control, it is necessary to inform them of early clues to depressed and yet is preparing for discharge.

That ap-
watch for, such as changes in sleep and sexual patterns, parent contradiction must again be discussed in patient
so that the therapist can take active preventive mea- and staff meetings.
sures. As with all hospitalized patients it is useful to gradu-
In the termination phase the manic’s appearance and ally help the manic assume his previous roles when
behavior are quite appropriate and well integrated. appropriate and new or modified ones when indicated,
Frequently he has taken on useful strong leadership That is often accomplished by partial hospitalization,
roles in the therapeutic community and has a positive such as on a day or night basis. For the manic it is
influence over other patients. At this time therapists important to begin to deal with people who are not as
tend to delay discharge planning with the patient be- accepting and tolerant of his expansive behavior as the
cause of conscious or unconscious needs, such as the therapeutic community has been, since it is unlikely
need to have a well-organized, smoothly functioning that outside groups will allow him to be the center of
community with strong leadership. Occasionally as the attention. Therefore, it is essential that the manic’s
manic reconstitutes, he is finally able to undergo a discharge be a gradual cautious move back into society.
delayed mourning process over real losses, such as the Just as it is necessary to carefully coordinate the admis-
death of a loved one, that might have precipitated the sion of the manic patient to the hospital, it is important
manic episode months before. Sometimes other that discharge planning receive the same attention.
patients and staff observed a person who was admitted When that is achieved, successful inpatient treatment
“not looking sick at all” and who now appears quite of the manic can be accomplished.U

The Therapeutic Community

in Theory and Practice

TOKSOZ B. KARASU, M.D. mailed to authors ofrecently published articles or books

Director, Department of Psychiatry on the subject, 27 of whom responded with ratings of
Bronx(N.Y.) Municipal Hospital Center the degree to which each Item was characteristic of a
therapeutic community. The validated questionnaire
ROBERT PLUTCHIK, PH.D. was then completed by 22 staff members on four psy-
Director chiatric wards ofa university-affiliated municipal hoi-
HOPE R. CONTE, PH.D. tal, who rated the Items In terms of real and Ideal
Research Associate conditions on the ward. Comparisons of the real and
BARBARA SIEGEL, M.A. Ideal ratings are discussed.
Research Assistant
Program Evaluation and Clinical Research UThe concept of a therapeutic community arose partly
Department of Psychiatry from interpersonal psychiatry, partly from the historical
Albert Einstein College of Medicine tradition of moral treatment, and partly from experi-
Bronx, New York ences of British psychiatrists during World War II.1’8
The initial enthusiasm for the therapeutic community
MARC HERTZMAN, M.D. in Europe was followed by equally hopeful in-
Executive Assistant to the Director troductions in America.7’ By the late 1950s a full-scale
National Institute of AlcoholAbuse and Alcoholism revival of interest in the importance of the milieu in
Rockville, Maryland
Andrew Skodol, M.D., associate director of the psychiatric emergency
To obtain an operational description of the therapeutic room at the Bronx Municipal Hospital Center, assisted in the prepara-
tion of this paper. Dr. Karasu’s address is Department of Psychiatry,
community, the authors reviewed recent literature and
Albert Einstein College of Medicine at the Bronx Municipal Hospital
composed a 40-Item questionnaire describing aspects of Center, Pelham Parkway South and Eastchester Road, Bronx, New
the therapeutic community. The questionnaire was York 10461.

436 HOSPITAL & COMMUNITY PSYCHIATRY

therapy was occurring.9 reported successful outcomes for their patients.’8 New
However, by the early 1960s notes of caution were offshoots of the therapeutic community appeared to be
being sounded about the limitations of the therapeutic promising ways of integrating patients back into the
community for treatment of schizophrenics and others. general town community.’9 Substantial improvements
The therapeutic community was increasingly viewed as in the material environment of hospitalized patients,
a more ideological than practical model.1#{176}This growing probably under the stimulus of the community mental
disillusionment with the idea of a therapeutic commu- health movement in the 1960s, were taking place.#{176}’21
nity was based on experience with the personal limita- At the present time, the therapeutic community is
tions of patients and staff in implementing the thera- being adapted, often quite uncritically, into new areas
peutic community model.”2 of treatment such as drug addiction and geriatric care.
There were also problems associated with the way These therapeutic communities may differ greatly in
hospitals operated that severely circumscribed the ther- the type of patient population treated and the particu-
apeutic community’s effectiveness.’3”4 Attempts to lar kinds of services offered. The result is that a wide
adapt the therapeutic community to a general hospital variety of programs all call themselves therapeutic com-
with a rapid turnover of patients and staff and a dis- munities.
tinctly medical orientation met with limited success.” These developments pointed to the need for an oper-
By 1965, in a review of the sociology of hospitals as ational description of a therapeutic community. The
organizations, Perrow concluded that the basic fault of study reported here undertook to provide such a de-
the advocates of the therapeutic milieu was their failure scription and to demonstrate to what extent a therapeu-
to develop a technology of treatment that was a con- tic community was currently in operation on the four
crete improvement over previous modalities for curing psychiatric wards of Jacobi Hospital, a large university-
patients. ‘ affiliated general hospital serving low-income patients
Curiously enough, at the same time that increasing in the Bronx. The patients are almost equally divided
criticism was being directed at the concept of the thera- between whites and minority groups. Most are diag-
peutic community, certain hospitals using the model nosed as having different types of schizophrenic or
depressive disorders, and their hospitalization is rela-
tively brief. The therapeutic community is one of the
1 T. F. Main, “The Hospital as a Therapeutic Institution,” Bulletin
treatment modalities used on the wards. Psychiatric
of the Menninger Clinic, Vol. 10, May 1946, pp. 66-70.
I H. S. Sullivan, Schizophrenia as a Human Process, Norton, New residents who receive training on the wards are re-
York City, 1962. quired to read and discuss some of the contemporary
2 A. Deutch, The Mentally Ill in America, 2nd edition, Columbia literature in the field. Other staff members are exposed
University Press, New York City, 1949. to the therapeutic community both formally and infor-
4 D. Mechanic, Medical Sociology: A Selective View, Free Press,
mally.
New York City, 1968.
#{149}
A. A. Baker et al., “A Community Method of Psychotherapy,”
British Journal of Medical Psychology, Vol. 26, 1953, pp. 222-244. DEFINING A THERAPEUTIC COMMUNITY
S , Caplan, Principles of Preventive Psychiatry, Basic Books, New
York City, 1964.
To obtain an operational description of the therapeutic
7 M. Jones, “The Concept of a Therapeutic Community,” Amen-
community, recent literature was examined and a ques-
can Journd of Psychiatry, Vol. 1 12, February 1956, pp. 647-650.
#{149}
H. Wilmer, Social Psychiatry in Action, Thomas, Springfield, tionnaire containing 40 brief descriptions of various
Illinois, 1958. aspects of the therapeutic community was constructed.
#{149}
T. Parsons, “The Mental Hospital as a Type of Organization,” in Those items, which were compiled from descriptions of
The Patient and the Mental Hospital: Contributions of Research in
both theoretical and existing therapeutic communities,
the Science of Social Behavior, M. Greenblatt, D. J. Levenson, and
R. H. Williams, editors, Free Press, Glencoe, Illinois, 1957, pp. 108- are presented in Table 1. Several statements of prob-
129. able characteristics were worded negatively to reduce
10 R. N. Rapoport, Community as Doctor: New Perspectives on a possible bias. The questionnaire was sent to 47 authors
Therapeutic Community, Thomas, Springfield, Illinois, 1960.
of current articles and books on the therapeutic com-
“ M. Jones, Beyond the Therapeutic Community: Social Learning
and Social Psychiatry, Yale University Press, New Haven, Con-
munity, people who were considered to be experts on
necticut, 1968. the subject. They were asked to give their opinions
12 M. I. Hen, “The Therapeutic Community: A Critique,” Howl- about which items definitely characterized a therapeu-
to! & Community Psychiatry, Vol. 23, March 1972, pp. 69-72. tic community, which were desirable but not essential,
‘ M. Edelson, Sociotherapy and Psychotherapy, University of Chi-
cago Press, Chicago, 1970.
‘ Parsons, op. cit. J
1#{149} K. Wing and C. W. Brown, “Social Treatment of Chronic
A. Fischer and M. R. Weinstein, “Mental Hospitals, Prestige, Schizophrenia: A Comparative Survey of Three Mental Hospitals,”
and the Image of Enlightenment,” Archives of General Psychiatry, Journal of Mental Sciences, Vol. 107, September 1961, pp. 847-861.
Vol. 25, July 1971, pp. 41-48. C. W.
1#{149} Fairweather et a!., Community Life for the Mentally Ill:
‘ D. Hamburg, Therapeutic Hospital Environments: Experience An Alternative to Institutional Care, Aldine, Chicago, 1969.
in a General Hospital and Problems for Research, Walter Reed Army 20 L. S. Linn, “ State Hospital Environment and Rates of Patient
Institute of Research, Government Printing Office, Washington, Discharge,” Archives of General Psychiatry, Vol. 23, October 1970,
D.C., 1957. pp. 346-351.
“C. Perrow, “Hospitals: Technology, Structure, and Coals,” in 21 R. H. Moos and P. 5. Houts, “Assessment of the Social Atmo-
Handbook of Organizations, C. James, editor, Rand McNally, Chi- spheres of Psychiatric Wards,” Journal of Abnormal Psychology, Vol.
cago, 1965. 73, December 1968, pp. 595-604.

VOLUME 28 NUMBER 6 JUNE 1977 437

and which were definitely not characteristic. mean responses equal to or greater than 0 were consid-
Twenty-seven of the experts returned their question- ered to describe a therapeutic community according to
naires. Their responses were evaluated by giving a the pooled opinions of the experts. Items with mean
weight of 1 to each item rated as characteristic of a responses less than 0 were not considered descriptive.
therapeutic community, a weight of 0 to each item The questionnaire of items validated by the experts
rated as desirable but not essential, and a weight of -1 was then administered to a 20-per-cent stratified ran-
to each item rated as definitely not characteristic. Mean dom sample of all staff members directly involved in
scores for each of the items were computed. Items with patient care on the four psychiatric wards. While the

TABLE 1 Mean staff responses to the therapeutic comm unity questionnaire’

Real Ideal
Characteristics ward ward

Items rated by experts as desirable or essential:

Work programs are a form of therapy, not cheap labor. 2.6 2.0
Patients are allowed to wear their own clothing. 2.0 2.2
Staff explain the patient’s treatment to him. 2.0 2.5#{176}
Ward rules are explicitly made known to all patients. 2.2 2.8#{176}#{176}
Patients are permitted to have their own money. 2.2 2.4
Activities and entertainments are readily available. 1.7 2.7#{176}#{176}#{176}
Everyone, including patients, helps make decisions about ward rules. 0.9 1.6#{176}#{176}
Everyone, including patients, helps make decisions about how to handle misbehavior. 1.1 2.0#{176}
Patients and staff tell each other when their behavior does not make sense. 1.6 2.5#{176}#{176}
The staff act on patient suggestions. 1.2 1.8#{176}
The healthier patients help take care of the less healthy ones. 1.3 1.7
Patients can talk freely about their hallucinations, but everyone should encourage them to talk sense. 2.0 2.4
There is great emphasis on what patients will be doing after they leave. 1.9
Staff members take on responsibilities on the ward that are not part of their usual job. 1.4 1.7
Patients help staff decide who should have passes and other ward privileges. 0.3 1.5#{176}#{176}#{176}
Families can feel free to say anything they like before staff and patients. 1.2 1.5
Contacting families and outside agencies is a shared responsibility of patients and staff. 1.0 1.8#{176}
Patients can call staff by their first names. 1.7 1.8
The family is part of the therapeutic community from the moment a patient enters the hospital. 1.0 1.7#{176}
Patients are permitted to have razor blades. 0.0 0.6#{176}#{176}
Group meetings may be run by anyone, including the patient. 0.9 1.7#{176}
Patients and staff go out into the community and meet with former hospital patients. 0.4 1.3#{176}#{176}
A major goal is to make patients function better outside the hospital than they ever did before. 1.9 2.3
Staff members do not discourage verbally abusive patients from speaking out. 1.4 1.7
Regularly scheduled small group meetings are the most important therapeutic modality. 1.3 1.6
Patients keep control over patients who lose control. 1.0 1.4
Everyone, including the patients, makes decisions about discharges from the ward. 0.7 1.0
Appropriate outside agencies are part of the therapeutic community. 1.2 1.6

Items rated by experts as not descriptive:

The patient is still part of the therapeutic community when he leaves the hospital. 0.8 1.4#{176}
Once a schedule is arranged for a patient, the patient must follow it. 1.2 1.6
Interested citizens in the outside community participate in therapeutic community meetings. 0.3 0.9#{176}
Everyone, with the exception of patients, makes decisions about the discharge of patients from the
ward. 1.1 1.1
Staff members do not argue among front of patients.
themselves in 1.9 1.2
Patients can leave without saying where they are going. 0.1 0.4
Patients can leave the ward whenever they want to. 0.1 0.5#{176}
Individual psychotherapy is the preferred mode of therapy for most patients. 2.0 2.4
The staff discuss their personal problems in front of patients. 0.2 0.3
There is very little emphasis on making plans for getting out of the hospital. 1.3 1.7
Doors are always locked. 0.9 0.9
Patients are kept waiting when they have appointments with staff. 0.7 0.6

1 Items are ranked in order of their endorsement by 27 experts. Scores are based on a scale ranging from 0 for never true to 3 for always true.
p < .05
..p<.01
...p<.ool

438 HOSPITAL & COMMUNITY PSYCHIATRY

sample was relatively small-only 22-the selection Patient participation
procedure ensured that staff members in each job cate-
in ward management
gory would be proportionately represented. The sample
included one ward attending psychiatrist, one psychol- was one area
ogist, two psychiatric residents, one social worker, one where significant
rehabilitation worker, two occupational therapists, six differences were
nurses, one licensed practical nurse, and seven aides.
The 22 staff members were each given two copies of
consistently found
the questionnaire. On one they were instructed to between the staff’s
indicate the extent to which each statement described ratings of the
actual operations on their wards (real ward); on the real ward and
other, they were asked to indicate the extent to which
they would like to see the statement describe the wards’
the ideal ward.
operations (ideal ward). Weights of 0, 1, 2, and 3,
respectively, were assigned to the four possible an- that all 28 items supported by the experts received
swers: never true, sometimes true, usually true, and higher ideal- than real-ward ratings. That meant that in
always true. T tests comparing mean ratings for the real general the staff would ideally like to see their wards
ward and the ideal ward were used to provide a mea- function more like a true therapeutic community. For a
sure of the staff’s satisfaction with current practices and number of items the difference between real and ideal
an indication of areas in which they would like to see ratings was fairly small, indicating that in those areas
changes. staff were relatively satisfied with the current function-
ing of their wards. However, as shown in Table 1, t tests
REAL AND IDEAL CONDITIONS of mean real and ideal scores indicated that the differ-
ences were significant for 17 of the 40 items. Those
The 40 items on the questionnaire, ranked in order of items pointed to several areas where the staff would like
the experts’ pooled opinions, are presented in Table 1. to see changes toward a more ideal therapeutic commu-
For example, there was complete agreement that it is nity.
essential that ‘ ‘Work programs are a form of therapy, Patient participation in ward management was one
not cheap labor’ ‘and that ‘ ‘ Patients are allowed to wear area where significant differences were consistently
their own clothing. ‘ ‘ Items such as Patients
‘ ‘ keep con- found between the staff’s ratings of the real and ideal
trol over patients who lose control’ ‘ and Appropriate
‘ ‘ ward. It was felt that patients should be able to share
outside agencies are part of the therapeutic commu- more in some of the role functions currently assumed
nity’ ‘were considered desirable, but not essential. The primarily by staff, such as running group meetings,
last 12 items were considered to be neither essential nor intervening in a situation where another patient has lost
desirable for a therapeutic community. Half of the 12 control, or telling members of the therapeutic commu-
items were concerned with the extent to which personal nity when their behavior does not make sense. The staff
staff issues should be discussed in front of patients and also believed that patients should participate more in
the extent to which the therapeutic community should decision-making about ward rules, misbehavior, patient
be separated from the outside community. The other discharges, and passes and other privileges. Similarly,
half were ideas endorsed in the literature but stated they would like to see an increase in the extent to which
negatively. staff act on patient suggestions.
Correlations of the experts’ rating of the items with There were also considerable differences between
staff ratings for the real ward and ideal ward were found staff’s real and ideal perceptions of the degree to which
to be .48 and .69 respectively. That indicates that the the therapeutic community should extend into the real
staff’s description of their ideal ward is more closely community. Staff felt that ideally the ties should be
related to the experts’ description of the therapeutic stronger, for both hospitalized and discharged patients;
community than is the real ward. that the patient’s family and other interested individ-
Almost all of the 28 items sanctioned by the experts uals should be included more in the therapeutic corn-
were considered by staff members to be sometimes true rnunity; and that the hospitalized patient’s ties to the
or usually true of actual ward operations. However, external community should be fostered more. That feel-
several items, those whose real-ward mean scores were ing was indicated by the staff’s interest in increasing the
less than 1 were perceived
, to be rarely true in current emphasis on what patients will be doing after they
ward functioning. According to the staff’s observations leave the hospital, in involving patients in contacts with
of their wards, patients were rarely included in deci- families or outside agencies, and in having patients
sion-making concerning ward rules, patient discharges, accompany staff on follow-up home visits to former
or the granting of passes and other ward privileges. hospital patients. Staff also felt that more emphasis
They were never permitted to have razor blades on the might be placed on maintaining ties between dis-
ward and did not go into the community with staff to charged patients and the wards.
meet with former hospital patients. The results of the study clearly show that the staff
A comparison of real- and ideal-ward ratings showed were interested in increasing the degree to which many

VOLUME 28 NUMBER 6 JUNE 1977 439

aspects of the therapeutic community were in- staff’s acceptance of the therapeutic community on
corporated into actual ward operation. However, many their wards seems to reflect both a positive regard for
aspects of the therapeutic community endorsed by the the therapeutic community milieu as a treatment mo-
experts could not consistently be put into practice on dality and an understanding of its limitations in their
their wards. That points to the staff’s implicit judgment setting.
of the limits of the applicability of the therapeutic At the present time, a large variety of treatment
community model to their particular setting. programs have adopted the principles of the therapeu-
Several diverse factors may be operating to restrict tic community. Although all are called therapeutic
the practicality or desirability of complete adoption of communities, in practice they tend to differ greatly in
therapeutic community principles on the psychiatric patients served, in services offered, and in the way staff
wards that were studied. They include the rapid turn- interact with patients. The questionnaire developed for
over of a sizable proportion of the patient population, this study, validated by a group of experts in the field,
the precautions necessary for that minority of patients should be a useful instrument for assessing the func-
who are suicidal or homicidal, and the emphasis on the tioning of the therapeutic community in other settings.
practice of individual psychotherapy in the training of Similar surveys of other staffs could identify the par-
the psychiatric residents who staff the wards. Never- ticular aspects of the therapeutic community that are
theless, most of the therapeutic community concepts most functional in various types of treatment programs,
were, to varying degrees, already in effect or were and could highlight areas in which changes would be
considered desirable by the staff. The extent of the most desired and most readily accepted by staff.#{149}

Outpatient Group Psychotherapy

for the Elderly: An Alternative
to Institutionalization

CHRISTINA BOROWSKY DUETSCH, B.S.N., M.S, work, renewed contact with family and friends, and
Nurse Clinician, Crisis Clinic were better able to deal with life’s stresses.
Baltimore City Hospital
Baltimore, Maryland UThe elderly, whom many of our society do not value as
productive in the job market or in the family, often
NANCY KRAMER, M.S.W. have feelings of inadequacy and uselessness that lead to
Gundry Psychiatric Hospital depression. Retirement, which at one time was eagerly
Baltimore, Maryland anticipated, is now resented because it has brought
loneliness and frustration. The loss of a spouse or of
Two case studies Illustrate the positive effects of group close friends also tends to separate and isolate the el-
psychotherapy for elderly outpatients of a municipal derly, reinforcing their feelings of loss and alienation.
hospital in an industrial community of Baltimore. Most While providing service in an emergency room and
of the outpatients were depressed about physical, men- an outpatient psychiatric clinic of a 600-bed municipal
tal, or social losses. A total offive brief therapy groups hospital, located in an industrial, ethnic community of
were established. Each group had a maximum of 12 Baltimore, we found that many older patients were
members and met in the hospitalfor an hour and a half depressed or had psychosomatic complaints that related
once a week for 12 consecutive weeks. Members could to specific physical, economic, and social losses. In eval-
continue in subsequent 12-week sessions If they de- uating older people in crisis, we discovered that atti-
sired. As a result of their participation in groups, many tudes of feeling useful and necessary were lacking.
members became Involved in volunteer or part-time Therefore, we started holding therapy groups for this
population.
Ms. Borowsky Duetsch’s address at the hospital is 4940 Eastern
The purposes of group therapy were threefold: to
Avenue, Baltimore, Maryland 21224. Ms. Kramer formerly was a
medical social worker in the emergency room at Baltimore City emphasize the fact that the aging process is a normal
Hospital. part of the life cycle, to generate positive attitudes and

440 HOSPITAL & COMMUNITY PSYCHIATRY