Psychoanalysis and Psychotherapy

Free Associations

ALIENATION:

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 opposite characteristics.

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.

Ethical relations

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[1].

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 health production

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.

Therapeutic relations

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 called insight.

We might distinguish the external world of the therapeutic community from the internal world of the person. Clearly both are interconnected. Many 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 behaviour. These near-psychotic personalities (sometimes borderline and narcissistic disorders) have a profound disturbance of the internal organisation of their minds.

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)[1].

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 anti-therapeutic potentials.

Responsibility: 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[1] 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 guilt. Psychoanalytically 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 relationship. Psychoanalytically 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 well-being.

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 choice

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 choices.

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[1]. 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.

People operate 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.

Conclusions

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 vulnerable people.

References

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 [1975].

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.

Address for correspondence: bobhinshelwood@compuserve.coml