The inception of the unit in Villa 21 in January 1962 was brought about in an effort to satisfy three principal needs with which I was confronted in the actual situation in the mental hospital in which I worked.
First, there were practical organizational problems: I felt it to be unsatisfactory that adolescents who presented acting-out disturbances and also young schizophrenics1 in their first acute breakdown were treated in wards in which the majority of patients were far advanced in a series of recurrent psychotic breakdowns. Such breakdowns acquire a limiting ritualistic character through repeated hospital admission. Sometimes young people would even go into long-stay or very disturbed wards. There seemed an obvious need for a separate unit with less ritual and less rigid role-structuring, where the patients could encounter themselves through their relationships with others and come to terms more successfully with their conflicts, rather than take the easy exit into narrowly stereotyped self-definition which is only too readily available to people in more conventional wards.
I felt too, somewhat uncertainly, that staff anxiety about adolescent sexual and aggressive acting-out might less readily result in disastrous blind repressive measures if this acting-out were more geographically localized within the total institution. I was, however, very aware of the possibility of the unit becoming to some extent a scapegoat into which 'badness' in the hospital would be projected, with consequent administrative conflict, rather than becoming a coping mechanism for the wider institution.
Secondly, there were research needs. In particular there was the need for a suitable working-situation for group and familyinteractional research in schizophrenia and, more generally, in disturbed adolescence. Observations on such interaction had proved difficult in the hectic atmosphere of a general admission ward with its extreme heterogeneity of personal problems. Also there was the need for comparative data on interaction in families and in specialized therapeutic groups.
Thirdly, there was the need to establish a viable prototype for a small autonomous unit which could function in a large house in the community, outside the psychiatric institutional context. It was the author's belief that such small units might form the optimal therapeutic milieu for the sort of patients we had in mind, as they would allow a greater degree of freedom of movement out of the highly artificial staff and patient roles imposed on people by conventional psychiatry. But first of all it was necessary to explore the limits of change possible within the large mental hospital, to note the difficulties and contradictions that would arise, and to base future plans on such an assessment.
The insulin coma ward became available for the unit with the gradual cessation of insulin coma treatment. This ward comprised nineteen beds upstairs (a dormitory and four side-rooms) and downstairs accommodation including a sittingroom, dining-room, staff office and cloak-room, and two small rooms, one of which was used for small group meetings and the other as a quiet room. There were lavatories downstairs and lavatories and bathroom (one bath) upstairs. The main through corridor separated the staff office and the lavatories from the patients' living accommodation.
The patients were men aged between fifteen and the late twenties. Over two-thirds had been independently diagnosed as schizophrenic, the rest bore such labels as adolescent emotional crisis or personality disorder. At first we took in patients in these categories from other wards in the hospital, some of them with a history of several years of hospitalization. Gradually, over the first few months these patients moved on and we took in people in their first or second psychotic breakdown who had had relatively little experience of institutionalization.
Staff selection was made over a period of a year prior to the opening of the ward as a'treatment unit'. This entailed many individual and group discussions. The selective process centred on the younger charge and staff nurses whose attitude to their work was less likely to be institutionally deformed and who seemed best able to tolerate the inevitable anxieties of grouptherapeutic work. One charge nurse and one staff nurse were finally selected for each of the two day shifts. In addition there was to be a student nurse on each shift, but this staff member would have to change ward every two to four months to gain experience in other wards as part of his training programme.
A special request was made to the Nursing Office to minimize change of the night nurse, as this form of inconstancy has frequently been noted to disturb psychotic patients. A full-time female occupational therapist for the ward was selected and one of the psychiatric social workers accepted her normal professional role in the unit along with her responsibilities for other wards.
Initially three doctors worked in the unit - each in a daily therapeutic group of between five and seven patients. At this stage community meetings (all the patients and all the staff) were held only twice a week. After some months, partly due to the felt need for more regular community meetings and partly because of a reorganization of the doctors' time-commitments, it was decided to hold daily community meetings from 9.45 to 10.15 a.m. followed by two 'doctors' groups' from 10.30 to 11.30 a.m. One of the doctors (the author) was then able to allocate most of his time to therapy and research in the unit (although his other work included the care of 120 long-stay patients and six to ten hours per week outpatient work). One other doctor, who was officially employed only on a part-time basis, in fact far exceeded her obligatory time-commitments: although she spent most of her time in the unit she also, together with another doctor, worked with about 200 long-stay and 'refractory' patients and held a weekly outpatient clinic. This situation reflected the general problem of gross staff shortage, but it was nevertheless possible to achieve a working minimum of psychiatrist time-commitment in the unit.
The original programme of the unit was deliberately a highly structured one, not unlike that of the 'classical' therapeutic community. This was not because I had any illusions about the limitations of such a model, but because it seemed strategically necessary to start off from a point that was not too 'far out'.
In the initial programme, groups were regarded as either 'scheduled' or 'spontaneous'.2 Scheduled groups consisted of:
(a) The daily community meeting which ran from 9.45 to 10.15 or 10.30 a.m. (prior to 9.45 a.m. the doctors and social worker attended the divisional meeting of doctors on the male side of the hospital). This meeting, which was attended by all the patients and staff of the ward, was geared to communication about problems which affected the whole ward - usually disturbing acting-out on the part of an individual or subgroup, or staff or patient grumbles, or practical arrangements for the work and recreational activities.
(b) The two more formal therapeutic groups in which half the patients met from 10.30 to 11.30 a.m. with one of the doctors and either the charge or staff nurse who constantly attended that particular group: the nature of these groups is described more fully later.
(c) Work groups - two groups which met from 2.00 to 4.30 p.m., each afternoon - one group with the occupational therapist, the other with a staff nurse; each group had its own project, the two longest-term projects in the first year being an interior decoration group and a toy-making group.
(d) Staff group meetings - the staff group met daily, briefly and informally, before and after the community meeting, and again often late in the afternoon; there was also a'changeover' meeting once a week in which both nursing shifts met with the doctors and occupational therapist to discuss in particular unit policy matters for which cross-shift continuity was essential; once a week there was a full staff meeting for one hour, attended by the ward staff, the psychiatric social worker, and often a representative from the nursing administrative office and the head of the occupational therapy department.
'Spontaneous' groups formed at any time of the day or night around some particular issue - anything from discussion of a television programme to attempts to deal with disturbing acting-out on the part of some patient. A staff member would be 'in on' most of such groups, but the expectation was set up in the structuring of the unit that someone would communicate significant happenings in spontaneous groups to the community meeting.
In setting up the unit, I had one central conviction. This conviction, founded on repeated unhappy experiences in conventional wards, was that before we have any chance of understanding what goes on in patients we have to have at least some elementary awareness about what goes on in the staff. We therefore aimed to explore in our day-to-day work the whole range of preconceptions, prejudices, and fantasies that staff have about each other and about the patients.
This is undoubtedly a major task. The psychiatric institution throughout its history has found it necessary to defend itself against the madness which it is supposed to contain - disturbance, disintegration, violence, contamination. The staff defences, in so far as they are erected against illusory rather than real dangers, I shall term collectively institutional irrationality. What then, is the reality of madness in the mental hospital and what is illusion? What are the defining limits of institutional irrationality? In this chapter I shall attempt at least to sketch in some of these limits.
It has long been recognized that a great deal of violent behaviour in mental patients is directly reactive to physical restraint. If any member of the public were to be seized by several burly men and thrust into a strait-jacket for reasons which were obscure to him, and if his attempts to find an explanation were without avail, his natural reaction would be to struggle. We are no longer in the era of strait-jackets, and padded rooms are on the way out, but it is not so long ago that the writer saw a patient, kicking and screaming in a straitjacket, carried by several policemen into the observation ward: one had only to dismiss the policemen and remove the strait-jacket dramatically to terminate the patient's violent reactions.
Today many psychiatrists resort to 'chemical restraint' - sedatives and tranquillizers - and to electro-shock and bed-rest. The effect of these apparently less drastic measures, however, is much the same as the more drastic if they are used, as they often are, without any reasonable explanation. The expectation set up when a patient is given a large dose of tranquillizer is that there is danger in him which must be controlled. Patients who are very sensitive to such expectations often oblige by providing the violence - at least until they are subdued by a larger dose of the same 'treatment'. This is not to say that disturbed patients should not sometimes be given tranquillizers, but simply that there should be clarity in the doctor and in the patient about what is being done. There rarely is. The meaning of this situation is only too often lost in the quasi-medical mystique of 'illness' and 'treatment'. Why should one not, for instance, tell the patient: 'I'm giving you this stuff called Largactil to quieten you down a bit so that we can get on with other pressing things without feeling too anxious about what you are going to get up to next!'
One of the commonest staff fantasies in mental hospitals is that if patients are not coerced verbally or physically into getting out of bed at a certain hour in the morning they will stay in bed until they rot away. Behind this is anxiety over nonconformity with the staff's time-regulation and general control in their own lives. The patient is that frightening aspect of themselves that sometimes does not want to get out of bed in the morning and come to work. It is obviously true that if they succumbed to this temptation, they would lose their jobs. It is also true that young schizophrenic patients will eventually leave hospital and take jobs which they will have to attend punctually. But all this ignores the life-historical significance of the 'staying in bed problem'. In the past the patient has probably depended entirely on his mother to get him up in the morning. Shortly prior to his admission he has often rebelled against this forced dependence by what, for various reasons, is the only course available to him, namely staying in bed despite his mother's efforts to get him up. This 'withdrawal' is often one of the 'presenting symptoms' of schizophrenia.
In hospital one can repeat the family pattern, that is to say, gratify the patient's dependent needs by getting him up, but this is really getting up for him. Or one can take the 'risk' of leaving the decision to him in the hope that he will one day get up himself.
In fact, after many heated discussions of this issue in the unit and a great deal of policy difference between the nursing shifts, it was found that if the usual vigorous rousing procedures were abandoned and patients left to get up themselves, they invariably did rise, even if in some cases they would spend most of the day in bed for several weeks. No one rotted away after all and the gain in personal autonomy seemed worth while.
Staff at first and then patients would comment in the community meetings on the getting-up problem in terms of dependent needs, but the point was also brought home in more active ways. At one time all the occupants of a six-bed dormitory rebelled against the community meeting by staying in bed until after eleven o'clock. Frank, one of the charge nurses, went upstairs to see what was going on. One of the patients left to go to the toilet and Frank seized the opportunity to take off his white coat3 and climb into the vacant bed. The patient, on his return, appreciating the irony of the situation, had little option but to take the vacated 'staff role', put on the white coat, and get the others out of bed.
Another fantasy prevalent in the mental hospital concerns patient work. It is held implicitly, and sometimes stated, that if patients are not fully occupied in domestic ward jobs and the various occupational therapy projects, or helping in hospital maintenance departments, they will become 'withdrawn', 'institutionalized', 'chronic patients'. The bitter truth is that if they submissively carry out all these required tasks, they become what is implied by these labels anyhow. If one wishes to encounter the ultimate in withdrawn chronic institutionalization, one has only to visit one of the more 'active' and productive 'factories in a hospital' or 'industrial occupational therapy departments'. There is, relatively speaking, something remarkably healthy about the chronic schizophrenic, preoccupied with his inner world, spending the day hunched over the central heating fitting in a decrepit back ward. If he does not have the solution to the riddle of life, at least he has fewer illusions.
In the unit we had some desperate confrontations on this matter. Patients resisted conventional occupational therapy projects. We had begun to question the ancient myth that tells us that Satan makes work for idle hands, or 'work and play, don't masturbate', but were not certain about where we went from there. Work projects would at least form a group, make a happy ward family. But perhaps people had come to the hospital to get away from 'happy families'. Or rather they had been sent to hospital to keep the family happy. We worked through a number of virile destructive jobs, knocking down an air-raid shelter, breaking up an aero engine: these jobs, some felt, would provide a'safe outlet' for 'dangerous aggressive impulses'. These jobs, however, were done without enthusiasm and we soon began to realize their irrelevance to the real problems of anger. People had real reasons to be angry with real other people at home and in hospital (this was not entirely reducible to projection). The aero engine was an innocent party.
Our anxieties led us to put forward, consider, and then reject a number of other typical hospital projects of a ludicrously trivial nature, such as putting together the manufactured elements in (ironically) toy doctor's sets. Patients reacted contemptuously to these tasks and we came to share their feelings. Most of them were young men of at least average intelligence, well able to acknowledge the incongruity of the projects offered them. We visited local factories in an attempt to find more 'realistic' work for the patients on commission for the firm but nothing effective was achieved. In retrospect this was hardly surprising. We concluded that the only realistic jobs for the young people who came to us were jobs outside the hospital.
It was only after the first year of the unit's life that the staff, including the young female occupational therapist, were able to tolerate a situation in which no organized work project was presented to the community. Whatever project had been offered disintegrated after some weeks when patients 'skived off' to private activities elsewhere within and outside the hospital. Sanctions in the form of reduction of pocket money4 did not affect the issue at all. What were we getting so anxious about, and what were we trying to do anyhow?
The occupational therapist, who had already abandoned her green uniform, found herself gravitating towards a role that seemed nearer to the nursing role. She even considered resigning and joining the staff as an assistant nurse. It was at this time that we became particularly aware of the fact of role diffusion, the breakdown of role boundaries, which was a necessary stage on the way to staff and patients defining themselves and their relationships with each other not on the basis of an imposed, abstract labelling system, reflecting a few technical or quasitechnical functions, but in terms of the personal reality of each member of the community.
There was a progressive blurring of role between nurses, doctor, occupational therapist, and patients. I have already examined some of the ambiguities surrounding the process of 'becoming a patient'. I shall now try to bring into focus a number of disturbing and apparently paradoxical questions: for example, can patients 'treat' other patients, and can they even treat staff? Can staff realize quite frankly and acknowledge in the ward community their own areas of incapacity and 'illness' and their need for 'treatment'? If they did, what would happen next and who would control it? Were not these categories 'illness' and 'treatment' themselves ultimately suspect.
It was at this point that the most radical departure from conventional psychiatric work was initiated. If the staff rejected prescribed ideas about their function, and if they did not quite know what to do next, why do anything? Why not withdraw from the whole field of hospital staff and patient expectation in terms of organizing patients into activity, supervising the ward domestic work, and generally 'treating patients'. The staff group decided to limit their function to controlling the drug cupboard as was legally required (some of the more 'overactive and impulsive' patients were on the tranquillizer, Largactil) and to dealing with ward administrative issues involving other hospital departments over the telephone.
A necessary prelude to this major policy change was explanation to the nursing office and other hospital departments. The kitchen staff for instance were informed that if the aluminium food containers were returned unwashed they should leave them until they were cleaned rather than telephone us complaining that the staff were not doing their job. If people wanted to eat they would have to clean the containers. These decisions were made quite clear to everyone in the community meetings.
Despite these explanations and the superficial acceptance of them, the events that followed were dramatic. In the first phase rubbish accumulated higher and higher in the corridors. Diningroom tables were covered with the previous days' unwashed plates. Signs of horror were evoked in visiting staff, in particular nursing officers on their twice-daily rounds. Patients decided their own leave periods, getting out of bed, attendance at meetings. Staff were anxious throughout, but particularly because no patients showed signs of organizing themselves to attend to these matters. A night nurse, who had previously worked as a day staff nurse in the unit, finally became so exasperated that he officially reported the filthy state of the ward to the night superintendent. The chief male nurse was informed and nursing officers visited the ward duly to express their disgust at the state of affairs. The anger of the night nurse we acknowledged as to some extent our fault: communication between day and night shifts was clearly inadequate (it had only been with considerable difficulty that we had been able to initiate regular cross-shift meetings between the two day shifts - an arrangement that was later replaced by a system in which most staff worked cross-shift).
External administrative pressure on the ward staff rapidly mounted. The patients were divided in their response. Some began to demand more nurse and doctor attention. Those less urgently dependent expressed some dissatisfaction but at the same time made it clear that they appreciated the more authentic elements in the policy change.
Subsequent events must be seen in relation to the problem of doctor-centredness in mental hospital ward administration. In conventional wards all but the most trivial decisions have to be either made by, or blessed by, the doctor. The doctor is invested, and sometimes invests himself, with magical powers of understanding and curing. Whether the formal training of psychiatrists includes qualifications in magical omnipotence is perhaps uncertain, but the image is reinforced and perpetuated in many ways. The same person who is supposed to have a psychotherapeutic relationship with patients assumes a general practitioner role in relation to their bodily ailments. Not only that, but psychiatrists attend the staff sick bay and medically care for nurses with whom they work. The resulting confusion of controlled frustration and wholesale gratification can well be imagined.