Psychoanalytic Thinking in Mental Health Settings

Marcus Evans

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000206937
• Edition: 1
• Topic: Philosophy
• Subtopic: Philosophy History & Theory

This book demonstrates the use of psychoanalytic thinking in front-line mental health settings and aims to make an approach to working with emotional and mental disturbance available to a wide range of clinicians within psychiatric and other mental health settings.

Rooted in the author's extensive clinical experiences, the approach explored in this book applies psychoanalytic thinking and discusses this in relation to the mental health conditions regularly encountered in psychiatric settings, such as Schizophrenia, Manic Depression, Psychotic Depression, Anorexia, Deliberate Self Harm, and Personality Disorder. The book therefore provides valuable and practical ways of working with these difficult, complex, and problematic conditions. It further makes sense of the relationships and emotions encountered when working in these settings and introduces possibilities for more effective and rewarding ways of working, including a model of support through supervision, reflective practice, and clinical discussion.

Illustrated by clinical examples from more than four decades of experience in the field, this book is ideal for the interested mental health practitioner.

Chapter 1

Introduction

Nurses from a mental health ward presented a patient, who had been admitted under a Mental Health Act Section, in a psychotic state. The patient had been preaching in a shopping centre and assaulted anyone who failed to acknow­ledge he was Christ. Brought into hospital by the police as he would not come voluntarily, once on the ward the patient complained that he was being locked inside an airless oven and feared he would asphyxiate and die.

When listening to patients in psychiatric settings, we need to tune in to the patient at different levels, both concrete and symbolic. At a concrete level, this patient is telling us that he feels threatened and believes his life is in danger. But what is being conveyed at a symbolic level by this concrete communication? My own thought listening to the nurses was that the patient was worried the staff were going to try to kill off his psychotic self. If my idea was correct, then in many ways, the patient is right. The psychiatric services want to help the patient return to a world of shared reality. I often think that we are working at cross-purposes with the patient. The patient defends himself from the depressing reality of his situation as a man with a psychiatric condition by moving into a delusion that he is Christ, a powerful man at the centre of a religion, who has healing powers. Patients often retreat into psychotic states of mind because they don’t believe they can bear the pain involved in facing reality. Psychotic states of mind can be extremely destructive, denying important aspects of reality and causing harm to relationships with self and/or others. However, the mental health services’ ambition to return the patient to the sane world may be experienced as a threat, as this involves attempts to crush the state of mind that the patient believes protects him from catastrophic breakdown. The diagnoses and active interventions employed by psychiatry can be experienced by the patient as more concerned with keeping them quiet and preventing the ward, the community, and society in general from being disturbed by their mental state.

Current mental health policy can be described as aimed at two main groups—individuals with severe mental illness, typically psychotic disorders like schizophrenia, and people with so-called “common mental disorders,” such as depression and anxiety.

Policy has tended to focus services for the former groups in secondary mental health care, with an emphasis on risk—i.e. prevention of harm to self and others. Secondary mental health services have been under great pressure, with cuts in bed numbers and a tendency for care to become increasingly procedural and coercive (with massive increases in rates of involuntary admission). There is a danger that as pressure for these services builds, staff become more mechanistic in response to the suffering of the patients they treat.

Meanwhile, for common mental disorders like anxiety and depression, policy has increasingly focused on the provision of brief therapies such as cognitive behavioural therapy (CBT) offered by healthcare professionals often with limited training, delivered within Increasing Access to Psychological Treatment (IAPT) services. However, these primary care services can fail to address more chronic underlying problems in the patients they see.

The reality is that people with chronic and/or acute mental disorders usually have long-standing difficulties caused by risk factors including disrupted parenting, childhood abuse, social disadvantage, and trauma. This often causes them problems in settling into education, staying in employment, and forming stable long-term relationships. Individuals may suffer from a range of difficulties, including psychosis, personality disorders, depression, anxiety, post-traumatic stress disorder, self-harm, and substance misuse.

Such individuals need an in-depth understanding of their psychopathology and any treatment needs to take account of the seriousness and long-term damage such early-life experiences can cause. The experience of disrupted relationships in the past with parents, carers, and authority figures can be unconsciously repeated in care settings and it is all too easy for services to become defeated or disengaged as the patient’s difficulties are deemed too intractable to be helped.

Psychoanalytic thinking offers just such an in-depth understanding for mental health practitioners, as well as providing long-term treatment for some patients. Not everyone will benefit from intensive psychotherapies, but psychoanalytic understanding and formulations can help clinical services—both in primary and secondary mental health care—to provide humane and thoughtful care.

Psychoanalytically informed work is interested in the complexity of human relationships and how an individual’s development is affected by their past. The approach looks in detail at how patterns of relating are repeated, including in therapeutic settings. Key to this is understanding the obstacles to engagement and resistance to recovery. It is concerned with gaining an understanding of a person’s disturbed and disturbing state of mind and working collaboratively with the patient. Rather than just dealing with a crisis, the emphasis is on gaining an understanding of the person’s self-defeating patterns of behaviour.

Serious and enduring mental illness and/or personality disorder can make it hard for patients to face the extent of their difficulties and suffering. This can lead to a withdrawal from the world of shared emotions and into psychotic and delusional thinking. Indeed, patients in disturbed states of mind often feel dislocated from the family of ordinary human experience. Mental health professionals need to spend time with these patients in order to understand their experiences. This can be challenging as it involves allowing themselves to be affected by the fragmented communications and delusional worlds of their patients. Ordinary communication may be stripped of its symbolic value and of all emotional significance. This creates a gulf that leaves mental health professionals and patients’ relatives feeling alienated and deprived of meaningful contact with the patient. The danger is that mental health professionals respond by becoming mechanistic in their thinking, leaving patients feeling they—and their damaged minds—are being kept at a distance. Indeed, mental health reports on patients’ views often state that staff spend more time in the office than face-to-face engaging with them.

Alternatively, mental health professionals may try to eradicate psychotic signs and symptoms with aggressive doses of anti-psychotic medication. This is an attitude which can be encouraged by a shortage of beds and the factory mentality which demands that patients be discharged as quickly as possible. Discharge is often based on the absence of positive symptoms, rather than an assessment of the patient's overall well-being. However, even though psychotic states of mind are serious and may cause considerable suffering and pain to patients and their relatives, the psychosis cannot be fully eradicated with drugs as it represents an aspect of the patient’s mind. This is not to say that psychosis and its side effects should not be treated medically; the danger is, rather, that professionals may further persecute patients by giving the impression that aspects of their minds are intolerable. This intolerance of damage mirrors the patient’s difficulty in mourning the loss of the ideal self.

In his paper “Mourning and Melancholia,” Freud (1917) described the way the depressed patient internalises the original object (e.g. the parent) as a way of avoiding the pain of separation and loss. The object then becomes part of the individual’s mind, where it is criticised and attacked for failing to be the ideal. In cases of melancholia, aggression is directed towards the self and away from the external object who has failed them. The self is omnipotently to blame for everything, and there is no attempt to differentiate between realistic or unreasonable guilt. This often develops into a sado-masochistic relationship between the ego and the super ego where the ego is blamed for everything. As Freud (1917) pointed out, the masochistic state of mind conceals considerable grandiosity and narcissism. The Masochism of the Melancholic says: “I am to blame for everything” because “I am responsible for everything” and no one else’s contribution, including the contribution of reality, makes any difference. Hence the victim of childhood sexual abuse may appropriately feel guilty about the perverse aspects of their own sexuality, which they feel degrades them. However, as a child victim they are not responsible for their abuser’s behaviour (Steiner, 2018). I suspect the repetitive nature of these patients’ cycle of recovery and relapse is driven by a need to avoid mourning the loss of the ideal version of the self. The capacity to mourn one’s previously held beliefs and identities is an essential aspect of a healthy mental life. Those that cannot adapt to feedback gained from external reality are doomed to fail because they cannot learn from experience.

Depressive experiences in psychotic patients are often difficult for patients to stay with (and for staff to witness). Indeed, feelings of despair about the extent of the damage can lead to a manic wish for a God-like figure that can cure all problems, reminding us of the patient I began this chapter with, who was found in a shopping centre claiming he was Christ. Patients often locate their fear of, and contempt for, their own psychological disturbance in other patients, whom they then see as disturbing. This allows them to adopt a superior attitude towards this aspect of their own mind, which they now see as residing in somebody else. They then try to control the “others” that are now believed to contain the damaged aspects of the self. Psychoanalytic thinking can help clinicians understand the way aspects of the self may be located in external objects, including themselves as members of staff.

Serious mental illness and personality disorder can deprive people of ordinary experiences, as their condition interferes with their ability to realise their dreams and aspirations. This can leave them feeling that they have been left on the margins of life, as indeed they often are. References to depressing states of mind therefore often accompany patients’ presentations. Even patients in manic states of mind talk about feelings of emptiness and fearfulness of catastrophic events, for example, nuclear explosions, as part of their presentation.

Registering these depressing experiences about the damage done by their illness and psychosis can prove hard for staff and patients as attention is more often drawn to the bizarre aspects of the presentation, such as manic mood or the real risk to self and others. Indeed, feelings of despair can lead to a manic wish for a figure who can cure all problems often represented by delusions of identification with a powerful figure, for example, God, Jesus, Mohammed, etc., but can also manifest as a child-like belief that the staff can offer a magical cure. This attitude can quickly flip over into grievance when staff fail to “cure” the patient of their difficulties.

In addition to experiencing feelings of anxiety, loss, and despair, patients who become aware of the extent of their difficulties are also prone to feelings of humiliation. Dependence upon professionals and the inevitable imbalance of power between the patient and the perceived authority can highlight patients’ feelings of inferiority. The fact that mental health professionals are required to assess the patient’s state of mind and functioning can also exacerbate feelings of being looked down on, judged, and shamed. Professionals need to be sensitive to these feelings and, whenever possible, help to support patients as well as manage the risks they pose. When professionals act in ways that are insensitive to the patients’ shame and humiliation, this may exacerbate historical feelings of resentment and unfairness in relation to authority figures. If these issues are not understood, they can become the locus of a grievance between the patient and the professional, which undermines the therapeutic relationship that is central to the process of recovery.

The patients’ communications and actions can have a disturbing effect on mental health professionals and can provoke them into reacting by trying to control the patient’s thinking or behaviour. Although at times actions taken by staff are appropriate and necessary, they may also be driven by a wish to curtail provocative or disturbing elements of the patient’s mind. Tuning into different levels of communication is a strain and may pull the staff member’s mind in several different directions at the same time. It is common for staff in mental health settings to leave work experiencing a headache, or feeling a need to go and have a drink. Staff also say they sometimes dream about their patients as they become affected by the disturbing nature of their work.

In his book Second Thoughts (1967), Bion described a patient in a lift who pushed the button for two floors at the same time as he believed he could go to two places concurrently. In my experience, this sense of having one’s thinking pulled in two directions—psychotic and non-psychotic—is common. It is important to note that psychoanalysts often use the term “psychotic” to describe psychotic mechanisms that operate in a broad range of mental states and presentations. This definition would encompass a mental activity that would not be described as psychotic from a psychiatric point of view. Although psychotic patients often deny their illness and complain they are being admitted against their will, they also fear being left to struggle with their psychosis on their own, without support. Ultimately, it is incumbent upon staff to try to understand both the disruptive and the destructive elements in their patients’ thinking. Without this, there is a risk that the underlying meanings of communications are lost, ignored, or crushed.

The mental health system is under enormous pressure as the reduction in the number of hospital beds has meant that only acutely ill patients are admitted to the hospital for relatively short periods of time. Staff are therefore expected to contain patients in disturbed states of mind in community settings. The current emphasis on services to manage risk in the community assumes that risk assessment is accurate. However, mental illness is, by nature, unpredictable and mental health professionals cannot assess patients’ behaviour with any degree of certainty. This leaves mental health professionals in the community managing large amounts of anxiety about blame, when patients act out against themselves or others in a violent or damaging way. The pressure on in-patient beds means that wards are full of acutely ill patients, a high percentage of whom will be detained under a Mental Health Act, often against their will. Wards have to be locked to prevent absconding, which creates a custodial atmosphere. The high level of disturbance on wards means that staff are dealing with a non-stop experience of their patients’ disturbed states of mind. Physical and verbal violence towards staff is common and, in many ways, accepted as being part of the job. Patients in these wards are often discharged as soon as they show any sign of “health,” and this early discharge deprives the patients of the opportunity to consolidate their improved condition by undertaking therapeutic and occupational programmes. It also deprives the ward of an opportunity to work with the patient in an improved state where healthier aspects of their personality may be supported and nurtured. This cycle can lead to a revolving door syndrome, as early discharge results in relapse and readmission, which can be demoralising for staff and patients alike.

Relationship with management

Lord Francis’s report on North Staffs outlined the way financial preoccupations provoked a top-down management system designed to control budgets. These systems are good at controlling resources but not so good at providing feedback back up the chain. Thus, anxieties about the quality of clinical services tend to reside with clinical staff while management become removed from front-line concerns. Pressure on services and high levels of disturbance in the patient population can also lead to high numbers of serious, untoward incident enquiries. Learning from experience is an important part of good institutional practice. However, anxiety about the management of risk can influence the culture of these enquiries and they shift from a wish to learn from experience into a need to attribute blame. These conditions can create an unhelpful “them and us” situation between management and staff. Good morale is one of the key ingredients of good mental health care. However, when hard-pressed staff in Mental Health Trusts feel unappreciated or mistrusted by management, it can lead to demoralisation. This, in turn, can have a damaging effect on the quality of clinical services as morale suffers. Mental health professionals need to feel that the management understand the conflicts and difficulties inherent in their work.

Support for clinic...

Table of contents

• Cover
• Half-Title
• Title
• Copyright
• Dedication
• Contents
• Foreword
• Preface
• Acknowledgements
• Background
• 1 Introduction
• 2 Theory in practice
• 3 Supervision and consultation: Tuning in to psychotic communications in front-line mental health settings
• 4 Therapeutic and anti-therapeutic factors in therapeutic relationships
• 5 Psychoanalytic understanding of depression and suicidal risk
• 6 Psychotherapeutic work with emotionally unstable personality disorder
• 7 Tuning in to psychotic communication on a psychiatric intensive care unit
• 8 Therapeutic work with treatment-resistant patients
• 9 The contribution of psychoanalytic perspectives on the patient’s relationship with their bodies
• 10 Social systems and social defence
• Index