WORK

JEAN R. NAGPIING-CELLO,MD
JUNE 12, 2021
THE RELEVANCE OF WORK FOR EGO
INTEGRITY

• Was recognized as central therapy by those most successful of practitioners

• It can be the most important single activity in the hospital, and it is culturally valued

• To fail at it is to be stigmatized as incompetent.

• Maxwell jones: there seems to be a fundamental human need to make use of mind and body in a
constructive way. To afford a man the opportunity to do this, particularly if in the process he acquires
new skills, would seem to add to self esteem. The factor of accomplishment seems to be particularly
important and appears to give the individual a feeling of control over his environment.
• A man’s occupation will probably predict a greater percentage of his behavior than any other fact that
can be known about him.
• Work as therapy is both old and successful. Chronic schizophrenics have successfully rehabilitated and
even returned to society through programs built around occupational retraining.

• Increased self esteem

• Related to accumulation of new, well differentiated ego sets
• Work provides a milieu in which the elementary social skills can be relearned as a by product.

• It greatly increases the chances of his leaving the hospital and remaining stabilized in the community.

• Involves specific skills carried out in affectively neutral contexts and leading to rewards of esteem and
approval
• It favors the development of relatively strong, well differentiated , and easily mobilized ego sets that are
fairly immune from spreading, both because they are repeatedly reinforced and because their neutrality
minimizes the likelihood of strong affects and unpleasant ego feelings becoming attached to them.
WORK AND SOCIAL COMPETENCE

• It comprehends sufficient socio-emotional skill for the worker to relate to and become a part of the
group of his fellow workers. Both the instrumental and the socio-emotional aspect of work are
important to its therapeutic potential.
• Instrumental success is not entirely sufficient for occupational success. Membership in a working group
is equally important, and a patient must possess communicative and social skills sufficient to attain this
membership

• Division of labor in an industrial society creates a need to posses a relational skills over and above the
level required for technical efficiency
• Work presents opportunities for ego growth to all patients

• For chronic patients who have been desocialized by long stays in a hospital and newly admitted patients
with long histories of occupational inadequacy, it is the treatment of choice
PREPARING THE DESOCIALIZED PATIENT FOR
WORK

• Many ego-damaged people have multiple problems: poor employment histories, difficulties in physical
health, and specially impoverished lives.

• The ability to work and to hold a job is one of the important prerequisites for a stable life outside a
mental hospital.
• 50% of a group discharged patients wanting to work were still unemployed a year after their release
from the hospital.

• Prejudice against the ex-patients is not a sufficient explanation of these figures, and Simon Olshansky, in
a pioneering inquiry into the problems met by a sample of discharged patients obtaining work in the
boston area.
• Those patients who had had good work histories before they went to the hospital were able to find
work quite easily after discharge; those with working records had been erratic or inadequate did not ,
by large, find work.

• Employer is less concerned with mental illness than with an unsatisfactory work history.
• Because of the interdependence of the instrumental and socio-emotional aspects of work, inability to
conform to group norms may be as important a reason for unsatisfactory work history as inefficiency in
the purely technical acceptance by the working group is likely to result in resignation or discharge.
• Norms are developed through interaction, and in a work group they are a distillate of day to day
experience. Seldom written down, they are nevertheless firm.

• It is easy to see why ex-patient must have both kinds of work skills. The schizoid ex-patient is particularly
disadvantaged due to his poorly developed interpretative sets resulting, in turn, in impaired affective
symbolic communication and apparent flatness of affect.
• Patients who have lost their social skills must be rehabilitated both socially and occupationally before
having to face the complexities of the working world.

• First step- creation on the wards of artificial groups, no larger than 12 patients, should be held as
constant in their composition as possible, under the supervision a single psychiatric aid with whom they
should work, eat, and spend their leisure hours.
• The most important product of this kind of program is that if one aide is assigned to small group of
patients, it is very difficult for the aide to keep himself from learning something about them as people in
the strictly human sense

• Begins to see them as people in the role

• These results will be greatly accelerated if the aide understands the object of the group activity and is
able to participate in it with interest and imagination.

• Aide should be taught first the reason for patients deterioration in large hospital is that illness makes it
difficult for them to initiate group relations and the hospital has done nothing to help them.
• The aide should be taught that all patients , even the most psychotic will respond to some degree of
social pressure

• If an aide forms a group and interacts intimately with this group, the norms that emerge will be likely to
conform to his standards of behavior.
• Early group activities can be focused on making the patients aware of one another and encouraging
them to communicate with one another.

• Activities to promote patient’s awareness of one another: group of patients imitate a letter of the
alphabet which has been written on the board by the aide.
• A technique for increasing interactional proficiency is the continuous translation of feelings reactions
into cognitive verbal terms.

• Example: instead of saying “come on pull your weight” “It’s making me and some of the others angry to
see what you are carrying fewer bricks than they are . We think that everybody should carry just about
the same number of brick unless there is real reason why he can’t do it”
• Using this seemed to help patients to learn what is expected to them in group situations,

• We can summarize the process of preparing chronic or inadequate patients for work in three basic rules
• Maximize all aspects of group living
• Maximize the opportunities for social interaction that goes on in the ward
• Learn to talk a new language to the patients in which affective metacommunications are explicit in clear
cognitive terms rather than implicit in the emotional cues.
NETHERNE HOSPITAL- A MODEL PROGRAM

• 1960
• 1457 of 1822 patients were employed
• 51% worked for wages- hospital utilities
• 25% handicrafts
• 22% industrial workshop
• 1.7% outside the hospital
• 5 hours a day
• Required to dress neatly
• Be on time, punch time clock
• Learn general norms of occupational world.
• Part of social rehabilitation program around their free time activities
• In experimental studies at Netherne reported that for certain chronic patients encouragement by staff
group leader resulted in increased production, but this production returned to base when the
stimulation was removed.

• An attempt to develop group cohesiveness and work norms among this group might have reduced the
percentage with irreversible ego damage.
• Nevertheless, irreversible loss of sets may have occurred in some cases of long neglect

• Normal work performance should probably not to be a goal of work programs until at least the
rudiments of the ability to relate to others in a group are learned.
• All work are carried out in pleasant but realistic situations.

• Patient starts with disassembling of telephone relays and the sorting of the parts for use in repairs or as
scraps.

• There is continuing contact with the outside world as trucks arrive with new raw materials and to take
away completed work.
• Most desocialized patients starts here.
• They work slowly and inefficiently, but the work takes place in a social context.

• Eventually most of them earn money and if they improve they are moved to a more difficult task.
• At the other end of the work scale is the printing shop. Patients operate at a level adequate for the
outside world
• It provides complex tasks similar to those that the patients will have to cope with outside.

• These two operations are the ends of the scale of graded tasks to which the patients are carefully fitted.
At the same time as they increase their instrumental skill they are encouraged to undertake more active
social arrangements
• Finally the patients are taught many simple facts about the outside world- which for many have
changed dramatically while they have been in the hospital.

• Netherne tries to equip patient with maximum social and occupational skills and then to see that he is
neither over placed nor under placed.
THANK YOU