On 8th June, 2018 the Cassel Hospital hosted a Symposium entitled Keeping Staff in Mind: The Psychoanalytic Contribution to Mental Health Work. Inspired by the recent publication of “Psychoanalysis, the NHS, and Mental Health Work Today”, edited by Alison Vaspe, the day was designed with dialogue in mind and in recognition that we ignore the emotional strain of working in mental health services at our peril. The vibrancy and applicability of psychoanalytic thinking to make sense of these staff experiences was central to this dialogue as were the different ways in which staff’s vulnerability can be heard and responded to.
The book, which has received excellent reviews, gave this Symposium a solid platform from which to explore the challenges staff face in keeping the services we offer from slipping into being overwhelmed by harmful dynamics. The participants came from different mental health services in different parts of the UK, and were nurses, doctors, psychologists, psychotherapists, researchers and managers.
Louise Lyons, Consultant Clinical Psychologist and Psychoanalyst, and Director of Quality and Patient Experience at the Tavistock and Portman NHS Foundation chaired the symposium. Through the day, she was able to illustrate how she drew upon her psychoanalytic background and thinking in her role in a number of Clinical Director positions. This experience has helped her to temper, but work with the often anxious demands for regulation that can arise when caring organisations help those in great need.
Oliver Dale, Consultant Psychiatrist and Jungian Analyst, began by setting the scene as Clinical Lead of the Cassel Hospital. He described the Hospital’s development over 97 years; starting as a psychoanalytic hospital and later developing a model of psychodynamic psychosocial nursing within a therapeutic community milieu. The latter being adopted so as to manage and work with the regression that can occur when delivering psychological interventions. He drew a link between this work and his work in a community personality disorder service where he works closely with the psychotherapy department and psychologists in the team. He talked about good care demanding a robust setting for therapeutic intervention and how this inherently demands a well-supported and reflective team and institution.
Alison Vaspe, as contributing editor, introduced the book around which the day was constructed. She illustrated the central role that psychoanalytic practice and theory continue to play in keeping our mental health organisations and the people within them healthy. Drawing on her own experience of working in the field, she outlined the different forms of containment described by Marilyn Miller in the first chapter of the book. She developed these definitions in order to show how staff, who may wish, above all, to work in ways that allow meaningful, compassionate contact with individual suffering, have also to navigate between the need to keep patients and staff themselves physically and psychologically safe, and the need to manage situations that are dangerous and deteriorating. The ‘dilemmas and disappointments’ of this work, to quote from Chris Scanlon’s chapter, can be highly stressful for staff, and psychoanalytic thinking is essential, not just to do good work but if they are also to be kept well in their own minds. Without this attention to unconscious processes, staff may burn-out, resort to abusive or neglectful practice, or suffer ongoing psychological health problems. Financially, the NHS then has to bear the cost of a bill for sickness absence that has increased significantly over the last decade.
Tim Dartington is a social scientist and an organisational consultant. He was a contributor to the book and developed the theme that we are all vulnerable (staff and patients) and presented a paper which weaved his professional experiences with his personal experiences as a carer. One vignette from his work consulting to a clinical team cut to the heart of the matter. This was the painful experience of a junior nurse caring for a dying young man. The nurse could not stay with the reality of such an eventuality and instead clung to false hope, leaving the patient alone and despondent. Developing this idea further he introduced the idea of a service giving micro-climate type experiences of care, each seemingly minor interaction combining to form a whole. Finally, he introduced the idea that all dependent relationships run the risk of slipping from care into something harmful, even abusive. This idea was developed by the participants in their dialogue as a group. They noticed that the motivation behind the “Recovery” model might at times seek to avoid such abuses zealously and in doing so paradoxically also remove the opportunity for care to occur.
The last speakers of the day were Turlough Mills, a Consultant Child Psychiatrist and Emma Sutcliffe, Nurse and ward manager of an adolescent inpatient service. They had also contributed to the book, and together they gave an account of the challenges of working with adolescents in extreme states of regression. The dynamics of power structures within teams became important themes in the subsequent dialogue with race, class and professional roles being examined. Through other examples from education and the criminal justice system, the group explored the reality of being in a position of responsibility for, and over, those who are struggling to manage their destructiveness and stay on the side of life. For staff, this might inevitably require then to act through force (eg force-feeding an anorexic patient), the impact of which must be managed lest it drives all to fragmentation and despair.
Both papers were presented in the “Tavistock Style” in which the audience became a Greek chorus and entered into a dialogue amongst themselves following the presentation of a paper. They were chaired by Lesley Day, previously Head of Service at the Cassel Hospital and Chris Scanlon Consultant Psychotherapist and Senior Professional Associate at the Tavistock Institute for Human Relations. Drawing upon their professional experience as psychotherapists and reflective practice and organisational consultants, this was safely contained even though the group found itself irresistibly striving after fact and reason at times and sought to bring back the speakers into the group discussion prematurely.
As the event was fundamentally structured experientially, this summary is meant only as an attempt to highlight some of the themes and discussion of the day. What did become apparent in the dialogue of the day is that the mandate to those in positions of responsibility and authority for the vulnerable is given with some ambivalence. Whilst there is recognition that there are many vulnerable people in society, the desire for “perfect care” i.e. which guarantees success and is without risk, paradoxically undermines the normal care of everyday life. The limited acceptance that care sometimes fails and that it can also be rough, even brutal at times, means that those in positions of authority and power can act anxiously by trying to keep control and paradoxically undermine the “good enough” caring relationship and the need for some autonomy in its everyday expression.
Providing any sort of care inevitably involves confronting the limitations of both carer and cared for and the ensuing guilt is often discharged through blame when those limitations are exposed. This is not an apology for failure, but casts a different complexion on the last decade in which we have seen a catastrophic reduction in the number of staff who work with those needing help. Our current allocation of resources might be better understood as an intolerance of guilt. If we have no services, there are then no users and no need to worry about. Our challenge is to know when the demands for better care are coming from a place of realistic creativity as opposed to omnipotent destructiveness.