The psychodynamics of psychiatric institutions, Bob Hinshelwood Jan 2016

Mostly psychiatry focuses exclusively on the symptoms and suffering of people with psychosis.  But for a long time it has been known that psychiatry itself, or at least its institutions, show their own symptoms, causing institutionalisation and desocialisation.  As a British psychoanalyst, a long time ago, incisively said, Within such [a traditional] setting, health and stability are too often bought at the excessive price of desocialization.  Sooner or later the patient, alone and unsupported, must face the difficult task of returning to the society in which he became unstable, and there regain social integration and a daily sense of values and purpose.  This is no light task for a desocialized man, however healthy he may have become (Main 1946, p. 7-8).Mental health workers never properly investigated these damaging effects of large mental hospitals.  They were dealt with in one of two ways.  In Britain, and Italy, these large mental hospitals were closed, and a move to 'community care' was instituted.  In other countries, especially the US, reliance was placed on medication to treat symptoms whether they arose within the patient or were caused by the institution.  These measures have been largely ineffective as, first, community care still exhibits the characteristics of institutionalisation (Leff 1997), and, second, increasing dosages of newer and newer anti-psychotic medication have led only to less active and more compliant inmates.Nevertheless there has been a long line of research by social scientists, starting with Stanton and Schwartz (1956) and Goffman (1961), and the more political work of R.D. Laing (1961).  This serious research has had little impact on psychiatry, in fact mental health workers are largely blind to the issues that have been pointed out. Part of the difficulty in facing this problem of institution-caused pathology is the fact that the processes are unconscious; and moreover that any discussion of the problems (as here) appears to put shame and blame on psychiatric staff.  The fact is that mental health workers on the whole are extremely dedicated carers devoting whole careers to people who are afflicted with the greatest suffering that can affect human beings.  The fact that dedicated staff end up creating and supporting institutions and services that cause harm is deeply sad and troubling.  How can it be that a dedicated service goes wrong? There is a lot to be said about that question (see for instance Gordon and Kirtchuk 2008).  It is likely that because  psychiatric staff are some of the most caring of people, they become the most affected by being with those who suffer most – and they do so for long shifts and many years.  It is easy to say they 'burn out' – well, they do, but that is merely a word.  There is here a profoundly human situation.  It is in the nature of human beings that when they are in the presence of others who are suffering, they also suffer in their own right. There is a key piece of research on nurses in general hospitals with physically ill patients (Menzies 1959).  These nurses are in the presence of patients who are in pain, dying, frightened, mutilated by operations, and so on.  It is a deeply emotional obstacle course, for the nurses as well as the patients.  As a result, it appears that nursing practice evolved in such a way that the nurses avoid too much close personal relationship with their patients, and they also avoid much responsibility for making decisions which could have far-reaching effects.  For instance a nurse will go round the ward taking temperatures, and another nurse will take around bed-pans, and so on.  In such a practice, nurses relate to only a part of each patient.  Often even minor decisions were passed upwards to be taken at the top of the nurse hierarchy.Something similar happens too in mental hospitals.  Donati (1989) noted how in psychiatric wards, nurses also avoided personal contact in a kind of ritualised touch-and-go tactic, as she called it.  Psychiatrists, as is well known, concentrate on symptoms and illnesses rather than people (see Barrett (1906), and Hardcastle et al 2007)); known as the medical model such a diagnostic focus has reaped enormous rewards in physical medicine, but in 'illnesses of the person' it is a mixed blessing.In other words the consensus on the dynamics of the service and psychiatric institutions points to a process of emotional distancing which is not recognised but becomes standard practice.  It helps staff cope with the impact of psychotic suffering, even if it does not help patients who suffer it.  Rather it causes increased suffering perhaps.  The effect of emotional distancing and the refusal of enduring relationships results in a depersonalisation at the root of institutionalisation and de-socialisation of patients discouraged from personal contact.  More than this, it is common – indeed it may be at the core of the problem – that people with psychosis often do not feel a proper secure identity and do not feel properly a person anyway.  They are readily depersonalised by a service that readily depersonalises them.  There is an unfortunate fit – between vulnerable people and an emotional challenged service. Saddest of all, is that the suffering of mental health workers is not recognised by themselves nor is it recognised by the professional and managerial hierarchies whose job would be to provide support.  There is a co-operative hiding of the problem.  And it is frequently a genuinely unconscious dynamic within the service.As a psychoanalyst, I have spent a significant part of my career trying to pay attention to staff stress of the kind discussed, on the grounds that a more emotionally secure and supported staff will ensure a more supported and healthy body of patients.  I can't say these endeavours were always welcome.  In fact I should say that those people I came in contact with might have been 50% in favour of these ideas, and the rest deeply suspicious that I was deliberately undermining their best efforts.  I should say that in my experience, opinion was not simply divided, but could be deeply oppositional.  There was more to this than a difference of opinion, it seemed to challenge deeply held (and indeed deeply needed) points of view (which I sometimes unkindly thought of as 'ideologies').  I was struck by Freud's view nearly a century ago that 'What is opposed to psycho-analysis is not psychiatry but psychiatrists' (Freud 1917, p. p, 254); I imagined that on the other hand psychiatrists might have felt equally personally that what is opposed to psychiatry is not psychoanalysis but psychoanalysts !  The personal cannot be excluded from psychiatry and its institutions.

References

Barratt, Rob (1996) The Psychiatric Team and the Social Definition of Schizophrenia.  Cambridge: Cambridge University Press. See webpage

Donati, Flavia (1989) A psychodynamic observer in a chronic psychiatric ward. British Journal of Psychotherapy 5, 317-329.  Republished in R.D. Hinshelwood and Wilhelm Skogstad (2000) Observing Organisations.  London: Routledge. See first page Pdf

Freud, Sigmund, (1916-17) Lecture 16 – Psychoanalysis and Psychiatry. In Introductory Lectures on Psycho-Analysis; Part III.  Standard Edition of the Complete Psychological works of Sigmund Freud, Volume  15-16: 243-256.  London: Hogarth. see amazon

Goffman, Erving (1961) Asylums: Essays on the Social Situation of Mental Patients and Other Inmates.  New York: Doubleday. see amazon

Gordon, John and Kirtchuk, Gabriel 2008  Psychic Assoults and Frightened Clinicians.  London: Karnac

Hardcastle, Mark, Kennard, David, Grandison, Sheila, and Fagin, Leonard (2007)  Experiences of Mental Health In-Patient Care.  London: Routledge. See cover ISPS book

Laing, R.D. (1960)  The Divided Self.  London: Tavistock. see amazon

Leff, Julian (1997) (ed.) Care in the Community: Illusion or Reality.  Chichester: Wiley. see webpage

Main, T.F. (1946) The hospital as a therapeutic institution. Bull Menninger Clinic, 10: 66-70. Republished (1989) in T.F. Main, The Ailment and Other Psychoanalytic Essays, London, Free Association, pp. 7-11.

Menzies Lyth, Isabel 1959 The functioning of social systems as a defence against anxiety: a report on a study of the nursing service of a general hospital.  Human Relations 13 95-121.  Republished 1988 in Menzies Containing Anxiety in Institutions.  London: Free Association Books; and in Trist and Murray (eds) 1990 The Social Engagement of Social Science.  London: Free Association Books.

Stanton, Alfred and Schwartz, Morris (1954)  The Mental Hospital.  New York: Basic Books. See amazon

Also:

Hinshelwood, R.D. (1979) Demoralisation and the hospital community.  Group Analysis 12, 84-93.  Reprinted 2001 in R.D. Hinshelwood Thinking about Institutions.  London: Jessica Kingsley.

Hinshelwood, R.D. (1999) The difficult patient: the role of ‘scientific’ psychiatry in understanding patients with chronic schizophrenia or severe personality disorder.  British Journal of Psychiatry 174: 187-190. See first page Pdf

Hinshelwood, R.D. (2004)  Suffering Insanity:  London: Routledge.see amazon

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