Below is a lecture by Paul Cavisiton given to his peers in 2007 reflecting on a period in his practice as Lead Consultant at Brookside, a residential child and adolescent mental health in patient unit in London. I found this very insightful in my research for Confinement and he has agreed to allow me reproduce it here.
VIOLENCE AND HOSPITALITY; THE (IM)POSSIBILITY OF MAINTAINING A THERAPEUTIC CULTURE IN AN ACUTE PSYCHIATRIC SETTING
Overview
The Institution threatened by violence can temporarily lose its authority to an external source such as the police & the mind pre-occupied with violence leaves little space for optimism & change. This paper lays out a framework for thinking about these matters & the re-clamation of Hope.
INTRODUCTION
I hope to create a meaningful link between my personal journey and the journey of the service called Brookside for which I am the Lead Consultant Psychiatrist. The journey of the institution and my personal journey mirror each other in several ways. Both are characterised by loss and trauma and feelings of despondency &, hopelessness; & at other times feelings of omnipotence, grandiosity, and certitude. And hopefully at least occasional glimpses of mature reflective practice & the good life. I want to illustrate how the hospitable mind can become violated and inhospitable and similarly how the hospitable institution can become traumatised and consequently traumagenic that it also becomes violated and even violent. Although I won’t necessarily be referencing their ideas as I go along I will be drawing on concepts from Bion, Klein, the work of the Tavistock Clinic and Institutions Workshop, Winnicott, & the Philadelphia Assoc. & Tom Main etc. I would like to end on a note of optimism by returning us to key ideas concerning Care, Hospitality, Community, Ordinariness, and Therapy – suggesting that this is a way forward even in the face of violence and violation.
FRAMEWORK
Before writing this paper, I bought several new textbooks and attempted to distill if not “Hoover up” a stockpile of knowledge, so that I would then have something valuable and worthwhile to present to you. This move grew out of a feeling that I had nothing to say. When I puzzled why this strange anxious nihilism had crept into my thinking, I realised that I was in far deeper water than I had previously recognised. So I will be hovering rather than “hoovering” around this idea of having something worthwhile to say (hope) and dealing with the tug or pull of malignant self criticism and despondency.
A key text for me over the years has been Homer’s Odyssey. I have been inspired by readings of this text which seek to relate the epic tale of the journeying hero to the experience of mental illness. In particular I have worked with ideas of hospitality and homecoming, which are major themes in The Odyssey and are also cornerstones of the work we do at Brookside. But what we learn from Homer’s epic is that homecoming can be a very bloody affair.
Recently I received several invitations to speak at meetings and it was always left open as regards to topic. I found myself repeatedly saying “violence” without much thought as to why I had chosen this. It was only when the dates were set & I began to write that I began to puzzle over my choice. Thinking about violence led me to think about violation. I felt my mind had become inhospitable to creative thoughts and the discourse around belonging, hope and the possibility of “a fresh start” I say fresh start to make a contrast with the language of NICE Guidelines Treatment & Cure. And so when I speak to you about Brookside, I would like to illustrate and discuss it in relation to the themes of violence, homecoming and hospitality.
Year in year out we have made significant changes such as increasing throughputs and extending bed numbers, establishing a day patient service as well as an outreach team, and are dealing with more recent pressures to develop immediate admission services to all under eighteens, twenty four hours a day, a so-called one big tent model. We have moved from an institutionally led agenda with a fixed therapy menu and a one year waiting list to a patient centred agenda with individualised treatment pathways. Previous changes were driven by us the staff but increasingly the demands of a top down managerial agenda predominate & I will return to this later.
Our Chief Executive Officer often takes visiting dignitaries to the Trust to view Brookside and it is seen as a showcase enterprise and I can always be relied upon to talk up the project and therefore the Mental Health Trust in general.
So why was it that at a moment of expansion and growth and an invitation to talk with you here in Dublin did I begin to feel an unpleasant sense of dread about personal “burn out”.
Part of the problem is that I ate, slept and proverbially drank Brookside all this time. For years doing one in two cover and more laterally one in three consultant cover. We have had our moments in the sun, for instance we were runners up in a national competition called Hospital Doctor Of The Year and attended the Awards Ceremony with dinner and stretch limos to the Dorchester Hotel in 2002.
(Note here you want to say more about identification with the project
Also maybe joke about being in the business of families as opposed to the family business ****)
But more to the point, three years ago my dear friend and psychiatric colleague of twelve years unexpectedly dropped dead after exactly thirty years dedicated work in the NHS.
We had a sibling-like relationship. He was older by approximately five years and at times wiser. I was tougher, more confrontational and a change driver. Ali was more cautious and often initially opposed the changes that I introduced. But I was appointed as the Lead Clinician which inverted and nuanced the sibling rivalry, sometimes for the good and sometimes created long impasses.
But his death led to a huge psychic wound for me. At a point when I should be flag waving for the project, I felt I was shroud waving for myself.
I felt I had taken a hit, torpedoed below my emotional water line and was limping across a hostile ocean with no clear port of call. He was like an older brother who shielded me from some of the systemic and larger system politicking and bullying. But there was also a collusive and insular aspect to our relationship that tended to keep or push away the external professional networks. So without this shield I felt that the soul of the project was jeopardised. But I was puzzled as to the depth of my feelings as if my own soul was in jeopardy.
Lets rewind to 1982 and my first experience of East End psychiatry.
A very hot August day and I arrived on Connolly Ward (not James Connolly) but John, the early advocate of non-restraint and moral therapy. Here I was on the threshold of my chosen speciality. I was aware of a strange crackling sound as I stood on the ward entrance. Looking down I noticed that the vomit yellow coloured carpet was totally worn and congealed into a sticky black goo. Like a really squalid pub carpet.
This was followed by my puzzling why no one seemed to pay any attention to my arrival. The “floor” as we euphemistically called the ward space was entirely run by young student nurses and all the trained staff sat drinking coffee poring over the “off duty” rotas in the splendid sanctuary of the glass pan-opticon safely insulated from the patients. An emblematic moment. The first thing a parent or patient encountered was an absence of hospitality and a lack of welcome. This stayed with me throughout my training. I vowed that this would not be a feature of any service I would lead as a consultant.
Forward to 1994, I was appointed to Brookside as Lead Consultant.
It had been a psychoanalytic therapeutic community in the 1970’s and had gone into terminal decline. Even though it had a staff clearout and a refurbishment in 1990-1992, the ghosts of its insularity and isolation still prevailed.
The entrance was not clearly marked and inside, you found yourself in a dark, unwelcoming reception area totally enclosed with no natural light and served by a small hatch from the secretaries’ office.
One of the psychologists told the story of his first day at work the year before I arrived. No one answered the bell and when he walked around the back of the building and knocked on a window to a room in which the staff were obviously meeting, no one responded to him. Perhaps they thought he was a wandering adult psychiatric patient best ignored. He actually went home and rang head office. So no obvious welcome and no obvious hospitality.
When I started we had eight patients and a legacy of riots and violence with young adolescent patients. My first consultant colleague, Tim, died of cancer in his late thirties a few months after I arrived. Somewhat sadistically, just before he died he gave me his set of office keys and dangling them in front of me he said “they’ll suck the life out of you, you know”.
So fast forward to 2007, 13 years and two dead colleagues later I found myself wondering if the life was being sucked out of me. More recently I became preoccupied and anxious about whether I would survive or whether it would also kill me. It didn’t help in this last year when two of my long term teaching colleagues developed cancer, breast and prostate respectively.
All in all it’s pitched me back to the couch three times a week. But it has allowed me to feel how close to burnout I can get (sail). Right at the edge of the precipice and you know almost willing myself to jump into the chasm. By that I mean a manic coping. Being so busy, too busy to think but feeling increasingly despondent as if my “soul” is in jeopardy and not just the project. But I have jumped too far forward. To understand what’s happened I need to tell you more about Brookside and our Model of Therapy.
MODEL OF THERAPY
If the subjective experience of illness is:
To be in bits
If we are lost then our language lends itself to the imagery of journeying, voyaging and travelling. Relationships act as a Transit (a sailing metaphor for finding a bearing). Companionship and accompaniment allows making a bearing in a new direction.
WHAT IS OUR MODEL OF THERAPY?
This involves the following components:
All these concepts interweave with one another
CARE
Jon Stokes in an article entitled “Institutional Chaos and Personal Stress” commented that “when the medical model of cure is transferred to psychiatry, the result can often be a denigration of ordinary care, often the only hope for the extremely mentally ill. What is idealised is the latest fashion in cure, which comes along one after another with manic rapidity. Care is a slow process not dramatic and is denigrated as ineffective, whereas cure which is exciting and offers a defence of omnipotent denial of the chronic nature of the problems, (and so Cure) is Idealised”.
The underlying unconscious “organisation in the mind” is one of a powerful cure for all mental illness and hence each failure to do so is a threat to the identity and sense of effectiveness of each individual member of staff.
WELCOME THE COMING AND SPEED THE GOING
This is a phrase we quote from Homer’s Odyssey, and use a lot at Brookside. It speaks of a code of conduct that insists upon an ethical obligation to welcome and protect strangers as they take a rest on their journey through an often treacherous world.
It is helpful because it metaphorically connects to the subjective experience of illness
HOSPITALITY
Once again quoting the Odyssey, “when all desire for food and drink is set aside there is an invitation to tell the story”, so the same order of priorities exists at Brookside. First there is shelter, food, warmth, the offering of a place, and then there are welcomes and introductions to all young people and staff. These are the corner stones of relationships at Brookside.
The arrangements are governed by ordinary human etiquette alongside the usual procedure of an admission into an inpatient setting. Careful attention is paid to the provision for young people of their own room, and to such matters as personalising the décor and their bedding; there is a strong emphasis on the centrality of eating together and on the preparation of food in general.
THE ORDINARY
We continue for the length of their stay to emphasise the ordinary and day to day life is anchored in rituals and a series of events and landmarks. There are the rituals of arrivals and leavings, marked with special meals and gifts, formal introductions of visitors, celebrations of birthdays, achievements and major festivals during the year, holidays away from the unit, the school timetable and exams to be sat for and certificates granted. The quality of life of the community matters in a simple way just as the quality of life you might argue ought to matter in a family household. The hospitality reflects the complexity of the culture within which we are embedded. It is an ethical position subject to different ‘takes’ and is not to be confused with the corporate hospitality training of call centres where it is a procedure that can be prescribed.
COMMUNITY & HOMECOMING
Another favourite quote of mine
‘If a person turns from the loneliness and despair of his or her alienation towards a community of fellow beings, turns towards the possibility of some re-orientation into the generative matrix of communal/community life – does this turning not suggest the notion of a homecoming. So if thinking of the ‘other’ is a form of hospitality so hospitality allows and facilitates homecoming.’
HOMECOMING
In the Odyssey homecoming also involved the Slaughter in the Halls, where Odysseus had to kill the predatory suitors who had gathered around his palace. We recognise that for our patients homecoming means encountering and dealing with multiple traumata: The trauma of the illness itself; Abuse and neglect; Stigma of mental illness; Isolation and a feeling of dereliction. This can be brutal, violent and frightening.
We understand that symptoms function as help seeking behaviours and lead the patient to a point of safety. Disclosure of, for example, sexual abuse involves facing up to traumata, and re-exposes the patient to overwhelming anxieties and the further production of symptoms. What I call the alpha loop - Going around and around endlessly. We try to develop a containing nurturing space that is safe. In our jargon this space is called the ‘milieu’. This is a form of Hospitality, which allows belonging such that healthy longing can be expressed.
Community & Milieu
The milieu is the encounter between two large groups approximately thirty patients and fifty staff.
The milieu is also our attempt to understand the complex interrelationships between these two groups.
The milieu is predicated on the ideas of containment, growth, development and change.
Brookside is a managed therapeutic environment run by the adults. It is a dense ecology of relationships with two basic aims, firstly providing “something that cannot be achieved on an outpatient basis” and secondly to return the youngster to their family, school and community.
We talk about coming in the psychiatric door and leaving by the educational door.
Psychotherapy
We use ordinary language to make sense of our psychotherapeutic endeavours and overtly welcome and help young people find their place as opposed to being put in their place. They are introduced to the Brookside story through a guide written by young people for young people which they can download on the website and each young person has an individualised timetable of group activities, individual therapies, educational activities and family and ordinary adolescent recreational opportunities. The school is utterly central to our model in kick starting the epistemophilic drive. If therapy is conceived as “a doing to” as in instrumental psychiatry and psychoanalysis as “a being with”. There is also a hybrid position of a “doing with”. Now we do all three all the time.
Without talking overtly about Bowlby, Winnicott, Bion, Klein, Freud, we use a language that talks about belonging such that a young person can begin to give expression to their longings. We need to get to know who the young person is and not only what’s wrong with them.
This necessitates that we are clear between calculative thinking and meditative thinking. We create openings between staff and young people in a myriad of ways whether it is over lunch, beside the table tennis and pool table, in school or in formal therapy sessions, these openings allow and foster openness.
Hopefully this gives rise in the young person to a sense of groundedness and sure footedness and this is what we call having a place to come from.
Psychotherapy & Homecoming
Therapy aims to facilitate a form of homecoming “being at home”
We are looking to move young people from gangs and gangs in the mind to groups where mutuality and love can be fostered. Where there is the possibility of authority without authoritarianism.
For our patients there is a fear of thinking, of having a viewpoint as it reminds them of their trauma, and desolation. Cutting, burning, poisoning occurs in young people who cannot accept the value of a new sexual body and a new inner self. One way to attack thinking and linking is the following, “I’m bored, I’m empty, I forget, I don’t know”.
Staff use their thoughtfulness to bring together the patient’s experiences in a vital and alive way. The staff communicate hope, change, survivability and the capacity to regenerate and not be destroyed by the thoughts and emotions and actions of the patients and their families.
Ordinariness and hospitality allows a genuine sense of commonality to emerge between the staff, young people and their families and that is the place to begin to rebuild lives – or so the theory goes. As I have already hinted it is not all plain sailing
THE QUENTIN TARANTINO WEEK
Now this piece conveys what I felt when I was writing this paper. On reflection it may sound a bit melodramatic. It not designed to shock as you all probably deal with tough in-patient dilemmas all the time.Its a very partial view as many positive things were also happening at the same time but I couldn’t see past my own pre-occupations.
It never fails to amaze me how institutional projects such as mine occasionally judder to a halt. Remain stationary in some sort of executive limbo, with little evidence of decision making happening.
Now what prompted the title of the talk, in addition to what I have previously alluded to (bereavement, despondency, illness) was one particular week in August that began with a discharge planning meeting involving a young man. His mother casually asked him for his house keys and then, cruelly told him that he was now homeless and she walked out... He proceeded to smash several windows and break a chair and leave us in quite a predicament.
Perhaps it the was time of year. Annual holidays, summertime, we all want to be on leave (our minds are elsewhere), plus the heat but that inaugurated a set of events that continued through the week.
Another fourteen year old was behaving aggressively and his diabetes was bizarrely not fitting any clear patterns. Blood sugars were veering wildly. The medical team sat around wondering whether he had an insulinoma. Journeys up and down to the A&E. A knife from the kitchen went missing, did he have it? A telephone call from his mother claimed that the boy had raped his twelve year old sister and made her pregnant. We finally figured out that he had stolen an insulin pen while in our treatment room but it was very traumatic for the staff and other young people when the police arrived to arrest him.
A day later, a seventeen year old young man with an acute psychotic illness and delusions centring on his circumcised penis, smashed up his bedroom. His dad refused to have him home but nonetheless fuelled his bizarre beliefs. The Dad downloaded Internet material about circumcision and psychosis and shouted at the staff, waving “Anti-Circumcision Pressure Group Leaflets” in our faces claiming it was all a mistake and that his son could be cured by rubbing hydrocortisone cream on his penis and pulling his foreskin to stretch it. A computer was stolen. When the police arrived yet again on the unit, he spontaneously blurted out “I haven’t seen the laptop” before any one had mentioned what had been stolen. This provided the leverage for the staff to move him out rather than any discussion about his well being. I felt as if my authority was undermined & passed to the Police.
The week continued with a fourteen year old boy with mild learning difficulties, possibly moving in and out of psychotic states. His foster carer requested a one week’s respite assessment as she thought he was “a bit paranoid”. One week into his admission she informed us that she didn’t want him back. On a quiet weekend on the unit he asked two healthcare assistants whether or not “they were paedophiles”. The healthcare assistants, perhaps already feeling the strain of the week, were very offhand and rude to him in a defensive manner. Taking no account that one of the other boys he was friendly with at Brookside had been raped anally when taken into care aged eight. So this boy’s fear of where he might end up became unacceptable, unpalatable, uncontainable and unthinkable to both parties and led to a standoff in the car park with yet again the police being involved due to his threats of violence.
The Quentin Tarantino week didn’t stop there. Three of the girls joined the uncontained toxic pleasure and excitement of the attack on all the values and the culture of Brookside.
One seventeen year old Zimbabwean girl who is a phenomenal football player came to us as she was threatening to throw herself under a train. The context was that her mother had died of AIDS She was brought to the UK to live with a maternal grandmother who had recently died and now her relatives wanted rid of her. She quickly showed a streetwise toughness that was not initially obvious at the time of the assessment. But her response to the uncontained violence and repeated violation of the unit was to claim that she had swallowed glass and she began throwing herself onto the ground. Brought to A&E she became uncooperative and walked out. Followed the next day by more histrionic behaviour. More blue lights. And no sooner had they arrived when she was up and about refusing any co-operation.
The Quentin Tarantino/Reservoir Dogs episode was concluded with more contagious “glass swallowing” from two much younger girls of thirteen and fourteen years. One had a violent alcoholic mother and the other caught in a tragic family set up where she claimed her dad raped her. She broke in through an open window of my consultant colleague’s office and with a marker wrote “you are a cunt” on his office wall.
This period of violent behaviour was unprecedented in Brookside not in terms of individual events but more in terms of the relentlessness within a brief timescale. I felt the authority of the Unit had been lost and had now become symbolised by the blue flashing lights of the police.
It rocked my stability, my sense of optimism and my sense that we had something of value to offer, the fresh start we talk about, a new beginning and hope for the future.
It was a moment of doubt for me. Was the whole project a failure, was I a failure, was it time to move on? And then that ghastly depressive certitude crept in, a feeling of burnout and uselessness and that “yes perhaps we are naïve, perhaps we are being utopian, perhaps we are caught up in some immature adolescent dream of ‘transformative change’.
But as I said earlier this doubt came to me at a time when the service was expanding and the demands on it to increase throughput, output, better outcomes and efficient disposal were greater than ever. Frighteningly de-humanising language but I don’t think I exaggerate.
You are probably quite rightly asking yourself at this point what happened to ‘the container’. Well, as it was August, we had a new SHO who promptly went off on leave, granted prior to his posting. Our long standing staff grade doctor who was an important anchor for the nursing team left for an SPR traineeship. We had absence followed by sickness and fragmentation in the staff group.
Two other significant changes happened at this period. The nurses were adjusting to the appointment of a new ‘modern matron’ (a man) who displaced a more traditional senior female nurse. Other colleagues wanted to resign with immediate effect citing illness, work stress and me as part of the problems.
So the staff container felt cracked from top to bottom with violence and destructiveness from the patient group spilling out in graphic fashion.
What should have been happening ,and wasn’t, was
the sharing of “the organisation in the mind”, sharing it in a coherent and optimistic way, putting as a priority the key belief that “we have something/many things of value” to offer to young people and families. That there was a value in “care” and “the going on of being”.
We were not coping with the attack on hospitality and the violation of the welcome offered . We had lost our sense of authority To use the language of Bion we had reverted to a basic assumption group.
WHAT IS THE TAKE HOME MESSAGE?
I am reminded of the image of ‘King Canute’ and him standing in the sea hand raised and the waves arising round him.
So at times acting with delusional omnipotence I thought I could solve it, stem the tide of the patient and staff craziness through my leadership alone and this I think is the path towards self-destruction and burnout. The other take on the ‘Canute’ story is that this is a wise king making a wise move and illustrating to his loyal subjects that he is a fellow human, heir to the same flesh as them and crazy to think he, could stop the waves.
At this point in time, it seemed or felt that the wave roar of the staff was akin to the Siren Voices
There was a collective amnesia, a forgetting of the past fifteen years of all the ups and downs. It felt like an attack on remembering, recollecting and gathering. There was no thinking, dwelling and lingering. Where was the thinking that acted as a form of homecoming and thus containment, security and safety?
Our staff model emphasises responsiveness and responsibility. Responsibility contains the Latin root, spondere which translates as a promise or to promise and re means again. In other words we promise again and again to attend, listen, think and accompany the patient despite our endless repetitive failings and forgetfulness. Why were we unable to do this? Was there something about our model of therapy which no longer worked?
STAFF MODEL
The team needs to facilitate the move from absorption in the narcissistic preoccupation with the inner world to a creative lived shared experience.
Violation & the Inconsolable
My predominant feeling was of inconsolability, entailing a loss of belief or value in the project & the youngsters. Secondly a lack of solidarity & working with colleagues. This gave rise to a growing desire to” pack it in”
There was a demand from staff & youngsters to get rid of the
mess immediately.
Now all this has happened before & will happen again.
But it triggered off memories of my early days as a trainee
Over the threshold of the gooey sticky carpet. I recalled coming to work & five landings in the Hospital were lined with Riot Police with batons & shields ready to re-claim the out of control wards. That was 1983 & Anthony Clare was our new Professor. We used to joke about being Psychiatric anaesthesiologists.
This was “a one tent model” that was brutal & dehumanising for all concerned. A model of Disposal if not Dispossession.
Gaston Bachelard comes to mind in The Poetics of Space ( 1969) when he says “ But the image has touched the depths before it stirs the surface”
So here was something that I thought was playing out in front of me that I thought I had left behind for good. The recurrent image of the filthy gooey black mess on the ward carpet. But I think it was me playing something out or me being played out by something.
But what “floored” me now was an additional reminder of quite painful childhood distress. I recognise in my work a powerful reparative urge- to set things right. It soothes my childhood distress.
But this childhood inconsolability now came back to bite me with a vengeance. A messy if not gooey inchoate anxiety which included a fear of also dropping dead like my colleagues or of becoming seriously ill before I could retire. Ones professional training usually act as a powerful shield against this distress.. I felt that I had lost another shield & and my sense of groundedness & sure-footedness. Trouble comes not single spies but whole battalions. So I think I contributed to the situation by being so despondent.
Now none more adolescent than adolescent staff for having unrealistic expectations mirroring adolescent dynamics, but this was not new in itself.
The familiar dynamics and battles between care and cure are well recognised and something we deal with every day. What I think added to the current difficulties was for me a new challenge, not of care or cure, but brutal and simple “disposal”.
It felt as if the message from a new management system was , “I don’t care if you can’t cure or treat or even offer a particular level of care, I want them off the A&E observation ward or the adult ward or off the street and I don’t care what the diagnosis is whether they are anorexic or violent and psychotic, just get them in and get them out of the way”. An arbitrary decision was made that every admission of an under eighteen year old patient to an adult ward, would be declared a serious untoward incident .
This has resulted in an unprecedented number of young people coming into the unit without the traditional induction process.
When our hospitality was attacked so very vigorously, we, the staff were drawn towards the jargon of our own disciplines and training and found ourselves talking about “processes, disclosures or even worse, the programme”.
We fell back on using The Mental Health Act, our language became dehumanised and we responded less and less with the context of our relationships in mind so that we acted in a more disconnected way using our powers as institutional custodians.
REBUILDING HOPE IN THE TEAM
Using psychoanalytic ideas it is possible to view some families as having suffered from an extremely poor early emotional environment and through idealisation and denigration of ordinary hospitality, they insist that no environment can look after them.
So what is the responsible way forward? How do we respond appropriately?
But responsibility is inherently dialogical and takes place in the ‘between’, in the relationship between staff and young people and their families.
At the heart of the project are two meetings, the community meetings which take place every day with Staff & young people. These are vigorous, alive and usually have very positive feedback and there is a staff meeting which has been very problematic. We have tried eleven different formats over the last five years to some avail .
Why is this the case?
Technical psychological ideas and talking in jargon can de-skill some members of the staff and make others feel omnipotent. Remembering the tradition of hospitality allows a genuine sense of commonality to emerge within the staff group and the young people. It takes a lot of effort to translate complex staff and patient dynamics into ordinary language and to embody those ideas in gestures of care that are intelligible to the patients and staff alike.
To quote from ‘The Renewal of Generosity: Illness, Medicine and How to live’ by Arthur Frank
‘Care is enacted in gestures that can console, far beyond what they accomplish as practical components of treatment. For touch to console and thus to heal it must be more than efficient. Touch must be generous, seeking contact with a person as much as it seeks to effect some task. Generosity is the resonance of touch, endowing the act with a capacity to give beyond its practical significance.’
Getting Going Again
I have been much helped by a trek to India, one to one time with an organisational consultant, my own analysis, writing this paper. Lake District & Berlin
We also pulled together senior colleagues & with more consultancy began sharing a more coherent, contained re-clamation of our philosophy & values. We re-claimed friendship & colleagueship. And the Tasks of Hope/Hospitality, Ordinariness Community, Therapy & Care
Perhaps in re-finding a sense of generosity again?
Adolescents expect a direct and genuine interpersonal contact even when they are themselves cut off and depressed. So staying with them at an Affective level and tuned to underlying unconscious themes is especially important but a difficult job on a busy psychiatric unit.
However it can be done, it needs to be done, it should be done and we will carry on doing it.
Paul Caviston Oct. 2007-10-31
Overview
The Institution threatened by violence can temporarily lose its authority to an external source such as the police & the mind pre-occupied with violence leaves little space for optimism & change. This paper lays out a framework for thinking about these matters & the re-clamation of Hope.
INTRODUCTION
I hope to create a meaningful link between my personal journey and the journey of the service called Brookside for which I am the Lead Consultant Psychiatrist. The journey of the institution and my personal journey mirror each other in several ways. Both are characterised by loss and trauma and feelings of despondency &, hopelessness; & at other times feelings of omnipotence, grandiosity, and certitude. And hopefully at least occasional glimpses of mature reflective practice & the good life. I want to illustrate how the hospitable mind can become violated and inhospitable and similarly how the hospitable institution can become traumatised and consequently traumagenic that it also becomes violated and even violent. Although I won’t necessarily be referencing their ideas as I go along I will be drawing on concepts from Bion, Klein, the work of the Tavistock Clinic and Institutions Workshop, Winnicott, & the Philadelphia Assoc. & Tom Main etc. I would like to end on a note of optimism by returning us to key ideas concerning Care, Hospitality, Community, Ordinariness, and Therapy – suggesting that this is a way forward even in the face of violence and violation.
FRAMEWORK
Before writing this paper, I bought several new textbooks and attempted to distill if not “Hoover up” a stockpile of knowledge, so that I would then have something valuable and worthwhile to present to you. This move grew out of a feeling that I had nothing to say. When I puzzled why this strange anxious nihilism had crept into my thinking, I realised that I was in far deeper water than I had previously recognised. So I will be hovering rather than “hoovering” around this idea of having something worthwhile to say (hope) and dealing with the tug or pull of malignant self criticism and despondency.
A key text for me over the years has been Homer’s Odyssey. I have been inspired by readings of this text which seek to relate the epic tale of the journeying hero to the experience of mental illness. In particular I have worked with ideas of hospitality and homecoming, which are major themes in The Odyssey and are also cornerstones of the work we do at Brookside. But what we learn from Homer’s epic is that homecoming can be a very bloody affair.
Recently I received several invitations to speak at meetings and it was always left open as regards to topic. I found myself repeatedly saying “violence” without much thought as to why I had chosen this. It was only when the dates were set & I began to write that I began to puzzle over my choice. Thinking about violence led me to think about violation. I felt my mind had become inhospitable to creative thoughts and the discourse around belonging, hope and the possibility of “a fresh start” I say fresh start to make a contrast with the language of NICE Guidelines Treatment & Cure. And so when I speak to you about Brookside, I would like to illustrate and discuss it in relation to the themes of violence, homecoming and hospitality.
Year in year out we have made significant changes such as increasing throughputs and extending bed numbers, establishing a day patient service as well as an outreach team, and are dealing with more recent pressures to develop immediate admission services to all under eighteens, twenty four hours a day, a so-called one big tent model. We have moved from an institutionally led agenda with a fixed therapy menu and a one year waiting list to a patient centred agenda with individualised treatment pathways. Previous changes were driven by us the staff but increasingly the demands of a top down managerial agenda predominate & I will return to this later.
Our Chief Executive Officer often takes visiting dignitaries to the Trust to view Brookside and it is seen as a showcase enterprise and I can always be relied upon to talk up the project and therefore the Mental Health Trust in general.
So why was it that at a moment of expansion and growth and an invitation to talk with you here in Dublin did I begin to feel an unpleasant sense of dread about personal “burn out”.
Part of the problem is that I ate, slept and proverbially drank Brookside all this time. For years doing one in two cover and more laterally one in three consultant cover. We have had our moments in the sun, for instance we were runners up in a national competition called Hospital Doctor Of The Year and attended the Awards Ceremony with dinner and stretch limos to the Dorchester Hotel in 2002.
(Note here you want to say more about identification with the project
Also maybe joke about being in the business of families as opposed to the family business ****)
But more to the point, three years ago my dear friend and psychiatric colleague of twelve years unexpectedly dropped dead after exactly thirty years dedicated work in the NHS.
We had a sibling-like relationship. He was older by approximately five years and at times wiser. I was tougher, more confrontational and a change driver. Ali was more cautious and often initially opposed the changes that I introduced. But I was appointed as the Lead Clinician which inverted and nuanced the sibling rivalry, sometimes for the good and sometimes created long impasses.
But his death led to a huge psychic wound for me. At a point when I should be flag waving for the project, I felt I was shroud waving for myself.
I felt I had taken a hit, torpedoed below my emotional water line and was limping across a hostile ocean with no clear port of call. He was like an older brother who shielded me from some of the systemic and larger system politicking and bullying. But there was also a collusive and insular aspect to our relationship that tended to keep or push away the external professional networks. So without this shield I felt that the soul of the project was jeopardised. But I was puzzled as to the depth of my feelings as if my own soul was in jeopardy.
Lets rewind to 1982 and my first experience of East End psychiatry.
A very hot August day and I arrived on Connolly Ward (not James Connolly) but John, the early advocate of non-restraint and moral therapy. Here I was on the threshold of my chosen speciality. I was aware of a strange crackling sound as I stood on the ward entrance. Looking down I noticed that the vomit yellow coloured carpet was totally worn and congealed into a sticky black goo. Like a really squalid pub carpet.
This was followed by my puzzling why no one seemed to pay any attention to my arrival. The “floor” as we euphemistically called the ward space was entirely run by young student nurses and all the trained staff sat drinking coffee poring over the “off duty” rotas in the splendid sanctuary of the glass pan-opticon safely insulated from the patients. An emblematic moment. The first thing a parent or patient encountered was an absence of hospitality and a lack of welcome. This stayed with me throughout my training. I vowed that this would not be a feature of any service I would lead as a consultant.
Forward to 1994, I was appointed to Brookside as Lead Consultant.
It had been a psychoanalytic therapeutic community in the 1970’s and had gone into terminal decline. Even though it had a staff clearout and a refurbishment in 1990-1992, the ghosts of its insularity and isolation still prevailed.
The entrance was not clearly marked and inside, you found yourself in a dark, unwelcoming reception area totally enclosed with no natural light and served by a small hatch from the secretaries’ office.
One of the psychologists told the story of his first day at work the year before I arrived. No one answered the bell and when he walked around the back of the building and knocked on a window to a room in which the staff were obviously meeting, no one responded to him. Perhaps they thought he was a wandering adult psychiatric patient best ignored. He actually went home and rang head office. So no obvious welcome and no obvious hospitality.
When I started we had eight patients and a legacy of riots and violence with young adolescent patients. My first consultant colleague, Tim, died of cancer in his late thirties a few months after I arrived. Somewhat sadistically, just before he died he gave me his set of office keys and dangling them in front of me he said “they’ll suck the life out of you, you know”.
So fast forward to 2007, 13 years and two dead colleagues later I found myself wondering if the life was being sucked out of me. More recently I became preoccupied and anxious about whether I would survive or whether it would also kill me. It didn’t help in this last year when two of my long term teaching colleagues developed cancer, breast and prostate respectively.
All in all it’s pitched me back to the couch three times a week. But it has allowed me to feel how close to burnout I can get (sail). Right at the edge of the precipice and you know almost willing myself to jump into the chasm. By that I mean a manic coping. Being so busy, too busy to think but feeling increasingly despondent as if my “soul” is in jeopardy and not just the project. But I have jumped too far forward. To understand what’s happened I need to tell you more about Brookside and our Model of Therapy.
MODEL OF THERAPY
If the subjective experience of illness is:
To be in bits
- To be all over the place
- To be gone
- To be shattered
- To be unhinged
If we are lost then our language lends itself to the imagery of journeying, voyaging and travelling. Relationships act as a Transit (a sailing metaphor for finding a bearing). Companionship and accompaniment allows making a bearing in a new direction.
WHAT IS OUR MODEL OF THERAPY?
This involves the following components:
- Care
- Hospitality
- Ordinariness
- Community & Homecoming
- Psychotherapy
All these concepts interweave with one another
CARE
Jon Stokes in an article entitled “Institutional Chaos and Personal Stress” commented that “when the medical model of cure is transferred to psychiatry, the result can often be a denigration of ordinary care, often the only hope for the extremely mentally ill. What is idealised is the latest fashion in cure, which comes along one after another with manic rapidity. Care is a slow process not dramatic and is denigrated as ineffective, whereas cure which is exciting and offers a defence of omnipotent denial of the chronic nature of the problems, (and so Cure) is Idealised”.
The underlying unconscious “organisation in the mind” is one of a powerful cure for all mental illness and hence each failure to do so is a threat to the identity and sense of effectiveness of each individual member of staff.
WELCOME THE COMING AND SPEED THE GOING
This is a phrase we quote from Homer’s Odyssey, and use a lot at Brookside. It speaks of a code of conduct that insists upon an ethical obligation to welcome and protect strangers as they take a rest on their journey through an often treacherous world.
It is helpful because it metaphorically connects to the subjective experience of illness
HOSPITALITY
Once again quoting the Odyssey, “when all desire for food and drink is set aside there is an invitation to tell the story”, so the same order of priorities exists at Brookside. First there is shelter, food, warmth, the offering of a place, and then there are welcomes and introductions to all young people and staff. These are the corner stones of relationships at Brookside.
The arrangements are governed by ordinary human etiquette alongside the usual procedure of an admission into an inpatient setting. Careful attention is paid to the provision for young people of their own room, and to such matters as personalising the décor and their bedding; there is a strong emphasis on the centrality of eating together and on the preparation of food in general.
THE ORDINARY
We continue for the length of their stay to emphasise the ordinary and day to day life is anchored in rituals and a series of events and landmarks. There are the rituals of arrivals and leavings, marked with special meals and gifts, formal introductions of visitors, celebrations of birthdays, achievements and major festivals during the year, holidays away from the unit, the school timetable and exams to be sat for and certificates granted. The quality of life of the community matters in a simple way just as the quality of life you might argue ought to matter in a family household. The hospitality reflects the complexity of the culture within which we are embedded. It is an ethical position subject to different ‘takes’ and is not to be confused with the corporate hospitality training of call centres where it is a procedure that can be prescribed.
COMMUNITY & HOMECOMING
Another favourite quote of mine
‘If a person turns from the loneliness and despair of his or her alienation towards a community of fellow beings, turns towards the possibility of some re-orientation into the generative matrix of communal/community life – does this turning not suggest the notion of a homecoming. So if thinking of the ‘other’ is a form of hospitality so hospitality allows and facilitates homecoming.’
HOMECOMING
In the Odyssey homecoming also involved the Slaughter in the Halls, where Odysseus had to kill the predatory suitors who had gathered around his palace. We recognise that for our patients homecoming means encountering and dealing with multiple traumata: The trauma of the illness itself; Abuse and neglect; Stigma of mental illness; Isolation and a feeling of dereliction. This can be brutal, violent and frightening.
We understand that symptoms function as help seeking behaviours and lead the patient to a point of safety. Disclosure of, for example, sexual abuse involves facing up to traumata, and re-exposes the patient to overwhelming anxieties and the further production of symptoms. What I call the alpha loop - Going around and around endlessly. We try to develop a containing nurturing space that is safe. In our jargon this space is called the ‘milieu’. This is a form of Hospitality, which allows belonging such that healthy longing can be expressed.
Community & Milieu
The milieu is the encounter between two large groups approximately thirty patients and fifty staff.
The milieu is also our attempt to understand the complex interrelationships between these two groups.
The milieu is predicated on the ideas of containment, growth, development and change.
Brookside is a managed therapeutic environment run by the adults. It is a dense ecology of relationships with two basic aims, firstly providing “something that cannot be achieved on an outpatient basis” and secondly to return the youngster to their family, school and community.
We talk about coming in the psychiatric door and leaving by the educational door.
Psychotherapy
We use ordinary language to make sense of our psychotherapeutic endeavours and overtly welcome and help young people find their place as opposed to being put in their place. They are introduced to the Brookside story through a guide written by young people for young people which they can download on the website and each young person has an individualised timetable of group activities, individual therapies, educational activities and family and ordinary adolescent recreational opportunities. The school is utterly central to our model in kick starting the epistemophilic drive. If therapy is conceived as “a doing to” as in instrumental psychiatry and psychoanalysis as “a being with”. There is also a hybrid position of a “doing with”. Now we do all three all the time.
Without talking overtly about Bowlby, Winnicott, Bion, Klein, Freud, we use a language that talks about belonging such that a young person can begin to give expression to their longings. We need to get to know who the young person is and not only what’s wrong with them.
This necessitates that we are clear between calculative thinking and meditative thinking. We create openings between staff and young people in a myriad of ways whether it is over lunch, beside the table tennis and pool table, in school or in formal therapy sessions, these openings allow and foster openness.
Hopefully this gives rise in the young person to a sense of groundedness and sure footedness and this is what we call having a place to come from.
Psychotherapy & Homecoming
Therapy aims to facilitate a form of homecoming “being at home”
- Being in the world
- At home and what you are doing
- Home and language
- At home with oneself
- At home with one another
We are looking to move young people from gangs and gangs in the mind to groups where mutuality and love can be fostered. Where there is the possibility of authority without authoritarianism.
For our patients there is a fear of thinking, of having a viewpoint as it reminds them of their trauma, and desolation. Cutting, burning, poisoning occurs in young people who cannot accept the value of a new sexual body and a new inner self. One way to attack thinking and linking is the following, “I’m bored, I’m empty, I forget, I don’t know”.
Staff use their thoughtfulness to bring together the patient’s experiences in a vital and alive way. The staff communicate hope, change, survivability and the capacity to regenerate and not be destroyed by the thoughts and emotions and actions of the patients and their families.
Ordinariness and hospitality allows a genuine sense of commonality to emerge between the staff, young people and their families and that is the place to begin to rebuild lives – or so the theory goes. As I have already hinted it is not all plain sailing
THE QUENTIN TARANTINO WEEK
Now this piece conveys what I felt when I was writing this paper. On reflection it may sound a bit melodramatic. It not designed to shock as you all probably deal with tough in-patient dilemmas all the time.Its a very partial view as many positive things were also happening at the same time but I couldn’t see past my own pre-occupations.
It never fails to amaze me how institutional projects such as mine occasionally judder to a halt. Remain stationary in some sort of executive limbo, with little evidence of decision making happening.
Now what prompted the title of the talk, in addition to what I have previously alluded to (bereavement, despondency, illness) was one particular week in August that began with a discharge planning meeting involving a young man. His mother casually asked him for his house keys and then, cruelly told him that he was now homeless and she walked out... He proceeded to smash several windows and break a chair and leave us in quite a predicament.
Perhaps it the was time of year. Annual holidays, summertime, we all want to be on leave (our minds are elsewhere), plus the heat but that inaugurated a set of events that continued through the week.
Another fourteen year old was behaving aggressively and his diabetes was bizarrely not fitting any clear patterns. Blood sugars were veering wildly. The medical team sat around wondering whether he had an insulinoma. Journeys up and down to the A&E. A knife from the kitchen went missing, did he have it? A telephone call from his mother claimed that the boy had raped his twelve year old sister and made her pregnant. We finally figured out that he had stolen an insulin pen while in our treatment room but it was very traumatic for the staff and other young people when the police arrived to arrest him.
A day later, a seventeen year old young man with an acute psychotic illness and delusions centring on his circumcised penis, smashed up his bedroom. His dad refused to have him home but nonetheless fuelled his bizarre beliefs. The Dad downloaded Internet material about circumcision and psychosis and shouted at the staff, waving “Anti-Circumcision Pressure Group Leaflets” in our faces claiming it was all a mistake and that his son could be cured by rubbing hydrocortisone cream on his penis and pulling his foreskin to stretch it. A computer was stolen. When the police arrived yet again on the unit, he spontaneously blurted out “I haven’t seen the laptop” before any one had mentioned what had been stolen. This provided the leverage for the staff to move him out rather than any discussion about his well being. I felt as if my authority was undermined & passed to the Police.
The week continued with a fourteen year old boy with mild learning difficulties, possibly moving in and out of psychotic states. His foster carer requested a one week’s respite assessment as she thought he was “a bit paranoid”. One week into his admission she informed us that she didn’t want him back. On a quiet weekend on the unit he asked two healthcare assistants whether or not “they were paedophiles”. The healthcare assistants, perhaps already feeling the strain of the week, were very offhand and rude to him in a defensive manner. Taking no account that one of the other boys he was friendly with at Brookside had been raped anally when taken into care aged eight. So this boy’s fear of where he might end up became unacceptable, unpalatable, uncontainable and unthinkable to both parties and led to a standoff in the car park with yet again the police being involved due to his threats of violence.
The Quentin Tarantino week didn’t stop there. Three of the girls joined the uncontained toxic pleasure and excitement of the attack on all the values and the culture of Brookside.
One seventeen year old Zimbabwean girl who is a phenomenal football player came to us as she was threatening to throw herself under a train. The context was that her mother had died of AIDS She was brought to the UK to live with a maternal grandmother who had recently died and now her relatives wanted rid of her. She quickly showed a streetwise toughness that was not initially obvious at the time of the assessment. But her response to the uncontained violence and repeated violation of the unit was to claim that she had swallowed glass and she began throwing herself onto the ground. Brought to A&E she became uncooperative and walked out. Followed the next day by more histrionic behaviour. More blue lights. And no sooner had they arrived when she was up and about refusing any co-operation.
The Quentin Tarantino/Reservoir Dogs episode was concluded with more contagious “glass swallowing” from two much younger girls of thirteen and fourteen years. One had a violent alcoholic mother and the other caught in a tragic family set up where she claimed her dad raped her. She broke in through an open window of my consultant colleague’s office and with a marker wrote “you are a cunt” on his office wall.
This period of violent behaviour was unprecedented in Brookside not in terms of individual events but more in terms of the relentlessness within a brief timescale. I felt the authority of the Unit had been lost and had now become symbolised by the blue flashing lights of the police.
It rocked my stability, my sense of optimism and my sense that we had something of value to offer, the fresh start we talk about, a new beginning and hope for the future.
It was a moment of doubt for me. Was the whole project a failure, was I a failure, was it time to move on? And then that ghastly depressive certitude crept in, a feeling of burnout and uselessness and that “yes perhaps we are naïve, perhaps we are being utopian, perhaps we are caught up in some immature adolescent dream of ‘transformative change’.
But as I said earlier this doubt came to me at a time when the service was expanding and the demands on it to increase throughput, output, better outcomes and efficient disposal were greater than ever. Frighteningly de-humanising language but I don’t think I exaggerate.
You are probably quite rightly asking yourself at this point what happened to ‘the container’. Well, as it was August, we had a new SHO who promptly went off on leave, granted prior to his posting. Our long standing staff grade doctor who was an important anchor for the nursing team left for an SPR traineeship. We had absence followed by sickness and fragmentation in the staff group.
Two other significant changes happened at this period. The nurses were adjusting to the appointment of a new ‘modern matron’ (a man) who displaced a more traditional senior female nurse. Other colleagues wanted to resign with immediate effect citing illness, work stress and me as part of the problems.
So the staff container felt cracked from top to bottom with violence and destructiveness from the patient group spilling out in graphic fashion.
What should have been happening ,and wasn’t, was
the sharing of “the organisation in the mind”, sharing it in a coherent and optimistic way, putting as a priority the key belief that “we have something/many things of value” to offer to young people and families. That there was a value in “care” and “the going on of being”.
We were not coping with the attack on hospitality and the violation of the welcome offered . We had lost our sense of authority To use the language of Bion we had reverted to a basic assumption group.
WHAT IS THE TAKE HOME MESSAGE?
I am reminded of the image of ‘King Canute’ and him standing in the sea hand raised and the waves arising round him.
So at times acting with delusional omnipotence I thought I could solve it, stem the tide of the patient and staff craziness through my leadership alone and this I think is the path towards self-destruction and burnout. The other take on the ‘Canute’ story is that this is a wise king making a wise move and illustrating to his loyal subjects that he is a fellow human, heir to the same flesh as them and crazy to think he, could stop the waves.
At this point in time, it seemed or felt that the wave roar of the staff was akin to the Siren Voices
- The patients are bad not mad
- They are the wrong kind of patients
- The community services are lazy
- The families are abandoning their children
- The young people are stuck in hospital they are homeless
- Put them in PICU
- Get rid of them ,send them to General Adult Psychiatry
There was a collective amnesia, a forgetting of the past fifteen years of all the ups and downs. It felt like an attack on remembering, recollecting and gathering. There was no thinking, dwelling and lingering. Where was the thinking that acted as a form of homecoming and thus containment, security and safety?
Our staff model emphasises responsiveness and responsibility. Responsibility contains the Latin root, spondere which translates as a promise or to promise and re means again. In other words we promise again and again to attend, listen, think and accompany the patient despite our endless repetitive failings and forgetfulness. Why were we unable to do this? Was there something about our model of therapy which no longer worked?
STAFF MODEL
- The model is a practice
- It is non-ideological
- It is pragmatic
- It promotes thoughtfulness
- It is responsive and responsible
The team needs to facilitate the move from absorption in the narcissistic preoccupation with the inner world to a creative lived shared experience.
Violation & the Inconsolable
My predominant feeling was of inconsolability, entailing a loss of belief or value in the project & the youngsters. Secondly a lack of solidarity & working with colleagues. This gave rise to a growing desire to” pack it in”
There was a demand from staff & youngsters to get rid of the
mess immediately.
Now all this has happened before & will happen again.
But it triggered off memories of my early days as a trainee
Over the threshold of the gooey sticky carpet. I recalled coming to work & five landings in the Hospital were lined with Riot Police with batons & shields ready to re-claim the out of control wards. That was 1983 & Anthony Clare was our new Professor. We used to joke about being Psychiatric anaesthesiologists.
This was “a one tent model” that was brutal & dehumanising for all concerned. A model of Disposal if not Dispossession.
Gaston Bachelard comes to mind in The Poetics of Space ( 1969) when he says “ But the image has touched the depths before it stirs the surface”
So here was something that I thought was playing out in front of me that I thought I had left behind for good. The recurrent image of the filthy gooey black mess on the ward carpet. But I think it was me playing something out or me being played out by something.
But what “floored” me now was an additional reminder of quite painful childhood distress. I recognise in my work a powerful reparative urge- to set things right. It soothes my childhood distress.
But this childhood inconsolability now came back to bite me with a vengeance. A messy if not gooey inchoate anxiety which included a fear of also dropping dead like my colleagues or of becoming seriously ill before I could retire. Ones professional training usually act as a powerful shield against this distress.. I felt that I had lost another shield & and my sense of groundedness & sure-footedness. Trouble comes not single spies but whole battalions. So I think I contributed to the situation by being so despondent.
Now none more adolescent than adolescent staff for having unrealistic expectations mirroring adolescent dynamics, but this was not new in itself.
The familiar dynamics and battles between care and cure are well recognised and something we deal with every day. What I think added to the current difficulties was for me a new challenge, not of care or cure, but brutal and simple “disposal”.
It felt as if the message from a new management system was , “I don’t care if you can’t cure or treat or even offer a particular level of care, I want them off the A&E observation ward or the adult ward or off the street and I don’t care what the diagnosis is whether they are anorexic or violent and psychotic, just get them in and get them out of the way”. An arbitrary decision was made that every admission of an under eighteen year old patient to an adult ward, would be declared a serious untoward incident .
This has resulted in an unprecedented number of young people coming into the unit without the traditional induction process.
When our hospitality was attacked so very vigorously, we, the staff were drawn towards the jargon of our own disciplines and training and found ourselves talking about “processes, disclosures or even worse, the programme”.
We fell back on using The Mental Health Act, our language became dehumanised and we responded less and less with the context of our relationships in mind so that we acted in a more disconnected way using our powers as institutional custodians.
REBUILDING HOPE IN THE TEAM
Using psychoanalytic ideas it is possible to view some families as having suffered from an extremely poor early emotional environment and through idealisation and denigration of ordinary hospitality, they insist that no environment can look after them.
So what is the responsible way forward? How do we respond appropriately?
But responsibility is inherently dialogical and takes place in the ‘between’, in the relationship between staff and young people and their families.
At the heart of the project are two meetings, the community meetings which take place every day with Staff & young people. These are vigorous, alive and usually have very positive feedback and there is a staff meeting which has been very problematic. We have tried eleven different formats over the last five years to some avail .
Why is this the case?
Technical psychological ideas and talking in jargon can de-skill some members of the staff and make others feel omnipotent. Remembering the tradition of hospitality allows a genuine sense of commonality to emerge within the staff group and the young people. It takes a lot of effort to translate complex staff and patient dynamics into ordinary language and to embody those ideas in gestures of care that are intelligible to the patients and staff alike.
To quote from ‘The Renewal of Generosity: Illness, Medicine and How to live’ by Arthur Frank
‘Care is enacted in gestures that can console, far beyond what they accomplish as practical components of treatment. For touch to console and thus to heal it must be more than efficient. Touch must be generous, seeking contact with a person as much as it seeks to effect some task. Generosity is the resonance of touch, endowing the act with a capacity to give beyond its practical significance.’
Getting Going Again
I have been much helped by a trek to India, one to one time with an organisational consultant, my own analysis, writing this paper. Lake District & Berlin
We also pulled together senior colleagues & with more consultancy began sharing a more coherent, contained re-clamation of our philosophy & values. We re-claimed friendship & colleagueship. And the Tasks of Hope/Hospitality, Ordinariness Community, Therapy & Care
Perhaps in re-finding a sense of generosity again?
Adolescents expect a direct and genuine interpersonal contact even when they are themselves cut off and depressed. So staying with them at an Affective level and tuned to underlying unconscious themes is especially important but a difficult job on a busy psychiatric unit.
However it can be done, it needs to be done, it should be done and we will carry on doing it.
Paul Caviston Oct. 2007-10-31