Hill End to reduce sedation (5.9.91)



[Frank Broadhurst: https://twitter.com/LiableClerk ]

There are only a few freely available documents I can find like the one I am to copy/read today. Certain expressions of phrase echo in the memory vaults of my cloudy teenage memories, especially this one:

“The way you are continuing to behave
is making us anxious and so we are going
to sedate you to relieve our anxiety”

What disturbs me most prominently is that what the late Peter Bruggen ( a former close mentor to Dr Raj Persaud)  wrote is quite seductive. How do I articulate what I mean? I imagine that he and his colleagues persuaded my father to allow strangers to have the authority to exclude and sedate me, in the very much the same way many conservative-minded voters were persuaded to vote for New Labour in 1997 and beyond. My father was wise enough to see through the party slogans leading up to the 1997 general election, and indeed he became immune from voting Tory too, maybe with the assistance of his consistent reading of Express newspapers since at least the 1970s. Any lingering resentment I have had towards my parents regarding this hazy but very loud area of my mind has evaporated.

I have read “Authority in work with young adolescents: a personal review.”
But I feel the need to read it slowly, and absorb it by copying it out. I will come back to this
again after police investigations have been completed.

It has been very interesting for me to read. What is described in the 1979 document is very similar to what I can recall in late 1991/ early 1992. (I wonder if parental regrets contributed to my parent’s General Election choices in 1997.)

The picture painted by Dr Bruggen would not seem very concerning for many people I imagine.

Just remember that ‘exclusion’ means being locked alone in a small cell, but not quite a padded cell.

The reachable parts of the four walls seemed to be chipboard of some sort. If one was to punch or headbutt the walls etc, it was unlikely to cause as much damage as the hard-plastered surface that the chipboard-type material surely covered.

There was a bean bag in the far-left corner. I imagine the cell to be about 6 feet by 8 feet in size with a high ceiling. The cell door had a couple of eye holes. There was adequate lighting to be able to see that the exclusion room had quite a worn and torn history. The bean bag doubled up as a urinal I imagine, if the stains I seem to remember are not a false memory.

I remember faint blood and s*** stains high up the walls, but I’ve seen so much trash tv, and dark films over the years, it’s hard to tell what fine detail is real and what isn’t.

‘School’ consisted or sitting in a grey mobile/portacabin classroom, all I can remember is that we would sit quietly in class and the ‘teacher’ would instruct us to help ourselves to the textbooks available. I chose my own syllabus, which consisted of mainly doing maths, I think.

There was an occasion when I made cookies, maybe some primitive painting
took place.

But to call it school is laughable, even by the standards of these ever darker days.

It was a substandard pseudo-nursery for a handful of girls and boys between the ages of 12 and just under 16:-

Journal of Adolescence 1979, 2, 345-354

Authority in work with young adolescents:
a personal review.


The importance of authority and external controls when working with adolescents was first put to me at the Tavistock Clinic by Derek Miller, in 1966 (Miller, 1974). Three years later, when the adolescent unit at Hill End Hospital was being set up, this teaching was in my mind when I read a paper on the control of behaviour in an all adolescent ward (Hendrickson and Holmes, 1959), which argued that placing aggressive adolescents in an environment in which there is a strong expectation of response to verbal controls; of obedience and respect to staff; of reasonable standards of personal appearance and conduct, will enable them more easily to abandon their anti-social behaviour and constructively internalise their conflicts.

Almost Victorian standards of behaviour were asked of the adolescents, and so limits set were likely to be easily met. “Easily” became the important word for me. It seemed increasingly evident to me that high or widely set limits were not easy; people got hurt.

Holmes (1964), in a later book, described the confrontation between a psychiatrist and the adolescent who called him a bastard. “Where did you get the idea it was all right for you to call me a bastard?” he asked. The boy said he didn’t get it anywhere but was just telling the psychiatrist what he was thinking. “That’s fine . . . . It’s O.K. to tell me you think I’m a bastard or you feel like calling me a bastard, but it’s not all right to go right ahead and call me a bastard”.

During the supervision of my psychoanalytic training, I discussed the setting up of the adolescent unit with Donald Winnicott and one of his responses was to give me a copy of “Adolescent Process and the need for Personal Confrontation”, which was later published posthumously in the

*Consultant Psychiatrist, Hill End Adolescent Unit, Hill EndHospital, St. Albans, Herts.
Based on a paper read at the annual conference of the Association of Child Psychiatry
and Psychology, Dublin 1979.


last chapter of Playing and Reality (1971). In it he concluded that adults
abdicate at their peril.

Dr Tom Pitt-Aikens and I put some of these ideas together in a paper (1975) in which we emphasised the key role of the issue of authority with younger adolescents. Rule breaking, challenge, confrontation, seeking the limit, defiance, may be used, we suggested, as the ticket for seeking professional help for troubles of a deeper nature. In some cases, we argued, facing the issue of confrontation firmly and offering the adolescent the model of an adult prepared to stand up for his rights may, of itself, allow for the recuperative forces of the adolescent, family or institution to take over, and further professional involvement to be avoided.

This paper reviews my thinking on authority over the past few years since

I became interested in a number of different things, including open communications in institutions, many aspects of the “new therapies” including body work (bio-energetics) and gestalt and much to do with the practice and philosophy of the medications.

I feel much less clear than I did, when I ask myself now what the place of authority is in my therapeutic practice. The answer, not surprisingly, lies in a paradox. Authority is just as important to me but I am less authoritarian. The difference between the two, I shall try to work out here in reference to various issues, including punishment. To put it descriptively, I still use limit setting, confrontation and sanction in my work but raise my voice, give orders and shout far less. As a developmental stage adolescence still appears special, because of the extent and intensity of changes in size, feelings and strength. It still appears to me that the rate of this change can be alarming to the person who is changing and that such a person will desperately seek for limits in order later to develop them from within.

Not to provide such limits, boundaries or containments from without, is to create as Holmes (1964) described, the greatest cruelty of all. Many of the tasks of adolescence have been made more difficult by adults (sometimes professional carers) who side with them, rather than contain them. Such people act as if they believe that children are always right.* Information, problems, secrets, anxieties, potentials, courses of actions—are all shared. with adolescents, prematurely, rather than being held up and held back, caringly. “It wouldn’t be half so difficult if only it was not so easy” could often be said by the frightened adolescent whom no-one will stop.

All the difficulties of the present day adolescent cannot, of course, be put down to a loss of authority in society although some of the most marked

*I learned this interpretation form Dr John Padel.

changes over the last few years have been in changing attitudes to authority (e.g. Government, Unions, schools, picketing, censorship, marital vows, penal legislation). However, Turle in an early paper (1960) on an adolescent unit, described the disadvantages of permissiveness; and the “overthrow” of a therapeutic community for adolescents was described ten years later by Crabtree and Cox (1971). The very words “therapeutic community” have become strongly associated with the giving up of staff authority that I try not to use them in describing my own work, although it is significant that Maxwell Jones (1976) in his “Maturation of the Therapeutic Community” emphasises that staff authority may remain latent, but should not be relinquished. The experimental work of Berkowitz (1978) and epidemiological evidence of Belson (1978), (both of which show the causal connection between the portrayal of violence on television and its enactment by adolescent witnesses) and, lastly, the anecdotal reports of the democratic wish of some school children for more teaching, more structure and more examinations, are other things, all of which help me to continue to value my interest in authority.


After I had become seriously interested in the detail and theory of psycho- therapy and was searching for something more than just being nice to patients (and of course being nicer than other therapists) and became intrigued and then impressed by the value of interpreting the hostility or the negative (I think that your not talking to your mum and dad and your not talking to me, are your ways of being very angry and of making us all pay for it”) and of the use of non permissiveness, structure and authority in clinical work itself—after I had become serious about all of that, I had little trouble in using authority forcefully with individual patients and families. I could lay down terms, stick to my side of contracts (e.g. by stopping seeing people or discharging them); I could confront, challenge or shout. The trouble was that I did not have any trouble. I see myself as having been helped to move from this position at three points:

Firstly, when Harold MacMillan remarked of Edward Heath and his throwing his weight around that when you are Prime Minister you are the boss and do not have to tell everybody.

Secondly, when I was angrily and not very coherently complaining about colleagues not mentioning negatives and all the things that people had not done, it was suggested to me that the “I statement” was “I wish that you would all confront each other more and then I would have to confront you less”.

Thirdly, when I realised how Salvadore Minuchin was able to talk pleasantly and with enjoyment about the authority with which he was invested by families and to exploit this to therapeutic advantage.


I was able to see that, although in some of my work, I had offered passive fathers a model of a more assertive man, I could often go too far. My search was to be less authoritarian, but without being permissive in the hope that others might be able to take more authority for themselves.

Other people being more aware of their authority might possibly make it easier for me to enjoy and use mine. And if I felt more easy with mine then they might become more confident with theirs. And so on.

It then became more important than ever to try to support the authority of others by, for example, encouraging an adolescent to make an arrangement (to which we were both party) and then offering support. (On Sunday evening at Hill End Adolescent Unit each adolescent is invited to decide what he or she is going to work on during the week and the list is available to all in the unit so that all may be able to offer support. “I want to work on my anger”, “I want to work on my mother’s death”, “I want to work on how not to get into arguments”, are examples).
Working with families, it became even more important to realise, discover, define, support, and develop whatever authority was there already. I started to return the authority invested in me, as a consultant, a leader and as a therapist, to the parents whom I see as the just arbiters of the
rules for their own children. I decide less but help them to decide more. Clichés and platitudes from which I would have cringed 10 years ago, I now recite without, it seems, driving people to boredom or to leave the room. Sometimes I rely on ambiguity in my attempts to communicate.
What you have got to face is a statement which means what there is in front of you (as in what you have got in your basket). It also implies an injunction (what you ought to face). Some of my earlier “I think that you are trying to get yourself locked up” interpretations of a few years ago are now replaced by “what you have got to face is that if you are not able to take control of yourself and your impulses by yourself, then sooner or later someone else is going to take control of the whole you—like a court locking you up. The question is, can you get enough help out of yourself,
or other people or me, to do it before that happens”. Perhaps, by having more confidence in my own authority—(that I will be heard) I do not need to make an interpretation like the throwing in a dart.

With my realisation that I was using ambiguity, something happened also in the quality of empathy. My tendency had been to confront adoles- cents with the limits as discerned by me (“my” discovery, “my” truth). Now, more often I assume that they do know all along and that all I have to do is to ally myself with that part of them that has the knowledge. Their trouble, of course, is that although they know, they have been protesting that they do not; they fear loss of face. If I am able to make such an alliance and communicate to them my knowledge of theirs (“We both know


that things can’t go on like this forever”) then perhaps the two of us can face the change together and feel less loss of face. Within family therapy, my practice of using my authority, either to
challenge weak authority of a parent to goad them into activity, or to support the authority of the parents in controlling the adolescent, has also undergone some change. I rarely do the first now, unless I do it lightheartedly and that seems to be just as effective as having a good row.

The second I still do often. “How can I support you to get him to be quiet?”

“Look it’s very difficult for any of us to work with Ian shouting so much and interrupting. Can you, father and mother, get him to stop—or at least tell him to stop” and then I would add my own authority “Be quiet” or “Sit down.—You father’s told you to”. But I say it more quietly and
lightheartedly than before.


Hill End Adolescents Unit’s reliance on authority and limit setting is illustrated by some examples of its structure:

The Boundary
Those in parental authority are expected to make all decisions about admission, discharge and weekend leave. No extra money is to be given over the rates fixed by the Unit. We will not become involved in new cases if there is a court case pending.

With very rare exceptions, no medicine is given in the unit unless it is to sedate an adolescent to relieve the staff’s anxiety. (“The way you are continuing to behave is making us anxious and so we are going to sedate you to relieve our anxiety”)

These are expected to start on time, with no smoking, eating, chewing, writing, holding bags or pencils. Participants are expected to sit up, keep still and to look into the meeting. Only one person should talk at once and point scoring arguing is not accepted. While staff do occasionally have business which takes them out of a meeting (if there is no secretary, the telephone must be answered), adolescents are not to leave meetings (“If you feel you are going to be sick, we will get a bowl”) unless excluded by whoever is running it—and that may be another patient.


Limits within the day-today-activities
Notices may be taken of swearing, shouting, dropping ash on the floor or running. If any hospital property (say a cup or saucer) is broken, the hospital will bill the adolescent concerned.

The law
No protection is given by the Unit if one of the adolescents commits an offence and the police is involved. The staff will call the police promptly if drugs or stolen property are found in the Unit. (This act takes place only every few years and yet seems well ingrained in the culture of the

The adolescents are expected to share with staff, doing many of the day-to-day chores such as washing-up. They take it in turns to chair the community meeting, to give a handover report to both the afternoon and night shifts of nursing staff and share, with staff, in the weekly inspection of the building and contents.

An adolescent unit leaning so heavily upon authority and limit setting sometimes seems strange for an open communications system of administration to have developed. We drew heavily on the development of Dingleton Hospital with Maxwell Jones in the 1960’s (Jones, 1968) and have the involvement of all staff in decision making. The authority message to the adolescents living there may be symbolised in the following cumbersome statements:

We are in charge of the place and are paid to be so; we will make the decisions about how it is run but we will welcome your views about those decisions and sometimes will consult you about them beforehand.

Your parents (or your social worker if you are subject of a care order) are in
charge of where you live and have said that you should be here and for a reason which you stated in your presence.

You are in charge of the rest. You are in charge of your bodies and your minds, or your feelings (whether they be pleasant or unpleasant) and ultimately, of course, of your life and whether you live or die. If you have any difficulties with these, we are available to be consulted about them all the time.

Within this setting we decided that the handover from the morning shift of nurses to the afternoon shift should no longer take place behind the closed door of the nurses office but should be done in front of the patients in the community meeting. In 1974 the adolescents suggested that they do that themselves. Later they suggested that they should chair the meeting as well. Our anxieties were great, but in each case the innovation has gone well and the adolescents have performed the task better than we, the staff, were ever able to do. Again, allowing the adolescents to use their


own authority within a structure, was paying off. When it has been difficult to find volunteers for these tasks, or when they have not been carried out responsibly, we have been able to remind them that it was they, or their predecessors, who had suggested it. In its turn, of course this reminds them that we still retain the ultimate authority which we have delegated to them. we have not had to take it back.

In a community meeting the chairperson will tell people to stop giggling or to stop looking out of the window. The most the staff have to do is to say to the conductor “Please would you do something about so-and-so”, or “Please would you tell Jane not to chew in the meeting”. The ultimate authority held by the conductor is to exclude somebody from the meeting, which is something which happens perhaps twice a year.

The latest innovations to the community meeting has been the structuring of a point for the adolescents to comment on the staff. As we opened up our communications and it became obvious that no sanction, (such as excluding a boy or girl from the group or sedating one
of them) should be administered except in an open meeting, it also became obvious that the adolescents, themselves, should have the right to call a meeting at any time (except during school time when only teachers may do so).

Now anyone may call a meeting and the focus, at least at the beginning and the end, must be on the mental state of the person who called it. A teacher called a meeting saying “I’ve called this meeting because I’m anxious about what is going on in school with the groups and you, David”. David then cried and spoke about his distress at the letter he had received at coffee time. The focus changed briefly. “O.K. are you able to hold that until the next meeting, until the community meeting?” David replied with an affirmative grunt. The focus returned to the teacher who called the meeting: “And how is your anxiety?” “It’s less now, I feel reassured and I’d like you all to come back to school”. The meeting closed.

An adolescent, Andrew, called a meeting saying: “I’ve called this meeting because I want support. My meeting (“review meeting” with his parents to review their decision to have him in the Unit) has been cancelled and I feel like running away”.

There followed an attentive and unrestless silence after which a staff member said “Well, do you feel just calling the meeting and having the group together has given you enough support to hold things till the community meeting?” “Yes, I don’t think I’ll run away”. The meeting closed.

The ritualised opening of these meetings (I’ve called this meeting because. . .) earmarks the person who will close it. We also feel that it is important to emphasise the simple reasons behind what we are deciding or doing; and that if it is a sanction which we, the staff, are administering
that this be in terms of the needs dictated by our own mental state. “We are excluding you from school”, or “We are excluding you from working


with the group because we are too anxious about the way you are behaving”. “We are excluding you and sedating you because we will not tolerate your violent threats and your hitting us”. The decision will always be reviewed at a subsequent meeting, which will take place within a few hours.

Incidentally, the only reason that we ever give for discharging somebody is that we cannot cope with their behaviour or will not tolerate what they are doing. Stating a reason for administering a sanction in terms of our own mental state (or the parents’ mental state) seems to make it less likely that it will be interpreted as a punishment. Punishment, as opposed to penalty or sanction, is after all, the deliberate inflicting of pain or suffering onto somebody who is seen to have done morally wrong.

The power of guilt is, however, so great (which of us hasn’t said “sorry” when meeting someone in the doorway) that non-punishment is often experienced as punishment by the recipient (or the giver) of sanction.

This remains an issue for indefinite work.

The opening of communications with the group of adolescents living in the unit, has been followed by other developments of their authority. In a community meeting a girl angrily cried out “You know my mother’s dead! Why do you go on talking about her?” “Because you don’t and you
need to” said a 15-year-old-boy. She listened to him and his “sapiential”
authority, when she wouldn’t listen to me.

The new therapeutic approaches of gestalt, bio-energetics, group fantasy, body work, “I statements”, confrontation, massage and so on are other experiences which have jolted my authoritarian views and attitudes, whilst leaving me with a strengthened respect for the use of authority.

I am impressed by the way in which the body finds it so hard to “lie” and, if I can be perceptive, then an authority greater than mine will communicate. “Your kicking foot suggests to me that you are feeling very angry inside” has been replaced by “I wonder what your foot is saying?” and now, more often, by “Would you try putting your foot on the ground”.

The first time that I tried this in a family meeting, the effect which was experi- enced and unleased was not the hostility, (which I had been holding myself in from interpreting) but grief. As she put her foot to the ground, the girl sobbed. Also, a running-away boy, who had run away many times from many places and a few times from us in two days was, in his second community meeting, tapping his feet restlessly on the floor. He was asked not “What are you trying to run away from?”, but rather “Try putting both your feet on the ground”. He had seen enough other people use or talk “body language” in his two days in the unit to be able to try it.

He cried quietly for 5 minutes.


Of course we do not have to agree and there is nothing basically wrong about sharing our disagreements in front of the adolescents, but we do have to get on together and work together. How well we get on together will affect how we make decisions, how we support them and how we guard against our punitiveness, all of which are important in influencing
how much we are able to use our authority consistently and caringly. We have decided that we can work together better, if we make a commitment to respect the boundary between our professional lives and our private lives, not to have secrets about work and not to talk about colleagues except in their presence.

In our society, individual liberty and authority are both important, and each can be taken to extreme. It is fashionable to say that authority can go too far, but more difficult to say it of the other. I think that in a society it is valuable and helpful to have an organisation (probably elected) which makes rules, changes some of them, bans things and draws some ridiculous lines.

I think that between the majority of us and that group in which we invest authority, the interaction of protest, rebellion, argument, discussion, enquiry and change is a healthy one.

For the younger adolescent (bursting with feelings of size and strength) individual liberty and authority are both important, but authority and the handling of it by older people who are prepared to receive hostility and confrontation without giving in, is especially important.

I conclude that it is in the interests of the adolescents that we, the adults and the professionals, should be prepared to be authoritarian. Troubled by an inner world peopled by confusing forces and persons in contradictory conflict, it is essential for adolescents to find the firm boundary of the limit-setting elder, who can give reasons in terms of him or herself. It is within that relationship, that there may develop, in the inner world, the inner authority which is their own. For me to try to offer this to the adolescents that I meet, may be unpleasant for me but, of caring, it remains an essential part.


Excerpts from “‘To the Parents from their Children” by an in-patient at
Hill End Adolescent Unit.

Don’t spoil me—I know quite well that I ought not to have all I ask for. I’m only testing you.

Don’t be afraid to be firm with me. I prefer it. It makes me feel more secure.

Don’t let me form bad habits. I have to rely on you to detect them in the early stages.

Don’t correct me in front of people if you can help it. I’ll take much more notice if you talk quietly with me in private.

Don’t be too upset when I say “I hate you”. It isn’t you I hate but your power to thwart me.

Don’t protect me from consequences. I need to learn the painful way, sometimes.

Don’t take too much notice of my small ailments. I am quite capable of trading on them.

Don’t make rash promises. Remember that I feel badly let down when promises are broken.

Don’t forget that I cannot explain myself as well as I should like. That is why I am not always accurate.

Don’t tax my honesty too much. I am easily frightened into telling lies.

Don’t be inconsistent. That completely confuses me and makes me lose faith in you.

Don’t ever think it is beneath your dignity to apologise to me and an honest apology makes me feel surprisingly warm towards you.

Don’t forget that I cannot thrive without lots of understanding love, but I don’t need to tell you that, do I?

Belson, W. A. (x978). Television Violence and the Adolescent Boy. Farnborough: Saxon House. Berkowitz, L. et al. (x978). Experiments on the Reactions of Juvenile Delinquents to Filmed Violence. In Aggression and Anti-Social Behaviour in Childhood and Adolescence. Hersov, L. A., Berger, M., Shaffer, D., Eds. Pp. 59-72. Oxford: Pergamon Press. Bruggen, P. and Pitt-Aikens, T. (x975). Authority as a key factor in adolescent disturbance. British ffournal of 3ledical Psychology, 49, x53-59. Crabtree, L. H. and Cox, J. L. D. (x972). The overthrow of a therapeutic community. lnternatlonal ffournal of Group Psychotherapy, 22, 3x-4x. Hendriekson, W. J. and Holmes, D. J. (x959). Control of behaviour as a crucial factor in intensive psychiatric treatment in an all-adolescent ward. American ffournal of Psychiatry, xx5, 969–73. Holmes, D. J. (x964). The Adolescent in Psychotherapy. Pp. 95 and x5. Boston: Little, Brown & Co. Jones, M. (x968). Beyond the therapeutic community. Social Learning and Social Psychiatry. New York and London: Yale. Jones, Maxwell (x976). Maturation of the Therapeutic Community. p. xoz. Human Sciences Press. /~iiller, Derek (x974). Adolescence Psychology Psychopathology and Psychotherapy. New York: Jason Aronson. Turle, G. C. (x96o). On opening an adolescent unit. ffournal of Medical Science, xo6, I32o–6. ~Vinnicott, D. W. (x969). Adolescent process and the need for personal confrontation. Paediatrics 44. P 75z–756 in “Contemporary Concepts of Adolescent Develop- ment and their Implications for Higher education”. Playing & Reality. Tavistock (x97x). (pp. x38-xSO).

Copyist. Plagiarist. Office clerk. In my spare time I think (it's not illegal yet), write, sing, read, watch, listen, go for walks, and drive my wife-to-be insane.

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