Making Room for Madness in Mental Health, by Marcus Evans

The Psychoanalytic Understanding of Psychotic Communication

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In her foreword of my book, Edna O’Shaughnessy says ‘that the psychoanalytic method does not keep insanity out of view, but tries to offer madness a habitat for human understanding’.  In this book I have tried to demonstrate how psychoanalytic thinking can make ‘Room for Madness in Mental Health’. One of the issues the book tries to address is the challenge of madness – both that which is identifiable as being madness and also madness that is disguised.

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” the long-standing tendency in mental health to respond to patients in a rather mechanistic way that lacks human understanding – treating the symptoms rather than the person”

There is always a drive to push madness away ‘out of sight, out of mind’ and modern psychiatry is keen to suppress any signs of it as quickly as possible through the use of psychotropic medication. Of course patients who are in disturbed states of mind may need the help of anti-psychotic medication to calm them down; however, there can be a tendency to idealise medication, which only provides a temporary respite and does not answer questions about the nature of the patient’s psychosis and/or disturbed state of mind. I, like many others, worry about the long-standing tendency in mental health to respond to patients in a rather mechanistic way that lacks human understanding – treating the symptoms rather than the person.

Arguably, this has always been the case, but the austerity measures have increased the pressure to offer short-term solutions. This can leave people with chronic conditions feeling as if they have been left to cope with their difficulties alone and/or that they have failed to make use of the treatment. I believe that quick-fix solutions and the suppression of symptoms, which keeps the patient and his/her disturbance at a distance in the short term, can conceal long-term costs to both the individual and the NHS.

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“Patients in disturbed states of mind need the receptivity of the psychoanalytic approach as well as the objectivity of the medical approach”

Patients in disturbed states of mind need the receptivity of the psychoanalytic approach as well as the objectivity of the medical approach. They also need to be cared for by staff who are emotionally available but not overwhelmed by contact with the patient. This involves individuals and staff teams who can tolerate madness to some degree without trying to suppress it, explain it away, or push it out of sight and out of mind.

The emotional availability of staff is in turn affected by the degree and quality of support provided to them. Staff need time for supervision and reflective practice. They also need supervision from experienced practitioners who allow them to separate from the effect of the patient’s communication and think symbolic meaning of the communication. A psychoanalytic approach, which pays attention to unconscious as well as conscious communication, helps staff tune into psychotic levels of communication that may underpin neurotic as well as psychotic thinking.

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“A psychoanalytic approach helps staff tune into psychotic levels of communication that may underpin neurotic as well as psychotic thinking”

In this book I argue that a psychoanalytic approach can help mental health practitioners understand the, at times, bewildering behaviour and/or bizarre symptoms of their patients. This understanding will help them improve their capacity to remain engaged and curious even in the face of behaviour or forms of communication that at times discourage meaningful thought. While ostensibly a guide for practitioners, I hope that it can offer helpful insights to anyone interested in the treatment of mental health. I have tried to write the book in an accessible way, using case studies and clinical examples, as well as keeping the language as jargon-free as possible. In this way I have tried to offer a place for and model for thinking about the ‘Madness in Mental Health’.

Making1 Room for Madness in Mental Health The Psychoanalytic Understanding of Psychotic CommunicationMarcus Evans is a consultant adult psychotherapist at the Tavistock & Portman NHS Foundation Trust with thirty-five years experience in mental health as a practitioner, lecturer and manager. He qualified as a psychiatric nurse in 1983 and went on to occupy nursing posts as charge nurse of St. Giles Day Hospital, clinical nurse specialist in liaison psychiatry and para-suicide in Kings College Hospital A&E, and clinical nurse specialist in psychotherapy at the Bethlem and Maudsley hospitals. After qualifying as a psychotherapist at the Tavistock & Portman NHS Trust, he took up a post as head of the nursing discipline with a brief to develop the nursing discipline within the Trust. He held the post of Head of Nursing and consultant Adult psychotherapist until taking on the post of Associate Clinical Director of the adult and adolescent departments between 2011 and 2015.

Marcus has supervised designed developed and taught outreach courses for front line mental health staff in various settings for the last twenty-five years in many mental health trusts including Camden and Islington, the Bethlem and Maudsley, and Broadmoor. He was also one of the founding members of the Fitzjohns Service for the treatment of patients with severe and enduring mental health conditions and/or personality disorder in the adult department and since stepping down as the associate clinical director he has started working as a consultant adult psychotherapist in the Portman clinic. His passion is the application of psychoanalytic ideas to the treatment and care of patients in mental health settings. His latest book, Making Room for Madness in Mental Health, has recently been published by Karnac.

Reviews and Endorsements

‘This book will help all health professionals who want to learn how to listen to their patients and try to understand what it feels like to be mentally ill. It can enable us all to tolerate the distress of psychiatric disorder and to make a place for it in our hospitals and clinics as well as in our minds.’
John Steiner, training and supervising analyst of the British Psychoanalytical Society and author of Psychic Retreats and Seeing and Being Seen

‘Marcus Evans has written a most important book that will be of great value to all who work with severe mental illness in front-line mental health teams.  I anticipate this book will be recommended reading for decades to come for nurses, psychologists and psychiatrists as well as psychotherapists of all modalities.’
Dr Brian Martindale, psychiatrist and psychoanalyst of the British Psychoanalytical Society; formerly chair of the International Society for the Psychological Treatments of the Schizophrenias and other Psychoses

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‘This is a book of great value for all concerned, in whatever way, with the treatment of severely mentally ill patients. We see the problems and sufferings of the patients, their strange and disturbing engagements with staff, and the resulting problems and need for support of the staff. But the paramount fact, as Marcus Evans shows, is the way that the psychoanalytic method does not keep insanity out of view, but tries to offer madness a habitat and human understanding.’
Edna O’Shaughnessy, distinguished fellow and training and supervising analyst of the British Psychoanalytical Society

‘Marcus Evans has produced a very valuable addition to the literature on applied psychoanalysis. Like many of us, he is deeply troubled by the current trend within mental health towards over-simplification and cost-cutting that fails to cut costs in the longer term. I strongly recommend this book to anyone interested in how psychoanalytic theories can be effectively put into practice in the course of delivering mainstream psychiatric care.’
Dr David Somekh, Network Director, European Health Futures Forum, forensic psychiatrist, psychoanalyst, British Psychoanalytical Society

‘The relationship between phenomenological and dynamic approaches to understanding mental health and illness has shaped the last century of British psychiatry. Marcus Evans highlights just how important the relationship remains if we are to understand and work with real humanity. Psychiatry needs dynamic understanding just as psychoanalysis needs psychiatry. This text should be essential reading therefore for anyone interested in deepening their practice.’
Dr Matthew Patrick, Chief Executive of the South London and Maudsley NHS FT, psychiatrist and a training and supervising analyst with the British Psychoanalytical Society

 

6 thoughts on “Making Room for Madness in Mental Health, by Marcus Evans

    • Currently very few places in the NHS offer psychoanalytic psychotherapy for patients who have a psychotic illness. However there are psychoanalysts and psychoanalytic psychotherapists providing support and clinical supervision for mental health professionals and teams.

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  1. At least there is some sort of interaction and connection with psychoanalysis then. I’m oddly optimistic about the future. I think CBT is just where the NHS is right now, it will go around again. 4th wave, back to Freud.

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  2. Glad to hear steps are being made, however tentative, in the right direction. The exclusion of psychoanalysis from current psychological discourse underscores a serious bias within the British orthodoxy, which too blindly favors those approaches based on logical positivism (which psychoanalysis isn’t). Aside from the fact this is counter to a healthy -read open- intellectual culture, this exclusion can only be detrimental to those undergoing or in need of treatment. This is apparent in the sheer glut of psychopharmacological drugs synthesised for clinical purposes which to my mind are far too readily prescribed for ailments and malaises that axiomatically defy easy categorisation – let alone those that aren’t. The efficacy of treating complex phenomenological states – such as those called depression and schizophrenia – solely within the confines of a unitary catalogue of symptoms and observable behaviour seems limited at best and exacerbatory at worst.

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