In line with recent postings on countertransference acting out in the guise of patient care witnessed on inpatient units, ISPS member Julie Kipp's doctoral dissertation on therapeutic community addresses the issue of the hospital treating itself. The principles of therapeutic community involve the processing of staff countertransference (something all too frequently disregarded in today's clinical settings).
From my own experience at a state psychiatric hospital, I remember so many instances of cruelty perpetrated against patients in the name of God knows what. One highly intelligent woman who refused to give blood (no one bothered to inquire as to why, explore her fears of getting HIV from needles, etc.) was literally dragged out, carried like an animal, with one staff member carrying the upper part of her body and another dragging her lower part, from a group therapy meeting. There was a chilling silence after this show of staff (craziness) power. Patients feared that they were in the hands of mindless persecutors who tolerated no resistances. One of my patients placed in seclusion for raising her voice started to fragment, crying and screaming for someone to help her, give her a cup of water (partly to disconfirm the utter and horrible lack of humanity she was experiencing), was left in this terrible organismic panic state in the name of good clinical practice. When I tried to intervene by trying to calm her through the little window of the seclusion room, I found myself days later being chastised for interfering and disobeying psychiatric orders. The psychiatrist in question had a habit of interrogating incoming patients in a style which reminded me of a counterterrorist agent hell bent on breaking someone's will down, to make a mockery of their symptoms in front of the 'treatment' team, etc.
There were countless examples of deception (e.g., patients normally sleeping in seclusion rooms because of lack of beds and then quickly moved to regular rooms during inspections and audits), cruelty (patients developing diabetes from a combination of Zyprexa, bad hospital food and no opportunities for exercise, patients literally stayed indoors for weeks at a time despite the hospital guidelines that there were to be two periods of daily courtyard time, etc.), unethical behavior (reports by patients of sexual abuse by staff--some of which were false, but some which seemed quite plausible, going unreported--patients making these allegations discovering that they were quickly being transferred to the 'chronic' longer term wards, Spanish-speaking-only patients being treated by monolingual English speaking staff, etc.), neglect (few patients had any regular weekly meetings or sessions with their treatment team members despite hospital charting notes to the contrary), etc. For my own sanity, I had to leave after many years of exposure to these practices. I felt terribly guilty for abandoning patients--my guilt being mitigated by my replacement who proved to be a very dedicated and intelligent clinician who actually met with her patients. This is not to say that there was a total absence of good clinical care, but so many of these practices, heretofore described, were so overwhelming, that it colored any experience and memories of decent clinical care. I still feel somewhat traumatized by these experiences after almost six years of leaving this setting. When I reflect on the patients there, I feel a deep sadness.
Many years ago, I spoke with thanatologist Elisabeth Kübler-Ross about her experiences working in a state psychiatric hospital. She stated that she observed "too little humanity" there. Personally, I believe underneath staff cruelty is often a personal terror akin to what Winnicott refers to in his "Fear of Breakdown" paper: patients are a painful reminder of breakdowns feared by, and actually having been experienced by staff at times in their lives when they felt utterly helpless. Weekly countertransference groups provide a 'potential' space in which personal, clinical and community issues can be therapeutically contained and understood. As Anna Freud pointed out: the voice of reason and understanding is a soft, but powerful one.
Brian Koehler
New York University
