The code of loyalty among delinquents, prison inmates, criminals, and certain oppressed minority groups is a well-known social phenomenon. This code of behaviour represents not only the acceptance of socially deviant group values but specifically prohibits a member of the group from consorting with members of other groups, especially those representing “authority”. A breach of code, resulting in the apprehension or punishment of other group members, is likely to result in social ostracism, ridicule, physical punishment or death for the transgressing member. Such epithets as “stool pigeon,” “stoolie,” “rat fink,” “teachers pet,” “ass-kisser,” and “brown-noser” are reserved for those individuals who cooperate with authority figures responsible for controlling or modifying the behaviour of the group in which these individual belong. Of interest is the ambivalent attitude of those in authority toward “informers”. On the one hand they are dependant on these people for vital information; and the other hand they regard informers as traitorous and despicable. In a sense, then, both the deviant sub cultural group and the group vested with authority have formed an unwritten and informal pact to withhold sanctuary and solace from people who break the group code.
Although such codes have been commented on widely, little has been written about the existence of similar type codes among hospitalised chronic schizophrenic patients. Not only are such codes operative in a closed ward setting, but attitude
of staff toward patients breaking the code often parallel those of persons in
1. Chairman, Department of Psychiatry, university of Kentucky Medical School, Lexington, Kentucky
2. Clinical Director, Family Social & Psychotherapy Services, Madison, Wisconsin
authority toward informers. A situation, therefore, is unwittingly created whereby patients find it difficult to relinquish their identification as chronic patients and to adopt more socialised values and attitudes.
To the degree that the foregoing is true, then one of the central problems in dealing with groups of chronic schizophrenics is to cope somehow with this code; as long as this rehabilitating the chronic schizophrenic becomes overwhelming.
The existence of such a code became readily apparent curing the early phase of our experimental treatment program for 30 chronic hospitalised schizophrenics. These patients, consisting of 16 males and 14 females, were selected from various wards throughout the hospital and housed together in a single building where the new intensive treatment program would take place. Included in this group were not only patients who had made themselves inconspicuous during their years of hospitalisation by virtually “crawling into the woodwork,” but also patients with a history of multiple elopements from the hospital and serious aggressive and sexual acting-out problems. All these patients had been intensively treated with a variety of activity, pharmacological and psychotherapies; the net result was pervasive staff pessimism about their response and prognosis.
Since a primary purpose of the ward was to evaluate various psych-social techniques for the modification of behaviours and the rehabilitation of patients, the general ward policy was to control patient behaviour without ready access to such convenient EST, tranquillisers and sedatives. For most patients and staff, this was a new experience and soon brought to the fore many therapeutic problems which previously had been suppressed by these traditional practices and procedures. For example, a heavily tranquillised patient is not likely to engage in either deviant of therapeutic group interaction.
Because of the limited number of unit staff and virtual elimination of pharmacological restraints to control behaviours, it became obvious that the patients themselves would have to assume the major brunt of the responsibility for modifying and channelling each other’s deviant of potentially harmful behaviour. In a word, since we could not adequately “police” them patients had to police
themselves. Once the unit staff had accepted this position, it soon encountered head-on a number of traditional attitudes held by chronic hospitalised patients, as well as staff, which made the enforcement of such a position extremely difficult.
These traditional attitudes and their consequent behaviours we have come to term “The Code of Chronicity.” This code, partially reinforced by staff and society, tends to perpetuate “crazy” behaviour, helps sustain a staff-patient barrier leads to the acceptance and rationalisation of continued hospitalisations and thus effectively eliminates any incentive for change, improvement, and eventual discharge.
Some of the essential components of the code which we have observed to date are described below.
Characteristics of Code of Chronicity
A. The Staff as Jailers
Since the therapeutic zeal of most staff has long since waned toward these patients, the patients eventually come to view hospital staff more as jailers, custodians, wardens, keepers or guards than as therapists. From the patient’[s perspective, the staff, similar to prison authorities, determine length of sentence (hospitalisation), grant parole (conditional release), award privileges, and mete out punishments,
Although staff may view themselves as therapists and regard all their efforts as “therapeutic2, they (as well as society) seem to reinforce these patient attitudes. Patients accurately perceive that staff do, in fact, “police” patient behaviour, suppress acting-out and determine privileges. Although staff may not be permitted to physically “punish2 patients for deviant behaviour, under the banner of “therapy” and the scientific appellation of negative reinforcement, they are permitted great latitude in handling this behaviour. Restraints, seclusion, EST, and drugs are effective ways for keeping patients “in line.”
B. The “Model Patient”
Most of our chronic patients seem content to reach the enviable goal of attaining the greatest amount of privileges, the least amount of restrictions, and minimal demands put upon them without having to leave the protective setting of the hospital. To attain this goal, all patients need to do is to participate perfunctorily in scheduled therapeutic activities, such as occupational and recreational therapy or group therapy meetings, perform a minimal work assignment, remain inconspicuous enough so that some staff member with therapeutic zeal might not be tempted to push them out of the hospital, and not act out overtly (a therapeutic taboo). If patients can meet these criteria, they are gratefully accepted by the hospital staff and administration as “key workers” who are “co-operative with ward routine” – a source of cheap help and essential to the maintenance and repair of hospital grounds, facilities and services. Thee model patient this becomes a sub-staff member.
C. The “Un-Dead” State
In Bram Stoker’s Dracula, there is a description of people who turn into huge vampire bats at night after remaining in an unfeeling, non-reacting, trance-like “un-dead2 state during the day. The expectation and behaviour of chronic patients often parallel this description. They can not tolerate emotional stress or discomfort of any kind, be it fear, anxiety, depression, love or human closeness, and immediately seek to quell these feelings. They seem to prefer the foggy, benumbed calm of tranquillizers, the stuporous feeling of sedatives, or the confused oblivion following EST to the unpleasant experience of their own thoughts and feelings. Minimal involvement, minimal feeling, minimal thought, and minimal stimulation by others help preserve the equilibrium of chronicity.
Hospital staff, on their part, help meet these patient needs. Out of sympathy and concern for the patient’s plight, staff minister the mental
healing balm of tranquillisers, sedatives, and anti-depressants as soon as the patient seems upset enough to gain the attention of staff. Since it is “inhumane” to allow the patient to continue to suffer, it becomes incumbent on empathic staff to dull the edge of patient anxiety or allay his fears. Moreover, the “quiet ward,” highly valued by administrators and staff, is considered necessary to the smooth functioning of a hospital and to “good therapeutic practice.”
D. Victims of Society
Though not true of all patients, many regard themselves as social pariahs – outcasts of a disinterested and uncaring society. They come to view society, or certain social agencies or institutions, as vaguely responsible for their present predicament. As a result of their being “short-changed,” society owes them recompense. After years of hospitalisation, they begin to consider themselves entitled to total care. They become chronically and aggressively dependent and come to feel that everything they receive they have coming to them.
Another variation of this all-pervasive attitude may take the form of a personal vendetta against society for its harshness and rejection. Patients feel that they have been “dealt a raw deal” by life, and their global response is not flight but fight – to strike back at, get even, and settle accounts.
As society’s representatives, hospital staff often do, in fact, appropriately feel sympathy toward patients for their past sufferings. However, through misguided kindness and understanding, they may reinforce a patient’s attitudes and behaviour by exonerating present “sins” on the basis of the horrible circumstances of his past life. Moreover, they may refrain from venting anger punishing a patient for acts, which under normal circumstances would be reprehensible, simply
because they understand the psychological genesis of his behaviour. To understand may be to forgive, but to forgive a deviant act without punishing it (euphemistically termed “negative reinforcement”) may be to condone, encourage and perpetuate it.
E. Representation Without Taxation
Patients have been well taught the principles of democracy, equality, therapeutic community and the virtues of teamwork – so much so that they vociferously claim their inalienable right to behave as they choose but speak in whispers, if at all, about their corresponding obligations and duties.
Hospital staff have provided patients with numerous opportunities and forums to voice their gripes and participate in decision affecting ward privileges and routine. However, under the banner of self – determination and therapeutic decision making, patients are frequently granted privileges without corresponding obligations – a situation which had no comparable model in society. In society, a person gains and prerogative or being heard by assuming the obligation of being productive and consistently fulfilling the role of responsible citizen. Where the model breaks down in the mental hospital is precisely at this point: patients are all too often granted representation without being expected to pay the taxes of appropriate socialised, responsible behaviour.
F. Insanity by Convenience
Chronic patients seem to harbour certain paradoxical attitudes whereby they expect to receive the prerogatives of both the crazy and the sane – the best of both worlds. If they act crazy, they “couldn’t help it”; if they act sane, they deserve rewards. They regard themselves as responsible and capable of handling things they want to but regard themselves as helpless and incapable of controlling impulses or confirming to unpleasant
staff or group demands. In other words, they expect plus points for sanity and no deductions for insanity.
Staff respond with double standards to the paradoxical expectational system and behaviours of the crazy-sane patient. If patients act crazy, they are not to blame; if they behave normally, they are given privileges. This situation does not pertain to real life; in the extra-hospital society, deviancy is punished, sanity is rewarded.
Anybody who has worked with many chronic schizophrenics over a considerable length of time also can see that their craziness does not remain full-blown constantly, but is a some-time thing. We have gained the distinct impression that patients may frequently turn their craziness off and on in both a predictable and non-predictable manner. We believe that the aperiodic nature of many patient’s craziness effectively pays off for them in a variety of ways, not the least of which is continued hospitalisation.
This pattern of patients’ behaviour tends to be met by complementary staff attitudes, which usually include the following components;
i. The patient must be sicker than we thought;
ii. He obviously is not ready for discharge;
iii. He had better be kept in the hospital for a while longer, a while longer, a while longer
G. Not My Brothers Keeper
After years of hospitalisation, patients begin to loos all sense of social or group responsibility. They regard their own problems as unique or overwhelming, and others be dammed. If they observe sexual acting – out in others or aggressively destructive behaviour, then it’s the staff’s job to intervene and re-establish equilibrium and ward peace. They have
enough problems of their own to worry about and can’t be bothered taking the responsibility for others. Their attitude is one of “me, myself and I”.
For the most part, hospital staff tend to perpetuate this attitude by intervening, subduing the offender, and not placing the burden of responsibility on the shoulders of the patient group. Unfortunately, staff unwittingly tend to discourage meaningful patient – to –patient interaction by protecting them from each other.
H. The weapons of Craziness
When a patient does lose control of his behaviour, strikes other patients or staff, he knows that staff cannot retaliate in like manner. Even when the staff feel that a good kick in the pants or a slap may be infinitely more therapeutic than a tranquilliser pill in controlling patient behaviour, they are bound by the “humane” principles of kindness, understanding or restraint. Physical punishment is taboo and has no place in a modern therapeutic institution. In the ongoing struggle for control between patients and staff, the staff must engage in battle with one hand tied behind. The patient can fight as dirty as he likes using alley rules (thumb in eyeball, knee in groin). Staff are conscientiously bound by the Marquis of Queensbury rules.
In addition to the limitations (well know by patients) i9mposed upon staff, patients may also utilise the weapon of “if you upset me, I’ll make you wish you hadn’t”. If confronted by staff, patients may implement this unspoken threat by losing “hard won therapeutic gains” staying up all night and bizarre behaviour. When patients respond in such a way following staff confrontations, staff inevitably assume that they have pushed the patient too fast and too far. The possibility of a patient getting upset is, in effect, a club held over the staff’s collective head.
It would also be noted that the patients utilise these and other weapons in an unflagging war of attrition against staff’s therapeutic efforts. The “Hard Core” patients are those who have successfully met and worn down staff group after staff group, until one gets the distinct impression that staff may come and staff may go, but his type of patient remains forever.
The Code in Operation
Shortly after the initiation of our experimental treatment program, it became clear that members of the chronic patient group, in order to enforce group solidarity, cold and did reward one another with affection, conversation, money, cigarettes and companionship. By the same token they could punish one another by ostracism, threats, physical assaults, and by with holding the above-mentioned rewards. Because these rewards and punishments given within the patient group were concrete, meaningful and immediately contingent upon certain deviant behaviours they were extremely potent in perpetuating the code of Chronicity. On the other hand, staff’s reward’s and punishments were viewed by the patients as relatively intangible, meaningless, and boo long-term; by default, then, the code could easily flourish.
Staff soon learned that a number of patients were engaging in various forms of acting out behaviour. However, few patients felt under any obligation to intervene or even inform staff of what was happening even though the behaviour of these other patients was potentially harmful to themselves or others. By engaging in this “conspiracy of silence,” the so called innocent patients were truly accessories after the fact. Many knew when certain patients either had planned to flee, fornicate or fight on the ward but preferred to let staff find out for themselves. When some patients were confined to the ward and denied coffee and cigarette privileges, others held break these rules by smuggling these items to the restricted patients. In short, the group of patients either actively or passively, either consciously or unwittingly, undermined staff efforts.
Attempts to Break the Code
Since we came to feel that the existence of such values and behaviour could only prove detrimental to patients and reinforce their Chronicity, we set upon a grogram to break the code. Obviously, we were not dealing with a group of fragile, broken spirited persons but rather with tough, formidable adversaries who were “pros” and who had successfully contended with many different staffs on various wards in defending their title of “chronic schizophrenia”. In attempting to break the code held by this group, we were specifically interested both in reinforcing the healthy aspects of group loyalty and eliminating the self and socially destructive aspects of group identification.
To contend successfully with patients, we were forced to adopt certain working assumptions. Basically, these assumptions, and the tactics derived form them, represented attempts to break away from a number of traditional staff attitudes and behaviours which we believe tended to perpetuate or, at the best were impotent against the code of Chronicity.
First, even though considered insane by psychiatric and social standards, we regarded all patients as responsible for their behaviour. If pressed to do so, they could exercise the choice of getting well. Granted this assumption did not conform to many notions regarding the biochemical etiology of schizophrenia, which may still be valid, but since no pharmacological cure was readily available, the question of such an etiology is purely academic at the present time for the purposes of treatment. If we were to act, we had no choice other than to adopt a psycho-social basis for patients’ behaviours and psycho- social techniques to modify them.
Second, since all patients were living together in one unit, the behaviour of any one member, for good or bad, reflected on and influenced the whole group. Just as the deviant behaviour of a family member can affect eh welfare of the whole family, we believed a similar phenomenon to be operating on the ward. Patients in fact were their brother’s keeper, whether they liked it or not, and they were obliged to intervene to prevent the deviant behaviour of their fellow patients from affecting the welfare of all patients on the ward. Instead of ward staff having the major
responsibility for modifying patient deviant behaviour, the patients themselves were expected to assume this task. Moreover, and just as important, in helping others, they were helping themselves.
Third, there was no need to snow someone with medication simply because he happened to be experiencing intolerable feelings of anxiety, fear, depression, or insomnia. Patients would have to learn to live with and live through these feelings without ready access to agents which would produce mental oblivion. They would have to find other constructive ways to coping with these feelings or just to bear some suffering, if they were ever going to learn to live humanly and productively on the outside.
Fourth, staff would provide as little reinforcement as possible for pathological or deviant forms of behaviour. Patients would have their craziness pointed out consistently and insistently. Furthermore, the privileges they received were not automatically coming to them but were contingent upon the performance of desired behaviours.
Fifth, patients’ present behaviours were judged all important. Even though we recognised that past experiences had shaped their present conflicts and behaviours, such psychological genesis was deemed irrelevant for two reasons. A variety of etiologically oriented treatment approaches had been tried with these patients and failed. In addition, present behaviours were the only ones which we could see, attempt to eliminate or reinforce, and measure.
Sixth, to become well, patients would have to think, feel, and behave similar to staff as persons. The concepts of normality and sanity as therapeutic goals were too intangible and vague; we would have to deliberately concretise these concepts by insisting that patients employ staff persons as models for behaviour. Despite our visible faults, foibles and inconsistencies, we would expect patients to “be like staff – warts and all”. Furthermore, we would not play at democracy in therapeutic community meetings; not the majority, but health and sanity, as defined by staff would rule.
With these initial assumptions as a basis, we began searching for effective methods to implement them. Our goal was to raise the price of Chronicity. Initially we tried talking at considerable length about patients’ behaviours at ward group meetings; these discussions and homilies had little if any impact. Appeals to reason failed, and attempts to compromise were either ignored or viewed as weakness by these patients. Obviously, if patients were to be rehabilitated, the cold war stalemate between patients and staff could not continue.
Once we had accepted this conclusion we were forced to employ a number of tactics aimed at undermining the unhealthy aspects of patient group solidarity. If patients chose to fight for and defend their maladaptive and self – destructive way of life, we would have to escalate out efforts in the battle for life, we would have to escalate out efforts in the battle for their sanity. To pursue the war analogy further, we fully realised that if patients “won” this battle=, the paradoxical outcome was that they would really lose in human and socially meaningful ways. The only real chance patients had to “win” would be for them to capitulate completely to the therapeutic efforts of staff and accept unconditional surrender to our value system.
Since our ultimate aim for all patients was to help them realise their fullest potential as human beings, we were committed to the notion that an occasionally unhappy but productive, socialised person out of the hospital was infinitely more desirable than a happy, unproductive institutionalised schizophrenic. Therefore, if we were to break the code of Chronicity, we had no other recourse but to employ strategies designed to “divide and conquer.” To this end, patients were deliberately played off against each other by making each patient not only suffer the consequences of his own deviant behaviour but also the consequences of other patients behaviours toward one another and toward staff.
In order to undermine further the chronic patients’ value system, we decided to utilise many of the same concrete, meaningful, and immediate rewards and punishments that patients themselves employed to perpetuate it. Minor infractions of ward rules were met by the usual loss of certain privileges. However, if any member of members of the patient group went AWOL from the hospital, or
engaged in forbidden aggressive or sexual activities, the entire population would be restricted to the ward and lose all privileges for three days if no one attempted to intervene or to inform staff.
Although we sanctioned and encouraged patients to vent their anger and to defend themselves appropriately against attack, to intervene and restrain other patients engaging in fights and to prevent fellow patients from funning away from the hospital, we never failed to insist that these behaviours be employed within the boundaries of moderation and discretion. Staff were always present on these occasions to guarantee that these boundaries would be observed.
Basically, the therapeutic rationale for our position was that we were not going to overprotect patients from the consequences of their own behaviours or from offending group members; we hoped to mobilise the potent forces of the peer group to modify inappropriate reactions and to increase coping behaviours.
In addition we clearly communicated the value that “squealing” on or actively controlling other group member’s unacceptable behaviours was good when it was against a bad code. Contrary to the generally ambivalent reactions of persons in authority toward informants, we offered sanctuary, concrete rewards, and staff approval for those patients who thwarted their own group’s destructive values and behaviours. The purpose of all these strategies was to make the survival of chronicity a luxury which patients could no longer afford.
After the first several times that the ward was placed on restriction, many patients began breaking out of their shell and directing their anger (which at first they expressed to staff) at the offending persons. Interaction at ward meetings became heightened, and patients who previously had only the staff to recon with, now had to take on their fallow patients as well. They soon came to see, in a very concrete way, that the behaviour of other patients did truly affect them and that they had to cope with other patients to preserve their own rights and privileges.
Soon patients began preventing others form eloping, either talking them out of it or informing staff of the proposed escape. At the encouragement of staff or on their own initiative, they intervened in fights, restraining the offending parties. They became offended at aberrant sexual behaviour and reported instances of this to the staff.
At the same time, these instances were discussed openly at general ward meetings. The discussions seemed to become more meaningful, and the topic of responsibility, which at previous meetings had seemed mainly of theoretical interest, now began to become a reality. Several patients voiced the bind they were in by “squealing” on their fellow patients or acting toward them as staff would. They felt if they betrayed their code, then they would not know who they were nor to whom they belonged.
We recognised their dilemma as painfully real; nonetheless, we actively manipulated ward situations and meetings in order to force them to stop procrastinating and make the agonising choice or which values they would adopt – patients or staffs. However, they knew that if they made the “wrong” choice, we would make it uncomfortable for them. In effect, we attempted to out – bind them.
At this point, it seems appropriate to change our focus and discuss briefly the process of modifying staff attitudes and behaviours toward the chronic schizophrenic. Such modification cannot take place without much soul searching. Most professional staff have been taught and have come to adopt a variety of humane and therapeutic attitudes concerning the general care of psychiatric patients. These notions, which are largely appropriate and helpful for the majority of patients, from our experience do not seem efficacious for institutionalised hard – core hospitalised chronic schizophrenics. The perpetuation of such staff attitudes and their concomitant behaviours had proven futile in the previous treatment of this particular category of patients.
Although the experimental treatment unit staff, for the most part, showed a great willingness and enthusiasm to change their treatment orientation toward these patients, we were (and probably will continue to be) confronted with a number of our own doubts and questions and those of respected colleagues – all of which constitute considerable pressure against such change. The pressures for therapeutic conformity are great, especially when staff receive opinions from others that the procedures employed are “punitive,” “unfair” and “inhumane”. None of us are immune or insensitive to the negative remarks of highly regarded colleagues or to our own doubts about the validity of non-traditional procedures. As a result, the unit staff have all spent many struggling, self-questioning hours at meetings focused on the ethics and efficacy of the procedures. Nonetheless, the one over-riding consideration remains the rehabilitation of these patients, and, at this juncture, we feel we are on the right track.
Finally, in presenting our conceptualisations and experiences, we do not wish to give the impression that we have successfully broken the code of chronicity at this point or that every patient has responded to our efforts. We are still in an early phase of our treatment research program and plan on employing and evaluation a variety of other techniques. At best we are engaged in on ongoing struggle with these chronic patients and our successes have been limited but discernible. A number of patients still seem too disorganised or uninvolved to respond to these techniques or even to attend to what is transpiring. Moreover, we also wish to emphasis that we do not necessarily regard our efforts to break the code as a therapeutic end-point in itself but rather as a beginning. We conceive of these assumptions and techniques as a sine qua non in making these patients more accessible to other forms of therapeutic intervention.
Arnold M Ludwig MD1 and Frank Farrelly ACSW2
Published in archives of General Psychiatry, December 15 1966