The
Planned Environment Therapy Trust
|
"Supporting, promoting, recording and valuing therapeutic work in caring and healing environments/communities/institutions..." |
|
Occasional Paper Number 2
The very atmosphere of the community springs in the first place from the staff, and it is in the handling of their potential that the authority of the therapeutic community is on test.
- Harry Wilmer
This document highlights activities related to the therapeutic community established by Dr. Harry A. Wilmer, whose workplace was the U.S. Naval Hospital, Oakland, California from July, 1955 to April, 1956. To my knowledge, this project was the first therapeutic community established in North America. I have drawn freely from various publications by Dr. Wilmer and other staff members. Many are located in military medical journals and reports which are not readily available outside specialized medical libraries or data banks. The best single reference, of course, is Dr. Wilmer's book, Social Psychiatry in Action: A Therapeutic Community, written in 1958.1
This is a Planned Environment
Therapy Trust Archive and Study Centre On-line Publication.
© Dennie Briggs 2000
To contact Dennie Briggs: DensGroup@aol.com
To contact the Archive and Study Centre:
archive@pettarchiv.org.uk
A large military hospital in the U.S. Navy, one of 27 others, was the locale these recollections. Its most distinct feature was that it contained a psychiatric treatment center.
The backdrop: America in the beginnings of a fundamental transition; it was amidst the Cold War with Nikita Khruschev and Dwight Eisenhower as principle protagonists. The Korean War had recently ended while the Geneva Convention now divided Vietnam. Back home, there were the continual reverberations of Senator Joseph McCarthy's gross violation of civil rights. Half of all the hospital beds in the nation were occupied by citizens with mental disorders; the American Psychiatric Association projected that one in 10 would be hospitalized at some point in their lives and called attention to the grave shortage of trained psychiatric personnel.
Important breakthroughs: color television appeared, a vaccine for polio was discovered, early computers were displayed. Socially, young people were beginning to question traditional values and practices; they dug the new pop art and rock music; writers brought out controversial poetry, drama, and fiction. San Francisco was rapidly becoming one of the key settings for what was to become the Beat Generation.
This was the early and mid 1950s.
After an exciting and often an exhausting day at the hospital, some of the staff would gather at the Officer's Club to watch the McCarthy hearings, and then later in the evening, we'd dash off to San Francisco's North Beach: there, at the hungry i or the Purple Onion, we'd whoop it up with entertainers Mort Saul and Phyllis Diller or we'd sing along with the Kingston Trio. Other nights we'd eye and participate in the political and social satire of The Committee. Some nights we'd frequent the Vesuvius bar, which had gold lettering on it's windows advertising "booths for psychiatrists." On a daring night some of us would surreptitiously enter the Black Cat, the notorious gay bar, off limits to service personnel. We'd often wind up at the City Lights Bookstore hoping to hear a reading by Ginsberg or Ferlinghetti, Kerouac or Burroughs. We'd often top off the evening with a Cappucino or White Nun at Tosca.
It was, as someone said, a time where we were waiting for something - something we only vaguely could sense. Later, on the larger screen, it was to become the Aquarian 1960s; the kairos, the tryst, the turning point - the rendezvous - between dominant and emergent times.
Closer to home base, it was the U.S. Naval Hospital, Oakland, California.
How could I possibly have known what would lie in store for me, as the Marine sentry saluted when I entered the gate of the hospital one overcast morning in the spring of 1952? The furthest thing from my mind was that I would become involved in the therapeutic community: In fact, I scarcely knew of its existence, although I was aware of Maxwell Jones' first book but I certainly could never have imagined that three years later I'd be at Belmont Hospital, attending the "8:30"; then in the evenings, be sitting by the fire with Max, "crunching out" my observations.2
For the past two years I'd been studying how submariners might react to long periods of confinement in preparation for launching the first atomic-powered submarines. Group morale and interpersonal relationships were to be crucial factors.3 Now, at 25, I was about to begin a new assignment and what for me was to become a much different way of life. The largest service at the hospital was its neuropsychiatric department, where Marines and Navy personnel and their families from the West Coast of the U.S. and the Pacific area were sent for diagnosis, "disposition," and, treatment for some; but for most of the patients, arrival on the admissions ward meant that they would be discharged from the military-some with pensions, most without.
I soon found that the staff was split between those who subscribed to various kinds of individual psychotherapy, those who were involved in group psychotherapy, and the others who were carrying out physical treatment-electroshock and insulin coma. Immediately, I began a personal psychoanalysis. Four mornings a week, I found myself lying on the couch, spilling out my emotional guts to Dr. Merton Gill, a psychoanalyst who was identified with "ego psychology" in contrast to classical psychoanalysis.4 At the same time he was one of seven training analysts at the more orthodox San Francisco Psychoanalytic Institute. Several of the staff at the Naval Hospital were undergoing psychoanalysis. So I identified myself with the "individual treatment" group.
In addition to administering psychological tests, I began to see Marine Corps and Navy patients for brief psychotherapy under the supervision of staff psychiatrists. I became totally involved and even entertained the vague hope that someday I might become a lay analyst.
All began well. I struggled with my own analysis, saw patients with more complicated mental problems, attended seminars for psychiatric residents, and re-read Otto Fenichel's "bible" which I'd toiled with in graduate school.5 To wind up the week, each Friday afternoon, the Chief of Neuropsychiatry held a two-hour seminar for the staff. Some of these seminars were devoted to reviewing case histories with outside consultants, on other occasions, visiting professionals would give theoretical sessions or presentations of their work.
It was on one such Friday afternoon in June 1955, three years after I'd arrived, that Dr. Harry A. Wilmer gave the seminar and showed slides he'd taken on a recent trip to England where he'd read a paper and re-visited some of the people and institutions pioneering in the emerging field of social psychiatry.6a
Maxwell Jones established a hospital that was for patients, which was the first hospital for psychopaths. . . . If anything to me was striking it was this: here were these really unsophisticated people dealing with each other in the most sophisticated manner. . . .Max, has this idea: We don't need a lot of doctors, but bring in people who have no experience in psychiatry, teach them something about people, let them live on the wards, let the patients find that there are these lovely people who still are sort of objects you can't touch, but are friendly and who will listen to you, and maybe you do something about these people. . . . They get well in relationships with each other. . . .It is the social conscience of the group that keeps down destructive behavior.6b
Harry was a new member of the staff, who'd come into the Navy to fulfill his two-year obligated service. He spoke of his plan to introduce a therapeutic community program to the admissions ward where he'd recently been put in charge (July, 1955). He invited any staff member who was interested to visit his ward. I took him up on his offer, visited the ward, and remained there with him for the next 10 months.
The locked admissions ward accommodated a maximum of 34 patients at a time; due to the constant arrival of new patients, the diagnostic process had to be completed within 10 days. At that time, patients were sent to one of several open or closed wards to begin treatment or to be discharged from the military, either on their own or sent to mental hospitals; very few, only 14 percent, would eventually be returned to duty. During the 10-month experiment, 939 patients (all male) were admitted to the ward. They were a youthful group, nearly three-fourths were under age 26; two-thirds were single; 69 percent were Naval personnel, the remainder, Marine Corps. Officers comprised four percent, rated servicemen, 37 percent, and the remaining 59 percent were non-rated (i.e., relatively new to the service).
This was a mental hospital but it was also a Naval hospital. The existing military culture was searched for areas which would foster adaptation to patient status, recovery, and acceptance of illness. Being a receiving ward with a transient population the group was constantly changing and the goals were not cures but acculturation in a mental hospital. . . By a process of group sharing, by allowing patients to act therapeutically towards each other and encouraged to acceptable social behavior by the staff and their own peer group, there grew up a culture rapidly passed from patient to patient and staff to patient in which socialization, self control, and empathic understanding were keystones. 7
As to their symptoms, 44 percent were diagnosed as psychotic (mostly with acute schizophrenic reactions), 26 percent as psychoneurotic, 28 percent as character and behavior disorders, and the remainder as "acute situational maladjustment". "Many had had difficulty adjusting to the conditions of military life-life aboard ship, life on [a] Pacific Island, with cultural conflicts, separation from home, et cetera," Dr. Wilmer wrote in his book, and speculated:
Thus a certain number had rapid spontaneous remissions when removed from their stressful situations. . . It is likely that the patients may not have seen the last of their illness and that the military stress merely served to bring out sooner what would have appeared later under usual life stresses. From the management point of view, however, many of these transient acute psychotic breaks were more extreme and were accompanied by greater excitement and panic than the more slowly evolving and chronic varieties. . . After all, a patient who already has difficulty sorting out reality and fantasy is made more deeply delusional by the guns of guards, the injections of barbiturates, and the mechanical restraints that mark his progress to the military hospital.8
The staff nurses and hospital corpsmen were assigned to the ward on a rotational basis and had no prior training in the therapeutic community. Some had had a limited exposure to psychiatric nursing through brief courses or had learned on-the-job in the various psychiatric wards. Others were allotted to the psychiatric service from various parts of the hospital to fill vacancies, or a few had requested the transfer. There were psychiatric residents in attendance from time to time.
Many of the patients arrived on the ward in elaborate mechanical restraints and heavily sedated. The restraints were immediately removed and never replaced while the patient was on our ward. . . In numerous instances also the records accompanying patients informed us that, in the hospital from which they had been transferred to Oakland, they had spent a large part of their time in the seclusion rooms because of violent or disruptive behavior on the ward.
Yet not one of the 939 patients who passed through our ward during the therapeutic community program was placed in the seclusion room by any member of the admission ward staff. From the beginning we operated as if we did not have seclusion rooms . . . Though we dealt with all the types of patients who are ordinarily secluded under conventional hospital practices, no emergency arose that required seclusion.9
Dr. Wilmer wrote extensively of this experimental therapeutic community, but briefly let me sum up: first, fundamental changes were to be made on the admissions ward which included the elimination of mechanical restraint and seclusion rooms; medications were to be used only in a few instances. A community meeting lasting 45 minutes, six days per week was introduced. Attendance by patients and staff was "expected." Following the community meeting, he met with the staff for a review.
Videotape was not available in those days. The Pacific Combat Camera Crew, however, spent one month on the ward producing 133,000 feet of film and made tape recordings of the community meeting, the staff review, and of informal contacts with patients on the ward.
More of them later. . .
To facilitate social controls on the ward and to recognize their status, Dr. Wilmer met with the higher rated men twice a week for 15 minutes in his office over coffee, as: ". . . officers, Marine sergeants, and Navy chiefs who in the normal course of their activities were accustomed to bringing a certain amount of order and acceptable behavior in the daily life of shipmates."10
Each patient was seen by Dr. Wilmer within a few hours after his arrival and later for a longer period in order to evaluate his situation and determine where he would be sent next. There was a "doctor's list" on the bulletin board where any patient could request an interview. The list also made public who was seeing the doctor. When the patient was seen, Dr. Wilmer would cross off his name.
As none of the ward staff had had training in the therapeutic community, and most had none in psychiatric nursing, on-the-job training was primarily accomplished through participation in the community and staff review meetings. In addition, Dr. Wilmer met with the hospital corpsmen each week for 45 minutes, and held another weekly seminar for the nurses from all the psychiatric wards.
Although the core staff of the ward consisted of nurses and hospital corpsmen, there were others who were present at the community meeting and staff review. The chief psychiatric social worker, a civilian who had formerly been a naval officer, attended along with the chief psychiatric nurse, and I was there in a rather ambiguous role. Although I was a member of the psychology department, which had three civilian personnel, the situation was one of finding my own role. Patients were referred to the psychologists for routine testing, however, when there were patients who were too disturbed to leave the ward or there were special circumstances, I administered the tests, primarily the Rorschach and other projective tests.
There was a psychiatric residency program for physicians of the U.S. Navy and other countries, so from time to time we had additional doctors on the ward for training. There was also a psychiatric technicians' training school and students were assigned to the ward for field work. The chief of nursing service for the hospital as well as the nurse who was in charge of its in-service training attended the meetings quite frequently. There were consultants who came on an intermittent basis, among them, ethnologist Dr. Gregory Bateson, Dr. William Barrett, then President of the American Psychoanalytic Association, various professors from Stanford University and the University of California such as Jurgen Ruesch and Karl Bowman. Fleet Admiral Nimitz, who was retired, visited the ward on two occasions and attended the community meeting and staff review.
On the day when Fleet Admiral Chester W. Nimitz came (accompanied by the Commanding Officer of the hospital, [Rear] Admiral J.Q. Owsley), the group behaved in an unprecedented way. It was as if they were trying to frighten the "brass"; and they did put on a show, talking about suicide and razor blades and hostility to the medical corps, and about being crazy and wanting to kill or hurt other people in the group. In a sense they caricatured the role of the psychiatric patient for a world-famous nonmedical visitor, who, however, was comfortable, poised and friendly in the group. He seemed to clearly understand what was going on. In the next day's group there was a manifest amazement and gratitude and appreciation that Admiral Nimitz had seen fit to visit them and talk with them.11
"The community meeting," Harry Wilmer wrote, "presents a therapeutic opportunity for the patients to examine the here-and-now situation intensively in the hope of adding something to the ego that will enable him to change-to master the mental chaos within him and the social chaos that he creates."12
The community meetings began with silence. The patients usually opened the meeting and, at the end, Dr. Wilmer gave a brief summary of what he saw as having happened. There were a few times in the meetings when he played recordings of fragments of sounds, of dialogues between parents and children; on one occasion of a dream-like fantasy with music. This rare use of recordings enabled patients to express feelings that they were perhaps not quite conscious of.13
Dr. Wilmer:
In the course of the 10 months these meetings dealt with many things. Frequently the patients struggled with their anxiety over the effect of psychiatric hospitalization upon their future, as if, like Melville's Captain Ahab, they bore a grim and ugly scar; this subject was a recurrent one in group after group. But, in general, as the weeks went by, one change became hearteningly obvious to us-a ward on which the patients had initially been almost exclusively preoccupied with questions of their disposition when they appeared before the board and with the compensation they might receive, or with complaints about the hospital itself or the military service, developed gradually into a socialized, often sophisticated community with remarkable evidence of self-control, improved morale, and the sense of being concerned in the meetings with an important task. Briefly it may be said that the discussion was permitted to take its direction very largely from the patients themselves and their immediate interests. 14
• My comments in the meetings were directed toward the therapeutic purpose of furthering the patients' understanding of themselves and their problems. . . . Thus I consciously played the role of therapist in the community meetings; constantly aware of the unconscious process implicit in their communications, I tried by my interpretations of them to guide the patients unobtrusively towards a deeper examination of their feelings and an understanding of the real significance of these feelings in terms of their present situation.15
• But the major therapy in the community meetings was that which the patients performed on one another. We frequently observed that when a patient had confided his feelings and thoughts in the meeting and had had them seriously considered by the group, he showed an almost immediate symptomatic improvement. In a number of instances, in particular, delusions confided to the group thereafter lost their force or were modified into more socially acceptable forms.
• There was an amazing tolerance of psychotic symptoms in the meetings. Even the most psychotic patients were received in the group and often participated in the discussion. As a result, many patients spoke freely of their hallucinations and delusions to the group. Such communications were examined by the group in a curiously matter-of-fact way.
• The effect of the community meetings also carried over to the life of the patients during the other 23 hours of their day. Observers who remained on the ward throughout the day were able to report a continuous and rather sophisticated discussion, usually stemming from the theme of the morning's community meeting. A comment made or a record played at a meeting often started a chain of thought that went on for days, and the patients talked among themselves about the ideas stimulated by the meetings long after the meetings had ended. 16
A five-fold recurrent direction of events then appeared evident during the course of the meeting.
1. The presence of an atmosphere in the community which included events occurring over the past 24 hours to individuals as well as to the group. Patients arrived and left; staff came and went; a multitude of things happened, some with little notice, others with great salvo. When Dr. Wilmer left the ward at day's end, another physician was on call to officiate medically; some were in synch with the project, others not. Most were young doctors with varying degrees of psychiatric sophistication, learning on-the-job. The nursing staff closest to the community, also changed.
In the morning, following sick call, each patient and staff took a chair to assemble for the meeting; where each chose to sit contributed to what was to follow. The meeting began with gravid silence.
2. As the first participant broke the silence, a theme began to emerge: who spoke first and what was said?
3. The theme evolved as it began to take form. Some themes were carried to completion, others were left open-ended; some were bypassed with the introduction of new themes or sub-themes.
4. Dr. Wilmer concluded the meeting with a short summary of what he saw happening, traced out dominant themes and left the community with further work to do which might take the form of unanswered questions, matters to be continued.
5. Aftermath. The staff met to review the meeting, the patients continued to ponder what had happened-or abandoned it. Further psychic work over the next 24 hours might take place on "problems" engendered in the meeting or those that were subsequently stimulated by it. New patients arrived, some left, staff went and came, and so the cycle continued.
The Oakland experiment differed in some respects from earlier military therapeutic communities such as those originated by Maxwell Jones at Mill Hill and Dartford, and by Tom Main at Northfield. While Dr. Main's experiment was within the military establishment, Dr. Jones worked in basically civilian hospital structures treating military and former military personnel. Harry Wilmer's multiple role included that of a military commander, physician, therapist, teacher, and researcher. One of the decisive components of his project was to integrate these multi-faceted leadership functions within the culture of the Navy.
As a military officer, he was in command of an ever changing "crew" of medical and allied personnel and patients: he wore "the uniform of authority," for which many of the patients, as he pointed out, recently had been in open conflict.
As a physician, Dr. Wilmer carried out medical examinations, prescribed medications, wrote reports, made decisions as to confinement and recommendations as to future aspects of the patients' lives both while in the hospital and beyond.
As a teacher, he imparted his knowledge to his staff through encouragement of active participation in the treatment of patients and in post-group reviews and seminars. He kept careful notes and collected other research data which he could use to describe and to some extent evaluate the experiment.
The cornerstone of the project was how to combine these functions when necessary and when to keep them relatively separate in order to, as he said, "fortify" the therapeutic aspect of his command. This enhancement was not simple to achieve, but he made certain essential provisions; for example, he made morning rounds and talked to each patient individually at his bed to inquire about medical concerns; he had an interview request list so that any patient could speak to him privately. In the community meeting, he was clearly a therapist, although there were times when military protocol called for a temporary switch, such as when a patient's "mental chaos" created "social chaos" in the community. There, he might apply a combination of administrative, medical, and therapeutic functions to cope with the crisis. And a half hour later in the review, he became teacher; later in the day while writing up his notes of the days' activities, researcher.
Dr. Wilmer again:
The fact that any person who gets patients together in a group meeting is ipso facto said to be conducting group therapy makes for considerable confusion as to what group therapy is and what it aims to accomplish. The technique employed in group therapy is a highly precise and complicated one, different from that employed in individual therapy and, I believe, more difficult.
It is a technique of creating an atmosphere in which the patients will take over the meeting as their own and, with a minimum of "guidance" from the therapist, will freely discuss their problems with each other and with him. Ideally, no patient will remain withdrawn from the group; all will sooner or later become involved in the discussion. To achieve this result, the leader must have the skill to set the patients at ease and to relieve emotional tensions that block communication. Thus he must be quick to catch clues to resistances, and apt at interpretations that will lead patients to a deeper examination and revelation of the feelings and thoughts that are troubling them. His manner must be informal and easy so as to encourage the patients to speak freely, and his interpretations of their communications must be simple and direct.17
Dr. Wilmer was impressed with how the unstructured community meetings soon were given form by the content that was introduced mainly by the patients. The patients brought forth various themes which they were readily aware of and others that were at a much less conscious level. To be able to read both levels in the context he believed was crucial to understanding and fostering movement in the meetings and in the larger essence of ward existence.
It was my custom to conclude each community meeting with a 3- to 5-minute summary. I chose the theme which seemed to weave most constantly through the hour and pointed out its development, the precise words used, and its ego level, meaning or interpretation. . . I illustrated the points in my summary of the meeting by quoting significant comments made during the hour and attributing these comments by name to the patients who had made them. This assured the patient that, though I might be silent, I was listening all the time. It also gave a feeling of status to the patients who talked and the pleasurable sensation of hearing their own words spoken back to them in a calm and quiet voice with the obvious inference that what they had said was meaningful. It gave a sense of structure to the group meeting which on the surface often sounded chaotic.18
The theme of the discussion was determined by the communications of the patients themselves. My comments in the meetings were directed toward the therapeutic purpose of furthering the patients' understanding of themselves and their problems. So also were the summaries of the discussion that I regularly made during the last few minutes of the meeting. Thus I consciously played the role of therapist in the community meetings; constantly aware of the unconscious process implicit in their communications. I tried by my interpretations of them to guide the patients unobtrusively towards a deeper examination of their feelings and an understanding of the real significance of these feelings in terms of their present situation. 19
Looking at themes gave a kaleidoscopic view of the community meetings which were at once ever changing, expectant, exciting, recurrent, and, for some, fearful. Varying patterns constantly appeared as multiple overlays to the basic structure and form which Dr. Wilmer provided by word and gesture: "expecting" everyone to be present, to be seated, and observe minimal social courtesies.
From this footing the drama unfolded over the next three-quarters of an hour. The meeting might be opened by a patient simply airing a current grievance (being locked up on the ward or a complaint about the food). Or a patient might be agitated and think that there were dangers present in the form of communists, devils or reincarnated evil spirits. On another day, a patient might begin the meeting by being overly hostile and physically threatening to another or abusive to the group as a whole.
There were meetings in which patients voiced what appeared to be psychotic delusions and believed they were a god or some eminent figure; reality was sometimes at stake and it took considerable sorting out to discover what was fantasy and what was matter of fact. A dream episode might further cloud existence. There were accounts of mistreatment at other hospitals, prisons, or duty stations. Sometimes patients remembered horrific events from earlier years in the form of punishment, deprivation, or confinement. The were meetings overlaid with depression and despondency, others with laughter or tears. Some patients were concerned about their role as a man and the expectations which their families, society, and the military had laid out to them. And the ever present question of being or not being "crazy" haunted the meetings.
For some patients, the theme centered around the structure of relationships on the ward which was surprising and sometimes confusing for a military organization where enlisted men and officers and two branches of the service lived together as one. Dr. Wilmer recounted an incident in one meeting in which a lieutenant had reminded the group that he was an officer and a man, not to be treated as a boy.
Why do you tell us to call you "Sir" when we are playing ping pong with you? [The patient] was speaking here about a field of operation where people meet, at least to some degree, on equal status-where winning or losing has nothing to do with rank; he was speaking also of the ongoing world of the ward, and of an experience in which all the patients could share.20
There was silence and a heretofore mute catatonic schizophrenic who had been on the ward for 10 days and had never spoken a word in all that time, stood up, walked across the room, faced [the lieutenant] squarely, and quietly and without expression made a judgement: "Over-rated." Then he returned to his chair and sat down, resuming his monumental silence. There was a burst of laughter from the group.21
In another meeting, the theme quickly came to light: a patient told how he had worked for the Navy's Secret Police who had drilled holes in his auto to be used as a get-away car for robberies. He had left the police and now was "preaching" to the group.
[T]he patients ignored the psychotic aspects of this communication, the delusion about the Secret Police. Instead they vigorously attacked the idea that the police would facilitate a robbery. . . Someone said loudly, "He doesn't make sense." There was no laughter; it was a simple observation rather than a jib.22
Dr. Wilmer described another meeting in which silence was the overlying dominant theme but underlying were possible multiple sub-themes; silence lasted for 20 minutes and then he discussed its possible meaning. A patient had wandered off the ward the previous day in a confused state and had been returned. He had told Dr. Wilmer that he was afraid and should have talked in the previous days' meeting. He urged him to speak up now, but the patient couldn't, so Dr. Wilmer asked if anyone in the group could help him. There was no response.
Nothing more was said. Possibly their silence was a sort of conscious or unconscious conspiracy stemming from their resentment against the doctor (carried over from the theme of yesterday's meeting), their resentment against the staff which had outnumbered them, [several had been transferred the previous day to other wards] and their fear that the dangerous subject of homosexuality might be raised [which had been in the last meeting]. But if this were the case, I felt that so long as I left their silence as their own production, they would be caught in the meshes of their own anxiety and feelings of guilt about it. The gist of my summary of this hour was, "I don't know what the silence is about because you don't tell me. But the hour is yours to use as you want."23
These vignettes are illustrative of the decisive connection between theme and action, word and actor, gesture and return. And, as we will soon see, in the very seating pattern of the meetings. "[T]his is not meant to imply," Dr. Wilmer wrote, "that the theme determined the seating pattern, for many other influences were operative on it. The seating pattern, however, did give a clue as to how the topic was likely to be handled in terms of participation, silence, rejection, et cetera."24
Following the community meeting, the staff assembled for 30 to 45 minutes in Dr. Wilmer's office to go over what had happened. With the assistance of the staff, Dr. Wilmer drew a seating chart on a blackboard. Where the patients, as well as the staff, seated themselves was noted from meeting to meeting and its meaning was speculated on. The themes of the meeting were listed and expanded. Often times staff recounted additional themes or sub-themes that Dr. Wilmer may not have been aware of. Staff members frequently related patients' behavior outside the meeting and made connections. They also made predictions as to individual behavior and postulated what might happen in future meetings.
In these meetings we reviewed fully and freely all aspects of interpersonal relationships in the therapeutic community in terms of both patients and staff. We began each meeting by diagramming on the blackboard the seating positions in the community meeting that had just ended. Then we analyzed the meeting in detail, step by step, trying to recall how each patient had behaved and to explain why. This daily forum was extremely effective in stimulating the staff's observations of the patients' behavior and developing their understanding of its significance. The insight which the staff gained not only enabled them to work with the patient in new and better ways, but also increased their interest in their work and their sense of partnership with me in the total venture.
The meetings also served as a vital means of managing tensions in staff relationships with one another. Hostilities and differences simply could not remain underground for any length of time with such intimate face-to-face interaction. In some measure, then, the staff meetings were group therapy sessions though never directed for long at the staff but at the staff-patient interaction.25
• Who sits next to whom?
• Who moves where, when and why?
• Who moves in relationship to whom, what and why?
• Do people similar in designated ways tend to attract or repel each other?
• Do likes repel or do birds of a feather flock together, or is it both, and if so, when, which and why?
• What is the nature of the nonverbal, conscious and unconscious significance of chair positions? 26
To find answers to these questions, Dr. Wilmer kept charts of where patients and staff sat for each community meeting. In time distinct patterns emerged which he put into graphic forms. The patterns became so consistent that the staff gave the "chairs" titles and found they could reasonably predict many of the stances that the patients would take and how the topics would be handled in the meeting from the chair they occupied.
In group after group the same type of patient chose the same position so frequently that certain positions acquire a specific name in staff terminology. . . . .Chair positions were not analyzed in the community meeting in order to preserve the spontaneity of this phenomenon.26
When the patients were relatively free of tension and felt friendly toward one another and the staff, they tended to congregate toward the solarium or in a close circle. When there was considerable tension on the ward, they tended to scatter toward the door leading out from the ward in what the staff called the "fire escape" formation. 27
Four months after the therapeutic community was established on the ward, we undertook a study designed to give more objective information on the flow of spoken messages in the community meetings and the patterns of interaction between participants in the discussions. Beyond our own curiosity we thought this study would help to compare methods and processes used in different therapeutic communities. Briefly the questions we sought answers to were: Who spoke to whom, when and how often, and what was said?
I assumed the role of a silent observer and recorder instead of my usual participant one for 40 consecutive meetings (October 28, 1956 to January 9, 1957). This was a time when the community was functioning rather well and had mastered a number of crises. The staff had by now become comfortable and effective with the new community therapy.
Each morning, as before, I came to the ward with the nursing supervisor and talked informally with the patients and staff. But when the meeting began, I seated myself slightly beyond the edge of the group and made notes in a spiral note pad. I first made a seating chart. Then as the meeting commenced, I recorded the verbal communication, keeping track of time sequences with a stop watch. Later the same morning, I tabulated my notes.
The interaction was seldom faster than could be recorded, for there were periods of silence that enabled me to complete my notation of what had been said. There were times when it was difficult to distinguish between material directed to the meeting and hallucinatory experiences, however they too were communication. Gestures and other forms of nonverbal communication, such as moving about, lighting cigarettes, going to the lavatory, and so on, were noted but not included in the study.28
Note-taking had not been done previously in the meetings nor had any form of hidden observation been allowed. Recording interaction presented many challenges. There was the inevitable risk that this activity might divert attention from discussion and furthermore, arouse suspiciousness among the patients. The fact that I had been a member of the community since its inception probably reduced the potential disruption to a minimum. The staff, in fact, were more concerned than the patients. Only two patients commented to me about my sudden change and the note-taking. One of these, who was diagnosed as having paranoid schizophrenia, sat on top of a bedside locker watching me for two meetings; finally, during the third meeting he came down and asked to see what I was writing. I handed him the notepad which he examined closely and gave it back without comment.
The other patient came up to me after the first day and asked what I was writing, although my new role had been discussed beforehand with the group. After I explained, he would frequently stop by at the close the meeting to ask me if I had recorded all his words and inquire if he'd talked too much and if he was "doing all right."
When new patients arrived on the ward, those who'd been there longer would tell them that I was helping out the doctor by keeping track of the meetings in case they wanted to see if a patient had made any progress.
Following the community meeting, I remained on the ward for a while to see what I could pick up of what the patients talked about. Many discussed the meeting, especially Dr. Wilmer's summary, which often left them a good deal to think about. ThenI would join the staff review which was in progress. My notes soon became a reality check for the staff. One day, for example, when the staff were discussing a prolonged period of silence, which they thought of as having lasted about 15 minutes, I pointed out that in fact, it was only six minutes. At other times, staff members turned to me to verify or correct their impressions from my notes. The fact that we had another means than memory tended to increase the keenness of the observations in the staff meeting.
During the 40 community meetings which I observed, 7,726 identifiable messages were spoken by 365 persons (283 patients and 82 staff) out of an accumulative total of 1,187 people who attended the meetings (815 patients and 389 staff). I analyzed the communication not as to its content, but as units of talk, "objects" quantifiable in various ways.
Simply in terms of who spoke to whom, the meetings were largely doctor-patient oriented: nearly two-thirds of the conversation occurred between Dr. Wilmer and individual patients. (As far as content was concerned, these bits of conversation had to do mainly with encouraging and helping individual patients to communicate their feelings, to give information based on their observations of one another, and appeals to exercise control over their impulses and behavior.) The patients both initiated and received the greatest number of verbal communications.
Of all those present (staff and patients) over the course of the 40 meetings, nearly one-third spoke. Among the patients, however, almost two-thirds were silent. This does not necessarily mean that they were not participating, but only that their involvement could not be seen in terms of talking.29
Dr. Wilmer believed that the community meetings should begin and end on time; that the meetings' very presence together with their length was an unwritten contract, something that both staff and patients could count on with some degree of consistency, but not rigidly so. There were times when a meeting was extended for a brief time and Dr. Wilmer would announce the departure to the group. There were other occasions when the group was so moving that it ran overtime. There were also groups that were ended before the allotted time. As I kept track of the time, it was possible to look at what happened to verbal communication when groups were extended past their allotted time.
A little over one half of the 40 meetings ran four minutes over the allotted time. I therefore considered the time of the 45 minute meeting to be plus or minus four minutes. This definition of the time of the meeting, left six meetings that were extended (average 10+minutes) and 11 undertime (average a little over six and a half minutes.) What I wanted to see was if these alterations would change the basic pattern of the group's interaction.
In those meetings which ran overtime, both Dr. Wilmer and the patients talked more than in those that ran for the regular amount of time. Dr. Wilmer also talked more to the group as a whole and the patients communicated more with one another and with the doctor, but only slightly more with the group. When I looked at the six overtime groups, I noticed that three of them began with a rather long silence. The time extension in a way made up for the time spent in silence, although Dr. Wilmer always said that silence was useful and not a waste of time. Active participation in the meetings was nevertheless valued; even though the staff grew accustomed to silence, it was still a time of uneasiness. The overtime seemed to give additional means to assist an acute crisis usually in a member's personal life. Dr. Wilmer also sometimes used the additional time to show how community members could assist one another.
In the groups that were shortened, Dr. Wilmer spoke more to the group as a whole and slightly less to individual patients than in those which were not. Of the 11 meetings that were extended, eight were concerned with acutely disturbed patients who were actively hallucinating, revealing delusional material or distressing sexual problems. In four of these, there were long initial silences; in five there were visitors; in two, patients described maltreatment in previous hospitals; in four Dr. Wilmer appealed to the community to assist in controlling a disturbed patient; and in three, a patient took over the leader's role.
Although Dr. Wilmer and the staff maintained that the time schedule was adhered to, in 43 percent it did vary in length, which suggested that belief in principles was more important than rigid conformity in this therapeutic community.
The meetings often got off to a slow start, especially when there were periods of silence at the beginning, and then picked up momentum as the meeting progressed. There seemed to be a kind of warm up while the community was searching for a theme on which to work. As a result, we would expect that the greatest concentration of verbal interaction would occur as the meeting was nearing the end.
In order to test this notion, I analyzed 10 consecutive meetings by separating them into three 15 minute intervals. Contrary to expectation, most of the verbal interaction occurred during the middle part of the meeting and the last one third of the meeting did not vary markedly from the first. Both Dr. Wilmer and the patients maintained their proportions of interaction throughout the meeting.
Dr. Wilmer always took a chair and sat at about the same place each day for the meeting, thus maintaining a relatively stable position; patients knew where he was and where to direct communication. His seat became a pivotal point spatially in the meeting. By his consistent position, we could see how the patients and staff seated themselves, and in time it was apparent that there was meaning as to where they chose to sit.
In order to have a closer look at where messages originated and their destinations, I arbitrarily divided the space where they were held into four equal areas. I took the message units from five consecutive meetings and divided them into quadrants. The total number of messages that were sent during this five-day period was 1,137. Of these, about 13 percent remained within the quadrant in which they originated; the remainder were transmitted across quadrants. The patterns of communication that were conveyed in the community-that is, talk between the doctor and patients, and between individual members and the group as a whole-occurred most often across quadrants.
• Quadrant A, in which Dr. Wilmer sat, had the least amount of internal communication; it also contributed the greatest amount in the group meeting, comprising more than two-thirds of the total. The chairs the staff had designated as the coroner's chair, the deputy leader's chair, the right-hand-of-God's chair, the chair of the invisible, and the speaker-of-the-house chair (south) were all in this area where Dr. Wilmer sat.
• In quadrants B and C, (the areas most frequently occupied by most of the patients), members originated approximately equal amounts of verbal communication. The speaker-of-the-house (north), the retreat chair, the chair of the departed, the guest-of-honor chair, and the sniper's chair were all in this area.
• Quadrant D contained no position sufficiently significant to the staff to receive an honorific title; yet nearly 60 percent of the internal communication was carried on in this area, and the smallest amount of outgoing traffic emanated here. This quadrant showed the most irregularities and fewer of the socially sanctioned types of verbal communication. It was nearest the nurses' station where a staff member frequently sat in order to have ready access to phone calls and the front door. Disturbed patients also sometimes sat in this area because it was close to the water fountain and the lavatory, both of which were seen as a means to withdraw from the group when a patient felt particularly uncomfortable. This is where I sat to take notes. The area may have offered some form of retreat in terms of verbal participation in the meetings both for patients and staff.
Dr. Wilmer's role was strikingly consistent regardless of the meetings' nature and tone. He seemed to have in his own mind such a persistent "model" of the therapeutic relationship that it could withstand the changing climate of the group; it formed a consistency for the entire community. His role in the meeting was more of a doctor-patient relationship in contrast to what I was soon to see in my first visit to Henderson. But then the terms were decidedly different: Dr. Wilmer's community was of a temporary nature (patients only stayed 10 days), he had a less well-trained staff, and his patients were male, highly mixed in terms of psychiatric conditions, in favor of those with schizophrenic disorders, and he was within the confines of the military in a locked ward.
Even when Dr. Wilmer addressed the group, it was usually in a manner of helping individual members to deal with one another, assisting them in understanding and helping a disturbed member. The doctor's role involved assuming a certain social responsibility toward each member of the community to the degree of his ability to assist. Had the patients remained longer and the staff been more permanent, Dr. Wilmer's efforts to maintain continuity of his type of interaction might well have changed. The purpose of rapid acculturation to the philosophy of the therapeutic community, however, with its emphasis on utilization of normal social controls seemed to be entirely compatible with the role he assumed here.
In the community meetings, as we've seen, Dr. Wilmer took a very active role both initiating conversation and receiving it from the patients. As he said, his participation was more active than that of a traditional group therapist. An opportunity arose to compare his approach with that of another doctor who conducted six consecutive meetings during Dr. Wilmer's absence. The doctor was a Navy captain, who was doing a residency in psychiatry at the hospital and had been a member of the ward for several weeks, so was familiar with the ward culture and the meetings. In comparison with Dr. Wilmer, his replacement talked less and the patients talked more.
Doctor-Patient interaction in the community meetings , as we've just seen, showed a consistent pattern. This model can be clearly seen in the analysis of two very different types of meetings, although in each of the meetings one patient was in a preeminent position.
Verbal communication in this meeting was largely between Dr. Wilmer and one acutely disturbed patient with schizophrenia. The patient initiated 131 of the 189 units of conversation that occurred during the meeting, and Dr. Wilmer, 54; three other patients and one other doctor contributed the remaining four units. Dr. Wilmer spoke to the patient only one-fourth as much as the patient spoke to him, in contrast to the other meetings which were mainly on a one-to-one basis between doctor and patient. All the conversation during the meeting directly concerned this patient, and 86 percent of it was between Dr. Wilmer and him.
During the last 15-minutes of the meeting, no communication occurred other than between Dr. Wilmer and the patient. Only four of the 31 units of conversation initiated here were directed to the group and these had to do with interpreting the patient's strange behavior while appealing to the other group members to understand and help him.
As the rest of the community was silent in this meeting, we may consider that the disturbed patient represented all non-doctor communication. Considered in this light, the pattern of doctor-patient interaction in this meeting closely parallels that in other meetings In the first 15-minute interval Dr. Wilmer talked somewhat less than in other meetings; in the second 15-minute interval, he gave the patient somewhat more of an opportunity to talk than usual. But in the last 15 minutes, he re-established the usual equilibrium of the meetings when he took over his role as interpreter and therapist to the group (in this case, with an individual patient). The patients' conversation diminished but did not cease to exist; he was able to observe some of the social expectation by being a listener when Dr. Wilmer talked.
A patient opened this meeting by recounting a dream he had had in Japan three months previously. He described in his dream about his return to a small, isolated mountain village where he was an old potter, making hibachi pots of clay on a primitive potter's wheel. The doctor, most of the staff and patients were unfamiliar with many of the cultural elements of the dream (Japanese places, terms, et cetera) and asked many times for clarification. But some of the patients had been to Japan and readily identified with the patient and his dream.
The dream experience and the manner in which it was told contained many elements of romanticism and wish fulfillment, of wanting to disappear and lead an idyllic existence far from the stresses of modern life. The group was noticeably affected by the account and, with bits of supplementary detail from other patients, it was difficult to distinguish between dream and reality. Staff members too, caught in the mood of the meeting, expressed in the review, a desire to experience the dream fantasy of the patient.
Conversation units initiated and received during this meeting are shown in table 6. Dr. Wilmer initiated 25 percent more of the total communication here than in the meeting with the disturbed patient on November 22 (10 percent more than for his average in all 40 meetings); and approximately 40 percent of the total units were addressed to him, as compared with two-thirds in the previous meeting. The patient who told the dream received 42 percent of the messages as contrasted to 23 percent received by the disturbed patient. During these two very different meetings, both largely dominated by one patient, the group received seven percent of the messages as compared with an average of 17 percent for all the meetings.
When the relative amount of talking by the doctor and the rest of the group in this meeting was compared with the average of the other meetings, the regularity in pattern was again remarkable. In terms of the functions of each phase of a community meeting, regardless of content, Dr. Wilmer's consistency was arresting: his pattern remained essentially the same, whether the meeting was one in which an acutely disturbed patient dominated the meeting and the other patients were silent or one in which a patient described a delightful dream-fantasy in which the whole community became absorbed. Gregory Bateson commented:
In general, both Dr. Wilmer and the group were extraordinarily patient even with very confused speech, when there was any indication that the speaker was groping towards saying something important to himself. Whenever this was so, they would let him take up long sections of time and would even join him in his groping. But both the doctor and the group were rather sharply impatient of crystallized delusional material. For the most part, this sample of patients contained few whose delusions were established to the point of becoming idiosyncratic cliches in the patients' utterance. For this sort of thing there was no tolerance. 30
Verbal communication of patients who remained in the therapeutic community for just 10 days cannot be considered to give a whole picture of how patients (or staff for that matter), experienced what went on in the meetings. We observed informally, for example, that some of the patients who did not talk in the meetings on the ward became quite active in similar meetings on other wards to which they were transferred. It was as if they had absorbed something of the workings of the therapeutic community even though for their own reasons they had not contributed in our meetings. But given another community setting, which was different in terms of doctor-patient orientation, they could then take on some of the model which they had been exposed to and usefully employ it in their new surroundings.
Similarly, staff members who spoke little in the community meetings, participated quite freely in the review. A number of factors were operative in their silence in the community meetings. These meetings were part of a learning process; and in making the transition to the new roles expected of them here, staff members often felt very unsure of themselves. Participation was often highly charged emotionally. Many, due to their medical or nursing training and military indoctrination, thought that the doctor's role was to lead and that theirs, as in surgery or any other active medical treatment, was to assist but not take a major part. The staff was silently learning, as with the patients who spoke little, to control their own anxieties and were trying to adjust their attitudes to a milieu that required of them quite new ways of dealing with patients.
There was, in addition, some apprehension among the staff about what might be said in the review where Dr. Wilmer each day carefully analyzed statements made in the community by staff members and in many instances interpreted their meaning before the others. Also, staff members wanted to give the patients the greatest amount of opportunity to participate. They frequently found that when they did not volunteer information in the meetings, a patient would eventually come forth with precisely the comment that they themselves would have made had they spoken.
It is significant that many of the staff members who remained on the ward for any length of time felt a personal obligation to employ therapeutic community methods of patient management and treatment on other wards and in other situations where they served. This contagion effect suggests that in spite of their relative silence in the community meetings, the staff members had rather completely absorbed the philosophy on which the meetings were based and were waiting for opportunities to play a leadership role.
Prior to Dr. Wilmer's arrival, the Chief of Neuropsychiatry, Captain David C. Gaede, asked me to undertake a study of morale factors on aircraft carriers with the the Navy's Seventh Fleet operating in the Pacific. There had been a number of fatal accidents with pilots who were engaged in edgy operations off the coast of China. As many of the accidents were attributed to pilot error, Captain L. E. MacDonald, the Senior Medical Officer for the Fleet, requested assistance.
During my recent experiences with submariners, I had developed a modification of the Thematic Apperception Test (N-TAT) in collaboration with its originator, Dr. Henry A. Murray of the Harvard Psychological Clinic.32 For that project, we had engaged a Navy artist to draw pictures of situations that submariners would face both while on duty and depictions of conditions they might have faced outside Navy life. They would then compose stories about these rather nebulous circumstances that would reveal some of their own dynamics in relation to military situations. We assembled a number of the men to talk in small groups about their reactions to these pictures.
I had befriended a very disturbed Marine patient, Gordon W., on one of the closed wards at the hospital, who was undergoing electroconvulsive and insulin coma treatment. There were times when he was so disturbed that he had to be confined without clothing in a seclusion room and would smear blood and feces on the walls. A Red Cross associate got him some crayons and paper and found he was quite talented as an artist. He developed the ink-resist technique of layering wax and then with a knife, scrape down through the various colors, and when he reached the paper, he would have formed designs. Then he would next infuse the paper with ink to outline his forms.
One of the psychiatric technicians, Hospital Corpsman Third Class Fred A. Holle, who also was a gifted artist, became interested in Gordon's efforts and applied them to some of his own. I believed Fred could modify the N-TAT for situations that just might be relevant to Navy pilots. After pre-testing, we arrived at a dozen plates we were to use to investigate morale problems on two aircraft carriers.
With our slides in hand, I flew to Hawaii where I joined the aircraft carrier, U.S.S. Oriskany during its voyage to China to relieve the U.S.S. Kersarge which had been deployed to patrol that region for several months in a very pressured situation. Fred arrived in Japan where we spent a week and visited the psychiatric service of the Naval Hospital at Yokosuka which sent a large number of patients to Oakland. Fred and I then joined the crew of the Oriskany to return and tested its pilots. After each testing session, we assembled the aviators in small groups to discuss what they had experienced while taking the test. In addition, we encouraged them to talk about the anxieties they had over flying in the tense zone and their concerns about the reunion with their families.33
After we returned from this assignment, I wondered how our procedure might be used to study interaction between staff and patients, and among the various staff members. I remembered my discussions with the late Dr. William Caudill at Yale Medical School who had used a similar method to study interaction on its psychiatric wards. "In order to gather material on the similarities and differences in attitudes and role perceptions of the various groups," he wrote, "an interviewing program was carried on by means of a series of pictures of hospital life which were drawn specifically for this research."34
Dr. Caudill used the pictures to gain additional information about the awareness of communication problems between staff and with patients, and in some instances he did not know what questions to ask. The unstructured interviews based on how the respondents saw the situations brought out information that direct questioning might not have been readily accessible.
[I]f the interviewer used direct question to ask a nurse how she conceived of psychotherapy, or directly asked a resident doctor about the nature of his relation to his senior staff supervisor, such questions might well raise the defensiveness of a nurse or resident, and in talking about the situation in the picture they found themselves getting into emotional material, they would usually feel a need to continue and to explain what they meant.35
And so, as with Dr. Caudill's study, our pictures became "visual questions" to structure situations but not determine how the staff and patients would see them.
Some of the information that Dr. Berg and I gathered for our study of leadership, which follows, came from interviews using these illustrations.
While I was on the temporary assignment in the Far East, I met the Pacific Combat Camera Group who were filming exercises on the aircraft carriers. They were interested in our projects and volunteered that they would be interested in filming them at some point. Remembering their offer, I discussed this possibility with Dr. Wilmer as an additional means of getting information on ward interaction.
When the plan was first proposed by the psychologist on the ward, Lt. Dennie Briggs, I had extremely ambivalent feelings about undertaking it. The films would, I realized, give us a valuable form of documentary evidence on the program. But I hesitated both because I felt that the showing of them would be an intrusion upon the patients' privacy and because I questioned that the filmed meetings could be truly representative. The very fact that they were being filmed would affect both patients and staff.
Before any decision was reached, Chief [Petty Officer] Kuhn [in charge of the Crew] visited our ward for several days to discuss the proposed plan with us. My doubts were largely dispelled upon meeting him and seeing how easily he moved among the patients, both in the meetings and during the rest of the day. He had been in the Navy a long time and was clearly the sort of respected Chief with whom the patients could easily relate. Plans were therefore formalized and the crew and their gear arrived by truck.36
A memorable moment was caught on film when a Marine patient, given to bizarre behavior, was admitted from another locked ward as a management problem. Provocative and challenging to the other patients, he had been teased and in turn, attacked on the other ward. On Ward 55, in a community meeting, he confronted a tough Marine threatening him with his fist. But at the last moment thrust his fist into the palm of his other hand, retreated from the scene and returned to his chair. Dr. Wilmer turned to him and said, "Now, What did you do a nutty thing like for?"
Chief Kuhn of the Camera Group took a fatherly interest in him and spent much time with him. Within a few days the new disturbed Marine patient attempted to show his friendliness to the other patients during the group meeting. He went about the group shaking their hands. But he sat close to the nurses. 37
We were not able to make as extensive use of the films on the ward as we would have liked because of the amount of time it took to process the film. By the time rushes were received, the patients who had appeared in the films had left the ward. The staff however, was able to view them and discuss what they saw, and as Harry said, the Crew played back the recordings each day for patients. 38
Early upon my arrival at the Naval hospital, I became aware of the sometimes unique interaction among the staff and between the staff and patients. On the psychiatric service there was a mixture of medical and allied officers, enlisted, and civil service personnel.
Presiding over the psychiatry department was a Board-qualified high ranking psychiatrist, and a clinical director, together with supporting and clerical staff (enlisted military personnel and civilians). There were various military and civilian consultants. This was the staff that had responsibility for approximately 350 Navy and Marine Corps patients.
Outside work at the hospital, other groups formed. The hospital corpsmen who were not married, who were in the majority, lived on the base in barracks and had very closely knit social groups, some of them quite hostile towards those who worked in psychiatry.
The team on any one ward might consist of a medical officer who was in charge, along with other medical officers, residents, and interns. A part time psychologist and social worker were usually present and there might be a Red Cross representative. A chief or charge nurse and other nurses would be there, who in turn supervised a number of hospital corpsmen and women, some of whom had psychiatric training and experience.
The remainder of the general hospital contained typical departments and there was a large outpatient service for military dependents, along with the usual support services. The hospital was equipped for large-scale peace time emergencies, an outgrowth of the Korean War build-up. There were extensive training facilities at the various levels (doctors, nurses, hospital corpsmen) within the medical specialties. Unmarried enlisted personnel and officers who chose to do so, lived in quarters provided on the grounds. All in all, the hospital was a community of some 3,000 people.
During my third year, when I was working with Dr. Berg, on his ward, we decided to do some studies to find out more about how the spontaneous groups formed that we'd seen and how they functioned. A psychoanalyst, Dr. Berg, trained at the Chicago Psychoanalytic Institute, and was serving his two-year obligated military service. We were especially interested in the emergence of leadership among patient groups and in staff teams. Those that operated somatic treatment seemed to be the best organized and trained teams and the morale appeared to be high. There was a considerable amount of what one might call "drama" associated with their operations, where patients were taken into and brought out of coma induced by insulin, or given electric shock; several patients had died in the interventions. But on other wards, the staff seemed to be more loosely organized; on some the effect seemed expeditious, while on others it appeared minimal to carry out their duties.
Similarly, there were associations and cliques among the patients. We saw groups formed sometimes by military rank or branch of service (Navy or Marine Corps). Sometimes there were interesting formations where older or higher ranking patients looked out for the younger and less experienced ones. There were also instances of patient groups that were hostile towards one another. Except for the admissions ward, the officers and the few women patients were housed in one ward, and all the enlisted men were housed on other wards.
Dr. Berg and I became interested in the language, perspectives and views among these different groups and curious as to what went on in them. What were the hierarchical arrangements and purposes served by the complex relationships? We were aware of the recent studies made by psychiatrists and sociologists, particularly those of Dr. William Caudill on the psychiatric service at Yale, in which he first went undercover as a patient to get a look at the relationships that were formed.
For a year, we carried out some studies in which we located social groups and asked the members if they would volunteer to participate in a project we were conducting. All of the groups were "natural" ones that we had become acquainted with as associates or through teaching. I administered a Rorshach test individually, which was a familiar procedure in the hospital; some of the staff were especially interested as they had been curious about the procedure having heard patients talk about it. Selection of the Rorschach test was both acceptable within the culture of the department and provided an unstructured element which we could build on in studying groups. A few became apprehensive and one corpsman stopped after the second card and said he didn't want to go any further as he felt like he was "undressing" in front of me and it troubled him.
After I administered the Rorschach test individually, we got the natural group together for a discussion and told them we were going to show them the Rorshach cards on slides, and tape their discussion of them. One of the group's members would operate the tape recorder and we made the tape available if they wanted to listen to it later. After the presentation and discussion, we had them rate one another on various items in variation of Renato Taguiri's "Relational Analysis" sociometric procedure.39 That way we could determine what impressions each group member had as to its leadership.
Finally, Dr. Berg saw each member individually in an interview designed to learn more about their lives in the manner in which they chose to reveal it-Felix Deutsch's "Associative Anamnesis" technique. These interviews were taped and transcribed. And I re-administered the Rorschach test individually.
Combining these data, we found, as might be expected, that people had many personal feelings and ideas they could not voice publically-their private ideas-and there were others that a person could not reveal as they were not conscious of them. We found that most members of the group could be categorized as:
(1) leaders,
(2) followers, or
In summary, we concluded:
(1) In group discussions, the members were selective in the material they brought forth, and tended to reveal those private ideas and feelings least disturbing or alien to the group; i.e., they revealed most often those ideas that were more acceptable to the group or "group syntonic".
(2)Where some of the group-apparent material coincided with ego-alien material (i.e., material which was unacceptable to the ego and therefore not previously capable of being integrated by the ego) the ego-alien material became integrated into the individuals' experience and following the group experience, some could safely add these ideas to their conscious repertory.
(3) The leader, as obtained by sociometric choice, was the one who was more capable of incorporating, by his ego-integrative capacity, ideas that come from the group, and possibly ideas that he could not previously have brought to acceptance; i.e., those that might have been unacceptable to him before. Interestingly enough, this factor appeared to operate in groups of psychiatric patients as well as in staff groups.
(4) The degree of freedom (via the group conscience) seemed to be more limited than that of the individuals composing the group. Socially unacceptable ideas that were not privately ego-alien still tended to be treated as unacceptable in the group. The group at times served to censor ideas and admitted those considered more socially mature and thus more socially acceptable. The individual privately entertained as acceptable ideas that in a social setting were voiced as unacceptable, thus establishing and reinforcing mores and social controls.
(5) The leader often subtly introduced his private ideas to the group. If they were rejected he did not enforce them. (He did not want to press the point when he noticed the tenuous status of his ideas with regard to acceptance by the group.) Did the other members take on his ideas privately, while not publicly?
(6) Those persons whose egos were more capable of integration, while not of leadership calibre, did this more often (i.e.,they functioned more at a private level). Are these persons capable of becoming more of a leader in another group, after absorbing something of the leader that they did not have before? We believed they were, depending on the "social climate" of the new group and the new dynamics involved.
(7) The "going-alongers" were the least affected by the responses in any group. They also were the most disturbed clinically, both socially and psychologically (less participation in community affairs, et cetera). They manifested ambivalences of their roles and ideas as contrasted to the leaders and followers, who presented active expressions of their roles. The members who went along with the others only hesitatingly raised points, mainly agreed, and went along with the others.
(8) In general, group experiences seemed to reduce potentials for expression (reduced the number of private ideas that were expressed publicly), but what was individually retained was more reality oriented and thus more socially acceptable. (After the group experience, ideas were less frightening to the individual. This is perhaps one of the most important processes involved in group therapy.)Original ideas were not lost, but were condensed or diluted.
(9)The leader was one who was more able to accept his private ideas plus the ideas of the group and integrate them into his own thinking.
(10) Leadership imparted to the follower and to other group members certain crucial and important information for integrative functions.41
Midway during my four year stay at the hospital, I had become involved in the training of Neuropsychiatric (NP) Technicians. In addition to a psychiatric residency program, the psychiatric service had a school for hospital corpsmen who elected to specialize in that area.
There were two NP Technician's schools in operation at that time; one at the U.S.N.H., in Philadelphia, trained technicians for Naval hospitals in the eastern part of the U.S. and Atlantic areas; Oakland for the West Coast and Pacific. Most other Naval hospitals had at least one psychiatric ward.
Trainees attended daily classes taught by the psychiatric nursing coordinator, supplemented by sessions from staff psychiatrists, psychologists, social workers, and other nurses. They were given placements on the various wards on a rotational basis so that they could gain practical experience in a variety of treatment modalities. They were taken on field trips to visit civilian psychiatric facilities in the area. And each was assigned to one of the senior staff for personal counseling sessions if they chose to do so. In addition, each student as a "big brother," selected a patient from one of the wards with whom he or she spent time for a few hours each week while taking the course.42
At that time the psychiatric service, for approximately 350 patients, had four closed wards-two that offered electroconvulsive and insulin coma treatment with highly trained staff teams; and there were several open wards, where on some, group therapy was supplemented with individual treatment. There was a brig ward where prisoners were sent for evaluation prior to or while they served sentences. There was one ward for officers and female personnel. And one locked ward that was a mixed bag-primarily for Sailors and Marines with character and behavior disorders who presented such management problems on the other wards they had been brought together here, mainly to contain them. Dr. Berg was in charge of that ward.43
In addition to administering psychological tests at the request of the various psychiatrists, during my first two years I had concentrated on brief, individual therapy and had continued my own analysis. I visited nearby psychiatric treatment facilities with the NP technician trainees. In addition, I was receiving supervised sessions with Dr. Berg and the Clinical Director Commander. Thomas Harris, MC, USN, who'd studied with and been analyzed by Frieda Fromm-Reichman and Harry Stack Sullivan at Chestnut Lodge.
As I indicated in an interview with Dr. Craig Fees, Dr. Berg invited me to attend a meeting on his ward during which he was called away for an emergency and didn't return for the remainder of the meeting.44 I knew very little about group therapy, but that session was my initiation. I was "adopted" by the ward, regularly attended the group sessions, did the psychological testing for the patients, and saw some of them individually for a year prior to Dr. Wilmer's arrival.
It was during this year that the director of the NP Technician's School, Captain Robert Deen,MC, USN, asked me if I would conduct a weekly discussion group with the trainees, to give them an opportunity to talk about the experiences they were going through and discuss their plans for the future. The trainees asked me, from time to time, to visit the other wards to see some of the practices and conditions they were experiencing.
So by the time Dr. Wilmer arrived, I had quite a good grasp of what NP Technicians were doing on the various wards and what their expectations were. I also had become a familiar figure on the wards, and as many of the trainees were subsequently assigned to the psychiatric service upon graduation, they readily entered into discussions about what they were doing and how they viewed the various programs.
When the therapeutic community began, NP Technician trainees were assigned to Ward 55, usually in pairs, as a new part of the training program. I continued the weekly group discussion sessions in the school, so became a kind of link with the new students as they rotated through Dr. Wilmer's ward. They were soon comparing the way patients were treated in that community with the practices on the other wards. They served an important function in bringing attention to what was going on in the community to the hospital corpsmen on the other wards. It was interesting that some began to write about their experiences and expressed their views.
One student, Hospital Corpsman, Second-Class, Rodney Odgers, who subsequently became assigned to the brig ward upon graduation, gave an especially vivid account of his own and fellow's perceptions of the psychiatric service.
At various times and on various occasions the neuropsychiatric service has come to be know as "Funny Farm," "Silly Hill," "Squirrel Canyon," "Mockingbird Hill," "The Squirrel Cage," and other anxiety-laden terms that denote the misconceptions and anxieties of others who do not understand emotional illness and treatment, or who cannot because of their own problems. . . Stories of the dangers inherent in working on psychiatric wards were frequent and created the impression that the working code of a psychiatric ward was a slightly modified form of "Jungle Law" or "kill or be killed." Everyone spoke of danger and the unpredictability of the emotionally ill patient. . . . They were the only authority present and their word seemed the truth at the time.45
The conditions and attitudes that Corpsman Odgers reported were in effect the year before Dr. Wilmer's project. He recounted how unsettled and disbelieving many of the staff were when it was learned that the therapeutic community was to operate without restraint and sedation.
One of my friends was working on the ward, and as he became converted to these newer ways of dealing with patients, I became curious to see just what they could accomplish. It happened that I was assigned to this ward, and after only two weeks of attending the daily patient groups and staff meetings, I began to see the advantage of this type of treatment over that used previously.46
Later when when the insulin and electroshock program was discontinued at the hospital and a new program was introduced, Mr. Odgers was made the senior corpsman. The two closed wards that had been used for physical therapy were combined and integrated with an open ward with a united staff. As he described the change, one closed ward was used for sleeping, the other for recreation. Patients from the open ward came to the new unit during the day and for the community meetings. Patients from the closed ward moved to the open ward but could return if they or the staff believed they needed a more secure environment. Corpsman Odgers and others took patients on weekend camping trips. It was to this new program that many of the patients from Ward 55 were sent.
Rod Odgers observed the changes he witnessed over the two years he participated in the spin-off therapeutic community program.
. . . social changes occur in the corpsman's lives as their working situation changes. Where formerly the neuropsychiatric corpsmen were seclusive and had little to do with general duty corpsmen, their relations on their off-duty time are continually being extended. Where formerly they frequently talked of "riots," destruction, and other situations charged with anxiety, they now discuss the merits of group therapy and of relating to patients, and compare the progress of various patients. Occasionally they review with amusement the anxieties involved in former methods of caring for patients, and point out how much less violence and tension is now present on the entire service.47
Hospital Corpsman Third Class, Kenneth Purdy, an NP Technician graduate, wrote of the effects of relationships with the patients. His views reflected the extent of the change in the beliefs of the technicians as they participated in the experimental therapeutic community and carried it over into other wards.
A corpsman once said, "Our job is to live with the patient," but the manner in which he conducts himself is important. he is many things to the ward and to the patient. First of all he is a friend; a real, understanding person whom the patient can confide in without fear of punishment or rejection. . . . In many ways the corpsman is like them, one of their peers; they see him as a person they would like to be, and will look to him for guidance.48
More important than any other type of therapy on the ward is the daily living of the patient. The friendships he makes on the ward, the relationships he builds with the staff and the patients, the people and situations he meets while on liberty-this is therapy too. Here the corpsman, who is with the patient more than anyone else, is very important to the team. His attitudes, his conduct, and his interest in the patient will determine as much as anything how much progress he will make. The observations and reports of the corpsman will tell the rest of the team what is occurring in the patient's life, because he will be living with the patient.49
One of the youngest and most inexperienced of the students, Hospitalman David Butterfield, (below, holding diploma) from Hospital Corps School and with only a few months in the Navy, was chosen to give the graduation address for his class at the NP Technician's School; the Navy's Medical Technician's Journal chose to publish it. He summarized his views by saying the most important factor in being an effective psychiatric technician was to know himself. He summarized his views into three areas of intrapersonal relationships:
1. Know yourself. Have some idea of your own problems even though you do not always know how to handle them. Unless you understand yourself you cannot be effective in helping others.
2. Be yourself. Be natural-you cannot fool the patient by assuming to be what you are not. Having an attitude of superiority toward them merely increases your own anxiety and intensified their distrust of people. The patients know that you are afraid of them and may even recognize you own inadequacies.
3. Be a good listening post; you must be able to support someone besides yourself. the patient on the ward looks to the technician for help. Be a source of strength, trust in him, and be someone whom he can respect and be identified with. This can be accomplished best by being a good listener. One does not have to know all the answers in order to help others. By providing a relationship of trust and mutual respect, the patient will be increasingly able to see his problems in a clearer light and gradually will be able to resolve them in more effective ways.50
Harry Wilmer spoke of the side effects of the therapeutic community on the other psychiatric wards of the hospital. We saw the gradual introduction of community meetings eventually on other wards. There were instances of its effects beyond the perimeters of the psychiatric department and of the hospital itself. These occurrences resulted in training of general nursing staff in interpersonal relationships.
One of the interesting extra-curricular activities of being a Medical Service Corps officer was the monthly "Officer-of-the-Day" (OOD) duties, which came as an overnight or weekend shift of duty. While each department had a military physician either on duty or on call, the general administration of the hospital was assumed by the OOD, who was responsible for its overall activities. There might be relatives or friends visiting patients who had questions or complaints about the treatment of their kin; there might be disputes among members of the medical and nursing services; the evening meal was to be sampled and approved; there were bodies which had to be inspected prior to being released from the morgue to civilian morticians; there were ambulances to be dispatched to transport critically ill or injured military personnel or their dependents. The ambulance drivers needed to get the OOD's authorization to use the siren, which they liked to do! And a host of other matters that arose: in essence, the OOD was the temporary commanding officer of the hospital.
I welcomed this opportunity to get a better glimpse of the rest of the hospital. In the mess hall, I could talk with the cooks and serving staff; I could walk around the hospital and converse with the doctors and nursing personnel. I could speak with the staff who ran the canteen, library, theater and other support services. Everything that happened of major concern was meticulously entered into a log as a permanent record. The OOD slept in a room in the administration building to be on call for any emergency that might occur during the night.
But for me, the most interesting aspect of being the OOD came the following morning when a meeting occurred with the Commanding Officer to review the events of the previous night or weekend. The hospital was extremely blessed at that time by the presence of Rear Admiral Bruce E. Bradley, MC, USN as its Commanding Officer.51 He was an exceptionally kind and perceptive physician who was especially concerned with the human factors both for patients and staff. After I went over the log and its contents, he would sign it, return it to me and move from his desk to his conference table, invite me to join him and send for coffee. Our official business now behind us, we would spend the next hour discussing hospital matters more generally. He was keenly curious to learn more about the project on Ward 55 and was eager to hear about recent happenings. Beyond, he was concerned about relationships and morale among the hospital staff. What could we apply to other ward staff from what we were learning in our experiment? How could teamwork be enhanced? Questions like that.
Following our discussion, in a few days I would inevitably receive a call from someone in the hospital to meet with them at Admiral Bradley's suggestion. One call that stands out in my mind was from the nursing educator Lieutenant Commander Dorothy Jones, NC, USN, who was responsible for in-service training for all the hospital corpsmen and women. Throughout the hospital, they were required to attend a fixed number of hours of training, which consisted mostly of lectures on medical and nursing procedures by physicians and nurses, followed by question-and-answer sessions. Hospital corpsmen who were having personal problems that interfered with their performance were also referred to Lieutenant Commander Jones for counseling.
I invited Ms. Jones to attend a meeting on Harry Wilmer's ward to see what we were doing both because I thought it would be important for her to know about the therapeutic community as a nursing procedure and that she might be able to pick up some ideas for her training program. She not only welcomed the invitation but became a regular attendee at the community and staff meetings. In turn, she invited me to conduct regular "seminars" for all the hospital corpsmen and women of the hospital on interpersonal relationships. She had an exceptionally sensitive and highly motivated assistant, Hospital Corpsman First Class, Joe Goble who co-led many of the discussion groups with me. I took along NPTechnicians to what amounted to sensitivity training sessions, both to "connect" with their peers, and for them to gain experience in a somewhat different type of group meeting.
At one repeat session, a young, relatively inexperienced Hospitalman reported how he had been able to use the information he'd gathered earlier. He was assigned to an orthopedic ward. He recounted an incident in which a patient, following surgery, had been given sedation every three hours. He was demanding and abusive to the nursing staff who gladly administered the dosages to keep him quiet. But the corpsman believed that the patient was really frightened as the operation had been a major one and there was some question about the extent of his ability to walk again.
The Corpsman spent most of the night at the patient's bedside; whenever the patient awakened, the Corpsman inquired about the patient's ship, his home town, his interests, and eventually, his plans for when he was discharged. The patient became less demanding during the night and the next morning at sick call, surprisingly asked the doctor to be taken off sedation as he felt it might be habit forming and he didn't want to run that risk. What the discussion group concluded was that the patient saw himself not only as a failure in the military but might be seen as such when he returned to his home. He had been formerly a champion "Bronco Buster."
Lieutenant Commander Jones also began to refer individual corpsmen for assistance with their personal problems. After an initial interview, I formed a small discussion group that met on a weekly basis with an NP Technician as co-leader. Both the sensitivity training and the referral groups eventually became a major source of recruitment for the NP Technician's School.52
Another spin-off from the talks with the commanding officer was a call from the Chief of Surgery for patients who'd been severely burned. The unit probably first came into being during the Korean War, and now was a center for both former Korean War casualties and patients who'd received extensive burns from other sources, such as explosions or vehicle accidents. We were fortunate at that time to learn about the work of psychiatrist Dr. David Hamburg at Stanford with patients who had been severely burned. His work gave us reference as to the dynamics, expected course of events, and prognosis in working with these patients.53 The result was formation of a support group for his patients consisting of both those who were in the hospital for prolonged periods and others who had been returned to duty but returned for extensive skin grafts. I took along NP technicians and patients who'd been through Ward 55 as co-leaders.
One especially memorable meeting occurred when a Marine Sergeant in the group was able to talk about his feelings concerning the profuse burns on his face. His condition resulted from a gasoline explosion in Korea. He'd been flown to a hospital ship for emergency treatment with sprayed plastic dressings, and he had been under heavy sedation during evacuation with only occasional periods of consciousness. He'd lost one ear completely and now, two years later, after numerous skin grafts, there was still noticeable scaring on much of his face. While at home he would hide in the bedroom when family and friends visited and never went anywhere without being in uniform, for then rarely would people ask about his scarring as they took it for granted it was a war wound. Now, he was facing discharge from the Marine Corps and was nearly panicky as he felt he was literally "marked for life" and that people would treat him as a curiosity rather than as human. The group resembled those on Ward 55 in many respects in that the situations were handled in a here-and-now fashion, without advice-giving or attempts at interpretation; rather, each member was encouraged to confront his or her situation and try to work out ways of integrating the personal effects of the disorder with the reality of one's life.54
There were other consultations outside the hospital that included sensitivity training sessions with the staff of the Navy's Brig on Treasure Island in San Francisco, and focus type groups which Harry Wilmer and staff conducted for senior Marine Corps officers stationed in the area.
All beginnings must end. As the project was coming to a close, in 1956, Dr. Wilmer was to be transferred to the U.S. Naval Medical Research Institute in Bethesda, Maryland, to spend the remaining year of his obligatory service writing up his experiences. He was to analyze his immense amount of data and put forth a U. S. Navy research report for the use of military personnel; a book would be forthcoming for civilian consumption.
What Harry Wilmer had set in motion had an incredible effect on the entire psychiatric service of the Oakland Naval Hospital. With the continued active support of Captain Roudebush, community meetings, accompanied by staff reviews, were expanded to all of the wards. The President of the American Psychiatric Association, Dr. Francis J. Braceland (1956) wrote:
If it were possible, Doctor Wilmer should be endowed and sent throughout the nation as a teacher and as a catalyst. He has the ability to enthuse his hearers and his dedication furnishes an excellent example for young physicians. A community should be started in every admission ward of every mental hospital in the country. 55
The Chief of Psychiatry, Captain David C. Gaede, was retiring, to be replaced by Captain Marion Roudebush, MC, USN. I was a career officer and my tour of four years at the hospital was about to end.
We had heard endless accounts of the cruelties inflicted by the staff on patients as they passed through the Naval hospital in Yokosuka, Japan, the only Navy hospital in the Far East. It had an open and a closed ward where psychiatric casualties from the various Navy and Marine Corps installations in the Pacific were stationed, and from ships deployed there. I'd visited the hospital briefly while on temporary duty with the U.S. Seventh Fleet. The clinical psychologist who was stationed at its hospital was about to leave the Navy. I don't recall exactly whose initial idea it was, but someone suggested I get orders to Japan, take along a nurse and some of the NP Technicians who'd worked in the project or been involved in transitions on other wards, and see if we could apply the therapeutic community methods we'd learned to alleviate conditions there.
Once this idea had been formulated and the transfer request had been approved, Dr. Wilmer thought I should get another perspective on the developments in social psychiatry that he'd witnessed in the U.K., especially those of Maxwell Jones. He arranged for me to go there prior to leaving for Japan. The Psychiatric Nursing Supervisor , Lieutenant Commander Lina Stearns, NC, USN, had been regularly attending the meetings on Ward 55. She would be assuming a lot of the continuity of the therapeutic community practices by her position as being in charge of the nurses and hospital corpsmen assigned to the psychiatric department. She and I received temporary orders and on military aircraft, went to London to spend a month.
Most of our time was spent with Max at his Social Rehabilitation Unit at what was then Belmont Hospital. We also visited T.P.Rees, Superintendent of Warlingham Park Hospital, which was run entirely with open wards, with Tom Main at the Cassel Hospital, and with Joshua Bierer at his Marlborough Day Hospital. Max arranged for me to spend an afternoon with Sir Walter Maclay, his former superior, at his first therapeutic community at Mill Hill. 56
A docudrama of Dr. Wilmer's work, "People Need People," was aired on July 10,1961, in prime time on the U.S. ABC, television channel. Fred Astair hosted the program, the first in the series, "Alcoa Premiere" which was introduced by wartime hero, Fleet Admiral Chester W. Nimitz, U.S.Navy, (retired):
Mr. Astair, your audience may be interested in what followed from Dr. Wilmer's work at Oakland. Dr. Wilmer continued to test the therapeutic community for over a year . . . Naval Medical Research Institute set up a project to analyze the results of the entire operation. On these findings, the Navy subsequently authorized the program at other Naval hospitals. It has since been adopted by several veterans' hospitals and many State institutions. In short, from this experiment inaugurated by the United States Navy, a valuable new technique has been added to the resources for treating severe mental illness, representing new horizons of hope.57
On April 20, 1962, while Dr. Wilmer was conducing a therapeutic community at San Quentin prison, the San Quentin Drama Workshop produced a stage version of "People Need People."58 The play was presented the following year in the San Francisco area, by the Menlo Park Players Guild for four weeks running.59
Some years later in the 1960s - and I can't remember the exact year, Harry Wilmer and I, who were no longer in the Navy, but had retained our commissions in the Naval Reserve, requested two weeks annual training duty at the hospital. We were both curious about what had taken place there after the experiment had ended. We were able to coincide our tour with a visit by Maxwell Jones and were gratified to find that so many of the practices and beliefs that had begun in the original experimental therapeutic community were still in place and furthermore, had spread to the other wards.
Oakland's psychiatric service was eventually transferred to be combined with that of the U.S. Naval Hospital in San Diego, California. I don't know if the therapeutic community momentum that Dr. Wilmer had initiated was carried on at that hospital. The Oakland Naval Hospital a few years ago was declared surplus and turned over to civilian use. There was one proposal that it be restored to the golf course it had been prior to World War II. But I read in the news at hearings for the community, that a non-profit organization applied to use one of the vacated wards as a small half-way house for disturbed teenagers. I was amused as I read how the neighbors were alarmed that trouble and violence would enter their peaceful, quiet community, not remembering-or perhaps not even knowing-of the 350 disturbed military personnel who had inhabited its quarters at any one time for so many years without disturbing them.
Two psychiatrists, Lieutenants Arthur Schwartz and Richard Farmer, MC, USNR, stationed at the Naval hospital at Newport, Rhode Island, (1965 to 1967), established a somewhat similar therapeutic community on an open and a closed ward. They instituted daily community meetings combining both wards and required attendance.
These community meetings became the major treatment modality on the service, as well as the focal point of community life. To reinforce group interaction as the main therapeutic focus, we abolished individual interviews except for initial consultation, discharge planning conferences, and family meetings where indicated.
We noted dramatic improvements in the schizophrenic patients, perhaps because of the tremendous support they received from their fellow patients. In addition, community pressure helped them to test reality and suppress psychotic material. The program was so successful that during the first six months not one psychotic patient was sent to the neuropsychiatric center in Philadelphia [U.S. Naval Hospital; the equivalent of Oakland]; during the entire 21 months of the study, fewer than 10 per cent were sent.60
I am immensely grateful to Harry Wilmer for the opportunity to have participated in this exciting and rewarding experiment. There were many times when I sat in awe and wonder as he pointed out the profundity of things that were happening before our eyes; we emerged with fresh outlooks and new concepts. Invariably, I witnessed examples of the deep respect he had for patients, how he revered their rights, and kept his word in a milieu where chaos sometimes seemed to be the norm. He made creative sense of chaotic times and showed that beneath disorder there was form and structure as physicists have discovered. He treated the staff in a similar manner. There is a photograph in his report, for example, of a community meeting in which he has had blinders put on the patients' eyes so their identity would not be revealed. But then, he put blinders on the staff's eyes as well, including his own-I suspect a double-entendre in his gentle humor.
I'm also very appreciative to fellow staff members for their comradeship, especially the late Lina Stearns who headed the psychiatric nursing staff and to Dr. Irving Berg who got me into my first group meeting where the patients came to my rescue. There were also the hospital corpsmen and women, and the many patients from whom I learned a great deal. I had great affection for all of them. I would like to single out Hospital Corpsmen Joe Goble, Fred Holle, Rodney Odgers, and Kenneth Purdy.
The U.S. Navy's Pacific Combat Camera Crew entered into the project with incredible sensitivity added to their expertise. It was with considerable sadness that I learned they were killed in an air crash while on a subsequent assignment in the Pacific.
Gregory Bateson was an inspiring and warm-hearted teacher who shared with us his vast and extraordinary experiences which he brought into the ward and translated them into our situation.
Maxwell Jones was always behind the scenes in one way or another. And there were times when he appeared in the drama itself. I've attempted to express my deeply felt gratitude and affection for him in a Memoir.2
Once again, I am grateful to Dr. Craig Fees for his editorial advice and the opportunity to share these experiences with a wider audience.
Lest I be accused of plagiarism, one source I've heavily relied on was readily available to me: the writings and memories of a junior Navy Medical Service Corps officer. I cannot attest to the accuracy of memories, but his writings vouch for those of a much younger, and in many respects naïve, struggling, clinical psychologist. I realize I do know more than I did at that time but have resisted the temptation to edit-and indeed to rewrite-remarks he made some 40 years ago. But I've learned to live with him over the years and I've grown to know him much better.
1. Harry Wilmer. Social Psychiatry in Action: A Therapeutic Community. Springfield, Illinois; Charles C. Thomas (1958) (hereafter referred to as Social Psychiatry in Action.) return to text
2. Dennie Briggs. Record of a Friendship: A Memoir of Maxwell Jones. Copy deposited with the Planned Environmental Therapy Trust Archive. (2000). See chapter 1 "Max and His Gangsters."return to text
From these studies and my own first-hand observations on submarine patrols, I'd become involved with a team of physiologists and psychologists in an experiment, "Operation Hideout," where we stationed a volunteer crew confined aboard a submarine at the New London, Connecticut submarine base docks. One of the objectives was to see what effect the accumulation of carbon dioxide might have on the body. My task was to investigate the results of prolonged confinement on morale.return to text
4. Merton Gill. "Ego psychology and psychotherapy." Psychoanalytic Quarterly. 20:62-71, 1951. return to text
5. Otto Fenichel. The Psychoanalytic Theory of the Neurosis. New York: W. W. Norton, 1945.return to text
6a. Harry Wilmer. "The psychology of the patient and relatives as a factor in successful treatment," paper presented at the National Association for the Prevention of Tuberculosis, Fourth Commonwealth Health and Tuberculosis Conference, Royal Festival Hall, London (June 23, 1955), reprinted in the Transactions, Tuberculosis in the Commonwealth. (1955).return to text
6b. (from a tape recording of Harry Wilmer's seminar) return to text
7. Social Psychiatry in Action. return to text
8. Harry Wilmer. Report on Social Psychiatry: A Therapeutic Community at the U.S. Naval Hospital Oakland, California. Bethesda, Maryland: Naval Medical Research Institute. Research Report NM 73 03 00.01. 01 (November, 1958), 884. (Hereafter referred to as NMRI) return to text
11. Social Psychiatry in Action, 164. return to text
13. "Sound stimuli permit the patients to form a representation of what is emotionally important to them, and this is felt to be preferable to the use of movies and similar complete, prefabricated stimuli. They can recognize the familiar, and find it easier to talk about things which otherwise might be beyond the scope of group therapy. The theory of unconscious auditory perception is a new field in psychiatry..." Harry Wilmer, "Use of sound recordings in group psychotherapy." International Journal of Social Psychiatry. 3:102-108. (Autumn, 1957); Dennie Briggs, David Gaede, and Harry Wilmer, "Projective sound testing of emotionally ill patients." Paper presented at the annual meetings of the American Medical Association, Boston, Massachusetts. (December, 1955), reprinted in the U.S.Armed Forces Medical Journal. 7:1764-1770. (December, 1956). return to text
14. Graphic ways of representing some aspects of a therapeutic community, Symposium on Preventive and Social Psychiatry. Walter Reed Army Institute of Research. (15-17 April, 1957). Washington, D.C., U.S. Government Printing Office, 1957. (hereafter referred to as Reed), 467. return to text
15. Social Psychiatry in Action, 143. return to text
17. Social Psychiatry in Action, 70. return to text
20. Social Psychiatry in Action, 240. return to text
21. Ibid., 2310. return to text
23. Ibid., 272. return to text
25. Ibid., 892. return to text
26. Ibid., 922. return to text
28. Ibid., 910. Example of scoring: Score
Sgt: I had a dream a few months ago.. 1
In this dream, I was trying to comb my hair, and it would only go forward... 1
Then it seemed like I took my head off... 1
and the doctor explained that something was wrong with my head. 1Dr. Were you upset the day before the dream? 1
Sgt: Yes 1Dr: Do you remember what it was that upset you? 1
return to text
Sgt: My mother died. 1
29. The silent member may well have been absorbing ideas and modifying thoughts; in other words, that, though silent, he was actively participating in the group but at another level, perhaps in meditation or prayer. We observed, for example, that a patient who was silent in one meeting might take a very active role in another. We also found out that concern over administrative problems was another factor in silence. Patients knew that the decision was made on this ward as to whether they would be sent to an open or a closed ward, and particialy for further treatment, or for discharge from the military. With these important decisions concerning them still in the balance, some were believed not to have revealed their feelings and thoughts in the group for fear it might tip the scales in the direction of being sent to a closed ward. But they may also have been absorbing the communications of others and silently participating in the therapeutic process. In fact, their subsequent behavior often indicated that this was so. return to text
30. Social Psychiatry in Action , 340-341.return to text
31. NMRI, 889-890. return to text
32. Dennie Briggs, "The navy thematic apperception test (N-TAT) Journal of Psychology. (January, 1954). return to text
33. Dennie Briggs, David C. Gaede, L.E. McDonald, "Versatility potentials of aviators flying with the U.S. seventh fleet." Paper presented at the annual meetings of the American Medical Association. (1956). return to text
34. The Psychiatric Hospital as a Small Society. Cambridge, Massachusetts: Harvard University Press, 1958, 132. William Caudill, et. al., "Social structure and interaction on a psychiatric ward." American Journal of Orthopsychiatry. 22:314-334. (April, 1952); return to text
35. Ibid., 133. return to text
38. Harry A. Wilmer, A photographic report on a therapeutic community at the U.S.Naval Hospital, Oakland, California. Bethesda, Maryland: National Naval Medical Research Institute. NP Research project NM 007.090.21, 1956. Photographs pages 38-45. return to text
39. Renato Tagiruri. "Relational analysis; an extension of sociometric choice with emphasis on social perception." Sociometry. 15: 91-104. (February-May, 1952). return to text
40. Dennie Briggs and Irving D. Berg, "Observations on the dynamics of leadership: a methodologic approach." Paper presented at the American Sociological Society, Washington, D.C., 1955, Reprinted in U.S. Armed Forces Medical Journal . 8:1658-1663. (November, 1957) return to text
42. Dennie Briggs and Norma Wood, "Advances in training the neuropsychiatric technician." U.S. Armed Forces Medical Journal 7:1615-1620. (November, 1956). return to text
44. "A conversation: Craig Fees talks with Dennie Briggs," Gloucester: Planned Environment Therapy Trust Archives. (1991). return to text