M a n a g e m e n t o f C h a r a c t e r D i s o r d e r s in a H o s p i t a l S e t t i n g * A L E X A N D E R

G R A L N I C K ,

M.D., F.A.P.A.t

| Port Chester, N.Y.

Management of the character disorders in a hospital is synonymous with the therapeutic process itself. No single mode of therapy is the answer. The key seems to be a structured social setting, a therapeutic milieu involving an interdisciplinary team approach in which harmony, mutual trust and relative agreement about patient goals prevail. T h i s a r t i c l e w i l l n o t address i t s e l f t o t h e m a n a g e m e n t o f t h e c h a r a c t e r d i s o r d e r s i n p s y c h i a t r i c hospitals g e n e r a l l y , b u t t o t h a t i n a particular hospital, namely, H i g h Point Hospital. A few words then w o u l d be i n o r d e r t o describe o u r f a c i l i t y . H i g h P o i n t H o s p i t a l is a 4 5 b e d , a c c r e d i t e d , licensed h o s p i t a l some 27 years o l d . I t has d e v o t e d i t self t o a n a n a l y t i c a l l y a n d d y n a m i c a l l y o r i e n t e d p r o g r a m o f i n t e n s i v e psychotherapy, m a i n l y i n d i v i d u a l , b u t s u p p o r t e d by g r o u p , f a m i l y , d r u g a n d m i l i e u t h e r a p y . I t has e x p o s e d its ideas t o t h e p r o f e s s i o n t h r o u g h w r i t i n g r e l a t i v e l y e x t e n s i v e l y , ' has m o d i f i e d a n d d e v e l o p e d its t h e r a p e u t i c p r o g r a m c o n s t a n t l y i n k e e p i n g w i t h its c l i n i c a l e x p e r i e n c e , a n d has b e e n i n n o v a t i v e i n several areas. W e have e m p h a s i z e d l o n g e r - t e r m t h e r a p y , e v e n i n t h e face o f t h e i n c r e a s i n g t r e n d t o w a r d b r i e f h o s p i t a l i z a t i o n , a n d have t r e a t e d l a r g e n u m b e r s o f y o u n g s c h i z o p h r e n i c p a t i e n t s . A s a m a t t e r o f fact, f o r m a n y years t h e b u l k o f o u r p a t i e n t s have b e e n y o u n g p e o p l e , m a n y o f w h o m i n m o r e r e c e n t years s h o w t h e stigmata o f the character disorders. 1

THERAPEUTIC

2

SETTING

W e basically believe t h a t social b a c k g r o u n d a n d e n v i r o n m e n t p l a y a l a r g e p a r t i n g e n e r a t i n g m e n t a l d i s o r d e r s , a n d t h a t these illnesses a r e l o n g i n d e v e l o p i n g , t h o u g h s e e m i n g l y o f t e n p r e c i p i t a t e d b y a single e v e n t . S i m p l y p u t , w e t h e r e f o r e believe t h a t a t h e r a p e u t i c e n v i r o n m e n t is essential i f such d i s o r d e r s a r e t o be successfully a r r e s t e d , a n d t h e p a t i e n t s i g n i f i c a n t l y assisted t o m o v e i n a h e a l t h i e r d i r e c t i o n . W e l o o k u p o n o u r i n s t i t u t i o n as a n e v o l v i n g social s t r u c t u r e — a n o r g a n i z a t i o n o f p e o p l e — w i t h its o w n h i s t o r y a n d its o w n v a l u e system. T h u s , i t is a v i * P r e s e n t e d at the F o u r t e e n t h N a t i o n a l S c i e n t i f i c M e e t i n g o f t h e A s s o c i a t i o n f o r the A d v a n c e m e n t o f P s y c h o t h e r a p y , A t l a n t a , G e o r g i a , M a y 7, 1 9 7 8 . f Medical Director, H i g h Point Hospital, Port Chester, N e w Y o r k , N . Y . A M E R I C A N J O U R N A L O F P S Y C H O T H E R A P Y , Vol. X X X I I I , No.

54

1, J a n u a r y

1979.

10573.

CHARACTER

DISORDERS

I N HOSPITAL

55

b r a n t society i n t o w h i c h t h e p a t i e n t is i m m e r s e d , a n d t h i s affects changes h i m .

and

I t does m o r e t h a n m e r e l y r e l i e v e h i m o f s y m p t o m s .

W e m a i n t a i n a r a t i o o f o n e f u l l - t i m e b o a r d - q u a l i f i e d o r c e r t i f i e d psyc h i a t r i s t f o r e v e r y six t o e i g h t p a t i e n t s . therapy.

T h e y alone do the p r i m a r y

A l l o f us a r e h o u s e d i n o n e c o m p a c t b u i l d i n g , a fact w h i c h

facilitates g o o d a n d easy c o m m u n i c a t i o n .

Frequent interdisciplinary

c o n f e r e n c e s are h e l d , a n d a l l m a j o r decisions a r e m a d e by consensus. T h e t e a m is p r i v y t o a l l i n f o r m a t i o n , a n d t h e p a t i e n t s a r e a w a r e o f t h i s . A n active, i n t e n s i v e r e g i m e p r e v e n t s a p a t i e n t d e v e l o p i n g " h o s p i t a l i t i s " even after extended

periods.

T h e therapist maintains direct relation-

ship w i t h the patient's family. I t is w o r t h n o t i n g t h a t t h e t h e m e "management"

of

t h i s c o n f e r e n c e deals w i t h

o f a particular psychiatric entity.

g o r i c a l l y r e f e r t o t h e " t r e a t m e n t " o f a disease. that

"management"

synonymously.

and

"treatment"

I do not know.

were

I t does n o t

cate-

P e r h a p s i t was i n t e n d e d to

be

thought

of

W h a t e v e r t h e case, t h e t e r m " m a n a g e -

m e n t , " r a t h e r t h a n " t r e a t m e n t , " w o u l d seem m o r e a p p r o p r i a t e w h e n r e f e r r i n g to the patient w i t h a character disorder i n the hospital setting. I n t h i s c o n t e x t t h e w o r d s " d e a l i n g w i t h " w o u l d p r o b a b l y be s y n o n y m o u s with "management."

F u r t h e r , these t e r m s m a y be m o r e a p p r o p r i a t e t o

o u r o w n p r e s e n t a t i o n a n d a p p r o a c h t o t h e subject m a t t e r as w e l l as t h e subject h i m s e l f — t h o u g h I t h i n k we w o u l d basically see o u r " m a n a g e m e n t " a c t u a l l y as t h e t r e a t m e n t process p r o p e r . T h i s a r t i c l e is t h e e n d r e s u l t o f s o m e t e n s t a f f c o n f e r e n c e s a t t e n d e d by o u r i n t e r d i s c i p l i n a r y t r e a t m e n t t e a m , each l e d by a d i f f e r e n t m e m b e r d e v o t i n g h i m s e l f t o a p e r t i n e n t aspect o f t h e subject m a t t e r .

We dealt

w i t h t h e d e f i n i t i o n a n d classification o f t h e e n t i t y , t h e v a r i o u s t h e r a p i e s , i n c l u d i n g d r u g , f a m i l y , a n d m i l i e u , as t h e y a p p l y t o t h e subject, a n d t h e r o l e o f t h e v a r i o u s specialists o f t h e t e a m , s u c h as t h e

psychotherapist,

n u r s e , a n d social w o r k e r , as each deals w i t h t h e c h a r a c t e r d i s o r d e r s .

In

a l l o f t h e discussions we b r a n c h e d o u t i n t o a v a r i e t y o f byways i n t o w h i c h o n e m u s t i n v a r i a b l y stray w h e n d e a l i n g w i t h t h e m a n a g e m e n t p a t i e n t i n a h o s p i t a l society.

of the

T h u s , t h i s a r t i c l e is t h e o u t c o m e o f t h e j o i n t

endeavor o f o u r professional team.

T h e c r e d i t , o r d i s c r e d i t , as t h e case

m a y be, c o m e s t o a l l as a t e a m , n o t t o a n y o n e i n d i v i d u a l , since o u r t h i n k i n g is t h e same w i t h r e g a r d t o t h e e n d r e s u l t a c h i e v e d i n t h e m a n a g e m e n t o f the patient. DEFINITION The

character

disorders.

disorders

are otherwise

k n o w n as t h e

personality

K n o w l e d g e o f t h e i r types is i m p o r t a n t , as is t h e fact t h a t t h e

n a t u r e o f one's p e r s o n a l i t y c o l o r s t h e a b n o r m a l state o f m i n d he m a y

56

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develop.

J O U R N A L OF

PSYCHOTHERAPY

T h e r e is s o m e a g r e e m e n t t h a t m a n y u n u s u a l p e o p l e exist w h o

are p s y c h i a t r i c " p r o b l e m s " b u t n o t g e n e r a l l y c o n s i d e r e d to be s u f f e r i n g f r o m one o f the m o r e f o r m a l l y recognized disorders.

Unfortunately

t h e r e is n o consensus as t o h o w s u c h u n u s u a l , i f n o t a b n o r m a l , p e o p l e s h o u l d be classified. M a n y believe t h a t c e r t a i n i n s t i n c t s , o r basic n e e d s , p r o v i d e t h e d r i v i n g p o w e r b e h i n d a p e r s o n a l i t y , a n d a r e u l t i m a t e l y r e s p o n s i b l e f o r one's b e h a v i o r , t h o u g h t h e i r e x p r e s s i o n a n d s a t i s f a c t i o n a r e m o d i f i e d b y one's environment and experience.

T r a i t s vary greatly a m o n g people and

their d i s t r i b u t i o n follows a n o r m a l curve.

T h u s , for example, the fre-

quency o f occurrence o f courage, like intelligence, will range f r o m a small m i n o r i t y w h o are u n u s u a l l y brave t h r o u g h a large m a j o r i t y w i t h an a v e r a g e a m o u n t o f c o u r a g e , t o a s m a l l m i n o r i t y w h o are f r a n k c o w a r d s . T h e same p r i n c i p l e a p p l i e s t o i r r i t a b i l i t y , s e n s i t i v i t y , s o c i a b i l i t y , a n d so on. W i t h c o n s t i t u t i o n a l a n o m a l i e s we d e a l w i t h e x t r e m e v a r i a n t s o f t h e n o r m a l i n one d i r e c t i o n or another.

T h e nature o f their distribution

suggests t h a t t h e r o o t s lie m a i n l y i n i n d i v i d u a l e n d o w m e n t m a y have b e e n m o d i f i e d by e n v i r o n m e n t a n d e x p e r i e n c e .

though it Those with

these c o n s t i t u t i o n a l a n o m a l i e s b e c o m e t h e subject o f o u r a t t e n t i o n because t h e i r d i f f i c u l t y i n a d j u s t i n g t o a c o m m u n i t y c o m p o s e d o f n o r m a l p e o p l e gives rise t o c o m p l a i n t s f r o m o t h e r s .

more

Some theorize that

t h e r e has b e e n n o i n h e r e n t d e f e c t , b u t t h a t t h e n a t u r e o f one's social background

a n d e x p e r i e n c e r e s u l t e d i n a m a j o r v a r i a n c e we call t h e

character or personality disorder. Antisocial Personality A t any rate t h e r e are the f o l l o w i n g personality types: the schizoid, cyclothymic,

h y s t e r i c a l , obsessional,

gressive, i n a d e q u a t e ,

explosive,

and

paranoid,

aesthenic,

passive-ag-

antisocial personality.

I n this

a r t i c l e , I w i l l d e a l m a i n l y w i t h p a t i e n t s w h o a r e a n t i s o c i a l f o r i t is t h i s t y p e o f d i s o r d e r w h i c h we l a r g e l y t r e a t .

T h e cardinal feature o f the anti-

social p e r s o n is his a n t i s o c i a l b e h a v i o r i n s o f a r as he acts w i t h o u t r e g a r d for

t h e consequences a n d i n a c c o r d w i t h i m m e d i a t e desires.

This

d i s o r d e r is f o u n d m o r e i n males, i n u r b a n areas, a n d a m o n g t h e l o w e r socioeconomic groups.

T h e r e is a b o v e - a v e r a g e f r e q u e n c y

separation or divorce, early death or desertion.

of parental

A n increased

frequency

o f alcoholics a n d c r i m i n a l s is f o u n d i n t h e f a m i l i e s o f t h o s e w i t h t h i s a b normality.

A n t i s o c i a l p e r s o n s a r e restless, h a v e s h o r t a t t e n t i o n spans,

a n d are u n d i s c i p l i n e d .

They

engage i n m u c h

fighting,

a n d have a

d i s t u r b e d s c h o o l e x p e r i e n c e , s u c h as d i s r u p t i o n o f classes, a c a d e m i c f a i l u r e s , a n d r u n n i n g away f r o m s c h o o l .

T h e i r j o b h i s t o r y is v e r y p o o r

CHARACTER

DISORDERS

a n d t h e y are u n d e p e n d a b l e . antisocial p a r t n e r .

57

I N HOSPITAL

T h e y m a r r y e a r l y a n d t e n d to m a r r y a n

T h e y l i e a n d steal, a n d c o n v e r s i o n

common among them.

symptoms

T h e i r I.Q.'s are o f t e n below n o r m a l .

are

Some-

t i m e s these p a t i e n t s are v e r y c h a r m i n g a n d s h o w n o g u i l t f o r t h e i r misdeeds.

F a m i l y studies o n

t h e m show that o n e - f i f t h o f the

d e g r e e relatives a r e sociopaths a n d o n e - t h i r d are alcoholics.

first-

I n female

felons, w h o constitute h a l f o f the female p r i s o n p o p u l a t i o n , o n e - t h i r d o f t h e m a l e relatives w e r e sociopaths a n d o n e - h a l f w e r e alcoholics.

The

studies o f d e l i n q u e n t c h i l d r e n h a v e s h o w n t h a t o n e - t h i r d o f t h e f a t h e r s and

one-tenth

of

the

mothers

were

either

antisocial

or

alcoholic.

C h i l d r e n o f c r i m i n a l s s h o w h i g h e r degrees o f p s y c h o p a t h y a n d c r i m i n a l b e h a v i o r e v e n w h e n a d o p t e d e a r l y by n o n r e l a t i v e s . T h e psychotherapy o f patients w i t h ah antisocial character i n a h o s p i t a l s e t t i n g is a m o s t d i f f i c u l t a n d f r u s t r a t i n g task.

disorder

T h i s is d u e

t o m a n y f a c t o r s , c h i e f o f w h i c h is t h e n a t u r e o f t h e p s y c h o p a t h o l o g y i t self.

O t h e r factors h a v e t o d o w i t h t h e n a t u r e o f t h e h o s p i t a l s e t t i n g ,

a n d are i m p l i c i t a n d e x p l i c i t t h r o u g h o u t t h i s a r t i c l e .

Additionally, the

p a t i e n t does n o t c o m e t o t r e a t m e n t w i l l i n g l y as a r u l e .

H e has b e e n

f o r c e d i n t o t h e h o s p i t a l by s o m e agency o f society o r p a r e n t a f t e r l o n g gross " m i s b e h a v i o r "

o f one k i n d or another.

H e does n o t o r d i n a r i l y

c o m p l a i n o f an endogenous depression o r anxiety, o r f r a n k psychotic s y m p t o m s , f r o m w h i c h he is s e e k i n g r e l i e f .

H i s r e a l i t y t e s t i n g is g o o d

a n d he can p r e s e n t a f a ç a d e o f n o r m a l i t y w i t h his c h a r m a n d a p p a r e n t l y a d e q u a t e social skills.

H o w e v e r , he has s p e n t m o s t o f his l i f e r e l y i n g o n

his wiles, w i t h p r i d e i n his a b i l i t y t o o u t s m a r t p e o p l e . proaches hospitalization w i t h fear h o u s e " w i t h " a b u n c h o f crazies" painstakingly created.

a n d anger.

N a t u r a l l y , he ap-

Placement

in a

tends to shatter the image

H e basically

prefers jail a m o n g

r a t h e r t h a n a h o s p i t a l f a c e d w i t h a m o r e i n d e f i n i t e stay.

his

"nut-

he

has

element

Nevertheless,

he a p p a r e n t l y takes t h e m o r e " s e l f - i n d u l g e n t " a p p r o a c h , a n d believes he w i l l s o m e h o w w h e e d l e h i m s e l f o u t o f his p r e d i c a m e n t . T h e patient's characteristic s y m p t o m s — l y i n g , stealing, i m p u l s i v i t y , evasion

of

responsibility—may

countertransference the conservative denying. effort

promote

the

therapist's

t h e r a p i s t w h o is l a w - a b i d i n g , h a r d - w o r k i n g a n d self-

T h e p a t i e n t is sensitive e n o u g h t o p l a y o n s u c h f e e l i n g s i n a n

to destroy

ground.

easily

r e a c t i o n , since o r d i n a r i l y t h e y a r e n o t p a l a t a b l e t o

t h e t h e r a p e u t i c r e l a t i o n s h i p b e f o r e i t gets o f f

I t is t h e r e f o r e

technically correct.

the

v i t a l t h a t t h e t h e r a p i s t be m o s t s k i l l e d a n d

T h e p a t i e n t m a y also o v e r w h e l m t h e t h e r a p i s t w i t h

his s e l f - d e s t r u c t i v e a p p r o a c h , his p e s s i m i s m , a n d f a t a l i s m ; a n d i f n o t t h e therapist, t h e n o t h e r professionals

o n t h e t e a m , w h o a r e n o t q u i t e as

close t o t h e p a t i e n t , w h o s o o n m a y be h e a r d t o say, " h e ' l l n e v e r c h a n g e ;

58

AMERICAN

J O U R N A L OF

he is a c h a r a c t e r d i s o r d e r , w h a t c a n y o u e x p e c t . "

PSYCHOTHERAPY

N a t u r a l l y , such at-

titudes play i n t o the patient's hands, are s e l f - j u s t i f y i n g to the patient, and self-defeating for the team. W h e n a p a t i e n t has a h i s t o r y o f v i o l e n c e a c e r t a i n d e g r e e o f w a r i n e s s is n a t u r a l f o r t h e t h e r a p i s t a n d s u p p o r t i n g t e a m .

T o be i n a n e n c l o s e d

r o o m w i t h such a p a t i e n t can be s o m e w h a t d i s c o n c e r t i n g , p a r t i c u l a r l y i f he is e m o t i o n a l l y upset.

Even the team m e m b e r s will have difficulty

d e n y i n g such a p a t i e n t w h a t h e w a n t s , t h o u g h t h e " p r e s c r i p t i o n " calls f o r it.

T h u s , i n a d d i t i o n t o s k i l l , o n e needs a f a i r d e g r e e o f i n t e s t i n a l f o r -

titude. I n t h e l i g h t o f t h e above, t h e t h e r a p i s t a n d t e a m have t o g u a r d n o t o n l y against c o v e r t h o s t i l i t y a n d o b v i o u s hopelessness, b u t also against g i v i n g i n to the patient's d e m a n d s — u n d o u b t e d l y

bad for h i m — o r opt-

i n g f o r a n e a r l y d i s c h a r g e j u s t t o be r i d o f h i m a n d t h e p r o b l e m s h e e n tails. THERAPY P s y c h o t h e r a p y w i t h c h a r a c t e r d i s o r d e r s is especially d i f f i c u l t o n t w o scores—the

resistance

of

the

p a t i e n t is especially

countertransference pitfalls are m a n y .

strong, and

approach

is i m p o r t a n t — b o t h t o advise t h e t h e r a p i s t o f his

problems

w i t h t h e p a t i e n t , a n d t o h i g h l i g h t resistance

t h e r a p i s t is u n a w a r e .

the

I t is o n t h i s a c o u n t t h a t t h e t e a m personal

o f w h i c h the

T h e m i l i e u t h e r a p y p r o g r a m is also o f h e l p i n e x -

p o s i n g some o f t h e p a t i e n t ' s p s y c h o p a t h o l o g y w h i c h is n o t so r e a d i l y a p parent i n the one-to-one relationship. Milieu I n psychotherapy

o n e needs t o focus o n t h e p a t i e n t ' s e v e r y d a y

be-

h a v i o r i n t h e h o s p i t a l — w h i c h r e a l l y is t h e social o r g a n i z a t i o n i n w h i c h he is " o p e r a t i n g . "

Discussion o f b e h a v i o r , h a n d l e d so as t o e a r n a n d w i n

t h e p a t i e n t ' s t r u s t , s h o u l d l e a d to i n c r e a s i n g o p p o r t u n i t y t o get at his p s y c h o p a t h o l o g y a n d p r o m o t e his w i l l i n g n e s s t o face, e x p l o r e , a n d o v e r come it.

H e r e t h e t h e r a p i s t is h a r d p u t t o a v o i d a c r i t i c a l a p p r o a c h ,

for

h e is p a r t o f t h e s t r u c t u r e d e s i g n e d t o p r o t e c t t h e h o s p i t a l ' s o t h e r i n h a b i t a n t s a n d v a l u e system.

T h e s e , o f c o u r s e , a r e o f n o special i m -

p o r t a n c e to t h e a n t i s o c i a l p a t i e n t , a n d yet we a i m t o m a k e t h e m so, t h u s r u n n i n g c o u n t e r t o his s e l f - i n d u l g e n t a p p r o a c h t o l i f e .

T h i s requires

t h e p a i n s t a k i n g e f f o r t o f a i d i n g t h e p a t i e n t see his b e h a v i o r i n v e r y c o n c r e t e t e r m s , a n d l e a d i n g h i m step by step t o u n d e r s t a n d t h e p r e d i c a m e n t h e is r e a l l y i n , as w e l l as t h e n e e d t o c h a n g e . t h a t he is l a r g e l y at f a u l t .

He must

finally

see

His ability to do this must ultimately s p r i n g

f r o m t h e b i r t h o f s o m e t r u s t n o t o n l y i n his t h e r a p i s t , b u t as i m p o r t a n t l y , i n t h e h o s p i t a l as a society w h o s e c h i e f a i m is t o assist h i m r a t h e r t h a n

59

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destroy h i m .

Needless t o say, t h e p a t i e n t ' s u n d e r l y i n g f e e l i n g s o f i n a d e -

q u a c y a n d helplessness, c o v e r e d by his a n t i s o c i a l b e h a v i o r , n e e d t o be recognized and overcome. psychotherapist

H e r e too, the entire hospital, not only the

plays a r o l e i n s u p p o r t i n g t h e p a t i e n t .

The

overall

p r o g r a m is d e s i g n e d t o d e v e l o p a n d b o l s t e r t h e p a t i e n t ' s c o n f i d e n c e a n d self-esteem.

T h e t h e r a p i s t m u s t be a l e r t t o t h e d e p r e s s i o n a n d a n x i e t y

w h i c h b e c o m e m a n i f e s t as t h e p a t i e n t faces h i m s e l f m o r e s q u a r e l y , especially as t h e r e m a y be a r e s u r g e n c e o f a n t i s o c i a l b e h a v i o r .

The

reap-

p e a r a n c e o f t h e l a t t e r m a y t e n d t o be d i s c o u r a g i n g , a n d l e a d t o a f a t a l hopelessness a m o n g s t a f f — a n a t t i t u d e against w h i c h t h e h o s p i t a l m u s t always be w o r k i n g . Chemotherapy We consider chemotherapy adjunctive treatment modality. symptoms symptoms

i n t h e m a n a g e m e n t o f t h e p a t i e n t as a n W h i l e some medications target certain

t h e r e are n o n e w h i c h are d i r e c t e d specifically against s u c h as

antisocial

behavior,

impulsivity, and

irresponsibility.

H o w e v e r , w h e n t h e p a t i e n t is a severe " m a n a g e m e n t p r o b l e m " — t h a t is, shows m u c h a c t i n g o u t a n d assaultive b e h a v i o r — w e m a j o r tranquilizers, usually T h o r a z i n e or H a l d o l .

d o prescribe

the

W e r e g a r d t h i s t o be

f o r the patient's protection a n d the welfare o f others.

O t h e r w i s e these

d r u g s m a y be p r e s c r i b e d t o m i n i m i z e a c t i n g - o u t , a n d p r e v e n t t h e p a t i e n t from

g e t t i n g i n v o l v e d i n situations w h i c h t h r e a t e n his relationships,

i n c l u d i n g progress i n the therapeutic one.

As w i t h o t h e r

patients,

h o w e v e r , i t is n o t u n c o m m o n f o r us t o w o n d e r w h e t h e r t r a n q u i l i z e r s a r e o r d e r e d t o lessen t h e staff's b u r d e n , r a t h e r t h a n f o r t h e p a t i e n t ' s g o o d . W h e n j u d i c i o u s l y used the m a j o r d r u g s are useful a n d h e l p f u l w i t h the character disorder.

I n c i d e n t a l l y , i f t h e use o f d r u g s h e l p s staff, i t c a n i n

t u r n be m o r e h e l p f u l t o t h e p a t i e n t .

T h u s , t h e r e is n o t h i n g i n h e r e n t l y

w r o n g i n p r e s c r i b i n g d r u g s sensibly i f i t also relieves s t a f f o f c e r t a i n undue

pressures.

T h e r e is n o r u l e o f t h u m b w h e n t h e use o f m e d i c a t i o n is i n d i c a t e d , e x c e p t , as o u t l i n e d a b o v e , t o g u a r d against h a r m f u l a c t i v i t y , i n w h i c h case we t e n d t o use T h o r a z i n e o r H a l d o l i n s u f f i c i e n t a m o u n t s — u p 1000 m g . p e r d a y o f t h e f o r m e r o r 30 m g . o f t h e l a t t e r .

to

W e believe t h a t

i f m u c h s m a l l e r doses o f m e d i c a t i o n e l i c i t a g o o d r e s p o n s e we s h o u l d q u e s t i o n t h e d i a g n o s i s o f c h a r a c t e r d i s o r d e r — t h a t w e m i g h t be d e a l i n g w i t h a case o f s c h i z o p h r e n i a .

P r e c a u t i o n s t o o m u s t be t a k e n t o m a k e

c e r t a i n t h a t t h e p a t i e n t a c t u a l l y ingests his m e d i c a t i o n , r a t h e r t h a n s u r reptitiously discarding it. S o m e b e l i e v e these a n t i s o c i a l p a t i e n t s t o be s u f f e r i n g f r o m a n u n derlying depression and accordingly

treat t h e m w i t h

W e t e n d t o t h i n k d i f f e r e n t l y i n m a n y cases.

antidepressants.

I n fact, we f e e l i f t h e p a t i e n t

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PSYCHOTHERAPY

shows d e p r e s s i o n as t r e a t m e n t progresses, t h a t t h i s is a sign o f i m p r o v e m e n t , a n d d e a l w i t h i t i n t h e r a p e u t i c sessions.

F u r t h e r i t is c o m m o n f o r

this p a t i e n t w h e n first a d m i t t e d t o r e a c t w i t h h o s t i l i t y a n d d e p r e s s i o n . W e see t h i s d e p r e s s i o n as reactive i n n a t u r e , a n d s e c o n d a r y t o his f a i l u r e t o achieve i m m e d i a t e

gratification.

I n o u r experience, this type

of

d e p r e s s i o n is n o t u s u a l l y a n d r e a d i l y r e s p o n s i v e t o m e d i c a t i o n . The

l i t e r a t u r e shows r e l a t i v e l y

therapy for the character disorder.

few

papers

written

about

drug

R e c e n t l y , h o w e v e r , t h e r e have b e e n

a g r o w i n g n u m b e r o f articles o n t h e use o f L i t h i u m i n t h e t r e a t m e n t o f this d i s o r d e r .

K l e i n suggests t h e use o f L i t h i u m f o r these p a t i e n t s w h o 3

have r e l a t i v e l y s h o r t m o o d swings, b o t h d e p r e s s i v e a n d Van Putten and A l b a n

4

hypomanic.

r e p o r t t h a t those d i a g n o s e d as e x p l o s i v e , a n t i -

social a n d h y s t e r i c a l are t h e best c a n d i d a t e s f o r a t r i a l w i t h L i t h i u m . Treatment Team M u c h c o u l d be said o f t h e r o l e o f t h e n u r s e a n d a i d e i n t h e m a n a g e m e n t process.

I t is t h e y w h o s p e n d m o s t t i m e w i t h t h e p a t i e n t , w h o b e a r

the b r u n t o f the battle, a n d , together w i t h the occupational a n d recreational therapist, attempt to i m p l e m e n t the m a n a g e m e n t p r o g r a m .

We

have f u s e d t h e activities d e p a r t m e n t s w i t h t h e n u r s i n g d e p a r t m e n t i n t o w h a t w e call t h e Social P s y c h i a t r i c N u r s i n g D e p a r t m e n t , u n d e r t h e D i rector o f N u r s i n g .

This consolidation

facilitates c o m m u n i c a t i o n

and

s h a r i n g o f p r o b l e m s a n d f u r t h e r s t h e m a n a g e m e n t process. T h e social w o r k e r plays a n i m p o r t a n t r o l e as a p a r t i c i p a t i n g m e m b e r o f t h e t r e a t m e n t t e a m , b o t h i n t h e o r i g i n a l assessment o f t h e p a t i e n t ' s i l l ness, t h e f o r m u l a t i o n o f a specific t r e a t m e n t p l a n , a n d t h e i m p l e m e n t a t i o n o f t h e g o a l set f o r t h e p a t i e n t d u r i n g t h e e x p e r i e n c e i n t h e h o s p i t a l society.

Special

t r a i n i n g by

us

and

intuitive

guarantee beneficial i n t e r a c t i n g w i t h patients. o n g o i n g conferences and

seminars

for

skills are

needed

to

I t is f o r t h i s r e a s o n t h a t

social w o r k e r s

and

nursing

p e r s o n n e l are most i m p o r t a n t . T h e social w o r k e r s ' f u n c t i o n o n a social level p e r m i t s f o l l o w - t h r o u g h f o r t h e p a t i e n t as he i n t e r a c t s i n t h e h o s p i t a l c o m m u n i t y . patient

firsthand

T h e y see t h e

i n his m a n y i n t e r p e r s o n a l r e l a t i o n s h i p s a n d c o n f r o n t a -

t i o n s o n t h e scene, r a t h e r t h a n i n t h e o f f i c e ; e n g a g e h i m i n t h e r e - e d u c a t i o n process, t e a c h i n g h i m t o d e a l m o r e r a t i o n a l l y w i t h his r e a l i t y s i t u a t i o n , t h a t is his e x p o s u r e t o t h e s t r u c t u r e d a n d c o n t r o l l e d e x p e r i e n c e h e is h a v i n g w i t h p e r s o n s m o r e a n d less stable t h a n h i m s e l f . supports

This approach

t h e c o r r e c t i v e g r o w t h e x p e r i e n c e w h i c h is o u r g o a l f o r

the

patient. T h e lack o f m o t i v a t i o n f o r t h e g o o d is a h a n d i c a p i n s t e e r i n g t h e p a t i e n t t o w a r d t h e h e a l t h i e r goals we have f o r h i m .

Advancement in

CHARACTER

DISORDERS

61

I N HOSPITAL

t h e g r o u p system f o r t h e a c q u i s i t i o n o f g r e a t e r f r e e d o m a n d p r i v i l e g e s , a s s i g n m e n t t o a t a s k - o r i e n t e d c o m m i t t e e w h i c h allows f o r l e a d e r s h i p a n d i n v o l v e m e n t i n socially u s e f u l a c t i v i t y , m o r e v i s i t i n g b e n e f i t s , p r a i s e a n d r e c o g n i t i o n as a g o o d c i t i z e n — t h e s e

are all h e l d o u t f o r the e a r n i n g .

T h e p a t i e n t m u s t u l t i m a t e l y see t h a t his o w n p a t t e r n s a r e r e a l l y sick a n d i n e f f e c t u a l i n g a i n i n g these n o r m a l l y d e s i r e d ends i n o u r h o s p i t a l society.

S i m u l t a n e o u s l y , he n e e d o n l y see t h a t t h e r e are h e a l t h y ways

w h i c h achieve these e n d s a n d s u p p l y s a t i s f a c t i o n — a n d t h a t these ways a r e a l l a b o u t h i m — r e a d i l y available w i t h m a n y o n l y t o o eager t o t e a c h t h e m to h i m a n d to help h i m make t h e m p a r t o f himself.

T h e presence

o f a s o l i d s t a f f t h a t c a n n o t be m a n i p u l a t e d because i t a d h e r e s t o a v a l u e system d i f f e r e n t f r o m h i s , a n d t h e loss o f p r i v i l e g e s as q u i c k l y as he gains t h e m i f h e resorts t o his o l d w a y s — t h e s e a r e facts w h i c h a r e e v i d e n t a n d r e i n f o r c e t h e l e a r n i n g process.

T h e social w o r k e r a n d n u r s e use t h e i r

social skills a n d a p p r o p r i a t e t e c h n i q u e s w i t h i n this d e s c r i b e d s e t t i n g t o interact w i t h a patient

firsthand.

When

t h e p a t i e n t is d e p r e s s e d o r

a n x i o u s , i t is also t h e i r r o l e t o s u p p o r t h i m actively a n d c o n s i s t e n t l y , a n d t o h e l p h i m o n a social level t o see a n d accept t h a t these s y m p t o m s i n d i cate p r o g r e s s t o w a r d o u r g o a l o f a m o r e s a t i s f y i n g social f u n c t i o n i n g f o r him. D i r e c t l y i n t h e e v e r y d a y scene t h e social w o r k e r a n d n u r s e use t h e i r skills t o d e t e c t a n d h e l p t h e p a t i e n t see a n d use w h a t e v e r social s t r e n g t h s a r e yet f u n c t i o n i n g i n h i m . tions he may p r o v o k e .

S u c h e f f o r t assists t h e p a t i e n t i n crises s i t u a -

For instance, to h e l p the patient gain better c o n -

t r o l o f his i m p u l s e s at t h e m o m e n t o f crisis i t s e l f , d i r e c t i n t e r p r e t a t i o n a n d sufficient e m o t i o n a l s u p p o r t are given simultaneously.

Otherwise,

d i r e c t p r o h i b i t i o n is e x e r c i s e d against i m m a t u r e , a n t i s o c i a l a c t i n g o u t , as t h e a t t e m p t is also m a d e t o h e l p t h e p a t i e n t be a n d f e e l a c c e p t e d d e s p i t e his p e c u l i a r i t i e s . Theoretical Orientation C r i t i c a l l y i m p o r t a n t t o o u r subject m a t t e r is t h e h o s p i t a l ' s t h e o r e t i c a l orientation and philosophy o f treatment.

I n c l u d e d h e r e is its b e l i e f

about the origins o f the character disorders.

Naturally, a treatment

t e a m t h a t c o n s i d e r s t h e c h a r a c t e r d i s o r d e r s t o be g e n e t i c i n o r i g i n w i l l m a n a g e t h e p a t i e n t d i f f e r e n t l y f r o m t h e t e a m w h i c h believes t h e m t o be socially d e t e r m i n e d .

W h a t c o m p l i c a t e s t h i s area are t h e fine d i s t i n c t i o n s

i n t h e beliefs o f t h e i n d i v i d u a l m e m b e r s o f t h e t e a m as o p p o s e d t o t h e general orientation o f the g r o u p .

I t is o b v i o u s , t o o , t h a t t h e t h e o r e t i c a l

o r i e n t a t i o n o f t h e h o s p i t a l ' s l e a d e r s w i l l d e t e r m i n e those selected f o r t h e professional program.

t e a m as w e l l as t h e o r i e n t a t i o n o f those a t t r a c t e d t o its

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O n e ' s c o n c e p t i o n o f w h a t c o n s t i t u t e s h e a l t h y b e h a v i o r w i l l also d e t e r m i n e t h e m a n a g e m e n t o f t h e i n p a t i e n t as w i l l t h e e f f e c t a p a t i e n t w i t h a c h a r a c t e r d i s o r d e r w i l l have o n o t h e r p a t i e n t s . O n e also has t o w e i g h the needs o f o t h e r p a t i e n t s against those o f t h e a n t i s o c i a l p a t i e n t .

To a

g o o d e x t e n t , t h e p a t i e n t ' s m a n a g e m e n t is d e t e r m i n e d by t h e n a t u r e o f the e n t i r e p o p u l a t i o n .

A s a p r o p r i e t a r y h o s p i t a l , we a r e m o r e subject t o

m a l p r a c t i c e suits, a n d w e m u s t confess t h a t t h i s is a social

pressure

which contributes to o u r manner o f m a n a g i n g a patient. T h e v a l u e system o f t h e h o s p i t a l as a s m a l l society is v e r y i m p o r t a n t , as

is t h e

value

system

professional employee.

of

each

and

every

professional,

and

non-

These play a large part i n the m a n n e r i n w h i c h

each relates t o a n d treats t h e p a t i e n t as a f e l l o w h u m a n b e i n g .

The

d e g r e e t o w h i c h t h e v a l u e system o f t h e i n d i v i d u a l p r o f e s s i o n a l is i n accord

w i t h t h a t o f t h e h o s p i t a l society

will determine the degree

h a r m o n y a n d m a n n e r w i t h w h i c h a p a t i e n t m a y be m a n a g e d .

of For

i n s t a n c e , i t is g e n e r a l l y a " v a l u e " o f o u r s t h a t a p a t i e n t s h o u l d

be

c o n s i d e r a t e o f a n o t h e r , t h a t i n d i v i d u a l w a n t s s h o u l d s o m e t i m e s be subm e r g e d f o r t h e g r o u p ' s n e e d s , a n d t h a t " f r e e d o m " is n o t w i t h license.

synonymous

T h e s e l f - i n d u l g e n t c h a r a c t e r - d i s o r d e r p a t i e n t w i l l place

t h e s a t i s f a c t i o n o f his needs b e f o r e t h a t o f a n y o t h e r p a t i e n t .

I t is easy t o

see t h e d i f f e r e n c e s o f o p i n i o n w h i c h m i g h t arise a m o n g s t a f f as t o w h a t e x a c t l y is " c o n s i d e r a t e " b e h a v i o r , l e t a l o n e d i f f e r e n c e s w h i c h m i g h t arise between staff a n d the patient's therapist i n a countertransference relationship.

A g a i n , i t is a v a l u e o f o u r h o s p i t a l t h a t p a t i e n t s c o n t r i b u t e

t h e i r energies a n d t a l e n t s f o r t h e g e n e r a l w e l f a r e t h r o u g h t h e w o r k d o n e by the variety o f patient committees.

T h e patient w i t h a character

d i s o r d e r w h o s h i r k s his r e s p o n s i b i l i t y has a d i f f e r e n t v a l u e s y s t e m . w i l l w a n t w h a t he w a n t s w h e n he w a n t s i t .

He

H e w i l l seek allies f o r his p o s i -

t i o n a m o n g p a t i e n t s a n d staff, a n d t o t h e e x t e n t t h a t he is successful t o t h a t e x t e n t w i l l he be d i v i s i v e .

H i s p r o g r e s s t h r o u g h t h e g r o u p system

w i l l be d e l a y e d , a n d a c c o m p a n i e d team.

by m u c h c l a s h i n g o f o p i n i o n i n t h e

M a n y o t h e r e x a m p l e s w i t h t h e i r r a m i f i c a t i o n s c o u l d be g i v e n ; l e t

the above suffice f o r this occasion. A s we have seen, one's c o n c e p t i o n o f t h e c h a r a c t e r d i s o r d e r s w i l l p l a y a p a r t i n d e t e r m i n i n g h o w he m a n a g e s t h e a f f l i c t e d p a t i e n t . d i a g n o s i s , o f c o u r s e , is c r i t i c a l l y i m p o r t a n t .

Proper

O r d i n a r i l y the antisocial

p a t i e n t is also p r o n e t o d r u g h a b i t u a t i o n a n d asocial b e h a v i o r o f s u c h a d e g r e e t h a t h e w i l l l a n d i n j a i l r a t h e r t h a n i n p a t i e n t care. do

n o t o r d i n a r i l y see

the worst o f t h e m .

We

A s a r e s u l t , we

m a y say t h a t t h i s is

f o r t u n a t e f o r us, t h o u g h i t d e p e n d s o n t h e n a t u r e o f t h e i n s t i t u t i o n i n which

we

practice.

However,

the masking o f the true u n d e r l y i n g

d i s o r d e r c a n be m i s l e a d i n g a n d cause us t o p a y m o r e a t t e n t i o n t o t h e

CHARACTER

DISORDERS

63

I N HOSPITAL

o v e r l a y t h a n t o t h e basic p r o b l e m .

T h e hospital must avoid the t e m p t a -

t i o n t o a p p e a r at its best by g e t t i n g t h e s y m p t o m a t i c

" c u r e " at t h e

e x p e n s e o f r e a l a l l e v i a t i o n o f t h e basic d i f f i c u l t y . Triage W e recognize that we are not t r e a t i n g the patients w i t h the worst c h a r a c t e r d i s o r d e r s i n o u r i n s t i t u t i o n , t h a t we a r e l i k e l y t o a v o i d s e l e c t i n g theni,

and

often

opt

to discharge

p r o p e r t y , a n d t h e social o r d e r .

the one

too

destructive

to

life,

I f a h o s p i t a l is c o m p e l l e d t o a d m i t t h e

w o r s t o f t h e m i n n u m b e r s so l a r g e t h a t t h e y w i l l c o n s t i t u t e a sizable p e r c e n t a g e o f its p a t i e n t p o p u l a t i o n , i t m u s t o b v i o u s l y s u f f e r t h e consequences, a n d — w e guess—be content w i t h p r o g r a m modifications w h i c h achieve o n l y p a l l i a t i v e r e s u l t s .

T h e h o s p i t a l w h i c h d a r e s a n d elects t o

t r e a t t h e t o o severe ones, p a r t i c u l a r l y i n m a l p r o p o r t i o n s , w i l l l i v e t o r e g r e t its c h o i c e .

W e k n o w this f r o m bitter experience.

T h e m o r e asocial a n d d e s t r u c t i v e p a t i e n t i n o u r

flexible,

giving and

l o w - k e y a t m o s p h e r e s o o n senses his p o w e r t o d i s r u p t , d i s o r g a n i z e , arouse those about

h i m , b o t h patients a n d personnel.

and

H e o f t e n is

c o n s i d e r e d as n o t w a n t i n g t o c o n t r o l his b e h a v i o r , o f b e i n g c o n s c i o u s l y c o n t r a r y a n d j u s t p l a i n u n w i l l i n g to c o n t r o l himself. by

h a v i n g delusions

or

H e is n o t p r o t e c t e d

h a l l u c i n a t i o n s , i n w h i c h case he

would

be

t o l e r a t e d a n d , m o r e i m p o r t a n t l y , u n d e r s t o o d r a t h e r t h a n resisted a n d condemned.

I t m a y be t h a t t h i s t y p e o f r e a c t i o n t o t h e

character-

d i s o r d e r p a t i e n t a c c o u n t s f o r o u r t h i n k i n g i n t e r m s o f his " m a n a g e m e n t " rather

than

professionals

his

treatment.

yet h a n d i c a p p e d

The

fault,

perhaps,

lies

with

us

as

by o u r o w n p e r s o n a l i t i e s , m o r a l s t a n -

d a r d s , i r r e s i s t i b l e d e m a n d s o f society u p o n us, a n d l i m i t e d t h e r a p e u t i c k n o w l e d g e i n t h i s area. Conclusion Success i n t h e

treatment of

the hospitalized

character-disorder

p a t i e n t d e p e n d s u p o n t h e closest t y p e o f c o m m u n i c a t i o n s t a n d i n g a m o n g t h e staff.

and under-

T h i s u n d e r s t a n d i n g m u s t be m u t u a l a n d i n -

c l u d e a s h a r e d awareness o f a n d s y m p a t h y f o r each p a t i e n t ' s n e e d s , as w e l l as f o r t h e p r o b l e m s

o f the staff most intimately involved i n the

patient's " m a n a g e m e n t . "

T h e atmosphere i n o u r hospital "convinces"

t h i s d i f f i c u l t p a t i e n t t h a t h e can get away w i t h " m u r d e r , " stir a n x i e t y , a n d e v o k e conflicts a m o n g t h o s e t r e a t i n g h i m , m a n i p u l a t e those d e d i c a t e d t o his c a r e , d r i v e t h e m t o d i s t r a c t i o n so t h a t t h e y u l t i m a t e l y m a y r e j e c t a n d eject h i m f r o m t h e g r o u p .

H e c a n t h e n savor his "success" a n d j u s t i f y

his w a y o f l i f e a n d b e l i e f i n t h e u n w o r t h i n e s s he feels b e n e a t h his d e v i l i s h defenses.

I t is o n l y by t h e p a t i e n c e a n d f o r b e a r a n c e o f a l l w h o are p i t -

64

AMERICAN

J O U R N A L OF

PSYCHOTHERAPY

t e d against t h e w o r s t i n t h e p a t i e n t , a n d w h o a r e s t r u g g l i n g t o ally t h e m s e l v e s w i t h t h e best i n h i m , t h a t these p a t i e n t s c a n be successfully managed and thus prevented f r o m letting their "demons" propel t h e m t o w a r d the inevitability o f being rejected. G r e a t care m u s t be e x e r c i s e d t o steer a c a r e f u l c o u r s e b e t w e e n s t r u c t u r e d m i l i e u , w h i c h is so essential t o successful t r e a t m e n t , a n d

a

flexi-

b i l i t y , w h i c h , i f c a r r i e d t o o f a r , plays i n t o t h e p a t i e n t ' s m a n i p u l a t i v e n e s s , and thereby threatens o u r efforts.

The

properly ordered

milieu in

w h i c h t h e p a t i e n t is i m m e r s e d is b o u n d t o f u r n i s h h i m a l e a r n i n g a n d corrective experience. u n f a m i l i a r one.

T h e social system o f t h e h o s p i t a l is a n e w a n d

T h e p a t i e n t m u s t be a i d e d i n a c c u s t o m i n g h i m s e l f t o i t

a n d t r u s t i n i t s u f f i c i e n t l y t o d a r e a t t e m p t l e a r n i n g h e a l t h i e r ways o f r e lating.

W e have t h e task o f h e l p i n g h i m t o believe i n t h e ways a n d v a l u e

system o f t h e h o s p i t a l society, a n d t o d e v e l o p t h e w i l l i n g n e s s t o use t h e professionals a b o u t h i m as m o d e l s f r o m w h o m h e m a y l e a r n m o r e successful social b e h a v i o r .

I t goes w i t h o u t s a y i n g t h a t t o achieve a n y

d e g r e e o f basic c h a n g e , m a n a g e m e n t

o f t h e p a t i e n t m u s t be o v e r a n

extended period of time. W h i l e g r o u p t h e r a p y i t s e l f is h e l p f u l we are m o r e i m p r e s s e d w i t h o u r group

system as a m e a n s o f assisting these p a t i e n t s .

I n s h o r t these

g r o u p s are satellite systems i n t o w h i c h p a t i e n t s a r e p l a c e d .

Each g r o u p

r e q u i r e s c e r t a i n b e h a v i o r a l c a p a b i l i t i e s a n d e m o t i o n a l sensitivities f r o m t h e p a t i e n t , a n d places its o w n r e s p o n s i b i l i t i e s o n t h e p a t i e n t i n s t e a d o f his d e m a n d i n g p r i v i l e n g e s .

T h e p r o f e s s i o n a l t e a m places t h e p a t i e n t i n

t h e g r o u p s , each o f w h i c h b e c o m e s m o r e p r e s s u r e l a d e n as t h e p a t i e n t ascends t h e l a d d e r t o t h e last g r o u p .

E a c h g r o u p gives t h e p a t i e n t

i n c r e a s i n g r e s p o n s i b i l i t y t o t h e l a r g e r social system.

I n t h e process o f

g o i n g u p t h e scale t h e p a t i e n t ' s o l d ways are t e s t e d , e v a l u a t e d , c h a n g e d o r d i s c a r d e d , a n d r e p l a c e d w i t h h e a l t h i e r ways o f r e l a t i n g . t h e needs o f o t h e r s a c t u a l l y d e v e l o p s .

Sensitivity to

Needless t o say, t h e e d u c a t i o n a l

process is s u p p o r t e d by t h e t r a n s f e r e n c e w h i c h d e v e l o p s i f t h e r e is a successful p a t i e n t - t h e r a p i s t r e l a t i o n s h i p . A l l o f us r e c o g n i z e t h e v a l u e o f " t h e s t r u c t u r e " o f a t h e r a p e u t i c setting.

A s i d e f r o m its o b v i o u s aspects o f r o u t i n e a n d s t a b i l i t y , t h e r e is a

m a j o r facet w h i c h r e q u i r e s e l a b o r a t i o n .

I refer here to " s t r u c t u r e " i n

terms o f an a p p r o x i m a t i o n o f u n a n i m i t y o f o p i n i o n o n the part o f the professionals,

particularly about

t h e t r e a t m e n t p r o g r a m as a w h o l e .

T h i s a m o u n t s t o a basic b e l i e f i n t h e hospital's t h e r a p e u t i c a p p r o a c h a n d its goals f o r p a t i e n t s , as w e l l as its a p p r o a c h t o t h e i n d i v i d u a l p a t i e n t himself.

Understandably, undeviating adherence w i t h o u t r o o m for i n -

d i v i d u a l d i f f e r e n c e is n e i t h e r d e s i r a b l e n o r h e a l t h y .

H o w e v e r , t h e ac-

c e p t a n c e o f t h e process o f a t t e m p t i n g t o achieve u n a n i m i t y a n d t h e

CHARACTER

DISORDERS

IN

HOSPITAL

65

r e c o g n i t i o n t h a t its a t t a i n m e n t is f o r t h e g e n e r a l w e l f a r e , is c r i t i c a l l y i m portant.

S u c h c o n d i t i o n s r e s u l t i n h e a l t h y f l e x i b i l i t y w h i c h also serves as

a m o d e l f o r patients. N o w , w h a t h e l p s us achieve t h e m o s t b e n e f i c i a l a t m o s p h e r e i n a hospital?

T h e selection a n d c a l i b e r o f t h e staff, o f c o u r s e .

T h e i r ability to

give a n d t a k e is essential, f o r this q u a l i t y is b e i n g s o u g h t f o r t h e p a t i e n t w i t h a character disorder.

Frequent conferencing u n d e r adequate a n d

able l e a d e r s h i p , a n d i n a n a t m o s p h e r e o f h o n e s t a n d f r e e e x p r e s s i o n o f o p i n i o n , u n t a i n t e d b y h o s t i l i t y , r a n c o r , a n d secretiveness a r e a l l essential. F r e q u e n t o p p o r t u n i t y f o r i n f o r m a l o n e - t o - o n e discussion is v e r y i m portant.

T h e r e a d y a b i l i t y o f t h e t h e r a p i s t t o accept f a u l t , s t a n d c o r r e c -

t i o n , a n d see his c o u n t e r t r a n s f e r e n c e p r o b l e m s is v i t a l .

Willingness to

t r u s t i n t h e p r o f e s s i o n a l t e a m r a t h e r t h a n one's r i g h t as " t h e t h e r a p i s t w h o k n o w s t h e p a t i e n t best" is a m u c h n e e d e d i n g r e d i e n t .

I n other

w o r d s , h u m i l i t y is o f t h e essence! I t is v e r y i m p o r t a n t t h a t t h e p a t i e n t k n o w t h e w a y o f t h e h o s p i t a l , a n d t h e v a l u e system i n h e r e n t i n its process.

Such knowledge tends to dis-

c o u r a g e i f n o t m i n i m i z e a n d d i s a r m his m o s t e f f e c t i v e a n d d e s t r u c t i v e ways.

A d d i t i o n a l l y , i t is a w a y o f l i f e f r o m w h i c h he c a n l e a r n a n d p r o f i t .

O n e m a y say t h a t t h e s t a f f m u s t be able t o act as a u n i t e d f a m i l y t h a t c a n n o t be m a n i p u l a t e d .

I m m e r s i o n i n t h i s m i l i e u w h i c h is r e a l l y a

h e a l t h y " w a y o f l i f e , " w i t h a d i s t i n c t i v e social s t r u c t u r e , c a n n o t h e l p b u t o f t e n a f f e c t t h e p a t i e n t p o s i t i v e l y a n d r e m o l d his c h a r a c t e r . is s i m p l e — i f a n u n h e a l t h y , d i s o r g a n i z e d

background

T h e theory

produced

the

p a t h o l o g y , its a r r e s t a n d r e v e r s a l w i l l t a k e place i n a r e l a t i v e l y stable a n d healthy milieu.

H o w e v e r , as is t h e case w i t h m o s t " s i m p l e " t h e o r i e s ,

t h e i r i m p l e m e n t a t i o n is m o s t d i f f i c u l t . SUMMARY T h i s p a p e r deals w i t h t h e d e f i n i t i o n o f t h e c h a r a c t e r d i s o r d e r s as w e l l as v a r i o u s t h e r a p i e s u s e d t o d e a l w i t h t h e m .

T h e patient with an anti-

social d i s o r d e r is a c c o r d e d m a i n a t t e n t i o n , d a t a a b o u t h i m is g i v e n , a n d his s y m p t o m s a n d m a n n e r o f o p e r a t i n g a r e d e s c r i b e d . m o d e s o f t r e a t m e n t discussed a r e p s y c h o t h e r a p y , therapy.

Among

drug, and

the

milieu

A d e s c r i p t i o n is g i v e n o f t h e r o l e o f s o m e o f t h e h o s p i t a l team's

specialists, s u c h as t h e p s y c h o t h e r a p i s t , n u r s e , a n d social w o r k e r .

Em-

phasis is g i v e n t o t h e c r i t i c a l i m p o r t a n c e o f g o o d t e a m w o r k w h i c h m u s t include m u t u a l u n d e r s t a n d i n g , h a r m o n y , trust, and relative agreement o n goals f o r t h e p a t i e n t . lignant

O n l y these c a n h e l p a r r e s t a n d r e v e r s e t h e m a -

process, o v e r c o m e t h e p a t i e n t ' s resistance,

and control

c o u n t e r t r a n s f e r e n c e p r o b l e m s o f those t h e r a p e u t i c a l l y i n v o l v e d .

the

Major

a t t e n t i o n is g i v e n t o t h e i m p o r t a n c e o f t h e h o s p i t a l as a social s t r u c t u r e

66

A M E R I C A N J O U R N A L OF

w i t h a b u i l t - i n v a l u e system. which

evolve

therein

The

exposes

PSYCHOTHERAPY

quality o f the h u m a n relationships the

patient's

disordered

relations

s u f f i c i e n t l y to e n c o u r a g e h i m to a d o p t h e a l t h i e r a n d m o r e h u m a n ways of relating. REFERENCES 1. G r a l n i c k , A . , E d . , New York,

The Psychiatric

Hospital

as a Therapeutic

Instrument,

Bruner/Mazel,

1969.

2.

G r a l n i c k , A . et a l . Humanizing

3.

Klein, D. F . ,

the Psychiatric Hospital,

Jason Aronson, New York,

1975.

W h o S h o u l d N o t B e T r e a t e d w i t h N e u r o l e p t i c s , B u t O f t e n A r e . I n Ra-

tional Psychopharmacotherapy

and the Rights

to Treatment,

Ayd, F. J . , Jr., E d .

Ayd

M e d i c a l C o m m u n i c a t i o n s , L t d . , 1974. 4.

V a n Putten, T . a n d A l b a n , J . , L i t h i u m Carbonate in Personality Disorders: H y s t e r i a . J . Nerv. Ment. Dis.,

164:218,1977.

A Case of