THERAPEUTIC COMMUNITY OPEN FORUM

An intersection of people, places and organizations...

Sources Open Sources Home

How Can I Help?


SourcesOpenSources:
Online Therapeutic Community Library

The aim of SourcesOpenSources is to compile a comprehensive list of publications relating to therapeutic community; to find and provide links to sources on the Internet; and to build up the library of publications available to the public Online.
"How can I help?"

Reflections on an Incident at Dingleton
Dennie Briggs


© the author
International Journal of Therapeutic Communities 12:2 and 3 (1991), pages 145-154


REFLECTIONS ON AN INCIDENT AT DINGLETON
Dennie Briggs

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 floor.

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:

 

25th November

DINGLETON HOSPITAL

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 others.

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.

Dennie: Yes.

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 most psychotherapies.

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 assumption.

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 occurs.

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 continue.

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 follow?

Dennie: Ummm.

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 mutual.

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 clues.

Let me review that situation at Din gleton as I saw it. Correct me if I'm wrong or leave out things you think important.

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?

Dennie: No.

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 term patients.

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 activity therapists.

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?

Dennie: Partly.

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 group.

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 groups.

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.

Max: Protested?

Dennie: Well, I meant raised it at the SSC.

Max: And what did you do with this information?

Dennie: Nothing.

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 delays.

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 distance.

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 discrimination?

Max: That's a strong accusation.

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.

May: And?

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 administrative matters.

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 acting-out.

Max: Being?

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 situation?

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 overlooked.

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.


Reference

Jones, M. (1956) `The concept of a therapeutic community'. American Journal of Psychiatry, 112, February, p. 649.

Notes

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 text]

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]

 



TC Sources Home

 

BOOKS AND ARTICLES (alphabetically by author)

A

B

C

D

E

F

G

H

I

J

K

L

M

N

O

P

Q

R

S

T

U

V

W

X

Y

Z

 

SEARCH ACADEMIC LITERATURE ON GOOGLE SCHOLAR


 

Subscribe to TC-OF
Powered by groups.yahoo.com

 

...therapeutic community...comunità terapeutica...comunidade terapêutica..."5@0?52B8G5A:>9 >1I8=K...terapines bendruomenes...terapeutiskt samhälle...communauté therapeutique...therapeutischen gemeinschaft...terapeutické komunity... comunidad terapeutica...therapeutische gemeenschap...thérapie par le milieu...milieu therapy...milieutherapie...miljoterapi...planned environment therapy...therapieboerderij...