Thinking About Institutions: Milieux and Madness

In Thinking About Institutions, R. D. Hinshelwood, a well-regarded psychiatrist and psychoanalyst, attempts to understand the history and transformation of the British public hospitals from traditional hierarchical institutions to therapeutic communities or milieu treatment environments. Hinshelwood believes that the lessons to be learned may reach beyond the institutions themselves and thus are especially worthy of study. His perspective is that of the psychoanalyst. He acknowledges that Freud "was pessimistic about psychoanalytic treatments of psychotic patients," but he goes on to argue that we can "substitute an optimism about addressing the caring institution with psychoanalytic ideas and descriptions." He further states that "psychoanalytic ideas must be applied rather than 'used'."

This book is difficult to read, convoluted in its presentation and argument, arcane in its perspective, and of limited value and relevance to a contemporary evaluation of mental health institutions and their processes. Perhaps it is best understood and appreciated by British practitioners or by psychoanalytically oriented readers.

At times Hinshelwood seems simply to pine for the good old days of reformed institutions and therapeutic communities. He tries to argue that from a psychoanalytic understanding of therapeutic communities we can generalize to issues in contemporary community care and an understanding of society in general. But it is not clear that he succeeds in showing that this is an appropriate and useful approach.

At a time when exciting new ideas and theories are emerging to better understand and manage complex systems, it is difficult to appreciate Hinshelwood's view as useful or relevant. For example, the science of complex adaptive systems (CAS) has been applied to a wide range of human endeavors, and it would be a worthwhile effort to consider psychiatric institutions through this lens. The Institute of Medicine, in a recent report on health care in America (1), includes an appendix on applying the CAS framework to health care system reform. The ideas are compelling and at once simple and powerful. The institute makes it clear that our entire health care system is in urgent need of reform and suggests that the CAS framework might be a powerful tool for understanding and facilitating change. Our institutions need a new paradigm, not a reworking of outdated and misapplied theories.