A young man is sitting in a group of 25 patients gathered around a doctor at the U.S. Naval Hospital in Oakland, California. In the group also sit hospital corpsmen, nurses, a social worker and a clinical psychologist. This is the community of people – patients and staff – in which the man will begin to recover from his first psychotic break. His chart bears a label: “Schizophrenic reaction, paranoid, acute, severe, #3007.” This is the admission ward of the psychiatric service, where patients remain for 10 days before being assigned either to locked or unlocked wards. It is a period of indoctrination and adjustment to the hospital and to their status as psychiatric patients.
This young man is sitting now in a large ward with 17 beds lined in a row along each side. In the group are almost all the professional and non-professional people he will see during the day. The group is quiet – for 10 minutes no one speaks. It brings to mind a Quaker meeting. People are very much aware of people. The staff observes the patients; the patients observe the staff. Half a dozen of them are hearing voices of people who are not there. These hallucinatory voices call the “hearer” names, tell him to do things or tell him that things are going to happen to him, or whisper his name, like his mother’s voice coming out of the night when he was a child.
All these patients are locked up in a “closed” psychiatric ward of which I am the ward medical officer. They are seamen and rated sailors, privates and rated marines, staff sergeants, chiefs and today there are two naval officers. They are all patients together, though they have not forgotten their military status. They have gathered for their daily community meeting – a special sort of group therapy – a meeting that lasts 45 minutes and is held at the same time six days a week. On one occasion the entire time passed in total silence. Usually the sessions are quite lively and often follow the threads of ideas from day to day.
This young man, who previously had been considered violent, suicidal and homicidal, who has spent the better part of his previous hospital stays locked alone in a cell called a “quiet room” where he could converse alone with his voices, undisturbed by the voices of reality, unbothered by real people whom he could see, touch, speak to, eat with and listen to, is now in a group. The silence presses in upon him although this is his first meeting, he having arrived from the Far East by airplane only yesterday, his wrists in leather restraints, tied by a waist restraint to the litter, his feet bound together.
When he had been brought to this ward he was at once untied, for restraints were never used here. Walking toward the ward, he had looked into the sinister little slot like windows of two former “quiet rooms”. One was now full of office furniture; the other contained a piano and other musical instruments. “We don’t use the quiet rooms on this ward,” the nurse said softly, matter of factly, to him. He looked doubting. For a few days it was his privilege to doubt.
Patients sense at once falseness and insincerity. Every patient admitted to the ward is seen within an hour by the ward medical officer if he is in the hospital, this despite days when 10 to 18 new patients are admitted at one time. There is a list on the ward bulletin board for patients who want to see the doctor individually. Patients write their names and are seen within 48 hours, and their names are conspicuously checked off for all to see. In this way it is impossible to promise to see a patient and forget.
Suddenly, in the group meeting, he felt comfortable enough to talk about the “voices”. Looking at the doctor but talking to the patients, he said, quivering with excitement, “God tells me I have to go home to save my brother and my father. He talks to me and says if I don’t get home in two days it will be too late. My brother is going to do something terrible and I must go to my father because I have done bad things – I must save them……”
From the attentive, silent group suddenly he is interrupted by the staccato voice of a Marine corporal.
He thinks, Yeah, and me too.
Another patient speaks up. “What’s the hurry? You’re a patient like the rest of us. Wouldn’t it be better to get well first here, and then go home to help others?”
He thinks, Get well….. He wonders, for he doesn’t believe he is sick.
“But God tells me – “
“Then pray,” commands an old Navy chief. “When Ike was sick, the nation prayed and he recovered. There is power in prayer.”
“Ya gotta look out for number one, buddy, before the others,” says a young angry Marine out of the side of his mouth.
“The question is,” interrupts another, looking at the angry patient, “are we our brother’s keeper?”
“But there’s nothing wrong with me”, says the first young man. The laughter is easy and friendly. He blushes and wonders.
Silence falls on the group, and after a while the doctor breaks it. “Yes”, he says, “are we our brothers’ keepers?”
“Who are our brothers?” Asks a Negro sailor.
“Yeah, that’s a good question – aren’t we all?” says a shy young man.
The first young man speaks again. “My brother will die if I don’t get home in two days.”
“You could be wrong,” says another patient.
“Could I?” He speaks more to himself, then adds, “but the voices – they couldn’t be wrong!”
“Could be!” Another schizophrenic patient sings out the words between his own hallucinatory voices, then retreats into his shadows and voices again. The face of the first young man shows a momentary flash of doubt, but he is silent.
Like alcoholics talking to alcoholics in AA meetings, here the mentally ill talk to the mentally ill in a way a doctor probably never could. The group continues talking and the doctor listens. But he is thinking …… thinking that the patient who said “could be” had not spoken a word for five days to anyone; thinking that on a patient’s first day on this ward he felt free to begin a group discussion talking about voices; and no one in the group ridiculed or laughed at him, joked or tried to argue him out of his strange experience. They had, rather, dealt with the meaningful content of the messages he was receiving; about helping and praying, about impatience and waiting, about accepting the reality of “not yet” and “here and now”. They were persuading and gently arguing with him. These men, with an average schooling not beyond the 10th grade, were talking like sophisticated therapists – kindly, intuitively, honestly, firmly. And some were silent and some sicker than he.
Then, in the listening corner of his mind, the psychiatrist heard the topic change to “good and evil” and heard another patient say with great feeling, “I am evil. I am bad, worthless. I have never been good for anyone. I don’t deserve to live!”
“In whose eyes, Roger,” come the soft spoken tones of another patient, “did you have to debase yourself as a child?”
“Bang!” says a schizophrenic patient supposedly living in another world.
“Bull’s-eye”, Roger says, with an uneasy laugh, and begins talking about his father.
So the group moves to its end. Afterward the staff gather in the psychiatrist’s office for their daily half hour meeting to discuss the group and its patients. They read the letter from the night crew telling how the ward had been in the night watch. During the staff meeting the patients gather in clusters on the ward and continue the discussion or talk about the staff. Such frequent meetings permit feelings to come out into words before they erupt in actions.
This is the day’s beginning on a receiving ward in a Navy psychiatric hospital. It is the bringing together of people. It is an understanding of what Robert Frost meant when he wrote:
“Something there is that doesn’t love a wall,
That wants it down!”
Its simple premise is that to live a good life, people need people; that to recover from mental illness, people need people even more; that the good in a man must be encouraged, fostered and approved, or else someone will exploit the bad. Except in extreme emergency, to isolate people in padded or unpadded cells makes them sicker; to restrain them makes them afraid, angry and more aggressive; to sedate them with sleeping medicine confounds and compounds their confusion. A sense of belonging, of relatedness, of togetherness can never come out of a patient’s withdrawal, for we must find the areas where he can be reached and give him a helping hand, not push him further into his sickness. We must not drive him to aggressive acts by unnecessary restrictions, limitations, locks and small closed places, by innumerable small acts that only mean we cannot trust him and therefore he has good reason to doubt his own self-trust.
The community meetings and the methods of psychiatric hospital treatment were called the “therapeutic community” in a book by the English psychiatrist Maxwell Jones. In this concept, all the patient’s time in the hospital, 24 hours a day, is considered therapy.
Early in 1955 the Navy sent me to England, where I revisited three famous mental hospitals near London which I had first seen in 1950. Dr Tom Main at the Cassel Hospital operates an unlocked neurosis hospital. Pre-school children live in rooms with their mothers. It is a democratic hospital in which the roles and attitudes of the staff are under as intense scrutiny as the patients’. Here they had learned that often sleeping pills are given to anxious patients because we doctors and nurses cannot tolerate our own anxiety. Unwilling to allow our patients to face sleepless nights because they may make our nights sleepless, we put them to sleep. At Cassel Hospital sleeping medication has largely been discontinued.
Dr. Main’s experience in a military hospital in World War 2 he described in an article as experience in “a therapeutic institution”.
The second English hospital is Warlingham Park, where Dr. T. P. Rees runs a famous state hospital with no locks; it has a capacity of over 1000 patients. There is intensive group therapy and emphasis on the hospital as a community. “No locks?” I asked. “What do you do if a patient gets violent?” Dr. Rees regarded me over his crescent-shaped glasses and replied, “They don’t”. It is difficult to say what I most truly learned from Dr. Rees but it was probably trust in people, whether or not they are psychotic; and also that patients must be able to trust the staff. It was clear to Dr. Rees, as it became clear to me, that occasionally patients are locked up not in the interest of therapy but punitively.
At Belmont Hospital, Dr. Maxwell Jones operates an unlocked social rehabilitation unit as a therapeutic community for psychopaths. Most of his patients are the social failures – the thieves, prostitutes, delinquents and criminals from London, sent by the courts. Here they are treated with humane dignity. They are particularly freed from their slavery and bondage to dissocial and antisocial behaviour. A majority have been chronically unemployed but a significant percent are returned to society to hold steady jobs. It is here that the therapeutic community functions at its exciting zenith. The element of trust is the highest goal where there is striving for open and free communication between patients and staff, staff and patients and within each group. The idea is that there should be a feedback of all information in the community, a verbal sharing.
There was value in daily community meetings, of daily staff meetings. What skilled therapists, what gentle, perceptive, penetrating helpers patients can be to each other! And what great value was Dr. Jones’ corps of non-professional young women trained as “social therapists”.
The dignity and freedom conferred on the “worst” of people was quickly earned here. The group culture demands of its members and gets a high degree of good behaviour and a high degree of social conformity. Here patients who for 20 to 30 years have failed to realise the social consequences of their behaviour (that is, that when they do or say something it has repercussions in other people), who have failed to mature, remain for intensive treatment for six months to a year. During this time emphasis is placed upon group living, group meetings and meaningful work: carpentry, painting, gardening, tailoring, maintenance, etc. These people who have been destructive in society are subjected to intensive therapy in a sort of “pressure cooker” way, accomplishing in a short period what longtime conventional treatment would do.
Dr. Jones is a man utterly dedicated to his work. He is showing to those who can see that the belligerent psychopath, under favourable circumstances, will behave as you might hope he would.
These ideas and feelings (and many more) I brought back to the U.S. Naval Hospital at Oakland. There Capt. D.C. Gaede, chief of the neuropsychiatric service, assigned me to the locked receiving ward of 34 beds housed in a temporary wooden structure. Instructions were simple: in addition to carrying the routine responsibilities of a medical officer on a locked receiving ward, I was free to organise the unit as I wished.
The staff of the receiving ward was called together and told the plan: eliminate the use of seclusion rooms; eliminate so far as possible all sleeping medication and all intravenous and intramuscular injection of barbiturates; no physical restraints of any kind would be tolerated on the ward – no restraining beds, belts, ties, cuffs, cold packs or locked rooms. There would be daily community and staff meetings.
“What will we do if someone becomes violent?” they wanted to know.
“They won’t”, I replied with borrowed conviction.
One of the healthy contributions of military psychiatry is its saying to patients: “It’s your problem, solve it”. The difference is subtle but enormous. To face a problem involves other people, social group experience. A soldier sent back to the front line, though his anxiety be under moderate control, may not solve his problem, but “sure as shooting” he will have to face it and face his own group. Moreover, he is sent back with the expressed or tacit encouragement that someone important “believes he can do it”, that is, “believes he can control himself when he fears he is going to go to pieces”.
The relationship of this to our non-use of restraint and the seclusion room is obvious. When a patient says he cannot control himself, he is afraid he is going crazy and will do something terrible, we are not frightened; neither do we act to confirm his testing words of fear. We do not put him in a quiet room where he has a “perfect right” to act crazy. Rather, we demand of him a return to community life, telling him that nothing will happen, he will not lose control of himself. But the validity of the proposition is directly proportional to one’s belief in it. If you don’t believe it, it won’t work. There is nothing magic about good human behaviour – it simply takes a lot of hard work, belief in people, caring for people.
Between July of 1955 and April of 1956 when the experiment was discontinued, 939 patients passed through the acute receiving ward, remaining for an average stay of 10days. This was a constantly changing group with 44.5% suffering from psychoses, 26.6% from psychoneuroses, 28.3% from character and personality disorders and 0.7% from acute situational maladjustment. For the first four months we used the new tranquilising drugs sparingly (in 10.8% of the patients), for we wanted to know whether the therapeutic community would work mainly by human efforts. When we found it would we began to use increasing amounts of these drugs, so that in the last four months of the study 27.9% of the psychotic patients were on these drugs at a given time. The drugs had limited but real value.
Not once did I find it necessary to put a patient in a seclusion room or to restrain him. Only three times did I find it necessary to give barbiturates by injection (to two patients with catatonic excitement and to one in an alcoholic psychotic furor). On five occasions the officer of the day put a patient in a seclusion room during the night, but the patient was promptly removed the next morning when I arrived at the ward. Chemical restraint was not substituted for physical restraint; rather, self-control was fostered in place of being controlled. In the first month of the therapeutic community 58 sleeping pills were given; by the fourth month this had been reduced to 6.
In the four months preceding the operation of the therapeutic community 440 patients were admitted to this ward and were given 314 oral or parenteral doses of barbiturates. In the last four months of the study 443 patients were admitted and received 29 oral or parenteral doses of barbiturates, most of these ordered by the officer of the day.
Night-time is a time of fears and insomnia and is best dealt with by talking to the patient. If one expects largely to eliminate sleeping pills – because of developing dependency on them, of thus allowing the patient to escape his conflict and the staff to assuage their own anxiety; because they frequently represent an indulgence by the staff, a gift easier given than denied; because it is part of the magic omnipotent potion doctors dispense – it is better to understand the need for them than to give them, for with understanding and firmness the need diminishes and then disappears.
A patient who was brought to us in a camisole, having, according to his record, “torn up two hospitals and one brig”, implored “put me in the quiet room or knock me out with medicine”, claiming he was going to go berserk, going to kill somebody, throw a chair or do something violent and desperate. He was told that he wasn’t going to do anything of the kind, that we were going to help him to control himself. He developed a severe headache from time to time on our ward and talked frequently about going berserk, but after 10 days he realised that he was quite responsible for his would-be violent actions. He no longer needed to convince anyone of his great uncontrollable strength, for we had shown him it took greater strength and greater courage to control violence than to unleash it. As a matter of fact, he was an exceedingly well-behaved patient. He had the best conceivable proof he was not going berserk: he didn’t.
As week after week went by it became clear to all of us on the staff that something more than meetings was taking place. It was not merely the transformation of a ward once disturbed with occasional violence, and people in quiet rooms exhausting themselves, destroying property.
We encountered many trying circumstances. We dealt with almost a thousand patients over ten months. One patient required electroshock treatment while on this ward; one made an ineffectual suicide gesture (a very depressed patient who had been transferred to our ward from another psychiatric ward in our hospital); we found it necessary to sedate three patients by injection; I prescribed sleeping pills a dozen times or so. The new drugs helped but did not account for the results. Two corpsmen were struck. Neither retaliated but stood firm, quieted the patient and were not struck again. One very psychotic, terrified, delusional patient, while being admitted to the ward and still in his uniform, swung at me. He did not hurt or frighten me but startled and surprised me. He was terribly sick and delusional; the staff and patients worked endlessly with him but it took them three days to persuade him even to eat with the other patients.
It is possible that for a very sick patient or some “criminally insane”, seclusion would be a necessary emergency measure. But this would not change the basic concept. Flexible therapy, not rigidity, forms the essence of the therapeutic community; also honesty, empathy, trust and a sincere desire to help people. Without these, no amount of technique, no deep knowledge of theory will make it work. It can work only with the cooperation of nurses and corpsmen and only when the doctor makes them a part of the group. It can work only when there is belief that there is always another and a better way.
A therapeutic community on a receiving ward of a psychiatric treatment centre at the U.S. Naval Hospital, Oakland, has been described. Almost 1000 patients were admitted, 44% of them psychotic. Patients remained for 10 days. No restraints were used; barbiturates were used sparingly, ataractic drugs occasionally. The seclusion room was not found necessary.
This is presented not as a panacea but as one of many possible contributions of social psychiatry. While we have cited a few dramatic illustrations the day by day work was rather simple, friendly and “a job of work”. Usually the ward looked and sounded like any medical or surgical ward, and the majority of patients were rational though often anxious or depressed.
The author wishes to express his appreciation to Rear Adm. Bartholomew W. Hogan, surgeon general, U.S. Navy; to Rear Adm. John Q. Owsley, commanding officer, U.S. Naval Hospital, Oakland; Capt. George Raines, chief of neuropsychiatry, Bureau of Medicine and Surgery, and especially to the staff of the admission ward, particularly the nurse in charge, Lt. Bethel Greene, NC, USN, and to Rear Adm. D.C. Gaede, MC (ret.), USN.