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GROUP-THERAPY FOR ALCOHOLISM
538
In
England Now
Letters to the Editor
A
Running Commentary by Peripatetic Correspondentt LAST week the wife of a small farmer (his farm was small) asked me to see her husband who had a mild influenzal illness. The problem was how to help him without putting him to bed. I suppose that in the long run none of us are indispensable, and if he had been carted off to hospital with acute appendicitis his cows would have been milked and most of his urgent chores performed somehow. However, as I am a singlehanded practitioner who also can take refuge in his bed only when all other measures fail, he had my full sympathy. In fact a new brotherhood of " Those who cannot go to bed " was nearly formed. I suppose that in the height of battle, injuries can be practically ignored, which, if received in the factory or in the field, would necessitate immediate treatment and variable times off work. Descending from these sublime thoughts to the humdrum life of a singlehanded practitioner-or any practitionerI wonder how many of our patients would remain with us, and how far our morbidity statistics would be cut, if we applied the same yardstick to their ailments as we do to our own. A sobering thought, but one which our political overlords would do well to ponder, for somewhere therein lies the answer to many of our problems today. *
*
*
During a Sunday game of golf we were distracted on the 16th tee by the loud calls of a wild duck coming from a high elm tree only a few yards away. We first thought that the duck had been attacked by a bird of prey, but on hearing also the cries of ducklings we realised that she had a nest on the sawn-off central trunk. The nest was fully twenty feet from the ground, and it was obvious that the mother was about to take the ducklings from the nest. As we gathered round she flew to the ground, calling all the time; and within seconds little yellow fluffy balls were falling from the tree, apparently without injury. Soon the mother and her seven ducklings set off for the nearest water some 400 yards away. It was interesting to see how mother duck alone supervised the whole operation of transferring her young; father duck did not appear to be anywhere in the neighbourhood. Perhaps he was having his weekly relaxation swim on some quiet reach of the Thames. *
*
*
Auntie is a gay 74 and is not averse to doing an occasional stint on a stand at the Ideal Homes Exhibition and similar gatherings where her ageless aquiline features and general aristocratic demeanour are much sought after. The other morning she went along to the railway station to buy a fashion magazine at the very moment the London express was about to depart. The guard blew his whistle; before Auntie could say a word a helpful porter whisked her into a first-class carriage and the train was in motion. At the next stop, a junction 20 miles nearer town, Auntie alighted, still clutching her nearly empty purse and Vogue and demanded to be returned home. "Diesel rail-coach in the bay, over the bridge, Ma’m," said a porter. What he didn’t say was that two diesel rail-coaches start from the same bay. After the first five miles it dawned on Auntie that this was an unfamiliar line which became even more unfamiliar as it penetrated further into rural Hampshire. She eventually got out at Basingstoke and after a suitable wait managed to get a return train back to the junction: another wait, this time for the correct diesel, and she eventually arrived home having missed lunch and tea and travelled 67 miles by British Rail without a ticket and with only a cup of coffee for sustenance.
Episodes like this don’t trouble her. " It’s nothing," she said, " compared with the time I had cramp on Paddington station and an engine-driver massaged my leg." Good old Western Region. * * * The Professor was walking across from the Infirmary to the University with the chest piece of his stethoscope dangling from his hip pocket when he was stopped by a respectful Boy Scout. " Excuse me sir, but your catheter is hanging out."
THE NOTTINGHAM MEDICAL SCHOOL SIR,-I have watched the mortar salvo from my learned Glasgow colleague, Prof. G. M. Wyburn (July 31), the elegant but irrelevant display of fireworks which was Sir George Pickering’s riposte (Aug. 14), and the second, briefer salvo in return (Aug. 21). It is not for me to comment upon the projected curriculum of a medical school in another jurisdiction ; but Professor Wyburn’s second letter does raise a point which concerns the Irish as much as the British (North or South). Our Government, by a prudent grace, permits the Visitors of the General Medical Council to inspect our medical schools, these Visitors being not too closely disguised as Visitors on behalf of our own Medical Registration Council. The recommendations of the G.M.C. are taken here as a norm, and I am one of the many teachers of medical undergraduates who feel strongly that the G.M.C. should be called upon to state openly and clearly what it is after. Up to now the recommendations of the G.M.C. could fairly be described as directions for a journey whose terminus was secret, if indeed it was known at all; the penultimate issue of this itinerary was particularly fatuous in this respect. Those who train arts-men, physicists, engineers, and agronomists have an adequate knowledge of what is intended by the grant of the corresponding degrees to successful candidates. He or she must have this minimum amount of knowledge, that minimum amount of skill. The Visitors of the General Dental Council not only know but are prepared to say what their idea of a passably good dentist is. We have never had any such direction about our goal for medicine and surgery from the final legal authority in this matter. It is time that we had. Every Irish university, from Queen’s southwards, grants a B.A.o. together with its M.B., B.CH. The B.A.o. is not a registrable qualification, but that part of the final examination which it represents connotes a perfectly definite set of knowledge and skills which the obstetricians and gynxcologists look for, and which is known to be looked for by them. Consequently the teaching, for example, of anatomy in respect of this degree is something that can be planned so that the student will have as much topographical, histological, developmental, and functional anatomy as is necessary, but no more than is sufficient, for this purpose. We have a right to know from the educational committee of the G.M.C., when it has finished its forthcoming deliberations, exactly what it expects the newly qualified graduate to be able to do. It will then be possible to plan the strategy and tactics of teaching, and to put an end to this present controversy, in which everybody appears to be talking at cross purposes and indulging in an orgy of Platonic piffle. Finally, it might be a good thing if those who have taken unto themselves the direction of the medical curriculum would remember that, even in these islands, there is a growing flood of barbarism, and that the young house-surgeon will have to consider urgently the consequences of the flick-knife —a matter not irrelevant to the study of this much-despised anatomy. Department of Anatomy, University College, M. A. MACCONAILL. Cork.
GROUP-THERAPY FOR ALCOHOLISM SIR,-I read with interest the views of Mr. Dougal Macphail (July 10) on the value of group-therapy in the treatment of alcoholism. I, also, am regarded as a recovered alcoholic, and I experienced a period in a group-therapy unit some eleven years ago. Since my departure I have kept in touch with the unit and its patients by means of monthly reunions, at which some of the ex-patients forgather with the hospital group to discuss problems connected with recovery and rehabilitation. Through these meetings I have been able to
539 great many of the reactions of alcoholics to groupand at the same time to define my own experience with greater clarity. As I see it, all alcoholics are firstly individuals, although their addiction is one that is common to all; and therefore their reaction to living within a group will vary according to the approach they make to it. In my opinion group-therapy offers the best prospect of recovery that we have at this time for alcoholics whose mental or physical condition requires hospitalisation. Alcoholics Anonymous, whose success in this field is world wide, also operates through a group-system by areas and not through selection by social or intellectual standards. I joined my own group after many years of chronic alcoholism and several attempts at recovery through admission to mental hospitals. I had come to admit my own helplessness, and to realise that salvation for me lay in getting at the root of my own problems and in building up a new outlook on life based on a different set of values. The group I joined consisted of alcoholics from a fair cross-section of social strata, including a patient who had served a number of prison sentences and who had now volunteered to accept treatment. The very fact that my fellow patients came from such varied backgrounds helped me considerably in breaking down my own unjustified image of myself. As a drinking alcoholic I was indistinguishable from any other sufferer, and if I had not taken to crime in order to obtain the means to drink it was only because I was fortunate in being able to procure money from legitimate sources. The problem of alcoholism that we faced was common to us all; therefore our discussions were on a mutual plane, and varying intellectual abilities were of no significance. Where we did differ, however, was in the sincerity of our approach to lifelong sobriety; and the majority of my group were not yet ready to undertake a full and searching self-analysis in order to seek out the character defects which lay at the root of their alcoholism. These patients were the ones who withheld a great deal from their life-histories, and so deprived themselves of vital clues in their search for contented sobriety. But their attitude was invaluable to others, who were thus enabled to see more clearly the need for a more determined effort on their own part. For example, one member of our group made a practice of secret drinking, and here we were able to sort out the twisted thinking which was the cause of so much of observe
a
therapy,
our own
undoing.
The psychiatric social worker joined us at some of our discussions in which we were helped to see that we must prepare ourselves for re-entry into the broken homes we had left behind. At the same time our families were encouraged to take an interest in the problems we were facing and to meet in groups of their own for this purpose. Nevertheless family rehabilitation remained a goal which we alone could achieve through adjustment and understanding on both sides. In my opinion the alcoholic does not enter a hospital unit to receive treatment in the same sense as a patient who enters a general hospital for some specific physical illness. The unit is there, with the expert assistance of the psychiatrist, the social worker, and the staff nurses, in order to provide an environment in which the alcoholic can set about his own problem and seek his own salvation. Through the individuals within the group he can study the varying facets of his own character defects, and in his efforts to help them he also helps himself. No-one can provide him with a formula by which to live out his own life, and he must learn to discard his dependence upon others in favour of the expression of his own personality and
abilities.
Inevitably a proportion of every group will be unproductive as regards immediate results, though not necessarily in the long term. On the other hand it frequently happens that a patient who begins group-therapy with little or no sincerity is converted by the example and efforts of others. As I see it, it is not the duty, even if it were possible, of those who select the members of the group to assure themselves that those chosen are of a right mind to achieve recovery; nor have they any grounds for
expelling a patient, unless his behaviour is such that it is impossible to retain him in the group. Anonymity serves the purpose of clearing the ground of social prejudice, and there is nothing to fear from blackmail if a recovered alcoholic is willing to admit his past to those who have any concern with it. Accurate statistics of recovery from alcoholism are obviously impossible to obtain, but public understanding of alcoholism is increased by the return to society of every alcoholic who can take his or her place as a useful citizen. X. THE NURSE’S LOAD
SiR,ņThe Queen’s Institute fully supports the statement in leading article (Aug. 28): " All concerned in nursing training must ensure that instruction is given in handling methods which ensure the safety of both the patient and the
your
nurse." As an organisation very much concerned in nurse training, the Institute has been undertaking work in this field since 1956 when one of its nursing officers visited Canada and the United States to study body dynamics. As a result of her findings, regular courses in posture and lifting have been organised for superintendents and tutors responsible for teaching this important subject to district nurses on their staffs. It is also included in the syllabus of district-nurse training and in the programme of refresher courses. In 1957 the Ministry of Health had already made a film on lifting in hospital, and they invited St. Thomas’s Hospital, King’s College Hospital, and the Institute to cooperate in the making of two further films, one showing correct lifting methods for use on the district, and another entitled Poise and Movement. A film-strip on lifting in the home was also made. Queen’s Institute of District Nursing, 57, Lower Belgrave Street, London, S.W.1.
L.
JOAN GRAY
General
Superintendent.
SiR,ņYour leading article concluded with the suggestion that the Ministry of Health might " ensure a wider dissemination of knowledge of lifting methods ". May I therefore draw the attention of your readers to the three films made by the Ministry on this subject, to be shown in nurse-training schools and elsewhere, which are all available on loan from the Central Film Library? They are: UK 1550, Poise and Movement (21 minutes, 2 reels); UK 1551, Lifting Patients: Part I, In Hospital (13 minutes, 1 reel); and UK 1552, Lifting Patients: Part II, In the Home (11 minutes, 1 reel). There is also a film-strip intended for use in conjunction with the last two films. S. A. HEALD
Ministry of Health, London, S.E.1.
Public Relations Officer.
AN EDUCATION IN OBSTETRICS AND GYNÆCOLOGY SiR,ņThe sagacious and provocative views expressed by Professor Rhodes (Aug. 28) should be welcomed by colleagues who practise his specialty. I notice he styles himself a professor of gynaecology. At a W.H.O. study group on Social Aspects in the Teaching of Obstetrics and Gynaecology1 we spent several hours trying to agree on a single name for both branches of the specialty. In Uruguay the name Ginecotocologica has been accepted (in Spanish tocologia from the Greek tokos, birth, logos, science, is used synonymously with obstetriciaobstetrics. In English, tocology " has the same meaning, but is seldom used). It would be retrograde to separate the subjects and divorce them from the undergraduate curriculum, although there are some sinister and disrupting influences that may prevail. Human reproduction (physiology and pathology) impinges on so many aspects of clinical science and social medicine that the student meets in his career. The revolution must come from the top-namely, the teachers--now that the General Medical Council has liberalised "
1. Tech.
Rep. Ser. Wld Hlth Org. 1963,
no. 266.
In
England Now
Letters to the Editor
A
Running Commentary by Peripatetic Correspondentt LAST week the wife of a small farmer (his farm was small) asked me to see her husband who had a mild influenzal illness. The problem was how to help him without putting him to bed. I suppose that in the long run none of us are indispensable, and if he had been carted off to hospital with acute appendicitis his cows would have been milked and most of his urgent chores performed somehow. However, as I am a singlehanded practitioner who also can take refuge in his bed only when all other measures fail, he had my full sympathy. In fact a new brotherhood of " Those who cannot go to bed " was nearly formed. I suppose that in the height of battle, injuries can be practically ignored, which, if received in the factory or in the field, would necessitate immediate treatment and variable times off work. Descending from these sublime thoughts to the humdrum life of a singlehanded practitioner-or any practitionerI wonder how many of our patients would remain with us, and how far our morbidity statistics would be cut, if we applied the same yardstick to their ailments as we do to our own. A sobering thought, but one which our political overlords would do well to ponder, for somewhere therein lies the answer to many of our problems today. *
*
*
During a Sunday game of golf we were distracted on the 16th tee by the loud calls of a wild duck coming from a high elm tree only a few yards away. We first thought that the duck had been attacked by a bird of prey, but on hearing also the cries of ducklings we realised that she had a nest on the sawn-off central trunk. The nest was fully twenty feet from the ground, and it was obvious that the mother was about to take the ducklings from the nest. As we gathered round she flew to the ground, calling all the time; and within seconds little yellow fluffy balls were falling from the tree, apparently without injury. Soon the mother and her seven ducklings set off for the nearest water some 400 yards away. It was interesting to see how mother duck alone supervised the whole operation of transferring her young; father duck did not appear to be anywhere in the neighbourhood. Perhaps he was having his weekly relaxation swim on some quiet reach of the Thames. *
*
*
Auntie is a gay 74 and is not averse to doing an occasional stint on a stand at the Ideal Homes Exhibition and similar gatherings where her ageless aquiline features and general aristocratic demeanour are much sought after. The other morning she went along to the railway station to buy a fashion magazine at the very moment the London express was about to depart. The guard blew his whistle; before Auntie could say a word a helpful porter whisked her into a first-class carriage and the train was in motion. At the next stop, a junction 20 miles nearer town, Auntie alighted, still clutching her nearly empty purse and Vogue and demanded to be returned home. "Diesel rail-coach in the bay, over the bridge, Ma’m," said a porter. What he didn’t say was that two diesel rail-coaches start from the same bay. After the first five miles it dawned on Auntie that this was an unfamiliar line which became even more unfamiliar as it penetrated further into rural Hampshire. She eventually got out at Basingstoke and after a suitable wait managed to get a return train back to the junction: another wait, this time for the correct diesel, and she eventually arrived home having missed lunch and tea and travelled 67 miles by British Rail without a ticket and with only a cup of coffee for sustenance.
Episodes like this don’t trouble her. " It’s nothing," she said, " compared with the time I had cramp on Paddington station and an engine-driver massaged my leg." Good old Western Region. * * * The Professor was walking across from the Infirmary to the University with the chest piece of his stethoscope dangling from his hip pocket when he was stopped by a respectful Boy Scout. " Excuse me sir, but your catheter is hanging out."
THE NOTTINGHAM MEDICAL SCHOOL SIR,-I have watched the mortar salvo from my learned Glasgow colleague, Prof. G. M. Wyburn (July 31), the elegant but irrelevant display of fireworks which was Sir George Pickering’s riposte (Aug. 14), and the second, briefer salvo in return (Aug. 21). It is not for me to comment upon the projected curriculum of a medical school in another jurisdiction ; but Professor Wyburn’s second letter does raise a point which concerns the Irish as much as the British (North or South). Our Government, by a prudent grace, permits the Visitors of the General Medical Council to inspect our medical schools, these Visitors being not too closely disguised as Visitors on behalf of our own Medical Registration Council. The recommendations of the G.M.C. are taken here as a norm, and I am one of the many teachers of medical undergraduates who feel strongly that the G.M.C. should be called upon to state openly and clearly what it is after. Up to now the recommendations of the G.M.C. could fairly be described as directions for a journey whose terminus was secret, if indeed it was known at all; the penultimate issue of this itinerary was particularly fatuous in this respect. Those who train arts-men, physicists, engineers, and agronomists have an adequate knowledge of what is intended by the grant of the corresponding degrees to successful candidates. He or she must have this minimum amount of knowledge, that minimum amount of skill. The Visitors of the General Dental Council not only know but are prepared to say what their idea of a passably good dentist is. We have never had any such direction about our goal for medicine and surgery from the final legal authority in this matter. It is time that we had. Every Irish university, from Queen’s southwards, grants a B.A.o. together with its M.B., B.CH. The B.A.o. is not a registrable qualification, but that part of the final examination which it represents connotes a perfectly definite set of knowledge and skills which the obstetricians and gynxcologists look for, and which is known to be looked for by them. Consequently the teaching, for example, of anatomy in respect of this degree is something that can be planned so that the student will have as much topographical, histological, developmental, and functional anatomy as is necessary, but no more than is sufficient, for this purpose. We have a right to know from the educational committee of the G.M.C., when it has finished its forthcoming deliberations, exactly what it expects the newly qualified graduate to be able to do. It will then be possible to plan the strategy and tactics of teaching, and to put an end to this present controversy, in which everybody appears to be talking at cross purposes and indulging in an orgy of Platonic piffle. Finally, it might be a good thing if those who have taken unto themselves the direction of the medical curriculum would remember that, even in these islands, there is a growing flood of barbarism, and that the young house-surgeon will have to consider urgently the consequences of the flick-knife —a matter not irrelevant to the study of this much-despised anatomy. Department of Anatomy, University College, M. A. MACCONAILL. Cork.
GROUP-THERAPY FOR ALCOHOLISM SIR,-I read with interest the views of Mr. Dougal Macphail (July 10) on the value of group-therapy in the treatment of alcoholism. I, also, am regarded as a recovered alcoholic, and I experienced a period in a group-therapy unit some eleven years ago. Since my departure I have kept in touch with the unit and its patients by means of monthly reunions, at which some of the ex-patients forgather with the hospital group to discuss problems connected with recovery and rehabilitation. Through these meetings I have been able to
539 great many of the reactions of alcoholics to groupand at the same time to define my own experience with greater clarity. As I see it, all alcoholics are firstly individuals, although their addiction is one that is common to all; and therefore their reaction to living within a group will vary according to the approach they make to it. In my opinion group-therapy offers the best prospect of recovery that we have at this time for alcoholics whose mental or physical condition requires hospitalisation. Alcoholics Anonymous, whose success in this field is world wide, also operates through a group-system by areas and not through selection by social or intellectual standards. I joined my own group after many years of chronic alcoholism and several attempts at recovery through admission to mental hospitals. I had come to admit my own helplessness, and to realise that salvation for me lay in getting at the root of my own problems and in building up a new outlook on life based on a different set of values. The group I joined consisted of alcoholics from a fair cross-section of social strata, including a patient who had served a number of prison sentences and who had now volunteered to accept treatment. The very fact that my fellow patients came from such varied backgrounds helped me considerably in breaking down my own unjustified image of myself. As a drinking alcoholic I was indistinguishable from any other sufferer, and if I had not taken to crime in order to obtain the means to drink it was only because I was fortunate in being able to procure money from legitimate sources. The problem of alcoholism that we faced was common to us all; therefore our discussions were on a mutual plane, and varying intellectual abilities were of no significance. Where we did differ, however, was in the sincerity of our approach to lifelong sobriety; and the majority of my group were not yet ready to undertake a full and searching self-analysis in order to seek out the character defects which lay at the root of their alcoholism. These patients were the ones who withheld a great deal from their life-histories, and so deprived themselves of vital clues in their search for contented sobriety. But their attitude was invaluable to others, who were thus enabled to see more clearly the need for a more determined effort on their own part. For example, one member of our group made a practice of secret drinking, and here we were able to sort out the twisted thinking which was the cause of so much of observe
a
therapy,
our own
undoing.
The psychiatric social worker joined us at some of our discussions in which we were helped to see that we must prepare ourselves for re-entry into the broken homes we had left behind. At the same time our families were encouraged to take an interest in the problems we were facing and to meet in groups of their own for this purpose. Nevertheless family rehabilitation remained a goal which we alone could achieve through adjustment and understanding on both sides. In my opinion the alcoholic does not enter a hospital unit to receive treatment in the same sense as a patient who enters a general hospital for some specific physical illness. The unit is there, with the expert assistance of the psychiatrist, the social worker, and the staff nurses, in order to provide an environment in which the alcoholic can set about his own problem and seek his own salvation. Through the individuals within the group he can study the varying facets of his own character defects, and in his efforts to help them he also helps himself. No-one can provide him with a formula by which to live out his own life, and he must learn to discard his dependence upon others in favour of the expression of his own personality and
abilities.
Inevitably a proportion of every group will be unproductive as regards immediate results, though not necessarily in the long term. On the other hand it frequently happens that a patient who begins group-therapy with little or no sincerity is converted by the example and efforts of others. As I see it, it is not the duty, even if it were possible, of those who select the members of the group to assure themselves that those chosen are of a right mind to achieve recovery; nor have they any grounds for
expelling a patient, unless his behaviour is such that it is impossible to retain him in the group. Anonymity serves the purpose of clearing the ground of social prejudice, and there is nothing to fear from blackmail if a recovered alcoholic is willing to admit his past to those who have any concern with it. Accurate statistics of recovery from alcoholism are obviously impossible to obtain, but public understanding of alcoholism is increased by the return to society of every alcoholic who can take his or her place as a useful citizen. X. THE NURSE’S LOAD
SiR,ņThe Queen’s Institute fully supports the statement in leading article (Aug. 28): " All concerned in nursing training must ensure that instruction is given in handling methods which ensure the safety of both the patient and the
your
nurse." As an organisation very much concerned in nurse training, the Institute has been undertaking work in this field since 1956 when one of its nursing officers visited Canada and the United States to study body dynamics. As a result of her findings, regular courses in posture and lifting have been organised for superintendents and tutors responsible for teaching this important subject to district nurses on their staffs. It is also included in the syllabus of district-nurse training and in the programme of refresher courses. In 1957 the Ministry of Health had already made a film on lifting in hospital, and they invited St. Thomas’s Hospital, King’s College Hospital, and the Institute to cooperate in the making of two further films, one showing correct lifting methods for use on the district, and another entitled Poise and Movement. A film-strip on lifting in the home was also made. Queen’s Institute of District Nursing, 57, Lower Belgrave Street, London, S.W.1.
L.
JOAN GRAY
General
Superintendent.
SiR,ņYour leading article concluded with the suggestion that the Ministry of Health might " ensure a wider dissemination of knowledge of lifting methods ". May I therefore draw the attention of your readers to the three films made by the Ministry on this subject, to be shown in nurse-training schools and elsewhere, which are all available on loan from the Central Film Library? They are: UK 1550, Poise and Movement (21 minutes, 2 reels); UK 1551, Lifting Patients: Part I, In Hospital (13 minutes, 1 reel); and UK 1552, Lifting Patients: Part II, In the Home (11 minutes, 1 reel). There is also a film-strip intended for use in conjunction with the last two films. S. A. HEALD
Ministry of Health, London, S.E.1.
Public Relations Officer.
AN EDUCATION IN OBSTETRICS AND GYNÆCOLOGY SiR,ņThe sagacious and provocative views expressed by Professor Rhodes (Aug. 28) should be welcomed by colleagues who practise his specialty. I notice he styles himself a professor of gynaecology. At a W.H.O. study group on Social Aspects in the Teaching of Obstetrics and Gynaecology1 we spent several hours trying to agree on a single name for both branches of the specialty. In Uruguay the name Ginecotocologica has been accepted (in Spanish tocologia from the Greek tokos, birth, logos, science, is used synonymously with obstetriciaobstetrics. In English, tocology " has the same meaning, but is seldom used). It would be retrograde to separate the subjects and divorce them from the undergraduate curriculum, although there are some sinister and disrupting influences that may prevail. Human reproduction (physiology and pathology) impinges on so many aspects of clinical science and social medicine that the student meets in his career. The revolution must come from the top-namely, the teachers--now that the General Medical Council has liberalised "
1. Tech.
Rep. Ser. Wld Hlth Org. 1963,
no. 266.