CLINICAL AND THERAPY

Mentals Hospitals and Therapeutic Communities. Between the Total Institution and Communitary Illusions

Mario Di Fiorino, Manuela Garuglieri *
* Psychiatric Department. General Hospital, Viareggio, Italy

Mentals Hospitals and Therapeutic Communities. Between the Total Institution and Communitary Illusions
presented at the Ukranian-Italian Meeting "Psychopharmacotherapy and Psychotherapy", Lviv, 9-11 October 1998

Summary.

While in the past and actually, the jatrogenic effects of mental hospital have been overvalued (Manfred Bleuler1, Luc Ciompi2) , the research has not still investigated enough the same effects if producted in therapeutic communities.

The Goffman3and Lifton4's classical conceptualizations of Total Institution and of milieu control will be discussed. The chronic course of the relationship between the inpatient and his illness seems to constitute the common end-pathway of several etiopatogenetic factors .

The Authors focuse the psychological reactions following the failure of expectation for the community goals: Idealization, Reaffirmation, Burn-out and Disillusion (Disenchantment).

The Total Institution.

In the research about jatrogenic effect of the group and of the institution an important place is occupied by "Asylums. Essay on the social situation of mental patients and other inmates", written by Erving Goffman in 1961 3.

This book has rappresented a livre de chevet for the antipsichiatrists and has played a role also in the cultural roots of Italian psychiatric reform law 5.

It is noteworthy that Goffman refers the literature about brainwashing 6 7 8 in order to describe the process of change in the inmates. . For example the arrangement for the elimination of urine and feces in the chinese concentration camps for Prisoners of War, described by Hinkle and Wolff.7(1956).

The "sloap jar" that is usually present in Russian cell is often absent in China. It is a Chinese custom to allow defecation and urination only at one or two specified times each day - usually in the morning after breakfast. The prisoner is hustled from his cell by a guard, doubletimed down a corridor, and given approximately two minutes to squat over an open Chinese latrin and attend to all his wants. The haste and the public scrutiny are especially difficult for women to tolerate. If the prisoners cannot complete their action in about two minutes, they are abruptly dragged away and back to their cells.

At some stage in his imprisonment the prisoner can expect to find himself placed in a cell with about eight other prisoners. If he was initially isolated and interrogated, this may be shortly after his first "confession" is accepted; but many prisoners are placed in group cells from the outset of their imprisonment. The cell is usually barren, and scarcely large enough to hold the group it contains. There may be a sleeping platform, but all of prisoners sleep on the floor; and when all lie down, every inch of floor may be taken up. The atmosphere is extremely intimate. Privacy is entirely nonexistent.

Goffmann describes "conversion" among the other modes of adaptation to the setting of a total institution.

The inmate appears to take over the official or staff view of himself and tries to act out the role of the perfect inmate...

The convert takes a more disciplinated, moralistic, monochromatic line, presenting himself as someone whose institutional enthusiasm is always at the disposal of the staff...

In most total institutions, most inmates take the tack of what some of them call "playing it cool". This involves a somewhat opportunistic combination of secondary adjustments, conversion, colonization, and loyalty to the inmate group, so that the inmate will have a maximum chance, in the particular circumstances, of eventually getting out physically and psychologically undamaged.

Goffman writes that brainwashingcamps and progressive mental hospitals "offer the inmate an opportunity to live up to a model of conduct that is at once ideal and staff-sponsored - a model felt by its advocates to be in the best interests of the very persons to whom it is applied".

However "except in some religious institutions, neither the stripping processes nor the reorganizing processes seem to have a lasting effect".

Thought Reform

The conceptualization of Robert J. Lifton 4 is quoted by Goffman.

The scens told by Lifton have been at first in the Fifties the chinese prisons and then in the Sixties the exclusive cults in U.S.A.

Any doctrine, any vision of man and his destiny, that is, any set of emotionally-charged convictions about men and his relationship to the natural or supernatural world - may be carried by its adherents in a totalistic direction. (But this is most likely to occur with those ideologies which are more sweeping in their content and more ambitious or messianic in their claim, whether a religious or political or "therapeutic" organization. And where totalism exists, a religion, or a political movement (or a therapeutic" group becomes little more than an exclusive cult).

Lifton has described a set of criteria, eight psychological themes against which any environment may be judged. In combination, they create an atmosphere which may temporarily energize or exhilarate, but which at the same time pose the gravest of human threats.

Our exercise in this meeting is to apply the criteria of Lifton 4 to the setting of a Therapeutic Community.

Milieu Control

Lifton describes atmosphere reminescent of George Orwell’s 1984.

The control of communication is the most basic feature of the thought reform environment.

If the control is extremely intense, it becomes internalized control - an attempt to menage an individual’s inner communication.

Like a God’s eye Community’s view control over all a person sees, hears, reads, writes (information control) creates conflicts in respect to individual autonomy

Groups express this in several ways: Group process, isolation from other people, psychological pressure, geographical distance or unavailable transportation, sometimes physical pressure.

Often a sequence of events, such as seminars, lectures, group encounters, which become increasingly intense and increasingly isolated, making it extremely difficult - both physically and psichologically - for one to leave.

Mystical Manipulation (or with a paradoxical espression Planned Spontaneity).

Extensive personal manipulation seeks to promote specific patterns of behaviour and emotion in such a way that it appears to have arisen spontaneously from within the environment, while it actually has been orchestrated

The leaders of the group claim to be agents chosen by history to carry out the mystical imperative

The "principles" can be put forcibly and claimed exclusively, so that the group and its beliefs become the only true path to enlightenment, health (or salvation ?).

The individual then develops a psychological attitude defined by Lifton of the pawn, and partecipates actively in the manipulation of others.

The group legitimizes the deception used to recruit new members and/or raise funds, and the deception used on the "outside world"

The Demand for Purity.

The world becomes sharply divided into the pure and the impure, into the absolutely good /the communitary group/ideology) and the absolutely evil (everything ouside the community)

One must continually change or conform to the group "norm"

Tendencies towards guilt and shame are used as emotional levers for the group’s controlling and manipulative influences

Once a person has experienced the totalist polarization of good/evil (black/white thinking), he has great difficulty in regaining a more balanced inner sensitivity to the complexities of human morality

The radical separation of pure/impure is both within the environment (the group) and the individual

Ties in with the process of confession - one must confess when one is not conforming

The Cult of confession

The confession is carried beyond its ordinary religious, legal and therapeutic expressions to the point of becoming a cult in itself.

Sessions where the patient confesses to one’s sin are accompanied by patterns of criticism an self-criticism, generally transpiring within small groups with an active and dynamic thrust toward personal change

It is an act of symbolic self-surrender and makes it virtually impossible to attain a reasonable balance between worth and humilty.

A person confessing to various sins of previous existence (before the belonging to the group) can both believe in those sins and be covering over other ideas and feelings that she is either unaware of or reluctant to discuss.

Often a person will confess to lesser sins while holding on to other secrets (often criticisms/questions/doubts about the group/leaders that may cause them not to advance to a leadership position)

"The more I accuse myself, the more I have a right to judge you"

Sacred Science

The milieu of community maintains an aura of sacredness around its basic doctrine (or ideology), holding it as an ultimate moral vision that offers a meaning and a order to the human existence

Questioning or criticizing those basic assumptions is prohibited.

A reverence is demanded for the communitary ideology/doctrine, the originators of the ideology/doctrine (S. Freud, M. Jones), the present bearers of the ideology/doctrine (the leaders of the group).

It offers considerable security to young-peolple because it greatly simplifies the word and answers a contemporary need to combine a sacred set of dogmatic principles with a claim to a science embodying the truth about human behavior and human psychology

Loading the Language.

The language of the highly coesive environment is characterized by the thought-terminating clichè (thought-stoppers).

"The language of non-thought". The kind of language is an expression of exclusiveness of the group and its proposals.

Often the outside world does not use the words or phrases in the same meanings.


Doctrine over Persone

Every issue in one’s life can be reduced to a single set of principles that have an inner coherence to the point that one can claim the experience of truth and feel it

The pattern of doctrine over person occurs when there is a conflict between what one feels oneself experiencing and what the doctrine or ideology says one should experience

If one questions the beliefs of the group (or the leaders of the group), one is made to feel that there is something inherently wrong with them to even question - it is always "turned around" on them and the questioner/criticizer is questioned rather than the questions answered directly

The underlying assumption is that doctrine/ideology is ultimately more valid, true and real than any aspect of actual human character or human experience and one must subject one’s experience to the "truth"

In the group the experience of contradiction can be immediately associated with guilt

If a doubt arises, conflicts become intense

Dispensing of Existence

Since the group has an absolute or totalist vision of truth, those who are not in the group are bound up in evil, are not enlightened, are not saved, and have not the right to exist.

Impediments to legitimate being must be pushed away or destroyed.

One outside the group may always receive their right of existence by joining the group.

Fear manipulation - if one leaves this group, one loses their transformation, for something bad will happen to them

The group is the "élite", outsiders are "of the world", "unenlightened", etc

The jatrogenic effects in help-professional workers.


A different perspective considers the reactions not only of the inpatients but also of the workers of the Therapeutic Community.

What happens in a very close-knit group, where there is a shared set of friendship ties? Which is the the devastanting impact of disconfirmation of the illusions?

Above 9 the speaker have described the psychological reactions following the failure of expectations for the communitary goals : Idealization, Reaffirmation, Burn-out and Disillusion (Disenchantment). This adaptation is a collective process within a highly cohesive group.

I have observed persons experiencing a great deal of dissonance between the cognitions and beliefs and the failure of the predicted events. It is very difficult for a member to reduce this dissonance without the social support.

After the disconfirmation of the predicted events (recovery of illness) the group (and expecially the workers) deny this failure and can reconcepualize their ideological framework.


Idealization.

The negation of failure: " Really there have been some changes. We aren't been able with our eyes to recognize them for our cultural luggage". Our mistake has been in the expected results. Then the focus is moved toward less evident aspects, dynamics more difficult to objectively observe.

Reaffirmation.

The project has not had the expected results for a betrayal. It is the most ideological attitude, in according to the mith of "betrayed revolution".

Burn-out.

After a great involvment in studies we have a lost of motivation, frustration and apathy, a following emotional distance from patient's problems.

Disillusion.

Help-professional worker’s disenchantment, with the unavailability for future projects and the consequent jatrogenic effect on the patient.

The psycho-physical damage doesn't involve the in patient only, but also the help-professional workers.



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