Read the Notes – Don’t Write the Notes
Two rather opposing forces have perhaps by chance come together in day-to-day mental health practice, making an odd but powerful alliance.
There was a time when psychoanalytic theory was an important current in mainstream psychiatry in the UK. The Royal College of Psychiatrists still has a Faculty of Medical Psychotherapy and psychoanalytically minded junior psychiatrists can still be picked out in generic mental health teams but, as they approach seniority, they tend to split off into more protected specialist services working with personality or eating disorders, for example. It is true that a big inner London mental health Trust recently had as its chief executive a psychoanalytically trained psychiatrist but he moved on after a few years without leaving a trace. Social workers (almost exclusively women, it has to be said), too, in their fleeting golden age of the 1960s and 1970s, topped up or maybe legitimised their innate sternness with a psychotherapy training.
A key tenet of such training was that the analytic session should, as Wilfred Bion neatly put it, consist of neither memory nor desire. That is to say, the analyst or therapist should approach the prescribed fifty minutes with a mind emptied of history and intention so that the patient’s associations are spontaneous and pure. However, an approach which is logically consistent with a treatment based on free association, projection and transference in vivo in which the therapeutic work is done in the moment has been borrowed by hard-pressed, or rather oppressed, mental health professionals looking for corners to cut.
A failure to understand the merits of knowing a history combined with a resistance to doing the unexciting trawling that this involves tends to be rationalised with statements such as we want to get to know X first or we want to hear it from Y himself. While it is much less time-consuming it is also cognitively or intellectually less demanding to focus on getting to know X than it is simultaneously to combine a knowledge of the history and an understanding of the complexity of his difficulties with an alert openness to him in the room.
The key to effective clinical work with patients is to see the individual but recognise the type. Staff who tend towards seeing the individual will find it much harder to encapsulate the essence of the problem and to be effective clinically whereas those who are more interested in type will have problems with engagement and trust, which will also get in the way of real therapeutic progress. The first group risk being overwhelmed, the second being experienced as cold or remote.
A failure to track back through the history and seek out reliable, sympathetic informants arises partly out of a lack of interest, a rare commodity in mental health services, but it is also a by-product or side-effect of institutional defensiveness borne out of an essentially paranoid stance. This requires staff, in particular ward staff, to document relentlessly the minutiae of a patient’s behaviour, the quantity of data collated about a person being mistaken for the quality of interaction.
The purpose of this bureaucratic approach to so-called clinical care, in which key, defining biographical information is often missing, is to prepare for criticism and insure the organisation against blame when things go wrong. Knowing and understanding the patient, without which real treatment is impossible, comes a poor second to loading, or rather overloading, the recording system with data which can later be used as chaff to confuse the radar of investigation. Most damaging of all is that it promotes a narrowing down of how the patient is seen with an emphasis on illness and pathology instead of widening the focus to take into account the unique complexity which brings the patient to the ward or service. This can be seen in the schizophrenia tariff in which early in his career he is described as “having psychotic symptoms”. This later becomes “he has schizophrenia” and then “he is schizophrenic”, with the endgame being “he is a schizophrenic”.
Underlying the move from a clinical imperative to a bureaucratic one is an unconscious deference to the machine. This requires that staff, unaware that they are being softened up for their replacement by artificial intelligence (AI), become interchangeable conduits for a certain kind of information which is no longer a route to understanding but an end in itself. Interactive relationships, subjectivity and agency, deemed dangerous, subversive and unpredictable in a world of machine-thinking, are soon to join CDs, Tippex and the fax-machine in the skip of history. Their redundancy has already begun.