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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.
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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.
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