I’m writing this editorial in mid-November, in the throes of the second lockdown in the UK imposed by its flailing government in an attempt to limit the devastating effects of the Coronavirus pandemic. Health services worldwide are overwhelmed by acute admissions of COVID patients, as well as the growing number presenting with more insidious and longer-term direct and indirect effects of the virus on physical and mental health; whilst other public services are struggling with the demands of increasing poverty, homelessness, unemployment and familial conflict. How might a psychoanalytic approach be of benefit to the suffering of so many people?
One psychoanalytically informed method that has been increasingly implemented in the UK since the start of the pandemic has been the provision of Balint groups for front-line health workers who are exposed to a relentless turnover of very sick patients and distressed relatives; who are explicitly or implicitly expected to prioritise the health of their patients before their own; and who in some cases are being forced to make decisions which severely test ethical standards about who receives treatment and who doesn’t in a system at breaking point. Such staff, who seem to be coping so well in such adverse and extreme circumstances, and who have been lauded with public displays of gratitude and admiration, maybe nevertheless experience feelings of anxiety, guilt, anger, resentment, exhaustion and despair that they are too ashamed to admit, but which emerge once the action subsides and their defences collapse.
Balint groups can provide a safe and supportive space in which to acknowledge and explore these emotional responses resulting from the trauma of working in such unprecedented conditions. Medical psychotherapists and other psychoanalytically oriented practitioners are delivering, and receiving increasing requests to deliver, Balint groups for trainee doctors, who have often been temporarily removed from their training posts to be redeployed in acute medical services to treat COVID patients beyond their levels of experience and expertise.
The first paper in this issue, ‘Balint groups with junior doctors: a systematic review’, by Emma Salter, Adrian Hayes, Roxanne Hart, Rose-Anne Orrell, Joseph Jameson, Christopher Knight, Jenny Pickhaver and Anna Baverstock, was written before this pandemic, but is timely in being the first published systematic review of studies of Balint groups for medical trainees, and follows nicely from a systematic review of Balint groups for medical students previously published in this journal. Although the methodology of the relevant studies included in the review is varied, and there were also differences in the formats of the Balint groups, limiting the generalizability of some of the studies’ findings, several looked at the impact of Balint groups on preventing burnout and other indices of work-related stress, with one study showing significantly reduced compassion fatigue in their work following participating in a Balint group, evidence that bolsters the legitimacy and effectiveness of conducting Balint groups in doctors suffering from COVID-linked stress.
The second paper, ‘Tinnitus, paranoid psychosis, homicide and the identificate in an amiable man’, by Phil Lucas, takes us away from the immediacy of the external threat of a real biological contagion, to the phantasies and paranoia of a patient in a forensic psychiatric unit who had become plagued by an infestation and intrusion of his internal world by tinnitus, causing him to commit a homicide. In this single case study, Lucas describes his five-year treatment with once-weekly psychoanalytic psychotherapy and how the patient’s psyche was dominated by an unconscious phantasy of an idealized maternal object represented by his love of classical music. This phantasy was violently interrupted by the tinnitus, which unconsciously represented a hated paternal object who destroyed the mother-infant union, and who in turn had to be destroyed by the patient by unconsciously projecting his oedipal murderousness into the victim who represented the paternal object. Understanding and working through these unconscious conflicts facilitated psychic development and integration, and the partial relinquishing of his psychotic defences.
The third paper in this issue, ‘Gripped by the chaos: A psychoanalytically-informed qualitative exploration of adolescent ADHD’, by Johanna Clancy, John O’Connor and Clodagh Ni Mhaolain, challenges the hegemony of biological psychiatry in taking a psychoanalytic approach to attention deficit hyperactivity disorder (ADHD), which is largely conceptualized as a neurodevelopmental disorder with strong heritability and the primary intervention being medication. Where psychological approaches are recommended these are usually cognitive behavioural treatment or social skills training, with an emphasis on behavioural modification, and do not focus on the emotional pain that many people diagnosed with the condition experience. Moreover, most research into effective treatments for the condition is quantitative and does not take account of patients’ subjective experiences and interpersonal difficulties. This paper addresses these gaps in the literature in describing a psychoanalytically informed qualitative study in which five adolescents were interviewed about their experiences of living with ADHD, which brought to the fore their struggles in managing overwhelming affect, their difficulties in self-soothing and eliciting care from others, and their lack of control of uncontainable stress and relational pain. The authors postulate that these deficits and conflicts in their relationships to themselves and others are linked to early disturbances in their object relationships and stress the need for interventions which provide understanding and containment for the unmet emotional and interpersonal needs which underlie their manifest symptoms.
Jeremy Clarke’s book review essay, ‘Some very important people are depressed; get over it!’, the first of a three-part narrative review of depression memoirs in the public sphere, highlights the supremacy that quantitative research continues to hold in the quest for effective treatments for mental disorders, as exemplified by the National Institute of Clinical Excellence (NICE)’s reification of the randomised controlled trial as the gold standard methodology. Single case studies, qualitative research and first-person accounts of living with mental illness, as described in the three aforementioned papers, are deemed inferior or inconsequential in revealing ‘evidence-based’ knowledge within the dominant paradigm of empirical science. By contrast, Clarke explores the respective writings of Al Alvarez, Hilary Mantel, Meri Nana-Ama Danquah and Jeanette Winterson about their suffering states of mind that are called depression, but which may be felt in the body or experienced as complex emotional responses to trauma that cannot be neatly packaged into the concept of a circumscribed mental illness divorced from their struggles with identity, meaning and place in a world too often dismissive of subjective distress. Experiences of stigma, sexism, racism and cultural negation of their emotional pain are interwoven in their narratives and bring home how the othering of the lives of people diagnosed with mental illness protects us from the realisation of our own vulnerability.
Finally, Penelope Campling’s review of Roger Kennedy’s book ‘The power of music: psychoanalytic explorations’ strikes chords of hope and enlightenment in its exploration of the origins of musical communication and its therapeutic potential. A significant factor which precipitated psychosis in Phil Lucas’ patient was the loss of his ability to hear and be comforted by classical music due to the onset of tinnitus. Inspired by her own immersion in music, Campling conveys to us the evocation and depth of feeling that cannot be verbalised, but which so moves us, that music arouses, and which Kennedy illuminates through his research into psychoanalysis, philosophy, musicology and neuroscience. This brings us back to the impossibility of pigeonholing psychoanalysis as a science or as an art, a false dichotomy that detracts from its power to create meaningful connections with ourselves and others in these uncertain times.