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The
Psychiatric Nurse Role in Fraser House
A
Paper Written by Fraser House Patients Posted Jan 2001
Updated
April 2014. Dr Neville
Yeomans, the founding director of Fraser House Therapeutic Community in
Sydney used patients being involved in action research as an integral aspect of
their transforming. This paper written by patients at Fraser House
Therapeutic Community provides a glimpse of their capacity. Patients also
wrote the Fraser House Staff Handbook that detailed the processes then in use
at Fraser House. One version of this same paper commenced with the words –
‘So you have decided to become a nurse at Fraser House; good career choice!’ Preamble As
with all new work situations, so to working as a new nurse in this community means
coming to grips with a degree of initial stress. The job is not easy at first, and one thing
is certain - it can only be done well by all staff members seeing themselves
as members of a TEAM. Only then can
new tasks become tolerable and the difficulties surmountable. This is the first and most important
working rule to be learned, and with the acceptance of it everything else
will tend to fall into place. This
basic point can’t be stressed too much, and new nurses are advised to lean
heavily on the team in the first few weeks in particular. By communicating
difficulties, responsibilities will be spread out and training will continue.
Nothing has to be faced alone. The staff
team gives the example on which the patients will perforce model themselves.
It has been a lesson well learned here, as in other therapeutic communities
all over the world, that when the staff team pulls together the patients tend
to do likewise, and from this comes the amalgamation of true community effort
that results in success all along the line in the treatment program. Perhaps the
most immediate observation made by a nurse coming to work in this therapeutic
community for the first time, is that the patients themselves have had a great
deal of authority delegated to them. Indeed, in some matters they are
virtually the sole authority. At first glance it will seem fantastic that
patients assess and admit new patients; review progress and institute
treatment procedures; make new rules and alter old ones; mete out discipline,
etc. To many new
nurses and doctors as well, and particularly to those whose previous
experience was connected with the physically ill in the general hospital
field, or who come from psychiatric settings more formalized in approach, all
of this will be right out of line with their training and role appreciation.
Adjustment will have to be made, and acceptance that this is necessary is the
first and most important step towards fitting into the altered (and ever changing)
role required. In sum,
nurses here at Fraser House are not so much doing FOR the patients as working
WITH and SHARING an experience. This is basically what is expected. Understanding the reason
behind the differences in work standards and altering roles helps - no one
would be willing to change his work pattern in, or the why he sees himself in
work without reasonable explanation.
If the therapeutic community can be viewed as necessary evolution
change towards democratic self-discipline, and if the nurses’ role can be
seen as becoming more therapeutic as it moves away from that of custodian
towards autonomy for the patients, then the first step is made. CONCEPT In the basic role of the nurse in
Fraser house is that of therapist and this means accepting the patients as
worthwhile and worthy of help and so, aiming to change their deviant
behaviour and the deviant ways they see themselves or others. The nurse also is a representative of
society, and becomes involved with patients in order to return their
neurotic, psychotic or other deviant behaviour to the norm of this society. The nurse remains as much
a therapist in being with one patient or with an informal group of patients
as in formal group therapy. To be a
therapist means to express real caring and times, discipline about
patients. Training in psycho and
socio-therapeutic techniques is a continuing process and the nurse enters
into research work and the domiciliary field as well. The nursing staff makes up the largest
portion of the staff team and has 24-hour close interpersonal contact with
the patients. The role is vital, and
in many ways is the most important. ROLE Nurses are assigned in teams to
regional areas at the moment - Lane Cove, Ryde, Rest of North Shore, Other
Areas. Each regional team is expected
to be responsible for knowing their area, its problems and helping agencies
etc.. Moreover nurses in each team are
expected to come to know all in-patients and outpatients of that area in; to
be specially involved in the appropriate regional small groups, both in the
community and in the Unit; to record progress notes on their regional
patients; be part of both for medical officer and follow-up committee
planning for the patients of their region. Nurses working in community and social psychiatry ‘steal’
many of the roles of psychiatrists, psychologists, medical offices,
sociologists and social workers. This
gives the nurse much more power to initiate and decide and also the
accompanying responsibility. So the role of the nurse in Fraser
house is seen as complex and wholly therapeutic, using a team approach in a
therapeutic community to set the climate for personality change and social
reorganization. The new nurse will at first learn
various areas, and these will be filled in to fit into shape as the tour of
duty lengthens. An hour or so will be spent with a senior staff member on the
first day for initial induction discussions, and the newcomer is paired off
to work with a nurse who is versed in Unit procedure. Experience has shown
how the patients actually give a great deal of help to new staff in aiding in
their orientation. The new nurse will receive plenty of support to fit into
the community. Fraser House traditions are now well established. There are no
great dissatisfactions to overcome. Nurses are on the staff to work as
members of a therapeutic team, and to receive a training that has profitable
personal and career rewards. Better training and greater work satisfaction
for staff are basic aims in therapeutic communities. GROUP THERAPY The significance of group therapy in
Fraser House may be gauged by the fact that there are about three thousand
groups structured in a year involving twice this number of man-hours by the
nursing staff. Reporting sessions, attended by nursing staff follow each of
these groups, also consume more man-hours devoted to analysis and
interpretation of each group, and exchange of information brought out by
these groups. These reporting sessions are also for continuous training in
all aspects of community and social psychiatry Small groups
are made up of from eight to twelve people, and are allocated daily. These
allocations are made to conform to different patterns according to age and
marital state, according to social class and marital state, according to sex
and marital state. Also, there are intergenerational groups consisting of
patients and their families, of each medical officer attached to the Unit,
and groups made up of ‘withdrawn’ patients. The
unstructured groups are special groups held for particular patients for
various reasons, e.g., they may be planned and scheduled for certain times
during the day or night when a patient’s relatives arrive from the country.
Or they may be spontaneous, when a relative arrives unexpectedly. Or they may
be held as and when a particular patient, or patient family becomes disturbed
over some crisis which arises. THE THERAPIST
IN SMALL GROUP THERAPY The role of
small group therapist and observer has always been the province of the nurse
in Fraser House, and represents part of the rise in therapeutic status.
Nurses have become therapists in their own right. The first
essential in taking a group is to see it as a meeting, and like all meetings,
there is a need for a chairman to conduct affairs and keep issues to the
point. The initial
function of the therapist is to see that the group functions as a group. It
may be necessary for him to be quite directive in order to achieve this in
some groups, but on the other hand it may just happen anyway even if he
adopts a completely passive and wordless role. How active or passive,
directive or non-directive the therapist is or chooses to be, may be
influenced by many things – e.g., the attitude or mood of the group itself
and tensions built up prior to and during its running; the type of group and
purpose, or the themes introduced during the group. The therapists own
personality is a basic factor which determines handling, and this may vary
from day to day depending on the therapist’s mood, and also on his attitude
to the type of group or even some of the people contained in it. It should be
said here that, whilst one might be influenced to some extent by the way
certain therapists conduct the group, it is inadvisable and unwise, and
indeed well nigh impossible for one therapist to copy another, for the
previously stated reason that the therapist’s own personality is a basic
factor in determining the handling of groups. So that even if one decided on
a particular therapist as ones ‘idol’, one should not attempt to emulate too
closely. Because of this ‘personality’ factor and other rather intangible
factors, there are not many rigid rules which can be generalized to apply to all
groups, but the following can be applied to most: THEMES If a theme is
introduced, and it is considered to be not too superficial or inappropriate,
the group should pay some attention to it, and not change the theme to
another without good reason. If an attempt to change the theme is made, it
may be done deliberately by a patient for a fairly obvious reason (such as a
personality clash with someone involved in the previous theme), or a less
obvious reason such as an unconscious identification and a consequent wish to
avoid the theme. It may also be done through plain insensitivity on the part
of the person making the attempt at the change. There are many reasons for
these moves, and it is the therapist’s role to decide on the dynamics of the
situations and then to make use of them by feeding them straight back into
the group at the time, and if necessary, to make an interpretation of the
dynamics operating in the events and occurrences. It is also in
the province of the therapist to direct the group away from superficial
themes or from discussing themes in a superficial manner. The therapist, in
order to discourage superficiality, may find it necessary to commence the
group immediately he enters the room, by physically structuring the group in
such a way that he gains attention, establishes some kind of control, and
incidentally builds some initial tension within the group. This, of course is
not always necessary or desirable, but is often helpful in dealing with
groups of teenagers who tend to spread themselves around the room, put their
feet up on chairs, and throw matches and cigarettes about. These practices in
themselves are quite harmless, but in group are often used as avoiding
tactics, and are apt to wreck and render valueless the group itself. So the
therapist can avert these disruptions when he enters the room by making
everyone get up and draw their chairs into a tight circle in the centre of
the room and disallowing feet up on chairs. In general,
the therapist should make use of what is going on in each particular group at
the time it is taking place. He has first to be able to recognize what is
going on and he can only do this through observation and experience. The way
he uses these things which are going on within the group depends to a large
extent on the therapist himself – again the personality factor. Even though a
therapist is inexperienced, and perhaps not very confident, he should keep in
mind that he brings something very valuable to the group with him – something
which no one else can do in the same way – the sum total of his own unique
life experience. When used with confidence, this is a very powerful force
which all nurses have at their disposal. INTERACTION
AND INTEREST If most of
the group is involved in interaction, it goes without saying that they are
also interested. However, interest can be very high even though there is not
much interaction. Look at their faces, their feet, their hands, their
respiration, the way they sit, and it will be known if they are interested or
not. Interaction may not be high if the therapist has found it necessary to
be active or directive. This sometimes must be the case. TENSION There will
usually be varying amounts of tension as the group progresses, both from the
group as a whole, and from individual members. Silences usually build up
while tension is mounting, and the best way to use this tension is not to
break these silences; let the members of the group do it as they will when
they can no longer stand the tension – and then see what is released with the
tension and make use of it. MOOD The mood of a
group is sometimes sustained throughout, but more often it changes, ranging
through many emotions and frequently depending to some extent on the build up
and release of tension, the themes discussed and the manner of the
discussion, the interaction and the interest, and the cross-identification of
those who interact. The role adopted by the therapist is also important here.
Once again, the emotions which set the mood for the group are used. BIG GROUPS Whereas much
has been achieved over the years in the way of explanation and handling of
individual and small group difficulties, little is to hand to clarify the
acknowledged emotional forces and the psycho-therapeutic techniques of large
community groups. Most
individual maladjustments can be readily recognized by seeing a personality
at conflict with himself and his environment. Small groups portray the
‘family’ setting and inter-personal interaction. But ‘Big Groups’ forming as
they do the backdrop to all therapy in this Unit, are not explainable
adequately in the term of psychology or psychiatry previously applied to the
individual patient or even to the classical group situation. The sciences
of sociology and social psychology, with their study of whole collections of
people and the interplay of these groupings within entire societies, are used
to explain both these dynamics of the Big Groups and the therapeutic
directions of the whole community. Theories of behaviour of crowds and audiences
apply to the Big Groups in particular. The
techniques used in handling these meetings are principally our own and have
evolved through testing and retesting of basic theories by adoption and
‘trimming’ of those found successful by some leaders, and by constant
discussion and evaluation of the problems these community groups pose. The
community meetings held at Fraser House are of two main types and a third is
gradually evolving. Morning community groups have two main therapeutic
functions; personality change is the aim of four meetings, while social
control is the focus of the Thursday morning administrative group. Evening
Big Groups, though not compulsory, are invariably well attended by
in-patients. But by far, the majority attending can be classified as
outpatients and these receive the bulk of the attention. With family therapy
as a principle, the projective interplay of the various families present
characterizes these meetings to such a degree as to almost typify the aim of
the evening Big Groups. The setting
is a large hall (the Centre Block) in which clear speaking is adequate,
central to both wings of the building. Seating is in two rows at the sides
and one end with a single row at the end nearest the entrance door. The group
leader usually sits in the centre of this row, but is free to move according
to his or her dictates. All of the chairs face centrally so that, as much as
possible, everyone is in view and speakers can face each other. But
principally the people are shoulder-to-shoulder as in an audience as well as
being members of a single crowd - usually numbering about one hundred
persons. Two members
of the nursing staff (one male - one female) observe and record the meeting
from a detached point behind the back row. Other staff members
(medical, nursing, research, etc) intersperse themselves among the patients,
paying particular attention to the three inner corners (notorious
geographically for the most destructive and resistive sub-groups) but leaving
the doorway clear of staff. Portion of a row is reserved here to lessen the
interruption made by latecomers. It has become
traditional that the four ‘therapeutic’ Big Groups commence with a reading of
the ‘Ward Notes’ by one of the patients. On Thursdays this is deferred till
after the various committee reports and elections. In essence these ward
notes serve the purpose of an informal Unit newspaper and comprises all
manner of notifications from grouches about yesterday’s foodstuff to staff
warnings against suspected ‘conmanship’. Usually the
therapist then allows the group to enter into spontaneous ‘free floating’
discussion until a general interconnecting theme is apparent. This may then
be pursued with promptings towards interaction between different generations
or social classes or psychiatric opposites – or perhaps to tie in together
for mutual support those with similar difficulties, personally or because of
family or life-crisis situation. At times the
focus might fall on one particular patient or family to highlight a special
need, and it is quite common for sub-groups or cliques to merit attention.
These latter are constantly forming, breaking and re-forming, and the group
leader much of the time finds it impossible to be aware of these changes and
undercurrents. The interspersing of staff members throughout does much to
obviate this as these moves can be discussed later in the reporting session,
or if urgent, brought to the attention in the group by the staff member aware
of the moves. Most meetings see the group as a whole reacting much like and
audience to a few main actors. This can be constructive as an insight-gaining
process as the personal, intra and inter-family or sub-group projections are
portrayed and leadership values rise or fall. At other times when matters affecting
the internal security of the community arise or pressures are brought to bear
from outside sources, interpersonal differences are dropped for combined
feeling and action and the Unit becomes united as its projection against
threat is shown. So the audience-type reaction displaces to behaviour more
attributable to that of a crowd. When these crowd-like emotional forces move
the whole community, the opportunity is presented to harness these towards a
therapeutic goal which can do more in a single hour towards personality
change for more people than many months of other therapy. Herbert Blumer says
of these forces: ‘People become aroused and more
likely to be carried away by impulses and feelings; hence rendered more
unstable and irresponsible. In collective excitement, the personal make-up of
individuals is more readily broken and in this way the conditions prepared
for the formation of new forms of behaviour and for the re-organization of
the individual. In collective excitement, individuals may embark on lines of
conduct which previously they would not have thought of, much less dared to
undertake. Likewise, under its stress and with opportunities for the release
of tension, individuals may incur significant re-organization in the
sentiments, habits and traits of personality (Blumer unknown).’ When
both the staff and patients are working well together in the Unit, a peak of
enthusiasm is reached at times when everyone sees almost any move at all as
being gainful. New enterprises are embarked upon with an eagerness that is
almost inspired and success is a certainty. Whereas perhaps a month earlier
the same move would have met an equally certain failure. All improvements in
expanded therapy services and the patient-government structure (and the
recent acquisition of the Unit vehicle) have been adopted at such times. The opposite
of gain is loss and this is felt most acutely in a feeling-wave by the entire
community at a time of bereavement, deprivation or mourning – when a fellow-patient’s
close relative dies; rejecting parents spurn pleas for help; or there has
been a serious or fatal attempt at suicide. Here the all-pervading shared
sadness can give rise to depressives becoming overwhelmed with emotional
forces of loss and breaking into bitter tears as a sign of externalizing
their feelings of aggression and loneliness. The sincere sympathy given by
fellow-patients and therapist at these times can do much to consolidate
future lessening of inhibition while false exaggeration of hope is avoided. Again, when
as a whole the Big Group is swayed by frustration, contagious aggression and
excitement result; just as contagious as the feelings of fear and panic
experienced due to a shared threat anywhere. The
recognition and use of these crowd feelings by the therapist are usually
intuitive. The leader must ‘feel’ these and employ them – they are of the
greatest value when utilized therapeutically towards corrective emotional
experience. This can be rated as either an individual, a family, the whole
group, or any combination of these being helped in this direction. Community
meetings are followed by a report by the two official observers, and comment
by all staff members present, including the therapist who took the group.
Points assessed are: Mood Theme Value and
interaction Therapist’s
role Techniques
employed From
these ‘post-mortems’ comes much of the knowledge needed. At the moment this
seems by no means exhaustive. The aim must be always to look at the community
in the ‘BIG’ – as a whole and this certainly is no easy matter. FURTHER
THEORY AND EXAMPLE The Fraser
House Therapeutic Community is a sub-community of Lane Cove and Ryde aimed at
all the different social problems of these areas. There is an inherent
movement towards change resulting from the emotional contact of people with
different problems. This change is a
therapeutic change if the atmosphere is one of help, respect for the
worthwhileness of each person, and discipline where necessary. A professional
man, father of a schizophrenic girl, once abused the patients and the Unit,
because he was sick of people of lower education etc. telling him what to do.
His education and professional knowledge were not in doubt, but his capacity
as a loving trusting father was. Those like him in age and education had
tried and failed to change him in the past. Those unlike him could do so with
much more effect. This
therapeutic community attempts to reproduce normal life in many ways,
particularly in allowing the development of emotional storms (as they occur
in families) and in not enforcing overly good behaviour, as is the usual
hospital pattern. Like normal life too, there are limits and so effective
discipline is a major part of the program, especially for those with
antisocial or hostile problems. The process
of change for the disturbed patient and family may be described in many ways.
One is that the Unit attempts to provide emotionally corrective experiences in
the conflict area. This can be seen in the spreading of a theme within a
group or in the contagion of feeling within the Unit that always most deeply
affects those with the problems in the area of conflict which set off the
emotion. When sexual interference becomes an emotional topic, the experienced
therapist can tell at a glance all those women and girls who have had a
similar experience - it screams from their faces. They can then be helped to
face this and all the covering up about it, in them and in their family. Success for a therapist is now known to
depend very much on how much the patient realizes that the therapist cares.
This cannot be acted by the therapist – and here lies the importance of
learning to relax and be oneself and express oneself in the therapeutic
situation Caring for
the patient does not mean loving and accepting everything he does. You don’t
care for someone if you let them wreck themselves or harm others. It means
coming to see and feel that the patient is a person worth helping and
changing. It means to accept the person, but reject their deviant problems
(e.g., love a depressed person, but NOT their depression – want to change
their depression). Particularly it means rejecting abnormal behaviour,
particularly that which is harmful to others. So here caring will mean love and
discipline. There are
some points which help in the therapeutic approach to whole families in
groups: 1.
Aim
to help the whole family 2.
Help
them not to push the most deviant member down when they are under tension 3.
Encourage
parents of the presenting patient to talk about their difficulties with their
own parents, and each other. 4.
If
the presenting patient has improved more than the rest of the family, suggest
they forget his problems and talk about their own 5.
Make
sure the different generations in the family attend different small groups
much of the time 6.
The
overt symptoms in the presenting patient usually indicate the key conflict
for all the family 7.
Suggest
family members who insist they have no problems, that you would like them to
be more selfish and talk about themselves anyway 8.
Don’t
reject the parents because of what you see they have done to their child –
find out what he has done to them 9.
No
parent ever purposefully wrecks his or her child. They should not be blamed
for a tragedy they were caught up in 10.
Don’t
adopt any of the above techniques unless you feel it The
emotional comfort and satisfaction of the Unit staff is one of the most
significant features of the therapeutic program. The numerous staff meetings
aim to foster this. Specifically their role is to prevent the development of
covert, hidden conflict between staff members about patients. Such conflicts
are proven to result in overt patient disturbance. The staff remains the most
powerful members of a therapeutic community and their welfare and comfort are
of paramount importance. Blumer, H. (unknown). Elementary Collective
Behaviour - Principles of Sociology. Links Other
Links: Cultural
Keyline - Chapter Seven - Governance and Other
Reconstituting Processes New Roles for Sociologists and
Psychologists |