Suffering Insanity

Psychoanalytic Essays on Psychosis

R. D. Hinshelwood

• Publisher: Routledge
• Year: 2004
• Print ISBN: 9781583918944
• eBook ISBN: 9781135445492
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

When madness is intolerable for sufferers, how do professional carers remain sane? Psychiatric institutions have always been places of fear and awe. Madness impacts on family, friends and relatives, but also those who provide a caring environment, whether in large institutions of the past, or community care in the present. This book explores the effects of the psychotic patient's suffering on carers and the culture of psychiatric services. Suffering Insanity is arranged as three essays. The first concerns staff stress in psychiatric services, exploring how the impact of madness demands a personal resilience as well as careful professional support, which may not be forthcoming. The second essay attempts a systematic review of the nature of psychosis and the intolerable psychotic experience, which the patient attempts to evade, and which the carer must confront in the course of daily work. The third essay returns to the impact of psychosis on the psychiatric services, which frequently configure in ways which can have serious and harmful effects on the provision of care. In particular, service may succumb to an unfortunate schismatic process resulting in sterile conflict, and to an assertively scientific culture, which leads to an unwitting depersonalisation of patients.

Suffering Insanity makes a powerful argument for considering care in the psychiatric services as a whole system that includes staff as well as patients; all need attention and understanding in order to deliver care in as humane a way as possible. All those working in the psychiatric services, both in large and small agencies and institutions, will appreciate that closer examination of the actual psychology and interrelations of staff, as well as patients, is essential and urgent.

Essay 1
Helping to help

The impact of madness on those who care

Schizophrenia is an expertise in producing disquiet in others.

(Berke 1979, p. 23)

All work makes us stressed, the simplest because of its tedium, the most difficult because of its responsibility. Some work is both tedious and responsible. The most stress comes when the work involves caring for other people – i.e. being responsible for others. Responsibility for other people is the greatest responsibility felt by humans.

Perhaps responsibility is a biological inheritance, due to becoming a social species. It has a central significance in human psychology. Responsibility for others is our foundation as ethical animals. Generally speaking, care work is that of the professions: pastoral, medical, nursing, educational. The professions entail work that is carried out on and for others, as persons. They contrast with the work of those who make cars, or who look at stars through a telescope, or whose main concern is the bottom-line of profit or loss on a sheet of accounts.¹

Schizophrenia has the effect of corrupting that responsibility. Our identity as professional carers becomes disquietingly merged with that of our patients, and, in another direction, our identity becomes unrealistically separate. I shall explore this problem of responsibility and the identity of carers in psychiatry in this first essay.

There are two major features to the experience of schizophrenia. One is responsibility and identity; the other is meaninglessness and understanding. In schizophrenia, the world loses meaning, and in place of that loss a patient reconstructs a new meaning. However, the new meaning comes out of his imagination to form convincing delusions and hallucinations, which populate his world in place of a true interest in the world we all live in. This means that the capacity to understand things in real ways and with reflective thought is hampered in the condition, and that spreads to those who care for schizophrenics. Understanding is the second core feature in the experience of psychosis and in the experience of caring for it.

These two areas - (a) responsibility and identity, and (b) meaninglessness and understanding - are not just key to the psychotic condition, but key areas in a psychology of care as well. That is to say, certain things specifically about schizophrenia have an impact on specific issues in the psychology of those who care for schizophrenics. In particular, the corruption of responsibility affects the identity of carers; and the meaninglessness of the schizophrenic’s world gives a priority to finding meaning and ‘understanding’: an understanding either of the condition or of the experience.

The psychology of care

The work of care is most arduous because of the psychological dimension, and that dimension results in the most stress (some 13.5 million hours per year are lost due to stress in the NHS, out of a workforce of around one million). The raw material of the work is other human beings. Therefore we have a human relationship with the work itself, so it is not ordinary work. It is emotional, and it involves us in personal ways as people. That sets caring apart. Also for that reason, it can acquire an elite status. Perhaps the most responsible work of all is caring for those with severe psychological difficulties. Because we are human beings, we must supplement the ordinary psychology of work, job satisfaction, morale, financial motivation, and so forth, with the psychology of human relations. Added to that, in psychiatry the human relations side of the work is a lot more difficult since the work is with particularly difficult people. We may frequently have to accept non-compliance with treatment and the misinterpretation of our good intentions. Because patients may be delusional and frightened, our role of carer may not be confirmed by those we care for.

We may not in the past have paid as much attention to the psychology of people who care for the mentally ill as they deserve, or need. There are certain reasons why this kind of work study has been neglected. The strongest of those reasons is that we look after not just humans but the irrational human, and irrationality of the most extreme kind.² Attitudes to rationality have been strengthened, and the emotive and irrational side of human beings has been progressively submerged into an unattended nether region. It may therefore be that psychiatric services are increasingly at variance with the encroaching ethos of Western institutions of all kinds. If we want to increase the scope of the psychology of work, then in psychiatry particularly we should turn to a psychology of the irrational. There are various kinds of psychology, and they do not all address the irrational. In this book, I use psychoanalysis because it does not place rationality at a higher level than irrationality. It does not simply say that the irrational is abnormal. To regard it as abnormal is irrational. Psychoanalysis can sometimes explain our irrationality about things, and can explain how we can react irrationally to irrationality.

Moreover, where attention has been paid to the psychology of mental health work, the most useful interventions may not have been adequately thought through. So, supporting the teams of staff may not have been effective. Supportive interventions need to take account of both the rationality and the irrationality in the working system.

The impact of psychosis

Psychiatric services are now more or less psychosis services. The concentration of psychotic people all together creates a rather specific kind of institution, one that is emotionally frightening. In such an institution, two ‘kinds’ of people, patients and staff, identify themselves as strictly one or the other. Often it is a negative identity -staff are not patients, for example. Group identity is then very strong, and staff and patients influence each other on this stereotyped basis (these phenomena will be discussed further in Essay 3). Staff aim to exert a beneficial influence: to aid patients to recover, and resume whatever level of life they can manage. But it does not work out so simply. We know the influence may not be beneficial. Unhealthy dependency and institutionalisation can afflict the patients, but there is also a reverse direction to the influence: patients affect staff. Sometimes they affect staff beneficially when patients recover and express gratitude, thus giving the staff an implicit emotional support. However, that kind of beneficial influence is often in short supply in psychiatry. Frequently, recovery is only partial, and gratitude is often numbed by the patients’ maladaptive relationships. So patients’ influence on staff can be detrimental.

The psychological states of staff and patients interact. This is called ‘parallel process’, a term introduced by Stanton and Schwartz (1954). They meant that something happening on the staff side of the institution would be reflected in the patient community. They were concerned particularly with emotional states that spread from one side of the institution to affect the emotional states on the other side. They observed that at a time of high levels of staff anxiety about financial survival, a larger number of patients were transferred to the secure ward. This kind of transport of anxiety occurred without intention and probably unconsciously. The opposite also happens, from patients to staff. That transmission is largely what we will discuss. The following, from when I was a young psychiatrist, was an individual interview:

A young woman came to the outpatient clinic. She had previously been in hospital for a number of months and, typical of a chronic schizophrenic person, she had little affect or initiative. Each time I saw her I found myself trying to instil some hope and enthusiasm into her - to think of a job, to make friends, to attend a psychiatric social club. Each time she agreed with me… and I felt better. Each time she came back to the next appointment, she had done nothing. I would feel despondent and set about renewing my efforts to enthuse her.

She came with her overwhelming despairing, and in the course of the contact I too became despairing. This could be repeated endlessly. In this case, a non-cognitive communication was exchanged between us. The upshot was my need to relieve my despair. She allowed that to happen, rather than making any real effort to improve her own life.

The process was that despair was transported from one person to another. We normally expect others to communicate with us through words, but in this case the primary communication was not exactly in words. She did not say ‘I am despairing’. Of course, ordinary relationships, too, are based on much more than words. In fact a certain kind of direct effect on another person’s emotions is especially effective in supplementing words. We might think of the cries of a baby, which affect mother very deeply without any clear semantic meaning or symbolic content to the noise. This is common in psychiatry, too. Hidden and often unwitting (unconscious) communications occur with great impact. In my example, the communication first of all was that the patient’s despair became my despair. In turn, the patient received from me a communication that I was despairing and needed her acquiescence to relieve me - which she loyally did. This was a completely different set of communications from the ones I thought we were making. Consciously, I thought I was giving her good ideas that met her need. I thought I enthused her with hope. Unconsciously, though, I clearly indicated my despair, and what I needed from her; and she picked up that unwitting communication.

A similarly complex transaction is the giving and taking of drugs. It involves a set of conscious communications. However, running beside them are other, and unconscious, communications frequently transacting something quite different. Sometimes we give drugs because we don’t know what to do, and it averts a feeling of impotence; or they help us avoid talking to patients and thereby keep us emotionally distant from psychotic people. Even psychotic patients can be attuned to such implicit messages.

We need to emphasise to ourselves, and to each other, these important conclusions when we work with psychotic people:

• they do affect their helpers;
• those effects are emotionally unpleasant;
• the effects may be communicated unconsciously;
• our actions may be unwittingly motivated to ease these communications for ourselves.

Whether we accept or are aware of it, an interactive psychological process is almost certainly taking place between us and even the most psychotic patient. This must be a beginning to a psychology of care.

Responsibility and professional identity

If we peer through a magnifying glass at the emotional currents during the admission of a patient to a psychiatric ward, we will see a complex turbulence. The following is a description of a psychotic patient who caused worry about herself with her outrageous behaviour, as effective as if she had removed her clothes and walked along Piccadilly in the middle of the road against the flow of traffic (Conran 1985, p. 40).

The feelings induced in the doctor and nurses were of the woman’s wildness and unpredictability and that they were called upon to manage her, to control her and, above all, to stop the incessant flow of unintelligible chatter. In common parlance, they felt called upon to ‘shut her up’… We may note that whatever the anxieties and opinions of those outside the hospital, these had now to find resolution within the hospital… the patient does not suffer her pain, rather as intolerable anxiety, of being bereft of self-control, it is projected into the hospital staff who are engaged to suffer it for her. The staff then deal with it… as best they are able, generally altogether ignorant as to the sources of the patient’s anxiety – indeed, they scarcely even recognise it as anxiety. (Conran 1985, p. 37)

The staff and the hospital had come to have charge of a patient who was no longer able to control or care for herself. So, having charge of her meant a fairly extensive burden of care. That care was literally to make up for the patient’s lack of self-control, and self-care.

This transmission, effected without words, is a radical communication. The patient lost her self-care function and it was transported, to all intents and purposes, to the caring staff. Moreover, this is not the care of a patient as in a general hospital, where there may be a need to care for the patient’s helpless body, even an unconscious patient’s body. In this instance it is the patient’s personality. It is the capacity to be a person that she has lost and the staff somehow have to find for themselves. A heavy onus falls on the staff in admissions of this kind. They must accept the government of the whole person.

This is often a thankless task. When a patient has dismantled the capacity to be responsible for himself, he has lost the capacity to know that staff are doing a good job for him. Staff must cope with little or no appreciation from the patient. We need appreciation from clients like all other professionals, but psychiatric staff are denied reliable support of that kind. Problems of job satisfaction crop up for professionals who work with clients who cannot properly express the value of the worker. Like everyone, we need the work to reflect back our skills and our achievements, but psychiatric staff have to face uncertain outcomes and successes with patients who may never feel grateful. Carers have to suffer the consequences of the responsibility they have and also that which is unnaturally placed upon them.

Institutionalisation

Staff who are responsible for patients’ decisions, for self-care and for the very meaning of their lives, can come to institutionalise this state of affairs. That is to say, they institutionalise a psychological state of affairs. In that state they are solely the responsible ones, and their patients are not responsible for their own decisions: only roles of health or illness are on offer; staff to be only healthy, knowledgeable, kind, powerful and active, and patients to be only ill, suffering, ignorant, passive, obedient and grateful. (Main 1975, p. 61)

A division comes down between patients and staff, in which patients become stereotyped; and of course staff become stereotypes of a complementary kind. Patients end up suffering more from the institution than from the illness. As David Clark commented about the old psychiatric institutions, the chronic schizophrenic ‘was the result, not of his schizophrenia, but of the way he had been “looked after” for several decades’ (Clark 1964, p. 14). This pernicious process is particularly connected with a specific disorder of schizophrenia. The patient has off-loaded his responsibility, in the most drastic but typical way. And the staff are obliged, and willing, to accept the divergent roles of patient and staff. By creating the stereotype of a patient, he becomes a different species of human. Staff treat such people accordingly, more as children, or as difficult children. One Flew over the Cuckoo’s Nest (Kesey 1962) was a painful likeness of that numbing obliteration of respectful human relations.

The separation between the perception of healthy staff and unhealthy patients has been well attested. It is interpreted in various ways: as power relations (Goffman 1961; Foucault 1967), as political relations (Laing 1967, Scull 1977), as a treatment relation (Main 1975, Rosenberg 1970), or as real and rational as in scientific, diagnostic psychiatry (e.g. the DSM; American Psychiatric Association 1994), and so on. Whatever the explanation, the stereotype is a cumbersome piece of baggage. And it is self-contradictory in that if staff really were so healthy and wise, they would not feel, and be, so endlessly in difficulties; in addition, the need for patients to be helplessly ill must militate against allowing them to grow and heal. Tom Main, writing primarily of doctors, says that:

the medical man, educated to play a grandiose role among the sick, finds it difficult to renounce his power and shoulder social responsibilities in a hospital and to grant sincerely to his patients independence and adulthood. But it is no easier for the rest of the staff. (Main 1946, p. 10)

The reality that the staff are themselves vulnerable, too, and they can feel disturbed, needs to be grasped, though we must balance that recognition with the reality that staff are not highly vulnerable, and are not as vulnerable as psychotic patients.

There is a motivated ‘stuckness’ about this institutionalised set of roles and professional identities. This is in part to do with the particular kind of care the psychotic patient requires, and with the vulnerability of the staff. The quality of concern and care that a schizophrenic patient asks is quite out of the ordinary. It goes beyond normal professional care, and has implications for the outcome of the care. In the instance of a physical illness, such as an appendicitis, the patient once physically recovering can psychologically recover too, and he ‘resumes the governance of himself’ (see Conran’s (1985) comparison of a psychotic woman with a surgical case of appendicitis, and also the epilogue). However, the resumption of self-governance and self-determination can be hindered, and that can occur in mental hospitals and with psychotic patients. In that situation, patients may not properly resume responsibility for themselves and we as staff go on ‘being’ their responsibility. Especially in the mental health sphere, staff may frequently have to know best, even though in contemporary medicine we are moving away from this paternalistic position to one where the patient is expected to know what is wrong and to choose her own treatment in an act of consent. It is not of course certain how much patients want to make, or psychologically can make, decisions when in severe pain, stressed or frightened. So informed consent is an ideal, officially required, but with human frailty it is not always attainable. When it comes to psychiatry there is a very pressured situation for staff to take on an extreme responsibility - responsibility for the actual person, not just his body. Very often psychotic patients are hardly recognisable as people. After a visit to a mental hospital, Samuel Beckett described a particular schizophrenic patient as a ‘hunk of meat’ (quoted in Knowlson 1996, p. 209).

Meaninglessness and understanding

This lump-of-meat quality arises largely because of the different worlds that patients live in, worlds that barely overlap with the world of the staff or ordinary people. It arises from the lack of shared meaning between patients and staff; indeed, it may even be the loss of meaning altogether in the schizophrenic’s world.

It is important for staff to have a meaning to their job, and what they do for their patients. Barrett (1996) approached this problem as an anthropologist. He showed how the ‘meaningless’ state of a schizophrenic on admission is processed in different ways at different stages, to bring the patient back towards an ordinary human condition. This ‘anthropology of psychiatry’ was elucidated as follows.

Anthropologists visit other cultures to record their myths and social systems. They try to understand how other people make sense of their own worlds, and what principles they use for giving meaning to the world and to their experiences. What does it mean that the sun rises each day, in a certain place on the horizon, and so on? What does it mean to feel bereaved, to lose someone, who no longer exists? There is an infinite variety of ways of making sense of these life experiences. To a degree the philosophy of life depends on what sort of place the people live in - if it is by the sea then their myths and meanings have to do with the sea and its fruits and dangers. In a crowded metropolitan environment, myths have to do with the busy bustle, cramped space and ambitions that mark out such places. Barrett observed a psychiatric ward in this way, anthropologically. What meaning did the staff give the patients’ behaviour, utterances, hallucinations and delusions, and so on? He recorded the characteristic ‘rituals’ ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Suffering Insanity
• Foreword
• Acknowledgements
• Introduction
• Essay 1: Helping to help
• Essay 2: What’s it like?
• Essay 3: Suffer the mad
• Epilogue
• References