ABSTRACT
This chapter examines the management of forensic psychiatric nursing care and the use of behaviour modifications programmes (BMPs) in the discipline and regulation of patient behaviour. As the name suggests, BMPs are schemes designed to improve or correct particular micro-behaviours to bring them into line with macro-social norms and expectations. More euphemistically, they are sometimes called “Rewards Programmes” or “Incentives and Earned Privileges” (Liebling 1999). BMPs are a form of psychological conditioning based on the work of the American behaviourist B.F. Skinner. Theoretically, the patient is (re)socialised through a system of positive and/or negative reinforcement, usually on the basis of a token economy, where “points” (for example) are earned, lost, and can be exchanged for “rewards.” Forensic psychiatry settings are “total institutions” that provide the perfect laboratory because environmental conditions can be tightly controlled. In these settings, simple “life rewards” and basic necessities can be offered or withheld as “reward” or “punishment,” positive or negative reinforcers. While Gendreau (1996) argues that the most effective ratio of positive to negative reinforcement is 4:1, in total institutions we suspect that the inverse ratio obtains, since operant conditioning extends and adapts the punitive model already in place at the prison. In any case, in these settings it is often difficult to distinguish positive from negative reinforcers in any unequivocal sense (there might be a negative “rewards” scheme, for instance). As we shall demonstrate, even relationships themselves are invested and mobilised as tokens of exchange in the everyday complexities, networks, and discrepancies of prison/hospital life. As nursing staff are enlisted to implement and supervise these programmes, they too become caught in the practical dispositions of power, privilege, and punishment: they become agents of a moral orthopaedics.
