Unresolved Neurosis in Clinicians Working Within Mental Health Services

Unresolved neurosis in Clinicians working within Mental Health services.

Bill Thorndycraft.

ABSTRACT.

This paper looks at unresolved neurosis in clinicians and its impact on relationships with colleagues, when working as part of a team.

The context of the current economic climate is also considered and the stress this places on those clinicians working in frontline services.

Key words. Stress, Clinicians Mental Health, Self-disclosure, Political context, Blank screen, Team Development and Reflective Practice Groups (TDRP),

The issue of the clinician’s mental health has virtually been ignored within the psycho- therapeutic literature, the assumption being that neurosis and narcissism will have been dealt with and resolved in personal therapy. However, in my working experience, over the last 15 years as a Team Development and Reflective Practice (TDRP) facilitator and supervisor, working in the NHS and the private sector, I have frequently observed how the mental health of clinicians is influenced, not just by the projections from patients, but more frequently by projections from colleagues whose neurotic and narcissistic issues remain unresolved. The clinician’s unresolved neurosis is often activated at times of stress, especially during periods of socio-economic uncertainty when many frontline services and resources are under attack and the threat of cuts is real. The mental health of frontline clinicians such as Doctors and Nurses who are expected to work long hours and make complex and challenging decisions when suffering from fatique, will often lead to anxiety and depressive illness with periods of time off sick but stress and fatique can also trigger neurotic manifestations in relationships at work creating negativity and poor morale amongst teams often leading to absenteeism. The projection of the unwanted and unmanageable aspects of the personality and character, I consider to be more challenging when between colleagues, and perhaps more insidious than when manifest in the therapeutic alliance with patients- a context where the psychotherapist will be ‘on guard’. However, with colleagues, defences are often relaxed and thereby the projections are more likely to take hold. In teams this invariably results in negative consequences. For example, poor team cohesion, diminished team morale, a decline in the mental health of the team as a whole, and ultimately a negative impact on delivery and quality of service to patients.

1 Mental Health.

In the same way that an infectious virus may be transmitted in the workplace, from colleague to colleague, so too can a colleague’s poor mental health become contagious, infectious and transmitted and shared, at times of stress. - Stress in the work place generally being a primary trigger. However, our personal life circumstances, internal world and mental wellbeing cannot be ignored and will affect our mood and impact on our relationships with colleagues and also the patients. However, the current Socio-Economic and Political Context cannot fail to impact on both the conscious and unconscious of us all. Primitive defence systems in dealing with anxiety and alienation are to be seen manifest both in the media and in our work in dealing with Mental health problems. Given this, as the wider political and social context within which clinicians are attempting to treat severe mental health problems, it is not surprising that it is not only patients who begin to rely on primitive defence mechanisms to survive. The impact of the external systems inevitably reduces the ego strength of the individuals and teams. More people than ever require antidepressants to help them face and cope with their anxieties and internal conflicts. Until recently, the subject of mental health has generally been given a low profile within society and the media, despite recent estimates that 6 million people in the UK currently suffer from depression and anxiety; ‘At present, only a quarter of the 6 million people in the UK with these conditions are in treatment, with debilitating effects on society’. NIMHE (2008). There still exists considerable social stigma, shame, prejudice, and fear associated with the subject, even amongst clinicians working in the mental health field who themselves are not immune from ubiquitous mental health issues, especially personality and narcissistic disturbance. In my working experience with Clinicians in Mental health teams, many have said they would be reluctant to discuss their mental health issues, even with colleagues or managers. In the present day work climate, it requires considerable courage and bravery to share these issues, even in the milieu of the caring professions. It is in these circumstances that defence mechanisms are adopted. So often, clinicians, like our patients, are not consciously aware of these issues, which generally present at a level which is not obviously incapacitating, as there is invariably an absence of apparent anxiety, depression or psychosis. However, manifest are other personality characteristics such as a lack of emotional display, disdainful attitudes to colleagues and sometimes patients, which supervision may fail to identify, especially if the supervisor focuses on the clinical dynamics and ignores exploration of counter transference and the supervisee’s mental wellbeing.

2 Unresolved Narcissism. Broadly speaking, psychoanalytic definitions of narcissism suggest the ego absorbs the self as an erotic love object. Freud explains that the two forces, the ego-libido and the object libido, are based on two primary instincts. The ego instinct being the need for self-preservation, and the sex instinct, the preservation of the species. However, like most psychological states, there are varying degrees of manifestation, impact and consequence in relational terms. Our personal therapy will provide the opportunity to explore the internal conflicts which trouble us and has probably influenced our decision to choose our profession, and our therapy will hopefully have provided better coping mechanisms and tools in dealing with our neurosis. However, Neville Symington writes: ‘I believe that we Psychotherapists have largely failed when it comes to narcissism. There are various criteria that signal the presence of narcissism, one of which is the capacity to receive criticism. One might think that someone who has been through a course of intensive psychotherapy would be able to receive criticism, but this is frequently not the case. Many of us come out of psychotherapy-even extended psychotherapy or psychoanalysis-still suffering from severe narcissistic disorders. Sometimes such disorders are crippling. This is a serious situation.’ Symington. (1993) p9. This begs the question as to whether we ever resolve or can be cured of the consequences of the developmental disturbance experienced in childhood and adolescence?

Group Dynamics.

Dynamics often displayed in teams and groups at times of stress, include envy, unresolved oedipal and Transference neurosis, jealousy, projective identification, bullying, scapegoating and splitting. Hanna Segal explains Melanie Klein’s view of envy: ‘Envy can fuse with greed, making for a wish to exhaust the object entirely, not just in order to possess all its goodness but also to deplete the object purposefully so that it no longer contains anything enviable. She adds, “Envy operates also by projection and often mainly so. When the infant feels himself to be full of anxiety and badness and the breast to be the source of all goodness, in his envy he wishes to spoil the breast by projecting into it bad and spoiling parts of the himself; thus, in phantasy, the breast is attacked by splitting, urinating, defecating, passing of wind, and by projective, penetrating looking (the evil eye). Segal (1988) p41

Morris Nitsun writes ‘Dealing with envy in groups is particularly difficult. The acknowledgement of envy usually leads to a sense of humiliation and shame, making it one of the most difficult feelings to admit to one-self and others. As such, it is particularly prone to deflection by projection and projective identification. (Nitsun1996) p130

The micro-situation and culture of groups whether it be Analytic Therapy groups or Groups of clinicians will often reflect and parallel the happenings in society at large. Also the constant change being imposed on organizations, especially the NHS, with the cuts and breaking down of existing structures, restructuring, new systems, increased 3 administration, the setting of often unattainable and unrealistic targets and excessive demands. places enormous stress on resources and frontline workers. In the current socio-economic climate, systems, performance indicators and targets (organisational needs) especially in the NHS, are often prioritised and cared for more than patients’ needs. Ian Simpson writing of his management challenges and experience in the NHS in 1995 said “We have a duty to maintain the highest professional and ethical standards. This is especially so when we come up against the constraints of an organisation which may place financial considerations above clinical ones” Simpson p224. Over 20 years later many would argue the situation remains.

This impacts negatively on many teams, manifest via splitting, scapegoating, displacement projections and envy. In therapy groups, the group Conductor often becomes the object of attack, but in staff groups, frequently the manager or team leader or even the organisation, are placed in the oedipal, transference position, and are the objects for attack. Sayers (1991) cites Bion. ‘rather than re-projecting feelings evoked by patients, analysts should instead ’contain’ and bear with such feelings just as ideally the mother takes in, contains, responds with appropriate anxiety, digests, thinks about and thereby detoxifies uncomfortable states of mind induced in her by the child. If she is capable of such ‘reverie’- rather than denying, refusing to be moved, collapsing, or becoming hostile in face of the infant’s distress- the mother enables the infant gradually to know, think about, and bear such feelings in itself rather than disown and split them off” p.250. However, such feelings, if uncontainable and not processed in supervision or therapy, can end up being displaced and deposited in others in close relationships. e.g. Friends, family and work colleagues. Thorndycraft and McCabe (2008) touch on the issue of clinician’s mental health and highlight these negative dynamics and the serious impact that can occur when a member of a team manifests unresolved attachment issues associated with Borderline Personality Disorder (BPD): ‘Even if a staff member clearly contravenes professional boundaries and responsibilities, it is often difficult to deal with. The episodic nature of the behavior and the splitting associated with BPD are often difficult for human resources departments to acknowledge, understand and manage. Unless contravening diversity policy or clearly guilty of professional misconduct, it may not be considered a disciplinary offence. It is not easy to pick up or address via appraisals or management supervision, as the negative and split transference will often distort the dynamic. They add: ‘Workers and management often accept colleagues having time from work with physical conditions such as colds, back problems, migraine, repetitive strain injury, asthma, and irritable bowel syndrome, but there is still reluctance to grant leave for clearly stated mental health reasons. We have frequently raised this issue within groups and have invariably received the response that it would not be acceptable to take time off with anxiety, depression or some other mental health problem. One way of getting our heads out of trouble is to somatize the effects of stress, and there would seem to be little understanding on a management level of the fundamental links between chronic mental strain and the physical symptoms of burnout’. Thorndycraft and McCabe (2008) p174 So often the organisation and managers are perceived as persecutory objects by employees which is understandable in a climate of austerity and cuts in public services.

4 Infection. When working in, or as part of a team, all team members are vulnerable to scapegoating and bullying, especially managers who are often required to implement unpalatable policies, which can trigger feelings associated with internal persecutory objects or a punishing super ego and unresolved negative transference. Managers, who themselves are under pressure, often feel powerless and bullied, not just by department heads but also from their staff, and at times, may themselves resort, to bullying, neglect, and avoidance of their duties in their role in relation to staff management. I believe that it is essential to the therapeutic process, not just to interpret dynamics such as transference, splitting and projective identification, but to explain and remind clinicians of these theories which they may often be acting out unconsciously. I have found the occasional sharing of information and knowledge to be helpful to the group process, certainly in mature therapy groups, and in TDRP groups and also when working with individuals in supervision. Reminding them of Psychological theory and its practical application, can help in making the unconscious conscious! Clinical supervision is accepted as essential in examining and exploring the dynamic between clinicians and patients but can often fail to identify the complex dynamics between colleagues which can be more mysterious and challenging. Working in the caring professions, can leave clinicians feeling uncared for by the ‘mother’ organisation which frequently threatens to withdraw the ‘good breast’ by cutting resources (downsizing, lean thinking) and can often feel like a persecutory object or a punishing super ego, sometimes replicating earlier developmental breakdowns and neglect from the therapists past. Malan suggests that ‘many healthcare professionals may suffer at least a degree of early insecure attachment and explains the ‘helping profession syndrome’ whereby those who experienced insecure attachments in early development would be most vulnerable to ‘Burnout’ in a working environment where they were subjected to repeated negativity and rejection by patients and an unsupportive organisation’ (Malan1979 p79). The negativity, when ingested by clinicians is often regurgitated and expelled via Projective identification on to and into colleagues or other close associates. Melanie Klein describes projective identification and the associated splitting off as follows.’ Projective identification is based on the splitting of the Ego and the projections of parts of the self, into other people.’ (Klein1975.p303). Projective identification in this paper will be used as referring to ‘a group of fantasies and accompanying object relations having to do with the ridding of the self of unwanted aspects of the self, the depositing of those unwanted ‘parts’ into another person, and finally with a recovery’ of a modified version of what was extruded. (Ogden1979 p.357) In my own supervisory work, I have witnessed supervisees often being mesmerised, and at times, paralysed by patients’ projections. In extreme circumstances, the effect of projective identification can be most disturbing and preoccupying for the clinician and

5 needs to be rigorously examined and worked through in supervision or therapy, in order to understand the connections and associations with unresolved neurotic and transference issues that are being activated in the clinician’s internal world. If the therapist or clinician has not resolved their transference issues, self-esteem deficiencies, anger and sadistic traits, then their potential to be influenced by the patient’s projective identification is considerable. It is in these circumstances that projective identification I believe, feeds the counter transference in a negative manner. Projection does not penetrate and connect in influencing the object in the same way as projective identification. The projector is not gratified at the same primitive level and the recipient is not moved or influenced significantly, essentially due to the quality and closeness of the relationship. For example, a drunk shouting obscenities at passers by will not have the same impact on others mental health as someone who has a close ongoing relationship. e.g. Family members, work colleagues, friends, neighbours. I do not believe projective identification can penetrate if no mirroring process occurs, and no identification takes place. In other words, there needs to be in the recipient, unresolved internal conflicts similar in essence to those of the projector, that act as a receiver within the psyche of the therapist, if a connection is to occur- rather like a television or radio needs to be tuned to the specific frequency to receive a broadcast transmission. The extent of the damage done to the recipient’s sense of well being will depend on the level of unresolved issues which are mirrored either consciously or unconsciously. Attachment theory studies show that ‘Children whose parents are responsive and sensitive and attuned are more likely to be securely attached; those with brusque rejecting parents, to be avoidant; those with inconsistent parents to be ambivalent; and those with parents who themselves have experienced major trauma, to be disorganised. Attachment styles seem to represent stable developmental pathways in which particular patterns of security or insecurity evoke care-giving responses which perpetuate those patterns and conversely in which particular care-giving behaviours are consistent across the life-cycle and so tend to reinforce pre-existing relationship styles. (Holmes 2000). The Wounded Healer. The impact of insecure attachments has been widely documented by Bowlby, Mary Ainsworth, Winnicott, Kernberg etc. I would not want to suggest that early attachment problems are a fundamental reason for entering the ‘Caring Professions’, but I have no doubt that a significant number of psychotherapists and other clinicians have experienced trauma, neglect, deprivation, developmental breakdown, shame and troubled childhoods which would have influenced their career decisions and choice. Plato and Jung more than touched on the subject and shortly before his death in 1961 he wrote that he believed only a wounded physician could heal effectively It might be argued that a troubled development is a prerequisite for being a ‘good enough’ clinician with the necessary sensitivity and ability to empathise and work face to face with others emotional pain and distress. Glickauf-Hughes and Mehlman (1995) quoted by Halewood and Tribe (2003) ‘suggest that ‘good therapists manifest sensitivity, empathy, and 6 awareness of the needs and feelings of others, the type of individuals that parents with intense narcissistic needs often misuse. From childhood these individuals are being prepared for a profession that involves listening to the messages and unspoken needs of clients. However, therapists with this background often struggle with their own unresolved narcissistic issues, which include audience sensitivity, perfectionism, imposter feelings, and unstable self-esteem’. The majority of clinicians I have worked with as a supervisor and therapist have experienced levels of attachment and developmental breakdowns ranging from abandonment, insecure attachments neglect and a general lack of good-enough parenting resulting in a desire to assist and rescue others in a professional capacity and career. It does seem that early childhood troubles and trauma which impact on healthy developmental growth, do often result in the desire and need to care for others vulnerability in adulthood. It would appear that the motivation to work in mental health and other care services is generally driven by unconscious identification and defences against our own vulnerability and anxiety.

Maturity. Being a Psychotherapist is a serious, grown up job requiring maturity and responsibility. As Winnicott often said, it requires the skills similar to those of being a good enough mother. The dealing with powerful emotions, distress and psychological trauma has serious consequences for the mental health and well being of our patients as well as our own mental health. The consequences for getting it wrong are enormous. “The capacity of the therapist to observe what happens in the patient’s mind, to comprehend it, rests on his own empathy. He can never emerge untouched as he goes through this process with his patients. At the same time, he must be free enough from personal problems not to be drawn into the emotional whirlpools of his patient. If occasionally this should threaten him, we can expect that he would take heed of early signals, and take counter measures. This by the way is necessary in the interests of his own mental hygiene. Foulkes (1964) p179 Neville Symington (2007) considers highly the importance of emotional maturity in the therapist, in order to communicate and construct interpretations effectively. He suggests that it is the ‘inner act of freedom’ in the analyst that leads to beneficial changes in patients, but acknowledges the resistance from many analysts to accept this view, as it is felt by some to devalue the importance of interpretation. Also training institutes that teach the importance of theory and interpretation cannot teach the maturational process. ‘ If maturity is an agent of change then the analyst is subservient to the process. It is humbling to know that the instrument that effects change is not in our possession. Self-esteem is closely linked to professional skill and mastery of a craft. For an analyst, it is inextricably linked to his or her relation to the maturational process and greed, envy, or impatience can interfere with it. He adds, ‘I believe that communication rather than interpretation is the essence of the psychoanalytic process. The emotional state of the analyst is also the foundation stone of communication. First the transferring of emotional experience into language is communication within the self, but, at the same time, to the other as well. It is a sharing of one’s own personal life with another that is healing’. (Symington2007) p88- 92. Harry Guntrip also considers the relationship with the patient to be of paramount importance in the attempt to achieve positive outcomes from the therapy;

7 .’You can go on analysing forever and get nowhere. It’s the personal relationship that is therapeutic” (Guntrip 1971) p 81.

The Blank Screen.

The fear of sharing professional uncertainties, insecurities, vulnerability, and being perceived by colleagues as not being a ‘good enough’ clinician is in my experience quite commonplace. As a defence against these concerns a ‘blank screen’ poise for protection, is often adopted which can be experienced by colleagues as being unsupportive,non-communicative, ‘cut off’ and anti-social. Let us not forget that groups can be scary and anxiety provoking, not just for patients but also clinicians who may also have experienced unpleasant dynamics previously in groups, especially family groups and school groups. The blank screen posture was encouraged by Freud (1912) as many early Psychoanalysts self disclosed to patients and, by doing so, diminished the negative transference. Freud placed great importance on provoking the negative transference in analysis, and many contemporary analytically trained psychotherapists adopt the ‘Blank Screen’ in the desire to access the patient’s unconscious. The negative transference will often replicate regressed feelings associated with unworthiness, neglect and the emotional detachment that so many traumatised and ‘shamed’ patients experienced earlier in their lives from significant authority figures. This is especially so, with many of the patients currently referred to the NHS, who present with symptoms of depression, anxiety and personality disorder, and also patients presenting for treatment of addiction. The negative transference provoked in these circumstances can become very difficult to work with, often resulting in patients terminating their therapy. ‘The development of psychoanalytic theory has, however, led to a more radical questioning of the usefulness of the blank screen concept. In contemporary models of psychotherapy, the importance of the contribution of the therapist to the therapeutic interplay is taken for granted.” Holmqvist (1996) p 488. Farhad Dalal writes: “ In arguing for responsivity, I am arguing against the convention which makes not- responding a virtue. Many therapists have turned not responding into an art form, of finding elegant ways of not answering questions and so forth, because they think that in responding they will be acting out in some way. And some times that is of course true. But it is also the case that this way of being reproduces and reinforces earlier experiences of being not responded to, of being treated as an ‘It’. Dalal 2012 p422 Maintaining professional boundaries are essential in making the relationship with the patient safe and also protecting the therapist’s privacy. However, the often perceived unequal, power relationship between the clinician and patient can be a significant source of resistance and hindrance in dealing with the patient’s presenting unconscious troubles, and paradoxically this contradicts a fundamental aim of therapy which is to deconstruct the patient’s negative issues associated with authority. i.e. the transference. ‘ The more the analyst’s technique and behaviour are suggestive of omniscience and omnipotence, the greater the danger of a malignant form of regression. On the other hand, 8 the more the analyst can reduce the inequality between the patient and himself and the more unobtrusive and ordinary he can remain in the patient’s eyes the better are the chances of a benign form of regression. (Balint, 1979, p173). For many clinicians there exists a fear of ‘crossing the line’ between the safety of the ‘Clinician’ position to the one where we become like the patient; i.e. vulnerable. They fear such a move diminishes their status, power and potentially invalidates and deskills them. This dynamic is often manifest in therapy groups, supervision groups and TDRP groups where the examination and exploration of concerns and uncertainties takes place and is shared within the group. However, it is often difficult for some clinicians to trust colleagues, trust the team facilitator and trust themselves for fear of unresolved neurotic issues leaking into the group and in a defence against unconscious shame and anxiety will avoid attending the group. ‘From the moment the patient joins the group there is often a strong unconscious desire to escape from the group and what it represents and symbolizes from the patient’s past’. Thorndycraft (2001). p279 This I have observed on many occasions when working with Teams of professionals in reflective practice and supervision groups, especially during the early stages of the group’s life when a desire not to be present is most apparent. I believe the transference will always be present, regardless of how remote, distant, paternalistic or maternalistic the therapist presents and behaves in relation to the client. We should also never lose sight of the fact that ‘The power and influence of the clinician and specifically the therapist, is often greatly underestimated. Though most therapists assist their patients in a positive way, some make them worse’ (Bergin1963) p 244-50.

The blank screen, non-communicative position, will be perceived by many patients as with- holding and sadistic. It often will enhance feelings of powerlessness and inequality in the therapeutic alliance, which often provokes termination of therapy. It will be argued by some Therapists that this is what needs to be worked with, but many patients find this mode of relating disrespectful, demeaning and unhelpful, as do colleagues when they encounter the ‘blanking’ from other professional colleagues, who can present as being distant and aloof in every day interactions.

Caring for others weaknesses.The wounded healer! At this point, I need to briefly mention the power dynamic of the ‘caring role’ especially the therapist /patient relationship. I propose that the decision to work in the caring professions is motivated by the unconscious desire, not just to rescue and heal, but the attraction of a power relationship between clinician and patient. -Caring for others neediness and the need to feel needed. There is the expectation that patients share their vulnerability, fears and concerns, with the clinician, yet so often, I have frequently experienced considerable resistance from clinicians in acknowledging, examining, and sharing their own vulnerability, professional insecurities, uncertainties, and neediness in both supervision and TDRP groups. There is so often a fear of connecting with the negative feelings provoked and mirrored in the counter- transference, which can range from dislike and hatred, to murderous or erotic desires,

9 for fear of shame, and not being a good enough professional. These emotions are frequently aroused in clinicians in relation to colleagues in groups which can feel like a competitive arena at times. Self-Disclosure. The National Institute for Mental health in England offers guidance for working with patients with personality disorder, ‘Users thought that staff need to be skilled to handle therapeutic relationships, particularly regarding attachment. They need to deal sensitively with issues of gender and sexual orientation in those who have a history of abuse. Staff, with their own experiences of mental health difficulties were perceived as having much more insight into the difficulties of patients. It was recognised however that in clinical settings problems arise when boundaries breakdown and staff begin to share their own problems with patients. However, it was felt to be therapeutically important for there to be a shared experience between patient and professional, and for professionals to be in touch with patient’s distress but not overwhelmed by it’. NIMHE (2003) p21. Foulkesian group analysis is based on the democratic principle that the group is the agent of change and the group analyst (conductor) is part of that process. “There is no objection to the analyst behaving like any other member of the group, relating his own experiences, stating his own associations. Our experience points to caution in this. All the groups seemed to prefer to leave the analyst in a position of authority and to make him the representative of the ideals by which they wanted to be guided. Again following analytic principles, we felt that, within limits, they should be allowed to do so”. Foulkes (1964) p25.A fundamental in our training is the need to provide a safe containing environment with clear safe boundaries within which the therapeutic work takes place. The therapeutic relationship should not be an arena for the therapist to use for personal catharsis or ego building. The most extreme violation of this being the clinician who becomes sexually involved with a patient. Many therapists working with patients on ‘Addiction Treatment Programmes’(ATP) are recovering addicts who have worked the ‘Twelve Steps programme’ via the various fellowships: Alcoholics Anonymous, Narcotics Anonymous, Gambler Anonymous, SLA etc and often use self disclosure as a tool. However, as a supervisor working for many years with ATP teams, I have often challenged therapist’s motives to self disclose to patients. For whose benefit is the self disclosure? How is the patient going to benefit and move on in the treatment? However, I have at times been impressed at how seriously disturbed patients have moved on from their resistance and defence systems when therapists have cautiously used self-disclosure in a considered and timely manner, to enhance the level and quality of the working relationship. I am of the opinion that occasional self-disclosure, if used as a good chef might use salt or spices to enhance the flavour of a dish, i.e. sparingly, can, potentially have a beneficial effect in fast tracking the building of trust in the therapeutic alliance, with positive outcomes for the patient. The sensitive and considered sharing of the counter- transference, is a means of not just self auditing, but can also be a way of gaining connection with the patient’s unconscious feelings, via our own self-analytic response 10 to the patient’s presentation. This can enhance the sense of connection and empathy, and the ‘feeling heard’ and understood. It is also importantly validating, and in many cases will diminish the negative transference, so often the barrier to the healing and empowering process. However, fear of patient intrusion into our personal life is a major concern for most clinicians. ‘What are the objections to therapist self-disclosure? Some therapists fear that if they open a door a little, patients will force it wider and demand more self-revelation. My personal experience is that this fear is unwarranted. I feel it is important to reveal my immediate, here and now feelings to the patient. I rarely find it necessary or particularly helpful to reveal many details of my personal past and current life. The desire of the patient is not that the therapist be stripped but that the therapist relates to him or her as a person and be entirely present in the immediate encounter. (Yalom. 1980) p414. Cognitive Analytic Therapy-CAT- is a model becoming more widely used within the NHS. The CAT brief therapy model –often limited to 16 sessions- has been successful in assisting many patients access to therapy, who would otherwise not have access to long term therapy. The collaborative CAT model requires considerable activity and sharing of information by the therapist through the construction of diagram. Ryle and Kerr (2002) to be doing CAT, a therapist must engage with the patient in a process of descriptive reformulation, itself a powerful alliance-generating activity, and must aim to use the descriptions and the therapy relationship to modify the identified problematic procedures. They add: There is no reason to believe that opaque, vague or emotionally blank therapists have a particular access to transference, for patients, like all of us, repeat their patterns wherever they go’. P106. The CAT model requires a high level of participation not only from the patient but also of the therapist. However, the importance of the therapist’s personal privacy is regarded.

In Conclusion. Earl Hopper has written much on the social unconscious and its links to transference and counter-transference. ‘The motivation for remaining unconscious of social objects is the regulation of the anxiety that would follow from the recognition of them, and from understanding the nature of both their constraints and restraints. Thus, a series of defensive or protective mental processes may be involved: The social unconscious involves the ‘non-conscious’, the ‘dynamic unconscious’ of the ‘repressed’ and the ‘split-off’, and the ‘pre-conscious’. (Hopper 2007) p287. The psychic management of the discomforting external national and global conflicts, which are often too disturbing and uncomfortable to countenance, are generally hidden away in our unconscious. -our internal world. There is not the space in this paper to expand on the influence of media driven hysteria, the power and imperative of consumerism (the need to seduce money out of our pockets by provoking discontent with our lot) obsession with inanimate objects and cyberspace, world poverty and immigration concerns and the uncertainty of global capitalism and terrorist threats, all of which

11 contributes to the social unconscious and belief systems. The impact of this on society cannot fail to touch us all at some levels. Working as a team member, with regular interaction with colleagues, requires sharing, compromise, tolerance and respect for difference, both culturally and professionally. Amicable relations! The atmosphere that we share with colleagues is very important in determining how we feel about our work and ultimately our sense of self. So often, behaviour and rudeness considered unacceptable in patients, is tolerated in colleagues and goes unchallenged. There is a general expectation, that a professional’s mental health is of a standard to be fit to practice, but when away from the power relationship with patients, competitiveness, envy, the with- holding of feelings, projecting and transference neurosis can often manifest and create an uncomfortable atmosphere which is non-conducive to the good delivery of treatment and service. I am led to consider the possibility that in some cases, the power relationship between clinician and client may compensate unconsciously, for the clinician’s social phobic residue and limited social competence in relationships outside of the therapeutic alliance which is related to unresolved narcissistic issues, not dealt with or resolved in personal therapy. This, I assume, will be considered by some clinicians as being controversial. However, it is the responsibility of the clinician and the organisation to ensure that a standard of good enough mental health in staff is a priority. I strongly suggest that, in addition to organisational supervision, (ticking boxes, performance indicators/outcomes, etc,) that organisations provide a regular Team development and reflective practice space as mentioned in Thorndycraft /Mc Cabe (2008). Group therapy is a powerful and important treatment for mental health problems. -The group being the place for individuals to learn interpersonal ‘social skills’ in a safe environment, and how to communicate in a meaningful, authentic manner. Reflective Practice groups provide the opportunity to share and learn from colleague’s experiences as well as continuing professional development. The TDRP group can feel a very uncomfortable and threatening place for clinicians who have unresolved transference neurosis. It can replicate in the unconscious, earlier uncomfortable group experiences associated with family, school, boarding school, etc, of not being good enough, of perhaps being bullied and shamed by peers. There is often a powerful need to deny and pretend we are ok and coping. It is then, that the ‘Blank Screen’ defence is often adopted and the work of the Reflective Practice group starts in the making conscious this defence mechanism, by encouraging self-disclosure, self-awareness in the safety and containing environment of the TDRP group. I do believe our profession is evolving to a point where professional exclusivity of theoretical models and ideas has started adjusting to a diversification of approach to patient’s needs. The psycho-dynamic embracing of knowledge and practice helps adapt to and make some sense of the changing social context, in a world where modes of relating and social relationships are radically changing and attachment disorders are endemic, and are a ubiquitous consequence. It is, after all, our responsibility to constantly take care and be aware of our mental health and psychological well being. This requires of us, more than CPD activities, but regular

12 monitoring via dynamic supervision of not just our relationships with client/patients but our relationship with our-self and colleagues.

REFERENCES; Balint M (1959) Thrills and regression. The Hogarth Press and the Institute of Psycho- Analysis, 1959 London p173 Bergin A.E (1963) The effects of Psychotherapy: Negative results revisited. Journal of counselling psychology 10: p 244-50. Dalal (2012) The 36th Foulkes Annual Lecture. Group Analysis. Sage London. 45.4 p422 Foulkes (1964) Therapeutic Group Analysis. Maresfield reprints. London. Freud, S. (1912) Recommendations to physicians practising psychoanalysis. In Standard Edition 12. London: Hogarth Press. pp. 109-20.

Fromm, Erich. (1962) Beyond the chains of illusion. New York. Continuum 2006. p70. Grosskurth, Phyllis (1985) Her World and her work. London. Maresfield Library.p48. Guntrip H. (1971) Psychoanalytic Theory, Therapy and the Self. Maresfield Library 1977. Halewood A and Tribe, R (2003) What is the prevalence of narcissistic injury among trainee counselling psychologists? Psychology and psychotherapy: Theory, Research and Practice in Glickauf-Hughes and Mehlman (1995)76, p87 Holmqvist R. 1996 Methods of Identifying Conspicuous Counter Transference Reaction. British journal of Psychotherapy p488 12(4).

Holmes J. (2000) Attachment Theory and Psychoanalysis: A Rapprochement. British Journal of Psychotherapy, 17.2 p163. Hopper. (2007) Theoretical and Conceptual Notes Concerning Transference and Counter Transference Processes in Groups and by Groups, and the Social Unconscious: Part 3. Group Analysis 40.2. P285-300 Klein (1975) Envy and Gratitude and other Works 1946-1963. London, Vintage p303. Malan D (1979) Individual Psychotherapy and the Science of Psychodynamics. London. Butterworth. Nitsun, M (1996) The Anti-Group. London. Routledge. NIMHE: Latest News - Our Work - Improving Access to Psychological Therapies National Institute for mental health in England. London.29 October 2008. NIMHE: (2003) Personality disorder: No longer a diagnosis of exclusion. London. National Institute for mental health in England p21. Ogden, Thomas, (1979) on projective identification, International Journal of Psycho-Analysis 60, p357. Ryle, A and Kerr, I.B (2002) Introducing Cognitive Analytic Therapy. Chichester West Sussex. John Wiley and sons. p106. Segal, H (1988) Introduction to the work of Melanie Klein.Karnac, London.p41 Symington, Neville, (1993). Narcissism. a new Theory. London, Karnac, p 9. Symington, Neville (2007) Becoming a Person through psychoanalysis. London, Karnac.p87-92. Sayers, Janet (1991) Mothering Psychoanalysis. Penguin books, London p250. 13 Simpson, I. (1995) Group therapy Within the NHS.We all know about ‘Good enough’ but is it ‘Safe enough’? Group Analysis. Sage. London.p224. Thorndycraft, B (2001) The Colditz Syndrome: The need to escape from Group Therapy. Group Analysis. Sage. London. p279. Thorndycraft B & McCabe J (2008) ‘The Challenge of working with staff groups in the caring professions’. British Journal of Psychotherapy 24 (2) p174. D. W. Winnicott (1947) 'Hate in the Counter transference', in Through Paediatrics to Psycho-analysis. Hogarth Press (1975), pp.194-203. Yalom.I.D. (1980) Existential Psychotherapy. Basic Books. New York.