Reflective Enquiry into Therapeutic Institutions

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Therapeutic practice needs constant examination to ensure that it remains responsive and dynamic. Living organisms must communicate with their environment if they are to survive, and institutions are no different. This monograph, the second of the Cassell Hospital series, explores this concept further. By reading it, ideas and thinking will be sparked off that will help other organisations promote their own culture of enquiry.- Kevin Healy, Director of the Cassel Hospital, from his ForewordThe contemporary Cassel Hospital was developed by Tom Main to create a self-exploratory institution. Main argued that, in order for the hospital to be therapeutic, it needs a "culture of enquiry". The individual and the institution might be seduced into ritualised working practices that no longer serve the needs of patients or staff. It is these "lapses from the continual enquiry" that are considered by this collection. It describes the mostly unconscious manoeuvres that inhibit reflection, and how the inappropriate use of psychoanalytic ideas can close off enquiry within a therapeutic community.Contributors:David Bell; Peter Grffiths; R.D. Hinshelwood; Tom Main; Agata Pisula; Pam Pringle; and Wilhelm Skogstad.

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CHAPTER ONE. Knowledge, learning, and freedom from thought

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Tom Main

This chapter discusses the acquisition of knowledge by one generation from another, and the problems inherent in the process. The difficulties are seen as falling into three areas: (i) the difficulty of understanding the knowledge itself; (ii) the difficulty that a fact or a theory becomes an internal object subject to all the vicissitudes of object relations; and (Hi) the difficulty of finding a training method that will enable the learner to assimilate knowledge and use it judiciously rather than to swallow it an uncomprehending way. Examples are drawn from the history of ideas in general, and from the author’s experience of therapeutic communities, particularly the Cassel Hospital. The danger of allowing a body of knowledge to become, in its passage from one person to another, a mere set of never-to-be-questioned beliefs is illustrated. The common frailties of both trainers and trainees are discussed and methods suggested for understanding and overcoming them.

Tlhe developments of knowledge, concepts, theories, and techniques represents man’s attempts at mental mastery of his environment by ego processes. Ego mastery gives a certain kind of pleasure which comes, in part, from the replacement of feelings of helplessness in the face of a mysterious reality by feelings of power over it and competence at dealing with it; in part, also from narcissistic admiration at the achievements of the ego, through the successful exercise of its skills and strengths. The new knowledge itself is valued not only because it gives the ego a tool for dealing with immediate reality, but also because it gives hope— promise of future usefulness as an aid for mastering later situations.

 

CHAPTER TWO. Enquiring into a culture of enquiry

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Peter Griffiths & R. D. Hinshelwood

This chapter describes the nature of a culture of enquiry and some of the difficulties that are associated with such a reflective practice. The term was originally coined by Main (1983), the Director of the Cassel Hospital between 1946 and 1976 where he set out to create a model hospital (Main, 1946). Other early experiments in forming therapeutic communities also used similar ideas, such as “analysis of all events” (Clark, 1964) and “reality-confrontation” (Rapaport, 1960).

Though the Cassel Hospital may differ from other therapeutic communities, there is now an increasing consensus that the hallmark of a therapeutic community is a “culture of enquiry” (Main, 1983; Norton, 1992). Main suggested that this was not a particular structure but a living human culture, which enquires into the personal, interpersonal, and intersystem problems that beset the culture, the impulses of its members, and the defences and relations as these are expressed socially (1983). However, Main was also aware that organizations can easily become unthinking, un-enquiring monolithic institutions. He particularly had in mind those old and large mental hospitals of the 1940s, as well as aspects of the organization of life in the army (1946). In an earlier paper entitled “Knowledge, Learning and Freedom from Thought”, which is reproduced here in chapter one, Main describes how within even well-intentioned organizations there are social and intrapsychic pressures to corrupt or erase thoughtful enquiry.

 

CHAPTER THREE. Internal and external reality: enquiring into their interplay in an inpatient setting

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Wilhelm Skogstad

In this chapter, I focus on the relationship between working on the internal reality and the external reality of patients in inpatient treatment at the Cassel Hospital. The hospital setting provides a space in external reality in which aspects of a patient’s internal reality can be played out and worked with through reflective enquiry and containment. I hope to be able to show that the combination of working on internal and external aspects of a patient’s pathology in a joint effort of therapy and nursing staff can have powerful therapeutic effects and can act against the strong regressive pull that patients experience in a hospital setting.

The hospital as a therapeutic institution

In psychoanalytic psychotherapy with severely disturbed patients, we hope to improve a person’s internal and external functioning. We try to achieve changes in the patient’s internal world and thereby not only to improve his or her emotional well-being, but to influence the way in which the internal world impinges on his or her functioning in the real world of relationships, work, and everyday life. In order to do this, we need to work on the complicated interchange between the internal and external world. For example, we need to watch carefully how parts of the external world are filled with projections, and aspects of the internal world are thereby got rid of; similarly, we need to recognize how aspects of internal reality are evaded by avoiding parts of external reality that represent them.

 

CHAPTER FOUR. Reflective space and group processes

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Agata Pisula

Earlier in this monograph, in chapter two, Griffiths and Hinshelwood emphasize the need for reflective space to be maintained in the face of defensive attempts to avoid it by both patients and staff. They also describe how specific structures have been built into the life of the Cassel Hospital in which reasons for success and failure in everyday situations are explored in order to sustain this culture of enquiry. In this chapter, I wish to use an example of one such structure—the parents’ meeting—to look more specifically at different ways the space for enquiry is maintained and the obstacles faced by both staff and patients in this joint endeavour.

As part of the treatment programme for parents who are inpatients in the Families Unit of the hospital, they attend a weekly parents’ meeting (D. Flynn, 1986, 1999; Kennedy, 1986). Families admitted to the Cassel have usually broken down to such an extent that their treatment will determine whether their children will remain with them, or whether they need alternative care arrangements. The aim of this structure is to allow parents a thinking space for exploration of issues concerned with their children, who may or may not be living with them in the community, and to discuss how they might support each other. This meeting is facilitated by the principal child psychotherapist, in partnership with the senior nurse on the Families Unit. The group membership varies depending on the number of patients on the Families Unit at the time, and some patients choose not to attend.

 

CHAPTER FIVE. Reflections on a supervisory relationship

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Pamela Pringle

In this chapter I explore a supervisory relationship with a junior nursing colleague following my own promotion to a nursing position with managerial responsibilities. Clinical supervision at the Cassel Hospital is recognized as an important tool that supports the often very difficult work with patients. This supervisory relationship presented me with challenges that came at a point in my career when I felt that I did not possess some of the skills required to help me cope adequately. However, with help from my own supervisor I was able to understand and integrate some of the interpersonal processes that occurred within this supervisory relationship, and I went on to develop a productive working relationship with my colleague. The chapters in this monograph explore some of the difficulties in allowing ourselves to enquire into practice. By examining the nature of the relationship between my colleague and myself, I discuss some of the problems we faced in achieving this. I then go on to look at how we managed to overcome our problems using clinical supervision as a reflective space. In order to give this relationship a context, I outline some of the staff meetings in the Cassel Hospital that support enquiry and understanding, which in themselves are vital to the work that we do with patients.

 

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