“Bringing people in a psychotic stupor which is very much those situations where people
feel totally alone…I would say an acute ward in those circumstances is the most horrible environment you can be in…over-agitated patients…are held down where they are physically constrained…they are…oooooofffffff…so a lot of our treatment methods on acute wards are totally counter-productive and harming patients.” (“Hans”)
Both mainstream and fringe psychiatrists referred to the organisation of psychiatric treatment in the NHS as untherapeutic. They felt powerless against the dominance of mass production principles in treatment, with the main objective of controlling costs. As in the above statement, the terrors and fears of annihilation in psychosis were ignored, with those suffering existential aloneness exposed to threatening and harmful environments instead of safe and growthful
relationships. Accordingly, some compared psychiatric wards to “holding pens rather than therapeutic environments” where treatment was experienced as assault. The resulting conscious and unconscious conflicts within the profession and between patients and psychiatrists was seen to lead to a fraught, adversarial treatment atmosphere, not conducive to the development of the thinking function, necessary in treatment.
The individual resistances and fears against the relational aspects that I highlighted above were augmented by the systemic tendency to prioritise economic factors above holism. Those fears and prejudices manifest in the design of services so psychiatrists lamented the ongoing divisions keeping the psychological and the social split from the biological in psychosis. Some of them recognised that, the fear of empathising with patients weathering the storms of psychosis, could result in their avoiding any signs of human vulnerability and fragility, in self and others. They acknowledged the damage to patients and psychiatrists alike, with the feelings of anxiety and fear removing the search for connections and flexibility in treatment systems. Recognition of these problems made some reassess their professional training and found it lacking. They wanted training to focus upon the links between their personal and professional identities and help them integrate, with a move away from monocultural biological psychiatry as an essential part of that. I cited evidence earlier of psychiatrists feeling more integrated and skilled through exposure to other therapeutic languages and contextualised phenomena. They learnt that emotional connections with the patients and their stories and their own context helped them to better understand the clinical picture of psychosis. Ultimately, they were disappointed to recognise that their training had not exposed them to the wider picture and felt the issue was too important to be left to chance or individual interests.
“They think its 3 different strands…of medication, CBT and psychodynamics...so oh...I like
medication because it works straightaway…I will go for that...some say…oooohhh psychodynamic...that looks nice to understand the meaning of it, I will go for that but nobody tells that all the three are needed in one patient” (“Raj”)
Psychiatrists complained about the splits imposed upon their individual understandings and psychiatric training due to institutionalised ontological splits within the system. The most
experienced psychiatrists knew that the most critical aspect of working with psychosis was to help integrate the patient but that the basic training did not help them to even recognise, let alone meet that need. Instead, they learnt to split their patients, believing that each strand of treatment whether it was medication, CBT or psychodynamics would all achieve the same result. Although it would be inaccurate to say that understanding patients was unimportant in general psychiatric training, my sample suggested that it lacked depth. A holistic understanding of the bio-psycho-social aspects does not seem to be an integral part of medical training and, according to some its significance is arrived at by chance.
“These groups are a resource to support the team and…help us clinically but they are
not used with the usual rationalisations of time…but the real reasons are our defences against exposure and vulnerability. As a senior medic, I should attend to show committment and leadership but I don’t.” (“Len”)
Systemic difficulties with relationships left psychiatrists confident in fixing technical problems but floundering with complex emotions in self and others. My final evidence relates to the systemic deficiency in helping psychiatrists manage the difficult emotions evoked in the course of their work. Facilitated process groups reflect a psychological approach where professionals learn to pay attention to the emotional impact of the work and understand the functioning of psychological defences in self and others. The aim was for the psychiatrists to recognise their emotional reactions so they could serve patients uncontaminated by their own difficulties. Most psychiatrists reported that such groups were abandoned due to resistance towards the vulnerabilities presented by emotions and relationships. Only those senior psychiatrists at ease with human frailty seemed to understand the rationale for such groups but even they felt helpless against the systemic dynamic. It appeared to be easier to ignore social and psychological realities allowing such approaches which tend to emotional needs in psychiatrists to wither away and, with them, any chances of meeting patient needs. The ultimate irony may consist in this denial of relational needs amongst the healers, another version of the original problem that had produced the psychosis in the patients. Systemic pressures towards a narrow perspective on life may be discouraging the very human search for meaning, hope and relationships.
Chapter 5.
Discussion
5.1
The need for synthesis
I set out to explore and understand the experience of psychosis treatment in the NHS amongst patients and psychiatrists. My data suggests that the conflict in the treatment results from an ontological clash; the psychiatric system and treatment does not reflect the real worlds lived in by the patients or the psychiatrists. Current systems of training and treatment do not support the human needs for meaning, hope and relationships. This ontological clash and the abyss between the inhabited and the imagined worlds need to be addressed so that the doctors and the patients share the same world.
The conflict manifests in patients fearing their treatment and resenting their healers’ misunderstanding of the psychotic process and their needs. This missing essence of the treatment became clear to patients when they encountered alternative paradigms within the Movement. Similar conflicts surfaced amongst psychiatrists when those who had ventured into other disciplines of psychotherapy and philosophy questioned the adequacy of their biomedical training and their psychiatric identity. For psychiatrists, the conflicts and resulting harm result from inadequate theorisation and understanding of the human subject, psychosis and psychiatry. Instead of splitting life into its social, biological, economic, psychological aspects, a synthesis is required because the problems stem from a lack of understanding of ‘the human’. The conflicts I found, impact both sides adversely, with patients unable to recover from their distress and the psychiatrists left professionally unfulfilled and unintegrated. The dominant analytic mode in psychosis treatment leads to a battle of wills, the need for a worthwhile life and self-determination pitted against the systemic need to control costs. This quote from one of the patients succinctly answers my research question by highlighting the reasons for conflict, raising questions of how to help sustain worthwhile lives.
“We fight due to the fact of different agendas, he wants to keep me out of hospital
whereas I want to keep my medication down to a minimum…in order to have a life up to a point” (“Amy”)