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Civilizing the Barbarian Journal of Nursing Management, 2011, 19, 293–301 Civilizing the ÔBarbarianÕ: a critical analysis of behaviour modification programmes in forensic psychiatry settings 1 2 DAVE HOLMES PhD RN and STUART J. MURRAY PhD 1Professor and University Research Chair in Forensic Nursing, School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada and Visiting Professor, Faculty of Health & Social Care, University of Chester, Chester, UK and 2Associate Professor of Rhetoric, Department of English, Ryerson University, Toronto, ON and Assistant Professor, Social and Behavioural Health Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada Correspondence HOLMES D. & MURRAY S.J. (2011) Journal of Nursing Management 19, 293–301 Dave Holmes Civilizing the ÔBarbarianÕ: a critical analysis of behaviour modification University of Ottawa programmes in forensic psychiatry settings Faculty of Health Sciences 451 Smyth Road Aim Drawing on the works of Erving Goffman and Michel Foucault, this article Ottawa presents part of the results of a qualitative study conducted in a forensic psychiatry ON setting. Canada K1H 8M5 Background For many years, behaviour modification programmes (BMPs) have E-mail: [email protected] been subjected to scrutiny and harsh criticism on the part of researchers, clinicians and professional organizations. Nevertheless, BMPs continue to be in vogue in some ÔtotalÕ institutions, such as psychiatric hospitals and prisons. Method Discourse analysis of mute evidence available in situ was used to critically look at behaviour modification programmes. Results Compelling examples of behaviour modification care plans are used to illustrate our critical analysis and to support our claim that BMPs violate both scientific and ethical norms in the name of doing Ôwhat is bestÕ for the patients. Conclusion We argue that the continued use of BMPs is not only flawed from a scientific perspective, but constitutes an unethical approach to the management of nursing care for mentally ill offenders. Implications for Nursing Management Nurse managers need to be aware that BMPs violate ethical standards in nursing. As a consequence, they should overtly question the use of these approaches in psychiatric nursing. Keywords: adverse event, behaviour modification programme, ethics, forensic nursing, management, psychiatry Accepted for publication: 20 October 2010 The disciplinary institutions secreted a machinery Medicine is a power-knowledge that can be ap- of control that functioned like a microscope of plied to both the body and the population, both conduct; the fine, analytical divisions that they the organism and biological processes, and it will created formed around men an apparatus of therefore have both disciplinary effects and regu- observation, recording and training. latory effects. Foucault, 1979, Discipline and Punish Foucault, 2003, Society Must Be Defended DOI: 10.1111/j.1365-2834.2011.01207.x ª 2011 The Authors. Journal compilation ª 2011 Blackwell Publishing Ltd 293 D. Holmes and S.J. Murray caultÕs sense of the term, forensic psychiatry settings Introduction operate as an integrated State apparatus (dispositif) that The present study examines the management of forensic comprises multifaceted and interrelated administrative, psychiatric nursing care and the use of behaviour mod- social, political and ethical systems (bringing together the ifications programmes (BMPs) in the discipline and reg- healthcaresystemandthepenalsystem,forinstance).State ulation of patient behaviour. As the name suggests, apparatuses are carefully designed to achieve specific BMPs are schemes designed to improve or correct macro-social objectives (treatment, education and pun- particular micro-behaviours to bring them into line with ishment, etc.) while being permeated by webs of power macro-social norms and expectations. More euphemis- relations. Although the macro-social functions of these tically, they are sometimes called ÔRewards ProgrammesÕ institutions are publicly known, in the present article we or ÔIncentives and Earned PrivilegesÕ (Liebling 1999). suggest that a critical analysis of BMPs in forensic psy- BMPs are a form of psychological conditioning based on chiatry settings will help expose the manner in which the work of the American behaviourist B. F. Skinner. institutional power is wielded, calling into question the Theoretically, the patient is (re)socialized through a scientific and ethical basis of the micro-practices we see system of positive and/or negative reinforcement, usually at work. on the basis of a token economy, where ÔpointsÕ (for The present article therefore hopes to shed light on example) are earned or lost, and can be exchanged for the tensions that arise when therapeutic ideals operate ÔrewardsÕ. Forensic psychiatry settings are Ôtotal institu- within the punitive setting of a prison, when care comes tionsÕ which provide the perfect laboratory because face to face with incarceration. The implementation and environmental conditions can be tightly controlled. In management of BMPs provides a prime instance where these settings, simple Ôlife rewardsÕ and basic necessities two contradictory ideals collide. Here, we might say can be offered or withheld as a ÔrewardÕ or ÔpunishmentÕ, that the body of the condemned (in Foucauldian par- positive or negative re-inforcers. While Gendreau (1996) lance) is doubled: known as ÔpatientsÕ to allied health argues that the most effective ratio of positive to negative professionals and ÔinmatesÕ to correctional staff, a new, reinforcement is 4 : 1, in total institutions we suspect apparently neutral, term had to be invented to describe that the inverse ratio obtains, as operant conditioning these individuals: ÔresidentsÕ. But it is not just the Ôneu- extends and adapts the punitive model already in place at tralizedÕ body that is doubled through the various the prison. In any case, in these settings it is often difficult identities or roles that it takes up: the ÔresidentÕsÕ body is to distinguish positive from negative re-inforcers in any not just the body of a patient subjected to medical and unequivocal sense (there might be a negative ÔrewardsÕ nursing knowledge and not just the body of a prisoner scheme, for instance). As we shall demonstrate, even subjected to incarceration and punishment; while the relationships themselves are invested and mobilized as body of the condemned is undoubtedly the target of a tokens of exchange in the everyday complexities, net- disciplinary apparatus (nursing management, medical works and discrepancies of prison/hospital life. As science and corrections), the ÔresidentÕ is also – and nursing staff are enlisted to implement and supervise perhaps foremost – a member of a society, a social these programmes, they too become caught in the prac- body, a being who shares in the lives of other resi- tical dispositions of power, privilege and punishment: dents, building relationships with them and with the they become agents of a moral orthopaedics. prisonÕs correctional officers, as well as with allied Prisons, penitentiaries and psychiatric hospitals health staff (indeed, psychotherapeutic rehabilitation (including their related nexus) are thought to be signs of requires this). It seems to us that while BMPs appear to modernity and civilization. These institutions help to shore up a residentÕs autonomy, rational decision- mediate the individualÕs relation with the state and making or even his individualism and entrepreneur- society, performing managerial roles through sanitary ialism, in actuality BMPs target distinctly social and political techniques, ideally for the benefit of those behaviours that are relational, value-laden and that being managed. While forensic psychiatry settings are take place in context. meant to provide care for mentally ill offenders, at the As we argue below, these relations extend beyond the same time they are places where captive patients are function of ÔdisciplineÕ, in FoucaultÕs sense of the term, held against their will and where penal sanctions hold to treat the population in its generality. According to sway. Forensic psychiatry patients therefore exist in Foucault, we suggest that this second form of power limbo, between care and incarceration – between lar- should be understood as biopolitical, it is powerÕs hold gely incommensurable techniques and objectives. Given over life itself, and it must be distinguished from disci- their broad social function and legal mandate, in Fou- plinary power: 294 ª 2011 The Authors. Journal compilation ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management, 19, 293–301 Civilizing the ÔBarbarianÕ this technology of power, this biopolitics, will tutions with the use of BMPs. Although this interven- introduce mechanisms with a certain number of tion was (and is still to a certain extent) celebrated as functions that are very different from the func- the new and more humane treatment strategy, critical tions of disciplinary mechanisms. The mechanisms literature has raised concerns regarding this practice, introduced by biopolitics include forecasts, sta- labelling it as inhumane, debilitating and infantilizing. tistical estimates, and overall measures. And their One professional organization after another has Ôre- purpose is not to modify any given phenomenon counted the abuses and denounced the barbarismsÕ as such, or to modify a given individual insofar as (Rothman 1975, p. 18) of total institutions where BMPs he is an individual, but,
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