Institutional psychotherapy (IP) is a humanistic model of psychiatric care, which was developed in France, during the 1950s in reaction against the organization of asylums developed in France from the XIXth century and the concentrationary experience of WWII.
First experimented by Tosquelles as a "therapeutic community" in Saint-Alban, institutional psychotherapy was put into practice by Oury and Guattari in several private psychiatric clinics (La Borde, La Chesnaie and Saumery).
During the following 1960s and 1970s, the IP movement spread throughout numerous psychiatric clinics in the world, before transforming the French mental health landscape in the 1980s, leading to hospital decentralization and sectorization in networks of in- and outpatient structures.
Description
Based both on psychoanalytic theory and on communitarian principles, IP counters the two main sources of alienation for the individual: the alienation of mental illness and the alienation inherent to social organization. Consequently care is not only applied to the patients, but to the institution itself.
Treating the institution as an organism that participates in the social aspect of mental illness requires a permanent analysis of the institutional organization and relationships. In other words, the institution itself is considered to have a group unconscious which can be grasped and which determines the therapeutic action.
(1) Open-door policy
In an IP clinic, patients are free to move around, and even to leave the institution if they are so inclined. This policy is aimed to bring the patients out of their isolation and of their repetition compulsion, by constantly enabling them new social connections and new forms of subjectivity.
The result is a homelike and convivial clinical setting, providing all sorts of meetings, committees, workshops, occupational and leisure activities that keep the social tissue alive and diverse and in which psychiatric patients cease to feel stigmatized, foreign to others and to themselves.
IP arises from the ambition of making psychoanalytic psychotherapy possible in the treatment of schizophrenia while taking into consideration the fragmentary structure of the psychotic self. Hence the concept of dissociated transference (Oury), which accounts for how the schizophrenic patient institutes a constellation of partial investments with several people, objects and spaces, as opposed to classic dual patient-therapist transference.
Consequently, the function of the constellation meeting(Tosquelles) is to gather these pieces of transference from caregivers and to collectively elaborate towards meaning. It’s all about telling a story out of a patient’s trajectory in time and space and therefore actively building up one’s “lost” identity.
(3) Transversality
Having a certain status (doctor, nurse, patient, gardener, etc.) does not confine you to a fixed role or function. Getting rid of uniforms and blouses embodies this basic rule in IP and allows the therapeutic process to pass between levels. Plus, utmost importance is given to context-based decision-making, so as to overcome an alienating pyramidal organization and favor one’s initiative.
Another illustration of transversality is the communitarian organization of tasks within the grid, a double-entry chart which helps rotating the daily assignments between caregivers and the service personnel, so that each staff member alternates between different kinds of activities, be it talk groups, doing the dishes or helping patients take their showers.
(4) Therapeutic club
Self-managed by both patients and caregivers, financially independent from the clinic, the therapeutic club is a non-hierarchical and non-profit organization where patients and caregivers can mix and mingle daily. It is central to life at the clinic, as it sets up stimulating creative and professional activities for the entire community. In addition to this cultural and social role, the club publishes a newspaper and serves as an agora for discussing problems or making requests during its weekly general meeting, as the patients are allowed to have a say on the conditions of their stay and their care.
By putting on an equal footing caregivers and patients, by giving them equal responsibilities in handling the administrative and financial matters, by allowing them to function within a social bond, the therapeutic club allows patients to truly belong to a community from which they were often denied access, due to their mental condition.
Indications
Although historically linked to schizophrenia, IP is not meant to be exclusively applied to psychotic patients. On the contrary, IP takes the unconventional approach of mixing patients and their pathologies, showing that a mixture of different pathologies and different age groups can mobilize potentially therapeutic vectors in patients.
Efficacy
Different studies in France and abroad have underlined that the patients’ participation in their everyday life changes drastically the way they experience their mental disorders. However, it must be emphasized that treatment in institutional psychotherapy demands time! IP takes into account the chronicity of schizophrenia and therefore organizes psychiatric care throughout a necessarily long timespan.
Duprez, M. (2012). Psychosocial Rehabilitation and Institutional Psychotherapy. L’Information Psychiatrique, 84(10), 907-912.
Pouillaude, É. (2012). Schizophrenia, Alienation and Institutional Psychotherapy. Revue de Psychothérapie Psychanalytique de Groupe, 59(2), 45-54.
Wenger, S. (2011). Paranoia and Institutional Psychotherapy. Adolescence, 76(2), 355-383.
Quotes from founders & experts
"Institutional psychotherapy is perhaps best defined as the attempt to fight, every day, against that which can turn the collective whole towards a concentrationist or segregationist structure", Jean Oury [1], co-founder of institutional psychotherapy and founder of La Borde clinic.
"By allowing patients to participate in the daily making of their institutional life, the therapeutic club makes it possible for them to rebuild a "better-organized inner home-body-psyche", with well-ordered thoughts and rules of life that are compatible with those of others", Antoine Fontaine, psychiatrist, psychoanalyst & director of Saumery clinic.
Comments from trainees
“I loved to experience the organization of institutional psychotherapy that shows the relevance of confidence that psychiatrist can give to their teams and patients. It is much easier to find relevant tools in patients' everyday life to work on: their autonomy, self-esteem, motivations and values. It can be a challenge to manage with shared decisions, but it makes everybody much more engaged and creative”, Thomas Gargot, psychiatry intern at Saumery clinic.
“Training in institutional psychotherapy made me realize how the majority of the clinical settings I had known were lacking in freedom of initiative for caregivers and patients alike and gave me several cues for more lucid, harmonious and effective teamwork. While visiting La Borde clinic, I realized how “psychotherapy” emerges through small gestures, events and interactions as long as one takes the time to notice them and make them part of one’s daily work and mission” David de Freitas, psychiatry intern in Brussels, 1-year training in institutional psychotherapy.
1-year University Certificate "Psychothérapie institutionnelle", Université Catholique de Louvain : http://www.uclouvain.be/397027
Bibliography
Dosse, F. (2011), La Borde, between myth and reality & Daily life at La Borde. In Gilles Deleuze & Félix Guattari: intersecting lives (pp. 40-54 & pp. 55-75), New York, NY: Columbia University Press.
Delion, P. (2005), Accueillir et soigner la souffrance psychique de la personne. Introduction à la psychothérapie institutionnelle, Paris, France: Dunod.
Bourg, J. (2007), Institutional psychotherapy & the La Borde psychiatric clinic. In From revolution to ethics: May 1968 & contemporary French thought (pp. 125-137), Montreal, Ithaca: McGill-Queen's UniversityPress.
Movies
Barère I. (1977)., La Borde ou le droit à la folie. France: Télévision Française 1.
Philibert N. (1996), La moindre des choses. France: Éditions Montparnasse.
Djemaï N. (2012), À peine ombre. France: Nazim Djemaï, Images de la Culture (CNC), La Maison du Doc.
Godard A. (2016), Au jour le jour, à la nuit la nuit. France: Abacaris Films.
Institutional psychotherapy throughout the world:
France:
Clinique de La Borde, Cour Cheverny.
Clinique de Saumery, Huisseau-sur-Cosson.
Clinique de La Chesnaie, Chailles.
Centre Psychothérapique, Saint-Martin de Vignogoul.
Institut Psychothérapique, Le Pin-en-Mauges.
Centre Antonin Artaud, Reims.
CHRU - Psychiatrie de l'Enfant & de l'Adolescent, Lille.
Centre de Santé Mentale Angevin, Sainte-Gemmes-sur Loire.
Centre Hospitalier Roger Prévot, Moisselles.
Institut Marcel Rivière, La Verrière.
Établissement Public de Santé de Ville-Évrard, Aubervilliers.
Centre Hospitalier Ferdinand Grall, Landerneau.
Centre Hospitalier Édouard Toulouse, Marseille.
Hôpital Psychiatrique Le Grandvalier, Pontarlier.
Centre Hospitalier de Montfavet, Avignon.
Belgium:
KaPP - Clinique Saint-Luc, Bruxelles.
La Devinière, Charleroi.
Hôpital de Jour Universitaire La Clé, Liège.
La Traversière, Nivelles.
Greece:
Aghia Sofia Children's University Hospital, Athens.
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