Institutional psychotherapy

1. Introduction

Version followed: the Saint-Alban to La Borde line of French institutional psychotherapy, mainly as Jean Oury sets it out in his lecture "Institutional Psychotherapy: From Saint-Alban to La Borde" (English translation in Tosquelles & Oury, Psychotherapy and Materialism, ICI Berlin, 2024; cited below as Oury 2024). It is supplemented by Tosquelles' Saint-Alban foundations, Guattari's transversality and grille (task grid) at La Borde, and Pierre Delion's later formalisation of the constellation meeting. Concepts Oury developed in books not drawn on here (Le Collectif, the diacritical function, pathoplasty) are flagged [uncertain].

What it is. Institutional psychotherapy is not a manualised therapy. It is a way of organising a care setting (hospital ward, clinic, day hospital, residential unit, club) so that the setting itself works as the treatment, mainly for psychosis. The clinician treats the patient and also treats the institution, because asylum structures make people sick in their own right. Oury calls these structures "concentrationary", and he defines the practice as methods for resisting that pull [source: Oury 2024, pp. 91–93]. Tosquelles said the approach must "walk on two legs": Marx for social alienation, Freud for psychopathological alienation. Both have to be treated together [source: French Wikipedia, Psychothérapie institutionnelle; Pratiques no. 66 interview]. Daumézon and Koechlin coined the name in 1952 [source: French Wikipedia].

How change happens. The psychotic person's transference is dissociated and spread across many people and places. Tosquelles describes it as "massive and multi-referential" [source: Gascuel, Carnets 114; Chaperot et al. 2014 abstract]. Change therefore depends on three things:

a varied milieu the person can move through freely;
many small, real encounters (with the cook, a fellow patient, the donkey);
a team that collects the scattered pieces of transference and works on them.

Patients also take real responsibility through a self-managed club. Oury calls this "setting up techniques of mediation" [source: Oury 2024, p. 111], and he says "mental illness is an illness of relationality" [source: Oury 2024, p. 117].

Who this guide is for. A psychotherapist working inside, or setting up, a team-based setting. The individual therapist is only one node in the treatment, not its centre [synthesis].

2. Framework

Not a phased protocol. None of the sources sets out phases, session counts or transition criteria. Oury says the term now covers practices that differ between regions and establishments, and Tosquelles held that institutional psychotherapy "does not exist" as a finished thing: institutional analysis has to be put back to work constantly [source: Oury 2024, p. 89; Pratiques no. 66]. Change "takes a very long time" [source: Oury 2024, p. 94]. The structure below is my working order for operating the approach [synthesis]. Where it draws on specific practices, those are cited.

Level A: building the institution (months to years)

Institutional diagnosis. Goal: identify segregating and depersonalising features such as uniforms, locked circulation, crowding and rigid hierarchy [source: Oury 2024, pp. 91–98]. Format: open meetings that include all staff categories. Move on when there is a shared list of concrete barriers and a group willing to work on them [synthesis].
Building the Collective and the meeting system. Goal: regular, ritualised meetings that cut across hierarchy [source: Oury 2024, p. 102]. Move on when meetings run reliably and non-clinical staff speak in them [synthesis].
Founding the club. Goal: an autonomous patients' association with a contract with the establishment [source: Oury 2024, pp. 105–108]. Move on when patients hold the elected offices and the club controls a real budget [synthesis].
Diversifying places and activities. Goal: a polycentric structure of workshops, bar and spaces that can open or close as needed [source: Oury 2024, p. 109].
Opening outward. Goal: two-way circulation with the sector, families, schools and the town [source: Oury 2024, pp. 115–117].

Level B: one patient's trajectory (weeks to years)

Welcome (accueil). Goal: receive the person into a group and avoid a depersonalising admission [source: Oury 2024, p. 96].
Finding places and people to invest. Goal: let the person settle on places, tasks and people of their own choosing. Format: free circulation, with workshops on offer but not compulsory [source: Oury 2024, pp. 98, 104].
Gathering the transference. Goal: the people who meet the patient pool what they see and hear in a constellation meeting [source: Chaperot et al. 2014; Delion 2022, [uncertain]].
Taking responsibility. Goal: a role in the club, a workshop or a commission [source: Oury 2024, pp. 102–107].
Leaving with continuity. Goal: a trial stay outside, backed by the solidarity fund, sector follow-up and family work [source: Oury 2024, pp. 110–117].

Rhythm. Individual psychotherapy sessions continue alongside the institutional work. The sources give no frequency [uncertain]. Ways to judge readiness to move along the trajectory [synthesis]:

the person uses several places and people, not only one;
the person speaks in, or attends, the meeting where they live;
the person takes on and keeps a small responsibility.

3. Guiding principles

Treat the institution as well as the patient. If the ward is sick, treat the ward. [source: Oury 2024, pp. 91–93; Robcis via La Vie des idées on Fanon's "soigner l'institution"]
Two alienations. Ask both what is happening in the person's psyche and what the social conditions are doing to them, every time. [source: French Wikipedia]
Freedom of circulation. Oury's axiom: "a maximum possibility of circulation must be created." In practice: unlock doors and cut the number of no-go zones. Circulation also needs places and occupations, or people go "round in circles." [source: Oury 2024, pp. 92, 98]
Dissociated, multi-referential transference. Expect the transference to be split across many staff, so no single therapist holds the whole of it. [source: Gascuel; Chaperot et al. 2014]
Psychotherapeutic coefficient of every function. The cook's or secretary's greeting matters clinically. In practice: include them in clinical thinking. [source: Oury 2024, p. 100]
Status, role and function are different things. A function can be therapeutic whatever the person's official status. Oury said La Borde's donkey had no status but did have a function. In practice: look at who actually helps, not at job titles. [source: Pratiques no. 66]
Heterogeneity and distinctiveness. "Y en a pas un pareil" (no two are alike). Do not group patients by category; recruit staff with mixed backgrounds. [source: Gascuel; French Wikipedia]
Conflict is material. "Without conflicts, there is no life." In practice: talk conflicts through. Do not suppress them. [source: Oury 2024, p. 99]
Anti-hierarchy in speech, not abolition of responsibility. Meetings only work "provided there are no hierarchical barriers." The doctor's word is always distorted by their status, and La Borde kept a medical hierarchy. [source: Oury 2024, pp. 102, 111; Pratiques no. 66]
Autonomy of the patients' society. The club must have "an autonomous existence" and must not depend on the doctor's wishes. It still needs framing by the team, or it turns into pleasing daddy. [source: Oury 2024, pp. 105–106]
No exploitation. Work is offered and never compulsory. Do not let a few "good workers" prop up the budget. [source: Oury 2024, pp. 103–104]
Mediation. Every exchange needs "some mediating structure" and "above all an occasion." In practice: build occasions (bar, task, outing) rather than summoning people to talk. [source: Oury 2024, p. 112]
Welcome, ambiance, tact. "Être là, faire signe" (be there, give a sign). Psychotic people are acutely sensitive to atmosphere. Take time, and do not crush "le peu qu'il y a" (the little there is). [source: Oury via Gascuel]
Do not interpret too early. Tosquelles' image is the damaged undergrowth (brande): pushing can bring down another tree. [source: Tosquelles via Gascuel]
Openness against fermentation. "Everything that's closed off becomes dangerous." Keep the setting porous to the outside. [source: Oury 2024, p. 116]
Care for the carers. "S'il n'y a pas de collectif, il n'y a rien qui tient" (without a collective, nothing holds). In practice: protect time for team elaboration. [source: Oury via Pratiques no. 66; GTPSI per French Wikipedia]
Precariousness as a base. Organisation stays deliberately provisional and gets re-made constantly. It does not harden into bureaucracy. [source: Oury via Gascuel]
The family is the first institution. Work with the family milieu as part of the treatment. [source: Oury 2024, p. 117]
Against pathoplasty. Oury holds that an institution shapes the clinical form patients' illness takes ("pathoplasty"), so the team keeps checking which symptoms the setting itself produces. Oury 2024 shows the idea at work (agitation and senility as products of camp-like life, p. 93), but the term itself does not appear in the sources. [uncertain]
Diacritical function and the distinguo. In Oury's later work: the capacity to keep distinctions (places, moments, roles, persons) so they do not merge into an undifferentiated mass. The Collective's job is to sustain those distinctions. Summarised from my knowledge of Oury's Le Collectif. [uncertain]

4. Intervention inventory

The sources describe institutional devices and team practices rather than scripted session techniques. Step lists below turn what Oury, Tosquelles and Guattari describe into actions a clinician can take. The ordering and operational detail are [synthesis] unless a step carries a citation. All example language is illustrative, unless it is a short quotation with a citation.

4.1 Institutional analysis ("treating the hospital")

Purpose: find and dismantle the features of the setting that segregate people and produce symptoms. Use it when starting in a unit, and again periodically. Oury traces much "agitation" and "senility" to life in a camp-like structure, and reports that both nearly disappeared when the setting changed [source: Oury 2024, p. 93]. Tosquelles held that institutional analysis must be "put back to work" constantly [source: Pratiques no. 66].
Steps:
1. Walk the unit with a cleaner, a nurse and a patient. List every locked door, uniform, queue, shared dormitory and rule that exists "for the staff" [synthesis; Oury 2024 names uniforms, registration, crowding, barricades, pp. 96–99].
2. For each item, ask in a cross-category meeting: "Whom does this serve? What does it produce in patients?" [synthesis]
3. Pick one barrier you can change this month. Changing it will cause conflict; work that conflict in meetings (4.10) [source: Oury 2024, p. 99].
4. Re-audit every few months. New rigidities come back [synthesis].
Example language (illustrative): "Before we talk about Mr B's agitation, let's look at what the evening on the ward is like for him: where can he go after six, and who will he meet?"
Watch for: reforms that are only architectural. Oury cites an expensive "social centre" that patients never used [source: Oury 2024, pp. 108–109]. It is working when there are fewer incidents where patients are confined together, and non-clinical staff raise observations unprompted [synthesis].
Historical note (do not reproduce): at Saint-Alban a nun who wanted straitjackets abolished had resistant nurses wear one for a week [source: e-flux review of Psychotherapy and Materialism]. This was a coercive experiential demand. Do not use bodily restraint as a training exercise. Any use of restraint or seclusion must follow current law and local policy [synthesis].

4.2 The welcome (accueil)

Purpose: reverse the "anti-welcome" of a standard admission (uniforms, registration, depersonalisation) and receive the person into a living group. Oury describes the welcome as a continuous function of presence: "Être là, faire signe, un clin d'œil" (be there, give a sign, a wink) [source: Oury 2024, p. 96; Oury via Gascuel].
Steps:
1. The first contact is a person, not a form. Whoever is present (nurse, monitor, a patient from the club) greets, offers a drink and shows the person around [synthesis; at La Borde admission was into a "familial group", Oury 2024, p. 96].
2. Keep administrative and medical procedures, but separate them from the first hour and keep them short [synthesis].
3. Name two or three people and places the newcomer can come back to [synthesis].
4. Let the person stay at the edge. Do not push them into activities; Tosquelles warns against acting too early [source: Gascuel].
5. Report the first impressions at the next meeting [synthesis].
Example language (illustrative): "You don't have to do anything today. The coffee is there, and I'm in the office if you want me. This evening there's a meeting; you can just sit in."
Watch for: staff "processing" the person rather than meeting them. It is working when the newcomer comes back, unprompted, to a place or person met on the first day [synthesis].

4.3 Freedom of circulation and the making of places

Purpose: give a dissociated transference several possible anchoring points. Oury's axiom is that "a maximum possibility of circulation must be created" [source: Oury 2024, p. 98; French Wikipedia]. Without places and occupations, circulation becomes going "round in circles" [source: Oury 2024, p. 92].
Steps:
1. Open the kitchen, office, pharmacy counter, garden and workshops to patients, with agreed times if needed [source: Oury 2024, p. 99].
2. Make sure each space has a person and an activity, so it is a place and not just a corridor [source: Oury 2024, p. 92].
3. Provide rest areas [source: Oury 2024, p. 98].
4. When a staff member barricades a space (Oury's example is the cook), do not overrule them. Set up an occasion that brings them into contact with patients, such as the bar (4.6) [source: Oury 2024, pp. 99–100].
5. Map each patient's actual route through the day and bring the map to the constellation meeting (4.13) [synthesis].
Example language (illustrative), to a staff member: "Rather than closing the kitchen, could Ms D help you peel vegetables on Tuesdays? Then she's there for a reason."
Watch for: conflicts at the new crossing points. These are expected and are material for meetings. Also watch for risk issues: assess individually and do not lock everyone down because of one person [synthesis]. It is working when patients' routes widen and they spend less time in one fixed spot [synthesis].

4.4 Polycentric structure: workshops (ateliers) and sub-spaces

Purpose: replace the pyramid (director, bursar, doctor, and "at the bottom" the patients) with many small centres. The aim is more encounters and somewhere conflict can be settled [source: Oury 2024, pp. 109–110].
Steps:
1. Set up workshops around a real activity: cooking, garden, printing, music, painting, video, horses and so on. These are examples from the sources; choose your own [source: Oury 2024; Robcis review; Fanon at Blida: sewing, pottery, gardening, sport, café, library].
2. Each workshop has a name, a time, a place, a lead (staff member or patient) and an open door. Attendance is never compulsory [source: Oury 2024, p. 104].
3. Let workshops be "mobile": they can be founded, merged or ended by decision of the club or a meeting [source: Oury 2024, p. 109].
4. Review in the meeting who goes where. Absences are information, not failures [synthesis].
Example language (illustrative): "The garden group meets Thursday. Come and look; you don't have to dig."
Watch for: workshops sliding into "occupational therapy" that keeps people busy. Machto quotes Oury: you don't send a patient fishing "pour l'occuper" (to occupy him) [source: Pratiques no. 66]. It is working when patients propose, run or close workshops themselves [synthesis].

4.5 The therapeutic club (club thérapeutique / Hospital Committee)

Purpose: an internal society of patients and staff that runs collective life, outside the hospital hierarchy. Oury calls it the cleverest solution found so far [source: Oury 2024, pp. 105–106]. Tosquelles proposed these committees in 1953, and a 1958 ministerial circular recommended them [source: Oury 2024, pp. 106–107].
Steps:
1. Constitute the club as a legal association, independent of the establishment (in France, a 1901-law association, which can receive donations) [source: Oury 2024, p. 107]. Elsewhere, use the nearest local equivalent [synthesis].
2. Hold elections. Patients fill the offices (president, secretary, treasurer). Staff may be members but "should not have the majority" [source: Oury 2024, p. 107].
3. Draw up a contract with the establishment: the establishment provides rooms, grounds and workshop spaces, and the club takes over running the workshops and activities [source: Oury 2024, p. 107]. Oury says that without the transfer of ergotherapy the arrangement is a sleight of hand [source: Oury 2024, p. 107].
4. The club keeps its own accounts under administrative oversight [source: Oury 2024, p. 108].
5. Hold a regular general assembly, plus commissions (bar, outings, newspaper, solidarity fund) [source: Oury 2024, pp. 109–111; weekly club meeting, e-flux review].
6. A staff member acts as framer: present, taking part, but not deciding. Without framing, the club drifts into "We're going to please daddy" [source: Oury 2024, p. 105].
Example language (illustrative), staff at an assembly: "That's for the club to decide, not me. What does the treasurer think the budget can carry?"
Watch for: the doctor's wishes silently steering decisions; the same few patients holding every office; a club with no money and therefore no reality. It is working when the club refuses something staff wanted, and the refusal is accepted [synthesis].

4.6 The bar or café as a "relationship trap"

Purpose: buying something creates a minimum of dialogue, and people recognise each other there. This is a daily mediating structure [source: Oury 2024, pp. 100, 112]. Fanon set up a similar "Café Bon Accueil" at Blida [source: Robcis review, La Vie des idées].
Steps: a small group of patients runs it under club authority. It sells coffee, drinks, sweets and so on, at set hours, and keeps simple accounts. Staff buy there too [source: Oury 2024, p. 100]. Rotate who serves [synthesis].
Example language (illustrative): "Can I get a coffee? How's the till looking today?"
Watch for: staff avoiding it; one patient guarding it as their own. It is working when withdrawn patients start to come in, at first only to buy something [synthesis].

4.7 Patients' newspaper, printing and expression

Purpose: a collective place for speech. The Saint-Alban club had a newspaper and a printing press; clandestine books were printed on the press [source: French Wikipedia; Zeavin via Everybody Wants to Be a Fascist, p. 72]. Fanon started a journal at Blida [Robcis, Disalienation, [uncertain]].
Steps: a newspaper commission of the club; an open call for texts and drawings; publication on a fixed schedule; distribution inside and outside the unit [synthesis].
Example language (illustrative): "The paper goes to print Friday. Would you write about the outing, or should I take down what you say?"
Watch for: staff editing for tone. It is working when patients write about the institution itself, including criticism [synthesis].

4.8 Valuing patients' work without exploiting it

Purpose: to stop occupational work from turning into unpaid labour that props up the institution, the "good workers" trap [source: Oury 2024, pp. 103–105].
Steps:
1. Make every work task voluntary. Being occupied is better than doing nothing, but it is never compulsory [source: Oury 2024, p. 104].
2. Estimate the value of patients' work "by substitution": what the establishment would pay staff to do it, net of social charges. Pay that sum to the club treasury, not to individuals [source: Oury 2024, p. 110].
3. Check that no staff member buys patients' handicrafts below their value [source: Oury 2024, pp. 104–105].
4. In meetings, notice when the same patients always do the same chores [synthesis].
Example language (illustrative): "The kitchen work this month is worth X to the hospital. It goes to the club. The assembly decides what to do with it."
Watch for: institutional dependence on a few patients; patients unable to leave because they have become "indispensable" [synthesis]. Local labour law takes precedence [synthesis].

4.9 The meeting system

Purpose: to create a recurring space where every category of person in the setting speaks, the Collective works on itself, and scattered observations come together. Oury: meetings must be repeated, follow a ritual, and include doctors, cleaners, cooks, educators, nurses and psychologists. Badly run, they are "an extraordinary waste of time" [source: Oury 2024, p. 102]. A later formulation is the "fonction réunion" (meeting function) [source: Chaperot et al. 2014].
Steps:
1. Fix a calendar: daily or near-daily life meetings (patients and staff), the weekly club assembly, team meetings that include non-clinical staff, and constellation meetings (4.13) as needed. Oury gives no frequencies [uncertain]. The weekly club meeting is mentioned in the e-flux review.
2. Keep the ritual: same time, same place, a named chair (rotating, and patients chair too), a written record that is read back at the next meeting [synthesis].
3. Lower hierarchical barriers. The chair invites the least "qualified" voices first. The doctor speaks last or briefly, aware of how status distorts their words [source: Oury 2024, pp. 102, 111].
4. Each meeting ends with decisions and who will carry them out [synthesis].
Example language (illustrative), chairing: "Before the doctors speak, what did the night staff see? Ms R, you were at breakfast."
Watch for: meetings becoming reporting rituals; staff turning into detached "psycho-sociologists" who comment but no longer take part [source: Oury 2024, p. 103]. It is working when previously passive patients start taking things in hand [source: Oury 2024, pp. 102–103].

4.10 Working conflict as an analyser

Purpose: conflicts that arise from circulation and shared work reveal how the institution and the person are functioning. "Without conflicts, there is no life." Talking conflicts through produces "better adapted" relationships [source: Oury 2024, p. 99; conflicts as analysers per e-flux review].
Steps:
1. Do not settle the conflict by decree in the moment, unless safety requires it [synthesis].
2. Bring it to the relevant meeting, with both parties present if possible [source: Oury 2024, p. 99].
3. Ask what the conflict shows about the setting (a rule, a barricade, crowding) and about each person [synthesis].
4. Record the decision. Revisit it [synthesis].
Example language (illustrative): "The cook and Mr T clashed over the fridge. What is the fridge rule protecting, and who made it?"
Watch for: scapegoating a patient; conflicts going underground. Crowding breeds conflict (Oury's second axiom: it is harmful "to live piled up"), so check the numbers and the space too [source: Oury 2024, p. 105].

4.11 The grid (la grille) and rotation of tasks

Purpose: at La Borde, the grid was a chart assigning every staff member ("monitor") across a rotating set of tasks: care, kitchen, cleaning, night duty, workshops, administration. Its aim was to break rigid role identities and spread the therapeutic function [source: Nazif, introduction to Everybody Wants to Be a Fascist, p. 12; La Borde founded on "a rotating basis for the division of labor", English Wikipedia, citation needed]. Guattari developed it, and his 1987 talk "La grille" sets out its logic. That talk is not drawn on [uncertain]. Exact categories and rotation periods at La Borde were not verified [uncertain].
Steps (adaptation) [synthesis]:
1. List all recurring tasks: clinical, domestic, administrative, night, outings.
2. Build a chart of persons × time periods × tasks, so that each person regularly does some tasks outside their professional category.
3. Review the grid in a regular meeting. Adjust it for each person's capacities and for patients' attachments: do not rotate away the one person a fragile patient has invested in without discussion (4.13).
4. Keep legally reserved acts (prescribing, medication administration, clinical decisions) with qualified staff. Rotation concerns presence and everyday tasks [synthesis].
Example language (illustrative): "Next month you're on breakfast twice a week. That's where you'll see who isn't eating."
Watch for: the grid turning bureaucratic, with no one remembering why; staff exhaustion. It is working when staff report new clinical observations from their non-specialist tasks [synthesis].

4.12 Role-crossing and the psychotherapeutic coefficient of all staff

Purpose: to fight the "dualistic prejudice" that only clinicians do therapy. Everyone's function has a psychotherapeutic dimension [source: Oury 2024, pp. 100–101, 114].
Steps:
1. Induct new psychologists and doctors through ordinary work. Oury asked a new psychologist to wash dishes for a month, "a fantastic job for observing" [source: Oury 2024, pp. 114–115; e-flux review on new doctors].
2. Include cooks, cleaners and secretaries in clinical meetings [source: Oury 2024, pp. 100–102].
3. Recruit some staff from outside health professions, for heterogeneity [source: French Wikipedia].
4. Value the distinction between status (official position), role and function (what someone actually does for a patient). La Borde's donkey had "no status but a function" [source: Pratiques no. 66].
Example language (illustrative), to a new psychologist: "For your first weeks, do the lunch washing-up. Then tell us at Thursday's meeting who talked to you there."
Watch for: professionals feeling demeaned. Oury reports that traditionally trained nurses found digging and dish-washing an "affront" [source: Oury 2024, p. 114]. Explain the clinical reason; do not impose it as humiliation [synthesis].

4.13 The transference constellation (constellation transférentielle) meeting

Purpose: to gather the fragments of a psychotic patient's dissociated, multi-referential transference, held by the different people around them, so they can be worked through and returned to the patient [source: Chaperot et al. 2014; Santé Mentale summary of Delion 2022]. The constellation is everyone in contact with the patient, regardless of status [source: Santé Mentale summary of Delion 2022]. The concept goes back to Tosquelles and Oury and was formalised by Delion; attribution of the term itself was not verified [uncertain].
Steps:
1. Convene it around one patient, usually when something is stuck or changing [synthesis].
2. Invite everyone who actually meets the patient: nurse, cook, driver, workshop lead, cleaner, fellow patients only with consent and great care, family if appropriate. Status does not decide who comes; contact does [source: Delion summary; Pratiques no. 66].
3. Each person describes, without judging, the small details of the patient's way of being with them: what they say, avoid, ask for, bring [source: Chaperot et al. 2014 on "small details"].
4. Map the investments: which people and places carry which affects (trust, hostility, silence, demand) [synthesis].
5. Work out, together, a hypothesis about what these fragments say, and who could return what, in which situation [source: Chaperot et al. 2014 on collective elaboration and interpretation].
6. Decide concrete small changes: who will stay close, who will hold back, which activity to offer. Set a date for the next constellation [synthesis].
Example language (illustrative), opening: "We're here for Ms L. I'd like each of us to say what she is like with us, starting with whoever sees her least."
Watch for: the meeting turning into case presentation by the doctor; gossip; discussing a patient without any plan to return something to them. It is working when the patient is seen differently by several people at once and clinical change follows. Chaperot et al. report a clear improvement after a phased interpretation from such a meeting [source: Chaperot et al. 2014].

4.14 Everyday micro-mediations ("occasions")

Purpose: make contact through a shared, concrete act rather than through a summons to talk. Oury writes that exchange needs "some mediating structure" and "above all an occasion"; offering a cigarette, for example, starts a dialogue [source: Oury 2024, p. 112]. Machto gives two examples: Oury asked the cook to take a withdrawn patient fishing, and the patient gradually opened up; another patient was given the job of feeding the donkey, and that mattered to him [source: Pratiques no. 66].
Steps:
1. In the constellation meeting or team meeting, identify one person (staff member or patient) the patient tolerates, and one concrete activity they share [synthesis].
2. Ask that person to do the activity together with the patient, on a regular basis, without a therapeutic agenda they announce aloud [source: Pratiques no. 66, the fishing example].
3. The person reports back at the next meeting [synthesis].
Example language (illustrative), the cook to the patient: "I'm going down to the river Sunday morning. I could use someone to carry the bait."
Watch for: turning it into occupational therapy "to keep him busy" [source: Pratiques no. 66]. It is working when the patient seeks the activity or the person out again.

4.15 The individual psychotherapist inside the institution

Purpose: keep individual sessions while knowing they hold only one fragment of a dissociated transference [source: on dissociated transference, Gascuel; Chaperot et al. 2014]. Oury notes that what happens with the cook or the secretary can count for more than the consultation [source: Oury 2024, p. 100].
Steps [synthesis]:
1. Keep a regular session frame, and accept that the patient may miss sessions, come late, or speak more in the corridor than in the office.
2. Bring what you hear in sessions to the constellation meeting, respecting confidentiality. Share themes and positions, not secrets. Agree the confidentiality rule with the patient at the start.
3. Bring back into the sessions what other people in the constellation report, as material for the patient to work on: "You seem easier with the gardener."
4. Do not set yourself up as the one person who "really" understands the patient. Tosquelles said "I'm an enemy of this personalization" and gave the credit to the collective [source: e-flux review].
Example language (illustrative): "You told me you can't stand meetings, but Jacques says you stayed till the end on Tuesday. What kept you there?"
Watch for: a split in which one carer is idealised and the others are made bad. This belongs in the constellation meeting. It is working when the patient is able to talk about several people, not only you [synthesis].

4.16 Tact, timing and not intervening too early

Purpose: protect the psychotic person's fragile defences. Tosquelles compared them to damaged undergrowth (brande): "N'insistons pas, ça va faire tomber encore un arbre" (let's not insist, another tree will fall). Oury says the aim is not to crush "le peu qu'il y a" (the little there is), and "Il faut du temps" (it takes time) [source: Gascuel, Carnets 114].
Steps [synthesis from source]: let the person finish what they are doing before you approach; delay interpretation; prefer presence and a sign (a nod, a wink) over a question; read the atmosphere before you speak.
Example language (illustrative): (say nothing, sit at the same table, then later) "Good to see you here."
Watch for: staff taking restraint as indifference. Tact is active attention [synthesis].

4.17 Transversality: adjusting the coefficient

Purpose: Guattari's concept, from his 1964 text. Every institution has a "coefficient of transversality": how open its channels of communication and perception are, both across levels of hierarchy and across compartments. He pictured it as horses' "adjustable blinkers". The aim is to turn "subjugated groups", which receive their law from outside, into "subject groups", which interpret and take charge of their own situation [source: Stivale commentary, deleuze-guattari-l; New Materialism Almanac].
Steps [synthesis]:
1. Look for where information stops: night staff never hear what day meetings decide, and patients never see the minutes.
2. Open those channels: shared minutes, mixed meetings, notice boards, the newspaper.
3. Watch whether groups (a workshop, a ward team) start making and owning decisions instead of waiting for orders.
Example language (illustrative): "Who on nights knows the new rule about the garden? Then the rule isn't ready yet."
Watch for: fake horizontality that hides decisions taken elsewhere. Stivale notes that changes to the coefficient tend to come from the top [source: Stivale].

4.18 Psychodrama, music and expressive ateliers

Purpose: create new routes for affect and speech. Fanon came across psychodrama and music at Saint-Alban; Tosquelles wanted madness to be able to "dire son mot" (have its say) [source: Robcis review, La Vie des idées]. The sources describe no technique for these groups [uncertain].
Steps: run these groups under the training and conduct rules of the method chosen (for example, a trained psychodramatist). Offer them as one workshop among others, and bring what comes up to the meetings [synthesis].
Watch for: expressive groups cut off from daily life; a group that asks too much, too early, of a fragile patient (see 4.16) [synthesis].

4.19 Solidarity fund and trial stays outside

Purpose: support the transition to life outside through the patients' own collective. Because the money comes from "friends", the person stays connected [source: Oury 2024, pp. 110–111].
Steps: a commission of nurses, doctors and patients reviews requests and grants support (Oury's example is a sum covering a fortnight's trial outside). Repayment can be requested. Review the outcome afterwards [source: Oury 2024, pp. 110–111]. Before a trial stay, do a standard risk assessment [synthesis].
Example language (illustrative), commission member: "The fund can cover two weeks. If it goes well, you can pay it back slowly. If not, come and tell us."
Watch for: the fund being run as charity rather than as a decision of peers [synthesis].

4.20 Opening outward: town, sector, schools, family

Purpose: keep the institution from closing in on itself. "Everything that's closed off becomes dangerous: it ferments" [source: Oury 2024, p. 116]. The hospital becomes a hub, an "anti-confinement" [source: Oury 2024, p. 113]. "The first institution… is the family" [source: Oury 2024, p. 117].
Steps:
1. Hold events that bring the local population in, such as open-air fairs or a "culture month" about the region. Avoid "the 'tender charity' of fairs" [source: Oury 2024, p. 115]. Tosquelles opened Saint-Alban to the village and the farms [source: Kelsey in Everybody Wants to Be a Fascist, p. 63].
2. Link up with sector services, outpatient "pre-care" units that prevent admission, social offices and schools, so that circulation goes both ways [source: Oury 2024, p. 117].
3. Include family members in meetings and constellations, with the patient's consent [source: Oury 2024, p. 117; method is [synthesis]].
Example language (illustrative), to a family: "We'd like you to come to Thursday's meeting. You see him in ways none of us do."
Watch for: outings that are tourist trips; families treated only as a source of information [synthesis].

4.21 Medication within the collective

Purpose: Oury does not oppose neuroleptics, but he argues for "original methods of prescription" that are part of the relational work, not a substitute for it [source: Oury 2024, p. 97]. This guide gives no dosing.
Steps [synthesis]: the prescriber discusses medication changes in team meetings; the effects that nurses, workshop staff and the patient observe all feed into prescribing; the patient is told the reasons.
Watch for: sedation used to replace the work of the institution [synthesis].

4.22 Training and care of the Collective

Purpose: the carers are themselves cared for. "S'il n'y a pas de collectif, il n'y a rien qui tient" (if there is no collective, nothing holds) [source: Oury via Pratiques no. 66]. The movement ran working groups (GTPSI, from 1960) [source: French Wikipedia], CEMEA training courses for nurses [source: Oury 2024, p. 94], and Delion describes a "Balint function" [source: Delion talk abstract, CY Cergy].
Steps [synthesis from sources]: regular supervision or Balint-type groups open to every category of staff; training placements in other institutional-psychotherapy settings; send trained staff in groups, not alone. Oury notes that a lone trained nurse ends up a discouraged minority back home [source: Oury 2024, p. 94].
Watch for: burnout; cynicism; the founders' charisma standing in for structure [synthesis].

5. Handling problems

Items marked [synthesis] are my own guidance. Items with a [source] tag come from the cited text.

A withdrawn patient who uses no place and no person. Do not prescribe activities. Hold a constellation meeting (4.13) to find the one point of contact that already exists, however small (the bar, a smoker on the terrace, the person who serves breakfast). Build an occasion around it (4.14) [source: fishing and donkey examples, Pratiques no. 66; method is synthesis]. Accept that this takes a long time: "Il faut du temps" ("it takes time") [source: Gascuel].
Resistance or refusal of meetings and workshops. Participation is voluntary [source: Oury 2024, p. 104]. Treat the refusal as information. Keep the door open, and let the person come and sit without taking part. Look at whether the meeting itself is unlivable, for example too long or dominated by staff [synthesis].
Overwhelm or agitation. Check the setting first: crowding, noise, blocked circulation, an abrupt change in the grid. Oury links much agitation to camp-like living conditions [source: Oury 2024, pp. 93, 105]. Offer rest areas and a familiar person [source: Oury 2024, p. 98]. Acute risk to self or others calls for a standard risk assessment and the local emergency protocol. Make any restriction individual and time-limited, and bring it back to a meeting afterwards [synthesis].
Suicide or self-harm risk in an open setting. Free circulation does not replace structured risk assessment. Assess each person individually, plan with the patient and the constellation, and record decisions. Do not lock down everyone because of one person [synthesis].
"Non-adherence" (missed sessions, abandoned workshops, refused medication). In this model, non-adherence often signals that the transference has moved somewhere else. Ask the constellation where the person now goes and who they now see [synthesis]. Medication problems belong to the prescriber, and they should be discussed with the team and the patient, not dealt with by coercion [source: Oury 2024, p. 97; synthesis].
Ruptures (a patient attacks or rejects a particular carer). Expect splits in a dissociated transference. Do not leave the attacked carer alone with it. Take it to the constellation, where another person can carry the bond for a time. The rejected carer stays present but less exposed [synthesis drawing on Chaperot et al. 2014].
Staff resistance to role-crossing or to open circulation. Oury reports that traditionally trained nurses found manual tasks an "affront", and that the cook built barricades [source: Oury 2024, pp. 99, 114]. Give the clinical reason. Start with occasions that make contact easier, such as the bar (4.6), and avoid orders [source: Oury 2024, p. 100]. Change one barrier at a time [synthesis].
A club that is a puppet or a paternalist façade. Signs: staff hold the majority, there is no real budget, ergotherapy has not been handed over, or decisions please "daddy". Remedies: patient-majority elections, a written contract with the establishment, and accounts held by the club [source: Oury 2024, pp. 105–108].
Exploitation ("good workers"). Check every month who does the unpaid work. Value that work by substitution and pay it to the club, not to individuals. Make sure no one is "indispensable" [source: Oury 2024, pp. 103–110].
Meetings that waste time or become a ritual of power. Rotate the chair, keep a fixed agenda, record decisions, and start with the least-heard voices. Watch for staff turning into commenting "psycho-sociologists" [source: Oury 2024, pp. 102–103; procedures are synthesis].
A grid that has become bureaucratic, or staff exhaustion. Review the grid's purpose in a meeting. Keep a patient's key attachments stable across rotations. Protect supervision time [synthesis]. Oury's account of "precariousness" says the organisation must be continually redone, not frozen [source: Gascuel].
Boundary blurring as roles mix. Shared tasks, outings and a shared bar raise the risk of dual relationships, financial entanglement and sexual or exploitative boundary violations. Keep the usual professional codes in full. Discuss gifts, money and outings in meetings. Report any boundary violation under standard procedures. Role-mixing never suspends professional ethics [synthesis; no source addresses this directly].
Confidentiality in a collective model. Constellation meetings include non-clinicians. Tell the patient at the start what is shared, with whom, and why. Share observations and themes, not therapy content. Follow local data-protection law [synthesis].
A charismatic founder, or dependence on one doctor. Tosquelles refused "personalization" [source: e-flux review]. Build structures (club, contract, meetings) that survive staff changes [synthesis].
Institutional resistance from management or regulators. Oury advises using recognised official structures (in France, Croix-Marine federations and the 1958 circular) as a protection against being shut down [source: Oury 2024, pp. 106–107, 119]. Elsewhere, find the local legal equivalent: patient associations, peer-run committees, co-production frameworks [synthesis].
Applying the model outside long-stay psychosis care (day hospital, short stays, community). Keep the core: welcome, multiple places, meetings, a club or patient association, constellations. Scale down the grid. For short stays, connect early with the sector and the family so the constellation continues after discharge [synthesis; on the sector, Oury 2024, p. 117].
Coercion and restraint. The movement grew up against the "concentrationary" asylum. Seclusion and restraint conflict with its aims. Where the law allows them, use them only as a last resort under current regulation, document them, and work them through collectively afterwards [synthesis; Oury 2024, p. 91].

Sources

Sources:

Further reading (not drawn on) [uncertain]:

Tosquelles, F. & Oury, J. (2024). Psychotherapy and Materialism, ed. M. Miguel & E. Vogman. ICI Berlin Press.
Oury, J. (1976). Psychiatrie et psychothérapie institutionnelle. Payot.
Oury, J. (1986/2005). Le Collectif (Sainte-Anne seminar). Scarabée / Champ social.
Tosquelles, F. (1967). Le travail thérapeutique à l'hôpital psychiatrique. Scarabée.
Guattari, F. (1964/2015). "Transversality", in Psychoanalysis and Transversality. Semiotext(e).
Guattari, F. (1987). "La grille" (talk at a La Borde training course).
Guattari, F. "La Borde: A Clinic Unlike Any Other", in Chaosophy (Semiotext(e), 2009).
Delion, P. (2022). La constellation transférentielle. Érès.
Robcis, C. (2021). Disalienation: Politics, Philosophy, and Radical Psychiatry in Postwar France. University of Chicago Press.
Pain, F. et al. (2025). Everybody Wants to Be a Fascist: Institutional Psychotherapy as a Resistance Movement. Semiotext(e).

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