One flew into the cuckoo’s nest—but how do we help them get out? We are all familiar with the usual images of the film and many of us have worked in mental health units and found wanting the knowledge base we have been presented with to help patients recover from mental ill health and get out of ‘the nest’ (hospital).
In my early career as a clinical psychologist in psychiatry, I was always dissatisfied with the conventional social learning models of understanding a patient with psychiatric illness. Biological psychiatry was of little help in trying to understand the mind of a person damaged by the horrendous effects of illnesses, such as schizophrenia and manic depression. I have not found cognitive behavioural models helpful in dealing with the clinical reality of working face to face with severe mental illness.
So in my latter years in the health service, I came across contemporary psychoanalytic concepts which helped me understand and offer psychological help to these patients which I applied in my twenty-five years in the voluntary sector (nine as the Training Co-ordinator and sixteen as CEO). So how can this book help you as a psychiatrist, clinical psychologist, social worker, psychiatric nurse, occupational therapist or as a professional involved in mental health and social care?
1.Realise what you’re up against: Most trainings (including my own as a clinical psychologist) fail to capture the reality of the negative states of mind we meet in mental health. The particular theoretical model I adopt focuses on the emotional processes in the internal world of the patient which, in clinical reality, are destructive. ‘Heart-sinking’ and ‘help-rejecting’ patients will often defeat our best efforts to help them. This book will help to know how to manage this.
2. It’s OK to have feelings: When I first came across this work I was relieved to know that it was OK to have negative feelings about my patient. In fact, this could help me understand their inner world and help me put into words their distress. I hope this book will give you the tools to do this.
3. Preventing burn out: I think one of the saddest realities in mental health is that we fail to take seriously that patients ‘drive us mad’. Kleinians (psychoanalytic theorists/clinicians on which this book is based) have known this for years. I hope this book can bring some sanity into your day to day work.
4. Therapeutic atmospheres can be created anywhere: The central message of the book is that wherever we work, we can, with some thought and concern, make a significant change in our atmospheres in mental health and so improve the therapeutic opportunities we offer to mentally ill patients to help them recover. In this book, ‘therapeutic’ is defined as thinking about the impact of ourselves on others (and vice versa), so creating a setting where thoughts and feelings are taken seriously.
Finally, I hope this book, based on the clinical and organisational reality of providing a service for people with severe mental illness, will help you to think differently about your work. I have also cited relevant research findings along with many clinical/real life examples and how I managed them. It is offered as an alternative to the other traditional models of helping a patient with severe mental illness to recover from this most devastating of human conditions.
Dr Raman Kapur MBE is a Consultant Clinical Psychologist specialising in psychotherapy, and is also the Chief Executive Officer of the mental health charity Threshold, based in Belfast, Northern Ireland. He is an Associate Fellow of the British Psychological Society and also holds an Honorary Senior Lectureship with the School of Psychology, the Queens University of Belfast, where he was formerly course Director of the MSc in psychoanalytic psychotherapy. In 2012 he was awarded an MBE by the Queen for his work in providing services to people with mental illness in Northern Ireland. His latest book, Psychiatric Rehabilitation: A Psychoanalytic Approach to Recovery, is published this week by Karnac.
Reviews and Endorsements
‘In this compelling, clear and honest account we encounter a master clinician’s “IQ” (Introspection Quotient, as he terms it) as he reflects on the dynamics of caring for people with severe mental illness. Based on deep experience, combined with a sensitive application of Kleinian concepts – splitting, envy, destructive narcissism – Kapur brings his non-authoritarian authority to real-life difficulties encountered in hospitals, clinics and the community, showing how hope can be maintained, without succumbing to hatred, evasion, or denial. This truly vital and original contribution is essential reading for all who work in mental health – not excluding those responsible for its management.’
– Professor Jeremy Holmes, MD, FRCPsych, University of Exeter, UK
‘This is an original, creative, comprehensive, and research-based approach to treatment and care for the increasing number of patients with severe and chronic mental disorders who are living in residential programs or at home. The proof is in the pudding: Dr Kapur’s Threshold program has succeeded for twenty-five years in providing optimal care to individuals and their families who have often foundered in other mental health systems. The author draws from his rich experience to provide detailed descriptions, with case examples, of individual, group, institutional, training, and consultations aspects of care that is rooted in a psychoanalytic model emphasizing the listening process, unconscious dynamics, and respect for patients’ autonomy.’
– Victor L. Shermer, MA, psychologist and Life Fellow of the American Group Psychotherapy Association