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The idea of the collaborative, healing relationship between nurse and patient is considered to be 'a cherished idea within psychiatric nursing' (Bray 1998). Yet almost inevitably, it seems, patients act out, staff burn out and collaboration and empathy between them subtly drop out of the equation. What is left in these circumstances and how should we handle it?

For the first six months of my R.M.N. training I was placed on an in-patient eating disorder unit, immersed in a milieu where I had to try to fathom just such a scenario.

The ward was in many ways divided. On the third floor of a recently built block, there was an eating disorder side (ten patients) and on the other side another speciality service (about ten patients again), with a few general psychiatry beds on each wing, thrown in for good measure. A 60 year old man occupying one of the latter beds suffered manic-depressive psychosis. At the time I worked with him he was destitute, following a huge spending binge in which he had blown his substantial life savings. He had clearly now swung to a depressive phase. Rather angrily, it always seemed to me, he would defecate where he sat, lay, or, on occasion, just where he stood, insisting he could not help it. He left the staff angry, in any event, whatever his experience. If it was 'overflow' from chronic constipation, as some argued, he certainly made the situation no easier by standing, for example, in the medication queue in his pyjamas and allowing diarrhoea to spill down his leg onto the carpet, aware of the fact but disinterested. Yet at times I found relief in scraping him down and cleaning him off in the bath (he was too unmotivated and resistant to do it by himself), particularly after an hour supervising the wrangling and antics of the anorexic patients at their meal table.

The ten of them would sit around the table comparing and disputing the size of their potatoes and the unfairness of their portions, distressed beyond measure at how much butter was spread on their toast, cutting peas into improbably small pieces before forcing themselves torturously, and with considerable 'encouragement', to swallow each bit.

After an hour's mind-warping effort to be with this sort of experience, something as earthed as cleaning Joe could indeed be a relief.

It was an intense entry to psychiatric nursing. In at the deep end.

Although my main interest was in psychodynamic work I was struck by the importance of having a range of interventions to offer, particularly as many patients were at a dangerously low weight and required quite focussed 'behavioural' intervention in relation to their eating patterns. I participated in running the eating programme that formed an essential component of in-patient treatment, supervising meals daily and regularly eating at the table with patients. Twice I helped in 'force-feeding' a patient whose weight was at a dangerously low level. With the luxury of more time, once 'danger periods' were averted, and with help, I saw some patients change the patterns that comprised their 'illness', breaking through maladaptive habits into a greater understanding of their situation, into an experience of new feelings and into an ability to choose different ways of being.

A university lecturer in nursing taught my set one day early on in our course about academic pathways in nursing. Her message was that research is not distinct from the ordinary human process of activity and reflection. We had surely been thrown into momentous experiences wherever we had been placed, she told us, and should try regularly to reflect and write about them, to keep us alive to the experiences we were involved in. All of us who were willing to write would be engaged in reflective practice, whether or not we were interested in formal research. It was good advice.

This paper is the product of some such writing. Both in its content, and in the fact of its existence, it also represents one answer to the question posed above regarding the deterioration of staff-patient relationships, to which I shall return in conclusion.

Jeremy sits moaning and sighing, holding his head, complaining of a migraine, staring at the mess on the table before him.

11.40 am. Shift evaluation time. Ulrike, coordinating, learns that Jeremy has vomited over the dining table and other patients are complaining. Someone kisses their teeth. Agreement ensues that if the vomit is still there after the meeting someone will offer him support in clearing it up. More contempt haemorrhages into the air - for Jeremy and for the idea of giving him support. It hangs there while we leave the staffroom.

Two hours later, Liselle, a patient, interrupts the afternoon shift's planning time to report that Jeremy, still at the table, has again been sick. She is met with a courteous but abrupt response: We are aware of this, but busy at the moment. Liselle wants something done. We let her know we have heard her. She leaves, exasperated, and the planning continues. The extent of our attempt to process Liselle's interruption is limited. It amounts to one of the nursing assistants wondering why Liselle "don't go and sort something out, instead of bleating to us."

More laughter.

Putting the most charitable gloss on these events, I privately observe that we probably do not convey to Liselle that we want Jeremy's disgusting behaviour to be addressed by the group together. But maybe there is no need to underline that; Liselle knows that it is ward policy for `peer group pressure' to play an important part in treatment. I am a student nurse, anxious to understand before criticising, so I say nothing.

`Peer group pressure' seems to mean something like the process of Jeremy's peers' making him feel bad for causing them distress and annoyance by his vomiting and other behaviour; accordingly, as Jeremy, like everyone else, needs to belong, to feel acceptance and approval, he will want to change his behaviour. Something as unsophisticated as this, however, seems unlikely to be effective with the in-patients here who are as low in weight as 4 stone and in some cases willing to starve themselves to death. The patients too seem unanimous in the view that for members of their group who do not want to eat, this sort of crude pressure is worthless.

I want to find a meaning to 'group pressure' a little more convincing if I am to believe that this is the indicated treatment. I think about the understanding of group process I am familiar with from my recent introductory course in groupwork.

From this viewpoint, eating disorders may acquire meaning seen against a background of complex intrapsychic, interpersonal and family dynamics (Lawrence, 1989; Palazolli, 1974; Crisp, 1980). For example there are five patients here in whom it has become clear there is a great desire to punish, as well as anger towards one or both parents. Where there has been childhood sexual abuse, painful marital breakdown and recriminations, or persistent neglect by alcoholic parents, these feelings are understandable to say the least. There is, at the same time, however, such terror at losing control and expressing this wrath, such unwillingness to look at these feelings (which would after all involve some degree of re-experiencing the traumatic events associated with them) that this anger and desire to punish gets expressed by way of a self-starvation programme.

The sense of control and self-determination afforded by adherence to such a starvation programme is also a significant factor in eating disorders (Duker & Slade, 1988; Moorey, 1991). One young woman on the ward, Madeline, has stated this explicitly in describing how her parents and siblings attempt to control so much of her conduct and her mental world that the only area where she feels she can exercise any autonomy is in her eating.

In group-analytic terms, whatever the specific complexities of these family relationships, the patient's interpersonal patterns of communication, the style of relationships between her and the most significant other people in her life, will sooner or later become manifest in her conduct and in the relationships she forms with others on the ward. This process, with other patients and staff (or indeed with the eating-disorder group as a whole or with the entire ward) having foisted upon them a role or roles that the patient more or less unwittingly assigns in recreating her familiar relational world, is of course transference (Heimann, 1950; Kreeger, 1987). From this viewpoint it is crucial that relationships between patients develop. And it is essential that difficult issues such as distaste with another patient's behaviour when he vomits over the dinner table, be aired and confronted. The hope is that this will contribute to the manifestation of transference, so that exploration and eventual resolution of the issues(s) underlying the eating disorder may take place in the context of the relationships on the ward.

This, then, I hope, is why Liselle is left, along with the other patients, to confront and deal with Jeremy's inability or unwillingness to keep his food down, even when he knows he will not be allowed to leave the table and must vomit there over his food while the other patients eat their meal and seethe, more or less silently, each in their own misery and isolation: They are developing relationships and allowing conflicts to arise which may eventually provide a basis for the understanding and resolution of whatever issues underlie the eating disorder.

I wonder whether Liselle understands all this. If she does she may just about be able to see Jeremy's being kept at the table to vomit as some sort of therapeutic agent - compelling her and the other patients to express their emotions and relate (as well as encouraging all of them to give whatever support or censure is necessary to help him stop, thus conditioning Jeremy not to want to vomit). Without such understanding, however, it is impossible to see the same episode as anything other than vindictiveness and insensitivity on the part of the staff. If Liselle and the other patients see it only in this way presumably they will be less inclined generally to co-operate in their treatment, and less motivated in particular to engage in whatever therapy is available. One needs to feel safe before risking `opening up' in a therapy situation, and a patient here is not likely to feel safe if she experiences the regime or staff as vindictive and hostile.

Here follows the sum total of formal explanation of the crucial 'relationship-forming' component of the theory behind our `peer group pressure' approach, given to patients on admission in a general booklet explaining policy on the ward:

If you should have difficulty in finishing your meals or in eating, we have devised a group therapy approach which relies heavily on peer support and peer pressure to assist you to overcome your problems in a supportive manner. The supervisor's role during mealtimes is to facilitate this process by calling on your fellow patients to support and assist you.

The idea of the staff's role as facilitative of `fellow patients [mutual] ... support and assist[ance]' is included, but, as can be seen, only in the context of mealtime protocol, and even then in such a muddy way as to leave the notion of patient interaction and trust and openness in the group as prerequisites for therapy, more or less obscure, so obscure in fact, that one may wonder if such issues are understood clearly by staff, let alone patients.

At the dinner table Ulrike is arguing again with Jeremy.

'So you're saying that because you've got a migraine you shouldn't have to eat, are you?'

'No, I'm not saying that.'

'And what about the last three days, then. I suppose that's your excuse for not eating then. If we listened to you, you'd never eat.'

'I'm not saying that, Ulrike. I know I have to eat. I'm just saying this migraine makes me feel even more sick. In fact I think its this food that brought the migraine on.'

'Jeremy, just get on with your food and stop arguing, or am I going to have to feed it to you myself?'

A staff nurse, Clive, is inducting a new student, Emma, onto the ward. This is her obligatory psychiatric placement within the training she is doing as a sick children's nurse. It is evening now, quiet, the bustle of ward rounds and meetings and appointments for patients and staff over for the day. The staff room is relaxed, and while I browse through some patients' files, Clive tries to reassure Emma, who is unsure of her role, scared of mental illness and extremely nervous about meeting any patients. His reassurance is addressed specifically at qualms that may well arise in response to the disturbing events likely to unfold at her first mealtime encounter here.

"They're a manipulative lot, these anorexics. Be careful about trusting your first impressions, you'll see what I mean when you've been here a while. They'll go on about how ill-treated they are, but take no notice. They're wrong. We don't care the way they'd like us to but we care enough to keep them from starving themselves to death, no matter how bloody difficult they are."

She has already been told by another student that "they're very crafty; they'll take laxatives when you're not looking and make themselves vomit in the toilet, stuff like that. We have to inspect the contents of the bowl before they flush it away with some of them, and they have to ask us before they go to the toilet."

Emma seems reassured. I too feel some reassurance but also a considerable degree of unease. I am invited, welcomed into an attitude that forms an important bond amongst members of staff; there is an impressive cohesiveness within the staff group, and amongst them in the staffroom I feel a great warmth and security. But this bond seems intricately linked to, perhaps even founded on a kind of oppressive suspicion and antagonism towards the patients.

Neither the patients nor the staff, it strikes me, are initiated into the theory of the therapeutic milieu of the ward, and a picture emerges of endless skirmishes and conflict between the two groups, taking place in a void, in the context of which it seems unrealistic to expect the patients to feel safe enough to 'open up', or even comply.

I feel in an unreal space between two worlds, each one trying to shield itself from the insecurity caused by a hostile 'them' in a sense of 'us'. The patients are undoubtedly manipulative. Presumably, like most people, they try to get what they want through devious means, subtly controlling, manipulating others' responses rather than asking straightforwardly. No doubt people who starve themselves to get a need or needs met could reasonably be said to be more manipulative than others, even if their conduct is 'the reasonable upshot of their life history' (Smail, 1987). But in our intense preoccupation with 'their manipulativeness' I just wonder what else is going on. Why do nurses so want this aspect of patients' characters to be highlighted? Why does 'manipulativeness' need to be understood as a defining characteristic of anorexic psychopathology? And why does such an understanding form an intrinsic part of induction for new staff on the ward, to the extent even that an injunction is subtly made in the name of self-preservation to put aside all other perceptions? Why is there such neglect of the theory underlying this group psychodynamic approach, such lack of attention to the facilitation of patient-group cohesion, and such an obvious absence of a forum for the safe airing of feelings in staff brought up by the patients. The patients are sometimes and in some degree manipulative, no doubt, but equally, the staff are sometimes and in some degree angry and unsupportive to the people on the ward, particularly to those patients least in charge of their eating patterns and presenting the greatest management problems, as above. No one is perfect!

A short time on, after an evening meal, I help Jeremy clear the vomit from the table, restricting myself as much as possible to advice on strategic issues such as where the dettol is kept, how to negotiate the doorway with a heavy bowl of water and when enough dettol has been administered so that the table can be rinsed and dried. With such support, Jeremy manages to clear the mess without too much fuss and in reasonably good part. However, I am left somewhat jangled. Jeremy seemed in misery and I felt sorry for him. I was not very harsh with Jeremy, and even spoke to him in quite a kindly way. Have I thus exposed myself to staff and patients as too sympathetic and not sufficiently dispassionate to provide the firm boundaries necessary to become part of the team and to get these people better? Should I have shouted and bullied, just a little? Will I now be seen merely as a walkover and become a soft target for manipulation?

Two months later, 1.15 pm, an argument rages around the dinner table. This time, though, it is between me and the anorexic patients.

"Oh c'mon, you two. Do stop playing with your food. What's the matter now?"

The words are barked from the comfort of some new found confidence after having run the psychodrama group on my own that morning, standing in for the qualified nurse who is on leave. I managed to get everyone participating in some trust-building exercises and role-plays recently learnt in school. It went well and I feel strong.

"Well don't look so shocked. Tell me what's going on. What's the problem?" Irritation spills out. I do not want to be supervising the meal.

The two girls who are making games, one of mashing up her sponge pudding with the custard and the other of chasing it around her plate, do not know quite how to react. The sad looking girl, Sally, who has occasional moments of quite astonishing fury unleashes some of it in their defence:

"If you had to eat this mess like us you wouldn't be so bloody smug."

I am somewhat taken aback. I wonder whether she sported the same snarl just before she stabbed her mother with a pair of scissors. Normally such a reaction would scare me, but I have taken the plunge and may as well now start swimming.

"Oh do stop complaining and get on with it. Its not that bad."

Liselle is as sharp as ever: "I suppose you're going to say that because we are anorexics our perceptions are distorted, are you, and really its hot although we all think its stone bloody cold."

"I'm not going to say that, no..."

"Oh, yes, lovely this is," says Sally. "I suppose Amanda's is really appetising too."

Everyone laughs. Amanda is faced with a plate of liquidised green mush, probably cold, and probably no easier for her to eat than the fish, potatoes and peas it used to be before staff got impatient with her complaints about being unable to swallow, and put it through the food blender. I feel a pang of protectiveness towards Amanda who is currently withdrawn beyond anyone's help, psychotic perhaps. Nigel offers an analogy of eating green cowpats, and the uproar continues. The patients are as angry with Amanda as the staff, it seems, just as they used to be with Jeremy before his discharge. It is some time before the baying and cackling abates. Take me on you idiots, not Amanda, I want to tell them. But I become placatory. "If you say its cold, you're probably right. I'm not going to argue." Then, not wanting to seem too conciliatory, I quickly add "So alright, its cold. So what?"

"Would you eat it?"

"I've just had some. It wasn't brilliant but it was edible."

"I suppose our perceptions are distorted if ..."

"Liselle, if you are going to say its cold, no, I don't expect your perceptions are distorted. But if you say its a cow pat then I think they are definitely distorted, deranged even. There's a difference between it not being very nice and it being inedible. Why don't you stop going on and eat the bloody stuff."

Scott's plate is suddenly empty. He looks at me menacingly, defying me to challenge him, ready to protect Liselle's honour.

Two courses and a further ninety minutes on, Sally is still there, and wants blood: "You've changed, just like the rest of them. You weren't like this when you started. Now you're bossing us around just like Malcolm and Sue. I think something must come over you, like you become power mad."

Where can I go? Sally, the only reason I would be eating as much as you have to three times a day would be if I were anorexic, and if I was I don't know what I would feel. But I'm not. And unfortunately you are. But somehow I'm in it with you and someone is paying me a pittance to get you out of it and I am scared to see that I don't really know how to but I will try to love you and see it through together with you... I do not say this though. I've gone in far enough for now.

I shake my head as it rests in my hands, elbows on the table. I imagine how I look and recognise the posture Jeremy used to adopt. "Do stop this. I've said I'm not questioning your perceptions. The food may not be particularly nice. But it is edible. Eat it."

"OK, you've had one portion now, but if you had to eat it three times a day with snacks in between, you'd be complaining just as much as we do."

Sally is a nineteen year old woman having a tantrum, her fury unleashed is precise and powerful and she rattles me. I retreat into a defensive retaliation, and putting on my aggressively rational tone, begin: "Sally, does it occur to you..." Then I decide to open the field again and go for safety with a brash attach on them all: "...do any of you wonder whether it might not be you who have changed towards me?" After a moment's silence I soften my tone. "Because it seems like this is the first time you've had a go at me personally for something to do with your food. The eating regime is obviously giving you a hard time, and these cock-ups the catering department keeps making must be infuriating. What was it the other day? Jacket potatoes with lentil filling and boiled potatoes to go with them? I'd be going mad. But today is the first time since I've been here that you have given me a lot of shit because of it, directed at me personally. I'm sorry if my attitude seems to have changed but I don't see why I should have to put up with a lot of shit when its not my fault."

Which of course is partly not true, as it was me who drew the fire in the first place by being unusually brusque with Madeline and Jo who were playing with their food. This is not lost on Sally who no doubt senses some mendacity afoot, and directs a parting shot my way.

"Oh lets just drop it, Ben, If I carry on you'd probably only go and tell Malcolm anyway, and then we'd all be in trouble. Just drop it."

Not just caught in an unreal space between two worlds but wanting to be accepted and esteemed in both of these two camps engaged in the open hostilities described above, I am aware that I have changed. Two months back I would have held my counsel and bargained for everyone's approval, terrified of losing esteem or doing harm. Now I am willing to be drawn into these skirmishes and feel I have some grasp of what is happening. I try fumblingly to facilitate some willingness in the group to open up and talk, on this occasion, admittedly, more about food, but also about my relationship with the group. I am also drawing their anger and then showing I can withstand it. (If I cannot, then how can they be expected to trust in the safety of the group sufficiently to let out their feelings about each other?) I am modelling a willingness to engage in intense interactions in the group and survive. I am trying at some level to enhance group cohesiveness.

The theory goes like this: The more risk-taking is modelled and endorsed by the facilitator as a group norm, the more people engage in it in order to enhance their esteem and belong. The more risks group members take in self-disclosure, or conflict, the greater the esteem in which they are held. And the greater the ensuing mutual esteem in the group, the greater the cohesion. Yalom (1985) defines cohesiveness as 'the attractiveness of a group for its members' or 'the attraction that members have for their group and for the other members':

Cohesiveness is a widely researched basic property in [successful] groups... In general there is agreement that... Group cohesiveness is not per se a therapeutic factor but is instead a necessary precondition for effective therapy, [and like] an ideal therapist-patient relationship [in individual therapy, it] creates conditions in which the necessary self-disclosure and intrapersonal and interpersonal exploration may unfold.'

(Yalom, 1985 pp.49-50)

The cohesiveness Yalom describes as a necessary precondition for effective therapy is in no small measure, within an in-patient group such as this, a function of the staff's willingness to disclose and interact, as well as patients'. Indeed, perhaps the staff's input here is more important as their role is in large part that of role model; the limits they set for themselves are also the boundaries described for the patients in their eating and their interactions.

This highlights how nurses are in an odd no-man's land between patient and therapist. Although staff enforcing the rigid eating regime on the ward are caught up in the interpersonal dramas being reenacted and inevitably become participants, they clearly need to be some steps back from complete patient involvement in the group. Maybe the ideal role nurses can adopt is that of 'facilitator of group cohesion' as a sort of preparatory step towards the work which a therapist might facilitate in more formal sessions. This work (at least to the extent that it takes place within the in-patient twice weekly group therapy sessions) is mentioned a little more explicitly in the ward brochure:

'The group aims ... to confront issues ... which are contributing [to] and perpetuating your eating disorder in order that positive change may take place ... The overall aim of the group is to provide a safe environment for you to explore ... your behaviour in a way that meaning can emerge.'

And of course 'a safe environment' in this context has to mean, if it is anything more than an empty cliché, an environment in which patients really do feel safe enough to disclose and explore their condition. Presumably an environment which patients experience as one where they are bullied and hectored by uncaring staff does not apply.

It should be emphasised that patients do not generally object to firm handling per se. Out of some six patients who I have heard complain at one time or another, all have confirmed that their treatment by the charge nurse Malcolm, whose reputation for noisy harangues is renown, is not what they are referring to. All six have intimated this clearly, stating that his treatment of them is 'reassuring', 'it comes through that he cares', 'it doesn't feel like he's shouting for the sake of it', and, perhaps most significantly, 'its different with him because you feel he knows what he is doing'. Which apparently he does, being the only figure on the ward with experience of analytic psychotherapy and training. One is left with the suspicion that the patients' objection is to the sort of 'firm handling' characterised earlier in this paper as being based around an antagonism towards them, which emerges as the only thing the staff group can use as a focus for their own need for group cohesion and support. And as suggested above, this may be in large measure a result of the absence of any proper dissemination of the ward philosophy from ward manager level, around which staff cohesion could more usefully develop, and the spelling out of such a philosophy in terms of specific roles and functions for nurses.

It strikes me now how easy it is to be swamped and influenced by the culture of a place and by one's own inertia, resistance and bad faith, however much one would like it to be otherwise. Above I have recounted the story of my six month placement, focussing on some of my preoccupations such as group and staff-patient dynamics and the staff-roles, procedures and structures of the ward. I may have avoided in this account the worst excesses of pathologising patients with whom I worked, but I have nevertheless also avoided introducing any of them as people in the context of the distressing life stories they told. As such, it is not just the culture of the ward or the permanent staff group that seems to have lost its empathic, collaborative heart, but myself too. I now wish to correct this imbalance.

While working on the in-patient unit I participated fortnightly in live, group supervision of a family therapist who would be seeing an eating disorder patient and their family for up to four sessions. Perhaps a good example of what is missing above is the material that came out of the family therapy sessions with patients, for example the sessions where the therapist saw Jeremy, his father and aunt.

Jeremy was thirteen, the youngest patient on the ward, transferred there after little improvement during his three month stay on a child and adolescent unit. His mother was recently deceased and his father was fast becoming an alcoholic. Prior to being admitted Jeremy had had on occasion to look after his father, getting him to bed when he passed out from drinking too much. He had had to shop, prepare meals and the like. He did not want to go back to boarding school, where he was bullied, but, equally, the situation at home must have been intolerable.

None of this was discussed in the patient group, either during formal therapy sessions or elsewhere. His eating patterns were so extreme that it was hard to focus on anything but Jeremy and his weight and his food and his vomit. What emerged dramatically during family therapy was that Jeremy had not been able to grieve properly for his mother, partly due to family taboo and partly because his role had changed in relation to his father from child to parent, as a result of his father's incapacity through drink. When the supervision group got the therapist to pass over the family's preoccupation with Jeremy's eating and push against their resistance to discussing the loss of Jeremy's mother, a well of blocked emotion was 'thrown up', both by Jeremy and the others in the family group (considerable emotion was also expressed in the supervision group), and progress began to be made. Jeremy subsequently stopped being sick, gained weight and was discharged to his aunt's care, while his father accepted treatment for his alcohol dependency.

Madeline's family therapy sessions with her domineering brothers and father were also revealing. The supervision group had at one point to help the therapist withdraw from conflict with the men of the family, who were speaking for Madeline. The therapist himself, although endorsing ideas that we knew Madeline held, had been drawn into doing exactly what the other men were doing, speaking for her rather than allowing Madeline to speak for herself. He pointed this out to the family during the session. In discussion between Madeline and her primary nurse after the session, it transpired that the men's dominance included unwanted sexual attentions. Madeline could not finally bring herself to tell the whole family that her brother had raped her. However, the fact that she had told someone and the threat she made subsequently to her brother that she would tell the whole family, including her father, if anything like it should ever happen again, seemed sufficient for her to gain the sense of control of her destiny that she had previously said was missing in her life except in relation to food. Our intuition that she would not relapse proved correct.

Scott's family dynamics, similarly, were revealing. The family meetings were attended by his mother, two aunts, sister and grandmother, all of whom, like many of us in the staff group, were influenced by this attractive fifteen year old boy's charm. The subject it seemed hard to discuss was his delinquency. Talk of his forthcoming court case on charges including aggravated burglary, and its implications, was persistently pushed aside out of greater concern for his illness. The only contact from his absent father was when word reached him of an intervention from the nurse Clive. The father stormed onto the ward threatening physical violence if ever again anyone suggested that his boy needed parental disciplining. The picture we were given of family dynamics could not have been clearer. Discipline and control of Scott, indeed criticism of the men in the family generally, were taboo, while an idealising, doting love for him was powerfully endorsed. Attempting to restore some balance to this equation without jeopardising our relationship with him, we subsequently focussed a lot in work with Scott on the court's likely use of its authority to 'discipline' him if he did not behave in a way that allowed us to report co-operation and progress, as we very much wanted to. We were surprised at how quickly Scott's eating disorder abated.

I planned to 'restore balance' to this paper by offering an empathic account of patients' experience. However, in the last few paragraphs I have recounted again the story of our work as much as patients own stories. It is painful to stay with the experience of pain, perhaps ultimately even more so when it is someone else's. I suppose this explains a range of phenomena. It explains staff's need to take a distant, hostile and callous stance vis-a-vis patients, such as in the situation described above. It explains the tendency to move away from the raw experience of a situation into abstractions regarding structure and philosophy, as to some extent in my writing. It is certainly a strange experience for me now, eight years on, to be recovering memories of my contact with such a disturbed group of people in such awful states of distress. And then I recall how my own eating, as well as drinking and sleeping patterns went haywire during this placement. I recall how patients' experience parallelled distress I was going through in my own life.

But that is another story, which, although inextricably interwoven with the above account, is outside the scope of this article. The question with which I opened this account, and to which, in conclusion, I now return, concerns the sort of circumstances detailed above where patients act out, staff burn out and collaboration and empathy between them drop out of the equation. I asked what, in these circumstances, is left in the relationship and how should we handle the situation?

To summarise, it seems to me that through reflection and writing we can struggle to get a conceptual grip on the situation. With a leap of faith we can open ourselves to honestly experiencing what is going on in our relationships. Even if the resultant understanding and experience is partial, it should yield a point of leverage where something that we can do is revealed. And if what we do turns out not to have the desired result, then at least we have new information with which to enhance our experience and aid further reflection. In the above account a useful role to adopt suggested itself to me increasingly, the more I struggled to understand what was going wrong on the ward to cause the antagonism between staff and patients. As far as possible I tried to make a difference using this point of leverage, which was little more than the role psychiatric nurses should adopt anyway: Helping people and groups to communicate their experience, in the context of an authentic, honest relationship.

When we find that, in our own relationships with patients, collaboration and empathy are largely absent, then I guess we can at least be honest about that. The influence one has on others is in any event marginal, and the only small corner of the universe over which one has control is one's own being (Huxley, 1946). If, as I have tried to show, we can at least struggle to maintain an honest, authentic relationship with ourselves through reflection on and writing about our experience, then this in itself may make a positive difference to our approach and to the outcome of any intervention we make. We will have shown at least that we can communicate our own experience, and perhaps others will follow suit.

Epilogue

The reception of an extended form of this article, both at the A.P.P. and G.A.S. (see footnote below) was very encouraging. The A.P.P. group responded with 30 minutes' animated discussion in which some powerful feelings were expressed. At the G.A.S. meeting I prepared some of the dialogue as a separate script, and had ten Qualifying Course students from the Institute of Group Analysis and other members of the audience take the parts of the patients and staff. I had bought ten large portions of chips en route to the venue, and set out some trestle tables and chairs so the room was like the eating disorder unit's dining area. Those of us enacting the script were seated around the table with mounds of cold, unappetising chips on plates in front of us. The other twenty or so attending sat in concentric circles around us. The reading was excellent and the whole event very powerful. Just as the paper was intended to bring alive the notion of writing as a tool of reflection, it seemed that reading passages of the script aloud as a participating group, using the group situation as well as the paper itself as a tool for reflection, might bring the subject alive still further - it did. Another lively discussion followed - although eating disorders, difficult patients, staff group splits etc. were more the focus of discussion than 'writing as a tool of reflective practice'. The chair of the meeting suggested that we debrief and 'de-role' after the paper, especially for the benefit of those who had been in more prominent roles. It was noted that in rearranging the room after we had got rid of the trestles, I had certainly not managed to 'de-role' from the bossy nurse position!

Subsequently several people approached me to say how it helped their own writing to know it was acceptable to write in forms of their own creation, and as a way of expressing their experience. The norm seems more often a feeling of intimidation at the prospect of using a foreign tool with stuffy rules. I hope that in publishing the paper here readers, whether looking for a tool to make sense of their experience or daunted at the prospect of adopting a contrived, academic voice in relation to course demands, may take heart and let their writing, properly referenced, simply express their experience.

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1. A version of this paper was given at the Tavistock Clinic in London to a meeting of Analytic Psychotherapists in the NHS (A.P.P.) in April, 1996, and at a Scientific Meeting of the Group-Analytic Society (G.A.S.) in September 1997.

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Ben Davidson, 8 Elsie Road, London SE22 8DX., England.

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