APPLYING PSYCHOANALYTIC THINKING IN A STAFF SUPPORT GROUP TO REFLECT ON SERVICE CHANGE AND CLINICAL PRACTICE IN A SPECIALIST PSYCHIATRIC SERVICE

Abstract

This paper describes how the nursing staff of a specialist psychiatric service used psychoanalytic thinking in a weekly staff support group to reflect on a structural change to the service and on clinical practice. This enabled the nurses to discover a system of defences, partly reflecting that of the patient group, from anxieties relating to the care of challenging and seriously ill patients.

The patients who were about to leave became extremely antagonistic to the nurses who reacted with relief on seeing them go.

It is suggested that the systematic use of psychoanalytic thinking for the support, training and supervision of staff makes a valuable contribution to the development and maintenance of safe practice with a view to meeting the Department of Health guidelines for clinical governance to improve quality of service, safeguard standards of practice and create an environment in which a high level of clinical care can be achieved and maintained.

Notes

The patients who were about to leave became extremely antagonistic to the nurses who reacted with relief on seeing them go.

Even though I refer to ‘the’ staff group, the material reported hereafter comes from staff group meetings held, separately, in each of the two wards. I have chosen the singular article because the topics and issues presented reflect common preoccupations to the staff in both wards.

Alongside the long term treatment programme the service offered also a short‐stay treatment programme. This was also based on voluntary admission and the acceptance by the patient of working towards a set of therapeutic goals.

This could happen for the most mundane reasons such as the failure of a nurse to respond without delay to a patient's request .

The fast‐growing services for personality disorders is but one example.

This dilemma was illustrated by the reaction of a member of an emergency team called in to help with a patient who needed frequent restraining for tube feeding. In the staff group a nurse reported the emergency team member saying that he did not consider eating disorders patients as having a mental illness and wondered why they could not be left to die. He would rather restrain a six foot schizophrenic man with a knife, he said, than a little, waif‐like, girl crying.

For a critical review of the concept of anorexia nervosa from a number of clinical and non‐clinical perspectives see Malson (1998).

The relationship between male nurses and patients had its specific issues, as well, which the group discussed on other occasions. These related mainly to anxieties relating to the upholding of sexual boundaries by the male nurses when patients in the treatment programme started to put on weight or, occasionally, to anxieties relating to rape as the sadomasochistic enactments of some emergency patients escalated.

Duranti (2004), writing on her work with a 13‐year‐old girl suffering from anorexia nervosa, conveys the powerfulness of the feelings induced by eating disorder patients as she describes how she found herself wondering how a 13‐year‐old child could evoke such a sense of fear in her.

This includes the advent of Primary Care Trusts (PCTs), hospital star rating systems, evidence‐based practice, the recognition and development of a wide range of psychological therapies alongside drug treatments and the increasing scrutiny of specialist services, to name but a few.