Ward environment in an inpatient drug dependence treatment unit: II. Attempts to improve ward environment.

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The International Journal of the Addictions, 10(4), pp. 539-555, 1975

Ward Environment in an Inpatient Drug Dependence Treatment Unit: 11. Attempts to Improve Ward Environment John D. Teasdale," M.A., Dip. Psych., Ph.D. Janice Evans, B.Sc., M.Sc. Sheila Greene, B.A., M.Phil. Caryl Hitchcock, M.A., M.Phi1. Heather Hunt, B.A., M.Phil. Phillip H. Connell, M.D., M.R.C.P., D.P.M., F.R.C. Psych. Drug Dependence Clinical Research and Treatment Unit Maudsley and Betblern Royal Hospitals and Psychology Department Institute of Psychiatry University of London London, England

* Present address (for reprints): University of Oxford, Department of Psychiatry, The Wameford Hospital, Oxford OX3 7JX, Oxford, United Kingdom. 539 Copyright 0 1975 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.

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INTRODUCTION A companion paper to the present one (Teasdale et al., 1975) reported the results of preliminary investigations into ward environment in a ward for the treatment of patients dependent on intravenous drugs, mainly heroin and other opiates, in the Drug Dependence Clinical Research and Treatment Unit, Bethlem Royal Hospital. These studies employed direct observation of behavior in the ward and the Ward Atmosphere Scale (Moos and Houts, 1968; Moos, 1969), and suggested that the ward environment was relatively poor. In particular, the proportion of time the patients spent engaged in what might be described as “constructive activities” seemed undesirably low. The present paper reports the results of two investigations of attempts t o increase the proportion of time spent on such constructive activities. The first investigation concerned the effects of the arrival of an occupational therapist in the ward, the second concerned a pilot study of the use of material reinforcers to increase constructive activity.

STUDY 1 : THE EFFECTS OF THE ARRIVAL OF AN OCCUPATIONAL THERAPIST Given the emphasis attached to the therapeutic value of constructive activities in the recommendations made for the management of heroin addicts [National Health Service, H . M . (67) 831, the importance of the contribution of the occupational therapist to the therapeutic value of the ward environment is obvious. From its opening, the closed ward of the Drug Dependence Clinical Research and Treatment Unit had the services of an occupational therapist, at first on a full-time basis, and later on a half-time basis. This occupational therapist was present on the first occasion the Ward Atmosphere Scale was used in the ward (see Teasdale et al., 1975). However, she left in the middle of 1969 and for some time the ward was without an occupational therapist. It was decided to undertake a pilot study of operant techniques to increase the amount of constructive activity, and baseline measures were started in the autumn of 1969. However, another occupational therapist was appointed soon after these began and it was decided to change the study into one of the effects of the arrival of an occupational therapist. This occupational therapist worked on a full-time basis in the ward, which had only 10 beds, enabling a fairly intensive interaction between the occupational therapist and the patients. The occupational

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therapist was female, young, and enthusiastic. She arrived on the unit on lO/l1/69 but did not appear on the ward until 17/11/69, when she spent a week acquainting herself with the staff, patients, and ward routine, and began her attempt to engage patients in occupational therapy on 24/11/69.

Method Measures

1 . Ward Atmosphere Scale. This instrument and its administration were described in the companion paper (Teasdale et al., 1975). It was administered to patients and staff on two occasions in the baseline period before the occupational therapist arrived (22/10/69 and 6/11/69), and once after she had been active on the ward for 3 weeks (12/12/69). These three occasions represent those occasions labeled 2, 3, and 4, respectively, in the companion paper. 2. Direct Observations to Give a “Time Budget.” This technique was also described in the companion paper. Observations were made continuously over a period starting 4 weeks before the arrival of the occupational therapist and finishing 4 weeks after her arrival (20/10/69 to 12/12/69). The first 4 weeks of this period were used as the baseline measure and the last 3 weeks as a measure of the activity occurring while the occupational therapist was in active operation. These two occasions represent those occasions labeled 1 and 2, respectively, in the companion paper. 3. Psychiatric Outpatient Mood Scale (P.O.M.S.) (McNair and Lorr, 1964). This is a relatively brief self-report measure of seven mood factors: Tension, Anger, Depression, Vigor, Fatigue, Friendliness, and Confusion. The subject is asked to indicate on a four-point scale the extent to which a number of adjectives, such as “anxious” and “carefree,” describe his mood. It was administered daily at 3:OO P.M. during the period of the study to patients in the ward with instructions to complete it “as you feel today.” Measures from the 3 weeks 27/10/69 to 14/11/69 were used as baseline measures in the absence of the occupational therapist, and from the three weeks 24/11/69 to 12/12/69 as measures of mood with the occupational therapist present in the ward.

Results 1. Ward Atmosphere Sccile. Tables 2, 3, and 4 in the companion paper give the detailed results of the Ward Atmosphere Scale, Occasions 2 and 3

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in these tables being the baseline measures, and Occasion 4 being the measure in the presence of the occupational therapist. There are no significant differences o n any measure, for patients or staff, between the two baseline measures. The only difference between a baseline measure and a measure with the occupational therapist present to reach significance is the increase in Practicality ( p < .05) from Occasion I to Occasion 3, noted by the patients. The increase in Practicality from Occasion 2 to Occasion 3 noted by the patients, while numerically greater than that from Occasion I to Occasion 3, did not reach significance as a result of a single extreme score on Occasion 2. Table 1 Time Budget for Ward under Baseline and Occupational- Therapist-Present Conditions

% Occurrence Behavior category A. Sitting doing nothing/lying down doing nothing B. Out of ward C. Asleep D. Talking with another patient or staff member E. Reading other than academic study F. Cards/chess/Scra bble G. Walking from one part of the ward to another H . Eating/drinking I. Seeing Dr/Psychologist/PSW/ having EEG J . Cooking K . “Constructive” activities other than cooking (washing up, cleaning, tidying, setting out meals, drawing, mending, making models, woodwork, studying, writing, pottery, table tennis, singing, playing ball, painting, knitting, sewing, etc.) L. Standing, doing nothing else M. Toilet/washing/personal care N. T.V. 0. Other

Baseline

O.T.

x2

P

14 14 14

14 18 12

4.66 2.82

.05 .I

10

8

2.18

NS

10

10

8 7

9.39

NS .01

6 4

3 4

6.95 -

-

4 1

5 7

-

-

2

2 3 I

3 1

2 I00

4 -

100

51.2

.01

,001



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2. “Time Budget.” Table 1 in this paper shows the percentage of observations falling in each category of behavior in the baseline and occupational-therapist-present (O.T.) conditions. The results of statistical tests comparing the proportions in the two conditions are also shown. The data in Table 1 of this paper are the same as the first two columns in Table 1 of the companion paper. Category K behaviors include most of those that would normally be described as occupational therapy. The results show that the arrival of the occupational therapist produced no significant increase in such behaviors, despite the repeated attempts of the occupational therapist to engage patients in such activity. However, there was a significant increase in Category J behavior (cooking) following the arrival of the occupational therapist. This was achieved by the occupational therapist canceling the daily lunch which was normally provided by the hospital, and arranging for provisions to be supplied with which the patients could cook their own lunch. The occupational therapist and nurses assisted and encouraged patients in this activity. To show that the increase in cooking was a function of the occupational therapist’s presence and not the result of other factors, such as change in patient population or withdrawal states, the ratio of number of Category J observations/number of other category observations, was calculated in the O.T. condition for observation periods when the occupational therapist was actually in the ward and for periods when she was not. Comparison of the ratios in these two conditions yielded a significant x2 of 10.47 ( p < .Ol), in the direction of more cooking when the occupational therapist was present. In the 3 weeks of the O.T. condition the mean percentage occurrence of cooking was 10 in the first week, 5 in the second week, and 6 in the third week, the fall from the first to second week being significant ( p < .05). Table 1 in the companion paper shows that cooking behavior was maintained at a level that was low, but above that in the baseline period, in the four subsequent periods of observation. The occupational therapist was present for only 1 day of the third period, had left the wa?J by the fourth, and another full-time occupational therapist was present for the fifth and sixth periods of observation. The persistence of the cooking behavior is not surprising, given the fact that if patients did not cook their own lunch they would have none provided. Table 1 in the companion paper shows that the frequency of Category K behavior appeared to be at more or less the same low level in the baseline period, in the O.T. period, after the first occupational therapist had left, and when the second occupational therapist was present. It appears that the main effect of the occupational therapist on “constructive” be-

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havior, in terms of the measures taken, was restricted to the increase in cooking. The significant increase in observations when patients were out of the ward from the baseline to O.T. conditions was probably related to the greater availability of passes in the second period. Statistical tests were used to check whether this increase in Category B observations could account for the lack of increase in Category K, or the decrease in Categories C, F, and G. It was found that it could not. The significant reductions in Category F and G behaviors, and the almost significant reduction in Category C behavior, from the baseline to O.T. periods were probably related to the increase in Category J behavior. 3. Psychiatric Outpatient Mood Scale. Results were available from five patients who had been in the ward during both the baseline and O.T. periods. Results in the period 27/10/69 to 14/11/69 were used as baseline measures, and results in the period 24/11/69 to 12/12/69 were used as measures in the period when the occupational therapist was in active operation. However, before statistically comparing the results from these two periods, it was necessary to check that patients were not showing any consistent trend t o change in mood over the baseline period, as this would confound the effects of the active presence of the occupational therapist. This was done by comparing the mean scores in the periods 27/10/69 to 7/11/69 and lO/l1/69 to 21/11/69. Only one patient showed any significant difference between these periods; he was significantly higher on Depression, Anger, Tension, and Fatigue, and almost significantly higher ( p < . l) on Friendliness in the second period than in the first. This patient was excluded from the subsequent analysis. The results from the remaining four patients are shown in Table 2. The most consistent findings are the increases in Vigor and Friendliness from the baseline to O.T. periods. These increases are shown by all four patients and, with the exception of one patient where the increase only approaches significance ( p < .I), to a statistically significant degree. The other significant differences observed appear to be idiosyncratic.

Discussion The results from the “time budget” investigation suggested that the effect of the arrival of an occupational therapist on increasing what has been termed “constructive activity” was relatively slight and restricted to the activity of cooking. Further, this lack of effectiveness did not seem

cn P cn

1

8.3 2.0 6.9 6.4 2.4 1.7 3.5

Mood factor

Confusion Vigor Depression Anger Tension Friendliness Fatigue 12.7 0.1 16.9 19.5 25.2 0.1 15.9

2.0 7.0 0.6 1.2 1.4 7.0 0

3

1.4

2.3 10.0 2.5 1.2 3.3 7.2

4 7.1 5.4 6.1 2.6 3.9 5.3 3.9

1

14.0

11.4 0.8 14.9 23.4 25.2 1.6

2 1.6 9.5 0.4 0 0.7 11.4 0

3

Patients

Patients 2

Mean in O.T.

Mean in baseline

0.6 15.6 1.4 0.8 1.1 11.4 0.6

4

Table 2 Comparison of P.O.M.S. Scores in Baseline and 0.T. Periods

NS

NS .01 NS .I NS .01

1

NS .I NS .05 NS .1 NS

2

3

NS

,001

NS .05 NS NS NS

Patients

Significance of difference


NS NS .I .02 NS

.002

.02

4


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restricted to the particular occupational therapist studied but was also shown by her successor. The effects on ward atmosphere were also slight: the staff perceived no significant change in atmosphere, and the only significant difference the patients perceived was an increase in Practicality. Given the number of statistical tests that were made, this significant increase could simply be a chance finding. However, the fact that it is on the scale that would be expected to be most sensitive to attempts to engage patients in realityoriented activity would suggest that it may not be. The results from the mood scales are very interesting. Although the effect of the occupational therapist in increasing constructive activity was slight, it did appear to result in consistent improvements in mood, the patients being more friendly and vigorous. It may be that by obtaining the mood measures at 3:OO P.M., which was generally soon after lunch had been prepared, the effect of the increased cooking activity on mood was maximized. Discussion of possible reasons for the apparent ineffectiveness of the occupational therapists in obtaining marked increases in constructive activity will be deferred to the general discussion at the end of this paper.

STUDY 2 : A PILOT STUDY OF THE USE OF MATERIAL REINFORCERS TO INCREASE CO NST R UCTlVE ACT1VlTY This study was originally only intended as a pilot study to explore the possibilities of an operant approach to increase the extent of constructive activity in the ward. In practice, considerable difficulties were encountered in conducting the study as a result, among other factors, of the high rate of turnover of patients in the study, and the limited time period available t o the particular psychologists engaged in the study to complete it. It thus cannot pretend to be a thoroughgoing scientific investigation, and is offered as much for the anecdotal and impressionistic material it generated as anything else.

Method The particular activity studied was the assembly of plastic model aircraft kits. This activity was chosen as it was easily observable, required minimal skill, and gave rapid results in the form of a completed model, required no assistance or supervision from the ward staff, and was an ac-



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tivity which patients in the ward had previously spontaneously engaged in. The necessary materials were made available between 3:OO and 4:OO P.M. on four afternoons a week for the period of the study. All patients in the ward had the opportunity to engage in the activity, and all were asked to complete the “right now” form of the Psychiatric Out-Patient Mood Scale at 2:50 and 4:OO P.M. each afternoon of the study, whether they had engaged in any activity or not. There were five phases of the experiment. In Phase I the patients who had repeatedly complained of the fact that they were bored and had nothing to do were told that the material for assembling plastic model airplanes would be available in a workroom in the ward between 3:OO and 4:OO P.M. each afternoon. They were told that whether they made model airplanes or not was completely up to them, and that no one would attempt to persuade or encourage them to engage in this behavior. The nursing staff and occupational therapist had previously been asked to adopt such a laissez-faire approach. In Phase I1 the patients were told that the ward staff would now like them to engage in plane building, and the nurses and occupational therapist were asked to use their skills of persuasion, encouragement, and praise to get them to engage in tlus behavior. I n Phase 111 the patients were told that they would receive 10 cigarettes if they spent the hour available for making model airplanes on this activity, or one cigarette for every 6 minutes spent on the activity if they worked for less than an hour. All the patients were regular cigarette smokers and, given their relatively impoverished financial state, free cigarettes were thought to be likely positive reinforcers. Ward staff were informed of the change in regime, and asked to cease their attempts at encouraging activity. In Phase IV the cigarette contingency was withdrawn, and patients and staff were informed of tlus. I n Phase V the cigarette contingency was again operative, and patients and staff were informed to this effect.

Results Activity

Figure 1 shows the extent of activity for each patient in each phase of the experiment. S1 engaged in no model-making activity in any phase of the experiment.


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Phase1 no reinforcement or enaxrragemeot

IPhasell lPhaselll staH reidor- cigarette 'cement a d

;F%aselV;PhaseV as I as Ill

I remlorcement I

1""'I 60 40 20

0

(MINS)

I I

I I

I

I

I I

I I I*

40. 20

I

I

I

I

I

I

20

I I

40

I I

I I

I

I

I

I

I

I

I

I

40

20

40 20

EXPERIMENTAL

DAY

I I

-3

Fig. 1. Pilot study of operant approaches t o increase constructive activity.



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At the beginning of Phase I11 he offered the other patients 12 cigarettes an hour if they would not cooperate in the model-making task, but did not have enough money to make good his offer. He continued, however, to attempt to exert social pressure on other patients against participating in model-making activity. S2 engaged fully in model-making activity at the beginning of Phase I, but this then declined and was not reinstated by staff pressure and encouragement. He did, however, resume activity at the beginning of the cigarette reinforcement phase, but was discharged from the ward after 2 days of this phase. S3 behaved in a similar way to S2 up to the second day of Phase 111, but thereafter he did not engage in any more model-making up to his discharge on the third day of Phase IV. S4 was admitted on the third day of Phase I, engaged fully in modelmaking that day, but only sightly further in that phase (Day 6), and generally retired to his room in the period 3:OO to 4:OO P.M. and did not engage in any further activity during the experiment, apart from a brief period on Day 3 of Phase IV. This patient was interviewed on a subsequent readmission, and explained that his reason for nonparticipation in model-making had been that he did not wish to appear to be cooperating with the staff’s “game.” S5 was admitted on the final day of Phase I1 when he participated in the model-making to a moderate level, which was maintained during every day of Phase 111. On removal of the cigarette contingency, this activity declined to a low level and was not reinstated by the reinstatement of the cigarette reinforcement contingency. S6 was admitted on the third day of Phase 111, participated to a moderate degree in that phase, but activity ceased after the removal of the cigarette reinforcement contingency and did not return with its reinstatement. S7 was admitted on the final day of Phase I11 and participated in no model-making activity during the remainder of the experimental period. Because of the nature of the data, it is difficult to draw any definite conclusions from this study. The data suggest that some patients spontaneously engaged in the model-making task, but that this behavior declined fairly rapidly. Staff encouragement and persuasion seemed ineffective in reinstating the behavior. The cigarette contingency did seem to have some control over behavior in that it reinstated activity in some cases, and ongoing activity declined on its removal. The second introduction of the contingency seemed to have no effect in producing activity, however. In the


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light of the specific instances noted, and of the general impression obtained by the experimenters, it was felt that the negative attitude of some patients t o others’ participation in activity was an important factor operating against the effects of procedures designed to promote activity, especially in the case of the second introduction of the cigarette reinforcement contingency.

Mood Owing to the rapid turnover of patients, the small extent of activity, and frequent refusals to complete the mood scales, sufficient data to compare the mood changes occurring in periods of model-making and nomodel-making was only available for one patient, S3. t Tests were used to compare changes from the 2 : 5 0 P.M. measure to the 4:OO P.M. measure in this patient. It was found that model-making was associated with significantly less increase in Depression ( p < .Ol), Tension ( p < .05), and Anger ( p < .05) than no model-making, and an almost significantly less ( p < . l ) fall in Vigor. However, the 2:50 P.M. measure was significantly higher for periods of model-making than for periods of no-model-making on Depression ( p < .05), Tension ( p < .05), and Anger ( p < .l), and there was a significant negative correlation (at least p < .05) between the 2 5 0 P.M. measure and ( 4 9 0 P.M. measure -2:50 P.M. measure) for Depression, Tension, Anger, and Vigor. This suggests that the differences in mood change between model-making and no-model-making may have been a result of initial differences in mood rather than the effects of modelmaking activity.

General Discussion The companion paper to the present one (Teasdale et al., 1975) suggested that the ward environment in the closed ward of the Drug Dependence Clinical Research and Treatment Unit was relatively poor, especially in terms of the extent of “constructive” activity. The present paper has reported investigations which suggest that the traditional approach of an occupational therapist to increasing such constructive activity was relatively ineffective, as was a brief, piecemeal attempt to apply operant reinforcement using cigarettes to increase the performance of one particular type of activity. It is intended to discuss possible reasons for the difficulties encountered in establishing a therapeutic environment in this ward, using attempts to increase constructive activity as an example for discussion. However, it would perhaps be useful first to suggest possible reasons


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why any attempt should be made to engage opiate-dependent patients in such activity : 1. As the National Health Service circular H.M. (67) 83 suggested, constructive activity may be useful in extending the intellectual and creative ability of addicts, and reinforcing a generally weak sense of personal worth by opportunity for short-term achievement. 2. If treatment should aim at creating a pattern of activities more similar t o that shown by most people than that common in the “drug culture,” then patients should engage in constructive activities, rather than sit around doing very little, for the bulk of the working day. This may be particularly important in establishing normal work habits. Further, if an aim of treatment is to provide an alternative life-style to that of drug use, it is important that patients should acquire other interests and leisure activities, in which they often seem relatively impoverished. 3. The evidence of the companion paper and of other published reports (e.g., Shapiro, 1969) suggest that constructive activity may have a beneficial effect on mood. It is interesting to note that patients frequently complained of being bored and having nothing to do. 4. If treatment is directed at modifying the patient’s behavior in his interpersonal function, work function, etc., then it is necessary for him to behave in a variety of situations so that such behavior may be observed and modified, rather than engage in mainly passive activities. 5. Given the inverse relationship between rate of processing stimuli from external and internal (thought) stimuli (Antrobus, 1968), it is likely that engagement in constructive activity, requiring the processing of external stimuli, may reduce the frequency of drug-related thoughts o r daydreams which often trigger feelings of craving.

Accepting the desirability of increasing constructive activity, what are possible reasons for its low rate of occurrence in the ward studied? 1 . It may be that the type of patients in the ward have chronically low activity levels, possibly related to heightened susceptibility to boredom as a result of some biological characteristic. Such a suggestion is obviously highly speculative. Dr. S. B . G. Eysenck (personal communication) has suggested that such low activity levels and susceptibility to boredom may characterize subjects scoring high o n the “psychoticism” dimension of personality, and drug users have been found to have unusually high scores on this measure (Teasdale, Segraves, and Zacune, 1971). 2. The traditional approach of occupational therapists to get people


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to engage in constructive activity seems to depend on using their social influence and reinforcement value, often in the context of a good interpersonal relationship with the patient. It may be that drug users are less susceptible than most patients to the social influence of hospital staff, whom they may regard as “straight” and different from themselves. It may consequently be difficult to establish a usable relationship with them. The apparently reduced social reinforcement value of “straight” people may be related to a reinforcement history i n which important figures in the patient’s life (e.g., parents or parent substitutes) have been more often punishing than rewarding. It may also be a feature of relationships between people who see themselves as deviant and those whom they see as nondeviant (Freedman and Doob, 1968). 3. Buehler, Patterson, and Furness (1966) report the results of an investigation of the social reinforcement contingencies operative in a residential institution for delinquents. They divided the behavior of the delinquents into prosocial and antisocial, and the contingent social reinforcements received from other delinquents and staff into positive and negative. They found that delinquent peers positively reinforced antisocial behavior and negatively reinforced prosocial behavior. Staff tended to positively reinforce prosocial behavior and negatively reinforce antisocial behavior, although not particularly consistently. Thus, as a result of the greater frequency and potency of reinforcements available from peers, a situation was maintained in which antisocial behavior was on the whole rewarded and prosocial behavior on the whole punished. The anecdotal evidence presented in this paper suggests that similar reinforcement contingencies were operating on the ward studied. It is probable that the nature of the reinforcement obtained from other patients was an important factor in reducing participation in constructive activities, and mitigating the effects of social reinforcement from the staff and of material reinforcement in the form of cigarettes. 4. If patients are not particularly susceptible to the staff’s attempts t o influence their behavior, then it is likely that such attempts will extinguish as a result of lack of reinforcement. If the patients not only fail to respond by producing the desired behavior but respond in a hostile way, then the same process is even more likely to operate. Thus, in the absence of a precisely formulated treatment program in which the staff member can see the value of the attempt to influence patient behavior and thus work on self-reinforcement rather than that obtained from the patient, backed up by support from other staff members, such influence attempts are



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likely to decline over time. This would probably lead to a further decline in ward environment. How could the ward environment be improved in the light of these suggestions? If this type of patient is not very susceptible to the social influence or reinforcement value of normal hospital staff, there might be a place for staff who have a higher influence or reinforcement value, such as exaddicts. This is the procedure adopted in a number of institutions attempting t o treat drug addicts, e.g., the Phoenix House programs (Rosenthal, 1969). Alternatively, the staff could try to increase their social influence or reinforcement value by a more intensive attempt at forming close relationships with the patients. Another approach would be to use material instead of social reinforcement in a token-economy approach. The brief attempt to use such procedures reported here suggested that it would be necessary to employ this as a total rather than piecemeal approach. In this way the attempts of some patients to dissuade other patients from participating in constructive activity could also be brought within the scope of the token procedure. While this might be a viable approach to improving the patients’ behavior while in a hospital, any generalization to situations outside the hospital would probably have to rely on their being “reconnected” with the type of reinforcements operating in the world at large, which would probably be mainly social. If the reinforcements obtained from peers are an important factor maintaining undesirable behavior in the ward, it might be advantageous to separate this type of patient from their peers by placing them in general wards in the hospital. However, this procedure would have the disadvantages of exposing other patients to their possible disruptive influence (Connell, 1970) and of precluding the development of specialized skills to handle such patients which could occur in the staff of a specialized unit. If staff are to maintain their attempts to modify patients’ behavior in a constructive direction in the face of a lack of any positive reinforcement, or even negative reinforcement, from the patients, then it would be necessary for them to depend on self-reinforcement or the reinforcement received from other staff members. For this to occur it would be necessary for the goals of treatment to be specified in terms of the specific behaviors required of the patients in the ward, and for staff to be convinced of the value of attempts to get patients to behave in this way, so that they can give themselves reinforcement for making such attempts and receive reinforcement from other staff members.

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NOTE It has been suggested that ward environment in the ward studied was relatively poor; this deficit has been most closely documented for what has been called “constructive activity.” It should be stressed that it is not the authors’ intention to suggest that this is related in any way to deficiencies in the staff of the unit; it has been the authors’ impression, corroborated by a number of independent observers, that the staff of the unit are certainly as competent and conscientious as staff of any other ward of the hospital. Rather, it appears that traditional methods of patient management do not bear fruit in this difficult group of patients. In contrast to a number of other treatment settings, especially in the United States where controlling influences may more readily be used, all patients in the ward had voluntary status. Consequently, the main coercive or disciplinary measure which could be used on patients was threat of discharge, which, given the ambivalent feelings of many patients to stopping drug use, was of limited and unpredictable effect. The authors would like to go on record as expressing their appreciation of nursing staff, occupational therapists, and others for their dedicated work with this extremely difficult group of patients whose demands and difficulties in behavior make them rank among the most difficult, challenging, and exhausting to be found in the psychiatric field. Without the help of these staff, the research reported would have been impossible.

SUMMARY Ward activity and atmosphere in a Drug Dependence Treatment Unit were found to be poor in a previous study. The results of two attempts to improve ward environment are reported. The arrival of an occupational therapist had a very slight and restricted effect on the level of patients’ constructive activity, and produced only one significant change on the Ward Atmosphere Scale; patients perceived an increase in Practicality. There was, however, a consistent improvement in patients’ Vigor and Friendliness mood scores following the arrival of the occupational therapist. A pilot project using cigarettes as reinforces for patient constructive activity produced little sustained effect. Possible reasons for the difficulties in managing drug-dependent patients are discussed, and suggestions made for improvement.

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REFERENCES ANTROBUS, J.S. Information theory and stimulus-independent thought. Brit. J. Psycho/. 59: 423-430, 1968. BUEHLER, R., PATTERSON, G.R., and FURNESS, J. The reinforcement of behaviour in institutional settings. Behay. Res. Therapy 4: 157-167, 1966. CONNELL, P.H. Research into D r i / r Adcfictiorr in an In-Patient Unit. Paper read to International Institute on The Prevention and Treatment of Drug Dependence, Lausanne, June 1970. FREEDMAN, J.L., and DOOB, A.N. Deviancy: The Psychology of Being Different. New York: Academic, 1968. McNAIR, D.M., and LORR, M . An analysis of mood in neurotics. J . Abnormal Sac. Psychol. 69 : 620-627, 1964. MOOS, R.H. Ward Atmosphere Scale Preliminary M a n i d Palo Alto, California: Department of Psychiatry, Stanford University School of Medicine, June 1969. MOOS, R.H., and HOUTS, P. Assessment of the social atmospheres of psychiatric wards. J. Abnormal P.rycI101.73: 595-604, 1968. NATIONAL HEALTH SERVICE H.M. (67) 83. The Rehabilitation and Afrer-Care of Heroin Addicts. 1967. ROSENTHAL, M.S. The phoenix house therapeutic community: An overview. In H. Steinberg (ed.) Scientific Basis of Drug Dependence, London: Churchill, 1969. SHAPIRO, M.B. Short-term improvements in the symptoms of affective disorder. Brit.J. Soc. Clin. Psycho/. 8 : 187-188, 1969. TEASDALE J.D., ET AL. Ward environment in an in-patient drug dependence treatment unit: I. Activity levels and ward atmosphere. Intern. J. Addictions 10: 401416, 1975. TEASDALE, J.D., SEGRAVES, R.T., and ZACUNE, J. “Psychoticism” in drug users. Brit. J. SOC.Clin. Psycho/. 10: 160-171, 1971.

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Gene-environment dependence creates spurious gene-environment interaction.

Identification, investigation and management of patient-to-patient hepatitis B transmission within an inpatient renal ward in North West England.

Patterns of drug prescriptions in an orthogeriatric ward as compared to orthopaedic ward: results from the Trondheim Hip Fracture Trial-a randomised clinical trial.

In the maternity ward.

Implementation of an acute surgical admission ward.

Randomized clinical trial of the impact of surgical ward-care checklists on postoperative care in a simulated environment.

Implementation of a ward round pro-forma to improve adherence to best practice guidelines.

4GL ward management system.

The analysis of distribution of multidrug resistant Pseudomonas and Bacillus species from burn patients and burn ward environment.