As a treatment manager of a forensic psychiatric hospital I may be considered an outsider in this conference of workers from psychotherapeutic communities.
Ours being a closed hospital with a primary objective in safeguarding society against our patients, who have proven to be dangerous and who have entered our hospital by order of the court, there seem to exist many fundamental differences between those therapeutic communities and our special type of hospital.
I will point out the characteristics of our hospital which particularly mark the difference.
1. Involuntary admission and lack of motivation for treatment
Because they have entered our hospital against their own free will, our patients usually lack in motivation for a treatment that will affect their personality. They feel that the offense they have committed was a mistake due to circumstances outside their own grasp of control. Most of them are convinced that such a mistake will never happen again, and that they have had their lesson already by the lawsuit, by the imprisonment and the consequences of those for their private and social life. On the other hand, the opinion of the court has also been that our patients cannot be held wholly responsible for their offenses, due to unsoundness of mind. In other words: the psychological problems our patients are supposed to have, have been defined as such by others. They themselves seem not to be suffering. They more often than not cling to the opinion that nothing would be the matter with them, if only society, or their family, or their wife, would have understood or treated them better.
2. Treatment in the service of safeguarding society
Our closed hospital has to use strict rules and material means to prevent patients from escaping and to prevent them to repeat offenses. Actually the government, who is financing our hospital, or, properly speaking, the public, expects us in the very first place to warrant its safety, and this objective seems to be incompatible with principles of treatment on the assumption of mutual trust between patient and treatment staff.
3. Extreme dependency of patients on the hospital
Due to the aforementioned features our patients are in many ways and to a large extent dependent on the hospital, on the opinions we have about their problems and the way to treat those problems in order to prevent dangerous acting-out. The responsibility for their own life and for their own decisions has been largely taken over by us.
This feature also seems at odds with to-days' treatment views, which stress the patients' responsibility for his own treatment.
4. Patients' lawful rights setting limits to treatment
Because of this extreme dependency of our patients, Dutch law imposes limits to the patient's dependency and to our freedom of choosing and using means for treatment and for dealing with dangerous or potentially dangerous behaviour of patients.
The legal position of our patients forces us to give account to the court and to an independent supervising board on our treatment and diagnosis regarding the patient's supposed dangerousness and the necessity of staying confined to our hospital. This means also that neither the patient nor we can decide independently on length of stay in our hospital. Actually this decision is taken by the court or by the Minister of Justice, although the patient's opinion counts to some extent and our advice is always being taken seriously into consideration. This legal position of the patient and our duty to report to and advise the court on length of stay often bring with them a more or less sharp difference of opinions between the patient and the hospital as a whole. Our dual task in providing treatment and at the same time to act in the interest of public safety usually leads to this antagonism.
As the patient feels that we are not acting in his own interests, at least as defined by himself, his mistrust adds to his resistance to treatment.
This resistance can take the guise of continually engaging in legal battles, aided by lawyers, against his confinement and against our controlling power.
The great majority of our patient-population can be diagnosed in terms of a personality disorder, mainly of the anti-social, narcissistic or borderline type. A major feature of this diagnosis is the patient's tendency to externalise and act-out his inner conflicts, fear and anger, in order to defend his vulnerable sense of identity and self-esteem.
According to many therapists personality disorders mean a bad prognosis and even, according to some, an inaccessibility to treatment; the more so in case the patient himself does not ask for treatment.
6. Non-selective admission policy
Although we have the right to refuse a patient who has been offered by the Minister of Justice for entry in our hospital, we seldom make use of this right. Within the limits of the relatively small total population of forensic psychiatric patients we hardly make our own selection of patients to be admitted.
This means that we admit all kinds of forensic psychiatric patients, regardless of age, type of offense and diagnosis. Grossly speaking they must in some way fit in our treatment setting, as regards to treatment philosophy, therapeutic climate and degree of material security.
But as we also intend to adjust to societal needs, our admission policy is basically not highly selective. The only unalterable terms are that the patient be a male and that he is ordered by the court to undergo treatment or to stay in a closed hospital.
After having summed up the main discriminating characteristics of our forensic psychiatric hospital I will in the following section indicate some of the roots and principles of our treatment-views.
By doing so I will also call your attention to the circumstance that, despite the differences between our hospital and psychotherapeutic communities in general, we originally shared with therapeutic communities some basic principles regarding to the view on disturbed and disturbing behaviour of patients and regarding to the necessary environmental conditions for treatment.
During the 26 years of our existence as a forensic psychiatric hospital we critically reexamined these principles in the light of the growing amount of our experience and in the light of theoretical and social developments. The resulting revisions have led to 3 major reorganisations of the treatment structure. They provided also new solutions to the everlasting dilemma between treatment- and security objectives.
Initial influences on treatment concepts
The era in which our hospital has been founded has deeply influenced and still influences to some extent the treatment culture of our hospital, our way of diagnosing our patients' disorders and our view on the necessary clinical environmental conditions in dealing with these disorders. I have traced three major influences which are tightly bound to the post-war period and to social and scientific developments in the sixties.
1. the so called modern school in penal law and jurisdiction, originated shortly after the Second World War by some outstanding criminologists and psychiatrists
2. criticism on traditional asylum psychiatry
3. criticism on the custodial prison system
These last two influences can be brought back to one: sociological criticism on total institutions and regarding their effects in causing and preserving symptoms of disorder. The patient's regressed behaviour was considered an artefact brought about by the depriving and dependency provoking institutional environment. Also these symptoms were considered as a way of surviving under environmental conditions which were thought to be threatening to personality integration.
Further on in this paper I will tell you more about the way we nowadays deal with these ideas. The first influence I mentioned must be more unknown to you, so I will have to give you a short explanation of the way in which this modern school in penal law still influences our way of dealing with our patients.
I have divided this material on the changes in treatment views in 4 subjects which each, from a different angle, highlight the changes and adaptations we brought about on the initial treatment concepts.
New practices for old rules
I. Interaction as a diagnostic and treatment instrument (vehicle)
As I said earlier, our hospital has been founded in 1965. Amongst the founders was an outstanding Dutch professor of penal law, professor Pompe, after who our hospital has been named. He was one of the leading criminologists of the modern school in penal law which I mentioned already to you. We try to keep alive his deep interest in and compassion with criminals as human beings. Inquiry into the offender's mental condition and in his motives to commit crimes, led in Holland from the 1950's to a close co-operation between the court and behavioural scientists, in order to do justice, not only to society in general and the victims in particular, but also to the offender's personality and life-circumstances.
Recognition of the offender's subjective construction of reality and its role in causing his offense, still today is of major significance to our claimed humane jurisdiction.
Also the concept of personal responsibility, and our Dutch tradition in founding the court's decision on assessment of the degree to which the offender can be held responsible for his offense, require cooperation, mutual respect and understanding between all parties that participate in the court's investigation, included the offender himself.
This modern school introduced also the phenomenological and humanistic notions of dialogue and encounter between all parties, instead of a one-sided moral and legal condemnation of the offender. This way of dealing with the criminal was thought to be the most respectful and humane way to come to an understanding of the criminal and his crime.
Brought to our hospital, this notion of encounter between staff and patients as human beings, instead of reducing their personality to a diagnosis or to the crime they committed, has from the start played a major role in our thinking about the best way to create a facilitating therapeutic environment. When I speak of environment in this respect I always mean the human and material environment of the hospital.
Recently our elaboration on the idea of the facilitating environment has led to a new hospital building, optimally designed to support our treatment views.
Instead of the terms encounter and dialogue we nowadays use the term interaction. We assume that by providing and stimulating all kinds of interaction between staff and patients and among patients, not only planned and with a narrowly defined therapeutic goal, but also spontaneous, playful, daily, domestic interactions, we create opportunities for our patients to develop their socio-emotional skills and ego-functioning, sense of reality, self-esteem and respect for other people's value.
Interaction is thus the major vehicle in bringing about personality-development and change. Also interaction, in any form, is in our view the most reliable way of assessing our patients' condition. Especially so, as our patients are not able to differentiate and verbalize their inner emotional state. From experience we know, that, if the patient is not rightly understood in his hidden conflicts, feelings and needs, then the only way for him is to act upon these needs, emotions and conflicts. And often this acting-out takes a destructive or self-destructive form. As long as the patient is not able to point out his real needs in a non-destructive manner, the staff has the task of understanding the patient's needs and to provide the care that is needed, be this in an emotional supporting way or by way of taking security measures.
The significance we attach to interaction as a vehicle for diagnosis and treatment has not been changed during the past 26 years. What we did change although is the management and structuring of these interactions. In earlier days our therapeutic attitude was non-directive. To a greater extent than today the patient was left free to engage in all kinds of activities and interactions throughout the hospital, regardless of his ability to integrate these experiences in a constructive manner. He was thought to be able to choose in a way that was beneficial and adjusted to his developmental needs if we did not interfere too much. We have learned from experience though, that the patient needs guidance and is far more dependent on our structuring, dosing and setting limits to his experiences, than we initially thought. Moreover the need for structuring and management of interactions has grown in consequence of the fact that the patients we nowadays have in our hospital are more severely disturbed and tend to regress in a more destructive way if their coping and integrating abilities are being overestimated.
There is always the danger that they feel neglected and abandoned if given a degree of freedom. On the other hand, if the interactions he engages in are getting too close in an emotional sense, then he is threatened by the fear of being annihilated, overwhelmed or destroyed.
Therefore the management and structuring of the impact of the human environment of the hospital have to be very carefully directed, in adjustment to each patient's needs and stage of development.
II. The clinical environment as an instrument of therapeutic change
From what I told you in the previous part, you may have noticed that we attach great significance to creating a facilitating environment as the major change-agent. In the past this view was mainly based on the sociological criticism regarding the pathogenic effects of the total institution, be it a psychiatric asylum or a prison. As we know, the therapeutic communities were to be alternatives to the custodial system of total institutions, which were said to be more concerned with survival of their system than with the real needs of patients/inmates.
Our clinic nearly did not survive the way the principles of the therapeutic community were carried out. Reality has taught us that our type of patients tend to regress to destructive, limit-testing behaviour if allowed a degree of responsibility that they cannot cope with.
Despite this experience we did not altogether abandon one of the basic principles of therapeutic communities. We are convinced, also by experience, that disturbed and disturbing behaviour can be preserved or reinforced by the clinical environment and by the way staff and patients interact.
We specifically attach meaning to this view, as we are dealing with patients who suffer from early environmental failure. The pattern of interaction that has been formed in their early socio-emotional development, tends to repeat and reinforce itself and to elicit reactions in the hospital environment which confirm the patient's need to maintain his disturbed pattern of interaction. This recognition of potential ill effects of the clinical environment means to us that we lay strong emphasis on critical self-examination and that we pay a great deal of attention to transference and counter-transference phenomena.
This only can be done in a working atmosphere that is sensitive to staff-needs and thereby permits staff to stay sensitive to and in touch with their own feelings and emotional reactions in interaction with patients and colleagues.
This is easier said than done, as we are dealing with extremely difficult patients who are clinging to their survival strategy and defense mechanisms, such as splitting, externalizing and acting-out. They also cling to their victim's role in order to avoid change.
We therefore have the difficult task of keeping a therapeutically effective balance between the required attitude of critical self-examination, in order to discover pathogenic effects of the clinical environment, and on the other hand to preventing disintegration of the clinical structure as a consequence of the destructive effects of the patient's defensive strategies. In the present stage of our hospital the need for keeping this balance is one of our main concerns.
III. Attachment and basic security
A third factor which has always been important to our treatment concept is the creation of an emotionally secure environment for the patient. Providing emotional security has always been a basic principle to us, as well as stimulating attachment. We see the development of attachment to the clinical environment as a vehicle for corrective emotional experiences and thus for change, although the patient tends to demonstrate his growing attachment in the disturbed and biased way that reflects his attachment history.
In the past we thought that the showing of respect, emphatic sensitivity and acceptance were sufficient as conditions in providing a secure base. Experience has taught us however that these are not sufficient environmental conditions.
The internal working model (term introduced by Bowlby) of relationships that the patient has developed through his early attachment history, thoroughly affects his social behaviour in the clinical environment. This means on the one hand that he is biased in his interpretation of the staff's behaviour and attributes motives of hostility, rejection and malicious intent when no such motives are present. On the other hand, the patient has also become an expert in provoking behaviour that confirms his internal working model of relationships. This means that he manipulates his environment so as to elicit the expected hostile, ambivalent or rejecting behaviour from the staff.
Instead of straining ourselves, as we did in the past, to avoid showing this behaviour and repeating the early environmental failures, we now use this kind of relational experiences and our failures, to gain insight in the patient's interaction patterns (internal working model) and in the real needs behind his behaviour. Responding to the patient's real needs, as perceived and examined by the staff, has to provide the secure base that in our view is of major significance. When the patient is thus being cared for, there is less chance that he has to express himself in a destructive or self-destructive acting-out manner. Providing a secure base from the patient's point of view means therefore that we also are taking care of other people's safety. In this way we reconcile the seemingly antagonistic objectives of treatment and safe-guarding society.
IV. Organisational design as a basic condition for effective treatment
I now will dwell on the fourth major principle of our treatment concept: organisational design as a basic condition in achieving treatment goals.
Stressing the link between treatment concept and organisational design has its root in the therapeutic community movement and in sociological criticism on total institutions.
Although in fact in our hospital this connection has always been demonstrable, we only recently have become aware of the powerful influence of the organisation's structure, the functional relationships and the quality of these relationships within the hospital staff, and the vital role of professional management on treatment result.
Precisely because effective treatment of severely disturbed patients requires a facilitating environment which is indestructible to the patients' defensive mechanisms, emphasis has to be laid on management and organisational design.
Management goals are: maintaining internal consistency and integration, directing therapeutic processes and interpretation of experiences with patients from some distance to the executive level and on the basis of an integral understanding of the patient and his needs.
Also the quality of functional relationships within the staff and the quality of communication and information on each level and between hierarchical levels in the organisation are basic to treatment success.
So, the quality of organisational functioning, is in my opinion as vital to treatment success as is the content of therapeutic activities.
The changes in our treatment views do not mean that we have abandoned initial assumptions. I would rather say that we have come to a better understanding of the old old rules on the basis of a better understanding of the patients' needs.
14 September 1992/Mariette Zomer
(The Prof. W.P.J. Pompe Clinic in Nijmegen)
This paper is presented here with the kind permission of the author