes. I think I had been
there only about a month.
Max: I was going to mention
that next. But do let me continue to reconstruct the situation. The reason I
brought along the former charge nurse was because I thought he knew the ward
and would be a familiar figure to the patients. And then I sent for Reg (and
Assistant Director of Nursing) because he was a strong person whom both the
staff and patients respected. He also represented authority from the standpoint
of the nursing administration.
Dennie: And he frequently spoke
out in opposition to your ideas.
Max: Personally, I didn't think
the crisis itself warranted so much attention. I mean, there were a number of
ways you could have handled it without my help. I didn't know if the patient's
reaction was partly due to his medication, or if this episode was so disruptive
to the group that he should have been removed until he got control of himself.
The important thing, how ever, was that it had opened up a whole range of
things that were going on in the ward at that time; things that hadn't been
worked through and resolved. You had a crisis of leadership on the ward that
wasn't being dealt with. And so it became focused on in the immediate crisis:
in my opinion, far more important than the situation itself.
But, really there was little I could
do. You and the others were just as competent to deal with it, and I'm sure you
would have done so had I not been available that day.
Dennie: It seemed scary at the
time to me.
Max: No doubt. But it was also
a perfect example of how a crisis can bring out situations that are unresolved,
and how over time patients act them out. You had long term patients with
schizophrenic and paranoid disorders and you had those with psychopathic
behaviour, a potenti ally explosive combination. And amongst them were patients
from the other wards around the hospital who were seen as unmanageable.
Dennie: Yes. The hospital
expected violence on that ward.
Max: Right. And you were there
in the midst of all this ferment, trying to introduce some changes yourself.
You'd inherited a few difficulties, like trying to coax some of the long-term
women into looking after the new men's hostel, in preparation for moving them
out of the hospital themselves into the cottages.
That plan had been in the works for up
to a year before you arrived. And then, as came out in the meeting, Joan (a
patient who'd been hospitalised over 30 years) had equated you with another
American who'd worked on that ward before your time; the centre of controversy
when he took a unilateral decision one day and had locked d own the ward. This
action upset the whole hospital, for it broke a tradition that had been
established back in 1939 as being the world's first all open wards hospital.
Did you know he had been there?
Max: What's important is that,
for whatever reason, an American showing active leadership at that particular
time got equated with what had gone before in the minds of some of the
patients. But most of the patients were quick to come to your support in the
meeting when Joan suggested it. You were already seen as a good influence on
the ward, especially by the young people and even by the majority of the long
Now we come to you as a person, and
what you brought with you when you arrived at Dingleton. This is where I'll
need your help. I bring this up because it illustrates so well how you cannot
sep arate the staff from the patients, clients, consumers, or whatever, in a
therapeutic community. Are you with me?
Dennie: Yes indeed.
Max: That was not only a new
setting for you, but your manner of operation was different. Just recently you
were involved in some exciting projects on the university campus and
politically in the community.
You came to Dingleton full of energy
and pitched right in, whereas I thought it would take you some time to acquaint
yourself with both the hospital and the local culture of the Borders. You
identified with the younger element of the staff-primarily with the social and
Dennie: That's right.
Max: This is all by way of
background-to show you how you as a person entered that ward; how your past
came with you and was manifest in the way you went about your work. Do you see
what I mean?
Max: Well, then let me continue
with another detail which I think is germane. It involves your belief in social
action. I don't think you'd been there very long when I heard that you were
eating with the patients rather than the staff in the dining room. Do you
remember that? How did that happen?
Dennie: I remember it well. The
work group had to scrub the floor and clean the dining room each morning. From
the day of my arrival I was rather irritated by the staff sitting on one side
and the patients on the other, in a place that was supposed to be so
democratic. Then they gave us a higher quality of soap to clean the staff's
section of the dining room and a government-i ssued detergent that smelled
horrible, for the patient's side. I was embarrassed for the patients, but they
seemed to accept this iniquity without comment. Well, one patient did say she
preferred the strong smell of the detergent, but then she'd been at the
hospital more than 20 years and had nothing to compare it with.
Sometimes the dining room staff asked
us to set the tables when they were short of help. I noticed that the staff had
more and better quality of silverware than the patients. After lunch, the staff
would retreat to the lovely glass-enclosed solarium sitting-room for coffee-to
get away from the patients. I got so uncomfortable that I began to avoid that
ritual and took instant coffee on the ward with the others in the cleaning
Max: I wasn't aware of all
this. Do continue.
Dennie: Well, the final blo w
was over the cleanliness of the silverware in the patient's dining room.
Patients on the ward had brought up in the meetings how dirty the silver was
and couldn't something be done about it. We complained to the nursing staff and
to the hospital secretary (administrator) who said bring it up in the
groups-"use the structure" is how they put it. We brought it up
endlessly in meeting after meeting and nothing changed. This must have gone on
for a month. I was getting fed up because it took so much of our time and was
such a simple matter. And there were so many more pressing things that we
didn't have time to get into.
Max: I have no recollection of
all this ...
Dennie: I don't know why I felt
any obligation to take action. I had followed through with complaints-written,
as well as going directly to the people in question and raising it in various
Then one day I overheard some nurses complaining how
they didn't like to eat in the dining room with no separation from the
patients. One remarked that they had such bad table manners and another said
that there was no supervision and regulation of the patients while they ate.
And finally another lamented that the staff had had to give up their separate
dining room after you had arrived, as you'd made it into the staff conference
room where they held the SSC (Senior Staff Council). When I asked if she'd
protested this decision, she told me that it wouldn't have done any good
because the work order to convert the dining room had already gone in.
Dennie: Well, I meant raised it
at the SSC.
Max: And what did you do with
Max: This is what the groups
were for-staff as well as the patients.
Dennie: I'd felt nothing could
be done because of all this hassle about the dirty silverware. One morning
while we were setting the table for lunch, the patients asked me to have lunch
with them. Before lunch I asked a couple of the charge nurses if they thought
it would be all right to have lunch with the cleaning group as they'd invited
me. They said they could see no objection, as you'd eaten with some of the
patients the day after you first arrived. Some nursing students, however,
overheard our conversation and said I would have to take this up at the SSC
before doing it. So, I was confused and frankly getting impatient with all the
Max: And the upshot was that
you took your lunch with th e patients.
Dennie: Yes, but by this time,
what should have been a pleasant event had turned into something that made me
feel anxious. I think I even sat at the table with my back to the staff hoping
not to be noticed.
Max: At Dingleton?
Dennie: Well, remember that I'd
only been there about a month. And I did identify with the patients. They had
no recourse really. The elaborate structure, it seemed to me, had emerged more
for the benefit of the staff than the patients. You did have some terribly
recalcitrant staff who were firmly entrenched and they needed constant checks
not to abuse their power. The patients had tried to use the official machinery
to get this matter attended to and the staff had blocked it-it didn't work for
them. I guess I was too emotionally involved by that time to have much
Max: Which was to be expected,
was it not?
Dennie: Well, you see Max, it
related to this whole question of distance. Trying to justify social distance
from patients-is it not just a highly rationalised form of
Max: That's a strong
Dennie: Frankly, Max, I don't
see the difference whether you're talking about students, or patients, or
prisoners for that matter. Remember that statement you made to me years ago
when I visited you at Henderson-about treatment for the patients and training
for the staff. You said in effect that for the time being, it's best to have
separate groups, until patients can be told the whole truth?
Max: I don't think that's
exactly what I said, but it's the essence.(fn2)
Dennie: Well, I thought at last
I'd found a place where the whole truth could come out. But I discovered it
wasn't the time.
Max: Dingleton, after all,
wasn't heaven either.
Dennie: No. We had a very
exciting seminar from Joy (Tuxford, psychiatric social worker)-we being the
social therapists-where she talked about social structure and gave us some
findings from her research. She described the "unofficial/official
structure", which could negate the efforts of the official structure.
Keeping proper distance from the patients was one example.
Dennie: There was the phrase
"you're being destructive" that a lot of the old timers had picked up
and used often. It was a stopper in any group. And then for us foreigners,
there was always, "You don't know the local politics", or "You
must be aware of the image of Dingleton to Melrose", or just plain,
"You're a transient".
Max: Which meant?
Dennie: That one was just
passing through and didn't really belong there. It's similar to the attitude
many faculty members have towards students when they want to become involved in
Max: In all fairness, we'd
found by experience-painful at times-that a person who came to Dingleton needed
about a year just to acclimatise oneself both to the hospital and to the
outside community. I don't know if there are ways to speed up this
process-perhaps the use of television you were experimenting with would have
hastened it. But I think for some things, you m ust allow for time. I don't
want to appear defensive, but as you said some of the staff were rather
recalcitrant; those you were impatient with at Dingleton were third generation
employees of the hospital and long-time residents of Melrose-it was their whole
way of life, in fact their world.
Dennie: I know. I know, Max.
But I missed the spontaneity and freedom that the elaborate structure seemed to
squelch. The incident with the silverware and eating with the patients was
interpreted by some as "acting-out" on my part. There seemed to be no
distinction between social action and yielding to impulses as in
Dennie: The difference between
taking responsible action and just going along with the status quo or being
irresponsible on the other hand.
Max: (After a pause) Again, I
don't want to appear defensive, Dennie, but I do want to add one further
comment to your account at Dingleton. In part, I was, it seems, living in an
illusionary world thinking that communication from top to bottom of the system
we'd set up was at that time relatively free and open. But had this discrepancy
become known in the SSC and handled as a social learning situation, I honestly
believe we could have worked it through to the benefit of the hospital as a
whole. As it was, it serves as a sobering reminder that no social system can be
assumed to be what it appears or believes to be and subcultures can exist in
isolation if communication is not kept free.
Dennie: Max: I want to ask you,
how was the conversation we just had different from a social learning
Max: It was similar to some
extent, but we both were emotionally involved and didn't have anyone with us
who was neutral and could spot things that we both might have
Dennie: A facilitator?
Max: Yes. You took some risks
by bringing up things that you did and at times this was not easy for you to do
... an example of "painful communication".
And I think the account we used
illustrates the importance of leadership in a therapeutic community.
Jones, M. (1956) `The concept of a
therapeutic community'. American Journal of Psychiatry, 112, February,
1. As medical
director and superintendent, Max made it known that he was always available to
assist any staff member or patient with an emergency, no matter what he was
doing or where he was. It was up to the person requesting the assistance,
however, to define what was an emergency. [return to
2. Max later wrote:
(1956) ". . . The patients are fully aware that we have frequent staff
meetings to deal with our own group and interpersonal tensions. Thus we are
patently at one with them in constantly needing treatment. The only reason for
separating the two treatment areas (patients and staff) is to give the patients
the feeling that our difficulties refer to immediate problems particularly in
the field of learning e.g. the training of new staff members, and are not of
such magnitude as to warrant the term `illness'. Clearly patients want to feel
that the staff can cope with their own problems, if they are going to be able
to treat them competently, so it is probably better to hold staff groups
separately until such time as community techniques have reached the point of
perfection when patients can safely be told the whole truth." [return to text]