Disturbances of “groupishness”? Structural violence, refusal and the therapeutic community response to severe personality disorder

Abstract

We explore the problematic dynamics in the relationship between societal systems of care and the chronically excluded, with particular reference to severe personality disorder and the “difficult-to-reach” patient. The individual who “refuses” is often met with a violent response: yet his violence must be understood as related to an experience of being violently excluded. We reformulate personality disorder as a disturbance of “groupishness” and suggest, as a paradigm for the problem of refusal, the story of Diogenes the Cynic, who “holed himself up” in a barrel; and of his legendary encounter with Alexander the Great, who tried unsuccessfully to persuade him to “come in from the cold.” We suggest it may be as important to focus on Alexander's violence as on that of Diogenes, and we examine modes of violence deployed by society against the excluded outsider, with particular reference to the hostile attribution of intentionality to the personality disordered individual's acts of violence and self-harm. We conclude by considering both the merits of the democratic therapeutic community model as a response to severe personality disorder and the dangers, inherent in this model among others, in an unconscious identification with Diogenes in his barrel.

Keywords:

• Cynicism
• exclusion
• homelessness
• intentionality
• nihilism

Acknowledgements

This paper was presented at a symposium at the Reichenau Hospital in Konstanz, Germany, and we are grateful to Dr Klaus Hoffman and Dr Tilman Kluttig for their invitation and their hospitality. This paper in part presents a synopsis and reworking of ideas we have put forward in our other recent writings, as listed in the bibliography below. We would also wish to acknowledge the immense contribution of the residents and staff of the Henderson Hospital Therapeutic Community.