Psychic Assaults and Frightened Clinicians: Countertransference in Forensic Settings

As you embark on reading Psychic Assaults and Frightened Clinicians: Countertransference in Forensic Settings, prepare to share the state of mind into which multidisciplinary professionals in forensic settings are plunged every day as they enter their high and medium secure work places. Psychic Assaults and Frightened Clinicians portrays in emotional depth this world of classic Greek tragedy, where each member of the multidisciplinary team - health care assistant, nurse, occupational therapist, arts therapist, social worker, psychologist, psychotherapist, psychiatrist - must, like Creon discovering the consequences of Oedipus' actions, contend with the intolerable:

I saw things in the darkness moving
many pale masks lifted and sinking
I saw dark rivers and marshes
I saw writhing things

I could hear human voices and the screeching and
laughing of mouths that were never on earth
I heard sobbing deeper than anything on earth

I saw every disease I knew their faces I heard them and knew their voices
I saw every torment every injury every horror
spinning like flames and shadows
sickening forms faces mouths reaching up clutching towards us and crying

I saw the plague of this city
bloated blood oozing from every orifice
grinning up on a sliding mountain of corpses i

This is "...Not a book to read before bedtime", warns Bob Hinshelwood in the Foreword, "...When I sat down to read this book, I decided to fasten my seat-belt." Psychic Assaults is a work in progress by members of a Forensic Psychotherapy Department in a large secure psychiatric hospital who, with multidisciplinary colleagues from other forensic services, have for many years been absorbed in the clinical task of thinking about the kind of seat-belt necessary to keep safe and respond creatively to the emotional realities of work with such damaged and catastrophically impulsive patients. The seat-belt they propose is a mental seat-belt, a framework for standing with the Creon in all of us, experiencing the inevitable emotional turmoil evoked by close contact with forensic patients, thinking about it, and only then formulating individual or team interventions. The approach is rooted in psychoanalysis, specifically in the intensive study of the emotional interactions between patient and analyst as they occur in the here-and-now of the analytic session: the transference-countertransference. Since about 1950, the model of the analyst as a blank screen, reflecting the emerging contents of the patient's mind, has given way entirely to a far more dynamic understanding of the clinical relationship. The focus is on the interaction between the participants, each contributing in different ways to the phenomena arising in their encounter. Transference, the unconscious repetition of past relationship patterns or scenarios, is common to both patient and analyst. The latter's training should develop a capacity to be aware of his personal equation: his tendency to assimilate his perceptions of the patient to unresolved personal issues and relationships. Psychic assaults are the mutual impacts of these transferences, usually in the form of subtle or blatant dramatizations of relationship scenarios between patients and staff, and within the staff group, which may reverberate out of awareness throughout an entire hospital, let alone between two individuals working together in a consulting room. Countertransference is the central concept of the book, the crucial locking mechanism in the mental seat-belt for staff. "Counter" refers to the worker's "counter"-transference to the patient's transference. To an angry criticism from the patient, who at that moment experiences his late-arriving nurse or doctor as a negligent mother, the staff member becomes overwhelmed with guilt, in turn experiencing her patient as her own chronically dissatisfied and rejecting father of childhood. Or the staff first explodes in retaliation and then bends over backward to assuage her father/patient, as well as her own guilt, and consequently loses sight of the patient's real need for boundaries. Transference from the patient has been countered with transference from the staff member. It is vital for staff to be held into their emotional responses and to hold on to them in order to understand what is happening between them and their patients. The application of the concept of projective identification to understanding countertransference reactions is another indispensable element in the mental seat-belt elaborated in Psychic Assaults. Projective identification is a phantasy that psychic surgery can be carried out by oneself on one's mind and personality, and that the removed parts can be forcefully located in other minds and personalities, which they inhabit. Real interpersonal pressures, including seduction, are used to trigger or induce others to react, in feeling and behaviour, in accordance with the projected elements of identity; this counter-response then convinces the projector that the disowned feature is truly part of the recipient's identity. Patients are able unconsciously to evoke such emotional reactions in their carers, who are recruited to experience especially those feelings and impulses that are so painful or frightening that patients are unable to know about and work with within themselves: that they fear and hate in themselves. These evoked-by-impact responses in staff members, their resonating counter-responses to their patients, accordingly become an untapped source of the most valuable, hidden information, not just about the staff members themselves (their transferences) but about their patients. To return to the above example, if the staff member can consider whether her responses of guilt, anger and appeasement could reflect aspects of the patient's own emotional experiences and relationships, a world of potential meanings opens up in which to contextualize their repetitive, fraught interactions. Perhaps the patient in the role of his hostile father was treating the staff member as he felt treated, evacuating unbearably intense emotional reactions, even an impulse to kill, into another. In this way, guilt over an index offence is transposed from patient to staff member, who "becomes" unconsciously the irreparably guilty perpetrator embroiled in attempts to undo her "crime" ; simultaneously, through appeasing the patient, the staff member ignores the patient's need for consistent limits and increases the risk of that patient acting on his impulses, rather than learning to contain them. Psychic Assaults poses a fundamental challenge to all mental health workers, not just those involved in forensic work. Why would anyone want to know about, and think about, the type of relationship just described? To realize first that one had become an unwitting actor in a patient's unconscious scenario: humiliating if not totally unprofessional! To feel like killing one's patient, or submitting out of guilt! To think that colleagues on the ward might have seen our reaction and also judged it "unprofessional"! To confront the possibility that the patient had become more dangerous because of one's response! This work is terrifying, and we do not want to think about it. We hate to think about it. Psychic Assaults and Frightened Clinicians: Countertransference in Forensic Settings shows how psychoanalysts, group analysts, psychiatrists, nurses and professional colleagues from all mental health disciplines attempt to come out of the consulting room and onto the ward where the "other 23 hours" must be lived, endured and transformed. If we are all seen to struggle with - and fail to struggle with - the ubiquitous psychic assaults involved in mental health, GP practices, social work, teaching, prisons; when we are all, regardless of professional training and status, witnessing others and being witnessed ourselves engaging in this struggle in ward Community Meetings, reflective practice groups for multidisciplinary teams and management, focussed team formulation of interpersonal dynamics, and other interventions which the contributors to Psychic Assaults discuss, we may earn the opportunity to talk to colleagues about our ideas for a mental seat-belt, based on group and organizational containment of the countertransference, to enable us to proceed with this most arduous work. Psychoanalysis and training organizations influenced by it have been in crisis for some time. Improving Access to Psychological Therapies (a new Government initiative based on expanding cognitive behavioural therapy in the NHS), the registration of psychotherapists, and a demand for Randomized Controlled Trials are central aspects of a very difficult future. Although it is ironic "that psychodynamic approaches are disappearing from the academic and therapeutic landscapes [particularly the National Health Service] just as empirical research [in cognitive neuroscience] has begun to corroborate some of their most important postulates" (Bradley and Westin, 2005), concerted effort will be required to weather the continuing psychic assaults, and their political accompaniments, which buffet the profession. The work reported in Psychic Assaults and Frightened Clinicians is a meaningful, useful and deeply relevant application of psychoanalysis, in a language that everyone can understand, to work in organizations within and beyond the helping professions. As David Armstrong wrote, it is "an unusually bold and uncompromising example of psychodynamically informed action research" (Psychic Assaults, 139-140): a mental seat-belt for staff based on the kind of practice based research which is vital to complement the required evidence based practice.

Bradley, R. & Westin, D. (2005). The psychodynamics of borderline personality disorder: A view from developmental psychopathology. Development and Psychopathology, 17: 927-957.
Hughes, T. (1969) Seneca's Oedipus. London: Faber & Faber.
i [Ted Hughes, Seneca's Oedipus, 1969: 34]

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