Chapters reproduced on the web

Democracy in Psychiatric Settings: Collectivism vs. Individualism

by Gary Winship (M.A., Dip. Gp. Psych., RMN, ENB 616).

Abstract

Democracy is a central canon of a maturing public psyche and also a maturing treatment setting. The relationship between politics and the delivery of health care is examined in light of political theory and it is argued that a model of therapeutic collectivism rather than a model of individualism is more likely to create an ethos where the patient will experience the necessary democratic empowerment for sustained health and recovery from psychiatric illness. A clinical narrative is presented illustrating how a democratic process evolved in a small psychiatric ward community over a period of four years. The applicability and/or generality of the work described in the narrative is discussed. As well as drawing from political, social and economic theory, the discussion also draws from psychoanalysis, namely object relations theory and group analysis, a perspective provided by the amalgam of the ideas of Foulkes and Bion. Broadly speaking, this essay falls into the realms of metasociological enquiry such as Brown (1985; p.218) has briefly described.

INTRODUCTION

The politics of pluralism, the deconstruction of the Soviet Union, the dismantling of the Berlin wall, are emblemic events exemplifying the blurring of many of the old (cold war) frontiers of geographical and political constitution. The distinction between left and right in politics has, arguably, become less visible and the debate about democratic ideals in this (post-) modern era is bristling as we approach the end of the millennium (Austin, 1994). According to Dunn (1992), the pre-dominance of democracy as the exclusive claimant of legitimate political power, is "in some respects remarkably recent" (p.239). Dunn's view of the "completeness of democratic triumph" (p.240) within a trusted system of capitalism ensuring prosperity and "long term overall advantage to it's participants" (p.254), needs to be contrasted with Chomsky's (1991) formidable study of democracy in the modern world and in particular in the US. Chomsky is more troubled about the current perception of democracy, feeling that it has become a rhetorical and propagandist political facade that disguises the brute authoritarianism of so-called democratic administrations.

The debate about democracy and the legacy of the systems of capitalism from which democracy emerges "cannot be reduced to a one dimensional formula" (Rustin & Rustin, 1983). For example, the divergence of views between Dunn and Chomsky, above, cannot be resolved by appeal to historical 'facts'. Such issues are fundamentally emotive and their debate is inevitably polemical, as personal and cultural interest are inextricable from political theory. It seems that currently our efforts to understand the operation of political power and organisation on our personal experiences are especially obscured. For any illumination we need to account for a far wider web of influence than in previous eras, perhaps with some sort of concept of inter-cultural globality such as Habermas (1989) has developed. The task of assessing how the political culture of 'democracy' and individualism impact upon the development of interpersonal theory and practice in psychiatry is therefore a complex one.

Democracy in health care treatment settings might be described as the introduction to therapeutic encounters of consensual decision making procedures, derived and adaptated from political theory. Democracy, from this perspective might be viewed as algorithm of patient empowerment. The interest in genuine (rather than tokenistic) democracy in therapeutic settings rests most explicitly with the application of the principles of the Therapeutic Community (TC). However, beyond the work of Rappaport (1960) and Crozier (1979), the discourse is rather limited. Of course the notion of emancipation of the mentally ill is a project founded long before Rappaport, dating back to Tuke and before in 1800's, but the focus of this essay are the indisputable radical changes in the second half of the twentieth century. These more immediate developments merit discussion, and in the following pages I shall examine how the changes in the theory of the therapeutic milieu have been interwoven with the co-existing political changes. The delivery of health care moves in tandem with the governmental politics of the day where there is a reciprocity of action, ideas and public influence through the various strata of social organization - an ebb and flow of influence between social bureaucracy and cultural forces. According to Habermas (1989) the structuring of the Welfare State and its relationship to the administrative strata, influencing organizations such as pressure and lobbying groups, and the public sphere, is not well understood. There is a kind of trickle-down/up effect where political ideologies, like moral and cultural values, move back and forth between societal strata. If we begin from the premise that no milieu is an island, then cultural and political forces will penetrate milieux such as welfare care systems and therefore be implicated in the development of ideas in treatment settings.

The impact of national crisis and political upheaval on therapeutic processes was examined recently in an especially extended section in the journal of Group Analysis (1995, 26, 1; 81-119). Papers from Mexico, Russia and Croatia showed how political and social crises impact directly upon the material that patients bring to therapy. Hailsham (1978) likewise posits that there is a link between an unstable political climate and it's social implications citing that a breakdown in family values, increased crime and violence, unemployment, sexual permissiveness and general unhappiness are all symptoms of political unrest. He goes as far to suggest that the cause of this "whole syndrome starts with political insecurity" (p.79). Whether we agree that the trickle down effect is primary or secondary cause of psychiatric illness (nurture versus nature causation) we can be sure that fundamentally the subsequent therapy necessary to alleviate distress can not be extricated from the sociopolitical climate of the day: Illness; family conflict, school experiences, unemployment, divorce, poverty, racism and other social phenomena are determinants both of distress (illness) and its alleviation. Are there ways in which we can see how the tandem between psychiatry and the over arching political infra-structure has evolved?

Therapeutic Collectivism

The cognizable growth in interest in group therapy following the second world war, was a concomitant of the political and social climate of the day where there was a generally perceived need a for a more socially inspired societal construction. In 1945, in spite of the national reverence for the Winston Churchill, the populous voted a Socialist government into power with a landslide majority. In his manifesto, Clement Atlee the incumbent prime minister, promised a programme of public ownership and a new social order. The devastation of the war had made some redefinition of human and moral values urgent. Health and life itself were the central focus of popular aspiration and there was a consensus in favour of sharing resources. This can be seen in the context of people's experience of food-rationing, also of communal shelter after the experience of the blitz in London, the Midlands and the North East. Neither such basics as food or shelter could for the moment be taken for granted. In this desire to share resources can also be seen a need for a reparative form of inter-relations, a will towards an integrative union of different people, pulling and pooling together. The concept of equality during the war had reached new heights as women shaped events with their commitment to undertaking tasks normally left to men.

The pioneering work of the therapeutic community movement has it's roots in this foundling atmosphere and it's early development co-incided with the need to have a collective sense of re-building, the need for affiliation, for community support and co-operation. The backbone to the TC approach arose out the discourse of group analytical psychotherapy. The early experiments with group therapy (in the UK) had began during the latter years of the war and the work of Bion and Foulkes at Northfield in Birmingham is notable here (for discussion of these developments see; Pines, 1983a; 1983b; 1985). Notable also is the work of Maxwell Jones at Mill Hill with the evacuated patients from the Maudsley Hospital. Bion and Foulkes, like Jones, found that a group therapeutic approach was an extraordinarily powerful tool in their work with soldiers who were suffering the painful psychological after-effects of the war. Self help and mutually led group support challenged the generally held belief that the therapist knew best (basic assumption leader dependence - Bion, 1961). It was a shift from the authoritarian version of the doctor-patient relationships, to one where the patients became co-physicians.

Thus the foundations for the proliferation of group therapy took place at a time when there was a need for a new vision of living with others. However, after the celebrations of victory had subsided, the nation faced years of rationing and the dream of houses fit for heroes floundered as a world recession took hold of the economy. Nevertheless, the plan for a fair and equitable system of health care was finally instituted in 1948 with the birth of the National Health Service. In the context of this nationalized and publicly owned health service, a social vision of therapy enjoyed such solid foundations that it thrived through subsequent offices of Conservative governments in the 1950's. Likewise, group therapy flourished. TC practice in psychiatric institutions also became exemplars of radical and progressive practice. In the 1960's, again in tandem with a new era of socialist government, a social model of therapy became firmly grounded in the philosophy of health care with the growth of social psychiatry (Jones, 1968). Here the traditional role and function of the doctor was superseded by the concept of a treatment community able to look after itself (Rappoport, 1960).

It may be useful to delineate the type of socially inspired therapy so far described. These modes of therapy, namely TC and group therapy, might be described as therapeutic collectivism. The term collectivism has been reviewed in some detail by Popper (1966) in the Open Society, although Popper somewhat hi-jacked the term for his remarkable deconstruction of Plato's Republic (circa 375 BC), rather misappropriating the conception of collectivism by merging it with totalitarianism. My use of the term here differs markedly from Popper. The term group or socially orientated therapy would be too narrow here because although TC and group therapy are clearly encounters that involve a collection of people, the term therapeutic collectivism is not intended to preclude the orientation of individual therapies which are inter-subjectively constructed, that is to say, therapies which consider the interpersonal interaction between the patient and the therapist as primary. Furthermore, these dynamically orientated interpersonal therapies do in fact pay close attention to the familial mental constructions that are within the patient, the collective inside so to speak. Richards (1987) describes that our understanding of society and the world around arises out of an experience of "others inside" (1987; p.46).

The notion that our inner world is many peopled is the foundation of object relations theory (see; Grotstein and Rinsley, 1994). Many psychotherapists talk about the family being under the couch when they see a patient individually. I have noticed on many occasions how a patient will gesture to an empty chair or space and speak as if the person they are thinking about is there. The term therapeutic collectivism, therefore, is one that envelops a conception of the therapeutic dyad as a social space. Here we are working from Rustin's (1991) notion that "social relationships are always primary" (p.20-21) and that individuality arises out of an intricate experience of dependence on others. In this way we may consider that group dynamic understanding has it's roots in our inherent social disposition, the very beginning of life being a group experience of sorts. The therapeutic dyad, considered in this way, becomes a question of group dynamics which Freud noted when he referred to Psychoanalysis as a group of two.

I am suggesting here that psychoanalytic theories of intersubjectivity, whether applied to individual, group or milieu therapies, begin from a premis that individuals do not exist and cannot recover health, in isolation. This psychoanalytic axiom begins with Foulkes (1938) who, in reviewing the work of Norbert Ellias said that psychoanalysts should consider the patients whole network of social inter-relations, there being; "no sharp line of demarcation between what we are accustomed to describe as inside and outside" (cited in Pines, 1983; p.284). I would now like to contrast this socially derived concept of therapy, which I have called therapeutic collectivism, with it's political counter-part, that of therapeutic individualism.

Therapeutic Individualism

Popper (1966) describes individualism as the "basis of Western Civilization", interpreting a central doctrine of Christianity as a prescrition which falls short of an all-encompassing sense of community: "Love thy neighbour say the scriptures not love thy tribe"(p.102). Popper tells us that it is also Kant's central doctrine that we should "always recognize that human individuals are ends and not means to your ends", (p.102) although this sounds rather more like a defence of the individual against the oppressive power of a group, rather than a denigration of the collective per se.

The concept of individualism arises out of the political philosophies of the eighteenth century. John Stuart Mill's (1895) notion of liberty was one such philosophy that viewed the collective of society as a "tyranny of the majority" (p.63), advocating instead a notion of personal sovereignty. The concept of individualism also runs through the ideas of Marx and Durkheim where it is conceived as a phenomena associated with the growth of labour where there is a development of occupational specialism which fosters the talents, capacities and attitudes which are not shared by everyone (Giddens, 1971). The concept of maintaining an elitist structure endorsed by Hailsham (1978), where certain individuals are seen to have the capacity to lead and govern,also derives from this source.

Therapeutic individualism has ridden in tandem with the influencing political climate and can be framed particularly within the last fifteen years in the UK which has been dominated by the politics of free market individualism. Individualism has come to represent a philosophy and psychology of 'self', although it is important to note that the concept is distinguishable from individuality, which pertains to the uniqueness of experience, and individuation, which has a rich psychoanalytic discourse relating to the differentiation between the infant and it's mother (cf: Rustin, 1991; p.168). The modern notion of individualism has redefined who may be seen as a worthy member of society. Individualism may be characterised by the belief that one should stand independently (look after number one) and take responsibility for yourself and your immediate family. The monetarist vision of individualism focussed on putting money back into people's pockets so as to give individual choice about how to spend money. With the philosophy of privatization and private ownership, and the capture of large markets by businesses selling private health care, private pensions and private insurance, the thrust towards a radical individualism has resulted in the deconstruction of collectives where the concept of public has been vilified and degraded (Figlio, 1989).

During the last fifteen years of individualism we have witnessed the denigration of not only collective organizations such as trade unions, but also the destruction of a large number of industrial production communities. In the wake of the dismantling of these communities is large scale unemployment and an increased gap between poverty and wealth. But the price of running down these large scale industries - steel, coal, shipping - should not be measured only in terms of the loss of manufacturing output, nor only in terms of the economic and emotional strain of massive unemployment. The attack on the National Health Service is a measure of how damaged the social perception of joint ownership is. Habermas (1989) has gone so far as to say that true conservatism would aim to maintain public and welfare services in their current state, but in the UK the process of their de-construction is well under way. On the surface perhaps we can see how organizations and communities have been assaulted, but less visibly, probably unconsciously, our ideology has also been violated. It is the concept of "collective" (and associated concepts such as group, union, movement, gathering, community, society) that have been the real casualties of the last fifteen years. This attack has inevitably filtered through the social matrix and therefore exerts an influence over treatment settings.

In the health service there has been a conflict between a philosophy of individualism and the process of patient empowerment. This is apparent in the reduced social orientation of the therapies of individualism. Approaches, such as cognitive and behavioral therapy have been the pre-dominant mode of therapy during the 80's and 90's. Individualistic approaches conceive of the patient in an insular way, viewing the patient in isolation from their historical interpersonal network. Taking no account of the dynamic of transference, the therapist is often in the role of teacher or educator. For instance in behaviour therapy the patient may be shown how to do thought-stopping exercises or is set "homework", emphasising the role of the therapist as director, where treatment is prescribed and therapist interventions are mainly authoritative. In my experience of the behavioral therapies, and notwithstanding efforts made on more progressive courses to address the need for a 'negotiation' of the pace and goals of treatment with the patient, disempowerment is contingent to the therapy and rather than being examined and combatted, it is in fact at some level always a pre-requisite to treatment.

CLINICAL NARRATIVE

It was against this backdrop of individualism that a small treatment community (Witley Two) attempted to develop a more collectively orientated approach to treating drug users. The process of empowerment was considered as basic to the work of the community in the treatment of patients whose drug addiction was symptomatic of their powerlessness over the course and destiny of their lives. The ward had a well established hierarchical structure with a ward manager, a charge nurse, several staff nurses and a care assistant. In 1988 the ward was not operating as a therapeutic community. The new ward manager was keen to develop a psychodynamic approach reminiscent of the work of Ward Six at the Maudsley hospital, which explicitly derived it's approach from other psychotherapeutic treatment milieus (see; Jackson and Cawley. 1992; Jackson and Williams, 1994). The approach on Witley Two therefore followed an approach where the transference dynamics in the nurse/patient relationship were observed and gently challenged, addressing the imbalance of power in the staff/patient relations on the ward. Gradually a culture emerged where the analysis of the nurse/patient dyad and the staff/patient group dynamics were extended to examining the total ward milieu from a psychoanalytic perspective.

Sharing food (for thought)

In 1988 the system for ordering and storing dry stores, for instance tea, coffee, biscuits, cereal, fruit juice etc, was entirely the responsibility of the staff. The staff would assess how much food the residents needed and then fill in the appropriate forms. When the dry food stores were delivered on a Tuesday morning the staff would check that the food was correct and then store the food in different places. Some of the food would go into the patients kitchen and some would be stored in the nursing office, unaccessible to the patients and then rationed out during the week. The ward manager suggested that the system for storing food in the nursing office should be changed, suggesting that the patients could take responsibility for their own food. Some of the staff thought this was a good idea but others thought it would be disastrous because the patients would eat all of the food at once. The staff were concerned that all the food may be eaten too quickly. At a staff business meeting it was apparent that some staff felt most strongly that the system should not change, however, at the end of the meeting there was a general agreement in favour of an experimental phase of two months with a system which involved the patients rationing and storing the food themselves. When the idea was discussed with the patients they too were worried that there would be a greedy consumption of the food. Some favoured continued control by the staff. However there was again a general concensus in favour of a trial period.

The first week was a disaster. The orange juice and biscuits were gone within two days of the food arriving on the ward. Other food stuffs, such as cereals, were consumed almost as quickly. The second week was not much better. However by the third week the food was beginning to last. In the ward therapy groups there was much discussion about greed and fair sharing, and an atmosphere of peer pressure and feedback. After two months there was much progress, the food was lasting through to the weekend and so it was decided to continue the trial. The advantages of the system were noted in so far as the patients did not have to keep asking the staff when they needed something like jam or sugar. The "ward rep" (a patient who acted as a representative of their peers, usually someone who was in the latter stages of their programme) was identified as the person who would liaise with the staff when ordering the food, assessing which food stuffs needed to be topped up and which items were already adequately supplied. The ward rep would also be jointly responsible for checking the food coming into the ward. After several months there was much less wastage as the amount of over-ordering decreased. Staff of the hospital kitchen stores department were impressed and noted that the previous wastage of milk pergals and other stuffs diminished. Eventually the patients found that the system allowed them to vary the type of food stuffs they ordered and so they were able to ensure that their favourite foods could be procured and less popular stuffs could be deleted from the order.

The ward rep role therefore took on the added responsibility of ordering food and dry stores. Over the folllowing two years the ward rep role began to assume further responsibilities. Eventually the ward rep's responsibilities included ensuring everyone was up in time for the morning programme and co-facilitating the weekly introductory group for new residents with a member of staff. The ward rep also became responsible for ordering and distributing the linen (this included holding the key to the linen cupboard), ensuring the bedrooms were prepared for the new residents, attending the staff business meeting and organizing the morning cleaning group. Because of the increased sharing of administration it was felt necessary to institute an evening business meeting, which the ward rep would chair, in order to air issues and discuss organizational matters. These business meeting were held every evening at 18:30 hours lasting up to half an hour. One might say that these developments simply served to ease the load of the staff. However, in reality these development presented a tremendous challenge to the staff team.

The business meeting became a place where grievances were aired, but also a place where plans for events and outings would be made. During one business there was a dispute about which videos would be hired for the weekend. The discussion did not lead to an agreement and at the end of the meeting it was still not apparent which video would be most agreeable. A show of hands was suggested and as a consequence the most popular video was selected. This was the genesis of a system of voting which became increasingly pivotal to the community.

Atmosphere of Democracy

As the culture of the community matured the number of matters that came under the scrutiny of a democractic process increased. It was rarely necessary to have a formal show of hands, indeed this was used as a last resort if a consensus was not arrived at otherwise, but there was a growing awareness that a democratic vote was a tool for resolution. However, there were occasions when the staff found themselves in a position of suggesting that the discussions be elongated rather than resorting to holding a vote. At these times it seemed necessary to promote the spirit of discussion, persuading the residents that even though a vote would resolve a dispute or summon up at a decision quickly, that it was the value of the discussion that was still uppermost and fundamentally therapeutic. So, although voting was occasionally used, it was more emblemic of an atmosphere of democracy rather than being the all pervasive system of decision making.

Three years into the period I am describing the culture took a final up-turn towards democratic functioning. There were often occasions when a resident stretched one of the of the house rules. Although there was a clearly defined list of house rules which the residents agreed to prior to coming to into the unit, that basically stipulated that violence and drug use were grounds for discharge, the rules were fluid enough to allow for a number of grey areas. Although the ambiguities in the rules proved to be continually problematic, it was the working through of the finer points that often carried the greatest therapeutic currency. For instance, residents repeatedly stretching the boundaries by coming back late from passes aroused conflicts which often re-capitulated, in the transference, the patient's root family conflict. Deliberating over the conflicts in the here and now was on the one hand a diagnostic tool and on the other, an opportunity for a reparative experience, allowing an opportunity for the resident to negotiate the developmental task at hand rather more successfully than previously.

But on the occasions when the boundaries were overstretched beyond tolerance, the staff would take the decision to discharge the client. These banishments would always cause consternation. In the atmosphere of the growing empowerment of the clients it seemed wholly inappropriate for the staff to decide about these grey areas alone. The ward manager began to air doubts in the community about the autocratic way that some discharge decisions were made. Over a period of several months the ward manager and soon other staff began consulting the residents about decisions regarding discharging clients. The process was described as a consultative one because the nursing staff took the final responsibility for discharge. These consultations gradually became more formalized until a system evolved whereby the resident who had transgressed the boundaries would have his or her transgression discussed in a formal group. The resident would then be asked to leave the group and the rest of the group would vote on whether or not they felt the person should be discharged or not. At first this done by a crude show of hands but this was superseded by a system of balloting using slips of paper with each resident and member staff voting. The votes would then be counted by a member of staff and the ward rep.

This balloting system on major issues occurred on less than ten occasions in the following eighteen months. Sometimes the community voted for sanctions, for instance, for a resident to be grounded for a period. On two occasions the resident was voted out. Subjectively, it appeared that, on most occasions, the decision reached by the community as-a-whole was the one that the staff would have arrived at independently, and certainly the decision the ward manager would have made.

Therapeutic Impact

What was the impact of these developments where the living learning experience (Jones, 1968) increasingly embraced a democratic ideology? One important outcome to these developments was noted in the results of audits on the ward. In 1988, at the beginning of the phase described in the narrative, an audit showed that the average programme completion rate was only 1:8 and the bed occupancy was only 55%. Four years later the completion rate was 1:3 and the bed occupancy rate was averaging over 80%. This data is important on it's own. However the most important off-shoot of this cultural shift was the improvement in communication between the residents and the staff. There was a much more harmonious atmosphere on the unit where conflicts could be aired. The milieu became one of a greater level of containment. A deeper understanding of the dynamics of the nurse/patient relationships from a sociocultural perspective went hand in hand with a psychodynamic conceptualization of the process (for further discussion of these issues see; Winship et al, 1995).

It seemed crucial that the residents found that the things that they felt and the things that they said were listened to. The residents began to identify that they had power and authority to influence the world around them. Authority was not so much of a dirty word and it was not something that was alien to them in so far as one of their peers was invested with authority. Being in the role of authority was a new experience for most of the residents. Authority for most of them resonated with an experience of punishment from police, school teachers and, commonly, abuse from parents. The aggregate experience of authority that the clients brought to the community was therefore essentially a negative one. The ward rep system served to confront this conception of a punishing and retributional type of authority. The community's therapeutic task was to create, nurture and maintain a system where authority was disciplining but also caring and 'holding' too.

DISCUSSION

Democracy, as described in the narrative, emerged as part of the endeavour to harness and quell the destructive power of primitive urges that caused disequilibrium in the community. The impulses and primitive drives towards sadism and self destruction - the forces at the root of the pathological addiction to drugs - were confounded by the community will towards a more benign and reparative constitution of relations. The process was an evolutionary one where democracy occurred as a result of piece meal social architecture as Popper (1966) has described, rather than through a radical upheaval and overturning of established structures. The principle of a therapeutic community emerged out of the general development of the milieu rather than being stipulated by the staff. For the most part the changes happened rather quietly. Had the changes that were taking place come under the scrutiny of hospital policy making bodies or ethical committees, some of the developments may have been thwarted. Ethical dilemmas were apparent throughout. The change in the food system in effect meant that the patients were without their full quota of rationed food for a short period (Bion was sacked for far less at Northfield). Allowing patients to co-facilitate introductory groups and chair business meetings might be said to impose too high expectations on them, compromising their right to therapy. Indeed many patients often said that they wanted to be treated like a patient and not like a resident with responsibilities. A system wherein patients in hospital make their own beds would still seem to be a radical notion, and one which may be quite disagreeable to many nurses. And from a therapeutic perspective, certainly from an analytical perspective, it might be said that the high expectations of community living deprived the patients of an opportunity to regress. This, in point of fact, was not, however, the case. The patients were still able to reconnect with those parts of themselves which struggled to be adult, though this work was contained with the all important therapeutic sessions. Once the formal therapy was over the business of getting on with the daily living began. The task for the staff, like the residents, was that of wearing different hats, moving between levels of therapy.

The capacity of the group to work between these levels of therapy is perhaps best illustrated with the brief following vignette. The residents had written to the hospital's catering manager to raise some points of concern about the uncooked food that was sent to the unit and had invited him down to a business meeting. The catering manager on receiving the letter had been very angry and wrote to the ward manager saying that he did not think that it was correct for the patients to be writing to him directly. The ward manager was persuasive with the catering manager and pointed out that the residents were encouraged to take such action, that this was part of the therapeutic experience. The catering manager eventually agreed to come to the ward for the meeting with the residents. This was first meeting of what was to become a regular fixture in the administration of the ward. The meeting was a mutual opportunity for discussion about how to make the most efficient use of the resources, for example there was often an unecessary wastage of milk on the unit. The residents were also able to plan to make better use of the funds allocated for food by the hospital. Following the meeting the catering manager congratulated the ward manager and said he was most impressed with the residents who had behaved with great maturity. Indeed the ward manager was impressed by the residents maturity which was a source of some frustration as he was experiencing them in the small psychotherapy groups as rather truculent and badly behaved adolescents. This type of splitting may be criticized by some. However, the feeling of the staff was that the difficulties and conflicts were being increasingly contained within the all-important formal therapeutic sessions. The concommitant outcome indicators, such as the eradication of drug use on the ward, were a measure of the effectiveness of developing such a seemingly "split" approach.

The approach to developing this partnership cum group democratic process, a type of collectivism (cf; Winship, 1995) was based on a belief in the common integrity of the community members, an idea that resonates with Foulkes (1948) notion that a group has a propensity towards a healthy wholeness. Foulkes (1948) found that the process of free associative discussion enabled an interplay of opinion where "disruptive forces are consumed in mutual analysis, constructive ones utilized for the synthesis of the individual and the integration of the group as a whole" (p.31). The notion that human nature is underpinned by innate capacity towards goodness, as in Foulkes' philosophy, bears close parity to the philosophy outlined by Rustin (1991; 1995) in his work conjoining traditional sociological enquiry with psychoanalysis.

The atmosphere of democracy that emerged served to offer a containing structure where the clients were empowered to take adult responsibility for many day to day organizational tasks. This experience of empowerment for the clients became a workbench for exploration, although this living/learning experience was not divorced from the formal psychotherapeutic work that took place individually and in group sessions: Each client received at least two individual sessions per week, often more, and attended three formal small psychotherapy groups. The relationship between the adult experience of dealing with the not-always-welcome expectations of the community, arising from the process of empowerment, were counterbalanced by the opportunity to be supported through the experience in the individual and group therapy sessions.

Fear of the Collective Approach

Psychoanalytical group therapy, allied to the principles of the TC, applied to the organization of a ward community, proved to be a most useful approach to adopt, as described in the clinical narrative. However, it is apparent that there is a great fear of groups in psychiatric practice. It is often said that; "groups do more damage than good". And yet, in fifteen years of working in acute psychiatry with at times very disturbed and violent patients, I have only ever witnessed one violent incident taking place in the formal setting of a group therapy session (one incident of violence in some 4,000+ hours of formal group therapy). In several years of supervising nurses group work, I can not recall hearing about a violent incident happening in a group therapy session, even on wards where proportionate to the overall incidence of violence one would expect a random violent incident to occur in a group. I have always been struck by the effectiveness of the simple containing structure of placing chairs in a circle and asking very angry people to sit down with each other. And yet many nurses and many more doctors, feel a good deal of antipathy towards group work. I would suggest that the antipathy towards group work rests in a more ubiquitous fear of collectivism.

It is not just in psychiatry that there is a fear of collectives or people gathering together. The U.K.'s Criminal Justice Bill (clauses 63-66 especially) appears to be the latest vivid emblem of how a fear of the collective can lead to political manipulation. To say that the Criminal Justice Bill is likely to make it difficult to organise peaceful collective protests and gatherings in the future, while undoubtedly true, trivializes the magnitude of the social and cultural forces that have brought this bill about. This bill did not emerge from the Home Secretary, Michael Howard's mind alone, and was perhaps to some extent even a response to public will. The bill suggests that by incarcerating more people, the streets will be a safer place, appearing to offer a sort of social containment by dissolution.

I would like to flag up here some of the false assumption about collectives which I believe are at the root of the fear of the collectivism, and in order to examine whence such assumptions may derive I shall re-visit the cultural climate that was the backdrop for the early experiments in milieu and group therapy during the Second World War.

Sprinklings of the fear of mass mentality germinated in Freud's writing long before the rise of fascism in Germany. In some ways it could be said that Freud and others had predicted the very worst of mass mentality that emerged, mid-century, in the masses' fanatical allegiance to despotic rulers. In "Group Psychology and the Analysis of the Ego" (Freud, 1921) Freud quoted extensively from Gustave Le Bon's (1895, trans: 1947) study of group mentality. Le Bon believed that when people assembled in a mass they became less individually identifiable and more subject to a contagion of racially inherited behaviour - an instinctive driving force that caused a herd mentality. According to Reicher (1991), le Bon's wish to understand crowds was subsumed by his desire to tame them. Le Bon was not alone in his rather disparaging theory of the mass. In Germany Friederich Nietzsche (1892, 1961) concluded that; "Once spirit was god, then it was man, now it is even becoming mob". This was a culmination of his ideas about the herd mentality of the human condition first outlined in "Beyond Good and Evil" (1886). Nietzsche philosophised about the human condition against the back drop of an ever more industrialized Europe. He saw the new democratic European as being a useful, highly serviceable industrious herd-animal. However he warned that this emerging mentality would result in the involuntary breeding of new tyrants to lead the herd slave race. These tyrants, he said, would be men of a dangerous and enticing quality. Nietzsche was prophetic in his pessimism. Unfortunately his ideas were hi-jacked by Hitler and used to ill ends as Hitler hailed Nietzsche as the founding father of the third reich philosophy.

Whilst Freud agreed with the basic thesis of Le Bon's and Nietzsche's concept of the crowd and it's propensity towards a herd mentality, he added that it was necessary to distinguish between unseen forces dictating group behaviour emerging out of an ancestral racial inheritance, as Le Bon described, and the unconscious behaviour of "social anxiety" (p. 7) that emerged as a result of the mechanism of repression. Freud attempted to distinguish between that which was natural group behaviour and those aspects which could be understood as a pathological attachment to an idealized leader. Schematically, from this point, Freud developed his argument about transference (object love) in the group, the group reverie which he applied to his study of the church and the army.

The extreme transferential, infantile attachment to a leader that Freud noted was clearly manifest in the relationship between Hitler and the masses in Germany. Freud's negative view about mass mentality, following Nietzsche, was an intuit about the winds of change in Europe in the early twentieth century, that proved to be well founded. But not even Freud's worst fears of the herd mentality could have predicted the eventual outcome of the rise of fascism. In 1938 when Freud was evacuated from Vienna with his family it was a close call, in particular for Anna. Had she stayed for another twenty four hours in Vienna, which she very nearly did, she would have been arrested and sent to a concentration camp. In a resigned letter at the time Freud wrote that the human race had progressed because now they were only burning his books. In the middle ages, he quipped sardonically, they would have burned him. He did not live to see how wrong he was. Freud's misreading of the world around him is interesting because he has always been considered as a champion of pessimism about the failings of the human condition. Yet even in his most distressing moment of fleeing from his home to die in freedom, we can see that he maintained a kernel of benignness about the world around.

The twentieth century has seen the very worst of collective persecution. That is indeniable and something which will perhaps haunt the memory of our epoch forever. There is perhaps something, however, that we might learn from these atrocities. Philosophically, Hitler's vision of social organization might be described as the omnipotence of individualism, where; "The Strong Man is Mightiest Alone" (Hitler, 1924, 1992; p.462). Hitler believed that the mass was ripe for leading and that it was the revolutionary intent of individual figures that had shaped the course of history. His belief was that the elite should take their rightful place at the willing sacrifice of fundamental morale values. For instance he compared the workers' collectives as a bunch of cripples that were held together by a "belief that eight cripples joining arms are sure to produce one gladiator" (p. 469). Hitler went on to say that "one healthy man among the cripples ... used his strength just to keep the others on their feet, and this way he was himself crippled" (p.469). Hitler's belief that the strong individual should be supreme and the weak sacrificed was apparent throughout his political, cultural and social engineering. To say this philosophy was misguided and narrow would be to greatly understate the desperate legacy of his influence. Hitler's conception of social change fuelled and led by the ambition of an individual, or elite, with a devalued and dispensible collective, influences us still. The symmetrically alternate view, argued above, is of leadership emerging through a more gradual evolutionary process that is born out of, and is congruent with, the collective.

The suppression of the collective is the fount of social stagnation. Even Freud (1922) said that "...in certain circumstances the morals of a group can be higher than those of the individuals that compose it, and that sometimes only collectives are capable of a high degree of unselfishness and devotion". He postulated that there was powerful force holding the group together. He couldn't disagree that there was something child-like in the adhesive processes Le Bon described, but for Freud it was not solely an unruly child, more importantly it was a manifestation of the capacity for love that held the group together; "...and to what power could this feat be best ascribed other than to Eros, which holds everything together the world" (p. 24). So for Freud, it was love which, at best, underpinned the group's unity.

To summarize, I have suggested that a belief in the healthy wholeness of the group and society, where the forces of goodness and love are primary, is the basis for a vision of democracy, where there is an explicit and effective trust in the judgement of the people. I have shown also, through a clinical vignette, how this political philosophy can manifest in a treatment milieu, where the atmosphere of democracy in an evolving therapeutic community became an algorithm of patient empowerment, a process of working which I have called therapeutic collectivism.

It remains to be seen if it is possible to rescue the notion of the collective as something other than a negative force that reeks havoc upon civility. If the notion of collectivism is to be seen more positively then it will be necessary to re-appraise the predominance of individualism and move towards a more optimistic view of human nature constructed out of a mutual trust of each other.

REFERENCES

Austin, D (1994) Democracy and Violence in India and Sri Lanka. London. Royal Institute of International Affairs.

Bion, W R (1961) Experiences in Groups. London. Tavistock.

Brown, D (1985) Bion and Foulkes: Basic Assumptions and Beyond. Chapter in: Bion and Group Psychotherapy. p.192-219. Edited by Pines, M. London. Routledge.

Chomsky, N (1991) Deterring Democracy. London. Verso.

Crozier, A (1979) Attempts At Democracy. Chapter in: Therapeutic Communities. Reflections and Progress. [p.263-271]. Edited by Hinshelwood, R D & Manning, N. London. Routledge.

Dunn, J [ed] (1992) Democracy. The Unfinished Journey. 508 BC to 1993 AD. Oxford. Oxford University Press

Figlio, K (1989) Unconscious Aspects of Health and the Public Sphere. in; Crises of the Self. (Ed. Richards, B). London. Free Association Books.

Foulkes, S H (1938) Review of Uber den Prozess der Zivilization by Norbert Elias. Int J Psycho-Anal 19; 263.

Foulkes, S (1948) Introduction to Group Analytic Psychotherapy. London. Heinemann.

Freud, S (1921) Group Psychology and the Analysis of the Ego. SE 18.

Habermas, J (1989) The New Conservatism. Cambridge. Polity Press.

Hailsham, Lord (1978) The Dilemma of Democracy. London. Collins.

Jackson, M & Cawley, R (1992) Psychodynamics and Psychotherapy on an Acute Psychiatric Ward: The Story of an Experimental Unit. Brit J Psychiatry, 160; 41-50.

Jackson, M & Williams, P (1994) Unimaginable Storms. A Search for Meaning in Psychosis. London. Karnac.

Jones, M (1968) Social Psychiatry. London. Tavistock.

Mill, J S (1859) On Liberty. Harmondsworth. Penguin, 1974.

Freud, S (1921) Group Psychology and the Analysis of the Ego. SE 18.

Nietzsche, F (1886) Beyond Good and Evil. Translated by R J Hollingdale (1973) - Penguin Books. Harmondsworth.

Nietzsche, F (1892) Thus Spake Zarathrustra. Translated by R J Hollingdale (1961) - Penguin Books. Harmondsworth.

Pines, M [editor] (1983a) The Evolution of Group Analysis. London. Routledge.

Pines, M (1983b) The Influence of S H Foulkes. Chapter in: The Evolution of Group Analysis. p.265-285. Edited by Pines, M. London. Routledge. 1983.

Pines, M [editor] (1985) Bion and Group Psychotherapy. London. Routledge.

Plato (1955) The Republic. London. Penguin.

Popper, K R (1945) The Open Society. Vol. I. London. Routledge.

Rappoport, N. (1960) Community as Doctor. London. Tavistock Routledge.

Reicher, S (1991) Politics of Crowd Psychology. The Psychologist. 14, 11; 487-491.

Richards, B (1987) Images of Freud. London. J M Dent & Sons.

Rustin, M (1991) The Good Society and the Inner World. London. Verso.

Rustin, M (1995) Lacan, Klein and Politics: The Positive and Negative in Psychoanalytic Thought. Chapter in: Psychoanalysis in Contexts. [p.223-245]. Edited by Elliot, A & Frosh, S. London. Routledge.

Rustin, M & Rustin, M (1983) Relational Preconditions of Socialism. Chapter in: Capitalism and Infancy. p.207-225. Edited by Richards, B. London. Free Association Books.

Winship, G (1995) Patient empowerment - Individualism v Collectivism. Therapeutic Communities, 16, 1; 113-116.

Winship, G; Harnimann, B; Burling, S; Courtney, J (1995) Countertransference and Object Relations in the Process of Nursing Drug Dependant Patients. Psychoanalytic Psychotherapy, 9, 2; 195-207.