Treating People with Psychosis in Institutions: A Psychoanalytic Perspective, by Belinda Mackie

How to Understand Institutions that Care for Patients

There are many paths that offer an understanding of the experience of people with psychosis, and numerous ways to consider the nature of institutional treatment approaches.  This book presents psychoanalysis as one path that provides a conceptual foundation for both the treatment of psychotic conditions and how to understand institutions that care for patients. It focuses on the priority that psychoanalysis places on the individual, how the treatment is conceived theoretically and the ways it can be incorporated in the overall organisation of an institution.

Psychoanalysis has its greatest efficacy in long-term treatments and has shown its suitability for patients diagnosed with psychosis when the method is adapted to the uniqueness of each person and is conducted by an experienced clinician. In many cases individual psychoanalysis is feasible but the treatment of psychosis cannot usually be conceived without considering some form of institutional care. Psychoanalysis offers a perspective on the clinical work by assisting clinicians to develop practice strategies that are strongly linked to a theoretical framework.

A high burden of ill-health and disability is experienced by people with psychotic disorders throughout their lifetime and only a minority gain an optimal level of functioning and wellbeing that is commensurate with a good quality of life. Therefore, psychotic disorders represent a major public health challenge. Psychosis is generally experienced by patients on a very broad continuum and is frequently episodic in nature. Psychiatry views psychosis is an impairment of mental functioning where there are fundamental disturbances in the person’s thinking, perception and emotional responses that can be manifest in delusions, hallucinations, confusion, and impaired memory. The treatment may or may not incorporate a support network or team approach; these days patients are managed in a range of outpatient and community based mental health services.

RetreatOriginalBuildingssm-The York Retreat (c. 1796) was built by William Tuke, a pioneer of moral treatment for the insane

The York Retreat (c. 1796) was built by William Tuke, a pioneer of moral treatment for the insane

Many people with a psychotic illness, especially those with schizophrenia, will be exposed to psychiatric treatment, in one form or other, during the course of their lives. As a result, the institutional context is indispensable in the treatment of patients with a high degree of risk. This is because patients who are potentially unsafe need a complex range of supports that include protection, containment, skilled personnel and tools that go beyond the range of a single treatment approach. No single theory can account for the complexity of psychotic phenomena.  It is generally agreed that the best way of managing the treatment of psychosis is a wide range or combination of approaches that address the uniqueness of the individual’s presentation, their level of disturbance, the severity of symptoms and the level of risk.

Conventional community outpatient settings often fail to provide a holding environment that allows the individual to transition to a more autonomous position at their own pace. Nor do these services offer a consistent containing function that assists the person to cope with times when they experience overwhelming anxiety or psychotic fragmentation that significantly interferes with their ability to determine a course of action or make a decision. In such cases, the patient’s psychotic symptoms can impede their ability to participate in the analytic treatment, at least until they can represent themselves better. In applying a psychoanalytic perspective to the treatment of people suffering from severe mental illness, the goal is to facilitate the patient’s continuing engagement in a working transference relationship because it has both therapeutic and protective value. It is, therefore, in the patient’s best interest to continue in the treatment with as little disruption as possible but with the support of a team, which may mean inpatient or community treatment.

Therapy based on psychoanalysis permeates contemporary psychological approaches. Freud saw psychoanalysis as a method of inquiry, which leads to observations that result in a body of theory, and the practical application of those theories that is the analytic treatment. At first the early practitioners of psychoanalysis had no way of knowing just which patients were treatable with the analytic method and which ones would require special changes or parameters. Some analysts significantly modified their praxis so that more problematic psychopathology could be available to treatment; others treated psychosis without much alteration to the method at all. Unfortunately, several of the analysts following Freud transformed his recommendations about psychoanalysis into rigid guidelines about what it was and the type of patient who would benefit from it. This process of reinterpretation has gradually created restrictions that were contradicted in Freud’s own practice. It is over a century since Freud and his colleagues from the Burghölzli Clinic in Switzerland attempted the use of psychoanalysis in the treatment of psychotic conditions in institutional settings, laying the foundation for future practice in the mental health field.

Burghölzli_Stich-Burghölzli Clinic in Switzerland 1880s

Burghölzli Clinic, Switzerland (1880s)

Major changes have occurred in treatment approaches since then and particularly since de-institutionalisation. The chapters of this book bring together the histories of a number of psychoanalytically informed facilities, and provide a synthesis of the different theoretical underpinnings in their institutional practices. Here an institution is the subject of the case study. Institutions that are theoretically orientated to psychoanalysis were chosen and examined, taking into account their various approaches to the treatment of patients with psychosis. A number of institutional models informed by psychoanalysis offer a guide to the treatment and present versions of institutional practice that are different from the prevailing models in psychiatry. This has implications for health services in the current climate of mental health reform.

Of particular interest is how psychoanalysts and psychoanalytically trained staff working in institutions, apply their theoretical understanding, and in what ways the psychoanalytic technique has been modified or adapted to the treatment of individual patients and to the workings of an institution. In the recent past, institutional treatment took the form of large hospital complexes but post-deinstitutionalisation patients are treated in a range of outpatient and community based mental health services that remain institutional in nature, even though the original buildings have been demolished or reallocated. An understanding of institutions is derived through the evolution of asylums from the past and more recently in the process of deinstitutionalisation to the state of mental health services today. With deinstitutionalisation the stability, structure and respite that institutions provided for patients were not considered in the overall drive to close them. Thus, the true concept of asylum was lost and the beneficial aspects of institutional care, such as security and protection, all but disappeared.

Generally the psychoanalytic approach to patients with psychosis is not well understood in contemporary psychiatry and yet therapy based on psychoanalysis permeates most psychological approaches. Psychoanalytic theory provides a foundational model for thinking about mental illness, including informed and ethical approaches to the practice of working with and treating patients. There is significant consensus that the psychoanalytic treatment of psychosis is different in its application to that of neurosis and that it is dependent on each persons unique presentation. A Lacanian orientation to psychoanalysis is the preferred approach in this book because it is consistent with the author’s training as a psychoanalyst, and the structure and treatment of psychosis is well elaborated by Lacan. In addition, there are a number of institutions whose practice and organisational administration are guided by Lacanian psychoanalysis. This creates interesting parallels with a number of other institutions in the area that apply alternate psychoanalytic models, such as object relations and post-Kleinian theory, interpersonal psychotherapy and ego psychology, that have made significant contributions to the field in their understanding of institutions and the treatment of psychosis.

quote-the-sufferings-of-neurosis-and-psychosis-are-for-us-a-schooling-in-the-passions-of-the-jacques-lacan-90-72-05 (1)

In the investigative process questions arose concerning the function of individual institutions and how they differ from each other, especially in areas of the prevailing philosophy that guides clinical practice and patient treatment models, treatment outcomes, historical perceptions, hospital administration and the training of staff. Services that applied psychoanalysis to the whole institution, as much as this is possible, were foremost in the decision of which institutions to study. These institutions are and were located in North America, Continental Europe and Great Britain; they cover the treatment of adults, adolescents and children. Given the surprisingly extensive number of psychoanalytically informed institutions internationally and the different theoretical models used as frameworks to guide patient treatment and administrative practices, a selection of institutions was made for a more detailed analysis. This was based on the depth and diversity of literature available about the chosen institution, the clinicians who worked there and their ability to theoretically explain their praxis, as well as, material available in the English language. Unfortunately it was on this basis that other examples of hospitals influenced by psychoanalysis in, for example South America, were excluded. A broad selection of institutions are presented and discussed in varying degrees of depth. Certain institutions are given particular attention: Austen Riggs Center, Bellevue Sanatorium, Henderson Hospital (Belmont), Bonneuil-sur-Marne, La Borde Clinic, Le Courtil, Cassel Hospital, Chestnut Lodge Sanatorium, GIFRIC Centre, Hollymoor Military Hospital (Northfield), Menninger Clinic, Schloss Tegel Sanatorium, Sheppard and Enoch Pratt Hospital, and Sonia Shankman Orthogenic School. Some are discussed less intensively: Burghölzli Clinic, Hampstead War Nurseries, Le Fondation Parent de Rosan and Nonette. Others are mentioned briefly or introduced by way of discussion: Claybury Hospital, Fulbourne Hospital, Littlemore Hospital, Mill Hill, St. Elizabeth’s Hospital, Soteria House, Tavistock Clinic, The Arbours Centre, Villa 21, The Philadelphia Association, Kingsley Hall, and The Maudsley Hospital.

partitioned-austen-riggs (1)

The following criteria were developed as a guide only to identifying common themes about the nature of institutions, how they functioned, their relationship to psychoanalysis and to the treatment of psychotic patients:

  1. The institution’s history and conceptual models that orient it towards psychoanalysis and psychiatry.
  2. The logic of the treatment of psychosis in its institutional application, including the influence of the psychiatric medical model.
  3. How the traditional psychoanalytic method is modified in its application to the treatment of patients.  What makes the treatment strategies and programs unique? What is the place of the patient in the treatment?
  4. The institution’s level of awareness and approach to examining itself psychoanalytically in the context of leadership and authority, administration and fiscal decision-making.
  5. The institution’s approach to staff and their education, analytic training, research, supervision, clinical meetings, case conferences, teamwork etc.
  6. How research is conducted, how efficacy is measured and how treatment outcomes are used.
Philippe_Pinel_à_la_Salpêtrière-Dr. Philippe Pinel at the Salpêtrière, 1795 by Tony Robert-Fleury. Pinel ordering the removal of chains from patients at the Paris Asylum for insane women

Dr. Philippe Pinel at the Salpêtrière, 1795 by Robert-Fleury. The doctor is ordering the removal of chains from patients at the Paris Asylum for insane women

For an institution to work effectively and ethically it needs a theoretical model to guide the work of a well-trained and supervised staff, together with an articulated approach to patient treatment and informed leadership. In addition, it is necessary to have an ethos that can be identified, understood and accepted by all those who populate the institution, staff and patients included. The place of psychoanalysis in psychiatry, approaches to the structure and treatment of psychosis, relevant aspects of the history of psychoanalysis and the nature of institutions are all considered in the initial chapters of the book, so as to better facilitate an assessment of the selected institutions discussed in the chapters that follow.

Today the same criteria believed to be useful in running a business are applied to institutions regardless of the type of business. In health systems, the nexus between patient and medical services has become an economic one for the reason that the organising metaphor of the provider has taken over, and economic realities tend to supersede the primary task of the delivery of health care. The origin of many problems in institutions is due to the failure of managers and practitioners to question their own practices. Psychoanalysis is often uncomfortably at variance with the dominant culture of a psychiatric institution. Thus, psychoanalysts have found different ways of dealing with the position they are required to adopt in an institution. Their unique contribution to an institution calls for a particular kind of response founded on a psychoanalyst’s training and formation. The adoption of a psychoanalytic orientation to the psychiatric field affords a way for complex dynamics and processes to be understood, monitored and used therapeutically in a wide range of settings with a variety of people.

The presence of psychoanalysis in psychiatric institutions takes on different connotations and meanings according to the psychoanalyst’s position and role. To work effectively in an institution, the analyst needs to be cognisant of the institutional dynamics within which the work proceeds. Applied psychoanalysis is the extension of the work of psychoanalysis into the institutional arena. When psychoanalysis is applied in an institution it takes place within a complex structure that comprises a network of relationships and it offers an effective integrating function. An institution is a social system within which any action can have meaning. Potential knowledge will only become known if systems are put in place to study the institution, and this means relinquishing power and control.

Belinda S. Mackie worked in public psychiatric institutions before and during deinstitutionalisation in Australia. She is a registered psychoanalyst with the Australian Centre for Psychoanalysis and is a member of the Forums of the Lacanian Field. She practices as a psychoanalyst in Melbourne. Her book Treating People with Psychosis in Institutions: A Psychoanalytic Perspective is published this week by Karnac Books.


Reviews and Endorsements

Mackie_thumb‘Psychoanalysis has from the beginning had a role to play in understanding human endeavour, way beyond the therapeutic work of the consulting room. Working with institutions is one of the biggest fields for its application. However, the combination of understanding both therapeutic and institutional work is a lot less common. Here is a book that makes a scholarly survey of the whole of this field in which institutions are the arena for therapy, for understanding the work practice of caring, and for developing healthy social systems. This book is a fine example of a coherent historical and geographical account of these dispersed mission-like centres of expertise.’
– Professor R. D. Hinshelwood, Centre for Psychoanalytic Studies, University of Essex, UK

‘This book is theoretically wide-ranging and examines how the conceptual frameworks of a variety of different psychoanalytic perspectives have informed the development of institutions for the treatment of the seriously mentally ill, including those diagnosed with psychoses or who have undergone psychotic episodes.’
– Susan Long, PhD, author of The Perverse Organisation and its Deadly Sins, and editor of Socioanalytic Methods

‘Belinda S. Mackie has written a rich and comprehensive historical and theoretical account of psychoanalysis in mental health institutions. She clearly and critically reviews a wide range of psychoanalytic approaches across different continents and eras. This important resource fills a large gap from which emerges a general assessment of the value and validity of utilising a psychoanalytic method in the institutional treatment of psychosis. The author skilfully conveys the sense of what made the particular institutions special – historically, theoretically and clinically.’
– Douglas Kirsner, PhD, Emeritus Professor, Philosophy and Psychoanalytic Studies, Deakin University; author of Unfree Associations; Honorary Member of the American Psychoanalytic Association

‘Exploring the advances in the treatment of schizophrenia and psychosis over the last hundred years or so, this fascinating book tells the story of the way in which psychoanalysis flourished in institutions in the twentieth century. If Freud had wished for psychoanalysis to inherit the promised land of psychiatry, then it was into the field of treating psychosis that psychoanalysis would need to venture. Belinda S. Mackie’s account, with a particular dash of Lacan, narrates the emergence of psychoanalysis as a mainstay idea in the treatment of psychosis and shows how Freud’s dream was at last realised. Demonstrating how the development of the best known psychiatric institutions were threaded together by common psychoanalytic family ties, Mackie’s book makes for essential reading.’
– Dr Gary Winship, Associate Professor, School of Education, University of Nottingham; Senior Fellow, Institute of Mental Health


Austen Riggs Center maintains a long-term residential treatment model in an era of managed care that emphasizes short-term hospitalizations and outpatient treatment

4 thoughts on “Treating People with Psychosis in Institutions: A Psychoanalytic Perspective, by Belinda Mackie

  1. This appears to be a a very important book for illustrating the use of psychoanalytic ideas in
    group settings. Since Bion’s seminal contributions to this area we have learned a great deal more
    about the biological, psychological, and social aspects of mental illness and its treatment. I will
    surely get this book.

    W.M. Bernstein

    Liked by 1 person

  2. Pingback: INTO TA—Personal reflections, by Bill Cornell |

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