patients. In the DTP, nurses, all of whom are women, have primary responsibility for medication administra tion by making sure that the patients drink the methadone in their presence. The way in which nurses are professionally trained in giving patient care is similar, in some respects, to the way parents exercise authority toward children. Because of this, some marginally disturbed patients relate in childlike ways to the nurses as maternal figures.
DTP staff subscribe to the theory that intravenous narcotic abuse is symptomatic of unresolved oral con flict. Etiology centers on the addicts' early relationship with a maternal figure. Some observed patient behavior p
traits
such
as
inconporativeness
and
aggressiveness
lend
credence to the theory. On a day-to-day basis, nurses are regarded as either love or hate objects. When they administer methadone (give love) to eligible patients, they are viewed affec tionately. However, when nurses refuse methadone (withhold love) for medical or regulatory reasons, they are viewed as unkind or rejecting. Invariably some patients consciously or unconsciously adopt childlike modes of passive behavior, apparently to wand off the maternal figure's disfavor and accordingly minimize the risks of not being medicated.
Of all the regulations that incur a patient's anger, none is more detrimental to the treatment relationship than that for urine surveillance. FDA regulations re quire every patient to give a urine specimen at least once a week. Urine specimens are tested to detect whether a patient is using nonprescribed drugs on medications. FDA specifies that the specimens are to be collected in a way that minimizes falsification of sam pies. Therefore, DTP staff supervise urine collections through direct observation; the gender of patient and staff observer are matched. Urine collection, although an important medical necessity, often compounds clinical problems in the psychosocial area of treatment. Urine surveillance prac tices convey to patients that they cannot be trusted to collect their own specimens. Patient trust is essential to the therapeutic relationship. Without this vital in gredient, positive patient growth is less likely to occur. Perhaps even more significant clinically, urine sun veillance has the inherent potential for negatively rein forcing infantile behavior. A staff member's supervision of urine collection closely resembles the parent's super vision of young children's toilet habits. It is possible that for a patient who had an unsatisfying emotional relationship with a parent figure during the genital stage, the practice of urine surveillance may reactivate certain conflicts and fantasies. Recognizing that various regulations tend to cm cumscnibe treatment efforts, DTP staff members try to minimize the harmful psychological affects on the patients wherever possible by keeping the counselor patient ratio low enough to allow for effective counsel ing. Although the FDA recommends a counselor patient ratio of 1 to 30, the DTP ratio is 1 to 20. The staff provide active plans of individualized treatment.
Also, patients are being given greater roles to play in program decision-making. Their involvement has significantly decreased feelings of powerlessness and dependency. A recent program development was the establishment of a patient-staff grievance board on which tWo elected patient representatives serve as om budsmen. They have successfully worked with staff in resolving major problems. The staff are also attempting to increase their own clinical understanding of the psychodynamics of nan cotj@ addiction and treatment through participation in ongoing conferences with the program psychiatrist. The conferences have helped staff become more sen sitized to changes in behavior and attitude that result from transference and countertnansference reactions. When staff members recognize that the application of certain regulations will create patient anxieties on negative transference, they make appropriate modifica tions in the treatment plan. For example, under certain circumstances, a patient is allowed to give an unsuper vised urine specimen because other steps are taken to minimize falsification of samples. Prim and other authorities on methadone treatment recognize the necessity of establishing controls.' However, where the human psyche is involved, rules and requirements should be flexible. As Prim points out, this flexibility is especially important in the treat ment of drug users. Patients should be accorded respect and trust and given positive reinforcements if treatment is to prove worthwhile. 1 B.
J.
Prim
et
al.,
‘¿ ‘¿ An
Experimental
Program
for
Providing
Incen
tives to Successful Methadone Patients,' ‘¿ in Proceedings of the Fourth National Conference on Methadone Treatment, NAPAN, New York City, 1972, pp. 191—197.
BUYING HUMANIZATION: DEALING WITH THE PROBLEM OF INSTITUTIONALIZATION David B. Schwartz,
MA.
SHumanization has become a much-used word in men tal hospital literature as we try to solve the problem of institutionalization. And funds for items tagged espe cially for relieving institutionalization are beginning to appear in departmental budgets. On the whole, how ever, because of the way the funds are spent, they have little influence on the lives of the patients. How they are to be spent is almost always a unilateral decision made in an administrative office of the facility. Some where in that office, an administrative assistant has an inspiration, and six months later the wards are flooded with objects that he has judged will relieve institutional ization. I remember that one year it was fishtanks, and now Mr. Schwartz is supervisor of the vocational unit of the department of rehabilitation services at the Willard Psychiatric Center, Willard, New York 14588.
VOLUME
26 NUMBER
12 DECEMBER
1975
833
every ward has an old fishtank and bubbler somewhere in a storage closet. The fish are long dead, and so is the interest. Before fishtanks it was toilet-stall doors, ban beque grills, and rhythm bands, and afterward came art reproductions and AM-FM radios. Attendants soon ne moved the toilet doors because of personal inconven ience. I have seen a rhythm band only once, and I have never been to a barbeque. Personally I like pictures, and the radios are a great comfort in the staff coffee rooms. Ironically it is precisely the way that funds for hu manization are disbursed that accentuates institutional ization on the wand level. In most places mental hospi tal structure has been broken down into individual units to avoid the blanket administrative, numbered ward character of institutions. But in the case of funds intended to humanize the institution, changes are still implemented in the same old-line-authority manner. A decision is made, and a hundred fishtanks appear. That one particular ward has a fishtank might be of interest, but all those dreary unwanted fish become as monotonous as the institutional-green corridors. Activity programs are coming into fashion now, and they do have a contribution to make toward the human ization of the institutional environment. However, such programs usually are not budgeted at all. Spending ten cents for some knitting needles that an aide can use to teach two patients to knit would be better than spend ing a dollar for fishtanks. Yet last year two hospitals in Maryland spent much of a $710,000 gift on 2500 dresser-beds (presumably all alike) to “¿ enhance the en vironment. ‘¿ ‘¿ ‘¿ So while such spending takes place, other staff slowly give up and become institutionalized themselves because they lack funds for activity pro grams on even for a can of paint to cover the peeling walls. If we really want to attack dehumanization, we must rethink the habits that brought it about in the first place. We must realize that humanization is not pun chased or programmed, it is merely permitted to grow. 1 “¿ Legacy
for
Hospitals,―
Hospital
&
Community
Psychiatry,
Vol.
genic relaxation training were so ineffective that patients would not continue with them, whereas patients practicing the TM technique reported enjoy ing the practice and showed significant improvements in mental health on a number of qualified indices, as well as homolateral and bilateral frontal alpha EEG synchrony not seen in other relaxation techniques.2 Psychiatrists P. Carnington and H. S. Ephron report that the TM technique accelerates progress in psycho therapy and psychoanalysis.3 Dr. Harold Bloomfield, director of psychiatry at the Institute of Psycho physiological Medicine in San Diego, California, has reported great success in treating a variety of psy chiatric outpatients with the TM technique and states that it is the therapy of choice for treating neuroses.4 Dr. Byron Rigby, while at St. George's Hospital in London, found that the TM technique accelerates the rehabilitation of nonhospitalized psychotic patients, producing effects not expected from the ordinary arma mentanium of therapies.' Dr. Mohammed Shafli and others at the University of Michigan Medical Center report that the TM technique effectively reduces the usage of marijuana, cigarettes, and alcohol.6 That con clusion is supported by eight other studies in the United States, Germany, and Sweden showing reduced usage of all classes of drugs as a result of the TM technique. The TM technique has also proven successful in pilot programs at federal correctional institutions in La Tuna, Texas, Lompoc, California, and Milan, Mich igan; at the state prison in Stillwater, Minnesota; and at the Nieder Shonenfeld and the Laufen-Lebenan pnis ons in Germany. No other relaxation techniques have been shown to be as profound in their effectiveness as the TM technique. The irrational mystics in this field are not those who investigate the usefulness of a new technology, irrespec tive of its cultural origin, but those whose ethnocentric predispositions restrict them from even looking at the data. Fortunately, such people are very few today.
25, April 1974, p. 267.
Dr. Donnelly
FEBDM@K
The only comment I wish to make is that Dr. David Orme-Johnson is the vice-chancellor of Mahanishi Eu ropean Research University.U
A REPLY TO DR. DONNELLY'S COMMENT ON TRANSCENDENTAL MEDITATION David Orme-Johnson,
‘¿B. C. Glueck and C. F. Stroebel, “¿ Biofeedback and Meditation in the Treatment of Psychiatric Illnesses,' ‘¿ Comprehensive Psychiatry, Vol. 16, July-August 1975, pp. 303-321.
Ph.D.
3― Meditation
UIn reference to Dr. John Donnelly's comment about Transcendental Meditation in the July issue, ‘¿ Dr. Don nelly apparently has not looked at the data on the TM technique on he would know that it is superior to other relaxation techniques. In his own hospital, for example, it was found
that
alpha
biofeedback
training
Dr. Orme-Johnson is vice-chancellor of the Maharishi search University in Weggis, Switzerland. ‘¿Vol. 26, July 1975, p. 456.
834
HOSPITAL
& COMMUNITY
and auto European
replies
Re
PSYCHIATRY
as
an
Adjunct
to
Psychotherapy,'
‘¿ The
World
Bien
nial of Psychotherapy and Psychiatry, S. Arieti and C. Chrzanowski, editors, Wiley, New York City, in press. 4Scientific Research on the Transcendental Meditation Program: Collected Papers, VQI. 1, Maharishi International University Press, Livingston Manor, New York, 1975. ‘¿St. George's Hospital Gazette, Vol. 58, No. 2, 1973. 6M. Shafli, R. Lavely, and R. Jaffe, “¿ Meditation and Marijuana,― American Journal of Psychiatry, Vol. 131, January 1974, pp. 60-63.
DTP staff subscribe to the theory that intravenous narcotic abuse is symptomatic of unresolved oral con flict. Etiology centers on the addicts' early relationship with a maternal figure. Some observed patient behavior p
traits
such
as
inconporativeness
and
aggressiveness
lend
credence to the theory. On a day-to-day basis, nurses are regarded as either love or hate objects. When they administer methadone (give love) to eligible patients, they are viewed affec tionately. However, when nurses refuse methadone (withhold love) for medical or regulatory reasons, they are viewed as unkind or rejecting. Invariably some patients consciously or unconsciously adopt childlike modes of passive behavior, apparently to wand off the maternal figure's disfavor and accordingly minimize the risks of not being medicated.
Of all the regulations that incur a patient's anger, none is more detrimental to the treatment relationship than that for urine surveillance. FDA regulations re quire every patient to give a urine specimen at least once a week. Urine specimens are tested to detect whether a patient is using nonprescribed drugs on medications. FDA specifies that the specimens are to be collected in a way that minimizes falsification of sam pies. Therefore, DTP staff supervise urine collections through direct observation; the gender of patient and staff observer are matched. Urine collection, although an important medical necessity, often compounds clinical problems in the psychosocial area of treatment. Urine surveillance prac tices convey to patients that they cannot be trusted to collect their own specimens. Patient trust is essential to the therapeutic relationship. Without this vital in gredient, positive patient growth is less likely to occur. Perhaps even more significant clinically, urine sun veillance has the inherent potential for negatively rein forcing infantile behavior. A staff member's supervision of urine collection closely resembles the parent's super vision of young children's toilet habits. It is possible that for a patient who had an unsatisfying emotional relationship with a parent figure during the genital stage, the practice of urine surveillance may reactivate certain conflicts and fantasies. Recognizing that various regulations tend to cm cumscnibe treatment efforts, DTP staff members try to minimize the harmful psychological affects on the patients wherever possible by keeping the counselor patient ratio low enough to allow for effective counsel ing. Although the FDA recommends a counselor patient ratio of 1 to 30, the DTP ratio is 1 to 20. The staff provide active plans of individualized treatment.
Also, patients are being given greater roles to play in program decision-making. Their involvement has significantly decreased feelings of powerlessness and dependency. A recent program development was the establishment of a patient-staff grievance board on which tWo elected patient representatives serve as om budsmen. They have successfully worked with staff in resolving major problems. The staff are also attempting to increase their own clinical understanding of the psychodynamics of nan cotj@ addiction and treatment through participation in ongoing conferences with the program psychiatrist. The conferences have helped staff become more sen sitized to changes in behavior and attitude that result from transference and countertnansference reactions. When staff members recognize that the application of certain regulations will create patient anxieties on negative transference, they make appropriate modifica tions in the treatment plan. For example, under certain circumstances, a patient is allowed to give an unsuper vised urine specimen because other steps are taken to minimize falsification of samples. Prim and other authorities on methadone treatment recognize the necessity of establishing controls.' However, where the human psyche is involved, rules and requirements should be flexible. As Prim points out, this flexibility is especially important in the treat ment of drug users. Patients should be accorded respect and trust and given positive reinforcements if treatment is to prove worthwhile. 1 B.
J.
Prim
et
al.,
‘¿ ‘¿ An
Experimental
Program
for
Providing
Incen
tives to Successful Methadone Patients,' ‘¿ in Proceedings of the Fourth National Conference on Methadone Treatment, NAPAN, New York City, 1972, pp. 191—197.
BUYING HUMANIZATION: DEALING WITH THE PROBLEM OF INSTITUTIONALIZATION David B. Schwartz,
MA.
SHumanization has become a much-used word in men tal hospital literature as we try to solve the problem of institutionalization. And funds for items tagged espe cially for relieving institutionalization are beginning to appear in departmental budgets. On the whole, how ever, because of the way the funds are spent, they have little influence on the lives of the patients. How they are to be spent is almost always a unilateral decision made in an administrative office of the facility. Some where in that office, an administrative assistant has an inspiration, and six months later the wards are flooded with objects that he has judged will relieve institutional ization. I remember that one year it was fishtanks, and now Mr. Schwartz is supervisor of the vocational unit of the department of rehabilitation services at the Willard Psychiatric Center, Willard, New York 14588.
VOLUME
26 NUMBER
12 DECEMBER
1975
833
every ward has an old fishtank and bubbler somewhere in a storage closet. The fish are long dead, and so is the interest. Before fishtanks it was toilet-stall doors, ban beque grills, and rhythm bands, and afterward came art reproductions and AM-FM radios. Attendants soon ne moved the toilet doors because of personal inconven ience. I have seen a rhythm band only once, and I have never been to a barbeque. Personally I like pictures, and the radios are a great comfort in the staff coffee rooms. Ironically it is precisely the way that funds for hu manization are disbursed that accentuates institutional ization on the wand level. In most places mental hospi tal structure has been broken down into individual units to avoid the blanket administrative, numbered ward character of institutions. But in the case of funds intended to humanize the institution, changes are still implemented in the same old-line-authority manner. A decision is made, and a hundred fishtanks appear. That one particular ward has a fishtank might be of interest, but all those dreary unwanted fish become as monotonous as the institutional-green corridors. Activity programs are coming into fashion now, and they do have a contribution to make toward the human ization of the institutional environment. However, such programs usually are not budgeted at all. Spending ten cents for some knitting needles that an aide can use to teach two patients to knit would be better than spend ing a dollar for fishtanks. Yet last year two hospitals in Maryland spent much of a $710,000 gift on 2500 dresser-beds (presumably all alike) to “¿ enhance the en vironment. ‘¿ ‘¿ ‘¿ So while such spending takes place, other staff slowly give up and become institutionalized themselves because they lack funds for activity pro grams on even for a can of paint to cover the peeling walls. If we really want to attack dehumanization, we must rethink the habits that brought it about in the first place. We must realize that humanization is not pun chased or programmed, it is merely permitted to grow. 1 “¿ Legacy
for
Hospitals,―
Hospital
&
Community
Psychiatry,
Vol.
genic relaxation training were so ineffective that patients would not continue with them, whereas patients practicing the TM technique reported enjoy ing the practice and showed significant improvements in mental health on a number of qualified indices, as well as homolateral and bilateral frontal alpha EEG synchrony not seen in other relaxation techniques.2 Psychiatrists P. Carnington and H. S. Ephron report that the TM technique accelerates progress in psycho therapy and psychoanalysis.3 Dr. Harold Bloomfield, director of psychiatry at the Institute of Psycho physiological Medicine in San Diego, California, has reported great success in treating a variety of psy chiatric outpatients with the TM technique and states that it is the therapy of choice for treating neuroses.4 Dr. Byron Rigby, while at St. George's Hospital in London, found that the TM technique accelerates the rehabilitation of nonhospitalized psychotic patients, producing effects not expected from the ordinary arma mentanium of therapies.' Dr. Mohammed Shafli and others at the University of Michigan Medical Center report that the TM technique effectively reduces the usage of marijuana, cigarettes, and alcohol.6 That con clusion is supported by eight other studies in the United States, Germany, and Sweden showing reduced usage of all classes of drugs as a result of the TM technique. The TM technique has also proven successful in pilot programs at federal correctional institutions in La Tuna, Texas, Lompoc, California, and Milan, Mich igan; at the state prison in Stillwater, Minnesota; and at the Nieder Shonenfeld and the Laufen-Lebenan pnis ons in Germany. No other relaxation techniques have been shown to be as profound in their effectiveness as the TM technique. The irrational mystics in this field are not those who investigate the usefulness of a new technology, irrespec tive of its cultural origin, but those whose ethnocentric predispositions restrict them from even looking at the data. Fortunately, such people are very few today.
25, April 1974, p. 267.
Dr. Donnelly
FEBDM@K
The only comment I wish to make is that Dr. David Orme-Johnson is the vice-chancellor of Mahanishi Eu ropean Research University.U
A REPLY TO DR. DONNELLY'S COMMENT ON TRANSCENDENTAL MEDITATION David Orme-Johnson,
‘¿B. C. Glueck and C. F. Stroebel, “¿ Biofeedback and Meditation in the Treatment of Psychiatric Illnesses,' ‘¿ Comprehensive Psychiatry, Vol. 16, July-August 1975, pp. 303-321.
Ph.D.
3― Meditation
UIn reference to Dr. John Donnelly's comment about Transcendental Meditation in the July issue, ‘¿ Dr. Don nelly apparently has not looked at the data on the TM technique on he would know that it is superior to other relaxation techniques. In his own hospital, for example, it was found
that
alpha
biofeedback
training
Dr. Orme-Johnson is vice-chancellor of the Maharishi search University in Weggis, Switzerland. ‘¿Vol. 26, July 1975, p. 456.
834
HOSPITAL
& COMMUNITY
and auto European
replies
Re
PSYCHIATRY
as
an
Adjunct
to
Psychotherapy,'
‘¿ The
World
Bien
nial of Psychotherapy and Psychiatry, S. Arieti and C. Chrzanowski, editors, Wiley, New York City, in press. 4Scientific Research on the Transcendental Meditation Program: Collected Papers, VQI. 1, Maharishi International University Press, Livingston Manor, New York, 1975. ‘¿St. George's Hospital Gazette, Vol. 58, No. 2, 1973. 6M. Shafli, R. Lavely, and R. Jaffe, “¿ Meditation and Marijuana,― American Journal of Psychiatry, Vol. 131, January 1974, pp. 60-63.
