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Psychiatric Nursing and the Myth of Altruism

by Joy Bray (.....?).

Abstract

Psychiatric nursing is moving, in theory at least, closer to a position where a central aspect of the nurse's role is to offer the sort of healing relationship outlined. Offering help, that is, so that people can experience their distress and then see it both as the reasonable upshot of their life history and an opportunity for growth. Perhaps, as argued, within the psyche-industry nurses occupy the ideal position to adopt this role. In chapter eight Joy Bray discusses the theoretical background to this move. She examines whether it is in fact taking place and then suggests another way in which self-interest operates within psychiatric nursing to interrupt progress. Drawing on themes developed in previous chapters in relation to pathologising the other, Joy holds up a mirror to explore the 'illness' of being a mental health professional. She insists that proper attention be given to our own mental health needs if we are to work effectively. In particular Joy addresses the need for therapeutic supervision and staff support groups. She acknowledges how unlikely it is that these needs will be adequately met in the current social and economic climate.

INTRODUCTION

There is a cherished idea within nursing, infrequently challenged, that the nurse and the patient have a close, collaborative relationship within which the person in need finds solace and relief from an overwhelming experience of psychic pain. The question that is seldom addressed is whether it is the nurse or the patient seeking the solace and relief, or both.

In the following chapter I address this question by exploring a number of related issues: Firstly I examine the ideology relating to nurse-patient relationships. Then I ask what patients want out of their relationships with nurses and whether they get it. Thirdly I pose similar questions of nurses in their relationships with patients: What might they hope to get and what do they get from the experience? And then, crucially, given the apparent frustration of both patients and nurses in their aims, I offer fourthly an analysis of the problems we face, and lastly a view of the potential for improvement.

The central ethical dilemma with which I am concerned relates to our status as mental health carers. We are viewed, and we may see ourselves, as in less need, as mentally healthier, as saner than those we enter into relationships with to offer them care. Is this right?

Setting the Scene: The 'Collaborative' Relationship

The close relationship between nurse and patient is usually considered the essential component of psychiatric nursing. Peplau (1994) acknowledges the significance and expected therapeutic benefit of the nurse's interactions with patients, stating:

'It is the responses of nurses to patients within nurse patient relationships, which provide the stimuli for constructive changes that psychiatric patients need to make in their thinking and in their behaviour'.

(p.5)

This emphasis on the centrality of the relationship within good nursing practice as a method of helping the patient is characteristic of Peplau's writings. Many other leading nurse theorists agree with her views, presuming almost without question that this sort of close relationship is firmly entrenched within nursing practice.

Even if this presumption is questionable (Dartington, 1993; Smith, 1992; Wright, 1991) there are structures within psychiatric nursing practice that underpin the close nurse-patient relationship, notably 'nursing process' and 'primary nursing'. Nursing process, the fourfold schema of assessment, planning, implementation and evaluation, was first presented in the U.K. in 1975, following work in the U.S.A. (De la Cuesta, 1983; ). Ideas within nursing process have become subsumed into primary nursing (Pearson, 1988) with its emphasis on accountability, and these two theories together are now being developed as the organisational structure for delivering care, underpinned by the statutory concept of the 'named nurse'. These structures all emphasise the need for nurse and patient to spend time together writing care plans, carrying out structured pieces of work, partaking in counselling sessions, evaluating outcome and so on. The emphasis throughout is on closeness, on time together.

Cementing these theoretical and structural trends towards nurse-patient collaboration, the Government's long anticipated report on mental health nursing recommends that care plans be developed with individuals based on their wishes and needs, not the convenience of the service (Department of Health, 1994). The report also emphasises that mental health services should be arranged so as to ensure that nurses spend the majority of the time responding to the needs of service users (Butterworth et al, 1994). The implication is clear: Nurses will need to spend time with patients to discover their wishes and needs, and in order to respond.

If we accept that the essence of psychiatric nursing is indeed a close, collaborative relationship between nurse and patient, two points need to be addressed. Firstly, do patients want or get a close involvement with their nurse? If so what do they value within it? Secondly, what type of closeness might nurses either want or get from their involvement with patients? And why?

2/ WHAT DO USERS OF THE SERVICE WANT AND GET?

Rogers et al (1993) in their survey of users' views of psychiatric services found that a preferred model of practice involved personal contact and understanding, being listened and responded to empathically. Users viewed the appropriate response to their distress as working, or talking through their problems with someone ready to listen, within a supportive and caring environment. In a similar vein McIntyre et al (1989) asked 'What do psychiatric inpatients really want'. The patients rated most highly getting out of the hospital environment! They also rated as helpful talking to a nurse. The findings of Carson et al (1994) concurred with this, finding also that nurses, when considering what was therapeutic for patients, rated most highly 'talking to nurses'. And again, looking into the value ascribed by patients to different forms of treatment, Pollock (1989) found that having already achieved their main objective, leaving hospital, community based patients continued to value very highly nurse involvement. Such patients identified 'the interest and concern' shown by their community psychiatric nurses as 'very considerably' helpful. These studies all thus reflected the felt importance of nurses' talking to patients, both for nurses and for their patients, both in hospital and in the community.

It may be worthwhile at this stage to examine the characteristics of the nurse-patient relationship historically. The research findings reproduced here will shed some light on whether in the past service users have in fact got what all seem to agree they want and need.

Two studies observing what happened between nurse and patient were completed at the same time as nursing process was introduced in the UK. Cormack (1976) observed psychiatric nurses working on an in-patient unit and found, as he had predicted, a discrepancy between what recent literature had suggested the nurse ought to be doing and what was actually happening. Cormack found that the nurses' interactions were on average of very short duration, typically thirty seconds to four minutes. Three quarters of such interactions were terminated by the nurse. This suggests very poor conditions for close, empathetic work. And it was not just staff nurses whose contact with patients was limited. Cormack's observations of charge nurses suggested that their managerial role precluded them from:

'... indulging in the prolonged patient contact which would be necessary for the performance of the prescribed role'.

(p. 87)

One suggestion was that the charge nurses were using their role as a way of avoiding patient contact.

Coincidentally, Towell (1975) was studying similar phenomena in England from a sociological perspective. His findings closely replicated Cormack's: An avoidance of prolonged patient contact by all grades of nurses. There was some evidence, however, that uninitiated (most frequently student) nurses did become 'involved' with patients. Ironically, this involvement was felt as a threat to staff norms. The involved member of staff was considered deviant and a variety of strategies were put into operation to reduce what would characteristically be termed over-involvement. An example of such a strategy was open discussion of the relationship in a staff meeting where strong group pressure could be applied. If such control processes were unsuccessful, a breach was likely in the staff group and the involved nurse was herself perceived as 'having a problem'. Naturally enough, having had this difficult experience, the 'deviant' nurse was likely to enter into subsequent relationships with patients at a more superficial level, seeking to avoid a repeat experience of being labelled deviant, then ostracised.

If we accept that these findings were true of psychiatric institutions generally, then, evidently, two decades ago nurses were being discouraged from spending time with their patients. More recent studies suggest there has been little improvement. Haugen Bunch (1985) studied aspects of nurses' communication with schizophrenic patients in a psychiatric ward in the USA. The findings have a familiar feel. The nurses engaged in passive nursing strategies when the ward was quiet, such as short episodes of social talking with patients. When the ward was busy the nurses engaged in strategies such as 'business talking', medicating and 'scheduling' patients. There was virtually no evidence of meaningful, therapeutic relationships. Similar findings have very recently been described by Gijbels (1995) in the U.K.

Handy (in Carson et al, 1995) too, has noted the lack of time spent with their patients by all but the most junior of nurses. She describes one of the methods used to deal with nurses deviating from the professionally accepted norm: Senior staff suggest that the involved nurse is herself mentally ill.

Over the past few years there has been a series of observational studies carried out by either non-nurses or nurses now practising as psychoanalysts (Sinanoglou, 1987; Donati, 1989; McKenzie Smith, 1992; Chiesa, 1993). Their method (psychodynamic observation) represents an attempt to gain access to the unconscious life and functioning of the institution and its participants (mostly patients and nurses). Sinanoglou's account is poignant:

'My initial impression of the atmosphere was one of intense anxiety, unknown fear, despair and chaos. The staff seemed harassed, overworked and with no time to breathe, let alone waste ... The faces of the patients were ghostlike, with an empty dead expression desperately looking towards the door which symbolised life.'

(p.28)

All four authors' presentations of their perceptions reflect the lifelessness felt, the predominance of apathy over enthusiasm and the defeat of any attempt to create a positive culture. Chiesa (op cit) suggests that even the sense of business observed on the ward represented a manic reaction which served to bypass anxieties about being fragmented, worthless and hopeless.

Why might it be that the goal of collaboration between nurses and their patients seems so rarely, if ever, attained? It is surely shortsighted to suggest that nurses be held individually to blame for this situation. However, it might be instructive to explore what nurses want and get from their involvement with patients.

3/ WHAT DO NURSES WANT AND GET?

The Myth of Altruism

Josie

Josie was a 28 year old nurse, the only child of professional parents who were absorbed in their careers and had left her between the ages of one and eleven with a succession of nannies, none of whom stayed for longer than two years. At age eleven she was sent to boarding school. After qualifying as an R.M.N. she joined a rehabilitation unit for patients with enduring mental health problems. She developed very rewarding relationships with the patients to whom she was primary nurse, most of whom had histories either of childhood neglect or abuse. Josie had difficulty in establishing close peer relationships and frequently felt that her most worthwhile relationships were the ones she had developed with her patients. Other staff were impressed with her work and noted patient improvement. During a session of clinical supervision, Josie was asked to consider whether and how she might be meeting her own needs as well as her patients' in bringing a stable relationship to them. Unfortunately this interpretation was made insensitively, with destructive results. One week later Josie became ill and subsequently left nursing. The patients were all delegated to other care workers.

Helping others is not an altruistic act. Dartington (1993) suggested that people are drawn into the caring professions out of a need to make something right, to heal one's own emotional wounds and the damaged figures of one's imagination. This is not necessarily a bad thing. It makes good psychic and economic sense to heal oneself whilst promoting healing in others. Moreover, as Skynner (1989) emphasised, mental health professionals are the only people willing and able to sustain their very difficult task of caring for others' mental illness perhaps precisely because they are getting something from it psychologically, something which they have been unable to obtain in the normal course of their life. If we did not have such a needy workforce we may have no workforce at all. Skynner suggests that a mutual satisfaction of needs is quite reasonable. Indeed the same needs may be satisfied in both worker and patient, though the worker has a responsibility to ensure that the exchange is not totally symmetrical.

The Need For Support

In order to ensure an asymmetry whereby the patient's needs are looked after by the worker in at least equal measure to her own, it is crucial that the worker's needs are given some space outside of her time with her patient where they can be acknowledged. As a supervisor it becomes clear just how crucial this space is when one considers the ill-advised clinical decisions that can be averted by helping nurses to address their own unresolved turmoil and unmet needs.

Susan

A very competent and caring charge nurse brought to clinical supervision a case that was bothering her: 'This woman is manipulating the team. I want to consider how to set really firm boundaries on her'. When asked to describe the problem behaviours she found it difficult to quantify any. Eventually she said: 'I know she's supposed to be depressed but I hate the way she ignores her children when they visit'. It eventually became obvious to us both that what she was feeling was out of proportion to the situation. Then she spoke about her own childhood where her mother had suffered recurrent bouts of depression, during which she had largely ignored her children. The charge nurse had of course found this extraordinarily painful. She had never spoken about it though, as she knew that 'Mum was ill and couldn't help it'. Instead, her unvoiced feelings about her own experience, her difficulty in this area, had become invested in the patient.

It's all the patient's problem

The transference onto a patient of feelings that one has towards a significant figure in one's own life, as in Susan's case above, is quite natural. It is one aspect of a process known as 'counter-transference'. A mother ignoring her children was, understandably, a sore-spot for Susan. Significantly though, the reason for the decision Susan was inclined to make in relation to this patient could easily have gone unnoticed, had there not been the space to explore what was happening. More worrying still, the angry, possibly punitive aspect of Susan's plan to 'set really firm boundaries' on the patient is very likely to have remained unacknowledged without a safe relationship where such dynamics could be explored. Without a way of acknowledging this aspect of her feelings towards the patient, this anger may in turn have been attributed to the patient herself, in a process known as projection: If the patient 'resisted' being treated in the way Susan planned, she would no doubt have been said to be angrily 'acting out' as a result of her inability to accept and work with the 'appropriate boundaries' Susan had attempted to enforce. Susan's limitations would have become the limitations of the therapy and the resulting impasse may in turn have been characterised as a product of the patient's pathology. This ethically dubious picture (Blackwell 1993) must be familiar to many nurses, if allowed the time to reflect on it.

The individual and institutional reasons why relationships with patients so often take this sort of turn are issues I shall return to. For now, I want to develop the idea that nurses have needs in their relationships with patients, and that this can be both acceptable and constructive. I shall now contrast the potential hazards to a therapeutic relationship if it is given insufficient support, with the potential benefits to both nurse and patient if the relationship is properly tended.

Therapists Can Grow Too

Clearly, a lot can go wrong when there is no space to disentangle one's own emotional experiences from one's patients', and at very least the therapist must be ready to be open about the feelings and experiences she has had in the therapeutic setting if she is to confront the problems that she is struggling with in her work. But when the nurse is willing to acknowledge that she is there for herself, not just the patient, there is immense therapeutic potential in the work situation for both patient and nurse, which has ramifications for the nurse in her life way beyond her work situation. For Susan in the above example, the self exploration she undertook, encouraged and supported by her supervisor, was not just an embarrassing difficulty to face as part of her job; it was a growth experience that affected her whole sense of self and her life. Indeed, Peplau (1988) advocated that the very purpose of therapy is for the patient and therapist to grow together. Certainly there is no clear difference in principle between exploring the blind-spots in our self-awareness and helping our patients to work on theirs. This is perhaps the root of many jokes (and arguments) about how (or whether) we enter the mental health field because of our own madness.

In the light of such arguments, any mental health care would best begin with an exploration by the worker of the self, an appraising of motives and a willingness to face parts of oneself normally kept hidden. Indeed, psychiatric nurse education, in parallel to Peplau's writings, has, since the 1982 Mental Health Nursing Syllabus, consistently endorsed this view, with 'self-awareness' or 'group dynamics' sessions prescribed as an integral part of training. Rioch suggests that quite a powerful and potentially life-changing experience of growth and development should be encouraged:

'If students do not know that they are potentially [or actually!] murderers, crooks and cowards, they cannot deal therapeutically with these potentialities in their clients'.

(in Hawkins et al, 1989, p.5)

However something seems to be failing. The work previously reviewed suggests that psychiatric nurses are not working consistently in close relationships with patients. Perhaps the depth of self-awareness encouraged in training is inadequate and inconsistent? And again, could it be that there simply is not the structure or time in busy clinical settings for staff to continue this work of reflection and individual growth and development, post-training?

4/ AN ANALYSIS OF THE PROBLEM

Why then is it so difficult for nurses to get on with the work of disentangling their emotional baggage from their patients, to their mutual benefit? Why do they find it so hard to express their own vulnerabilities and need for help with emotional healing? Why indeed do nurses view having these needs as failure? And why do the structures and cultures of the organisations in which they work seem invariably to inhibit the sharing of such vulnerabilities?

Psychic Complexity

The Need to Control

Lawton (1982) developed a framework to help understand the processes described (Figure 1).

He demonstrated how there was a need, shared by the social workers who were subjects of his study, to be in control.

footnote

The feelings described by Lawton (1982) as belonging to social workers, could parallel the feelings experienced by others in the helping professions. Although mental health nurses are not social workers, Aldridge (1994) argued that the two professions do now closely reflect each other. She emphasised how in 'new nursing', as she termed it, like social work, the major component is working with the individual in a close, collaborative relationship. With the movement of nurses into the community and the heightening of their accountability for patient care, their job now resembles even more closely that of the social worker.

This need originated from their childhood. Lawton maintained that there is a fairly specific type of 'professional carer' personality, which contributes to the maintenance of a system wherein relationships of control predominate. He described the type of child rearing encountered by children who go on to work in this field as that of psychic control, where the parents communicated a number of very strong expectations about how their children were to conduct themselves, usually in unspoken ways. The idea of deviating from these expectations seldom occurred to these workers when they were children. They were controlled without ever realising it, awareness of this and the resulting features of their character coming only in adolescence or adulthood. (Many had felt close to their parents and were not considered especially rebellious as children.)

Nightingale Ward

The nursing staff of a small, specialised unit have a good reputation for care of acutely distressed patients. They work hard to deliver 'good' nursing care. However, the 'good' nursing care that is planned is seldom delivered. The staff complain that 'they' (by this they mean unspecified management figures) are preventing them from carrying out 'good' nursing care. This perception is never challenged, the nursing staff never confront the management team about the fantasised lack of autonomy. Their self-confidence is limited, compounded by a nagging sense of failure, of never quite reaching the ideal of being a 'good' nurse.

Evidently the issue of control may move from the family to the place of work, where the 'controlling' management blocks both the creativity and fulfilment of staff, or even of a whole staff team. There is hostility felt towards the parent/management who never quite cares enough. This can not be expressed openly, however, because the result may be to lose whatever care there is. So it is absorbed, masochistically. This suffering, and the ability to endure it, may make a nurse feel special, one reason perhaps why we take a perverse but grandiose pleasure in being able to survive the institution. How often do nurses hear 'I couldn't do your job'.

We have experienced psychic control in our childhoods and we may imagine we are still suffering it, as above. We are also likely to exercise similar control in our relationships with patients. Lawton's suggestion is that we are bound to see the patient as childlike and dependent in order to live out our dependence and vulnerability through him. We identify with the patient as 'troubled child', we attempt vicariously to care for ourselves, as child, within the patient and we therefore 'enjoy' our patient's dependency. Instead of setting conditions where the patient (the person ostensibly more in need of help) can achieve independence, it seems that in general we unconsciously foster her dependency (Holden 1991). The patient in our care helps us to feel good about ourselves, for we are repairing something important that has gone wrong; it is as if helping her to work with her problems is helping ourselves. The control we exercise is in the more or less subtle manipulation of the role into which we place and in which we attempt to keep her.

There is a further aspect to the masochism described earler. We may not only enjoy the continuation of our being controlled, we may also enjoy experiencing an almost inevitable frustration of our own attempts to control.

footnote

The frustration is almost inevitable, since we have two mutually exclusive needs in this situation: To experience a vicarious healing through our sense of the patient's improvement, also to experience a continued sense that they remain the patient, the vulnerable one, not us.

The Need to Deny

A patient with a long term psychotic illness was discharged after an admission of six weeks. He was very stable and was returning to a job and a supportive family. In handover the charge nurse said: 'Things look good at the moment but you wait; he'll be back within a couple of months'. The charge nurse was unable to let go control, was unable to allow the patient to be anything but dependent and was unable to feel good about what the patient had achieved. Through presumably either envy, masochism a need to maintain the status quo in their respective roles, or all three, he could only feel good about the patient's prospective failure and the failure of his own attempts to heal.

It was in 1982 that Henry Lawton delivered the paper propounding the need to control, quoted from above. Its main theme was the ambiguous nature of altruism in mental health carers. He hoped that it would be well received:

'But colleagues that I have showed it to have generally been afraid to read it. Fantasies began to come to mind that its publication would bring attack and repartition. I saw myself standing alone in battle against a legion of detraction.'
(Lawton, 1983 p.399)

On studying his group of social workers Lawton had found not the altruistically motivated workforce he expected, but a group of very needy people. The amount of need seemed to mirror, if it did not overtake, that of their clients. This view was intolerable, it seems, to the workforce in question.

Skynner (1989) provided a picture of the health professional's family that explains to some extent this phenomenon. While agreeing with Lawton's basic premise regarding the 'psychic control' described above, he offered a different emphasis. He suggested that in a typical 'deprived' family, which maintains some sort of cycle of deprivation and control in the psyches of its children, the deprivation itself is not the main problem. Rather it is the denial of such. As I shall now describe, such denial functions as a form of protection to avoid the intolerable pain of loss or neglect that would otherwise be felt.

For our social worker or R.M.N., the cycle of control, deprivation and denial originates at some point in their family. Their parents, themselves deprived, would have been unable to face and control the pain of this and so would have split off and repressed the feelings of need within themselves. They would have just had to stay in control and cope. As Lawton depicts, they would then have projected the feeling and perceived the need not as their own but as if it were within their children. Instead of being able to perceive their own deprivation and therefore do something about it, they decide to give their children what they did not have themselves. The motive may have been good but the mechanism is flawed: The parents have not seen their children with their own individual and unique needs, but rather saw themselves and their needs within their children.

On reflection, many parents can identify with this mechanism. When you think about the needs you perceive in your children, they may bear a remarkable resemblance to your own unmet childhood needs. But the result is that children in these circumstances do not have their own needs met. Rather they have their parents' needs met in them. They get emotional warmth, for example, in circumstances where as a child the parent might have needed it, not when they do; or when the parent is currently feeling lonely, not when they are. The parents remain deprived and the children ultimately grow up deprived too. The convolutions of the cycle continue as the children perceive and identify with the role subtly foisted on them. This is known as projective identification. At some level the child will know that their role is to make their parent feel better, and may as a result try to nurture the parent. But the only way the child can nurture the parent without actually confronting the denial and thereby exposing the parent to distress, is by enhancing the parent's self esteem by treating him/her as the 'good' parent s/he pretends to be but is not. In this way they are joining in the collusive denial and perpetuating the cycle. What remains unacknowledged is the rage felt by the child (and the parent) at the deprivation suffered. This may get expressed in devious ways such as by disappointing the parent's expectations. By failing, they make the parent fail too. In turn the parent may undermine successes their children have.

This pattern can be related to nurse-patient relationships:

Steve

Steve was primary nurse to a patient who was well known to the service and had a history of alcohol abuse. He had been admitted following an overdose of tranquillisers and alcohol. Steve worked closely with him, concentrating on working through his feelings about his marriage breakup, considering this the exacerbating factor for the overdose. The patient was readmitted within a week of discharge, having taken another overdose. On readmission the patient told the admitting nurse that he felt confused and desperate as he was beginning to relive the feelings he had as a sexually abused child and was terrified he may in some way abuse his son. This readiness to tackle such painful issues may have been framed as a breakthrough. Instead, Steve refused to become his primary nurse again as he felt bereft of the empathy that he had previously felt. He had given everything and the patient had let him down. It was surely no coincidence that Steve's parents had divorced when he was six years old and he was currently experiencing profound difficulties in his relationship with his partner, which he was not discussing with anyone, feeling that he should just somehow cope. In working closely with this patient, Steve had clearly been seeing his own vulnerabilities in the patient's situation and missed a large area of the patient's own distress. He had not managed to heal the wounds he perceived in his patient, as that patient had bigger problems to tackle first. Neither had he therefore worked through his own deprivation and turmoil, as he saw it in the patient. All he could feel was let down by the patient's remaining ill after his caring input, and depressed, and all he seemed able to do as a result was punish and deprive the patient by rejecting him.

In nursing we feel so much more empathy if we can understand a person's pain as something that we have experienced and can identify with. In these circumstances the mechanism of projection described above is more benign: We perceive a patient's need because it has been our own. Hawkins (et al 1989) gives the example of an unsympathetic GP who was avoided by all patients until his grandson had leukaemia and '... slowly, through his own hurt and anger, he was able to touch his patients again ...' (p 153). By relating our own experience to our patients' we can achieve empathy. However, it may be that we are more likely to be taking care of our own denied distress by projecting it into the patient and looking after it there, as in Steve's case above, whatever the nature of their pain and distress: The patient is a passive figure in this equation, whose needs are not perceived individually, who is rather a recepticle for the professional's denied distress, whether such identification helps them or not.

This denial of need elaborated by Skynner relates to a suggestion made by Carson et al (1995) that staff in the NHS feel guilty when considering their own needs: Nurses view having needs as a failure on their part and suspect that any serious admission of need will mean that they lose credible professional standing in the eyes of their colleagues and superiors. There is an almost exact fit with the picture described by Skynner, a denial of need, ensuring feelings of guilt, inadequacy and despair develop when this need starts to surface at a conscious level, as for example in Steve's situation above. Such feelings were perhaps also behind Josie's compulsion, described above, to exit the situation as soon as aspects of her experience were named.

So far I have considered the question 'why do nurses not get what they want from their involvement with patients, or even manage to collaborate properly with them?' in terms of complexities within the psyche of the individual nurse. I have implied that at some level, the nurse desires to recapitulate former relationship(s) through contact with patients, but is hindered by her emotional baggage. But a question still remains unanswered: Why is any authentic form of such contact so rarely, if ever, attained? After all, the aim of therapy, we should recall, is for patient and therapist to grow together. And we have understood the mechanism of denial and the need to be in control in the context of the family dynamics experienced in childhood by individual nurses, ie as areas where such nurses may be ripe for growth. There is no obvious reason, therefore, why nurses should not be ready to leave behind the emotional conditioning they have received, and learn, along with their patients, new ways of being.

Perhaps it is now time to consider the nature of the organisation in which the individual works. How does it happen that mental health workers frequently find themselves working in institutions which are as depriving and unrecognising of their own needs as their parents were, equally controlling and apparently dedicated to maintaining such cycles of control, deprivation and denial in their staff?

Organisational Complexity

Hiller (in Carson et al, 1995) suggested that the culture in which nursing takes place is one that seeks to inhibit the development of close professional and supportive ties among nurses, leaving a residue of mistrust, hopelessness and alienation, such that vulnerabilities of any kind are unlikely to be shared, nurses'

'propensity for martyrdom ... thus exacerbated by their institutional setting and their colleagues, all of whom insist on the priority of clients' needs and the denial of their own. ... the culture of the "have nots"'

Blackwell (1993), p.303

Sines (1994) presented a very clear picture of the myriad of political and institutional issues affecting any nurse trying to work in the current climate of a repressive, established social order. Wright (1991) summarised the present situation:

'One hears the same story from throughout the country. The same issues of poor communication, splitting, lack of support, poor perception of the primary task, lack of resources and inadequate or inappropriate delegation of authority, surface time after time'.

(p.146)

Lawton (1983) described the public service agencies that he worked in and observed, as sharing certain characteristics (Figure 2):

He observed that these organisations demanded loyalty without encouraging adequate training. They generated rage in the workforce but also forced them to suppress it. Lawton summarised the position as follows:

'The agency is like a paradoxical bad/good mother, implacable in her power and appearing indicatively dedicated to hampering the effectiveness of her workers/children at every turn'.

(p.289)

The parents want to be seen as excellent but are actually making rather a mess of bringing up the children. Although Lawton suggested that workers who remain longer than a year or two might be able to relive important aspects of their childhood, he became increasingly uncertain that his agancy was actually helping people. He began to realise that the agency, comprising both those working in it and those served by it, was an inter-related system, neither good nor bad, but human, functioning on a social level in a way that replicated the primitive intra-psychic mechanisms of defence such as control, denial and projection described above. Menzies-Lyth's (1959) work, reviewed in chapter one, came to similar conclusions in relation to the institutional mechanisms employed within hospital-based general nursing to suppress and deny. Skynner (1989) too concurred that agencies working with clients trapped in a cycle of deprivation, often manifested a parallel cycle in their staff and organisational culture.

Both Lawton and Skynner suggested that within the arena of mental health care as a whole a division exists where public (that is state funded) agencies are worse in this respect. Lawton (1982) distinguished two types of worker. Firstly there are those that cling to the institution because they fear change and loss of support, they repeat patterns and use energy in maintaining the status quo. Secondly, there are more confident workers who become dissatisfied at the lack of change and move elsewhere. This mirrors the findings of Menzies Lyth (1959) with student general nurses, the more mature and confident of whom were more likely to become dissatisfied and terminate their training early. This is a bleak picture indeed, where our most deprived institutions are thus left with the most deprived and unconfident residual workforce.

Private institutions are apparently different, workers there having higher self esteem. Exceptions to this rule can be found in the UK, where institutions may be state funded but have access, for various reasons, to more of a lion's share of resources, e.g. the Cassel Hospital and the Maudsley Hospital, both of them clinical and teaching areas with excellent reputations. However in all areas there are institutional as well as individual difficulties in removing the mechanism of denial described above, as its removal allows the experience of pain. Indeed, Wright (1991) argues powerfully against it's removal until supportive mechanisms are in place. Aldridge, (1994) and Franks et al (1994) support this.

The complex economic and political frameworks supporting the maintenance of the sort of patterns of relationship described within an institution are vital to understand this situation. Such issues are detailed elsewhere in this text, particularly in the earlier chapters of this section of the book which deal with some of the murkier aspects of psychiatric power, society's demands on us based on commonly held views of dangerousness, and the professionalisation of care as a whole. The question to be asked now, though, is what to do about the situation within the context of the health service and social services in the 1990s.

Even if individual nurses are ready to understand their motivation in becoming R.M.N.'s, give up their need for control of their patients and cease operating mechanisms of denial, are there structures in place, at an institutional and wider level, to support them and enable truely collaborative relationships with their clients to develop?

5/ THE POSSIBILITY OF CHANGE

Wright (1991), Holden (1991), Aldridge (1994) and Skynner (1989) have prescribed the implementation of supervisory structures offering education, insight and support within a framework of psychoanalytical thinking. Zagier Roberts (in Obholzer et al, 1994) recognised the importance of interventions focused in this way:

'It is therefore of the greatest importance for helping professionals to have some insight into their reasons for choosing the particular kind of work or setting in which they find themselves and awareness of their specific blind spots, their valency for certain kinds of defences and their vulnerability to particular kinds of projective identification'.

(p.116)

Skynner (1989) suggests an actual structure which can be implemented, the result of which would be a sympathetic awareness in the professional of his deprivation and its denial, of his needs and his defences, and of his inability always to be the generous parent in relation to patients or the grateful child in relation to management. If the very real pain of this realisation can be accepted, then the professional carer will be able to experience his own need and want to satisfy it. This change will in turn evoke appropriate responses in others and the carer will be able to take the emotional food offered, integrate it and begin a maturing process whereby he will in turn also be able to give more authentically to others.

'The vicious cycle of deprivation becomes a virtuous cycle of mutual nurture'.

(Skynner, 1989 p.167)

When working with the deprived health worker, Skynner suggested that the worker's self esteem be carefully protected with a period of supportive teaching, highlighting skills and strengths, before any insight into dynamics can be considered. He suggested three types of groupwork, each related to a certain level of deprivation and denial. Peplau (1989) has made similar proposals, as depicted below in figure 3 where I have integrated her ideas into Skynner's suggested levels:

The suggestion is to give staff the time and support to think, reflect and learn about themselves, where they can be given permission and encouraged to acknowledge and express their own needs and conflict within a supportive environment in order to try and achieve greater self-awareness (Blackwell 1993).

The above might seem a hopeful prospect. However, two issues need addressing. Firstly, how will nurses feel about acknowledging their needs openly, needs which may well be severe enough to need help from the mental health services within which they are currently working. Secondly, the three suggested levels of intervention are not new in nursing. Other writers, notably Wright (1991), Dartington (1994) and Franks et al (1994) all suggest that work be carried out based on an awareness and acknowledgement of psychodynamic thinking and defensive structures. Lawton (1983) agreed that the types of system suggested by Skynner can be implemented but asks the vital question 'But will they?' (p.400).

How Will Nurses Feel About Acknowledging Their Needs?

Perhaps a good indicator of how we are prepared to accept need in the profession would be to look at the way nurses who have expressed mental health needs are treated. The answer is with great fear and ostracism. The need to keep the evidence of mental breakdown 'in the family' is so strong that a special psychiatric unit is created to deal with health service staff (Day, 1995), preventing patients from seeing evidence of nurses, social workers and other mental health professionals having the full extent of problems that they themselves suffer. There may of course be good reasons for the unit's development. Perhaps only away from other patients can health service staff be allowed the full exhibition of their 'madness'. But it seems, nevertheless, an example of our collusion in the idealisation of ourselves, whereby our mystique and alleged mental health remain unchallenged. It seems that we have to turn our backs on the possibility of patients being able to perceive us (and by implication themselves) as whole people and possibly learning to relate to such. Even when our mental health is such that we can no longer cope without support, it seems we remain locked within our family of origin and our defensive structures, terrified of any authentic, close relationship, acknowledging mutual need. The reality, as Wright (1991) suggests, is that nurses are drained, used up and discarded, perhaps so much so that the thought of taking away our defences is intolerable.

As already stated, nursing staff feel guilty about acknowledging need and fear a loss of credibility (Carson et al 1995). Radsma (1994) concurs with this in a literature review that strongly suggests caring behaviours between nurses are lacking: There is fragmentation, abuse and divisiveness amongst nurses, which she suggests is indicative of a lack of professional self esteem. The underlying theme of this review seems to be that nurses work from a position where the idealisation of our own group ha become a way of lifes and inevitably results in the denigration of another (eg patients, other nurses). This is borne out in nursing theory:

'... if caring is to be sustained, those who care must be strong, courageous and capable of inner love, peace, joy - both in relation to themselves and others'.

(Watson, 1990; quoted in Radsma, 1994, p.448)

In circumstances where respected nursing theorists are making such statements, one begins to lose any hope at all, as the nurse is subjected to an almost painful idealisation. The myth of the strong, loving nurse compounds the myth of altruism. We are not loving and caring at all times. If we pretend to this image it is likely that we will exhaust ourselves and be left unable to carry out any caring task, even care for ourselves.

At the moment the only credible way to explore needs and defences is to become a specialist, preferably working in a unit based on psychotherapeutic principals, where of course one must have therapy to do the job. This is a professionally acceptable way of getting help. As for less 'specialised' work situations, however, Davey (1992) put the case succinctly when he wrote:

'If and when emotionally damaged people need to create a life in which their own vulnerabilities are never challenged there is in many respects, no better place then working on a psychiatric ward'.

(p.7)

Barker (1994) publicised a movement begun in the U.S.A. generating the idea of the prosumer, a link between the professional and the consumer, where people with mental health problems can develop a professional service role and professionals can acknowledge their use of mental health services. The sad rider is that such acknowledgment may be difficult in the wake of the Clothier Report, one of the recommendations of which almost lends itself to a form of witch-hunting: No one with a major personality disorder, including those who have attempted suicide, should be employed in nursing (Friend, 1994). The acknowledgment of mental illness is already a problem, as preliminary research at a London hospital demonstrates in its finding that mental health workers do not seek help early enough for mental health problems (Friend, 1994). It seems likely that nurses will continue to find it difficult to acknowledge mental health needs.

To make matters worse, the N.H.S. has moved from being perceived as a caring employer to something approximating the social service agency described by Lawton. It is now seen as an uncaring, brutal and at times devious employer (Obholzer 1993). Obholzer views the health system as one which was at the time that Menzies-Lyth wrote, admittedly, defence ridden, committed to maintaining a denial of the stress, anxiety, anger and other feelings associated with the work it undertook. Yet it was functioning. It has, however, clearly now moved into a more sinister, paranoid, split position, resulting in a much more menacing and dysfunctional 'us and them' stand.

The good and bad are slpit. We, the good workers, against them, the bad managers; we, the sane staff, against them, the mad patients. This is the schizoid aspect of Klein's 'paranoid-schizoid position'; the suspicion of their motives (management's desire to dominate; patients' desire to manipulate) and fear of what they are planning (attacks on us) is an example of its paranoid aspect.

Nursing takes place in a psychologically complex and often painful relationship with another person. Nurses have learnt how to prevent that hurt by seldom taking part in the relationship to any deep level and by operating the defence mechanisms described. It seems we are resistant to changing this state of affairs. Although one might presume that any nurse would welcome an interest in their individual development via clinical supervision, Castledine (1994) suggests that this is not so. Because of the increase in numbers of general managers and decrease in nurse managers, many nurses may see supervision primarily as a method of control, of spying on their work. I would concur with this suggestion, having been involved with the development of clinical supervision over several areas. Nurses either do not attend or have problems maintaining any consistency. There are, I am sure, multiple reasons for this, all valid, relating to pressure of work, shift patterns and so on, but I suspect that underlying all such reasons are psychic mechanisms of denial, splitting and paranoia described above. Not that these are exclusive to nursing. Clulow (in Obholzer et al, 1994) writes about the ambivalence expressed by probation officers towards a supervisory experience. In all such professions there is at some level no doubt an inability to take freely given emotional support and care. This is part of the cycle of deprivation already described. There are areas where clinical supervision is a way of life and where there is no question of whether nurses should attend. Usually these are small, high profile units where staff feel valued and, as Skynner suggests, where they are the least deprived because they have moved themselves into working in such an agency. These are in contrast to the 'have nots', the emotionally deprived individuals working with emotionally deprived individuals. There seems an impasse in the latter situation which it may be hard to break, even with the provision of properly trained personnel who can work with this deprivation.

Holden (1991) suggested that in these circumstances nurses should stick with their primary practical tasks in nursing their patients, as a way of mitigating against emotional stress. However the primary task seems now to be the survival of the Trust (Obholzer 1993). Where does this leave the nurse and the patient? It seems even more unlikely in this climate that nurses will feel able to express real individual needs or collaborate with patients in authentic relationships, or even just practical, work related ones. Rather they will feel safe maintaining their self-idealisation as a professional group, resulting in a continuing need to view the patient as the only needy person.

Will Adequate Support Frameworks be Created?

It seems that an arena is needed where nurses are allowed to feel and are encouraged to talk, where self-understanding can be generated. Wright (1991) and Franks et al (1994) suggest a way forward is to establish support groups for student nurses where problems can be addressed intellectually, and presumably engaged with emotionally, in the context of ongoing peer-group relationships. The expectation is that the groups would be based on psychoanalytic principals and psychoanalytic theories of nursing. The individual would be initiated into them during training and would continue with them, once having finished training. Skynner's (1989) three levels of groupwork, allied with Peplau's Supervisory Conference (1989) could be instigated.

The structure of clinical supervision is currently being investigated (U.K.C.C., 1994) with a view to adopting a particular, suitable model. I fear that the implementation of any model may naively be seen as an immediate, cure-all answer to all the problems described above, whilst the underlying pathology simmers away. Perhaps this makes it all the more urgent now, while the U.K.C.C. offer consultation, for mental health nurses to state what they want from clinical supervision and what model they want developed, remembering that one of the reasons for advocating clinical supervision is to enable us to work in a close relationship with our patients ( Butterworth et al, 1994). I would argue that in these circumstances there is no model, other than the psychoanalytical, adequate to the task.

I am not advocating a totally psychoanalytical service provision, rather that an ecletic model is adopted, where there is an understanding of unconsious processes, which in turn generates the ability to carry out sustained work with patients utilising other models of therapy. It may be neccesary to move towards a more pragmatic idea of nursing, where no intervention is devalued for it's simplicity or brevity, neither is any upheld as the only worthwhile therapy because it takes a long time and deals with the 'underlying cause'.

The past decades have seen an emergence of psychodynamic nursing, fuelled in part, I suspect, by individual nurses' needing to know about themselves. The intention may be good, but I have seen wards where this is implemented in such a way that the patient then gets a rather raw deal: Regular formalised sessions with little contact between, and worse. This rather goes against what the users of the service have said they want, someone to listen to (not interpret) them and time out of the hospital enviroment (Rogers et al, 1993). Such developments can not be seen as progressive when there are practical techniques emerging for use with quite intractable problems. For example, Westacott (1995) reviews methods which may enable an individual gain some control over auditory hallucinations, one of which is social talking. Recall that patients also rated highly going for walks in the grounds, an activity which has a reassuring normality about it. Peplau has also suggested that patients need to be encouraged to keep active and to stay in shape physically (Smoyak, 1994). There seems a comfortable fit between these activities and what Laing suggested is the ability to

' ... just be with someone, no matter what state they are in, without needing to act on them in some way, without attempting to change them to suit one's own book, so to speak'.

(Quoted in Davidson, 1992, p.203)

The remaining and persistent problem is that without an adequate support framework a deprived individual, that is the nurse, may find it almost impossible to offer this presence.

6/ CONCLUSION

Although Menzies Lyth's work has been acknowledged in nursing for thirty years now, the processing of anxiety and other feelings within institutions has changed very little. Ramon (1992) suggested that feelings both of anxiety and guilt (as well, presumably, as despair, vulnerability and need) are normal reactions to an abnormal situation for a mental health professional. As she insists though:

'Locating them at the unconscious level is ... unhelpful. [Better] to support nurses and to encourage the development of a more productive repertoire of collective ... and individual ... responses.'

(p.90)

It would be difficult not to agree with Ramon. For sanity's sake, our own and our patients, we need a resolution to the current situation. Understanding of our situation, such as I have offered in this text, may help. It will be a beginning when you have a glimmer of understanding that you are not alone and that perhaps your feelings of inadequacy, confusion and failure represent no fault in you, but arise out of family structures and social defence systems. Alongside this, paradoxically, there is a need for the denial to be allowed to continue (Aldridge 1994). But there should also be some gentle encouragement for insight, enough insight at least to recognise that the collaborative relationships with our patients that we are finding so hard to implement are hard for a reason: We resist them, rightly, to protect our emotional well being.

To some, the above counsel may appear embarassingly näive. But we can only begin to address the lack of collaboration and relationship between professional and patient with an acceptance or at the least an exploration by mental health professionals of their own psychopathology. It is crucial that this at least becomes a focus for honest discussion amongst staff members and I would hope between staff and users of services, whilst retaining the necessary imbalance mentioned by Skynner (1989). This would be helped by an understanding of the psychodynamics of the institutions within which we work and the families in which we have grown, so that blame is not attributed either to them or to us; rather an attitude of acceptance and understanding is fostered. This may be impossible in the current climate. In which case perhaps there should be a return to task centred nursing, the tasks based around what patients value. Would it be so bad to resurrect what Bradshaw (1995) terms the classic framework of nursing? This may result in nurses' doing a richer variety of things with patients, working with them. I believe that not all nurses will be distressed to relinquish their quasi-therapeutic role. Who, in any case, asked the patients if that was what they wanted (Salvage, 1990)? In any event, there must certainly be an acknowledgment of the emotional labour that each nurse is carrying and acceptance that they may only be able to labour in this way for a few patients at any time. Nurses, who I believe are usually caring, genuine people, and who for all the reasons stated in this chapter, are finding nursing an almost impossible task, are unlikely to acknowledge such burden and needs without genuine permission and encouragement.

How long can we continue to conceive of our needs as subsumed within the patient? It is living a lie and makes our work and our lives impossibly hard. As Peplau (1991) has argued, until we access our own needs and vulnerabilities, nursing is a facade:

'A nurse cannot pay attention to cues in the situation when her own needs are uppermost and require attention in the situation. Her observations are, unwittingly, focussed upon the way her unrecognized needs are met by a patient ... Until the actual needs of the nurse are met or identified so that she is aware of what they are and how they function as barriers to the patient's goals, she does not have control such as is required for carrying out all of the 'shoulds' and 'musts' indicated in nursing literature.'

(quoted in Farkas-Cameron, 1995, p.32)

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