Academic journal article American Journal of Psychotherapy

Patient, Therapist, and Supervisor in a Psychiatric Institution: Inner Freedom and Inner Structure

Academic journal article American Journal of Psychotherapy

Patient, Therapist, and Supervisor in a Psychiatric Institution: Inner Freedom and Inner Structure

Article excerpt

The authors discuss issues concerning the psychotherapeutic process in a psychiatric institution, They develop the concept of the institution as an internalized object in addition to its being an objective object. As such, it has an effect on the inner freedom and the internal structure of the patient, the therapist, and the supervisor. It is claimed that it is crucial for the development of an identity as a psychotherapist that the supervisor be aware of the institution as an inner and real object. The authors raise questions about what kind of "space" is possible in a psychiatric institution and what influence that may have on the therapeutic process. The impact on the therapist's professional identity is discussed. They point to the process of becoming a therapist via supervision and examine some relevant dilemmas. The authors conclude by discussing the duality of inner freedom and internal structure, and their specific manifestations within an institution.


Dealing with the process of psychotherapy in a psychiatric institution means dealing with the inner and outer realities of the institution, the therapists, the patients, and the supervisors. Each side has a presence in the intimate space of the therapeutic encounter, which affects the inner process of building freedom and structure within patient and therapist.

In what ways do treatment and supervision in a psychiatric institution facilitate the creation of inner freedom and therapeutic space? How do they limit the ability of patient, therapist, and supervisor to "feel alive, awake and feel good?," as Winnicott (1) stated? How can therapists in a psychiatric hospital utilize their supervision so as to work-still feeling creative- within a space essential for therapeutic treatment and for the therapists' capacity of building their own professional identity? We shall discuss some of the ways in which patients are influenced by being treated in an institution and the effect on their ability to use the therapy for personal growth.

Although Winnicott (2) claims that tyrannical regimes and psychopathology both threaten inner freedom and creativity, he also quotes the well-known saying "It is not the brick wall that creates the prison nor the bars that create the cage." His perspective is that many people have surprisingly discovered that they have a greater sense of freedom when they are under restrictions. Accordingly, the walls of the psychiatric institution absorb the insanity and set the limits by locked doors and rigid rules that are contradictory to freedom, yet at the same time, facilitate a sense of freedom. Bohm (3) describes the therapists' tendency to become overly dogmatic by idealizing knowledge, or at the other extreme, idealizing "not-knowing." Bohm says that an effort should be made to integrate structure and rules with freedom, to progress in the direction of the unknown. Within the hospital, patients, therapists, and supervisors play a role in this quest for integration.

In the development process as therapists and supervisors, quite counterintuitively, we realized that the limits, rules, hierarchies, and complexities of the institution have driven us to invest great effort in developing freedom within the framework. In the psychiatric institution, we meet the scientific model that is aimed at knowing and organizing the mental being in frames or diagnoses. Therefore, as a counterbalance, we should present the option of not-knowing and try to integrate knowing and not-knowing. Bion (4) sets a very good example, as he developed his theory that emphasizes the unknown, the creative, and the obscure, while working with groups in a military mental institution that by definition would not allow for much individual space.


When we speak of a psychiatric institution we refer to a large mental hospital that is a medical institution but includes staff of many disciplines. …

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