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UBC Theses and Dissertations

Creating the therapeutic reality : an ethnographic account of an outpatient therapeutic community at… Brown, John 1974

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CREATING THE THERAPEUTIC REALITY AN ETHNOGRAPHIC ACCOUNT OF AN OUTPATIENT THERAPEUTIC COMMUNITY AT A UNIVERSITY PSYCHIATRIC HOSPITAL by JOHN BROWN B.A., B.A.I., T r i n i t y College, Dublin, 1953 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in the Department of ANTHROPOLOGY AND SOCIOLOGY of THE UNIVERSITY OF BRITISH COLUMBIA We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA July 1974 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f t h e r e q u i r e m e n t s f o r an a d v a n c e d d e g r e e a t t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y p u r p o s e s may be g r a n t e d by t h e H e a d o f my D e p a r t m e n t o r by h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f The U n i v e r s i t y o f B r i t i s h C o l u m b i a V a n c o u v e r 8 , C a n a d a ABSTRACT This thesis i s an ethnographic account of the daily l i f e of an outpatient centre for the treatment of non-psychotic patients. The centre i s located in a university setting and i s nominally attached to a university mental hospital. The setting i s described and the case i s made that i t normally allows for only two categories of participant: patients and therapists. The situated a c t i v i t y of these two groups in structuring the setting i s a major focus of the work. The roles embodied in the two categories are described in d e t a i l and the way in which these roles interlock to create the social r e a l i t y that i s understood by the participants as a "therapeutic community" is set out. A b e l i e f system which i s embedded i n , and a determinant of each role i s proposed. The practice of "doing therapy" i s described and a preliminary formulation of this practice as a situated a c t i v i t y which depends on the social structure of the setting i s attempted. A section which describes the observer's experiences in the setting i s included as an appendix. It i s argued that because the setting allows f o r only two classes of participant, the observer role i s seen as deviant and that this leads to mistrust on the part of both sets of p a r t i -cipants. ACKNOWLEDGEMENTS I would l i k e to express my appreciation to the patients who were present in the setting at the time of my pa r t i c i p a t i o n (or non-pa r t i c i p a t i o n ) . Their acceptance of my presence in a setting in which any stranger was a source of concern and potential embarrassment was greatly appreciated and t h e i r patience in answering what I thought were sociological questions was of considerable assistance. To the s t a f f at Theta I must express a s i m i l a r appreciation. Despite my ineradicably intrusive role which was sometimes a source of legitimate i r r i t a t i o n to some members, I was received with a considerable degree of tolerance. The access which I was eventually given to a l l parts of the program, a f t e r an i n i t i a l and understandable reluctance, was gen-erous, i f short l i v e d , and the openness with which my questions were answered was a testament to the good w i l l that I often experienced. The work of s t a f f members at Theta i s an extremely demanding one. It was ap-parent that the centre was a setting in which patience and affection were extended to an appreciative group of voluntary participants who frequently expressed t h e i r enthusiasm and s a t i s f a c t i o n with a process that they saw as a s i g n i f i c a n t intervention in t h e i r troubled l i v e s . I wish to extend my warmest thanks to a l l those who were, involved during the period of my observation. - i i i -ACKNOWLEDGEMENTS CHAPTER 1 CHAPTER 2 CHAPTER 3 CHAPTER 4 CHAPTER 5 CHAPTER 6 APPENDIX I APPENDIX II APPENDIX I I I APPENDIX IV APPENDIX V APPENDIX VI BIBLIOGRAPHY TABLE OF CONTENTS Introduction Page 1 The World of Theta 10 The Therapist Role 51 The Patient Role 67 The Relationship Between 99 the Therapist Role and the the Patient Role Doing Therapy 121 The Observer Role 156 Floor Plan of Theta 172 Heading f o r Self-Description 173 Form Standard Questions to be Asked 174 Co l l e c t i v e l y of Persons Before the Group for Admission Footnotes Added by the I n s t i - 175 tution Introduction by the Author 175 Footnotes 184 Schedule of Attendance at Theta 201 Correspondence with C l i n i c a l 202 Supervisor 213 - 1 -CHAPTER ONE INTRODUCTION This thesis i s an account of the everyday l i f e of an out-patient therapeutic community for non-psychotic patients who seek help with troublesome interpersonal problems. I have called the centre "Theta". My purpose i n writing the thesis was to provide some ethno-graphic d e t a i l about the way i n which therapy gets done i n such a set t i n g . It i s a feature of psychiatric writing that, while there i s a vast l i t -erature which describes how therap ught to be done, there i s l i t t l e or no l i t e r a t u r e on how i t actually (,:. J done. That i s not,to propose that there i s a sharp contrast between theory and practice but to suggest that the equation between the two i s an unknown one. Ethnography An ethnographic account d i f f e r s ( i d e a l l y ) from other accounts c h i e f l y i n two ways. The f i r s t i s that i t refrains from making any judgments about the details of the setting that i t describes; that i s , - 2 -i t i s n o t a n interested a c c o u n t . T h e s e c o n d i s t h a t i t c o n t a i n s o n l y m a t e r i a l w h i c h i s r e l e v a n t t o " t h e c u l t u r a l l y s i g n i f i c a n t b e h a v i o u r o f a p a r t i c u l a r s o c i e t y " J I t i s s o m e t i m e s d i f f i c u l t t o p e r s u a d e n o n - s o c i o l o g i s t s t h a t t h e f i r s t r e q u i r e m e n t h a s b e e n m e t . I f a n e t h n o g r a p h e r w a t c h e s ( f o r e x a m p l e ) a t r a f f i c p o l i c e m a n d i r e c t i n g t r a f f i c f o r s e v e r a l d a y s a n d s u b -s e q u e n t l y p r o d u c e s a d e s c r i p t i o n o f h i s b e h a v i o u r w h i c h r e f e r s t o h i s a c t i v i t i e s a s " s t a n d i n g i n t h e m i d d l e o f t h e s t r e e t w a v i n g h i s a r m s i n t h e a i r i n c e r t a i n r e g u l a r w a y s " , t h e p o l i c e m a n i s l i k e l y t o be o f f e n d e d . T h e d e s c r i p t i o n d e p r e c i a t e s t h e a c t i v i t y . T h e p o l i c e m a n k n o w s a n d e v e r y -b o d y e l s e k n o w s t h a t h e i s n o t " w a v i n g h i s a r m s i n t h e a i r " , h e i s " d i r -e c t i n g t r a f f i c " . T h e k n o w l e d g e o f t h e s o c i a l o r d e r t h a t t r a n s l a t e s h i s b e h a v i o u r i n t o s o c i a l l y m e a n i n g f u l a c t i v i t y p r o v i d e s i t w i t h a m o r a l f o r c e . G a r f i n k e l , i n " S t u d i e s o f t h e r o u t i n e g r o u n d s o f e v e r y d a y a c t i v i t i e s " , r e f e r s t o t h i s m o r a l f o r c e i n t h e s e t e r m s : A s o c i e t y ' s m e m b e r s e n c o u n t e r a n d k n o w t h e m o r a l o r d e r a s p e r c e i v e d l y n o r m a l c o u r s e s o f a c t i o n - f a m i l i a r s c e n e s o f e v e r y d a y a f f a i r s , t h e w o r l d o f d a i l y l i f e k n o w n i n common w i t h o t h e r s a n d w i t h o t h e r s t a k e n f o r g r a n t e d . T h e y r e f e r t o t h i s w o r l d a s t h e " n a t u r a l f a c t s o f l i f e " w h i c h , f o r m e m b e r s , a r e t h r o u g h a n d t h r o u g h m o r a l f a c t s o f l i f e . F o r m e m b e r s n o t o n l y a r e m a t t e r s s o a b o u t f a -m i l i a r s c e n e s , b u t t h e y a r e s o b e c a u s e i t i s m o r a l l y r i g h t o r w r o n g t h a t t h e y a r e s o . 3 T h e e t h n o g r a p h e r who a t t e m p t s t o s u s p e n d h i s c o m m o n - s e n s e k n o w l e d g e o f w h a t e v e r y b o d y k n o w s i n o r d e r t o make f a m i l i a r s c e n e s s t r a n g e i s l i k e l y t o be s u s p e c t . W h a t i s he up t o ? How c a n he n o t s e e - 3 -what i s " r e a l l y happening"? What has he done to our world? It i s j u s t by suspending his common-sense understandings that the ethnographer at-tempts to discover the rational properties of everyday a c t i v i t i e s and thus remain loyal to the program of his enterprise. In order to be auth-entic to his own description, the ethnographer may at times display him-s e l f as being inadequate i n terms of what has been indicated above yet as a person he may in fact embrace the presumptive facts espoused by the i n s t i t u t i o n i f his investment i s large enough. He must, however, be on his guard against t h i s : "For no one who wholeheartedly shares i n a given s e n s i b i l i t y can analyze i t ; he can only, whatever his intention, exhi-b i t i t . " 4 The second requirement i s what distinguishes ethnography from newspaper reports, from exposes from gossip and i d l e c u r i o s i t y . The det a i l s of an ethnographic account are selected to i l l u s t r a t e facets of " c u l t u r a l l y s i g n i f i c a n t behaviours". I t i s up to the ethnographer to defend his selection on these grounds and to show how the social organi-zation i s determined by and determines what facts are s i g n i f i c a n t in the setting. Facts are not selected for thei r human c u r i o s i t y value, for t h e i r shock content or for prurient interest but are selected because they are relevant to the way in which the putative social order i s crea-ted. The ethnographer has, thus, this r e s p o n s i b i l i t y to his material: to report what i s there not what he would l i k e to be there. - 4 -The Data The observations which form the foundation f o r this document were collected over a period of approximately one year. My i n i t i a l con-tact with the i n s t i t u t i o n was brought about by my desire to expand my observations of a small group. I had been studying small group behav-iour by observing and p a r t i c i p a t i n g in "leaderless" groups constituted to study group process. I wanted to continue my a c t i v i t y during a sum-mer vacation. The centre was known to my advisor and he corresponded with the c l i n i c a l supervisor i n an attempt to gain access for me to what we both thought would be an appropriate setting. After some i n i t i a l contact with the centre i n which I ex-plained my group focus, I was permitted to attend for one afternoon a week to watch the formally constituted therapy groups which were one feature of the setting. For a long period of time I attended one day a week, f i r s t during the afternoon session and l a t e r at an evening ses-sion which took place one evening a week. I was conscious, during this period, of the fact that the group focus which I had developed p r i o r to entering the i n s t i t u t i o n was d i f f i c u l t or impossible to sustain, especially as I was absent for over ninety per cent of the a c t i v i t i e s at the centre. I requested that I be allowed to attend more frequently and was eventually permitted to expand my observations to two days. Even t h i s , I f e l t , was inadequate and dur-ing the l a s t two weeks of my observation I attended f u l l - t i m e . The de-t a i l s of my experiences as an observer in the setting are set out in - 5 -Appendix I . I believe that i t i s worth recording that, p a r t i a l l y as a resul t of my d i f f i c u l t i e s in deriving an adequate group focus in the set t i n g , my perspective changed quite r a d i c a l l y during the period of my observations. I had become more interested i n doing ethno-graphy in any case and the setting was in many ways i d e a l l y suited to thi s enterprise. Ethnography i s said to require "a long period of i n -timate study and residence in a small, well-defined community, know4 ledge of the spoken language, and the employment of a wide range of observational techniques including prolonged face-to-face contacts with members of the lo c a l group, di r e c t p a r t i c i p a t i o n i n some of that group's a c t i v i t i e s , and a greater emphasis on intensive work with informants than on the use of documentary or survey data." Theta met a l l these requirements. Throughout the period of my observations I was known to everyone in the setting as an observer and attempted to be as unobtrusive as poss-i b l e . I appeared in the setting as nearly as possible i n the dress and style of the other participants. I took no notes during the sessions although tape recordings were occasionally available to me via the re-cording equipment operated by the Theta s t a f f . In general my observa-tions were recorded during natural breaks in the schedule and elaborated at the end of the day. The material in the text which i s written single spaced and - 6 -indented i s taken from my f i e l d notes unless otherwise indicated. These f i e l d notes are unreconstructed apart from occasional corrections where I have done unusual violence to grammar or syntax. Where conver-sations have been included they are sometimes closely paraphrased ver-sions of the o r i g i n a l utterances and sometimes l i t e r a l transcriptions obtained from the available recordings. The transcriptions are evident in the de t a i l recorded which includes a l l parts of the utterances as nearly as possible exactly as they were heard. My concern was with the patterns of behaviour which recurred with regular and stable dependability and which could be seen as the appropriate normal natural behaviour of the individuals in the setting and also, of course, with behaviour which was e x p l i c i t l y condemned as inappropriate. I used the members of the setting as competent i n f o r -mants about the setting insofar as they were seen by t h e i r colleagues as competent informants, and I t r i e d as far as possible to check my ob-servations and constructs against the subsequent behaviour which I ob-served. Much of the material should, however, be considered as a tent-, ative formulation at this stage because of the r e s t r i c t i o n s that were imposed on my schedule of observations by the s t a f f and by my own time-table.^ Themes and Focuses The thesis attempts to describe the " s o c i a l l y standardized and standardizing, 'seen but unnoticed', expected background features"^ of the setting. The sociological questions that I address were succinct-- 7 -l y s t a t e d b y S h e r r i C a v a n : W h a t a r e t h e c o u r s e s o f a c t i o n t h a t h a v e t h e c h a r a c t e r o f t a k i n g p l a c e a n d b e i n g e x p e c t e d t o t a k e p l a c e i n [ t h i s ] s e t t i n g a s a m a t t e r o f c o u r s e a n d w i t h o u t q u e s t i o n ? a n d : W h a t k i n d s o f a s s u m p t i o n s w o u l d be r e q u i r e d t o g e n e r -a t e t h e s e c o u r s e s o f a c t i o n a s r e g u l a r a n d r e c u r r e n t p h e n o m e n a ? 8 I p r o c e e d b y d e s c r i b i n g t h e s e t t i n g i n w h i c h t h e a c t i v i t y t o o k p l a c e a n d d e a l i n g w i t h some o f t h e d i m e n s i o n s o f t h e a c t i v i t y i n t h a t s e t t i n g . I d e s c r i b e t h e t w o m a j o r s o c i a l r o l e s t h a t m a t u r e i n t h e s e t t i n g a n d s u g g e s t t h e " k i n d s o f a s s u m p t i o n s [ t h a t ] w o u l d b e n e c e s s a r y t o g e n e r a t e t h e c o u r s e s o f a c t i o n " t h a t a r e d e s c r i b e d i n t h e r e s t o f t h e t h e s i s . I d e s c r i b e t h e w a y s i n w h i c h t h e t w o m a j o r r o l e s i n t e r a c t t o p r o d u c e t h e f e a t u r e s o f t h e s e t t i n g t h a t make i t r e c o g n i z a b l e a s a t h e r a p e u t i c c o m m u n i t y . I n a f i n a l c h a p t e r I a t t e m p t a p r e l i m i n a r y f o r m -u l a t i o n o f t h e w a y s i n w h i c h d o i n g t h e r a p y i s c a r r i e d o u t a n d how t h e s u c c e s s o f t h i s e n t e r p r i s e i s d e t e r m i n e d b y t h e r o l e s , b e l i e f s a n d i n -t e r r e l a t i o n s h i p s o f t h e p a r t i c i p a n t s , t h a t I s , t h e m u t u a l o r i e n t a t i o n o f t h e p a r t i c i p a n t s t o w h a t k i n d o f p l a c e i t i s . A n o n y m i t y T h e c l i n i c a l s u p e r v i s o r o n c e r e m a r k e d t o me t h a t t h e r e w a s o n l y o n e T h e t a . T h e i m p l i c a t i o n w a s t h a t a n y a t t e m p t t o d i s g u i s e t h e s e t t i n g was e m p t y b e c a u s e i t w o u l d be i m m e d i a t e l y r e c o g n i z a b l e t o e v e r y -b o d y who was f a m i l i a r w i t h t h e u n i v e r s i t y . O f c o u r s e my p r e s e n c e w a s k n o w n t o t h e s t a f f a n d t h e t h e n c u r r e n t p a t i e n t p o p u l a t i o n , many o f whom - 8 -expressed an interest in my work. My academic committee knew of my work and its location. Al l I can do is to follow the conventional practice of eliminating names of individuals. I have5 however, taken the addi-tional step of removing certain references and footnotes that might allow Theta to be ident i f ied. Footnotes This thesis contains three separate sets of footnotes. The references that are made to the l i terature are footnoted by means of superscript numbers which refer to footnotes that are appended at the end of each chapter. Throughout the text there are a number of issues which appeared to have alternative readings or which raised points which would, perhaps, have intruded in the immediate argument. To deal with these matters, I have added footnotes on the pages on which the issues came up which are indicated by asterisks. The third set of footnotes have been included at the request of the Theta staff . This document is a sociological analysis of the inst itut ion and raises issues that the staff fe l t should be addressed in psychiatric terms. The points that the inst i tut ion wished to take issue with are indicated by a series of superscript let ters . The footnotes to which these refer are included in Appendix V. - 9 -FOOTNOTES 1. Harold C. Conklin, "Ethnography", International Encyclopedia of the Social Sciences, ed. David L. S i l l s , The Macmillan Co. and Free Press, 1968, Vol. 5, p. 172. 2. Harold Garfinkel, Studies in Ethnomethodology , New Jersey, Prentice H a l l , 1967. 3. Ibid. p. 35. 4. Susan Sontag, "Notes on 'Camp'", Against Interpretation, New York, Farrar, Straus and Giroux, 1964, p. 276. 5. Harold C. Conklin, op. c i t . , p. 172. 6. For a discussion of a study which i l l u s t r a t e s what an adequate schedule of observations can amount to, see (for example), Howard S. Becker and Blanche Geer, "Participant Observation: The Analysis of Qualitative F i e l d Data", Human Organization Research, ed. R. N. Adams and J . J. Pre i s s , Homewood, 111., Dorsey Press, 1960, pp. 267-289. 7. Harold Garfinkel, op. c i t . , p. 36. 8. Sherri Cavan, Liquor License. An Ethnography of Bar Behavior, Chicago, Aldine, 1966, p. 8. CHAPTER TWO THE WORLD OF T H E T A T h e t a i s a w o r l d w i t h i n t h e w o r l d , a s p e c i a l i z e d w o r l d t h a t i s t h e j o i n t c r e a t i o n o f t w o g r o u p s o f p e o p l e : p a t i e n t s a n d t h e r a p i s t s . I n t h i s c h a p t e r I s h a l l d e s c r i b e t h e s e t t i n g a n d some o f t h e p r i n c i p a l a c t i v i t i e s t h a t g o o n i n t h e s e t t i n g . I s h a l l a t t e m p t , i n a p r e l i m i n a r y w a y , t o o u t l i n e s o m e o f t h e f o c u s e s , n o r m s a n d v a l u e s t h a t t h e t w o g r o u p s i n t h e s e t t i n g a t t e n d t o a n d w h i c h p r o v i d e t h e s e t t i n g w i t h i t s a c c o u n t a b l e 1 c h a r a c t e r . T h e o r e t i c a l T h e r a p y B e f o r e I d e s c r i b e a n y o f t h e a c t i v i t i e s a t T h e t a , i t s e e m s a p p r o p r i a t e t o a d d r e s s t h e e x p l i c i t a i m s a n d g o a l s o f t h e i n s t i t u t i o n . T h e s t a f f s a w t h e i n s t i t u t i o n a s b e i n g m o d e l l e d o n a n d a n a t u r a l d e v e l o p -m e n t o f a t h e r a p e u t i c c o m m u n i t y i n a n o t h e r l o c a t i o n w h i c h h a s b e e n w r i t t e a b o u t t o some e x t e n t i n t h e E n g l i s h l a n g u a g e l i t e r a t u r e o f t h e r a p e u t i c 2 c o m m u n i t i e s . T h e f o l l o w i n g d e s c r i p t i o n p i c k s o u t a f e w p o i n t s i n t h a t - 11 -l i t e r a t u r e which appear to be relevant to the present document. Group Focus The focus in the l i t e r a t u r e i s on group treatment and the group i s described as "much more suitable as a frame of reference for 3 the study of individual human behaviour;... This b e l i e f i s explained in terms of the determinants of neurosis: Neurosis i s anchored i n the vicious c i r c l e of i n t e r -action between the neurotic individual and the rest of the group. The neurotic co-determines the reactions of the group i n such a way that i t provides f o r hira the stimuli reinforcing his neurotic stereotypes. The paper goes on to argue that ...[The neurotic i n d i v i d u a l ] i s unaware of any re l a t i o n between his a c t i v i t y and the reactions of others...5 and that ...an important aim of psychotherapy must be the re s t i t u t i o n of [the awareness of the re l a t i o n s h i p ] . The mechanism to accomplish this i s the group. The neurotic individual i s seen as having a permanently distorted and invariable perception of the world which he successfully operationalizes in every social context. He sees the group . . . i n a distorted way and sees i t s members in roles different from those they actually play: he acts or tends to act accordingly...? Such an exceedingly erroneous interpretation of a group i s called...a pseudogroup. 8 - 12 -Therapeutic Process The therapeutic setting provides a framework for the i n d i v i -dual which allows him to act out his neurotic i n t e r a c t i o n . One of the main concerns i s to have a group p l a s t i c enough to allow patients to reproduce the structure g t y p i c a l of t h e i r r e l a t i o n s , without preventing change. The patient in the therapeutic community i s assumed to reproduce his standard interactional behaviour ("to r e l i v e his neurotic vicious c i r -c l e " ^ ) in the therapeutic setting which provides "a broad spectrum of r e a l - l i f e situations in which the patients quickly reveal t h e i r t y p i c a l behaviour patterns, and the others t y p i c a l l y react to them."** The therapeutic process, then, consists of observing the patient and discerning how he interacts to "...confirm [his] self-image 12 and [ h i s ] expectations about others..." , that i s , how the patient 13 brings about his own " s e l f - f u l f i l l i n g prophecy". When i t has become apparent what i s being done, th i s can be exposed to the patient in order 14 to "...correct the 'hypothesis' of the individual about other people." "A patient learns that not a l l persons i n a certain role (as f o r example 15 authority, peer, e r o t i c partner) perform in the way he expects." It i s recognised that the patient may r e s i s t the exposure of his behaviour through fear, and i t i s argued that the tendency to avoid 1 fi the confrontation "through...anxiety-determined avoidance" can be "readily seen in the therapeutic group"*'7, which can address this as a relevant part of the problem. - 13 -The second stage i n the therapeutic process i s not so clear-ly explicated. I t appears to involve the patient in experiments in which he can try out alternative behaviour which violates the norms of his false "hypotheses". [H]e can act, f o r the f i r s t time in his l i f e , his a c t i v i t y takes the form of learning by t r i a l and error. 18 The group i s seen as a valuable resource f o r this experimentation. The patients, as co-therapists, may experiment on a much larger scale than the therapist with his thera-peutic means. 19 To sum up, the theory argues that behaviour of neurotic i n d i -viduals i s sensibly invariant over a l l social situations and the centre provides an adequate theatre for the social actor to display his false assumptions and pathological deterministic behaviour which can be inex-orably exposed to him. The exposure i s assumed to be therapeutic for the patient, and he also has the opportunity to try out alternative be-haviour in a r e l a t i v e l y safe environment. Other Considerations The l i t e r a t u r e has other focuses: an early emphasis on hard work and spartan l i v i n g which i s less apparent in the l a t e r w r i t i n g , and a continuous stress on the economy of the treatment method. It i s em-phasized that the centre should be wordly though isolated (the stress on i s o l a t i o n can be seen to decrease too and has largely disappeared to Theta i t s e l f ) . For example i t i s stressed that the work " i s not occupa-- 14 -t i o n a l t h e r a p y , b u t g e n u i n e w o r k i n t h e f i e l d s , g a r d e n s a n d w o o d s " * " " a n d t h a t " s i n c e t h e p a t i e n t s a r e c i t y p e o p l e u n a c c u s t o m e d t o f a r m w o r k , t h i s s i t u a t i o n c o n t r i b u t e s t o [ t h e p a t i e n t s ' ] s t r e s s e s , f r u s t r a t i o n s a n d c o n -21 f l i c t s , j u s t a s i n r e a l l i f e . " N e x t , i t i s e m p h a s i z e d t h a t t h e s t a f f , a l t h o u g h t r a i n e d , a r e n o t t r a d i t i o n a l p s y c h o t h e r a p i s t s . F o r e x a m p l e , i n d i s c u s s i n g t h e r e s i d e n t " s o c i a l t h e r a p i s t s " , t h e l i t e r a t u r e n o t e s : We r e g a r d a s f a v o u r a b l e , t o o , t h a t t h e y n e v e r w o r k e d i n a n y t r a d i t i o n a l p s y c h i a t r i c i n s t i t u t i o n b e f o r e , s o t h a t n o t r a n s f e r o f u n f a v o u r a b l e t r a i t s ( l i k e p a t r o n -i z i n g a t t i t u d e t o w a r d p a t i e n t s ) c o u l d t a k e p l a c e . 2 2 T h e P h y s i c a l S e t t i n g T h e t a i s l o c a t e d o n t h e f r i n g e s o f a u n i v e r s i t y c a m p u s a d j a -c e n t t o a n i n p a t i e n t p s y c h i a t r i c h o s p i t a l . T h e p h y s i c a l s e t t i n g o f T h e t a i s a l a r g e t i m b e r f r a m e h o u s e s e t i n i t s own g r o u n d s . T h e e n t r a n c e i s l o c a t e d on a w i d e b o u l e v a r d a n d i s u n d i s t i n g u i s h e d f r o m o t h e r e n t r a n c e s a l o n g t h e s t r e e t . A s i g n on t h e g a t e p o s t a n n o u n c e s t h e a d d r e s s a n d t h e n a m e . T h e p r e s e n c e o f a l a r g e r t h a n u s u a l p a r k i n g l o t w i t h u n i v e r s i t y " f a c u l t y a n d s t a f f o n l y " p a r k i n g s i g n s i d e n t i f i e s i t a s a u n i v e r s i t y -r e l a t e d b u i l d i n g . T h e r e i s a s m a l l v e g e t a b l e g a r d e n , a b r i c k p a t i o a n d f r o n t l a w n . T h e b u i l d i n g i t s e l f c o n s i s t s o f a T - s h a p e d g r o u n d f l o o r a n d a s e c o n d f l o o r a b o v e t h e v e r t i c a l p a r t o f t h e T . ( S e e A p p e n d i x I I ) B e l o w t h i s , on t h e g r o u n d f l o o r , t h e a r e a i s d i v i d e d i n t o a n e n t r a n c e , k i t c h e n a n d w o r k r o o m ( w i t h a t t a c h e d b a t h r o o m ) a t t h e s o u t h e n d o f t h e T . T h e r e m a i n d e r o f t h i s a r e a i s f u r t h e r s p l i t up b y a s t a i r c a s e w h i c h - 15 -leads to the second f l o o r and a waist-level p a r t i t i o n , both of which produce subspaces that can be organized for various purposes. A long coat closet has been constructed behind the s t a i r s . The largest part of the area adjacent to the kitchen has been furnished with long tables and benches and the north end of the room contains couches and chairs. There i s a fireplace in the north w a l l . The left-hand part of the head of the T contains e s s e n t i a l l y a single room. At the extreme west end of th i s room a small semi-circu-* l a r stage has been constructed. I t i s two steps high and occupies roughly half of the end wa l l . There i s a piano beside the stage i n the north-west corner which has a sign attached to i t admonishing people not to move i t . The whole south wall of the room contains windows which look out on the sunken patio and behind i t to the parked cars of the Theta occupants. The end of the room opposite the stage has what was once a bar set into i t . This i s currently being made over into an "Audio-Visual (AV)" room and w i l l be f i t t e d with one-way mirror, TV cameras and recording equipment. Microphones hang from several locations in the timber-beamed c e i l i n g . The room i s carpeted throughout and contains twenty or t h i r t y chrome steel and black p l a s t i c stackable chairs which constitute the only furniture. - 16 -The o p p o s i t e s i d e o f t h e T c o n t a i n s a s m a l l e r room ( t h e " b a c k room") w i t h a s t o r a g e s p a c e o f f i t . T h i s room i s a l s o c a r p e t e d and i s s c h e d u l e d t o be w i r e d f o r sound r e c o r d i n g . The s e c o n d f l o o r i s d i v i d e d down i t s e n t i r e l e n g t h by a c o r r i -d o r . A s e r i e s o f i n d i v i d u a l rooms open o f f i t on e i t h e r s i d e . T h e s e rooms have been f u r n i s h e d as o f f i c e s f o r t h e s t a f f , a w a i t i n g room f o r i n d i v i d u a l p a t i e n t s and a room w h i c h i s c u r r e n t l y b e i n g s h e l v e d t o p r o -v i d e a s t a f f l i b r a r y . The d o w n s t a i r s s p a c e c o n t a i n s a minimum o f " p r o p s " . The s m a l l room a d j a c e n t t o t h e k i t c h e n has been f i t t e d o u t as a w o r k s h o p . I t c o n -t a i n s l a r g e rough c u p b o a r d s , p e g - b o a r d s f o r s t o r i n g t o o l s , a s t u r d y t a b l e and a s e v e r e l y n e g l e c t e d s i n k w h i c h i s u s e d f o r c l e a n i n g b r u s h e s and p a i n t t r a y s . The room i s u n d e c o r a t e d and c o n v i n c i n g l y d i s p l a y s an a t m o s -p h e r e o f c a r p e n t r y and m a i n t e n a n c e . The work o f d o i n g t h e r a p y a t T h e t a encompasses an a s s u m p t i o n t h a t "work i s p a r t o f l i f e " and t h e w o r k s h o p , b e i n g t h e f o c u s o f w o r k , i s r e f e r r e d t o as t h e " o c c u p a t i o n a l t h e r a p y " (OT) room. The b a t h r o o m a d j a c e n t t o t h e OT room i s n e g l e c t e d and i t s shower and b a s i n s have t h e s l i g h t l y g rubby unused l o o k t h a t a b a t h r o o m has i n a house u n d e r c o n s t r u c t i o n . The e n t r a n c e i m m e d i a t e l y a d j a c e n t t o t h e k i t c h e n has a s i g n - 17 -p o s t e d i n t h e window a n n o u n c i n g t h a t " T h i s i s a t h e r a p e u t i c communi ty " and a d v i s i n g v i s i t o r s t h a t t h e y s h o u l d " r e p o r t u p s t a i r s " . The k i t c h e n i t s e l f c o n t a i n s a l a r g e r e f r i g e r a t o r , s t o v e , c o f -f e e m a c h i n e and two w a l l s o f c u p b o a r d s . The c u p b o a r d s , a l t h o u g h o f r a -t h e r rough c o n s t r u c t i o n , a r e newly p a i n t e d and c l e a n . K i t c h e n m a i n t e n -ance i s one o f t h e t a s k s o f t h e T h e t a p a t i e n t s and t h e e q u i p m e n t and c o u n t e r t o p s a r e c l e a n e x c e p t where t h e a luminum c o f f e e p o t d r i p s on them, and t h e f l o o r h e r e , as e l s e w h e r e i n t h e h o u s e , i s unmarked . The p a r t o f t h e l a r g e room a d j a c e n t t o t h e k i t c h e n , b e s i d e s t h e l o n g t a b l e s a r r a n g e d end t o e n d , c o n t a i n s a l a r g e s i d e b o a r d . The w a l l above t h i s i s hung w i t h n o t i c e b o a r d s and t h e p a r t i t i o n w a l l w i t h t h e k i t c h e n has a b l a c k b o a r d on i t . The most s t r i k i n g i t e m on t h e n o t i c e b o a r d s above t h e s i d e -b o a r d i s a m e d i u m - s i z e d p o s t e r s h o w i n g an e l e p h a n t u r i n a t i n g . The c a p -t i o n r e a d s " i t n e v e r r a i n s b u t i t p o u r s " . B e s i d e i t , t h e r e i s an o l d p o s t c a r d a d d r e s s e d t o " D e a r T h e t a " w i t h a p i c t u r e o f H a w a i i . B e s i d e a map o f t h e u n i v e r s i t y and a s c r i b b l e d poem, t h e r e i s a t y p e - w r i t t e n l i s t o f r u l e s f o r T h e t a and a t i m e t a b l e o f t h e d a i l y a c t i v i t i e s . N e x t t o t h i s t h e r e i s a s e t o f i n s t r u c t i o n s on how t o m ix p a i n t , p o l l y - f i l l e r and cement . The w h o l e e f f e c t i s o f t h e k i n d o f f a m i l i a r u n n o t i c e d n o -t i c e s t h a t abound i n a l l i n s t i t u t i o n s . - 1 8 -The v i s i t o r who " r e p o r t s u p s t a i r s " i s p r e s e n t e d w i t h a s e r i e s o f d o o r s , a few w i t h n e a t c a r d s on t h e m , a n n o u n c i n g t h e names o f t h e o c c u p a n t s . The namecards a r e c h a r a c t e r i z e d by t h e use o f f i r s t names i n s t e a d o f f a m i l y names. S e v e r a l o f t h e d o o r s a r e unmarked . One i s s p l i t i n t o two h a l v e s w i t h a s h e l f on t h e l o w e r h a l f . A s i g n a t t h e head o f t h e s t a i r s i n d i c a t e s t h a t s o m e t h i n g t o t h e r i g h t i s t h e " o f f i c e " . A v i s i t o r w a n d e r i n g a r o u n d i n t h e p h y s i c a l s e t t i n g o f t h i s " t h e r a p e u t i c communi ty" w o u l d g a i n v e r y few i n s i g h t s i n t o what k i n d o f s o c i a l w o r l d was c r e a t e d w i t h i n t h e c o n f i n e s o f t h i s s e t t i n g , what a " t h e r a p e u t i c community" a m o u n t e d t o , o r how t h e a c t i v i t i e s a t t h i s i n s t i -t u t i o n were d i s t i n g u i s h e d f r o m t h e many a c t i v i t i e s t h a t c o u l d p o t e n t i a l l y be c a r r i e d on h e r e . I t c o u l d be a n y t h i n g f r o m a b o r d e l l o t o a c h u r c h . The a c t o r s have t o a p p e a r b e f o r e t h a t can be r e s o l v e d . D u r i n g t h e d a y , t h e s p a c e i n T h e t a t o o k on some a d d i t i o n a l a s p e c t s . As a rough g e n e r a l i z a t i o n i t can be s a i d t h a t t h e ma in f l o o r a r e a was p u b l i c s p a c e and t h e f i r s t f l o o r ( " u p s t a i r s " ) was p r i v a t e 23 s p a c e . T h i s , i n f a c t , d e l i n e a t e d t h e f i r s t d i s t i n c t i o n be tween p a t -i e n t s and t h e r a p i s t s f o r w h i l e t h e r a p i s t s had f r e e a c c e s s t o a l l p a r t s o f t h e b u i l d i n g a t a l l t i m e s ( w i t h d e f e r e n c e t o i n d i v i d u a l r i g h t s t o i n d i v i d u a l o f f i c e s ) , t h e p a t i e n t s had u n l i m i t e d a c c e s s o n l y t o t h e p u b l i c s p a c e on t h e main f l o o r and c o n d i t i o n a l a c c e s s t o some o f t h e s e c o n d f l o o r s p a c e . In g e n e r a l t h i s meant t h a t t h e y c o u l d go i n t o t h e u p s t a i r s rooms o n l y i f t h e y were i n v i t e d by t h e o c c u p a n t s o r w i t h p e r -- 19 -m i s s i o n , u n l e s s t h e y w e r e c o n s t i t u t e d a s a w o r k p a r t y w h i c h g a v e t h e m w a r r a n t e d e n t r y t o a n y s p a c e t h a t w a s g o i n g t o be w o r k e d o n . T h e p a t i e n t s ' t r e a t m e n t o f t h e u p s t a i r s s p a c e was q u i t e w e l l i l l u s t r a t e d i n t h e u s e o f t h e T h e t a t e l e p h o n e s w h i c h w e r e a l l s i t u a t e d i n t h e " u p s t a i r s " a r e a . When t h e t e l e p h o n e r a n g a t T h e t a i t w a s u s u a l l y a n s w e r e d b y t h e s e c r e t a r y b u t , i n h e r a b s e n c e , o n e o f t h e s t a f f m e m b e r s w o u l d a n s w e r i t . I n g e n e r a l , p a t i e n t s d i d n o t a n s w e r t h e t e l e p h o n e e v e n i f n o b o d y e l s e d i d , a n d t h i s was s e e n a s p r o p e r p r o t o c o l : S o m e b o d y a s k e d i f [ a b s e n t m a l e p a t i e n t ] h a d c a l l e d . He h a d n o t b u t i t w a s p o i n t e d o u t t h e t h e t e l e p h o n e h a d r u n g s e v e r a l t i m e s b e f o r e 9 o ' c l o c k a n d n o b o d y h a d a n s w e r e d i t . T h e p a t i e n t s c o u l d u s e t h e t e l e p h o n e s u p s t a i r s a n d s h o w e d a n i c e s e n s e o f t h e d i f f e r e n t i a l p u b l i c n e s s , a n d i n d e e d o f t h e s t a f f h i e r a r c h y , i n d o i n g s o . F o r e x a m p l e , t h e o c c u p a t i o n a l t h e r a p i s t w a s , p e r h a p s , t h e m o s t j u n i o r membe r o f t h e s t a f f a n d t h e p a t i e n t s t h a t I o b s e r v e d g e n e r a l l y u s e d h i s t e l e p h o n e i n p r e f e r e n c e t o o t h e r s . I f h e was i n h i s o f f i c e a n d a n o t h e r o f f i c e d o o r was o p e n a n d t h e o f f i c e o b s e r -v a b l y e m p t y , t h e p a t i e n t w o u l d u s e t h e t e l e p h o n e i n t h a t r o o m . T h e c l i n i c a l s u p e r v i s o r ' s d o o r was s e l d o m i f e v e r o p e n a n d h i s t e l e p h o n e w a s n e v e r u s e d b y p a t i e n t s . T h e s e c r e t a r y ' s o f f i c e r e p r e s e n t e d a s l i g h t d e p a r t u r e f r o m t h e r e s t o f t h e s p a c e i n t h a t a n y b o d y c o u l d h a v e b u s i n e s s w i t h t h e s e c -r e t a r y , a n d t h i s was c o n s i d e r e d a d e q u a t e g r o u n d s f o r g o i n g t o t h a t o f f i c e . - 2 0 -E v e n h e r e t h e r e w a s s t i l l some d i f f e r e n t i a t i o n b e t w e e n p a t i e n t s a n d t h e r a p i s t s . T h e r a p i s t s r e g u l a r l y w a l k e d i n t o t h e s e c r e t a r y ' s o f f i c e t o o b t a i n r e c o r d s , l e a v e w o r k o r s e t up t h e s o u n d r e c o r d i n g e q u i p m e n t w h i c h was m o u n t e d on t h e w a l l . P a t i e n t s , by c o n t r a s t , h a d o n l y s p e c i f i c k i n d s o f b u s i n e s s t h a t p r o v i d e d t h e m w i t h l e g i t i m a t e g r o u n d s f o r b e i n g t h e r e a n d w e r e e x p e c t e d t o s t a t e t h e i r b u s i n e s s on a r r i v a l . I n f a c t , t h e d o o r was o r i g i n a l l y s p l i t t o k e e p p a t i e n t s o u t . T h e s e c r e t a r y d i d n o w o r k f o r t h e p a t i e n t s b u t c o u l d s u p p l y t h e m w i t h r e l e v a n t p a r t s o f t h e i r own f i l e s , T h e t a f o r m s , a n d s o f o r t h i f t h e y p r o v i d e d g r o u n d s f o r t h e i r r e -q u e s t . T h e T h e t a s e t t i n g , t h e n , w a s d i v i d e d i n t o s t a f f s p a c e w h i c h was r e s t r i c t e d f o r p a t i e n t s , a n d p a t i e n t s ' s p a c e t o w h i c h t h e s t a f f a n d e s p e c i a l l y t h e t h e r a p i s t s h a d f r e e a c c e s s . A c t i v i t i e s T h e p a t i e n t p o p u l a t i o n o f T h e t a , u s u a l l y n u m b e r i n g a b o u t t w e n t y , a t t e n d e d a t t h e c e n t r e f o r s e v e n a n d a h a l f h o u r s e a c h d a y f r o m M o n d a y t o F r i d a y . T h e d a y s t a r t e d a t 9 a . m . , e x c e p t on T u e s d a y w h e n t h e r e w a s a n e v e n i n g s c h e d u l e a n d t h e d a y s t a r t e d a t 1 p . m . T h e s t a f f k e p t a p p r o x i m a t e l y t h e s ame h o u r s a s t h e p a t i e n t s a n d c o n s i s t e d o f f i v e f u l l - t i m e e m p l o y e e s p l u s t h e d i r e c t o r o f t h e i n s t i -t u t i o n a n d some o c c a s i o n a l m e m b e r s . T h e s t a f f c o n s i s t e d o f t h e f o l l o w -i n g p e o p l e : - 21 -C l i n i c a l Supervisor (M.D.) * Rotating Psychiatric Resident (M.D.) * Resident Psychologist * R.N. trained in psychiatric nursing * Occupational Therapist Part-time C l i n i c a l Fellow * Secretary V i s i t i n g P sychiatrists from other i n s t i t u t i o n s . The c l i n i c a l supervisor, although he did not attend f u l l - t i m e , was largely responsible for the design and direction of the program while the resident psychologist acted as his executive assistant. The Theta week was divided up into a varied program of work, play and therapy, and although the schedule changed i n de t a i l from time to time, the version of i t which i s shown i n Figure 2.1 i s representa-t i v e of a typical week. 9:00 10:00 11:00 12:00 1:00 2:00 4:30 6:00 8:30 pm Monday Sports Work Tuesday Free Time Wednesday Dance Therapy Interviews Weekends" Family Groups Whole-Group Therapy Lunch and_Fem_ly_ Rep_o£ts_ Flect ions Thursday Auto-biographies Work Discussion Work Work Discussion Sports Supper Family Night Whole-Group Therapy Daily) Family Groups Work Friday Whole-Group Therapy Work Theatre Goodbyes Family Groups F ig . 2.1 Approximate Schedule of Theta Ac t i v i t i es The work which was carried on in the centre was usually d i r -ected at improving the physical amenities of the building and i t s suit-* The fu l l - t i m e employees of Theta. - 22 -a b i l i t y for i t s present purpose. The most common a c t i v i t y during the nine months of the period I attended consisted of painting. In fact the place smelled of paint almost continuously over that period of time and as the a c t i v i t y was intended to be therapeutic, I was going to c a l l my description "Paint Yourself Well". During the l a s t few months of my observation, the patients were engaged in converting what had previously been a small bar adjacent to the "theatre" into a room with a one-way mirror which could be used for t e l e v i s i o n cameras. The cameras were to be used to record the a c t i -v i t i e s during the whole-group therapy which the c l i n i c a l supervisor said would "improve the treatment". This room was referred to as the "Audio-v i s u a l " (AV) room. Another project that was being worked on in the l a t e r period was shelving for the s t a f f l i b r a r y and the c l i n i c a l supervisor's o f f i c e . Other inside work that was carried out included such things as recovering worn furniture. During the spring and summer months, work was also done on the garden. A vegetable garden and flower beds were c u l t i v a t e d , along with the usual clean-up chores. The inside of the building was maintained by the patients who were responsible for carpet sweeping and keeping the stove and r e f r i g -erator clean, washing dishes and the rest. On Fridays a group of pat-ients was assigned to prepare a meal for the whole group from food which was ordered for the purpose. - 2 3 -"Play" may not be a very satisfactory label for the next group of a c t i v i t i e s that I describe, because they were occasionally traumatic for some members and were at a l l times considered part of the therapy. This group of a c t i v i t i e s included sports, such as f l o o r hockey, volley-b a l l and team games of that sort which took place in a nearby gymnasium, also bowling, swimming and other physical a c t i v i t i e s . I t also included "dance therapy" in which a dance instructor led the group, including most of the s t a f f , in body movement exercises to music. Art workshops were occasionally run in which the patients constructed collages or made paintings which were expressions of t h e i r world. F i n a l l y , I would i n -clude a s k i t which was put on every Friday afternoon, usually by two patients who had volunteered t h e i r services, and which was always an occasion for considerable chaotic excitement and was usually very entertaining. The therapy that was done at Theta i s the subject of a chapter in this thesis and I sha l l only deal with i t very b r i e f l y here. Therapy was generated from a l l the a c t i v i t i e s described above and also indepen-dently of them. For example i f somebody had trouble playing games or dancing or acting in the patient play, that became a resource with which the therapists worked to reveal some aspects of the patient's problem. Therapy generated independently could be started simply by asking some-body to talk about his troubles or to report why he f e l t as he did about another group member. Therapy consisted of various a c t i v i t i e s in which patients - 24 -either acted out roles that they reported, acted out roles of other people that they were involved with, spoke to each group member in turn, trying out some putative feeling that they had, or acted out t h e i r anger or aggression with another patient who usually played the role of a s i g n i f i c a n t other. Padded clubs were used to express anger and h o s t i l -i t y by harmlessly beating fellow patients in a l i e n roles. The clubs produced more noise than pain and were anyway heavy and t i r i n g to wield and quickly exhausted most participants. Patients were imitated and imitated each other to show c h a r a c t e r i s t i c behaviour and commented with-out reserve on whatever perceptions of each other they had. Patients were encouraged to express t h e i r feelings about each other and themselves at a l l times and not to conceal t h e i r good or bad impulses or opinions. In p a r t i c u l a r , patients were encouraged to engage in what appeared to be a modified form of "Primal" therapy which was referred to at Theta as 2 4 "Abreaction Therapy". This a c t i v i t y consisted of getting the patient to l i e on the f l o o r or a mattress a f t e r his emotions began to appear. In t h i s position he was encouraged and physically manipulated i n various ways in an attempt to escalate his emotional reaction to the point at which his emotions had taken over completely. I believe that the b r i e f sketch of Theta a c t i v i t i e s that I have given above w i l l provide enough of a rough outline for my present purposes which are to focus on some aspects of the setting and to show more of the members' perspectives before embarking on the major task of attempting to formulate the determinants of the social order at Theta. - 25 -Structur ing the Sett ing Theta was const i tuted to some extent as a medical s e t t i ng . This focus was not usual ly heavi ly emphasized and i t s r e l a t i v e l y minor pos i t ion in the Theta value system was pointed to when a new MD who was v i s i t i n g the centre spent the afternoon paying unusual attent ion to the physical symptoms of patients doing abreaction therapy. She frequently checked for signs of se izure , measuring pulse and checking eye pupi ls and reassuring the therapist who was working that everything was under cont ro l . Apart from th is being an unusual procedure (I never saw i t done apart from th i s once), the conversation afterwards appeared to i n -dicate that while her behaviour was not t o t a l l y inappropriate, i t was perhaps an emphasis that was unnecessary. This i s an impression formed from the po l i t e d i s in te res t her comments in the after-group meeting evoked, rather than any e x p l i c i t statement. The medical focus was a lso noticeably absent when three patients got s l i g h t l y in jured during a par-t i c u l a r l y vigorous game of f l o o r hockey one day. One of the three had a leg in jury of s u f f i c i e n t sever i ty that made i t d i f f i c u l t f o r him to walk. I drew the c l i n i c a l superv isor 's attent ion to th is and he to ld the pat ient that he should go and have i t x-rayed. There was no sug-gestion that i t was their medical problem but rather the problem was treated the way i t would have been in any lay se t t i ng . Despite the low p r i o r i t y of the medical emphasis, i t was pre-sent and appeared to have some consequences. There were, not infrequent-l y , patients in the se t t ing who considered part of the i r symptomology the fact that they were overweight. One such patient asked i f a specia l - 26 -d i e t c o u l d be a r r a n g e d f o r p e o p l e w i t h t h i s p r o b l e m . W h i l e t h i s was f o u n d t o be i m p o s s i b l e (due t o t h e i n t r a c t a b l e n a t u r e o f t h e o u t s i d e c a t e r i n g a r r a n g e m e n t s ) , t h e c l i n i c a l s u p e r v i s o r s u g g e s t e d t h a t p e o p l e s h o u l d be s e l e c t i v e a b o u t t h e i r e a t i n g and c h e c k t h e m s e l v e s on t h e w e i g h s c a l e s . He was t o l d t h a t t h e r e were no w e i g h s c a l e s and he was o b v i o u s -l y a s t o n i s h e d a t t h i s . A t t h e m e e t i n g a f t e r w a r d s he a s k e d t h a t a s c a l e be o b t a i n e d and t h e r e was g e n e r a l ag reement t h a t i t s h o u l d be a m e d i c a l s c a l e and n o t j u s t a b a t h r o o m s c a l e w h i c h w o u l d be i n a p p r o p r i a t e t o t h e s e t t i n g . T h i s d e s p i t e t h e f a c t t h a t i t p r e s e n t e d some p r o b l e m s b e c a u s e o f t h e p r i c e o f a m e d i c a l s c a l e w h i c h t h e b u d g e t w o u l d n o t a l l o w . A n o -t h e r i s s u e t h a t a r o s e a t one t i m e was what s t a n d a r d m e d i c a l k i t was a -v a i T a b l e i n t h e c e n t r e : A m e d i c a l k i t was d r a g g e d o u t o f t h e back o f f i c e l o o k i n g as i f i t has n e v e r been u s e d . [ C l i n i c a l S u p e r v i s o r ] a s k e d i f b l o o d p r e s s u r e r e a d i n g s e t c . were t a k e n h e r e . They a r e n o t . P e o p l e were s u p -p o s e d t o have a p h y s i c a l b e f o r e t h e y come i n . I t was d e c i d e d t h a t some a d d i t i o n a l e q u i p m e n t s h o u l d be a c q u i r e d : an o p h t h a l m o s c o p e and a n e u r o l o g i c a l hammer. The f o r m u l a t i o n o f T h e t a as a m e d i c a l s e t t i n g was a l s o o b s e r v a b l e i n t h e q u a l i f i c a t i o n s t h a t were c o n s i d e r e d a p p r o p r i a t e t o p e o p l e who were b e i n g c o n s i d e r e d f o r t h e r o l e o f t h e r a p i s t . S e v e r a l p o t e n t i a l t h e r a p i s t s a p p e a r e d a t T h e t a d u r i n g t h e p e r i o d o f my o b s e r v a t i o n . One who v i s i t e d f o r a s h o r t p e r i o d g e n e r a t e d t h e f o l l o w i n g a t a t h e r a p i s t s ' a f t e r - g r o u p m e e t i n g : [ Female MD] was i n t r o d u c e d . She i s MD. She was i n v i t e d t o work a t T h e t a . [ C l i n i c a l S u p e r v i s o r ] s a i d t h a t she d i d n o t have any p s y c h i a t r i c t r a i n -i n g a p a r t f r o m a few l e c t u r e s i n t h e normal c o u r s e o f h e r MD t r a i n i n g , b u t d i d n ' t t h i n k t h i s m a t t e r e d . C o u l d [ c u r r e n t a l t e r n a t i v e c a n d i d a t e ] s t a y ? No , i t must be an MD. - 2 7 -Of course several members of the s t a f f were not medically trained but i t was apparent that medical tra i n i n g by i t s e l f was considered r e l e -vant q u a l i f i c a t i o n for membership i n the therapist group. The category of people who have warranted access to Theta was severely limited. In general i t was r e s t r i c t e d to two groups: ther-apists and patients. The eff o r t s that are described in the appendix on the observer role to persuade me to go to the centre as a patient rather than as an observer appeared to confirm the d i s s a t i s f a c t i o n of the i n -s t i t u t i o n with people in the setting that did not f a l l in either of the two principal categories. A nurse from the psychiatric hospital applied to do her train i n g at Theta during my period of observation and was re-quired to attend as a patient and to follow the regular routine i n entering. [ C l i n i c a l Supervisor] said she must spend at least four weeks in the patient role. The question of when she could s t a r t was raised. [Resident Psych-o l o g i s t ] was adamant that the routine process should be followed. She must go through the interview, group screening, etc. Apart from the therapists and patients, there were a few v i s i t o r s who came to Theta, although i t was emphasized, as the Theta secretary ex-plained to a patient one day: It was very important that nobody come i n without permission from one of the therapists. The most common v i s i t o r s were MDs from other settings who came to Theta for an occasional afternoon or evening session. Provided that these were psychiatrists they f i t t e d e a s i l y and naturally into the therapist role and were accepted as such by the patients, even when they were - 2 8 -p r e v i o u s l y unknown. I was i n t e r e s t e d , f o r e x a m p l e , i n t h e e a s e w i t h w h i c h a v i s i t i n g p s y c h i a t r i s t f i t t e d i n t o t h e c e r e m o n i a l " g o o d b y e s " w h i c h were s c h e d u l e d i n t h e day she a t t e n d e d . Goodbyes were an o c c a s i o n when p a t i e n t s and t h e r a p i s t s a l i k e p r o d u c e d a s h o r t s p e e c h , o f t e n a summary o f t h e i r p e r c e p t i o n o f t h e p a t i e n t who was l e a v i n g . They were f r e q u e n t l y o c c a s i o n s o f c o n s i d e r a b l e i n t i m a c y . T h e r e was t h e u s u a l t a l k a b o u t how good p e o p l e f e l t a b o u t p e o p l e who were l e a v i n g . The unknown t h e r a p i s t p r o d u c e d some good ad h o c r e m a r k s . To [ F e m a l e P a t -i e n t ] she s a i d t h a t she had been v e r y moved by t h e t h i n g s t h a t p e o p l e had s a i d t o [ t h e p a t i e n t ] and t h o u g h t t h a t she must be a v e r y w o n d e r f u l p e r s o n . To [ M a l e P a t i e n t ] , who came t o h e r a b o u t t h i r d , she s a i d t h a t s h e t h o u g h t he s o u n d e d v e r y " s o l i d " i n t h e changes he had made a t T h e t a . I r e p o r t , i n A p p e n d i x I , a c o n t r a s t t h a t was made between me i n my o b -s e r v e r r o l e and a v i s i t i n g p s y c h i a t r i s t who u s e d t o a t t e n d o c c a s i o n a l l y a t t h e c e n t r e . The p a t i e n t s p o i n t e d o u t t h a t she was a h e l p e r , w h i c h p r e s u m a b l y t r a d e d on h e r b e i n g c a t e g o r i z e d as a t h e r a p i s t . They had no t r o u b l e a c c e p t i n g h e r o c c a s i o n a l v i s i t s , w h e r e a s t h e o c c a s i o n o f t h e q u e s t i o n was b r o u g h t a b o u t by my b e i n g a s k e d t o e x p l a i n my p r e s e n c e . Any v i s i t o r , t h e n , who c o u l d be c o n s t i t u t e d as a t h e r a p i s t was r e c e i v e d a t T h e t a w i t h o u t c h a l l e n g e . In c o n t r a s t t o t h i s I was f r e q u e n t l y c h a l l e n g e d by new p a t i e n t s . 9 I u s e d t o a t t e n d l u n c h e s t o i n t r o d u c e m y s e l f t o new p a t i e n t s d u r i n g t h e p e r i o d o f my o n c e - a - w e e k o b s e r v a t i o n and a t one l u n c h , a f t e r b e i n g i n t r o d u c e d , I j o k i n g l y s a i d t h a t I came " s o t h a t p e o p l e c o u l d know what t h e h e l l I was d o i n g h e r e . " A new p a t i e n t a c r o s s t h e t a b l e a s k e d , "What t h e h e l l a r e y o u d o i n g h e r e ? " A c h a l l e n g e w h i c h v i s i t i n g t h e r a p i s t s were n e v e r c o n f r o n t e d w i t h . - 2 9 -In another instance a nurse from the psychiatric hospital attended for a day to observe Theta and had not apparently been authen-ticated to the patients. During the afternoon group meeting she was s i t t i n g in the c i r c l e of chairs when a patient, going round each group member in turn, stood in front of her. I can only reproduce a rough * version which followed: Female Patient to V i s i t i n g Nurse: [Name], i s n ' t i t ? Nurse : Yes. Male Patient (on f a r side : Would you please of c i r c l e ) introduce yourself? Nurse : I'm a nurse from the hospital. I'm here so that I can see what you do here so that I can understand how our records should be kept. The nurse's answer, although only an approximation of what she said, appeared to show that she c l e a r l y recognised the male patient's question as a challenge. Whether i t was or not, she formulated her answer as an explanation to legitimate her presence, appealing to the understanding that everybody had that Theta was part of the hospital and that her business, the records, was hospital business and therefore warranted her attendance. One night of the Theta week was designated "Family Night" and on family night patients were in v i t e d to bring t h e i r fathers, mothers, sexual partners and s i g n i f i c a n t friends so that they could interact with * This conversation i s a paraphrase obtained from a recording made on the occasion by the i n s t i t u t i o n . Its shortcomings derive from my incomplete record of the d e t a i l s of the utterances. - 3 0 -them. On these occasions there were often s i g n i f i c a n t numbers of v i s i -tors in attendance, t h e i r legitimacy being that they were brought by a current patient of the centre and the relationship with that patient was i d e n t i f i e d . These evenings started with "introductions" in which the i d e n t i t y of each v i s i t o r was established. The v i s i t o r s were present, however, only as instruments in the therapy of the patients and when a v i s i t o r asked for advice about some aspect of the relationship that seem-ed to be his problem rather than the patient's, he was told that that couldn't be addressed because "you're not one of ours". One additional category that was recognized at Theta was that of ex-patient. Ex-patients were expected to attend at Theta one day a week, for three weeks, for "after-care" and were seen as warranted mem-bers of the patient group on those occasions. Invoking the category "ex-patient" was also seen as adequate explanation for some continued contact with the centre. There were some on-going ex-patient groups which met for several months after the formal treatment was over. An organization was also proposed that would keep some contact between for-mer patients and the centre. Being an ex-patient was also seen as ade-quate warrant for entering Theta (although not, except as above, taking part in a current group). At the end of one after-group meeting ...two former patients were s i t t i n g in the dining room with a t h i r d person. [Female Ex-patient] ex-plained that she had brought her mother out to see the place. This explanation for her presence and that of her mother was accepted without comment. - 31 -T h a t t h e c a t e g o r i e s " t h e r a p i s t " and " p a t i e n t " were s e e n as e x h a u s t i v e o f a l l p e o p l e p r e s e n t w a s , f i n a l l y , i l l u s t r a t e d by t h e e x -p e r i e n c e r e p o r t e d t o me by t h e T h e t a s e c r e t a r y . She c o m p l a i n e d t o me t h a t she f e l t h e r u n i q u e n e s s v e r y s h a r p l y . She was n o t an a c c r e d i t e d member o f e i t h e r c a t e g o r y s e t and s a i d t h a t she " d i d n ' t r e a l l y b e l o n g t o e i t h e r g r o u p " . She d e c i d e d t o go t h r o u g h T h e t a as a p a t i e n t so t h a t she c o u l d more r e a d i l y i d e n t i f y w i t h t h e p a t i e n t s a n d , p r e s u m a b l y , have * b some s t a t u s as an e x - p a t i e n t . A l l p a r t s o f t h e p r o g r a m a t T h e t a were c o n s i d e r e d p a r t o f t h e t h e r a p y and t h i s p e r s p e c t i v e was i n s t r u m e n t a l i n d e t e r m i n i n g much o f t h e b e h a v i o u r i n t h e c e n t r e . In f a c t , t h e p e r v a s i v e n e s s o f t h i s v i e w among p a t i e n t s was t h e s o u r c e o f some t r o u b l e s w h i c h were e s p e c i a l l y e v i d e n t i n t h e t a l k a b o u t t h e p l a c e and p r a c t i c e o f work a t T h e t a . As t h i s p r o b l e m , a r i s i n g f r o m d i f f e r e n t p e r s p e c t i v e s o f what was r e a l l y h a p p e n i n g , i s r e l e v a n t t o t h e c o n s t i t u t i o n o f T h e t a as " a r e f l e c t i o n o f t h e w o r l d " and a l s o t o t h e s t r u c t u r i n g o f t h e s e t t i n g , i t seems a p p r o -p r i a t e t h a t i t s h o u l d be d e a l t w i t h h e r e . An i m p o r t a n t e m p h a s i s i n t h e t h e o r y p r e s e n t e d a b o v e , and i n t h e t a l k o f t h e T h e t a s t a f f , was t h a t T h e t a must be a r e f l e c t i o n o f t h e w o r l d . T h i s was p a r t i c u l a r l y s t r o n g i n d i s c u s s i o n s a b o u t t h e w o r k . [ C l i n i c a l S u p e r v i s o r ] s a i d t h a t i t was i m p o r t a n t t h a t * I t has been p o i n t e d o u t t h a t t h e s e c r e t a r y ' s d e s i r e t o a t t e n d as a p a t i e n t had o t h e r d i m e n s i o n s t h a n t h e ones I p r o p o s e . I t was t h e s u b -j e c t o f a c l i n i c a l a s s e s s m e n t w h i c h was c a r r i e d o u t by s t a f f members. - 32 -the work r e f l e c t "real l i f e " . He got very annoyed when [Female Patient] said that they were not r e a l l y working but ju s t "playing at working". The emphasis throughout the Theta program was that work was part of the therapeutic program at the centre. In f a c t , i t was probably t h i s emphasis that was most persuasive i n getting prople to do work that they would not o r d i n a r i l y do. Whether this was the case or not, every-body was e x p l i c i t l y required to p a r t i c i p a t e , as the introductory l e t t e r to Theta explained: A l l [the parts of the program enumerated in the l e t t e r ] are elements of a unified therapeutic programme and every aspect must be attended. While patients did, then, attend every aspect of the program, they also attended to i t s therapeutic focus and this produced some c o n f l i c t with the usual everyday focus which was especially evident in the work part of the program. In the f i r s t place, the work at Theta was directed by a member of the s t a f f who was referred to as the "occupational therapist" although he was usually addressed by his f i r s t name and the label was not much i n evidence. The room in which tools were kept, paint mixed, and some car-pentry done was referred to as the "OT room". Probably not many people associated "OT" with occupational therapy; nevertheless, the label was there. That the work was instigated and.directed by the occupational - 33 -therapist was evident and unquestioned. When a new patient work co-ordinator asked, at a patient committee meeting, what she had to do, she was directed to the occupational therapist: [Female Patient] t r i e d to pick up some clues about what a work co-ordinator was and found he had to be in at 8:30 a.m. tomorrow to meet [Occupational Therapist]. Every time a new work co-ordinator took over from his predecessor, he was given a l i s t of work in progress and to l d several times to "check with [Occupational Therapist]" about the d e t a i l s . I asked a work co-ordinator whether she thought she had the authority to change de t a i l s of the work and she replied: "[Occupational Therapist] usually knows what he's doing". The fact that the work was directed i n th i s way was accepted by the patients as reasonable and proper, in f a c t , pre-eminently a r e f l e c t i o n of the world where decisions about what should be done are routinely made by the people in whom the authority of the i n s t i t u t i o n (whether i t be General Motors or the o f f i c e typing pool) i s rooted. When the patients' acceptance of this structure was questioned one day (be-cause the work was generally recognized to be going badly) there was a dismayed silence followed by a long conversation with many references to the fact that the work did not r e f l e c t real 1 i f e . ^ I t was l i k e asking the o f f i c e t y pists why they didn't do something about the design of a * At a weekly e l e c t i o n , two patients were elected to off i c e s desig-nated as "work co-ordinator" and "chairman". These two o f f i c e r s , to-gether with one patient elected from each of three subgroups of the patient population constituted a patient committee whose functions are described l a t e r . The three patients elected from the subgroups f i l l e d the off i c e s of "Diary Dealer" and acted as "foreman" or "family leader" for the subgroup from which they were elected. - 34 -building whose specifications they were typing because they had grumbled about i t s ugliness. The therapists' perspective in questioning the ac-ceptance was apparent and accorded with the notion that the i n s t i t u t i o n must question displays of inappropriate dependence. The patients' shock appeared to derive from t h e i r being told that they should question what they saw as normal, natural authority. The selection of work co-ordinator and foreman and the respon-s i b i l i t i e s that were expected of them showed s i m i l a r contrasting perspec-t i v e s . The i n s t i t u t i o n ' s position was frequently stated that the people who f i l l e d these jobs must be trustworthy and competent. The discussions about who should be chosen showed, however, that t h i s was almost never the case. Attention was paid to the therapeutic value of holding these positions in contrast to the " r e a l - l i f e " values of competence and e f f i -ciency. The issues that got people chosen as work co-ordinator, etc., were much more often things l i k e : "Who hasn't done i t yet?"; "You should do i t because you say you can't do i t , i t would be good for you"; " I t would be therapeutic for you to try and we w i l l help you"; "You w i l l f i n d out about yourself i f you t r y " . On th i s basis, i t very often happened that the people who got these jobs were the least f i t t e d for them in a " r e a l -world" sense and they were precisely the people that would never get cho-sen in "real l i f e " . In a s i m i l a r way, patients recognized that the business of being foreman, etc., was q u a l i t a t i v e l y d i f f e r e n t from holding that posi-tion in the real world. While the aggressive exercise of authority i s - 35 -routinely the subject of surreptitious grumbling or veiled complaints, foremen at Theta were commonly confronted with the suggestion they were "power t r i p p i n g " , "pushy", or "aggressive". A family report noted: We talked with [Male Patient] about his being work co-ordinator. He said he l i k e d the r e s p o n s i b i l i t y although he had "taken over" u n t i l Tuesday when he was a b i t more relaxed. Some people commented that [Male Patient] has a tendency to power t r i p with his r e s p o n s i b i l i t y : that he didn't treat the people work-ing as responsible workers or friends. The difference, however, amounted to more than t h i s . Patients expected of each other that they should care about t h e i r fellow patients and the foreman was no exception: It's what puts people uptight i s , y'know, as i f l i k e , the only thing you're interested in i s . , y'know.. the .. th'work and not the people., y'know.. l i k e produc-tion versus human relati o n s . A male patient who had considerable experience in working with foremen and as foreman himself in his regular job was c r i t i c i z e d f o r not paying enough attention to his crew. He replied that he had told them what to do and could see that they were doing i t , but t h i s was not considered adequate: [Patient] said that she had been disappointed that [the foreman] had not gone to see how his family had been working. ' [Foreman] said that he had been able to see that they were working a l l r i g h t . [Patient] said that she had wanted him to come and see how they were. In addition to the periods that were set aside for the work i t s e l f , a number of periods were set aside for work discussion, These discussions generally attended to the occupational therapy focus Of the work and took the form of discussions about how people f e l t about each - 36 -o t h e r d u r i n g t h e work p e r i o d , how t h e y f e l t a b o u t t h e fo reman o r b e i n g f o r e m a n . The c l i n i c a l s u p e r v i s o r once c o m p l a i n e d , on b e i n g t o l d a b o u t t h i s f o c u s , t h a t t h e d i s c u s s i o n s "must be v e r y u n r e a l i s t i c " , b u t t h e i r b e i n g u n r e a l i s t i c depends on t h e a s s u m p t i o n t h a t t a l k a b o u t work i s s i t -u a t e d i n a n a t u r a l work s e t t i n g . They were a n y t h i n g b u t u n r e a l i s t i c f o r t h e p a t i e n t s i n t h e s e t t i n g t h e y were s i t u a t e d i n . A good e x a m p l e o f t h e s i t u a t e d m e a n i n g o f t a l k a b o u t work o c c u r r e d when I a s k e d a work c o - o r d i n a t o r w h e t h e r she t h o u g h t t h a t she c o u l d change t h e work t h a t was s e t by t h e o c c u p a t i o n a l t h e r a p i s t . I was t r y i n g t o g e t a t t h e amount o f autonomy t h e p a t i e n t c o m m i t t e e saw i t s e l f as h a v i n g b u t : She t o o k t h e q u e s t i o n as a p s y c h o l o g i c a l o n e . C o u l d she do t h a t ? I f o u n d t h a t i n a s k i n g q u e s t i o n s a b o u t t h e w o r k , t h e q u e s t i o n s were r o u t i n e l y t r e a t e d as t h e r a p y q u e s t i o n s . . . " I know t h a t i s my p r o b l e m " . The s t a n d a r d s o f work a t T h e t a w e r e , o f c o u r s e , a l s o d e t e r -m i n e d by t h e s e t t i n g . I t was e x p l i c i t l y a c k n o w l e d g e d t h a t many p e o p l e w o u l d n o t do t h e k i n d o f work t h e y were d o i n g a t T h e t a i n t h e " r e a l w o r l d " . A f t e r a day i n w h i c h t h e s t a f f had c o m p l a i n e d a b o u t t h e w o r k : [ Female P a t i e n t ] , when I was d r i v i n g h e r home, s a i d t h a t she t h o u g h t t h a t most o f t h e t r o u b l e a r o s e b e -c a u s e a l o t o f p e o p l e a t T h e t a w o u l d n o t do t h a t k i n d o f work t h e m s e l v e s . The w o r k , h o w e v e r , had t o be done and so p e o p l e j u d g e d i t s s a t i s f a c t o r -i n e s s on t h e b a s i s n o t o f p r o f e s s i o n a l " r e a l w o r l d " s t a n d a r d s n o r o f t h e i r own a m a t e u r d o - i t - y o u r s e l f s t a n d a r d s , b u t on t h e s i t u a t e d s t a n d -a r d s o f t h e i n s t i t u t i o n . I t was p o i n t e d o u t t h a t some o f t h e work was o f c o m p a r a t i v e l y l o w q u a l i t y . The o b j e c t i o n was r a i s e d t h a t p e o p l e d i d n o t have e x p e r i e n c e i n d o i n g t h e work t h a t was e x p e c t e d a t T h e t a . The - 37 -foreman often knew that the work was not the best, but i t was considered to be the best that so-and-so could do. One new patient that I observed e x p l i c i t l y checked out the i n s t i t u t i o n ' s standards and made his own i n t e r -pretation of them from the reply that he received: [Male Patient] said that he wondered what kind of job was expected - any old job, an okay job or a super good job. He asked [Occupational Therapist] whether he wanted an undercoat put on the shelves and when [Oc-cupational Therapist] said "no", [Male Patient] assumed that the quality of the work was j u s t so-so. Patients recognized that the i n s t i t u t i o n ' s standards were not t h e i r own but were determined by the exigencies of the si t u a t i o n at Theta. Thus when a set of l i b r a r y shelves was found to have been badly prepared by a previous patient group, the patients who were attempting to erect them continued to do so even though: [Female Patient] said that she couldn't believe the mess the shelves she was working on were i n . She said that i f she had been doing the job herself she would have junked the s t u f f that was there and started a l l over again. The work co-ordinator, who also thought the shelves "could have been done again", recognized that this was not an appropriate reaction: She said that a l o t of work had been put into the things already and that they now had to do the best they could. The work was, then, recognized as taking place within the context of a setti n g , one in which people were inexperienced at what they were doing, had to do i t , and a setting in which there was a continuous turn-over so that one might i n h e r i t somebody else's troubles and i t was up to him to make the best of i t . - 3 8 -Resources From the patients' point of view, Theta had two resources which were in scarce supply. These were time and therapists. The two resources were inte r r e l a t e d in that time was s t i l l a factor when the desired therapist was present, but I shall attempt to treat them separ-ately because there are aspects of both time, generally, and therapists' time which are of in t e r e s t . The patients recognized that the d i f f e r e n t therapists at Theta were d i f f e r e n t i a l l y q u a l i f i e d to give help and valued the help of some above others. Thus, when a proposal was made to change the * system of family groups so that they would be stable throughout the patient's stay in the centre, one of the f i r s t questions that was asked was: I l i k e the current therapist attached to the family very much but can we rotate the therapists? Apart from individual patients' recognition of individual therapists' q u a l i t i e s , as for example in a diary entry: ...of course, [Therapist] i s very much on top of any situa t i o n that comes up. I admire ( ) a great deal. the whole group acknowledged the d e s i r a b i l i t y of working with the c l i n -i c a l supervisor. Two patients remarked to me that "you usually got about two chances to work out with [ C l i n i c a l Supervisor] during your stay". The c l i n i c a l supervisor himself traded on this knowledge and offered his * "Family" was the name given to the three subgroups among which the patient population was distributed. The "family" subgroups are discussed in a subsequent section. - 39 -services to the family group whose members had currently accumulated the most points in a system of scoring in which patients received points for work a c t i v i t i e s . When the scores were not available in a subsequent lunch meeting, and the c l i n i c a l supervisor refused to attend with any . family, there was a considerable amount of anger at the family foremen because of th i s l o s t opportunity. In the formally constituted group therapy sessions, so-called "big group", a l l or most of the therapists were usually present together. As there were usually about twenty patients at Theta and only one or occasionally two patients could work at any one time in big group, time in this setting was especially valuable. This meant that there was considerable competition for the time that was available and i t frequen-t l y happened that strong feelings were generated i n patients who f e l t that they had not obtained enough group time. I'm very bothered that there never seems time for me to ask for help...I almost envy members in the group who are given an opportunity to work out. When the session was ended [Female Patient] angrily complained that she had not been given time to work, she had asked for time and had been promised i t . . . t h is happened again and again... The pressures on big-group time could be seen in the complaints of patients about time being wasted on non-therapeutic a c t i v i t i e s : I thought we didn't want to waste big-group time t a l k -ing about business matters, that's why there's a committee. We're wasting so much time with dead discussion. - 4 0 -Wasting time was regarded as a strongly disapproved a c t i v i t y . Wasting time was seen as asking for the opportunity to do therapy and then not using i t . A patient would ask to work and then spend the time granted to him in silence or in argumentative talk or asking questions of other patients or therapists. Even conversation was seen as inappropriate a c t i v i t y in big-group and, as such, a waste of time: [ C l i n i c a l Supervisor] brought [Female Patient] up to the stage and talked with her for a while...As the discussion went on, several people became impatient with the amount of time [Female Patient] was taking up. A patient who was granted time was expected to work on his own problem, to " l e t go" and be v i s i b l y making good use of the time granted to him. Any member of the group at any point could challenge the a c t i v i t y on the grounds that i t was "wasting time" and i f he could muster enough support, the a c t i v i t y would be terminated. The member who had been granted time usually recognized the moral force of the complaint that had been raised and terminated his performance. In f a c t , that she "wasted time" was given as adequate reason for arguing against the granting of an extension to one patient: Several patients objected to [Female Patient] being granted an extension, feeling that i t was an i n t r u -sion on t h e i r own chance to do work. [Female Patient] had wasted so much time already. Patients monitored t h e i r own a c t i v i t y so as not to take up too much time in the group, as was expressed, for example, in a diary entry: I f e l t very much a part of the group today, eager to - 41 -work on a l o t o f t h i n g s , b u t d o n ' t want t o f e e l t h a t I am demanding t o o much t i m e . A n o t h e r g r o u p a c t i v i t y i n w h i c h t h e p r e s s u r e s o f t i m e were s e v e r e was t h e " f a m i l y n i g h t " a t w h i c h s i g n i f i c a n t f r i e n d s , r e l a t i v e s and o t h e r s were b r o u g h t t o T h e t a . T h i s s e s s i o n l a s t e d two and a h a l f h o u r s and a l t h o u g h t h e r e was c o n s i d e r a b l e v a r i a t i o n i n a t t e n d a n c e , i t was o f t e n a t t e n d e d by l a r g e numbers o f p o t e n t i a l p a r t i c i p a n t s . In c o n t r a s t t o t h e d a i l y a c t i v i t i e s w h i c h were s e e n as t h e r a p e u t i c r e g a r d l e s s o f who was p a r t i c i p a t i n g a c t i v e l y , t h e r e was a s t r o n g f e e l i n g among p a t i e n t s and v i s i t o r s t h a t a t t e n d a n c e a t f a m i l y n i g h t was s u f f i c i e n t r e a s o n f o r demanding t h e r a p e u t i c t i m e . B o t h p a -t i e n t s and v i s i t o r s were c o n s c i o u s t h a t v i s i t o r s had come, o f t e n f r o m a c o n s i d e r a b l e d i s t a n c e , n o t f o r e n t e r t a i n m e n t o r i n f o r m a t i o n , b u t b e -c a u s e t h e y c o u l d h e l p t h e p a t i e n t . The p r e s s u r e t o a l l o w e v e r y v i s i t o r t o have t i m e was a t t e n d e d t o by t h e t h e r a p i s t s who t r i e d t o make a v i r -t u e o u t o f n e c e s s i t y by p r o p o s i n g t h a t t h o s e who were p r e s e n t f o r t h e f i r s t t i m e c o u l d j u s t w a t c h . In t h a t way t h e y c o u l d s e e what k i n d o f t h i n g was done on f a m i l y n i g h t and t h e n have t i m e on a s u b s e q u e n t n i g h t . Even s o , an a t t e m p t was f r e q u e n t l y made t o have e v e r y b o d y p r e s e n t g i v e n a t l e a s t some t i m e on t h e s t a g e . One o f t h e r e s u l t s o f t h i s was t h a t i t was o f t e n run on a r a t h e r r i g i d s c h e d u l e , f o r e x a m p l e : [ C u r r e n t P a t i e n t C h a i r m a n ] was k e e p i n g s t r i c t t i m e i n e a c h g r o u p and t e l l i n g them t o s t o p when t h e i r f i f t e e n m i n u t e l i m i t was up . - 42 -I t seems n o t i n c o n s e q u e n t i a l t o o , t h a t two o f t h e v e r y few c o n f r o n t a -t i o n s w i t h t h e s t a f f t h a t I o b s e r v e d a t T h e t a t o o k t h e f o r m o f a r e f u -s a l t o s t o p f a m i l y n i g h t on s c h e d u l e b e c a u s e t h e r e were s t i l l v i s i t o r s t o be h e a r d f r o m . A p a r t f r o m t h e p r e s s u r e s o f t i m e i n i n d i v i d u a l p a r t s o f t h e p r o g r a m , t h e w h o l e s t a y a t T h e t a was a h i g h l y c o m p r e s s e d a f f a i r . The l e n g t h o f s t a y f o r p a t i e n t s was d e t e r m i n e d by t h e i n s t i t u t i o n and was u s u a l l y s i x w e e k s , w i t h t h e p o s s i b i l i t y o f an e x t e n s i o n f o r one o r o c -c a s i o n a l l y two weeks a t t h e o p t i o n o f t h e p a t i e n t who o n l y had t o ask f o r i t . T h a t t h e p r o g r a m was a c o n c e n t r a t e d one was a c k n o w l e d g e d by t h e t h e r a p i s t s : [ C l i n i c a l S u p e r v i s o r ] , [ i n e m p h a s i z i n g t h e v a l u e o f t h e p r o g r a m ] , s a i d t h a t a p e r i o d a t T h e t a was e q u i v -a l e n t t o a y e a r o u t s i d e . [ V i s i t i n g P s y c h i a t r i s t ] s a i d t h a t s i x weeks a t T h e t a was e q u i v a l e n t t o s i x months anywhere e l s e . B o t h p a t i e n t s and t h e r a p i s t s e x p e r i e n c e d t h e c o n c e n t r a t i o n o f t h e p r o -gram as o p p r e s s i v e . The s c h e d u l e was s u c h t h a t t h e w h o l e day was f i l l e d w i t h a c t i v i t i e s and l e f t v i r t u a l l y no t i m e f o r r e l a x a t i o n : We 've g o t t h e day s c h e d u l e d now t o t h e p o i n t where o u r l u n c h t i m e ' s f i l l e d w i t h d i s c u s s i o n . I d o n ' t even f i n d somet imes t h a t t h e r e ' s t i m e t o go t o t h e b a t h r o o m . I f i n d t h a t t h e t i m e f o r t h e p r o g r a m . , t o be v e r y t i g h t . The c l i n i c a l s u p e r v i s o r f r e q u e n t l y e x p r e s s e d h i s e x p e r i e n c e o f t h e p r e s -s u r e s o f t i m e and e x p l a i n e d t h a t many o f t h e r e s e a r c h and e x p e r i m e n t a l a s p e c t s o f t h e p rog ram were d e l a y e d b e c a u s e o f l a c k o f t i m e . A n o t h e r - 4 3 -s t a f f member expressed the general feeling that there was l i t t l e time when I made a suggestion about some a c t i v i t y : [Staff Member] said, "we should do i t " . . . b u t complained that there was never time to do the things they wanted to do, suggested more time should be spent on whole group. Of course the fact that the days were f i l l e d with a c t i v i t y made the time pass quickly which caused the patients to be conscious of the f l e e t i n g -ness of t h e i r stay at the centre. This was most frequently commented on in t h e i r " r e f l e c t i o n s " in t h e i r d i a r i e s : ...only three weeks to go a long way. This week I have been very aware of the fact that there i s only two weeks to go. Patients' attention to the location of the current time in t h e i r atten-dance had relevance for some of t h e i r a c t i v i t i e s in the centre, and t h i s point i s addressed in the chapter on the patient role. When one considers the amount of attention that was paid to therapy time and time with therapists, i t i s not hard to understand why the whole group was divided up into "families" for several periods during the week. The families were three roughly equal subgroups among which the patient population was distributed. The d i s t r i b u t i o n was made f a i r l y a r b i t r a r i l y , and no attempt was made to achieve any p a r t i c u l a r balance of sexes or age groups, or to group people with "a complementary patient on 2 5 whom he can show how his neurotic vicious c i r c l e works". In f a c t , the 2 6 probability of his finding a "neurotic 'complement'" or of finding 2 7 "others in the same role , but performing more normally" in the sub-group was obviously much smaller than i t was in the whole group. - 4 4 -The d i v i s i o n was a puzzle to me, in addition, because there was some evidence to suggest that t h e i r constitution was counter to some of Theta's own tenets. For example, i t was e x p l i c i t l y recognized that everything important should be brought into big-group. This point i s made in Chapter 6, "Doing Therapy", as i s the point that exploring a par t i c u l a r incident i s not a repeatable exercise. I f a l l matters of im-portance must be brought up in big-group and i f discussing them elsewhere i s seen as exhausting the subject, the scope of the family groups must be severely limited. In f a c t , much of the family group time that I observed was taken up with talk of a sort that would have been considered "wasting time" in big group. The f a m i l i e s , moreover, were not constituted in any way d i f -ferent to the big group except that they had less members. Although there was a foreman, l a t e r c a l l e d "family leader", he appeared to have no function when the family was gathered for "family meeting". It was not the case that the families attempted to reproduce the roles of the nuclear family in order to explore those role relations.-One thing about the family groups was apparent, though, and that was that they had fewer members than the big group. The thing that this provided above a l l else was greater opportunity to work (the fami-l i e s a l l met in separate locations) and greater access to the therapist. When a l l the members were present in the big group, the a c t i v i t i e s were generally directed by one or two therapists, so in a sense the remain-ing s t a f f members present were "wasted". In the family groups, the - 4 5 -therapists were distributed among the families and every therapist was working. The fact that some therapists were valued more highly than others was adequately accommodated by the rotation of the therapists among the d i f f e r e n t f a m i l i e s . When a highly valued therapist came to a pa r t i c u l a r family, every member of that family had more opportunity to work with him. The establishment of family groups can be seen, then, as a natural response of the i n s t i t u t i o n to the pressures of group time and the demands for access to therapists. Although i t may have involved some contradictions, i t appeared to provide a way to di s t r i b u t e Theta's valuable resources in an equitable and manageable way. It can thus be seen as a kind of " f i s c a l " policy rather than a therapeutic policy. With the whole group divided into subgroups, each with a therapist assigned to i t , three times as many people could work simultaneously and each person had, presumably, three times as much opportunity to have access to the therapist. Values Many of the Theta values are embedded in the roles of the two principal participants, the patients and the therapists, and, as such, are discussed in the chapters on those roles. In this section I would l i k e to introduce some of the values that are encapsulated in the pat-ients' system of beliefs and which are a determinant of the role. - 46 -F i r s t o f a l l , T h e t a was seen as a s e r i o u s p l a c e w h i c h s h o u l d be t a k e n s e r i o u s l y and n o t s o m e p l a c e t h a t one went t o b e c a u s e i t was f a s h i o n a b l e , o r " i n " t o do s o . M o r e o v e r , i t was n o t a p l a c e t h a t was one o f a s e r i e s w h i c h one c o u l d t r y i n a c a r e e r o f g o i n g t o c u r r e n t l y f a s h i o n a b l e g r o w t h c e n t r e s . T h e t a was a u n i q u e i n s t i t u t i o n and c o u l d n o t be t r e a t e d i n any o t h e r way . One p a t i e n t who was b e i n g i n t e r v i e w e d by t h e c u r r e n t g r o u p was a l m o s t e x c l u d e d b e c a u s e i t was s u s p e c t e d t h a t he was n o t t a k i n g t h e p l a c e s e r i o u s l y e n o u g h : You s a i d s o m e t h i n ' a b o u t t r y i n ' t h i s p r i m a l t h i n g b e f o r e ' n now y o u ' r e gonna t r y T h e t a , i t ' s l i k e a f a d d i s h t h i n g : now I 'm i n t o t h i s , now I 'm i n t o t h a t . . . i t seems y o u ' r e n o t t a k i n g i t s e r i o u s l y . Do y o u wanna change y o u r l i f e o r j u s t t r y a n o t h e r t h i n g ? and a g a i n : D ' you r e a l i z e how s u p e r - h e a v y t h i s i s h e r e ? I t ' s a r e a l l y s e r i o u s t h i n g , i t ' s n o t s o m e t h i n g y o u d o . . . j u s t b e c a u s e i t ' s a f a r - o u t t h i n g t o d o . . . P a t i e n t s i n t h e s e t t i n g who s a i d t h a t t h e y w o u l d "go on t o o t h e r g r o u p s " i f t h e y d i d n o t s u c c e e d a t T h e t a were a s s u r e d t h a t t h e y w o u l d n o t s u c c e e d . The e x p e c t a t i o n t h a t t h e r e were " o t h e r g r o u p s " a v -a i l a b l e was seen as a way t o a v o i d d o i n g t h e n e c e s s a r y work a t T h e t a t o a c h i e v e what t h e p a t i e n t w a n t e d t o a c h i e v e . The n o t i o n t h a t a s e r i e s o f g r o u p s e x i s t e d was seen as e f f e c t i v e l y n e u t r a l i z i n g a l l g r o u p work b e -c a u s e i t c o u l d a l w a y s be p u t o f f t o t h e n e x t g r o u p . T h e t a was seen as a p l a c e t h a t r e q u i r e d commitment and t h e - 47 -absence of this was adequate reason to refuse entry to any new patient. This i s further discussed under "Patient Role", but i t can be said that lack of commitment was always available as a transformation of any appar-ently counter-productive a c t i v i t y at Theta. The f i r s t foreman said that the group was not working wel l . [Female PatientJ's lateness was cit e d as an ex-ample of the lack of commitment of the group. ...again raised the objection about [a patient] refus-ing to be chairman. This was made out to be lack of commitment to the group. [Male Patient] was only digging with one hand. This was seen as showing his lack of commitment. To be accused of lack of commitment was to be accused of a serious breach of the Theta ethic and was often accompanied by a demand that the accused patient demonstrate his commitment by doing something for the centre in his spare time. This was referred to as "making up a commitment" and involved writing poetry, making some a r t i f a c t or painting a picture which could be brought to the centre for display. Theta was seen as a place in which the t r a d i t i o n a l moral judg-ments were suspended. Patients regularly exchanged reports of behaviour that in the ordinary course of events would c a l l for moral judgments on the part of the hearer. Those ranged from descriptions of what would conventionally be received as "bizarre" sexual practices, matters of marital commitment, accounts of aggressive, even viol e n t , behaviour, etc. It was not so much a matter that they were i n d i f f e r e n t to these descrip-tions but that they were certain that anybody's moral decisions were his own business and nothing to do with therapy. The necessity of speaking - 4 8 -about one's feelings had p r i o r i t y and as those feelings frequently i n -volved g u i l t about conventionally proscribed behaviour, the speaker had enough troubles without adding retrospective moral judgements to his burden. On one occasion, an a t t r a c t i v e woman who was a s i g n i f i c a n t member of the current group reported that she would continue to be a pros-t i t u t e a fter she l e f t Theta. Although the group was apparently d i s s a t i s -f i e d with this state of a f f a i r s and several people said they could not understand i t , the strongest comment that was made was that i t was "a waste". Instead, people questioned the g i r l about her other a c t i v i t i e s such as professional dancing and modelling, and made much of her poten-t i a l i n those directions. Summary In this chapter I have attempted to set the scene in a p r e l i -minary way and to introduce some of the matters that constitute the "seen but unnoticed r e g u l a r i t i e s that constituted the everyday scene which mem-bers i n the setting saw as the normal natural features of Theta. Some of the theoretical underpinnings of a separate i n s t i t u t i o n that Theta owed much of i t s i n s p i r a t i o n to have been discussed and the physical arrange-ment of the centre has been described. I have introduced the participants whose a c t i v i t i e s produced the therapeutic r e a l i t y and described the scope of those a c t i v i t i e s . The setting t y p i c a l l y allows for only two categories of participant: patients - 49 -and therapists. These categories embrace p a r t i c u l a r values, some of which generate pressures which lead to i n s t i t u t i o n a l structures such as the fami l i e s . One aspect of the program, the work, has been described as a situated a c t i v i t y in which members attend to the immediate context i n seeing how "work" should be done and what i t means in the Theta setting. In the next two chapters I shall attempt to develop my theme by describing in det a i l the roles embedded i n the two categories of p a r t i -cipant in order to elaborate the way in which these roles were created and sustained. - 5 0 -FOOTNOTES 1. The word is Garfinkel's. In discussing "What is ethnomethodology?" he describes i t s meaning as "...observable-and-reportable, i . e . available to members as situated practices of looking-and-telling." Garfinkel writes that the practices "...consist of an endless, on-going, contingent accomplishment; that they are carried on under the auspices of, and are made to happen as events i n , the same or d i -nary a f f a i r s that i n organizing they describe;..." Harold Garfinkel, Studies in Ethnomethodology, New Jersey, Prentice H a l l , 1967, p. 1. 2. To protect the anonymity of the i n s t i t u t i o n the references cited i n footnotes 3 through 22 and 25 through 27 have been eliminated from the published version of the thesis. The corresponding items i n the bibliography have also been eliminated. These references are a v a i l -able from the author who w i l l supply them under certain circumstances provided the appropriate guarantees are received that the i n s t i t u t i o n ' s anonymity w i l l be preserved. 23. For a discussion of the use of space in mental hospitals see Erving Goffman, Asylums, Garden C i t y , N. Y., Doubleday (Anchor Books), 1961. Goffman deals with space i n terms of parts of the i n s t i t u t i o n that were " o f f - l i m i t s " for patients, parts which were, what he c a l l s "surveillance space" and parts c a l l e d "free spaces". The character of Theta made "free spaces" r e l a t i v e l y unnecessary as the patients were able to leave at the end of the day. The private space that I i d e n t i f y i s roughly equivalent to Goffman's areas that were "off-l i m i t s " . 24. The practice of primal scream therapy i s described in Arthur Janov, The Primal Scream, New York, Dell (Delta Books), 1970. Janov addresses himself to the theory supporting his enterprise in The Anatomy of Mental Illness, New York, Berkley (Medallion), 1971. I have not attempted to compare abreaction therapy with Janov's descriptions to see how far they appear to coincide. CHAPTER THREE THE THERAPIST ROLE When a new patient (or a new observer) arrives at Theta, i t is sometimes d i f f i cu l t for him to distinguish therapists from patients. The therapists wear no dist inct ive uniform or indeed clothing style and as not a l l members of the staff are present on a l l occasions, one is sometimes presented with a new face which may belong to either the pa-tient group or the staff group. A not infrequent remark from a new patient is "I thought [Patient] was a therapist" , or less frequently, "I thought [Therapist] was a patient". Within a few days, however, this d i f f i cu l ty disappears and everybody can see that the patients are pat-ients and the therapists are therapists. In this chapter and the next, I wil l attempt to delineate the qualit ies of the two roles that make them recognizable to the occupants and to the people with whom they interact. - 52 -Therapists as a Coherent Group The f i r s t strong determinant of the therapist role i s the label i t s e l f . Given the varying q u a l i f i c a t i o n s which people that occupy the role have, i t could be said that the only thing they have in common is that they are a l l labelled therapists. This c e r t a i n l y i d e n t i f i e s them as a coherent group for the patients. The coherence of the therapist group i s partly formulated in terms of a contrast with other groups in or related to the setting and with the world in general. This kind of we-they contrast i s most evident with respect to the patient group. The way in which the patients' world was working was a recurrent theme at s t a f f meetings of the therapists which regularly took place at the end of therapy sessions. The very meeting i t s e l f , with the therapists as warranted participants, was of course a s i g n i f i c a n t matter in formulating them as a coherent group. There were, however, v i s i t o r s at these meetings: for example, I was per-mitted to be present and other authorized v i s i t o r s who had attended the preceding session were usually present along with the secretary. I t was never the case, however, that any patient was present at these meetings and this sharply d i f f e r e n t i a t e d them as a group from the therapists. This exclusion of patients was heavily emphasized on any occasion when a patient knocked on the door of the meeting room. When this happened, usually because some matter had to be attended to by some therapist, the therapist s o l i c i t e d would leave the room and shut the door behind him before tal k i n g to the patient, reinforcing the privileged status of the people in the room. The way in which the patients' world was working - 5 3 -was, of course, subject to troubles of various kinds: resistances and other types of counter-therapeutic behaviour, unsatisfactory organiza-tion which should be revised, and so forth. These troubles and the good aspects of the patient world were uniformly discussed in a way that made i t clear that i t was their world that was having troubles and organiza-* tional changes, and not the j o i n t world of Theta. The second contrast that was made was between the therapist group at Theta and the s t a f f at the neighbouring hospital to which the centre i s nominally attached. The hospital s t a f f were reported not to "understand what we do here". This was evident on one occasion on which a s t a f f member from the hospital spent a day at the centre as a resul t of the discovery of some inconsistency in the way s t a t i s t i c s were kept at the two centres. In the discussion after the group the c l i n i c a l super-visor asked the hospital member whether she could understand the d i f f i r c u l t i e s in meeting the hospital's demands: The nurse from the hospital talked about integrated systems for record keeping. [ C l i n i c a l Supervisor] and [Resident Psychologist] explained why they could not be used at Theta. "You can never predict what i s going to happen here." The hospital demands for standardized records was an issue that came up from time to time and was a source of minor i r r i t a t i o n to .the Theta s t a f f . The we-they contrast was nicely i l l u s t r a t e d one day when the secretary: ...reported that she had had an argument with (some common enemy) at the hospital for sending over incom-plete charts. * I am not suggesting here that the therapists were u n c r i t i c a l of the i r own behaviour, only that they made the contrast. - 5 4 -There was considerable amusement among the Theta group at having caught the hospital in this shortcoming. c Of course, whatever feelings the therapist group had that the hospital did not real ly understand what they were doing was multipl ied tenfold with respect to the rest of the world. On one occasion on which I had a disagreement with the therapists in which I attempted to re in -force my demands for more observation time by presenting a letter from my thesis advisor, one of the complaints that was made was that my ad-visor did not understand what went on at Theta. This was formulated as a reason why his intervention should be discounted. The most exclusive meeting at Theta and the one which most clearly defined the therapists as a coherent group was the "feelings meeting". The "feelings meeting" was a weekly meeting at which the therapists were supposed to ventilate whatever tensions or host i l i t i es had been generated among themselves. Both the secretary and I were ex-cluded from these meetings although, as is recorded elsewhere, I actually did get to attend one and part of a second. The therapist label was a necessary and suff ic ient condition for being admitted to these meetings. A therapist who attended at the centre on one afternoon a week was read-i l y admitted on his own request but despite the fact that I attempted to argue that I might have feelings about the therapists, the c l in ica l sup-ervisor, smiling (as I thought at my clever ploy), said "no, we would exclude you from that". - 5 5 -The therapist group so c i a l i z e d with one another to some extent and while I know nothing of t h e i r a c t i v i t i e s outside of being i n -vited to a few of these events, i t was clear to me that they did not s o c i a l i z e with the patients. On one occasion, I was in v i t e d to attend a "Theta Christmas party". I went along f u l l y expecting to see both patients and therapists present but found that the party was for current and past s t a f f . There was eventually a j o i n t party but i t was known as "the patients' party". This event was attended by the current s t a f f and had the same kind of atmosphere as a school dance at which s t a f f and pupils are rather self-consciously negotiating a temporary suspension of t h e i r usual distance. Creating and Sustaining a Hierarchy Although the Theta s t a f f was c l e a r l y organized as a coherent group with stable boundaries, this did not mean that everybody within the group had the same status. I t was quickly apparent to me that there was a f a i r l y well-defined hierarchical structure within the group. My own f i r s t application to attend at the centre was made to the c l i n i c a l supervisor and this was seen as e n t i r e l y understandable and appropriate. That the c l i n i c a l supervisor was the proper person to deal with in mat-ters demanding an administrative decision was acknowledged by a l l members of the s t a f f . The resident psychologist who was nominally the senior fu l l - t i m e s t a f f member (the c l i n i c a l supervisor only attended on a part-time basis) t o l d me on several occasions on which she disapproved of my a c t i v i t y that I "should see [ C l i n i c a l Supervisor]". When she told me one time that they were a l l interested in what I was finding out about Theta, - 56 -she added parenthetically, " [ C l i n i c a l Supervisor] too", presumably to add weight to what was about to be formulated as a request to report about my findings. The forms of address that were used among the s t a f f further constructed the c l i n i c a l supervisor as the most important s t a f f member. The other members of the s t a f f , whether they were MD's or not, were ad-dressed by t h e i r f i r s t name. In contrast, the c l i n i c a l supervisor was commonly addressed as "Dr. [Name]" or "Dr. N". In fact the only member of the s t a f f who addressed him by his f i r s t name on a l l occasions of t h e i r interaction was the resident psychologist. This i t s e l f nicely placed her in a privileged position in the hierarchy. This position was car e f u l l y nurtured and when I once, in conversation with her, re-ferred to the c l i n i c a l supervisor as "his nibs", this drew an immediate blank look which I took to be rejection of th i s conspiratorial form of reference that would have placed me i n a position of quasi-equality with her. The c l i n i c a l supervisor was always referred to as "Dr. [Name]" or "Dr. N" in conversation with the patients who addressed him in the same way. The resident psychologist was acknowledged to have a position of authority in some si m i l a r ways. When I presented myself for an i r r e g -ular day's attendance during some free time I had over the Christmas break, I was told that she had been unhappy about this and this was appar-ently a matter of some consequence. It had not been enough that I had cleared the day with the therapists who were on duty that day. Again I - 5 7 -was referred to the c l i n i c a l supervisor but on the instructions of the resident psychologist: [Resident MD] and I talked about my coming another day. [Psychiatric Nurse] said that [Resident Psych-o l o g i s t ] had been s l i g h t l y annoyed - I "should ask [ C l i n i c a l Supervisor]". The resident psychologist's location in the structure was acknowledged by the resident MD in a conversation about the silences which occasion-a l l y occurred in group: [Resident MD] said she would l i k e sometimes to l e t the silences go on, but [Resident Psychologist] didn't l i k e that. The resident psychologist also asserted her position in formal ways, as for example when she wrote a memorandum to the occupational therapist which my notes record as "the-ship 1s-not-tight-enough kind of l e t t e r . " Because of the passing consideration of Theta as a medical set t i n g , the status of MD's was, to some extent, the t r a d i t i o n a l one i n a hospital se t t i n g , and so the resident MD and c l i n i c a l fellow were treated with somewhat more deference by the resident psychologist than might otherwise have been the case. Managing the Helping and Caring Appearance The Theta brochure had a picture on i t s front cover of three s t y l i z e d figures facing l e f t . The front one was seated on the f l o o r , the second bent forward with hands l a i d upon the shoulders of the f i r s t and the t h i r d stood with hands i n the same position. The intended e f f e c t appeared to be one of loving contact, growth and interdependence. The - 58 -brochure i t s e l f talked about: openness and honesty, people helping people, inten-sive group therapy for 6 to 8 weeks, taking respon-s i b i l i t y for s e l f and others. ...we provide support and share problems and suffer-ing... The series of interviews that formed the induction process i s described in more de t a i l in the next chapter, but some aspects of the interviews are relevant to the creation of the helping and caring appearance. The l e t t e r which was given to the patient at the pre-orientation interview announced that "On our part, we sh a l l be with you through a l l these phases and commit our eff o r t s to help you to work through your d i f f i c u l t i e s . The pre-orientation interview i t s e l f gave the patient the f i r s t opportunity to t e l l what his troubles were. The account was re-ceived with careful attention and the attendant therapist might ask a few questions to elaborate some d e t a i l s . The general appearence was one of sympathetic interest in the patient's problems. The next stage i n the intake process was an individual interview at which the patient, once again, got a sympathetic non-judgmental hearing. The therapist asked questions about each aspect of the problems that the patient had descri-bed and made out a "problem-list". This was a l i s t of items from the patient's story that were recorded under various prescribed headings. The preparation of the l i s t created the appearance of a f i r s t analysis of .the problem into i t s individual elements and the patient was asked to assess the elements by a t t r i b u t i n g a score to each one on a 1 - 6 scale. - 5 9 -The l i s t also helped to formulate the problem as the individual's own unique problem while the whole process emphasized the interest that the centre had in getting at what the patient's trouble r e a l l y was. Some aspects of the helping and caring appearance were appar-ent in behaviour which was absent in the presence of the patients but which appeared when the necessity of sustaining the necessary appearance was removed. Erving Goffman^ has developed the notion of what he c a l l s "front region" and "back region" behaviour in connection with the pre-sentation of p a r t i c u l a r kinds of performances in social i n t e r a c t i o n . Goffman uses the term "front region" "to refer to the place where the performance is given". He goes on to argue that "[t]he performance of an individual in a front region may be seen as an e f f o r t to give the appearance that his a c t i v i t y in the region maintains and embodies cer-3 t a i n standards". A "back region", by contrast, i s a place " r e l a t i v e to a given performance, where the impression fostered by the performance i s knowingly contradicted as a matter of course".^ Goffman says that "[h]ere the performer can relax; he can drop his front, forego speaking his l i n e s , 5 and step out of character". The contrast between the behaviours can be instrumental in illuminating the appropriate front region behaviour in terms of the ab-sence of behaviour which appears in the back region, or vice versa. During the interviews and throughout the patients' stay at Theta, care was taken to maintain an a i r of disinterested acceptance of - 6 0 -whatever the pat ient reported as his a c t i v i t i e s in the past. Thus, moral judgments were suspended and the pat ient was encouraged to report whatever reprehensible ( in his own view) actions he might have engaged i n . The bland acceptance of reports of p ros t i tu t ion and "b i za r r e " sex-ual behaviour that characterized the front region was emphasized on one occasion by the speculation that a woman who had, apparently, three lovers , was a p ros t i t u t e . In another instance, the routine acceptance of homosexuals was in strong contrast with a small performance upstairs a f te r a par t -i c u l a r l y t ry ing day of therapy. Two therapists were discussing the (very evident) f rus t ra t ions of t ry ing to get a homosexual man to con-front an issue that they thought was important to him. One produced a v i v i d car icature of his highly id iosyncra t i c way of gett ing angry, a noticeably absent feature of therapist (although not always pat ient) behaviour in the front region. Apart from moral neu t r a l i t y , other dimensions of the helping and caring appearance were emphasized in a conversation in the back re -gion which would have been inappropriate in the front region. Many of the patients at Theta exhibited an extreme dependence on the therap is ts . While th is was attended to as a matter to be addressed in therapy, the fac t of the i r dependence was rare ly i f ever presented as a trouble to the therap is ts . The pat ient was, rather, led to make decisions for him-s e l f with the support of the therap is ts . It would have been a serious breach of the therapeutic code to t e l l the pat ient that you "cou ldn ' t - 61 -s t a n d h i s d e p e n d e n c e " . F o r e x a m p l e , on a p a r a l l e l i s s u e , I was o n c e m i l d l y a d m o n i s h e d by a t h e r a p i s t who s a i d " i t w o u l d n ' t do t o t e l l h e r t h a t she i s m a s o c h i s t i c " . T h i s a t t i t u d e was p o i n t e d up one day when I was s u r p r i s e d t o h e a r two t h e r a p i s t s ' r e a c t i o n t o a t e l e p h o n e c a l l f r o m a o n e - t i m e p a t i e n t a t T h e t a " [ E x - p a t i e n t ] , i t s o u n d e d l i k e , w a n t e d s o m e t h i n g l i k e p e r s o n a l d i s c u s s i o n w i t h [ C l i n i c a l S u p e r v i s o r ] . [ R e s -i d e n t P s y c h o l o g i s t ] d i d h e r b e s t t o d i s c o u r a g e h e r -"What d i d she want f r o m [ C l i n i c a l S u p e r v i s o r ] , e t c . " . . . [ M a l e T h e r a p i s t ] s a i d a f t e r w a r d s t h a t he g o t r e a l l y annoyed w i t h p e o p l e l i k e [ E x - p a t i e n t ] who were d e p e n -d e n t and [ R e s i d e n t P s y c h o l o g i s t ] a g r e e d . I t s h o u l d be e m p h a s i z e d t h a t t h e s e i n c i d e n t s a r e n o t i n c l u d e d t o r e p r e s e n t t h e t h e r a p i s t s as i n s i n c e r e o r " p h o n e y " , w h i c h I do n o t b e -l i e v e t h e y w e r e . They a r e i n c l u d e d t o i l l u s t r a t e b e h a v i o u r t h a t w o u l d have been i n a p p r o p r i a t e i n p a r t s o f t h e s e t t i n g so as t o p o i n t up what b e h a v i o u r was a p p r o p r i a t e t h e r e . A c o m p a r i s o n c o u l d be made w i t h i r -r e v e r e n t r e m a r k s a b o u t o n e ' s b o s s w h i c h m i g h t make i t i m p o s s i b l e t o s u s -t a i n t h e r o l e r e l a t i o n s h i p i f made i n p u b l i c b u t w h i c h may b e , and com-mon ly a r e , made i n p r i v a t e however w e l l - d i s p o s e d one may f e e l t o w a r d s t h e b o s s . A p a r t f r o m f r o n t and back r e g i o n p e r f o r m a n c e s , o t h e r a s p e c t s o f t h e h e l p i n g and c a r i n g a p p e a r a n c e c o u l d be seen i n some o f t h e a c t i v i -t i e s o f t h e t h e r a p i s t s a f t e r t h e r a p y s e s s i o n s . Whenever t h e r a p y was done a t T h e t a , p a r t i c u l a r l y a b r e a c t i o n t h e r a p y , and t h e p a t i e n t was seen t o be s u f f e r i n g , t h e t h e r a p i s t s made a p o i n t o f e m b r a c i n g the p a t i e n t a f t e r t h e e v e n t . In f a c t e v e r y b o d y who had been i n v o l v e d w i t h t h e p a t i e n t who had - 62 -been d o i n g t h e r a p y , u s u a l l y hugged h im a f t e r t h e e v e n t , b u t t h e r e o f t e n a p p e a r e d t o be a s p e c i a l q u a l i t y a b o u t t h e t h e r a p i s t ' s i n t e r a c t i o n w h i c h s u g g e s t e d t h a t he e m p a t h i z e d w i t h and c a r e d f o r t h e p a t i e n t i n h i s e x -p e r i e n c e . A p a r t f rom t h i s d e m o n s t r a t i o n o f s y m p a t h e t i c u n d e r s t a n d i n g , t h e t h e r a p i s t was u s u a l l y p h y s i c a l l y c l o s e t o t h e p a t i e n t a t t i m e s o f e m o t i o n a l s t r e s s . As i s d e s c r i b e d l a t e r , t h e p a t i e n t was u s u a l l y l y i n g on t h e f l o o r and i t was t h e p r a c t i c e o f t h e r a p i s t s t o t o u c h and c a r e s s t h e p a t i e n t and t o e n c o u r a g e o t h e r p a t i e n t s t o t o u c h t h e p e r s o n who was d o i n g t h e w o r k . T h e r a p i s t s e x p l i c i t l y d i r e c t e d p e o p l e t o g a t h e r a r o u n d i n a c l o s e c i r c l e and o c c a s i o n a l l y l i e b e s i d e t h e p a t i e n t o r i n s t r u c t e d somebody t o do s o . T h e r a p i s t s were a v a i l a b l e t o p a t i e n t s d u r i n g t h e u s u a l h o u r s t h a t T h e t a was open a l t h o u g h t h e y d i d n o t e n c o u r a g e p e o p l e t o i n d u l g e i n u n s c h e d u l e d c o n s u l t a t i o n s . The e x p e c t a t i o n was r a t h e r t h a t p e o p l e w o u l d b r i n g t h e i r p r o b l e m s i n t o t h e f a m i l y g roup o f w h i c h t h e y were a member and w h i c h was u s u a l l y a t t e n d e d by a t h e r a p i s t . One f o r m a l i n t e r v i e w was s c h e d u l e d a t t h e m i d - p o i n t o f t h e p a t i e n t ' s s t a y a t t h e c e n t r e and was e a g e r l y s o u g h t a f t e r by t h e p a t i e n t who f r e q u e n t l y r e p o r t e d i t as a s i g -n i f i c a n t e v e n t i n h i s t h e r a p e u t i c c a r e e r . P a t i e n t s were n o t e n c o u r a g e d t o c o n t a c t t h e r a p i s t s o u t s i d e t h e h o u r s t h a t t h e c e n t r e was open b u t were a c t i v e l y e n c o u r a g e d t o a p p e a l t o e a c h o t h e r f o r h e l p i f h e l p was n e e d e d . The g r o u p was r e p r e s e n t e d as t h e most p o w e r f u l r e s o u r c e t h a t was a v a i l -a b l e f o r p r o v i d i n g h e l p d u r i n g t h e s e p e r i o d s . - 63 -Therapist Beliefs Peter Berger and Thomas Luckmann, writing on "Society as Objective Reality" argue the following: If the integration of an institutional order can be understood only in terms of the "knowledge" that its members have of i t , i t follows that the analysis of such "knowledge" will be essential for an analy-sis of the institutional order in question. It is important to stress that this does not exclusively or even primarily involve a preoccupation with com-plex theoretical systems serving as legitimations for the institutional order. Theories have to be taken into account, of course. But theoretical knowledge is only a small and by no means the most important part of what passes for knowledge in a society. Theoretically sophisticated legitima-tions appear at particular moments of an institu-tional history. The primary knowledge about the institutional order is knowledge on the pretheore-tic level. It is the sum total of "what everybody knows" about a social world, an assemblage of maxims, morals, proverbial nuggets of wisdom, val-ues and beliefs, myths and so forth, the theoreti-cal integration of which requires considerable intellectual fortitude in i tself , as the long line of heroic integrators from Homer to the latest sociological system-builders testifies. On the pretheoretic level, however, every institution has a body of transmitted recipe knowledge, that is , knowledge that supplies the institutionally appropriate rules of conduct. 6 The therapist beliefs which are set out in this section are not exhaus-tive of the total belief structure which determines the activities of members in the setting but I would like to propose that they are rele-vant to the determination of some of the Theta reality, especially "doing therapy" which is discussed in chapter 6. Some of the beliefs which I posit are derived from incidents and examples in the preceding section and some require further elaboration which does not appear until later in the work. - 64 -I t s h o u l d be n o t e d t h a t t h e b e l i e f s t h a t a r e s e t o u t a r e n o t i n t e n d e d t o r e p r e s e n t t h e r a p i s t s ' avowed t h e o r e t i c a l b e l i e f s a b o u t t h e r -a p y . T h i s p o i n t i s made i n t h e q u o t e above and must be h e a v i l y empha-s i z e d . The b e l i e f s t h a t a r e s e t o u t b e l o w a r e , I w o u l d p r o p o s e , m a t t e r s w h i c h t h e r a p i s t s must t a k e f o r g r a n t e d i n o r d e r t o s u s t a i n t h e s o c i a l r e a l i t y w h i c h c h a r a c t e r i z e s t h i s s e t t i n g . They a r e my p e r c e p t i o n s o f t h e t a c i t b e l i e f s y s t e m w h i c h i s i m p l i e d i n t h e a c t i v i t i e s a t T h e t a . The b e l i e f s a r e as f o l l o w s : 1 . T h a t anyone c a n and does have p r o b l e m s t h a t ( p r o -v i d e d t h e p r o b l e m s a r e n o t subsumed u n d e r c e r t a i n c a t e g o r i e s and p r o v i d e d c e r t a i n c o n d i t i o n s a r e met ) c a n be t r e a t e d i n t h e t h e r a p e u t i c s e t t i n g . 2 . T h a t p a t i e n t s have p r o b l e m s t h a t a r e beyond t h e i r own c a p a c i t y o r c o m p r e h e n s i o n . 3 . T h a t p a t i e n t s a r e c o m p e t e n t r e p o r t e r s on t h e i r own p r o b l e m s . * 4 . T h a t p r o b l e m s i n v o l v e e m o t i o n a l s t a t e s . 5 . T h a t p a t i e n t s c a n have e m o t i o n s w i t h o u t b e i n g aware o f them and t h a t r a g e , h a t e , , h u r t , j e a l o u s y , f e a r , g u i l t , p a i n , l o n e l i n e s s , s a d n e s s , l o v e e t c . a r e u n i v e r s a l s o f e x p e r i e n c e and r e l e v a n c e t o e v e r y -o n e ' s p r o b l e m s . 6 . T h a t e m o t i o n a l s t a t e s have r e l i a b l e and d e t e r m i n i s -t i c i n d i c a t o r s s u c h as f a c i a l e x p r e s s i o n , body s t a n c e , * I t i s n o t i n t e n d e d t o s u g g e s t t h a t p a t i e n t s a r e c o m p e t e n t t o p r o v i d e a d e q u a t e therapeutic f o r m u l a t i o n s o f t h e i r t r o u b l e s , o n l y t h a t t h e y a r e c o m p e t e n t r e p o r t e r s on t h e t r o u b l e s t h e y e x p e r i e n c e . T h e r e i s an u n f o r -t u n a t e t e n s i o n i n my use o f t h e word " p r o b l e m s " . In g e n e r a l I use i t r a -t h e r l o o s e l y as a l a b e l f o r t h e t r o u b l e s t h a t p a t i e n t s e x p e r i e n c e . T h i s i s done w i t h o u t any i n t e n t i o n o f d i s t i n g u i s h i n g s o u r c e f r o m symptom. A t h e r a p e u t i c use o f t h e word m i g h t r e q u i r e t h a t t h i s d i s t i n c t i o n be c a r e -f u l l y p r e s e r v e d . - 6 5 -and more e x p l i c i t l y , laughter, crying etc. but with the caveat that the indicators for some i n d i v i -duals may be related to states in idiosyncratic re-lationships which are themselves detectable. 7 . That troubles are "inside" i n the sense that they are part of the personal internal experience of the actor and must be brought "outside" in order to be corrected. That i s , they must be r e i f i e d in verbal or v i s i b l e behaviour. 8 . That verbal behaviour may be "just acting" and that this i s q u a l i t a t i v e l y d i f f e r e n t from "doing therapy". 9 . That emotional distance can be reflected by phy-s i c a l distance, and that other emotional dimensions can be o b j e c t i f i e d in drama, exercise, work, dance, games, art etc. where they can be detected for ther-apeutic purposes. 10. That certain kinship categories are always relevant to emotional problems, in p a r t i c u l a r "father and mo-ther" and that other categories such as " s i b l i n g " may be relevant. 11. That relationship categories such as "spouse", "lover" etc. are relevant to emotional problems. 1 2 . That patient sex categories are irrelevant in deter-mining t h e i r q u a l i f i c a t i o n s for membership in the group and are r e l a t i v e l y unimportant as far as t h e i r adopting roles in therapy i.e. that female patients can adequate-l y play male roles. T3. That patients know the roles embodied i n the relevant categories well enough to produce a display of these roles that i s adequate for a l l p r a c t i c a l purposes i n evoking the emotions related to the rel a t i o n s h i p s . * * I t has been pointed out that s t a f f members were well aware that role playing might f a i l and did f a i l to produce an adequate display and that they proposed the role playing in the hope that something useful would come of i t but knowing that i t might be unsuccessful. I t was the case, however, that role playing was a frequently proposed a c t i v i t y and i t appeared to be believed that the incidence of success was high enough to warrant an almost dai l y demand that i t be attempted. Rather than belabour the " b e l i e f " with p r o b a b i l i t i e s and p o s s i b i l i t i e s , I have added this footnote in recognition of the s t a f f ' s clear knowledge that this and indeed any therapeutic t a c t i c coul d f a i 1 . - 66 -FOOTNOTES 1. Erving Goffman, The Presentation of Self in Everyday Life, New York, Doubleday (Anchor Books) 1959. 2. Ibid. p. 107. 3. Loc. s i t . 4. Ibid. p. 112. 5. Loc. s i t . 6. Peter L. Berger and Thomas Luckmann, The- Social Construction of Reality, New York, Doubleday (Anchor Books) 1967 [Copyright 1966]. - _7 -CHAPTER FOUR THE PATIENT ROLE The patients are the raison d'etre of Theta and the patient role is the second determining role at the centre. The patient comes to Theta because he has troubles in the world and frequently reports that he "had to do something" or that Theta is his " last chance". A not untypical explanation was: I.. I feel that my problems are are real ly bothering me and I can't go on in the space I am any more, eh. , i t ' s get t in . . I feel ups an' downs 'n i t l ike ehm.. some days I feel better about the progress I have made., about dealing with them and other days I., et 's ehm.. there's nothing happening at a l l and eh.. I've just come to the point that I jus wanna.. I can't l ive with myself l ike this without bein' able to do some-thin ' about i t because I'm unhappy with., with where I'm at . . Patients were recruited from the nearby hospital and by referrals from doctors who have heard about the centre. I have done no study of the recruitment process and know l i t t l e or nothing about i t . There seems - 6 8 -to be some evidence that many patients came to Theta because they heard from ex-patients that i t was a good place to be. Patients, then, f re -quently came to the centre highly motivated and well disposed to the program. The patient role had to be learned and this process took place over a series of interviews and in the f i r s t few days of the patient's residence at the centre. Although the interviews were important in learning the role, I have chosen to describe them under the heading * "getting in " because the main focus for the potential patient at that stage is gaining acceptance as a patient. The section on "learning the patient role" which follows this I have reserved for describing the learning work that went on after the patient had been accepted. In fact the learning process was probably about evenly divided between the two stages. Getting In The potential patient's f i r s t contact with Theta was at a pre-orientation meeting. The meeting was held in one of the smaller upstairs rooms and was usually attended by more than one candidate for admission. A member of the Theta staff was present and i t was reported that the current patient "chairman" sometimes attended: [Psychiatric Nurse] re-ported that the "chairman used to attend" but with the suggestion that her non-attendance was a matter of oversight rather than policy. She * It should be noted that this description deals essential ly with a successful entry. The inst i tut ion 's screening process is not discussed because l i t t l e or no data was obtained on that aspect of the centre. - 6 9 -did not, however, rush out and get the chairman, and the matter was l e f t as a pract ice that had not much importance. Each candidate was given some typewritten information and asked to read i t , in pa r t i cu l a r a l e t t e r which was referred to as the Dear Friend l e t t e r . "Dear Fr iend" i s a s u f f i c i e n t l y unusual form of greeting as to adequately iden t i f y the document and appeared to have the desired mixture of s u f f i c i e n t general i ty for a form l e t t e r along with some ind ica t ion of the at t i tude that the c l i n i c a l supervisor wished to fos te r . The l e t t e r emphasized commitment and r e s p o n s i b i l i t y , the fact that the patient came of his own choice, and at the same time the group focus of the community. I t could be the subject of a deta i led analysis in i t s e l f , but su f f i ce i t to say that i t appeared to create an impress-ion of s t ructure : group therapy in various forms, such as verbal groups, a c t i v i t y groups, e . g . , gymnastics, various sports such as v o l l e y - b a l l , swimming and outdoor a c t i v i t i e s such as walks and outdoor games, as well as work-gardening, housework, carpentry. . . . therapy through...modes such as ar t work, music, theatre, games and dancing. along with professional competence: ind iv idua l therapy w i l l play a lesser role as we believe that the combined complex programme we are o f fe r ing to be [ s i c ] superior for people with your types of problems -the present state of knowledge in Psychiatry substanti-ates this, [emphasis mine] A l l these are elements of a un i f ied therapeutic pro-gramme..." - 7 0 -"...[Pjeople with your types of problems..." appeared to indicate a l -ready an understanding of what "your types of problems" were and, pre-sumably, confidence in the relevance of the program. The "dear friend" l e t t e r , along with the Theta brochure, were the f i r s t resources that the potential patient had for determining not only what Theta amounted to but, to some extent, what he himself amount-ed to. The brochure told him that Theta was "not for people with a history of serious mental i l l n e s s " and the l e t t e r t o l d him that he was going to "do more than get r e l i e f from [ h i s ] immediate symptoms". Both references along with the i n i t i a l welcome to the "health sciences centre hospital" implied that the new a r r i v a l was to be a "patient" and there was e x p l i c i t reference in the l e t t e r to "patients and s t a f f " . Although the brochure invoked a more neutral category: "member", the frequent re-ferences to the "health sciences centre h o s p i t a l " , to "mental i l l n e s s " (whether "serious" or not) c l e a r l y prescribed the role the new p a r t i c i -pant was to play: that of "patient" doing "therapy". The participant had only the most diffuse and non-specific knowledge of what th i s amount-ed to unless he had friends who had been through the program (a not un-common circumstance). A female patient told me that she thought i t would be a "rap session". After the patients had time to read the introductory l i t e r a t u r e , the s t a f f member asked i f there were any questions. There might be some cu r i o s i t y about the more esoteric d e t a i l s of the brochure, for example patients might confess that they did not know what "kinesic therapy" or - 71 -"Gestalt" was. The fact was, however, that the patients at this point usually had very few questions and were shortly asked to explain for the f i r s t time their reasons for wanting to come to Theta. The potential patient took this as an invitation to display a set of descriptions of his previous or current feelings and autobiograph-ical events which could be understood as representing a problem for him. This required that he select from the events of his l i f e an appropriate subset which could be seen to be relevant to his self-formulation as somebody who needed help. Every candidate for admission was able to produce some subset which he saw as relevant for this task, and the staff member treated whatever l i s t that was produced as relevant to the question that had been asked. 9 One feature of the account that was given of the problem was that i t had to have current relevance. It was not enough that the pat-ient had troubles in the past and he now wanted to review them and dis-* It has been pointed out that this allows for any kind of des-cription to be presented as a relevant l i s t of problem items. The staff at Theta, of course, were not prepared to accept any descrip-tion as an adequate formulation of the problem, and had clear pr ior -i t ies and theoretical focuses that they attended to. The staff member asked questions to probe for parts of the biography that had been omitted and to elaborate parts that were described. The point that I wish to make is that despite the logical poss ib i l i ty that the pat-ient could talk about anything at a l l , in the interviews that I ob-served he appeared to have a good grasp of what was an appropriate subset, and the subset produced was seen to be relevant to the question. - 72 -cover some interesting psychological fact about them, but they had to be related to recent feelings or a c t i v i t i e s that drove the patient to appear at Theta. A female patient, after speaking about "contributing factors" in the past, told about two extra-marital pregnancies that she had "not got over yet". A male patient said that the problem of his shyness had been bad since he had given up drugs. He used to be into a l o t of "heavy drugs" and had quit. "That's when the problem got r e a l l y bad". He was a jazz musician and was having great trouble meeting "the public". He was "uptight" and i t affected his playing. A male patient said he had "too much going rig h t now and [he couldn't] take care of any of i t . " After the pre-orientation interview, the patient took away a second form l e t t e r referred to by the heading: "Self Description". He was invi t e d to write a brief summary of himself under nine headings. The headings and suggestions f o r the s e l f description are shown i n Ap-pendix I I I . They were designed to ensure that the patient's s e l f des-c r i p t i o n addressed a l l matters that were of importance to the i n s t i t u -t i o n . The patient brought this " s e l f description" to the next encounter with Theta which was an individual interview conducted by one of the s t a f f members. The " s e l f description" was used as a resource by the s t a f f member during the individual interview to formulate a l i s t of s p e c i f i c problems to be treated at Theta. A female s t a f f member told me that the s e l f description was "very useful" during the individual interview. It was d i f f i c u l t to do interviews and they took much longer i f i t was - 73 -not available. The staff member read through the se l f description and selected items from i t that he wrote down on a Theta form referred to as the "problem l i s t " . The headings on the "problem l i s t " were the same as the headings in the se l f description form. The patient was invited to select a number from 1 to 6 for each item which indicated how severe a problem i t was. This problem l i s t subsequently became an inst i tut ional * ar t i fact and was used to assess the progress the patient was making in the inst i tut ion. 1 I do not have a complete record of an individual interview, and the interpretive work done by the staff member in selecting items from the autobiographical account for inclusion in the problem l i s t is thus not available to me. One feature of the process which was evident is that the staff member treated the se l f description as a true account of the events of the patient's l i f e . She also assumed, once again, that the account was a relevant account. Although she might ask questions to elaborate the items that were described, she knew that there were a whole collection of events, incidents, relationships, feelings and the l ike which were not described. The selection depended on the patient having an impressive amount of knowledge about social relationships, kinship structures, what i t was to be healthy, both physically and mentally, what parts of his education and work history were relevant and what persons were signif icant in his l i f e . * This word has a sl ight pejorative sense in some contexts, which I do not intend. I can find no adequate synonym. - 74 -When the patient came out of the individual interview, he had been made aware of what facets of his autobiography were of suff ic ient interest to the inst i tut ion to be included in the problem l i s t . He also knew what items of his report had been explored and what items had been passed over. It was now available to him to attend to the explored items as psychologically s igni f icant . He might begin to be aware of the fact that his problems had a different slant to what he thought they had. The process was further refined in the last step of the entire procedure: the group interview. The group interview took place on a Wednesday following the individual interview (usually the next Wednesday). The potential pat-ient came to Theta at nine o'clock in the morning and took part in any act iv i ty which preceded the interview. Dance therapy was often scheduled at this time, although i f there were a great many interviews or the dance instructor fa i led to show up this was truncated or abandoned. The patient group along with a number of the staff members and former patients attending for "after-care" gathered in the theatre. They formed their chairs into a large horseshoe shape and the potential pat-ients to be interviewed sat at the focus or sometimes at the end of one leg of the horseshoe. The interview started with the current chairman (of the patient group) asking the potential group member "why [he wanted] to come to Theta" or "What's brought [him] to Theta". There followed for - 7 5 -a third time a display of autobiographical details and feelings that amounted to good reasons that anybody could understand for wanting to come to Theta. The good reasons frequently started with general statements l ike "I'm depressed" or "I suffer from depression", "I can't relate to people", "I can't get close to people". Sometimes the descriptions turned on events, l ike "I tr ied to commit suicide" or "My marriage is breaking up (or has just broken up)". The group then questioned the interviewee about the details of the events that led to his arriving at Theta. A tradit ion had grown that vagueness in reporting troubles was unsatisfactory and the details of the troubles had to be elaborated. The group would ask the inter -viewee "what form [his] depression [took]" or "what are your relations with people", also "what people" and what their current status was, i . e . , were they l iv ing together, was he l i v ing with his parents, how often he saw them, etc. In the event that the patient had tr ied to commit suicide, the group would want to know what means he had used and what events had led him to decide to do i t . Where a marriage was said to have collapsed, the members would want to know the current status of the collapse: separ-ation or divorce, and i f separation, whether t r ia l or terminal, temporary or permanent. - 76 -As each aspect of the subject's explanation was elaborated, further elaboration was demanded u n t i l the group f e l t that i t had under-stood for a l l prac t i c a l purposes what the features of that part of the problem were. An i l l u s t r a t i o n of this aspect of the interview can be seen in the group's pervasive interest in drugs and alcohol. Every patient was asked about his use of drugs and alcohol. The patient might readily admit that he was "into the drug scene" or he might admit the he "used to be into drugs", that he "drinks quite a b i t " or was a "heavy drinker for about three years". The group generally asked questions to establish the precise dimensions of the problem and then went on to decide on the basis of t h i s report whether the descrip-tion amounted to "a problem". The c r i t e r i o n f o r this appealed to a norm-ative standard that would constitute a large percentage of the drinking population as problem drinkers and was a r e f l e c t i o n of the extreme ser-iousness with which the patient group viewed drugs and alcohol. [Female Patient] said she had a " s l i g h t drinking prob-lem". Several people wanted to know what that amounted to. About a bottle of wine per day. Would she make a commitment to stop drinking today? A long argument ensued. [Female Patient] said she didn't see why today ...[Female Patient] pointed out that there were other drugs: eating (especially for her), coffee, T.V.; why single out alcohol. [Male Patient]- said that this was the worst problem and everybody, many group members knew i t . After much struggling [Female Patient] re-luctantly agreed to go along with the ban and made the commitment. The next problem was "drugs" - would she give a s i m i l a r commitment? She had explained about asthma. She occasionally took Librium to cut o f f a serious attack and anyway used [Spray]. There was a ong d i s -cussion about whether she could continue with these or not. [Resident M.D.] suggested that her outside (re-- 7 7 -f e r r i n g ) M . D . h a d k n o w n a b o u t t h e d r u g s a n d i n t e n d e d , b y s e n d i n g h e r t o T h e t a , t o h a v e h e r d r o p t h e m . [ R e s i d e n t M . D . ] e v e n t u a l l y a g r e e d t o c h e c k i n t o t h i s . T h e D r a c o n i a n s e v e r i t y o f t h e d r i n k i n g a n d d r u g s s t a n d a r d s i s f u r t h e r i l l u s t r a t e d b y t h e f o l l o w i n g e x t r a c t f r o m a p a t i e n t i n t e r v i e w : * FP 1 : How much do y o u d r i n k now? I : U h m . . v e r y r a r e l y ; i f I h a v e a b e e r . . I d r i n k b e e r b e c a u s e I l i k e t h e t a s t e a n d I m e a n . , m y s e l f a n d my f r i e n d s we make o u r own e h / / FP 2 : B u t how m u c h d o y o u d r i n k , l i k e how m u c h a w e e k o r / / I : T h r e e o r f o u r b o t t l e s . FP 2 : W e l l , how d o y o u f e e l ? MP : I w o u l d n ' t c a l l t h a t a d r i n k i n g p r o b l e m . FP 2 : I w o u l d n ' t e i t h e r . I t ' s b e e n a l o n g t i m e . FP 3 : D ' y o u g o t o b a r s o f t e n ? I : I ' m n o t a p u b - t y p e p e r s o n . FP 1: W h a . . w h a t a b o u t d r u g s ? I : A h m . . I d o n ' t s m o k e t h a t much a n y m o r e , I ' v e c u t down q u i t e a b i t a h m / / MP 2 : W o u l d y o u s t o p ? I : S u r e , v e r y w i l l i n g t o FP 2 : a n d y o u d o n ' t t a k e t r a n q u i l i z e r s o r a n y t h i n g ? I : N o , I.. I ' m o n some m e d i c a t i o n now b u t i t ' s e h . , b e c a u s e o f . , o f e h [ 2 s e c o n d s ] a n - i n f e c t i o n - I -h a v e [ v e r y q u i e t l y ] a n d i t s h o u l d be o v e r i n a b o u t a w e e k . FP 4 : I s i t a n t i b i o t i c s o r s o m e t h i n ' ? I : A h m . . " T e t r a c y c l i n " FP = F e m a l e P a t i e n t MP = M a l e P a t i e n t I = I n t e r v i e w e e - 7 8 -FP How much dope do you smoke? I I've had a eh., an ounce of ehm.. hash for over six months, seven months FP S.. so you don11 ( I No FP 2 OK, so (reads series of questions from protocol.) Another patient interviewed generated the following f i e ld note: More talk about drugs and alcohol with the next g i r l . [Interviewee] was admitted from the in-patient side. When asked about the drug commitment, she explained about a bad back - result of an accident. She was taking 292's. Two per day, plus sleeping p i l l s . [Resident MD] said the hospital MD must be aware of her dependence on 292's and asked her to refrain from using them while she was at Theta. [Interviewee] reluctantly agreed to do so, although she said that some days she could not get out of bed without them. The therapists at Theta occasionally remarked that the stan-dards that the patients demanded in some things were more severe than those demanded by the inst i tut ion, but the interviews that I observed suggested to me that the standards were a jo int production of patients and staff . Why the standards were so r ig id and why the subject of drugs and alcohol was of such pervasive concern to the patients is not clear to me. I could propose that, from the patients' point of view, the reason was related to the commitment demanded of the patients by both group and staff . It was pointed out on one occasion that the patients had to depend on the group for support now instead of relying on chemi-cals. It may be the case that, as argued elsewhere, the attraction of escaping from therapy was a siren song for patients at Theta. The de-sire to escape was sometimes large and threatening and drugs and alcohol - 7 9 -represented a way of escaping from the rigors of therapy without being * physically absent. For this reason they had to be heavily censured. When the patients had decided that they had determined the facts about the potential member to their satisfaction and had obtained an assurance about drugs and alcohol, the patient chairman read a set of standard questions to the interviewee which were prepared by the staf f . The questions that were asked are presented in Appendix IV and were usually read with r i t ua l i s t i c solemnity while the group s i lent ly watched the interviewee. Provided that every question was answered in the nega-tive or the affirmative, whichever was appropriate to the question, the group interview was over and a l l that remained was a vote which was taken in the presence of the candidate, on whether he should be admitted or not. The matter of admitting or refusing a patient was a serious business for the patient group. If they admitted him then he was going to be with every one of them until they le f t Theta unless he dropped out. Dropping out, as I argue elsewhere, was a very threatening business for the remainder of the group and i f the new patient showed signs of lack of commitment, this had to be carefully considered. On the other hand, i f the patient was refused, this was seen to be consequential for him. The patients in the group knew how urgently they themselves had wanted to get in and assumed that the new patient, at least possibly, was in the same posit ion. * From the s ta f f ' s point of view, the use of drugs and alcohol was seen as being counter-therapeutic. - 80 -I was present for one group interview at which the group found themselves presented with a potential patient that they believed to be in need of therapy but were reluctant to accept as a group member. They d i s -cussed at great length the p o s s i b i l i t y of not voting on him so as not to hurt him by a refusal. They attempted to get an assurance from the thera-p i s t present that she would arrange to have him admitted someplace else.. When the therapist explained that she could not guarantee to do that, that they "must decide", they voted the patient i n , despite clear evidence that they thought that he was not a suitable candidate for the centre. When the vote was being taken, i t was the practice of the group members who voted against a candidate to present t h e i r reasons. "Yes" votes were occasionally accompanied by cautions or arguments ag-ainst "No" vote arguments, but were more commonly given without comment. "No" votes were almost always accompanied by an explanation. There was a strong feeling that the explanations that accom-panied "no" votes must "make sense". For example, the following incident took place during one vote: * MP 1 : You remind me so much of myself (laughter). I have to vote no (gasps and crescendo of laughter and protest) Yeh FP 1: How does that make sense?// MP 2 : I don't understand that at a l l / / MP 1 : It doesn't make sense but I// * MP = Male Patient FP = Female Patient - 81 -FP 2: I don't understand that either MP 1: I got such a feeling that he., he's holding back., agh-h [very emotional] I don't know, It doesn't make sense but this is the feeling I've got ' n i t doesn't FP 3: So do you think he can make it? MP 1: I dunno I eh get the feeling that. , i t i sn ' t rea l l y . , yeh I think he can make i t , I ' l l change my vote yes. . sorry. "Making sense" was not a question of formulating a logical argument but of giving reasons that everybody could understand as relevant and impor-tant. The one reason that above al l others was seen in this way was that the candidate was "not committed". If a group member said he voted "no" because he "didn't see the commitment there", this was accepted as an ade-quate reason without any further explanation. A variation on this theme which e l i c i t ed no protest can be seen in the following: FP : I'm gonna have to vote no because I have very mixed feelings l ike [Patient]. To me I think you think that this is real ly a faddy trippy thing to do and I don't feel that you're going to cont r i . . give of yourself and let us help you in ( ). I'm sorry. Patients were admitted on a simple majority of the group members, former group members and therapists present, and provided the decision was favorable, the committee chairman followed the vote with the r i t ua l i s t i c greeting "welcome to the group". - 82 -Learning the Role The reason I have devoted so much space to the section on "getting i n " i s that i t was during this period that the patient picked up many of the norms and values that related to the patient role. Be-fore I proceed I would l i k e to write a b r i e f summary of these norms and values. The patient frequently saw himself as coming to a haven where there was structure, security and expert help, dispensed by a professional s t a f f interested in his problem. The setting was a medical one and the basic role he was assigned was that of a patient doing ther-apy. The problems that beset him had been noted and analyzed into d i s -crete elements and he knew what parts of his story had been of p a r t i -cular interest to the i n s t i t u t i o n . The group interview had been ri g o r -ous and his acceptance had not been automatic; in f a c t , i n some cases i t might have been marginal. He was therefore a privileged member of an exclusive group. The group had emphasized commitment and he was aware that his continued acceptance was conditional upon his demonstrating his commitment. Drugs and alcohol had been heavily emphasized and he knew that the group had r i g i d standards with which he must comply although he did not know, yet, what these standards were, except in the most general terms. The day chosen for new patient interviews included a family meeting and a whole-group therapy session under the direction of the c l i n i c a l supervisor. The luncheon included a patient committee elec-- 8 3 -t ion. The new patient was thus presented with a considerable spectrum of the Theta act iv i ty and proceeded, at w i l l , to part ic ipate, albeit tentatively. For example, the patient, once admitted by the group, had the privi lege of voting on the candidate who followed him and was ex-pected to do so. He also had the privi lege of voting for committee members at lunch time although i t frequently happened that new patients pleaded ignorance of the candidates and did not vote. In fact a tenta-tive tradit ion to offer new patients this excuse was growing during my attendance. The new patient was judged, therefore, to be competent to assess the stories of potential patients (which apparently required no special sk i l l s to assess) but not to assess the qual if icat ions of commit-tee members with whom he had not yet become acquainted. The new patient attending to the luncheon talk might learn that there were something called "commitments" and a practice of "making up a commitment". He might hear talk about punctuality, d iar ies, fami-l i e s , family night, working out, and a l l the rest of the concerns that made up the routine daily l i f e of Theta. Somehow he had to find out what a l l these references amounted to. Towards the end of the lunch there would be a cal l for "family reports" and several members of the group would read a short written summary of the events of the previous day's family ac t i v i t i es . The patient would learn that the "famil ies" were Theta subgroups and would begin to get some idea from what was worth reporting which act iv i-- 8 4 -ties were valued and which act iv i t ies were censured in these settings. He would learn that some members of the group had the status of report-ers and, in the subsequent committee report, which act iv i t ies of the whole group were "news". After the reports had been read there was an election which, * he might learn, was not taken very seriously, although i t had the form of a regular elect ion. He would note that the qual if icat ions for cer-tain elected positions appeared to depend on other positions having been held: for example, that so and so could not be chairman because he had not been work co-ordinator. He would learn what were considered good reasons for refusing off ice and the attention people paid to the length of time patients had been at Theta in considering who should be nomina-ted: for example, that someone ought to be nominated because i t was his " f i f t h week". This pointed also to the assumption that everybody should occupy at least some of the positions during his stay at Theta. The new patient was assigned to a family during his f i r s t ** day, and after the lunch he joined this family for the f i r s t time. He found, in the family group, that members could elect to work on a prob-lem and that a l l members of the family were expected to contribute ob-servations about that problem. The new patient quickly found that his * This is discussed in a subsequent section. ** The methods of assigning patients to families were in a state of flux during my period of observations; sometimes i t was done by lo t , sometimes arb i t ra r i l y . There was talk of "bargaining" for new members. - 8 5 -opinions, experiences and observations were considered equally with o other family members, although he might have reservations about expres-sing them. One patient who made a remark in her f i r s t family meeting prefaced i t with "maybe I'm outa l i n e . . . " and was quickly reassured on the point. The whole-group therapy session started immediately after the family group was over. It appeared that the whole-group therapy session was organized to provide the new patient with a display of what was currently considered as "doing therapy". Of course "doing therapy" was the reason the whole-group was assembled on this occasion, but i t normally tended to be a heavy session and the c l in ica l supervisor f re -quently told new patients that the " f i r s t day is the worst". The new patients were spectators at this session and were rarely expected to work. The work that was done during my period of observation usually involved abreaction therapy and the new patients were able to see the emotional dimensions that were demanded during therapy. New patients frequently reported this afternoon therapy ses-sion as a frightening experience. They could see that the emotional displays were orchestrated and approved by the therapists present, but often remarked afterwards that they couldn't see themselves doing the same thing. They observed the reactions of the veteran group-members as the therapy proceeded and attempted to adopt what appeared to be appropriate postures and expressions. They joined the group surrounding the patients who were "working out" and made themselves as inconspicu-- 8 6 -ous as possible. After the session was over the new patients were asked what they thought of their f i r s t day at Theta. It was at this point that they admitted their fear or perhaps even distaste of the act iv i t ies which they had observed. This was then taken as an opportunity for the staff to order the reactions of the new patient so that he now saw what had happened during the day as the normal approved and proper a c t i -vity of doing therapy. At the end [Cl inical Supervisor] brought the new pat-ients up to the front. [New female patient] said she was frightened by what had happened in the morning: "Everybody at each other's throats". [Female Patient] said i t wasn't usually l ike that. [Second new patient] said she could not see herself doing what [Patient who had done therapy] had done. [Male Patient] said i t was very different from what he had expected. He would come because he "had to" . The notion that the f i r s t day was the worst was evoked to assure the new patient that however shocked or dismayed he was at what he saw, this shock and dismay was something he should accept because what had happened was therapy. Moreover, strong reactions were completely proper, even desirable. In one incident reported again later in another context a patient was very upset by the f i r s t afternoon's therapy session. [Cl inical Supervisor] brought the new patients into the centre where they sat on the mattress [which had been used in the preceeding therapy]. He asked them ind i v i -dually what they thought and went on to explain that the f i r s t day was the worst. Some said they were scared or very scared. [New Female Patient] said that she thought i t was a bad sign that she broke down on the f i r s t day. [Cl inical Supervisor] said i t was a good sign - some people took weeks to achieve what she achie-ved, some never did. - 8 7 -The patient, then, had come to observe some of the Theta a c t i -v i t ies and had heard some of the Theta talk. What he had not understood, he had probably asked a patient about who would have told him "the facts" about that act iv i ty . He had participated in an election and learned some of the preoccupations among patients. He had seen a family group and had watched therapy being done. He reactions to this had been checked and interpreted in the l ight of the Theta culture. The new patient now le f t the setting to return for full-time act iv i t ies on the following Monday with some expectations of what was going to go on and how he should behave in the sett ing. Time and the Patient Role It has already been argued that time was experienced as oppres-sive at Theta. Time, however, had other references for the patients in the sett ing, some of which were instrumental in determining behaviour. The current point in a patient's career through Theta was frequently located as a relevant factor in determining what should be done. Thus a patient who was in this " f i r s t week" was not expected to be available for any off ice on the patient committee, whereas a patient who was in his "fourth week" was under considerable pressure to occupy some off ice i f he had not done so yet. In selecting between alternative candidates for chairman, too, the fact that " i t ' s his f i f t h week" was frequently cited as good reason that someone should be chosen over an alternative candidate who had a longer time lef t to him. - 8 8 -Patients in their f i f t h or sixth week used this fact as a resource to demand "big-group" time over patients who were less ad-vanced in their careers. The location of the current point in a pa-t ient 's career at Theta was also seen as a source of trouble: One of the reasons for people being antagonistic to [Female Patient] was that she was a bad example. Some-body said that they knew that she had been there for six weeks and apparently had not changed at a l l . That was real ly threatening. Role Relations Among Patients The patient population was treated by the therapists as a uniform group insofar as no special privileges (apart from the group time discussed above) were extended to patients of any class or senior-i ty . Patients occupying the various positions in the patient committee were also treated uniformly with a l l other patients apart from being required to give certain reports which they prepared. The only variation from this among the patients themselves was that patients of longer standing were sometimes seen as forming a minor subgroup of "old hands". [Female Patient] was asked who was making demands on her. She identif ied [the four most senior group members]. Despite th is , the group saw i t s e l f as essential ly a society of equals. This was perhaps emphasized in the elections of committee members which was operated as a means to let everybody have a chance, rather than as a seriously competitive enterprise. A frequent cal l on - 8 9 -election day was "who hasn't been chairman?" This was done even though the c l in ica l supervisor was in the habit of lecturing the group on the importance of the chairman. [Cl inical Supervisor] asked who was dissat is f ied with the chairman. He said the chairman was very important to the group: could be a centre of group resistance. The group chose the chairman. If the chairman was not good, the group was not good. The essential ly r i t u a l i s t i c emphasis of the election can also be seen in the fact that although the election was carried out with a show of rules of order, nominations, voting and the rest, i t was the source of jokes which tended to emphasize the emptiness of the formality. [Male Patient] made a joke during the elect ion. He said he wanted to know what [nominee's] position on drinking was. After her election [Female Patient] said that she was going to forbid drinking. This joke depends for i ts force on the consequential ly of questions asked of candidates at real elections. If the candidate's position on drinking (for example) is going to affect the people he is going to have administrative power over, his answer to the question is clearly going to be important. The question asked in this context emphasized the fact that the chairman was going to have no such power. In fact the candidate did not even attempt to answer i t . She just smiled. The selection of other positions at Theta followed a similar pattern. For example, in selecting the work co-ordinator on one occa-sion, the group were discussing the relative merits of the three candi-dates in the usual terms. The c l in ica l supervisor happened to be present: - 90 -Halfway through the elections [Cl inical Supervisor] interrupted to say that the work co-ordinator should be competent. It was pointed out that nobody was real ly competent. It was also pointed out that he should be enthusiastic. [Cl in ical Supervisor] ag-reed. Some votes now went to [Male Patient] but the group insisted on having i ts candidate - [Female Patient], self-confessed incompetent. Despite the attempt by the c l in i ca l supervisor to influence the process, the group attended to i ts own pr ior i t ies in selecting a patient to f i l l the role. It was a noticeable feature of the committee's work i t s e l f that i t was reluctant to make decisions that had not been checked out by the whole group, even in relat ively t r i v i a l matters such as renaming the foreman "family leader". An early discussion today was about what the foreman should be cal led. The committee decided "family lead-er" and then had great doubts about whether they could choose that one. The group had chosen "family head" and [some other name]; could they change that? Fami-l ies had suggested these names and points were to be awarded [to the family whose suggestion was selected]. The committee saw i t s e l f , then, as having very l i t t l e power to influence the process even in the most t r i v i a l way and was mostly concerned with reporting the day's ac t i v i t i es . Even this was seen as a relat ively empty process. The feeling was that "you don't have to l isten to the committee report anyway because you were there". The therapists made attempts to reduce the emptiness of the committee's act iv i ty by having the members select people who ought to be working. I was at a committee meeting immediately after this had been - 91 -suggested (or re-emphasized, perhaps) and i t was obviously a trouble for that committee: After they [the committee] had discussed the day's happenings for about two hours they found that they had produced a description of the day (just what the resident psychologist had objected to at lunch). They then started to produce a l i s t of "who should, work on themselves", "who was not contributing to the group", "who was contributing especially we l l " . . . It was clear that the committee fe l t very ambivalent about their judgments because [Female Patient] was proposed as a candidate for both the delinquent l i s t and the honor l i s t . . . The l i s t of people who should work on themselves got so long eventually that the committee decided to pick one name. They eventually came up with [Female Patient] "more because she pisses me off right now than anything e lse" . There followed a careful composition of just the right phrase - "the committee recommends that [Female Patient] needs to work on her problems". They were clearly delighted with th is . It seemed that the unvarying triteness and vacuity of the published com ments and recommendations about fellow patients: "[Patient name], te l l us what you're fee l ing . " "[Patient name], work for yoursel f . " "[Patient name], let us see your anger [or warmth o r . . . ] " "[Patient name], what's happening with you?" were far from documents of the lack of imagination, perception or ab i l i of the Theta participants, but rather deliberate cliches to escape the * d i f f i cu l t y of making public judgments about fellow group members. Abdicating the Role The most direct way of abdicating the patient role was by ab * Group members regularly and wi l l ingly made judgments in therapy sessions and in lunch time talk but i t was always tac i t ly assumed that they were "for right now" and could be and usually were revised within the period of the interaction. The public judgments did not have this quality of being corr ig ib le . - 9 2 -senting oneself physically from the scene. This was a not infrequent occurrence at Theta. People just stopped coming either temporarily or permanently. Absence was always a concern for the patient group as well as for the therapists. It was apparent that in a setting in which the major sanction was discharge, voluntary absence was part icular ly threat-ening to the whole inst i tut ion. Any unexplained absence immediately generated an inquiry into the absent patient's whereabouts: "Had he phoned?" Some member of the group was assigned to telephone the absent member i f he had not. If i t was not possible to contact him by te le -phone a number of group members would v i s i t his address to see i f they could find him. Even the absence of a patient on the f i r s t regular day of her attendance was an important issue, so that i t was not a question of concern for fellow patients whose troubles were well known; any ab-sence was a threat. I was in the room on one occasion when a new patient who had fa i led to arrive on the f i r s t day was telephoned. The patient who cal led produced a long, clever and forceful argument for the new patient to at-tend. In the course of this dialogue she dealt with d i f f i cu l t i e s l ike the new patient denying that she wanted to change: "You don't have a desire to change? We won't let you f a i l " , and fearing that she would lose her identity: "Part of your identi ty, but what kind of part is that? You' l l replace i t with something more posi t ive" . The patient-caller ac-knowledged the attractiveness of absence from the sett ing: "It 's not an easy place to be but i t gets easier; I've considered leaving but I just d idn ' t " . - 9 3 -Apart from patients who fa i led to arrive at the centre, patients occasionally absented themselves or threatened to absent themselves from the room in which therapy was being carried out. Once or twice threatened absence brought the threat of discharge from the c l in ica l supervisor which certainly tested the patient's s incerity in the action as well as the power of the group to generate a commitment to stay at Theta. Apart from the concern of the therapists at this kind of absence, i t was clearly a patient's concern too: The day ended with a long discussion on the question of absences. This is a big problem at Theta at the moment. [Patient] led the "hard-line" movement: he said that i f people said that they were going to leave, they should be told to go. The problem of formulating a satisfactory rule was discussed at length. ...[Female Patient] was cited as a case in which the device was used to get attention. [Male Patient] said that he thought that [another patient] had done the same thing on Tuesday. [Patient] pro-tested. The difference that was ident i f ied was be-tween "I'm going", followed by action, and "I'm feeling l ike leaving and I wonder what is causing i t " . The second was identif ied as good behaviour, the f i r s t was bad The discussion included a lot of talk about intention. If someone said that they were leaving and then headed for the door, they intended to leave. Someone objected to this on the grounds that they might be looking for attention or they might not have any other way of expressing their anxiety. The concern about absences, then, appeared to be very serious among both patients and therapists. That physical absence was treated more gravely than other kinds of detachment such as being s i lent or perhaps pa r t i c i -pating in a way that directed attention away from oneself (being con-spicuously active as a co-therapist for example) was evident. The con-cern of the therapists was, of course, obvious. Absence removed the patient from the strongest threat of the inst i tu t ion , that of discharge. - 9 4 -For the patients i t seemed entirely reasonable in that everybody proba-bly fe l t the need to escape at some time and when somebody actually did i t , i t became that much more r ea l i s t i c . The only val id reason for absence from the setting was s ick-ness. The sick role was invoked by a large number of patients during my stay at the centre and I was aware of the frequency of sick absence after a patient had been involved in a "heavy" therapy session. The incidence of "one-day f l u " was so high at one stage that the staf f inst ituted a system of individual ly identi f ied drinking cups to reduce the apparent infectiousness of the disease. The staf f was aware, of course, of the ease with which a patient could claim that he was sick and attempted to find remedies for th is : At lunch there was some talk about [two patients]. [Cl inical Supervisor] asked what was happening with them. It was explained that they were sick. [ C l i n i -cal Supervisor] asked what temperature they had. No-body had asked. [Cl in ical Supervisor] said.that people should know "deta i ls " when someone was sick. The patient group were also well aware of the potential power of the sick role explanation in absences and distinguished to some extent between "known to be s ick" : I enquired where [Patient] was and was told that she had been injured on the previous day playing f loor hockey. and "reported sick" when the patient's immediate past history might be searched to see i f there were reasons to suspect that he was malingering: [Absent Patient] had been put on probation in her family on the previous day. When she had not come in today [Female Patient] had cal led. She said that - 95 -she was sick. [Female Patient] was somewhat discour-aged. She said that she doubted i f [Absent Patient] would come back. I observed one other method of abdicating the role while I was at Theta and that was by redefining the problem so that the setting was now inappropriate. A female patient had i d e n t i f i e d her shaking and excess weight as aspects of her problem. These were characterized as symptoms by the i n s t i t u t i o n and considerable time was spent in attempts to get beyond these symptoms. She was questioned frequently in group about aspects of her past and current l i f e in an attempt to f i n d the source of her troubles but was highly resistant to any attempt at de-t a i l e d exploration. As she proceeded through her stay at Theta, i t became apparent that she was not prepared to entertain the notion that her troubles could have sources beyond the observable symptoms. In f a c t , she combined a natural d i f f i c u l t y with the English language with a devastating a b i l i t y to misunderstand the questions. The net effect of this was that she blocked the inquiry and was the source of considerable f r u s t r a t i o n to her family and the group as a whole. After about three weeks, she decided that her problem was merely a weight problem. I f this was the case, of course (from her point of view), Theta was an inappro-priate place to be and she in fact l e f t shortly afterwards. Patient Beliefs P a r a l l e l with the therapists' b e l i e f s , there i s a system of patients' b e l i e f s which are instrumental in determining patient behaviour - 96 -in the setting and in their seeing what goes on at Theta as sensible, reasonable and understandable. These be l ie fs , l ike the therapists' beliefs posited in the previous chapter, are neither defended nor used in this section, but I hope to show in the two succeeding chapters how the social real i ty that is created at Theta depends on the bel iefs of the two groups and their mutual dependence. The bel ief system which I propose exists as follows: 1. That Theta is a special place where one can explore one's troubles in ways that are not available outside the sett ing. 2. That i t must be taken seriously and requires commitment on the part of i ts members. 3. That therapists are helpers and hence that they are motivated to improve the patients' well-being. 4. That they are professionally qual i f ied to observe and interpret behaviour and that this gives their observa-tions and interpretations a special status which is not accorded to lay observations and interpretations. 5. That the therapists' presence in the therapeutic setting is assurance that whatever comes up wi l l be "handled" in a way that is not threatening for patients and is "safe" for the patient involved. 6. That reciprocity of confidences is suspended in re la -tions between patient and therapist and that while the therapists should properly know a l l about the patient, the patient should not expect to know anything about the therapist except that he is a therapist. 7. That the social structure of Theta is properly defined by the therapists who may properly propose, question or redefine any act iv i ty at any time on the grounds that i t is or is not therapeutic, therapeutic effectiveness a l -ways being suf f ic ient grounds for any rule, interdict or act iv i ty without further explanation. 8. That although therapists' observations may confirm one perspective over another, they wil l be essential ly neu-tral in any interaction among patients and wil l not take - 97 -sides in disputes involving patients. 9. That both therapists and patients wil l suspend their traditional moral judgments. 10. That the group at Theta is more important than any ind i -vidual in the group and hence that behaviour invidious to the group must be suppressed. Further that commit-ment of a l l members to the group and to whatever is therapeutic is essential to the therapy of every member. 11. That patients should show their emotions and express their feelings about other group members. 12. That patients should have goals. 13. That time is a valuable resource and should not be wasted. 14. That suicide, whether attempted or threatened, is of immediate and pressing relevance to patients' well-being and should be attended to. 15. That alcohol and drugs are serious threats to the i nd i -vidual that should be abnegated and must be interdicted in cases of questionable dependency. One is tempted to add "et cetera"^ after a l i s t which cannot, of course, be exhaustive. The bel iefs that I have set out above and in the chapter on the therapist role appear to be some of those most f re -quently and clearly evoked and form the warp and woof of the unique moral order of Theta. - 9 8 -FOOTNOTES 1 . T h e p r o b l e m o f p r o v i d i n g a n e x h a u s t i v e s e t o f n o r m s o r r u l e s i n " a c c o u n t s " h a s b e e n a d d r e s s e d b y G a r f i n k e l . S e e , H a r o l d G a r f i n k e l , Studies in Ethnomethodology, p . 3 . G a r f i n k e l a r g u e s t h a t " W h e n -e v e r a membe r i s a s k e d t o d e m o n s t r a t e t h a t a n a c c o u n t a n a l y z e s a n a c t u a l s i t u a t i o n , he i n v a r i a b l y m a k e s u s e o f p r a c t i c e s o f ' e t c e t e r a ' , ' u n l e s s ' , ' l e t i t p a s s ' t o d e m o n s t r a t e t h e r a t i o n a l i t y o f h i s a c h i e v e m e n t . " a n d " T h e d e f i n i t e a n d s e n s i b l e c h a r a c t e r o f t h e m a t t e r t h a t i s b e i n g r e p o r t e d i s s e t t l e d b y a n a s s i g n m e n t t h a t r e p o r t e r a n d a u d i t o r make t o e a c h o t h e r t h a t e a c h w i l l h a v e f u r -n i s h e d w h a t e v e r u n s t a t e d u n d e r s t a n d i n g s a r e r e q u i r e d . CHAPTER FIVE THE RELATIONSHIP BETWEEN THE THERAPIST ROLE AND THE PATIENT ROLE In a sense therapists can be no therapists without patients and patients no patients without therapists. The idea of a special class of professionals labelled "therapists" with a specialized disc ip l ine labelled "therapy" depends on the corresponding idea of a special class of people labelled "patients" on whom therapy can be practised. Without therapists and therapy, patients are mainly part of a large group of people with unorganized diffuse troubles. It is only when they enter into a re lat ion-ship with therapists that they can properly be called patients.* A special feature of the relationship between therapists and patients is their different relationship with the inst i tut ion in which they * Of course once the relationship has been ident i f ied they are patients for everyone to see. Once labelled patients are patients not only for ther-apists but for fellow patients as well . - TOO -meet. The inst i tut ion i s , fcr patients, a "special place", a sanctuary to which they have come for a limited period of time. It is different in many ways from their everyday world and despite the assumption of the inst i tut ion that Theta should be a ref lect ion of the world, i t is recog-nized by the patients for what i t i s : a setting within but different from their outside world. In fact i t is this special quality that pro-vides i ts usefulness for them. In contrast to this perspective, Theta is the everyday world of the therapists. It is their place of business as members of one of the helping professions. They are not there for a limited time, they are "always" there. For this reason, i t is seen as proper for them to have a special part in determining what should go on there, in providing s tab i l i t y and continuity in what is seen by the pa-tients as a stable and continuing ins t i tu t ion , special ly constituted to give them help. Making the Difference Vis ible It can be said that every act iv i ty at Theta works to construct therapists as therapists and patients as patients. The two preceding chapters could now be discussed a l l over again to show that a l l the act-ions of therapists were seen as appropriate to their role by patients and allowed by patients as such. Similarly patients' actions could not be successfully operationalized without the tac i t assistance and approval of the therapists. The items that are discussed here, then, are a few of the more v is ib le minor matters that have not already been incorporated in the discussion of the separate roles. - 101 -It has already been noted that the absence or lateness of a patient was a matter of concern for both patients and therapists. In fact, even when the matter was reported by the patient there was some residual concern that he might be malingering. In contrast to th is , therapists who were late or who reported sick were seen as having good reasons for being late or absent and, i f s ick, were assumed to be gen-uinely so. Therapists occasionally took days off or l e f t early and in fact did a l l the things that employees of any inst i tut ion do, without any more comment from either patients or their fellow therapists than is usually accorded this kind of behaviour. Formally constituted group meetings were occasionally attended by the c l in ica l supervisor at times when he was not regularly scheduled to attend. On these occasions he could arrive during the proceedings and leave before they ended without generating any comment then or later . During group meetings, patients who engaged in private conver-sations were usually challenged and invited to share their comments with the whole group but this act iv i ty was seen as entirely appropriate for therapists. The therapists could also interrupt the proceedings and i t was seen as their right to decide that some process that was currently in progress should be discontinued. For example during one "weekends" ses-sion at which patients reported what they had done since the previous Friday the contrast between patient interruptions and therapist interrup-- i o a , -tions was evident. [Female Patient] spoke las t , was f i r s t interrupted by [Patient] who was "shushed" by [Male Patient]. [Fe-male Patient] resumed. [Cl inical Supervisor] arrived and after looking at the table. . .started to talk in a loud voice about charting. Several people seemed uncomfortable - he had interrupted [Female Patient] 's "weekend"...[Female Patient] eventually got a couple more sentences in but was interrupted again by [ C l i -nical Supervisor]. He wanted the charting started -i t was about 12:50. The proceedings of formal groups was interrupted on another occasion when the therapist decided that i t would be appropriate to introduce some music during an afternoon group. During much of the last part [Cl inical Supervisor] was attempting to operate the intercom. He kept buzzing and saying "he l lo" . At f i r s t there was no reply, then a buzz in return. The act iv i ty was the total centre of attention. He was saying, " l e t ' s have some music" or some such. After a second buzzing, there were gales of laughter. This behaviour from a patient would not have been tolerated by either patients or therapists. That the behaviour that was expected of therapists and patients was different was nicely i l lustrated in one after-group meeting at which a therapist was te l l ing the (therapist) group about the act iv i ty in that afternoon's family group. [Resident Psychologist] also reported about [Name] -she had been "going on" in family. [Resident Psycho-logist ] had let her go on. [Cl inical Supervisor] misheard and thought [Resident Psychologist] was ta lk-ing about [staff member with almost identical name]. He v/as obviously very surprised that [Staff Member] would do th is . Therapists were clearly expected not to "go on" in the setting but were expected to reserve their emotional problems, complaints, e tc . , for the - 103 -feelings group constituted for that purpose. Another aspect of the contrast between therapists and patients was v is ib le at a group interview at which a candidate for Theta exhibited signs of behaviour which simultaneously constituted him as somebody with serious problems v is ib le at the group interview reported in Chapter 4 in which the candidate for Theta exhibited signs of behaviour which simul-taneously constituted him as somebody with serious problems and somebody that i t was not desirable to have at Theta. The insistance of the ther-apist that the group make a decision resulted in the candidate being admitted despite the patients' clearly stated opinion that he should be elsewhere. No patient's argument could have carried the weight of the therapist 's demand that the patients vote and no patient was asked to intercede on his behalf after the therapist refused to do so. The points that have been made above i l l us t ra te , in part, the patient bel ief in the control of the therapists. Their understanding that they could and should assume the security of the patients in the setting is i l lustrated by an incident concerning patients' focus on suicide. A l -though the Theta brochure declared that the centre was "not for people.. . presently suicidal as other programs are more useful" (emphasis added), i t quite frequently happened that patients who had recently attempted to commit suicide were included in the group. There was occasionally though, talk or threats of suicide among the members. This talk was treated as a serious matter that the therapists ought to attend to. On one occasion their apparent non-attention was a source of annoyance to the group. - 104 -Several people objected to [Therapist] on ground he invoked feelings about suicide and then terminated the session - source of [Patient's] annoyance. [Patient] was supported by [several other patients] in her protest: allusions to therapist 's respon-s i b i l i t y . The therapists' behaviour was open to cr i t ic ism from the group on any occasion on which they violated what was seen as the norms of their role by the patients. For example, the possible partisan behaviour of a therapist during a session was the object of a long discussion at lunch one day. There was quite a<lot of talk about "Family Night". One of the issues was whether [two therapists] had "taken sides" in some of the interaction. An item was that [the therapist] had said that [Male V is i tor ] had to seduce his [g ir l friend who is a patient] every time he met her . . . " I t wasn't f a i r to support [Male V is i tor ] just because he was a European too." The patients appeared to be agreed that therapists should not "take sides". There was a lengthy discussion as to whether, in fact , this was a case of i t . Control and Democracy The business of managing the proceedings during actual therapy sessions is largely dealt with in the next chapter where I attempt to show that every detail of the patient doing therapy is managed by the therapist. Likewise, the rest of Theta time, apart from the detailed pro-duction of therapeutic behaviour, was almost tota l ly managed by the ther-apists. - 1 0 5 -The day to day business of the centre followed the schedule which is i l lustrated in Chapter 2 (Fig. 2.1) and this schedule was a production of the inst i tut ion which revised i t from time to time as c i r -cumstances demanded. The patients had no input into the production of this and consulted i t with the same uncrit ical curiosity that a school-boy consults his class timetable. "What we should be doing now" was written down for them and displayed so that they could know i t . Although the formal questions asked of new patients in the group interview may have formed a re lat ively small part of that total process, the formal questions were always asked and had to be answered in the prescribed manner. The formal questions were prepared by the inst i tut ion and the reading of them was part of the duty of the chairman. The patients' interpersonal relations were prescribed by the inst i tut ion. Apart from the s t r i c t taboo against sexual relat ions, there was a curious ambivalence about the inst i tut ion 's attitude to relations in general among the patients. New patients who had just been accepted in the group interview were routinely told that they were now "part of the group" and as such were expected to cal l group members i f they needed help between the day of their interview (Wednesday) and the day of their starting at Theta, which was the following Monday. - 106 -Now i t is known that a member of society does not turn to "just anybody" when he is in need of help. Sacks^ has shown with respect to suicidal persons who seek help that there are rules which "provide from whom help may and may not be sought." The rules provide for co l l ec -tions of paired relational categories which invoke certain rights and obligations concerning the act iv i ty of giving help. Furthermore, these collections are ordered sets; people seek help from the one at the top of the l i s t f i r s t , and proceed from there in s t r i c t order. It was clear that new patients did not see the members of the current patient group 3 as belonging to "classes whose incumbents are proper to turn to" just because they had been told they were, for example: [New Patient] reported sipping beer a l l day every day between intake [Wednesday] and Monday. [Male Patient] and eventually everybody took her up on th is . She had made a commitment to quit dr ink ing. . . Why hadn't she called somebody? She said that she wouldn't have called anybody from Theta even i f she had had the numbers, because she didn't know any of them. The staf f members at Theta, who might have been seen to be in an appro-priate "paired relational category" to the patient were not available to be cal led. After the patient had spent sometime at Theta, the other Theta patients appeared to be placed in a high position in the class whose " i n -cumbents are proper to turn to" and patients frequently called each other for help. - 107 -The danger now arose that the patients would form subgroups outside the centre which would act to prevent the troubles being brought into the sett ing. [Female Patient] was jumped on towards the end of ' the session. [Patient] said that she had been feeling suicidal and had called [Female Patient]. [Cl inical Supervisor] was extremely angry with [Fe-male Patient] for not reporting the incident to the group. She said that she had thought i t would be "betraying a t rust" . The fa i lure to report this incident has obvious dimensions other than sub-group formation. In fact , however, [Female Patient] did mention the i n c i -dent to a staf f member and i t was known to a few patients. The outrage that descended on the female patient appeared to suggest sharp l imits to the amount of helping that the inst i tut ion expected of the patients out-side the sett ing. Patients who social ized outside the setting were expected to report this act iv i ty in subsequent talk at Theta. The Monday lunch meet-ing was regularly constituted as a time to talk about "weekends" and any social act iv i ty that had taken place over the weekend was normally reported there. There was, however, no other formalized occasion for this and week-night meetings quite often did not get talked about. Staff members occa-sionally asked i f anybody had "seen anybody" the previous evening and were frequently asked i f this was allowable. The c l in ica l supervisor in pa r t i -cular usually answered that i t was "not forbidden", i t was a matter of choice; he did not "recommend i t " . The l ine , then, was drawn between "soc ia l iz ing" which was mildly proscribed and "asking for help" which was, rather ambivalently, approved. - 108 -The point that appears to come out of the ambivalent a t t i -tude of the inst i tut ion toward patients' interaction outside of the cen-tre is that too much act iv i ty of this kind could potential ly form power-ful all iances among the patient population which could effect ively reduce the control of the inst i tut ion over i ts charges. The most powerful a l l i -ance that could be formed was an expl ic i te ly sexual one and the strong reaction of the inst i tut ion to sexual al l iances was further evidence of their discomfort with act iv i ty that was outside their control. The f i r s t patient, for example, to be discharged for this reason during my period at Theta had had sexual intercourse with a patient who was in her last week at the centre. Despite the fact that she was no long-er present in the sett ing, the male patient, who had a week remaining, was discharged. It could be argued that the female patient was scheduled to attend for "after-care" (which she did not, in fact , attend) but there was at least one instance in which a homosexual couple were allowed to overlap their respective periods so that they were both present on the after-care day. A second patient who was discharged was present in group con-currently with his sexual partner. Just before family groups I was upstairs when [Staff Member] came up with al l the rest of the staf f . [Staff Member] was quite excited, said that there was a piece of excitement - [Male Patient] had slept with [Female Patient] the previous night. [Female Patient] had reported i t in her diary. [Staff Member] said that one of them would have to go now. - 109 -Although the group was extremely angry with (particularly the male) participant, they appeared reluctant to discharge either one. It was argued, for example, that there was "a difference between going to bed with someone and having a love a f f a i r " . The c l in ica l supervisor, however, insisted that one of the two must leave. He said that [Male PatientJ's actions had damaged the whole group. This had a v is ib le effect on several of the patients, one of whom remarked that he was not "prepared to sacr i f ice [his] own therapy for [Male Pat ient] . " The opposi-tion to the discharge continued and the c l in i ca l supervisor eventually said that [Male Patient] could be readmitted at a later date, but must wait at least three months. This was transparently a token gesture to reduce the heat, because he remarked to me afterwards that ...[Male Patient] could not get treated in this group. There should be places where people l ike him got treated. He might do better in the hos-p i t a l . The combination of intransigence, threat, and apparent concil iatoriness eventually had i ts effect and the group decided to discharge the male patient. The female patient was allowed to stay but was admonished not to see the male patient again; i t would " interfere with her treatment". Now i t was generally the case that patients currently at Theta were engaged in some sort of sexual relationship outside the centre, and at least a few patients were involved with former patients. (As I have remarked, patients not infrequently attended as a result of recommendations from their fr iends.) The explanations that were given (for the rules) in the centre were either explanation by f i a t : " i t damages the therapy", - no -" i t interferes with the treatment", or were characterized by the kinds of inconsistencies that have been discussed above. Why the re la t ion-ships which originated at Theta were so severely censured is thus a puzzle which i t seems only possible to explain in terms of con t ro l . e I would l ike to propose that the control involved was control of the boundaries of intimacy within the centre. Much of the act iv i ty at the centre involved people in intimate emotional and physical contact. Some of the non-verbal games involved bodily contact, and bodily contact was encouraged during and after abreaction therapy. The disclosure of intimate personal details about one's former l i f e was a routine part of doing therapy. In the l ight of a l l this act iv i ty i t seems eminently reasonable that the boundary should be clearly defined. I speculate that the strong taboo against and strong reaction to sexual intercourse was a clear statement of the precise boundaries of that intimacy which made i t "safe" to practice what might otherwise have been threatening behaviour. The next dimension of control I wish to discuss is time. It has already been said that the lateness of therapists was not an issue in the centre, while the lateness of the patients was. Punctuality was heavily emphasized at Theta, although i t was not uniformly enforced. Punctuality in the morning was s t r i c t l y monitored and a system of fines and "commitments" was levied against people who arrived late. Punctuality - i n -in other parts of the program was available as a resource to find that patients lacked commitment or were "slacking o f f " : The afternoon meeting started about 2:10. [Resident Psychologist] made this an issue: she said that people were getting slack about starting times. At these times i t was never an argument that the group often started a few minutes late, but the lateness was accepted as a bad sign. The pa-tients themselves addressed themselves to the same issue: [Female Patient]: Enthusiasm is at a all-time low...nobody comes on time, no one enforces the rules. Apart from punctuality, the patients were required to spend the fu l l day at the centre and were generally forbidden to leave early unless there were very special extenuating circumstances which were known from the time of their f i r s t admission. [Male Patient] l e f t early so as to be in time for his job. He was told to make other arrangements so that he didn't have to leave early. At lunch a g i r l asked to leave early Tuesday so as to get to [Theatre] on time - was refused by another group member. The fact that the patient in the f i r s t example above was not allowed to leave early to go to his job leads to another dimension of the control question. The inst i tut ion expected that people would devote their whole time to Theta during the six-week period of their stay and generally asked them i f they could support themselves during this period. "Moon-l ight ing" was frowned upon and the patient above, for example, was ques-tioned very closely about his necessity to work during the evening hours: - 112 -[Male Patient]'s job was the next subject. He explained that he drove taxi until 2 a.m. He was asked i f he was t ired the next day. . He said "no" again. Somebody asked i f he was just passing the time. He smiled and said "yes", he was "just passing the time". He was asked why he didn't need the money, explained he was e l i -gible for unemployment insurance. It was sug-gested he had a "thing" about working. He said he did. People asked how he worked at Theta. The foreman said that he worked wel l . This patient was eventually persuaded to stop working his sh i f t be-cause i t " interfered with his treatment". In general the patients made almost no decisions about any-*d thing at Theta and, as can be seen in the work of the committee, saw themselves as having l i t t l e or no power to affect the procedure. Therapists exercised their authority in exp l i c i t matters such as the schedule, and on occasions such as when the group made recommendations as to who should work. The patients' choice might be followed or not depend-ing on the judgment of the therapist. The therapists also exercised con-trol in more subtle ways such as, for example, when they voted f i r s t on occasions on which they wished to have the weight of their opinion behind a particular decision: * An obvious exception to this was the group decision to admit new patients. I feel somewhat ambivalent about this point because I never saw the group refuse any patient. I inquired about this and was told that "we nearly refused so and so" but could find no case of an actual refusal . Some votes regularly went against new patients which was, perhaps, a safe way to exercise some autonomy provided i t was apparent that the votes would not influence the process. The only occasion on which I saw the patients attempt to influence the procedure (discussed in the text) , the attempt was frustrated by a therapist. I neglect minor matters l ike the patients deci -ding on the menu for the lunch they cooked, choosing material for. chair coverings and the l ike . - 113 -The group voted on whether [Female Patient] should stay or not...The chairman asked [Male Patient] to vote f i r s t . He said he voted "no" and gave his reasons. . . . [C l in ica l Supervisor] said there was no time to go around with every-body giving reasons and that i t should just be a hand vote. He asked for a show of hands of people who thought that [Female Patient] should be allowed to stay. He immediately raised his own hand as did [Resident Psychologist]. The few people who had or ig inal ly objected to [Fe-male Patient] staying voted against her but she was allowed to stay by a large majority. During the early period of my observations the family groups were arranged so that their members were picked by lot on Wednesday. There was discussion about this arrangement in the therapists' after-group meetings during the period when a point system (discussed below) was being worked out. The author of the point system was in favor of having the family groups stable throughout the patients' stay and persua-ded the other staff members of the advantages of this system. The patients were asked i f they would agree to have the family groups changed to the new system and said that they would not. After further persuasion, how-ever, they agreed to let them run two weeks instead of one. About a week after th is , i t was decided that the family groups would remain stable but that families could "bargain" for members from other famil ies. What the "bargaining" would amount to and how i t would be effected was not explain-ed and I did not see any done during the remainder of my observations. The talk about "bargaining" did, however, produce an i l lus ion of f l e x i -b i l i t y which sweetened the p i l l enough to make i t swallowable. - 114 -Sanctions and Rewards It was an interesting paradox at Theta that while the f inal sanction available to the inst i tut ion was that the patient could be d i s -charged, one of the primary tasks was to keep the patient in . This meant that a nice balancing act had to be continuously accomplished. If the threat of discharge loomed too large, this reduced the patient's commit-ment to the centre, whereas i f i t was taken too l ight ly i t was no longer effective in achieving the control that was needed. In the l ight of this balancing act, the need to have the pa-tient heavily committed to the program is apparent and this provides an effective explanation for the extremely heavy emphasis Once the patient was thoroughly committed to staying at Theta, the threat of discharge became very weighty. Actually, very few people were discharged during my stay. The cases that I have already reported stood out as exceptional events. One patient was discharged for coming to the centre smelling of drink: They confronted him and [Female Patient] confirmed that she had smelled i t too. [Male Patient] said that he had been drinking the night before. [My informant] said that everybody was very angry with [Male Patient]. I asked her who had suggested that he leave, she said she thought i t was [Resident Psy-chologist] . They had had a vote. Only one person voted against i t . She said that only a couple of people had been positive but they needed him to leave. - 115 -The notion that the discharge was cathartic for the whole group appeared on two of the three occasions that I was aware of a patient being discharged. On the f i r s t one a staf f member told me: . . . i t was necessary for [Male Patient] to be d is -charged to cleanse the group. He said the group had been much better since [Patient] l e f t . This suggests that an attempt was made to offset the traumatic feelings associated with the responsibi l i ty of voting out a fellow-member by repre-senting i t as an essential ly therapeutic act. The threat of discharge was much more widely apparent than d i s -charge i t s e l f . [Female Patient] hurt, annoyed, sulky, declared she was going home. [Cl inical Supervisor] told her she could not go, he would discharge her. She eventually stayed. The threat was not often used as exp l i c i t l y as this and was more often em-bedded in the implications of a system of probation. Patients who had trans-gressed against the rules of Theta were "put on probation" with the impl i -cation that discharge would probably follow i f they did not reform. This was often enough to produce a change in behaviour and seldom resulted in actual discharge. Patients who had transgressed against the rules were sometimes fined small sums of money, for example when they were late in the morning or absent without cause. A system of "make-ups" was also in effect in which patients were expected to make something for the centre such as a picture or some art or craft object or occasionally to write a poem. The make-up had to be negotiated with the group but was generally considered - 116 -as a rather minor matter. It was only when the group became d issat is f ied with the member that they looked to the make-ups to see whether, in fact , they had been done and what form they took. This was then available as further evidence (perhaps) that the patient lacked commitment or was not taking the business seriously enough. The inst i tut ion i t s e l f started a system of rewards and sanc-tions in the form of points which were given for good or bad performance in the work at Theta. Although the o f f i c i a l document describing this system predicted that "[The] direct effect [that i s , the effect on the individual patient] wi l l probably be quite n e g l i g i b l e " , the document argued that the system would "[increase] the group members' awareness of being part of the group (family here)...[and] the group members' con-cern for other members' disturbing behaviour which could otherwise be 'kindly' [s ic ] tolerated." Also, "It certainly increases the attention paid to the rules of the game, that i s , increased [s ic ] d i sc ip l ine . " The group members treated the point system as another ar t i fact of the inst i tut ion which ought to be "taken seriously" but which generally didn't appear to mean very much apart from that. To be f a i r , i t should be said that the system was s t i l l being worked out at the end of my per-iod of observation but already the kind of attention that was paid to the system could be seen. For example a family that had very few points one week had a lot of absences. Far from motivating the family to brow-beat their absentees, the absences were seen as adequate explanation for - 117 -the low points. A Patient remarked "that's real ly good for only two members".[referring to the number of accumulated points]. Insofar as i t had developed, the achievement of high points had no payoff. The c l in ica l supervisor tentatively started to offer himself to the family group with the highest number of points for family meeting, which caused a certain amount of interest but in general the point system was being treated for what i t was: an a r t i f i c i a l , mis-leading (insofar as members could see that there were "good reasons" for low points) and irrelevant (from the patients' point of view) a r t i -fact of the inst i tut ion which, l ike the charts, had to be attended to because the inst i tut ion considered i t useful. The commitment and control that the system was supposed to influence was well established without the system and the success or fa i lure of the families was apparent with-out the points which either reflected i t : C l in ica l Supervisor: Which family has the highest score? Patient : Family 3. Cl inical Supervisor: I thought so. or i f i t did not was viewed under the auspices of what everybody knew was * the explanation for that. * It has been pointed out that the fact that there was no apparent payoff produced a useful therapeutic paradox and that in any case the point system did produce an observable change in the commitment of the group to punctuality and attandance. My fai lure to produce an explanation in sociological terms is characterist ic of the fact that i t is not always possible for the observer to discern al l the dimensions of any act iv i ty in a setting and in this case I was unable to find any explanation in terms of the perspective I had developed. - 118 -Before I go on to the next chapter, I would l ike to review some of the matters that I have attempted to draw out in discussing the way in which the patient role and the therapist role meshed. I have argued that Theta was "home base" for the therapists and a special place for the patients; a place, moreover, in which the act iv i t ies were r ightfu l ly directed by the therapists. I have attempted to show that this difference was apparent in attendance, time keeping, and in the authority that patients expected therapists to exercise. I have attempted to show the wide range of act iv i t ies in which the auth-ority vested in the therapists was exercised. The control the inst i tut ion exerted over the proceedings could be seen in the schedule of ac t i v i t i es , in the conduct of interviews, in the act iv i t ies of patients within and without the sett ing, and in the ways in which patients interacted with each other. Control was backed by a system of rewards and sanctions, the most powerful of which was discharge or the threat of discharge. This sanction was especially effective because of the strong commitment that was generated in most patients. I have attempted to show that the principal feature of the interrelationship was that the authority of the therapists was seen as appropriate authority which should be accepted without question in a l l - 119 -Theta act iv i t ies whether the usefulness of those act iv i t ies was immediate-ly apparent or not. - 120 -FOOTNOTES 1. Harvey Sacks, "An Init ia l Investigation of the Usabil ity of Conversational Data for Doing Sociology", Studies in Social Interaction, ed. David Sudnow, New York, The Free Press, 1972. 2. Ibid. p. 40. 3. Loc. c i t . 4. "The Rationale of the [Theta] Marking System", In-house Memorandum. 5 . Ib id . CHAPTER SIX DOING THERAPY The central purpose of Theta is to provide a place in which therapy can be done. The centre is designed to give assistance to peo-ple who have neurotic problems and the ways in which i t is organized are designed to fac i l i t a te the treatment of these problems. The actual ac-t i v i t y of doing therapy depends on the way the patients are formulated as patients and on the way the therapists are formulated as helping pro-fessionals. The parts of the thesis which have been developed so far , are intended to provide the foundations for a description of the p r inc i -pal act iv i ty of the centre and in this chapter that act iv i ty is discussed. I shall attempt to show how the roles of patient and therapist and the relationship between them are used as resources to allow the busi-- 122 -ness of doing therapy to be carried out. I shall attempt to use the pa-tient and therapist bel ief systems to show that therapy is a rational act iv i ty that depends on the beliefs embedded in the two roles : I shall attempt also to show (at least by implication) that the commitment and control that the inst i tut ion demands and exercises are necessary to the act iv i ty . Some Features of the Therapeutic Act iv i ty The Theta ethic was that everything that went on in the set-ting was therapeutic. It was the case, however, that some act iv i t ies were considered more important than others and among a l l the ac t i v i t i es at the centre the "big group" was primary. A perennial complaint of therapists was that important matters were not brought up in "big group" and the Cl in ica l Supervisor frequently made references to i t as the most important act iv i ty at Theta: [Male Patient] said that he had been annoyed with [Male Patient] in family but had said i t there. [Cl inical Supervisor] said he should say i t again because everything must be brought into big group. This was the summit - the highest form of Theta act iv i ty . I have argued in a preceding section that the reasons for forming the smal-le r , "family" groups appear to be related to the necessities of d is t r ibu -ting Theta resources rather than their therapeutic effectiveness. In any event, no therapy that was carried out in the smaller groups was neglected in big group and I focus most of my attention in this chapter on that sett ing. - 123 -The Cl inical Supervisor once agreed rather "half in fun and whole in earnest" that therapy (and part icular ly abreaction therapy) was a "kind of exorcism". The force of this metaphor appears to be that i t focuses on the peak therapeutic act iv i ty at Theta which was the genera-tion of strong emotional reactions: "abreactions". I am not attempting to argue that this was the primary therapeutic focus but that i t was the act iv i ty that was valued by patients and therapists alike as the summum of "doing therapy" while I was at the centre. This act iv i ty was referred to as "working out" and people who did i t were said to be "on the mat". Patients who resisted this act iv i ty or who were unable to " let go" when they were "on the mat" were frequently seen not to have benefitted from their period at Theta, even though they might have participated in "blind walks", "role playing", dance, theatre, families and the rest. As this may be a rather controversial point, I would l ike to cite some of the evidence which has led me to make i t . F i rst of a l l there was a marked contrast to the reaction among therapists after a session in which one or two patients had "worked out" and sessions in which no one had done so. Sessions in which patients had "worked out" were described as heavy but good sessions. The therapist who had worked most direct ly with the patient was often t ired but was f re -quently congratulated on the "good work out" that had occurred. - 124 -At one session a new patient reacted to the abreaction of a patient who was "working out" by herself crying, which was a f a i r l y com-mon occurrence. It often happened that behaviour of this kind was used as a resource to get the second patient to "work out" at the same time. This was not, however, usually done with new patients. At this session the new patient was taken by a v i s i t ing therapist who was unaware of her new status ( i t was the patient's f i r s t day). The v is i t ing therapist attempted to lead her into an abreaction which scared her considerably as she had not yet seen enough of the centre to absorb the norm that this behaviour was useful. Her lack of commitment to this norm was exp l i c i t l y stated after the session when she said that she thought i t was a "bad sign" that she had "broken down on the f i r s t day". My f i e ld note further re-cords: [Cl inical Supervisor] said i t was a good sign. Some people took weeks to achieve what she achieved. Some never did. [Female Patient] reinforced this - she hadn't been able to do i t at a l l . The abreaction, then, was an achievement for patients: something to be desired. This was readily observable among patients who frequently talked of "real ly wanting to work out". It was also observable among patients who had "worked out" in the sense that i t was "news": [Female Patient] came up tc me as I entered and said she had "worked out" on Wed-nesday, obviously delighted with herself. It was "news" too in that i t was recorded on the daily report by the patient committee who would re-port that they had worked with a therapist but "didn't get into anything" or "nothing came out" when their act iv i ty did not lead them to a workout. - 125 -The patients' attitude to abreaction can be seen, f i na l l y , in their attitude to the different therapists in the sett ing. Of the five regular staff members at Theta, only two ordinari ly did abreaction therapy. It was sometimes remarked that [Staff Member] was good but did not "work out" with people or that [Staff Member] was good in family because he or she made people work. That the two staff members who did abreaction therapy were more highly valued may have been attributable to their greater all-round sk i l l and experience, but i t seemed to be the case that at least some of the attitude was attributable to the part icu-lar kind of therapy they did. Doing therapy, then, at i ts most highly valued leve l , involved the patient in the display of strong emotions and in behaviour which, while extremely threatening to new patients, was eagerly sought by com-pletely social ized members of the group. In fact , "working out" was the acme of group involvement and had some of the qual i t ies of an in i t i a t ion ceremony which provided a warrant for fully-fledged membership in the group. In a setting in which therapeutic act iv i t ies are valued above a l l others, the therapist is valued above a l l others as the dispenser of therapy. Although the ethic was that everything was therapeutic, the most clearly acknowledged therapeutic periods were when a therapist was present. The therapist 's absence was frequently the cause of complaints, * Therapists were not often absent but on the occasions on which they were, the frequency of complaints was high. - 126 -for example this extract from a patient's conversation about the a c t i v i -ties of his family group: " . . . there was an opening there...we..we were...weren't qua l i f i ed . , just didn' t know how to handle i t . Eh . . i f a therapist had been there 'n i f we had had more time, I think we could have f a i r l y s ignif icant progress there. A stronger statement was made by a male patient at the end of a session in which there had been a f a i r amount of acrimony. I was waiting out-side the door and he burst out of the room with: "Where are a l l the god-damn therapists?" The anger and indignation in the question are ev i -dent. Actually one of the staf f was present at the meeting and this i l lustrates another detail of the therapist 's attributed qual i t ies which I shall discuss below. "Where are the therapists?" was a common ques-tion when the group was assembled and nothing was happening. It was asked on occasions on which therapists were present but unnoticed and the work of the group had not started, as well as on occasions on which the therapists were late. The occurrence of this question as a reaction to lack of act iv i ty points to an important feature of "doing therapy", that i s , that i t is an act iv i ty that i s , l ike a l l other ac t i v i t i es , pro-perly directed by the therapist. In the discussion of therapeutic a c t i -vity that follows in the rest of this chapter, a characterist ic of the act iv i ty is that i t is negotiated with, sanctioned by, produced by, managed by and (at least optionally) terminated by the therapist. There i s , of course, co-operation on the part of the patient but the therapist is the impresario. To return to the angry question about the therapists' absence, - 127 -this seems to me to point to another dimension of the therapists' presence in the setting while therapy is going on. The therapist 's presence is assurance that the situation wil l not get out of hand, that i s , he not only properly does control the act iv i t ies in "doing therapy" but that he can control them. In the absence of therapists, therapy is seen as a d i f f i c u l t and potential ly dangerous task. The quotation re-corded on the previous page was followed by a further one in which the patient sets out the dimensions of the problem seen by the group mem-bers: " . . . t h i s is l ike amateurs trying to do an appendectomy, i t just didn't work and we had to leave i t . . . " . I watched at least one event which pointed to the troubles of attempting to "do therapy" without the protection and direction of the therapists. The incident occurred on a family night on which the scheduling had been such that when the end was announced by the therapist a patient who had brought a friend had s t i l l not had an opportunity to do therapy. The patient protested;) that she wanted to work but the therapist declared that there was no time. He went on to explain that he believed that the patient's problem was better work-ed on in the regular group. The explanation was so transparently ad hoc that nobody present appeared to believe i t and i t was exp l i c i t l y disputed by one patient who proposed that the group should continue. The therapists a l l l e f t and went upstairs. The self-appointed leader started to do a fa i r imitation of the therapist at family night but i t was clear that there was a lot of anxiety among some of the members. It very quickly became appar-ent that the interaction between the patient and her guest was not going to - 128 -"go anywhere" and more and more people began expressing their concern about the group. About f i f teen minutes after the "coup", a male patient said "It 's just l ike the therapist said, [Female Patient] would be better off in group". Five minutes later the therapists returned and announced that the session must end because they had to lock up the building. The group broke up with considerable re lef . Emotions I have attempted to demonstrate above that the summum of doing therapy is abreaction therapy and would want to argue that much of ther-apy involves emotions as at least one i f i ts dimensions. It seems appro-priate, therefore, that I should discuss how emotions appear to be under-stood and talked about at Theta. The most frequently discussed emotions at Theta were anger-* hosti l i ty-hate, occasionally jealousy, with closeness as a probable second. It seems not inconsequential that anger-hostility-hate are emotions that are most readily acted out while loneliness, sadness, fear and gu i l t , to name a few others that were reported, are less available for this mode of treatment. This seems reasonable in a centre where the treatment tends to be action-oriented rather than talk-oriented. One could speculate, too, that "closeness" is available for demonstration * Closeness was never defined and appeared to have physical as well as emotional dimensions. It was used to indicate the attachment of friendship and comradeship as well as interpersonal intimacy and can perhaps be seen as the opposite of anger-hostility-hate. - 129 -via the non-verbal methods which were used at Theta whereas love, ten-derness etc. is not. This i s , of course, pretty speculative and any-body who has seen Marcel Marceau would probably disagree with the last part. That anger-hostility-hate were believed to be the emotions most relevant to doing therapy appeared to be supported (at least nega-t ively) by a statement made by a female patient who complained to the group: "I want to gain from therapy and I can't i f everybody is going to be so nice". It was routinely the case that patients' experiences were searched to find someone at whom they were angry so that the anger could be ventilated in the group and phrases l ike "[Patient] expressed anger at her father" were commonplace in the daily reports of the committee. Like "working out", they were "news", whereas "[Patient] cr ied" or "[Patient] expressed loneliness, sadness, fear or gu i l t " were not part of the stock of cliches that produced the "business as usual" character of the daily report. Recognizing emotions is part of the task of doing therapy. Both patients and therapists attended to the usual indicators of laugh-ter, tears, facial expression, body posture and the rest but in addition to th is , both patients and therapists acknowledged that recognizing emo-tions could be a problem. Emotions might not be what they appeared to be. For example, when a female patient started to cry at one group meet-ing the therapist said "that 's how you express your anger" and a few mo-ments later the second therapist at the meeting reiterated "when you're - 130 -angry you cry, you must have some feel ings, I saw i t " . Not only might emotions not be what they appeared to be but they apparently could be present without the owner's knowledge. A female patient wrote after reading her autobiography to the group "I was happy that no hate feelings appeared for Dad". It was regularly assumed that i f someone recounted being in a situation in which anger was appropriate, then they had been angry even though they weren't aware of i t . Emotions are infectious and one person's emotional outburst may trigger emotions in another. This was especially true of abreaction therapy when one or several spectators frequently started to cry while the principal actor was "working out". The reaction that was attended to was always the same. It was not the case that anybody searched to see i f anger had invoked anger or hate, hate, but whatever emotion was being expressed, the searched-for reaction was tears. It was known, of course, that people could be having reactions that were not so apparent but this was not attended to among patients. On one occasion a therapist remarked to me after a session that I was "feeling something". Although the ther-apists ' "feelings meeting" (which I did not attend) was scheduled at the time, the therapist told me to come upstairs so that I would not have to spend the rest of the day suffering. This attention to my-reaction was, perhaps, generated by the knowledge that I had a vested interest in not displaying emotions and so I was subject to closer scrutiny for more sub-tle signs of having been infected. Final ly i t was frequently the case that an attempt was made to - 131 -demonstrate emotional dimensions by physical distance. Enough has been written about group ecology in the l i terature of non-verbal communica-tion to make i t unnecessary to argue for the significance of physical distance in group settings. At Theta i t was assumed that an equation could be made between emotional "closeness" and physical closeness. On Family Night, families were routinely asked to demonstrate the way they fe l t about each other by arranging themselves on the stage, for example: [Female Patient] appeared to be very frustrated with the whole process and eventually rearranged the chairs (under.[Male Patient] 's request) to express how she fe l t about her two parents. " She put her mother beside her father and herself outside the c i r c l e . [Male Patient] was asked how close he fe l t to members of the group and he said that he f e l t equally close to a l l of them. He was invited to place them at the phy-sical distance he would l ike to have them and placed them in a c i rc le around him...[Resident Psychologist] asked him i f he would l ike people to be closer to him and he said he would. [Resident Psychologist] then asked people to show how close they would l ike to be to [Male Patient] and there was an immediate move to surround him. [Male Patient] said that he fe l t that [Male Patient], who was well outside the c i r c l e , should be closer. [Male Patient] said he didn' t want to be any closer. Categories for Therapy The patient population at Theta, during my period of observ-ation, was' usually predominantly female. No attempt was made to redress this imbalance by making special efforts to recruit male patients and i t appeared to be believed that the sex category was irrelevant to therapy. The categories "Patient" and "Therapist" are, of course, sexually neutral, and both category classes contained male and female members who were, in pr inciple, treated uniformly without regard to their sex status. - 132 -The irrelevance of sex categories was further evidenced in that the same therapy was done on patients regardless of their sex and even sexual problems themselves were discussed without apparent refer-ence to the individual sex involved: women's sexual problems were treated essential ly in the same way as men's even though some of the male prob-lems discussed were sex-specific. In role playing the imbalance of the group sometimes presented some problems in that there were frequently insuff ic ient men present to f i l l the roles required. The c l in ica l supervisor frequently remarked that the person a patient chose to play some male role "could be a woman" and apparently believed that their actual sex category was relat ively un-important to the act iv i ty . Occupational categories, too, appeared to be completely i r -relevant to the therapeutic act iv i ty . I was frequently conscious of sud-denly becoming aware of the occupational category of some patient (for example when I found out that one of them was a policeman) and being sur-prised to notice that in general I had no idea what people did in their ordinary l ives . In a few cases categories l ike "housewife" were alluded to as part of the problem in the sense that the patient did not feel f u l -f i l l e d in that role. There was also occasionally some talk about what kind of work people would do after they le f t the centre, but as far as doing therapy went, there were no differentiat ions made in the kind of treatment that was administered that rested on occupational categories. - 1 3 3 -Some relationship categories were considered universally relevant for therapy. The most noticeable of these were "father" and "mother" which were sex discriminated, and "s ib l ing" which was not except in so far as the names used were inevitably discriminatory. Every patient was asked about his or her father and mother and was asked to explain his past and current relationship with them. This occurred in the various pre-admission interviews and was carried into the therapeutic setting as a routine and ongoing preoccupation. Patients were assumed to have strong feelings about their parents and their s ib l ings. Other categories that were considered relevant were "homosex-ua l " , "black" (which was formulated as a problem-relevant category by a West Indian patient) and " re l ig ion " . That someone was "homosexual" was taken by the patient population to be an adequate reason for his coming to Theta without any further explanation and i t was always available as a possible category that could be invoked to explain feelings and behav-*i iour, even though the patient did not himself invoke i t . J The patient f i l es that were prepared for the inst i tut ion routinely recorded the pa-t ient ' s re l ig ion . The rather random l i s t that appeared: Protestant, Lutheran, Mennonite, Roman Catholic, NDS (?), None, N i l , seemed to ind i -cate that i t had not much signif icance. It rather seemed that every-day stereotypes had as much force as any therapy-relevant consideration or sheer classifacatory schema. *This assertion is disputed by the inst i tut ion who deny that homosex-ual ity by itself was enough to get the patient accepted. A staf f member told me that doubts about sexuality, or fears that one might be homosex-ual might be considered but that homosexuality, even i f that was declared to be the problem, would not be accepted as such. - 134 -The c l in ica l supervisor once asked, on being told that a patient had a mother problem: "Is she Jewish?" It was the case, however, that pa-tients were sometimes asked i f they had "rel igious conf l i c t s " . I never saw this used as a resource in doing therapy. Roles and Therapy The most important resources in doing therapy are the patient and therapist roles. These have been formulated to make the practice possible and the practice i t s e l f depends on the bel iefs embedded in these roles which have been set out in the relevant chapters. The therapists' assumption that anyone can have problems a l -lowed them to accept whatever formulation of the problem the patient pre-sented as evidence of actual trouble and his presence in the setting could be seen as reasonable and understandable in the l ight of the be-l i e f that his problems were beyond his capacity. No further enquiry was conducted to find i f the patient was malingering and there was no sus-pension of bel ief in the story the patient to ld. The attention that was paid to the patient's story was evidence that he was considered a compe-tent reporter and this was a determinant of what was counted as troubles in the therapeutic sett ing. The attention that was paid to emotional states and part icu-lar ly to the emotions, generated by fathers, mothers, s ib l ings, husbands, wives and the rest were determined by the understandings that these were relevant matters for doing therapy, and their invariably being involved - 135 -made them essential elements of the act iv i ty which was carried out. The patient bel ief that Theta was a special place was essen-t i a l in that he had to be able to behave in ways which would convention-a l ly be disallowed. The ways in which he behaved had to be prescribed under the auspices of a characterization which eliminated the poss ib i l -i ty that he was "throwing a tantrum" or "being a cry-baby" or "disturb-ing the peace" or whatever characterization might have been put on the behaviour in another sett ing. As the therapists were, presumably, the people who "real ly knew what was therapeutic", i t was entirely reason-able that the behaviour should be directed by them. They were, moreover, characterized as helpers, which was both necessary and suff ic ient for the behaviour they suggested to be pursued. This was especially so as the behaviour was suf f ic ient ly removed from what is conventionally received as reasonable to be extremely threatening to the actor. Categorizing the therapist as a professional helper immediat-ely invoked special roles and rights to which professionals are due which included the assumption that when you take your problem to him you des-cribe i t to him but he does not reciprocate with information about his own troubles. It further located him as a proper person to take troubles to, a specia l ist on troubles whose specia l ist training qual i f ied him to deal with troubles. The patient and therapist roles, then, allowed the business of going to therapy to get done. In contrast, there were a few roles - 136 -that were either deliberately or unconsciously invoked which blocked or interfered with doing therapy. The role of worker which was impl ic i t in the discussion of work in Chapter 2 tended to have this qual i ty ; that i s , i t was to some extent incompatible with doing therapy. In similar ways the role of player (in the sports) and of actor in the Theta dramas had to be suspended before therapy could be done. In fact, as I shall show, the therapy that revolved around these act iv i t ies was car r iedout after they were over, when the group reconvened to view what had been going on in the l ight of i ts therapeutic relevance. Another role that I saw invoked to prevent therapy being done was that of comic: [Male Patient] put in a tremendous performance and had most people in the room in f i t s of laughter. A com-pulsive attention-seeker with a good sense of his aud-ience...[He] real ly had control of the group for a while. This role in which the proceedings are treated as essential ly non-ser-ious, seems to preclude the kind of business which is understood as ther-apy from being transacted at Theta. This so much annoyed the therapist in charge that he remarked afterwards: . . . that he thought [Male Patient] might be suffering from "minor brain damage" from some fa l l he had when he was a youth. He said that [the patient] "lacked the ab i l i t y for abstract thought"... The essential ly emotional character of the therapeutic pro-cess also tended to make the intel lectual role incompatible with i t . One of the ways in which this could be seen was in the pejorative use of - 137 -the term " in te l lec tua l iz ing" . Any attempt to explain or interpret the process on the part of the patient rather than just to experience i t was open to the challenge that i t was "just in te l lec tua l iz ing" which was seen as a worthless and counter-therapeutic act iv i ty . This term was not, however, applied to therapists' interpretations which were accepted as having a different status to that of the patients' comments. The business of doing therapy i t s e l f involved patients in the playing of certain secondary roles such as the parents, sibl ings and other s ignif icant figures in the l ives of patients who were work-ing: [Cl inical Psychologist] asked [Patient] to select some people who could stand in for her father, her mother, her uncle and her grandparents. [Patient] selected A as her mother (some people referred to her as the group mother and she was frequently chosen as mother in these tableaux), B as her f a -ther (the group has currently only three men B, C and D. D is new and unknown and C is gay and small. B is large and hirsute and is chosen to play almost a l l male roles at the moment.) [Cl inical Supervi-sor] frequently says that people can "choose a wo-man i f you l i ke " . [Female Patient] used to get chosen for any and every role. Once the role players were chosen, the patient would give them some mini-mal information about the kinds of people they were supposed to represent and then attempt to address them as those persons. Being a reasonable facsimile of some person was not always successful as for example: [Female Patient] was playing the role of [the patient 's] mother and did not seem to have much idea of what a woman who had been brought up in an Austrian convent would be l ike . - 138 -[Male Patient] tr ied to talk for K's father but i t sounded very much l ike the performance he had given with M. He was pretty well at. a loss as to how a reserved upper-class Dutch autocrat would behave. The success or fa i lure of the enterprise depended on there being either some correspondence between the role-players in terms of stereotypes or in terms of the role-player producing a display of his own (say) father's behaviour and this being similar to that of the pat ient 's . Making the fai lure expl ic i t was a way to stop the act iv i ty : [Two patients] were persuaded to arm-wrestle on the f loor. This was a stand-off too. N said very mat-ter-of-factly that she thought she was arm-wrestling with [Patient] and not with her father. [Patient] got up and started a round-robin to find out what people thought of her. In general, the more successful role playing was, not surpr i -singly, by patients of people that they knew intimately. This often pro-duced noticeably different characteristics from those displayed by the patient. After some time [Cl inical Supervisor] asked her to s i t on a chair and pretend to be [her lover]. She did this and her demeanor immediately changed. She became less defiant and more subdued. The creation of the second role in a relationship such as this frequently led people to understandings of how the two roles f i t ted together. Patients were also asked to play themselves in roles which had been discerned as part of their spectrum of behaviour and sometimes to carry on a dialogue between two apparently contrasting roles that they espoused: - 139 -[Resident Psychologist] asked [Patient] to speak to [Herself]. The demanding Y to the real Y. Y said she would be making i t up, but tr ied anyway. [Sev-eral patients became engaged in the role playing, some speaking on behalf of one Y, some interacting with Y.] Y actually was playing at least two roles herself, a nasty, vindictive role: "What're you going to do now?" in a minor 5th sing-song voice, (I'm the king of the cast le ) ; "I'm not going to let you". Meanwhile the other Y roared at her, big voice, "You aren't good enough for the group"; "The group won't let you stay"; "you can't make i t " . Patients did not always choose the roles they were to play themselves and the group could suggest roles that they thought the patient should try out: A was told to choose a surrogate husband and chose B. . . [C l in ica l Supervisor] suggested that people show the relationship between the two non-verbally. After a few suggestions [a patient] came up with the following: She should put her arms around his neck and hang there. [Cl inical Supervisor] told her to take this posit ion. A tr ied i t and def ini te ly didn't l ike i t . She " fe l t funny". That patients fe l t uncomfortable in roles they were playing was often taken as a sign that the role was psychologically s ignif icant for them. This applied to incidents l ike the one immediately above where the patient was assumed to have discovered something about herself, but also to incidents in which the discovery was less deliberate. For ex-ample, i f a patient in the patient play f e l t uncomfortable in the role he was cast in , this was made a resource for doing therapy on the presu-med aspects of the patient's l i f e that that role encapsulated. - 140 -Learning What's Wrong It has already been said that whatever the patient reported as troubles were assumed to be troubles for him. This meant that the l i s t of what could count as the source or symptom of neurosis was, in p r i n c i p l e , inexhaustible. I f this i s true, there can, i n p r i n c i p l e , be no standard decision procedure for determining what i s r e a l l y wrong or discerning cause from symptom. The l i s t of troubles that was generated during my stay at Theta ran from amputated limbs and physical deformity to not being able to open mail or pay b i l l s . The f i r s t formulation of the trouble too, was not always sus-tained during the period that the patient was i n the centre and things that had not been suspected as a trouble could be found to be a trouble in the course of the treatment. How i s your o r i g i n a l problem? Wasn't i t something to do with loneliness? I asked [a patient who was f i l l i n g in numbers on her chart] why she had changed "Roman Catholic" from 6 to 5 [which indicated that i t was more serious]. She said she thought she had problems that she didn't know about at the beginning. It was also always open to the therapists to propose that what had f i r s t been formulated as the problem was not r e a l l y the problem at a l l but only a symptom of the problem. A accused B of withholding some talk about his wife. He fears she w i l l leave him i f he admits he has had homosexual re l a t i o n s . [Therapist] suggested that that was not r e a l l y his problem and he asked for help in formulating his problem. - 141 -The resources that the centre used for discerning the dimen-sions of the problem were al l the act iv i t ies that were engaged in . These ac t i v i t i es , such as dance, theatre, work etc. were routinely scrutinized to see whether they had e l i c i t ed feelings in the patient that could be used to discover the real trouble. Q was questioned about why she had not pa r t i -cipated in the whole of the dancing. She said she hated that kind of thing...R said he hated that kind of thing too. He said he had an ab-solute horror of i t . S said that he had been told to participate less [in the play] and so he had not pa r t i -cipated at a l l . The group picked up on this as something he habitually does. T said she had fe l t " real ly uneasy in the role" [in the play]. She fe l t that she was "under attack"...She said the part was "very r ea l " , she didn ' t feel she was acting. It was "scary". V [who had been working extremely hard on re-building the AV room] was asked why he worked so compulsively. Was he "dependent" on the work? In fact , any incident or talk or behaviour at Theta was available to be treated as part of the patient's pathology. When a patient objected to part of the proposed points system, this was examined under the auspices of the therapeutic model to discount her objection: [Patient] said that she didn't l ike the idea of introducing competition into Theta. She thought that competition was "very destructive". This was immediately formulated as part of her prob-lem. It became "very interesting" that she had objected to this . Through this process along with the i n i t i a l work which is done at the interviews, the patient comes to see many aspects of his l i f e under the problem heading. As time passes in the sett ing, the patient usually begins to integrate a l l the various parts of the troubles that have been empha-- 142 -sized into a pattern of trouble. The discovery of a pattern of trouble often coincided with the construction by the patient of his autobiography. This document was written by the patient during the f i r s t two weeks of his stay at Theta. There were no particular ground-rules for i ts production; peo-ple made of i t whatever they thought an autobiography ought to look l ike in the setting. The situated character of the autobiography was mainly ev i -dent in that i t tended, perhaps, to emphasize the unhappy aspects of the patients' l ives and tended to be another document which found good rea-sons why a patient had the troubles he did. In fact , there was a f a i r amount of confusion between autobiographies and self-descriptions and i t was routinely pointed out at the pre-orientation interview that the self-description was not an autobiography, but that that would come later. The two documents were seen to be somewhat s imi lar . That the autobiography frequently led the patient to discover that there was a pattern to his l i f e was amply evidenced in the Theta diar ies: In typing my autobiography over the weekend, I kept wishing I had done i t before. There's some-thing about writing i t a l l down which exposes the patterns in a way which haphazard thinking doesn't do. - 143 -I got very depressed tonight writing my autobio-graphy and lett ing my feelings come to the top regarding my family. . . I can also see a pattern emerging from my Dad towards me l ike his mother to him and i t scares me. I keep seeing more and more things I do wrong and have done wrong in the past . . . ...autobiography...I feel very anxious when I see what stupid ways. I chose to l ive my l i f e . This discovery that there was a pattern to the patient's behaviour ap-peared to be viewed by the patient with mixed feel ings. While the d i s -covery that he had been l i v ing his l i f e in "stupid ways" was frequently accompanied by some depression, i t was also accompanied/or shortly follow-ed by a period of hope and optimistic expectation. It seemed as i f the pattern, while depressing in i ts discovery, produced the expectation that, now that i t was known, i t could be cured. The "high" that patients experienced in their second week at Theta was frequently followed by a low. It was as though the experience of discovery accompanied by optimism was followed by a wave of pessimism generated by feelings that cure was impossible. I checked this observation with the resident psychologist who said that she had noticed the same pat-tern. This tentative observation is supported by some evidence from pa-tient comments: For the f i r s t time since I arr ived, I am scared that I cannot get better . . . The problems that I have overwhelm me sometimes. Where do I start? How does one deal with such a large thing as gu i l t ? . . . - 144 -I have been depressed for quite a few days now... I don't notice any change in myself. . . The confusion is back again just as strong as ever, the future looks uncertain again. I have not had. the opportunity to explore this changing perspective in enough detail to allow more than a tentative formulation. It i s , how-ever, a suf f ic ient ly interesting point that seems worthy of additional study, part icular ly for Theta staff who might wish to adjust patient schedules in accordance with the mood-phases of the patients' exper-ience. 0 Correcting It Actually the division of the process along the lines that I have used is highly a r t i f i c i a l in that the process of discovering the real trouble would i t s e l f have been therapeutic. It is mainly the tentative conclusion that the patients experience the process as having two phases that has led me to make the d iv is ion. In this section I shall discuss some of the procedures that were used and some of the troubles that were encountered in doing therapy. The selection of the person who should do therapy on any par t i -cular occasion was achieved by a number of devices. The simplest and pro-bably the commonest one was for the therapist to ask "Who wants to work?" It was then up to anybody who fe l t that their troubles were pressing to - 145 -ask for group time. It has already been pointed out that only a few people could work on any particular occasion when therapy was being done and i t was assumed that everybody's problems were not equally pressing at a l l times. The therapist in charge would sometimes ask "What do you re-gard as most important?" or "Who needs to work the most?". If a number of candidates for work were ident i f ied , the selec-tion could be influenced by the length of time the candidate had le f t at Theta, so that candidates in their last week were seen to have pr ior i ty over candidates who would have a subsequent opportunity on some other day. Candidates who were v i s i b l y in emotional states were selected over candidates who were not, but apart from these p r i o r i t i e s , the selection appeared to be quite arbitrary: "Therapist picked A to work for no ap-parent reason". The selection of the patient who should work could be made on the basis of some interaction that went on at the beginning of the meet-' ing: [Patient] stated that she had objections to the use of primal scream therapy. She didn't want i t for herself. Several people..said that [Pa-t ient] resisted a l l forms of therapy which she denied...She got quite angry with some of the men. [Cl inical Supervisor] brought [Patient] up to the stage and talked with her for a while. or in another instance: Patient : I understand, but I started to say some-thing and B put me off . Therapist : Tel l him now - 146 -Patient : You pissed me off . Therapist : Go closer and te l l him. If either patient in an exchange of this kind became emotional during the exchange, he was selected as someone who should be working and ther-apy proceeded from there. Once a candidate had been selected and had started to work, the rest of the group were no longer potential candidates until the work with that patient was completed.* They now became resources with which to do work with the selected candidate. The group could be used to play the roles that have been previously described or they could be used as fellow group members on whom opinions and feelings could be tr ied out for example: [Cl inical Supervisor] asked J what he thought of people at Theta. He said he had no animosities i f that is what he meant. [Cl inical Supervisor] i n -dicated either/or and asked him to go around and say what he fe l t about each member... D said that he didn't give a shi t . Hung his head. Looked uncomfortable. [Cl inical Supervisor] asked him to go around and te l l people, naming them, that he didn't give a shit about them. No response was required of these kinds of comments although group mem-bers often appeared to feel an obligation to take a turn in the potential * How i t was known that the work was completed could be the sub-ject of a separate study. The act iv i ty could be terminated by the sche-dule: therapy stopped at certain hours and although i t occasionally ran s l ight ly overtime, the schedule was recognized as having pr ior i ty over the immediate act iv i ty . Therapy could be terminated by the therapist declaring i t to be over or deciding that the patient was "just acting" and giving up the attempt to work with him. Therapy could be terminated by the e l i c i ta t ion of inappropriate responses l ike laughter or by the fa i lure to e l i c i t any response at a l l . - 147 -conversation after they had been addressed. The therapist, however, would sometimes invite the other group members to express how they f e l t about the patient who was working: Next [Cl inical Supervisor] asked everybody to do what they wanted to D. Several g i r l s went up and kicked him in the pants. The group gathered around him and pushed him from side to side. The reaction of group members to unresponsive patients has already been recorded insofar as they were seen as wasting time. The reaction reported above was another which was sometimes generated under the circumstances and one which had the tac i t support of the therapists present who did not interfere with i t . M said she fe l t alone and sad. She was questioned about what she was going to do about i t . She went around and told everybody in turn that she didn't trust them. After a couple of rounds she got to A who said that she was doing the same thing that he-had been doing. He said he wasn't going to let her. He started to push her around and the.whole group joined in pushing her from side to side and shout-ing "come on M". The purpose of this act iv i ty was to generate emotion. The test that useful work was being done was that the patient had noticeably lost control of his emotions which could then be worked on. It didn't seem to matter whether the emotion e l i c i t ed was anger or tears but i t should appear. If the f i r s t appeared, then the patient was given one of the Theta padded clubs and invited to pound some second patient to work out his anger. If the second patient was playing a ro le , the anger was assumed to be directed at the person whose role he was playing. After a few minutes of dialogue [Resident Psychologist] went and got the boppers and invited A to te l l his father how angry he was with him. A said he was wor-ried about this and was afraid that he would go at [the second patient] with his f i s t s . - 148 -This patient had no trouble distinguishing the person he was going to fight with from his father before the incident started, but i t was as-sumed that his anger would be directed at the father-image embodied in the role performed by the other patient. As soon as i t was apparent that the patient had achieved a state in which his emotions had gained ascendency over his intel lectual control he was usually invited to l i e down on the f loor or on a styrofoam mat that was available for the purpose. This was the signal for a l l the group members to gather around him, kneeling or s i t t i ng . Usually the therapist who was directing the session would kneel at his side facing his head. It did not always happen that the patient's emotions had in fact completely taken over, but i f they had not, the work which was to follow was seen as more d i f f i c u l t . A therapist reported of one margi-nally successful event, "We spent a lot of time fighting his mind". When the patient was on the f loor , the therapist encouraged him to breathe rapidly, sometimes accompanying his instructions with a kind of a r t i f i c i a l respiration in which he stimulated the breathing by alternatively pressing and releasing his lower chest. This was ex-plained as a means to get him to "hyperventilate". While a l l this was going on the patient was encouraged to speak, or fa i l ing that to make any sound that he fe l t l ike making. The therapist and the group members fed him lines that they thought would be appropriate - 149 -such as "leave me alone" or "don't leave me"; "I hate you"; "I want you to love me". The patient had the option of repeating the phrases as they were given to him or dealing with them as "conversational" items which could be responded to. The therapist, meanwhile encouraged him to " let out that sound", or to repeat an apparently s ignif icant phrase or to do so "louder". Patients were seen as having physical manifestations of their troubles and one of the tasks appeared to be to get the trouble "out" in a l i t e ra l physical sense. D...appeared to be unsuccessful despite some pretty impressive shouting crying and several determined efforts to vomit. [Therapist] described this afterwards as a block and said he had got D to spit out the mucous that coN lected. [Cl inical Psychologist]: "good". In another context the c l in ica l supervisor described a patient as having a pain which started low down in his body and gradually worked i t s way up as the therapy proceeded. The abreaction therapy usually continued until the patient had exhausted his repertoir of shouting, crying, cursing, and sounds and was himself t i red. Some of the ways that therapy was terminated have already been mentioned. In general i t appeared to be negotiated jo int ly between patient and therapist with the therapist having the option not to discon-tinue the act iv i ty i f , in his judgment useful work could be done by con-tinuing. At the very least the therapist had to consent to the ending for i t to be successfully accomplished. After the process was over the patient - 150 -who had been working was warmly hugged by the therapist and by a l l mem-bers of the group of people who had surrounded him, a l l of whom would have been holding some part of his body throughout the event. There were a few reports of patients' reactions to this process in the diar ies , some of which appeared to be favourable: I had a workout today. I s t i l l feel physically drained but I don't remember too much about what I said. It feels l ike a plug got pulled in my brain and let the dirty water out. A l l that's l e f t is the ring in the tub. It is strange, a lot of things came out I have not thought of in years. Old feelings and fears. The same patient wrote of a second "workout": Tonight I feel much better - worked out today. For some reason my headache disappeared for a while although i t came back later. Another patient, however, reported a less favourable reaction: I f e l t very defeated also today after my ses-sion on the mat. Felt worse than I have for weeks. That doing therapy could be unsuccessful in i ts immediate reaction was, of course, one of the hazards of the process and one of several troubles that the process had for patients. Some other troubles that were encoun-tered are discussed below. Troubles One of the f i r s t troubles that could be experienced by patients was not being able to "do therapy", not being able to "get into anyting". This usually meant that no emotional reaction had appeared to whatever therapeutic procedure was being practiced which was sometimes found to be - 151 -evidence that i t had been a fa i lure . Patients reported being aware of troubles that they had but not knowing how to do therapy on them: J said to M that she was real ly annoyed with her because she wasn't working. M said that this was true, she had things to get out but didn't know how to do i t . Even when they had directions or suggestions as to how to do i t , some patients complained that they could not comply with them: H was told to talk to J and to te l l him to leave her alone. Somebody went and got the boppers. H objected. She didn't want to hit him. She wanted to be friends. J bashed at her half-heartedly. H said she couldn't hit J and let the bopper hang limply by her side. It has already been said that some role playing did not come off and this was a source of trouble insofar as the i l lus ion that the pa-tient was beating his father dissolved into the real ization that he was beating his fellow patient. When R was working out about his mother... he stopped after a few minutes and said "I don't think he means what he's saying". This diary report of an incident in which a male patient was playing the role of another male patient's mother occurred when the female who started playing the role got t ired and the male patient took over for her. The incident was a source of trouble for both the therapy and for the role player who reported that he: ...had mixed feelings about th is . F i rs t I f e l t real ly good that he knows I don't think l ike that and second i t automatically put me on the defensive to te l l him I was playing his mother, not my own. - 152 -The danger of the therapeutic real i ty slipping away and being replaced by some other interpretation which would make the participant look ridiculous was always present at Theta. The act iv i ty had to be car-ried out under the auspices of the appropriate understandings in order to be sustainable. Thus when a patient was unable to see the procedure in the appropriate l ight he found himself r idiculous: [Cl in ical Supervisor] asked who she would pick as her father. She said "R". She was invited to use the boppers with R. R said he didn't want to do i t again. [Cl inical Supervisor] asked him why not. He said he fe l t l ike a spectacle when he did i t . There was some talk about what i t was to be a spectacle. Was M a spectacle on the floor? R said "no". An-other patient said she could appreciate what R meant. [Cl inical Supervisor] said he was there for therapy, he was not supposed to "enjoy" i t . Although he did not have to enjoy i t to be able to do i t , he did have to believe in the appropriate rea l i ty . The fact that he did not made him a "spectacle". In fact , the patient le f t Theta shortly after this incident. Another trouble that occasionally interfered with the business of doing therapy was the experience that recreating troubles that had a l -ready been ventilated was something that could not necessarily reproduce the feelings associated with them. This was experienced in "big group" when a patient was invited to report on some incident with a view to work-ing out the problems associated with i t in this highly valued sett ing: [Cl inical Supervisor] went on to ask for the new patients to come up one at a time, P was f i r s t . P had been having some reaction to the group members already. She ident i f ied J and D who she had had a row with a couple of days previously. P could not find any-body that she f e l t strongly about at that minute. - 153 -[Resident Psychologist] said that there was some "important group business" [The group was reported to be working poorly]. R said he had been annoyed with J in family but had said i t there. [Cl inical Supervisor] said he should say i t again...R made a half -hearted attempt to resuscitate the issue but i t didn't get off the ground. In fact , the feeling among patients appeared to be that attempting to reproduce an event of this kind ought not to be done: [Cl inical Supervisor who had been absent on the previous day] asked H to show how she would te l l M to leave her alone. Several people pointed out that she had done that on the previous day. Apart from the troubles that doing therapy could have in the sett ing, i t could occasionally have troublesome consequences. The patient in the above f i e ld note went home to te l l M to leave her alone after re-hearsing the scene at Theta. She returned the next day with a large bruise overhereye that she received when she acted out the scene that she had rehearsed in the safety of the centre. Although not an exhaustive description of the process of doing therapy, the sections above have attempted to bring out some aspects of the act iv i ty in the l ight of the Theta culture. The assumption of the centre that everything at Theta is therapeutic has been described and the emphasis on abreaction therapy has been detailed. The patients' attention to and involvement in this aspect of therapy has been documented. - 154 -The role of the therapists in doing therapy and in providing direction and protection has been set out and i t has been shown that the process of doing therapy cannot be sustained in the absence of the thera-p ists . The part played by emotions in doing therapy has been discus-sed and i t has been argued that certain emotions are attended to above a l l others. The emotions that are most frequently developed l i e along the dimensions of anger and closeness and are most accessible to the therapeutic procedures used at Theta. The categories that were used in doing therapy have been d i s -cussed and the place of roles in the act iv i ty has been delineated. In part icular, the two principal roles at Theta, that of patient and thera-pist and the bel ief systems embedded in these roles, have been proposed as major resources for doing therapy. Other roles played by the patients in the process have been discussed. It has been argued that patients experience their passage through Theta as having two phases. In the f i r s t , the patient discovers a pattern of behaviours that he often sees as of long standing. This discovery is accompanied by optimism. The question of how the pattern wi l l be changed follows the discovery and may be accompanied by a corresponding depression. The actual work of formal therapy i t s e l f has been described as well as some troubles deriving from the act iv i ty . - 155 -Throughout this chapter and the rest of the study I have attemp-ted to show that the act iv i t ies at Theta can be seen as situated in and determining of the environment that members understand as a therapeutic community. I have attempted to point to the situated act iv i ty of the par-ticipants as having the moral force referred to in the introduction. If I have been true to my ethnographic aims, I wi l l have descr i -bed the culture as i t is seen by members in the sett ing. As an ethno-grapher I wil l have reported what I found without reference to what I f e l t about the f inding, independent of personal ties or enthusiasms that I developed but remembering that my f i r s t loyalty was to my ethnographic ac-count. Of course any enterprise must, to some extent, f a l l short of the ideal and this no less than others will have offended against the p r inc i -ples (not to say the best practice) of the ethnographic ideal in major and minor ways. That, however, is a shortcoming of this work and not of the ideal which attempts to discover how the social order is created and sus-tained. APPENDIX I THE OBSERVER ROLE As a naive observer, arriving at a therapeutic out-patient centre, I suffered from al l the usual anxieties of the new patient with the additional problem that I knew that my role was not going to be defined for me. Although I had some vague beliefs about how observers behave in settings, I was very conscious of not knowing how this observer would behave in this setting or what would be expected of him. I had been told that I would be expected to participate but how much? And what was my participation supposed to consist of? My previous group exper-ience seemed i l l-sui ted to formulating any suitable role and the role of non-participating observer was repeatedly discussed at Theta. Negotiating a Role I have already described the categories of therapist and patient as exhaustive of a l l the usual roles that are prescribed in the centre. Now while i t was clear that I could not be a therapist, one im-- 157 -mediate poss ib i l i ty was that I could go in as a patient. This role was suggested to me by the c l in i ca l supervisor when I f i r s t proposed that I should expand my observations from the rather casual weekly v is i ts that I maintained during the f i r s t several months of my contact, to full-time observation. In subsequent negotiations, the c l in ica l supervisor pressed fa i r l y hard for me to become a patient. I refused to do this because (apart from a reluctance to expose myself in a way that would, I f e l t , be very demanding emotionally) I was convinced that the perspective that I wanted to develop was better seen from the s idel ines. If I was invo l -ved in the process I thought that I would not be able to attend properly to what was happening. I did not want to write an account of my exper-ience and influence at Theta; I wanted to write about how the people there jo int ly created their own rea l i t y . That my role was deviant was clearly recognized by the pat-ients as well as being a concern of the staf f . The same demand (that I be a patient) was frequently made of me by other patients. I once de-fended my stance on the grounds that my time was limited but a patient dismissed this on the grounds that i t was a " rat iona l izat ion" , a common pejorative description at Theta. The fact that my role was seen as dev-iant is further evidence of the exhaustiveness of the "therapist" and "patient" labels and I have described some of the incidents that seem to i l lust ra te this below. Having rejected the role of patient, I was the object of a certain amount of suspicion from both therapists and patients. This led - 158 -to my act iv i t ies being circumscribed in various ways. I was required to attend on a f a i r l y r ig id schedule which I negotiated with the c l i n i -cal supervisor. The schedule of my v is i ts to the centre had always been a matter of some concern to the staff . The explanation that was given was that I "upset the patients". At one point I changed from coming on Wednesday afternoon to coming on Tuesday evening without much immediate comment. When, however, I arranged to come on a day that I was free over the Christmas holidays, not only was that i rregular i ty a source of annoy-ance to the resident psychologist, but my previous change became evidence of my unpredictable habits of attendance. I was asked to renegotiate my schedule with the c l in ica l supervisor. My new schedule allowed me to attend at meetings of the whole group, formally constituted for the business of doing therapy. When I departed from this to come to a Monday lunch which I had been attending at the patients' request, I was again in hot water. I should only attend when the c l in ica l supervisor was present. I eventually negotiated a period of time during which I was allowed to attend full-time at Theta and at the end of this period was granted an extension. I was careful to be present during al l the sched-uled hours at f i r s t , but as time went on I found I was able to be more selective. My extension was granted with good grace and there were no more incidents about i r regular i ty . It was s t i l l the case, however, that when I was leaving and casually mentioned that I s t i l l f e l t my time had been too l imited, the c l in ica l supervisor said once again that I should - 159 -have been a patient. The role of observer is a very d i f f i c u l t one. Apart from minor incidents l ike not knowing i f I was a " v i s i to r " at an early meet-ing that I observed ( i t turned out that I was not) one never real ly knows quite what to do. There is considerable pressure to participate in the group process, not the least of which is to let people know that you are human. I have at least one doodle on a sheet that was drawn to show my neighbour that I was bored and human: "We learn from Horace Homer sometimes sleeps". [Byron: Don Juan] The pressure to participate when someone is "working out" is enormous. It was fe l t immediately by new patients who invariably joined the group on the f loor and made some gesture to show that they were i n -volved. I frequently did the same. Another device that I used was to lean forward on a chair just above the group, resting my elbows on my knees. In general I participated as l i t t l e as possible after some i n i -t ia l mistakes (see "Troubles" below) and was well-accepted by most pat-ients who showed a very sympathetic understanding and tolerance of my posit ion: "I know you can't be involved because that would affect the interaction". In fact my occasional lapses from the role were frequently challenged: "What are you doing now? You seem to be participating some of the time!" I said that I did participate some-what in the families and in some things l ike the dance therapy. I would continue to participate as l i t t l e as possible. I said I was involved and did feel many of the emotions that other people fe l t but believed that my role was not to participate any more than I could - 160 -help. [Female Patient] said: "Okay, we'l l just play i t by ear". I think that f i e ld note describes the stance I eventually adopted which, allowed me several things. I participated enough to satisfy the i n s t i -tutional requirement that everyone must do so. I was, hopefully, reason-ably unobtrusive and at the same time, indulged myself in a gratifying display of "I'm real ly human y'know". Troubles One of the early troubles I had was in overdoing my part ic ipa-t ion. On several occasions I got carried away with the certainty of my Laingian insights on Family night. On one part icular ly bad occasion I spent the evening making fa i r l y wild speculative guesses in role playing with patients and v i s i to rs . This caused a considerable amount of d i s -satisfaction with both therapists and patients. The c l in ica l supervisor told me that the patients had put me in a psychodrama and the patient chairman told me that the patients were upset with me. It was at this point that I was asked to come to Monday lunches so that the patients could get to know me and what I was doing. A persistent trouble in a setting in which you are an ident i -f ied observer is trying to explain what you are doing: A male patient sat beside me and after s i t t ing in s i l -ence for some time, asked me what I was doing. I told him my M.A. thesis was in Sociology and talked obscurely about the social construction of real i ty in a way which didn't mean much to me and must surely have meant much 1 less to him. Apart from the i r r i t a t ing vagueness and unsatisfactory obscurity of such - 161 -talk, there is the pervasive idea that you are treating the people you are observing as things. On another occasion I noted: The next question that was brought up was - did I treat the patients at Theta as objects to be studied? I had to admit (after much hesitation) that I did. I t r ied to explain that as much as they treated me as "just soc io logis t " , so much I treated them as "just objects". This did get some response eventually. By the end of the lunch I was getting quite a lot of support. This explanation, in terms of "bad fa i th " was so successful (and, I hope, genuine on my part) that I regularly reproduced i t whenever the question arose. I made a point of being as straight-forward with patients as possible. I asked them whether they would allow me to read their diaries and sensing that i t was a sensitive issue, said I would give them a week to think about i t before I pressed them for an answer. I suspected at the time that there would be considerable resistance to this but in the event only two people refused me permission. In fact the two people who refused were confronted on their refusal by the other patients who seemed to see i t as a part of their neurosis. I did not read the diaries I was refused and i f I had been refused a s ignif icant number I would have been without some valuable information on "patterns". A more serious trouble arose when I arranged to have my thesis advisor write a letter to assist me in expanding my period of observation. The letter was written in f a i r l y strong terms as I was anxious to put pressure on the c l in i ca l supervisor because my time was rapidly running - 162 -out. The c l in i ca l supervisor was extremely angry and expressed his total dissat isfact ion with the let ter in the strongest terms. The issue came up on a day on which the s ta f f ' s "feelings meeting" was scheduled and I got to attend my f i r s t one. I was invited to present a written interpretation of my advisor's le t ter there and then, which I did. The s taf f members' reaction to the letter was generally more moderate and after some discussion in which I found support from the c l in i ca l fellow, the matter was settled but there were a few moments when I thought I might be excluded ent ire ly . Another f a i r l y serious incident involved a patient who l e f t Theta prematurely. I had spent a few minutes talking to her before her f inal group. During the group meeting she was confronted by both pat-ients and therapist on a matter unrelated to my conversation. She had already expressed misgivings about Theta in group (and to me) and after the group meeting she l e f t the centre and did not return. In searching for a reason, the c l in i ca l supervisor said that I had provided a warrant for her leaving by giving her tac i t support. The observer had "great influence". This incident was cited on several occasions as a reason for l imit ing my free access to the setting although the c l in i ca l super-visor eventually admitted that she might have le f t anyway and had d i s -cussed doing so. F inal ly , during the early period of my attendance, an incident occurred which I was total ly innocent of but which shook me at the time. During a group meeting a remark was made by the patient to my le f t which - 163 -was attributed to me by the therapists present. The therapists were s i t t ing several seats to my right in a straight l ine . The remark was one in which I appeared to support a vocal and troublesome minority over an issue of what kind of therapy should be done. Despite my de-n ia ls , I was confronted over this incident in the c l in ica l supervisor's o f f i ce . I presented my f i e ld notes for the evening which contained some evidence that there were other sources for the therapists' annoy-ance at me that night (I had stayed behind to watch a minor rebell ion on the part of the patients when a l l the therapists l e f t ) , the best I could get was a grudging admission that 'maybe he [the patient] was throwing his voice". I suddenly had some insight into what i t must be l ike to be accused of witchcraft - there is no defence and any attempted defence is constituted as evidence of gu i l t . Distrust The kind of paranoid feeling that I had that night was some part of my early experience at Theta. Because my role was deviant and because I was there on sufferance, I frequently f e l t that I was being sus-pected of some act iv i ty that would result in my ejection. I think, how-ever, that there may have been some distrust on the part of the staff as wel l , so with the serious intention that i t may help some other observer to know he is not alone but with tongue s l ight ly in cheek, I add this somewhat whimsical commentary. - 164 -Staff Distrust The staf f at Theta were perennially concerned with "what I was finding out". This was often explained as an attempt to understand my role. The staf f was quite capable of deciding what parts of the Theta process I should be watching: big group was "more interesting" for me, but apparently quite mystified as to what I was "doing". My f i e ld notes have fa i r l y frequent references l ike the following: [Resident Psychologists] said again she was interested in what I was doing, wanted to hear me say what I was finding out: [Cl inical Supervisor] too - I should give a talk. A l l this was couched in terms of how valuable my comments would be to Theta. My problem was that I didn't think I had anything that was of value to Theta at the time and had only the most vacuous and esoteric details to talk about. I had no penetrating visions and certainly was not in the process of formulating an expose as the staf f may have / suspected. Of course my paucity of ideas made me evasive and compounded the problem. The poss ib i l i t y that this was distrust and not the d is in ter -ested curiosity i t claimed to be may be supported by the fact that the c l in ica l supervisor insisted that I give him written assurance that I would submit a draft of my thesis to him (which I readily agreed to do). He said he would add comments which should be included in the f inal docu-ment. - 165 -My Distrust My distrust derived from what I saw as my very insecure role at the centre. As I said, I f e l t that I was there on sufferance. I was aware of the suspicion and mild antagonism of some of the s taf f mem-bers and realized that almost anything I did (or did not do) could be made a problem for the patients, the s ta f f , or the inst i tut ion. My being dismissed would have been highly consequential for me as I had a consider-able amount of the time invested in the f i e ld work and had no alternative subject on which to write my thesis. A number of incidents wil l i l lus t ra te some of the dimensions of the problem. In the incident reported above in which the patients decided to continue the group after being told to stop, I decided that I should continue to watch the group. The group continued for about twenty minutes during which time I was conscious of some misgivings that my decision would be interpreted as a sign of lack of neutrality or divided loyalty. When the therapists returned to break up the meeting once and for a l l , I was sure that the psychiatric nurse was unusually cool to me. On another occasion I thouqht I detected some i r r i t a t ion from the resident psychologist when I gave her some.information about immigration services that I had obtained for a female patient. Immediately after this she told me about an incident with a patient that I thought was s i g n i f i -cant. I recorded the whole event as follows: - 166 -[Resident Psychologist] came up and I asked her to give a message to [Female Patient] about immigra-tion information. She seemed mildly resistant to th is . As we were about to leave and go downstairs, she told me that [Male Patient] had been discharged because i t had been found out that he was having an a f fa i r with one of the other patients I won-dered whether [Resident Psychologist] had told me a l l this because I had asked her to give a message to [Female Patient]. It was a rather unusual kind of conversation for [Resident Psychologist] who has been f a i r l y formal with me so far . The other possi -b i l i t i e s seemed to be that i t was just a piece of gossip, or that [Resident Psychologist] told me by way of making some sort of gesture of welcome after my alienation of a couple of weeks ago. This kind of feeling occupied me throughout my stay at Theta. It was not confined to therapists for I noted after giving a female pa-t ient a ride into town one day "[Female Patient] seemed somewhat cool to me after I drove her home - which may have been a kind of seduction and consequent betrayal of the group". The worst incident occurred one day when I so far stepped out of my role as to offer to "push" with a male patient. He was having trouble expressing emotion and I thought he might be able to do something physical better. I had the idea that what he real ly wanted to do was to push everybody away and offered myself as a guinea-pig. We placed our arms on each other's shoulders and leaned against each other. He was very strong and pushed me around without any trouble. Not only that but he wanted to continue to push me around the room long after I had decided the act iv i ty was well past i ts termination point. Nobody interfered and I suddenly had the fantasy that no therapist would bail me out at a l l because - 167 -I deserved whatever was coming or some such. Actually my act iv i ty was praised after the group meeting and I was in no danger. B i t , in an atmos-phere of uncertainty, distrust expands to dimensions far beyond i ts rational boundaries. Observer as Deviant In describing the observer as deviant I am appealing to a model of deviance along the lines of Becker's "outsider"/' A l l social groups make rules and attempt, at some times and under some circumstances, to enforce them. Social rules define situations and the kinds of behaviour appropriate to them, specifying some actions as "r ight" and forbidding others as"wrong". When a rule is enforced, the person who is supposed to have broken i t may be seen as.a special kind of person, one who cannot be trusted to l ive by the rules agreed on by the group. He is regarded as an outsider. I was exp l i c i t l y recognized as " 'outside' John" by one patient writing in her diary and frequently as "observer John" which was a style of label that was unique in the sett ing. But my outsider status was more than just a nametag. On one of the f i r s t lunches that I was invited to so that I could explain my role, a contrast was made between me and one of the other occasional v is i tors to Theta who was a psychotherapist. The contrast turned on the fact that the psychotherapist was present as a helper, some-one who was of value to the patients, while I was of no value to them. This question of my value came up on several separate occasions when I was being questioned by patients about my role and was an issue that I rarely heard raised in any other context (although i t was occasionally raised at group interviews when a potential patient seemed to be unsuitable for admis-sion). - 168 -Even when I was clearly recognized as a potential resource to some member of the group, i t was usually the case that the member avoid-ed taking advantage of that fact. One patient exp l i c i t l y acknowledged my s imi lar i ty to her father and wanted to "work on feelings about him". Despite this she chose a female patient to represent him in the ensuing role playing. I asked her afterwards why she didn't pick me and she said that she "didn't know she could do that". It hardly seems necessary to say that my behaviour contras-ted sharply with everybody else 's in the sett ing. I was not usually ex-pected to vote at Theta elections but was occasionally questioned about why I would not. The questioning i t s e l f was undoubtedly the best i nd i -cator of the deviant character of this refusal but on one occasion i t was made the object of a joke. A patient in the "family" group which followed the election asked who she thought should work and said that she thought I should. She said I had refused to vote and she thought that that was part of my "problem". On another occasion a patient com-mittee was making up a l i s t ' o f patients who "needed to work". After a long discussion in which almost everybody in the group was included in the l i s t until i t became completely unmanageable, I was added for l ight re l i e f . This was clearly a joke and was the cause of considerable merri-ment among the members who decided that i t was an excellent idea. When the "serious" business of writing out the formal version of the report was undertaken, my name was omitted. - 169 -When i t came to my last day at Theta, I was invited to par-t ic ipate in the "goodbyes" r i tual and was happy to do so. I went around the group and spoke to each person, te l l ing them some of the things that I had wanted to say for some time. This was quite uncalculated and was of course a violation of the usual procedure in which each patient says a few words to the person who is leaving. Somebody said "he's doing i t a l l wrong" but a second patient said "I know, but that's okay". I com-pleted my round with tolerant resignation of the fact that everything I did there was unusual. Becoming Accepted The sections above, while they contain references to the recog-nit ion of the deviant character of my role , show too the amount of accep-tance that I had at Theta. In general the patients appeared to find me very l i t t l e trouble which fact was exp l i c i t l y acknowledged by the c l in i ca l supervisor towards the end of my stay. My introductions to new members contained references to me as "a trouble maker" in tones that clearly indicated that I was not and matter-of-fact phrases l ike "John...comes Tuesday nights and to lunch Mondays...sociologist with sociology depart-ment at [University]". These were accepted as adequate explanations of my presence in the setting on most occasions. Despite my occasional troubles with the staff (and theirs with me) I was generally treated with consideration, friendliness and, even-tually I believe, understanding tolerance of my " d i f f i cu l t role" as i t was characterized by one therapist. I was allowed to stay at the Theta - 170 -house after hours to l isten to tapes of sessions and invited into the homes of staff members. I ended up with a considerable amount of em-pathy for the work that staff members were doing, with their " d i f f i c u l t role" that they put themselves in . - 1 7 1 -FOOTNOTES 1. Howard S. Becker, Outsiders: Studies in the Sociology of Deviance, New York, Free Press, 1966 [copyright 1963], p. 1. 172 APPENDIX II W A I T I N G e T A p r (2E-5ID&NT M.P. OCCUPATIONAL THE-[2APie>T — P 5 Y C M I A T E I C W.C C L I N I C A L SUPE-QVI 'SOE PFrSlDErNT PSYCHOLOGI5T-5 E - C O N P P L O O B II II • A . V . ROOM S tage • < ( 2 efeps up)] "THE-ATR? . " J "DN BCICK PAT 1 0 ^ U 9 U A L E-NTEANCr?-ID 6-ide b o a r d , Tab lee1.[ * I I — i n r-PINING I L KIT-6T0RA<4E-•Codf" c lose j" fable fennis J^jj—BATH £ 0 0 M MAIN pLoog FLOOP PLAN OF TUE-TA - 173 - APPENDIX III HEADINGS FOR SELF-DESCRIPTION FORM 1. Mental and Physical Health -- (for example, headaches, afraid to be alone, etc.) History of symptoms and treatments. 2. Personality Changes Desired — What would you l ike to change about your personality? (for example, shyness, short-tempered). 3. Education and Work -- Describe your education; short history of work: Complaints about work situation (abi l i ty or interest to work). 4. Sexual Partners, Marriage, Children -- Short history of your dating and love relationships. Describe your present relationship (marriage) and any problems in i t . Relationship with children. Short history of your sex l i f e -- including complaints, worries, def ic iencies, abnormalities. 5. Life Style -- What would an observer say about you and your household i f he could observe you for one day? Friends? Sports? Usual week-end act iv i t ies? Any harmful habits? (for example, eating problems or over-eating, lack of sleep, heavy smoking, drinking, prescribed and unprescribed drugs, e tc . ) . 6. Philosophy of Life -- Religion and other beliefs about the world, man-kind, community, sex relat ions, astrology, etc. 7- Family -- Br ief ly describe your childhood in terms of your re lat ion-ships with your father, mother, brother(s), s ister(s) and important others. What are the present relations? 8. Physical Hea l th— General health, past serious i l lnesses , surgery, in jur ies , pregnancies, abortions, menstrual d i f f i c u l t i e s , etc. 9. Hope -- What do you think has been causing your problems? What hope do you have that: (a) your mental health can be improved? (b) you can change your personality? (c) you can change your l i f e situation? - 174 - APPENDIX IV STANDARD QUESTIONS TO BE ASKED COLLECTIVELY OF PERSONS APPEARING BEFORE THE GROUP FOR ADMISSION 1. Are there any health or other physical problems that would l imit you in any way from participating in f a i r l y strenuous sports and swimming? 2. Do you have any commitments, appointments and the l ike that would fa l l in the next six weeks of your stay in the group? 3. Do you have or have you had a habitual use of any drugs or alcohol? If so are you prepared to completely abstain during your stay at Theta? 4. Are you prepared to return after six weeks for three successive Wednesdays for after-care? 5. Are you wi l l ing to make a sincere effort to encourage s ignif icant persons in your l i f e to come on Tuesday evening to the group? 6. Do you understand that your commitment to the group allows for no exceptions, nothing holding back, no time of f , that i t is a total commitment? 7. Are you prepared to write an autobiography, starting out the f i r s t week for presentation as early as the Tuesday of your second week? 8. Are you aware that fa i lure to follow the rules and neglect to contr i -bute may result in probation and, i f not corrected, discharge? APPENDIX V FOOTNOTES ADDED BY THE INSTITUTION Introduction by the Author The footnotes which follow have been prepared by the c l in i ca l supervisor of Theta in accordance with an understanding which was devel-oped during my observation period. In order to ensure that the meaning of the document not be inadvertently altered, the footnotes of the c l in ica l supervisor have been typed exactly as received except as follows: 1. The page numbers which referred to the draft have been altered so that the reference now pertains to the corresponding section or quotation in this f inal version. 2. Minor typographical errors have been corrected where the intended word was clearly apparent (for example "they" for "the"). Therse corrections have been indica-ted with square brackets. Where the text of the f inal document di f fers from the draft , the fact of The footnotes begin on page 184. - 176 -this difference has been indicated. The original text to which the footnotes refer has been retained in the notes to preserve their com-plete sense. I do not wish to comment extensively on the notes which must be judged on their own merits although I shall draw the reader's atten-tion to a few points where I feel that the notes raise issues which, apart from not bearing direct ly on this document, appear to me to be errors of fact which i t is necessary to correct. That I do not address myself to the notes in detail should not be taken to indicate that I agree with a l l or any of the points raised. Many of the comments stem from the difference in perspective between myself writing as a sociologist and the c l in i ca l supervisor writing as a psychiatrist in a setting in which he is an interested participant. I am not, as the c l in ica l supervisor appears to believe, tota l ly ignorant of the psychiatric theories that "serve as l e g i t i -mations for the inst i tut ional order"(quote from Berger, in text, p. 63). Most descriptions of psychiatric settings, however, buy into those theories and i t was essential to my ethnographic account that I adopt an indifferent posture to that theory. The c l in ica l supervisor's com-ments appear to indicate that I have been successful in at least that part of my enterprise. To address the question of "systematic error of observation and interpretation", (as the c l in ica l supervisor characterizes my ac-- 177 -count), It is up to the c l in ica l supervisor to make his case. I can only assume that the notes are intended to do th is . I leave i t to the reader to judge the success or fa i lure of the attempt. As I have said, I believe that some of the comments derive from our different perspec-t ives; some appear to me to be simply differences of opinion about the meaning of observations. Some of the crit icisms are, however, made of fragments of the document l i f t ed out of context and do not appear to give the reader the proper sense of what was intended by the fu l l ethno-graphic account. For example, the treatment of my description of the c l in ica l supervisor's intervention in the patient-committee election appears to discount a l l the material on the emptiness of the elections. In fact, I would suggest that his fa i lure to influence the elections was further evidence of my point. The quotation that follows appears also out of context. The text describes that the patients, once again, treated i t as a ceremonial rather than an instrumental occasion, which reduces the significance of their decision-making in this matter. With-out wishing to belabour the point, I underscore this particular example in order to stress the importance of considering the c l in i ca l supervisor's footnotes in relation to the total text in which they are embodied. The last question which needs to be addressed derives from the several references to promises, agreements and contracts that have been allegedly broken. Without wishing to do more than correct what could be an erroneous impression created by the statements that are made by the c l in ica l supervisor about these arrangements, I set out below the details of the communications, meetings and conversations which appear to - 178 -constitute the subject matter of this controversy. Ordinarily a matter of this kind would have no place in this document. I have chosen to report the details of this controversy, however, because a s ignif icant focus in the c l i n i ca l supervisor's commentary which follows expresses a serious concern about the probity of my own conduct in f u l f i l l i n g our agreement that he should have adequate opportunity to comment on the thesis. My i n t i i a l approach to Theta was through my thesis advisor who wrote to the c l in i ca l supervisor and introduced me. I had a series of telephone conversations with the c l in ica l supervisor in February and March, 1973, which resulted in my coming to Theta at his request on April 6, 1973, to observe a formally constituted group meeting. I spoke to him subsequent to that group and obtained his permission to attend once a week. I was unable to continue to attend the afternoon sessions during the summer of 1973 as I had a job and asked the staf f i f I could come to the evening sessions which they agreed to let me do. I subse-quently talked to the c l in ica l supervisor about this change although we had not had much contact over the early period as he was rarely present at the evening meetings. At Christmas," I attended somewhat irregularly for a couple of weeks which, as is reported in the text, was a source of i r r i t a t ion to some staf f members. Because of this I stopped attending altogether dur-ing January so that my schedule of observations could be renegotiated with the c l in i ca l supervisor. On February 4, 1974, my thesis advisor and - 179 -I met with the c l in ica l supervisor with a view to arranging the schedule of my observations for the remainder of my observation period. My notes of that meeting record that: [Cl inical Supervisor] suggested that I came in as a patient, suggested that this would be less disruptive. [Thesis Advisor] and I objected that process would or might become focused on me as a deviant patient but [C l in ica l Supervisor] was not impressed by this argu-ment. He suggested that i f I d idn' t want to come in as a patient my observations would be severely limited -to maybe two days a week. The c l in ica l supervisor said he would discuss the matter with the Theta staff . He made-a reference to my thesis at that meeting and asked . . . that the staf f be given an opportunity to read the thesis - not to suppress anything but to make sugges-tions. I said I would look to him for help i f there was time. He said time was a great trouble. One of the reasons that I had requested that neeting was that I had accepted a job for the coming summer which was scheduled (at that time) to start in June. I had agreed to go to Afr ica with a company that I used to work for . Both my thesis advisor and I presented this as a reason for requesting a more intensive observation schedule, stressing that the time I had available to f in ish my MA was not much more limited than before. In a subsequent telephone conversation the c l in ica l super-visor said that I could attend Mondays, Wednesdays and Fridays and that other times might be arranged. During the next week the schedule of my attendance was hardened and I was variously requested to attend "only when the c l in ica l supervisor was present" and "only during big-group - 180 -meetings". In a conversation at Theta on February 13, 1974, I asked once again for more observation time. The c l in i ca l supervisor said that they "would think about that", that I "had great influence" (on the patients at meetings). On February 15, I had another conversa-tion with the c l in ica l supervisor about attendance. My notes record: . . .he said that I should wait until he talked about i t . About 15 minures later he came down stairs and said: 2:30 Monday, lunch Wednesday, and 9 a.m. Friday. He said I had been present for many Monday lunches already. I was s t i l l not sat is f ied with this and asked my thesis advisor to intercede on my behalf. He wrote a let ter (dated February 19, 1974. See Appendix VI) requesting a more extensive schedule. I, myself, wrote a let ter on the same issue (see Appendix VI). It was my thesis advisor's let ter of February 19 that so angered the c l in i ca l supervisor that he asked me to jot down immediatley my thoughts about what I thought i t meant. My attempted explanation is also included in Appendix VI. I read my explanation out at the staf f meeting of February 22. After some discussion of this issue between myself and the s taf f members who were present at this meeting, the c l in i ca l supervisor agreed to allow me to supplement my then current observation schedule by attendi full-time for my last ten days of observation. This period started on March 6, 1974 and ended on March 15, 1974. I attended a staff meeting on March 15 which I recorded as follows: I went to the "feel ings" meeting and talked for a few minutes. I said that I was just beginning to get some ideas about the place and was very impressed. I talked a l i t t l e about the confl icts that I had seen during the last week between the individuals and the group about people leaving. The people at the meeting seemed quite - 181 -well disposed to me and [Cl inical Supervisor] said that he had not made i t any easier for me himself which I agreed with. I asked for a week's extension and [C l in -ical Supervisor] agreed to let me stay after checking with the others who agreed readily enough. I attended full-time from March 8 to 22 which was the last day of my observations at Theta. The issue of the staf f seeing my thesis was raised rather casually at the meeting of February 4 and was raised again at a staff meeting on Februaly 11. My f i e ld notes for that date record the following: Went upstairs to [Cl inical Supervisor] 1s o f f i ce . He started by asking me to give him written assurance that he would have a copy of my draft of my thesis -" in case i t got forgotten what arrangement had been made". [Emphasis added] The letter which my thesis advisor wrote on February 19 states: We sincerely welcome your suggestion that the f i r s t draft of his thesis be shown to you, and, indeed we would be eager to have you discuss i t with your staff so that your col lect ive reactions can be integrated with the f inal version. [Emphasis added] As far as I know this is the only statement giving the "[promise] in writ ing" that is referred to in the c l in ica l supervisor's text. In the l ight of the reasonably cordial discussions that were taking place at that stage of my contact with the Theta staf f , I fu l l y expected that the staff would have some input into the f inal document. Of course they could have no input until they saw what the document looked l ike and i t was certainly never my intention to spring a f i n a l -ized version on them, as this would have frustrated the purpose of - 182 -their getting i t in advance. In accordance with my perception of the agreement between us, which I have documented above, I submitted a copy of the f i r s t draft to the c l in ica l supervisor on June 14, 1974, the same day that I submitted i t to my thesis committee for comment. As my time had by now become extremely pressing due to my rapidly approaching departure for A f r i ca , I asked everyone concerned to give me their reaction to my draft as quickly as possible and scheduled a meeting with my committee on June 20. The c l in i ca l supervisor wrote on June 17 to say that the draft was incomplete. There was no suggestion in this l e t te r , included in Ap-pendix VI, that he was surprised to receive a draft. I was away at the time and went to see him on June 21 to enquire about the missing parts of the draft I had given him. I showed him another copy of the last page of the document and he told me that his copy was in fact complete. The June 21 meeting was an extremely angry one in which the c l in ica l super-visor said that my thesis had been unfair to the sett ing. I spoke with him again on the telephone on June 21 and real iz ing that he had consider-able objections to the thesis, wrote him the let ter dated June 23 which is also included in Appendix VI. Despite the several pleas for discussion on the thesis con-tained in the letters cited above, there was no discussion between the c l in ica l supervisor and myself. There was a discussion with another staff member which resulted in my making some changes in the document. - 183 -Al l the issues that had been drawn to my attention, I examined with considerable care. I had already introduced some modifications by the time of my le t ter of June 23 and indicated this in that le t ter . Some other issues were reported to me by the staf f member and prompted further changes. Apart from some major revision of the introductory chapter, the changes referred to above are the only s ignif icant alterations of the original draft. I believe that the above description details the relationship between myself and the inst i tut ion in a way that wil l be of assistance in understanding the import of the matters in the notes about our "agree-ment". I believe I have l ived up to the sp i r i t as well as the let ter of that agreement and that my doing so is documented in the above report. - 184 -July 4, 1974. Notes of the Cl in ica l Supervisor of "Theta" to the thesis of Mr. J . Brown. "Creating the Therapeutic Reality. A Phenomenological Account of an Outpatient Therapeutic Community". [T i t le of f i r s t draft] 1. Introduction. 2. Specific Comments. 3. Methodological Remarks. 4. Notes on the Theory of Therapeutic Community. 5. Background Information. 1. INTRODUCTION In February, Mr. J . Brown promised in writing that I, the Cl in ica l Super-visor of "Theta", would receive the text of his thesis in order that I would have an opportunity to write my comments, which would be part of the thesis as footnotes. I did not hear from him until June 14, 1974, although, according to his words in February, our staff expected to hear from him much ear l ie r . As late as June 14, 1974, he sent me the f i r s t draft of his thesis. I asked to write my notes to his f ina l thesis, according to our agreement, but he explained that I would not have an opportunity to write my comments to the f inal thesis, as the defence would be on July 4, 1974, and that the f inal thesis would be typed on July 3, 1974. Later he informed me that the defence would be on July 9, 1974 and that "Your footnotes wi l l be included in the f inal bound copy of the thesis regardless of when they are submitted. If they are avail-- 185 -able by approximately July 5, they can be included in the f inal form before defence.. ." ( letter of Mr. Brown to the Cl in ica l Supervisor of June 23, 1974). Although I feel that the promise of Mr. Brown, made in Feb-ruary, has not been kept, I am writing these notes to the "F i rs t Draft not knowing, of course, what changes Mr. Brown wi l l make in his f inal thesis as a result of discussions with myself and members of "Theta" s taf f , or otherwise. I offered to take into account any changes he wi make in the text, and that I should receive these in writing before starting to write my notes (beginning of July) , but to date I have not received any of this information. Mr. Brown promised that these notes would be included, disregarding any changes he may make in his f inal version. In writing these notes, I am, of course, not concerned with the evaluation of the thesis. My only concern, and I was asked to do this by the staf f of "Theta", is to correct the misinformation about various aspects of "Theta", given by the author, and comment on the source of systematic error of observation and interpretation of "Theta1 I wi l l not, therefore, deal with the parts which correctly describe the inst i tut ion - and I agree that there are such parts. These notes are written in a hurry as I am extremely busy with a task of great importance for the Department. The "Specif ic Com-ments" are only a random selection of incorrect observations and unwar-- 186 -ranted generalizations and can be extended in future. **************** 2. SPECIFIC COMMENTS [p. 28]: "Any v is i tor then, who could be constituted as a therapist, was received at "Theta" without challenge. In contrast to this I was frequently challenged by new patients." Incorrect generalization: It was not only the difference o[f] roles. Mr. Brown does not see the difference in behaviour of a know-ledgeable v is i t ing psychotherapist and his. At one time, when he made remarks and gave advice, incompatible with psychotherapeutic strategy, one v is i t ing psychiatrist remarked after the session: "What is the ama-teur psychotherapist doing here?" (Mr. Brown admits once - [p. 160]: "On one part icular ly bad occasion I spent the evening making fa i r l y wild speculative guesses in role playing with patients and v i s i to r s " . However, he is not aware to what degree his comments and behaviour ran contrary to the therapeutic strategy of the Centre). At other times, M.D. v i s i to rs , without knowledge of psychotherapy, were challenged by patients. [p. 31]: (Secretary) "She decided to go through "Theta" as a patient so that she could more readily identify with the patients and, presumably, have some status as an ex-patient." Not correct. Mr. Brown distorts to prove his point. The secretary decided to become a patient, only after she decided to f in ish - 187 -her job and go to study. Her decision was motivated by her problems, for which she sought psychiatric help outside "Theta". [p. 54]: "There was considerable amusement among the Theta group at having caught the hospital in this shortcoming." Again, Mr. Brown distorts to prove his point. The amusement was in regard to one lady in the hospital only, and the "hospital" had a similar attitude towards her as we did. Are distorted gossips [ s i c ] part of "phenomenological method"? [The reference is to the introduc-tion to the draft which has been extensively rewritten. "Ethnographic" could be substituted for "phenomenological" without loss of meaning in this case.] [p. 112]: "In general the patients made almost no decisions about anything.. . " Incorrect. It is a pity Mr. Brown deals so superf ic ia l ly with the intr icate problem problem [ s i c ] of power d is t r ibut ion, where a knowledgeable sociologist could be of help. Instead of using our mass-ive material studying this question, I wi l l mention his own statements contradicting his general statement: [p. 90] a. "Halfway through the elections the Cl in ica l Supervisor interrupted to say that the work coordinator should be competent. Some votes now - 188 -went to [Male Patient], but the group insisted on having i ts own candi-date [Female Patient] self-confessed incompetent. Despite the attempt of the Cl in ica l Supervisor to influence the process, the group attended to i ts own pr ior i t ies in selecting a patient to f i l l the [ r ]o le. " b. One of the most serious decisions of the Centre, admitting a patient, is a group decision. [P. 81]: "The patient was admitted on a simple majority of the group members, former group members and therapists " c. It is true that the therapist uses his influences, as in instances where not a l l means have been exhausted and the group wants to discharge the patient. d. Although the staff is against the patients meeting outside the group, no s t r i c t rule is included in the rules. e. Despite what Mr. Brown says, the patient having a function is ap-prehensive \_sio\ and has an opportunity to be [p. 35] "power t r ipp ing" , "pushy", "aggressive". e [p. 109]: "The reaction of the inst i tut ion to sexual relations among i ts patient population was extremely d i f f i c u l t to understand. The ex-planations that were given in the centre were either no explanation at - 189 -a l l : " i t damages the therapy", " i t interferes with the treatment", or were "shot through with inconsistencies". And [p. 110]: "Why the re la -tionships which originated at Theta were so severely censored is thus a puzzle which i t seems only possible to explain in terms of control " . [The f inal version of this quotation has been somewhat changed.] Mr. Brown did not bother to ask. Here only main reason wil l be given, [sic?] No patients who are in a relationship of important de-pendency (husband-wife, boss-employee, two co-workers) are admitted at the same time. Sexual (or love) relationship deprives the persons of f l e x i b i l i t y for changing their behaviour; i t is d i f f i c u l t for them to be completely open and they support themselves in their resistance. Such a love relationship is usually a symptom of resistance, " f l igh t into love". (The mentioned patient discharged, l ied for several weeks.) Experimentation in the past led to this practice; often, the other partner was admitted later. (The relationship normally turned out to be a traumatic one.) This arrangement may be given up one day, i f new knowledge and techniques wi l l allow us to deal with the complex prob-lems, which such a re[la]tionship causes. f [p. 33]: Mr. Brown summarizes that the work "does not ref lect real * l i f e " . It ref lects real l i f e to the degree necessary for therapy, that i s , showing some typical problems of behaviour (see [p. 92-93]). It is * In this case i t seems necessary to point out that the text has not been changed since the draft. The reader should note that the quotation cited should not have been attributed to me but was a report of an appar-ent consensus among patients. JB - 190 -true, however, that a 24-hour therapeutic community gives more oppor-tunities in that respect. g [p> 71]^ "It is an interesting sociological fact that every candidate for admission is able to produce some subset which he sees relevant for this task [which he sees to be relevant to his se l f formulation as somebody who needs help] and that the staff member also treats what-ever l i s t is produced as relevant to the question that has been asked." [Amended in f inal version; see text. ] Equivalent statement [sic] would be about a grocery: "It is an interesting sociological fact that every shopper produces a set of demands and the store owner treats also whatever l i s t is produced as relevant to the question "What can I do for you?" But how [does] Mr. Brown [explain] the fact known to him that some patients are sent away from these interviews? He also missed that [the] psychiatric interview checks the consistency of statements with non-verbal behaviour and that the group interview is a further step in this checking. On [p. 73] he says again: "One feature of the process which is evident is that the staf f member treats the self-des-cription as a true account of the events of the patient's l i f e . " Is this the "phenomenological analysis" [p. ] "an essential - 191 -fact ic i ty which i t does not make sense to question"? [The introduction to the draft contained references to phenomenological analysis which were removed in the f inal document.] Mr. Brown simply does not know anything about psychiatric interview [sic] (though he was once present) and continuous checking in a therapeutic community. Although mistakes cannot be excluded, they are highly unlikely. Here, something essential escaped Mr. Brown. h [p. 47]: "Theta was seen as a place in which the tradit ional moral judg-ments are suspended. It was not so much a matter that they were ind i f f e r -ent to these descriptions but of the certainty that anybody's moral deci -sions were his own business and had nothing to do with therapy." [This has been amended in the f inal document although the sense has been pre-served. See pp. 47-48.] This is a wrong observation and conclusion. Not only that moral decisions have to do with therapy [sic], neurotic breakdown is often caused by chronic moral conf l i c t . However, the group does not use the usual means to help the patient in his moral conf l ic t - that i s , by reproach, advice and persuasion, as they proved mostly inef f ic ient in his previous l i f e . Instead, the treatment is designed to modify his motivational network, so that he is able to make a decision. i [p. 73]: "This problem l i s t subsequently becomes an jnst i tut ional a r t i -fact and is used to demonstrate the progress the patient is making in the ins t i tu t ion . " [This has been s l ight ly amended in the f inal version.] - 192 -This courageous statement is based on specif ic use of the problem l i s t , where a patient himself was questioned about not making pro-gress on a problem l i s t . But Mr. Brown, in one sentence, judges exten-sive work of the last years about problem oriented record [ s i c ] , which is now a routine part of the work in many branches of medicine, includ-ing psychiatry. j [p. 133]: "That someone was "homosexual" was taken to be an adequate reason for his coming to Theta without any further explanation and i t was always available as a possible category that could be invoked to explain feelings and behaviour, even though the patient did not himself evoke i t . " [This quotation has been s l ight ly amended in the f inal version.] The f i r s t statement is simply not true and is a not uncommon example of Mr. Brown's careless statements. We went through a l l problem l i s t s of homosexual patients and they al l suffered from neurotic symptoms and problems, such as depression, hopelessness, forfe i t ing uncertainty about sexual orientation, etc. Why would a happy homosexual ask admission to the demanding treatment of Theta? The other half of the sentence is a vague generalization, which cannot be answered. k [p. 164]: "The staf f of Theta were perenially concerned with "what I was finding ou[t]" . The staff was quite capable of deciding what parts of - 193 -the Theta process I should be watching " The sarcasm is unwarranted. Mr. Brown became a burden for Theta and we did not interrupt his stay out of charity. He evidently interprets, in his idiosyncratic way, the tactful remarks of therapists relating to which parts of the programme he would be least harmful.[sic] He also misinterprets our concern with his f indings. He should know that we asked every guest about his observations even i f he visited only once. I asked each staf f member in each staff meeting following the group session routinely about observations and personal feel ings. I could go on and on with remarks to Mr. Brown, but Mr. Brown does not give us suff ic ient time and I am too busy. Also, i t would save time to read f i r s t a textbook of psychotherapy. Mr. Brown looked into a complex factory through a keyhole and made hasty conclusions about everything. However, he is not even aware of i t . 3. METHODOLOGICAL REMARKS Let us imagine a student of sociology who wants to study the organization of a surgical ward, but who knows very l i t t l e about anatomy, physiology, and antisepsis. As he studies a task group, he cannot under-- 194 -stand this behaviour unless he has either extensive information of the f ie lds of knowledge in question, or unless he asks them why they are behaving in certain ways. He may also, and probably w i l l , find some discrepancies between what they intend to do, and what they do, which may be of general interest. If, however, he neither has the necessary knowledge, nor for reasons of his own does not ask them, i t would be hopeless to explain their acts (based on their knowledge and bel iefs) observing their behaviour for a short time. He may obtain quite a false picture as to what is going on. For example, he may interpret their behaviour, such as not touching certain objects, going through stereotype sequences of movement - as their phobias and r i t ua l i s t i c be-haviour. He may interpret restr ict ions put upon his behaviour by the team, e.g. that he is not allowed to touch certain objects which they do - as unfriendliness towards him. The same observer may study the behaviour of hunters of an African tribe and interpret their behaviour as superstitious and compulsively repet i t ive, only because he does not know enough about animal l i f e and technology of tools and weapons. It may be debatable where psychotherapy stands on the con-tinuum of systematic knowledge between the two human organizations men-tioned. Whatever the case may be the tasks of Theta are approached with the help of a conceptual framework which has i ts basic views broadly accepted in the f i e ld of psychiatry. I introduced, of course, the ex-ample of surgery, since psychotherapy has less prestige than surgery and the absurdity of the situation is more obvious, but i t is not less absurd in the case of Theta. - 195 -The remarks just made would be irrelevant, i f i t were true what Mr. J . Brown writes at the beginning of his thesis characterizing his stance as a phenomenological one. He describes i t [by] means of a quotation of P. Berger that phenomenological analysis "refrains from any causal or genetic hypothesis " and says further, "That i s , I describe a commonsense real i ty without making any judgments about mem-bers' understandings as being right or wrong but (provided I have been successful in discerning them), as, for members, an essential f ac t i c i t y * which i t does not make sense to question". Leaving aside the question whether this methodological "stance" is a sound one, i t can be shown that Mr. Brown does not keep to his promise and makes daring generaliza-tions and interpretations, and not knowing the theory underlying the act iv i t ies of Theta (and, as he mentioned in a discussion with me, even programmatically not being interested in i t , nonetheless, in fact , sub-st i tut ing i t with a commonsense view) misinterprets the act iv i t ies of Theta and the behaviour of the staf f , even diagnosing them psychiatr ical ly ("paranoia") . There is a close paral lel to the imagined example of a * The quotations are taken from the introduction to the original draft. JB ** The word "paranoia" has been eliminated in the f inal version. My original use of the word was not intended to be a psychiatric diagnosis but a members' categorization. I attempted to disavow the psychiatric implications of "paranoia", arguing that the word was in common use by members, but eventually recognized that the inescapable psychiatric roots of the word made i ts retention inadvisable. It has been replaced with "mistrust" which is not intended as a synonym. See, pp. 163-165. JB - 196 -surgical ward, as this and other misinterpretations are caused by Mr. Brown's not having even an elementary knowledge of the theory. 4. NOTES ON THE THEORY OF THERAPEUTIC COMMUNITY I am not going to, of course, develop here the theory of group psychotherapy in general and of therapeutic communities in par t i -cular. I wi l l deal only with the minimum for present purposes. One of the cornerstones of modern psychotherapy broadly accepted by psychotherapists of different orientations (not only psycho-analysts), is Freud's discovery of resistance. The patient is divided in his motivation: in his treatment he co-operates in order to get bet-ter, but at the same time, with changing intensity, he tr ies to keep status quo of his neurosis. As Menninger says (Menninger, K.A., Holzman, P.S., Theory of Psychoanalytic Technique, Basic Books, 1973): " every patient, in spite of his co-operativeness and eagerness to do whatever he is told in order to "get better", is at the same time part ia l ly "on the defensive". He unintentionally but purposely, obstructs the very process upon which he counts so heavily to benefit him. He may obstruct i t so effect ively as to "terminate i t soon after i t has begun." Freud compared individual treatment to a battle where on one side of the l ine is the therapist and the reasonable part of the patient, and on the other is the resist ing part of the patient. The conf l ict is only the ref lect ion of the inner neurotic conf l ic t of the patient. Far from being only a nuis-ance, the manifestation of resistance is unavoidable in treatment and i ts - 197 -handling is an essential part of the treatment. This holds also for [the] therapeutic community, only the handling of resistances is more d i f f i c u l t , as the patients in periods of increased resistance form coal i t ions. The mentioned picture of a battle in individual psychotherapy holds for [the] therapeutic community also, where each patient is partly [an] a l ly of the therapists in achieving therapeutic goals, partly contributing to the group resistance (both his al l iance and resistance fluctuating in time). The d i f f i c u l t and challen-ging task of the therapists is to handle the indiv idual , subgroup and group resistances. This they try to do using the patients as co-thera-p is ts . The more the patients take responsibi l i ty for the treatment, the more e f f i c ient [the] treatment can be. The more they are able to do i t through the patients themselves, the better. However, the patients are unreliable a l l i e s , because of their fluctuating resistances. From time to time, they try to drive a wedge between the therapists. It is almost inevitable that they succeed with a psychotherapist-beginner. Under these circumstances, a high degree of unity of therapists is nec-essary, strengthened by staf f meetings where not only the observations of s ta f f members, but also their emotional reactions are discussed and channelized. 5 . BACKGROUND INFORMATION Even from this short description i t should be apparent that there is no place in the system for a long-time observer, unless he - 198 -takes either a therapist 's or a patient's role (at least at the present stage of knowledge). Otherwise, he becomes a nuisance l ike a neutral person walking in the bat t le f ie ld , where one side has taken into consid-eration his presence and the other misuses i t . This happened already during the half year when Mr. Brown attended once a week only. Without any knowledge of psychotherapeutic strategy, he "played therapist" from time to time, so that one v is i t ing psychiatrist asked after one session in surprise, "What is the amateur therapist doing here?" Several ther-apists (not only one, as he thinks) found his behaviour disturbing, and not only on one occasion which he is aware of. When,in February, Mr. Brown asked to be present for longer times he was given, in the presence of the Supervisor, a choice of stay-ing for 4 - 6 weeks in the role of a patient (what we have done in the past with new staff members for training purposes), or to be in Theta for a whole week as an observer and continue coming once a week for * the rest. Both he and his supervisor accepted the second alternative; I promised I would discuss with the staff possible extension. However, in our meeting we decided against extension, as Mr. Brown's presence had been, even so far , an additional burden for the already overworked staf f , and his stay for longer than one week was expected to lead to * The details of the negotiations have been recorded in my intro-duction to this appendix. The schedule of my attendance is shown in Appendix VI. JB ** Actually, as recorded in my introduction to this appendix, I was granted an extension at the end of my f i r s t ten days of full-time observation. JB - 199 -further complications (time for patients to develop transference reactions to him, e tc . , which could not be analysed. So the principle of closed system in which the causal chains of interaction can be anal-ysed (and which Mr. Brown erroneously thinks was discarded) would be seriously violated. In the next days after the agreement, Mr. Brown put pressure through his supervisor to change the agreement (February 19, 1974): "I do not believe that John would give me a distorted version of his exper-ience and from what he reports, i t is hard for me to understand why there should be so much fuss. As you know, he wi l l be in (Theta) for another month or so " . It is unfair that Mr. Brown quotes me as saying that the * let ter is "outrageous" without quoting this le t ter . We were "making a fuss" about lett ing Mr. Brown stay for a month, because we would not let any observer who did not have an extensive knowledge of psychotherapy stay for a month. This complete lack of understanding led Mr. Brown to a systematically biased observation and he jumped to unwarranted con-clusions. He never tr ied to understand the theory and beliefs of the staf f , and as a result , he misinterpreted the s ta f f ' s behaviour as "para-noia" [p. 164]. "I think, however, that there may have been some paranoia on the part of the staff as wel l . . . . the fact that this was * In view of this objection and the relevance of this correspondence to my introductory remarks.to this commentary, the letter is included in Appendix VI. JB ** Again, the reader is reminded of the change in the f inal text from "paranoia" to the less ambiguous members' word "d is t rust " . JB - 2 0 0 -paranoia and not the disinterested curiosity i t claimed to be may be supported by the fact that the Cl in ica l Supervisor insisted that I give him written assurance that I would submit a draft of my thesis to him He said he would add comments which should be included in the f inal document." (Mr. Brown's d istort ion: "draft" - instead of " thesis" . ) That this was a rea l i s t i c assessment and not paranoia is apparent from the fact that although this was my only condition for his stay in Theta, he has not given me his f inal thesis for comment to date. (As our contract was that my comments would be included in the f inal thesis [p. 164], I did not expect, of course, to write them to a draft , but rather to the f inal thesis.) Although Mr. Brown regards us as paranoid, we freely opened our Institution, including informal staf f meetings, to his observations. He even had an opportunity (in the role of a patient) to observe i t uninterrupted for four to six weeks. We doubt very much whether another department, including the Department of Sociology, would allow the ad-mission of a student to their informal staff meetings. But we may try this in the future, and ask for permission for a student of medicine to conduct a psychological study. APPENDIX VI SCHEDULE OF ATTENDANCE AT THETA 1973 April 6, 13, 27 May 4, 9 June 13, 26 July 10, 16, 18, 24, 31 August 7, 14 October 2, 9, 23, 30 November 6, 8 [F i rst lunch attended], 13, 19, 20, 26 [Lunch], 27 December 17 [Lunch], 18, 27 1974 February 11, 13, 15, 18, 20, 22, 25, 27 March 4, 6, 7, 8; 11 through 15; 18 through 22. [F i rst draft of thesis submitted June 14, 1974.] - 202 -February 19, 1974 Dear Dr. In accordance with your request, I attach a further copy of the current working draft synopsis of my M . A . thesis focus. This is identical with the copy given to you on February 1, 1974. This document was discussed at the meeting of February 4, 1974 with yourself ar^ d , tny advisor from the Department of Sociology. At thnt meeting I elaborated on my request to you to attend at . to make further observations of the institution for the purpose of obtaining information for."my thesis. In a subsequent telephone conversation with you on-.February.••£"". .you advised me that you had discussed this matter with the staff and that it would be permissible for rae to attend at , yoft? Monday, Wednesday and Friday and that other tines might be negotiated. This has subsequ-entlv further refined so that the present agreed times are Monday, 2:30 - 4:00 p.m., Wednesday 12:00 noon - 4:C0 p.m. and Friday, $5:00 -11:00 a.m. You also indicated that during my last week I could be at throughout the week. I certainly wish to express ray appreciation for whatever times you can see f i t to al&ow rae to attend. I believe i t would be helpful if I set out wL.it activities I would be interested in at times of the day other than the formally constituted group meetings. The culture of the setting, the ways in which patients view and v i e w what is appropriate behaviour in the setting are problematic for tha new arrival. I am interested in learning how new patients become acculturated to this setting. I am interested in learning what the patients view as the "facts" about therapy and . It is not ny task (or my intention) to demonstrate that t!:c:y have the "facts" wrong, that they don't understand,.have been misled or should have knovn better, but rather to discover the prevailing /2/... - 203 - 2 D r . c o m m o n sense u n d e r s t a n d i n g s t h a t d e t e r m i n e t h e b e h a v i o u r p a t i e n t s v i e w a s a p p r o p r i a t e i n t h e s e t t i n g , i . e . t h a t a l l o w t h e m t o b e h a v e r a t i o n -a l l y i n t h e s e t t i n g . I n o r d e r t o d o t h i s i t w o u l d b e o f g r e a t a s s i s t a n c e i f I c o u l d b e a r o u n d a t t i m e s , s u c h a s l u r c h h o u r s a n d w o r k p e r i o d s , a u t o b i o g r a p h i e s a n d p s y c h o d r a m a p r e p a r a t i o n , c o m m i t t e e m e e t i n g s a n d t h e r e s t w h e n t h e p a t i e n t s a r e f r e e l y e x p r e s s i n g t h e i r o p i n i o n s a b o u t , a n d o r g a n i z i n g , t h e i r a f f a i r s . I h a v e d i s c u s s e d t h i s m a t t e r a t l e n g t h w i t h m y c o m m i t t e e b e f o r e p r e s e n t i n g y o u w i t h t h i s l e t t e r a n d D r . h a s d e c i d e d t o w r i t e a s e p a r a t e l e t t e r t o y o u , s e t t i n g o u t h i s c o n c e r n s i n t h e m a t t e r . I f , a f t e r a n o t h e r w e e k o r c o , y o u c a n s e e y o u r w a y t o d i s c u s s i n g t h i s m a t t e r f u r t h e r , I s h a l l b e h a p p y t o s e t o u t o n c e a g a i n , a d e t a i l e d s c h e d u l e o f w h a t e v e r r e v i s e d t i m e s y o u c a n a l l o w m e t o b e p r e s e n t i n t h e s e t t i n g . Y o u r s s i n c e r e l y , J o h n B r o w n - 204 -F e b r u a r y 19.1974 Dear Dr. A f t e r our c o n v e r s a t i o n i n y o u r heme, I was h o p e f u l t h a t he S o c i o l o g y graduate s t u d e n t •—John Brown-- would be gra n t e d , l i t t l e more a c c e s s t o o b s e r v i n g y o u r programme than seems t o be the c a s e . I f u l l y a p p r e c i a t e the r e a s o n s f o r the h e s i t a t i o n e x p r e s s e d by a t l e a s t one member o f y o u r s t a f f , but I a l s o f e e l t h a t any f e e l i n g s o f r e s e r v e o r a p p r e h e n s i o n s h o u l d be weighed a g a i n s t the p o s s i b l e v a l u e o f John's s t u d y t o what ou are s e e k i n g t o a c c o m p l i s h a t ._. I do not b e l i e v e h a t John would, g i v e me a d i s t o r t . C i i . v e r s i o n o f h i s e x p e r i e n c e D f h i s impact upon what goes on a t the Centre., and from vhnt tie r e p o r t s , i t i s h a r d f o r me t o u n d e r s t a n d why t h e r e s h o u l d be so much f u s s . As you know, he w i l l o n l y be a t f o r another month o r so, and, t h e r e f o r e , t o t h o s e who may r e g a r d l i s p r e s e n c e as something of an i r r i t a t i o n , t h e y can t a k e r e l i e f i n the thought t h a t k h i s he w i l l o n l y be t h e r e f o r a r e l a t i v e l y s h o r t w h i l e . A p a r t from these e x p r e s s i o n s o f my own p e t u l a n c e , John and E are a c t u a l l y v e r y g r a t e f u l f o r whatever time you a l l o w him t o spend at the C e n t r e . .The c o n c e r n f o r more o b s e r v a t i o n a l time i s t i e d t o the problem of knowing what t o make o f o b s e r v a t i o n s t a k e n Ln one c o n t e x t , which Kinc can be r e p o r t e d d i f f e r e n t l y when t h e y i r e made i n o t h e r s e t t i n g s where t h e i n t e r a c t i o n a l p e c u l i a r i t i i e s are not the same. In a d d i t i o n , t h e r e i s the problem o f s e e i n g as nuch as can be seen when t h e r e i s o n l y a month i n which t o c a r r y Dn t h e s e o b s e r v a t i o n s . I g a t h e r t h a t a ma tior problem i s t h a t some o f y o u r s t a f f a re i i s t u r b e d by the f a c t t h a t t h e y a r e s r not e n t i r e l y s u r e .just when John w i l l a r r i v e 0 :1 the scene, and t h a t t h i s , i n d e e d , can be l i e r u p t i v e . Kay I suggest t h e f o l l o w i n g : S- In the f i r s t week t o t e n days, John f o l l o w a p r e c i s e s b h e d u l e x ( e . the one a l r e a d y proposed by y o u ) , and t h a t d u r i n g t h i s time lie attempt t o d e v e l o p f i r m i d e a s about what o t h e r e v e n t s o r s e t t i n g s he s h o u l d be o b s e r v i n g . ?- In the second and t h i r d weeks, he add t o the o b s e i ^ v a t i o n a l s i t e s and times of the f i r s t week, the f u r t h e r hours t h a t he hos been a b l e t o d o t e r m i n e t h a t he s h o u l b e a t;\ t h u s , p r o v i d i n g the s t a f f w i t h a n o t h e r p r e c i s e s c h e d u l e for:: t h i s p e r i o d , so t h a t they are - 205 -not g r e e t e d v;ith any unwelcome s u r p r i s e s . 5~ That John adopt your t e n t a t i v e s u g g e s t i o n t h a t he devote the l a s t v; a ok oi' h i s o b s e r v a t i o n s t o a complete d a i l y c y c l e , and t h a t he n3h-?re f a i t h f u l l y t o t h i s schedule so t h a t your s t a f f w i l l not then be d i s r u p t e d by any u n a n t i c i p a t e d absences on John's p a r t . I f you can agree t o t h i s s o r t of sc h e d u l e , I b e l i e v e t h a t i t w i l l be p o s s i b l e f o r John t o see enough to' make an i n t e l l i g e n t commentary on what he observes. V/e s i n c e r e l y welcome' your s u g g e s t i o n t h a t the f i r s t d r a f t of h i s t h e s i s be shown t o you, and, in d e e d , v/e would be eager to have you d i s c u s s i t w i t h your s t a f f so t h a t your c o l l e c t i v e r e a c t i o n s can be i n t e g r a t e d w i t h the f i n a l v e r s i o n . A g a i n , I am h o p e f u l t h a t you w i l l f i n d some way t o accommodate John's needs so t h a t he has a decent qj-ififice t o produce something w o r t h w h i l e . - 206 -From: J. Brown COPY February 22, 1974 To: Di-Letter of Feb. 1,9: Request for Written Comment Dr 's letter was written as a reaction to my own concerns about the very structured schedule of observations that had been imposed on the observations of the setting. 1 had expressed my concern that the only facets of that I would see were the formally constit-uted group meetings. I cannot, of course, provide an interpretation of Dr, 's total perspective, which derives from his whole biography and experience with therapeutic groups. His use of the word "fuss", while i t may be unfortun-ate, can only be understood in the total context of the letter, which I take to be an expression of his own concern that my perspective would be distorted and a plea for some reconsideration on your part. He does identify i t as an "expression of (his) own petulance" and, 1 believe, an attempt to state his case as directly and forcefully as he thought appropriate. I strongly urge you to talk to Dr himself, with or without my being in attendance, i f you wish to have the matters he descussed explicated further. This is particularly so as I have considerable hesitation in comment-ing on his letter to you in his absence -John Brown. - 207 -June 13, 1974. Dear D r . In accordance with our agreement, I enclose f o r your information one copy of the f i r s t d r a f t of my M.A. thesis. This copy i s delivered to you at the same time i t i s submitted to my committee. As I understand you may wish to make comments which should be included i n the f i n a l document i n the form of foot notes, I would l i k e to advise you that my committee has kindly agreed to have a meeting on t h i s draft i n about one week. The reason f o r the haste i s , of course, my imminent departure f o r A f r i c a and the fact that I am hoping to have a f i n a l draft f i n i s h e d before I leave. I am sure you w i l l understand the need for any response you wish to make being submitted as soon as possible. I s h a l l be happy to discuss any point that you wish to make and would value your observations whether you wish them included or not. I f you do wish to have any part footnoted, I would appreciate i t i f you would send me th i s copy narked up via - .. and I s h a l l make the necessary adjustments to the o r i g i n a l . Yours s i n c e r e l y , JB:jw John Brown. - 208 -June 17, 1974 Dr. John Brown, Dear John: Thank you for your draft of your manuscript received June 14th. I received 142*f'pages which does not seem to be the entire manu-scr ipt . That i s why I cal led Dr. _ , since according to your statement, both and I expected to receive the manuscript ear l i e r . According to our agreement, I do want to make comments included in the footnotes. However, I am extremely busy organising an , and I do not see any point in spending my time writing comments to a draft which can be changed. As soon as you provide me with a f inal version, I wi l l write my comments. I expect", of course, reasonable time in which to do that. You may, of course, have comments to my comments. If you have any questions or comments-please call me, either at the of f i ce ! I or at home i •••; Yours s incerely , - 209 -June 23, 1974 Dear Dr: : Further to our telephone conversation of June 22, 1974, and your request for written assurance on several points ar is ing from that conversation, I wish to advise you as follows. I shal l make every e f for t to have your comments included as part of the permanent document at the time my thesis is presented for defense. I should bpgfebtcut that we have revised the date of the defense to July 9 so as to give you as much time as possible to prepare your comments. As I am currently scheduled to leave for Afr ica on July 10, you wi l l see that this is the latest date that I can accomodate. Your footnotes wi l l be included in the f ina l bound copy of the thesis regardless of when they are submitted. If .they are available by approx-imately July 5, they can be included in f ina l form before the defense. If, however, they are not f inished unt i l af ter that date, i t may be necessary to mark up the superscript letters in ink on the defense copies. Every person who attends wi l l be given a copy of your notes. I wish to confirm that I do not currently expect to publish the thesis outside the university in i t s current form. The question of what kind of publication might develop from this work has not arisen as yet. I an quite prepared to discuss any paper or work with you should the occasion ever ar ise , cr to correspond with you about i t i f I am not in et the time. I arc attempt!no to have the f ina l version of ny thesis available by July 6 or 7. This would include your footnotes and allows two days for their insert ion. This date allows approximately one week for typing and reproduction which means that my target date for having the revisions complete is Jur.o 28 or 29. As I have a.lrescly pointed out, I do not exnect this version to be rad i -cal ly different from the current version. I would l ike at this point to male a nle-? for some more constructive communication between us. If you have strong objections to some parts of the document, as you c lear ly have, I would urge you very strongly to consider discussing them with me or perhaps having a meeting / 2 / . . . - 210 -Dr. 2 v/iiich could include several members of your staf f and some members of my cor^.ittce. I have already examined the points that you have raised so far and find your objections to the penultimate sentence on paqe 140 (for example) to be well-founded. I believe the sentence is cast in an unfortunately strong form and have modified i t accordingly. Your last point concerned my report of your categorization of one sentence of Dr. 's le t ter about my attendance as "outrageous". I have examined the passace and am quite prepared to rewrrte i t so-that i t is less objectionable to you. In this regard, I understand you w i l l make ava i l -able a copy of the le t ter and I would appreciate i t i f this cculd be dene as soon as possible. Once again, I believe that a reasoned discussion of points of this kind could eliminate a lot of the f r i c t i on between us. You have said that my report of the above incident is a total distortion of the facts, which at the very least indicates that there is a strong difference of opinion about the incident which (without attempting to deny i ts importance to you)-is a re lat ive ly minor one in terms cf my total document. It would be most unfortunate i f matters such as this that can be discussed and possibly corrected should become instances of acrimonious discussion in the text, discussion which, moreover, is bound to lead to interpretations by readers whose part icular bias may lead them to unwarranted conclusions about the motives behind the discussion. I believe that this fcdmd' of controversy can do more harm than good by drawing unnecessary attention to matters that might hawerwise be received indi f ferent ly by readers who had not been Involved in the issue. On the matter of my making "psychiatr ic interpretations about the staff members" which, you indicated, referred to the matter of "paranoia", I have consciously striven to avoid psychiatr ic interpretations throughout the document. I can appreciate your objection and concern about the def in i t ive ' use of the word paranoia, which has inescapable psychiatric roots. I shall add the necessary qual i f icat ions to the section to make i t clear that I intend the word in i t s lay sense. F inal ly on the issue cf anonymity, I recognize that tin's is a serious problem. I have been extremely careful to avoid any reference to , or indeed ;my necorsnhicol location in th? text. No name appears in any part of the document; even a loce.l theatre which could have been iden-t i f i ed has been characterized as "(Theatre"). ! i f you can make any su<;-(C->tiG:i that fur ther protects the anonym'ty of the se t t ing I would ce r ta in l y Appreciate your advice. I hooe that th i s l e t t e r convoys to you my readiness to hear and / 3 / . . . - 211 -Dr. ' . . . . . 3 consider your opinions on parts of my !"A dissertation that you consider to be controversial. I have no wish for i t to become a point of confrontation be-tween yourself and the Sociology Department and believe that this can be avoided by the suggestions I have mice, f'y committee has asked ne to te l l you that they welcome Dr. 's attendance at the defense, and that a fo r -mal invitat ion would have been sent to you as soon as the date was f ina l i zed . Yours sincerely, John Brown JB/wc I - 212 -July 4, 1974 •Mr. John Brown, Dear Mr. Brown: I am sending my Comments which according to your promise wi l l be i n -cluded in your thesis before defence. I am also expecting, according to your promise,to have a f inal text of your thesis before the defence. I waited until July 3, 1974 for either your f inal version or for written changes in places which I told you were distorted. Since, however, I have not received them I have to ins i s t that my notes are published in the thesis disregarding changes you make in the f inal version, which you also promised me. Yours s incere ly , - 213 -BIBLIOGRAPHY Becker, Howard S. Outsiders: Studies in tlie Sociology of Deviance. New York, Free Press, 1966 [copyright 1963]. Becker, Howard S. and Blanche Geer. "Participant Observation: The Analysis of Qualitative Field Data". Human Organization Research. ed. R. N. Adams and J . J . Preiss. Homewood, 111., Dorsey Press, 1960. Berger, Peter L. and Thomas Luckmann. The Social Construction of Reality> New York, Doubleday (Anchor Books) 1967 [copyright 1966]. Cavan, Sherri. Liquor License. An Ethnography of Bar Behavior. Chicago, Aldine, 1966. Conklin., Harold C. "Ethnography". Inter-national Encyclopedia of the Social Sciences, ed. David L. S i l l s . The Macmillan Co. and Free Press, 1968, Vol. 5. Garfinkel, Harold. Studies in Ethnomethodology. New Jersey, Prentice Hal l , 1967. Goffman, Erving. The Presentation of Self in Everyday Life. New York, Doubleday (Anchor Books) 1959. Goffman, Erving. Asylums. Garden City, N. Y., Doubleday (Anchor Books), 1961. Janov, Arthur. The Primal Scream. New York, Dell (Delta Books), 1970. The Anatomy of Mental I l l n e s s . New York, Berkley (Medallion), 1971. "The Rationale of the [Theta] Marking System". In-house Memorandum. Sacks, Harvey. "An In i t ia l Investigation of the Usabil ity of Conversa-tional Data for Doing Sociology". Studies in Social Interaction. ed. David Sudnow. New York, The Free Press, 1972. Sontag, Susan. "Notes on 'Camp'". Against I n t e r p r e t a t i o n . New York, Farrar, Straus and Giroux, 1964. 

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