ABSTRACT: During the course of a year the authors changed a psychiatric
ward from primary reliance on drugs to an intensive psychological
approach. There were both strong institutional supports and resistance's?reflecting
the ambivalence attending efforts to develop more personal, humanized
ways of relating to mental patients. An openwork community setting
evolved in which staff became highly accessible and caring,patients
shared major caring and treatment responsibilities, and certain
special psychological treatment techniques were developed.
Many previously "untreatable" patients were involved and
the improvement criteria were ambitious: the results suggest that
such an approach is superior in long-term cost/benefit effectiveness
to the prevalent "revolving door" programs which emphasize
drugs and "dischargeability."
During the course of a year the authors and their colleagues changed
a psychiatric ward from primary reliance on drugs to primary reliance
on an intensive psychological approach. The evolution of the psychological
treatment approach, revealing many of the resistance's and hazards
in the way of such programs, is presented in this article, an approach
to psychological treatment of severe depression is presented.3 It
is hoped that our accounts will encourage and stimulate further
work with intensive psychological treatment of severely disturbed
patients within, hospital settings.
The setting for our efforts was in many respects typical of psychiatric
teaching hospitals. The hospital was physically old and decrepit.
There was no air conditioning, though it was greatly needed, and
the noise level was high because of the lack of carpets, drapes
or sound proofing. Psychiatric residents and clinical psychology
interns or fellows rotated through the ward every six moths. Medical
students and nurses in training rotated every four to six weeks.
The permanent staff of each ward consisted of a psychiatrist who
was ward chief, a clinical psychologist, a psychiatric social worker,
an occupational therapist, and several psychiatric nurses and aides.
Prior to our beginning the new ward program treatment
throughout the hospital was characterized by heavy reliance on drugs,
much more so, it was later revealed, that most staff realized. Nearly
all patients were admitted through a psychiatric emergency room
in the nearby general hospital. An independent researcher found
that all of the many patients diagnosed schizophrenic were placed
immediately on phenothiazines before they could be observed in the
psychiatric hospital. Such established prescription regimens would
then be carried on routinely by the resident on the ward.Virtually
all patients regardless of diagnosis,were quickly placed on some
kind of medication to reduce symptoms, thus obliterating the opportunity
to observe individuals in the their natural condition. Further,
the habit of placing patients on drugs was so ingrained that non-drug
alternatives for the hastily diagnosed "schizophrenic"
patients were considered "malpractice" by some residents.
In accord with the reliance on drugs, the main
focus of staff concern
seemed to be reduction of the patient's symptoms and early discharge,
hopefully before thirty days when most insurance converges ceased.
surprisingly, the average length of stay turned out to be slightly
thirty days. A nurse's performance tended to be judged by her superiors
on the basis of whether or not the ward was quiet: thus, patients
who were noisy often had their tranquilizing medications increased.
psychotherapy was difficult to obtain. Patients were not transferred
department of psychiatry's large outpatient clinic but were sent
facility originally set up to provide group psychotherapy but which
was used only to dispense medications.
Psychological approaches were not impressive.
Individual therapy was
usually supervised by the resident's off-ward psychiatrist supervisor
who had little knowledge of the ward and was likely to concentrate,
as did the
resident on the resident's outpatients. Some residents conducted
therapy" usually without supervision. The hospital also provided
occupational therapy and the social worker was utilized primarily
disposition and "after care" planning. Almost all staff
and patients were
involve in daily "patient-personnel meetings which like the
often seemed without clear conceptual guidelines and goals. As it
psychiatric hospitals, "milieu therapy" was ore a vague
notion than a
practical reality. However, on balance, the hospital would have
quite favorably with the average, in Rosenhan's (1973) sample.
Beginning the New Ward Program
The new ward program began when the senior author of this article,
D., became ward chief just prior to the annual July changeover of
psychiatric residents. He informed the staff that he intended to
new policy. Whereas previously, the goal had been to reduce symptoms
so patients could leave the hospital; now, the treatment goal for
most patients would be for them to become psychologically stronger
than they were before they had decompensated. In other words, the
patients' own psychological abilities were to be increased to the
point that they were before they were hospitalized. An important
feature of this policy was that drug treatment with new patients
would not be instituted until the ward had attempted to treat them
psychologically, and such efforts had failed. It was emphasized
that all behavior, that of the staff as well as the patients, was
expressive of motives and meanings that influenced the clinical
course of the patients on the ward. Ward staff initially reacted
to the new ward chief's announcement with considerable apprehension.
They expressed their doubts that a program that did not rely on
drugs could be effective and they were anxious in their uncertainty
as to how to proceed.
Specific Therapeutic Methods
An important feature of the ward was a special form of group psychotherapy.
Each group met four times a week and each was composed of five to
eight patients, the supervising psychologist (the co-author, Dr.
W.), a psychiatric resident, and a psychology intern or postdoctoral
fellow. The therapists-in-training and the supervisor met by themselves
on the fifth day for a supervisory hour.An important aim of group
therapy was to clarify and bring about a change in the negativism
of psychotic patients. This negativism was expressed directly and
indirectly in three typical forms:
"I am a hopeless case, therefore it makes no sense for
me to participate or care about what happens, so leave me alone"
or "My problem is that the world is rotten"
or "I need something, but your can't provide it"
Until such negativism could be reduced, a therapeutic alliance could
not be established, and individual psychotherapy could hardly be
To cope with this problem. We made much use of
irony, role playing and
satire to demonstrate the absurdity of self-defeating assumptions.
following is an example of how the "I am a hopeless case"
sometimes dealt with in group therapy. Each patient would be asked
his or her opinion as to whether or not the other patients were
hopeless. The patient being questioned would invariably say that
none of the patients were hopeless. Then when asked about himself
or herself, the patient would affirm vigorously that he or she,
however, was hopeless.
The same procedure would e repeated with each patient in the group
until each patient had maintained that he or she was hopeless while
the other were not, and the absurdity of the situation became too
evident to be ignored. After a while, the m most resolutely hopeless
patient would begin smiling despite the grimmest of intentions.
In a similar fashion, other typical defensive
responses or inappropriate behaviors were focused upon and dramatized
to that their invalidity and illogic would be made clear to the
point of blatant absurdity. Many supportive, empathic and sympathetic
communications were offered also, as patients developed more positive
orientations which naturally drew such positive reactions. As a
result of this process which was directed to the basic beginning
dilemma of many psychotic individuals, patients tended to make constructive
use of the individual therapy offered them.
Sometimes the entire group's attention would
be focused by the therapists on a single individual for entire sessions
at a time, often in conjunction with psychodrama-like playing out
of important vignettes in a patient's life which we felt were central
to the patient's core conflicts. Role playing of both the maladaptive
original situation and a hypothetical adaptive situation was done
regularly in sequence, occasionally over the span of as many as
three sessions. This kind of concentration on an individual in the
group in a major subject of Part II of this article and is detailed
Individual psychotherapy was conducted by the
residents three to four
times a week with most patients, and was supervised by the ward
generally. The theoretical orientation was that of Artiss (1959)
(1962). Residents were encouraged to work actively with their patients,
challenging behavioral defenses verbally as well as offering emotional
support and encouragement. They were taught to regard the patients'
overt symptoms as communications and to use their own emotional
response as their guide to understanding the dynamics of the therapy
situation, as well as the content of the patient's message. For
example a resident might be helped to become aware of his rage at
a patient who regularly used muteness to express anger and defiance.
The resident's anger resulted from the threat to his or her self-esteem
at being unable to exercise his "doctor" skills around
which his esteem was based. The resident's resulting helplessness
and suppressed fury was a reenactment the patient's feelings in
dealing with controlling parental figures. Once the resident could
acknowledge and understand his rage, he no longer felt trapped abut
could use this understanding to communicate with the patient. In
the course of this work, the residents had many opportunities to
gain insight about their own conflicts, as well as those of their
patients. It was not until the ward milieu had developed fully into
a psychological treatment unit that the roles and responsibilities
of staff and patients could be clearly defined, however.
Development of the Milieu
The ward's development seemed to stem from our insistence that
psychological treatment approach be attempted prior to considering
the use of tranquilizing drugs.In the past, when the staff had to
deal with an acute disturbance on the. They would often resort to
drugs or to discharging the patient. Now they were instructed that
a ward disturbance involved everyone and should be dealt with by
the entire ward. A policy was established that the nursing staff
could and should call a meeting of the entire ward any time they
felt they needed h help in dealing with a disturbance. As basic
and routine a this procedure might seem to be, however, In practice,
the nursing staff needed repeated encouragement to follow it, for
reasons discussed below.
Staff learned about themselves, as well as the
patients, at such meetings.
For example, at one point most of the staff had expressed strong
that a particular patient should be discharged, although there was
evidence of improved functioning, because it was feared that the
would remain in the hospital "forever." As a full discussion
became clear that the staff thought the patient (and others, as
become totally "dependent." When confronted with the physical
reality of the ward, which was overcrowded, noisy, and bleak, the
staff began to see that their own wishes to be taken care of and
treated as patients were playing dominant roles in their response.
It also became possible to see that if, indeed, a patient preferred
the hospital ward to the outside world then the outside world must
appear to be a very frightening place and that was the very problem
we sought to treat.
Once the patients and staff, as a group, began
considering the circumstances surrounding a specific incident, they
could see that whether or not a particular patient's behavior got
"out of hand" depended on whether the ward group wished
it to get out of hand and, consequently, whether the group members
were spectators, instigators, or moderators of the behavior. Often
it was possible to point out a pattern of covert reinforcement of
the "sick" behavior of a particular patient while his
or her healthier behavior was ignored. It became apparent that subtle
choices were being exercised by patients and staff alike.
It was very sobering to discover that the nurses
and attendants had been
insufficiently trained for a primarily psychological therapeutic
as our ward program required. Their training has been for the usual
medical role and they were implicitly, if not explicitly, instructed
to hide their
feelings and maintain a "professional", i.e. distant attitude
patient. When deprived of the pill-dispensing function, they seemed
that they had no other resources at their display they did not trust
emotional responses and therefore could not make use of them to
understand a given situation. Despite specific encouragement at
staff "feelings meetings", it was only with great difficulty
that nurses and attendants acknowledged the anger that they experienced
toward patients. They felt quite guilty about these feelings and
thought they meant that they were bad therapists. As we discussed
this problem, everyone saw haw hart it was to tolerate screaming
and rage and, conversely, how much easier to tolerate apathy and
depression. It became clear that in the past, staff anger had often
been covertly expressed in recommendations that certain patients
be put on drugs or given electric shock or transferred elsewhere.
Recognition of their own anger, frustration, anxiety and dependency
wishes was an important step for the entire staff. It enabled them
to begin using their own feelings as a guide to what the patients
were communicating and what was taking place in a given situation
on the ward.
From the beginning of the new ward program, the
nursing staff expressed a wish for more responsibility and decision-making
power than they had in the old program, but when explicitly given
that power and urged to call ward meetings on their own initiative,
they were slow to do so. This slowness was directly related to their
feeling a lack of competence to conduct meetings and their fear
of the emotional flux of an expressive ward meeting,. As the nursing
staff's confidence increased, however, and they became more experienced
in the use of their emotions as guides, it became a regular procedure
for the nurses and attendants on duty to call ward meetings rather
frequently, as they sensed the need for them.
Medical students and nursing students has been
allowed in the past to form
a treatment relationship with a particular patient for a relatively
significant period of time and then leave abruptly at the end of
six-week rotation. Clinical experience suggests that the loss of
person is often the trauma precipitating a psychotic episode. Unwittingly,
these students had been reinstituting prior traumas without the
opportunity to help resolve them. Their abortive encounters reinforced
patient's tendency to withdraw and made future therapeutic relationships
more difficult.Consequently, the practice of assigning patients
to students of
extremely limited stay was discontinued. Instead, the students were
the role of functioning as part of the nursing team and working
patient group as a whole in the various activities of the milieu
For the medical students there was also the option of participating
group therapy sessions. For the same reasons, psychiatric residents
assigned to the ward for an entire year and encouraged to continue
with some of their patients on an outpatient basis the following
Having begun to change the roles of staff from
relatively passive onlooker and drug dispensers to active, concerned,
and personally caring roles, it was then possible to help patients
become active, concerned, and personally caring instead of passive,
drug-dependent and powerless objects.
Our daily, one-hour patient-personnel meetings
were increasingly influence by the initiative patients began to
take.Prior to the new program, patients' questions in these meeting
were often simply turned back on them in away that paralyzed thought
and action and keep staff aloof. For example, a patient might ask.
"What is this meeting supposed to be about?"
The patient might be brave enough to venture an answer dispute the
implication that everyone else knows the right answer. He or she
might say, "I think it's to try to help us but I'm not sure
how," whereupon staff would ask other patients what thought
until the topic was changed. Patients were thus given to understand
that there was no point in asking questions because you never got
an answer. The defensive and destructive nature of such interchanges
was pointed out to the staff who then were encouraged to tell the
patients what they thought the meeting should be about and set an
example by active participation. In response, gradually, the patients
began to venture forth with ideas they had for improving the usefulness
of the meetings and they were given the latitude to try almost any
idea they recommended if the patient group as a whole seemed to
be in favor of it. In October the ward milieu took a decisive turn
in the direction of greatly increased patient responsibility and
Opening the Door
During the first three months of its development,
the ward had operated as
a locked unit. Some of the sixteen patients had full ground privileges,
others could go off the ward only with an attendant, and some were
restricted to the ward. The nurses' jobs involved a great deal of
time scurrying to and from the door to let people in or out and
checking to see who was on the ward. Patients broke out and "eloped"
regardless of closed door regulation, and it became apparent that
the closed door was exceedingly irksome to all staff. Other wards
that made use of phenathiazines had their doors open much of the
time. Our staff became increasingly insistent that they cease to
be "jailors" and spend more time with the patients.
The ward chief felt strongly that establishing
an open ward would sacrifice treatment possibilities for a significant
number of patients who could not be held in the h hospital long
enough to get treatment underway, However, when faced with the intensity
and unanimity of staff feelings against his position, he capitulated.
A general ward meeting was then called, and the patients were asked
if they wanted the door to be open. There was an overwhelming affirmative
response, with the exception of two patients who were constantly
escaping -- they wanted they wanted it closed!
The patients were told that we did not have the personnel to
conduct dooropen--dooor ward without the patients themselves being
involved; we needed their help in watching and accompanying whatever
patients were acutely disturbed at the time. The patients readily
agreed to this plan, and at the conclusion of the meeting the doors
of the ward were unlocked and left unlocked from that time forward.
Not only was the open door policy greeted with
much relief by the patients
and the staff, but it led to a further development participation
If the patients were to be assigned responsibilities in watching
patients and alerting the staff to other patients who became suicidal,
had to be included in the treatment planning and given knowledge
particular patients. The regular ward
meetings with patients thus began to include more and more discussions
of the status of individual patients until the time came when a
therapist, if he or she became concerned about a patient, would
bring that concern to the ward meeting to ask for suggestions and
By this time, there was a gradual abut noticeable
increase in the "family
feeling" of the ward. There developed a sense that the ward
was a unit where everyone belonged and where everyone was the object
of care. Viewed introspect, this "caring" feeling may
have been a more potent therapeutic force than any of the formal
therapeutic activities. At times when the group focused on an individual
patient, it seemed almost a palpable force. It arose, in part, out
of the specific ethos of the small therapy groups: the role of each
patient was to talk about his or her problems, to listen to
others when they spoke of theirs, and to try to help one another.
time of the open-door meeting, this ethos was extended and made
explicit for the entire war. The patients readily accepted this
principle and referred to it frequently, confronting one another
on matters that arose on the ward.As patients became more involved
in the treatment process, they would
spontaneously carry on small group activities on their own. In one
group therapy work was carried on late at night with a particularly
withdrawn, psychotically depressed woman, by the patients belonging
to her regular therapy group. The morning at the ward meeting, another
patient complained: "Why didn't anybody wake me up so I could
be in on it?"
Patients were often encouraged to share their feelings and were
essentially that it was good to do so. Yet in the initial phase
development of the ward program, staff did not share their own feelings,
thereby conveying the opposite message to patients. It soon became
apparent that getting staff to share their feelings with other staff,
much less the patients, was our most difficult task. The staff,
especially the nursing
staff, had been accustomed not to show disagreement with one another
publicly, or even to share irritation: they had been trained not
their own feelings, attitudes or beliefs in the presence of patients.
gradually, and with much reluctance, did the staff begin to speak
up, and it
was with some help from the patients that they did so.By the end
of October, the patients had become quite outspoken and took
considerable initiative in ward functions. They had begun to run
some of the patient-personnel meetings that were held routinely
each morning. On some occasions patients determined the topics to
be discussed, the specific purposes of the meetings and even whether
staff would play the roles of patients and patients would play staff
roles during a particular meeting. We found that both staff and
patients welcomed these temporary role reversals and that they gave
a sense of perspective that simply could not be obtained any other
Opposition from other wards
The new ward program was supported by the hospital
director. Furthermore, there was considerable positive feedback
and encouragement from other service divisions in the department
of psychiatry. Despite this, there was strong opposition from other
wards in the hospital and from the nursing administration.. News
of our "no drug" policy had spread immediately throughout
the other wards and brought forth an anxious and angry response
from other personnel, no dissimilar from the anxiety that our own
staff had experienced at first at the idea of managing psychotic
patients without relying on drugs. The other wards feared the possibility
that they would be required to do the same and they resented the
implication that the new procedures being instituted were superior
to what hey had been doing.
Consequently, the ward found itself vehemently criticized and had
to devote considerable energy to fending off attacks from the rest
of the hospital.Staffing vacancies were not filled by the hospital's
nursing administration because prospective nurses and attendants
were told that our ward was "experimental" and that the
personnel there were "unhappy." The ward's acting head
nurse found herself eating alone in the hospital dining room and
other staff continually received messages of anger and criticism,
often directed at the ward chief. Nurses on our ward found that
they were being harshly criticized by the hospital's nursing administration
office, harassed in a variety of ways and threatened with bad nursing
evaluation reports. At the same time these were some staff on other
wards who became positively interested in our approach.
Residents on the emergency psychiatric service
supplied virtually all admissions to the hospital. These residents
plus those who had been on the old ward attempted to shunt all "schizophrenic"
patients away from our ward, declaring that withholding drugs from
these patients constituted "malpractice." The "war"did
have one benefit: u under the constant outside attack, the feeling
of group loyalty and cohesion on the new ward increased out to necessity.
It was not until later, when the ward's position was more secure,
that intragroup conflicts came to the fore.
The staff's hopes that the ward would "get
into shape" and become "stable" finally seen to be
unrealistic.Involvementnt with patients meant allowing oneself to
be vulnerable to the emotional onslaught that is often the medium
of communication of these patients. Eventually, we realized that
the emotional level of the ward would always fluctuate, and that
lows and highs would tend to be the rule. The lows occurred out
of frustration with particularly difficult patients and in situations
in which the staff's own
dependency wishes had become intensified. A sign of the latter was
readily apparent in the eagerness staff often exhibited to do the
patient-staff role reversals described earlier.The highs came about
in situations in which staff and patients felt a real identity,
a oneness as people, a oneness based on the fact that the foundation
of their being turned out to be loved and not hate and that they
could all function best as collaborators rather than adversaries.
Such highs occurred quite often enough to balance the lows and at
this stage the ward began attracting staff who wanted a meaningful
psychological treatment role. The acquisition of a very capable
and strong head nurse in the latter phase of the ward's development
gave the nursing staff some of the leadership that they had been
The easing of the struggle with the other wards
made it more possible for the staff to express some of their own
discomforts in staff meetings. It became clear that the staff needed
a great deal of support and understanding just as the patients did..
There had to be a place where the staff could clarify their feelings
and receive encouragement and support from their colleagues. "Feelings
meetings", usually called in the evening, became the means
for such activity. These meetings helped resolve personal and interpersonal
conflicts among the staff that had been interfering with their effectiveness.
Staff fatigue is a constant problem in working
psychotic patients and the staff often experienced the feeling of
overwhelming burden and of endless demand. However, when the ward
developed to the point where the staff members could bring the treatment
problems to the staff group or to the entire ward, we discovered
that patients and staff could provide help, support, and creative
solutions to treatment problems, that the therapist was not able
to solve alone. Staff, as well as patients, felt themselves to be
part of a family and could draw on the group's
resources and strengths as needed.
An unexpected result of the program was its marked
influence on a number
of the ward staff. Some experienced personal crises stemming from
necessity to confront their own feelings and goals. Those who chose
on the ward and face themselves experienced considerable personal
growth. Most of the residents matured as professionals, a number
of ward attendants decided to go on for further schooling, some
excellent personal relationships developed, and we were led to conclude
that the ward experience could be "therapeutic" for staff
as well as patients. In the long run many staff experienced a strong
desire to continue to have the kinds of involvement and personal
satisfaction in their future occupational lives that they had experienced
in the ward program.
The year of the new or "experimental"
ward ended in midsummer with the
turnover in residents, new and increased responsibilities assigned
to one of
us (Dr. W.) and a decision by the ward chief (Dr. D. ) not to continue
because of his obligation to complete a long term research project
before the ward program began. Finally, there were important financial
considerations for the hospital which began to impose sharp limits
of stay because of decreasing outside funding. Other wards had begun
emulate the "experimental ward" in some respects but without
implications We did, however, begin then to follow-up many of our
patients and id intensive follow-up studies on a few of the most
The "new ward program: was fully operative
for ten months. During this
period there were a total of 51 patients treated:20 patients were
in 30 days or less another 31 were on the ward more than 30 days.
The latter group averaged 4.7 months of hospital stay. The first
represented mostly milder disturbances, most often neurotic depressive
reactions with rapid symptomatic improvement. The other 31 patients
represented much more sever disturbances usually, some of the kind
that would have been transferred from other wards to a state hospital
for "longer term care."
We did not start our program with a research effort
that would have
permitted us to make rigorous statistical statements about the overall
results. There was no control group with which to compare our experimental
group and we did not gather independently arrive-at evaluations
We were as much interested in the methods and dynamics of developing
such a program as we were in the results. Furthermore, we had not
anticipated much of the professional resistance which often preoccupied
us in the early months and which we feel helped to develop an understanding
of why such programs are seldom developed. We did, however, attempt
to follow up those patients who were in the program more than 30
days and whose disturbance had been relatively severe. While not
suggesting that this data is in any way definitive, we regard it
as more adequate than the usual criterion of "dischargeability"
with no follow-up.
Table I shows the diagnoses of the 31 "long-term"
patients together with ratings of degree of improvement by the authors.
Each rating on our six-point scale was based on ward observation,
plus follow-up observations, after discharge. In several cases the
authors interviewed former patients several months after discharge
and, in a few cases, there was extensive follow-up including psychological
testing and interviews as long as two years afterward. We emphasized
follow-up observation in cases we regarded as especially severe.
Each evaluation of improvement was based on a comparison of the
patient's adaptation level before the crisis leading to hospitalization,
to his or her adaptation level several months to two or more years
after discharge. Thus, a patient might have a good clinical course
on the ward but be rated low due to poor adaptation after discharge,
unless we felt that life circumstance after discharge were much
more adverse than before hospitalization. One such exception was
a chronic schizophrenic man we rated 2, rather than 0 or 1, despite
a rehospitalization within a year after discharge, which was precipitated
by especially destructive alcoholic b his alcoholic mother. He was
nevertheless much improved on second admission to his condition
on first admission.The 4 rating position, representing no improvement
is illustrated by the case of a man who eloped from the ward after
a few weeks' stay and, as far as we could tell, simply resumed his
sociopathic behavior Likewise, not improvement was shown by two
chronic schizophrenic patients both patients were young but had
long insidious psychotic disintegration's featuring considerable
drug abuse (LSD) and had entered the hospital before the new ward
program began; their treatment got off to very poor starts with
several changes of therapists. Each subsequently required long-term
treatment at another hospital before they could be safely discharged
to outpatient treatment.
At the other extreme, illustration the 5 position,
is a woman whose
psychotic depression had progressively worsened during the year
before she entered the new ward program. At the time she entered
the ward, she was almost mute, never expressed positive affect,
and was delusional. The
patient progressed on the ward to a distinctly nonpsychotic level.
months after discharge, psychological testing (Rorschach, TAT, WAIS)
clinical interview revealed excellent reality testing, very creative
her superior intellectual resources, and strongly adaptive social
An example of the 4 position is a 19-year-old
girl who appeared to be
psychotically depressed. The entire staff of the ward had predicted
future to be one of suicide or becoming an extremely long-term state
hospital patient. She was treated intensively, especially in group
and individual outpatient psychotherapy and married. Almost two
after discharge ,it was reported by reliable sources close to her
that she was doing fairly well, in marked contras to the original
prognosis, and she was interviewed by one Of the authors who had
similar impressions. A detailed account of this patient is given
in Part II of this article.
The two character disorder cases rated 3 were
treated painstakingly over a long period. They showed a definitely
improved level of functioning several months after discharge but
still needed considerable attention as outpatients to sustain further
improvement from what were still fairly vulnerable positions. However,
we felt that each of these patients would have gone on to chronic
state hospital status or penal institutions had there been less
Showing less, but still appreciable, improvement
were two chronic
schizophrenic patients, rated 2, who showed less vulnerability to
disablement months after discharge but were not impressive in their
The only patient we rated 1 was an older chronic
alcoholic man who was severely suicidal with frequent previous hospitalizations.
He made definite progress on the ward and did not commit suicide
in the ear following discharge, and did not require hospitalization.
There was, however, no marked change in his precarious life style.
There are two further indices of treatment outcome.
rate for patients in our program was somewhat less than the going
the rest of the hospital, despite our choosing to treat extremely
patients on our ward instead of sending them to the state hospitals.
the initial summer one patient eloped and committed suicide. After
for the ten months that the ward was in full operations, there were
suicides, no serious suicide attempts and only one permanent elopement.
contrast another ward experienced three suicides during the same
ten-months period. Also, as far as we have been able to tell, there
have been no
suicides of any of our patients since they were discharged several
We do not regard the program described as the
solution to the problem of
psychosis or of other severe emotional disturbances. We do believe,
however, that our experience suggests that much more is possible
in the psychological treatment of severely disturbed patients than
is usually believed. After less than a year of this program, we
felt we had just begun to tap the therapeutic power that can be
developed in the ward situation.
While our theoretical orientation was in our minds,
that of ego psychology, a psychologist trained in gestalt therapy
felt strongly that we doing gestalt therapy: another psychologist,
an acknowledged "expert" in behavior therapy, insisted
that we were doing behavior therapy. One of us. Dr. W., often practiced
psychodrama approaches. What finally appeared to be
of overwhelming importance theoretically, was an evolving philosophy
power-building and power-sharing. It began to dawn on staff and
alike that we had either to win together or to lose together and
needed each person to be as powerful and competent as possible in
order to maximize the effectiveness of our collective efforts. Thus,
emphasize a theory of organizational development more than any specific
"school" of psychotherapy.
The question remains, "Why are drugs the
dominant treatment mode in most hospital settings?" In answering
this question we would point to certain economic considerations
or the one hand and to certain psychological factors on the other.
In the short run, it would appear economic to hospitalize patients
for less than thirty days: many insurance plans will not pay for
more than this length of stay. Thus, rapid reduction of symptoms
becomes the criterion for successful treatment outcome. Adequate
outpatient psychotherapy afterward is usually lacking. Once these
goals are set, there is a premium placed on any measures which will
"restore" the patient to his prehospitalization level
with minimum involvement of expensive hospital and staff time. The
treatment which is still considered to be most useful in such efforts
is drug treatment. Certain other goals of treatment, such as were
established in our program, tend to be set aside in these efforts.
The prevalent goals are strongly reinforced by the usual basis of
reimbursement: bed occupancy, per se, for up to thirty days, rather
than evidence of treatment effectiveness.
Among the appeals of drug treatment, there are
some which are peculiar to the doctor-patient relationship. Kartus
and Schlesinger (1957) have
discussed how the counter-transference potential" of the physician
activated so that sedatives will be prescribed for nontherapeutic
antiherapeutic reasons. They advise that physicians be aware of
the possible meanings of patients asking for sedatives and their
own wishes prescribe them. Deikman (1971) observes that remarkable
little attention is paid to the unconscious motives of staff in
prescribing phenothiazines and similar drugs and discusses the wish
of staff to "disidentify" with such patients to avoid
the communication of the psychotic's perspective; to avoid the intensity
of psychotic affect and dependency wishes; and to express the
unconscious rage that is provoked in them when the patient frustrates
their wish to"help."
The question may still be raised to whether drugs should
not be treatment of choice for severely disturbed psychiatric hospital
patients if they promote quick discharge, for more rapid discharge
would seem to be economically advantageous. Quick discharge, however,
really begs the question of treatment effectiveness since it does
not say whether an individual will be able to function productively.
In New York State, for example, it has been found that patients
do not function productively when merely discharged, that enormous
community problems ensue, and that patients often return to the
hospital, thereby creating a "revolving door" effect which
in the long run is more expensive. The "miracle" of drug
treatment is then rather like the fable of the emperor's new clothes.
Recently three excellent studies have been reported demonstrating
that drug treatment may well be inferior to psychological approaches.
Bockhoven and Solomon (1975) reported the results
of comparing two five-year follow-up studies on hospitalized persons,
one on patients receiving modern psychotropic medication and the
other on patients treated in the absence of psychotropic drugs.
The finding of no substantial change in the outcome of schizophrenic
patients was not expected in view of the absence of psychotropic
during the entire 5 years of the Boston Psychopathic Hospital follow-up
period, compared with the extensive use of psychotropic drugs at
Solomon Center for both initial treatment on admission and the entire
period of aftercare. This finding suggests that the attitudes of
personnel toward patients, the socioenvironmental setting, and community
helpfulness guided by citizen organizations ma be more important
in tipping the balance in favor of social recovery than are psychotropic
drugs... Their extended use in aftercare may prolong the social
dependency of many discharged patients.
Carpenter et al., (1977) showed a significantly superior outcome
acutely schizophrenic patients given psychosocial treatment and
sharply limited medication versus similar patients receiving the
usual treatment emphasizing drugs. These authors remark that "the
schizophrenia has become so extensively drug oriented that a significant
impediment has arisen to the exploration of alternative therapeutic
Evidence of the potentially greater economy offered
by the psychological treatment of severely disturbed persons is
found in the work of Karon and Vanderbos (1975). They have shown
in their studies of treatment costs of psychotherapy versus medication
for schizophrenic patients "that despite the expense of psychotherapy,
there were savings of 22% to 36% in total treatment costs because
of the shorter hospitalization of patients." We would not be
surprised if similar studies with psychotically depressed individuals
would also show savings for the psychotherapy approach. Arieri (1974)
has stated, "In my experience psychotic depressions tend to
recur unless adequately treated with psychotherapy." And that
"Drug therapy...in my experience is not sufficient in most
cases to cure affective psychoses even from the manifest symptomatology."
Psychological approaches in hospitals have long
had the advantages of
considerable thought. For example, the work of Cumming and Cumming
(1970) presented excellent theoretical and practical approaches
to psychiatric hospitalization. It becomes difficult then to fathom
why it is that
psychological approaches are so neglected in practice except that
represent the wish for a cheaper, easier way of dealing with difficult
patients. In our opinion, the extreme reliance on drugs is wishful
deception on the part of the psychiatric profession.
In the long run, a practical approach to psychological
treatment of severe emotional disturbance will have to be based
on revised concepts of what constitutes good treatment and an implementation
of these concepts in treatment plans. Such concepts would emphasize
outcome measures of ability to function productively not merely
decreases in disturbing symptomatology and quick discharge. Diagnostic
assessment, which now is so limited to superficial observation of
behavioral proclivities should emphasize meaningful predictive measures
of an individual's ability to think and to behave adaptively, both
before and after treatment (Whitaker, 1973; Whitaker, 1978; Whitaker,
Reimbursement plans would emphasize out-patient
services both as preventive and after-hospital treatment. We believe
that adequate reimbursement for follow-up psychotherapy would make
it possible to shorten hospital stay compared to our program.
For the present treatment of severely disturbed
individuals will have to be accomplished in special settings where
appropriate administrative support, financial backing and suitable
personnel are available.
1 Dr. Deikman is Associate Clinical Professor of
Psychiatry, University of California at San Francisco,
supervising Physician, Community Mental Health Services
City of San Francisco, and does private practice in
2 Dr. Whitaker is Assistant Director of Mental Health
Services, University of Massachusetts Health Services,
Amherst, Massachusetts 01003, and Professor of Phy-
chology, and does private practice in Amherst.
3 Whitaker, L.C. & Deikman, a. J. Psychotherapy
of severe depression.