RCPsych Psychotherapy Faculty Newsletter, Autumn/Winter 2014
While it is debatable whether emotional containment is sufficient for an effective psychotherapy, it is widely admitted that it is an essential and even necessary component of therapy. Without emotional containment, the patient, feeling threatened, is likely to develop defences that interfere with the therapeutic process, with the exploratory task and with the therapeutic alliance. Even more, among the disruptive reactions to intense anxiety that a patient may undergo we can find clinical deterioration and disorganization.
It is not only patients who need emotional containment but every person who faces anxiety provoking situations, namely mental health professionals. The amount of anxiety that this kind of professional faces can be massive, to the point that up to very recently mental health workers in the NHS could retire at age 50 in the understanding that a professional life in their environment could be harmful. Even if the emotional pressure has been reduced with the use of medication, the strain of working with mental illness is quite a significant one and can lead to defensive processes such as the fatigue of compassion, behaviours with higher or lower psychopathic degrees, alcoholism and disturbance in their family relations. Disorganization and mental illness are also a possibility when the stress is too high.
Beyond the individuals, groups are also affected by uncontained anxiety. What Bion called basic assumption ways of functioning or antigroup phenomena can be triggered by distress. Groups can disorganize, split, scapegoat or otherwise fail to perform their function of linking individuals into a whole greater than its parts to work on a common task while protecting its members.
Mental health professional teams are groups that can succumb to the pressures of their task. Facing, containing and treating the distress of mentally ill patients and their families, dealing with limited resources and ever newer «cunning plans» from the management chain, enduring the challenges of a legal system increasingly encroaching on the clinical work and progressively losing worker rights and social respect are just a few of the circumstances of the job that test both the cohesion and the capacity to think and care of professional teams, often leading to a breaking point.
Most therapeutic communities develop a culture that is aware of the emotional pressure on the team and implement structures and activities in order to deal with it. Among these, there are assemblies where the team hears its members and internal splitting phenomena can be addressed, supervision groups where a fresher perspective is brought in by an external supervisor and can re-centre a team that is going astray, Balint groups that can help to understand unconscious communications and their bearing on both professionals and patients, individual therapy for professionals, away days, etc. All of these contribute to the well being of the team and therefore, of the patients they treat.
However, outside therapeutic communities most mental health teams focus just on treating the patients but not on their own emotional well being. While it can be argued that the stress in therapeutic communities is potentially higher than in other mental health teams, I don’t think they are the only ones facing distressing feelings. Actually, CMHTs, inpatient wards, forensic settings, etc, face enormous difficulties, but often without well developed structures to provide emotional support to its professionals.
Medical psychotherapists are in a unique position to lead the process of implementing structures and activities that protect professional teams outside therapeutic communities. They have the capacity to understand the emotional world of professionals and teams and their need of support, can look into the human mind beyond a model of putative biology, have leadership experience to plan and implement some of the necessary changes and possess the professional prestige that doctors still keep in order to being listened by other professionals.
This initiative can be applied widely throughout different mental health settings, but also in Medical wards, GP surgeries and many other professional environments where teams need to face strong emotional pressures.
It is the responsibility of Medical psychotherapists to lead in a reorganization of services to make them mindful and protective for all parties involved, rather than just carrying out a linear approach to care for patients while the rest of the system crumbles (and takes the patients with it). In a situation where most reforms are led by the economy and commercial ideologies, we are at risk of seeing the collapse of the NHS structure as we know it. Should the emotional well-being of patients and professionals be neglected, Medical psychotherapists would become obsolete and redundant, and rightly so, for having failed to perform their basic duty: to look, understand and to find ways to make people emotionally healthier.
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