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?"

BEGINNINGS OF A THERAPEUTIC COMMUNITY
Establishing Group Meetings on a Closed Word

FRANK L. RUNDLE, Lieutenant, MC, USNR
DENNIE L. BRIGGS, Lieutenant, MSC, USN

Text and Permissions: Dennie Briggs
html: Craig Fees


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 COMMUNITY
Establishing Group Meetings on a Closed Word

FRANK L. RUNDLE, Lieutenant, MC, USNR
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 Wilmer’s 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.

INITIAL CONDITIONS

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 to cover.

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 restraint.

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 Far East.

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 PROGRAM

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 couldn’t 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 staff’s attitudes remarked, “We are all emotionally unstable and can’t 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. In the 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.

IMMEDIATE PROBLEMS

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 discussed.

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 along.

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 leader’s 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 indicated.

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 outside them.

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.

Aggressive Behavior. Occasionally, 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 person’s feelings should be discussed.

Relaxation of Old Restrictive Measures. A 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.

 

SUMMARY AND CONCLUSIONS

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 general.

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 study.

 

REFERENCES

 

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.


Open Sources Home / How Can I Help? / Copyright / Bibliographies and Contents Lists / Portfolios / Catalogue of Books and Articles (by author)


 

SourcesOpenSources 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

BIBLIOGRAPHIES AND CONTENTS LISTS

SEARCH ACADEMIC LITERATURE ON GOOGLE SCHOLAR

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

 

...therapeutic community...comunità terapeutica...comunidade terapêutica...terapeutiskt samhälle...communauté therapeutique...therapeutischen gemeinschaft...terapeutické komunity... comunidad terapeutica...therapeutische gemeenschap...thérapie par le milieu...milieu therapy...planned environment therapy...