MONEY FOR GOOD BEHAVIOUR Peter Sykes To enable them to work and live in

the community as quickly as possible, groups of maladjusted subnormal adolescents are involved in group discussions and incentive payment schemes at a hospital in Morpeth, Northumberland, where Dr. Sykes is

physician superintendent

done with subnormal adolescents at Northgate and District Hospital arose as a part Work

being

of the overall

hospital policy?that a subnormality hospital should provide the facilities for the management and treatment of all problems affecting the subnormal and severely subnormal. Of course, this is an ideal which is not easily obtained, but

we feel that it is one which we should try to achieve (I use the term 'we', for the hospital is organised on social psychiatric lines and decisions tend to be taken by teams of people involved in the care of a patient rather than by individuals). This policy has been gradually developing over the past four years. Originally we started with two units for delinquent subnormals, for twenty male patients and for twenty female patients. Their ages ranged up to about forty years old. All had been before the courts and came to us either directly from court or via approved schools,

borstals

or prison. rapidly became clear that the regime we were adopting (which consisted of two basic incentive scales, coupled with group and individual psychotherapy) achieved best results with the younger patients in the group, and, more noticeably, the adolescents. Most of the patients in these original units, which are still functioning at the hospital, were over school age and worked during the day in the industrial therapy department of the hospital. Two years ago, as part of a process of improvement of services and development on the main hospital site, we transferred the hospital school,

It

which had been fifteen miles away from the main site, back to Northgate and, since at this time the appointment of a new headmaster?with extra qualifications in the teaching of handicapped children?was made, we were able to take a look at the hospital policy for the school, and the way in 14

which the school was going to be incorporate within the overall hospital unit. It soon became apparent to us that, instead ( providing a service that was similar to that pr' vided by the local authority and geared towaf( the same type of child, we should provide in tf school a service primarily geared to doubly han
system. The two delinquency units are dealt with as group for case conference purposes, but the lescents with behaviour disorders attending j school are dealt with in the case conference wb|1 covers school children as a whole. The peof present at these discussions are the relevant P? chiatrists, the social worker, psychologist, and"' the case of those attending the industrial ' unit?the man in charge of the therapy unit. of staff from the ward and?in the case nursing school children?the headmaster. Both groups are involved in an incentive P3 ment scheme, but this is different for each group

thefa{

delinquent

adolescents scale is based

on

work

and social

attitudes, 50% of the points being for each. This is scored on a daily basis and is payable at

the end of the week so that a maximum of one can be obtained. The marking on this scale Is carried out by nursing staff and staff working the industrial therapy unit. The incentive scheme ?r those in the children's ward is slightly different ~^t is based on social attitude only between

P?und

J.1

Sch?ol and ward and is marked jointly, after disCussion between the school teachers and ward staff.

Some difficulties have arisen with this scheme ecause it is quite common for a disturbed adolesCent to adopt two different patterns of behaviour

^?ne at school and one in the ward situation. At Present the school and ward staff are discussing modification of this scheme which could take ese variations into account. Coupled with these basic incentives a series of r?Up meetings, and also individual therapy in ,any cases, are being carried out by the psychialsts with their own patients. The children attend? the school with maladjustment problems have on Friday afternoon at which the school aff, a psychiatrist and the ward nursing staff are these meetings started a considerportion of the time was spent by the patients v Rising their aggression, both towards the Sv stem5 the staff5 an(j their parents but, over a of time, this has tended to decrease and ,e meetings have become more constructive and

^"I^ting ahTent"

t^r'?d

^apeutic. discussions

range of problems from ward improvements through j ,1Scussions concerning the problem of sexual developing on a mixed ward of this type, VVard staff feel that there is definitely less 'a Ing out' behaviour on the ward than before system developed and that, by and large, the tend to 'hold back' their aggressive bursts until the Friday meeting when it can be fr expressed with a feeling that they are acPted during the time they behave in this manner, staff themselves feel that many of the req. made by the children, both at the Friday a?d at the smaller discussion groups held sim

Pie suggestions

cover a on

T,elln8s f-

a.s

^scents

Ceeely

^ts

m on

abl

wafd

itself,

are

extremely

reason-

that they are considerably hampered by ^ted facilities in the compromise ward they

thee,.and Use

at Present- I would

certainly agree with this with transfer into the new units, these irritations which upset the patients " be removed. he older adolescents have meetings a minimum tvvo days a week on the ward involving the ty S^a^' -^2a^n' a similar pattern developed with of compi 0riginal meetings consisting mainly ets, petty jealousies, etc., but these have gradu-

hope that,

^

tyilfu

the^ .

now the meetings discuss things much less emotional and more rational basis. The staff are convinced that this system is of benefit both to themselves and to the patients. They are much more aware of what is actually going on in their wards and it has given us all a better insight into why subnormal patients frequently behave in what is apparently an anti-social manner for no real reason. One thing which has surprised many members of staff is the ability of patients previously considered to be 'low grade' (with all that that implies) to verbalise their problems when given the time and encouragement to

ally reduced and on a

do

so.

with this system of meetings and incentives each patient is, of course, under the care

Coupled

psychiatrist who admitted them. Several drug therapy, others will be undergoing abreactive techniques or individual psychotherapy. People who visit the unit often ask 'What is your system?' I think the answer is that we have of the will be

no

on

overall system into which

we

try

to mould the

patient. The system is, by means of everyone discussing the problem together?patients and staff, to try to approach the patient each from our own viewpoint, medical, nursing, educational, social or psychological.

From the interaction of these approaches we then jointly decide on an individual course of action for the case under discussion so that all persons involved in the case present a joint course of action to him. No system is perfect, but we feel that working together and learning from our mistakes, we are likely to give the subnormals living in the community we serve a better service than they would receive from a traditional hospital approach. ?

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