UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

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

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1974_A8 B76.pdf [ 8.88MB ]
Metadata
JSON: 831-1.0093190.json
JSON-LD: 831-1.0093190-ld.json
RDF/XML (Pretty): 831-1.0093190-rdf.xml
RDF/JSON: 831-1.0093190-rdf.json
Turtle: 831-1.0093190-turtle.txt
N-Triples: 831-1.0093190-rdf-ntriples.txt
Original Record: 831-1.0093190-source.json
Full Text
831-1.0093190-fulltext.txt
Citation
831-1.0093190.ris

Full Text

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 i n the Department o f ANTHROPOLOGY AND SOCIOLOGY of  THE UNIVERSITY OF BRITISH COLUMBIA  We accept t h i s t h e s i s as conforming t o the required standard  THE UNIVERSITY OF BRITISH COLUMBIA J u l y 1974  In  presenting  an  advanced  the I  Library  further  for  degree shall  agree  scholarly  by  his  of  this  written  this  thesis  in  at  University  the  make  that  it  purposes  for  freely  permission may  representatives. thesis  partial  be  It  financial  for  gain  of  The U n i v e r s i t y o f B r i t i s h V a n c o u v e r 8, Canada  of  Columbia,  British  Columbia  for  extensive by  the  understood  permission.  Department  of  available  granted  is  fulfilment  shall  Head  be  requirements  reference copying  that  not  the  of  agree  and  of my  I  this  or  allowed  without  that  study. thesis  Department  copying  for  or  publication my  ABSTRACT  This t h e s i s i s an ethnographic  account of the d a i l y l i f e of  an outpatient centre f o r the treatment of non-psychotic  patients.  The  centre i s located i n a u n i v e r s i t y s e t t i n g and i s nominally attached to a u n i v e r s i t y mental h o s p i t a l .  The s e t t i n g i s described and the case i s made that i t normally allows f o r only two categories of p a r t i c i p a n t : patients and t h e r a p i s t s . The s i t u a t e d a c t i v i t y of these two groups i n s t r u c t u r i n g the s e t t i n g i s a major focus of the work.  The r o l e s embodied i n the two categories are described i n d e t a i l and the way  i n which these r o l e s i n t e r l o c k to create the s o c i a l  r e a l i t y that i s understood by the p a r t i c i p a n t s as a "therapeutic community" i s set out.  A b e l i e f system which i s embedded i n , and a determinant of  each r o l e i s proposed.  The p r a c t i c e of "doing therapy" i s described and a preliminary formulation of t h i s p r a c t i c e as a s i t u a t e d a c t i v i t y which depends on the s o c i a l s t r u c t u r e of the s e t t i n g i s attempted.  A section which describes the observer's s e t t i n g i s included as an appendix.  experiences  i n the  I t i s argued that because the s e t t i n g  allows f o r only two classes of p a r t i c i p a n t , the observer r o l e i s seen as deviant and that t h i s leads to m i s t r u s t 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 p a t i e n t s who were present i n the s e t t i n g a t the time o f my p a r t i c i p a t i o n (or nonparticipation).  Their acceptance of my presence i n a s e t t i n g i n which  any stranger was a source o f concern and p o t e n t i a l embarrassment was g r e a t l y appreciated and t h e i r patience i n answering what I thought were s o c i o l o g i c a l questions was o f considerable assistance.  To the s t a f f a t Theta I must express a s i m i l a r a p p r e c i a t i o n . Despite my i n e r a d i c a b l y i n t r u s i v e role which was sometimes a source o f l e g i t i m a t e i r r i t a t i o n t o some members, I was received with a considerable degree of tolerance.  The access which I was eventually given t o 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. work of s t a f f members a t Theta i s an extremely demanding one.  The  I t was ap-  parent that the centre was a s e t t i n g i n which patience and a f f e c t i o n were extended to an a p p r e c i a t i v e group o f voluntary p a r t i c i p a n t s 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 i n t e r v e n t i o n i n 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 o f my observation.  - iii  -  TABLE OF CONTENTS  ACKNOWLEDGEMENTS CHAPTER 1  Introduction  CHAPTER 2  The World of Theta  10  CHAPTER 3  The Therapist Role  51  CHAPTER 4  The P a t i e n t Role  67  CHAPTER 5  The Relationship Between the Therapist Role and the the P a t i e n t Role  99  CHAPTER 6  Doing Therapy  121  APPENDIX I  The Observer Role  156  APPENDIX I I  Floor Plan of Theta  172  APPENDIX I I I  Heading f o r S e l f - D e s c r i p t i o n Form  173  APPENDIX IV  Standard Questions to be Asked C o l l e c t i v e l y of Persons Before the Group f o r Admission  174  APPENDIX V  Footnotes Added by the I n s t i tution  175  APPENDIX VI  BIBLIOGRAPHY  Page 1  Introduction by the Author  175  Footnotes  184  Schedule of Attendance a t Theta  201  Correspondence with C l i n i c a l Supervisor  202 213  -  1  -  CHAPTER ONE INTRODUCTION  This t h e s i s i s an account of the everyday l i f e of an outp a t i e n t therapeutic community f o r non-psychotic patients who seek help with troublesome interpersonal problems. "Theta".  I have c a l l e d the centre  My purpose i n w r i t i n g 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 s e t t i n g . I t i s a feature of p s y c h i a t r i c w r i t i n g t h a t , while there i s a vast erature which describes how therap  lit-  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 a c t u a l l y (,:. J done.  That i s not,to propose that  there i s a sharp contrast between theory and p r a c t i c e 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 r e f r a i n s from making any  judgments about the d e t a i l s of the s e t t i n g that i t describes; that i s ,  -  it  is  not  material a  an  particular  first  example)  is  relevant  is  sometimes  requirement a  sequently  traffic  as  the  air  certain  The  description  body e l s e ecting  force.  into  a  he  The  the  that  it  contains  significant  the not  only  behaviour  to  this  granted. They  everyday  to  this  for  miliar  scenes,  life.  right  The  or  members,  For  wrong  that  ethnographer  what  likely  everybody to  be  his  activity the  of  in  others  world are  not  they  they  who  the  only  are  are  so  in  is  the  of  -  "natural  he  is  every"dir-  a  his  moral  everyday  moral  to?  order  life  taken  facts  i t  make up  and  he  with  daily  matters  suspend to  offended.  familiar  through  3  to  be  in  translates  of  others  because  order  What  know  are  it  his  arms  knows  that  sub-  terms:  action  and  to  and to  his  air",  grounds  world  so.  attempts  knows  suspect.  as  order  and w i t h  through  the  provides  and  the  likely  in  these  of  waving  that (for  days  refers  policeman  routine  force  which  is  arms  social  courses  members but  The  watches  several  street  policeman  affairs,  common w i t h  refer  the  encounter  normal  for  behaviour  of  the  of  moral  members  which, of  of  non-sociologists  ethnographer  traffic  his  the  meaningful  refers  of  an  "waving  "Studies  in  If  activity.  knowledge  perceivedly  persuade  middle  in  known  of  ways",  is  socially  scenes  is  is  to  directing  ,  as  strange  in  regular  A society's  of  second  culturally  met.  description  that  Garfinkel  knowledge  been  depreciates  knows  activities",  has  "standing  traffic".  behaviour  "the  d i f f i c u l t  policeman  produces  activities in  to  The  society"J  It the  account.  interested  which  2 -  his  of  moral  so  is  for  life"  about  facts  morally  fa-  common-sense  familiar How c a n  scenes he  not  see  -  what i s " r e a l l y happening"?  3  -  What has he done to our world?  It is just  by suspending h i s common-sense understandings that the ethnographer a t tempts to discover the r a t i o n a l properties of everyday a c t i v i t i e s and thus remain l o y a l to the program of his e n t e r p r i s e .  In order to be auth-  e n t i c to h i s own d e s c r i p t i o n , the ethnographer may at times d i s p l a y hims e l f as being inadequate i n terms of what has been i n d i c a t e d above y e t as a person he may i n f a c t embrace  the presumptive f a c t s espoused by the  i n s t i t u t i o n i f h i s 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 h i s i n t e n t i o n , e x h i bit i t . "  4  The second requirement i s what d i s t i n g u i s h e s ethnography from newspaper r e p o r t s , from exposes  from gossip and i d l e c u r i o s i t y .  The  d e t 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 h i s s e l e c t i o n on these grounds and to show how the s o c i a l organiz a t i o n i s determined by and determines what f a c t s are s i g n i f i c a n t i n the setting.  Facts are not selected f o r t h e i r human c u r i o s i t y value, f o r  t h e i r shock content or f o r p r u r i e n t i n t e r e s t but are s e l e c t e d because they are relevant to the way i n which the putative s o c i a l order i s created.  The ethnographer has, thus, t h i s r e s p o n s i b i l i t y to h i s m a t e r i a l :  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 t h i s document were c o l l e c t e d over a period of approximately one year.  My i n i t i a l  con-  t a c t 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-  i o u r by observing and p a r t i c i p a t i n g i n " l e a d e r l e s s " groups c o n s t i t u t e d to study group process. mer vacation.  I wanted to continue my a c t i v i t y during a sum-  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 f o r me to what we both thought would be an appropriate s e t t i n g .  A f t e r some i n i t i a l contact with the centre i n which I explained my group focus, I was permitted to attend f o r one afternoon a week to watch the formally c o n s t i t u t e d therapy groups which were one feature of the s e t t i n g .  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 t h i s p e r i o d , of the f a c t 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 s u s t a i n , e s p e c i a l l y as I was absent f o r 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 e v e n t u a l l y permitted to expand my observations to two days. ing  Even t h i s , I f e l t , was  inadequate  the l a s t two weeks of my observation I attended f u l l - t i m e .  tails  and durThe  of my experiences as an observer i n the s e t t i n g are set out i n  de-  -  5 -  Appendix I .  I b e l i e v e that i t i s worth recording t h a t , p a r t i a l l y as a r e s u l t of my d i f f i c u l t i e s i n d e r i v i n g an adequate group focus i n the s e t t i n g , my perspective changed q u i t e r a d i c a l l y during the period o f my observations.  I had become more i n t e r e s t e d i n doing ethno-  graphy i n any case and the s e t t i n g was i n many ways i d e a l l y s u i t e d to this enterprise.  Ethnography i s s a i d to require "a long period o f i n -  timate study and residence i n a s m a l l , w e l l - d e f i n e d community, know4 ledge of the spoken language, and the employment of a wide range o f observational techniques  i n c l u d i n g prolonged  face-to-face contacts with  members o f the l o c a l group, d i 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 i n t e n s i v e work with than on the use o f documentary or survey data."  informants  Theta met a l l these  requirements.  Throughout the period of my observations  I was known to everyone i n  the s e t t i n g as an observer and attempted to be as unobtrusive as possible.  I appeared i n the s e t t i n g as nearly as p o s s i b l e i n the dress and  s t y l e of the other p a r t i c i p a n t s .  I took no notes during the sessions  although tape recordings were o c c a s i o n a l l y a v a i l a b l e to me v i a the r e cording equipment operated by the Theta s t a f f .  In general my observa-  t i o n s were recorded during natural breaks i n the schedule and elaborated at the end of the day.  The material i n the t e x t which i s w r i t t e n s i n g l e spaced and  -  6  -  indented i s taken from my f i e l d notes unless otherwise i n d i c a t e d . These f i e l d notes are unreconstructed  apart from occasional c o r r e c t i o n s  where I have done unusual violence to grammar or syntax.  Where conver-  sations have been included they are sometimes c l o s e l y paraphrased versions of the o r i g i n a l utterances and sometimes l i t e r a l t r a n s c r i p t i o n s obtained from the a v a i l a b l e recordings.  The t r a n s c r i p t i o n s are evident  in the d e t a i l recorded which includes a l l parts of the utterances as nearly as p o s s i b l e e x a c t l y as they were heard.  My concern was with the patterns of behaviour which recurred with regular and s t a b l e dependability and which could be seen as the appropriate normal natural behaviour of the i n d i v i d u a l s i n the s e t t i n g and a l s o , 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 s e t t i n g as competent i n f o r -  mants about the s e t t i n g i n s o f a r as they were seen by t h e i r colleagues as competent informants, and I t r i e d as f a r as p o s s i b l e to check my  ob-  servations and constructs against the subsequent behaviour which I observed.  Much of the material should, however, be considered as a t e n t - ,  a t i v e formulation at t h i s 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 t h e s i s attempts to describe the " s o c i a l l y standardized and s t a n d a r d i z i n g , 'seen but unnoticed', expected background features"^ of the s e t t i n g .  The s o c i o l o g i c a l questions that I address were s u c c i n c t -  -  ly  stated  by  Sherri  What of  -  Cavan:  are  the  taking  [this]  7  courses  place  setting  and as  of  action  being  that  expected  a matter  of  have to  course  the  take and  character  place  in  without  question? and: What ate  kinds  these  phenomena?  I  proceed  took  place  that  setting.  setting to  and  the  thesis. produce  I  assumptions  courses  of  8  by  dealing  with  the  some  the  courses  of  be  regular  the  that  are  the  the  features  of  the  In  a  final  chapter  I  which  doing  therapy  is  ulation  of  the  ways  success  of  this  in  enterprise  terrelationships  of  the  the  to  what  participants  is  which  setting  that  determined  participants, kind  of  roles  two  make  by  Is,  it  is.  the  the  in  mature be  the  a  in  in  the  necessary rest  roles  of  interact  recognizable  roles, the  activity  activity  would  carried  the  recurrent  major it  gener-  that  attempt  that  place  of  [that]  the  to  which  described  describe  community.  in  in  social  assumptions  action"  and  dimensions  I  therapeutic  required  setting  major  of  ways  as  the  of  two  "kinds  would  action  describing  describe  suggest  generate  the to  and  of  as  a  preliminary out  and  beliefs  mutual  how  formthe  and  i n -  orientation  of  Anonymi t y The only  one  setting body known  Theta. was  who was to  clinical  the  The  empty  once  i m p l i c a t i o n was  because  familiar staff  supervisor  and  with the  it  would  the then  be  remarked  that  any  to  attempt  immediately  university. current  me t h a t  Of  patient  to  there  disguise  recognizable  course  to  my p r e s e n c e  p o p u l a t i o n , many  was the everywas of  whom  - 8 -  expressed an interest in my work. and i t s l o c a t i o n .  All  My academic committee knew of my work  I can do is to follow the conventional  of eliminating names of i n d i v i d u a l s .  I have  5  practice  however, taken the addi-  tional step of removing certain references and footnotes that might allow Theta to be i d e n t i f i e d .  Footnotes This thesis contains three separate sets of footnotes.  The  references that are made to the l i t e r a t u r e are footnoted by means of superscript numbers which r e f e r 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 a s t e r i s k s .  The third set of footnotes have been included at the request of the Theta s t a f f .  This document is a s o c i o l o g i c a l analysis of the  i n s t i t u t i o n and raises issues that the s t a f f f e l t should be addressed in psychiatric terms.  The points that the i n s t i t u t i o n wished to take issue  with are indicated by a series of superscript l e t t e r s . which these refer are included in Appendix V.  The footnotes to  - 9-  FOOTNOTES  1.  Harold C. C o n k l i n , "Ethnography", International Encyclopedia of Social Sciences, ed. David L. S i l l s , The Macmillan Co. and Free Press, 1968, V o l . 5, p. 172. the  2.  Harold G a r f i n k e l , Studies H a l l , 1967.  3.  I b i d . p. 35.  4.  Susan Sontag, "Notes on 'Camp'", Against Interpretation, F a r r a r , Straus and Giroux, 1964, p. 276.  5.  Harold C. C o n k l i n , op. c i t . , p. 172.  6.  For a d i s c u s s i o n o f a study which i l l u s t r a t e s what an adequate schedule of observations can amount t o , see ( f o r example), Howard S. Becker and Blanche Geer, " P a r t i c i p a n t Observation: The A n a l y s i s of Q u a l i t a t i v e F i e l d Data", Human Organization Research, ed. R. N. Adams and J . J . P r e i s s , Homewood, 111., Dorsey Press, 1960, pp. 267289.  7.  Harold G a r f i n k e l , op. c i t . , p. 36.  8.  Sherri  Cavan, Liquor  in  License.  Chicago, A l d i n e , 1966, p. 8.  Ethnomethodology  An Ethnography  , New Jersey, Prentice  of  Bar  New York,  Behavior,  CHAPTER  THE  Theta is  the  joint  In  this  to  I  that  in  the  accountable  some  ment about  of to  a  of  the the  world,  of  the  attend  to  specialized world  people:  setting  setting. focuses,  a  I  patients  and  shall  norms  of  attempt,  and  and which  some  and  values  provide  principal  a  that  the  therapists.  the in  that  preliminary  the  setting  two with  its  Therapy  appropriate staff  groups  describe  in  the  THETA  character.  Before  The  two  shall  setting  1  Theoretical  of  go on  outline  groups  a world within  creation  chapter  activities way,  is  WORLD OF  TWO  to  saw  I  describe  address the  the  any  explicit  institution  therapeutic some e x t e n t  as  community in  of  the  the  aims  being in  English  activities and  goals  modelled  another  at  on  of  the  and  location  language  Theta,  a  seems  institution. natural  which  literature  it  has  of  develop-  been  writte  therapeutic  2 communities.  The  following  description  picks  out  a  few  points  in  that  - 11 l i t e r a t u r e which appear t o be relevant to the present document.  Group Focus The focus i n 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 s u i t a b l e as a frame of reference f o r 3  the study o f i n d i v i d u a l human behaviour;...  This b e l i e f i s explained  i n terms of the determinants of neurosis: Neurosis i s anchored i n the v i c i o u s c i r c l e of i n t e r action between the neurotic i n d i v i d u a l and the r e s t 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 s t i m u l i r e i n f o r c i n g h i s neurotic stereotypes. The paper goes on t o argue that ...[The neurotic i n d i v i d u a l ] i s unaware of any r e 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 r e s t i t u t i o n of [the awareness of the r e l a t i o n s h i p ] . The mechanism to accomplish  t h i s i s the group.  The neurotic i n d i v i d u a l  i s seen as having a permanently d i s t o r t e d and i n v a r i a b l e perception of the world which he s u c c e s s f u l l y o p e r a t i o n a l i z e s i n every s o c i a l He sees the group . . . i n a d i s t o r t e d way and sees i t s members i n roles d i f f e r e n t from those they a c t u a l l y play: he acts or tends t o act accordingly...? Such an exceedingly erroneous i n t e r p r e t a t i o n o f a group i s c a l l e d . . . a pseudogroup. 8  context.  - 12 Therapeutic  Process  The therapeutic s e t t i n g provides a framework f o r the  indivi-  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 s t r u c t u r e 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 p a t i e n t i n the therapeutic community i s assumed to reproduce his standard i n t e r a c t i o n a l behaviour ("to r e l i v e h i s neurotic v i c i o u s c i r c l e " ^ ) i n the therapeutic s e t t i n g which provides "a broad spectrum of r e a l - l i f e s i t u a t i o n s i n which the patients q u i c k l y 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 i n t e r a c t s to "...confirm [ h i s ] self-image 12  and  [ h i s ] expectations about others..."  , that i s , how the p a t i e n t 13  brings about h i s own apparent what  " s e l f - f u l f i l l i n g prophecy".  When i t has become  i s being done, t h i s can be exposed to the p a t i e n t i n order 14  to " . . . c o r r e c t the 'hypothesis' of the i n d i v i d u a l about other people." "A p a t i e n t learns that not a l l persons i n a c e r t a i n r o l e (as f o r example 15  a u t h o r i t y , peer, e r o t i c partner) perform i n the way  I t i s recognised that the p a t i e n t may  he  expects."  r e s i s t the exposure of  his behaviour through f e a r , and i t i s argued that the tendency to avoid 1 fi  the confrontation "through...anxiety-determined  avoidance"  can  be  " r e a d i l y seen i n the therapeutic group"*' , which can address t h i s as a 7  relevant part of the problem.  - 13 -  The second stage i n the therapeutic process i s not so c l e a r ly e x p l i c a t e d .  I t appears to involve the p a t i e n t i n experiments i n  which he can t r y out a l t e r n a t i v e behaviour which v i o l a t e s the norms of his  f a l s e "hypotheses". [H]e can a c t , f o r the f i r s t time i n h i s l i f e , h i s a c t i v i t y takes the form of learning by t r i a l and e r r o r . 18  The group i s seen as a valuable resource f o r t h i s experimentation. The p a t i e n t s , as c o - t h e r a p i s t s , may experiment on a much l a r g e r s c a l e than the t h e r a p i s t with h i s therapeutic means. 19  To sum up, the theory argues that behaviour of neurotic i n d i viduals i s s e n s i b l y i n v a r i a n t over a l l s o c i a l s i t u a t i o n s and the centre provides an adequate theatre f o r the s o c i a l actor to d i s p l a y h i s f a l s e assumptions and pathological d e t e r m i n i s t i c behaviour which can be inexorably exposed to him. the  The exposure i s assumed to be therapeutic f o r  p a t i e n t , and he also has the opportunity to t r y out a l t e r n a t i v e be-  haviour i n 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 e a r l y emphasis on hard work and spartan l i v i n g which i s less apparent i n the l a t e r w r i t i n g , and a continuous s t r e s s on the economy of the treatment method.  I t i s em-  phasized that the centre should be wordly though i s o l a t e d (the s t r e s s on i s o l a t i o n can be seen to decrease too and has l a r g e l y disappeared to Theta i t s e l f ) .  For example i t i s stressed that the work " i s not occupa-  tional that  therapy,  "since  situation  but  the  genuine  patients  contributes  -  14 -  work  in  are  to  city  [the  the  fields,  people  gardens  unaccustomed  patients']  stresses,  and woods"*""  to  farm work,  frustrations  and this  and  con-  21 flicts,  just  although  as  in  real  trained,  discussing  the  are  life."  not  resident  Next,  traditional  "social  it  is  emphasized  that  psychotherapists.  therapists",  the  the  For  literature  staff,  example,  in  notes:  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 any 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 , so t h a t no 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 (like patroni z i n g a t t i t u d e toward patients) could take place. 22  The  Physical  Setting  Theta cent  to  is  large  a  an  located along name.  related front  a wide  boulevard  and  staff  building.  floor  this,  kitchen The  of  a  only"  parking  There  is  a  in  is  the  larger  of  hospital.  set  and  on  fringes  its  a  university  The  physical  own  grounds.  undistinguished  gatepost than  usual  signs  small  parking  identifies  vegetable  the lot  it  garden,  other  a  Theta is  entrances  address  a  of  entrance  with  as  adja-  setting  The  from  announces  campus  and  the  university university-  brick  patio  and  lawn.  second  Below  house  A sign  presence  the  psychiatric  frame  The a  on  timber  street.  The  "faculty  located  inpatient  on  the  is  on  building above the  of  the  this  consists  vertical  ground  and workroom  remainder  itself  (with area  floor,  part the  attached is  of  a  of  the  area  T-shaped  is  T.  further  split  (See  divided  bathroom) up  at by  ground  the a  floor  Appendix into south  an  II)  entrance,  end  staircase  and  of  the  which  T.  -  15 -  leads t o the second f l o o r and a w a i s t - l e v e l p a r t i t i o n , both of which produce subspaces that can be organized f o r various purposes.  A long coat c l o s e t has been constructed behind the s t a i r s . The l a r g e s t part of the area adjacent t o the kitchen has been furnished with long tables and benches and the north end of the room contains couches and c h a i r s .  There i s a f i r e p l a c e i n 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 s i n g l e room.  A t the extreme west end of t h i s room a small semi-circu-*  l a r stage has been constructed. roughly h a l f of the end w a l l .  I t i s two steps high and occupies 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 p a t i o and behind i t t o the parked cars of the Theta occupants.  The end of the room opposite the stage has what was once a  bar set i n t o i t .  This i s c u r r e n t l y being made over i n t o an "Audio-  Visual (AV)" room and w i l l be f i t t e d with one-way m i r r o r , TV cameras and recording equipment.  Microphones hang from several l o c a t i o n s i n  the timber-beamed c e i l i n g .  The room i s carpeted throughout and contains twenty o r t h i r t y chrome s t e e l and black p l a s t i c stackable c h a i r s which c o n s t i t u t e the only f u r n i t u r e .  -  The o p p o s i t e  side  room") w i t h a s t o r a g e  rooms  have been  individual vide  individual  furnished  patients  a staff  to  trays.  phere  of  being (OT)  the  the  room i s a l s o c a r p e t e d a n d  down i t s  open  as o f f i c e s  off  for is  space c o n t a i n s  k i t c h e n has b e e n  The  room i s  it  entire  length  on e i t h e r  the s t a f f , currently  by a  side.  a waiting  being  undecorated  an a s s u m p t i o n  focus  of work,  that is  a minimum o f  f i t t e d out  peg-boards  and m a i n t e n a n c e .  is  corri-  These room  for  shelved to  pro-  for  referred  tools,  and c o n v i n c i n g l y  is  part  of  t o as t h e  doing life"  small  It  con-  a sturdy  c l e a n i n g brushes  The w o r k o f  "work  The  as a w o r k s h o p .  storing  used f o r  "props".  displays  and t h e  "occupational  and an  therapy  table  at  atmosTheta  workshop, therapy"  room.  The b a t h r o o m shower and b a s i n s have has  divided  neglected sink which i s  carpentry  encompasses  "back  recording.  rooms  rough c u p b o a r d s ,  and a s e v e r e l y paint  This  a s m a l l e r room ( t h e  library.  room a d j a c e n t large  it.  a n d a room w h i c h  The d o w n s t a i r s  tains  is  -  the T c o n t a i n s  sound  The s e c o n d f l o o r A s e r i e s of  of  space o f f  s c h e d u l e d t o be w i r e d f o r  dor.  16  i n a house  under  adjacent the  t o t h e OT room i s  slightly  grubby unused  n e g l e c t e d and look  that  a  its  bathroom  construction.  The e n t r a n c e  immediately  adjacent  to  the  k i t c h e n has a  sign  - 17  posted in  t h e window a n n o u n c i n g  and a d v i s i n g  visitors  that  fee machine ther  a n d two w a l l s o f  one o f  countertops  the tasks of  are  and the f l o o r  The p a r t the  long  wall  tables  above  this  should  newly  the  arranged is  large  a large The  painted  the  hung w i t h  tion  a medium-sized  reads  "it  never  contains  n o t i c e boards  poster  rains  and c l e a n .  but  stove,  although Kitchen  coffee is  pot  cof-  of  ra-  mainten-  and t h e e q u i p m e n t  aluminum  and  drips  on  unmarked.  to the a large  kitchen,  besides  sideboard.  The  and t h e p a r t i t i o n w a l l  with  n o t i c e boards  s h o w i n g an e l e p h a n t it  pours".  above  the  urinating.  Beside i t ,  there  sideThe  is  an  capold  postcard addressed to  "Dear Theta" w i t h a p i c t u r e  of  Hawaii.  map o f  a n d a s c r i b b l e d poem,  is  a type-written  of  the u n i v e r s i t y  rules  this  f o r Theta  there  and cement. tices  that  is  and a t i m e t a b l e  a set of  instructions  The w h o l e e f f e c t abound i n a l l  them,  it.  T h e m o s t s t r i k i n g i t e m on t h e is  refrigerator, cupboards,  room a d j a c e n t  community"  upstairs".  i n the house,  end t o e n d ,  t h e k i t c h e n has a b l a c k b o a r d on  board  a therapeutic  the Theta p a t i e n t s  as e l s e w h e r e  of  is  "report  cupboards.  c l e a n e x c e p t where  here,  "This  contains  rough c o n s t r u c t i o n , are  ance i s  that  they  The k i t c h e n i t s e l f  -  is of  of  the  there  daily  activities.  on how t o m i x p a i n t , the k i n d of  institutions.  Beside a  Next  list  to  polly-filler  f a m i l i a r unnoticed  no-  -  18  -  The v i s i t o r who " r e p o r t s of  doors,  a few w i t h n e a t  occupants.  The namecards  i n s t e a d of  family  split  two h a l v e s  into  head o f  names.  the s t a i r s  c a r d s on t h e m , are  Several  social  indicates that  be c a r r i e d on h e r e . The a c t o r s have  It  doors  to appear  are  the  to the  very  the  of  o r how t h e  this  that  a r e a was p u b l i c s p a c e a n d t h e  first  it  "office".  this  s e t t i n g , what  could  of a  insti-  potentially  to a church.  resolved.  on some  c a n be s a i d t h a t  floor  the  the  i n t o what k i n d  from a b o r d e l l o  c a n be  at  is  a c t i v i t i e s at this  the space i n Theta took  As a rough g e n e r a l i z a t i o n  is  names  s e t t i n g of  f r o m t h e many a c t i v i t i e s t h a t  before  the  One  A sign  right  series  of  first  unmarked.  few i n s i g h t s  confines  names  use o f  lower half.  c o u l d be a n y t h i n g  During the day, aspects.  the  something  amountedto,  t u t i o n were d i s t i n g u i s h e d  announcing  on t h e  would gain  community"  presented with a  around i n the p h y s i c a l  w o r l d was c r e a t e d w i t h i n  "therapeutic  of  with a shelf  community"  is  c h a r a c t e r i z e d by t h e  A v i s i t o r wandering "therapeutic  upstairs"  ("upstairs")  additional  the main was  floor  private  23 space. ients of  This,  and t h e r a p i s t s  the b u i l d i n g  individual public  in fact,  for while  at a l l  offices),  times  upstairs  space.  rooms  only  (with  In if  floor  the  first  therapists  the p a t i e n t s  s p a c e on t h e m a i n  second f l o o r  delineated  d i s t i n c t i o n between  had f r e e  deference  to  had u n l i m i t e d  and c o n d i t i o n a l  general they were  t h i s meant invited  that  by t h e  access  to a l l  individual access access they  patparts  rights  only  to  to  the  t o some o f  the  c o u l d go i n t o  occupants  or with  the per-  - 19 -  mission,  unless  warranted  entry  The illustrated in  the  if  to  in  by  nobody  any  the  the  answer  were  use  of  else  did,  the  of  Theta  but,  general, and  this  as  was  When t h e  secretary In  that  treatment  area.  it.  constituted  space  patients'  "upstairs"  answered would  they  going  the  to  seen  did as  space  which  rang  absence,  patients  which  be w o r k e d  telephones  her  party  upstairs  telephone  in  was  a work  at  one  not  gave  them  on.  was  were  quite  all  Theta  it  well  situated was  usually  of  the  staff  answer  the  telephone  proper  members even  protocol:  Somebody a s k e d i f [ a b s e n t male p a t i e n t ] had 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 telephone had rung s e v e r a l times b e f o r e 9 o ' c l o c k and nobody had answered it.  The nice  patients  sense  of  the  hierarchy,  in  doing  the  observed  generally  in  vably  his  empty,  clinical never  most  office the  by  The the  rest  retary,  so.  of and  For  junior used and  his  the  telephones  publicness,  example,  member  of  the  the  telephone  another  patient  supervisor's  used  use  differential  perhaps,  was  could  office  would  use  d o o r was  indeed  and  preference  d o o r was  open  telephone i f  the  ever  open  showed  the  and  that and  I  If  office  room.  his  was,  that  others. the  a  staff  therapist  patients to  in  and  of  occupational  staff in  the  seldom  and  upstairs  he obser-  The  telephone  was  patients.  secretary's  the this  space was  in  office that  represented  anybody  considered  could  adequate  a  slight  have  grounds  departure  business for  going  with to  from the  that  secoffice.  - 20 -  Even  here  there  therapists. obtain was of  records, on  business  and were  s t i l l  Therapists  mounted  leave the  that  originally  for  the  Theta  differentiation  regularly  work  or  set  walked  into  up  sound  the by  provided  them w i t h  legitimate  to  state to  but  forms,  their  keep  could and  supply  so  forth  on  out.  i f  they  secretary's  had  arrival.  provided  office  to  which  specific  kinds  for In  being fact,  secretary  relevant  and  equipment  only  grounds  The  them w i t h  patients  recording  contrast,  business  patients  between the  Patients,  split  patients  some  wall.  expected  was  files,  was  did  parts  grounds  there the  no  door  work  of  their  own  for  their  re-  quest.  The was  Theta  restricted  especially  for  the  setting,  then,  patients,  therapists  and  had  was  divided  patients'  free  into  space  to  staff  space  which  the  which  staff  and  access.  Activities The attended  at  Friday.  The  evening  the  consisted  tution ing  day  schedule  The and  patient  and  people:  centre  some  for  seven  started  at  and  day  staff of  population  the  kept  five  of and  9 a.m., started  Theta, a  full-time  occasional  half  except at  approximately  1  The  hours  numbering each  on T u e s d a y  day when  about  twenty,  f r o m Monday there  was  to  an  p.m.  the  employees  members.  usually  same plus  staff  hours the  as  the  director  consisted  of  patients of the  the  insti-  follow-  - 21  -  C l i n i c a l Supervisor (M.D.) Rotating P s y c h i a t r i c Resident (M.D.) Resident Psychologist R.N. t r a i n e d i n p s y c h i a t r i c nursing Occupational Therapist Part-time C l i n i c a l Fellow * Secretary * * * *  V i s i t i n g P s y c h i a t r i s t s 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 l a r g e l y responsible f o r the design and d i r e c t i o n of the program while the resident psychologist acted as his executive a s s i s t a n t . The Theta week was d i v i d e d up i n t o a v a r i e d program of work, play and therapy, and although the schedule changed i n d e t a i l from time to time, the version of i t which i s shown i n Figure 2.1 i s representat i v e of a t y p i c a l week. Tuesday  Monday 9:00 10:00 11:00  Dance Therapy  Sports Free Time  Work  12:00 1:00 pm 2:00  Thursday  Wednesday  Weekends" Family Groups  4:30  Interviews  Lunch and_Fem_ly_ Rep_o£ts_ Flections Work Work Discussion  WholeGroup Therapy  Autobiographies  WholeGroup Therapy  Work Discussion Daily) Family Groups Work  Sports  Friday WholeGroup Therapy Work  Theatre Goodbyes Family Groups  Supper  6:00  Family Night  8:30 Fig.  2.1 Approximate Schedule of Theta  Activities  The work which was c a r r i e d on i n the centre was u s u a l l y d i r ected at improving the p h y s i c a l amenities of the b u i l d i n g and i t s s u i t *  The f u l l - t i m e employees of Theta.  - 22 -  a b i l i t y f o r 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 p a i n t i n g .  In f a c t  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 t h e r a p e u t i c , I was  going to c a l l  my d e s c r i p t i o n "Paint Yourself Well".  During the l a s t few months of my observation, the p a t i e n t s were engaged i n converting what had p r e v i o u s l y been a small bar  adjacent  to the "theatre" i n t o a room with a one-way mirror which could be used f o r 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 s a i d would "improve the treatment". v i s u a l " (AV) room. period was office.  This room was  Another p r o j e c t that was  r e f e r r e d to as the "Audiobeing worked on i n the l a t e r  shelving f o r the s t a f f l i b r a r y and the c l i n i c a l  Other i n s i d e work that was  supervisor's  c a r r i e d out included such things as  recovering worn f u r n i t u r e .  During the spring and summer months, work was a l s o 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 i n s i d e of the b u i l d i n g was maintained  by the patients  were responsible f o r carpet sweeping and keeping the stove and erator clean, washing dishes and the r e s t .  who  refrig-  On Fridays a group of pat-  ients was assigned to prepare a meal f o r the whole group from food which was ordered f o r the purpose.  -  23 -  "Play" may not be a very s a t i s f a c t o r y label f o r the next group of a c t i v i t i e s that I describe, because they were o c c a s i o n a l l y traumatic f o r 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 s p o r t s , such as f l o o r hockey, v o l l e y b a l l and team games o f that s o r t which took place i n a nearby gymnasium, also bowling, swimming and other physical a c t i v i t i e s .  I t a l s o included  "dance therapy" i n which a dance i n s t r u c t o r l e d the group, i n c l u d i n g most of the s t a f f , i n body movement exercises t o music.  A r t workshops  were o c c a s i o n a l l y run i n 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, u s u a l l y by two patients who had volunteered  t h e i r s e r v i c e s , and which was always an  occasion f o r considerable chaotic excitement and was u s u a l l y very entertaining.  The therapy that was done at Theta i s the subject of a chapter in t h i s t h e s i s and I s h a 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 independently of them.  For example i f somebody had trouble playing games or  dancing or a c t i n g i n the p a t i e n t play, that became a resource with which the t h e r a p i s t s worked to reveal some aspects of the p a t i e n t ' s problem. Therapy generated independently could be s t a r t e d simply by asking somebody t o t a l k about his troubles or t o report why he f e l t as he d i d about another group member.  Therapy consisted of various a c t i v i t i e s i n which patients  - 24 -  e i t h e r acted out roles that they reported, acted out roles of other people that they were involved w i t h , spoke to each group member i n t u r n , t r y i n g out some p u t a t i v e f e e l i n g that they had, or acted out t h e i r anger or aggression with another p a t i e n t who u s u a l l y played the r o l e 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 f e l l o w p a t i e n t s i n a l i e n r o l e s .  The clubs  produced more noise than pain and were anyway heavy and t i r i n g to w i e l d and q u i c k l y exhausted most p a r t i c i p a n t s .  P a t i e n t s were i m i t a t e d and  imitated each other t o show c h a r a c t e r i s t i c behaviour and commented w i t h out reserve on whatever perceptions of each other they had. P a t i e n t s were encouraged to express t h e i r f e e l i n g s 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 , p a t i e n t s were encouraged to engage i n what appeared to be a modified form of "Primal" therapy which was r e f e r r e d t o a t Theta as 24  "Abreaction Therapy".  This a c t i v i t y consisted of g e t t i n g the p a t i e n t  to l i e on the f l o o r or a mattress a f t e r h i s emotions began to appear. In t h i s p o s i t i o n he was encouraged and p h y s i c a l l y manipulated i n various ways i n an attempt to e s c a l a t e h i s emotional r e a c t i o n to the point a t which h i s emotions had taken over completely. I b e l i e v e 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 o u t l i n e f o r my present purposes which are to focus on some aspects of the s e t t i n g and to show more of the members' perspectives before embarking on the major task of attempting to formulate the determinants of the s o c i a l order at Theta.  - 25 -  S t r u c t u r i n g the S e t t i n g Theta was c o n s t i t u t e d to some extent as a medical s e t t i n g . This focus was not u s u a l l y h e a v i l y emphasized and i t s r e l a t i v e l y minor p o s i t i o n i n 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 a t t e n t i o n to the physical symptoms of patients doing abreaction therapy.  She frequently  checked f o r signs of s e i z u r e , measuring pulse and checking eye p u p i l s and reassuring the t h e r a p i s t who was working that everything was under control.  Apart from t h i s being an unusual procedure (I never saw i t  done apart from t h i s once), the conversation afterwards appeared to i n dicate that while her behaviour was not t o t a l l y i n a p p r o p r i a t e , i t was perhaps an emphasis that was unnecessary.  This i s an impression formed  from the p o l i t e d i s i n t e r e s t her comments i n the after-group meeting evoked, rather than any e x p l i c i t statement.  The medical focus was a l s o  noticeably absent when three patients got s l i g h t l y i n j u r e d during a part 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 i n j u r y of s u f f i c i e n t s e v e r i t y 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 s u p e r v i s o r ' s a t t e n t i o n to t h i s and he t o l d  the p a t i e n t that he should go and have i t x-rayed. gestion that i t was their  There was no sug-  medical problem but rather the problem was  treated the way i t would have been i n any lay s e t t i n g .  Despite the low p r i o r i t y of the medical emphasis, i t was p r e sent and appeared to have some consequences.  There were, not i n f r e q u e n t -  l y , patients in the s e t t i n g who considered part of t h e i r symptomology the f a c t that they were overweight.  One such patient asked i f a s p e c i a l  - 26 -  diet  c o u l d be a r r a n g e d  f o u n d t o be i m p o s s i b l e  for  people with t h i s  (due  catering arrangements),  problem.  While  to the i n t r a c t a b l e nature  the c l i n i c a l  of  t h i s was  the  outside  supervisor suggested that  people  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 a n d c h e c k t h e m s e l v e s on t h e  scales.  t h e r e w e r e no w e i g h s c a l e s  ly  He was t o l d t h a t  astonished at t h i s .  At the meeting afterwards  be o b t a i n e d a n d t h e r e was g e n e r a l scale  and n o t j u s t  setting. of  This  the p r i c e of  a bathroom  agreement  he a s k e d t h a t it  a  it  scale  s h o u l d be a m e d i c a l  p r e s e n t e d some p r o b l e m s  s c a l e which the budget would not  ther issue that  a r o s e a t one t i m e was w h a t s t a n d a r d m e d i c a l  vaiTable  centre:  i n the  obvious-  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  d e s p i t e the f a c t t h a t a medical  that  a n d he was  weigh  to  the  because  allow.  Ano-  k i t was  a-  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 b a c k 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 . [Clinical S u p e r v i s o r ] asked i f blood pressure readings e t c . were taken h e r e . They a r e n o t . People were s u p p o s e d t o h a v e a p h y s i c a l b e f o r e t h e y come i n . It 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 a n d 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 a s 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  the 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 being  considered for  the  appeared at Theta during for  a short  role  of t h e r a p i s t .  Several  t o p e o p l e who w e r e potential  t h e p e r i o d o f my o b s e r v a t i o n .  period generated  the  in  One who  following at a therapists'  therapists visited  after-group  meeting: [ F e m a l e MD] was i n t r o d u c e d . S h e i s MD. She was i n v i t e d t o work a t T h e t a . [Clinical Supervisor] s a i d t h a t s h e d i d n o t h a v e 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 m u s t be an MD.  - 27 -  Of course several members of the s t a f f were not medically t r a i n e d but i t was apparent that medical t r a i n i n g by i t s e l f was considered  rele-  vant q u a l i f i c a t i o n f o r membership i n the t h e r a p i s t group.  The  category  was severely l i m i t e d . a p i s t s and p a t i e n t s .  of people who have warranted access t o Theta In general  i t was r e s t r i c t e d t o two groups: ther-  The e f f o r t s that are described i n the appendix on  the observer r o l e t o persuade me to go t o the centre as a p a t i e n t 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 i n the s e t t i n g that d i d not f a l l i n e i t h e r of the two p r i n c i p a l categories.  A nurse from the p s y c h i a t r i c h o s p i t a l applied  to do her t r a i n i n g at Theta during my period of observation and was r e quired to attend as a p a t i e n t and t o f o l l o w the regular routine i n entering. [ C l i n i c a l Supervisor] s a i d she must spend at l e a s t four weeks i n the p a t i e n t r o l e . The question of when she could s t a r t was r a i s e d . [Resident Psycho l o g i s t ] was adamant that the routine process should be followed. She must go through the i n t e r v i e w , group screening, e t c . Apart from the t h e r a p i s t s and p a t i e n t s , there were a few v i s i t o r s who came t o Theta, although i t was emphasized, as the Theta secretary explained to a patient one day: I t was very important that nobody come i n without permission from one of the t h e r a p i s t s . The most common v i s i t o r s were MDs from other s e t t i n g s who came to Theta f o r an occasional afternoon  or evening session.  Provided that these  were p s y c h i a t r i s t s they f i t t e d e a s i l y and n a t u r a l l y i n t o the t h e r a p i s t r o l e and were accepted as such by the p a t i e n t s , even when they were  -  previously  unknown.  28  -  I was i n t e r e s t e d ,  which 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 which were s c h e d u l e d i n when p a t i e n t s summary  of  frequently  the  perception  occasions of  into  example, the  day s h e a t t e n d e d .  and t h e r a p i s t s  their  for  i n the ease  ceremonial Goodbyes  "goodbyes" w e r e an o c c a s i o n  a l i k e produced  a short  of  who was l e a v i n g .  the p a t i e n t  considerable  with  speech, often  a  They  were  intimacy.  T h e r e was t h e u s u a l t a l k a b o u t how g o o d p e o p l e f e l t a b o u t p e o p l e who w e r e 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 g o o d a d h o c r e m a r k s . To [Female P a t i e n t ] s h e s a i d t h a t s h e h a d b e e n 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 s h e m u s t 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 , s h e 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 c h a n g e s he h a d made a t T h e t a . I  report,  i n Appendix  server  role  at the  centre.  presumably trouble  I,  a c o n t r a s t t h a t was made b e t w e e n me i n my  a n d 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 The p a t i e n t s  traded  on h e r  being  was b r o u g h t a b o u t  Any  visitor,  that  t o new p a t i e n t s lunch,  after  during being  the  visiting  asked,  I  period  hell  "What t h e h e l l  therapists  They  had  the occasion of  the  a s k e d t o e x p l a i n my  were n e v e r  In  contrast to  used t o a t t e n d  introduced,  c o u l d know w h a t t h e  the t a b l e  9  whereas  which  of  lunches  my o n c e - a - w e e k  I jokingly  I was d o i n g are you  confronted  to  here?"  with.  I was  I  was  frequently  introduce  observation  said that  here."  doing  this  no  presence.  who c o u l d be c o n s t i t u t e d a s a t h e r a p i s t  challenge.  c h a l l e n g e d by new p a t i e n t s .  occasionally  s h e was a h e l p e r ,  c a t e g o r i z e d as a t h e r a p i s t .  by my b e i n g  then,  received at Theta without  people  out  a c c e p t i n g her o c c a s i o n a l v i s i t s ,  question  one  pointed  ob-  myself  and  came " s o  A new p a t i e n t A challenge  at that  across which  -  29  -  In another instance a nurse from the p s y c h i a t r i c h o s p i t a l attended f o r a day to observe Theta and had not apparently been authent i c a t e d to the p a t i e n t s .  During the afternoon group meeting she  was  s i t t i n g i n the c i r c l e of chairs when a p a t i e n t , going round each group member i n t u r n , stood i n f r o n t of her.  I can only reproduce a rough  * version which followed: Female P a t i e n t to V i s i t i n g Nurse:  [Name], i s n ' t i t ?  Nurse Male P a t i e n t (on f a r side of c i r c l e ) Nurse  Yes. Would you please introduce y o u r s e l f ? I'm a nurse from the h o s p i t a l . 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 s a i d ,  appeared to show that she c l e a r l y recognised the male p a t i e n t ' s question as a challenge.  Whether i t was or not, she formulated her answer as an  explanation to l e g i t i m a t e her presence, appealing to the  understanding  that everybody had that Theta was part of the h o s p i t a l and that her business, the records, was h o s p i t a l business and therefore warranted her attendance.  One night of the Theta week was designated "Family Night"  and  on family night p a t i e n t s were i n v i t e d to bring t h e i r f a t h e r s , mothers, sexual partners and s i g n i f i c a n t f r i e n d s so that they could i n t e r a c t 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 . I t s shortcomings derive from my incomplete record of the d e t a i l s of the utterances.  -  them.  On these occasions  30 -  there were often s i g n i f i c a n t numbers o f v i s i -  tors i n attendance, t h e i r legitimacy being that they were brought by a current p a t i e n t of the centre and the r e l a t i o n s h i p with that p a t i e n t was i d e n t i f i e d .  These evenings s t a r t e d with " i n t r o d u c t i o n s " i n which  the i d e n t i t y of each v i s i t o r was e s t a b l i s h e d .  The v i s i t o r s were present,  however, only as instruments i n the therapy o f the patients and when a v i s i t o r asked f o r advice about some aspect o f the r e l a t i o n s h i p that seemed to be his problem rather than the p a t i e n t ' s , he was t o l d that that couldn't be addressed because "you're not one of ours".  One a d d i t i o n a l category that was recognized of ex-patient.  at Theta was that  Ex-patients were expected to attend a t Theta one day a  week, f o r three weeks, f o r " a f t e r - c a r e " and were seen as warranted members o f the patient group on those occasions.  Invoking the category  "ex-patient" was also seen as adequate explanation f o r some continued contact with the centre.  There were some on-going ex-patient groups  which met f o r several months a f t e r the formal treatment was over.  An  organization was also proposed that would keep some contact between f o r mer patients and the centre.  Being an ex-patient was also seen as ade-  quate warrant f o r entering Theta (although not, except as above, taking part i n a current group).  At the end o f one after-group meeting  ...two former patients were s i t t i n g i n the dining room with a t h i r d person. [Female Ex-patient] explained that she had brought her mother out to see the place. This explanation f o r her presence and that of her mother was accepted without comment.  - 31  That exhaustive of  the c a t e g o r i e s " t h e r a p i s t "  all  perience reported that  she f e l t  member o f  people  to e i t h e r group".  very  of  therapy  i d e n t i f y w i t h the  problem,  happening,  that  of  i n the  t a l k of  world.  she " d i d n ' t  really  is  it  belong  and,  so  that  presumably,  have  b  centre.  In  relevant  fact,  in determining  the pervasiveness  of  of much  this  t h e p l a c e and p r a c t i c e o f w o r k a t T h e t a .  to the  p e r s p e c t i v e s o f w h a t was  c o n s t i t u t i o n o f T h e t a as  s h o u l d be d e a l t w i t h  emphasis  the Theta s t a f f ,  in  the s e t t i n g ,  "a r e f l e c t i o n it  T h i s was p a r t i c u l a r l y s t r o n g  As  really  seems  of  appro-  here.  the theory  presented above,  and  was t h a t T h e t a m u s t be a r e f l e c t i o n o f  Supervisor]  view  some t r o u b l e s w h i c h w e r e e s p e c i a l l y  a r i s i n g from d i f f e r e n t  [Clinical  * It patient j e c t of  an a c c r e d i t e d  the program a t Theta were c o n s i d e r e d p a r t  t a l k about  An i m p o r t a n t the  She was n o t  patients  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 priate  She c o m p l a i n e d t o me  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 the  ex-  ex-patient.  among p a t i e n t s was t h e s o u r c e o f  this  i l l u s t r a t e d by t h e  She d e c i d e d t o go t h r o u g h T h e t a a s a p a t i e n t  parts  the behaviour  evident  sharply.  c a t e g o r y s e t and s a i d t h a t  *  the  " p a t i e n t " were s e e n as  t o me by t h e T h e t a s e c r e t a r y .  s h e c o u l d more r e a d i l y some s t a t u s a s an  and  present was, f i n a l l y ,  her uniqueness  either  All  -  i n d i s c u s s i o n s about  said that  the  i t was i m p o r t a n t  in the  work.  that  h a s 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 had o t h e r d i m e n s i o n s t h a n t h e o n e s I p r o p o s e . I t was t h e s u b 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 m e m b e r s .  -  32 -  the work r e f l e c t "real l i f e " . He got very annoyed when [Female P a t i e n t ] s a i d that they were not r e a l l y working but j u 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 g e t t i n g prople to do work that they would not o r d i n a r i l y do. Whether t h i s was the case or not, everybody 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 o f the program enumerated i n the l e t t e r ] are elements of a u n i f i e d therapeutic programme and every aspect must be attended. While patients d i d , then, attend every aspect of the program, they also attended  to i t s therapeutic focus and t h i s produced some c o n f l i c t with  the usual everyday focus which was e s p e c i a l l y evident i n the work part of the program.  In the f i r s t place, the work a t Theta was d i r e c t e d by a member of the s t a f f who was referred to as the "occupational  t h e r a p i s t " although  he was u s u a l l y addressed by h i s f i r s t name and the label was not much i n evidence.  The room i n which t o o l s 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 i n s t i g a t e d and.directed  by the occupational  - 33 -  t h e r a p i s t was evident and unquestioned. ordinator  When a new p a t i e n t work co-  asked, a t a p a t i e n t committee meeting, what she had to do,  she was d i r e c t e d to the occupational t h e r a p i s t : [Female P a t i e n t ] t r i e d to pick up some clues about what a work co-ordinator was and found he had to be i n a t 8:30 a.m. tomorrow to meet [Occupational Therapist]. Every time a new work co-ordinator took  over from h i s predecessor, he  was given a l i s t o f work i n progress and t o l d several times to "check with [Occupational  T h e r a p i s t ] " about the d e t a i l s .  I asked a work co-  ordinator whether she thought she had the a u t h o r i t y to change d e t a i l s of the work and she r e p l i e d : "[Occupational what he's doing".  Therapist] u s u a l l y knows  The f a c t that the work was d i r e c t e d i n t h i s way was  accepted by the patients as reasonable and proper, i n f a c t , pre-eminently a r e f l e c t i o n o f the world where decisions about what should be done are r o u t i n e l y made by the people i n whom the a u t h o r i t y o f the i n s t i t u t i o n (whether i t be General Motors o r the o f f i c e typing pool) i s rooted.  When  the p a t i e n t s ' acceptance o f t h i s s t r u c t u r e was questioned one day (because the work was generally recognized  to be going badly) there was a  dismayed s i l e n c e followed by a long conversation with many references to the f a c t that the work d i d 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 p i s t s why they didn't do something about the design o f a  * At a weekly e l e c t i o n , two patients were e l e c t e d to o f f i c e s designated as "work co-ordinator" and "chairman". These two o f f i c e r s , t o gether with one patient e l e c t e d from each of three subgroups o f the patient population c o n s t i t u t e d a p a t i e n t committee whose functions are described l a t e r . The three patients e l e c t e d from the subgroups f i l l e d the o f f i c e s o f "Diary Dealer" and acted as "foreman" or "family leader" f o r the subgroup from which they were e l e c t e d .  -  34  -  b u i l d i n g whose s p e c i f i c a t i o n s they were typing because they had grumbled about i t s ugliness.  The t h e r a p i s t s ' perspective i n 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 d i s p l a y s of inappropriate dependence.  The p a t i e n t s ' shock  appeared to derive from t h e i r being t o l d that they should question what they saw as normal, natural a u t h o r i t y .  The s e l e c t i o n of work co-ordinator and foreman and the respons i b i l i t i e s that were expected of them showed s i m i l a r c o n t r a s t i n g perspectives.  The i n s t i t u t i o n ' s p o s i t i o n 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.  A t t e n t i o n was paid to the therapeutic value of holding these  p o s i t i o n s i n 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, e t c . ,  were much more often things l i k e : "Who hasn't done i t y e t ? " ; "You should do i t because you say you can't do i t , i t would be good f o r you"; " I t would be therapeutic f o r you to t r y and we w i l l help you"; "You w i l l f i n d out about y o u r s e l f i f you t r y " . On t h i s b a s i s , i t very often happened that the people who got these jobs were the l e a s t f i t t e d f o r them i n a " r e a l world" sense and they were p r e c i s e l y the people that would never get chosen i n "real  life".  In a s i m i l a r way, patients recognized that the business o f being foreman, e t c . , 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 p o s i t i o n i n the real world.  While the aggressive exercise of a u t h o r i t y i s  -  35  -  r o u t i n e l y the subject of s u r r e p t i t i o u s grumbling  or v e i l e d  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 t a l k e d with [Male P a t i e n t ] about h i s being work co-ordinator. He s a i d 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 P a t i e n t ] has a tendency to power t r i p with h i s r e s p o n s i b i l i t y : that he didn't t r e a t the people working as responsible workers or f r i e n d s . The d i f f e r e n c e , however, amounted to more than t h i s .  P a t i e n t s expected  of each other that they should care about t h e i r f e l l o w p a t i e n t s and the foreman was no exception: I t ' s what puts people uptight i s , y'know, as i f l i k e , the only thing you're i n t e r e s t e d i n i s . , y'know.. the .. th'work and not the people., y'know.. l i k e product i o n versus human r e l a t i o n s . A male p a t i e n t who  had considerable experience  i n working with foremen  and as foreman himself i n his regular job was c r i t i c i z e d f o r not paying enough a t t e n t i o n to his crew.  He r e p l i e d that he had t o l d them what to  do and could see that they were doing i t , but t h i s was not  considered  adequate: [ P a t i e n t ] s a i d that she had been disappointed that [the foreman] had not gone to see how his family had been working. ' [Foreman] s a i d that he had been able to see that they were working a l l r i g h t . [ P a t i e n t ] s a i d that she had wanted him to come and see how they were.  In a d d i t i o n to the periods that were set aside f o r the work i t s e l f , a number of periods were set aside f o r work d i s c u s s i o n ,  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 -  other  during  foreman. this  t h e work p e r i o d ,  The c l i n i c a l  focus,  that  about  t h e d i s c u s s i o n s " m u s t be v e r y  uated i n a n a t u r a l in  felt  on t h e a s s u m p t i o n  work s e t t i n g .  the  the foreman  s u p e r v i s o r once c o m p l a i n e d ,  b e i n g u n r e a l i s t i c depends  the p a t i e n t s  how t h e y  on b e i n g  or  being  told  u n r e a l i s t i c " , but  that  their  t a l k about work  They were a n y t h i n g  s e t t i n g t h e y were s i t u a t e d i n .  but  about  is  sit-  unrealistic  A good example  for  of  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 w o r k o c c u r r e d when I a s k e d a w o r k c o - o r d i n a t o r whether  she t h o u g h t t h a t  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 . of  autonomy t h e  patient  s h e c o u l d c h a n g e t h e w o r k t h a t was  I was t r y i n g  c o m m i t t e e saw i t s e l f  to get at the  as h a v i n g  amount  but:  She t o o k t h e q u e s t i o n a s a p s y c h o l o g i c a l o n e . Could she do t h a t ? I found t h a t i n a s k i n g q u e s t i o n s about the w o r k , the 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 m i n e d by t h e would not world".  setting.  do t h e  It  o f work a t T h e t a w e r e , was e x p l i c i t l y  course, also  deter-  a c k n o w l e d g e d t h a t many  people  k i n d o f work they were d o i n g  A f t e r a day  i n which the s t a f f  of  at Theta i n the  had c o m p l a i n e d a b o u t  "real the  work:  [ F e m a l e 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 ,  however,  h a d t o be done a n d s o 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 -  iness  on t h e  their  own a m a t e u r d o - i t - y o u r s e l f  ards of not  of  the  b a s i s not o f  institution.  comparatively  professional  It  low q u a l i t y .  have e x p e r i e n c e i n d o i n g  "real  standards,  was p o i n t e d o u t  world" but  standards  on t h e  that  nor  situated  some o f  of  stand-  t h e w o r k was  The o b j e c t i o n was r a i s e d t h a t  people  t h e w o r k t h a t was e x p e c t e d a t T h e t a .  did 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 p a t i e n t 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 h i s own i n t e r p r e t a t i o n of them from the reply that he received: [Male P a t i e n t ] s a i d that he wondered what kind of j o b was expected - any o l d j o b , an okay j o b or a super good job. He asked [Occupational Therapist] whether he wanted an undercoat put on the shelves and when [Occupational Therapist] s a i d "no", [Male P a t i e n t ] assumed that the q u a l i t y 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 s i t u a t i o n at Theta.  Thus when a s e t of l i b r a r y shelves was found to have been badly  prepared by a previous p a t i e n t group, the p a t i e n t s who were to erect them continued  attempting  to do so even though:  [Female P a t i e n t ] s a i d that she couldn't believe the mess the shelves she was working on were i n . She s a i d that i f she had been doing the job h e r s e l f she would have junked the s t u f f that was there and s t a r t e d a l l over again. The work co-ordinator, who also thought the shelves done again", recognized  "could have been  that t h i s was not an appropriate r e a c t i o n :  She s a i d that a l o t of work had been put i n t o the things already and that they now had to do the best they could. The work was, then, recognized  as taking place w i t h i n the context o f a  s e t t i n g , one i n which people were inexperienced  at what they were doing,  had to do i t , and a s e t t i n g i n 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 .  - 38 -  Resources From the p a t i e n t s ' point of view, Theta had two resources which were i n scarce supply.  These were time and t h e r a p i s t s .  resources were i n t e r r e l a t e d i n that time was s t i l l  The two  a f a c t o r when the  desired t h e r a p i s t was present, but I s h a l l attempt to t r e a t them separa t e l y because there are aspects of both time, g e n e r a l l y , and t h e r a p i s t s ' time which are of i n t e r e s t .  The patients recognized  that the d i f f e r e n t t h e r a p i s t s a t  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. * system of family  Thus, when a proposal was made to change the  groups so that they would be s t a b l e throughout the  patient's stay i n the centre, one o f the f i r s t questions  that was asked  was: I l i k e the current t h e r a p i s t attached t o the f a m i l y very much but can we rotate the t h e r a p i s t s ? Apart from i n d i v i d u a l p a t i e n t s ' r e c o g n i t i o n of i n d i v i d u a l t h e r a p i s t s ' q u a l i t i e s , as f o r example i n a diary entry: ...of course, [Therapist] i s very much on top o f any s i t u a 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 p a t i e n t s remarked to me that "you u s u a l l y 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 t h i s knowledge and o f f e r e d h i s  * "Family" was the name given to the three subgroups among which the patient population was d i s t r i b u t e d . The "family" subgroups are discussed i n a subsequent s e c t i o n .  -  39 -  services to the family group whose members had c u r r e n t l y accumulated the most points i n a system of scoring i n which p a t i e n t s received points f o r work a c t i v i t i e s .  When the scores were not a v a i l a b l e i n a subsequent  lunch meeting, and the c l i n i c a l supervisor refused to attend with any . f a m i l y , there was a considerable amount o f anger a t the f a m i l y foremen because o f t h i s l o s t opportunity.  In the formally c o n s t i t u t e d group therapy sessions, s o - c a l l e d "big group", a l l or most o f the t h e r a p i s t s were u s u a l l y present together. As there were u s u a l l y about twenty patients a t Theta and only one or o c c a s i o n a l l y two patients could work a t any one time i n big group, time i n t h i s s e t t i n g was e s p e c i a l l y valuable.  This meant that there was  considerable competition f o r the time that was a v a i l a b l e and i t frequent l y happened that strong f e e l i n g s were generated  i n p a t i e n t s who f e l t  that they had not obtained enough group time. I'm very bothered that there never seems time f o r me to ask f o r help...I almost envy members i n the group who are given an opportunity to work out. When the session was ended [Female P a t i e n t ] a n g r i l y complained that she had not been given time to work, she had asked f o r time and had been promised i t . . . t h i s happened again and again...  The pressures on big-group  time could be seen i n the complaints  of patients about time being wasted on non-therapeutic  activities:  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 d i s c u s s i o n .  -  40 -  Wasting time was regarded as a s t r o n g l y disapproved a c t i v i t y .  Wasting  time was seen as asking f o r the opportunity to do therapy and then not using i t . A p a t i e n t would ask to work and then spend the time granted to him i n s i l e n c e or i n argumentative t a l k or asking questions of other patients or t h e r a p i s t s .  Even conversation was seen as inappropriate  a c t i v i t y i n big-group and, as such, a waste of time: [ C l i n i c a l Supervisor] brought [Female P a t i e n t ] up to the stage and talked with her f o r a while...As the discussion went on, several people became impatient with the amount of time [Female P a t i e n t ] was taking up. A p a t i e n t 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 o f the group a t 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 u s u a l l y recognized the moral force of the complaint that had been r a i s e d and terminated his performance.  In f a c t ,  that she "wasted time" was given as adequate reason f o r arguing against the granting o f an extension to one p a t i e n t : Several p a t i e n t s objected to [Female P a t i e n t ] being granted an extension, f e e l i n g that i t was an i n t r u sion on t h e i r own chance t o do work. [Female P a t i e n t ] 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 i n the group, as was expressed, f o r example, i n a diary entry: I f e l t very much a part of the group today, eager to  - 41  -  w o r k on a l o t o f t h i n g s , b u t d o n ' t w a n t t o f e e l I am d e m a n d i n g t o o much t i m e .  Another group a c t i v i t y i n which the p r e s s u r e s o f s e v e r e was t h e  "family  night"  at which s i g n i f i c a n t f r i e n d s ,  and o t h e r s were b r o u g h t t o T h e t a . hours  and a l t h o u g h  was o f t e n  therapeutic strong night  numbers o f p o t e n t i a l  and v i s i t o r s t h a t demanding  and v i s i t o r s were c o n s c i o u s t h a t  a c o n s i d e r a b l e d i s t a n c e , not cause they c o u l d help  for  the p a t i e n t .  n e c e s s i t y by p r o p o s i n g  time could j u s t watch.  t h i n g was done on f a m i l y  Even s o , present this  half  in attendance,  it  participants.  night  In  attendance  or  The p r e s s u r e  run  Both  information, to  pafrom  but  allow every  that  t h o s e who w e r e p r e s e n t  t h a t way t h e y  for  c o u l d see what k i n d  a n d t h e n h a v e t i m e on a s u b s e q u e n t  made t o  on a r a t h e r  rigid  One o f  have the  schedule,  be-  visitor  t h e r a p i s t s who t r i e d t o make a  an a t t e m p t was f r e q u e n t l y  i t was o f t e n  family  v i s i t o r s had come, o f t e n  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 .  was t h a t  at  therapeutic time.  entertainment  t o h a v e t i m e was a t t e n d e d t o by t h e  first  relatives  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  was s u f f i c i e n t r e a s o n f o r  tue out o f  were  c o n t r a s t t o the d a i l y a c t i v i t i e s w h i c h were seen as  f e e l i n g among p a t i e n t s  tients  time  s e s s i o n l a s t e d two and a  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  a t t e n d e d by l a r g e  In  This  that  virthe of night.  everybody results for  of  example:  [ 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 u p .  - 42 -  It  seems n o t  tions with sal  inconsequential  the s t a f f  to stop  family  t o be h e a r d  length  I observed  the  at Theta  very  took  pressures  two w e e k s a t  it.  That  the  therapists:  time  p a t i e n t s was d e t e r m i n e d  s i x weeks, w i t h the  for  of  in  s t a y a t T h e t a was a h i g h l y  stay for  casionally  two o f  the  few  confronta-  form of  a  on s c h e d u l e b e c a u s e t h e r e w e r e s t i l l  from the  the whole  of  usually  night  that  refu-  visitors  from.  Apart program,  that  too,  p o s s i b i l i t y of  the  option  of  individual  parts  of  compressed a f f a i r .  by t h e  institution  an e x t e n s i o n  for  t h e p a t i e n t who o n l y  the The  and was  one o r had t o  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  ocask by  [ C l i n i c a l S u p e r v i s o r ] , [ i n emphasizing the value of 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 alent to a year outside. [ 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 was e q u i v a l e n t t o s i x m o n t h s a n y w h e r e e l s e . Both p a t i e n t s  and t h e r a p i s t s  gram as o p p r e s s i v e . with a c t i v i t i e s  experienced  the  concentration of  The s c h e d u l e was s u c h t h a t  and l e f t  virtually  no t i m e f o r  I find tight. The c l i n i c a l sures  of  aspects  that  supervisor  the  sometimes  time  for  frequently  that  of  the  program were d e l a y e d  there's  expressed his the  where  time  t o be  to  filled  experience  lack  of  our  go  very  r e s e a r c h and  because of  pro-  relaxation:  the program.,  t i m e a n d e x p l a i n e d t h a t many o f  the  t h e w h o l e d a y was  W e ' v e 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 lunch time's f i l l e d with d i s c u s s i o n . I d o n ' t even f i n d to the bathroom.  Theta  of  the  pres-  experimental  time.  Another  -  s t a f f member expressed  43  -  the general f e e l i n g 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 : [ S t a f f Member] s a i d , "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 f a c t that the days were f i l l e d with a c t i v i t y made the time pass q u i c k l y which caused the p a t i e n t s 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 their "reflections" in their diaries: ...only three weeks to go a long  way.  This week I have been very aware of the f a c t that there i s only two weeks to go. P a t i e n t s ' a t t e n t i o n to the l o c a t i o n of the current time i n t h e i r attendance had relevance f o r some of t h e i r a c t i v i t i e s i n the centre, and t h i s point i s addressed i n the chapter on the p a t i e n t r o l e .  When one considers the amount of a t t e n t i o n that was paid to therapy time and time with t h e r a p i s t s , i t i s not hard to understand  why  the whole group was d i v i d e d up i n t o " f a m i l i e s " f o r several periods during the week.  The f a m i l i e s were three roughly equal subgroups among which  the patient population was d i s t r i b u t e d .  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 p a t i e n t on 25  whom he can show how h i s neurotic v i c i o u s c i r c l e works".  In f a c t , the  26  p r o b a b i l i t y of his f i n d i n g a "neurotic 'complement'"  or of f i n d i n g 27  "others i n the same r o l e , but performing more normally" group was obviously much smaller than i t was  i n the sub-  i n the whole group.  - 44 -  The d i v i s i o n was a puzzle to me, i n a d d i t i o n , because there was some evidence to suggest that t h e i r c o n s t i t u t i o n was counter to some of Theta's own tenets. everything important  For example, i t was e x p l i c i t l y recognized  should be brought i n t o big-group.  that  This point i s  made i n Chapter 6, "Doing Therapy", as i s the point that exploring a p a r t i c u l a r i n c i d e n t i s not a repeatable  exercise.  I f a l l matters of im-  portance must be brought up i n big-group and i f discussing them elsewhere i s seen as exhausting the subject, the scope of the family groups must be severely l i m i t e d .  In f a c t , much of the family group time that I observed  was taken up with t a l k of a s o r t that would have been considered  "wasting  time" i n b i g group.  The f a m i l i e s , moreover, were not c o n s t i t u t e d i n any way d i f ferent t o the b i g 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 f o r "family meeting".  I t was  not the case that the f a m i l i e s attempted to reproduce the r o l e s of the nuclear family i n order to explore those r o l e relations.-  One thing about the family groups was apparent, though, and that was that they had fewer members than the b i g group. t h i s provided  above a l l else was greater opportunity  The thing that  to work (the fami-  l i e s a l l met i n separate l o c a t i o n s ) and greater access to the t h e r a p i s t . When a l l the members were present i n the b i g group, the a c t i v i t i e s were generally d i r e c t e d by one or two t h e r a p i s t s , so i n a sense the remaining s t a f f members present were "wasted".  In the family groups, the  - 45 -  t h e r a p i s t s were d i s t r i b u t e d among the f a m i l i e s and every t h e r a p i s t was working.  The f a c t that some t h e r a p i s t s were valued more highly than others was adequately accommodated by the r o t a t i o n of the t h e r a p i s t s among the d i f f e r e n t f a m i l i e s .  When a highly valued t h e r a p i s t came to  a p a r t i c u l a r f a m i l y , 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 o f group time and the demands f o r access to t h e r a p i s t s .  Although i t may have involved  some c o n t r a d i c t i o n s , i t appeared t o provide a way to d i s t r i b u t e valuable resources i n an e q u i t a b l e and manageable way.  Theta's  I t can thus be  seen as a kind of " f i s c a l " p o l i c y rather than a therapeutic p o l i c y .  With  the whole group divided i n t o subgroups, each with a t h e r a p i s t 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 i n the roles of the two p r i n c i p a l p a r t i c i p a n t s , the p a t i e n t s and the t h e r a p i s t s , and, as such, are discussed i n the chapters on those r o l e s .  In t h i s section I would  l i k e to introduce some of the values that are encapsulated i n the pati e n t s ' system of b e l i e f s and which are a determinant of the r o l e .  - 46 -  First  of  a l l , T h e t a was s e e n as a s e r i o u s  be t a k e n s e r i o u s l y a n d n o t fashionable, one o f  " i n " t o do s o .  Moreover,  a s e r i e s w h i c h one c o u l d t r y  fashionable not  or  someplace t h a t  growth  be t r e a t e d  centres.  i n any o t h e r  i t was n o t  in a career of  was  a place that  going  to  was  currently  institution  and  could  current  group  way.  interviewed  by t h e  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 seriously  should  one w e n t t o b e c a u s e i t  T h e t a was a u n i q u e  One p a t i e n t who was b e i n g  place  place which  he was n o t  taking  the  enough:  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 g o n n a 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  again: D ' y o u 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 ? r e a l l y s e r i o u s t h i n g , i t ' s not something you j u s t because i t ' s a f a r - o u t t h i n g to d o . . .  Patients other  groups"  would not ailable  if  in  they  succeed.  t h e s e t t i n g who s a i d t h a t d i d not  groups  was s e e n as a way t o a v o i d d o i n g  t h e r e were  c o u l d a l w a y s be p u t  "go on  off  The n o t i o n  neutralizing  to the next  T h e t a was s e e n as a p l a c e  that  "other  to  they  groups"  av-  the n e c e s s a r y work a t T h e t a  wanted t o a c h i e v e .  e x i s t e d was s e e n as e f f e c t i v e l y  cause i t  they would  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  The e x p e c t a t i o n t h a t  a c h i e v e what t h e p a t i e n t  It's a do...  all  that a series g r o u p work  be-  group.  required  to  commitment  and  the  of  - 47 -  absence of t h i s was adequate reason to refuse entry to any new p a t i e n t . This i s f u r t h e r discussed under "Patient Role", but i t can be s a i d that lack of commitment was always a v a i l a b l e as a transformation ently counter-productive  of any appar-  a c t i v i t y at Theta.  The f i r s t foreman s a i d that the group was not working w e l l . [Female P a t i e n t J ' s lateness was c i t e d as an example of the lack of commitment of the group. ...again r a i s e d the objection about [a p a t i e n t ] r e f u s ing to be chairman. This was made out to be lack of commitment to the group. [Male P a t i e n t ] was only digging with one hand. was seen as showing h i s lack of commitment.  This  To be accused of lack of commitment was to be accused o f a serious breach of the Theta e t h i c and was often accompanied by a demand that the accused patient demonstrate h i s commitment by doing something f o r the centre i n his spare time.  This was r e f e r r e d to as "making up a commitment" and  involved w r i t i n g poetry, making some a r t i f a c t or p a i n t i n g a p i c t u r e which could be brought to the centre f o r d i s p l a y .  Theta was seen as a place i n which the t r a d i t i o n a l moral judgments were suspended.  Patients r e g u l a r l y exchanged reports of behaviour  that i n the ordinary course of events would c a l l f o r moral judgments on the part of the hearer.  Those ranged from d e s c r i p t i o n s of what would  conventionally be received as " b i z a r r e " sexual p r a c t i c e s , matters of m a r i t a l commitment, accounts of aggressive, even v i o l e n t , behaviour, e t c . It was not so much a matter that they were i n d i f f e r e n t to these d e s c r i p t i o n s but that they were c e r t a i n that anybody's moral decisions were h i s own business and nothing to do with therapy.  The necessity of speaking  - 48 -  about one's f e e l i n g s had p r i o r i t y and as those f e e l i n g s frequently i n volved g u i l t about conventionally proscribed behaviour, the speaker had enough troubles without adding r e t r o s p e c t i v e moral judgements to h i s 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 prost i t u t e a f t e r she l e f t Theta.  Although  the group was apparently d i s s a t i s -  f i e d with t h i s state of a f f a i r s and several people s a i d 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 p r o f e s s i o n a l dancing and modelling, and made much of her potent i a l i n those d i r e c t i o n s .  Summary In t h i s chapter I have attempted to s e t the scene i n a p r e l i minary way and to introduce some of the matters that c o n s t i t u t e the "seen but unnoticed r e g u l a r i t i e s that c o n s t i t u t e d the everyday scene which members i n the s e t t i n g saw as the normal natural features of Theta. the t h e o r e t i c a l underpinnings  Some o f  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 arrangement of the centre has been described.  I have introduced the p a r t i c i p a n t s 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  s e t t i n g t y p i c a l l y allows f o r only two categories of p a r t i c i p a n t : p a t i e n t s  - 49 -  and t h e r a p i s t s . 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 s t r u c t u r e s such as the f a m i l i e s .  One aspect of the program, the work, has been described as a s i t u a t e d a c t i v i t y i n which members attend to the immediate context i n seeing how "work" should be done and what i t means i n the Theta s e t t i n g .  In the next two chapters I s h a l l attempt to develop my theme by d e s c r i b i n g i n d e t a i l the r o l e s embedded i n the two categories of p a r t i cipant i n order to elaborate the way i n which these r o l e s were created and sustained.  -  50 -  FOOTNOTES  1.  The word i s G a r f i n k e l ' s . In d i s c u s s i n g "What i s ethnomethodology?" he describes i t s meaning as "...observable-and-reportable, i . e . a v a i l a b l e to members as s i t u a t e d p r a c t i c e s o f l o o k i n g - a n d - t e l l i n g . " Garfinkel w r i t e s that the p r a c t i c e s " . . . c o n s i s t of an endless, ongoing, contingent accomplishment; that they are c a r r i e d on under the auspices of, and are made to happen as events i n , the same o r d i nary a f f a i r s that i n organizing they describe;..." Harold G a r f i n k e l , Studies i n Ethnomethodology, New Jersey, P r e n t i c e H a l l , 1967, p. 1.  2.  To protect the anonymity o f the i n s t i t u t i o n the references c i t e d i n footnotes 3 through 22 and 25 through 27 have been eliminated from the published version o f the t h e s i s . 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 c e r t a i n 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 o f the use o f space i n mental h o s p i t a l s see Erving Goffman, Asylums, Garden C i t y , N. Y., Doubleday (Anchor Books), 1961. Goffman deals with space i n terms o f parts o f the i n s t i t u t i o n that were " o f f - l i m i t s " f o r p a t i e n t s , parts which were, what he c a l l s " s u r v e i l l a n c e 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 a t the end o f the day. The p r i v a t e space that I i d e n t i f y i s roughly equivalent to Goffman's areas that were " o f f limits". 24. The p r a c t i c e of primal scream therapy i s described i n Arthur Janov, The Primal Scream, New York, Dell (Delta Books), 1970. Janov addresses himself to the theory supporting his e n t e r p r i s e i n The Anatomy of Mental Illness, New York, Berkley ( M e d a l l i o n ) , 1971. I have not attempted to compare abreaction therapy with Janov's d e s c r i p t i o n s to see how f a r they appear to coincide.  CHAPTER THREE THE THERAPIST ROLE  When a new patient (or a new observer) arrives at Theta,  it  is sometimes d i f f i c u l t for him to distinguish therapists from patients. The therapists wear no d i s t i n c t i v e uniform or indeed clothing style and as not a l l members of the s t a f f are present on a l l occasions, one is sometimes presented with a new face which may belong to either the pat i e n t group or the s t a f f group. patient is "I  A not infrequent remark from a new  thought [Patient] was a t h e r a p i s t " , or less frequently,  thought [Therapist] was a p a t i e n t " .  Within a few days, however,  d i f f i c u l t y disappears and everybody can see that the patients are ients and the therapists are  therapists.  "I  this pat-  In this chapter and the next,  I w i l l attempt to delineate the q u a l i t i e s 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 o f the t h e r a p i s t r o l e 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 r o l e have, i t could be s a i d that the only thing they have i n common i s that they are a l l l a b e l l e d t h e r a p i s t s . 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 f o r the p a t i e n t s .  The coherence o f the t h e r a p i s t group i s p a r t l y formulated i n terms o f a contrast with other groups i n or r e l a t e d to the s e t t i n g and with the world i n general.  This kind o f we-they contrast i s most evident  with respect to the p a t i e n t group.  The way i n which the p a t i e n t s ' world  was working was a recurrent theme at s t a f f meetings o f the t h e r a p i s t s which r e g u l a r l y took place a t the end of therapy sessions.  The very  meeting i t s e l f , with the t h e r a p i s t s as warranted p a r t i c i p a n t s , was o f course a s i g n i f i c a n t matter i n formulating them as a coherent group. There were, however, v i s i t o r s a t these meetings: f o r example, I was permitted to be present and other authorized v i s i t o r s who had attended the preceding session were u s u a l l y present along with the secretary.  I t was  never the case, however, that any p a t i e n t was present a t these meetings and t h i s sharply d i f f e r e n t i a t e d them as a group from the t h e r a p i s t s . This e x c l u s i o n of p a t i e n t s was h e a v i l y emphasized on any occasion when a p a t i e n t knocked on the door o f the meeting room.  When t h i s happened,  usually because some matter had to be attended to by some t h e r a p i s t , the t h e r a p i s t s o l i c i t e d would leave the room and shut the door behind him before t a l k i n g to the p a t i e n t , r e i n f o r c i n g the p r i v i l e g e d status of the people i n the room.  The way i n which the p a t i e n t s ' world was working  -  53 -  was, of course, subject to troubles of various kinds: resistances and other types of counter-therapeutic behaviour, u n s a t i s f a c t o r y organizat i o n which should be r e v i s e d , and so f o r t h .  These troubles and the good  aspects of the p a t i e n t world were uniformly discussed i n a way that made i t c l e a r that i t was  their  world that was having troubles and organiza-  t i o n a l changes, and not the j o i n t world of Theta.  *  The second contrast that was made was between the t h e r a p i s t group at Theta and the s t a f f at the neighbouring  h o s p i t a l to which the  centre i s nominally attached.  The h o s p i t a l s t a f f were reported not t o  "understand what we do here".  This was evident on one occasion on which  a s t a f f member from the h o s p i t a l spent a day at the centre as a r e s u l t of the discovery of some inconsistency i n the way s t a t i s t i c s were kept at the two centres.  In the d i s c u s s i o n a f t e r the group the c l i n i c a l  v i s o r asked the h o s p i t a l member whether she could understand the  super-  diffir  c u l t i e s i n meeting the h o s p i t a l ' s demands: The nurse from the h o s p i t a l systems f o r record keeping. and [Resident P s y c h o l o g i s t ] not be used at Theta. "You i s going t o happen here."  t a l k e d about integrated [ C l i n i c a l Supervisor] explained why they could can never p r e d i c t what  The h o s p i t a l demands f o r 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 n i c e l y 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 h o s p i t a l f o r sending over incomplete charts. * I am not suggesting here that the t h e r a p i s t s were u n c r i t i c a l of t h e i r own behaviour, only that they made the contrast.  -  54 -  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 r e a l l y understand what they were doing was m u l t i p l i e d 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 r e i n force my demands for more observation time by presenting a l e t t e r from my thesis advisor, one of the complaints that was made was that my advisor 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 c l e a r l y defined the therapists as a coherent group was the meeting".  "feelings  The "feelings meeting" was a weekly meeting at which the  therapists were supposed to ventilate whatever tensions or h o s t i l i t i e s had been generated among themselves.  Both the secretary and I were ex-  cluded from these meetings although, as is recorded elsewhere, did get to attend one and part of a second.  I  actually  The therapist label was a  necessary and s u f f i c i e n t condition for being admitted to these meetings. A therapist who attended at the centre on one afternoon a week was readi l y admitted on his own request but despite the fact that I attempted to argue that I might have feelings about the t h e r a p i s t s , the c l i n i c a l  sup-  e r v i s o r , smiling (as I thought at my clever p l o y ) , said "no, we would exclude you from that".  -  55  -  The t h e r a p i s t group s o 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 v i t e d to a few of these events, i t was s o c i a l i z e with the p a t i e n t s . a "Theta Christmas party".  c l e a r to me that they did not  On one occasion, I was  i n v i t e d to attend  I went along f u l l y expecting to see both  patients and t h e r a p i s t s present but found that the party was and past s t a f f .  f o r current  There was eventually a j o i n t party but i t was  "the p a t i e n t s ' party".  known as  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 p u p i l s are rather s e l f - c o n s c i o u s l y 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, t h i s did not mean that everybody w i t h i n the group had the same s t a t u s .  I t was q u i c k l y apparent to me that there  was a f a i r l y w e l l - d e f i n e d h i e r a r c h i c a l own  s t r u c t u r e w i t h i n the group.  My  f i r s t a p p l i c a t i o n to attend at the centre was made to the c l i n i c a l  supervisor and t h i s was  seen as e n t i r e l y understandable and  That the c l i n i c a l supervisor was  appropriate.  the proper person to deal with i n mat-  ters demanding an a d m i n i s t r a t i v e decision was acknowledged by a l l members of the s t a f f .  The resident psychologist who was nominally the senior  f u 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 t o l d me time that they were a l l i n t e r e s t e d i n what I was  one  f i n d i n g out about Theta,  - 56 -  she added p a r e n t h e t i c a l l y , " [ 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 f i n d i n g s .  The forms of address that were used among the s t a f f f u r t h e r 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 addressed by t h e i r f i r s t name.  In c o n t r a s t , the c l i n i c a l supervisor was  commonly addressed as "Dr. [Name]" or "Dr. N".  In f a c t 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 o f t h e i r i n t e r a c t i o n was the resident psychologist.  This i t s e l f n i c e l y  placed her i n a p r i v i l e g e d p o s i t i o n i n the hierarchy.  This p o s i t i o n  was c a r e f u l l y nurtured and when I once, i n conversation with her, r e f e r r e d to the c l i n i c a l supervisor as "his n i b s " , t h i s drew an immediate blank look which I took to be r e j e c t i o n o f t h i s c o n s p i r a t o r i a l form o f reference that would have placed me i n a p o s i t i o n of q u a s i - e q u a l i t y with her.  The c l i n i c a l supervisor was always r e f e r r e d to as "Dr. [Name]" or  "Dr. N" i n conversation with the p a t i e n t s who addressed him i n the same way.  The resident psychologist was acknowledged to have a p o s i t i o n of a u t h o r i t y i n some s i m i l a r ways.  When I presented myself f o r an i r r e g -  u l a r day's attendance during some free time I had over the Christmas break, I was t o l d that she had been unhappy about t h i s and t h i s was appare n t l y a matter of some consequence.  I t had not been enough that I had  cleared the day with the t h e r a p i s t s who were on duty that day. Again I  -  57  -  was r e f e r r e d to the c l i n i c a l supervisor but on the i n s t r u c t i o n s of the resident psychologist: [Resident MD] and I t a l k e d about my coming another day. [ P s y c h i a t r i c Nurse] s a i d that [Resident Psycho 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 l o c a t i o n i n the s t r u c t u r e was acknowledged by the resident MD i n a conversation about the s i l e n c e s which occasiona l l y occurred i n group: [Resident MD] s a i d she would l i k e sometimes to l e t the s i l e n c e s go on, but [Resident P s y c h o l o g i s t ] didn't l i k e that. The resident psychologist also asserted her p o s i t i o n i n formal ways, as f o r example when she wrote a memorandum to the occupational t h e r a p i s t which my notes record as "the-ship s-not-tight-enough 1  kind of l e t t e r . "  Because of the passing consideration of Theta as a medical s e t 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 h o s p i t a l s e t t i n g , and so the resident MD and c l i n i c a l f e l l o w 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 p i c t u r e on i t s f r o n t cover of three s t y l i z e d figures facing l e f t .  The f r o n t 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 p o s i t i o n .  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, i n t e n sive group therapy f o r 6 to 8 weeks, taking respons i b i l i t y f o r s e l f and others. ...we provide support and share problems and s u f f e r ing... The s e r i e s o f interviews that formed the induction process i s described in more d e t a i l i n the next chapter, but some aspects of the interviews are relevant to the c r e a t i o n of the helping and caring appearance.  The  l e t t e r which was given to the p a t i e n t at the p r e - o r i e n t a t i o n interview announced that "On our p a r t , we s h a l l be with you through a l l these phases and commit our e f f o r t s to help you to work through your d i f f i c u l t i e s .  The p r e - o r i e n t a t i o n interview i t s e l f gave the p a t i e n t the f i r s t opportunity to t e l l what his troubles were.  The account was r e -  ceived with careful a t t e n t i o n and the attendant t h e r a p i s t might ask a few questions  to elaborate some d e t a i l s .  The general appearence was one  of sympathetic i n t e r e s t i n the p a t i e n t ' s problems.  The next stage i n the  intake process was an i n d i v i d u a l interview at which the p a t i e n t , once again, got a sympathetic non-judgmental hearing. questions  The t h e r a p i s t asked  about each aspect o f the problems that the p a t i e n t had d e s c r i -  bed and made out a " p r o b l e m - l i s t " .  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 a n a l y s i s of .the problem i n t o i t s i n d i v i d u a l elements and the p a t i e n t 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 s c a l e .  -  The  l i s t also helped to formulate  59  -  the problem as the i n d i v i d u a l ' s own  unique problem while the whole process emphasized the i n t e r e s t that the centre had i n g e t t i n g at what the patient's trouble r e a l l y  was.  Some aspects of the helping and caring appearance were apparent i n behaviour which was  absent i n the presence of the p a t i e n t s but  which appeared when the necessity of s u s t a i n i n g 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 i n connection  with the pre-  sentation of p a r t i c u l a r kinds of performances i n s o c i a l i n t e r a c t i o n . Goffman uses the term "front region" "to r e f e r to the place where the performance i s given".  He goes on to argue that "[t]he performance of  an i n d i v i d u a l i n 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 i n the region maintains and embodies cer3  t a i n standards".  A "back region", by c o n t r a s t , 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 r e l a x ; he can drop his f r o n t , forego speaking his l i n e s , 5 and step out of character". The contrast between the behaviours can be instrumental i l l u m i n a t i n g the appropriate f r o n t region behaviour i n terms of the  in ab-  sence of behaviour which appears i n the back region, or vice versa.  During the interviews and throughout the p a t i e n t s ' stay at Theta, care was  taken to maintain an a i r of d i s i n t e r e s t e d acceptance of  -  60  -  whatever the p a t i e n t reported as his a c t i v i t i e s i n the past.  Thus,  moral judgments were suspended and the p a t i e n t was encouraged to report whatever reprehensible (in his own view) actions he might have engaged in.  The bland acceptance of reports of p r o s t i t u t i o n and " b i z a r r e " sex-  ual behaviour that characterized the f r o n t region was emphasized on one occasion by the speculation that a woman who had, apparently,  three  l o v e r s , was a p r o s t i t u t e .  In another i n s t a n c e , the routine acceptance of homosexuals was i n strong contrast with a small performance upstairs a f t e r a p a r t i c u l a r l y t r y i n g day of therapy.  Two t h e r a p i s t s were d i s c u s s i n g the  (very evident) f r u s t r a t i o n s of t r y i n g to get a homosexual man to conf r o n t an issue that they thought was important to him.  One produced  a v i v i d c a r i c a t u r e of his highly i d i o s y n c r a t i c way of g e t t i n g angry, a noticeably absent feature of t h e r a p i s t (although not always p a t i e n t ) behaviour i n the f r o n t r e g i o n .  Apart from moral n e u t r a l i t y , other dimensions of the helping and caring appearance were emphasized i n a conversation i n the back r e gion which would have been inappropriate i n the f r o n t r e g i o n .  Many of  the patients at Theta e x h i b i t e d an extreme dependence on the t h e r a p i s t s . While t h i s was attended to as a matter to be addressed i n therapy, the f a c t of t h e i r dependence was r a r e l y i f ever presented as a trouble to the t h e r a p i s t s .  The p a t i e n t was, r a t h e r , led to make decisions f o r him-  s e l f with the support of the t h e r a p i s t s .  It would have been a serious  breach of the therapeutic code to t e l l the p a t i e n t that you " c o u l d n ' t  - 61  stand his mildly that  dependence".  -  For example,  on a p a r a l l e l  issue,  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  she i s m a s o c h i s t i c " .  This  a t t i t u d e was p o i n t e d  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 '  from a one-time  at  patient  I was o n c e  do t o t e l l  her  up one day  when  r e a c t i o n to a telephone  call  Theta"  [ E x - p a t i e n t ] , i t sounded l i k e , wanted something l i k e personal discussion with [ C l i n i c a l Supervisor]. [Resi d e n t P s y c h o l o g i s t ] d i d her best to discourage her "What d i d s h e w a n t 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 a n n o y e d w i t h p e o p l e l i k e [ E x - p a t i e n t ] who w e r e 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 .  It to represent lieve  s h o u l d be e m p h a s i z e d t h a t the  they were.  t h e r a p i s t s as i n s i n c e r e o r They  have been i n a p p r o p r i a t e b e h a v i o u r was  remarks  tain  role  the  monly the  are,  in parts there.  about one's  relationship  of  included  " p h o n e y " , w h i c h I do n o t  i l l u s t r a t e behaviour  that  t h e s e t t i n g s o as t o p o i n t  made i n  up  what ir-  impossible to  p u b l i c b u t w h i c h may b e ,  h o w e v e r w e l l - d i s p o s e d one may f e e l  be-  would  A c o m p a r i s o n c o u l d be made w i t h  b o s s w h i c h m i g h t make i t  if  made i n p r i v a t e  sus-  and comtowards  boss.  Apart of  are i n c l u d e d to  appropriate  reverent  these i n c i d e n t s are not  the  ties  of  helping the  at Theta,  from f r o n t  and c a r i n g a p p e a r a n c e  therapists after  therapy  the  event.  f a c t everybody  performances,  other  c o u l d be s e e n i n some o f sessions.  p a r t i c u l a r l y abreaction therapy,  suffering, In  and back r e g i o n  t h e r a p i s t s made a p o i n t  of  aspects  the  Whenever t h e r a p y  activiwas d o n e  a n d t h e p a t i e n t was s e e n t o embracing  the  patient after  who had b e e n i n v o l v e d w i t h t h e p a t i e n t who  be the  had  -  been d o i n g t h e r a p y ,  perience.  -  u s u a l l y hugged him a f t e r  a p p e a r e d t o be a s p e c i a l suggested that  62  quality  about  the  therapist's  he e m p a t h i z e d w i t h a n d c a r e d f o r  Apart  from t h i s  demonstration  of  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 emotional  stress.  on t h e f l o o r the p a t i e n t doing  somebody  As i s  described later,  a n d i t was t h e p r a c t i c e o f and t o e n c o u r a g e  the work.  in a close  and o c c a s i o n a l l y l i e  unscheduled c o n s u l t a t i o n s . t h e i r problems  ex-  understanding, at  times  of lying  t o t o u c h t h e p e r s o n who was  d i r e c t e d people  to gather  beside the p a t i e n t  after  or  around  instructed  of  the p a t i e n t ' s  therapeutic career. the  a c t i v e l y encouraged  to each o t h e r  to appeal  people  during  hours  these  usual to  hours  indulge  that people  One f o r m a l  stay at the  in  would  i n t e r v i e w was  c e n t r e a n d was  reported  P a t i e n t s were not  that  the for  The g r o u p was r e p r e s e n t e d a s t h e m o s t p o w e r f u l help  the  g r o u p o f w h i c h t h e y w e r e a member  by t h e p a t i e n t who f r e q u e n t l y  in his  for providing  during  The e x p e c t a t i o n was r a t h e r  to contact therapists outside  able  his  t h e r a p i s t s t o t o u c h and c a r e s s  they d i d not encourage  i n t o the family  scheduled at the m i d - p o i n t  n i f i c a n t event  in  t h e p a t i e n t was u s u a l l y  a n d 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 .  sought  often  i n t e r a c t i o n which  to the p a t i e n t  were a v a i l a b l e t o p a t i e n t s  t h a t T h e t a was o p e n a l t h o u g h  eagerly  there  so.  Therapists  bring  but  the p a t i e n t  sympathetic  other patients  Therapists e x p l i c i t l y  circle  t o do  the e v e n t ,  periods.  it  as a  encouraged  c e n t r e was o p e n help  sig-  but  were  if  h e l p was  needed.  resource  t h a t was  avail-  - 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 analysis of the institutional order in question. It is important to stress that this does not exclusively or even primarily involve a preoccupation with complex 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 legitimations appear at particular moments of an i n s t i t u tional history. The primary knowledge about the institutional order is knowledge on the pretheoretic level. It is the sum total of "what everybody knows" about a social world, an assemblage of maxims, morals, proverbial nuggets of wisdom, values and beliefs, myths and so forth, the theoretical integration of which requires considerable intellectual fortitude in i t s e l f , as the long line of heroic integrators from Homer to the latest sociological system-builders t e s t i f i e s . On the pretheoretic level, however, every institution has a body of transmitted recipe knowledge, that i s , knowledge that supplies the institutionally appropriate rules of conduct. 6 The therapist beliefs which are set out in this section are not exhaustive of the total belief structure which determines the activities of members in the setting but I would like to propose that they are relevant 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.  -  It intended apy. sized.  s h o u l d be n o t e d t h a t  t o represent  This  64 -  point  therapists'  the beliefs  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  the t a c i t  belief  above  i n order  setting.  about  and m u s t be h e a v i l y  t h a t a r e s e t o u t below a r e ,  r e a l i t y which c h a r a c t e r i z e s t h i s  are s e tout are not  avowed t h e o r e t i c a l b e l i e f s  i s made i n t h e q u o t e  The b e l i e f s  that  I would propose,  ther-  emphamatters  to sustain the social  T h e y a r e my p e r c e p t i o n s o f  system which 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 Theta.  The b e l i e f s a r e a s f o l l o w s : 1.  T h a t anyone c a n a n d 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) can 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 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.  That p a t i e n t s a r e competent r e p o r t e r s own p r o b l e m s . *  4.  That problems  5.  T h a t p a t i e n t s can have e m o t i o n s w i t h o u t b e i n g a w a r e o f t h e m 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 , fear, g u i l t , pain, l o n e l i n e s s , sadness, love e t c . are 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 one's problems.  6.  That 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 such as f a c i a l e x p r e s s i o n , body s t a n c e ,  involve emotional  a r e beyond  their  on t h e i r  states.  * I t i s n o t intended t o suggest t h a t p a t i e n t s a r e competent 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 , only t h a t they a r e competent 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 . There i s an u n f o r t u n a t e t e n s i o n i n my u s e o f t h e w o r d " p r o b l e m s " . In general I usei t r a ther l o o s e l y as a label f o r the troubles that p a t i e n t s experience. This i s done w i t h o u t a n y 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 s y m p t o m . 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 preserved.  -  65  -  and more e x p l i c i t l y , laughter, crying e t c . but with the caveat that the i n d i c a t o r s f o r some i n d i v i duals may be r e l a t e d to states i n i d i o s y n c r a t i c r e l a t i o n s h i p s which are themselves detectable. 7.  That troubles are " i n s i d e " i n the sense that they are part of the personal i n t e r n a l experience of the actor and must be brought "outside" i n order to be corrected. That i s , they must be r e i f i e d i n verbal or v i s i b l e behaviour.  8.  That verbal behaviour may be " j u s t a c t i n g " and that t h i s 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 r e f l e c t e d by phys i c a l distance, and that other emotional dimensions can be o b j e c t i f i e d i n drama, e x e r c i s e , work, dance, games, a r t e t c . where they can be detected f o r therapeutic purposes.  10. That c e r t a i n kinship categories are always relevant to emotional problems, i n p a r t i c u l a r "father and mother" and that other categories such as " s i b l i n g " may be relevant. 11. That r e l a t i o n s h i p categories such as "spouse", " l o v e r " etc. are relevant to emotional problems. 12.  That p a t i e n t sex categories are i r r e l e v a n t i n determining t h e i r q u a l i f i c a t i o n s f o r membership i n the group and are r e l a t i v e l y unimportant as f a r as t h e i r adopting r o l e s i n therapy i . e . that female patients can adequatel y play male r o l e s .  T3. That patients know the r o l e s embodied i n the relevant categories well enough to produce a d i s p l a y of these roles that i s adequate f o r a l l p r a c t i c a l purposes i n evoking the emotions r e l a t e d to the r e l 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 r o l e playing might f a i l and d i d f a i l to produce an adequate d i s p l a y and that they proposed the r o l e playing i n 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 r o l e 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 d a i 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 t h i s footnote i n r e c o g n i t i o n of the s t a f f ' s c l e a r knowledge that t h i s and indeed any therapeutic t a c t i c coul d f a i 1 .  - 66 -  FOOTNOTES  1.  Erving Goffman, The  Presentation  of  York, Doubleday (Anchor Books) 1959.  Self  in  Everyday  Life,  New  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 " l a s t chance".  A  not untypical explanation was: I.. I feel that my problems are are r e a l l y bothering me and I can't go on in the space I am any more, e h . , i t ' s g e t t i n . . I feel ups an' downs 'n i t l i k e ehm.. some days I feel better about the progress I have made., about dealing with them and other days I., e t ' s ehm.. there's nothing happening at a l l and e h . . I've j u s t come to the point that I jus wanna.. I can't l i v e with myself like this without bein' able to do somet h i n ' about i t because I'm unhappy w i t h . , with where I'm a t . . Patients were recruited from the nearby hospital and by r e f e r r a l s from doctors who have heard about the centre. recruitment process and know l i t t l e  I have done no study of the  or nothing about i t .  There seems  - 68 -  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 r e -  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 residence at the centre.  and in the f i r s t few days of the  patient's  Although the interviews were important in  learning the r o l e , I have chosen to describe them under the heading * "getting i n "  because the main focus for the potential patient at that  stage is gaining acceptance as a patient.  The section on "learning  the patient r o l e " which follows this I have reserved for describing the learning work that went on a f t e r the patient had been accepted.  In  fact  the learning process was probably about evenly divided between the two stages. Getting In The potential p a t i e n t ' s f i r s t contact with Theta was at a preorientation 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 s t a f f was present and i t was reported that the current patient "chairman" sometimes attended: [Psychiatric  Nurse] r e -  ported that the "chairman used to attend" but with the suggestion that her non-attendance was a matter of oversight rather than p o l i c y .  She  * It should be noted that this description deals e s s e n t i a l l y with a successful entry. The i n s t i t u t i o n ' s screening process is not discussed because l i t t l e or no data was obtained on that aspect of the centre.  -  69 -  did not, however, rush out and get the chairman, and the matter was l e f t as a p r a c t i c e that had not much importance.  Each candidate was given some typewritten information and asked to read i t , i n p a r t i c u l a r a l e t t e r which was r e f e r r e d to as the Dear Friend l e t t e r .  "Dear F r i e n d " i s a s u f f i c i e n t l y unusual form of  greeting as to adequately i d e n t i f y the document and appeared to have the desired mixture of s u f f i c i e n t g e n e r a l i t y f o r a form l e t t e r along with some i n d i c a t i o n of the a t t i t u d e that the c l i n i c a l supervisor wished to f o s t e 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 f a c t that the p a t i e n t came of h i s own choice, and at the same time the group focus of the community.  I t could be the subject of a d e t a i l e d a n a l y s i s  in i t s e l f , but s u f f i c e i t to say that i t appeared to create an impression of s t r u c t u r e : group therapy i n 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. . . . t h e r a p y through...modes such as a r t work, music, t h e a t r e , games and dancing. along with professional competence: i n d i v i d u a l therapy w i l l play a l e s s e r r o l e as we believe that the combined complex programme we are o f f e r i n g to be [ s i c ] superior f o r people with your types of problems -  the present ates this,  state  of  knowledge  [emphasis mine]  in  Psychiatry  substanti-  A l l these are elements of a u n i f i e d therapeutic p r o gramme..."  -  70  -  "...[Pjeople with your types of problems..." appeared to i n d i c a t e a l ready an understanding of what "your types of problems" were and, presumably, confidence  i n the relevance of the program.  The "dear f r i e n d " l e t t e r , along with the Theta brochure, were the f i r s t resources  that the p o t e n t i a l p a t i e n t had f o r determining not  only what Theta amounted to but, to some extent, what he himself amounted t o . The brochure t o l d him that Theta was "not  f o r people with a  h i s t o r y 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  h o s p i t a l " 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 i n the l e t t e r to "patients and s t a f f " . the brochure invoked a more neutral category:  Although  "member", the frequent r e -  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 r o l e the new p a r t i c i pant was to play: that of " p a t i e n t " doing "therapy".  The p a r t i c i p a n t  had only the most d i f f u s e and n o n - s p e c i f i c knowledge of what t h i s amounted to unless he had f r i e n d s who had been through the program (a not uncommon circumstance).  A female p a t i e n t t o l d me that she thought i t would  be a "rap session".  A f t e r 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  c u r i o s i t y about the more e s o t e r i c d e t a i l s of the brochure, f o r example patients might confess that they d i d not know what " k i n e s i c 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 t h e i r reasons for wanting to come to Theta.  The potential patient took this as an i n v i t a t i o n to display a set of descriptions of his previous or current feelings and autobiographi c a l 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 s t a f f member treated whatever question that had been asked.  l i s t that was produced as relevant to the 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 desc r i p t i o n to be presented as a relevant l i s t of problem items. The s t a f f at Theta, of course, were not prepared to accept any d e s c r i p tion as an adequate formulation of the problem, and had clear p r i o r i t i e s and theoretical focuses that they attended to. The s t a f f 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 l o g i c a l p o s s i b i l i t y that the patient could talk about anything at a l l , in the interviews that I observed 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 i n t e r e s t i n g psychological f a c t about them, but they had to be r e l a t e d to recent f e e l i n g s or a c t i v i t i e s that drove the p a t i e n t to appear at Theta. A female p a t i e n t , a f t e r speaking about " c o n t r i b u t i n g f a c t o r s " i n the past, t o l d about two extra-marital pregnancies that she had "not got over y e t " . A male p a t i e n t s a i d that the problem o f h i s shyness had been bad since he had given up drugs. He used to be i n t o a l o t of "heavy drugs" and had q u i t . "That's when the problem got r e a l l y bad". He was a j a z z musician and was having great trouble meeting "the p u b l i c " . He was "uptight" and i t a f f e c t e d h i s playing. A male p a t i e n t s a i d he had "too much going r i g h t now and [he couldn't] take care of any of i t . "  A f t e r the p r e - o r i e n t a t i o n i n t e r v i e w , the p a t i e n t took away a second form l e t t e r r e f e r r e d to by the heading: " S e l f D e s c r i p t i o n " .  He  was i n v i t e d to w r i t e a b r i e f summary of himself under nine headings. The headings and suggestions f o r the s e l f d e s c r i p t i o n are shown i n Appendix I I I . They were designed to ensure that the patient's s e l f desc 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 tion.  The p a t i e n t brought t h i s " s e l f d e s c r i p t i o n " to the next encounter  with Theta which was an i n d i v i d u a l interview conducted by one of the s t a f f members.  The " s e l f d e s c r i p t i o n " was used as a resource by the s t a f f member during the i n d i v i d u a l 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 t o l d me that  the s e l f d e s c r i p t i o n was "very u s e f u l " during the i n d i v i d u a l interview. I t 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 a v a i l a b l e .  The s t a f f member read through the s e 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 s e 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 i n s t i t u t i o n a l  *  artifact  and was used to assess the progress the patient was making in  the i n s t i t u t i o n .  1  I do not have a complete record of an individual  interview,  and the interpretive work done by the s t a f f member in selecting items from the autobiographical account for inclusion in the problem l i s t thus not available  to me.  is  One feature of the process which was evident  is that the s t a f f member treated the s e l f description as a true account of the events of the p a t i e n t ' s  life.  the account was a relevant account.  She also assumed, once again, that Although she might ask questions to  elaborate the items that were described, she knew that there were a whole c o l l e c t i o n of events, incidents, r e l a t i o n s h i p s , feelings and the  like  which were not described.  having  The selection depended on the patient  an impressive amount of knowledge about social r e l a t i o n s h i p s , 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 s i g n i f i c a n t in his  life.  * This word has a s l i g h t 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 s u f f i c i e n t interest to the i n s t i t u t i o n 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 i g n i f i c a n t .  He might begin to be aware of the fact  that his problems had a d i f f e r e n t slant to what he thought they had.  The  process was further refined in the l a s t 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 a c t i v i t y 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 f a i l e d to show up this was truncated or abandoned.  The patient group along with a number of the s t a f f members and former patients attending for "after-care" gathered in the theatre.  They  formed t h e i r chairs into a large horseshoe shape and the potential patients 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 f o r  -  75 -  a t h i r d 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 l i k e "I'm depressed" or "I people", "I  s u f f e r from depression", "I  can't get close to people".  turned on events, l i k e "I  statements  can't relate  to  Sometimes the descriptions  t r i e d to commit s u i c i d e " or "My marriage is  breaking up (or has j u s t broken up)".  The group then questioned the interviewee of the events that led to his a r r i v i n g at Theta.  about the d e t a i l s  A t r a d i t i o n had grown  that vagueness in reporting troubles was unsatisfactory and the d e t a i l s of the troubles had to be elaborated. viewee "what form [his]  The group would ask the i n t e r -  depression [took]" or "what are your relations  with people", also "what people" and what t h e i r current status was,  i.e.,  were they l i v i n g together, was he l i v i n g with his parents, how often he saw them, etc.  In the event that the patient had t r i e d to commit s u i c i d e , 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 c o l l a p s e : separation or divorce, and i f separation, whether t r i a l or permanent.  or terminal, temporary  -  76  -  As each aspect of the subject's explanation was  elaborated,  f u r t h e r elaboration was demanded u n t i l the group f e l t that i t had understood f o r a l l p r a c 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 t h i s aspect of the interview can  be  seen i n the group's pervasive i n t e r e s t i n drugs and a l c o h o l .  Every patient was  asked about his use of drugs and a l c o h o l .  The p a t i e n t might r e a d i l y admit that he was  " i n t o the drug scene" or he  might admit the he "used to be i n t o drugs", that he "drinks quite a b i t " or was a "heavy drinker f o r about three years". asked questions  The group g e n e r a l l y  to e s t a b l i s h the precise dimensions of the problem and  then went on to decide on the basis of t h i s report whether the d e s c r i p t i o n amounted to "a problem".  The c r i t e r i o n f o r t h i s appealed to a norm-  a t i v e standard that would c o n s t i t u t e a large percentage of the d r i n k i n g 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 p a t i e n t group viewed drugs and a l c o h o l . [Female P a t i e n t ] s a i d she had a " s l i g h t d r i n k i n g problem". Several people wanted to know what that amounted to. About a b o t t l e of wine per day. Would she make a commitment to stop d r i n k i n g today? A long argument ensued. [Female P a t i e n t ] s a i d she didn't see why today ...[Female P a t i e n t ] pointed out that there were other drugs: eating ( e s p e c i a l l y f o r her), coffee, T.V.; why s i n g l e out a l c o h o l . [Male Patient]- s a i d that t h i s was the worst problem and everybody, many group members knew i t . A f t e r much s t r u g g l i n g [Female P a t i e n t ] rel u c t a n t l y 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 o c c a s i o n a l l y 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-  -  ferring)  by  M.D.  sending  [Resident  The  Draconian  illustrated  by FP I  FP  I  her  1: :  2:  *  Theta,  about to  eventually  of  following How m u c h  extract do y o u  drink  B u t how m u c h week o r / /  do y o u  FP  2:  Well,  how d o y o u  MP  :  I  wouldn't  call  FP  2:  I  wouldn't  either.  FP  3:  D'you  I  MP I FP I  1:  I'm  I  go  not  to a  what  Ahm..  I  2:  Would  you  :  Sure,  very  2: :  cut  4: :  = Female  and  drop  to  check  drugs  intended,  them. into  this.  standards  patient  is  further  interview:  now?  and you No,  week.  Ahm..  Patient  It's  been  a  long  time.  drugs?  smoke a  that  bit  much  ahm//  any  more,  I've  to  take  on  about it  problem.  person.  willing  of.,  Is  drinking  stop?  because  a  a  a  often?  about  don't  [very  how m u c h  that  pub-type  I'm  like  feel?  bars  don't  I..  drink,  bottles.  down q u i t e  have  FP  four  Wha..  :  drugs  her  Uhm..very r a r e l y ; i f I have a b e e r . . I d r i n k beer because I l i k e the t a s t e and I m e a n . , m y s e l f a n d my f r i e n d s w e m a k e o u r o w n e h / /  or  FP  agreed  from a  Three  :  the  have  t h e d r i n k i n g and  :  I  FP  -  known  to  M.D.]  severity the  had  77  of  tranquilizers  some eh  quietly]  antibiotics  medication  [2  or  now  seconds]  and  it  or  anything? but  it's  eh.,  an-infection-I-  should  be  over  in  somethin'?  "Tetracyclin"  MP  = Male  Patient  I  =  Interviewee  -  78 -  FP  How much dope do you smoke?  I  I've had a e h . , an ounce of ehm.. hash for over six months, seven months  FP  S..  I  No  FP 2  OK, so (reads series of questions from protocol.)  so you don 1 ( 1  Another patient interviewed generated the following f i e l d note: More talk about drugs and alcohol with the next g i r l . [Interviewee] was admitted from the in-patient s i d e . 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 r e f r a i n 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 standards that the patients demanded in some things were more severe than those demanded by the i n s t i t u t i o n , but the interviews  that I observed  suggested to me that the standards were a j o i n t production of patients and s t a f f .  Why the standards were so r i g i d and why the subject of drugs  and alcohol was of such pervasive concern to the patients is not c l e a r 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 s t a f f .  It was pointed out on one occasion that the patients  had to depend on the group for support now instead of relying on chemicals.  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-  s i r e to escape was sometimes large and threatening and drugs and alcohol  -  79 -  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 t h e i r s a t i s f a c t i o n and had obtained an assurance about drugs and a l c o h o l , the patient chairman read a set of standard questions to the interviewee which were prepared by the  staff.  The questions that were asked are presented in Appendix IV and were usually read with r i t u a l i s t i c solemnity while the group s i l e n t l y watched the interviewee.  Provided that every question was answered in the nega-  t i v e or the a f f i r m a t i v e , 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 u n t i l they l e 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 c a r e f u l l y 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 p o s s i b l y , was in the same position.  * From the s t a f f ' s point of view, the use of drugs and alcohol was seen as being counter-therapeutic.  - 80 -  I was present f o r one group interview at which the group found themselves presented with a p o t e n t i a l p a t i e n t that they believed to be i n need of therapy but were r e l u c t a n t 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 o f not voting on him so as not to hurt him by a r e f u s a l .  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 t h e r a p i s t explained that she could not guarantee to do t h a t , that they "must decide", they voted the p a t i e n t i n , despite c l e a r evidence that they thought that he was not a s u i t a b l e candidate f o r the centre.  When the vote was being taken, i t was the p r a c t i c e of the group members who voted against a candidate to present t h e i r reasons. "Yes" votes were o c c a s i o n a l l y accompanied by cautions o r arguments aga i n s t "No" vote arguments, but were more commonly given without comment. "No" votes were almost always accompanied by an explanation.  There was a strong f e e l i n g that the explanations that accompanied "no" votes must "make sense".  For example, the f o l l o w i n g i n c i d e n t  took place during one vote: * MP 1 : You remind me so much o f myself (laughter). I have to vote no (gasps and crescendo o f laughter and p r o t e s t ) Yeh  *  FP 1:  How does that make sense?//  MP 2 :  I don't understand that at a l l / /  MP 1 :  I t doesn't make sense but I / /  MP = Male Patient  FP = Female P a t i e n t  - 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 i t ?  MP 1:  I dunno I eh get the f e e l i n g t h a t . , i t i s n ' t r e a l l y . , yeh I think he can make i t , I ' l l change my vote y e s . . sorry.  "Making sense" was not a question of formulating a l o g i c a l argument but of giving reasons that everybody could understand as relevant and important.  The one reason that above a l l  the candidate was "not committed".  others was seen in this way was that If  a group member said he voted "no"  because he " d i d n ' t see the commitment t h e r e " , this was accepted as an adequate reason without any further explanation.  A variation on this theme  which e l i c i t e d no protest can be seen in the following: FP  :  I'm gonna have to vote no because I have very mixed feelings l i k e [ P a t i e n t ] . To me I think you think that this is r e a l l y a faddy trippy thing to do and I don't feel that you're going to c o n t r i . . give of y o u r s e l f and l e t 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 u a 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 s e c t i o n on "getting i n " i s that i t was  during t h i s period that the patient picked  up many of the norms and values that r e l a t e d to the p a t i e n t r o l e .  Be-  fore I proceed I would l i k e to w r i t e a b r i e f summary of these norms and  values.  The p a t i e n t frequently saw himself as coming to a haven where there was  s t r u c t u r e , s e c u r i t y and expert help, dispensed by a  professional s t a f f i n t e r e s t e d i n his problem. one and the basic r o l e he was apy.  The s e t t i n g was a medical  assigned was that of a p a t i e n t doing ther-  The problems that beset him had been noted and analyzed  into dis-  crete elements and he knew what parts of his story had been of p a r t i c u l a r i n t e r e s t to the i n s t i t u t i o n .  The group interview had been r i g o r -  ous and his acceptance had not been automatic; i n f a c t , i n some cases i t might have been marginal. e x c l u s i v e group. that his continued commitment.  He was  therefore a p r i v i l e g e d member of an  The group had emphasized commitment and he was acceptance was  aware  c o n d i t i o n a l upon his demonstrating his  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, y e t , what these standards were, except i n the most general terms.  The day chosen f o r new p a t i e n t interviews included a family meeting and a whole-group therapy session under the d i r e c t i o n of the c l i n i c a l supervisor.  The  luncheon included a patient committee e l e c -  - 83 -  tion.  The new patient was thus presented with a considerable spectrum  of the Theta a c t i v i t y tentatively.  and proceeded, at w i l l ,  to p a r t i c i p a t e ,  albeit  For example, the patient, once admitted by the group, had  the p r i v i l e g e of voting on the candidate who followed him and was expected to do so.  He also had the p r i v i l e g e of voting f o r 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-  t i v e t r a d i t i o n to o f f e r 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 s k i l l s to assess) but not to assess the q u a l i f i c a t i o n s of committee 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 i a r i e s , fami-  l i e s , family night, working out, and a l l the rest of the concerns that made up the routine d a i l y l i f e of Theta. what a l l  Somehow he had to find out  these references amounted to.  Towards the end of the lunch there would be a c a l 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  activities.  The patient would learn that the " f a m i l i e s " were Theta subgroups and would begin to get some idea from what was worth reporting which a c t i v i -  - 84 -  t i e s were valued and which a c t i v i t i e s were censured in these s e t t i n g s . He would learn that some members of the group had the status of reporters and, in the subsequent committee report, which a c t i v i t i e s  of the  whole group were "news".  A f t e r the reports had been read there was an e l e c t i o n which,  *  he might learn, was not taken very s e r i o u s l y , of a regular e l e c t i o n .  although i t had the form  He would note that the q u a l i f i c a t i o n s for c e r -  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 o f f i c e and the attention people paid to the length of time patients had been at Theta in considering who should be nominated: 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.  ** day,  The new patient was assigned to a family during his  first  and a f t e r the lunch he joined this family for the f i r s t time.  He  found, in the family group, that members could e l e c t to work on a problem and that a l l members of the family were expected to contribute observations about that problem. *  The new patient quickly found that his  This is discussed in a subsequent s e c t i o n .  * * The methods of assigning patients to families were in a state of flux during my period of observations; sometimes i t was done by l o t , sometimes a r b i t r a r i l y . There was talk of "bargaining" for new members.  - 85 -  opinions, experiences and observations were considered equally with o  other family members, although he might have reservations about expressing 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 a f t e r 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  it  normally tended to be a heavy session and the c l i n i c a l supervisor f r e quently t o l d 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 session as a frightening experience.  They could see that the emotional  displays were orchestrated and approved by the therapists present, but often remarked afterwards same t h i n g .  that they couldn't see themselves doing the  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-  - 86 -  ous as possible.  After the session was over the new patients were asked what they thought of t h e i r f i r s t day at Theta.  It was at this point that  they admitted t h e i r fear or perhaps even distaste of the which they had observed.  activities  This was then taken as an opportunity f o r  the s t a f f 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 v i t y of doing therapy. At the end [ C l i n i c a l Supervisor] brought the new patients up to the f r o n t . [New female patient] said she was frightened by what had happened in the morning: "Everybody at each other's t h r o a t s " . [Female Patient] said i t wasn't usually l i k e 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 d i f f e r e n t from what he had expected. He would come because he "had t o " . 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. desirable.  Moreover, strong reactions were completely proper, even In one incident reported again l a t e r in another context a  patient was very upset by the f i r s t afternoon's therapy session. [ C l i n i c a l 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 i n d 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. [ C l i n i c a l Supervisor] said i t was a good sign - some people took weeks to achieve what she achieved, some never d i d .  - 87 -  The patient, then, had come to observe some of the Theta a c t i v i t i e s and had heard some of the Theta t a l k .  What he had not understood,  he had probably asked a patient about who would have t o l d him "the f a c t s " about that a c t i v i t y .  He had participated in an e l e c t i o n and learned  some of the preoccupations among patients. and had watched therapy being done.  He had seen a family group  He reactions to this had been checked  and interpreted in the l i g h t of the Theta c u l t u r e .  The new patient now  l e f t the setting to return for full-time a c t i v i t i e s  on the following  Monday with some expectations of what was going to go on and how he should behave in the s e t t i n g .  Time and the Patient Role It sive at Theta.  has already been argued that time was experienced as oppresTime, however, had other references for the patients  in  the s e t t i n g , some of which were instrumental in determining behaviour.  The current point in a p a t i e n t ' 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 o f f i c e on the patient committee, whereas a patient who was in his "fourth week" was under considerable pressure to occupy some o f f i c e i f he had not done so y e t .  In selecting between  candidates for chairman, too, the fact that " i t ' s  alternative  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 l e f t to him.  - 88 -  Patients  in t h e i r f i f t h or sixth week used t h i s f a c t as a  resource to demand "big-group" time over patients who were less advanced in t h e i r careers.  The location of the current point in a pa-  t i e n t ' 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. Somebody said that they knew that she had been there for six weeks and apparently had not changed at a l l . That was r e a l l y threatening.  Role Relations Among Patients The patient population was treated by the therapists as a uniform group insofar as no special p r i v i l e g e s  (apart from the group  time discussed above) were extended to patients of any class or seniority.  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 " o l d hands". [Female Patient] was asked who was making demands on her. She i d e n t i f i e d [the four most senior group members].  Despite t h i s , the group saw i t s e l f as e s s e n t i a l l y a society of equals.  This was perhaps emphasized in the elections of committee  members which was operated as a means to l e t everybody have a chance, rather than as a seriously competitive enterprise.  A frequent c a l l on  - 89 -  election day was "who hasn't been chairman?"  This was done even though  the c l i n i c a l supervisor was in the habit of lecturing the group on the importance of the chairman. [ C l i n i c a l Supervisor] asked who was d i s s a t i s f i e d 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 e s s e n t i a l l y 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 r e s t , i t was the source of jokes which tended to emphasize the emptiness of the formality. [Male Patient] made a joke during the e l e c t i o n . He said he wanted to know what [nominee's] position on drinking was. After her e l e c t i o n [Female Patient] said that she was going to f o r b i d drinking. This joke depends for i t s force on the c o n s e q u e n t i a l l y of questions asked of candidates at real e l e c t i o n s .  If  the candidate's position on  drinking (for example) is going to a f f e c t the people he i s going to have administrative power over, his answer to the question is going to be important.  clearly  The question asked in this context emphasized  the fact that the chairman was going to have no such power. the candidate did not even attempt to answer i t .  In  fact  She j u s t smiled.  The selection of other positions at Theta followed a s i m i l a r pattern.  For example, in selecting the work co-ordinator on one occa-  s i o n , the group were discussing the r e l a t i v e merits of the three candidates in the usual terms. present:  The c l i n i c a l supervisor happened to be  - 90 -  Halfway through the elections [ C l i n i c a l Supervisor] interrupted to say that the work co-ordinator should be competent. It was pointed out that nobody was r e a l l y competent. It was also pointed out that he should be enthusiastic. [ C l i n i c a l Supervisor] agreed. Some votes now went to [Male Patient] but the group i n s i s t e d on having i t s candidate - [Female P a t i e n t ] , self-confessed incompetent. Despite the attempt by the c l i n i c a l  supervisor to influence the process,  the group attended to i t s own p r i o r i t i e s in selecting a patient to  fill  the r o l e .  It was a noticeable feature of the committee's work  itself  that i t was reluctant to make decisions that had not been checked out by the whole group, even in r e l a t i v e l y the foreman "family  trivial  matters such as renaming  leader".  An early discussion today was about what the foreman should be c a l l e d . The committee decided "family leader" 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? Famil i e s had suggested these names and points were to be awarded [to the family whose suggestion was s e l e c t e d ] . The committee saw i t s e l f ,  then, as having very l i t t l e  the process even in the most t r i v i a l reporting the day's a c t i v i t i e s . process.  power to influence  way and was mostly concerned with  Even this was seen as a r e l a t i v e l y empty  The f e e l i n g was that "you don't have to l i s t e n to the committee  report anyway because you were there".  The therapists made attempts to reduce the emptiness of the committee's a c t i v i t y working.  by having the members select people who ought to be  I was at a committee meeting immediately a f t e r 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 e s p e c i a l l y w e l l " . . . It was clear that the committee f e l t very ambivalent about t h e i r 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 o f f right now than anything e l s e " . There followed a careful composition of just the r i g h t phrase - "the committee recommends that [Female Patient] needs to work on her problems". They were c l e a r l y delighted with t h i s . It  seemed that the unvarying triteness and vacuity of the published com  ments and recommendations about fellow patients: "[Patient "[Patient "[Patient "[Patient  name], name], name], name],  t e l l us what you're f e e l i n g . " work for y o u r s e l f . " l e t us see your anger [or warmth o r . . . ] " what's happening with you?"  were far from documents of the lack of imagination, perception or a b i l i of the Theta p a r t i c i p a n t s , but rather deliberate cliches to escape the  * d i f f i c u l t y of making public judgments about fellow group members.  Abdicating the Role The most d i r e c t way of abdicating the patient role was by ab  * Group members regularly and w i l l i n g l y sessions and in lunch time talk but i t was they were " f o r right now" and could be and the period of the i n t e r a c t i o n . The public quality of being c o r r i g i b l e .  made judgments in therapy always t a c i t l y assumed that usually were revised within judgments did not have this  - 92 -  senting oneself p h y s i c a l l y from the scene. occurrence at Theta. permanently.  This was a not infrequent  People j u s t stopped coming either temporarily or  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 p a r t i c u l a r l y ening to the whole i n s t i t u t i o n .  threat-  Any unexplained absence immediately  generated an inquiry into the absent p a t i e n t ' 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 t e l e -  phone a number of group members would v i s i t his address to see i f could find him.  they  Even the absence of a patient on the f i r s t regular day  of her attendance was an important i s s u e , so that i t was not a question of concern for fellow patients whose troubles were well known; any absence was a threat.  I was in the room on one occasion when a new patient who had f a i l e d to arrive on the f i r s t day was telephoned.  The patient who c a l l e d  produced a long, clever and forceful argument for the new patient to a t tend.  In the course of this dialogue she dealt with d i f f i c u l t i e s  like  the new patient denying that she wanted to change: "You don't have a desire to change?  We won't l e t you f a i l " , and fearing that she would  lose her i d e n t i t y :  "Part of your i d e n t i t y , but what kind of part is that?  Y o u ' l l replace i t with something more p o s i t i v e " . knowledged the attractiveness  of absence from the s e t t i n g : " I t ' s  easy place to be but i t gets e a s i e r ; didn't".  The p a t i e n t - c a l l e r  I've  ac-  not an  considered leaving but I j u s t  -  93 -  Apart from patients who f a i l e d 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 i n i c a l supervisor which c e r t a i n l y tested the p a t i e n t ' s s i n c e r i t y  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 c l e a r l y a p a t i e n t ' 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 s a t i s f a c t o r y 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] protested. The difference that was i d e n t i f i e d was between "I'm going", followed by a c t i o n , and "I'm f e e l i n g l i k e leaving and I wonder what is causing i t " . The second was i d e n t i f i e d as good behaviour, the f i r s t was bad The discussion included a l o t 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 t h e i r 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 l e n t or perhaps p a r t i c i pating in a way that directed attention away from oneself (being conspicuously active as a co-therapist for example) was evident. cern of the therapists was, of course, obvious.  The con-  Absence removed the  patient from the strongest threat of the i n s t i t u t i o n , that of discharge.  -  94 -  For the patients i t seemed e n t i r e l y reasonable in that everybody probably f e l t the need to escape at some time and when somebody actually it,  did  i t became that much more r e a l i s t i c .  The only v a l i d reason for absence from the setting was s i c k 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 s t a f f i n s t i t u t e d a system of i n d i v i d u a l l y i d e n t i f i e d drinking cups to reduce the apparent infectiousness of the disease.  The s t a f f was aware, of course, of the  ease with which a patient could claim that he was sick and attempted to find remedies for t h i s : At lunch there was some talk about [two p a t i e n t s ] . [ C l i n i c a l Supervisor] asked what was happening with them. It was explained that they were s i c k . [Clinical Supervisor] asked what temperature they had. Nobody had asked. [ C l i n i c a l Supervisor] said.that people should know " d e t a i l s " when someone was s i c k .  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 i c k " : I enquired where [Patient] was and was t o l d that she had been injured on the previous day playing f l o o r hockey. and "reported s i c k " when the p a t i e n t ' 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 c a l l e d . She said that  - 95 -  she was s i c k . [Female P a t i e n t ] was somewhat discouraged. She said that she doubted i f [Absent P a t i e n t ] would come back.  I observed one other method of abdicating the r o l e while I was  at Theta and that was  was  now  inappropriate.  by r e d e f i n i n g the problem so that the s e t t i n g  A female patient had i d e n t i f i e d her shaking  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 to get beyond these symptoms.  and  spent i n attempts  She was questioned frequently i n group  about aspects of her past and current l i f e i n an attempt to f i n d the source of her troubles but was t a i l e d exploration.  highly r e s i s t a n t to any attempt at de-  As she proceeded through her stay at Theta, i t  became apparent that she was  not prepared to e n t e r t a i n 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. t h i s was  that she blocked the i n q u i r y and was  The net e f f e c t of  the source of  f r u s t r a t i o n to her family and the group as a whole.  considerable  A f t e r about three  weeks, she decided that her problem was merely a weight problem. was  the case, of course (from her point of view), Theta was  an  If this  inappro-  p r i a t e place to be and she i n f a c t l e f t s h o r t l y afterwards.  Patient B e l i e f s P a r a l l e l with the t h e r a p i s t s ' b e l i e f s , there i s a system of p a t i e n t s ' b e l i e f s which are instrumental  i n determining  p a t i e n t behaviour  - 96 in the setting and in t h e i r seeing what goes on at Theta as s e n s i b l e , reasonable and understandable.  These b e l i e f s , l i k e the t h e r a p i s t s '  b e l i e f s posited in the previous chapter, are neither defended nor used in this s e c t i o n , but I hope to show in the two succeeding chapters how the social r e a l i t y that is created at Theta depends on the b e l i e f s of the two groups and t h e i r mutual dependence.  The b e l i e f 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 setting.  2.  That i t must be taken seriously and requires commitment on the part of i t s members.  3.  That therapists are helpers and hence that they are motivated to improve the patients' well-being.  4.  That they are professionally q u a l i f i e d to observe and interpret behaviour and that this gives t h e i r observations and interpretations a special status which is not accorded to lay observations and i n t e r p r e t a t i o n s .  5.  That the t h e r a p i s t s ' presence in the therapeutic setting is assurance that whatever comes up w i l l be "handled" in a way that i s not threatening for patients and i s "safe" for the patient involved.  6.  That r e c i p r o c i t y of confidences is suspended in r e l a tions between patient and therapist and that while the therapists should properly know a l l about the p a t i e n t , the patient should not expect to know anything about the therapist except that he is a t h e r a p i s t .  7.  That the social structure of Theta is properly defined by the therapists who may properly propose, question or redefine any a c t i v i t y at any time on the grounds that i t is or is not therapeutic, therapeutic effectiveness a l ways being s u f f i c i e n t grounds for any r u l e , i n t e r d i c t or a c t i v i t y without further explanation.  8.  That although t h e r a p i s t s ' observations may confirm one perspective over another, they w i l l be e s s e n t i a l l y neut r a l in any interaction among patients and w i l l not take  - 97 -  sides in disputes involving patients. 9.  That both therapists and patients w i l l suspend t h e i r t r a d i t i o n a l moral judgments.  10.  That the group at Theta is more important than any i n d i vidual in the group and hence that behaviour invidious to the group must be suppressed. Further that commitment 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 t h e i r emotions and express t h e i r 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 s u i c i d e , whether attempted or threatened, is of immediate and pressing relevance to patients' wellbeing and should be attended to.  15.  That alcohol and drugs are serious threats to the i n d i vidual that should be abnegated and must be i n t e r d i c t e d in cases of questionable dependency.  One is tempted to add "et cetera"^ a f t e r a l i s t which cannot, of course, be exhaustive.  The b e l i e f s that I have set out above and in  the chapter on the therapist role appear to be some of those most f r e quently and c l e a r l y evoked and form the warp and woof of the unique moral order of Theta.  -  98  -  FOOTNOTES  1.  The  problem  "accounts"  of  has  providing  an  exhaustive  addressed  set  of  norms  or  rules  in  by G a r f i n k e l . See, Harold G a r f i n k e l , Studies in Ethnomethodology, p. 3. G a r f i n k e l argues that "Whene v e r a member i s a s k e d t o d e m o n s t r a t e t h a t an a c c o u n t a n a l y z e s an 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 makes u s e o f p r a c t i c e s o f 'et cetera', ' u n l e s s ' , ' l e t i t pass' to demonstrate the rationality o f h i s a c h i e v e m e n t . " and "The d e f i n i t e and s e n s i b l e c h a r a c t e r of 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 by an a s s i g n m e n t that r e p o r t e r and 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 nished whatever  been  unstated  understandings  are  required.  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 t h e r a p i s t s .  The idea of a special class of  professionals l a b e l l e d " t h e r a p i s t s " with a s p e c i a l i z e d d i s c i p l i n e l a b e l l e d "therapy" depends on the corresponding idea of a special class of people labelled "patients" on whom therapy can be p r a c t i s e d .  Without  therapists  and therapy, patients are mainly part of a large group of people with unorganized diffuse t r o u b l e s .  It  is only when they enter into a r e l a t i o n -  ship with therapists that they can properly be c a l l e d p a t i e n t s . *  A special feature of the relationship between therapists and patients is t h e i r d i f f e r e n t relationship with the i n s t i t u t i o n in which they  * Of course once the relationship has been i d e n t i f i e d they are patients for everyone to see. Once labelled patients are patients not only for therapists but for fellow patients as w e l l .  - TOO -  meet.  The i n s t i t u t i o n i s , f c r p a t i e n t s , a "special p l a c e " , a sanctuary  to which they have come for a limited period of time.  It  is  different  in many ways from t h e i r everyday world and despite the assumption of the i n s t i t u t i o n that Theta should be a r e f l e c t i o n of the world, i t is recognized by the patients for what i t i s : from t h e i r outside world.  setting within but d i f f e r e n t  In fact i t is this special q u a l i t y that pro-  vides i t s usefulness f o r them. is  a  In contrast to this perspective, Theta  the everyday world of the therapists.  It  is t h e i r place of business  as members of one of the helping professions. limited time, they are "always" there.  They are not there for a  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 t a b i l i t y and continuity in what is seen by the patients as a stable and continuing i n s t i t u t i o n , s p e c i a l l y constituted to give them help.  Making the Difference V i s i b l e It can be said that every  activity  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 a c t -  ions of therapists were seen as appropriate to t h e i r role by patients and allowed by patients as such.  Similarly  patients'  actions could not  be successfully operationalized without the t a c i t assistance and approval of the therapists.  The items that are discussed here, then, are a few of  the more v i s i b l e minor matters that have not already been incorporated in the discussion of the separate r o l e s .  - 101 -  It  has already been noted that the absence or lateness of a  patient was a matter of concern for both patients and t h e r a p i s t s .  In  f a c t , even when the matter was reported by the patient there was some residual concern that he might be malingering.  In contrast to t h i s ,  therapists who were late or who reported sick were seen as having good reasons for being late or absent and, i f s i c k , were assumed to be genuinely so.  Therapists occasionally took days o f f or l e f t early and in  fact did a l l the things that employees of any i n s t i t u t i o n do, without any more comment from either patients or t h e i r fellow therapists  than  is usually accorded this kind of behaviour.  Formally constituted group meetings were occasionally attended by the c l i n i c a 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 l a t e r .  During group meetings, patients who engaged in private  conver-  sations were usually challenged and invited to share t h e i r comments with the whole group but this a c t i v i t y was seen as e n t i r e l y appropriate for therapists.  The therapists could also interrupt the proceedings and i t was seen as t h e i r right to decide that some process that was currently progress should be discontinued.  in  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-  - ioa,-  tions was evident. [Female Patient] spoke l a s t , was f i r s t interrupted by [Patient] who was "shushed" by [Male Patient]. [Female Patient] resumed. [ C l i n i c a l Supervisor] arrived and after looking at the t a b l e . . . s t a r t e d to talk in a loud voice about charting. Several people seemed uncomfortable - he had interrupted [Female P a t i e n t ] ' 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 [ C l i n i c a l Supervisor] was attempting to operate the intercom. He kept buzzing and saying " h e l l o " . At f i r s t there was no r e p l y , then a buzz in return. The a c t i v i t y 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 t h e r a p i s t s .  That the behaviour that was expected of therapists and patients was d i f f e r e n t was n i c e l y i l l u s t r a t e d in one after-group meeting at which a therapist was t e l l i n g the (therapist) group about the a c t i v i t y  in that  afternoon's family group. [Resident Psychologist] also reported about [Name] she had been "going on" in family. [Resident Psychol o g i s t ] had l e t her go on. [ C l i n i c a l Supervisor] misheard and thought [Resident Psychologist] was t a l k ing about [ s t a f f member with almost identical name]. He v/as obviously very surprised that [ S t a f f Member] would do t h i s . Therapists were c l e a r l y expected not to "go on" in the s e t t i n g but were expected to reserve t h e i r emotional problems, complaints, e t c . , for the  - 103 -  feelings group constituted for that purpose.  Another aspect of the contrast between therapists and patients was v i s i b l e at a group interview at which a candidate for Theta exhibited signs of behaviour which simultaneously constituted him as somebody with serious problems v i s i b l e at the group interview reported in Chapter 4 in which the candidate for Theta exhibited signs of behaviour which simultaneously 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' elsewhere.  c l e a r l y stated opinion that he should be  No p a t i e n t ' s argument could have carried the weight of the  t h e r a p i s t ' 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 u s t r a t e , patient b e l i e f in the control of the t h e r a p i s t s .  in p a r t ,  the  Their understanding that  they could and should assume the security of the patients in the setting is i l l u s t r a t e d by an incident concerning patients'  focus on s u i c i d e .  Al-  though the Theta brochure declared that the centre was "not for p e o p l e . . . presently suicidal as other programs are more u s e f u l " (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  t h e i r 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 [ P a t i e n t ' s ] annoyance. [Patient] was supported by [several other patients] in her protest: allusions to t h e r a p i s t ' s responsibility.  The t h e r a p i s t s '  behaviour was open to c r i t i c i s m from the group  on any occasion on which they violated what was seen as the norms of t h e i r 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 i n t e r a c t i o n . An item was that [the therapist] had said that [Male V i s i t o r ] had to seduce his [ g i r l f r i e n d who is a patient] every time he met h e r . . . " I t wasn't f a i r to support [Male V i s i t o r ] j u s t because he was a European t o o . " The patients appeared to be agreed that therapists should not "take s i d e s " . There was a lengthy discussion as to whether,  in f a c t , this was a case of  it.  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 t o t a l l y managed by the therapists.  -  105  -  The day to day business of the centre followed the schedule which is i l l u s t r a t e d in Chapter 2 (Fig. 2.1)  and this schedule was a  production of the i n s t i t u t i o n 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 u n c r i t i c a l c u r i o s i t y that a schoolboy consults his class timetable.  "What we should be doing now" was  written down f o r 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 r e l a t i v e l y  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  i n s t i t u t i o n and the reading of them was part of the duty of the chairman.  The patients' institution.  interpersonal relations were prescribed by the  Apart from the s t r i c t taboo against sexual r e l a t i o n s ,  there  was a curious ambivalence about the i n s t i t u t i o n ' s attitude to relations in general among the patients.  New patients who had j u s t been accepted in the group interview were routinely t o l d that they were now "part of the group" and as such were expected to c a l l group members i f they needed help between the day of t h e i r interview  (Wednesday) and the day of t h e i r s t a r t i n g 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 s u i c i d a l persons who seek help that there are rules which "provide from whom help may and may not be sought." tions of paired r e l a t i o n a l  The rules provide for c o l l e c -  categories which invoke certain rights and  obligations concerning the a c t i v i t y c o l l e c t i o n s are ordered s e t s ;  of giving help.  Furthermore, these  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 c l e a r  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" because they had been t o l d they were, for example:  just  [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 this. She had made a commitment to quit d r i n k i n g . . . Why hadn't she c a l l e d somebody? She said that she wouldn't have c a l l e d anybody from Theta even i f she had had the numbers, because she d i d n ' t know any of them. The s t a f f members at Theta, who might have been seen to be in an appropriate "paired r e l a t i o n a l  category" to the patient were not available  to  be c a l l e d .  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 c a l l e d 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 s e t t i n g . '  [Female Patient] was jumped on towards the end of the session. [Patient] said that she had been feeling suicidal and had c a l l e d [Female Patient]. [ C l i n i c a l Supervisor] was extremely angry with [Female Patient] for not reporting the incident to the group. She said that she had thought i t would be "betraying a t r u s t " .  The f a i l u r e to report this incident has obvious dimensions other than subgroup formation.  In f a c t , however, [Female Patient] did mention the  dent to a s t a f f member and i t was known to a few patients.  inci-  The outrage  that descended on the female patient appeared to suggest sharp l i m i t s to the amount of helping that the i n s t i t u t i o n expected of the patients outside the s e t t i n g .  Patients who s o c i a l i z e d outside the setting were expected to report this a c t i v i t y  in subsequent talk at Theta.  The Monday lunch meet-  ing was regularly constituted as a time to talk about "weekends" and any social a c t i v i t y there.  that had taken place over the weekend was normally reported  There was, however, no other formalized occasion for this and week-  night meetings quite often did not get talked about.  Staff members occa-  s i o n a l l y asked i f anybody had "seen anybody" the previous evening and were frequently asked i f this was allowable.  The c l i n i c a l  supervisor in p a 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 i n e , then, was drawn between  " s o c i a l i z i n g " 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 i n s t i t u t i o n toward p a t i e n t s ' i n t e r a c t i o n outside of the centre is that too much a c t i v i t y  of this kind could p o t e n t i a l l y form power-  ful a l l i a n c e s among the patient population which could e f f e c t i v e l y reduce the control of the i n s t i t u t i o n over i t s charges.  The most powerful  alli-  ance that could be formed was an e x p l i c i t e l y sexual one and the strong reaction of the i n s t i t u t i o n to sexual a l l i a n c e s was further evidence of t h e i r discomfort with a c t i v i t y  that was outside their c o n t r o l .  The f i r s t patient, for example, to be discharged f o r this reason during my period at Theta had had sexual intercourse with a patient who was in her l a s t week at the centre.  Despite the fact that she was no long-  er present in the s e t t i n g , the male p a t i e n t , who had a week remaining, was discharged.  It  could be argued that the female patient was scheduled to  attend f o r "after-care"  (which she did not, in f a c t , attend) but there  was at least one instance in which a homosexual couple were allowed to overlap t h e i r respective periods so that they were both present on the after-care day.  A second patient who was discharged was present in group concurrently with his sexual partner. Just before family groups I was upstairs when [ S t a f f Member] came up with a l l the rest of the s t a f f . [Staff Member] was quite e x c i t e d , 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. [ S t a f f Member] said that one of them would have to go now.  - 109 -  Although the group was extremely angry with  (particularly  the male) p a r t i c i p a n t , they appeared reluctant to discharge e i t h e r one. It was argued, f o r 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 i n i c a l  however, i n s i s t e d that one of the two must leave. PatientJ's actions had damaged the whole group.  supervisor,  He said that [Male This had a v i s i b l e  e f f e c t on several of the patients, one of whom remarked that he was not "prepared to s a c r i f i c e [ h i s ]  own therapy for [Male P a t i e n t ] . "  The opposi-  tion to the discharge continued and the c l i n i c a l supervisor eventually said that [Male Patient] could be readmitted at a l a t e r 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 i k e him got treated. He might do better in the hospital. The combination of intransigence, threat, and apparent c o n c i l i a t o r i n e s s eventually had i t s e f f e c t 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 " i n t e r f e r e 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 r e s u l t of recommendations from t h e i r f r i e n d s . ) the centre were e i t h e r  The explanations that were given (for the rules) explanation by f i a t :  in  " 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 r e l a t i o n -  ships which originated at Theta were so severely censured is thus a puzzle which i t seems only possible to explain in terms of c o n t r o l .  e  I would l i k e to propose that the control involved was control of the boundaries of intimacy within the centre.  Much of the  activity  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 a f t e r 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 i g h t of a l l  this a c t i v i t y  i t seems eminently  reasonable that the boundary should be c l e a r l y 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 l a t e .  Punctuality  - in  -  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 s t a r t i n g times. At these times i t was never an argument that the group often started a few minutes l a t e , but the lateness was accepted as a bad s i g n .  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 f u 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 t h e i r f i r s t admission. [Male Patient] l e f t early so as to be in time for his job. He was t o l d to make other arrangements so that he d i d n ' t have to leave e a r l y . 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 i n s t i t u t i o n expected that people would devote t h e i r  whole time to Theta during the six-week period of t h e i r stay and generally asked them i f they could support themselves during this period.  "Moon-  l i g h t i n g " was frowned upon and the patient above, for example, was questioned very c l o s e l y about his necessity to work during the evening hours:  - 112 -  [Male P a t i e n t ] ' s job was the next subject. He explained that he drove taxi until 2 a.m. He was asked i f he was t i r e d the next day. . He said "no" again. Somebody asked i f he was j u s t passing the time. He smiled and said " y e s " , he was "just passing the time". He was asked why he d i d n ' t need the money, explained he was e l i gible for unemployment insurance. It was suggested he had a " t h i n g " about working. He said he d i d . People asked how he worked at Theta. The foreman said that he worked w e l l . This patient was eventually persuaded to stop working his s h i f t because i t " i n t e r f e r e d 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 a f f e c t the procedure. Therapists exercised t h e i r authority in e x p 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-  t r o l 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 t h e i r 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 f i n d no case of an actual r e f u s a l . 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 t e x t ) , the attempt was frustrated by a therapist. I neglect minor matters l i k e the patients d e c i ding on the menu for the lunch they cooked, choosing material for. chair coverings and the l i k e .  - 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 r e a s o n s . . . . [ C l i n i c a l Supervisor] said there was no time to go around with everybody giving reasons and that i t should j u s t 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 o r i g i n a l l y objected to [Female 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 t h e i r members were picked by l o t on Wednesday. There was discussion about this arrangement in the t h e r a p i s t s '  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 p a t i e n t s '  stay and persua-  ded the other s t a f f 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 l e t them run two weeks instead of one. after t h i s , i t was decided that the family groups would  About a week  remain stable but  that families could "bargain" for members from other f a m i l i e s .  What the  "bargaining" would amount to and how i t would be effected was not e x p l a i n ed and I did not see any done during the remainder of my observations. The talk about "bargaining" d i d , however, produce an i l l u s i o n 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 i n a l sanction available to the i n s t i t u t i o n was that the patient could be d i s charged, one of the primary tasks was to keep the patient i n . that a nice balancing act had to be continuously accomplished.  This meant If  the  threat of discharge loomed too l a r g e , this reduced the p a t i e n t ' s commitment to the centre, whereas i f i t was taken too l i g h t l y i t was no longer e f f e c t i v e in achieving the control that was needed.  In the l i g h t of this balancing a c t , the need to have the pat i e n t heavily committed to the program  is apparent and this provides  an e f f e c t i v e explanation for the extremely heavy emphasis  Once the patient was thoroughly committed to staying at Theta, the threat of discharge became very weighty. were discharged during my stay. stood out as exceptional events.  A c t u a l l y , very few people  The cases that I have already  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 Psychologist]. 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.  reported  - 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 s t a f f member t o l d me:  . . . i t was necessary for [Male Patient] to be d i s 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 o f f s e t the traumatic  feelings  associated with the r e s p o n s i b i l i t y of voting out a fellow-member by representing i t as an e s s e n t i a l l y therapeutic act.  The threat charge  of discharge was much more widely apparent than d i s -  itself. [Female Patient] hurt, annoyed, sulky, declared she was going home. [ C l i n i c a l Supervisor] t o l d her she could not go, he would discharge her. She eventually stayed.  The threat was not often used as e x p l i c i t l y as this and was more often embedded in the implications of a system of probation. Patients who had transgressed against the rules of Theta were "put on probation" with the i m p l 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 e f f e c t  in  which patients were expected to make something f o r 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 i s s a t i s f i e d  with the member that they looked to the make-ups to see whether, they had been done and what form they took. further evidence (perhaps)  in f a c t ,  This was then available as  that the patient lacked commitment or was not  taking the business seriously enough.  The i n s t i t u t i o n i t s e l f started a system of rewards and sanctions 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] d i r e c t e f f e c t [that i s , the e f f e c t on the individual patient] w i 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' concern for other members' disturbing behaviour which could otherwise be 'kindly'  [sic]  tolerated."  A l s o , "It  c e r t a i n l y increases the  paid to the rules of the game, that i s , increased [ s i c ]  attention  discipline."  The group members treated the point system as another  artifact  of the i n s t i t u t i o n which ought to be "taken s e r i o u s l y " but which generally d i d n ' t appear to mean very much apart from that. be said that the system was s t i l l  To be f a i r ,  i t should  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 l o t of absences.  Far from motivating the family to brow-  beat t h e i r absentees, the absences were seen as adequate explanation for  - 117  the low points.  -  A Patient remarked " t h a t ' s  r e a l l y good for only two  members".[referring to the number of accumulated p o i n t s ] .  Insofar as i t had developed, the achievement of high points had no payoff.  The c l i n i c a l supervisor tentatively  started to o f f e r  himself to the family group with the highest number of points for family meeting, which caused a certain amount of interest but in general point system was being treated f o r what i t was:  the  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 i r r e l e v a n t  (from the p a t i e n t s '  point of view) a r t i -  fact of the i n s t i t u t i o n which, l i k e the charts, had to be attended to because the i n s t i t u t i o n considered i t u s e f u l .  The commitment and control  that the system was supposed to influence was well established without the system and the success or f a i l u r e of the families was apparent without the points which either r e f l e c t e d  it:  C l i n i c a l Supervisor:  Which family has the highest score?  Patient  Family 3.  :  C l i n i c a l Supervisor:  I thought so.  or i f i t did not was viewed under the auspices of what everybody knew was  * the explanation f o r 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 f a i l u r e to produce an explanation in s o c i o l o g i c a l terms is c h a r a c t e r i s t i c of the fact that i t is not always possible for the observer to discern a l l the dimensions of any a c t i v i t y 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 i k e 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 p a t i e n t s ;  a place, moreover, in which the  a c t i v i t i e s were r i g h t f u l l y directed by the t h e r a p i s t s .  I have attempted  to show that this difference was apparent in attendance, time keeping, and in the authority that patients expected therapists to exercise. have attempted to show the wide range of a c t i v i t i e s  I  in which the auth-  o r i t y vested in the therapists was exercised.  The control the i n s t i t u t i o n exerted over the proceedings could be seen in the schedule of a c t i v i t i e s , in the a c t i v i t i e s  in the conduct of interviews,  of patients within and without the s e t t i n g , 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 e s p e c i a l l y e f f e c t i v e because of the strong commitment that was generated in most patients.  I have attempted to show that the principal feature of the i n t e r r e l a t i o n s h i p was that the authority of the therapists was seen as appropriate authority which should be accepted without question in a l l  - 119 -  Theta a c t i v i t i e s  whether the usefulness of those a c t i v i t i e s  ly apparent or not.  was immediate-  - 120 -  FOOTNOTES  1.  Harvey Sacks, "An I n i t i a l Investigation of the U s a b i l i t y 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.  Ibid.  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 f a c i l i t a t e the treatment of these problems. tivity  The actual ac-  of doing therapy depends on the way the patients are formulated  as patients and on the way the therapists are formulated as helping professionals.  The parts of the thesis which have been developed so far  , are intended to provide the foundations for a description of the p r i n c i pal a c t i v i t y of the centre and in this chapter that a c t i v i t y  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 b e l i e f systems to show that therapy is a rational activity  that depends on the b e l i e f s embedded in the two roles :  I shall  attempt also to show (at least by implication) that the commitment and control that the i n s t i t u t i o n demands and exercises are necessary to the activity.  Some Features of the Therapeutic A c t i v i t y The Theta ethic was that everything that went on in the s e t ting was therapeutic.  It was the case, however, that some a c t i v i t i e s were  considered more important than others and among a l l the a c t i v i t i e s centre the "big group" was primary.  at the  A perennial complaint of therapists  was that important matters were not brought up in "big group" and the C l i n i c a l Supervisor frequently made references to i t as the most important activity  at Theta: [Male Patient] said that he had been annoyed with [Male Patient] in family but had said i t there. [ C l i n i c a l 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 activity.  I have argued in a preceding section that the reasons for forming the small e r , "family"  groups appear to be related to the necessities of d i s t r i b u -  ting Theta resources rather than t h e i r therapeutic e f f e c t i v e n e s s .  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 s e t t i n g .  - 123 -  The C l i n i c a l Supervisor once agreed rather " h a l f in fun and whole in earnest" that therapy (and p a r t i c u l a r l y abreaction therapy) was a "kind of exorcism". focuses  The force of this metaphor appears to be that  on the peak therapeutic a c t i v i t y  tion of strong emotional reactions:  it  at Theta which was the genera-  "abreactions".  I am not attempting  to argue that this was the primary therapeutic focus  but that i t was the  a c t i v i t y that was valued by patients and therapists a l i k e as the summum of "doing therapy" while I was at the centre.  This a c t i v i t y was referred to as "working out" and people who did i t were said to be "on the mat".  Patients who resisted this  activity  or who were unable to " l e t go" when they were "on the mat" were frequently seen not to have benefitted from t h e i r period at Theta, even though they might have participated in " b l i n d walks", " r o l e p l a y i n g " , dance, theatre, families and the r e s t .  As this may be a rather controversial p o i n t , I  would l i k e to c i t e some of the evidence which has led me to make i t .  F i r s t of a l l  there was a marked contrast to the reaction among  therapists a f t e r 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 d i r e c t l y with the patient was often t i r e d but was f r e 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 common 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 i n g therapist who was unaware of her new status ( i t was the p a t i e n t ' s f i r s t day).  The v i s i t i n g 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 e x p l i c i t l y  stated a f t e r the session when she said that she thought i t was a "bad s i g n " that she had "broken down on the f i r s t day".  My f i e l d note further r e -  cords: [ C l i n i c a l Supervisor] said i t was a good sign. Some people took weeks to achieve what she achieved. Some never d i d . [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 " r e a l l y 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 Wednesday, obviously delighted with h e r s e l f .  It was "news" too in that  it  was recorded on the daily report by the patient committee who would r e port that they had worked with a therapist but " d i d n ' t get into anything" or "nothing came out" when t h e i r a c t i v i t y did not lead them to a workout.  - 125 -  The patients' attitude to abreaction can be seen, f i n a l l y , in t h e i r attitude to the d i f f e r e n t therapists in the s e t t i n g .  Of the  f i v e regular s t a f f members at Theta, only two o r d i n a r i l y did abreaction therapy.  It was sometimes remarked that [ S t a f f Member] was good but  did not "work out" with people or that [ S t a f f Member] was good in family because he or she made people work.  That the two s t a f f members who did  abreaction therapy were more highly valued may have been attributable to t h e i r greater all-round s k i l l and experience, but i t seemed to be the case that at least some of the attitude was attributable to the p a r t i c u l a r kind of therapy they d i d .  Doing therapy, then, at i t s most highly valued l e v e l ,  involved  the patient in the display of strong emotions and in behaviour which, while extremely threatening to new patients, was eagerly sought by comp l e t e l y s o c i a l i z e d members of the group.  In f a c t , "working out" was the  acme of group involvement and had some of the q u a l i t i e s of an i n i t i a t i o n ceremony which provided a warrant for fully-fledged membership in the group.  In a setting in which therapeutic a c t i v i t i e s  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 c l e a r l y acknowledged therapeutic periods were when a therapist was present.  The t h e r a p i s t ' 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 p a t i e n t ' s conversation about the a c t i v i ties of his family group: " . . . t h e r e was an opening there...we..we were...weren't q u a l i f i e d . , just d i d n ' t know how to handle i t . Eh..if 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 i g n i f i c a n t 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 damn therapists?" dent.  the god-  The anger and indignation in the question are e v i -  Actually one of the s t a f f was present at the meeting and t h i s  i l l u s t r a t e s another d e t a i l of the t h e r a p i s t ' s attributed q u a l i t i e s 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 s t a r t e d , as well as on occasions on which the therapists were l a t e .  The occurrence of this question as a reaction  to lack of a c t i v i t y points to an important feature of "doing therapy", that i s , that i t is an a c t i v i t y perly directed by the therapist.  that i s , l i k e a l l other a c t i v i t i e s ,  pro-  In the discussion of therapeutic a c t i -  v i t y that follows in the rest of this chapter, a c h a r a c t e r i s t i c of the activity  is that i t is negotiated with, sanctioned by, produced by,  managed by and (at least optionally) terminated by the t h e r a p i s t .  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 t h e r a p i s t s ' presence in the setting while therapy is going on.  The t h e r a p i s t ' s  presence is assurance that the s i t u a t i o n w i l l not get out of hand, that i s , he not only properly does but that he can control them.  control the a c t i v i t i e s  in "doing therapy"  In the absence of t h e r a p i s t s , therapy  seen as a d i f f i c u l t and p o t e n t i a l l y dangerous task.  is  The quotation r e -  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 members: " . . . t h i s  is l i k e amateurs trying to do an appendectomy, i t  d i d n ' t work and we had to leave i t . . . " .  just  I watched at least one event  which pointed to the troubles of attempting to "do therapy" without the protection and d i r e c t i o n of the t h e r a p i s t s .  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 p a t i e n t ' s problem was better worked on in the regular group.  The explanation was so transparently ad hoc  that nobody present appeared to believe i t and i t was e x p l i c i t l y disputed by one patient who proposed that the group should continue. a l l l e f t and went upstairs.  The therapists  The self-appointed leader started to do a f a i r  imitation of the therapist at family night but i t was clear that there was a l o t 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 t h e i r concern about the group. said " I t ' s  About f i f t e e n minutes a f t e r the "coup", a male patient  j u s t l i k e the therapist s a i d , [Female Patient] would be better  o f f in group".  Five minutes l a t e r the therapists returned and announced  that the session must end because they had to lock up the b u i l d i n g .  The  group broke up with considerable r e l e f .  Emotions I have attempted to demonstrate above that the summum of doing therapy is abreaction therapy and would want to argue that much of therapy involves emotions as at least one i f i t s dimensions.  It seems appro-  p r i a t e , therefore, that I should discuss how emotions appear to be understood and talked about at Theta.  The most frequently discussed emotions at Theta were anger-  * h o s t i l i t y - h a t e , occasionally jealousy, with closeness second.  It  as a probable  seems not inconsequential that anger-hostility-hate  are  emotions that are most readily acted out while l o n e l i n e s s , sadness, fear and g u i l t , to name a few others that were reported, are less for this mode of treatment.  available  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, tenderness etc. is not.  This i s , of course, pretty speculative and any-  body who has seen Marcel Marceau would probably disagree with the l a s t part.  That anger-hostility-hate were believed to be the emotions most relevant to doing therapy appeared to be supported (at least negat i v e l y ) 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 n i c e " .  It was routinely the case that patients' experiences were  searched to f i n d someone at whom they were angry so that the anger could be ventilated in the group and phrases l i k e "[Patient] expressed anger at her father" were commonplace in the d a i l y reports of the committee. Like "working out", they were "news", whereas "[Patient] c r i e d " or "[Patient] expressed l o n e l i n e s s , sadness, fear or g u i l t " were not part of the stock of cliches that produced the "business as usual" character of the d a i l y report.  Recognizing emotions i s part of the task of doing therapy. Both patients and therapists attended to the usual indicators of laught e r , tears, f a c i a l expression, body posture and the rest but in addition to t h i s , both patients and therapists acknowledged that recognizing emotions could be a problem. be.  Emotions might not be what they appeared to  For example, when a female patient started to cry at one group meet-  ing the therapist said " t h a t ' s how you express your anger" and a few moments l a t e r the second therapist at the meeting reiterated "when you're  - 130 -  angry you cry, you must have some f e e l i n g s , 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 a f t e r  reading her autobiography to the group "I appeared for Dad".  was happy that no hate feelings  It was regularly assumed that i f someone recounted  being in a s i t u a t i o n in which anger was appropriate, then they had been angry even though they weren't aware of  it.  Emotions are infectious and one person's emotional outburst may trigger emotions in another.  This was e s p e c i a l l y true of abreaction  therapy when one or several spectators frequently started to cry while the p r i n c i p a l actor was "working out". was always the same.  The reaction that was attended to  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 " f e e l i n g something". apists'  Although the ther-  "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 s u f f e r i n g .  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 subt l e signs of having been infected.  F i n a l l y 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 t e r a t u r e of non-verbal communication 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 f e l t about each other by arranging themselves on the stage, for example: [Female Patient] appeared to be very frustrated the whole process and eventually rearranged the (under.[Male P a t i e n t ] ' s request) to express how f e l t about her two parents. " She put her mother her father and herself outside the c i r c l e .  with chairs she beside  [Male Patient] was asked how close he f e 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 phys i c a l distance he would l i k e to have them and placed them in a c i r c l e around him...[Resident Psychologist] asked him i f he would l i k e people to be closer to him and he said he would. [Resident Psychologist] then asked people to show how close they would l i k e to be to [Male Patient] and there was an immediate move to surround him. [Male Patient] said that he f e l t that [Male P a t i e n t ] , who was well outside the c i r c l e , should be c l o s e r . [Male Patient] said he d i d n ' t want to be any c l o s e r .  Categories for Therapy The patient population at Theta, during my period of observa t i o n , was' usually predominantly female.  No attempt was made to redress  this imbalance by making special e f f o r t s to r e c r u i t 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, p r i n c i p l e , treated uniformly without regard to t h e i r sex status.  in  - 132 -  The irrelevance of sex categories was further evidenced in that the same therapy was done on patients regardless of t h e i r sex and even sexual problems themselves were discussed without apparent r e f e r ence to the individual sex involved: women's sexual problems were treated e s s e n t i a l l y in the same way as men's even though some of the male problems discussed were s e x - s p e c i f i c .  In role playing the imbalance of the group sometimes presented some problems in that there were frequently i n s u f f i c i e n t men present to fill  the roles required.  The c l i n i c a l supervisor frequently remarked  that the person a patient chose to play some male role "could be a woman" and apparently believed that t h e i r actual sex category was r e l a t i v e l y important to the  un-  activity.  Occupational categories, too, appeared to be completely relevant to the therapeutic a c t i v i t y .  ir-  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 surprised to notice that in general I had no idea what people did in t h e i r ordinary l i v e s .  In a few cases categories l i k e "housewife" were alluded  to as part of the problem in the sense that the patient did not feel f i l l e d in that r o l e .  ful-  There was also occasionally some talk about what  kind of work people would do a f t e r they l e f t the centre, but as far as doing therapy went, there were no d i f f e r e n t i a t i o n s made in the kind of treatment that was administered that rested on occupational categories.  -  133  -  Some relationship categories were considered universally relevant for therapy.  The most noticeable of these were "father" and  "mother" which were sex discriminated, and " s i b l i n g " which was not except in so f a r 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. pre-admission interviews  This occurred in the various  and was carried into the therapeutic setting as  a routine and ongoing preoccupation.  Patients were assumed to have strong  feelings about t h e i r parents and t h e i r s i b l i n g s .  Other categories that were considered relevant were "homosexu a l " , "black" (which was formulated as a problem-relevant category by a West Indian patient)  and " r e l i g i o n " .  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 i o u r , even though the patient did not himself invoke i t .  J  The patient  f i l e s that were prepared for the i n s t i t u t i o n routinely recorded the patient's religion.  The rather random l i s t that appeared:  Lutheran, Mennonite, Roman C a t h o l i c , NDS (?), cate that i t had not much s i g n i f i c a n c e .  It  Protestant,  None, N i l , seemed to i n d i rather seemed that every-day  stereotypes had as much force as any therapy-relevant  consideration or  sheer c l a s s i f a c a t o r y schema. *This assertion i s disputed by the i n s t i t u t i o n who deny that homosexu a l i t y by itself was enough to get the patient accepted. A s t a f f member told me that doubts about s e x u a l i t y , or fears that one might be homosexual 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 i n i c a 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 " r e l i g i o u s c o n f l i c t s " .  I never  saw t h i s used as a resource in doing therapy.  Roles and Therapy The most important resources in doing therapy are the patient and therapist r o l e s .  These have been formulated to make the practice  possible and the practice i t s e l f depends on the b e l i e f s 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 presented as evidence of actual trouble and his presence in the setting could be seen as reasonable and understandable in the l i g h t of the bel i e f that his problems were beyond his capacity.  No further enquiry was  conducted to f i n d i f the patient was malingering and there was no suspension of b e l i e f in the story the patient t o l d .  The attention that was  paid to the p a t i e n t ' s story was evidence that he was considered a competent reporter and t h i s was a determinant of what was counted as troubles in the therapeutic s e t t i n g .  The attention that was paid to emotional states and p a r t i c u l a r l y to the emotions, generated by fathers, mothers, s i b l i n g s , husbands, wives and the rest were determined by the understandings that these were relevant matters for doing therapy, and t h e i r invariably being involved  - 135 -  made them essential elements of the a c t i v i t y which was c a r r i e d out.  The patient b e l i e f that Theta was a special place was essent i a l in that he had to be able to behave in ways which would conventiona l l y be disallowed.  The ways in which he behaved had to be prescribed  under the auspices of a characterization which eliminated the p o s s i b i l i t y that he was "throwing a tantrum" or "being a cry-baby" or " d i s t u r b ing the peace" or whatever characterization might have been put on the behaviour in another s e t t i n g . people who " r e a l l y  As the therapists were, presumably, the  knew what was therapeutic", i t was e n t i r e l y reason-  able that the behaviour should be directed by them.  They were, moreover,  characterized as helpers, which was both necessary and s u f f i c i e n t for the behaviour they suggested to be pursued.  This was e s p e c i a l l y so as the  behaviour was s u f f i c i e n t l y removed from what is conventionally  received  as reasonable to be extremely threatening to the actor.  Categorizing the therapist as a professional helper immediately invoked special roles and rights to which professionals are due which included the assumption that when you take your problem to him you describe 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 s p e c i a l i s t on troubles whose s p e c i a l i s t training q u a l i f i e d him to deal with troubles.  The patient and therapist r o l e s , 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 i m p l i c i t  in the discussion of work in Chapter 2 tended to have this q u a l i t y ; i s , i t was to some extent incompatible with doing therapy.  that  In s i m i l a r  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 f a c t , as I shall  show, the therapy that revolved around these a c t i v i t i e s was c a r r i e d o u t a f t e r they were over, when the group reconvened to view what had been going on in the l i g h t of i t s 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 compulsive attention-seeker with a good sense of his audi e n c e . . . [ H e ] r e a l l y had control of the group f o r a while. This role in which the proceedings are treated as e s s e n t i a l l y non-serious, seems to preclude the kind of business which is understood as therapy from being transacted at Theta.  This so much annoyed the therapist  in charge that he remarked afterwards: . . . t h a t he thought [Male Patient] might be s u f f e r i n g from "minor brain damage" from some f a l l he had when he was a youth. He said that [the patient] "lacked the a b i l i t y for abstract t h o u g h t " . . .  The e s s e n t i a l l y emotional character of the therapeutic process also tended to make the i n t e l l e c t u a l  role incompatible with i t .  One of the ways in which this could be seen was in the pejorative use of  - 137 -  the term " i n t e l l e c t u a l i z i n g " .  Any attempt to explain or interpret the  process on the part of the patient rather than j u s t to experience i t was open to the challenge that i t was "just i n t e l l e c t u a l i z i n g " which was seen as a worthless and counter-therapeutic a c t i v i t y .  This term  was not, however, applied to t h e r a p i s t s ' interpretations which were accepted as having a d i f f e r e n t 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, s i b l i n g s and other s i g n i f i c a n t figures in the l i v e s of patients who were working: [ C l i n i c a l 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 i s new and unknown and C is gay and small. B i s large and hirsute and is chosen to play almost a l l male roles at the moment.) [ C l i n i c a l Supervisor] frequently says that people can "choose a woman i f you l i k e " . [Female Patient] used to get chosen for any and every r o l e . Once the role players were chosen, the patient would give them some m i n i 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 p a t i e n t ' 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 i k e .  - 138 -  [Male Patient] t r i e d to talk for K's father but i t sounded very much l i k e 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 f a i l u r e 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) behaviour and t h i s being similar to that of the p a t i e n t ' s . f a i l u r e e x p l i c i t was a way to stop the  father's  Making the  activity:  [Two patients] were persuaded to arm-wrestle on the floor. This was a stand-off too. N said very matter-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 s u r p r i s i n g l y , by patients of people that they knew intimately.  This often pro-  duced noticeably d i f f e r e n t c h a r a c t e r i s t i c s from those displayed by the patient. After some time [ C l i n i c a l Supervisor] asked her to s i t on a chair and pretend to be [her l o v e r ] . 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 led people to understandings of how the two roles f i t t e d  frequently  together.  Patients were also asked to play themselves in roles which had been discerned as part of t h e i r 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 t r i e d anyway. [Several 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 h e r s e l f , a nasty, v i n d i c t i v e r o l e : "What're you going to do now?" in a minor 5th sing-song voice, (I'm the king of the c a s t l e ) ; "I'm not going to l e t you". Meanwhile the other Y roared at her, big voice, "You aren't good enough for the group"; "The group won't l e t you s t a y " ; "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 i n i c a 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. [ C l i n i c a l Supervisor] t o l d her to take this p o s i t i o n . A t r i e d i t and definitely didn't like i t . She " f e l t funny". That patients f e l t uncomfortable in roles they were playing was often taken as a sign that the role was psychologically s i g n i f i c a n t for them.  This applied to incidents l i k e the one immediately above where  the patient was assumed to have discovered something about h e r s e l f , 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 i n , this was made a resource f o r doing therapy on the presumed aspects of the p a t i e n t ' s l i f e that that role encapsulated.  - 140 -  Learning What's Wrong It has already been said that whatever the p a t i e n t reported as troubles were assumed to be troubles f o r him.  This meant that the  l i s t of what could count as the source or symptom of neurosis was, i n p r i n c i p l e , inexhaustible. no standard  I f t h i s i s t r u e , there can, i n p r i n c i p l e , be  d e c i s i o n procedure f o r determining  discerning cause from symptom.  what i s r e a l l y wrong or  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 sustained during the period that the p a t i e n t 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? to do with l o n e l i n e s s ?  Wasn't i t something  I asked [a p a t i e n t who was f i l l i n g i n numbers on her c h a r t ] why she had changed "Roman C a t h o l i c " from 6 to 5 [which i n d i c a t e d that i t was more s e r i o u s ] . She s a i d she thought she had problems that she didn't know about at the beginning.  It was also always open to the t h e r a p i s t s 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 t a l k about h i s wife. He fears she w i l l leave him i f he admits he has had homosexual r e l a t i o n s . [Therapist] suggested that that was not r e a l l y his problem and he asked f o r help i n formulating h i s problem.  - 141 -  The resources that the centre used for discerning the dimensions of the problem were a l l activities,  the a c t i v i t i e s  that were engaged i n .  These  such as dance, theatre, work e t c . were routinely s c r u t i n i z e d  to see whether they had e l i c i t e d feelings in the patient that could be used to discover the real  trouble.  Q was questioned about why she had not p a r t i cipated in the whole of the dancing. She said she hated that kind of t h i n g . . . R said he hated that kind of thing too. He said he had an absolute horror of i t . S said that he had been told to p a r t i c i p a t e less [in the play] and so he had not p a r t i cipated at a l l . The group picked up on this as something he habitually does. T said she had f e l t " r e a l l y uneasy in the r o l e " [in the p l a y ] . She f e l t that she was "under attack"...She said the part was "very r e a l " , she d i d n ' t feel she was acting. It was " s c a r y " . V [who had been working extremely hard on r e building the AV room] was asked why he worked so compulsively. Was he "dependent" on the work? In f a c t , any incident or talk or behaviour at Theta was available to be treated as part of the p a t i e n t ' 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 d i d n ' t l i k e the idea of introducing competition into Theta. She thought that competition was "very d e s t r u c t i v e " . This was immediately formulated as part of her problem. It became "very i n t e r e s t i n g " that she had objected to t h i s . 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. to integrate a l l  As time passes in the s e t t i n g , the patient usually begins 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 p a r t i c u l a r ground-rules for i t s production;  peo-  ple made of i t whatever they thought an autobiography ought to look l i k e  in the  setting.  The situated character of the autobiography was mainly e v i dent in that i t tended, perhaps, to emphasize the unhappy aspects of the patients' l i v e s and tended to be another document which found good reasons why a patient had the troubles he d i d .  In f a c t , 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 selfdescription was not an autobiography, but that that would come l a t e r .  The  two documents were seen to be somewhat s i m i l a r .  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 diaries: In typing my autobiography over the weekend, I kept wishing I had done i t before. There's something 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 autobiography and l e t t i n g my feelings come to the top regarding my f a m i l y . . . I can also see a pattern emerging from my Dad towards me l i k e 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 p a s t . . . ...autobiography...I feel very anxious when I see what stupid ways. I chose to l i v e my l i f e . This discovery that there was a pattern to the p a t i e n t ' s behaviour appeared to be viewed by the patient with mixed f e e l i n g s .  While the d i s -  covery that he had been l i v i n g his l i f e in "stupid ways" was frequently accompanied by some depression, i t was also accompanied/or shortly ed by a period of hope and o p t i m i s t i c expectation.  It  seemed as i f  followthe  pattern, while depressing in i t s discovery, produced the expectation that, now that i t was known, i t could be cured.  The "high" that patients experienced in t h e i r 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 pattern.  This  tentative  observation is supported by some evidence from pa-  t i e n t comments: For the f i r s t time since I a r r i v e d , I am scared that I cannot get b e t t e r . . . The problems that I have overwhelm me sometimes. Where do I start? How does one deal with such a large thing as g u i l t ? . . .  - 144 -  I have been depressed for quite a few days now... I don't notice any change in m y s e l f . . . The confusion is back again j u s t 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 s u f f i c i e n t l y interesting point that seems worthy of additional study, p a r t i c u l a r l y f o r Theta s t a f f who might wish to adjust  patient  schedules in accordance with the mood-phases of the p a t i e n t s ' experience. 0  Correcting  It Actually the d i v i s i o n of the process along the lines that  have used is highly a r t i f i c i a l trouble  I  in that the process of discovering the real  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 i v i s i o n .  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 p a r 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 f e l t that t h e i r troubles were pressing to  - 145 -  ask f o r group time.  It  has already been pointed out that only a few  people could work on any p a r t i c u l a r 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 r e -  gard as most important?" or "Who needs to work the most?".  If  a number of candidates f o r work were i d e n t i f i e d , the s e l e c -  tion could be influenced by the length of time the candidate had l e f t  at  Theta, so that candidates in t h e i r l a s t week were seen to have p r i o r i t y 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 s e l e c t i o n appeared to be quite a r b i t r a r y :  "Therapist picked A to work f o r no ap-  parent reason".  The selection of the patient who should work could be made on the basis of some i n t e r a c t i o n that went on at the beginning of the meet-' ing: [Patient] stated that she had objections to the use of primal scream therapy. She d i d n ' t want i t for h e r s e l f . Several people..said that [Pat i e n t ] resisted a l l forms of therapy which she denied...She got quite angry with some of the men. [ C l i n i c a l Supervisor] brought [Patient] up to the stage and talked with her for a while. or in another instance: Patient  :  Therapist :  I understand, but I started to say something and B put me o f f . T e l l him now  - 146 -  Patient  :  You pissed me o f f .  Therapist  :  Go closer and t e 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 therapy 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 t r i e d out for example: [ C l i n i c a l Supervisor] asked J what he thought of people at Theta. He said he had no animosities i f that is what he meant. [ C l i n i c a l Supervisor] i n dicated either/or and asked him to go around and say what he f e l t about each member... D said that he d i d n ' t give a s h i t . Hung his head. Looked uncomfortable. [ C l i n i c a l Supervisor] asked him to go around and t e l l people, naming them, that he d i d n ' t give a s h i t about them. No response was required of these kinds of comments although group members 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 subj e c t of a separate study. The a c t i v i t y could be terminated by the schedule: therapy stopped at certain hours and although i t occasionally ran s l i g h t l y overtime, the schedule was recognized as having p r i o r i t y over the immediate a c t i v i t y . Therapy could be terminated by the therapist declaring i t to be over or deciding that the patient was "just a c t i n g " and giving up the attempt to work with him. Therapy could be terminated by the e l i c i t a t i o n of inappropriate responses l i k e laughter or by the f a i l u r e to e l i c i t any response at a l l .  - 147 -  conversation a f t e r they had been addressed.  The t h e r a p i s t ,  however,  would sometimes i n v i t e the other group members to express how they  felt  about the patient who was working: Next [ C l i n i c a l 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 t a c i t support of the therapists present who did not i n t e r f e r e with i t . M said she f e 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 d i d n ' t trust them. After a couple of rounds she got to A who said that she was doing the same thing that hehad been doing. He said he wasn't going to l e t her. He started to push her around and the.whole group joined in pushing her from side to side and shouting "come on M". The purpose of this a c t i v i t y was to generate emotion.  The  test that useful work was being done was that the patient had noticeably l o s t 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 e d 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 r o l e , the anger was  assumed to be directed at the person whose role he was playing. A f t e r a few minutes of dialogue [Resident Psychologist] went and got the boppers and invited A to t e l l his father how angry he was with him. A said he was worried about this and was a f r a i d 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 f i g h t with from his father before the incident s t a r t e d , but i t was assumed 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  intellectual  control he was usually invited to l i e down on the f l o o r or on a styrofoam mat that was available for the purpose.  This was the signal for a l l  group members to gather around him, kneeling or s i t t i n g .  the  Usually the  therapist who was d i r e c t i n g the session would kneel at his side facing his head.  It did not always happen that the p a t i e n t ' 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 . nally successful event,  A therapist reported of one margi-  "We spent a l o t of time f i g h t i n g his mind".  When the patient was on the f l o o r , the therapist encouraged him to breathe r a p i d l y , sometimes accompanying his instructions with a kind of a r t i f i c i a l alternatively  r e s p i r a t i o n in which he stimulated the breathing by  pressing and releasing his lower chest.  plained as a means to get him to  This was ex-  "hyperventilate".  While a l l this was going on the patient was encouraged to speak, or f a i l i n g that to make any sound that he f e l t l i k e 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"; you to love me".  "I  hate y o u " ;  "I  want  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 t h e r a p i s t , meanwhile encouraged him to  " l e t out that sound", or to repeat an apparently s i g n i f i c a n t phrase or to do so " l o u d e r " .  Patients were seen as having physical manifestations of t h e i r troubles and one of the tasks appeared to be to get the trouble "out" in a literal  physical sense. D...appeared to be unsuccessful despite some pretty impressive shouting crying and several determined e f f o r t s to vomit. [Therapist] described this afterwards as a block and said he had got D to s p i t out the mucous that c o N lected. [ C l i n i c a l Psychologist]: "good".  In another context the c l i n i c a 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 u n t i l the patient had exhausted his r e p e r t o i r of shouting, c r y i n g , c u r s i n g , and sounds and was himself t i r e d . been mentioned.  Some of the ways that therapy was terminated have already In general i t appeared to be negotiated j o i n t l y between  patient and therapist with the therapist having the option not to discontinue the a c t i v i t y tinuing.  if,  in his judgment  useful work could be done by con-  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 members 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 d i a r i e s , some of which appeared to be favourable: I had a workout today. I s t i l l feel p h y s i c a l l y drained but I don't remember too much about what I said. It feels l i k e a plug got pulled in my brain and l e t the d i r t y water out. A l l t h a t ' s l e f t is the ring in the tub. It is strange, a l o t 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 l a t e r . Another p a t i e n t , however, reported a less favourable reaction: I f e l t very defeated also today a f t e r my session on the mat. Felt worse than I have f o r weeks. That doing therapy could be unsuccessful in i t s immediate reaction was, of course, one of the hazards of the process and one of several that the process had f o r patients.  troubles  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 f a i l u r e .  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 r e a l l y annoyed with her because she wasn't working. M said that this was true, she had things to get out but d i d n ' 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 t o l d to talk to J and to t e l l him to leave her alone. Somebody went and got the boppers. H objected. She d i d n ' t want to h i t him. She wanted to be f r i e n d s . J bashed at her half-heartedly. H said she couldn't h i t J and l e t the bopper hang limply by her side. It  has already been said that some role playing did not come  o f f and this was a source of trouble insofar as the i l l u s i o n that the pat i e n t was beating his father dissolved into the r e a l i z a t i o n that he was beating his fellow  patient.  When R was working out about his mother... he stopped a f t e r 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 p a t i e n t ' s mother occurred when the female who started playing the role got t i r e d and the male patient took over for her.  The  incident was a source of trouble for both the therapy and f o r the role player who reported that he: ...had mixed feelings about t h i s . First I felt r e a l l y good that he knows I don't think l i k e that and second i t automatically put me on the defensive to t e l l him I was playing his mother, not my own.  - 152 -  The danger of the therapeutic r e a l i t y  s l i p p i n g away and being  replaced by some other interpretation which would make the participant look ridiculous was always present at Theta.  The a c t i v i t y  had to be car-  r i e d 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 i g h t he found himself r i d i c u l o u s : [ C l i n i c a l Supervisor] asked who she would pick as her father. She said "R". She was invited to use the boppers with R. R said he d i d n ' t want to do i t again. [ C l i n i c a l Supervisor] asked him why not. He said he f e l t l i k e 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 f l o o r ? R said "no". Another patient said she could appreciate what R meant. [ C l i n i c a l 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 r e a l i t y . "spectacle".  The fact that he did not made him a  In f a c t , the patient l e f t Theta shortly a f t e r 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 working out the problems associated with i t in this highly valued s e t t i n g : [ C l i n i c a l Supervisor] went on to ask for the new patients to come up one at a time, P was first. P had been having some reaction to the group members already. She i d e n t i f i e d J and D who she had had a row with a couple of days previously. P could not find anybody 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. [ C l i n i c a l Supervisor] said he should say i t again...R made a h a l f hearted attempt to resuscitate the issue but i t d i d n ' t get o f f the ground. In f a c t , the f e e l i n g among patients appeared to be that attempting to reproduce an event of this kind ought not to be done: [ C l i n i c a l Supervisor who had been absent on the previous day] asked H to show how she would t e 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 s e t t i n g , i t could occasionally have troublesome consequences.  The patient  in the above f i e l d note went home to t e l l M to leave her alone a f t e r r e 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 a c t i v i t y  in the l i g h t 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 d e t a i l e d .  The patients'  to and involvement in this aspect of therapy has been documented.  attention  - 154 -  The role of the therapists in doing therapy and in providing d i r e c t i o n 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 therapists.  The part played by emotions in doing therapy has been discussed 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 a c t i v i t y  has been delineated.  In  p a r t i c u l a r , the two p r i n c i p a l roles at Theta, that of patient and therap i s t and the b e l i e f systems embedded in these r o l e s , 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 t h e i r 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. accompanied by optimism.  This discovery i s  The question of how the pattern w i 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  activity.  - 155 -  Throughout this chapter and the rest of the study I have attempted to show that the a c t i v i t i e s  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 a c t i v i t y  of the par-  t i c i p a n t s as having the moral force referred to in the introduction.  If  I have been true to my ethnographic aims, I w i l l have d e s c r i -  bed the culture as i t is seen by members in the s e t t i n g .  As an ethno-  grapher I w i l l have reported what I found without reference to what I about the f i n d i n g , independent of personal t i e s or enthusiasms that  felt  I  developed but remembering that my f i r s t loyalty was to my ethnographic account.  Of course any enterprise must, to some extent, f a l l  short of the  ideal and this no less than others w i l l have offended against the p r i n c i ples (not to say the best practice) minor ways.  of the ethnographic ideal in major and  That, however, is a shortcoming of this work and not of the  ideal which attempts to discover how the social order is created and sustained.  APPENDIX I THE OBSERVER ROLE  As a naive observer, a r r i v i n g at a therapeutic out-patient centre, I suffered from a l 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 b e l i e f s about how observers  behave in s e t t i n g s , I was very conscious of not knowing how this would behave in this  setting or what would be expected of him.  been told that I would be expected to participate but how much? was my p a r t i c i p a t i o n supposed to consist of?  observer I had And what  My previous group exper-  ience seemed i l l - s u i t e d 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 centre.  the usual roles that are prescribed in the  Now while i t was clear that I could not be a t h e r a p i s t , one im-  - 157 -  mediate p o s s i b i l i t y was that I could go in as a patient.  This role was  suggested to me by the c l i n i c a l supervisor when I f i r s t proposed that I should expand my observations from the rather casual weekly v i s i t s  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 i n i c a l supervisor pressed  f a 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 be very demanding emotionally)  felt,  I was convinced that the perspective that  I wanted to develop was better seen from the s i d e l i n e s .  If  I was i n v o 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 j o i n t l y created t h e i r own r e a l i t y .  That my role was deviant was c l e a r l y recognized by the patients as well as being a concern of the s t a f 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 " r a t i o n a l i z a t i o n " , a common pejorative description at Theta.  The fact that my role was seen as dev-  iant is further evidence of the exhaustiveness of the " t h e r a p i s t " and "patient" labels and I have described some of the incidents that seem to i l l u s t r a t e this below.  Having rejected the role of p a t i e n t , I was the object of a certain amount of suspicion from both therapists and patients.  This led  - 158 -  to my a c t i v i t i e s  being circumscribed in various ways.  to attend on a f a i r l y cal supervisor.  I was required  r i g i d schedule which I negotiated with the  clini-  The schedule of my v i s i t s to the centre had always been  a matter of some concern to the s t a f f . was that I "upset the p a t i e n t s " .  The explanation that was given  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 r r e g u l a r i t y a source of annoyance to the resident psychologist, but my previous change became evidence of my unpredictable habits of attendance. schedule with the c l i n i c a l  I was asked to renegotiate my  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 i n i c a 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. uled hours at f i r s t , selective.  I was careful to be present during a l l  the sched-  but as time went on I found I was able to be more  My extension was granted with good grace and there were no  more incidents about i r r e g u l a r i t y .  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 been too l i m i t e d , the c l i n i c a l  f e l t my time had  supervisor said once again that I should  - 159 -  have been a patient.  The r o l e of observer is a very d i f f i c u l t one.  Apart from  minor incidents l i k e not knowing i f I was a " v i s i t o r " at an early meeting that I observed ( i t knows quite what to do.  turned out that I was not) one never r e a l l y There is considerable pressure to p a r t i c i p a t e  in the group process, not the least of which is to l e t 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 s l e e p s " . [Byron: Don Juan]  The pressure to participate when someone is "working out" is enormous.  It was f e l t immediately by new patients who invariably joined  the group on the f l o o r 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 j u s t above the group, resting my elbows on my knees.  In general I participated as l i t t l e  as possible a f t e r some i n i -  t i a l mistakes (see "Troubles" below) and was well-accepted by most patients who showed a very sympathetic understanding and tolerance of my p o s i t i o n : "I interaction".  know you can't be involved because that would a f f e c t the In fact my occasional lapses from the role were frequently  challenged: "What are you doing now? You seem to be p a r t i c i p a t i n g some of the time!" I said that I did p a r t i c i p a t e somewhat in the families and in some things l i k e the dance therapy. I would continue to p a r t i c i p a t e as l i t t l e as possible. I said I was involved and did feel many of the emotions that other people f e l t but believed that my role was not to p a r t i c i p a t e any more than I could  - 160 -  help. [Female Patient] s a i d : "Okay, w e ' l l j u s t play i t by ear". I think that f i e l d note describes the stance I eventually adopted which, allowed me several things.  I participated enough to s a t i s f y 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 g r a t i f y i n g display of "I'm r e a l l y human y'know".  Troubles One of the early troubles I had was in overdoing my p a r t i c i p a tion.  On several occasions I got carried away with the certainty of my  Laingian insights on Family night.  On one p a r t i c u l a r l y bad occasion I  spent the evening making f a i r l y wild speculative guesses in role playing with patients and v i s i t o r s .  This caused a considerable amount of d i s -  s a t i s f a c t i o n with both therapists and patients.  The c l i n i c a 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 i d e n t i f i e d observer is trying to explain what you are doing:  1  A male patient sat beside me and a f t e r s i t t i n g 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 r e a l i t y in a way which d i d n ' t mean much to me and must surely have meant much less to him.  Apart from the i r r i t a t i n g vagueness and unsatisfactory obscurity of such  - 161 -  t a l k , 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 d i d . I t r i e d to explain that as much as they treated me as "just s o c i o l o g i s 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 l o t of support. This explanation, in terms of "bad f a i t h " 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 t h e i r d i a r i e s  and sensing that i t was a s e n s i t i v e i s s u e , 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 f a c t the two people who  refused were confronted on t h e i r refusal by the other patients who seemed to see i t as a part of t h e i r neurosis.  I did not read the d i a r i e s I was  refused and i f I had been refused a s i g n i f i c a n t number I would have been without some valuable information on " p a t t e r n s " .  A more serious trouble arose when I arranged to have my thesis advisor write a l e t t e r to a s s i s t me in expanding my period of observation. The l e t t e r was written in f a i r l y strong terms as I was anxious to put pressure on the c l i n i c a l supervisor because my time was rapidly running  - 162 -  out.  The c l i n i c a l supervisor was extremely angry and expressed his  total d i s s a t i s f a c t i o n with the l e t t e r in the strongest terms. came up on a day on which the s t a f f ' s and I got to attend my f i r s t one.  The issue  "feelings meeting" was scheduled  I was invited to present a written  interpretation of my advisor's l e t t e r there and then, which I d i d .  The  s t a f f members' reaction to the l e t t e r was generally more moderate and a f t e r some discussion in which I found support from the c l i n i c a l  fellow,  the matter was s e t t l e d but there were a few moments when I thought I might be excluded e n t i r e l y .  Another f a i r l y serious incident involved a patient who l e f t Theta prematurely. f i n a l group.  I had spent a few minutes t a l k i n g to her before her  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 a f t e r the group meeting she l e f t the centre and did not return.  In searching  for a reason, the c l i n i c a l supervisor said that I had provided a warrant for her leaving by giving her t a c i t support. influence".  The observer had "great  This incident was c i t e d on several occasions as a reason  for l i m i t i n g my free access to the setting although the c l i n i c a l  super-  v i s o r eventually admitted that she might have l e f t anyway and had d i s cussed doing so.  Finally,  during the early period of my attendance, an incident  occurred which I was t o t a l l y  innocent of but which shook me at the time.  During a group meeting a remark was made by the patient to my l e f t which  - 163 -  was attributed to me by the therapists present.  The therapists were  s i t t i n g several seats to my right in a s t r a i g h t l i n e .  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 i a l s , I was confronted over this incident in the c l i n i c a l office.  supervisor's  I presented my f i e l d notes for the evening which contained  some evidence that there were other sources for the t h e r a p i s t s ' ance at me that night (I  had stayed behind to watch a minor r e b e l l i o n  on the part of the patients when a l l the therapists l e f t ) , could get was a grudging admission that throwing his v o i c e " .  annoy-  the best I  'maybe he [the patient] was  I suddenly had some insight into what i t must be  l i k e to be accused of witchcraft - there i s no defence and any attempted defence is constituted as evidence of g u i l t .  Distrust The kind of paranoid f e e l i n g 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 suspected of some a c t i v i t y  that would r e s u l t in my e j e c t i o n .  I think, how-  ever, that there may have been some d i s t r u s t on the part of the s t a f f as w e l 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 i g h t l y in cheek, I add this somewhat whimsical commentary.  - 164 -  Staff  Distrust The s t a f f at Theta were perennially concerned with "what I  was finding out". my r o l e .  This was often explained as an attempt to understand  The s t a f f was quite capable of deciding what parts of the Theta  process I should be watching:  big group was "more i n t e r e s t i n g " for me,  but apparently quite mystified as to what I was "doing".  My f i e l d notes  have f a i r l y frequent references l i k e the following: [Resident Psychologists] said again she was interested in what I was doing, wanted to hear me say what I was finding out: [ C l i n i c a l Supervisor] too - I should give a t a l k .  A l l this was couched in terms of how valuable my comments would be to Theta.  My problem was that I d i d n ' t think I had anything  that was of value to Theta at the time and had only the most vacuous and esoteric d e t a i l s to talk about.  I had no penetrating visions and c e r t a i n l y  was not in the process of formulating an expose suspected. the problem.  as the s t a f f may have  Of course my paucity of ideas made me evasive and compounded The p o s s i b i l i t y that this was d i s t r u s t and not the d i s i n t e r -  ested c u r i o s i t y i t claimed to be may be supported by the fact that the c l i n i c a l supervisor i n s i s t e d 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 i n a l ment.  docu-  /  - 165 -  My Distrust My d i s t r u s t derived from what I saw as my very insecure role at the centre.  As I s a i d , 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 t a f f members and realized that almost anything I did (or did not do) could be made a problem for the p a t i e n t s , the s t a f f , or the i n s t i t u t i o n .  My being  dismissed would have been highly consequential for me as I had a considerable amount of the time invested in the f i e l d work and had no alternative subject on which to write my t h e s i s .  A number of incidents w i l l i l l u s t r a t e some of the dimensions of the problem.  In the incident reported above in which the patients  decided to continue the group a f t e r being t o l d to stop, I decided that should continue to watch the group.  I  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 n e u t r a l i t y or divided loyalty.  When the therapists returned to  break up the meeting once and  f o r a l l , I was sure that the p s y c h i a t r i c nurse was unusually cool to me.  On another occasion I thouqht I detected some i r r i t a t i o n from the resident psychologist when I gave her  some.information about immigration  services that I had obtained for a female patient.  Immediately a f t e r  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 immigration information. She seemed mildly resistant to this. As we were about to leave and go downstairs, she t o l d me that [Male Patient] had been discharged because i t had been found out that he was having an a f f a i r with one of the other patients I wondered 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 f a r . The other p o s s i b i l i t i e s seemed to be that i t was j u s t a piece of gossip, or that [Resident Psychologist] told me by way of making some sort of gesture of welcome a f t e r 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 a f t e r giving a female pat i e n t a ride into town one day "[Female Patient] seemed somewhat cool to me a f t e r 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 f a r stepped out of my role as to o f f e r 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 r e a l l y  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. strong and pushed me around without any trouble.  He was very  Not only that but he  wanted to continue to push me around the room long after I had decided the a c t i v i t y was well past i t s 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 a c t i v i t y  praised after the group meeting and I was in no danger.  Bit,  was  in an atmos-  phere of uncertainty, d i s t r u s t expands to dimensions f a r beyond i t s 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 i g h t " 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 i v e by the rules agreed on by the group. He is regarded as an  outsider.  I was e x p l i c i t l y recognized as " ' o u t s i d e ' John" by one patient writing  in  her diary and frequently as "observer John" which was a style of label that was unique in the s e t t i n g . a nametag.  But my outsider status was more than j u s t  On one of the f i r s t lunches that I was invited to so that  I  could explain my r o l e , a contrast was made between me and one of the other occasional v i s i t o r s to Theta who was a psychotherapist.  The contrast  turned on the fact that the psychotherapist was present as a helper, someone who was of value to the p a t i e n t s , 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 admission).  - 168 -  Even when I was c l e a r l y recognized as a potential resource to some member of the group, i t was usually the case ed taking advantage of that f a c t .  that the member avoid-  One patient e x p l i c i t l y acknowledged  my s i m i l a r i t y 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 d i d n ' t pick me and she  said that she " d i d n ' t know she could do t h a t " .  It  hardly seems necessary to say that my behaviour contras-  ted sharply with everybody e l s e ' s in the s e t t i n g .  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 n d 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 i g h t relief.  This was c l e a r l y a joke and was the cause of considerable m e r r i -  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 l a s t day at Theta, I was invited to part i c i p a t e in the "goodbyes" r i t u a l and was happy to do so.  I went around  the group and spoke to each person, t e l l i n g them some of the things that I had wanted to say for some time.  This was quite uncalculated and was  of course a v i o l a t i o n of the usual procedure in which each patient says a few words to the person who is leaving. a l l wrong" but a second patient said "I  Somebody said "he's doing i t  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 recogn i t i o n of the deviant character of my r o l e , show too the amount of acceptance that I had at Theta. very l i t t l e  In general the patients appeared to find me  trouble which fact was e x p l i c i t l y acknowledged by the c l i n i c a l  supervisor towards the end of my stay. contained references to me  My introductions to new members  as "a trouble maker" in tones that  indicated that I was not and matter-of-fact phrases l i k e  clearly  "John...comes  Tuesday nights and to lunch Mondays...sociologist with sociology department at [ U n i v e r s i t y ] " .  These were accepted as adequate explanations of my  presence in the setting on most occasions.  Despite my occasional troubles with the s t a f f  (and theirs with  me) I was generally treated with consideration, f r i e n d l i n e s s and, eventually  I believe, understanding tolerance of my " d i f f i c u l t r o l e " as  was characterized by one therapist.  it  I was allowed to stay at the Theta  - 170 -  house after hours to l i s t e n to tapes of sessions and invited into the homes of s t a f f members. pathy for  I ended up with a considerable amount of em-  the work that s t a f f members were doing, with their  r o l e " that they put themselves  in.  "difficult  -171-  FOOTNOTES  1.  Howard S.  Becker, Outsiders:  Studies  in  the  Sociology  New York, Free Press, 1966 [copyright 1963], p. 1.  of  Deviance,  APPENDIX  172  WAITING  II  CLINICAL SUPE-QVI'SOE  e T A p r  W.C  (2E-5ID&NT M.P. OCCUPATIONAL THE-[2APie>T  —  PFrSlDErNT PSYCHOLOGI5T-  P5YCMIATEIC  5E-CONP  II  PLOOB  II  •A.V. ROOM •<  Stage ( 2 efeps up)] "THE-ATR?."  J  "DN  ID  6T0RA<4E-  6-ide b o a r d , Tab lee .[ 1  *  I  I—in  •Codf" c l o s e j"  r-  PINING  BCICK  PAT 1 0 ^  I L  fable f e n n i s J^jj—BATH  KITU9UAL  £00M  E-NTEANCr?-  MAIN pLoog  FLOOP PLAN OF TUE-TA  - 173 -  APPENDIX  III  HEADINGS FOR SELF-DESCRIPTION FORM  1.  Mental and Physical Health -- (for example, headaches, a f r a i d to be alone, e t c . ) History of symptoms and treatments.  2.  Personality Changes Desired — What would you l i k e to change about your personality? (for example, shyness, short-tempered).  3.  Education and Work -- Describe your education; short history of work: Complaints about work s i t u a t i o n ( a b i l i t y or interest to work).  4.  Sexual Partners, Marriage, Children -- Short history of your dating and love r e l a t i o n s h i p s . Describe your present relationship (marriage) and any problems in i t . Relationship with c h i l d r e n . Short history of your sex l i f e -- including complaints, worries, d e f i c i e n c i e s , abnormalities.  5.  L i f e Style -- What would an observer say about you and your household i f he could observe you f o r one day? Friends? Sports? Usual weekend a c t i v i t i e s ? Any harmful habits? (for example, eating problems or over-eating, lack of sleep, heavy smoking, d r i n k i n g , prescribed and unprescribed drugs, e t c . ) .  6.  Philosophy of L i f e -- Religion and other b e l i e f s about the world, mankind, community, sex r e l a t i o n s , astrology, e t c .  7  -  Family -- B r i e f l y describe your childhood in terms of your r e l a t i o n ships with your father, mother, brother(s), s i s t e r ( s ) and important others. What are the present relations?  8.  Physical H e a l t h — General health, past serious i l l n e s s e s , surgery, i n j u r i e s , pregnancies, abortions, menstrual d i f f i c u l t i e s , e t c .  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 i m i t you in any way from p a r t i c i p a t i n g in f a i r l y strenuous sports and swimming?  2.  Do you have any commitments, appointments and the l i k e that would f a l l i n the next s i x weeks of your stay in the group?  3.  Do you have or have you had a habitual use of any drugs or alcohol?  4.  Are you prepared to return a f t e r six weeks for three successive Wednesdays for after-care?  5.  Are you w i l l i n g to make a sincere e f f o r t to encourage s i g n i f i c a n t 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 f o r no exceptions, nothing holding back, no time o f f , that i t is a total commitment?  7.  Are you prepared to write an autobiography, s t a r t i n g out the f i r s t week for presentation as early as the Tuesday of your second week?  8.  Are you aware that f a i l u r e to follow the rules and neglect to c o n t r i bute may result in probation and, i f not corrected, discharge?  If so are you prepared to completely abstain during your stay at Theta?  APPENDIX V FOOTNOTES ADDED BY THE INSTITUTION  Introduction by the Author The footnotes which follow have been prepared by the c l i n i c a l supervisor of Theta in accordance with an understanding which was developed during my observation period.  In order to ensure that the meaning of the document not be inadvertently a l t e r e d , the footnotes of the c l i n i c a 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 i n a l version. 2. Minor typographical errors have been corrected where the intended word was c l e a r l y apparent (for example "they" for " t h e " ) . The se corrections have been i n d i c a ted with square brackets. r  Where the text of the f i n a l document d i f f e r s from the d r a f t , the fact of  The footnotes begin on page 184.  - 176 -  this difference has been indicated.  The o r i g i n a l text to which the  footnotes refer has been retained in the notes to preserve t h e i r complete sense.  I do not wish to comment extensively on the notes which must be judged on t h e i r 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 d i r e c t l y 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 s o c i o l o g i s t and the c l i n i c a l  supervisor  writing as a p s y c h i a t r i s t in a setting in which he is an interested participant.  I am not, as the c l i n i c a l supervisor appears to b e l i e v e ,  t o t a l l y ignorant of the p s y c h i a t r i c theories  that "serve as l e g i t i -  mations for the i n s t i t u t i o n a l order"(quote from Berger, in t e x t , p. 63). Most descriptions of p s y c h i a t r i c s e t t i n g s , however, buy into those theories and i t was essential to my ethnographic account that I adopt an i n d i f f e r e n t posture to that theory.  The c l i n i c a 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 i n t e r p r e t a t i o n " ,  (as the c l i n i c a l supervisor characterizes my ac-  - 177 -  count), It  is up to the c l i n i c a l supervisor to make his case.  only assume that the notes are intended to do t h i s .  I can  I leave i t to the  reader to judge the success or f a i l u r e of the attempt.  As I have s a i d ,  I believe that some of the comments derive from our d i f f e r e n t perspect i v e s ; some appear to me to be simply differences of opinion about the meaning  of observations.  Some of the c r i t i c i s m s are, however, made of  fragments of the document l i f t e d out of context and do not appear to give the reader the proper sense of what was intended by the f u l l ethnographic account.  For example, the treatment of my description of the  c l i n i c a l supervisor's intervention in the patient-committee e l e c t i o n appears to discount a l l In f a c t ,  the material on the emptiness of the e l e c t i o n s .  I would suggest that his f a i l u r e to influence the elections  was further evidence of my point. also out of context.  The quotation that follows appears  The text describes that the patients, once again,  treated i t as a ceremonial rather than an instrumental occasion, which reduces the significance of t h e i r decision-making in this matter.  With-  out wishing to belabour the point, I underscore this p a r t i c u l a r example in order to stress the importance of considering the c l i n i c a l  supervisor's  footnotes in r e l a t i o n to the total text in which they are embodied.  The l a s t 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 i n i c a 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.  O r d i n a r i l y a matter  of t h i s kind would have no place in this document.  I have chosen to  report the d e t a i l s of this controversy, however, because a s i g n i f i c a n t focus in the c l i n i c a 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 i n i c a l supervisor and introduced me.  I had a series  of telephone conversations with the c l i n i c a l supervisor in February and March, 1973, which resulted in my coming to Theta at his request on A p r i l 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 s t a f f i f I could come to the evening sessions which they agreed to l e t me do.  I subse-  quently talked to the c l i n i c a 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 i r r e g u l a r l y for a couple of weeks which, as i s reported in the text, was a source of i r r i t a t i o n some s t a f f members.  to  Because of t h i s I stopped attending altogether dur-  ing January so that my schedule of observations could be renegotiated with the c l i n i c a l  supervisor.  On February 4, 1974, my thesis advisor and  - 179 -  I met with the c l i n i c a 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: [ C l i n i c a l Supervisor] suggested that I came in as a patient, suggested that this would be less d i s r u p t i v e . [Thesis Advisor] and I objected that process would or might become focused on me as a deviant patient but [ C l i n i c a l Supervisor] was not impressed by t h i s argument. He suggested that i f I d i d n ' t want to come in as a patient my observations would be severely limited to maybe two days a week. The c l i n i c a l supervisor said he would discuss the matter with the Theta staff.  He made-a reference to my thesis at that meeting and asked . . . t h a t the s t a f f be given an opportunity to read the thesis - not to suppress anything but to make suggestions. 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 time) to s t a r t in June. I used to work f o r .  that  I had agreed to go to A f r i c a with a company that  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 i n i s h my MA was not much more limited than before.  In a subsequent telephone conversation the c l i n i c a l  super-  v i s o r 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 i n i c a 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 i n i c a l supervisor said  that they "would think about t h a t " , that I "had great influence" the patients at meetings). tion with the c l i n i c a l  (on  On February 15, I had another conversa-  supervisor about attendance.  My notes record:  . . . h e said that I should wait until he talked about i t . About 15 minures l a t e r he came down s t a i r s and s a i d : 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 s a t i s f i e d with t h i s and asked my thesis advisor to intercede on my behalf. 19, 1974.  See Appendix VI)  He wrote a l e t t e r  (dated February  requesting a more extensive schedule.  myself, wrote a l e t t e r on the same issue (see Appendix VI).  I,  It was  my thesis a d v i s o r ' s l e t t e r of February 19 that so angered the c l i n i c a l supervisor that he asked me to j o t down immediatley my thoughts about what I thought i t meant. Appendix VI. 22.  My attempted explanation i s also included in  I read my explanation out at the s t a f f meeting of February  After some discussion of this issue between myself and the s t a f f  members who were present at this meeting, the c l i n i c a l  supervisor agreed  to allow me to supplement my then current observation schedule by attendi full-time for my l a s t ten days of observation. March 6, 1974 and ended on March 15, 1974.  This period started on  I attended a s t a f f meeting  on March 15 which I recorded as follows: I went to the " f e e l i n g s " meeting and talked for a few minutes. I said that I was j u s t beginning to get some ideas about the place and was very impressed. I talked a l i t t l e about the c o n f l i c t s 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 [ C l i n i c a l 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 i n i c a l Supervisor] agreed to l e t me stay after checking with the others who agreed readily enough. I attended full-time from March 8 to 22 which was the l a s t day of my observations at Theta.  The issue of the s t a f f seeing my thesis was raised rather casually at the meeting of February 4 and was raised again at a s t a f f meeting on Februaly 11.  My f i e l d notes for that date record the  following: Went upstairs to [ C l i n i c a l Supervisor] s o f f i c e . He started by asking me to give him written assurance that he would have a copy of my draft of my thesis " i n case i t got forgotten what arrangement had been made". [Emphasis added] 1  The l e t t e r 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 s t a f f so that your c o l l e c t i v e reactions can be integrated with the f i n a l version. [Emphasis added] As far as I know this is the only statement giving the "[promise]  in  w r i t i n g " that is referred to in the c l i n i c a l supervisor's text.  In the l i g h t of the reasonably cordial discussions that were taking place at that stage of my contact with the Theta s t a f f ,  I  fully  expected that the s t a f f would have some input into the f i n a l document. Of course they could have no input u n t i l they saw what the document looked l i k e and i t was c e r t a i n l y never my intention to spring a f i n a l ized version on them, as this would have frustrated the purpose of  - 182 -  t h e i r 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 i n i c a 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 c a , I asked everyone concerned to give me t h e i r reaction to my d r a f t as quickly as possible and scheduled a meeting with my committee on June 20.  The c l i n i c a l supervisor wrote on June 17 to say that the draft was incomplete. pendix VI,  There was no suggestion in this l e t t e r ,  that he was surprised to receive a draft.  included in Ap-  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 l a s t page  of the document and he t o l d me that his copy was in fact complete. June 21 meeting was an extremely angry one in which the c l i n i c a l visor said that my thesis had been unfair to the s e t t i n g .  The  super-  I spoke with  him again on the telephone on June 21 and r e a l i z i n g that he had considerable objections to the t h e s i s , wrote him the l e t t e r dated June 23 which is also included in Appendix VI.  Despite the several pleas for discussion on the thesis contained in the l e t t e r s c i t e d above, there was no discussion between the c l i n i c a l supervisor and myself.  There was a discussion with another  s t a f f member which resulted in my making some changes in the document.  - 183 -  A l l the issues that had been drawn to my a t t e n t i o n , I examined with considerable care.  I had already introduced some modifications by the  time of my l e t t e r of June 23 and indicated this in that l e t t e r .  Some  other issues were reported to me by the s t a f f member and prompted further changes.  Apart from some major revision of the introductory chapter,  the changes referred to above are the only s i g n i f i c a n t alterations of the original  draft.  I believe that the above description d e t a i l s the relationship between myself and the i n s t i t u t i o n in a way that w i l l be of assistance in understanding the import of the matters in the notes about our "agreement".  I believe I have l i v e d up to the s p i r i t as well as the  letter  of that agreement and that my doing so i s documented in the above report.  - 184 -  July 4, 1974. Notes of the C l i n i c a 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 l e of f i r s t d r a f t ]  1.  1.  Introduction.  2.  S p e c i f i c Comments.  3.  Methodological Remarks.  4.  Notes on the Theory of Therapeutic Community.  5.  Background Information.  INTRODUCTION  In February, Mr. J .  Brown promised in writing that I,  the C l i n i c a l Super-  v i s o r 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 s t a f f expected to hear from him much e a r l i e r . draft of his t h e s i s .  As late as June 14, 1974, he sent me the f i r s t I asked to write my notes to his f i n a l t h e s i s ,  according to our agreement, but he explained that I would not have an opportunity to write my comments to the f i n a l t h e s i s , as the defence would be on July 4, 1974, and that the f i n a l 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 w i l l be included in the f i n a l bound copy of the thesis regardless of when they are submitted.  If  they are a v a i l -  - 185 -  able by approximately July 5, they can be included in the f i n a l form before d e f e n c e . . . " ( l e t t e r of Mr. Brown to the C l i n i c a l Supervisor of June 23, 1974).  Although I feel that the promise of Mr. Brown, made in February, has not been kept, I am writing these notes to the " F i r s t  Draft  not knowing, of course, what changes Mr. Brown w i l l make in his f i n a l thesis as a r e s u l t of discussions with myself and members of "Theta" s t a f f , or otherwise.  I offered to take into account any changes he wi  make in the t e x t , and that I should receive these in writing before s t a r t i n g to write my notes (beginning of J u l y ) , 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 i n a l version.  In writing these notes, I am, of course, not concerned with the evaluation of the t h e s i s .  My only concern, and I was asked to do  this by the s t a f f of "Theta", i s 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 "Theta  1  I w i l l not, therefore, deal with the parts which correctly describe the i n s t i t u t i o n - 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 " S p e c i f i c 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 i s i t o r then, who could be constituted as a t h e r a p i s t , was received at "Theta" without challenge.  In contrast to this I was  frequently challenged by new p a t i e n t s . "  Incorrect g e n e r a l i z a t i o n : roles.  It was not only the difference  o[f]  Mr. Brown does not see the difference in behaviour of a know-  ledgeable v i s i t i n g psychotherapist and h i s .  At one time, when he made  remarks and gave advice, incompatible with psychotherapeutic  strategy,  one v i s i t i n g p s y c h i a t r i s t remarked a f t e r the session: "What is the amateur psychotherapist doing here?"  (Mr. Brown admits once - [p. 160]:  "On one p a r t i c u l a r l y bad occasion I spent the evening making f a i r l y wild speculative guesses in role playing with patients and v i s i t o 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 t o r s ,  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 i d e n t i f y with the patients and, presumably, have some status as an ex-patient."  Not correct.  Mr. Brown d i s t o r t s to prove his point.  The  secretary decided to become a patient, only a f t e r she decided to f i n i s h  - 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 d i s t o r t s to prove his point.  The amusement  was in regard to one lady in the hospital only, and the " h o s p i t a l " had a s i m i l a r attitude towards her as we d i d . part of "phenomenological method"?  Are distorted gossips [ s i c ]  [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 s u p e r f i c i a l l y  with the i n t r i c a t e problem problem [ s i c ] of power d i s t r i b u t i o n , where a knowledgeable s o c i o l o g i s t could be of help.  Instead of using our mass-  ive material studying this question, I w i l l mention his own statements contradicting his general  statement:  [p.  90]  a.  "Halfway through the elections the C l i n i c a l Supervisor  to say that the work coordinator should be competent.  interrupted  Some votes now  - 188 -  went to [Male P a t i e n t ] ,  but the group i n s i s t e d on having i t s own candi-  date [Female Patient] self-confessed incompetent.  Despite the attempt  of the C l i n i c a l Supervisor to influence the process, the group attended to i t s own p r i o r i t i e s in selecting a patient to f i l l  b.  the [ r ] o l e . "  One of the most serious decisions of the Centre, admitting a p a t i e n t ,  is a group d e c i s i o n .  [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 s t a f f is against the patients meeting outside the  group, no s t r i c t rule is included in the r u l e s .  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 i p p i n g " ,  "pushy", "aggressive".  e  [p. 109]: "The reaction of the i n s t i t u t i o n to sexual relations among i t s 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 e i t h e r no explanation at  - 189 -  all:  " i t damages the therapy",  "it  interferes with the treatment", or  were "shot through with i n c o n s i s t e n c i e s " .  And [p.  110]: "Why the r e l a -  tionships which originated at Theta were so severely censored is thus a puzzle which i t seems only possible to explain in terms of c o n t r o l " . [The f i n a l version of this quotation has been somewhat changed.]  Mr. Brown did not bother to ask. be given, [sic?]  Here only main reason w i l l  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 f o r changing t h e i r behaviour; i t i s d i f f i c u l t for them to be completely open and they support themselves in t h e i r resistance. Such a love relationship is usually a symptom of resistance, into l o v e " .  "flight  (The mentioned patient discharged, l i e d for several weeks.)  Experimentation in the past led to this p r a c t i c e ; o f t e n , the other partner was admitted l a t e r . be a traumatic one.)  (The relationship normally turned out to  This arrangement may be given up one day, i f new  knowledge and techniques w i l l allow us to deal with the complex problems, which such a r e [ l a ] t i o n s h i p  f  causes.  [p. 33]: Mr. Brown summarizes that the work "does not r e f l e c t * life".  It  real  r e f l e c t s 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 t h i s case i t seems necessary to point out that the text has not been changed since the d r a f t . The reader should note that the quotation cited should not have been attributed to me but was a report of an apparent consensus among patients. JB  -  190 -  true, however, that a 24-hour therapeutic community gives more opport u n i t i e s in that respect.  g  [p> 71]^ "It  is an interesting s o c i o l o g i c a l fact that every  for admission is able to produce some subset which he sees  candidate relevant  for this task [which he sees to be relevant to his s e l f formulation as somebody who needs help] and that the s t a f f member also treats  what-  ever l i s t is produced as relevant to the question that has been asked." [Amended in f i n a l version; see t e x t . ]  Equivalent statement [sic]  would be about a grocery: "It  is  an interesting s o c i o l o g i c a l 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? that [the]  He also missed  p s y c h i a t r i c 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 s t a f f member treats the s e l f - d e s c r i p t i o n as a true account of the events of the p a t i e n t ' s  Is this the "phenomenological a n a l y s i s " [p.  life."  ] "an essential  - 191 -  f a c t i c i t y 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 i n a l  document.]  anything about psychiatric interview  Mr. Brown simply does not know [sic]  (though he was once present)  and continuous checking in a therapeutic community. cannot be excluded, they are highly u n l i k e l y .  Although mistakes  Here, something essential  escaped Mr. Brown.  h  [p. 47]: "Theta was seen as a place in which the t r a d i t i o n a l moral judgments are suspended.  It was not so much a matter that they were i n d i f f e r -  ent to these descriptions but of the certainty that anybody's moral d e c i sions were his own business and had nothing to do with therapy."  [This  has been amended in the f i n a l document although the sense has been preserved.  See pp. 47-48.]  This is a wrong observation and conclusion. moral decisions have to do with therapy [sic], often caused by chronic moral c o n f l i c t .  Not only that  neurotic breakdown i s  However, the group does not  use the usual means to help the patient in his moral c o n f l i c t - that i s , by reproach, advice and persuasion, as they proved mostly i n e f f i c i e n t his previous l i f e .  in  Instead, the treatment is designed to modify his  motivational network, so that he is able to make a d e c i s i o n .  i  [p. 73]: "This problem l i s t subsequently becomes an j n s t i t u t i o n a l  arti-  fact and is used to demonstrate the progress the patient is making in the i n s t i t u t i o n . "  [This has been s l i g h t l y amended in the f i n a l  version.]  - 192 -  This courageous statement is based on s p e c i f i c use of the problem l i s t , where a patient himself was questioned about not making progress on a problem l i s t .  But Mr. Brown, in one sentence, judges exten-  sive work of the l a s t years about problem oriented record [ s i c ] ,  which  is now a routine part of the work in many branches of medicine, i n c l u d 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 i g h t l y amended in the f i n a l  version.]  The f i r s t statement is simply not true and is a not uncommon example of Mr. Brown's careless statements. l i s t s of homosexual patients and they a l l  We went through a l l problem  suffered from neurotic symptoms  and problems, such as depression, hopelessness, f o r f e i t i n g about sexual o r i e n t a t i o n , etc.  uncertainty  Why would a happy homosexual ask admission  to the demanding treatment of Theta?  The other half of the sentence is a vague g e n e r a l i z a t i o n , which cannot be answered.  k  [p. 164]: "The s t a f f of Theta were perenially concerned with "what I was finding o u [ t ] " .  The s t a f f 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 c h a r i t y . i n t e r p r e t s , in his i d i o s y n c r a t i c way, the t a c t f u l  He evidently  remarks of therapists  r e l a t i n g to which parts of the programme he would be least  harmful.[sic]  He also misinterprets our concern with his f i n d i n g s .  He  should know that we asked every guest about his observations even i f he v i s i t e d only once.  I asked each s t a f f member in each s t a f f meeting  following the group session routinely about observations and personal feelings.  I could go on and on with remarks to Mr. Brown, but Mr. Brown does not give us s u f f i c i e n t time and I am too busy.  A l s o , 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. of  However, he is not even aware  it.  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 a n t i s e p s i s .  As he studies a task group, he cannot under-  - 194 -  stand this behaviour unless he has either extensive information of the f i e l d s of knowledge in question, or unless he asks them why they are behaving in certain ways.  He may a l s o , and probably w i l l ,  discrepancies between what they intend may be of general i n t e r e s t .  If,  find some  to do, and what they do, which  however, he neither has the necessary  knowledge, nor for reasons of his own does not ask them, i t would be hopeless to explain t h e i r acts (based on t h e i r knowledge and b e l i e f s ) observing t h e i r behaviour for a short time. f a l s e picture as to what is going on.  He may obtain quite a  For example, he may interpret  t h e i r behaviour, such as not touching certain objects, going through stereotype sequences of movement - as t h e i r phobias and r i t u a l i s t i c haviour.  be-  He may interpret r e s t r i c t i o n s 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 t r i b e and interpret t h e i r behaviour as superstitious and compulsively r e p e t i t i v e , 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 continuum of systematic knowledge between the two human organizations mentioned.  Whatever the case may be the tasks of Theta are approached with  the help of a conceptual framework which has i t s basic views broadly accepted in the f i e l d 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 i r r e l e v a n t ,  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 " r e f r a i n s from any causal or genetic hypothesis  " and says f u r t h e r ,  "That i s ,  I  describe a commonsense r e a l i t y without making any judgments about members' understandings as being r i g h t or wrong but (provided I have been successful in discerning them), as, f o r members, an essential  facticity  * 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 g e n e r a l i z a tions and i n t e r p r e t a t i o n s , and not knowing the theory underlying the activities  of Theta (and, as he mentioned in a discussion with me, even  programmatically not being interested in i t , nonetheless, in f a c t , subs t i t u t i n g i t with a commonsense view) misinterprets the a c t i v i t i e s  of  Theta and the behaviour of the s t a f f , even diagnosing them p s y c h i a t r i c a l l y ("paranoia")  .  There is a close p a r a l l e l  to the imagined example of a  * The quotations are taken from the introduction to the o r i g i n a l d r a f t . JB * * The word "paranoia" has been eliminated in the f i n a l version. My o r i g i n a l 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 p s y c h i a t r i c roots of the word made i t s 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 t o , of course, develop here the theory of group psychotherapy in general and of therapeutic communities in p a r t i cular.  I w i l l deal only with the minimum f o r present purposes.  One of the cornerstones of modern psychotherapy broadly accepted by psychotherapists of d i f f e r e n t orientations analysts),  is Freud's discovery of resistance.  (not only psycho-  The patient is divided  in his motivation: in his treatment he co-operates in order to get bett e r , but at the same time, with changing i n t e n s i t y , he t r i e s to keep status quo of his neurosis. P.S.,  As Menninger says (Menninger, K.A., Holzman,  Theory of Psychoanalytic Technique, Basic Books, 1973): "  every  patient, in spite of his co-operativeness and eagerness to do whatever he is t o l d in order to "get b e t t e r " , defensive".  is at the same time p a r t i a l l y  He unintentionally but purposely, obstructs the very process  upon which he counts so heavily to benefit him. effectively  "on the  He may obstruct i t so  as to "terminate i t soon a f t e r i t has begun."  Freud compared  individual treatment to a battle where on one side of the l i n e is the therapist and the reasonable part of the p a t i e n t , and on the other is the r e s i s t i n g part of the patient.  The c o n f l i c t is only the r e f l e c t i o n of  the inner neurotic c o n f l i c t of the patient.  Far from being only a nuis-  ance, the manifestation of resistance is unavoidable in treatment and i t s  - 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 c o a l i t i o n s .  The mentioned picture of a battle  in individual psychotherapy holds for [the]  therapeutic community a l s o ,  where each patient is partly [an] a l l y of the therapists in achieving therapeutic goals, partly contributing to the group resistance (both his a l l i a n c e and resistance fluctuating in time).  The d i f f i c u l t and c h a l l e n -  ging task of the therapists is to handle the i n d i v i d u a l , subgroup and group resistances. pists.  This they try to do using the patients as co-thera-  The more the patients take r e s p o n s i b i l i t y for the treatment,  more e f f i c i e n t [the]  treatment can be.  the  The more they are able to do i t  through the patients themselves, the better.  However, the patients  unreliable a l l i e s , because of t h e i r fluctuating resistances. to time, they try to drive a wedge between the therapists.  are  From time It  is  almost inevitable that they succeed with a psychotherapist-beginner. Under these circumstances, a high degree of unity of therapists is necessary, strengthened by s t a f f meetings where not only the observations of s t a f f members, but also t h e i r 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 f o r a long-time observer, unless he  - 198 -  takes either a t h e r a p i s t ' s or a p a t i e n t ' s role (at least at the present stage of knowledge).  Otherwise, he becomes a nuisance l i k e a neutral  person walking in the b a t t l e f i e l d , where one side has taken into consideration 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 i s i t i n g p s y c h i a t r i s t asked a f t e r one session in s u r p r i s e , "What is the amateur therapist doing here?"  Several ther-  apists (not only one, as he thinks) found his behaviour d i s t u r b i n g , 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 staying for 4 - 6 weeks in the role of a patient (what we have done in the past with new s t a f f members for t r a i n i n g purposes), or to be in Theta for a whole week as an observer and continue coming once a week f o r * the r e s t .  Both he and his supervisor accepted the second a l t e r n a t i v e ;  I promised I would discuss with the s t a f f possible extension. in our meeting we decided against extension,  However,  as Mr. Brown's presence  had been, even so f a r , an additional burden for the already overworked s t a f f , and his stay for longer than one week was expected to lead to * The d e t a i l s of the negotiations have been recorded in my i n t r o duction to this appendix. The schedule of my attendance is shown in Appendix VI. JB ** A c t u a l l y , 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 t c . , which could not be analysed.  So the p r i n c i p l e  of closed system in which the causal chains of interaction can be a n a l ysed (and which Mr. Brown erroneously thinks was discarded) would be seriously v i o l a t e d .  In the next days a f t e r 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 experience and from what he reports, i t is hard for me to understand why there should be so much fuss. another month or so  It  As you know, he w i l l be in (Theta) for  ".  is unfair that Mr. Brown quotes me as saying that the  * l e t t e r is "outrageous" without quoting this l e t t e r .  We were "making  a fuss" about l e t t i n g Mr. Brown stay for a month, because we would not l e t 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 conclusions. staff,  He never t r i e d to understand the theory and b e l i e f s of the  and as a r e s u l t , he misinterpreted the s t a f f ' s behaviour as "para-  noia" [p. 164].  "I  think, however, that there may have been some  paranoia on the part of the s t a f f as w e l l . . . . t h e  fact that this was  * In view of this objection and the relevance of this correspondence to my introductory remarks.to this commentary, the l e t t e r is included in Appendix VI. JB * * Again, the reader is reminded of the change in the f i n a l text from "paranoia" to the less ambiguous members' word " d i s t r u s t " . JB  - 200-  paranoia and not the disinterested c u r i o s i t y i t claimed to be may be supported by the fact that the C l i n i c a l Supervisor i n s i s t e d 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 i n a l document." (Mr. Brown's d i s t o r t i o n : " d r a f t " - instead of  "thesis".)  That this was a r e a l i s t i c assessment and not paranoia is apparent from the fact that although this was my only condition f o r his stay in Theta, he has not given me his f i n a l thesis for comment to date. (As our contract was that my comments would be included in the f i n a l thesis [p. 164], I did not expect, of course, to write them to a d r a f t , but rather to the f i n a l  thesis.)  Although Mr. Brown regards us as paranoid, we f r e e l y opened our I n s t i t u t i o n ,  including informal s t a f f meetings, to his observations.  He even had an opportunity (in the role of a patient) uninterrupted for four to six weeks.  to observe  it  We doubt very much whether another  department, including the Department of Sociology, would allow the admission of a student to t h e i r informal s t a f f meetings.  But we may try  this in the f u t u r e , and ask f o r permission f o r a student of medicine to conduct a psychological study.  APPENDIX VI SCHEDULE OF ATTENDANCE AT THETA  1973  1974  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 r s t lunch attended], 13, 19, 20, 26 [Lunch], 27  December  17 [Lunch],  February  11, 13, 15, 18, 20, 22, 25, 27  March  4, 6, 7, 8; 11 through 15; 18 through 22.  18, 27  [ F i r s t 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 i t would be permissible for rae to attend at , yoft? Monday, Wednesday and Friday and that other tines might be negotiated. This has subsequentlv 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  Dr. 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 as a p p r o p r i a t e i n the s e t t i n g , i . e . that a l l o w them to behave r a t i o n a l l y i n the setting. I n order to do be around autobiographies and the r e s t when the p and o r g a n i z i n g , t h e  t h i s i t would be of great assistance i f I could at times, such as l u r c h hours and work p e r i o d s , psychodrama p r e p a r a t i o n , committee meetings and atients are freely expressing their opinions about, ir affairs.  I have d i s c u s s e d t h i s m a t t e r at l e n g t h w i t h my committee b e f o r e p r e s e n t i n g you w i t h t h i s l e t t e r and D r . has decided to w r i t e a separate l e t t e r to you, setting out his concerns i n the matter. I f , a f t e r another week o r co, you can see your way to d i s c u s s i n g this matter further, I s h a l l be happy to set out once again, 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 me t o b e p r e s e n t i n the setting. Yours  John  sincerely,  Brown  - 204 -  February  19.1974  Dear Dr. A f t e r o u r 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 g r a d u a t e s t u d e n t • — J o h n B r o w n - - w o u l d be g r a 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 t h a n seems t o be t h e c a s e . I f u l l y a p p r e c i a t e t h e r e a s o n s f o r t h e 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 , b u t I a l s o f e e l t h a t a n y 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 w e i g h e d a g a i n s t t h e p o s s i b l e v a l u e o f J o h n ' s s t u d y t o what ou a r e s e e k i n g t o a c c o m p l i s h a t ._. I do n o t b e l i e v e h a t J o h n 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 i m p a c t u p o n what g o e s o n a t t h e C e n t r e . , a n d f r o m v h n t 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 s o much f u s s . A s y o u know, he w i l l o n l y be a t for a n o t h e r month o r s o , a n d , 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 s o m e t h i n g o f an i r r i t a t i o n , t h e y c a n t a k e r e l i e f i n t h e t h o u g h t t h a t k h i s h e w i l l o n l y be t h e r e f o r a relatively short while. A p a r t f r o m t h e s e e x p r e s s i o n s o f my own p e t u l a n c e , J o h n a n d E are a c t u a l l y very g r a t e f u l f o r whatever time you a l l o w him t o spend a t t h e 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 t i m e i s t i e d t o t h e p r o b l e m o f k n o w i n g 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 , w h i c h Kinc c a n 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 w h e r e 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 n o t t h e same. I n a d d i t i o n , t h e r e i s t h e p r o b l e m o f s e e i n g a s nuch a s c a n be s e e n when t h e r e i s o n l y a m o n t h i n w h i c h 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 m a i o r p r o b l e m i s t h a t some o f y o u r s t a f f a r e i i s t u r b e d b y t h e f a c t t h a t t h e y a r e s r n o t 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 t h e s c e n e , and t h a t t h i s , i n d e e d , c a n be l i e r u p t i v e . Kay I s u g g e s t t h e f o l l o w i n g : t  S- I n t h e f i r s t week t o t e n d a y s , J o h n f o l l o w a p r e c i s e s b h e d u l e x ( e . t h e one a l r e a d y p r o p o s e d b y y o u ) , a n d t h a t d u r i n g t h i s t i m e lie a t t e m p t t o d e v e l o p f i r m i d e a s a b o u t 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 . ?- I n t h e s e c o n d a n d t h i r d w e e k s , he a d d t o t h e o b s e i ^ v a t i o n a l s i t e s and t i m e s o f t h e f i r s t week, t h e f u r t h e r h o u r s t h a t he h o s b e e n 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 t h e 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 f o r : : t h i s p e r i o d , so t h a t t h e y a r e  - 205 -  5~  n o t g r e e t e d v ; i t h any unwelcome s u r p r i s e s . That John adopt y o u r t e n t a t i v e s u g g e s t i o n t h a t he d e v o t e t h e 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 c o m p l e t e 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 s c h e d u l e so t h a t y o u r s t a f f w i l l n o t t h e n 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 a b s e n c e s on John's p a r t .  I f you can agree t o t h i s s o r t o f s c 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 J o h n t o see enough to' make an i n t e l l i g e n t commentary on what he o b s e r v e s . V/e s i n c e r e l y welcome' y o u r s u g g e s t i o n t h a t t h e f i r s t d r a f t o f h i s t h e s i s be shown t o y o u , and, i n d e e d , v/e w o u l d be e a g e r t o have y o u d i s c u s s i t w i t h y o u r s t a f f so t h a t y o u r c o l l e c t i v e r e a c t i o n s c a n be i n t e g r a t e d w i t h t h e 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 y o u w i l l f i n d some way t o accommodate J o h n ' s needs so t h a t he h a s a decent qj-ififice t o p r o d u c e s o m e t h i n g worthwhile.  - 206 -  From:  J . Brown  To:  Di-  COPY  Letter of Feb. Dr  February 22,  1974  1,9: Request for Written Comment  's l e t t e r 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.  that the only facets of  1 had expressed  my concern  that I would see were the formally c o n s t i t -  uted group meetings.  I cannot, of course, provide an i n t e r p r e t a t i o n of Dr, t o t a l perspective, which derives from his whole biography and with therapeutic groups.  's  experience  His use of the word "fuss", while i t may  be  unfortun-  ate, can only be understood i n the t o t a l context of the l e t t e r , which I take to be an expression of his own  concern that my perspective would be d i s t o r t e d  and a plea f o r some reconsideration on your part. "expression of (his) own  He does i d e n t i f y i t as an  petulance" and, 1 believe, an attempt to state his  case as d i r e c t l y and f o r c e f u l l y as he thought appropriate.  I strongly urge you to talk to Dr  himself, with or without  my  being i n attendance, i f you wish to have the matters he descussed explicated further.  This is p a r t i c u l a r l y so as I have considerable h e s i t a t i o n i n comment-  ing on his l e t t e r to you i n 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 o f the f i r s t d r a f t of my M.A. t h e s i s . This copy i s d e l i v e r e d t o you a t the same time i t i s submitted t o my committee. As I understand you may wish t o make comments which should be included i n the f i n a l document i n the form of f o o t notes, I would l i k e t o advise you t h a t my committee has k i n d l y agreed t o have a meeting on t h i s d r a f t i n about one week. The reason f o r the haste i s , o f course, my imminent departure f o r A f r i c a and the f a c t t h a t I am hoping to have a f i n a l d r a f t f i n i s h e d before I leave. I am sure you w i l l understand the need f o r any response you wish t o make being submitted as soon as p o s s i b l e . I s h a l l be happy t o discuss any p o i n t t h a t you wish t o make and would value your observations whether you wish them included o r not. I f you do wish t o have any p a r t footnoted, I would appreciate i t i f you would send me t h i s copy narked up v i a .. and I s h a l l make the necessary adjustments t o 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 f o r your d r a f t of your manuscript received June 14th. I received 142* 'pages which does not seem to be the entire manus c r i p t . That i s why I c a l l e d Dr. _ , since according to your statement, both and I expected to receive the manuscript earlier. f  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 w r i t i n g comments to a draft which can be changed. As soon as you provide me with a f i n a l v e r s i o n , I w i l l write my comments. I expect", of course, reasonable time in which to do that. You may, o f course, have comments to my comments. If you have any questions or comments-please c a l l me, e i t h e r at the o f f i ce ! I or at home i •••; Yours s i n c e r e l y ,  - 209 -  June 23, 1974  Dear Dr:  :  Further to our telephone conversation of June 22, 1974, and your request f o r written assurance on several points a r i s i n g from that conversation, I wish to advise you as follows. I s h a l l make every e f f o r t to have your comments included as part of the permanent document at the time my thesis i s presented f o r defense. I should bpgfebtcut that we have revised the date of the defense to J u l y 9 so as to give you as much time as possible to prepare your comments. As I am currently scheduled to leave f o r A f r i c a on July 10, you w i l l see that t h i s i s the l a t e s t date that I can accomodate. Your footnotes w i l l be included i n the f i n a l bound copy of the thesis regardless of when they are submitted. If .they are available by approximately J u l y 5, they can be included in f i n a l form before the defense. If, however, they are not f i n i s h e d u n t i l a f t e r that date, i t may be necessary to mark up the superscript l e t t e r s in ink on the defense copies. Every person who attends w i 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 u n i v e r s i t y in i t s current form. The question of what kind of publication might develop from t h i s work has not arisen as y e t . I an quite prepared to discuss any paper or work with you should the occasion ever a r i s e , c r to correspond with you about i t i f I am not in et the time. I arc attempt!no to have the f i n a l version of ny thesis a v a i l a b l e by J u l y 6 or 7. This would include your footnotes and allows two days f o r t h e i r i n s e r t i o n . This date allows approximately one week f o r typing and reproduction which means that my target date f o r having the revisions complete i s Jur.o 28 or 29. As I have a.lrescly pointed out, I do not exnect t h i s version to be r a d i c a l l y d i f f e r e n t from the current version. I would l i k e at this point to male a nle-? f o r some more constructive communication between us. If you have strong objections to some parts of the document, as you c l e a r l y 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 s t a f f and some members of my cor^.ittce. I have already examined the points that you have raised so f a r and f i n d 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 l a s t point concerned my report of your categorization of one sentence of Dr. 's l e t t e r 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 a v a i l able a copy of the l e t t e r 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 l o t of the f r i c t i o n between us. You have said that my report of the above incident is a total d i s t o r t i o n of the f a c t s , which at the very least indicates that there is a strong difference of opinion about the incident which (without attempting to deny i t s importance to you)-is a r e l a t i v e l y minor one in terms c f 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 t e x t , discussion which, moreover, is bound to lead to interpretations by readers whose p a r t i c u l a r bias may lead them to unwarranted conclusions about the motives behind the d i s c u s s i o n . I believe that this fcdmd' of controversy can do more harm than good by drawing unnecessary attention to matters that might hawerwise be received i n d i f f e r e n t l y by readers who had not been Involved in the issue. On the matter of my making " p s y c h i a t r i c interpretations about the s t a f f members" which, you i n d i c a t e d , referred to the matter of "paranoia", I have consciously s t r i v e n to avoid p s y c h i a t r i c interpretations throughout the document. I can appreciate your objection and concern about the d e f i n i t i v e ' use of the word paranoia, which has inescapable p s y c h i a t r i c roots. I shall add the necessary q u a l i f i c a t i o n s to the section to make i t clear that I intend the word in i t s lay sense. F i n a l l y 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 ident i f i e d has been characterized as "(Theatre"). !  i f you can make any su<;(C->tiG:i that f u r t h e r protects the anonym'ty of the s e t t i n g I would c e r t a i n l y Appreciate your a d v i c e . I hooe that t h 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 d i s s e r t a t i o n that you consider to be controversial. I have no wish for i t to become a point of confrontation between y o u r s e l f and the Sociology Department and believe that this can be avoided by the suggestions I have mice, f'y committee has asked ne to t e l l you that they welcome Dr. 's attendance at the defense, and that a f o r mal i n v i t a t i o n would have been sent to you as soon as the date was f i n a l i z e d . Yours s i n c e r e l y ,  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 w i l l be i n cluded in your thesis before defence. I am also expecting, according to your promise,to have a f i n a l of your thesis before the defence.  text  I waited until July 3, 1974 for e i t h e r your f i n a l version or f o r written changes in places which I t o l d you were d i s t o r t e d . S i n c e , however, I have not received them I have to i n s i s t that my notes are published in the thesis disregarding changes you make in the f i n a l version, which you also promised me. Yours s i n c e r e l y ,  - 213 -  BIBLIOGRAPHY  Becker, Howard S. Outsiders: Studies in tlie Sociology New York, Free Press, 1966 [copyright 1963].  of  Deviance.  Becker, Howard S. 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 . P r e i s s . Homewood, 111., Dorsey Press, 1960. Berger, Peter L. and Thomas Luckmann. Reality>  The Social  Construction  of  New York, Doubleday (Anchor Books) 1967 [copyright 1966].  Cavan, S h e r r i . Liquor License. Chicago, Aldine, 1966.  An Ethnography  of Bar  Behavior.  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. H a l l , 1967.  Studies  in Ethnomethodology.  Goffman, Erving. The Presentation of Self Doubleday (Anchor Books) 1959. Goffman, Erving. 1961.  Asylums.  in Everyday  Life.  Prentice New York,  Garden C i t y , N. Y., Doubleday (Anchor Books),  Janov, Arthur. The Primal Scream. The Anatomy of Mental I l l n e s s . "The  New Jersey,  New York, Dell (Delta Books), 1970. New York, Berkley (Medallion), 1971.  Rationale of the [Theta] Marking System".  In-house Memorandum.  Sacks, Harvey. "An I n i t i a l Investigation of the U s a b i l i t y of Conversational Data for Doing Sociology". Studies in Social Interaction. ed. David Sudnow. New York, The Free Press, 1972. Sontag, Susan. "Notes on 'Camp'". Against Farrar, Straus and Giroux, 1964.  Interpretation.  New York,  

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0093190/manifest

Comment

Related Items