In: Making Room for Madness in Mental Health: Psychoanalytic Understanding of Psychotic Communication.
Chapter 3. Psychoanalytic Supervision in Mental Health Settings
Introduction
Patients who suffer from a serious and enduring illness often need psychological, chemical and sometimes physical containment. The types of settings that provide this containment and the balance of the interventions used will vary according to the patient and their level of disturbance at any given time. It should also be remembered that the patient’s state is dynamic and changes according to many influences, including the clinical care setting. For example, patients in psychotic states may present as calm and controlled in a psychiatric intensive care unit but become more disturbed once transferred to a less intensive setting. Patients need to be cared for by staff who are receptive to their experiences and who are willing to take in the patient's communications. To sustain this receptive capacity in the minds of the staff, they have to feel they are also looked after and that senior clinical management takes their concerns and feelings seriously. When staff do not feel that they are cared for by management, this affects staff morale and they tend to become more anxious and less psychologically receptive to their patients.
This chapter will outline how psychoanalytic insights can help health professionals understand and manage patients. Staff can benefit from understanding how these unconscious communications can draw them into responses and actions, bypassing the development of meaning and understanding. It can also help to prevent staff from colluding with the part of the patient’s mind that wishes to deny their illness. This results in an increased risk of clinical decisions being made which fail to consider the underlying disorder, exposing the patient to the risk of relapse. It is equally important that managers understand these dynamics to look after their staff. I have found that psychoanalytic supervision expertise is much needed and valued by front-line staff. However, it would help if psychoanalytic psychotherapists with supervision had relevant clinical experience with the patient group.
Coping with intimidation
A community Psychiatric Nurse (CPN) from a health team presented the case of Ms T. Ms T suffered from anorexia and had locked herself in her flat in order to starve herself. She had a habit of hoarding rubbish until it became a health hazard and threatened other residents, where Environ Health Officers had to be alerted. Ms T telephoned the nurse and said that she felt suicidal and wanted to die. The nurse visited the patient at home, but Ms T refused to open the door, so the nurse conducted a restrained interview with the patient through the letterbox. The nurse said she was worried about her and would talk to her general practitioner (GP) to arrange a domiciliary visit. Ms T threatened to take legal action against the nurse if she spoke to the GP.
A solicitor then telephoned the CPN to complain about her attempt to speak to the patient through the letterbox, saying that she “would take out a charge of harassment” and that the nurse was “interfering with the patient’s human rights”. Several days later, the nurse received a letter from Ms T’s solicitor confirming this threat and stating that she should not contact the GP under any circumstances. The CPN said she felt she could not take any action to help the Ms T because she feared prosecution. The CPN thought she was losing her mind as, on the one hand, she had a duty of care and Ms T was ill, while on the other hand, she was in danger of litigation if she took what she considered to be appropriate action.
Bion (1957) described a division in the patient’s mind between the psychotic and the non-psychotic (or sane) part. The psychotic part of the mind hates all emotional contact, psychic pain and meaning. This part of the mind uses violent projection to get rid of any awareness of painful conflicts or emotions. The non-psychotic part (of the patient’s ego) has the job of thinking about neurotic problems and conflicts associated with emotional pain and meaning. The patient’s mind may fluctuate between these two states, which Bion described as ‘a never-ending fight between the life and death instinct’ (Bion, 1957). When the psychotic part of the mind is in ascendency, it may fragment and project the non-psychotic part of the ego to undermine the person’s capacity to think about themselves in relation to reality (Bion, 1957, 1967). The vacuum left in the ego is filled with magical thinking based on omnipotence and omniscience rather than based on reality testing.
In the case of Ms T, we can see how the sane part of the mind was being held hostage by the psychotic part. Although the sane part of Ms T made fleeting contact with the nurse to make her aware of her predicament, the psychotic, murderous part stepped in and attacked the contact. This was done by threatening the nurse with accusations of professional misconduct if she went against Ms T’s wishes. The solicitor had also been coerced by propaganda emanating from the psychotic part of the patient designed to undermine the nurse’s role and authority. However, Ms T’s sane awareness relied upon the nurse’s resilience and capacity to hold on to the bigger clinical picture. The nurse’s gut reaction was to realise that the threats were part of the patient’s illness and that the psychotic part of her personality had taken the sane part of Ms T’s ego hostage. Indeed, we could see that the sane part of the patient’s mind was only allowed very limited contact with the nurse, represented by the initial phone call expressing her suicidal feelings.
Ms T’s behaviour left the nurse trapped and caught in a dilemma. If she did nothing, her patient’s condition would deteriorate further, while if she acted, she would be accused of abusing Ms T’s human rights. This feeling of being trapped gave the nurse an experience of what it was like to be in Ms T’s shoes, as the psychotic part of her mind was attacking the sane part of her mind if she drew attention to the extent of her illness. The message from the sane part of Ms T’s mind was undermined and weakened by the psychotic part with its accusations and attacks.
We can see how Ms T’s state fluctuated as the dynamics of her internal world changed. At one stage, the non-psychotic part of her mind became aware that she was trapped inside a murderous, psychotic state that wanted to starve her to death. This sane part of her mind was then able to let the nurse know that she was afraid she was in the grip of the murderous part wanting to kill her through starvation. However, once Ms T had made the nurse aware of her precarious state, she withdrew back into the psychotic internal structure, denying there was a problem. The psychotic internal structure then insisted Ms T attack and undermined the helpful contact with the nurse by threatening her with legal action.
In the discussion, the nurse said that she felt intimidated and trapped by Ms T’s threat of legal action on the one hand, and she knew she could not leave the patient on her own on the other. The nurse said the discussion was helpful as it enabled her to think clinically about the situation. She also realised she needed the consultant psychiatrist’s support in standing up to the intimidation from the psychotic part of the patient. The nurse subsequently reported that she conducted a domiciliary visit with the consultant, who told Ms T that unless she complied with psychiatric care, he would be forced to request a health act assessment. The patient agreed to comply and the need to section the patient was avoided.
Thus, the supervision group were able to support the nurse in her difficult work with the patient by providing a space for thinking about the underlying psychotic process, which allowed us to consider the meaning of this anxiety-provoking and frustrating situation. Once we could think of the fluctuating influence between the psychotic and non-psychotic parts of Ms T’s personality, it was possible to understand her perplexing presentation. The supervision group was able to help the nurse separate from the tyrannical influence of Ms T’s psychosis by restoring her relationship with her consultant psychiatrist. The restoration of the relationship between the nurse and psychiatrist formed an authoritative clinical structure that could withstand the threats and projections emanating from the psychotic part of Ms T’s mind. (We discussed that the solicitor would also need some help to free herself from the influence of Ms T’s psychotic propaganda). Investigation of the patient’s mind is an important part of good health practice; health professionals need the authority and skill to carry this out humanely. The nature of psychosis means that destructive aspects of the personality, which hate any acknowledgement of need, may attack and undermine either the patient’s sanity or the health professional’s attempts to help. From time to time, the non-psychotic part of the patient’s mind may become overwhelmed by psychosis in a way that forces them to act out their destructiveness in a physical way, resulting in a threat either to themselves or others. When this happens, the patient may need to be physically contained (under the Health Act, 1983) and treated with medication. These interventions are not a substitute for psychological care but may be necessary to safely care for the patient (Alanen, 1997).
Denial and Rationalisation
A ward manager from an acute admission ward presented the case of Mr S, a 26-year-old male who had paranoid schizophrenia. He had been admitted to the ward several weeks previously under Section, believing that he was Jesus Christ. The ward manager said that Mr S upset the other patients as he tended to talk aggressively, ordering them around. She described his sexually inappropriate behaviour with the female staff. Mr S spoke to them in a sexually disinhibited way, as though he believed female staff found him irresistible. After several weeks, his behaviour began to settle down and he appeared less aggressive with other patients, although he always acted in a superior manner. He requested a Health Review Tribunal and successfully appealed against his Section. The tribunal stated that although they agreed Mr S was ill, they did not think he needed to be under Section to receive treatment.
On the day the ward manager presented the case to the supervision group, she said that she thought Mr S’s behaviour worsened following the tribunal. Mr S would lie in bed until midday, refusing to get up for groups or occupational therapy, then leave the ward. The staff suspected that he smoked marijuana while out, as he was often more disinhibited upon his return to the ward late at night. Mr S would then sit in the day room and argue with the night staff as he sat watching television until very late. The ward manager said there were continuing reports of niggling rows with other patients, as he would talk to them in a high-handed manner, and staff said, “it was a miracle that none of the other patients had hit him”.
The ward manager said that Mr S had been admitted four times in the previous three years. He would be brought to hospital on a Section after being found naked, preaching to passers-by in the street. Once on the ward and anti-psychotic medication, he would calm down. However, he invariably maintained a superior air and distance from other patients and staff. Mr S would then make a successful appeal against his Section, and several weeks later, he would be discharged. Several months after being discharged, he would tell the Community Health Team that he did not require any follow-up. Several months after that, he would start preaching again, end up in an altercation and be readmitted.
Once in the hospital, the positive symptoms related to Mr S’s psychosis were quickly controlled by the medication and containment provided by ward staff. However, the effect of his psychotic beliefs continued to influence his behaviour and this was evidenced through his high-handed attitude towards other patients and staff. The removal of the Section made it easier for Mr S to leave the ward and self-medicate on marijuana. This, in turn, made him increasingly ‘spaced out’, detached and withdrawn. Although there was no objective evidence of Mr S having any substantial insight into his condition, he was sufficiently aware of his circumstances to keep his psychotic ideas ‘quiet’ when talking to the Health Review Tribunal. Health professionals often report that patients display their best behaviour during ward rounds or tribunals. The patients’ presentations in these formal meetings can be significantly different to the picture presented to the nursing staff on the ward.
We can see how Mr S was able to conceal the positive symptoms of psychosis for a short period and in response to leading questions. Although he did not talk about his delusions in an open way, the ongoing influence of the delusional system was evident in his behaviour and high-handed attitude towards others. Mr S acted as if he was Jesus Christ, the son of God, and above the ordinary ward rules. Indeed, he expected ward staff to recognise his special status and provide him with what he wanted without needing acknowledgement or gratitude. The negative symptoms of his illness also caused him to withdraw from meaningful contact with himself and others.
Diagnosis can be an important clinical tool as it helps with decisions about treatment and prognosis; however, when assessment is narrowly based on the current clinical picture and concentrates too much on the presence or absence of symptoms, it leaves out important information about changes in the patient’s presentation over time. Lack of insight and presence of negative symptoms are as important in the diagnosis of a psychotic condition as the presence or not of positive symptoms. There is always a danger that health professionals withdraw from emotional contact with their patients to protect themselves from the psychologically disturbing impact of the work. This withdrawal sometimes takes the form of a rather mechanical and formulaic way of thinking that excludes curiosity about the relationship between her clinical presentation and the underlying personality structure. Distinctions between illness and health may be necessary to help categorize the patient’s presentation and issues concerning treatment and clinical responsibility. However, this thinking can also be used defensively as diagnosis does not invite the clinician to link symptoms and behaviour with questions about the patient’s underlying personality structure, history and ways of thinking.
Patients in psychotic states of mind often want to get away from the ‘headache’ of thinking about their problems and can develop a condescending attitude towards their difficulties as a defence (Sohn, 1997). They may project their responsibility into the individuals or teams caring for them. Nurses and other health professionals have the job of engaging with the sane part of the patient about their illness and psychological difficulties. This relationship, which is based on the need for help and support, conflicts with the psychotic part of the patient’s mind. Denial and rationalisation are used by the psychotic part of the patient's minds in order to cover up the reality of their illness and the fragmentation of their minds. Indeed, the health professional can become the target of the patient’s condescending attitude towards their own difficulties as the psychotic part of the patient's mind tries to distance themselves from any difficulties and/or any need for help.
In the example outlined above, Mr S withdrew into a drugged haze and detached state of mind, free of worry or concern about his situation. At the same time, the nursing staff became increasingly agitated about his detached and ‘irresponsible’ behaviour in the ward. The staff became irritated that Mr S showed no interest in his rehabilitation but came and went as he pleased without attending occupational therapy or ward groups. This irritation came through in the presentation of his case as the ward manager described Mr S as “treating the ward as if it was a hotel”.
A psychoanalytic approach to clinical work can provide a model for thinking about psychotic symptoms and the relationship between different parts of the personality. This can help clinicians develop curiosity and interest in their patient’s mind. In a paper about psychotic processes, Lucas describes how psychotic patients rationalise and deny their illnesses. He also illustrates the importance of clinicians being receptive to and tuning in to what he calls the ‘psychotic wavelength’ (Lucas, 1993). If teams start to discuss their thoughts and ideas together, they can begin to think about how to engage with the patient in a new way; this gives an opportunity to turn a psychotic monologue attached to a delusional system into a dialogue with the patient about their mind and the way they think (Taylor & Lucas, 2006).
The irritation in the ward manager’s counter-transference was due to Mr S’s delinquent attitude towards his illness and high-handed attitude towards ward staff and patients. Although he knew when to keep his grandiosity quiet, Mr S’s actions showed his delusional beliefs still dominated his mind. In that state of mind, he was above ordinary considerations about how he was going to manage his life or the need to take some responsibility for his illness. Instead, he projected responsibility for worrying about this onto the staff. It was as though he believed he was staying at a hotel in a holiday resort with paid staff to look after his every need. The projection of his anxieties from the psychotic part of his mind left him free to imagine he was communicating with God. His belief that he was in communication with God meant that he did not have to listen to the authority of the ward staff. In other words, he had his own omnipotent and omniscient version of reality, which blocked out any uncomfortable or painful realities. This part of Mr S’s mind was worried that the psychotic part was always on holiday and denied reality in a dangerous way, whilst the psychotic part remained determined to maintain the grandiose state that insulated him from the acknowledgement of non-psychotic concerns.
The Significance of Countertransference Responses in the Assessment of Risk
The following presentation was made in a seminar on one of the educational programmes at the Tavistock Centre.
A primary nurse from a high-security hospital presented the case of Mr A, a 31-year-old man who had committed murder. Mr A had requested that he be referred to a medium secure unit, and the multi-disciplinary team was considering this decision. The nurse said he was worried about the request, believing that Mr A remained highly dangerous. When the panel asked Mr A what he imagined for his future, he said he would like to live an ordinary life in a flat on his own.
Mr A had been sentenced to prison in his late teens for the murder of an elderly man. Mr A’s victim had been unable to protect himself and had been subjected to various sadistic acts over several hours. Before his prison sentence, Mr A had a history of drug abuse and burglary, but not one of violence. While in prison, he started to hear voices commanding him to kill himself. After informing the staff about the voices, he committed a serious assault on another prisoner. Mr A was diagnosed as suffering from schizophrenia and transferred to a high-security hospital.
The nurse reported that Mr A’s father had left his mother before he was born. When he was ten years old, Mr A’s mother found his behaviour too much to handle, and consequently, he was passed between a series of relatives. One particular uncle used to beat him regularly for minor misdemeanours. Mr A became a bully at school and was eventually expelled for his behaviour.
At the time of the presentation, Mr A had been in the high-security hospital for nine years, and his stay had been largely uneventful. Indeed, the fact that he was so undemonstrative meant that he was often moved around the hospital. Throughout this time, he was maintained on a low dose of anti-psychotic medication. The seminar asked the nurse why he was convinced that Mr A remained a risk. The nurse said that Mr A sent shivers down his spine because he was so distant, cold and aloof and that despite the fact there had never been any serious violence during his stay in high security, he also felt Mr A was an intimidating man who kept everyone at a distance. I asked the nurse if Mr A had any delusional beliefs. He told the seminar that Mr A had never mentioned any delusions, but he added that it was difficult to know what was going on in his head. The following week, the nurse reported back to the group that on further investigation of Mr A’s notes, he had found out that when Mr A was first admitted, he was suffering from paranoid psychosis. Part of his delusional thinking was that he had been put on the earth by God to murder anyone weak or vulnerable. The nurse also told the seminar that Mr A had never demonstrated any acknowledgement of guilt over the violence of his attacks on his victims.
We can see how Mr A identified with the intimidating and bullying uncle to deal with his feelings of vulnerability. The voices commanding him to kill himself when he was first in prison represented projected suicidal thoughts connected to a threatening acknowledgement of his guilt. This suicidal state, which threatened to break back into his mind, was then projected onto his victims (Sohn, 1997). In the psychotic part, he believed he could rid his mind from the threat of the suicidal thoughts by first projecting them in a concrete and wholesale way and then by murdering the recipient of the projections. The whole process was justified in the psychotic part of Mr A’s mind by a delusional belief that God had asked him to put these vulnerable and suicidal men out of their misery. Thus the grandiose delusion concealed the feelings of depression and worthlessness. He concealed the whole psychosis through his air of cool superiority on the ward. Following the nurse’s presentation to the seminar, he discussed his concerns with the clinical team, but the majority of the team thought there was no evidence of psychosis and that Mr A no longer posed a risk.
Several years later, I was informed that there was going to be an inquiry into the care of Mr A after he had committed another murder. He had been discharged from his medium-secure unit and, while in an acute paranoid state, murdered an elderly man.
In the case of Mr A, we can see how he could promote a picture of himself as a reasonable man with neither an illness nor a history of serious violence. His distant and superior approach to staff and other patients represented a condescending attitude towards the staff's concerns regarding his illness and his risk to others. In his delusional system, he believed he was put on earth to attack and torture weak and vulnerable people. This protected him from any sense of guilt for the damage done or responsibility for managing his illness and risk factors. The projection of his sanity and any sense of responsibility for his illness and risk factors meant that Mr A remained a considerable risk. The change in the security of the clinical setting and all the containing structures, which had previously supported his functioning as an in-patient, were removed. As a consequence, his state catastrophically deteriorated.
In my experience, the influence of the clinical setting and the support available to the patient are underestimated in decision-making and risk assessment. For example, many patients' clinical picture can change as they move from high dependency to admission or outpatient settings as the increase in responsibility also increases the persecutory anxiety, which in turn increases the likelihood of acting out. The loss of relationships with significant staff members is often given little thought when planning discharge. When these issues are neglected, the patient is left alone, feeling lost and anxious about future expectations. This can herald in a return to regressive behaviour, which may increase risk.
Risk assessment is not an exact science and all risk assessment tools tend to produce a percentage of false positives. It is also easy to be wise after the event, but people who suffer from a severe and enduring illness can be unpredictable by nature. However, some important lessons may be learned from Mr A's case with his assessment. Certain patients project different elements of their minds into different parts of the clinical team. These patients are particularly difficult to assess because the projective process, which temporarily rids the patient of unwanted elements of their mind, may, help the patient present a false impression of coherence and sense. This picture can quickly break down when there is a change in the clinical setting, as the patient loses the containing structure and the split-off projections come flooding back into the ego, causing conflict and disruption.
Patients who split and project are often sensitive to existing splits in the clinical team as they pick up on rivalries between individual members of staff or disciplines. They may also pick up on divisions between lower and higher-graded staff in overly hierarchical teams. For example, the ward domestic often sees a different side of the patient to the ward consultant. Patients may also tune into the way different teams privilege the views of particular disciplines or psychological theories. When a patient can locate and project into existing splits in the team, it may become a blind spot in their clinical assessment and thinking. For this reason, relying on any one particular member of the multidisciplinary staff or assessment tool can leave out vital elements of the overall picture.
When working with patients in psychotic states of mind, counter-transference can be a beneficial clinical tool as it gets behind the patient’s denial and rationalisation (Garelick & Lucas, 1996). The problem for the clinician is that the patient can ‘hold things together’ for a state examination or review tribunal and use rational and logical thinking stripped of emotion that appeals to the clinician’s logic. The counter-transference can help the clinician to gain access to the patient’s underlying emotional state. The counter-transference is particularly important when assessing psychotic states of mind, as the level of denial and rationalisation may mask psychotic states. Of course, the evidence of the counter-transference cannot be used on its own and has to be corroborated with other sources of clinical evidence. It is also an essential risk assessment component because it can nudge the clinician into thinking about the patient differently. Indeed, it should be remembered that a particular member of the team may be in touch with a suicidal or homicidal aspect of the patient. This approach can alert the team to risks unconsciously pushed out of the clinician’s mind by the patient’s denials and rationalisations.
Nursing staff are in a good position to assess the patient’s psycho-social functioning over time as they can witness the patient ‘in action’ during ward activities and through their interactions with the patient. However, exposure to this disturbance can leave professionals with complicated, undigested counter-transferential feelings. When these feelings get lodged inside, it can make health professionals feel guilty or uncomfortable because the individual is caught between professional ideals of being endlessly tolerant and caring and other negative feelings of irritation, fear, disgust, or even hatred. The individual can dismiss these feelings as too subjective and personal and, therefore, irrelevant. Thus, counter-transference and intuitions (gut feelings) can be treated as if they are the individual’s problem and irrelevant to the clinical discussion. Although, at times, this might be true, a wholesale dismissal of the professional’s intuitions or gut reactions can deprive the clinical team of valuable information about the patient at an unconscious level. Good team leaders of multi-disciplinary teams take an interest in patients' impact on the team and individuals. This shows an interest in staff and acknowledges that counter-transference and intuitive feelings can be used to think about the clinical picture in different ways. Intuition and gut feelings are insufficient information to guide decision-making, but they can alert the clinician to unconscious processes and blind spots in clinical thinking. For example, suppose the nurse had been able to corroborate her feelings about Mr A’s coldness and aloofness with other objective observations. In that case, she may have influenced the thinking of the clinical team. Where the work's emotional impact is excluded from the clinical picture, it may lead to resentment among team members, and vital evidence of the clinical picture may be excluded.
Issues of confidentiality
In the following example, I shall describe how a supervision group discussion helped free a staff member from the effects of their counter-transference. This discussion changed the staff’s attitude toward the patient and allowed room for freedom of thought. This change in approach also seemed to have a dramatic effect on the clinical picture.
A newly qualified social worker presented the case of Ms R, a regressed young woman with personality disorder who had been on the ward for several months but showed no signs of progress. When I asked the social worker to describe the patient’s history, she said that the psychiatric team was completely in the dark. Apart from Ms R saying that her father had sexually abused her, she refused to talk about her history, saying it was too traumatic. The staff team knew from the referral that Ms R had been cared for by various other psychiatric services over many years. However, Ms R was adamant that she did not want the team to contact these other services.
In the supervision group, we talked about Ms R’s wish to control the treatment setting by making the staff feel they would betray her if they contacted the previous services. She also said it would be traumatising to her if they asked her to tell them about her history. In the counter-transference, the staff team were made to feel that they would become the abusive father in the patient's mind if they went against her wishes.
Ms R presented in a traumatised, infantile state, where there was only one possible version of reality and that was hers. She feared that any other views would destroy her version of events. Although I did not know the history, I thought she was like a baby who believed parents could only love one child. It was as though she was convinced that the birth of any second baby would deprive her of the love she needed to live. Thus, on the ward, she had to maintain a tyrannical hold on her version of events, which allowed no other version to emerge. Compliance with this demand allowed Ms R to stay in a baby-like state within the ward while the source of her disturbance – the second baby – was phobically projected outside the ward. Going along with this, it was as though the staff agreed with the patient that there was only one version of events or that parents could only ever love one child. Any new information would constitute a traumatic assault and rival to her view.
In the supervision group, we discussed the need for a broader assessment of the patient, including her history, the history of contact with other services and possibly even her estranged family. We also discussed the need for the social worker to talk to Ms R about her fears of being dropped and discounted as an unlovable child if other versions (of reality) came to light. Even if there were conflicting accounts of her history, it did not mean that the staff team would dismiss her.
Several weeks later, the social worker reported to the group that, following a discussion with the consultant and the multi-disciplinary team, a decision had been made to contact the patient’s previous clinical team. The social worker said she had also discussed this issue with Ms R, saying the team needed to gather more of a picture. Ms R became extremely agitated, saying she was worried that other services would lie about her and present her badly. As we had discussed in supervision, the social worker told Ms R that although they were interested in what other services had to say about Ms R’s history and her treatment, they also wanted to understand her version of events. The team tried to understand different people's thoughts, as all views may be valid or contain helpful perspectives. She reiterated that they were trying to get as full a picture of the situation as possible to better understand the patient and her difficulties.
The team social worker contacted Ms R’s previous social worker, who reported on the patient’s history in care homes. Ms R did have a history of disruptive behaviour, splitting and making allegations of mistreatment. With the help of further discussions in the supervision group and gathering various pieces of information together, staff were able to establish a picture of a very vulnerable, traumatised and deprived woman. Staff could also see that although Ms R did try to manipulate staff and services, this was mainly done to try and maintain some fragile control over her environment. A plan was made to place the patient in an appropriate hostel for care leavers. The clinical picture continued to improve until the patient was appropriately discharged.
Health services must respect their patient’s wishes regarding their treatment and rights to confidentiality. However, problems arise when services adhere to their patients’ requests and wishes in a literal or unquestioning way, ignoring the patient's clinical needs. In the case of Ms R, the patient was controlling the staff team’s method of gathering information to make a meaningful assessment. This meant that the different aspects of Ms R’s clinical care were being split and kept apart. Although patients’ wishes should be respected, problems arise when their desires are confused with their needs. Health professionals must feel free to explore the patient’s difficulties by gathering the fullest possible picture as part of their state examination and risk assessment. In my experience, it is often true that less experienced staff are understandably reluctant to challenge or overrule the patient's wishes, as they fear being seen as authoritarian. In the interests of getting things right, they may also be prone to interpret guidelines more concretely than they were intended.
The discussion in the supervision group and then with the consultant in the multi-disciplinary ward round helped the social worker free herself from the effects of the counter-transferential fear that she would be traumatising an already traumatised patient if they went against her wishes. Instead, they were able to discuss the issue of her fears and beliefs as a clinical problem, thus changing a conflict into an opportunity for a clinical discussion with Ms R about the nature of her beliefs. In the case of Ms R, this was the idea that there could only be one version of events and that any new version would destroy hers. This was like the idea that a mother could only have and love one child. It was essential to discuss with Ms R that although staff understood this, it was not the only way of looking at things. Indeed, staff could hold different versions of events in mind without necessarily meaning that one version of the event automatically discounted another.
Discussion
Patients in disturbed states of mind often communicate in ways that put pressure on the recipient to act rather than think. Psychotic communications have the emotional register squeezed out, leaving concrete communication that does not invite a symbolic response. Borderline psychotic patients also put pressure on their objects in ways which cohere with their internal model. This reassures them that the object contains those aspects of the self which he/she would like to register in the object. However, although the patient may well be putting pressure on the staff team to react in a preordained way, problems can arise when the patients’ wishes are carried out without any clinical thought or examination of the meaning behind the communication. Clinical teams and managers must understand and examine communications before any action is decided upon. Particular consideration must be given to which part of the patient is communicating and for what purpose. In the first clinical example, we can see how the psychotic part of Ms T’s mind tried to suffocate the part of her that wanted to get help. The psychotic part then tries to stop the nurse from acting by threatening her with legal action if she went against Ms T’s wishes. However, the nurse had already registered that Ms T was dominated by a psychotic tyrant who threatened to starve her to death. Understanding the dynamic struggle between the psychotic and non-psychotic aspects of the patient helps the nurse understand the fluctuating communications. This then enables her to discuss the most appropriate course of action with the consultant psychiatrist.
When staff concretely respond to patients' concrete demands, they miss the underlying communication. For example, when health professionals, health managers or Health Review Tribunals listen to patients’ wishes or complaints in an uncritical or unexamined way, they can collude with the patient’s denial of their illness. This can lead to the patient, at some level, feeling that the staff have lost touch with the nature of their difficulties and can make them feel less secure. In the second clinical example, we can see how Mr S can conceal the extent of his psychotic thinking for the duration of the tribunal. However, once the section is removed, the psychotic part of the patient's mind is free to reassert its hold. This leads to a deterioration in Mr S’s behaviour and state.
The MHA section acknowledges the extent of the patient’s psychotic state of mind. Although the psychotic part of the patient’s mind might argue against the section, the sane part of his mind can feel reassured that the health system understands the extent of the problem that needs to be contained.
When the psychotic part of the mind dominates the patient, the non-psychotic part of the patient needs the support of health professionals. This sometimes means talking to the non-psychotic part of the mind about the problem they have managing the psychotic part of the mind. It also means that the patient may need to be detained under health legislation or treated against his/her wishes when the patient is believed to be a danger to himself/herself or others. Freud believed the unconscious was timeless, and although symptoms may disappear, they remain in the unconscious part of the mind and may return to their repressed state at any moment. Indeed, the repressed is particularly likely to return to the conscious mind when the individual is under stress. For this reason, it is best to assume that even if the psychosis is not apparent, it might still be present somewhere in the patient’s thoughts or actions. Patients can need professionals to keep different aspects of their personality in mind even when they may not be currently apparent. In the third clinical example, we can see how Mr A managed to conceal the nature of his psychosis for long periods in the hospital. The threat posed by Mr A was picked up by the nurse at her countertransference; however,, unfortunately,, this did not feature in the clinical team's assessment of the case.
Patients who suffer from a serious and enduring illness need services that take a long-term view of their difficulties. They also need settings that offer psychological, medical and sometimes physical support. Patients may move between different parts of the health system as they go through different stages of life and illness. The usual rules of confidentiality may need to be overridden by clinical need, as it is essential for services to communicate. Patients also need teams that understand that patients may split off and project different aspects of their minds into different parts of the clinical team or system. When this is not understood, it can cause unhelpful splits between staff and or between different clinical teams, which may exacerbate the problems of understanding and managing the patient. In the fourth clinical example, we can see how Ms. R tried to control the clinical situation by discouraging the team from contacting health services that had previously cared for her. The supervision group was able to point out not only the possible meaning behind this controlling attitude but also the way it fuelled her omnipotent attitude to the clinical situation. Patients who split and project may fear that the services or professionals may gang up on them if they talk to one another. However, integrating the clinical picture is essential to good health work. Indeed, patients often feel relieved when the different professionals and agencies talk to one another. This reduces the patient’s omnipotent control of the health system, which can help professionals deepen their understanding of the clinical picture.
Health professionals can use psychoanalytic thinking to help them understand and support their patients with their difficulties. This understanding can also help health professionals stay engaged and emotionally available with their patients even in bizarre behaviours or communications discouraging interest (Martindale, 2006). Psychoanalytic supervision provides a model to help staff think about these different symptoms and forms of communication. More than anything else, patients who suffer from a severe and enduring illness need staff who are human, curious about them as people and willing to see behind the bizarre behaviours to the human communication that lies beneath. Psychoanalytic supervision in health settings can provide a clinical structure that supports clinical thought and enquiry, looking for the meaning underlying the patient’s communications. In doing this, it also supports therapeutic factors in the relationship between the patient and clinician.
References
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Bion W. R. (1967). A theory of thinking, Second Thoughts (pp. 110-119). London: Heineman.
Garelick, A., & Lucas, R. (1996). The role of a psychosis workshop in general psychiatry training. Psychiatric Bulletin, 20: 425–429.
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Sohn, L. (1997). Unprovoked assaults: Making sense of apparently random violence. In D. Bell (Ed.), Reason and Passion: A Celebration of the Work of Hannah Segal. Tavistock Series. London: Duckworth.
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