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Beyond excluding discourses in forensic institutions*

Ulrich Kobbe

Abstract

The special hospital's concept of integrativediscoursehas to follow institutional Standards which havebeen drawn up within "institutional psychotherapy ": It involves theorganizational structurcand functioning of a special hospital not only in its external relationshipshut also andmoreimportantlywithrcgardto its intrainstitutional comprehension, i.e. thediscursive development of

- non-hierarchical cooperative management structures and also basically dcmocratic and transparent decision-making processes. This structural view of the hospital policy Claims that the individuals of a collective cannot be treated without a treatmcnt of this collective äs a whole with all its Subsystems and com- plementary relationships.

Key words and phrases

institutional Standards - special hospitals - integrativc discourse-institutional psychotherapy

- psychiatric reform

Zusammenfassung

Jenseits ausschließender Diskurse in forensischen Institutionen

DasKonzept eines integrativen Diskurses der Maßregelvollzugseinrichtung muß institutionellen Standards folgen, wie sie innerhalb der französischen "institutionellenPsychotherapie" ent- wickelt wurden: Dies bedeutet, daß die organisatorischeStruktur und die Abläufeeincs Maß- regelvollzugskrankenhauses nicht nur hinsichtlich seiner Außenbeziehungen, sondern zu- gleich und wesentlicher mit Blick auf ihre intrainstitutionellen Beziehungen untersucht werden müssen. Gefordert wird die diskursiveEntwicklung nicht-hierarchischer kooperativer Leitungsstrukturenund zugleich basisdemokratischer und transparenter Entscheidungsprozesse. Diese strukturalistische Sicht der Krankenhauspolitik beinhaltet, daß die Individuen eines Kollektivs nicht behandelt werden können, ohne das Kollektivals Ganzes mit all seinen Sub- systemen und komplementären Beziehungen mitzubehandeln.

Schlüsselwörter

institutionelleStandards -Maßregelvollzug- integrativcrDiskurs- institutionelle Psychotherapie

- Psychiatriereform

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Resume

Au-delä des discours excluants dans les institutions de psychiatrie legale

Le concept d'un discour integratif des C.H.S. de la psychiatrie legale doit reprendre les Standards developpes par la «Psychotherapie institutionnelle» en France: c.ä.d. que la structureet les fonctions du C. H. S. judiciaire ne concernent pas seu lement les relations inter- institutionnelles mais encore plus eminent sä comprehesion intrainstitutionnelle. Ceci de- mande le developpement d'un discour permettant

- des structures de direction non-hierarchisees et cooperatives ainsi que des processus decisifs democratiques et transparents.

la politiquehospitaliere impliqueque les individus d'un collectif

Cette vue structuralistede

nepeuvent pas etre traites sans un traitement du collectif dans sä totaliteavec toutes ses sous- systemes et relations complementaires.

Mots-cle

Standard institutionnel - psychiatrie legale- discour integratif- Psychotherapie institutionnelle

- reforme

psychiatrique

Introduction:

The principle of mutual exclusions

Analysis of the approaches to psychiatrie reform in West Germany in- dicates that there are typical interinstitutional developments and com- plementary intrainstitutional trends within the field of tbrensic psychiatry:

The interinstitutional policy of total institutions can be characterised in that it functions on principles of excluding or defensive discourse. The spe- cialization of psycliiatric institutions, and in particular here of special hospitals, tends to promote a negating form of institutional discourse which excludes all contents, patients, demands and institutions which do not seem to be absolutely congraent with the implicit and/or overt (psycho)therapeutic concept.

hl concrete terms it is possible to describe the policies of both general psychiatrie hospitals and penal institutions äs that they orten attempt to push the responsibility for unruly, difficult or troublesome patients or inmates onto others - a practice on which i.a. Schumann (1989, 5) reported. This means that these institutions function in the same or analogously to the transfer dynamics of their patients who project the responsibility or guilt away from themselves.

This development

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is without doubt also to be seen against the fact that

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general psychiatrie hospitals Claim certain progressive developments in which chronic or longterm patients are a disturbance. Parallel to this development, a trend is to be observed in the (in the meantime) better equipped tbrensic psychiatrie clinics which culminates in a discussion on the "wrong patients". Although tliis leads on the one hand to an urgently needed discussion about false diagnoses and incorrect committals, there is

a danger on the other liand of the ill criminals and the criminally ill being

played off against one another. This type of exclusion by specialization, however, implies tliat the particular institution gives a negative definition of what it is not able to do - a procure which inust be characterized in the organizational dynamism äs revaluation of the narcissistic defence.

On tlüs point, Duncker (1993b, 208) underlines programmatically tliat the institution must adapt itself to the demands of the committed patients with

a more integrative approach, since criminality and criminal development

cannot be isolated from the development of disorder and personality. The corrective institutions should, not least due to the lack of the sociotherapeutic institution, offer a therapy which meets the needs of both parts in the

personality of the patient.

The dialectic of individual and collective

Both the intrainstitutional and interinstitutionalexclusion mechanisms are the historic result of a pragmatic and order-related institutional policy lacking any elaborated organizational theory or concrete therapeutic reasoning. On the one hand, a normalizing custodial discourse is to be

found in the old institutions, whilst on the other hand there is a risk of new psychological discourses in reform institutions with trends towards stractural or latent psychotherapeutic totalization (Kobbe 1992, 58-60; Feuling 1988, 43). Furthermore there is undoubtedly the risk tliat even "psychoanalysis äs a fundamentally self-reflective process aimed at

during the course of its institutionalization" at the same

emancipation

time tends rather to reproduce "hierarchy and increasing downward

interdiction" (Fabricius 1990, 338).

Particularly in order to prevent such negative dialectic reversals of the reform it appears to us, beyond the use of an "emancipatory recogm'tion theory" (Habermas) obliged meta-theory, to be essential furthennore tliat the admitted patients cannot be treated äs individuals of a collective without the institution itself äs a whole being queried and treated äs a collectivewith

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all its Subsystems and complementary relationships.

Such collective develop a common language (Oury 1991, 70) so that it is

possible to speak of them äs relatively closed Systems of meanings. Of significance here is the fact that corrective institutions are thus also "imaginary institutions" which cannot be reduced to functionality but "in their continued existence and in their effects" follow their own logic and dynamism "going beyond their task, their 'objectives' and their 'justi- fications'" (Castoriadis 1975), since it is exactly this collective System of meaning which is passed on by language which links the "ensemble transfini" of the institutions (Oury) with the groups and individuals so that from the point of view of organizational psychology, institutions cannot be described outside the structure and dialectic of the language (Tosquelles

1976,

14).

This description of the Institution regards it primarily from the Standpoint of the subject (Hofmann 1983, 30) and understands this 'sub-ject' äs an element subordinate to the System which is not a passive object but an active element in a structure of exchange. Individuality is understood äs the result of this interaction dynamism so that an institution oriented towards this aim cannot fimction without friction, without conflict and without wishes, äs the individual would find no place in such a technical apparatus. There is far more a need for institutional possibilities, i.e. for gaps which the in- dividual can fill or can create for himself. As far äs the dynamic dialectic of the individual and the collective is concerned, the institution must thus be understood äs a social structure organized around group processes with changing degrees of structuring (Kernberg 1971) which confronts the individual with participation in an experimental setting (Kobb6 1992; Duncker 1993a) which strengthens the activation of primitive object relationships to varying degrees.

At this point, a brief comment should be made on other approaches to institutional organization: The idea of a therapeutic Communityis frequently proclaimed in widely differing forms also for forensic institutions, but seldom justifiably and far too often unjustifiably claimed (Nedopil & Ottermann 1991). Furthermore it is often not recognized on the one band that the idea of the therapeutic Communitycan only have significance under the dynamic aspect of temporal development phases to give form to the concept in the institution, and cannot be either a final actual state or a desired state, nor a rigid institutional structure. On the other hand, the idea

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of the therapeutic Community is additionally instrumentally misconstrued

or misused (Bopp 1980, 38) tliat it sliould in concept serve äs an instrument

for "deprisonification" (Rasch 1977, 47-50) or must serve äs apretext for keeping strings on patients. It is therefore liardly surprising that according to a survey by Wittling (1980, 251) no effective results of this rather idealistic concept can yet be presented, particularly äs it tends i.a. to blur to a certain extent the undeniable differences between the staff and the

patients.

Differences which make a difference

Particularly here we underline the fact tliat differences must not be denied and tliat difference äs defined by Lyotard (1983) and/or Habermas (1992) must be acknowledged, äs only the definition of the difference and by constant work on and with the particular differences is it possible to form

an identity - both with respect to the individual in the institutional System and to the Overall System of the institution. This automatically means tliat

a differentiation between the individual and the collective is made and the principle of the psychotherapy in and with the collective is emphasized.

As you can see, we adopt a dialectic standpoint which demands in any case

a further evaluation of the fundamental theoretical relationslüps. As lias

already been indicated the conceptualization of tlüs integrative versus excluding discourse took place within the field of institutional psychotherapy (Oury 1977) to which further reference is also made here. The understanding of institutionalpsychotherapy is based on a certain experience of psychoana- lysis and on a pliilosophy of organizational psychology which examines and dictates the structure and functioning of the institutionwith respect to both its external (interinstitutional) relationslüps and to its internal (intrain-

stitutional) activities.

Particularly in special clinics, the specification of minimum conditions wlüch an institution has to satisfy in order to be able to treat patients is of major significance. It is - according to Oury (1991, 72-76) - essential tliat they do not crush the wishes of the subjects, particularly äs within the con- ventional institutions, alienating treatment and living conditions exist together with totally stereotype relationslüps in the form of rivalry, aggressivity or behaviour tending towards paranoia. Such involvements unavoidably result in monotonies wlüch lead üito the deadend of the "rigid practice" - Sartre would describe these äs "pratico-inert" situations. The

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ftinctioning of an Institution is consequently not possible without constant theoretical evaluation which - according to Buchinger (1993, 67) - can only develop a constructive effect when it is compulsory and institutionalized within the clinic and, äs organizational self-reflection, is clearly distinguished from psychoanalytical self-reflection.

The functioning of the institution can and must therefore only be under- stood against the background of the Systems which make up the collective. These Systems can be described in concrete terms äs strategy, information, decision and psychotherapy Conferences which represent institutional points of reference for the creation of the collective System of meanings and develop "complementary relationships" between one another. The term "complementarity" appears to offer a good description of the

dynamics of institutional groups äs the institutional fabric consists not of

a simple network of functional Systems but of a symbolically and

imaginarily underlaid ensemble of structured mechanisms which appear to obey the laws of a "changing Gestalt".

The policy of the institutional

psychotherapy

One of the basic rules of institutional psychotherapy is the permanent battle against the small kingdoms or similarly isolated places in which pathogenic Systems grow rampantly, particularly under enclosed conditions, and which can become a source of collective hysteria (Oury 1991, 72-73). These initially self-centred Subsystems must be incorporated by different ways and means into the development and dynamism of the collective äs a whole. But it is exactly this battle against local rigidity, however, which often results in strains and conflicts to which the staff react according to their personal balance and flexibility and their ability to give up traditional roles.

The institutional organization of therapeutic work can consequently not be separated from a generalized continuous organizational psychological view if we wish to avoid the absurd climate of many institutions with all

its imaginary demands, rivalries and artefacts. Under the assumption that

the individuals of a collective cannot be treated without treating the collective äs a whole, this principle demands a series of basic institutional conditions.

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It requires:

- differentiated discussions,

- a graduated delegation and distribution of responsibilities,

- a wide availability of additional activities, and

- accompaniment by suitable supervision which, in turn, ensures tliat the institutional activities are governed by reflective interpretation and not by sanctions äs an expression of hierarchical power. What makes the therapeutic work in institutions so special is thus in

particular the joint confrontation of patient and therapist with this symbolic institutional grammar, their growing consciousness and common cliange,

äs far äs this is possible under the given conditions (Wulff 1971, 215).

And it is exactly tlüs that involves, by analogy, also the management of forensic institutions. The institution must therefore not be rigid or operate according to a predetermined pattern; it must be queried and restructured

in

line with the Situation and development of the individual. Particularly

in

view of the excluding discourse, this means tliat each group or institution

runs the risk of limiting the exchange with other groups, of placing itself

in a "uniform" and of negatively criticizing other institutions, areas of

treatment or fonns of therapy. Institutional psychotherapyisconsequently

oriented to the recognition of the desirable difference and to the collective

of the patients and staff which maintains a networkof relationships through

open, transparent and comprehensive exchange which must not function

under limitations or covertly.

The principle of openness for clianging and developing wishes implies an organizational pattera characterized by a polycentricnetwork of decision- making organs with limited responsibilities which, however, presupposes

a wide and open flow of information so tliat "tlüs complex institutional

machinery does not run chaotically idle" (Hofmann 1983, 38). Against tlüs background, the institution can and must declare its responsibility for all psychically ill offenders and must, on the other hand both accept inmates from prison and reject harmless but troublesome patients from the general psycliiatry. But not only this: Furtliennore, from tlüs understanding the üistitution must demand the responsibility of the general psycliiatry for certain forensic patients and must try to implement this in the sense of local

treatment principles.

A precondition for such extramural demands, liowever, is a removal of

intramural exclusion practices, disparaging meclianisms, principles of

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arbitrariness. This is aimed at the narcissism of the institution already described through which the collective defence processes and their occurrence are determined: The lack of differentiation in the psychiatric institutions lead to paranoid projections in which the other institutions are seen äs persecuting omnipotent "others", insufficient distinctions are made between psychodynamism and institutional dynamism so that i.a. support is given to predominant trends towards symbiotic team relationships. But exactly these dysrunctional defence mechanisms rnust be reconsidered both with respect to the individual and to the collective and given up in favour of conceptionally balanced, integrative worksharing, responsible and self-reflective methods of relationships and treatment in the institution itself.

The necessity of a meta-theory

The comprehensiveness of this conceptual presentation is given at this point for two reasons: On the one liand, even the medical and psychological specialists in forensic psychiatry are generally poorly equipped for the confrontation of institutional and organizational problems, and their training has often given them defence Systems which they allow to seize in recognized roles and which easily become "rusty" even within the collective (Oury 1991, 70). On the other band, psychodynamically trained doctors and psychologists in particular make two mistakes in institutions which Buclünger (1993) recently pointed out in a long article: They tend to confüse psychodyamism and institutional dynamism äs well äs regarding the organized Professional groups in the institutions äs one family in which motivating encouragement and emotionalrelief canbe found. Inorder to overcome suchmisconceptions,

Buchinger pleads for a strict Separation of the two very different levels of reality and describes institutions äs "non-trivial machines" which exhibit

a high degree of complexity and pursue an objective logic which cannot be

adequately described either psychodynamically or familialistically. It is more important to learn to think and act in structures and not only in persons

and relationships,

i.e. to also train and establish an organizational self-

reflection.

It is particularly in this respect tliat the approach of institutional psychotherapy

appears to us to be important in which the concrete individual is abstracted and the patient is regarded e.g. äs an individual fbllowing a vector. Particularly äs the desire of the legally committed patient very often masks

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bis real desire, this "therapeutic vector" must be seen äs a desire for treat- ment or for relationship since particularly in forensic psychiatry, a defen- sive battle for independence by the individual takes place against repressive conditions which threatens to supersede the original and genuine desire and in some cases is no longer identified äs an artetact in its legalization. But it is exactly this genuine desire of the patient which justit'ies the existence of the treatment collective in forensic psychiatry beyond the confinement order. This means tliat it is institutionally a question of justifying both ones own existence and the existence of the patient and of the institution, which is by no means selfexplanatory, äs a corrective (special) clinic is more frequently a place of confinement and exclusion tlian a place of psy- chotherapeutic overtness.

Intrainstitutional

discourse

in Eickelborn

hi order to give more concrete form to these comments so rar it must be illustrateted by some of the basic principles of the current Situation and policy within the Westphalian Centre for Forensic Psychiatry Lippstadt. For something more tlian 6 months now, the institution has been in a state of tlux insofar äs the prevalent myth that "we are all one big family" has been demystified and a new understanding of institutional procedures and (infra)structures lias been introduced. This lias meant in particular that the decisions on relaxation of the controls and 011 approvals or non-approvals of other kinds has now been delegated äs competences for decision-making and responsibility back to the departmental heads. Tlüs means we are now in a deliberately induced process of forced democratization of the institution.

This naturally results in conflicts with respect to communication,

demarcation, roles and competences äs the delegation

must, at the same time, also have a considerable effect on the processes of decision-making within the treatment areas. This also involves the fact already described above that an institution must, from the point of view of organizational psychology, have different levels or hierarchies of decision- taking, tliat contents cannot be discussed at will with all the staff or patients

and that certain contents have their clearly defined place.

of responsibility

Such principles presuppose the institutionalresistance to the temptation of exercising hierarchical power by monopolization of infonnation, by direct instructions or by sanctioning controls, i.e. they require the assurance of

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adequäte iüfonnation such äs the gaarantee of cooperative management styies within the treatment areas. A precondition for tliis is the prior establishmett of committees at the different levels in whichthe "intimidation of destruction (even the own) 'pseudoaprioris'" which in some cases only comes to Light directly in practice is not only made possible but is even assured in order to prevent the "instrumentalization of the practician for kaowledge-dictating interests" which are not seldom in reform projects (Niemeyer 1987, 210).

On the basis of this we are currently developing, in particular, a differentiated, functional and in no way exclusively professionai ßroup- specific distribution of tasks and competences, i.e. we are currently at a stage in which nurses, trainers, psychologists, social workers and doctors are discussing the division of work, the definitions of roles and demarcations and the forms of interdisciplinary cooperation and communication. Finally the changes in the institutional assignment of roles and competences for actions mean that a competent and cooperative management must both permit and be responsible for tliis complex interdisciplinary development

- a task which can involve equally the possibilities of an arbitrary exercise of power and the timidity for accepting responsibility.

This means that this process of disposing with traditional and the organizational development of new methods of work in particular requires

a reflection process, i.e.

- systematic accompaniment and supervision,

- the possibility of constructive criticism and self-criticism,

- the institutional patience and support for difficult renewal processes in part areas of the Institution and

- guaranteed Information on the content of the instructions and institutional boundary conditions and changes.

Annotations

*Revised report presented during a regional Conference of the IALMH at Munich (Kobbe

1993)

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SCHUMANN,

Anschrift des

Verfassers

Dipl.-Psych. U. Kobbe Westf. Zentrum für Forensische PsychiatrieLippstadt

Eickclbornstr.21

D-59556 Lippstadt

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