Nurses and Their Patients: Informing practice through psychodynamic insights

Society)

Introduction

This book belongs to a context wider than nursing, where different authors have written about the way psychoanalytic thought can be usefully used to illuminate the work of health care practitioners who are not themselves psychotherapists or psychoanalysts (Obholzer and Zagier Roberts, 1994, Hinshelwood and Skogstad, 2000, Goldie, 2005). This suggests that psychoanalytic thought is fertile territory for new ideas to aid thinking about health care. Transferring such ideas, however, from their original context to more general use has to be done mindfully, for the obvious reason that the contexts are vastly different. For instance, many psychoanalytic psychotherapists work in such a way as to deliberately reveal very little of themselves. This enables a study of phenomena such as ‘transference’ and ‘counter-transference’. Nurses, however, share quite a lot of themselves with their patients in the course of their daily work.

This means that whilst ideas like ‘transference’ and ‘countertransference’ may be helpful ways of thinking about nurse–patient encounters, their analysis is inevitably ‘muddied’ by the ordinary conversational way that nurses relate. Another important difference is that the patient in therapy has signed up for something called ‘therapy’ or ‘analysis’. The patient in a general hospital, on the other hand has signed up for no such thing. Therefore, any interpretation by nurses of the unconscious meaning of a patient’s behaviour is unlikely to be confirmed or disconfirmed through dialogue with the patient. This means that such thoughts must remain tentative and speculative.

In the psychoanalytic/psychotherapeutic setting, interpretations are used to help the patient to change. In the settings described in this book, such understandings are used to help nurses make better sense of their relationships with patients, survive the distress of their work and achieve more depth of understanding of their nursing role. Ultimately, the justification for using ideas out of their original context has to be that it increases the possibilities for human creativity, kindness and tolerance.

In addition to the tradition of using psychoanalytic thought to assist health care practitioners generally, another, smaller tradition has arisen, aiming to influence nursing care specifically. This has not been limited to the psychiatric nursing setting (Dartington, 1993; Fabricius, 1991, 1995). Other publications that capture some of this work include Barnes (1968) about the work of the Cassel Hospital (a psychoanalytically informed, therapeutic community) and Barnes et al. (1998) about the application of psychosocial nursing principles. That the authors of this current book have an interest in this approach should come as no surprise when it is learnt that two of us (de Raeve and Rafferty) worked in the 1970s and 1980s at the Cassel Hospital. Doreen Weddell, the first matron of this hospital developed the idea of ‘psychosocial nursing’ with her team of staff. This influenced people such as Anna Dartington (an ex-Cassel nurse) who for many years ran courses at the Tavistock Institute for Human Relations, for nurses. Sadly, she died recently.

The discerning reader may notice that many references in this book are common to many of the chapters. The explanation for this is that this book grew out of a Master’s level module on Psychodynamic Perspectives of Nursing and Midwifery. Most of the students doing this eleven-week course had no previous knowledge of this way of thinking. The case-study section of this book is formed from the assignments that these students submitted, although these have been extensively re-worked for this publication. The resulting chapters demonstrate how these ideas can be used to make sense of the complex, everyday experience of nursing. The powerful explanatory capacity of these contributions offer nurses a significant way of explaining why they feel the way they do. Such understanding can lead to insights, which inform responses, thereby enhancing the capacity to practice with integrity (de Raeve, 1998). The fresh, and lively way in which these authors have approached the task of translating psychodynamic ideas and applying them to their practice, provides a means by which they can be easily grasped by other nurses to inform their practice.

This book is therefore intended as a resource for experienced and inexperienced nurses from across the professional spectrum, wishing to think more deeply about their practice in a psychodynamic way. The editors have a long-standing interest in, and commitment to, the value of these ideas to inform patient care and to protect the thinking capacity and emotional well-being of the nurse. Ultimately, such ideas inform what can be considered to be the proper and healthy nature of health care systems.

There is relatively little literature on the relevance of psychodynamic thinking for nurses and nursing. A literature search produced the following list: Kenney (2001), Terry (1997) and Barnes et al. (1998). None of these take the same approach as this book, which offers perspectives arising from the practice of ordinary nurses with little previous exposure to such ideas.

The focus in this book is upon significant psychosocial events in nursing and how these can be understood through a psychodynamic perspective. The themes concern ordinary, rather than pathological development and behaviour in the life cycle. The structure of the book supports the core chapters written by those who did the psychodynamic module. There are three sections: 1. Theoretical, 2. Case-study, 3. The wider context.

Theoretical section

Theoretical section

This part of the book consists of four chapters, which provide an overview of key theoretical ideas that preoccupy the authors of the case-study chapters. Inevitably, this analysis is selective and no attempt is made to give a comprehensive overview of psychodynamic theory in this book. Rather, the aim is to show how such ideas when applied to health care, help us to make better sense of:

making relationships, attachment and separation

the experience of illness and loss

the ways we manage anxiety.

Some of the specific theoretical ideas considered include: the nature of the unconscious, the nature of the parent–child relationship (good-enough parenting), attachment theory, object relations, the meaning of illness and loss, defence mechanisms (individual and social) and projective mechanisms including transference and counter-transference. The ideas derive from the work of people such as: Melanie Klein, Donald Winnicott, Eric Bowlby, Mary Ainsworth, Colin Murray Parkes, Isabel Menzies Lyth and others. Behind all these people stands Sigmund Freud, the father of psychoanalytic thought.

Case studies

Case studies

This section contains the seven core chapters. These stories have been grouped to capture the primary themes of each. To begin with there are three chapters which address the theme of attachment:

Lois Jones writes about her personal experience of serious illness and her search for an attachment figure.

Mary Isaac explores the significance of a daughter’s presence at the bedside of her elderly mother and the way the sister in charge of the ward understood this need.

Sally Williams uses an account of her care of a dying child to consider the complex meaning of attachment and the importance of play in this relationship. Sally also introduces the ideas of transference and counter-transference

These are followed by two chapters that also explore attachment but, in addition, introduce the perspective of transitional objects and transitional phenomena:

Grace Sansom defends an interpretation of the significance of a baby doll to the well-being of a woman with dementia. The intuitive understanding of this is enhanced by appeal to the theory of transitional objects.

Wendy Kennedy reflects upon her interactions with patients in the pre-operative environment of the anaesthetic room, using three different encounters, one of which includes a ward nurse.

The two final chapters in this section explore projective mechanisms and either overtly or implicitly, transference and counter-transference:

Mary Paget writes about the wife of a dying man who accuses her of attempting to murder her husband, via the use of a syringe driver. Mary attempts to make sense of this by understanding the relationships of everybody involved and their history.

Alyson Charnock as a mental health nurse, describes an agonising situation concerning the suicide of a patient and her sense of burden when dealing with the responses of the mother.

Each chapter is followed by a brief commentary written by the editors, which attempts to summarise the key points, draw attention to some of the more implicit issues and suggest the wider implications for individual nurses and health care systems.

The wider context: research and supervision

The wider context

Three chapters are included in this section. The theoretical ideas explored in Sections one and two are re-visited with a consideration of how these ideas may be further used to inform practice. The first chapter by Heather Davies gives an extensive review of the research background that supports a psychodynamic way of thinking and more specifically, its application to nursing. Clearly in a world where CBT (Cognitive Behavioural Therapy) is a dominant voice and supported by research evidence, it behoves those of other persuasions to either produce similar evidence or, if this cannot be done for conceptual as well as practical reasons, to articulate clearly why this is so. It is not the editors’ intention to imply that the psychodynamic perspective is better than CBT, only that in a realm as complicated as the mind, where positions taken may ultimately reflect different values, irrespective of research evidence, there needs to be diversity, rather than hegemony of thought.

In the chapter which follows, Alun Jones presents an overview of his research project, investigating the impact of clinical supervision on a small group of palliative care nurses. The last chapter, by Mic Rafferty, considers how clinical supervision may help nurses think in a psychodynamic way about their work and it offers a model derived from the work of Winnicott (Rafferty 2000) to make sense of the process of supervision.

In the chapters that follow all patients’, relatives’ and other members of staff’s names have been changed, to protect confidentiality.

References

Barnes, E. ed. (1968). Psychosocial Nursing: Studies from the Cassel Hospital, London: Tavistock Publications.

Barnes, E., Griffiths, P., Ord, J. and Wells, D. eds. (1998). Face to Face with Distress: The Professional Use of Self in Psychosocial Care, Oxford: Butterworth Heinemann.

Dartington, A. (1993). ‘Where angels fear to tread: idealism, despondency and inhibition in thought in hospital nursing.’ Winnicott Studies 7 (Spring): 21–41.

de Raeve, L. (1998). ‘Maintaining integrity through clinical supervision.’ Nursing Ethics 5(6): 486–96.

Fabricius, J. (1991). ‘Running on the spot or can nursing really change?’ Psychoanalytic Psychotherapy 5 (2): 97–108.

Fabricius, J. (1995). ‘Psychoanalytic understanding and nursing: a supervisory workshop with nurse tutors.’ Psychoanalytic Psychotherapy 9 (1): 17–29.

Goldie, L. (2005). Psychotherapy and the Treatment of Cancer Patients: Bearing Cancer in Mind, London: Routledge.

Hinshelwood, R.D. and Skogstad, W. eds. (2000). Observing Organisations: Anxiety, Defence and Culture in Health Care. London: Routledge.

Kenney, J.W. (2001). Philosophical and Theoretical Perspectives for Advanced Nursing Practice, Boston: Jones and Bartlett.

Obholzer, A. and Zagier Roberts, V. eds. (1994). The Unconscious at Work: Individual and Organizational Stress in the Human Services. London: Routledge.

Rafferty, M.A. (2000). ‘A conceptual model for clinical supervision in nursing and health visiting based upon Winnicott’s (1960) theory of the parent-infant relationship.’ Journal of Psychiatric and Mental Health Nursing 7 (2): 153–61.

Terry, P. (1997). Working with the Elderly and their Carers: A Psychodynamic Approach, Houndmills, Basingstoke: Palgrave

Part I

Theory

Chapter 1

The nature of the unconscious

Louise de Raeve

Introduction

Nurses are well used to caring for unconscious patients and they may be observant of the fact that some unconscious patients sometimes give indications of mental life, such as dreaming. Indeed on regaining consciousness, patients will sometimes recall that, while they were aware of things happening to them and around them, they thought they were somewhere other than a hospital, on board a ship for example (personal communication). It is not, however, this idea of unconsciousness that is the focus of this chapter. Instead I aim to present some aspects of a theory of the mind which has a specific conception of ‘the unconscious’. This theory of mind was created by Sigmund Freud and his associates in the early days of the development of psychoanalysis, towards the end of the nineteenth century and the beginning of the twentieth century (Freud 2001). As Laplanche and Pontalis state: ‘If Freud’s discovery had to be summed up in a single word, that word would without doubt have to be unconscious’ (Laplanche and Pontalis, 1988, p. 474). Despite its long history, this view of the mind, while disputed by some, has many adherents. Eric Kandel, who won the 2000 Nobel Laureate in Physiology or Medicine stated that ‘psychoanalysis still represents the most coherent and intellectually satisfying view of the mind’ (Kandel 1999). In what follows in this chapter, I hope to be able to demonstrate how such ideas may usefully illuminate nurse– patient relationships, although it may take the content of the whole book to demonstrate how this knowledge can also enhance the opportunity that nurses have to nurse well.

Freud (2001) spoke about ‘conscious’, ‘pre-conscious’ and ‘unconscious’ aspects of the mind. What is conscious is all the thoughts and feelings that we have, that we are aware of. The ‘preconscious’ is just below the surface, it contains things we might be about to become aware of and dreaming may feature here. The ‘unconscious’ is a surmised part of mental life that we are not able to be aware of directly. Such descriptions tend to make these aspects of the mind sound as if they are entities which have a geographical location. This would be to misunderstand that primarily, they are metaphors and hypotheses that are trying to first describe and then to explain our mental life. Having a mind at all is dependent upon having a brain and a body in which it can be located. Current ideas would locate the basis of the ‘unconscious’ in the right hemisphere of the brain and the conscious mind in the left hemisphere (Mollon, 2000, p. 63, citing Schore, 1993) but this is not the same as saying the mind equals the brain; it is a different sort of ‘thing’ and actually not a ‘thing’ at all. Failing to distinguish this would lead to what Ryle called a category mistake (Ryle, 1963). For the purpose of this chapter, it is more useful to think of the ‘unconscious’ as a dynamic force in the mind, which sometimes enhances and sometimes undermines conscious mental life. By definition, it is unknowable in its totality but rather as a jet leaves a trail in the sky, the ‘unconscious’ may leave evidence of its presence: evidence which can then be interpreted.

Mollon (2000, p. 5) suggests that the idea of unconscious motivation ‘is an inference that provides an explanation for the gaps and distortions in our consciousness’. One such gap would be the distinction that can sometimes occur between what we consciously intended to do or say and what we actually end up doing or saying. This gap can be amusing or embarrassing, depending on the circumstances, but it is always baffling until the unconscious symbolism of what has taken place can be grasped. Sometimes this is not far from our conscious awareness and, as Mollon suggests, it may be best to think of gradations of consciousness, rather than of an absolute, impermeable distinction between what is conscious and unconscious. A colleague provided this example of a slip of the tongue: ‘Cynical supervision’ instead of ‘clinical supervision’. One might say this is a mistake with no meaning but if it were the case that the speaker was cynical about the benefits of supervision, one might conclude that this had been unconsciously revealed by the slip of the tongue. If one finds it slightly amusing, the question arises as to why! Supervision provokes mixed feelings in people and such humour works by revealing what may hitherto have been covert. We laugh in recognition.

Another illustration of unconscious activity is ‘forgetting’. This can be understood as an ‘active process which usually serves some [unconscious] personal purpose’ (McGhie, 1979, p. 145).

… I had an argument with a colleague during which I said something which, unknown to me, both hurt and annoyed my friend. A few days later I asked to borrow a book which he had at home. Although he prided himself upon an excellent memory he nevertheless forgot to bring the book on three consecutive mornings (McGhie, 1979, p. 146).

He goes on to observe that ‘A similar explanation is often applicable when we forget appointments with people whom we dislike or to whom we feel hostile’ (McGhie, 1979, p. 146). One can see from these illustrations that unconscious processes have a tendency to break through unbidden into conscious mental life. In the previous examples, enactments (slips of the tongue, forgetting etc.) can also be understood as unconscious communications. We can experience these ‘breakthroughs’ as amusing, embarrassing, frightening, baffling, illuminating and so on, depending on the circumstances. What they have in common is that their expression bypasses ordinary conscious thought and it is only later, upon reflection, that we may ‘catch-up with ourselves’, as it were.

Mollon (2000) gives a helpful analogy of his own to try and describe what the relationship might be between the conscious and unconscious areas of the mind:

Consciousness could be compared to what is visible on a computer screen. Other information could be accessed readily by scrolling down the document or switching to a different ‘window’. This would be analogous to the conscious and the preconscious parts of the mind. However, some files on the computer may be less easily explored. They may have been encrypted or ‘zipped’, or they may require a password or are in other ways rendered ‘access denied’. Some may also have been corrupted, so that information is scrambled and thereby rendered incomprehensible. (Mollon 2000, pp.8–9, citing Freud 1923)

Freud would not have been familiar with computers, as he died long before their arrival in the public domain but the metaphor of something being ‘encrypted’ or ‘zipped’ or with ‘access denied’ is to try and convey the inaccessibility of the unconscious to our conscious mind. It was Freud’s view that the unconscious is formed of repressed material, impressions and experiences that have been expelled from consciousness. Some of what is expelled may be simply obsolete but some consists of experiences that would be too disturbing to recall in their entirety. Everybody would have these experiences, not just those people who have had very traumatic childhoods. This is because what counts as disturbing to an infant may be to do with inner, rather than outer reality, or to do with the uniqueness of the weave between the two, for any given individual.

This idea of dynamic, unconscious mental life was not popular with those who wished to retain a view that the human adult was largely in charge of his/her own life. In the free will versus determinism debate, it weighs in heavily on the side of determinism, or at least it appears to. Interestingly, a therapeutic goal of psychoanalysis would be to bring the unconscious mind into better communication with the conscious self, so that there is greater opportunity for interplay between these two aspects of mind and thus an enhancement of individual creativity, imagination and free will. Seen this way, psychoanalysis is committed to individual liberation.

The social and cultural impact of there being ‘conscious’ and ‘unconscious’ aspects of the mind has been far reaching. Expressionism and Surrealism in fine art can be seen as related to a culture where there is an interest in ‘the unconscious’ and this influence has also permeated theatre, where plays like Peter Shaffer’s (2006) ‘Equus’ (originally published in 1973) make explicit reference to unconscious motivation and symbolism. To bring this influence closer to health care, consider how common it is to talk about ‘denial’ when somebody who is recently bereaved seems to behave partially or totally as if they were not. Yet this is an idea of an unconscious defence (nobody decides to deny, it just happens) against intolerable levels of anxiety and emotional pain, in this case, the death of a loved one. One could not talk of ‘denial’ without a conception of the unconscious underpinning it. Such denial is protective but also worrying to friends of the bereaved if it goes on too long, since a person using that defence is impaired in their ability to adapt to reality (there has been a death). Complete denial in such circumstances is rare but most of us will have encountered partial denial in ourselves and others in such circumstances. It is also possible to help someone move from this position to a greater grasp of the reality but not by pointing out the irrationality of their perception of events, since to do so would imply a failure to grasp that this is an unconscious process. Only by bearing with such a person how intolerably painful their situation feels, might one slowly be able to help them to face the reality that has befallen them.

Relevance to nursing

Relevance to nursing

Working with death and bereavement is a common occurrence for nurses and it is not surprising that several of the case study chapters, which follow this section, focus on this theme. A broader provenance for such ideas, however, and more specifically, for the idea of unconscious phenomena, lies in the illumination they can offer to help explain ordinary, as well as difficult nurse–patient interactions in any nursing context.

It may be remembered that in the 1970s and 1980s, when nursing research was in its infancy but being developed by a few feisty pioneers, several uncomfortable studies emerged which examined nurse–patient interactions: Felicity Stockwell (1972) for instance, with her research on the ‘Unpopular Patient’; Jill Macleod Clark (1981) with her work which explored how nurses ‘block’ communication from patients. The trouble with these studies is that while they indicated serious problems in nurse–patient relationships, with the suggestion that something needed to change, they were thin on theory and hence on any substantial explanatory story which might have helped lead to a solution. At best they indicated some need for change in nurse education and at worst, they induced a sense of guilty helplessness in nurses, who recognised themselves in such accounts, did not wish to behave this way and yet found that they did. The educative response is valuable but inadequate in isolation, because it fails to grasp the power of what is taking place. This ‘gap’ between what nurses consciously want to see themselves doing and the reality of what they find themselves doing is, I believe, helpfully bridged by the idea of the unconscious. To assume that one can master unconscious forces by education is delusional, since it assumes that primitive impulses (such as love, hate, fear, lust) can be checked and mastered by appeal to rational argument. In fact, a purely educative approach is likely to broaden the gap between the nurse’s vision of an ideal nurse-self and the reality of the nurse she discovers herself to be in practice. Fairbairn and Mead (1990) refer to this sense of dissonance as a ‘a loss of innocence’. If nursing as an institution offers no way forward to help to narrow this gap, nurses cannot be blamed for trying to desensitise themselves from perceiving it. It may be simply too painful to do otherwise.

Preceding the era of Stockwell’s and Macleod Clark’s research, Isabel Menzies Lyth (1988) wrote her seminal paper: ‘The functioning of social systems as a defense against anxiety’, the first version of which appeared in 1959. Whilst this research and ensuing papers contributed to ensuring Menzies Lyth’s fame as a psychoanalytical social scientist, it seemed to leave mainstream nursing largely untouched. We couldn’t seem to hear what she had to say, partly I think because we did not understand it and partly because we were frightened that we were being criticised and found wanting. However, in my reading of this paper, there is much that is compassionate and insightful about both the unconscious worlds of nurses and their patients and how these may interact. Menzies Lyth points out that nursing is very difficult work:

Patients and relatives have very complicated feelings towards the hospital, which are expressed particularly and most directly to nurses, and often puzzle and distress them. Patients and relatives show appreciation, gratitude, affection, respect; a touching relief that the hospital copes; helpfulness and concern for nurses in their difficult task. But patients often resent their dependence; accept grudgingly the discipline imposed by treatment and hospital routine; envy nurses their health and skills; are demanding, possessive and jealous. Patients, like nurses, find strong libidinal and erotic feelings stimulated by nursing care, and sometimes behave in ways that increase the nurses’ difficulties: for example by unnecessary physical exposure. Relatives may also be demanding and critical, the more so because they resent the feeling that hospitalisation implies inadequacies in themselves. They envy nurses their skill and jealously resent the nurse’s intimate contact with ‘their’ patient (Menzies Lyth, 1988, p. 48).

Some of these feelings and reactions will be consciously expressed and consciously perceived and understood by others but they may also be defended against unconsciously, because of their disturbing quality. Such feelings may then emerge in distorted and unexpected ways which can puzzle and disturb other people. For instance, a patient’s relative may find fault with the nurses because of feelings of inadequacy and guilt on his/her part. The nurses may see nothing in their own care of the patient that would give reasonable cause for the relative’s annoyance. Such nurses may become puzzled and flustered and, then feeling unjustly accused, become angry. It is likely to be helpful to the nurses at this point, if they have some understanding of what might be going on, because they then have more responses in their repertoire than simply an angry reaction or the stifling of anger. The options might include tolerating the accusations because of knowing that sharing the patient can be very difficult for relatives, or it might be openly acknowledged that today the relative really seems to need to find fault with the nurses, or someone might comment that it must be very hard being the relative who until now did all the care required and suddenly finds themselves faced with nurses who have taken it over. Some nurses might still feel angry and say so but there are reasons why this may not be the most helpful reaction. To understand this, one has to consider the role of anxiety and unconscious defences against it. At some semi-conscious level, the relative may know that their accusations are unfair but if nurses become defensive and angry in response, this becomes a justification for the relative’s anger to continue and possibly intensify. Nothing is understood, nothing resolved and it is likely that in future, nurses will try to avoid that relative as much as possible. Fighting is often preferable to facing the pain and guilt of helplessness and uselessness but if deeper feelings are faced, creative solutions may emerge. Both nurses and relatives may actually share intense anxiety in the face of their mutual helplessness, concerning the needs of some patients. Avoiding facing this may lead nurses to seek to be the all-important carer, thereby rendering relatives more useless than is necessary.

The ‘blocking’ that Macleod Clark (1981) drew attention to in her research needs to be understood, not as the ignorant responses of nurses who need to be educated to know better but as a semi-conscious, sometimes unconscious response to anxiety. Macleod Clark was familiar with the work of Menzies Lyth but she cannot square how it can be that nurses seemed to ‘block’ communication from patients, in situations that were not apparently stressful. Her suggestion is that ‘the nurse was behaving in an automatic way simply from habit’ (Macleod Clark, 1981). The solution to a bad habit is presumably some notion of breaking the habit, through example and training but this overlooks the possibility that such behaviour is