PSYCHIATRY: JOURNAL FOR THE STUDY O F IXTERPERSONAL PROCESSES

VOLULXE 23, NUAIBER 1, FEBRUARY, 1360 Copyright 1960 by The Wilharn Aiansoii White Psychiatric Foundation, Inc.

Interpersonal and Structural Factors in the Study of Mental Hospitals? ,

Amitai Etzioni* HE YOUNGEST BRANCH of organizational theory is the study of mental hos- T pitals. Twenty years ago, when Rowland pioneered in the field, the major

sources of information on the mental hospital were books m-ritten by former patients.’ Todzy there are a number of escellent studies of the organizational structure of the i ~ e n t a l hospital.? The new studies follow in the steps of organizational research in other areas,3 especially in the area of industrial relation^.^ Such a transfer of ideas, concepts, and perspectives from one area of study to another benefits both the new studies and the theory of organization i t ~ e l f . ~ But there is a constant dar,ger that the a::~log,.y will be overdrau-n. Moreover, in this particular instance organizational ‘:ud’es had certain childhood diseases that tended to be contagious when the earlier models were applied to the new areas of research. This paper nil1 discuss the coiise- r.?ltiices c~i transferring one set of ideas-the human-relations approach-from indus- trial relztions theory, and appiying those ideas to analysis of the struct‘clre of the x n t a i hospital, without fully considering the implications of other aspects of the theory.

The study of industrial relations is . -E c r less split into two camps. On

siGe are the advocates of the human- iTiGllS approach, including disciples of

L*rc.n XaFo and Kurt L e w h 6 OR the ?t?.er side are the sciiolars n-ho object to

iiuman-rciations school, which they ic “managerial eociolcgy,” and which - criticize for being manipulative, ed in favor of management-for ex-

~ :’;!31e> earlier studies ignored the role ‘For two outstandine criticirms, see Reinhard

Bendix and Licyd H. Fisher, “The Perspectlves of ~l~~~ &Iayo,*# Review o j Economjcs and S t a t b t k s (1949) 31:3:?-3?1; and Clark Kerr and L?o:;d H.

or a rrcer,t discussion and bibljographr, see Fisher. “?iaiit Sociology: The Elite and the A b L’. 3:. Arensberg, and others, editors. Reiearch rigines,” pp. 231-309; in Common Frontiers of the

liicti.s:rie! H w n a n Relations; Kew Sork, Harper, Social Sciences, edited by Mirra Komarovsky; Glen- coe, Ill., Free Press, 1957. ic -“ .’J I .

of the trade unions-and unrealistic.? Anorher via:\. of putting the difference is to say that the human-relations school is for “peace in industry,” harmony, and “under-.+arding” between the em- ployer and employees, while the op- ponents emphasize the objective signifi- cance and positive function of industrial

*- B.A. (Sociolom and Economics) 54, M.A. (Sociology and Philosophy) 56. Hebrew Univ., Jerusalem, i-rar.!: Ph.D. (Sociclogy) Ilnir. of California 58. Instr., Asst. Prof., Columbia Univ. 5%.

t This paper vas n-ritten while the author was a graduate student and research assistant at the - :iver.sj:y of California, a t Berkeley.

Howard Rowland, “Interaction Processes in the State Mental Hospital,” PSYCHIATRY (1935) 1:323-337. * F o r exam]Ae, William Caudill, Fredrick C. Redlich, Helen R. Giimore. and Eugene B. Brcdy,

. - u c k I Srrucrurc and Interaction Processes on a Psychiatric \5Tard.” Amer. J . O r t h o p s y c k h t q (1952) --:214.33.4; and Nfrel! E. Stanton and Morris S. Schwartz, The arer,iaZ Hospital; New York, Basic Books,

For a recent outstanding review and analysis of organlzational research, see James G. &larch ‘Id Eierbert A. S h o n , Organizations; New Tork. J. Wiley, 1958.

Charles K. Andrew, “lndustrial Technics Cn? Be Used.“ dfodern Hospital (h’c. 6, 1955) 84:67-72. Caudiil finds “a very direct parallel” to his work in a study of a factory by Rice. Willjam Caudill

. - L i ’ ~ ~ : ~ h i u : r ; c Ho.-pito’ As a .SniaIl Socicty: Cambridge. IIarvard Univ. Press, 1958. A. K. Rice. “Th; + of L-zrwhqnizcd Cuilural Mechanisms in an Expanding Machine-Shop,” Human Relations (1951) 4:143- ; See also >IS:oii G-ccnbktt, Richard E. Tork, and Esther Lucile Brown. Prom CzlstodiaZ to Theropeutic ‘ .c . i t Cirt. i,i . lfcntaL l iosp i ta l s ; Xew Tork, F i ~ i ~ l l Sage Foundation, 1955; p. 21, n. 1.

An e:aborate dibcwLion of a tenta:i\-e model oi organizational analysis. and the problems involved 1 : : . :!j?p!icat~on to The studs of organizztions in particular lwciustries, is included in the author’s “Indus-

- . . I .

:S! Sociology: The Study of Economic Organizations,“ Social Research (1958) 25:303-324.

I13 3

i

i

[Iucsts and explanations 601. Often parallel lines of comm were to be setrlcd.’k Greenbh

”See footnote 2; p. 239.

conflict. The human-relations people em- phasize two-way communication, while the opponents stress the role of the trade unions. The human-relations school sug- gests therapeutic interviews and partici- pation in decision-making; the opponents point to economic, political. cultural, and other ‘real’ differences between workers and management.

Although it is difficult to integrate the two approaches on the ideological level, an unbiased examination of them reveals that in illuminating two aspects of industrial organization, both schools are vital to a better understanding of the organizational process. Interpersonal relations are bet- ter understood if structural factors are taken into account. The process of com- munication within small groups can be better analyzed when the outside com- munal and political ties of the workers and managers are considered. Structural analysis benefits from study of interper- sonal relations. as shown, for example, by studies of informal relations. In short, a theoretical integration of the two ap- proaches is possible.*

Where do the new studies of the mental hospital fit into this picture? In general, many of these studies are inclined to ac- cept the human-relations approach. Many studies of mental hospitals focus on the communication system among the per- sonnel, emphasizing the importance of “understanding” among the various mem- bers and ranks of the staff. They see the mental hospital as a “therapeutic com- munity” 9 or “small society,” rather than as a large-scale organization and a work placr . Finally, they favor conferences and w i G c . participation in the process of de- cisi:-xr.-making. I shall examine all these pol: in detail subsequently.

:. ,’: of the reasons why the human-rela-

R J : is important to note that a leading scholar of : : :e human-relations school pointed out that s t u d m which apply the human-relations approach are increasingly often covering what are referred to here a s “structural factors.” William Foote Whpte. “Human Relations Theory-A Progress Re- port,” H U T U T ~ Biisiness Review (1956) 34:Sept.- Oct., 123.132. For further elaboration of this point see Erzioni. “Human Relations and the Foreman,” Pacific Sociologienl Review (1958) 1:33-38.

*For a discussion of thls concept and the fdeas associated with it, see Maxwell Jones, The Thrro- peutic Community; New York, Basic Books, 1953.

tions approach is so readily accepted in the study of the menta: hospital is I:,:,: there is a high congruence between I!;,. ideas and techniques of psychot]lcr+,:. and those of the human-relations oricn:;- tion.I0 Psychological insights in gcneI-;,l and psychoanalysis in particular playc,j an important role in the early deve]ol,- ment of the human-relations schm!.ll The ideas of increasing self-understandipo by communication with a trained profc.. - sional, and of solving or accepting conflicts by becoming aware of their existence, arc very close to the idea of increasing Un. derstanding between worker and man- agement by increasing communication between them with the help of the hu- man-relations expert. Increased com- munication is expected to reduce indus- trial conflict, if not to abolish it altogether. From this it is only one step to the suc- gestion that the mental hospital staff har to be made more aware of the organizz- tional process. “Being aware” is consid- ered an important therapeutic factor or, the organizational level.’*

Xot all studies of mental hospitals fol- Ion- this line. One of the outstanding CY- ceptions is the Stanton and Schxart:: study.13 The authors combine an analpi. of the communication system xith 3n analysis of the power structure. Stanton and Schn-artz, as well as a few other in- vestigators, put much emphasis on the relation between formal and informal structures,14 on the lines of authority.’“ and on the relation between “functional” and “scalar” status.Is But even in these studies many of the other structural fac-

1oEspecially as formulated by H a r v Stack Su!lL van. The InterpersonaI Theory of Psychiatry, ediml by Helen Swick Perry and Mary Ladd Gawel; se\q York. Norton. 1953.

11 See F. J. Roethlisberger and William J. Dickwn. nfanogcmcnt and the 1t.or::cr; Cambridge, Han‘nrcl Univ. Press, 1939.

=See Caudill, footnote 2, p. 323; and Caudill. footnote 4.

u s e e footnote 2. 11 I ran Belknap, Hitman Problems of a Stole

tu2 Hospital: Kew Tork. 3lcGraa-Hill. 1056. 16 Jules Henry, “The Formal Social StrUCtute Of a

Psychiatric Hospital.” PSYCHIATRY (1954) 17:139-151. I*Harvep L. Smith and Daniel J. Levinson. "The

Major Aims and OrFanizationnl Characterir!icS 0: Mental Hospitals,” pp. 3-8: In The Patient U t l d I h r Mentat Hospital , edited by Milton Greenblatt. Dan- iel J. Levinson, and Richard H. Williams; blencoc. Ill., Free Press, 1957.

FACTORS I N T H E ,

4

are supplied, the blocks are removed and, 2s Stanton and Schwartz said in describ- ing one such instance, “Misunderstanding

. after misunderstanding disappeared like r.ia;ic.”ls There is no doubt that some problems arise from communication

.. blocks whose removal a1lorr.s the prob- i e ~ s to be solved. Eut it is necessary to

_. specify more clearly which problems can Le handled Ly increased communication

. 2nd n-hicii cannot. In the case described : by Stanton and Schwartz, the nurses com- ., plained that the soap supply was rationed

and insuficient. In a conference with the administrator the nurses learned that no Each rationing had been intended and :!]at the amount of soap available was for d l practical purposes unlimited. The nurses‘ complaint had resulted from an inquiry from the housekeeper about the mount of soap used, which had been mis- interpreted tc mean that soap would be xtioned. There was no ‘real’ problem. Since the whole problem was created by

3

* -- ll“In many such Instances, con5icting spheres of

’ ‘”pons !>illty and interest, which in themselves

.ivsis a )(! esplanations going through long and :ten paxllel lines of ~ ~ m m u n i ~ a t i o n If problems cre to be settled.” Greenblatt, footnote 4; p. 269. “See footnote 2; p. 239.

...,, -.dine ’ older intergroup tensions, necessitated re-

TV “privileges.” Actually they would have preferred to forbid watching TV al- together. The head of the hospital saw this as a problem of communication. First of all, he believed that there was insufi- cient information about the deeper, “psy- chodynamic” reasons which motivated the patients to hand in the petition. As the “meaning” of the petition was not clear, the head of the hospital felt that he was unable to decide how to react. Second, there seemed to him to be too little com- munication with the nurses about the therapeutic significance of the “other twenty-three hours,” in which the social activities of the patients and presumably watching TV were included.

I doubt that the situation required so complicated an approach. The patients wanted to watch TV because they were bored and liked to watch fights. The nurses did not want the patients to watch TV because it meant that they would be late for the 11 : 15 bus and because it would interfere with the change of shifts. While “communication” brought these factors out during the administrative conference,

1sCaudil1, footnote 4: Ch. 4, pp. GSdG.

I .

16 AMITA I E T Z I O s i

I I

FACTORS I N

1

‘ I i

! i

!

it seems that the training of the hospital head prevented him from seeing the sig- nificance of these simple facts. Moreover, it seems that no additional communica- tion about these factors could change them. The issue was solved, typically. after the session was over, by a simple bargaining process; it was decided in a discussion between the hospital head, who sided with the patients, and the nurse supervisor to enable the patients to watch TV two nights a week but not to serve food after the program so that the nurses could catch their buses. Like so many con- flicts of interests, this one was solved by bargaining and compromise and not by a sheer increase of communication.20

If the nurses, who often have no special training for work in mental hospitals, do not feel free to establish “warm” personal relations with patients, it is not because the information that this is necessary has not reached them, but because it does not fit into their professional image. which is based on long training. and is reinforced by interaction among the nurses and by other mechanisms. This cannot be greatly changed by communication sessions any more than psychiatrists can be changed. in the same or similar ways, from, for ex- ample, psychoanalysts to group therapists.

Many of the problems discussed in studies of state mental hospitals semi to be the result of objective conditions which no communication can overcome-such as questions of budget. Some of the prob-

WThe settlemerit reached in each case depends to a considerable degree on the relative poxer of the interacting groups. It is important to keep in mind that power. defined as the ability of ego to affect the behavior of alter, is only in part based on communication. Other sources of power include command over means and rewards, such as force and material objects. The adherents of the human- relations approach-and also other scholars who do not identify with this approach-tend to see com- munication as the only source of power. For vari- ous discussions of this issue, see: Harold D. Lass- well and Abraham Kaplan, Power and Society: h’ew Haven. Tale Univ. Press. 1950: Chester I . Barnard, Thr Funcriom of the Erecut ice; Cambridge, Har- vard Unir. Press, 1956; esp. Ch. 12, pp. 161-181; Robert E Agper. “Power Attributions in the Local Community: Theoretical and Research Considera- tions,’’ Social Forces (1956) 34:322-331. Richard H. McCleery focused on this issue in an empirical study of Po:icy Chanpe i n Prison Management; East Lansing, Governmental Research Bureau, Michigan State Univ., 1957.

]ems seem related to establishing and maintaining working and social conditions which will secure enough people who arc willing to work in the mental hospita!, Other problems might be decreased if personnel were trained more specifically in accordance with the needs of the men- tal hospital. Still others might be mini- mized if the objective organizational stwc- ture were adapted to the special needs of the mental hospital. If these basic needs were satisfied, some of the remaining problems might be solved by better com- munication.

But even within these limits, the im- portance of better communication is much less than some of the studies of mental hospitals seem to assume. “Being awarc” might decrease the emotional tension in- volved ir, a conflict, but it might also dran. more clearly the line between manage- ment of the hospital-especially in profit- making organizations-and the employ- ees, thus increasing tensions and potenti,l; conflicts. There is also the danger of a utopian approach to communication. Evcn if it can be shown that some difficultk~ disappear when communication is in- creased, it does not follow that all prol.1- lems yield to this technique. The effect acd flon- of communication are limiicti and icfluenced by structural conditionz The demands on psychiatrists’ time linii: communication. A psychiatrist devotes a limited number of hours to a hospital, 0: which a considerable part is devoted it’ nonprofessional activities.?’ An increast in communication, by writing and readil?:: reports or by participating in administrn- tive and “therapeutic team” conferenrt-. would mean that even less time was avail- able for therapy. Psychiatrists already seem to feel deprived because administra- tion does not leave enough time for their professional activities, in which they do not usually include communication Wit)] lay personnel.

Increased. communication is r e c m

“According to Belknap, 60 percent of the time I?

physicians in South Mental Hospital is derotrfl I ” administrative work. See footnote 14; p. 10s.

’ mended for si vocated as a n :ification of s ranization. Ir ;art of the kverybody rnt on.” I t is e a s ~ information w.

. ing of particip derstanding oi roles of others bers should un :he hospital, an progress of tht

’ crease commur neans taking i and arousing : -insidedopeste iul to the organ xientation coni her, some peopl at least will fet sill be left out

The assumptj :hat everybody :ne organizatiol :hat the hospita

, :ial group to wl should want to 2ot the case. T: I! best a group (

.m feel quite a ‘hey are well-in ‘r tm’small gr ‘xmed about w: M y leaders of 5

he interest and n greater detail n the hospital c( n other and hig This brings up tf xture of the soc 31 hospital?”

THE HOSPITAL

If the term soc xiological way,

1 Iciety, because : -itonomy and h

1 mal autonomy . Jnctional needs (

i 17 YdCTORS I S THE STFDI’ OF MENTAL HOSPITALS

/

. gended for still another reason. It is ad- -mated as a means of enhancing the iden- -,?cation of staff members with the or- znization. I n order to feel that they are ?art of the “therapeutic community,” crerybody must know “all that is going m.” I t is easy to understand that certain :nformation will give the personnel a feel- in: of participation and an increased un- .:‘erstanding of their own roles and the :des of others. For example, staff mem- bers should understand the basic policy of :;:e hospital, and should be informed about p g r e s s of the patients. Attempts to in- crease communication beyond that point ::ems taking time from other activities, :.nil arousing rather than satisfying an .,in-.ide-dopester” attitude which is harm- ::: to the organization. Even with a daily ‘:.ie:i:ation conference for each staff mem- w. some people will be “uninformed,” or ..: ieast will feel that they are, and thus .::iii be left out of the group.

Tne assumption behind the suggestion ‘ X L everybody should be informed about .ne organizational process in general is :hat the hospital staff constitutes one so- .::! group to s-hich everyone wants to or r:-,ould want to belong. This is obviously :.Y the case. The hospital community is : txst a group of groups. Most members :Ln feel qyite at home in the hospital if

:!ley are well-integrated members of one tx-o small groups and if they are in-

irrned about what their clique is doing. 1315: leaders of such groups usually have .:ie interest and the need to be informed n greater detail about what is going on .n the hospital community in general and n other and higher cliques in particular. This brings up the question, “What is the !stwe of the social structure of the men- al hospital?”

I

ternally regulated.22 Since the hospital secures staff, patients, and facilities from the outside, and only partially controls their recruitment, it cannot technically be seen as a society.

But even if the term is defined more loosely, the assumptions and associations that such terms as “small society” and “therapeutic community” bring to mind are quite misleading. Use of the terms often indicates a tendency to neglect the influence of external factors on the in- ternal process of the mental hospital, and also to oversimplify some aspects of the internal process.

This limited perspective is not acciden- tal. I t is one of the most important trade- marks of the human-relations approach to the study of industry. Historically, i t fol- lows from the application of anthropologi- cal techniques to the study of large-scale organizations. The anthropologist tends to see each social unit as an isolated so- ciety. This approach often overlooks such factors as trade unions and professional associations; communal ties such as social groups, governing boards, political insti- tutions, and other structures and attitudes which affect the organizational process; and such internal factors as the influence of multigroup membership.

The Influence of Professional Associations

The various professional and semipro- fessional groups which interact in the mental hospital have clear images of their respective roles.?3 Attempts to change these roles within a single hospital seem to be almost always doomed to failure be- cause these role-images are created and reinforced by many factors which are ex- ternal and beyond the control of each hospital. While the image is usually cre- ated during the training period, it is con-

THE HOSPITAL AS A “SMALL SOCIETY”

If the term society is used in a strictly Jciological way, a hospital is not a small Jciety, because societies have functional Iconomy and hospitals do not. Func- mal autonomy means that all the basic ‘nctional needs of a social system are in-

=For a discussion of the concept, see Talcott Parsons, The Social System; Glencoe, Ill,, Free Press, 1951; p. 19.

OTwo recent studies are devoted to this subject. Ivar E. Bery, Jr.. studied the nurses from this viewpoint in Role, Persondity , and Social S t m c - ture: A Study of h’ursing in a General Hospital; unpublished Ph.D. dissertation, Haward Univ., 1960. Charles Perrow studied doctors and administrators in Authority, Coals, and Prcstiae in a Geneto1 Hos- pital; unpublished Ph.D. dfssertation, Berkeley, Univ. of California. 1960.

--

Sociological Reriew (1959) 24 :F??-s~I). Robert Dubin. “Industrial W’orkers’ worlds: A

Study of the ‘Central Life Interests’ of IndustrlJ! Workers,” Social Problems (1956) 3:131-142. a For an outstrinding study, see Elizabeth Rot’

Family and Sorial Networl:; London, Tavistm! Publications. 1957.

I

! 1

i !

j i I *

stantly reinforced by the professional as- sociations and professiona! social groups.z4 The professional associatlons also act as interest groups lvhich support their mem- bers in the struggle to maintain or im- prove their professional image and posi- tion. At the same time these associations serve as reference groups in terms of standards and professional ethics, as well as prestige One cannot expect basic changes in the techniques applied by hospital psychiatrists, for instance, or in the relationships between psychiatrists and clinical psychologists, without taking such factors into account.2E With few ex- ceptions, the influence of such associations is not analyzed. Often they are not even mentioned. I wonder if the scholars who have explored these issues have found those associations uninfluential, or have preferred to focus on other aspects of the material, or have been limited by their conceptual scheme to the study of what was going on in the “small society,” to the neglect of influences on the behavior of the staff from outside the walls of the hospital.

The Influence of Communal Ties

The mental hospital is usually a “total institution” 2 i only for patients. The staff, as a rule, does not live on the premises, Even in cases where the lou-er-level staff lives in the hospital, most of the physi-

*‘The same problem comes up in other areas of interaction among various groups of proiessionals. See. for instance, \Yilliclm Caudill and Bertram H. Roberts. “Pitfalls in the Organization of Interdis- ciplinary Research.” H u m a n Organization (1951) 10:lYinter. 12-15: Fredrick C. Retllich and Eu:ene B. Brody, “Emotional Problems of 1nterciiscipIinar-y Research in Psychiatry,” PSYCHIATRY (1955) 18: 233-239.

%This is discussed and documented in a different context by Harold L. lvilensky, Intellectuals in Labor Unions; Glencoe, Ill., Free Press, 1956; pp. 134- 136; Alvin W. Gouldner. “Cosmopolitans and Locals: Toward an Analysis of Latent Social Roles-?.” Ad- ministrative Science Quarterly ( 1957) 2:281-306; esp. pp. 297-269: Leonard Reissman. “A Study of Role Conceptions in Bureaucracy,” Social Forces (1949) 27:305-310.

=See August B. Hollingshead and Fredrick C. Redlich. Social Class and Mental 1Ilness; h’ew York, Wiley, 1958: esp. pp. 370-390; Maurice H. Krout. editor. Psychology, Psychiatry. and the Public In- terest: Minneapolis, Univ. of Minnesota Press, 1956; Edgar F. Borgatta. “The Certification of Academlc Professlons: The Case of Psychology,” Amer. Socio- Iogical Review (i95S) 23:302-306.

R See Erving Goff man, “The Characterlstics of Total Instit~itionn.” pp. 43-34: in S ? / ~ I ~ U S ~ I L ? R on PW- yenrive and Sociol Psychiatry: Washington. D. C., Walter Reed Army Institute of Rescarch, 1937.

cians and other professional personn, live outside. Studies Of industries hs.-., found it fruitful to examine the SociLl I!:, and relationships of workers and Vario.; levels of management outside the f s r .

tory.** Similar studies of the Off-thc.j,,;, social relations of and among various st;: groups of mental hospitals would be much interest. Some studies of the SOcjL,:

background and social ties of the patient, are of great help.2s But if more were. known about the social life of the physi- cians and nurses, better understandin: might result of their conflicting aspirk. tions and reference groups, and of the ’

lack of common language: which hayc been described in several studies.30 Such data reveal, for example, some of thC mechanisms which reinforce the profe.;. sional image of the nurse and are respon- sible for the fact that she quite often prc.. fers to work on the closed rather than 01;. the open ward, and prefers to increase thk patient’s assurance by wearing a stiff cai, and handing the patient his medication rather than by smoking a cigarette anti engaging in informal talk with him.

For a long time it was believed tha: the main primary relations of workers were based on on-the-job relationships. But some recent studies cast doubt on this generalization. One study, for in- stance, reports that only 10 percent of thc workers stated that their main prima?- relationships were based on work relation- s h i p ~ . ~ ~ I t seems now that other primal.!. groups-such as families, neighbors, and so forth-have much influence on thL aspirations and attitudes of the actors ir: organizational contexts.52 A fuller under-

FACTORS I

standing of be achieved are taken ii

There is ,

which seen but is only I \%rho study cause access tional strue. and middle thority are of the orga most no or higher auth trustees, the ernor, and E of the comn and the lo( While highe of great sig organization in the case mental hosp therefore mc thority than Also, the ful pita1 is higl munity ‘lice cerning wha ods of care.3:

Communit: already a b1

=For one of “Reactions to Ac Zions (1955) 8:: of these relatio Temple Burline. The Give and Ta 1956; esp. pp. 3 framework for : Mental HospItal . 129: in Greenbl;.

“Some of the tion in organizai a re analyzed in and Organizatio, Science Quarterl; analysis of the thorities and in included in Amir “Innovations in 1 on Innovations i interpreted by monograph, Plan ing in Social Rr Some of the met analyzed by Alle? Change Organizatfonol In an Orr A-

New York, Hem, Everett Hugh

quire and have 11 operation. See “I in Hughes’ Mrn 0 Press, 1855. The tions which have organizations as T

* 19 FACTORS I X T H E STGDI’ OF d€Eh’TAL HOSPITALS

standing of aspirations and attitudes will be achieved only when the communal ties are taken into account.

There is another type of communal tie which seems to be of much importance but is only rarely analyzed by the scholars who studr mental hospitals, perhaps be- cause access to this aspect of the organiza- tional structure is limited. Usually lower and middle levels of organizational au- thority are studied; sometimes the head of the organization is also covered. Al- most no organizational study considers higher authorities-such as the board of trustees, the health department, the gov- ernor, and so for th-or such expressions of the communal structures as the press and the local chamber of commerce.33 11-hile higher and external authorities are of great significance in the study of all orgmizations, they are of special interest in the case of mental hospitals.3’ Most mental hospitals are state hospitals and therefore more dependent on external au- thority than many other organizations. Xiso, the functioning of the mental hos- piiai is highly influenced by the com- munity ‘license‘-that is, attitudes con- cerning \That are right and wrong meth- G ~ S of care.sc

Community pressure can affect what is already 2 built-in strair. in the mental

=For one of the few exceptions, see Cyril Sofer, “P.esctions t o Administrative Change.” Hunion Rela- L;c:is (I l iX) 8:291-316. For an informative study of these re!ationships in a general hospital, see Temple Bu:.:inc. Edith hI. Lentz. I:obert N. \\;ikon,

ana Tckc in Nospiiols; New Sork, Putnam. . pp. 39-80. For a systematic conceptual k for analysis, see Tnlcott Parsons, “The

. ,~e . ,~ . . i EIr~spital as a Th-pe of Organization,” pp. 108- 1 2 ~ ; in Greenb;att. footnote 16.

*Some of the characteristics of top administra- tion ir. organizations which hare professional goals are 3nnl::ze.d in the author’s “Authority Structure end Organizational Effectiveness,” Admfnistratiue Scicncc Qitarferly (1559) 4:43-C7. A model for the ~112ly,:i; of the relationship between external au- thnrx ies and internal organizational processes is ixc:xi?c in Amitai Etzioni and Paul F. Lazarsfeld, “Innox ations in Universities.” in Historical MateTiol on I>tnor.at;ons in Higher Education, collected and interpreted by Bernhard J. Stern (unpublished n.w.ograph, Pianning Project for Advanced Train- ir,g in Social Research, Columbia Univ.. 1952-53). Socle of the methodological problems involved are annlgzrd by Allen H. Barton and B. Anderson, “A Change in an Organizational System”; in Readpr in 0r~cn i ;o : ionaZ Ana!ysis, edited by Amital Etzioni; ?<$ ::; Tsrl;. Henry Holt, IDGO.

L Everett Hughes pointed out that professions re- quire and have to sustain a social license for their ri;,craiion. See “License awl Mandate,” pp. 7s-87; ii: liughec’ B!cn and Their Work: Glencoe, 111.. Free pr- <.::, - _ 19;s. The same points hold for organiza- tions \vhich hare professional goals-and for other orgnnirations as well.

7 - ,....

hospital, the conflict between the thera- peutic and custodial functions. To some degree, custodial activities are means for therapeutic goals. If the patients cannot be kept in the hospital, they cannot benefit from its service. Some suicide-prone pa- tients have to be controlled for their own safety. But community pressure some- times results in considerable expansion of custodial activities beyond the therapeutic needs. The community often does not want to be bothered by patients or is afraid of them. On the other hand, the community may also be the source of initiative and pressure to introduce more humane methods of treatment into the mental hospital.SE The internal conflict between custodial and therapeutic func- tions cannot be fully understood unless the community orientation and the chan- nels of its expression are studied.

The Influence of dlultigroup Membership

One of the most important early dis- coveries of industrial sociolo,gy was that workers act as group members and not alivaj-s on rational grounds. Studies of the mental hospital have rediscovered this tendency. “Recent literature shows a refreshing new point of view. There is an awareness of the fact of inter- action, of the importance of the group. . . .” 37 But with the rediscovery of the significance of small groups, some of Alayo’s early mistakes in applying the human-relations approach to industrial theory have also been repeated. The as- sumption is often made that the patient or staff member is a member of one group a t a time. While this may be true in some marginal cases, people are usually mem- bers of more than one group at a time. Consequently, adjustment problems de- velop, especially when these groups are competing for the loyalties and resources of the members. One of the most impor- tant characteristics of a person in modern society is that he knows how to adjust to

For interesting stud& of community attltudes toward mental illness, see Elaine and John Cum- ming. Closed Ranks; Cambridge, Commonwealth Fund, Harvard Univ. Press, 1057; hlarian Radke Yarrow, John A. Clausen, Paul R. Robbins, “The Social Meaning of Mental Illness,” J . Socfnl Issues (1955) 1l:No. 4. 3348.

“Starton and Schwartz, footnote 2; p. 22.

multigroup membership, to be at the same time a trade union member and a factory xvorker, a member of two families-orien- tation and procreation-or an obedient soldier and a good buddy.

The patients in the mental hospitals quite often seem to have difficulties along this line. They tend to become overin- volved in one group and to reject their obligations to other groups. Part of the therapeutic process is the reconstruction of the ability to participate in multigroup situations. Several hospital practices, often pursued quite unwittingly, either help to satisfy or interfere with the need of the patient to maintain or to recon- struct his ability for multigroup participa- tion. The widespread practice of sending patients on furloughs instead of giving them simple. direct discharges, seems to have positive effects, such as supplying the patient with an esercise in multigroup activity. On the other hand, the ambira- lent. if not hostile, attitude of the hospital staff toward a patient’s relatives endan- gers any ties that the patient may have to the external social lifeS5 and tends to increase his investment in the hospital coxxunity. This may later make mean- ing from the hospital more difficult and block his recovery.35 Similariy, the objec- tion of some personnel to transferring pa- tients from room to room and ward to ward on the basis that it will weaken their group ties40 is not aln-ays justified. The patient may need these opportunities to become a member of two or more groups at the same time. Such movement might also provide the patient with more social permissiveness and some immunity from the group pressure to conformity. By learning to play his membership in one

= F o r a review of earlier studies and a report on new data on the function of the family in the re covery of the patient, see Ozzie G. Simmons and Howard E, Freeman. “Familial Expectations and Posthospital Performance of hlental Patients,” Human Relations (1959) 12:233-242.

p Many studies have pointed out the therapeutic role of fel\o\v patients. See, for instance. J. Fremont Bateman and H. Warren Dunham, “The State Men- tal Hospital as a Specialized Community Experi- ence.” Amcr. J . Psychioiry (1018) 105:445-448.

&See E. F. Galion& R. R. h’otman. A. H. Stanton, and R. H. Williams, “The h’ature and Purpose of Mental Hospital Wards,” pp. 327-379; in Greenblatt, footnote 16.

group against that in another group, the patient may gain some privacy and inde- pendence. Some patients seem to use various groups as a ladder on their way to convalescence. With improvement in their mental health, they climb to more ‘advanced’ patient groups.‘l The hospital, it seems, should encourage such mobility, and support and create opportunities for multigroup membership for patients who are ready for it.

COhTERENCES AND PARTICIPATION IN DECISION-MAKING

The human-relations school is in favor of conferences and group discussions be- tween the superior and his subordinates where information about future activity is given and a group decision is made. That support of the subordinates for a new activity is enhanced in this way has been proved in a number of important es- periments conducted by Lewin and others.’* These conferences, however, may be evaluated digerently according to their purp0se.~9 If they are used to spread information in a way which diminishes unnecessary anxiety, they can certainly be of great help. One human-relations training movie shows a case in which tension is created among workers when new machines, which they believe will create unemployment, are brought into the factory. Once management esplains that the new machines will be used for expansion of the factory and that new workers will be hired, anxiety is com- pletely dispelled. The film does nor deal with a case in which anxiety would be justified because the new machines mean that some workers will have to be fired. A conference of the type shown in the movie is just another channel of com-

UReported by CaudU1, footnote 4; p. 330; and Belknap, footnote 14; pp. 171ff. a Kur:, Lewin, “Group Deckion and Sorb1

Change, pp. 459473; in Readings in Social I’sY chology (rev. ed.). edited by Guy E. SwanCol1. Theodore 11. Newcomb, and Eugene L. Hartlr‘: New York, Holt. 1952. Lester Coch and John R. 1’. French. Jr.. “Overcoming Resistance to Change.” Human Relations (1918) 1:512-532.

u F o r statistics on the use of conferences in hoc. pitals, see a report on 316 hospitals by HarV k: Panhorst in “Department Heads Make the HosPL- tal,” Nodern Hospital (19.55) 84:h’O. 1. 81-83.

inunication, mhjch, previously, can func!: tain structural condjlj

But conferences arc tion not only as char or upward communica believed to offer an pmonnel, and even th ticipate in the process, thus increasing their c, decisions made. Demo, be a more efficient XvaJ -4 study by Caudill,

notes of 63 administ: n-ere taken, gives a d of “conferences” Ivith and of their “self-gover in a discussion by the pital:

Xiss S u g e n t lnursel: . have a gripe session?

DT. Scott: I’m persor. gripe sessions.

DT. Shaic: So am I, pa. Tienrs feel that they are sessions and find out latc.1

Dr. Scott: The only go! ses-cinns do is that if you i as a group t o scrutinize 11 their behavior. . . .*e

In other words, conf patients, dis,%ised as u cation (“gripe sessions” for downward communi :ion. Similarly, in soma man-relations techniquc the extent that conL- term are used as the model] orders, but the directior remains the same. Thu can be turned into a mi nique, not ,a way of shar decide. What about the admir

ences? Although paticr. lated, does the staff real:

Sydney H. Croog, “Patient Aspects of Participation and T u o Psychiatric Wards,” Ps\

‘;See Robert N. Rapoport and Port. “ ‘Democratization’ ant1 ‘A I)@UtiC Community,” Bcliot‘ioro: 126-133.

aCaudill, footnote 4; p. 78.

203-207.

21 FACTORS I N T H E STUDY OF MESTAL HOSPITALS

munication, which, like those discussed previously. can function only under cer- 13 in structural conditions.

But conferences are supposed to func- tion not only as channels of downward or upward communication. They are also believed to offer an opportunity for the personnel, and even the patients,d* to par- ticipate in the process of decision-making, thus increasing their con;mitments to the decisions made. Democracy is believed to be a more efficient way of management.45

A study by Caudill, in which verbatim notes of 63 administrative conferences n-ere taken, gives a different evaluation of “conferences” with groups of patients and of their “self-government,” as shown in a discussion by the heads of the hos- pital:

Jfiss Nugent Cnursel . . . Are you going to have a gripe session? DT. Scott : I‘m personally against these

gripe sessions. Dr. Sfraw: So am I, particularly if the pa-

t ients feel that they are legislating at these sessions and find out later that they are not. DT. Scott: The oniy good that these gripe

scsioris do is that if you can get the patients ;is a ?roup to scrutinize what is going on in :heir behavior. . . .4c

In other words, conferences with the palients, disguised as upward communi- calion ( “gripe sessions” ), serve actually ior do\vnu-ard communication and direc- lion. Similarly, in some industries, hu- nian-relations techniques are applied to The extent that confereiices with workers are used as the modern way of giving orders, but the direction of order-giving remains the same. Thus “participation” can be turned into a manipulative tech- nique, not .a way of sharing the power to decide.

What about the administrative confer- ences? Although patients are manipu- lated, does the staff really participate in

Sydr ?y H. Croog. “Patient GovemmentSome .kpc-c?s ‘ I f Participation and Social Background on Ti: o PSI 2hiatric Wards,’’ PSYCHIATRY (1956) 19: 203.20;.

‘j See R,lbert h’. Rapoport and Rhona Sofer Rapo- I 8 w L ‘‘ ‘De nocratization’ and ‘Authority’ in a Thera- cir.Li:ic Cor:munity.” Behavioral Science (1957) 2: :25-1.:3.

4aCaudill, footnote 4; p. 78.

the decision-making process? A detailed analjsis of the material supplied by Cau- dill shows that these conferences are either manipulative or blocks to communi- cation, and serve as a source of anxiety rather than as a positive influence. Stan- ton and Schwartz reach a similar conclu- sion in their discussion of staff conferences in another mental hospital. They state: “Conferences and discussions were re- garded as a means of rationalizing hos- pital interference, and as discussions which might interfere with clear personal insight into the problem” (italics mine).47

In one sense, the administrative confer- ences of mental hospitals seem to have gone even further than similar confer- ences in industry. In industrial confer- ences, usually only two levels of authority confer and there is only one representa- tive of the higher level. These are con- ferences between a superior and his sub- ordina?es-that is, the people he works with. Special attention is paid to arrang- ing conferences in a way which will not confuse the lines of authority. I n the ad- ministrative conferences described in the studies of mental hospitals, the heads of hospitals, nurse supervisors, charge nurses, staff nurses, senior and junior physicians, and others participate. This creates several peculiar and unnecessary tensions: (1) Conflicts among superiors are acted out in front of those who ordi- narily have to accept their orders. (2) Conflicts of superiors with their superiors are discussed in front of subordinates. (3) Subordinates’ actions, which have been based on orders or general directions from superiors, are scrutinized by the su- periors’ colleagues in front of the sub- ordinates. (4) Subordinates attempt to undermine directions to .which they object by by-passing their immediate superior and asking the opinion of the conference about the action which should be taken.

The implicit assumption on which these conferences seem to rest is that since “we are all part of the therapeutic com- munity,” things can be discussed freely

47See footnote 2; p. 113.

i . ., i 2.

. AMlTAl ETZIOXI 22 -

with disregard of statuses and lines of authority. But this assumption is un- realistic, as indicated by the behavior of the participants in the conference. As Caudill shows, they tend to participate in the communication process according to their rank. Thus, the subordinates tend to be more passive. Also, much of the conference time is wasted on defensive behavior in response to the tensions de- scribed previously. Further, actors in the conference frequently do not transfer in- formation upward, thus avoiding the pos- sibility that it will be used against them. Subordinates in general tend not to pass upward information which is disadvan- tageous for them, but the conference ag- gravates this tendency.

Although the studies of mental hospi- tals indicate the helpfulness of transfer- ring concepts and theorems from one area of organizational studies to another, they show that inappropriate and incomplete

,

ideas can be transferred as well. In adopt- ing the human-relations approach used in industrial theory, some studies of mental hospitals seem to overemphasize (1) the importance of communication, (2) the totality of the institution, and (3) the benefits of participation in decision-mak. ing conferences. In so doing, the studies neglect somewhat the study of structural factors, such as budget and time limita- tions; real differences in personnel; the influence of such external factors as pro- fessional associations, communal ties, and so forth; and the unchangeable locus of certain decisions. A balanced analysis of the influence of interpersonal and struc- tural factors, of internal process and ex- ternal ties, and of the origins of authority, will ensure a fruitful, realistic develop- ment of this young branch of organiza- tional theory.

DEPARTMENT OF SOCIOLOGY COLUMBIA UNIVERSITY

NEW P O R K 27, NEW P O R K

hT E

IN RECE sociolog the rela

1 the org; ’ “formal

groups. structure and perf organiza L

. research.: ; to system

external I

! The re: three poi:

1 that is, t! the past i i i unions th level. Rec izations, st

poiice de1 compariso entials am’

, between rc ! political sc j for exampl c from this I I 1 between th

sions. The i j tween two

+ EDITOILS’ : annual meetii 1 For recent

i Arensberg anc pp. 25-50: He i : *One of thc 1 viewpoints disc Society and Soc

i i Relations in :