Who watches the watchers? Observing the dangerous liaisons between forensic patients and their carers in the perverse panopticon Abstract As a central part of their role in working with mentally disordered offenders in secure settings, frontline workers such as mental health nurses are expected, on behalf of us all, to keep watch over their patients. They must observe and assess their movements, their progress and regress, whilst themselves being subject to scrutiny, inspection and surveillance from the wider system of care. The fact of the patients’ involuntary status means that they are both dependent upon and under threat from the treatment they receive from their watchers. They too are ever vigilant and always on watch for potential threats arising from the enforced proximity with their watchers in the ward as well as from the wider judicial review systems. Disastrously the hostile dependency that is at the heart of these reciprocal roles is, from time to time, enacted in more overt violence, resulting in significant numbers of injuries, affronts and offences on both sides. There is nowhere for either group to hide to escape the scrutiny of the other. With reference to Jeremy Bentham’s Panopticon (Bentham, 1995) and Michel Foucault’s (1975) exploration of Bentham’s ideas, our aim is to present a systems-psychodynamic exploration of the ways in which the potentially corrosive effects of these dangerous liaisons are played out between these would-be watchers and their hyper-vigilant charges. We also discuss the ever-present dynamics of shame and shaming: the illicit libidinal excitements that become invested in ‘the gaze’ and in the reciprocal roles of voyeur and exhibitionist as they pass between the watcher(s) and the watched in this perverse panopticon. Key words: Therapeutic milieu, panopticon, forensic mental health, reciprocal violence, hostile dependency, voyeurism, exhibitionism Introduction Quis custodiet ipsos custodes? Juvenal, Satires 6: 346-348. In 1787 Jeremy Bentham, the British Utilitarian philosopher, wrote a series of letters proposing the implementation of the ‘panopticon’ for use in institutions charged with the surveillance of those who resided within them and, in particular, for the correction of deviance, anti-social behaviour and criminality (Bentham, 1995). The panopticon was a design for a form of ‘penitentiary inspection-house’ (Letter II, p. 35) in which the living quarters of the inmates would be sufficiently transparent that they could be viewed from all angles at any time by an unseen Inspector, without them being able to tell whether or not they were being watched. The Watcher was to be invisibly located in a 1 central tower and the inmates were to be placed in conditions of total visibility in peripheral enclosures. Bentham’s notion was that the panopticon, as a kind of psychologically informed planned environment, would give rise to states of mind within which the unseen, actual and imagined, shaming scrutiny of others would induce pro-social attitudes in the offender. These would in turn force the offender to reflect upon his or her behaviour and so come to appreciate the error of his or her ways. Bentham himself described the panopticon as ‘a new mode of obtaining power of mind over mind, in a quantity hitherto without example’ (Preface, p. 31). Michel Foucault (1975) widened out the concept of the panopticon to describe and critique the wider social implications of the increasing use of surveillance and state regulation as means of governing and controlling the citizenry in the modern age. He used the image of ‘plague’ as a metaphor for the need of the state to exercise this control in order to protect the population from the contaminating effects of psycho-social social unrest and dis-ease [our hyphen]. He made links to an earlier historical fear of leprosy that led to the establishment of the lazar houses and the confinement of the sufferer within them (Foucault, 1961). Bentham also explicitly proposed the panopticon as a remedy against ‘the danger of infection’ (Letter VI, p. 46) as well as a treatment for deviance. Foucault suggested that madness and criminality too brought with it a fear of contagion, but in this case a contagion of the mind: the idea that social deviance and indiscipline was also ‘catching’. Accordingly, the mad, the bad and sad, like the lepers, also needed to be removed from society and placed under surveillance, a function central to his notion of disciplinary power (1980), until they were observed to be no longer so disturbing. We have previously noted (Scanlon and Adlam, 2008a) how similar ideas are evoked and explored by Albert Camus in his allegorical novel La Peste (1947). In this work Camus examines the problematic dynamics that emerge both within an enclosed setting, and between that ‘enclosure’ and the wider society, when bubonic plague breaks out in the Algerian town of Oran. Camus evokes the fear, within the enclosure, of the potential for physical contagion alongside the actual disturbed and disturbing relational fear of ‘the other’. These fears rapidly spread when the healthy and the contaminated are both forcibly cast out into an external exile when the whole town is sent into quarantine by the wider society that is itself fearful of contamination. The resulting enforced proximity gives rise to an interpersonal exile and profound feelings of alienation that are experienced as threatening to both their minds and their bodies. In these circumstances the townspeople must take their chances; each fearing the dangerousness of the dis-ease of the other. Exiled by the state, they are forced into a hostile dependency which threatens them to the core of their being: longing to turn to one another for comfort but terrified of and hating the prospect of the plague spreading by these very means. In this paper we wish to comment on the impact of the spreading of an analogous fear of the other that we have observed in staff working in 2 secure psychiatric settings with detained or restricted mentally disordered offenders and it to this that we now turn. Symmetry and dissymmetry in the Panopticon A central design feature of Bentham’s Panopticon was its reliance on an essential ‘dissymmetry’ (Foucault, 1975, p. 202). The Inspector could be perceived to be present without being visible, so that the inmate could never know whether his watcher was in reality there, nor, if so, where his attention might be directed at any given moment: the essential principle was that of ‘seeing without being seen’ (Letter V, p. 43). However, within modern secure mental health units we have also observed a curious inversion in the dynamic of the panopticon which has been brought about, in part at least, by the contemporary architecture and design of such secure accommodation. In these Units, nursing stations and observation platforms that were ostensibly set up to enable nurses to observe patients, have in their design and in effect also become ‘goldfish bowls’ within which the nursing staff are subjected to the constant scrutiny, and associated fear and hostility of the patients who depend upon them. This coincidence of an apparently more symmetrical process of observation and scrutiny stands as if in defiant opposition to, and as a defence against, knowing about (Bollas, 1987) the very real power differentials that exist between the ‘would be watcher’ and ‘wont be watched’. This gives rise to the disturbed and disturbing claustrophobic environment that we are calling the perverse panopticon within which this more conscious, and intentional reciprocal scrutiny becomes suffused with more primitive forms of unconscious communication rooted in processes of projective and introjective identification (Klein, 1946; Bion, 1959, 1962; Ogden, 1979; Rogers, 1987; Meltzer, 1998, 1992 inter alia). In the perverse panopticon there is nowhere to run and nowhere to hide from the hostile and fearful gaze of the other, and the consequences for all who are party to the intimacies of this enforced proximity are potentially severe. This version of the panopticon is perverse, rather than ‘merely’ utilitarian, in that it represents a systemic turning away from the primary task of custodial healthcare and a turning towards an excited enactment of the devious and instrumental, sexualised and aggressive fantasies that ‘the system’ is set up to counter, to contain or to treat. Rather than simply serving to socialise the anti-social, the ‘perverse panopticon’ provides a context within which there is an increased potential for pro-social forces to be corrupted. The nursing staff, as the agents of these would-be pro-social forces, are thus at risk of becoming contaminated and, in their contaminated states of mind, to present a clear and present danger to those whom they watch over. As was the case with the historical lazar-houses and the fictional citizens of Camus’ Oran, the very omnipresent threat to the body – in this case a fear of violent 3 enactments – contains within it an equally powerful relational fear of being contaminated or corrupted by the disturbed mind (the dis-ease) of the other. It is as if the very atmosphere of the Ward is contaminated by a terrifying yet invisible environmental pollution which cannot easily be symbolised, nor can it be avoided or ignored: an enclosed and claustrophobic place where even ‘angels fear to tread’ (Dartington, 1994). Living and working in a surveillance culture “There can be no doubt that behind all the actions of this court of justice ... there is a great organisation at work. ... But considering the senselessness of the whole, how is it possible for the higher ranks to prevent gross corruption in their agents? It is impossible.” ‘Josef K’ in Kafka, The Trial ([1925] 1953) pp. 54-55. Foucault (1975) commented that the major effect of Bentham’s Panopticon was “to induce in the inmate a state of conscious and permanent visibility that assures the automatic functioning of power” (1975, p. 201). The unmeasurable and unknowable possibility of being observed is enough to ensure security and compliance and so enable a mending of deviant ways. Likewise, in Kafka’s The Castle ([1926] 1997), the protagonist ‘K’ imagines the elusive official Klamm as like an eagle with his ‘piercing downward gaze that could never be proven, never refuted’ (p. 104). Speed cameras, that are now visible throughout the road system in the UK, but which are not necessarily active, might be a contemporary example of this dynamic. Another example transpired in 2010, when UK police piloted a scheme to use portable camera equipment openly fitted to the side of the officers’ helmets – one officer commented that in order to have a deterrent effect on ‘anti-social’ behaviour, the cameras did not even have to be switched on (Guardian, 2010a). The panopticon, Foucault points out, separates two experiences that are normally linked, that of seeing and being seen: “in the peripheric ring, one is totally seen, without ever seeing; in the central tower, one sees everything without ever being seen” (1975, p. 202). In the perverse panopticon this dissymmetry has been lost: the watcher and the watched become the watched-watcher and the watcher-watched, each trying to outdo and avoid the scrutiny of the other. The reciprocally voyeuristic mapping of speed camera locations by UK drivers’ associations, which necessarily involves a collusive relationship with law-breaking, might be a more ordinary example of this dynamic. The perversity of the voyeur and the exhibitionist can only be perfectly catered for if each is in their proper respective places – watching or watched respectively – and each becomes frustrated and potentially terrified if they are put into the others’ place in the perverse panopticon. Now, we know from experience that ‘close observations’ of disturbed patients on inpatient units offers no guarantee that the object of this ‘therapeutic surveillance’ will ‘mend’ his or her ways. On the contrary, this technique – 4 which has a history of being called ‘specialing’ – creates a uniquely perverse game of hide-and-seek; a game, which even at its most benign, is an expression of an exhibitionist-voyeur dynamic that can be exhausting for both parties. At its most malign, it can provide an invitation, from one or other party, to reinforce and to gratify highly sexualised, sado-masochistic engagements that have an inherent potential to corrupt and debase (Welldon, 1996; 2011; Jukes, 1997). Nursing staff (male and female) are invited bodily to restrain male and female patients in the process of violent enactments which unconsciously parallel and recreate, in the here-and-now, the patients’ own violent, sexualised and often highly sadistic patterns of offending (Norton and Dolan, 1995; Shine and Morris, 2000). At other times this perverse desire for bodily contact inverts as well as perverts the victim-perpetrator dynamics, as nurses are recruited, by the masochistic part of the patients’ minds, physically ‘to put them down’. We can learn from experience, perhaps: but sometimes, under undoubted extremes of provocation, mired in the shit, piss, blood and spittle of the highly charged perverse panopticon, there is little space to think. Indeed, in these highly charged and highly traumatised environments there is often little incentive to come together to learn from experience. To do so would involve having to consider the interpersonal and psycho-social meaning of these perversely gendered and highly sexualised interactions, which cast forensic workers in roles that are often highly ego-dystonic and, therefore, very disturbing (Hopper, 2003, 2011 in press; Scanlon and Adlam, 2009, 2011b in press). Brutal cultures: the dynamics of shame and shaming Georgie Porgie, pudding and pie, Kissed the girls and made them cry; When the boys came out to play, Georgie Porgie ran away. (Traditional nursery rhyme) In earlier papers (Adlam and Scanlon, 2005; Scanlon and Adlam, 2008b; 2011a) we have explored notions of homelessness and dangerousness as metaphors or ciphers, which stand for reciprocal, circular and re-iterative violence that is played out between ‘society’ and some of its most vulnerable citizens. We suggest a powerful correlation between the violence arising from individuals’ ‘un-housed’ states of mind and the dangerous and endangering psycho-social (dis)organisations out of which these individual acts of violence emanate. We also wish to link with others (Adshead, 1995; Norton and Dolan, 1995; Aiyegbusi and Clarke, 2008; Campling et al, 2004; Hinshelwood, 2002; Hopper, 2003, 2011 in press; Aiyegbusi and Kelly, 2012, forthcoming inter alia) to explore the existence and persistence of ‘brutal cultures’ in forensic settings (although by no means only in forensic settings): institutional cultures 5 in which there is a reciprocal process of shame and shaming, often referred to under the twinned rubrics of ‘bullying’ and ‘scapegoating’. There are strong parallels between the unhoused and dis-membered states of mind of the actually homeless and really dangerous amongst us and the un-housed and dis-membering qualities of individual practitioners, teams and organisations traumatised by their work with such patients (Scanlon and Adlam, 2011b in press). In these brutal cultures it seems that someone is always pushing someone around and sometimes it appears that everyone is pushing everyone around. We suggest that shame, or the contempt that defends against it, is the ‘bubonic’ toxin; the relationally transmitted dis-ease which subtly and violently contaminates these dangerously intimate exhibitionistic-voyeuristic inter-dependencies. A central endangering and shaming group dynamic at the heart of this work is one of inclusion/exclusion – both in its interpersonal and in its social manifestations. Practitioners, teams and the system of care as a whole, become inevitably caught between conflicting and oscillating impulses when faced with the inherently antisocial and/or perverse position of un-housed and dis-membered patients. One impulse is violently and shame-fully to exclude the patient from services and from the practitioners’ minds. On the other hand, there is the impulse violently and shame-fully to dis-member them from mainstream society and into an enforced membership of what is seen as a more appropriate grouping within the forensic system: to lock ‘em out or to lock ‘em up. Elsewhere (Scanlon and Adlam, 2008b, 2011b in press) we have made use of Levi-Strauss’ (1955) concept of anthropoemic and anthropophagic responses to difference, to describe phenomena associated with these oscillating impulses. In the former case the invader is vomited out with the socially shared unconscious aim of rendering such people ‘out of sight and out of mind’. In the latter case, the invader is swallowed up, incorporated by the system and detained in order to neutralise any threat that they might pose. These societal impulses correlate with a corresponding impulse from the offender patients who, feeling understandably endangered by these forceful efforts to push them away or to put them inside, are forced into shamed and violent flight/fight states of mind in which actual violence is employed to protect themselves (Glasser, 1996; Gilligan, 1996; Motz, 2008; Scanlon and Adlam, 2009). So it is that a pre-existing vicious circle of reciprocal fear and loathing, between the anti-social and those who would ‘socialise’ them, becomes a very real spiral of fear and humiliation. To return to our nursery rhyme, Georgie, we might imagine, has been shamed and humiliated for being overweight, and has consequently become more so. He passes his shame into the girls upon whom he forces his attentions. He is then doubly shamed when the (pro-social?) ‘gang’ appears and he leaves the scene, knowing they will not play with him – and when his shamed retreat is noticed by the girls. 6 Here we are also reminded that Juvenal’s poetic question, posed at the top of this paper, was asked in relation to the imagined impossibility of ensuring that those men whose duty it was to watch over the women of the harem would not be corrupted by, or corrupting in, these duties. When this reciprocal vicious cycle of shaming is transposed into the forensic treatment setting, each is watching the other for any signs of weakness to be exploited, or for any signs of the aggression and violence which would put them in harm’s way. Bentham wrote that ‘[A]ll punishment is mischief: all punishment in itself is evil ... it ought only to be admitted in as far as it promises to exclude some greater evil’ (Bentham, 1988, p. 170). In Utilitarian terms, the reduction of the sum of happiness, in the impact of punishment upon the individual, could only be justifiable if, by means of its shaming spectacle, a greater deterrent good was established for the greater number (see Bentham, 1995, Editor’s Introduction, pp. 3-8). Bentham never saw a panopticon come into existence but we may think he would have been appalled at the contemporary version of his dream. In the glassed-in and claustrophobic spaces of the perverting panopticon, be you ‘watcher’ or ‘watched’, no-one will spare your blushes and everyone will hear you scream. Organisational structures and institutional violence ‘Look you, Mr Turnkey,’ said I, ‘there is one thing that such fellows as you are set over us for, and another thing that you are not. You are to take care we do not escape; but it is no part of your office to call us names and abuse us.’ [William Godwin, Caleb Williams (1794, pp. 204-205)] Gilligan (1996), in his study of the American prison system, maintains that it is impossible to understand individual acts of violence without interrogating the relationship between the haves and the have-nots, the included and the excluded, within the wider system. Violence and dangerousness are not decontextualised phenomena. They are not only trans-generationally transmitted ‘from father to son’ (Holmes, 2001; Pfäfflin and Adshead, 2004; de Zuluetta, 1993) but are also psycho-socially manifested by those who have previously experienced themselves as endangered and violated within a shameful, disrespectful and offensive society (Žižek, 2008; Gilligan, 1996; Scanlon and Adlam, 2011a). Gilligan writes that he has “yet to see a serious act of violence that was not provoked by the experience of feeling shamed and humiliated, disrespected and ridiculed, and that did not also represent the attempt to prevent or undo this ‘loss of face’ no matter how severe the punishment” (Gilligan, 1996, p. 110). Forensic settings, established by society for the containment and confinement, and sometimes for the treatment, of the shamed and dispossessed, not only represent, in microcosm, the societal shaming of the dispossessed but can often re-enact and reinforce this shaming dynamic. Goffman (1961) described many such de-humanising rituals of ‘admission’ as ‘the outsider’ is brought into ‘total-institutions’ that have their 7 own overt and tacit rules of engagement with which the newcomer must comply. Some of these shaming rituals of admission may have changed since Goffman – or Bentham himself (Bentham, 1995, Editor’s Introduction, p. 5) – described them; but the requirement that the individuals (staff and patients alike) must consciously subjugate themselves to the explicit rules of the Institution has changed little (Adlam and Scanlon, 2011) and the underlying unconscious organisational dynamics (Menzies, 1959; Dartington, 1994; Armstrong, 2005 inter alia) which support and maintain these rituals have probably not changed at all! In one contemporary example of the ‘institutional’ response to this metaphorical fear of contagion, recent years have seen the introduction of ‘policy guidance’ in many psychiatric hospitals in the UK which requires mental health nurses to wear small disinfectant bottles on the ‘utility belt’ which also contains their keys, badges, personal alarms and other powerfully symbolic ‘paraphernalia of their office’. The ostensible reason for requiring nurses to disinfect themselves prior to and following physical contact with patients is to reduce the possibility of ‘cross’ infection – which we might perhaps mischievously translate as being the risk of becoming infected with ‘crossness’? This policy was introduced at a time when there was a fear of an avian flu pandemic in the winter of 2009. However, despite the fact that there were no reported cases of avian flu in any psychiatric hospital and that the public health risk has since abated, nurses still continue to carry their disinfectant bottles. Could this now seemingly institutionalised practice be understood as a contemporary manifestation of the way in which social systems defend against the psychosomatic fear of contamination that we have observed above? Evidence for this hypothesis might be cited in relation to the operationalisation of the policy itself. If the policy really was to reduce the risk of cross-infection (rather than an infection of crossness), then surely it would have made sense to also offer these disinfectant bottles to the patients, as they are the ones living together 24 hours a day. But the patients are not offered disinfectant bottles and this begs the question as to who is protecting whom from the infection of whose real or imagined ‘crossness’? Perhaps it is that the patients are being protected from the possibility that the nurses, who go-between patients and also go out into the ‘infected’ external world, will infect the patients – except of course that patients also come and go-between, as do their visitors. But what is the psychotic part of the patients’ minds to make of nurses ‘disinfecting themselves’ following contact with them? Who do they imagine is infecting whom, and with what? Could it also be that this practice persists, despite the minuscule risk of crossinfection, not only as a social defence against anxiety but also as a concrete manifestation of an institutionalised violence which serves to keep the mentally disordered offender patients firmly in their proper, patronised, disempowered and humiliated place? But however we imagine this feared 8 outbreak of infection, or crossness, and whether we locate it within the nurses or within the patients – within the hospital or within the wider community – the fact remains that it is only the staff members who get to dangle the disinfectant bottles on their utility belts. Inclusion/exclusion and the neighbourhood watch? “The rich man in his castle, the poor man at his gate He made them high and lowly, and ordered their estate.” From the Anglican hymn All Things Bright and Beautiful (1848) Both Gilligan (1996) and Žižek (2008) explore, along similar lines, the projection of ordinary institutional violence into the dangerous and the dispossessed and the problems that follow when these projections are dangerously identified with or dangerously refused. Gilligan, using an epidemiological analogy, maintains that behavioural violence, by which is meant the acts of violence of identifiable individuals (in Žižek’s terms, ‘subjective’ violence), always takes place in the context of a wider structural violence, i.e. within the formal structures, strictures and expectations of an infected and sick society from which the deviant must be excluded. Both Gilligan and Žižek’ argue that societally we have a need for there to be victims of violence, power differentials and relative deprivation, in order that ‘we’ can feel more ‘at ease’ in relation to ‘them’, the dis-eased: “there is nothing so reassuring to the rich man as the beggar at the gate” (Luke, 16: 19-31). This psycho-social analogy is supported by the epidemiological research of Wilkinson and Pickett (2009), who provide a wealth of empirical data to demonstrate that more unequal societies almost always have poorer health and happiness, across a very wide range of physical, mental health and ‘wellbeing’ indicators, than more equal societies. Their research has had so much impact on the political debate, if not the action plan, that a minor industry has sprung up in some quarters in order to de-bunk it (Guardian, 2010b, 2010c; Policy Exchange, 2010). Gilligan (2011) has recently presented another powerful epidemiological case correlating rates of violent death and other contingent social ailments in the United States to the key variable as to which political party is in power. He links epidemic ‘spikes’ in the violent death rates over the last century or so to the shame, humiliation and relative deprivation generated by what he describes as the anti-egalitarian policies of the (Republican) ‘Grand Old Party’. Dorling’s analysis of the perpetuating factors of injustice (2010) likewise joins with these structural arguments in suggesting that we can only really understand the reason for much behavioural and social violence by thinking how humiliating and dis-easing [sic] it is for people to live in relative poverty and disadvantage compared to their near neighbours: those with whom they live in a too-intimate proximity. 9 The envy and the shame born of such profound, yet relative, social disadvantage arising out of these power differentials can be psychologically, emotionally as well as physically crippling. The emergent violence is born of the experience of having been, and continuing to be, psycho-socially violated and so rendered relatively helpless. The patient in the secure unit has to experience on a daily basis the potential humiliation of their relative poverty and disadvantage (and infectiousness) as compared to those who keep watch over them at great cost to their health. However, as Wilkinson and Pickett (2009) point out, in more unequal societies, like the more unequal context that we are describing here, it is not just the disadvantaged that suffer illhealth. In our observation of the neighbourhood that is the forensic ward, the ‘staff’ too suffer very real and severe occupational stress and burnout problems (Fruedenburger and Richelson, 1980; Maslach and Leiter, 1997) not only as a consequence of their too-intimate proximity with the patient neighbours, but also as a result of themselves being the subject of the constant scrutiny and inspection of the ‘the authorities’ in the neighbourhood: the rich man in his castle? Through this experience of being watched from above the nurses encounter further potential for humiliation and ill-health when their efforts are unappreciated, their needs are denied or when they are mis-handled by those relatively advantaged others who ‘manage’ and ‘direct’ them in their work. In one recent and not atypical example, members of a nursing team on a ‘Psychiatric Intensive Care Unit’ (PICU) – the contemporary name for a ‘disturbed ward’ – were reminded of their worth when, for economic reasons, their only seclusion room – a powerful tool in their armoury for managing frequent patient violence – was ‘de-commissioned’ so that it could be turned into another bedroom. The outcome of such a measure is both a quantitative increase in the threat of violence from the increased number of disturbed patients and, simultaneously, a potentially dangerously humiliating decrease in the staff’s capacity to manage it. This problem is made all the more perverse when, for the lack of a seclusion room, highly aroused patients have, in these highly charged, almost ‘post-coital’ states of minds, to be taken by staff back to their own bedrooms to be settled. For Žižek (2008), objective violence is the invisible background out of which an act of subjective violence emerges. He breaks objective violence down into two categories. Symbolic violence is the violence contained, in terms of this present paper, in the ordinary language and conceptual frame of day-to-day work in the forensic setting. The contemptuous familiarity contained in terms used to describe patients’ behaviour, such as ‘attention-seeking’ or ‘manipulative’ or ‘behavioural’ that attribute a ‘deliberateness’ to patients’ unconscious ‘acting-out’ of their experience of disempowerment and humiliation, would be one example of the symbolic violence ‘done unto’ the patient population (Aiyegbusi and Clarke, 2008; Norton and Dolan, 1995; Scanlon and Adlam, 2009). The wearing of a disinfectant bottle, which might be taken by either side to be a powerful symbolic communication to the 10 mentally disordered offender of the reality of his guilt, of his shame and of the ‘dirtiness’ of his deeds, might be another. Similarly, the idea that getting rid of a seclusion room might be described as ‘de-commissioning’, when in reality it is a ‘cut’ in the quality of service provision which jeopardises the health and safety of its workers and their ‘customers’, might be yet another example of an institutional, symbolic violence done to all. Žižek’s point is that if we were more mindful of the systemic or structural violence – if the environmental pollutants were more visible – we might then perhaps be less startled when the subjective violence or other forms of psycho-social dis-ease manifest themselves. We might then pay more attention to the ‘ordinary institutional prejudices’ that provide the socially denied and shaming backdrop out of which the apparently ‘random’ act of violence emerges; and so better understand it as a self-preservative, facesaving action which sets itself against these prejudices. Therefore, whilst dangerousness has an obvious social reality, in the sense in which we are using the term here it could also be understood as a manifestation of a dangerous and endangered indentification with an institutional violence that shames and humiliates already disadvantaged people and makes them feel small, helpless and contaminated. Direction and inspection: ‘Clinician, surveil thyself’ In the original plans for the Panopticon, the Inspector’s assistants were always potentially under the gaze of his all-seeing and beneficent authority and Bentham, anticipating the protests of Godwin’s Caleb Williams and Kafka’s protagonist Josef K, was enthusiastic that this system of governance would pre-empt any departure from the standard of performance required of them (Letter VI, pp. 45-46). Under the conditions of the ‘perverse panopticon’, where everyone is watching everyone, it is therefore often the nurses and their colleagues who find themselves being ‘specialed’. Under this close observation they are forced to take up a position parallel to that primarily occupied, in Bentham’s imagination, by the miscreant: except that, caught between a rock and a hard place, they are subject both to the imagined prosocial direction and inspection of unseen ‘generals’ and the really anti-social persecutions of the patient group. In Siegfried Sassoon’s famous poem ‘The General’ (1917), two doughty Tommies off to the trenches at Arras comment on their leader’s cheery disposition, perhaps to reassure themselves that their ‘manager’ would never order them to their deaths: yet he ‘did for them both’ with his eventual plan of attack. Bentham’s answer to the age-old philosophical question about who watches the watchmen (Moore and Gibbons, 2007) was to have the watchmen managed and directed by a beneficent ‘Good Authority’ – represented in Bentham’s mind as people like him. If any optimism about this elitist, deference-based solution were ever widespread in UK society and did, 11 for example, survive the debacle that was the Charge of the Light Brigade, it suffered a blow in the trenches of World War One from which it never recovered. In the perverse panopticon the watchers-watched and the watched-watchers are not only pinned down by each other’s scrutiny but also subject to the omnipresent scrutiny of ‘the establishment’. The patients are subject to the ‘Field Marshalls’ in the Ministry of Justice and the nursing staff more directly to their ‘Generals’ in the management. There may be shared moments of cease-fire when the officers are distracted, like the apocryphal Christmas game of football in no-man’s-land; however, as the Harry and Jack of Sassoon’s poem discover to their cost, this precarious co-existence persists alongside the shared knowledge that, at any moment, a fellow is as likely to become the victim of bureaucratic or strategic decisions made far away from the line of fire, as s/he to be caught in the enemies’ cross-hairs. In the claustrum (Meltzer, 1992) that is the perverse panopticon, even though nursing staff may not be actually under scrutiny by any given manager at any given moment, or subject to the patients’ direct hostilities, our observation is that they feel themselves to be constantly watched, both by their friends in the ‘management’ and their adversaries in the field. These experiences leave them, as ‘combatants’, feeling anxious and ‘got at’. Some of the ‘hostile fire’ comes by way of the overt threats and aggression from the patients that we have outlined above. However, it also comes in the form of patients’ more subtle attempts at grooming and seduction that seem ‘friendly’ but, in their intimacies, serve only to make matters more confusing. Managerial ‘friendly fire’ takes the form of ever greater demands to do more for less (as in the example of the de-commissioned seclusion room). These demands are coupled with the widespread implementation of bureaucratic technologies in which ‘clinical’ intervention is increasingly monitored by remote and faceless watchers who proceed on the basis that if it is not recorded on the electronic data collection systems then it did not happen. The shaming face of remote surveillance is then experienced as an incontinent management culture that pounces on any mistake and subjects the mis-taker to the ‘third degree’ in an ever-more demanding and structurally violent culture of inquiry, inspection and blame (Rustin, 2004a, 2004b; Cooper and Lousada, 2005). Whether any of these surveillance measures do in fact have a remedial effect on bad practice, we may doubt; but in our observation what is beyond doubt is that they do induce a sense of humiliation, fear and loathing in very many able and experienced practitioners. The effect is to move away from an emphasis on greater relational security, reflective practice and team development and inevitably towards an anxious pre-occupation with personal survival, physical security and other offensive and defensive practice measures (Pfäfflin and Adshead, 2004; Aiyegbusi and Clarke, 2008; Gordon and Kirtchuck, 2008; Scanlon and Adlam, 2008a; 2011b in press; Rubitel and Reiss, 2011; Aiyegbusi and Kelly, 2012 forthcoming). As in the combat situation, the workers might reasonably expect hostility from one direction but not from the other and once they realise that even the guns of their own 12 generals are also trained upon their positions, the only available solution is to dig ever deeper trenches of defensive practice. Whether the focus is on hostile or on friendly fire, the anxiety generated locks staff and patient alike into an enforced proximity that perverts, contaminates and polarises. It is often observed that the ward staff who are most often charged with ‘observations’ of the patients are often the most junior or least well trained staff who are also often, though not always, the younger members of staff. As well as watching out for signs of danger, their job is essentially to watch over, protect, look after and to care about the objects of their gaze. To gaze, look at or ‘watch over’ another, as well as being potentially intrusive, is also an intimate and engaging transaction: either an invitation to avert your gaze or a welcome invitation to look back, to reciprocate. In this context the patients are never only the passive recipients of others’ scrutiny: they too are gazing into the others’ eyes, watching and gazing longingly and care-fully. Sometimes they are looking out for ordinary human kindness in the kind of dance of attunement and reciprocal gaze described by Stern (1977); at other times they are looking to identify a perceived weakness, for opportunity to give offence; to seduce, reduce or debase. In this enforced proximity of the perverse panopticon, there is a much more symmetrical form of intimacy which brings with it a longing for ‘care’ as well as a profound fear of it (Adshead, 1995; Norton, 1996; Hinshelwood, 2002). There are patients who, in their need ‘to be special’ or to be treated well, sometimes succeed in befriending, or seducing, their watcher and become inappropriately close to them: an everyday manifestation of what has been described as ‘Stockholm Syndrome’ (Namnyak et al, 2008). There are also workers who attach to their ‘patient-watchers’, along similar lines, and motivated by similar needs. In either event, the potential for complaint against a nurse caught up in this agoraphobic/claustrophobic dilemma, for being too close-in (or too far-away), carries with it the ever-present threat of an automatic-suspension-pending-investigation: a very real threat to their livelihood that makes it next to impossible for the nurses confidently to know how and where to place themselves. The nursing staff in these settings find themselves unwittingly the very embodiment of the dream that Bentham had for his prospective prisoners, which Foucault summarises as “the principle that power should be visible and unverifiable” (1975, p. 201). The staff, caught between the ever-present scrutiny of both the patients and ‘the establishment’, end up exercising the persecutory surveillance upon themselves. Their watchers are not entirely dispensed with, of course, but neither are they any longer strictly necessary. The simple possibility of them being ‘caught out’ in some way, either by patients, supervisors, managers or so-called whistle-blowers, suffices to keep them in their proper place (Rancière, ([1983] 2004); Adlam et al, 2010). Conclusion 13 "For now we see through a glass, darkly; but then face to face" Corinthians, 1: 13 Forensic nurses, and the institutional settings in which they work, are under continual pressure, both from external and internal sources, to inhabit unhoused and violent states of mind and to accommodate others’ unhoused and violent states of mind. In a context characterised by the dynamics of shame and humiliation, inclusion/exclusion and care/control staff and patients are forced to live and to work in the poisonous and contaminating effects of the surveillance culture. On the one hand, out of a fear of being, or being seen to be, pushed around, staff find themselves becoming overly controlling and seeking to dominate the social spaces belonging to the patients; on the other hand, out of a fear of pushing, or being seen to be pushing, they are overly appeasing, in a futile attempt to be housed within the interpersonal world of the patients. The consequence is that the apparently socially responsible and altruistic motivation of staff becomes corrupted and replaced by a tendency to dogmatism, coercion and control and/or by an abdication of their professional responsibility for setting appropriate professional boundaries (Scanlon and Adlam, 2008a; 2011b in press; Gordon and Kirtchuk 2008; Aiyegbusi and Kelly, 2012 forthcoming). The invitation to the worker is to become a colluding member of a corrupt association: an ostrich culture that looks the other way as a way of avoiding being looked at. The situation is often exacerbated because in general terms, mental health nurses and other front-line workers occupy roles with relatively low reward and status compared with their neighbours within the wider multi-disciplinary team. They also live and work cheek by jowl with some of the most detested people in society and they often experience themselves as damned by association with them. It is this darkness that Bentham sought and failed to illuminate with his ‘Inspector’s lantern’ (Letter VI, p. 46). The environment within the perverse panopticon, as we hope to have evoked, remains smoggy because the projective and dynamic processes that characterise it are ubiquitous, toxic and pervasive. As we have described above there is nowhere to run and nowhere to hide and so Juvenal’s rhetorical question about ‘who watches the watchers’ has perhaps never been more relevant and immediate. We make these observations, in part, by way of a plea, not for greater surveillance but for a different sort of watchfulness rooted in a greater tolerance and understanding of the difficulties of staff who work in these deeply complex, conflicted and claustrophobic environments. This tolerance may in itself be crucially important in enabling them to do a very difficult job: one for which we might wish society would show greater appreciation and gratitude in terms of professional support as well as in terms of social status, job security and financial reward. 14 Acknowledgements: In the writing of this paper we have benefitted from discussions with very many mental health nurses (and others) in many different contexts, but in particular we would like to thank our friends and colleagues Anne Aiyegbusi, Janet Chamberlain, Steve McCluskey, Maria MacMillan, Rebecca Neeld, Harjinder Sehmi, Gillian Tuck, Lyn Suddards and Diane Turner. References Adlam, J., Pelletier, C. and Scanlon, C. (2010) ‘‘A Citizen of the World’: Cosmopolitan Responses to Metropolitan Models of Social Inclusion’, unpublished conference paper presented at ‘Education and Citizenship in a Globalising World’, Institute of Education/Normal University of Beijing, London, November 2010. Adlam, J. and Scanlon, C. (2005) ‘Personality disorder and homelessness: membership and 'unhoused minds' in forensic settings’, Group Analysis, 38(3): 452-466 (Special Issue – Group Analysis in Forensic Settings). Adlam, J. and Scanlon, C. (2011) ‘Working with hard-to-reach patients in difficult places: a democratic therapeutic community approach to consultation’, in A. Rubitel and D. Reiss (eds), Containment in the Community: Supportive Frameworks for Thinking about Antisocial Behaviour and Mental Health. London: Karnac. Adshead, G. (1995) ‘Psychiatric staff as attachment figures: understanding management problems in psychiatric services in the light of attachment theory’, British Journal of Psychiatry, 172: 64-69. Aiyegbusi, A. and Clarke, J. (eds) (2008). Relationships with Offenders: An Introduction to the Psychodynamics of Forensic Mental Health Nursing. London: Jessica Kingsley. Aiyegbusi, A. and Kelly, G. (eds) (2012, forthcoming). Professional and Therapeutic Boundaries in Forensic Mental Health. London: Jessica Kingsley. Armstrong, D. (2005). Organization in the Mind: Psychoanalysis, Group Relations and Organizational Consultancy. London: Karnac. Bentham, J. (1988). An Introduction to the Principles of Morals and Legislation. Buffalo: Prometheus Books. Bentham, J. (1995). The Panopticon Writings. London: Verso. Bion, W. R. (1959) ‘Attacks on linking’, reprinted in W. R. Bion (1967) Second Thoughts. London: Maresfield. Bion, W. R. (1962). Learning from Experience. London: Maresfield. Bollas, C. (1987) The Shadow of the Object: Psychoanalysis of the Unthought Known. London: Free Association Press. Camus, A. (1947). La Peste (The Plague). New York: Vintage Books. 15 Campling, P., Davies, S. and Farquharson, G. (eds) (2004). From Toxic Institutions to Therapeutic Environments: Residential Settings in Mental Health Services. London: Gaskell. Cooper, A. and Lousada, J. (2005). Borderline Welfare: Feeling and Fear of Feeling in Modern Welfare. London: Karnac. Dartington, A. (1994) ‘Where Angels Fear to Tread: Idealism, despondency and opportunities for thought in hospital nursing’, in A. Obholzer and V. Z. Roberts (eds), The Unconscious at Work: Individual and Organizational Stress in the Human Services. London: Routledge. Dorling, D. (2010). Injustice: Why Social Inequality Persists. Bristol: Policy Press. Foucault, M. ([1961] 2007). Madness and Civilization. London: Routledge. Foucault, M. (1975). Discipline and Punish: The Birth of the Prison. New York: Vintage Books. Foucault, M. (1980). Power/Knowledge: Selected Interviews and Other Writings 1972-1977. New York: Pantheon. Fruedenberger, H. and Richelson, G. (1980). Burn Out: The High Cost of High Achievement. What it is and how to survive it. Bantam Books Gilligan, J. (1996). Violence: Reflections on our Deadliest Epidemic. London: Jessica Kingsley. Gilligan, J. (2011). Why Some Politicians are more Dangerous Than Others. London: Polity. Glasser, M. (1996) ‘Aggression and violence in the perversions’, in I. Rosen (ed.), Sexual Deviation. Oxford: Oxford University Press. Goffman, I. (1961). Asylums: Essays on the Condition of the Social Situation of Mental Patients and Other Inmates. London: Pelican. Godwin, W. (1794). Caleb Williams. London: Penguin Classics. Gordon, J. and Kirtchuk, G. (2008) (eds.). Psychic Assaults and Frightened Clinicians: Countertransference in Forensic Settings. London; Karnac. The Guardian (2010a) ‘Someone to watch over you’ Rowenna Davis 09.06.10. The Guardian (2010b) ‘The Spirit Level is not on the level’ Natalie Evans 08.07.10. Downloaded (17.03.11) from http://www.guardian.co.uk/commentisfree/2010/jul/08/spirit-level-bookcritique The Guardian (2010c) ‘The Spirit Level: how ‘ideas’ wreckers’ turned book into political punchbag’ Robert Booth 14.08.10. Downloaded (17.03.11) from http://www.guardian.co.uk/books/2010/aug/14/the-spirit-level-equalitythinktanks Hinshelwood, R. D. (2002) ‘Abusive help – helping abuse: the psychodynamic impact of severe personality disorder on caring institutions’, Criminal Behaviour and Mental Health, 12 (2 Suppl): 20-30. Holmes, J. (2001). The Search for the Secure Base: Attachment Theory and Psychotherapy. London: Brunner-Routledge. Hopper, E. (2003). Traumatic Experience in the Unconscious Life of Groups: The Fourth Basic Assumption: Incohesion: Aggregation/Massification or (ba) I:A/M. London: Jessica Kingsley. Hopper, E. (2011 in press). Trauma In Organisations. London: Karnac. 16 Jukes, A. (1997). Why Men Hate Women. London: Free Associations. Kafka, F. ([1925] 1953). The Trial. London: Penguin Modern Classics. Kafka, F. ([1926] 1997). The Castle. London: Penguin Modern Classics. Klein, M. (1946) ‘Notes on some schizoid mechanisms’, reprinted in M. Klein (1997) Envy and Gratitude and Other Works 1946-1963. London: Vintage. Levi-Strauss, C. (1955). Tristes Tropique. Harmondsworth: Penguin. Maslach, C. and Leiter, M. P. (1997) The truth about burnout: How organizations cause personal stress and what to do about it. San Francisco, CA: Jossey-Bass. Meltzer, D. (1992). The Claustrum: an Investigation of Claustrophobic Phenomena. Strathclyde: Clunie Press. Meltzer, D. (1998). The Kleinian Development. London: Karnac. Menzies, I. E. P. (1959) ‘The functioning of social systems as a defence against anxiety – a report on a study of the nursing service within a general hospital’, Human Relations, 13: 95-121. Moore, A. and Gibbons, D. (2007). Watchmen. London: Titan. Motz, A. (2008). The Psychology of Female Violence: Crimes Against the Body, 2nd Edition, London: Routledge. Namnyak, M., Tufton, N., Szekely, R., Toal, M., Worboys, S. and Sampson, E. L. (2008) ‘'Stockholm syndrome': psychiatric diagnosis or urban myth?’, Acta Psychiatrica Scandinavica, 117(1): 4-11. Norton, K (1996) ‘Management of difficult personality disordered patients’, Advances in Psychiatric Treatment, 2: 202-210. Norton, K. and Dolan, B. (1995) ‘Acting out and the institutional response’, Journal of Forensic Psychiatry, 6: 317-332. Ogden, T.H. (1979). ‘On Projective Identification’, International Journal of Psycho-Analysis, 60: 357-373. Pfäfflin, F. and Adshead, G. (eds) (2004). A Matter of Security: The Application of Attachment Theory to Forensic Psychiatry and Psychotherapy. London: Jessica Kingsley. Policy Exchange (2010). Beware False Prophets: Equality, the Good Society The Spirit Level. Downloaded (17.03.10) from and http://www.policyexchange.org.uk/assets/Beware_False_Prophets_Jul_1 0.pdf Rancière, J. ([1983] 2004). The Philosopher and his Poor. Durham: Duke University Press. Rogers, C. (1987) ‘On putting it into words: the balance between projective identification and dialogue in the group’, Group Analysis 20 (2): 99-108. Rubitel, A. and Reiss, D, (2011) (eds). Containment in the Community: Supportive Frameworks for Thinking about Antisocial Behaviour and Mental Health. London: Karnac. Rustin, M. J. (2004a) ‘Re-thinking Audit and Inspection’, Soundings, 64: 86107. Rustin, M. J. (2004b) ‘Learning from the Victoria Climbié Inquiry’, Journal of Social Work Practice, 18(1): 9-18. 17 Sassoon, S. (1917) ‘The General’, p. 97 in B. Gardner (ed.) Up the Line to Death: The War Poets 1914-1918. London: Methuen. Scanlon, C. and Adlam, J. (2008a) ‘Nursing dangerousness, dangerous nursing and the spaces in between: learning to live with uncertainties’, in A. Aiyegbusi and J. Clarke (eds), Relationships with Offenders: An Introduction to the Psychodynamics of Forensic Mental Health Nursing. London: Jessica Kingsley. Scanlon, C. and Adlam, J. (2008b) ‘Refusal, social exclusion and the cycle of rejection: a Cynical analysis?’, Critical Social Policy, 28(4): 529-549. Scanlon, C. and Adlam, J. (2009) ‘“Why do you treat me this way?”: reciprocal violence and the mythology of ‘deliberate self harm’’, in A. Motz (ed.), Managing Self Harm: Psychological Perspectives. London: Taylor and Francis. Scanlon, C. and Adlam, J. (in press 2011a) ‘Cosmopolitan minds and Metropolitan societies: social exclusion and social refusal revisited’, Psychodynamic Practice, 17 (3). Scanlon, C. and Adlam, J. (in press 2011b) ‘Disorganised responses to refusal and spoiling in traumatised organisations’, in E. Hopper (ed.), Trauma in Organisations. London: Karnac. Shine, J. and Morris, M. (2000) ‘Addressing criminogenic needs in a prison therapeutic community’, Therapeutic Communities, 21: 197-219. Stern, D. (1977). The First Relationship: Infant and Mother. Cambridge, MA: Harvard University Press. Welldon, E. V. (1996) ‘Contrasts in male and female perversions’, in C. Cordess and M. Cox (Eds), Forensic Psychotherapy: Crime, Psychodynamics and the Offender Patient. London: Jessica Kingsley. Welldon, E. V. (2011). Playing With Dynamite: A Personal Approach to the Psychoanalytic Understanding of Perversions, Violence and Criminality. London: Karnac. Wilkinson, R. and Pickett, K. (2009). The Spirit Level: Why More Equal Societies Almost Always Do Better. London: Allen Lane. Žižek, S. (2008). Violence. London: Profile Books. Zuluetta, de F. (1993). From Pain to Violence: The Traumatic Roots of Destructiveness. London: Whurr. 18