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 relationships hut 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 " institutionellen Psychotherapie" 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 diskursive Entwicklung
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 Kollektiv als Ganzes mit all seinen Sub-
systemen und komplementären Beziehungen mitzubehandeln.

Schlüsselwörter

institutionelleStandards -Maßregelvollzug- integrativcr Diskurs - institutionelle Psychotherapie

- Psychiatriereform

160 WsFPP l.Jg. (1994) H.l

161
Wsr-'PP l.Jg. (1994) H.l
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.
Cette vue structuralistede la politiquehospitaliere impliqueque les individus d'un collectif
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 is without doubt also to be seen against the fact that
162 WsFPP l .Jg. (1994) H. l
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 interinstitutional exclusion 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
emancipation ... during the course of its institutionalization" at the same
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 collective with
WsFPP l.Jg. (1994) H.l 163
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 Community is 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 Community can 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
164 WsFPP l .Jg. (1994) H.l
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 institution with 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
WsFPP l .Jg. (1994) H.l 165
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.
166 WsFPP l Jg. (l994) H. l
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 psychotherapy is consequently
oriented to the recognition of the desirable difference and to the collective
of the patients and staff which maintains a network of 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 polycentric network 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
WsFPP l Jg. (1994) H. l 167
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
168 Wsl-PP I.Jg. (1994) H. l
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 of responsibility
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.
Such principles presuppose the institutional resistance 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
WsFPP l .Jg. (1994) I I . l 169
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)
170 WsFPP l.Jg. (1994) H.l
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Anschrift des Verfassers

Dipl.-Psych. U. Kobbe
Westf. Zentrum für Forensische Psychiatrie Lippstadt
Eickclbornstr.21
D-59556 Lippstadt

172 WsFPP l.Jg. (1994) H.l