deliberation in a crisis situation. If one is aware of other therapists’ innovations as possible alternatives, and if the innovations have been practiced. one may have useful additions to a repertoire of therapeutic responses to the assaultive patient. Role-playing techniques. in which the therapist takes the role of an assaultive patient. are one useful way to gain insights into the feelings and impulses of such patients and into the
in (‘omnparison t/i e traditional
in a cotnmnumiitv
PSYCHIATRIC and generally hospital
the need ly and more
suddenly is always concern traditional-
the reason for using of psychiatric hospithe use of male aides is
years ago we transitional
were asked to reorganize a pneward of a private psychiatric
at the 128th annual Anaheim. Calif..
Ms. Levy Menninger
is Senior Memorial
Staff Nurse Hospital.
I. Lion JR. Pasternak lent patients. AmJ
2. Macdonald Thomas,
hospital into an autonomous treatment unit. The unit had been operating for several years with a reduced nursing staff. all of whom were women-an unusual anrangement in psychiatric hospitals. We were impressed with the fact that the unit had a very low incidence of violence. The fact that all of the nursing staff were women was thought to be an outgrowth of the virtual absence of behavior problems on the unit. but we chose to interpret it as the cause rather than the result of the unit’s history of nonviolence and to make it part of the new unit’s program. Specifically. we hypothesized that violence-prone patients may find female nurses and aides less provocative than male staff and that. conversely. when confronted with threatening patients in the absence of male aides, female staff may be more apt to rely on nonaggressive manners and feminine intuition rather than resort to reactive. policelike methods. which are typical of masculine behavior and values in our culture.
PATIENTS may destructive
of stomnemi ac(’ording to mnal(’ andfemnale nursing pa ttern T/i e Umlit st(lfJ(’d h’ st’omnen had nO iticidemits of otherdirected violemice it, th e Oml(’-Vear period of th e studs’, hilt the traditionally staffed unit had 13 t’iolet,t ill(id(’mlts initi(lt(’d h’ 5 patiellts. The authors state that th e expectatioli of t’i01?1l(’4? (lFfl01l psvchziatru’ j)a tiCtI ts and the conseque/It use o,fmnale ,lursing aides to control t’iOl(’11(’? miia’ represeilt a selffiilfilliizg prophecy’. liUrsilig
studied the incidence oft’ioleiice uiiit orgamiized as a therapeutic
of the American 1975.
and Dr. Topeka.
Hartocollis is Director. Kans. 66601.
The new unit, which had 20 beds and an open-door policy, was located in a private psychiatric hospital that included two other long-term inpatient units of approximately equal size. Our unit was staffed with the following personnel: 3 part-time psychiatrists. I resident psychiatrist. I full-time and 2 part-time social workers, I psychologist. 3 activities therapists. and 15 nurses and nursing aides; all of the nurses and aides were women. The patient population included slightly more women than men, was predominantly young (ranging from 17 to 55 years of age). and represented all diagnostic categories (the predominant diagnosis. Am J P.svhiatry
however. was borderline personality organization). The average length of patient stay during the one-year study period was six months. The unit’s treatment program was based on the primciples of a therapeutic community. Sharing of problems and confrontation by fellow patients and staff members took place in group meetings of patients with staffevery day ofthe week. The meetings could be formal or informal and small or large. Patients elected their own government representatives. who had the right to negotiate issues affecting the patient commumity in regular meetings with authorities. Responsibility for treatment and the welfare of the community was to be shared by patients as well as staff. This cxpectation. along with the explicit renunciation of violence. constituted the cardinal value of the unit’s philosophy. The program was designed for direct but voluntary admissions. Preselectiom was expected to be minimal; the only patients excluded from the unit were those who were currently assaultive. Variables known to contribute to episodes of violence-crowded quarters. shortage of staff. social disorganization. and problems in communication-were carefully monitored and controlled to the best of our ability. We defined violence’ as behavior that involved aggressive action between 2 or more persons on the unit and produced at least minor physical injury (including scratches and bruises) ordestruction ofpnoperty. Data about violence were obtained from written daily nursing reports. Data from a unit staffed according to the traditional female and male nursing pattern but similar in all other respects were used for control purposes. ‘
During the one-year period of the study. the incidence of violence in our unit was zero. There were several crises and episodes of disorganization that involved threatening behavior and abusive language, but there were no acts of physical violence on this unit. One young male patient verbally insulted the staff several times but repeatedly assured them and his fellow patients that he would not strike a woman. An older male patient made aggressive gestures toward staff members during a hypomanic episode. He shook his fists, pointed his finger at the staff, and once touched a nurse’s nose angrily, but he never hit anyone. Staff members were impressed with the high degree of self-control patients were able to exercise. Noteworthy. too, is the fact that male patients helped the nursing staff contain the aggression of their fellow patients. providing a source of reassurance for both staff and disturbed patients during stressful times. For example, when a young male patient threatened to strike anyone who tried to prevent him from leaving the unit, other male patients chose to remain in the area until the crisis was resolved. Thus the nursing staff were able to maintain their self-awareness, contain their own fear 430
Am?! J P.sc/iiatrs
and anger. and deal with the threatening patient firmly but kindly, managing to prevent him from regressing further into violent action. In spite of the facts that there was no violence among the patients and no external threat developed, the nurses on the night shift felt vaguely anxious after hours, when no male staffwere around and most of the patients were in bed. For example, when a female patient had a male visitor who persisted in prolonging his visit on the unit after midnight. the nursing staff called the night supervisor. who came accompanied by a male aide. Male patients later expressed the wish to be awakened when this sort of incident occurred. On several occasions when this was done. the patients proved very effective in helping nurses deal with problems during late hours. even though their methods did not always satisfy the nurses. Although there were no episodes of violence against others, self-directed violence did occur a number of times. However, there were no fatal injuries or injuries serious enough to require treatment outside of the unit during the study period. Suicidal threats were fairly frequent. In contrast. the nursing notes for the control unit showed 13 instances ofassaultive behavior initiated by S different patients. No systematic count ofepisodes ofviolence was carried out in the other long-term treatment units of the hospital. which continued to use the traditional female and male nursing staff pattern. but a sampling of the records of these units and anecdotal data indicate that oven the one-year study period they experienced a proportionally greater amount ofviolence. Whether the incidence of self-directed violence or threats of such violence was different in other sections was not investigated.
Even though the incidence ofviolence may not be as great in psychiatric hospitals as it is in other total-care institutions. the idea that patients in a psychiatric hospital may suddenly become assaultive is prevalent, not only among laymen but also among psychiatric personmel-especially nurses and nursing aides (I). The cxpectation of violence and generally destructive behavion may constitute a self-fulfilling prophecy that needs to be recognized and treated as a transference on countertransference problem. When nursing staff fear that patients under their cane may become violent, the probability is that they are concerned about their own propensity for violence and the fear that they may not be able to contain it if sufficiently provoked. Feelings of inadequacy concerning the staff’s ability to handle a difficult situation, when accompanied by frustration and anger, may scare a disturbed patient to the point of driving him to violence (2). Spiegel (3) pointed out that confrontation is an effective means of resolving group conflict and promoting
social change but that it carries with it ‘the strong possibility of physical violence. Confrontation is the technique most widely used to resolve conflict and to effect change in a therapeutic community. However. for confrontation to become dangerous, there must be an intent and a reciprocal expectation of violence, based on the belief that for confrontation to be effective there should be violence or the option to do violence. When a male aide is used as an instrument of confrontation, the probability ofviolence becomes greatly enhanced because the male aide’s formal on informal role as masculine authority is based on the intent to do violence. This intent is potentiated by female nursing personnel who expect the male aide to confront troublesome patients for them. Storr (4) found that male aggression tends to occur spontaneously in a wide array of conditions, such as rivalry, territoriality. and display, but that aggression in females is fully aroused only or mainly in response to a threat that involves their young. Bigelow (5) noted that one of the causes of severe aggression in animals is “the crowding ofstrangers. especially near such valued resources as food or mates.” Crowded conditions in a hospital, which are known to cause violent episodes and regression of all sorts. mean not only deprivation of space and privacy but also shortage of personnel in the sense that relatively few patients can get the attention they need from very busy staff members (6). Patients who cannot or are not allowed to use their own potential for mutual assistance and sharing of responsibility tend to compete for the attention of nurses and aides. whom they perceive as “valued resources” to obtain aggressively on, if denied. to destroy in frustration. In our experience, the possibility of violence threatened the nursing staff most when the structure of the patient-staff community was weak. When the ability of the community members to support each other or, more generally. when its ability to adhere by the common rules and values (beginning with the renunciation of violence) were not trusted, fear and unrest prevailed. External controls were then desired, and, as a crisis developed, they were sought in the form of phone calls to an authority outside of the unit and in the importation of male aides. The night personnel were more apt to mistrust the community’s controls and often failed to make full use of the community because they had the least exposure to its working sessions. All of the regular community meetings took ‘
place during the day. Nurses and some patients longed for the presence of male aides, especially after dark. In nonhuman primate social groups as well as in primitive human societies, order is maintained through the power of males (5). Likewise. in mental hospitals male aides have been traditionally employed to contam aggressive patients on to enforce unpopular rules by a show of sheer muscular force. In the case of night personnel, there is also the neal or imaginary fear of intruders. Perhaps a metaphor, or dynamic. can be applied to nurses-as wives who wish for their husbands to come home at night. The patients’ wish for a male aide in the evening may express a parallel dynamicthe wish for a father to come back home when a day of work is over. The wish for the presence of male nursing staff, especially at night when other male staff are not around, may also indicate concern about the sexual feelings of the female nursing staff or of the patients toward these women and the need to safeguard the nurses’ professional roles as substitute mothens.
We believe that the exclusive use of female aides may keep the incidence ofother-directed violence in a psychiatric hospital to a minimum. We also feel that the absence of male aides should not necessarily hampen the treatment process. The wish of some female nurses and aides to have the benefit of the presence of male aides seems to us less related to good treatment and more related to professional, cultural, or dynamic factors that could interfere with treatment.
I. 2. 3. 4. 5.
Linn L: national Hartocollis
A Handbook of Hospital Psychiatry. New York. InterUniversities Press. 1955 P: Aggressive behavior and the fear of violence. Adolescence 7:479-490, 1972 Spiegel JP: The dynamics of violent confrontation. Int J Psychiatry 10:93-108. 1972 Storr A: Human Aggression. New York, Atheneum, 1968
Bigelow R: The evolution of cooperation. aggression. and selfcontrol, in Nebraska Symposium on Motivation 1972. Edited by Cole JK. Jones DD. Lincoln, University of Nebraska Press. 1972,
6. Stanton Basic
Ani J Psychiatry