Journal
of Psychosomatic
Research,
Vol.
THE EFFECT
20, pp. 363-366.
Pergamon
OF TREATMENT
ALISTAIR
Press,
1976.
Printed
in Great
Britain
ENVIRONMENTS
M. GORDON
DEPARTMENT OF PSYCHOLOGICAL MEDICINE ST. MARY'S HOSPITAL MEDICAL SCHOOL LONDON, W.2. Although environmental psychology is a relatively recent field of on psychological health is a study, the impact of environment subject already dear to the heart of the media and the public. Hospitals as stressful environments have evoked less clamour than council estates, high rise building, traffic congestion, pollution and disaster zones, but the early studies by sociologists have influenced hospital planning and design. In the past 15 years, psychiatrists have expressed increasing awareness of the effect of hospital and treatment environments though published observations from surgical and medical colleagues remains sparse. Hospital staff soon develop defences to protect themselves in their work environment and become less perceptive of its potential effects on others. Technological advances and the increased use of apparative techniques have accentuated stress and revealed more clearly that clinical reactions to hospital environments do occur. Studies of treatment environments have aimed at identifying either the potentially stressful aspects of the physical and emotional environment or the psychological characteristics of patients which influence adaptation in specific treatment procedures. Mendelsohn in 1956 described acute psychotic reactions in poliomyelitis patients, during artificial respiration in the tank respirator. He ascribed the acute confusional state with hallucinations and delusions to the sensory deprivation of the environment. Improved design has rendered the tank respirator therapeutically obsolete though it is still used experimentally to create conditions of sensory monotony. The advance of open heart surgery was followed by reports of a high incidence of post operative delirium which linked with aspects of the treatment environment. Patients were nursed post operatively in open, well lit recovery areas, immobilised by pain and tubing, encased in a plastic oxygen tent with its monotonous hiss and deprived of sleep by discomfort and observations. Removal from this environment,which combined sensory monotony with sleep deprivation,to the conventional ward setting usually resolved delirium in 1-2 days. Heller's replication study in 1970 revealed a marked decrease in the incidence of delirium which now related to organic features such as severity of cardiac illness, time on cardiac by pass and He ascribed this decreasing incidence to modifications in age. both the physical environment and the psychological atmosphere in recovery units - too late to prevent the emergence of a new 363
364
A. M. Gordon
disease in the literature - "the intensive care syndrome". Hackett, studying a coronary care unit and Sgroi studying an ICU have questioned environmental features as a major contribution to psychological disturbance in more recent ICU, but no comparative study of different models of ICU has appeared. Studies of renal dialysis units focus more on individual differences and their interaction with the strict therapeutic regime than on physical aspects of their environment. Greenberg's evaluation of patients on a dialysis programme relates successful adjustment to high IQ, family support, reduced defensiveness about anxiety and less generalised psychosomatic complaints. Patient interaction, both competitive and supportive aspects, contribute to successful maintenance and rejection of the group milieu correlates with poor adaptation. Preoccupation with A-V shunts, hostility displaced to dietary regimes,and distrust of new staff members, are frequent problems in dialysis patients. A recent advance in apparative techniques, now appearing in British hospitals, is treatment in gnotobiotic isolation. Isolation systems which provide a protected sterile environment have been developed to reduce the incidence of exogenous infection in various medical situations: organ transplants, thoracic surgery, burns, immune disease, radiation injury and cytotoxic therapy. Ten adults with acute leukaemia treated in isolator therapy were studied over a 2 year period in the leukaemia unit of Hammersmith Hospital. The isolator is an impervious plastic tent enclosing a bed, a Patients remain in their isolator service hatch and a chair. Successful throughout treatment which ranged from 7-14 weeks. psychological adaptation to isolator treatment involves acceptance of the systematised therapeutic routine, adjustment to the experience of enclosed isolation in a confined space and the ability to regain psychological equilibrium in an alien environment under the threat of fatal illness. The isolator routine includes a 7 day countdown period of reversed barrier nursing. After entry to the isolator, the daily programme begins with washing and stripping of the bed, sterile washing of of drugs, and twice daily all internal walls, administration All patients described feelings of anxiety on physiotherapy. entry which were augmented by the strictures of the preceding Anxiety resolved quickly, though 2 patients barrier nursing. experienced panic reactions, expressing fears of inaccessibility Anxiety tended to re-emerge at times of to staff in emergency. Isolator patients must take an active physical deterioration. part in their treatment and female patients adapted more readily than males to the routine which accorded more with their habitual The predominant complaints concerned monotony of the activities. However, routine and the unpalatable taste of the irradiated food. no patient requested termination of treatment because of the rigors of the routine and all expressed willingness to accept readmission if required. Social isolation is a familiar feature of any hospital admission. Although the physical barriers of the isolation situation might appear to the external observer to augment social isolation, no Patients felt able increase in social isolation followed entry.
The Effect of Treatment Environments
365
to maintain ready social rapport and were aided by liberal visiting arrangements and access to a private telephone. Social withdrawal is a familiar feature in adaptation to fatal illness, and 4 patients expressed awareness that they employed the isolator situation to avoid social contact. Patients in the isolator experience an alteration in sensory input, particularly restricted mobility, limited visual patterns, loss of human touch and altered taste sensation but the 'hypnoid' syndrome was not A period of 'touching' behaviour followed discharge. observed. Entry to the isolator was associated with an attitudinal shift. Before entry, patients viewed isolation as signifying more advanced disease, but following isolation described their treatment as 'special', 'more forceful' and 'better value'. Acceptance of isolation increased with length of treatment. All patients experienced renewed anxiety on discharge, most marked in patients with the longest period of treatment. A diagnosis of fatal illness combined with a treatment regime in such a restrictive environment imposes considerable stress on individual adaptation. As in any fatal illness, defence mechanisms fluctuated throughout treatment but major mechanisms emerged in each patient. Seven patients manifested a manic defence admitting their diagnosis though not its unfavourable prognosis, attempting to master and control the outcome by enthusiastic cooperation, search for knowledge, insistence of explanation, expressing aggressively optimistic attitudes and rejecting pessimistic information. Three patients adopted a regressive defence - denying their diagnosis, seeking little information, revealing no sustained interest in treatment though complying accepting solace but limiting social contact and passively, showing little affective response. The isolator situation Since all activities require staff enforces dependency. participation, it removes autonomy, yet demands an active contribution. Ambivalence develops as the patient must sustain co-operation while yielding independence. The regressive group adapted more readily to this situation and their anergia was partially dispersed by the obligatory activities. The manic defended group, though initially appreciative of their potential for active contribution, soon found the limited flexibility of isolation restricted their independence and struggles for control led to paranoid expression, feelings of disparagement and hostility projected towards staff. The manic patient has an understandable appeal for most physicians and though medical factors are the primary consideration in selection for isolation, it is not surprising to find the manic patients highly represented in this series. It is not only patients who have to adapt to treatment environments. The combination of complex equipment, serious illness and limited patient contact creates a tense work environment for staff and such units have high staff turnover. Nurses are particularly vulnerable as they receive the major part of any pro%jected hostility. Although able to establish a familiar role with the dependent patient, they are perplexed by the fluctuations in rapport with the manic defended patient and tend to rely on isolator routine to protect themselves from anxiety. A psychiatrist ways:
can contribute
to an isolator
unit
in several
366
A. M. Gordon
1.
Identifying patients who might fail to tolerate therapy. Management of psychotic illness would disrupt isolator treatment.
2.
Predicting reactions adaptive behaviour.
3.
Cautioning about the problems of managing the manic defended patient and tempering rejection of the regressed patient.
and increasing
psychological 4. Strengthening their tendency to abrogate alone.
staff
awareness
of
skills in staff while avoiding responsibility to the psychiatrist
effects of the environment, often 5. Indicating the psychological modified by small, subtle changes and easily explicable to physicians whose focus on primary care may have obscured their alertness to its secondary effects. The participation of a psychiatrist in complex treatment environments can reduce morbidity, alleviate staff difficulties and contribute to the effective maintenance of therapy. REFERENCES 1. 2.
3.
4.
5. 6.
7. 8.
9.
aspects of isolator therapy in Gordon, A.M. Psychological acute leukaemia. B.J.Psych. 127 : 588-90 (1975). Greenberg, R.P., Davis, G. and Massey, R. Psychological evaluation of oatients.for a kidnev transnlant and haemodialysis programme. Am.J.Psych. 130': 274-7 (1973). Hackett, T.P., Cassem, N.H. and Wishnie, H.A. The coronary of its psychological hazards. E care unit: An.appraisal En g . J. Med. 279 : 1365-1370 (1968). Heller, S., Frank, K., Maim, J. et al. Psychiatric complications of open.heart.surgery. New Eng.J.Med. 283 : 1015-1019 (1970). Its impact on the Kornfeld, D.S. The hospital environment: patient. Adv. psychosom. Med., vol. 8, pp 252-270 Mendelsohn, J., Solomon, P. and Lindeman, E. Hallucinations of poliomyelitis patients during treatment in a respirator. J. Nerv. ment. Dis. 126 : 421-428 (1958). reactions Sgroi, S., Holland, J. and Marwit, S. Psychological to catastrophic illness. Psychosom. Med. 30 : 551-552 (1968). Winkelstein, C., Blather, R.S. and Meyer, B. Psychiatric observations on surgical patients in recovery rooms. N.Y.St. J. Med. 65 : 865-870 (1965). of mental symptoms found in acute Ziskind, E. An explanation sensory deprivation. Am.J. Psych. 121 : 939 (1965).
of Psychosomatic
Research,
Vol.
THE EFFECT
20, pp. 363-366.
Pergamon
OF TREATMENT
ALISTAIR
Press,
1976.
Printed
in Great
Britain
ENVIRONMENTS
M. GORDON
DEPARTMENT OF PSYCHOLOGICAL MEDICINE ST. MARY'S HOSPITAL MEDICAL SCHOOL LONDON, W.2. Although environmental psychology is a relatively recent field of on psychological health is a study, the impact of environment subject already dear to the heart of the media and the public. Hospitals as stressful environments have evoked less clamour than council estates, high rise building, traffic congestion, pollution and disaster zones, but the early studies by sociologists have influenced hospital planning and design. In the past 15 years, psychiatrists have expressed increasing awareness of the effect of hospital and treatment environments though published observations from surgical and medical colleagues remains sparse. Hospital staff soon develop defences to protect themselves in their work environment and become less perceptive of its potential effects on others. Technological advances and the increased use of apparative techniques have accentuated stress and revealed more clearly that clinical reactions to hospital environments do occur. Studies of treatment environments have aimed at identifying either the potentially stressful aspects of the physical and emotional environment or the psychological characteristics of patients which influence adaptation in specific treatment procedures. Mendelsohn in 1956 described acute psychotic reactions in poliomyelitis patients, during artificial respiration in the tank respirator. He ascribed the acute confusional state with hallucinations and delusions to the sensory deprivation of the environment. Improved design has rendered the tank respirator therapeutically obsolete though it is still used experimentally to create conditions of sensory monotony. The advance of open heart surgery was followed by reports of a high incidence of post operative delirium which linked with aspects of the treatment environment. Patients were nursed post operatively in open, well lit recovery areas, immobilised by pain and tubing, encased in a plastic oxygen tent with its monotonous hiss and deprived of sleep by discomfort and observations. Removal from this environment,which combined sensory monotony with sleep deprivation,to the conventional ward setting usually resolved delirium in 1-2 days. Heller's replication study in 1970 revealed a marked decrease in the incidence of delirium which now related to organic features such as severity of cardiac illness, time on cardiac by pass and He ascribed this decreasing incidence to modifications in age. both the physical environment and the psychological atmosphere in recovery units - too late to prevent the emergence of a new 363
364
A. M. Gordon
disease in the literature - "the intensive care syndrome". Hackett, studying a coronary care unit and Sgroi studying an ICU have questioned environmental features as a major contribution to psychological disturbance in more recent ICU, but no comparative study of different models of ICU has appeared. Studies of renal dialysis units focus more on individual differences and their interaction with the strict therapeutic regime than on physical aspects of their environment. Greenberg's evaluation of patients on a dialysis programme relates successful adjustment to high IQ, family support, reduced defensiveness about anxiety and less generalised psychosomatic complaints. Patient interaction, both competitive and supportive aspects, contribute to successful maintenance and rejection of the group milieu correlates with poor adaptation. Preoccupation with A-V shunts, hostility displaced to dietary regimes,and distrust of new staff members, are frequent problems in dialysis patients. A recent advance in apparative techniques, now appearing in British hospitals, is treatment in gnotobiotic isolation. Isolation systems which provide a protected sterile environment have been developed to reduce the incidence of exogenous infection in various medical situations: organ transplants, thoracic surgery, burns, immune disease, radiation injury and cytotoxic therapy. Ten adults with acute leukaemia treated in isolator therapy were studied over a 2 year period in the leukaemia unit of Hammersmith Hospital. The isolator is an impervious plastic tent enclosing a bed, a Patients remain in their isolator service hatch and a chair. Successful throughout treatment which ranged from 7-14 weeks. psychological adaptation to isolator treatment involves acceptance of the systematised therapeutic routine, adjustment to the experience of enclosed isolation in a confined space and the ability to regain psychological equilibrium in an alien environment under the threat of fatal illness. The isolator routine includes a 7 day countdown period of reversed barrier nursing. After entry to the isolator, the daily programme begins with washing and stripping of the bed, sterile washing of of drugs, and twice daily all internal walls, administration All patients described feelings of anxiety on physiotherapy. entry which were augmented by the strictures of the preceding Anxiety resolved quickly, though 2 patients barrier nursing. experienced panic reactions, expressing fears of inaccessibility Anxiety tended to re-emerge at times of to staff in emergency. Isolator patients must take an active physical deterioration. part in their treatment and female patients adapted more readily than males to the routine which accorded more with their habitual The predominant complaints concerned monotony of the activities. However, routine and the unpalatable taste of the irradiated food. no patient requested termination of treatment because of the rigors of the routine and all expressed willingness to accept readmission if required. Social isolation is a familiar feature of any hospital admission. Although the physical barriers of the isolation situation might appear to the external observer to augment social isolation, no Patients felt able increase in social isolation followed entry.
The Effect of Treatment Environments
365
to maintain ready social rapport and were aided by liberal visiting arrangements and access to a private telephone. Social withdrawal is a familiar feature in adaptation to fatal illness, and 4 patients expressed awareness that they employed the isolator situation to avoid social contact. Patients in the isolator experience an alteration in sensory input, particularly restricted mobility, limited visual patterns, loss of human touch and altered taste sensation but the 'hypnoid' syndrome was not A period of 'touching' behaviour followed discharge. observed. Entry to the isolator was associated with an attitudinal shift. Before entry, patients viewed isolation as signifying more advanced disease, but following isolation described their treatment as 'special', 'more forceful' and 'better value'. Acceptance of isolation increased with length of treatment. All patients experienced renewed anxiety on discharge, most marked in patients with the longest period of treatment. A diagnosis of fatal illness combined with a treatment regime in such a restrictive environment imposes considerable stress on individual adaptation. As in any fatal illness, defence mechanisms fluctuated throughout treatment but major mechanisms emerged in each patient. Seven patients manifested a manic defence admitting their diagnosis though not its unfavourable prognosis, attempting to master and control the outcome by enthusiastic cooperation, search for knowledge, insistence of explanation, expressing aggressively optimistic attitudes and rejecting pessimistic information. Three patients adopted a regressive defence - denying their diagnosis, seeking little information, revealing no sustained interest in treatment though complying accepting solace but limiting social contact and passively, showing little affective response. The isolator situation Since all activities require staff enforces dependency. participation, it removes autonomy, yet demands an active contribution. Ambivalence develops as the patient must sustain co-operation while yielding independence. The regressive group adapted more readily to this situation and their anergia was partially dispersed by the obligatory activities. The manic defended group, though initially appreciative of their potential for active contribution, soon found the limited flexibility of isolation restricted their independence and struggles for control led to paranoid expression, feelings of disparagement and hostility projected towards staff. The manic patient has an understandable appeal for most physicians and though medical factors are the primary consideration in selection for isolation, it is not surprising to find the manic patients highly represented in this series. It is not only patients who have to adapt to treatment environments. The combination of complex equipment, serious illness and limited patient contact creates a tense work environment for staff and such units have high staff turnover. Nurses are particularly vulnerable as they receive the major part of any pro%jected hostility. Although able to establish a familiar role with the dependent patient, they are perplexed by the fluctuations in rapport with the manic defended patient and tend to rely on isolator routine to protect themselves from anxiety. A psychiatrist ways:
can contribute
to an isolator
unit
in several
366
A. M. Gordon
1.
Identifying patients who might fail to tolerate therapy. Management of psychotic illness would disrupt isolator treatment.
2.
Predicting reactions adaptive behaviour.
3.
Cautioning about the problems of managing the manic defended patient and tempering rejection of the regressed patient.
and increasing
psychological 4. Strengthening their tendency to abrogate alone.
staff
awareness
of
skills in staff while avoiding responsibility to the psychiatrist
effects of the environment, often 5. Indicating the psychological modified by small, subtle changes and easily explicable to physicians whose focus on primary care may have obscured their alertness to its secondary effects. The participation of a psychiatrist in complex treatment environments can reduce morbidity, alleviate staff difficulties and contribute to the effective maintenance of therapy. REFERENCES 1. 2.
3.
4.
5. 6.
7. 8.
9.
aspects of isolator therapy in Gordon, A.M. Psychological acute leukaemia. B.J.Psych. 127 : 588-90 (1975). Greenberg, R.P., Davis, G. and Massey, R. Psychological evaluation of oatients.for a kidnev transnlant and haemodialysis programme. Am.J.Psych. 130': 274-7 (1973). Hackett, T.P., Cassem, N.H. and Wishnie, H.A. The coronary of its psychological hazards. E care unit: An.appraisal En g . J. Med. 279 : 1365-1370 (1968). Heller, S., Frank, K., Maim, J. et al. Psychiatric complications of open.heart.surgery. New Eng.J.Med. 283 : 1015-1019 (1970). Its impact on the Kornfeld, D.S. The hospital environment: patient. Adv. psychosom. Med., vol. 8, pp 252-270 Mendelsohn, J., Solomon, P. and Lindeman, E. Hallucinations of poliomyelitis patients during treatment in a respirator. J. Nerv. ment. Dis. 126 : 421-428 (1958). reactions Sgroi, S., Holland, J. and Marwit, S. Psychological to catastrophic illness. Psychosom. Med. 30 : 551-552 (1968). Winkelstein, C., Blather, R.S. and Meyer, B. Psychiatric observations on surgical patients in recovery rooms. N.Y.St. J. Med. 65 : 865-870 (1965). of mental symptoms found in acute Ziskind, E. An explanation sensory deprivation. Am.J. Psych. 121 : 939 (1965).
