SOCIAL RELATIONS AND THERAPEUTIC RELATIONS
This paper is about the
social relations of institutions involved in the care of those diagnosed
as mentally ill. In 1980, the Italian government stopped admissions to
large mental hospitals. And
in England a similar processes has been going on, more slowly, for 30
years. In both countries
there was a belief that these institutions did not do the job they should. In fact, we believed, they damaged the mental health of their
residents. I shall say something of the therapeutic community which has,
over the last 50 years, introduced new ways of thinking about the social
relations in mental health institutions.
At first, we had simplistic
views about those large institutions, and we tried to change them blindly.
For instance, sometimes those hospitals seemed too large, so
therefore we made small institutions.
Sometimes they seemed too far away from the community, so therefore
new ones were in the community. Sometimes
we said they worked with a medical model therefore we must stop labelling
patients, or turn the power relations upside down.
Sometimes, patients seemed to be idle and unproductive so they must
have work to do. And so on.
It was simple just to
reverse any observed features, to create institutions which had the
These ideas are not exactly
wrong. But they lack a deep
understanding of how an institution has its effects on the inmates.
We need to examine the social relations within these institutions
in detail. And also the
social relations of these institutions with the wider society.
We need to understand the social relations that are involved in
health production. And those
social relations of the institution within the wider capitalist society.
I shall start with the
social relations within those old institutions, and draw more
sophisticated conclusions about the good or bad influence on those people
in the institution. In short,
we are dealing with the ethical relations in care institutions.
The mental hospitals were thought to be unethical because they harmed the personalities of the patients. During the 1950s, there were many publications which described the bad effects of mental hospitals (for instance, Barton 1959 Goffman 1961). One of the earliest descriptions of institutionalisation was by Dennis Martin:
the patient has ceased to rebel against, or to question the fitness of his position in a mental hospital; he has made a more or less total surrender to the institution's life... he is co-operative. Here `co-operative' usually implies that the patient does as he is told with a minimum of questioning or opposition. This response on the part of the patient is very different from that true co-operation essential to the success of any treatment, in which the patient strives to understand, and work with, the doctor in his efforts to cure... [the] patient, resigned and co-operative... too passive to present any problem of management, has in the process of necessity lost much of his individuality and initiative" (Martin I955, p. II88-90)
That institution has
distorted the personalities of vulnerable people.
The power relations are clear.
But the patient has lost not just power, he has lost other
significant aspects of himself as well ñ individuality, initiative,
enquiry and self-determination. He
has lost his active self. There
is a stripping away of whole areas of identity from these patients, people
who are already vulnerable to 'loosing their mind'.
There is now a very extensive literature on this, but none is more vividly concise than Main's characterisation of the personalities of the individuals within the mental hospital institution,
only roles of health or illness are on offer; staff to be only healthy, knowledgeable, kind, powerful and active, and patients to be only ill, suffering, ignorant, passive, obedient and grateful. In most hospitals staff are there because they seek to care for others less able than themselves, while the patients hope to find others more able than themselves. The helpful and the helpless meet and put pressures on each other to act not only in realistic, but also fantastic collusion... [The] helpful will unconsciously require others to be helpless while the helpless will require others to be helpful. Staff and patients are thus inevitably to some extent creatures of each other. (Main I975 p. 6I)
Patients lose aspects of
their personalities. And, in
contrast those characteristics accumulate in the identity of the staff.
Personality characteristics are then redistributed and relocated
between patient and staff.
I think this is a vivid
description of unethical relations. But
there is an indication here of the precise psychological problem involved
in the damage. The
patient’s personality stripped of valuable characteristics.
And those characteristics are attributed to, and indeed activated
in, the staff. Eventually
positive harm is done to those who would be helped by a care institution.
And perhaps to the staff as well.
Elsewhere (Hinshelwood 1995, 1997a & b) I described these processes, discovered in the psychoanalytic setting. These are the processes of splitting and projection. Let me illustrate these processes in a brief example from a psychoanalytic patient who was much less ‘ill’ than most patients in hospital:
A patient came to analysis for understanding her problems with men. During the earlier part of the analysis she met and eventually married a man who made no sexual demands on her. She embarked on a virtually celibate marriage. The patient had a senior academic job and was clever and productive in her work. She was very clever and thoughtful in her analysis, often taking away the interpretations of her lack of sexuality, and thinking hard about them between her sessions. The problem was that her hard thinking did not change her problem. Instead of the analysis changing her relation to her body and her feelings, it seemed that the analysis itself was changed into one which was as sterile as her marriage. Much of the task of the analyst was to control his frustration and a strong wish to push the patient into a more emotional awareness.
In this very brief
description we can see two things. Firstly,
the patient’s wish to improve her sexual relationships with men
disappeared quickly; and she institutionalised in marriage a non-sexual
relationship. In a way the
problem was solved. But she
continued with her analysis as if she still consented.
The second thing is that
the wish for the analysis to progress and for her to change, did not in
fact disappear completely. Although
the patient did not want to progress, instead the analyst did want that!
In other words, the patient resisted the work of analysis, whilst
the analyst contained the strong wish for her to change. The consent had
changed its location.
The alternative choices in
the conflict resided not just in different parts of one mind but emerged
in different minds altogether. The
conflict was avoided by putting the separate choices in different
persons’ minds. The intra-psychic conflict was converted into an
interpersonal conflict - a conflict between patient and analyst.
Proper choice by the patient was therefore made impossible.
And therefore, without proper choice, she could no longer consent
to treatment properly.
So, the question: Who is
consenting? makes us consider a very odd situation. The wish for the treatment appears to be the analyst’s,
since he now represents both the patient’s consent, as well as the
analyst’s. The patient
represents a consent for something else - a rather sterile form of
relationship, resembling the marriage.
If the mind is to make
decisions between alternatives, that person must have those alternatives
alongside each other in his own mind.
I claim that, in order for someone to make his own decisions, he
needs to be integrated in his mind in this way - sufficiently integrated
to be at war with himself. But
in this case the patient’s solution to her problem depletes her of the
power to make her decisions properly - and in particular the decision
about what to use the analysis for. Ordinarily,
in a medical practice the doctor would consider finishing the treatment if
the patient is no longer consenting.
But, a psychoanalyst actually does something different.
Instead of debating continuing treatment, he continues treatment by
working upon the processes of splitting and projection.
He achieves a kind of meta-level of treatment ñ treating the
conflict over consent.
This kind of approach,
using the psychoanalytic understanding of splitting and projection enables
us to expose another simplistic judgement.
That is about power relations.
Commonly the place of an expert is regarded with suspicion, since
it can be a powerful one and can render a patient/client in a weak
position. This view is based on the assumption that expertise is power,
and moreover it is bad power. Simplistically,
we then want to curtail the professional’s power.
However, the understanding of my psychoanalytic case shows what bad
power is. The expertise leads
him to become her motivation, and thereby making her consent inadequate.
This is powerful but what makes it bad power, and professionally
unethical, is if he retains that position in which the personalities of
both parties were redistributed ñ as the mental hospitals used to do.
If he works to help the patient to understand that process, and
reverse it, he can be said to practice ethically.
The social relations of
Moving back to the
hospital, we can make a similar distinction.
It is simplistic to say that all admissions to a mental hospital
are necessarily unethical because they deplete the patient.
Of course very often they are unethical because they
institutionalise the relocation of personality characteristics.
This makes the power
relations in a professional practice complex.
It is not true to say that the professional always uses his
expertise benignly -- clearly he can damage his patient.
But, nor can we say it is always unethical.
It can be benign when the ‘lost’ parts are returned to the
patient, often with a gain in personal insight.
After all, expertise means the expert is more experienced than the
patient. The problem arises
when the professional does not return those good personality
characteristics to the patient. In
the latter, unethical situation, the professional accumulates health in
himself, or in the staff group in the hospital.
This is equivalent to a different kind of accumulation: the capital
accumulation of wealth within one class. We,
of course, are speaking of a kind of capital accumulation of health.
Typically, admission to a
psychiatric service ñ whether a mental hospital or a new community based
service ñ occurs in a context of a social crisis. Increasing numbers of people, family, relatives, friends and
neighbours become involved and increasingly anxious. They feel responsible and become more and more intrusive into
the patient. This is a two
way process; the patient is not just a victim of this social crisis. The patient exploits the surrounding group of anxious
well-wishers in order to leave them to carry responsibility for him/her.
The patient is in process of losing his active self even before
admission. He contributes to
splitting it off. Eventually,
the psychiatric service accepts the patient and agrees to take care of
him. His ability, and
capacity, to take care of himself disappears (just as my patient lost her
ability to make a proper decision and give consent for treatment).
But it re-appears in the staff, as their capacity to take care of
the patient. His personal
responsibility is more or less forced onto others.
They, in the form of family, police and eventually the psychiatric
team, through projection and introjection assume the patient’s
self-control and responsibility. They,
the helping professionals become, in a sense, the patient’s lost self
control, and have in this sense accumulated ‘health’.
The patient, equally has lost healthy aspects of himself.
I want now to relate this
to a more political theorising, and to suggest that this redistribution of
a kind of capital is natural enough in a society where there is a class
structure in which one class does accumulate wealth and another class
which accumulate poverty (alienation).
In early capitalism, social relations were arranged around the
alienation of the machine worker in the factory; and the accumulation by
capital with the employer and capitalist.
With the advent of mass production, the identity of the worker
evolved from managing a machine, to becoming equally machine-like and
eventually therefore being replaced by machines ñ factory robots.
With the help of major
tranquillisers psychotic patients are subdued and exhibit so-called
negative symptoms. The
reduction of the patient to a depersonalised reactive entity, does indeed
resemble a machine more than a person (Hinshelwood 1999).
Some time ago, I described
an interesting similarity; that between psychoanalytic descriptions of the
depleted states when splitting and projection takes place, and Marx’s
description alienation in mid-nineteenth century workers (Hinshelwood
1983). For instance, ‘The worker becomes poorer the more wealth he
produces, the more his production increases in power and extent’ (Marx,
I844, pp. 323). In these 1844
Economic and Philosophical Manuscripts, alienation is described as a
depleted psychological state: ‘the object that labour produces, its
product, stands opposed to it as something alien, as a power independent
of the producer’ (Marx, I844, pp. 324).
He talks of a kind of ‘objectification’ of the creativity of
the work as a loss when the product is appropriated by others, and the
worker becomes estranged from something that was his own power and
creative work. The object
'stands opposed', as he says, alien and independent, yet retaining an
identity with the worker. In
other words, products of the person's (worker's) body are felt to have
become separated off, to become located as a characteristic of someone
else. ‘the more powerful
the alien, objective world becomes which he brings into being over and
against himself, the poorer he and his inner world become and the less
they belong to him’ (p. 324). This
is a very accurate description of those processes which psychoanalysts
call splitting and projection and which I have illustrated above.
One person is psychologically depleted whilst others become built
up. Marx is explicit that
these psychological process accompany the economic redistribution of
wealth. Indeed it is not
simply that the economic relations produce the psychological problems,
‘Though private property appears to be the source, the cause of
alienated labour, it is really its consequence’ (p. 332).
So, in a strikingly similar way, Marx described the relocation of
personality characteristics (as well as the relocation of wealth).
We have to understand that
these psychological processes are correlates of the economic relations.
Therefore, the processes in the mental hospital can proceed exactly
as elsewhere in a capitalist society, even though there is no material
production. The production of
the mental hospital is a psychological production and not a material one
ñ it is the production of health. Nevertheless
in a capitalist culture, it bears all the same distortion of social
relations as the social relations of material production.
To some extent, we have to
expect the social relations in all our institutions to reflect those of
the dominant means of production. However,
it does not mean that there is nothing we can do.
Taken seriously our views of these processes behind power, could
contribute alienation to a counter-hegemonic project, as Gramsci would
call it. So, a form of psychiatric service that goes against the typical
depletion in mental health institutions will have a subversive influence,
however small. I claim that
the therapeutic community is such a form of practice; and will now
describe how therapeutic communities have developed in Britain over 50
years. We have moved on from simplistic solutions.
Our current understanding takes account of the crucial unconscious
processes I have concentrated on here.
Like any form of therapy,
if the therapeutic community has any influence on its members, it must do
so in some deeply personal or internal way.
But the therapeutic community, above all other therapies consists
of social relations. In any
therapy, the client is expected to take away inside him/herself new
knowledge and new understanding, especially about himself ñ this is
We might distinguish the
external world of the therapeutic community from the internal world of the
person. Clearly both are
patients, who are sufficiently disturbed to need in-patient care (or even
in a day care setting), will have an internal world which is fragmented
and deeply split apart with inconsistent and conflicted attitudes and
near-psychotic personalities (sometimes borderline and narcissistic
disorders) have a profound disturbance of the internal organisation of
When a number of such
people with internal disorganisation are gathered in one institution, they
are likely to have an impact on the organisation of the institution
itself. Equally, the state of
organisation of the institution will have a reciprocal impact on the
internal state of its members. For
example, poorly organised institutions will risk enhancing the internal
disorganisation of their severely disordered members, who in turn will
tend to dismantle and disturb the organisation of the institution.
From this psychoanalytic point of view, they mutually influence
each other. A depressive
patient with an internal world composed of despair and emptiness can
easily fill those around him, his community, with similar feelings.
And similarly a demoralised community can enhance the internal
despair of its depressed members. However,
a sufficiently well-maintained organisation enables disturbed people to
take into themselves a strong sense of being together in themselves.
This continuum between a state of mind and the state of the
organisation has been described by Jaques (I955).
This reciprocal to-and-fro
process: projection ñ the members projection of their disturbance into
the community around them ñ and introjection - they internalise the state
of organisation of the community ñ has both therapeutic and
The aim of the work in the community is to support this healthy
side within the context of everyday life - the ‘work of the day’
(Kennedy I987, James I987). Thus
the patient and the nurse work together in different roles.
A patient who is regarded as capable of carrying very considerable
degrees of responsibility provided they get enough initial support and the
nurse works ‘alongside’ to offer that support (Barnes, Griffiths, Old
and Wells I997). The work of
the day comprises
quite ordinary activity like cleaning the bedroom, but also significant
responsibility such as helping to cook supper for all, to quite major
responsibilities that include managing a work team (or a leisure activity)
chairing meetings, caring for each others’ well-being and providing a
rota of support for those in crisis.
At the Cassel Hospital, where I worked for four years, whole
families are admitted. Much
effort is devoted by patients to enable the parents to be supported
sufficiently to explore new ways of caring and parenting the children.
Also prominent is the work of preparing practically for separation
- leaving the Hospital eventually, or weekends at home.
All this can feel a very
heavy responsibility; and responsibility is a powerful source of guilt.
A person’s own aggressive phantasy life often leads to the
experience that others were
damaged by himself. Whilst
people do in reality hurt each other, these phantasies tend to be of a
very much greater degree of violence, and truly of a phantasy intensity.
It can then be difficult for more disturbed people to sort out the
reality of what they have done and what they have phantasised.
In terms of the community
practice, responsibility is the key concept.
So many fragmented disturbed people feel their lack of personal
resources has ebbed away with their fragmented selves.
Their ability to put right what they think they may have done seems
to them so inadequate. Much
that is required from them feels an overwhelming task.
In the place of responsibility there looms failure and usually
this scene is an internal one in which a harsh slave-driving conscience
or, super-ego, berates the person, in an internal replica of an external
abuse which the person has usually encountered in the past.
The slightest failings appear as huge ones. The ferocity of their own expectations, coupled with their
sense of depletion in themselves, is an explosive mixture. They break into behaviour which is intolerable for everyone.
Their worst fears of themselves are confirmed.
A life of such circular defeat is frequently ended early and often
brutally. It is no surprise that they split off and project such an
active self, and a responsible self.
So, their work in the
therapeutic community must always be in the context of a supporting
this represents a very concrete external support that the patient
initially needs, and can then eventually internalise.
The result aimed for is an internal support to a sense of personal
Often there is a history
from childhood of unreliable adult supports, frequently abusive adults.
This is internalised as a persecution from within; and many
patients resorts to alarming self-abuse, and horrific self-harm.
Such self-abuse, clearly related to childhood abuse at the hands of
another, is required to be given up in the community.
Instead a substitute is demanded of them:
That is, to talk to others, to talk about their feelings and
desperation. In other words,
the expectation is that turning to new relationships of support
(eventually to be internalised) will gradually take the place of symptoms
and dangerous behaviour.
The community is thus a
network of relationships for support and self-enhancement. All patients are expected to play a part as both supporter
and supported (and this is to some extent true of staff). The ‘work of the day’ thus draws out the maximum
responsibility; but a responsibility which rests on the support that is
available everywhere. If
abuse (as a child) leads to self-abuse as an adult, then a supportive
understanding can lead to a self-support.
Greater confidence and a greater understanding of one’s resources
and limitations can be internalised to combat internalised abuse.
I have described the
therapeutic community to emphasise the redistribution of help in a
therapeutic community. Pressure
is put on alienated people to internalise an active, responsible self
again. This reverses the
psycho-dynamics of alienation in the large mental hospitals.
I claim that it goes beyond the simple solutions I mentioned at the
beginning. It is not a blind
surface change. It takes
account of deep and internal processes too.
I claim this form of psychiatric practice can contribute in a small
way to just that that change in society away from capital accumulation.
The falseness of autonomous
Responsible choice and
action are complex and closely related to the social context ñ including
the relations with care. If
professional expertise is seen as bad power, so clients’ and patients’
personal autonomy and choice must be strengthened.
In truth such strengthening and support is important as I have just
been saying, as it can protect against the bad use of expertise.
But we must question whether the rhetoric of choice in our society
does really strengthen responsibility and choice.
The increasing cultural
emphasis on personal and individualised choice leads to another false
consciousness. This comes from a shift within capitalism itself. Just as the exaggerated redistribution between the helpers
and the helpless is a false consciousness, so is the exaggerated emphasis
on autonomous choice. The
alienation of the first phase of capitalism, has been supplanted.
A person’s depletion has now been filled in by a specific
identity; the identity of the consumer.
S/he is the (supposed) engine of market forces.
This, though, is a false
consciousness, too. Choice is
now fetishised as autonomous choice in what s/he consumes.
In other words, the consumer has been shrunk down to his/her
Moreover, a consumer’s
choice is subverted by the technology of psychology.
The great achievement of psychology has been in advertising.
This combines a need psychology, as exemplified by Freud ñ the
human organism is innately a need-satisfying organism ‘with a subtle
process of giving information, but in a way which actually determines
choices. Advertisers not only
determine which ‘product’ will satisfy the need best, but indeed
create needs which we must satisfy. Thus the
rhetoric of autonomy and choice leads straight back into the same problem
of who in effect makes the choices.
This combination of forces
ñ advertising plus the rhetoric of choice ñ in fact, plays on an aspect
of human beings that is not their autonomy.
It plays on their ability to give up higher functions of the mind
by projecting them into some authoritative other, as I have illustrated.
interpersonally (and therefore in their ‘ensemble of social
relations’) in a manner that is quite at variance from the rhetoric of
autonomy and democracy as proclaimed by liberal democracies.
The psychoanalysis of personality and of its dispersal within the
ensemble of social relations undermines the idea of autonomy that is
dominant in our culture.
So, autonomous choice
reveals itself to be a cobbled-together idea, and its dominance is carried
over into issues of ‘consent’. That
too becomes an aspect of a false consciousness.
Care is reduced to making a choice of alternative ‘products’.
It begins to eliminate the notion of a relationship between persons
whose work together can be ethical or unethical.
Simplistically, the only ethical requirement is that the person has
made an autonomous choice.
In fact, consent for
treatment itself was confused by the processes of splitting and
projection, even with my relatively mildly neurotic patient.
A therapy based in the psychoanalytic setting or in the group and
therapeutic community settings, so visibly shows how a personality can be
dismantled. As my example
showed, no real ethical protection can come from an emphasis on the
original consent to treatment.
But expertise has
potentially a good use as well. That
consists of work on the issues (personal and of course social) which
subvert individual choice ñ those issues which are hidden by the rhetoric
of choice itself. The
psychodynamic revelations suggest that psychoanalysis and the therapeutic
community in particular can in this sense be a subversive practice.
They directly reveal the dynamics which are hidden by the rhetoric. Psychoanalysis achieves a meta-level of work on the
obstructions to consent (personal and social obstructions), and the
therapeutic community engages directly with that active and responsible
self which has so destructively been given up to those destructive forces.
Briefly, I have tried to
follow the psychological aspect of widespread cultural processes in
Western society. I have tried
to deconstruct the notion of power, at least the professional power of the
expert, and to show that it is in danger of being too quickly discredited
as bad, and how the emphasis on autonomy and consumer choice is in danger
of being too quickly credited as all good.
We need to recognise that mental ill-health, professional power,
and autonomous choice are all dialectical notions.
Fitted together one way they form a false consciousness; but in
another way they can point to an ethical professional practice with
Barton, Russell 1959 Insitutional Neurosis. Bristol: Wright.
Goffman, Erving 1961 Asylums. New York: Doubleday.
Hinshelwood, R.D. 1983 Projective identification and Marx's concept of man. International Review of Psycho-Analysis 16: 221-226.
Hinshelwood, R.D. 1995 The social relocation of personal identity, Philosophy, Psychology, Psychiatry 2: 185-204.
Hinshelwood, R.D. 1997a Primitive mental processes: psycho-analysis and the ethics of integration. Philosophy, Psychology, Psychiatry 4: 121-143.
Hinshelwood, R.D. 1997b Therapy or Coercion: Does Psycho-Analysis Differ from Brain-Washing? London: Karnac Books.
Hinshelwood, R.D. 1999 The difficult patient: the role of ‘scientific’ psychiatry in understanding patients with chronic schizophrenia or severe personality disorder. British Journal of Psychiatry 174: 187-190.
Marx, Karl 1844 1844 Economic and Philosophical Manuscripts. London: Penguin .
1. I will not in this paper go into the harm to staff. It is to be found in terms of the stimulus to their omnipotent thinking and the ensuring demands of themselves that lead ultimately to the syndrome of burn-out.
2. This correspondence has been stressed recently by the notion of the ‘organisation in the mind’ (Hirschorn I995, Armstrong I997).
3. Termed this at the Cassel Hospital.
4. Freud’s theory of drives was that in the human organism provided at the outset with certain standard instincts, these are unusually ‘plastic. In other words the human being is particularly capable of changing the object which satisfies his needs ñ or providing himself with substitute satisfactions which seem to do the job as well as the original object. Advertisers have discovered this ‘plasticity’ to be highly useable.
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The Human Nature Review © Ian Pitchford and Robert M. Young - Last updated: 28 May, 2005 02:29 PM