[The patient] related to me in a passive, submissive, dependent manner until he began to pay me; with the switch to my private office, he began to express some hostile and competitive feelings, although rather fearfully and obliquely. This behavior culminated in his burning my new table with his cigarette at the end of an hour. He became quite panicky and offered to pay for the damage. Although 1 was aware that the accident was in reality a symptomatic act, I was unable to deal with the situation on the spot (I was then just starting to deal with the same problems in my own analysis); I told the patient not to worry about the cigarette bum. He never came back.1
In this candid vignette, Gedo captures the relationship between an aggressive act and the patient's need to make reparation; if this need is not met by holding the patient responsible, the loss not only of therapeutic effect but also of the patient to therapy may result. Such responsibility and its implications are the subjects of this article.
We wish to describe the institution of a policy, on an inpatient ward at the Massachusetts Mental Health Center (M.M.H.C.), whereby patients would be charged, in an accounting separate from the hospital bill, for the windows they had broken. We suggest that, while it is necessary to emphasize the effectual origin of such acts by encouraging the patients to put their feelings into words instead of breaking things, it is critical in the management of window breaking as a symptom (and property destruction in general) to make the act one for which the patient is responsible. The therapeutic rationale is that the patient should not be automatically branded as irresponsible; rather, the patient should be offered, as an adult, the chance to prove that he or she is responsible by paying for damage to property. We will examine the clinical-dynamic issues around two sample case illustrations in order to introduce discussion of a spectrum of fiscal and ethical issues that arise.
Case #1. A middle-aged man suffered from chronic schizophrenia. Aside from a short-lived delinquency phase in childhood and a single ineffectual suicide gesture, the history revealed no tendency toward acting-out behavior. During hospitalization for psychotic decompensation, the patient, to the surprise of everyone, broke four window panes by punching them, receiving minor cuts on the fingers. Since it was his therapist's style to stress the central importance of individual responsibility, the patient was presented with a bill for the damage at the instigation of the therapist. Patient and therapist discussed the meaning of the act, the bill, and the experience of paying. It was the therapist's impression that charging for the breakage, as an event quite consistent with the long-term approach of responsibility, was not experienced as a particularly unusual occurrence. The patient acknowledged some satisfaction at managing the transaction "like an adult."
In this example, charging for the breakage was entirely consistent with the therapist's approach and, consequently, with the patient's expectations. In addition, charging permitted the staff to present a unified and consistent front to the patient as regards accountability. Such unification prevented a commonly encountered potential split between the staff (who have to deal at first hand with the disruptive behavior) and the therapist (who might otherwise be viewed as the patient's "advocate," tending to "excuse" the patient's actions instead of holding him accountable).
The second illustration, presented in more detail, illustrates charging for breakage as a deviation from previous approaches, in a manner that occasioned a turning point in the treatment.
Case #2. A middle-aged woman had a long and tumultuous history of chronic illness that included window breaking. Upon transfer to M. M. H. C, she entered a day hospital unit and was encouraged to live in an apartment. However, in the day hospital she would either come in and fly into rages of destruction and window breaking or not appear and would take drug overdoses at home. Following a windowbreaking rampage resulting in a severe self-induced laceration, she was transferred to an inpatient unit, where she was restricted to the ward while her rages continued. After her second episode of window breaking on the inpatient unit, she was presented with a bill for property destruction. Thereupon ensued a two-month period of negotiation with her therapistadministrator and the head nurse over her responsibility to pay for the breakage. During this period she stubbornly resisted payment, but no further window breaking took place. She then paid the bill in two installments, and in the one year since there has been no further window breaking - a phenomenon apparently unprecedented since the time of her first hospitalization. There has been only one further incident of property destruction: the breaking of some items of state property when the head nurse (who had presented the original bill) ivas leaving the service. The succeeding head nurse presented the patient with a second bill for the damaged property, which the patient paid after a three-week struggle. Nine months after the payment of this bill, there have been no further acts of property destruction, assault, or selfwounding. The patient has been on leave from the hospital in her apartment, maintains contact with her therapist, and, with the exception of occasional threats of an overdose, appears to her therapist and the hospital staff to be considerably improved and more responsible with her money and her life.
A few weeks after the above sequence of events, a patient from another ward in the hospital was overheard asking a patient on the subject ward, "Is this the ward where they make you pay if you break windows?" This incident, showing the hospital grapevine in action, was followed by a several-month period during which not one window was broken.
At certain hospitals, windows are never broken. The reasons vary: shatter-proof glass, screened-in windows, the threat of instant transfer to a more restrictive facility, perhaps even a form of ward "culture" to the effect that this is "not done." At the M.M.H.C. the windows on the inpatient services are constituted of innumerable little panes of ordinary glass, each suitable in size to be broken with a single blow of the fist.
In most cases, window breakage occurs from the actions of two classes of patients: patients with borderline personality organization and schizophrenic patients in panic or rage. With borderlines, window breaking is not uncommonly accompanied by wrist slashing, either as a simultaneous concomitant of the blow itself or as a separate procedure performed with the broken glass shards thus made available.
A number of reports2"* hypothesize that wrist slashing in certain patients serves to release the accumulated tension accompanying, and perhaps producing, a dissociated state; the selfinjury appears to terminate the altered state of consciousness through a variety of postulated mechanisms. It would not be implausible that the window breaking itself might perform a similar function in a similar state of altered consciousness. Certainly this act can be related to dysphoric affects - e.g., feelings of loss or rejections - for which the patient may seek temporary relief in the discharge of anger and destructive impulses. We have also observed that it can be a deeply ingrained habit pattern providing discharge of unverbalized frustration of a specific or nonspecific, acute or chronic nature.
Until recently the management of this symptom on the subject ward had been highly idiosyncratic, determined by clinical considerations (diagnosis, mental status at time) leading to administrative responses (e.g., increase of medications, decrease of privileges, even administrative discharge if so indicated). Individual accountability for breakage as damage to property requiring financial recompense was uniformly not a part of the standard management of the symptom. It was, however, extremely common to hear it murmured at staff meetings: "That patient should be made to pay for what he did." But until the institution of the policy of billing the patient, as described in the case examples, this idea was not usually translated into action. In fact, the idea of billing was vaguely equated with expressions of possible countertransference anger towards the "irresponsible, acting-out patient."
It is not at all obvious why this should be so. One might speculate that hospitalized patients have a built-in insanity defense, as it were, exempting them from accountability. This view, however, runs counter to the modern trend of having patients, even inpatients, assume more responsibility for themselves than at other points in the history of hospital psychiatry. Perhaps a more forceful yet subtle factor is a fiscal one: since a large fraction of the patient population in the hospital is supported by the state or by some state agency, even beyond the cost of the hospitalization itself, it may seem no more appropriate to charge for broken windows than for use of soap and paper towels - items that are included in the "base cost." At worst, charging for windows may seem like extorting from the poor, "taking from those that have not even that which they have."
Although M.M.H.C. is the major teaching program in psychiatry for Harvard Medical School, it is also a state hospital subject to the fiscal uncertainties of state budgeting. It is one of the realities of a state system that while many are called to pay their bills, few have chosen to do so. State bureaucracies breed the viewpoint in both patients and staff that "the state will take care of it." On numerous occasions those very words have been used not only as an expression of the patient's wish but also as an answer to the patient who worries about the cost of his hospital care.
While our case examples appear to make a convincing argument for the benefits accruing from charging on a regular basis for any property damage done by the patient, we are primarily interested in the opportunity to explore questions of theoretical, practical, and ethical significance surrounding the concept of charging for windows broken.
In another context, Main notes that "the sufferer who frustrates a keen therapist by failing to improve is always in danger of meeting primitive human behavior disguised as treatment."5 In light of this caveat (since it has not been customary to charge patients for breaking windows), we must ask if charging them is a form of acting out by treatment personnel of their own anger, counterentitlement, and retaliatory impulses. In short, is it a form of primitive behavior disguised as treatment?
Moreover, covert envy may enter in, as with other forms of acting out. In speaking of borderline patients, Day has noted that one difficulty in the countertransference with these patients is the fact that they are "getting away with the murder we would like to get away with."6
Partial safeguards against these pitfalls are consultation and supervision from senior staff, group discussion, and consensual validation. Such procedures, of course, do not ensure against the well-rationalized phenomenon described by Wesselius7 as milieu countertransference, wherein the patient recapitulates, with staff, the pattern of pathogenic relationships with primary objects. It might also be argued, however, that the direct accountability of payment may break the patient's repeated pattern of nonaccountability for destructive behavior, as in the second case described.
In the course of exploring this area, predictably, there commonly occurs the mobilization of useful and relevant material. For example, after the second patient had been billed and had paid for her broken windows, she revealed to her therapist that the last time she had seen her sister and mother she had broken a window in her sister's home but had never dared return to face their anger. In another session she told her therapist that she felt that the state "should pay for me" because "my family are taxpayers and they didn't care about me."
As regards group countertransference, billing served an important milieu purpose: channeling of staff anger at the "unrepentant" patient into a constructive response in the service of accountability. This response tends to decrease the acting out of group hostility towards the patient, who has "paid the dues."
One objection not fully answered by the foregoing is that of arbitrariness in separating from the total picture one piece of behavior (window breaking) to be treated in a specific way (charging). To examine this issue, we must consider charging in the context of state support.
For the patient on state support, the message conveyed by charging for window breaking is that breakage will be the patient's individual fiscal responsibility; the state will "take care of" the rest of the costs. There is an inherent paradox here. State support, in the form of inpatient hospitalization, is understood to replace individual responsibility in areas that would ordinarily require money from the individual (e.g., food, clothing, and shelter). Concomitant with this replacement there occurs an implicit transfer of fiscal responsibility from the individual to the state taxpayers at large. In contrast, charging for window breaking blurs the effect of this transfer of fiscal responsibility: one part of the bill is handed, as it were, to the taxpayers and another to the patient. In sum, the implications of charging the patient in part run counter to the implications inherent in complete state support of the patient. It must be acknowledged, however, that such an approach is very much in keeping with present trends toward fostering in the patient more independence and responsible acceptance of "real life."
The issue of responsibility stands at the core of treatment of the psychiatric patient. Hospitalization may be considered a transient "regency" of responsibility until the patient is able to "resume the throne." Clinical administration in the hospital (restrictions, privileges, passes, etc.) might further be viewed as a graduated, behaviorally based retraining in responsibility directed towards eventual discharge. In this context, charging is quite consistent with the general responsibility-fostering thrust of treatment as a whole. While there are a variety of methods of invoking accountability in the treatment of psychiatric patients, there are unique advantages to the use of money.
Window breaking differs from other forms of acting out or acting up in that - unlike making noise, assaulting staff, or inciting a riot - it represents damage against property of a quantifiable sort; that is, repair of the broken window has an objective, specific cost on the current market. Other forms of response to window breaking, including "working it off" (performing some constructive chore in recompense), lack both the precision and objectivity of the cost. In these respects, the money resembles time, also a precise and objective phenomenon, to which both patient and staffare subject. Like time, cost is an incorruptible reality, free from contamination by countertransference and ambiguities of intent.
The source of the money that is used to pay for windows broken clearly becomes an important variable. To illustrate this point, one need only consider the different significances of money derived from savings, job earnings, theft, or prostitution or even from another source of state support, such as Social Security income! In order to prevent the therapeutic intent of charging the patient from being vitiated by having him use money from inappropriate sources, considerations similar to those applicable to fee setting in private practice might suitably be invoked.
In some families, children are "charged" by parents for property damage as part of the normal course of things. While we know that the families of our patients negotiate with each other - for the most part in ways that are arbitrary, inconsistent, and extreme - the role played by this family custom in influencing future relationships between patient, property, and money remains an unanswered question (and an area for future investigation).
As each cell contains chromosomal information about the entire organism, so each interaction between patient and environment contains elements of the patient's whole range of relationships to self and world. The brief case vignettes remind us how transference, countertransference, reality, dynamics of the milieu, the repetition compulsion, and therapeutic consistency fuse in each bit of behavior in revealing and instructive ways, could we but anatomize them. The issue of charging for window breaking has served us as the point from which to view elements of the clinical/economic matrix within which every patient must find a place. Our purpose has been not to recommend a specific mode of intervention or to demonstrate startling therapeutic results with a "new" technique but to elaborate the ways in which money resonates with behavioral issues in the setting of the inpatient ward - a resonance undeservedly underestimated in the literature on ward dynamics, responsibility, and acting out.
The authors acknowledge their indebtedness to Pamela Ryan, R.N., and Susan Freedman, R.N., for their aid as head nurses in the subject cases.
1. Gedo, J. Some difficulties of psychotherapeutic practice. Arch. Gen. Psychiatry 1 (1959), 21-22.
2. Pao, P. N. The syndrome of delicate self-cutting. Br. J. Med. Psychol. 42 (1969), 195-206.
3. Grunebaum, H. U., and Klerman, G. L. Wrist slashing. Am. J. Psychiatry 124 (1967), 527-534.
4. Graff, H.. and Mallín. R. The syndrome of the wrist cutter. Am. J. Psychiatry, 124 (1967). 36-42.
5. Main, T. F. The ailment. Sr. J. Med. Psychol. 30(1957), 129-145.
6. Day, M. Personal communication.
7. Wesselius. L. F. Countertransference in milieu treatment. Arch. Gen. Psychiatry 18 (968), 47-52.