The Transitional Approach in Action

Gilles Amado, Vansina Leopold, Gilles Amado, Vansina Leopold

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429922510
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The chapters in this volume cover a wide range of topics that concentrate around four themes: transitional change in therapeutic communities; in working conferences for professional development or training; in organisation consulting with an emphasis on organisational learning; and in self studies of working systems in action. In all these psychic activities, "time and space" were created to allow for transitional processes to become alive. A therapist, a manager, a consultant or a layman may create conditions that facilitate or hinder human beings to become engaged in these normal, healthy processes, but the persons concerned undertake the basic psychic work.'It is encouraging to notice that more and more clinical institutions, organisations and even professional associations are becoming aware of the important and complex interactions between psychic processes and organisational realities. The engagement in transitional processes, however, demands courage. Courage that is proper to any pursuit of truth and social justice. At times, this search generates excitement, at other times we become scared by the realities we discover.

CHAPTER ONE
The discovery of the therapeutic community

The Northfield experiments¹

Harold Bridger

Introduction

One of the most important achievements of social psychiatry during the Second World War was the discovery of the therapeutic community. The idea of using all the relationships and activities of a residential psychiatric centre to aid the therapeutic task was first put forward by Wilfred Bion in 1940 in what became known as the Wharncliffe Memorandum, a paper to his former analyst, John Rickman, then at the Wharncliffe neurosis centre of the wartime Emergency Medical Service (EMS). When he tried to put this idea into practice, Rickman got virtually nowhere in the face of strong resistance from medical and administrative staff. It entailed a radical change in staff-patient relations that produced a figure-ground reversal² in the traditional authoritarian hospital. In order to achieve active patient participation in treatment, power was to be redistributed away from its monopolization by the doctor and shared by other staff and patients in appropriate ways.

The opportunity to test the efficacy of the therapeutic community idea arose in the autumn of 1942 at Northfield Military Hospital in Birmingham, when psychiatrists were invited to try out new forms of treatment that would enable as many neurotic casualties as possible to be returned to military duties rather than be discharged to civilian life. Rickman, by ibis time in the Royal Army Medical Corps, had been posted to this hospital for some weeks when Bion joined him from the War Office Selection Boards (WOSBs).

The therapeutic community created by Bion in the training wing (TW), of which he was in charge, existed for only six weeks before it was stopped by the Directorate of Army Psychiatry. The scheme had begun to succeed, enabling a number of alienated individuals to re-engage with the soldier's role. The chaos created, however, was intolerable to the wider hospital staff, who citing to the traditional medical model. This brief project became known as the First Northfield Experiment.

A year or so later, after discussion between Bion and Ronald Hargreaves (the anchor man throughout the war in the Directorate of Army Psychiatry), the scheme was revived in a new form. It was decided to put the TW under non-medical direction. Having had relevant experience in the WOSB organization, I was chosen as the officer in charge. Thus came into being the Second Northfield Experiment, which for the first time embodied the therapeutic community idea in a whole organization. The success of the scheme had a profound effect on the civil resettlement units for repatriated prisoners of war, which followed on from it, and on many post-war developments. A new paradigm had been born.

Out of a personal, historical description I will draw some key principles affecting the nature of therapeutic communities as open systems, considered as part of, and interacting with, the wider society. I shall distinguish such principles from those that govern a community endeavouring to operate as a relatively "closed system", that is, one regarded as sufficiently independent to allow most of its problems to be analysed with reference to its internal structure and without reference to its external environment.

The experience to be revisited was the first attempt at creating a therapeutic community as an open system by intention and not just by accident. It was conducted as an integral part of army psychiatry during the Second World War at a critical phase of the conflict. I shall be reviewing that endeavour with the insights, knowledge, and experience of the more than forty years that have followed that beginning.

The country-at-war emphasized an environment that could not be denied by the professional staff and patients of a hospital. Yet returning people to health in that setting posed considerable problems and difficult decisions for both staff and patients. All were military personnel, with the professional staff in various therapeutic roles. The issues arising were not dealt with explicitly but appeared in stressful and rationalized forms, as when decisions had to be made concerning the return of men to the armed forces or to civilian life. It is important to consider how far the professional staff member's own purposes, values, and approach to treatment were affected by the wartime environment. In the community and organizational life of today such problems and choices may not appear so sharply, but they are just as real and critical.

Northfield I

The philosophy

While Bion and his colleagues at the WOSBs (Bion, 1946) were coming forward with new ideas about groups, some serious problems were affecting military psychiatric hospitals dealing with breakdowns in battle and in units. The withdrawal of psychiatric casualties back to base and then to hospital seemed to be associated with a growing proportion of patients being returned to civilian life. It was as if "getting one's ticket", as it was called, had replaced the objective of hospital treatment—to enable rehabilitated officers, NCOs and men to return to the army. Even at one of the largest hospitals, with 800 beds, Northfield Hospital near Birmingham, where the military medical staff appointed to develop their own treatment methods were highly qualified, the psycho-review of patients before leaving for the army or "civvy street" had no better statistics than in the rest of the military hospitals.

Bion was appointed to the command of the TW to develop his own approach, based not only on the experience gained in WOSBs but on the Wharncliffe Memorandum in which he had adumbrated the idea of a therapeutic community. He undertook a double role as officer commanding the TW and as psychiatrist helping his men to face the working through of issues following their treatment and enabling them to make decisions about their immediate future. Returning to the army might include changes of role, unit, and conditions of work; returning to civilian life might entail relocation or learning a new job. Either course meant confronting not only the conscious and unconscious attitudes and desires of individuals, but the values and norms that had been established in the TW and hospital as part of the war effort.

Bion has made two public statements about the First Northneld Experiment, one with Rickman (1943) and one (1946) in an issue of the Bulletin of the Menninger Clinic devoted to Northfield.

An observer with combatant experience could not help being struck by the great gulf that yawned between the life led by patients in a psychiatric hospital, even when supposed to be ready for discharge, and the military life from which their breakdown had released them. Time and again treatment appears to be, in the broadest sense, sedative; sedative for doctors and patients alike. Occupational therapy meant helping to keep the patients occupied—usually on a kindergarten level. Some patients had individual interviews; a few, usually the more spectacular, were dosed with hypnotics. Sometimes a critic might be forgiven for wondering whether these were intended to enable the doctor to go to sleep.

It thus seemed necessary to bring the atmosphere of the psychiatric hospital into closer relationship with the functions it ought to fulfil. Unfortunately for the success of any attempt to do this, psychiatry has already accepted the doubtful analogy of physical maladies and treatments as if they were, in fact, similar to neurotic disorders. The apparatus of the psychiatric hospital, huge buildings, doctors, nurses, and the rest, together provide a magnificent smoke-screen into which therapists and patients alike disappear when it becomes evident that someone may want to know what social function is being fulfilled, in the economy of a nation at war, by this aggregate of individuals.

It must, of course, be remembered that in a psychiatric hospital there are collected all those men with whom ordinary military procedures have failed to cope. Briefly, it was essential first to find out what was the ailment afflicting the community, as opposed to the individuals composing it, and next to give the community a common aim. In general, all psychiatric hospitals have the same ailment and the same common aim—to escape from the batterings of neurotic disorder. Unfortunately, the attempt to get this relief is nearly always by futile means—retreat. Without realizing it, doctors and patients alike are running away from the complaint.

The first thing, then, was to teach the community (in this case the TW) to seek a different method of release. The flight from neurotic disorder had to be stopped; as in a regiment, morale had to be raised to a point where the real enemy could be faced. The establishment of morale is, of course, hardly a prerequisite of treatment; it is treatment, or a part of it. The first thing was for the officer in charge not to be afraid of making a stand himself; the next to rally about him those patients who were not already too far gone to be steadied. To this end discussions were carried out with small groups. In these the same freedom was allowed as is permitted in any form of free association; it was not abused. These small groups were similar in organization and appearance to the leaderless group tests, known as group discussions, which had already been used, though for a different purpose, in the WOSBs.

As soon as a sufficient number of patients had been persuaded in this way to face their enemy instead of running away from it, a daily meeting of half-an-hour was arranged for the whole TW, consisting of between 100 and 200 men. These meetings were ostensibly concerned only with live organization of the activities of the wing. The wing by now had been split up into a series of voluntary groups whose object varied from learning dancing to studying the regulations governing army pay. In fact the problems of organization, of course, hinged on the problems of personal relationships. Lost tools in the handicraft section, defective cinema apparatus, permission to use the local swimming baths, the finding of a football pitch, all these matters came back to the same thing, the manipulation and harmonization of personal relationships. As a result almost immediately these big meetings, as well as the small ones, spontaneously became a study of the intra-group tensions, and this study was established as the main task of the whole group and all smaller groups within it.

Consequently the group began to think, and a deputation voiced the thought that eighty per cent of the members of the TW were "skrim-shankers". "work-shys", malingerers, and the rest, and ought to be punished. A month before the TW had complained indignantly that inmates of a psychiatric hospital were regarded by the rest of the community as just these things. It was disconcerting, but a revelation of what psychiatry could mean, when the psychiatrist refused to accept this wholesale diagnosis and simple proposal of punishment as the appropriate form of therapy, as a sound solution of a problem that has troubled society since its commencement. The therapeutic occupation had to be hard thinking and not the abreaction of moral indignation. Within a month of the start of this metier these patients began to bear at least a recognizable resemblance to soldiers.

Throughout the whole experiment certain basic principles were observed. In order of their importance they are set down here, even though it involves repetition:

• The objective of the wing was the study of its own internal tensions, in a real-life situation, with a view to laying bare the influence of neurotic behaviour in producing frustration, waste of energy, and unhappiness in a group.
• No problem was tackled until its nature and extent had become clear, at least to the greater part of the group.
• The remedy for any problem thus classified was only applied when the remedy itself had been scrutinized and understood by the group.
• Study of the problem of intra-group tensions never ceased— the day consisted of twenty-four hours.
• It was more important that the method should be grasped, and its rationale, than that some solution of a problem of the wing should be achieved for all time. It was not our object to produce an ideal training wing. It was our object to send men out with at least some understanding of the nature of intragroup tensions and, if possible, with some idea of how to set about harmonizing them.
• As in all group activities the study had to commend itself to the majority of the group as worthwhile, and for this reason it had to be the study of a real-life situation.

One of the difficulties facing a psychiatrist who is treating combatant soldiers is his feeling of guilt that he is trying to bring them to a state of mind in which they will have to face dangers, not excluding loss of life, that he himself is not called upon to face. A rare event, but one that does occur, is when an officer is called upon to stop a retreat that should not be taking place. His prominence at such a time will certainly mean that he will be shot at by the enemy; in extreme cases he may even be shot at by his own side. Outside Nazi Germany psychiatrists were not likely to be shot for doing their job, though of course they could be removed from their posts. Any psychiatrist who attempts to make groups study their own tensions, as a therapeutic occupation, is in today's conditions stopping a retreat and may as a result be shot at. But he will lose some of his feeling of guilt.

In conclusion it must be remembered that the study of intragroup tensions is a group job. Therefore, so long as the group survives, the psychiatrist must be prepared to take his own disappearance from the scene in not too tragic a sense. Once the rout is stopped even quite timid people can perform prodigies of valour, so that there should be plenty of people to take his place.

Abrupt termination

Within six weeks Bion had achieved dramatic success in getting the large majority of the men in the TW to re-engage with the soldier's role and to return to military duties. But there was a price. The disorder created on the way so disturbed the rest of the hospital that the experiment was abruptly terminated by order of the War Office. Patrick de Maré (1985) who was on the psychiatric staff at the time comments as follows:

Bion saw the large meeting of 100-200 people as the main trunk of the tree which could explore the tensions of the smaller activity groups—once he could persuade them to meet—which he arranged, partly by persuasion through small group meetings of chosen members, and partly by simply issuing an order to parade every day at 12:10 p.m. for announcements and other business of the TW. The result of this radical approach was that it produced a cultural clash with the hospital military authorities. The fear that Rickman's and Bion's approach would lead to anarchy and chaos occasioned War Office officials to pay a lightning visit at night. The chaos in the hospital cinema hall, with newspaper- and condom-strewn floors, resulted in the immediate termination of the project.

I personally helped Rickman and Bion to pack. Clearly, Bion was put out by these events. Rickman, on the other hand, merely exclaimend unrepentantly and unperturbedly: "Pon my soul!" in the high-pitched tone he sometimes adopted in mock surprise. [De Maré, 1985, p. 110]

The notorious indiscipline, slackness, and aggressive untidiness of the unit that Bion took over was one form of showing him and the review panel how unsuitable it was for returning any of its members to the army. Main (1983), among others, ascribes Bion's premature departure to the inability of the commanding officer and his professional and administrative staff to tolerate the early weeks of chaos. He was only partially correct. Bion was facing the TW and the hospital professional staff with the responsibility for distinguishing between their existence and purpose as a military organization and their individual beliefs that in the majority of cases health entailed a return to civilian life.

The degree of success Bion achieved in that six weeks demonstrates not only the validity of the principles he and Rickman had evolved but says even more for the double professional approach he had employed: he was in uniform, an officer in the organization (i.e., the army) confronting his men with the state of their unit; he was also a professional psychiatrist consulting with these same men in assessing their condition and deciding with them their future in a nation at war.

Lessons

On succeeding Bion to the command of the TW and making my own analysis of the situation, there seemed to me to be critical lessons to be derived from his "sacking". While he had established his own approach, he had not appraised the effect this would have on the very different psychiatric and organizational approaches of his colleagues. In my discussions with him between the time of his leaving and my appointment, it became clear that his philosophy, value system, and technical and organizational appreciations were poles apart from those of the other psychiatrists and medical administrators then at Northfield. This is not to say that it was Bion versus the rest. There were differences between the others' approaches too, but in general they were consistent in their aim of assessing the present and future life needs of the individual regardless of hospital, army, or war needs. As one of them said to his patients in a first group session, "I want you to look on me as you would the doctor in a white coat and not as someone in uniform." With this view Rickman and Bion voiced their total disagreement.

Foulkes, who came to Northfield later, began by using the small group setting as a way in which the problems of any one individual could be observed and reflected upon by other patients, so that an interactive group therapeutic process was created. I was able to enlist his full co-operation in working with activity groups where the strength and persistence of the forces operating towards the attainment, distortion, or avoidance of group goals demonstrated to him their relevance for treatment in the military setting. He was to say later "The changes which went on in both patients and staff were nothing short of revolutionary" (Foulkes, 1964). His part in subsequent developments has been described by de Maré (1983). These experiences played an important part in forming his approach after the war, which led to the establishment of the Institute for Group Analysis (Foulkes, 1964).

The introduction of change processes requires a search for a common understanding of purpose and methods. While only a few of the likely consequences may be predictable, it is important to explore th...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• ACKNOWLEDGEMENTS
• CONTRIBUTORS
• Introduction
• CHAPTER ONE The discovery of the therapeutic community: The Northfield experiments
• CHAPTER TWO A therapeutic community: a space for multiple transitional change
• CHAPTER THREE The therapeutic community: its potential for development and choice of future
• CHAPTER FOUR A journey towards integration: A transitional phase in the organizational life of a clinic
• CHAPTER FIVE A transitional approach to management education: the Sextant experience
• CHAPTER SIX Leadership dimensions of the physician's role: a transitional approach to training in paediatric haematology/oncology
• CHAPTER SEVEN Intermediate cultural space
• CHAPTER EIGHT Action research and transitional processes: risk prevention in a hospital in Burundi
• CHAPTER NINE The role and limits of methods in transitional change process
• CHAPTER TEN The art of reviewing: a cornerstone in organizational learning
• CHAPTER ELEVEN Self action research: An institution reviews itself
• REFERENCES
• INDEX