A Personal Account of An Arts Therapy Group in A Secure Rehabilitation Ward
Locked psychiatric wards evoke spectres in the imagination. Often featuring in popular narratives which draw on themes of horror and abuse of power they still occupy a dark corner of the collective consciousness, despite recent attempts to rehabilitate their image. Foucault in his seminal ‘History of Madness’ described psychiatric asylums (the forerunners of today’s hospitals) as arising to fill the void left by the closure of leper colonies. A place to put the ‘Others’.. People, illnesses and emotions which we would rather not be confronted with in day to day life. Asylums were seen as Pandora’s boxes concealing those who did not fit our society and were considered ‘sick’ or ‘disturbed’.Although the asylums are now closed they cast a long shadow: If there is a single theme which connects the many depictions of psychiatric hospitals and asylums in popular culture it is the lack of any human warmth, connection or intimacy alongside institutionalized abuse. It is these qualities which linger in the collective memory and which have been actively combatted by the NHS since their closure.
Foucault in his seminal ‘History of Madness’ described psychiatric asylums (the forerunners of today’s hospitals) as arising to fill the void left by the closure of leper colonies. A place to put the ‘Others’
As a trainee psychotherapist I was enthusiastic although nervous about being able to see for myself the inner working of a locked psychiatric rehabilitation ward. In this setting the majority of the patients were paranoid schizophrenic and a large number of them also possessed a forensic background (a criminal record), which I admit did add a level of gothic danger to the idea of working there. I wondered if the collective fantasy of the ‘asylum’ would be dispelled by the practical experience of working at a modern NHS ward. Having worked in other areas of mental health, I felt hopeful that inpatient treatment had been modernized, made effective and centered around psychological well-being.
The residents of this exclusively male rehabilitation ward were deemed as too ‘difficult’ for other areas of the hospital (although the hospital itself was considered to be a hard place to work). I was told that it was not your ‘average’ ward. This may explain the more disturbing, difficult parts of my experience. I feel that I have to add the disclaimer that my aim in writing this piece is not to discredit the NHS, or psychiatric treatment in general but to give a voice to what I feel was unsaid or unchallenged in this ward.
I was working within this setting as an assistant arts therapist. The therapist I was assisting was enthusiastic and had recently led a successful, cohesive and lively group in one of the accompanying wards to ours. As well as working with him I was attending ward rounds; here I was able to see how the psychiatrist and other members of the staff (such as psychologists and occupational therapists) interacted with the patients. This included me as an observer-participant in the many levels of power dynamics that patients were forced to navigate during ward life.
For many people the idea of students paying to volunteer might seem like something out of George Osbourne’s darkest erotic fantasies, unfortunately, however, this has been accepted as de rigueur in psychotherapeutic training
Here I feel I need to have a little personal gripe about the fact that I had to pay hundreds of pounds for my placement.. For many people the idea of students paying to volunteer might seem like something out of George Osbourne’s darkest erotic fantasies, unfortunately, however, this has been accepted as de rigueur in psychotherapeutic training. Students are hard pressed to find psychiatric observational placements to complete their training in line with the UKCP guidelines and the NHS has seen a way of making money from them. This not only provides the NHS with revenue but also a supply of unpaid and relatively enthusiastic therapists to farm out to their institutions.
This arrangement is a double-edged sword for patients: although there are many more therapists available, they are usually on a short-term contract. Fragile patients who have often experienced great losses and wrenching abandonment in their lives may be forced to relive their trauma. The experience of forming a deep relationship with a therapist or group and losing them after such a short period can be painful, often repeating the disorganized attachment styles fostered by parents or families of psychotic patients. Our ward in particular had patients who were so disordered that the period we had to conduct our group was barely enough for them to register that we were there.
the healing containment of the therapeutic relationship was secondary to the power of the system we were embedded within
I also had deep concerns witnessing the movement of patients where therapists would not be given a clear ending date, meaning that the intimate, therapeutic relationship was ripped apart by a third party (the medical system), utterly without warning to the patient. This prevented therapists from being able to bring their work to a properly managed ending, and served as a traumatic reminder that the healing containment of the therapeutic relationship was secondary to the power of the system we were embedded within. Sometimes therapists even had to conceal their knowledge of the patient moving – undermining the basic trust needed for intimacy in the relationship. The whim of the unreachable, unpredictable and omnipotent medical system took precedence.
Adding to this pervasive feeling of fragmented chaos (mirroring the internal chaos of the patients) was the high turnover of staff – in the ward in which I worked we lost an occupational therapist, a psychologist, and a doctor within the space of a few months… I felt a part of the ‘old crowd’ after having been there for only a short period of time. There was seemingly very little attempt to understand why this was happening; of how the disorganized inner world of the patients may have been playing out in the body of the institution itself. Everything was transient and temporary; shifting sand under which we were all sinking.
The medical model, drug regimes and behaviorism seemed to be first priority – with much of the discussion on ‘ward round’ to do with insurance risks, medication changes or how patients would reflect on the hospital, rather than the psychological wellbeing of the patients themselves which came a distant second
This lack of appreciation (or even vague interest) of how this lack of secure relationships and stability would effect the inner world of patients from anyone except the therapists was disturbing to me. The medical model, drug regimes and behaviorism seemed to be first priority – with much of the discussion on ‘ward round’ to do with insurance risks, medication changes or how patients would reflect on the hospital, rather than the psychological wellbeing of the patients themselves which came a distant second, if addressed at all. Patients seemed objectified and although behaviour was addressed there was very little attention paid to their inner world. At one point I was aghast to hear a staff member telling a patient “It’s fine that you have these delusions, but just keep them to yourself – otherwise we can’t let you out”… Essentially an injunction on opening up and communicating, a punishment for intimacy.
“It’s fine that you have these delusions, but just keep them to yourself – otherwise we can’t let you out”
My general feeling after a few months of work was that the place was functioning as a sort of dustbin. Patients on the whole did not get ‘better’ but instead existed in a zombie like medicated apathy, learning which hoops to jump through to have leave extended. Eventually one would jump through enough hoops to be moved to a lower security ward and would invariably regress and be back within a few weeks – again, no attempt to find out why, just an acceptance that this is how the patient’s functioned. A veil of paranoia overlay patient’s relationships with staff and each other, preventing healthy relationships from forming. Intimacy was impossible. None of this suppressed anger was expressed openly: most patients had been in secure wards for so long that they were institutionalized to the point of no return. The place seemed to be working through the means of operant conditioning; if the patients jumped through the right hoops, pressed the right levers and did not cause trouble there was ‘no questions asked’ in respect of their psychological state.
Finally for two of the months that i attended the ward there were no psychologists working there! This surreal spectacle of a psychiatric ward without an operative psychology department gave me the impression of a ‘ghost ship’; all of the institutional bureaucracy in place for the machinery to work without the actual exploratory, psychological factor which would allow it to function as a place of healing and rehabilitation.
The unconscious dynamics flying around the hospital were the ‘blind spot’. Countertransferentially I was aware of tension around patients at the beginning of my time working; perhaps being affected by the societal ‘shadow’ that they held and in some cases the long and lurid criminal records that some of them also possessed. Through my time at the placement this dissolved to a much more potent sense of anger at my witnessing of systematic failure. Not just failure of treatment that these men had received from the mental health system, but also from wider society. Part of this anger was my own; a rational response to watching men who suffered unthinkably severe illness and who had been forced to hold the collective shadows of their communities and families being let down once again. Part of it may have also been projective identification with the anger which was not allowed a space in the heavily regimented, repressive culture inside of the hospital.
I feel that there was projective identification with the patients tied in with my experience of being unable to speak about the issues I found within the ward.
Transference in the ward was exceptionally heavy – I felt while in ward rounds that I was unable to speak up, especially not in contradiction of the consultant psychiatrist. I was acutely aware, as were the patients, that his word was unchallengeable in the hospital. Ward rounds effectively consisted of dictation rather than more open models of communication. Being simultaneously aware of my status as a lowly trainee and aware also of the collusion of the rest of the staff with this top-down pyramidal structure, I felt swallowed in the unconscious power dynamics of the place. I imagine the patients to feel similar dynamics yet far more acutely. Only with the arrival of two clinical psychologists (two ‘outsiders’) was I able to refind my voice and began to vocalise my concerns with the management of the ward. I began to express my concerns in the last month of work and continue to do so in writing this piece.
I feel that there was projective identification with the patients tied in with my experience of being unable to speak about the issues I found within the ward. The institutionalized patients knew to present an adapted front in which they jumped through the right hoops. The disowned, let down, angered part of them did not emerge in their interactions with the staff – except in one of the periodical explosions of violence and frustration, seemingly erupting from nowhere. I acutely felt this repressed and repressive energy whilst I was working on the ward and through my own experience of the power dynamics which unconsciously permeated patients and staff. I was caught up in this and presented an ‘adapted’ front for much of the time I was there.
Our art therapy group process reflected the disjointed and disorganized internal world of the patients and the ward itself. Me and Matteo spent many sessions sharing the tense experience of sitting opposite each other in an otherwise empty art room. We waited patiently for patients. Often only one or two of them came, sometimes only briefly or without actually engaging with the art itself. The room did however seem like a refuge where there could be a relaxing of the coercive need to present as a ‘perfect patient’. Descriptions of psychosis or painful experiences in the outside world would be communicated to us with less reserve and deliberation than I witnessed on the ‘ward rounds’. The patients were perhaps less conscious of the need to ‘perform for the judges’ in quite the same way. It was a space where they could be human.
Sometimes ‘perfect patient’ would raise his head. This would normally consist in someone coming in for the briefest possible time, telling us what a great job that we were doing as therapists, and leaving. These ‘brief encounters’ felt to me like a byproduct of being institutionalized. Showing your face in therapy meant ticking a box and you would be praised for it in the following ward round. This was indicative to me of the lack of authenticity in the relationships between staff and patients throughout the ward.
We never really (in 5 months of weekly meetings) managed to get a cohesive group operating. It felt more like disintegrated fragments shifting in and out of the therapeutic space. Sometimes a patient would come for a few weeks in a row, before forgetting we were there – or having some form of relapse. Patients did not really interact with each other, even when they were in the group together with the exception of one or two fragile friendships, soon to be broken. Often patients would compete for attention or paradoxically seemed to be almost oblivious of the presence of each other.
Within the group, in an all male ward, with two male facilitator the figures of good and bad father were played out in the group. Suspicion would fall either on me or Matteo depending on who the patient was, with the schizoid splitting making them unable to integrate the two parts. Distrust was palpable; I feel I often took the brunt of ‘bad’ as a result of my attendance of the more formal, more threatening, experience of the ward round.
Art which I produced often had themes of large vicious animals devouring each other
Art which I produced often had themes of large vicious animals devouring each other (the experience of being consumed by another), the sun and moon (perhaps showing a schizoid splitting), kabbalistic diagrams showing connections between many separate points (perhaps reflecting the paranoid connections of the clients which I was working with) -and for some reason snails shells. I experienced Matteo occasionally insinuate that I should not use felt tips as they were too ‘contained’. This was an interesting experience for me, as i felt that there was an encouragement to become what he wanted – to adapt, to become institutionalized.
Clients produced some amazingly creative pieces of work and there was a palpable enthusiasm in those who regularly took part. The process of making art not only gave an outlet for clients creative work but also inspired thought around creative outings the clients wanted to participate in: An exhibition of a famous artist, lessons on how to create stained glass. These were not followed up by the institution, yet the creation of these dreams in the imaginary seemed a therapeutic act in itself.
As I left the ward I felt a sense of sadness at the experience. Not the sadness of loss, but the sadness of abandoning the men that i had met on the ward. Voiceless and anonymous in the abyssal recesses of the NHS mental health system
As I left the ward I felt a sense of sadness at the experience. Not the sadness of loss, but the sadness of abandoning the men that i had met on the ward. Voiceless and anonymous in the abyssal recesses of the NHS mental health system, I could not imagine many of their situations would be changing in the near future. I wonder if this hopelessness is also something they are forced to carry.
There was some light at the end of the tunnel. The arrival of two experienced clinical psychologists (who by virtue of their position had more scope to challenge the practices of the ward) brought to me a sense of relief and the vague hope that things might change. I felt worried for Matteo, who was also in a voluntary position, despite being fully qualified – unpaid and not even compensated for travel expenses. I wondered how tenable this position was.
I was left looking back at an understaffed and underfunded ward, filled with the unwanted of our society. Everything precarious, nothing stable or certain. intimacy secondary to coercive compliance. Yet within the therapeutic space itself there was the tiniest window where not only could authentic relationships be created, but the imagination could cut through the locks, doors and power for the briefest second.