Institutional power

Michel Foucault gave a series of lectures at the College Of France in 1973 and 1974 on psychiatric power where he traces the development of psychiatry in the 19th century which saw the birth of the asylum.

I started my career working in two State Hospitals, both in New York State, Kings Park State Hospital on Long Island and Rochester State Hospital in Rochester, NY. I began in 1968 and worked in State Hospitals until 1976. These were the days of deinstitutionalization and the birth of the Community Mental Health Centers.

The practice of psychiatry was rapidly changing during these times as psychiatric power shifted from institutional care to outpatient care and the psychiatric role shifted from dictator of institutional directives to the prescriber of powerful neuroleptic pharmaceuticals.

As a Psychiatric Social Worker, I was both the object and servant of this power, and to some extent the wielder of this power by proxy. I quickly discovered I had much more power in the Community Mental Health Centers than I did at the State Hospitals where the power was much more bureaucratic and hierarchial.

Psychiatric power is not something which mental health professionals like to discuss and yet mental health professionals are sanctioned by society in various ways to wield a fair amount of it.

Foucault points out that psychiatric power in an institutional setting comes from the order it imposes on the inmates. There are rules that must be complied with and deviance from the rules requires admonishment, penalties, and at times physical restraint.

This kind of institutional power is present in hospitals, prisons, schools, community residences. Staff are empowered to coerce and exert this power to maintain order and obedience. This coercion can be done kindly with the velvet fist or clumsily with barbaric exertion of force depending on situation and circumstance. In some settings, the utlimate sanction is expulsion as when people are disciplinarily discharged from a community residence or suspended from school.

The power to exert this influence usually resides ultimately in a superintendent, a program director, a warden, a doctor, or some other type of socially sanctioned offical. His or her power often gets delegated to his/her subordinates. If clients, patients, students, inmates object to the power being exerted by subordinates, the superordinate then sits in judgement to resolve the dispute, usally in favor of the superordinate's subordinate and not in favor of the inmate, client.

The "help" offered to recipients is subtly coercive and, sometimes, in the recpients best interests. Yet all institutions function in self serving ways to preserve their own benefits, and client interests are only a secondary concern. Therefore, institutional power is always suspect as being in the client's best interests.

As a psychotherapist, I hear stories from my clients all the time about their tales of oppression and subjugation by the institutions with which they interact. There is a long history of advocacy in Social Work on behalf of clients with the institutions by which the client is oppressed. To be effective in this advocacy work, the Social Worker and the client must become sophisticated about institutional power and how it operates.

This is article #1 in a series on psychiatric power.