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The Royal College of Psychiatrists Improving the lives of people with mental illness

Introduction: Drawing from Life

Drawing from Life: Psychoanalytic Pictures of Psychiatry  

Psychoanalytic pictures of psychiatry

People who turn to mental health services are very stuck in their lives - often drawing away from life, and sometimes being drawn towards death. Past despair, disturbance and destructiveness can permeate the professional encounter in the present, sometimes leading to an impasse in care, repeating a stuck or abusive situation from the past between patient and professional.

Psychoanalytic thinking can be of help in offering an understanding of the dynamics of this drawing from life and the emotional impact the disturbance of this experience has on the practitioner and their professional behaviour.

My drawings act as a ‘Trojan horse’ to show some of the challenging aspects of the patient and professional relationship and despite their deceptive humour contain a serious underlying message about an unseen enemy of empathy which unconsciously gets under the skin.

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For psychoanalytic thinking to be applied in everyday mental health services, psychoanalytic thinkers need to be trained and skilled in the task of helping other professionals reflect on their disturbing experiences and fears about their work, their conflicts and their feelings of failure.

Psychoanalytic understanding of destructiveness and its manifestations as attacks on self, attacks on others and attacks on the attempts to help can open a space for professionals to find a new vantage point on a patient who becomes not only a victim of their past but also a victim of their own mind.

The application of psychoanalytic thinking in clinical settings in which professionals are exposed to psychosis, personality disorder, violence against the staff and others, self harm and suicide is like offering supervision to a frightened and fast moving target. The NHS is preoccupied with risk and institutional managerial anxiety about shameful exposure of negligence percolates through the corridors into the veins of the clinicians.


Hitting the target but missing the point is characteristic of a culture in which a blind eye can be turned to the disturbed patient who is psychotic, but safe, while eyes are turned to observe those deemed less disturbed but who are perceived to be unsafe. Patients who belong are those diagnosed ill and therefore legitimate, those who do not belong are un-diagnosed as ill and become illegitimate. The ill legitimate patients, the mad, are the daily bread and butter of mental health work, the illegitimate patients, the bad, are the poisoned chalice.


Professional life lines 

Professionals are expected to feel empathy for the people they try to help, but with some of their patients they do not have or lose empathy.

Empathy, understood as the capacity to be aware of the thoughts and feelings in the other person, is limited in some of the people who develop problems in relationships that are described as indicative of personality disorder. In the development of those who lack empathy, a lack of empathy in those tasked to care for them as infants and children is common. The echo of this early developmental absence or loss of empathy from childhood repeated in the adolescent and adult professional environment which is the focus of my psychoanalytically informed reflective practice groups and consultation service.

Understanding the different ways in which professional empathy can be disturbed and diminished can help to increase professional awareness of this repetition of past disturbance in the present and thereby attenuate the damaging echo of repetition.

The peace of mind symbolised as a dove is invaded by a sense of shame which pervades the patient and professional relationship. Stigma and a sense of shameful exposure experienced by the patient unconsciously ‘gets under the skin’ of the professional who, through projective identification, feels caught in the spotlight and anxious that their failure to help will leave them cruelly exposed to harsh judgement or attack.

Drawing on the life interest of professionals in the meaning of their patient’s disturbance and its echo in their own experience can improve the quality of care and it could act as a bridge for those who wish to develop the interest in psychoanalytic thinking further. At the very least, the sustained interest of a psychotherapist in them and their work offers a model for the value of recognising and listening to the counter-transference to try to understand.



Drawing from Life

The art of listening by Dr James JohnstonDrawing from Life describes my experience of exploring the complexities of offering psychoanalytic thinking in the form of reflective practice and case discussion groups in acute and community mental health settings over many years. This application of psychoanalytic thinking on behalf of the most complex patients has convinced me of the crucial place of helping professionals to reflect on their counter-transference to enhance patient care.

Drawing from Life includes a ‘Trojan mouse’, based on the humbling principle of recognising the very limited potential in us to change the mind of another.

In teaching doctors learning about psychiatry and beginning psychotherapy I always ask them to try not to resolve their patient’s pain as soon as they feel it. I put this to them as ‘learning to sit on their hands’ (metaphorically) and to develop the art of listening. One definition of containment is in containing the desire to cure and learning the value of listening, bearing uncertainty and attempting to find meaning in the disturbance evoked by the patient in the professional.

By not responding too quickly to resolve pain, the pain the patient experiences may be also experienced to some degree by the professional. The wish to treat can be a wish to treat not the patient, but the professional, to relieve recognition of a shameful limit in what can be done to repair damage done.

I hope the humour and humanity of my cartoons allow some thought about feelings arising in mental health work which would otherwise remain hidden, because they are experienced as shameful.


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