The Psychiatric Nurse Role in Fraser House
A Paper Written by Fraser House Patients
Posted Jan 2001 Updated April 2014.
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.
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.
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.
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:
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.
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.
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.
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:
Value and interaction
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.