Journal of 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, , Ottawa, ON, Canada and Visiting Professor, Faculty of Health & Social Care, , 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 , , 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 , 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

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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:

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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, essentially, to intervene at are deployed. Despite this criticism, BMPs continue to the level at which these general phenomena are be used within psychiatric and correctional settings. determined…. [R]egulatory mechanisms must be Some psychiatrists, psychologists, social workers and established to establish an equilibrium, maintain nurses continue to believe that operant conditioning an average, establish a sort of homeostasis, and holds the key to effective treatment. compensate for variations within this general In brief, our research design involved ethnographic population and its aleatory field. In a word, principles, including semi-directed interviews, field notes security mechanisms have to be installed around and document analysis (mute evidence). In the present the random element inherent in a population of article our analysis is limited to the mute evidence living beings so as optimize a state of life. (Fou- gathered in the course of our fieldwork. Drawing on cault 2003, p. 246) FoucaultÕs double understanding of bio-power as disci- plinary and biopolitical, coupled with Erving GoffmanÕs So we have two axes of bio-power at play: disci- sociological analysis of total institutions, this article plinary power, which takes the individual as its object, emerges from qualitative research conducted in a and biopolitical power, which takes the life of the Ôstate-of-the-artÕ secure forensic psychiatry institution population as its means and its end, Ôlife as both its operating under the authority of a provincial justice sys- object and its objectiveÕ (Foucault 2003, p. 254). Thus, tem in Canada. Using a number of key documents gath- while BMPs seem to act directly on the individual, in a ered in the course of data collection, we assess the use of disciplinary sense, they must also act biopolitically – a BMPs from a political and an ethical standpoint, dem- dimension that is rarely discussed in the literature. We onstrating not only how a disciplinary bio-psychiatric cannot say that these two axes of bio-power map neatly model permeates several aspects of the management of onto the two management ÔstylesÕ found in forensic nursing care in forensic psychiatry, but also how, in the psychiatry settings (i.e. care and incarceration), but ra- quest ofdoingÔwhatis bestÕforthepatientsinterms ofcare ther, that nursing staff in particular find themselves and rehabilitation, nurses become part of a machine that imbricated in both axes of bio-power, just as they find harms rather than heals. themselves involved in practices associated with cor- rections, and not just healthcare (the line between ÔcorrectionsÕ and ÔhealthcareÕ is often fluid). BMPs are Theoretical framework located at this complex juncture, they provide an alle- gory for the tensions of prison/hospital life, and so we In this section we turn to the work of Goffman and must complicate this scene in order to give a more just Foucault to describe how power operates in forensic account of the myriad factors at play as well as the psychiatry settings, one instance of what Goffman ethical implications of BMPs as they feature as part of a calls Ôtotal institutionsÕ. These perspectives offer a treatment plan. strong framework for analysis (Lagrange 1976). Hack- Throughout the 1970s and 1980s, BMPs were used ing (2004) suggests that FoucaultÕs ÔarchaeologyÕ and widely in the psychiatric domain after being developed GoffmanÕs interpersonal sociology are complementary. and popularized by psychologists in the post-World Using a Ôbottom-upÕ approach, Goffman (1961) studied War II period (Rothman 1975). Interventions aimed at the internal structure and function of Ôtotal institutionsÕ correcting deviant behaviours were regarded and con- but did not situate them within a larger (macro) per- tinue to be regarded (in specific settings) as a Ôproper use spective. GoffmanÕs micro-sociological perspective is of authorityÕ (p. 17); as a consequence, many total thus useful in describing and analysing social relation- institutions have made BMPs one of their preferred ships between the many different actors of Ôtotal insti- techniques to correct deviance and to reform patients/ tutionsÕ, especially the interactions between staff and prisoners. Indeed, we commonly associate total insti- patients/inmates.

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From a Foucauldian Ôtop-downÕ or systemic perspec- ÔunitsÕ or cells or seclusion rooms, for instance) through tive, practitioners such as psychiatrists, psychologists, the analytical arrangement of architectural space; he is social workers and nurses might be understood as bol- measured against a norm. Discipline, Foucault writes, stering state apparatuses by implementing and provid- Ôtries to rule a multiplicity of men to the extent that their ing crucial power/knowledge in order to shape and multiplicity can and must be dissolved into individual transform human material (Ransom 1997). As such, bodies that can be kept under surveillance, trained, health care professionals working in forensic psychiatry used, and, if need be, punished, (Foucault 2003, p. 242). settings are directly involved in what Foucault calls the Knowledge and power operate to justify and legitimate discipline of individuals at the anatomo-political level one another, forming a practically unitary phenomenon (at the level of the body) (Foucault 1978). In his dis- Foucault calls Ôpower/knowledgeÕ. cussion on discipline, Foucault deploys the model of While disciplinary bio-power treats the individual Jeremy BenthamÕs panopticon, a prison structure orga- body and ÔindividualizesÕ that body anatomo-politically, nized around a central watchtower, with prisonersÕ cells as we mentioned above Foucault also points to a second arranged concentrically so as to afford the guard(s) a axis of bio-power that he describes as biopolitical – that direct line of sight into the cell, while preventing pris- is, a power that treats the life of the population or ÔmassÕ oners from seeing the guard(s) or seeing and commu- more generally, according to weights and measures, the nicating with each other. While the panopticon serves principles of risk management, statistics and probabil- as a metaphor for the ways that disciplinary power ities, management techniques and policies to control operates, we found this architectural structure dupli- random events, etc. not so much as to discipline indi- cated in the forensic psychiatry setting, where a cen- viduals but to regulate and regularise a specific group trally-located glassed-in nursing station (which nurses and its social relations. And while disciplinary power is call Ôthe bubbleÕ) affords views down radiating corridors Ôthe easier and more convenient thing to adjustÕ (Fou- and into the shared Common Room. The architecture is cault 2003, p. 250), biopolitics is more subtle and dif- significant for its effects on the prisoner/patient, as fuse because it intervenes ontologically, at the level of Foucault describes: ÔHe who is subjected to a field of life itself. Under biopolitics, then, the function of med- visibility, and who knows it, assumes responsibility for icine and nursing is regulatory, turning to Ôpublic hy- the constraints of power; he makes them play sponta- giene, with institutions to coordinate medical care, neously upon himself; he inscribes in himself the power centralize power, and normalize knowledgeÕ (Foucault relation in which he simultaneously plays both roles; he 2003, p. 244). What emerges is Ôa new body, a multiple becomes the principle of his own subjectionÕ (Foucault body, a body with so many heads that, while they might 1979, pp. 202–203). Because the inmate never knows if not be infinite in number, cannot necessarily be countedÕ or when he is being watched, he becomes the object of (Foucault 2003, p. 245). For an extreme example of his own surveillance, internalizing the disciplinary gaze biopolitical intervention we might look to eugenics in his ÔsoulÕ: ÔThe soul is the effect and instrument of a programmes, with their reticulate and capillary vectors political anatomy; the soul is the prison of the bodyÕ of political power and moral duty – intersecting State, (Foucault 1979, p. 30). This process does not require biomedical and popular discourses on race and hygiene consent; the question of consent is pre-empted from (Nazi Rassenhygiene), on the high socioeconomic ÔcostsÕ the start because these disciplinary systems are defined of preserving the unproductive lives of the weak, the as self-justifying, as Ôlegitimate and unobjectionableÕ mentally handicapped, the homosexual, the Gypsy, the (Ransom 1997). Jew and other Ôlife unworthy of lifeÕ (Lebensunwertes The disciplinary systemÕs legitimacy is tied to the Leben).Andironicallyenough,itisinthenameofÔlifeÕthat scientific knowledge that the apparatus enables, deploys all manner of atrocities can be justified and legitimated. and produces, in an almost circular fashion. Power and The point here is that biopolitics relies on complex, knowledge form a unitary structure: Ôthe Panopticon interrelated and totalizing technologies and techniques, was also a laboratory; it could be used as a machine to coupled with a deeply moralistic understanding of ÔlifeÕ. carry out experiments, to alter behaviour, to train or In Ôtotal institutionsÕ, pervasive disciplinary and bio- correct individualsÕ (Foucault 1979, p. 203). Here we political technologies and techniques ultimately strip see that discipline works by individualizing. Not only individuals of agency through a complex and powerful are individuals separated from each other, the individ- Ômortification processÕ, where they ÔdieÕ from their old ualÕs symptoms and behaviour are observed, taxonom- lives and are Ôre-bornÕ (as it were) into the life of the ized and classified (according to DSM-IV diagnoses, for institution. This process is said to be successful when instance); he is medicated, he is organized (in individual inmates have internalized institutional rules (Goffman

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1961). The mortification process is not a matter of healthcare is subordinated to Ôcorrectional servicesÕ, acculturation or assimilation of one group under the does the quality of that care suffer? In its discussion of auspices of the total institution, but is something ÔpriorityÕ and its promotion of a two-tier system, the more pernicious still. In effect, the forensic psychiatry Policies and Procedures Manual clearly defines the patient comes into the institution with a specific goals of ÔcorrectionsÕ and the goals of mental health care representation of himself; upon admission, he is stripped as incommensurable – or, if they are commensurable, of his ÔdomesticÕ reference schemes and mortified we are led to believe that such a plan is worth neither through procedures and standardized plans of care. ÔIn the effort nor the expense. the accurate language of some of our oldest total insti- In the same manual created by the institution, the tutions, he is led into a series of abasements, degrada- stated objective of the forensic psychiatry facility is to tions, humiliations, and profanations of self… and his provide care and treatment for mentally ill or disordered self is systematically, if often unintentionally, mortifiedÕ offenders. However, the specific objectives are as fol- (Goffman 1961, p. 14). The mortification process is a lows: Ôto improve reintegration into the community on standard(ized) procedure in total institutions epitomized release and to reduce re-offending rates and/or further in prisons and psychiatric institutions. InmatesÕ personal admissions to mental health facilitiesÕ (Institution Name, belongings are taken away from them while institutional Policies and Procedures Manual, 1997/2010, p. 1). Here, substitutes are provided (Goffman 1961). In short, a ÔcorrectionalÕ language once again takes priority, and standardized defacement occurs. mental illness is linked explicitly to Ôoffending ratesÕ, The encompassing or ÔtotalÕ character of total institu- suggesting that a patientÕs mental health care is not the tions is symbolized by the barrier to social intercourse unitÕs primary concern. Under the rubric of the Program with the outside world that is often built into the archi- Description, the following assumptions are outlined: tectural design: locked doors, high walls, barbed wire, • hospital standards of health care will allow offenders cliffs and water, open terrain and so forth. In forensic to receive needed (psychiatric) care; settings, for instance, almost every aspect of the patientsÕ • development of all aspects of the forensic psychiatry daily life is strictly controlled and monitored. And yet, facility programme will be synergistic with Research these are also social environments, which presents an- and Education to create a rich environment for health other problem for management to devise techniques to care delivery and advancements; control and monitor sociability itself. We have suggested, • standards of practice will include standards specified then, that not only is disciplinary bio-power at play in in the legislation (Mental Health Act), the standards these settings, but the logics of biopolitical power are of practice set by each disciplineÕs College; and the pervasive, as the social life of the population is both an patientÕs care set by the hospital; object and an objective, always with an eye to rehabili- • the staff will be employees of the hospital and will be tation and reintegration into the ÔnormalÕ population, Ôon subject to credentialing and peer review; the outsideÕ. Nowhere is this tension more palpable than • the mental health services provided by the unit will be in the implementation and management of so-called subject to external review through the Canadian ÔscientificÕ regimens and treatment plans, such as BMPs. Council of Health Services Accreditation process. In addition to these principles, a strict code of ethics Research findings (Institution Name, 1997/2010) applies to all individuals The wider research project took place in a (forensic) who work, volunteer or study at the hospital (as part of psychiatry unit of a Canadian provincial correctional a large university-teaching hospital). Despite the rhe- institution. torical purpose of these official documents, however, it At the outset, it is important to note that, according is difficult to explain the following passage from an to the Policies and Procedures Manual, the facility is internal document, which stands at odds with the Ôfirst and foremost a correctional institutionÕ and that principles presented above: Ôthe operational needs of correctional services and The Ministry of Justice and Corrections (MJC) the administration of justice… will have priority in will continue to be responsible for all offenders the manner in which the Ministry of Correctional and will contract the hospital for the provision of Services approaches its relationship with the hospitalÕ mental health assessment and treatment ser- (Institution Name, Policies and Procedures Manual, vices…. In summary, the responsibility for provi- 1997/2010, p. 1; emphasis added). This statement sion of treatment services will fall under the speaks to the hybridity of the setting under study. When

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jurisdiction of the hospital as outlined by the Segregation, the patient persists with Type 1 behaviour, Ministry of Justice and Corrections in its contract; it is then considered as Type 2. while the MJC maintains ultimate responsibility Type 2 behaviours include Ôrefusing to comply with a for the care, safety, and security of all offenders. direct orderÕ, Ôverbal aggressionÕ, Ôdamage to government (Institution Name 1997/2010, p. 6) propertyÕ, Ôinterfering with other residentsÕ treatmentÕ, Ôsexual activityÕ, ÔtouchingÕ and Ôcreating or inciting a In other words, once again we see that mental health disturbance likely to endanger the institutionÕ. These care is subordinated to correctional services. This ten- behaviours lead to segregating the patient in his cell for sion is dramatized in those departments of the forensic 24 hours, with permission to come out restricted to psychiatry facility where BMPs are privileged. The meals, medications and assigned programmes. The pa- BMPs presented in the present article reflect disciplinary tient is then submitted to a ÔReintegration ProgrammeÕ and biopolitical techniques used by nursing and cor- during which time he remains in his cell at all times for the rectional staff in order to eliminate what are deemed first 72 hours, except for 1 hour in the morning and inappropriate or dangerous behaviours and to inculcate 1 hour in the afternoon or evening, during which time he new behaviours deemed more acceptable. may go to the Common Room. During the next 96 hours, this is upgraded to 2 hours in the morning and 2 hours in the afternoon or evening. If there are no further incidents, The deployment of BMPs within the forensic the patient can then reintegrate into the unitÕs routine. psychiatry units Type 3 behaviours include Ôthreats to othersÕ and Our data revealed that three out of four units were Ôphysical aggressionÕ, which leads to confinement until a sites where BMPs are employed (not including the psychiatrist can perform an assessment. If the patient is admission/evaluation department). Not all patients clinically determined not to require seclusion, and if the were subjected to this medical/nursing regimen but the correctional staff do not place him in segregation, he is potential for large-scale application of this form of then confined to his cell for 48 hours except to attend treatment was sufficient enough to develop Ôbehaviour therapeutic programmes. He begins the Reintegration plansÕ for each of these departments. The behaviour Program described above. If, at any step, the patient plans for departments X, Y, and Z have been devel- engages in inappropriate behaviours, he returns to the oped to Ôassist residents in managing appropriate previous step. behaviours interfering with their treatment and treat- Internal documents state that patients need to recog- ment of co-residentsÕ (Hospital Institution, Internal nize the unit Ôas a good experience, which will be helpfulÕ Document, 2009, p. 1). Although all departments were to them. BMPs are thus presented as a way to defuse bound by this objective, slight differences were found situations, to avoid acting out and to promote alternative amongst them. behaviours. Patients are also encouraged Ôto make sug- BMPs constitute a regimen that specifies how the gestionsÕ and to work together with staff Ôto avoid trou- residentsÕ time, access to other parts of the unit and bleÕ. However, these documents go on to state that specific rewards are managed. Problematic behaviours cooperation is expected. Time outs, which are reminis- are categorized as Type 1, Type 2 or Type 3, as the cent of childrenÕs discipline, Ôwill be used by staff when- behaviours escalate. Type 1 behaviours are listed under ever they feel the situation needs it at their discretionÕ. general designations, some of which are left to the dis- cretion of correctional or nursing staff, such as Ôinap- Discussion propriate dress codeÕ, Ôhorse playÕ and ÔteasingÕ. Others include arm wrestling, gambling, tapping the window It should be relatively easy to see how BMPs strategi- of the nursing station to capture the staffÕs attention, cally deploy an ÔindividualizingÕ disciplinary bio-power, trading food and Ôcrossing the yellow lineÕ, which refers while the biopolitical aspects of this management to a mark on the floor behind which patients are to strategy may seem somewhat more abstract. But BMPs stand at all times when interacting with staff. Type 1 are designed to intervene at the level of a residentÕs behaviours lead to an ÔAdministrative SegregationÕ social life, reshaping his social relationships, his soci- (essentially, a Ôtime outÕ: a number of hours spent alone ality in general and to modify it to fall within the ac- locked in the residentÕs cell, with no permission to leave cepted norms of the population at large. BMPs rely on a until directed to do so by staff) and counselling by nurses token economy, an economy of exchange that operates in order to address the behaviour and suggest alternative according to the principles of the market economy – so behaviours. If, despite counselling and Administrative this is a particular kind of socialization. It is no surprise,

298 ª 2011 The Authors. Journal compilation ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management, 19, 293–301 Civilizing the ÔBarbarianÕ then, that Foucault devotes a large part of his lectures for Type 2) – depending on a particular nurseÕs reaction on biopolitics (Foucault 2008) to neoliberal economies, in a given instance. Is this arbitrariness a positive or as neoliberalism has become the dominant ideology negative reinforcer? And what are the wider (counter-) governing our democratic populations. BMP strategies therapeutic effects when the interpersonal relationship undoubtedly look beyond the forensic setting towards between nursing staff and residents is shaped Ôeconomi- macro-social values and norms, as the stated goal of the callyÕ, through the threat of punishment and the loss of unit is Ôto improve reintegration into the community on ÔrewardsÕ? Will this build trust and confidence in the release and to reduce re-offending rates and/or further residentÕs sociability, or will it not encourage him to admissions to mental health facilitiesÕ (Institution Ôwork the systemÕ through the cold, economic calcula- Name, Policies and Procedures Manual, 1997/2010, tion of a cost–benefit analysis (something we praise in p. 1). Therefore, these do not constitute neutral insti- the business world)? A hegemonic theory of consump- tutional settings in which care takes place free from the tion is presumed throughout, and ÔcriminalÕ activity is larger influences that operate within society. And it is redefined as any behaviour that is an ÔinvestmentÕ, where no surprise that management strategies have silently a certain ÔprofitÕ is hoped for, but that carries a certain appropriated the biopolitical logic that governs our measurable ÔriskÕ of penal sanctions understood in eco- neoliberal democracies – where individuals are seduced nomic terms (Foucault 2008, p. 253). into seeing themselves as Ôhuman capitalÕ within a sys- The management of nursing care, as far as BMPs are tem that calculates, quantifies and otherwise measures concerned, participates in the Ôbuilding of a world all manner of human relationships according to the around these minor privilegesÕ, according to Goffman, terminology of the ÔfreeÕ market. In FoucaultÕs words, which Ôis perhaps the most important feature of inmate neoliberalism Ôextends the economic model of supply culture, and yet it is something that cannot easily be and demand and of investment-costs-profit so as to appreciated by an outsider, even one who has previ- make it a model of social relations and of existence ously lived through the experience himselfÕ (Goffman itself, a form of relationship of the individual to himself, 1961, p. 50). BMPs therefore cannot and do not work time, those around him, the group, and the familyÕ as part of a Ôcare planÕ if mental health care involves (Foucault 2008, p. 242). The extent to which we ÔfreelyÕ restoring the patientÕs sense of autonomy, real or sym- appropriate this model is questionable, although it is bolic; BMPs are infantilizing, they work through petty now the ÔnormÕ; however, it is worth repeating that the privileges. While BMPs allow the forensic psychiatry token economies of the forensic setting are imposed patient to exercise some control over acquiring rewards absolutely on residents, they are coercive rather than and privileges, or avoiding punishments, this infantile ÔincentiveÕ programmes, and residents have not been world is hardly analogous to the real world, and hence involved in their creation. at cross-purposes with Ônursing careÕ if the ultimate Thus, while BMPs might appear to ÔindividualizeÕ objective is Ôto improve reintegration into the commu- residents in a positive way, compelling them to be nity on releaseÕ. Any autonomy the forensic psychiatry responsible for themselves, to foster a deeply Ôentrepre- patient does experience is a false autonomy, as it is clear neurialÕ spirit in relation to their own self-management, that his submission to institutional order is total. as well as to better socialize themselves, we must bear in Certainly, some will argue that BMPs are therapeutic, mind that these are not workers freely joining an em- even if they are from some perspectives ÔinfantilizingÕ. ployee incentive programme, nor are they consumers By analogy, one might argue, parents must take some signing up for a retailerÕs rewards scheme. Indeed, rather unpopular – even punitive – decisions with re- workers are rewarded for their productivity or out- gard to the care of their children. But in the wider comes, which might bear little relation (or perhaps even context, in the fullness of time, children come to realize an inverse relation) to their social skills or sociability in that these decisions are usually loving and protective, general. Similarly, retail rewards schemes are based on a guiding the child as she or he develops into a fully customerÕs loyalty, and customers are free to shop else- autonomous being in her or his own right. It is ques- where. Here, instead, the residentsÕ social behaviours are tionable, however, to what extent the parent–child being regulated according to a points system that is analogy holds in the context of a prison, where the standardized, one-size-fits-all: the same number of relationship is between keeper and kept, or in the con- points is lost for the same offence, and these rules apply text of a therapeutic relationship, between a healthcare equally to every resident in the population, while the provider and his or her mentally ill or disordered pa- severity or leniency of enforcement is at times arbitrary tient/client. These residents are not children. Where the (ÔdiscretionaryÕ) for Type 1 violations (and less explicitly child grows and learns to interpret a parentÕs decisions

ª 2011 The Authors. Journal compilation ª 2011 Blackwell Publishing Ltd, Journal of Nursing Management, 19, 293–301 299 D. Holmes and S.J. Murray as she or he gains experience in her or his own decision- lack sufficient autonomy and willpower: they do not making processes, the resident lacks that luxury, he has want to change. But this view ignores the wider forces neither the time nor the place to experience something at play in the formation of the individual; it refuses to similar; he is apt to experience nursing staff as incon- begin to take account of the myriad socioeconomic, sistent, if not cruel. He will not see beyond the prisonÕs political and environmental factors – the conditions – walls. As Foucault writes, ÔIt is not the family, neither is that have contributed to the patient being where he is it the State apparatus, and I think it would be equally today. In most cases, these individuals lack infrastruc- false to say, as it often is, that asylum practice, psy- tural support, the conditions in and through which an chiatric power, does no more than reproduce the family act of sovereign will seem possible. To speak of these to the advantage of, or on the demand of, a form of individuals as ÔautonomousÕ, to hold them to the State control organized by a State apparatusÕ (Foucault Ôprinciple of autonomyÕ, could itself be regarded as a 2006, p. 16). violent demand, one that might be incomprehensible to Consequently, we must call into question the func- someone who lacks the mental and emotional – not tional notion of ÔautonomyÕ that circulates in the dis- to mention financial, institutional, familial, etc. – course on the effective management of residents in resources necessary for comprehension. It would be an forensic settings and in the use of BMPs to foster ethical unethical practice, then, to place this individual in a comportment amongst residents and in relation to those situation in which ÔautonomyÕ is demanded, and, as we with whom they share – and will share – a social life. stated above, perhaps it is time to question the nor- Mainstream biomedical ethics tend to privilege one mative force of this term as desirable in and of itself (for notion of autonomy as the founding principle of ethics instance, how ethical is the economic model that it (Beauchamp & Childress 2008). But forensic psychiatry presumes?). But it is perhaps worse to place him in an settings are not places where autonomy is encouraged. institutional context governed by BMPs. Even if BMPs In effect, as Goffman clearly states, Ôtotal institutions give the illusion of fostering a sense of autonomy, they disrupt or defile precisely those actions that in civil understand ÔautonomyÕ only in a limited and impover- society have the role of attesting to the actor and those ished sense, and they fail to acknowledge or to begin to in his presence that he has some command over his redress some of the wider infrastructural conditions of world – that he is a person with ÔadultÕ self-determina- mental illness, crime and their connections. BMPs rep- tion, autonomy, and freedom of actionÕ (Goffman 1961, resent the perfect example of a bio-psychiatric model p. 43). But a critical approach to ethics will delve fur- that has gone uncontrolled, where symptoms are treated ther still, asking what we mean by ÔautonomyÕ as we and underlying causes ignored. Not only is this treat- continue to use the word so freely: a critique would ment unethical and ineffectual in the real world, not question the ideals of neoliberalism, calculative reason only is its refusal to see the underlying causes tanta- and Ôrational choice theoriesÕ, and it would look beyond mount to professional negligence, we assert that this the kinds of ÔindividualsÕ produced by disciplinary bio- form of ÔtreatmentÕ undoubtedly exacerbates certain power to begin, instead, with the intimate and often forms of mental illness while causing others – what fragile social relationships without which ÔethicsÕ is Illich (1976/1995), in his classic text, has called clinical meaningless, without which it is reduced to just one and social iatrogenesis. more management strategy. It is for this reason that we ÔThe barbarian…is someone who can be understood, have emphasized the biopolitical valences of BMPs, for characterized, and defined only in relation to a civiliza- it is here, where one intervenes in the life of a popula- tion, and by the fact that he exists outside itÕ (Foucault tion, a life that is first and foremost a shared life, that 2003, p. 195). Civilization needs its barbarians; indeed, we must begin again if we hope to imagine an ethics civilizational norms are defined in contradistinction to that would be commensurable with the lives of these barbarism, and vice versa – barbarism is civilizationÕs inmates, patients – ÔresidentsÕ – and the lives of those constitutive outside. Civilized, barbarian, these concepts who care for them. In light of the ÔlifeÕ that is produced are deeply related. They are dialogical, even as the latter biopolitically, we must imagine an ethical life, a life that term is suppressed, silenced, hidden away and institu- would be the domain of bioethics. tionalized to shore up the ÔnaturalnessÕ or evidentiary ÔgoodnessÕ of the first. We might think of these as two populations, governed by two, nevertheless related, sets Conclusion of tactics, strategies, and knowledges. We hope that this The popular view of forensic psychiatry patients – and paper has raised some ethical questions concerning the possibly of any other recidivists – is that they merely ways that nurses have been co-opted to police the border

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