Psychoanalytic treatment of psychosis in institutions.

Psychoanalysis can provide a conceptual foundation for the treatment of psychosis and for understanding how institutions that care for patients with psychosis function. The research of this thesis aims to examine theoretic, therapeutic and institutional approaches to psychosis. What is of significance is the priority that psychoanalysis places on the individual patient's treatment, how it is conceived psychoanalytically and incorporated in the overall organisation of an institution. Psychoanalytic theory, especially in relation to the structure of psychosis, offers ways for adapting clinical practices to the treatment environment by helping to develop strategies for the clinical work and a framework for the institutional structure. Psychoanalysis has its greatest efficacy in long term treatments and has shown its suitability for patients diagnosed with psychosis when the method is adapted to the uniqueness of each patient's presentation. Even though individual psychoanalytic treatment is feasible in many cases, the treatment of psychosis cannot usually be conceived without consideration of institutional care, which depends on the level of individual patient's psychopathology. This is because the majority of psychotic patients, especially those with schizophrenia, will be exposed to inpatient or community treatment, in one form or other, during their lives. Therapy based on psychoanalysis permeates contemporary psychological approaches. It is over a century since Freud and analysts from the Burghölzli Clinic in Switzerland attempted the use of psychoanalysis in the institutional treatment of psychosis, laying the foundations for current practice in the mental health field. Major changes have occurred in treatment approaches since then and particularly since deinstitutionalisation. A number of institutions were chosen for study on the basis of their theoretical orientation to psychoanalysis, taking into account their historical and administrative influences, sociological and anthropological studies, the treatment approaches to psychosis, the training of staff and research outcomes. These institutions are located in North America, Continental Europe and Great Britain, and cover the treatment of adults, adolescents and children. This thesis used psychoanalysis as a method of research that provides a set of operations for processing data and drawing inferences. Clinical psychoanalytic research is based on psychoanalytic case studies where the complexity of the patient's social reality is maintained in the data. In this instance the institution is the subject of the case study. A number of institutional models informed by psychoanalysis offer a guide to the institutional treatment of psychosis. They present a version of institutional practice that is different from the prevailing models in psychiatry and this has implications for mental health services in Australia's current climate of mental health reform. A number of themes emerged from the research, the most important of which were the value of conceptual models in orienting the clinical approach to a patient's treatment and the knowledge institutions gain from examining themselves psychoanalytically. The thesis brings together the history of a number of psychoanalytically informed hospitals and provides a synthesis of their different theoretical underpinnings that are manifest in institutional practice.