U. S. ARMED FORCES MEDICAL
JOURNAL (Vol. VIII, No. 6 June 1957) 811- 819
From the U. S. Naval Hospital, Yokosuka, Japan.
BEGINNINGS OF A THERAPEUTIC
Establishing Group Meetings on a Closed Word
FRANK L. RUNDLE, Lieutenant, MC,
DENNIE L. BRIGGS, Lieutenant MSC, USN
That the closed admission ward
of a psychiatric service in a military hospital can be operated as a
therapeutic community" in accordance with the principles of social
psychiatry developed in England1, has been demonstrated and
reported by Wilmer.2,3 He described his experiences in
operating an acute admission ward without use of traditional suppressive and
restraining measures, particularly quiet rooms and sedation. The results were
impressive and the prospect of using similar methods under other circumstances
was appealing. It seemed that such a method of ward management and patient
treatment would be ideally suited to the operation of the closed ward in this
overseas naval hospital.
Having had no experience in
group therapy and lacking more detailed information than that appearing in
Wilmers article, the senior author, who was Ward Medical Officer, was
reluctant to initiate such an undertaking. However, with the aid of the junior
author, who was a clinical psychologist and had had such experience, the
program of establishing the closed ward as a therapeutic community was begun.
In this article some of the practical problems involved during the first six
weeks of that program will be discussed.
The physical arrangement of the
closed ward presented great disadvantages, as it had not been originally
planned as such and the facilities were far from adequate. The ward was long
and narrow with a capacity, including three quiet rooms, of 33 patients. There
was a small enclosed courtyard at the rear where patients could play basketball
and volleyball. Patients were not allowed off the ward except in the custody of
a corpsman and at the specific order of a medical officer. Except for playing
ball and a daily movie on the ward, the only entertainment and recreation for
the patients was provided by the Red Cross.
Prior to the initiation of the
therapeutic community program, nurses were not regularly assigned to the closed
ward. Usually the nurse on an adjacent ward covered the closed ward as well,
being there only briefly to dispense medications and care for administrative
details. At nights it was covered by the supervisor, who usually had six wards
The hospital corpsmen on the ward
had had no formal training in the care of psychiatric patients or in the
management of a psychiatric ward. All had volunteered to work on the
neuropsychiatric service. Most of them were basically friendly and
understanding in their dealings with patients, but there were some who were so
insecure and felt so threatened that they needed to use means of physical
This is the only fully staffed
naval hospital West of Guam and serves naval and Marine
Corps personnel in Korea, Japan, Okinawa, Formosa, and aboard ships operating in
the encompassed areas. The average monthly psychiatric admission rate is about
70 patients. Patients frequently arrive without prior consultation with our
staff, hence many are admitted when consultation would suffice. Frequently brig
prisoners from the surrounding activities are sent for admission for little
other reason than not being able to accept their status as prisoners. Sometimes
of necessity acutely intoxicated and disturbed individuals are admitted to the
ward overnight because there is no other place to put them. Frequently persons
involved in administrative or legal action because of homosexuality are
admitted for administrative reasons. Patients who have made a suicidal gesture
or attempt are unusually common due to special factors and circumstances in the
All the above factors caused the
ward population to be extremely heterogeneous and often difficult to manage,
and adversely affected therapeutic aims in some instances.
INITIATING THE NEW
The only preparations made for
initiating the new regime" as it came to be known were these: (1)
The bunks on the ward were rearranged so a large enough area could be provided
for the patients and staff to be seated in a circle. (2) The corpsmen were told
that we were about to try something new in the way of ward management and that
the objective was to abolish suppressive technics and place as much
responsibility as possible for control and management upon the patient, both
individually and collectively. (3) Patients and staff were informed that a
meeting would be held on the ward every morning except Sunday and that everyone
would be expected to attend.
There were 26 patients on the
ward when the new program began. These patients had been on the ward in some
instances for only a day, and in one case for six months. Twelve patients were
diagnosed as schizophrenic, 3 as having a neurotic depressive reaction, and 1
as having an anxiety reaction. The remaining 10 were classified as having
character and behavior disorders.
Plan of the Day. The working day on the ward began
at 0745 hours when the staff doctors and nurse interviewed newly admitted
patients. Sick call followed, and the group meeting took place soon thereafter
and lasted 45 minutes. A staff meeting followed the patient meeting, in which
the group meeting was analyzed and pertinent information about the behavior of
the patients on the preceding day was discussed. A report from the night
corpsmen was made known to the staff.
The First Group Meeting.
For the first
meeting, the physician, the clinical psychologist, the nursing supervisor, a
recently assigned ward nurse, 2 Red Cross workers, the master-at-arms, 6
hospital corpsman, and 23 patients were gathered in a circle in the rear of the
ward. Three patients absolutely refused to attend the meeting.
The meeting was opened by the
Ward Medical Officer who stated that the group would meet daily six times per
week for 45 minutes, and that all present were invited to use this opportunity
to express their feelings about the way the ward was run, to ask questions, and
to bring up any personal problems with which they desired help.
The first patient to speak was
the one who had been on the ward the longest (six months) and who was tacitly
recognized as the leader by most of the patients. This patient asked why the
radio couldnt be located at the rear of the ward rather than at the
nurses station and why the corpsmen considered it dangerous to have it in
the limited recreation area. One patient, half sarcastically and with insight
into some of the staffs attitudes remarked, We are all emotionally
unstable and cant be expected to control ourselves, and then got up
and nervously paced the floor for the remainder of the meeting. Another patient
declared to the group that now that a nurse would be regularly assigned to the
ward, the patients would have to watch their language. At another time a
patient asked if a quiet hour could be observed, and after considerable
discussion by the group it was decided that due to weekday activities such a
quiet hour could be observed only on Sundays.
The general tone of the meeting
was lively and at times several persons spoke at once. In addition, there was
laughter and sarcasm, and some patients held private conversations with other
patients and with staff members. The Ward Medical Officer interceded to
encourage order and recognition of a single speaker. Throughout the meeting
there was a display of real interest in improving ward conditions, but the
revealing of personal feelings and problems was minimal.
Afterward the staff assembled in
a small office on the ward and recounted the events of the meeting just held.
The ward physician, psychologist, and nurses felt encouraged and optimistic,
but most of the corpsmen seemed skeptical. The corpsmen later explained that
they initially believed their position of authority and means of control of the
patients were in jeopardy.
Subsequent Group Meetings.
succeeding weeks, the group meetings continued to develop in the direction of
open and free discussion. Initially, considerable time was spent in questioning
and evaluating past restrictive measures and in some cases deciding to change
them. Immediate interpersonal entanglements, both between patients and between
patients and staff, were more freely aired as time passed. As the atmosphere of
receptiveness and tolerance of discussion developed, more and more problems of
an inner personal nature were introduced. At the end of six weeks, the period
covered by this article, the group meetings were effectively utilized in
working out difficulties between individuals, problems of ward management, and
personal problems of considerable intensity and importance.
The following points that arose
in the first six weeks of operating the closed ward as a therapeutic community
are considered to be of importance for others who might be interested in
starting such a program but who are lacking in experience, as was the senior
author. Some of the errors made in beginning this undertaking, from the
standpoint of the mechanics of running the daily groups, will be
Attendance. We did not insist initially that
every patient attend the meetings, but strongly urged them to do so, stating
that we expected everyone to attend. We found that attendance must be required
in the operation of a community type treatment program, as the feelings and
behavior of every patient and staff member influence the others. We found that
those patients who refused to attend, thus not allowing their attitudes and
actions to be considered and inspected by the community, were those who caused
the most difficulties on the ward. We eventually realized that we had to
exercise our military prerogative as officers and require every patient to attend.
We then found that those who formerly refused would attend without overt
resistance. It appeared that an important part in their subsequent change in
attitude was due to our providing them with an acceptable reason to save
face and join the community, which apparently they had wanted to do all
The problem of attendance at
meetings now rarely causes difficulty, but when it does come up with individual
patients, it always has significance and is brought up in the meetings. Once in
a while, if a patient refuses to attend, the group waits for him and the leader
does not allow the meeting to proceed until all are present. The other patients
will usually convince the patient that he should be there; an appeal to
courtesy and good behavior is frequently all that is necessary.
Seating. The area used for the meetings
should be fairly small so as to encourage patient and staff to sit close to
each other and to allow each to be visible to all. This in itself fosters
social control as each member of the group is under scrutiny by all others.
Despite all efforts to maintain group solidarity in seating, some patients and
staff tend to occupy positions indicative of their resistance or need to avoid
scrutiny. Permitting persons to sit on table tops, on the floor, and behind
objects allows them to remain outside the group physically as well as
psychologically and to escape being members of the group. It is desirable for
the staff to disperse themselves in the group to meet the immediate needs of
the patients; however, it was often obvious that they placed themselves in
accordance with their own needs.
If a patient is resistive or
upset, a staff member may personally extend an invitation to the patient to sit
by him in the meeting. Initially some of the staff did not sit, but stood in
the fringes of the group. After repeated fruitless discussions in staff
meetings this matter was finally resolved simply when the leader on one
occasion offered a corpsman his chair. We believe that the leader should sit in
the same position at each meeting but that the rest of the staff should
distribute themselves throughout the group. The patients soon seem to reserve
the same position for the leader and we believe it symbolically provides some
bit of security upon which the insecure patient can depend. On one occasion
when the leader had to be absent from the meeting, the senior corpsman carried
on the meeting, sitting in the leaders chair, which resulted in the
expression of good-natured indignation.
Time. Our groups met for 45 minutes 6
days per week, and we adhered to the beginning and ending times quite strictly.
At times it was thought necessary to run over the allotted time when a patient
was especially distressed or a ward problem was crucial. At such times we
always announced to the group that we were taking the extra time, but that we
believed it was important. On one occasion we thought it necessary to hold an
extra group in the afternoon, and once at midnight, as important ward problems had
remained unresolved or had arisen and all the patients were disturbed. Patients
tend to bring up important personal matters near the end of the hour, and
rather than extend the time, we acknowledge the importance of the material and
encourage them to bring it up at the beginning of the next hour and enlist the
aid of the other patients to help the patient during the day if it seems
Opening Remarks. Except when a number of patients
are at the group meeting for the first time, we open the group with silence and
allow the patients to bring up the first material, always noting who speaks
first and what is said. When new patients are present, we acknowledge them and
explain briefly the purpose of the group, as a social courtesy. We early
cautioned the staff to let the patients open the meetings and if the staff had
material to bring up, to save it for the last 15 minutes. We later found they
either misinterpreted this or used it to their advantage in not talking in the
group at all and so abolished that practice. We still believe that the patients
should open the discussion, but encourage the staff to participate whenever
they feel inclined to do so. The meetings frequently open with prolonged
silence and the staff has learned in most cases to tolerate their own tension.
One group opened with 35 minutes of silence and we commented upon how unusual
it was for so many people to sit together for so long without talking and that
perhaps silence was helpful, for it gave them a chance to sit together and
think. Sometimes we used recordings to stimulate group discussions, but this is
not often required. We closed the meetings by summarizing what had been said
and by making some broad general interpretations of the meaning of individual
and group relationships and interactions.
Distractions. Initially distractions seemed to
appear in frequencies far beyond chance and were used as excuses to not attend
meetings. Telephone calls during the meetings and people being called out to
attend to other matters tended to disrupt the meetings and detract from the
tone of seriousness and importance which we attempt to create. When the staff
did not regard the meetings important enough to attend, the patients often
patterned their behavior accordingly. Consequently for 45 minutes each morning,
we attempted to have all activity cease on the ward. We put forth the idea that
this daily meeting was the most important single treatment procedure
for the day and required that the staff participate as a treatment team and
attempt to hold possible distractions to a minimum. The group leader should
never answer the telephone or leave the group meeting except in absolute
emergency. He should allow no staff member or patient to leave except if
unavoidable. Patients always noticed closely which staff members attended and
often commented on their presence or absence both during the meetings and
Withdrawal. Except in rare instances,
patients were not permitted to withdraw or leave the group. If a patient became
angry and left the group we waited to see if another patient would attempt to
retrieve him; if not, a staff member would try. If these means were not
successful, the leader would always go after the patient, and in few instances
has a patient refused to return. When he returned, the matter was discussed and
the group attempted to help him control himself and his anger more adequately.
In one instance, an aggressive, angry patient made a lunge for the door as a
corpsman was opening it, making loud angry statements to the group. A nurse,
with no prior training or experience in psychiatry, went after the patient and
brought him back to the group and held his arm gently for the remainder of the
meeting. Previously his scuffles had required several corpsmen to help him gain
control of himself.
tempers flared and erupted and patients verbally or more rarely physically
(once during this period) attacked other patients. A sharp verbal attack can
usually be handled by promoting ventilation and making interpretations of
obvious factors involved. Physical violence must, if necessary, be physically
constrained by the staff in a matter-of-fact, nonhostile manner; then, if
possible, the persons feelings should be discussed.
Relaxation of Old Restrictive
great part of the initial group discussions concerned the questioning and
re-evaluation of old restrictive measures such as are practiced on most closed
psychiatric wards. As much as was possible, the group was encouraged to arrive
at their own decision as to whether such measures were any longer necessary.
However, in some cases the medical officer found it necessary to contradict
group opinion and decision concerning such matters, because of administrative
necessity or because of his own philosophy of treatment. Events subsequent to
the period with which this article deals demonstrated that external control
measures can be safely relaxed only gradually as patient group solidarity and
acceptance of responsibility for individual actions are developed. Perhaps it
would be even more important that the staff feel confident and un-threatened by
changing of security measures.
Some of the immediate problems
encountered in the initial phases of establishing a therapeutic community type
of management and treatment on a closed psychiatric ward in an overseas
military hospital have been discussed. This article was prepared to give others
who are inexperienced in methods of community therapy some idea of the more
concrete problems arising in the undertaking.
The immediate goals in using the
therapeutic community approach were to: (1) improve ward management by dealing
openly with patient-staff tensions and resentments and the adjustment of
patient-staff roles and relationships which this involved; (2) prepare patients
for continued treatment and hospitalization by acculturating them to the
hospital; (3) promote realistic acceptance by patients of their roles as
patients; and (4) encourage patients to take an active part in their own
treatment and that of other patients. These goals have been attained in
Through the therapeutic community
method, the number of acute management problems occurring on the ward has been
greatly reduced, and except for occasional use of the quiet rooms for acutely
disturbed drunk patients, the need for restraint has been entirely eliminated.
Informal communications received from other hospitals to which some of our
patients have been evacuated indicate that many of them take their
hospitalization more seriously and work harder in their treatment than do
patients from most hospitals. In some instances, they reportedly assisted the
other patients in learning to accept their status. Long-range plans for using
this method of treatment at this hospital include development of procedures for
returning more patients to duty from this command and improving the condition
of those who require evacuation to the United States for further treatment.
It is possible by applying
therapeutic community technics to materially improve the over-all quality of
patient care, particularly as regards socio-environmental aspects of treatment,
on the psychiatric service in a military hospital not designated a
treatment center. It appears that continued use of traditional
suppressive management because of inadequate facilities, lack of trained staff,
and rapid turnover of patients is not justifiable, considering that all these
disadvantages were initially present in this case and did not prevent the
successful use of the therapeutic community method. Of primary importance in an
undertaking such as described herein is that the staff have a sincere interest
in and a genuine desire to help people. Specialized technical training is not
essential, although provisions for training ward personnel within the program
are important. Absolutely essential is a general attitude on the part of the
staff which embodies kindness, understanding, sincerity, and an unfailing
conviction of the worth and dignity of the human being.
ACKNOWLEDGMENT: The authors are grateful to
Captain Ira C. Nichols, MC, USN, and Commander Harry A. Wilmer, MC, USN, for
their encouragement and advice, and to the Nurse Corps and Hospital Corps
personnel and Red Cross workers for their co-operation in this
1. Briggs, D. L., and Stearns,
L.: Developments in
social psychiatry; Observations in five selected English hospitals. U.
S. Armed Forces Medical Journal. 8: 184-194, February. 1957.
2. Wilmer, H. A.: Psychiatric
service as therapeutic community. U. S. Armed Forces Medical Journal. 7:
640-654, May 1956.
3. Wilmer, H. A.: Psychiatric
service as therapeutic community; 10-month study in care of 939 patients. U.
S. Armed Forces Medical Journal. 7: 1465-1469, October. 1956.