A psychodynamic interpretation of staff accounts of working with people who have learning disabilities and complex needs
Abstract
Accessible summary
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We asked eight members of staff who were working with people who had a learning disability, and also, complex mental health needs to tell us how they felt about their work.
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These workers told us that not having enough staff and having a wide range of patients with different needs to look after made their job difficult. We felt they tried to put a ‘brave face’ on but we felt they worried greatly about working with patients who had complex mental health needs.
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We did not feel these workers were given enough opportunity to think and talk about their feelings about their work. Staff tried to cope with these difficult thoughts and feelings about their work by trying to forget them or by thinking about other things.
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Staff need to be given time to think and talk about their work and their feelings towards their patients. This may help them to feel less stressed and more able to cope with their patients and their work.
Summary
Experiences of eight staff working with people who have a learning disability and complex mental health needs were explored by interviews and analysed using the free association narrative interview approach (Hollway & Jefferson 2000). Participants reported that organisational factors such as not having enough permanent staff and having to manage a complex patient mix impacted upon their work. Participants’ unconscious communications were interpreted as evidence that they were experiencing projected anxiety from their patients. Participants did not appear to be given opportunities in work to reflect upon their emotions and often coped by repressing painful experiences or displacing these onto the organisation. Staff would benefit from exploring their conscious and unconscious reactions to their patients.
Introduction
Research exploring the experiences of staff working with people who have a learning disability have to date focused mainly upon staff experiences of challenging behaviour. This work has predominantly utilised a quantitative research methodology. It has attempted to isolate measurable variables such as the topography of the patients’ behaviour, or the emotions, beliefs or actions of staff (Hastings 1995 and Dilworth et al. 2011). One of the main recommendations from this type of research has been that staff should be trained to implement behavioural approaches to address challenging behaviour. Such recommendations are supported by evidence that suggests behavioural approaches are successful in reducing challenging behaviour (Didden et al. 1997), and the view that staff feel more confident in addressing patient behaviour, and experience fewer negative emotions in response to such behaviour (Hastings 1995). However, such training does not always increase staff morale nor change practice (Rose et al. 1998).
There is evidence to suggest that organisational factors such as staff shortages and patient mix are more stressful than challenging behaviour itself and prevent staff from implementing behavioural approaches (Emerson & Emerson 1987 and Hatton et al. 1995). It is therefore possible that the recommendation of more training in behavioural approaches may make staff feel blamed, threatened and unlikely to explore their feelings about patients’ behaviour for fear of further scrutiny.
The recommendation for more training does not appear to take into account the emotional impact that the patient’s behaviour has upon the staff member despite research that suggests working with patients who experience and express extreme emotional distress can be extremely challenging (Mavromatis 2000). To address this, Mavromatis (2000) suggested it may be beneficial for staff to acknowledge their countertransferential reactions to these patients.
The exploration of countertransferential feelings can be emotionally demanding for staff as it may involve admitting they have experienced extremely negative emotions; it is also a phenomenon that is often in the staff’s unconscious, necessitating psychoanalytically oriented supervision (Evans 2006; Main 1957). Given the dominance of behavioural and pharmacological approaches as treatments of choice in learning disabilities, (Didden et al. 1997) attempting to introduce psychodynamic approaches may involve too much of a cultural shift for some practitioners (Fauth 2006). As Clegg (1994) explains, this is because behavioural and psychodynamic approaches are based upon two different epistemological and ideological positions.
The appropriateness of focusing on staff countertransference has not been explored in recent years within the learning disability field, despite the relevancy (Symington 1992) and the evidence that emotions are possibly more intense in a staff team situation (Book et al. 1978) and the developments made in other related disciplines regarding this concept (Gordon & Kirtchuk 2008). Other approaches such as cognitive behavioural interventions appear to remain more popular and used more frequently to explore staff reactions, although such research has been critical when staff express negative emotions towards patients (Hastings 1995). This approach risks creating a defensive staff group who feel unsafe to express negative feelings. Perhaps in response to this, Evans (2006) called for the re-introduction of psychodynamic approaches within mental health.
Aim
To examine whether a psychoanalytical analysis deepens our understanding of staff accounts of their work with patients who have a learning disability and complex mental health needs.
Methodology
The research drew on Hollway & Jefferson’s (2000) methodology. This psychoanalytical approach examines the participants, the researcher and the social context from a framework of the ‘defended psycho-social subject.’
‘Defended’ is a psychoanalytical term (Malan 1979), which refers to unconscious psychological defences that all of us are thought to use to protect ourselves from ‘seeing’ and experiencing potentially distressing feelings and anxieties. These intra-psychic defences are thought to significantly influence people’s actions, lives and accounts. This assumes that it is not always possible to take people’s accounts of their experiences at ‘face value’ because such defence mechanisms may be employed. It does support the view that it is possible to uncover participants’ emotions by exploring how the participants share their accounts with the researcher (Hollway & Jefferson 2000).
The term ‘psycho-social subject’ is used to illustrate simultaneously the psychological and social aspects of an individual participant (and researcher). It argues that people’s inner worlds cannot be understood without knowing how they experience their social world, and their experiences of their social world cannot be understood without knowledge of the way their inner world allows them to experience their outer world. Therefore, the ‘subject’ cannot be known except through another ‘subject’– the researcher (Hollway & Jefferson 2000).
Ethical approval was sought and obtained from the Local National Health Service (NHS) Research Ethics Committee. Permission to approach staff within a particular service was then sought and obtained from the relevant service development manager. This manager also gave permission for staff to participate in the research during working hours. Once this permission had been given, the first author arranged an informal meeting with staff at their place of work to discuss the research. After this meeting, forty descriptions of the research were given to a staff member who had volunteered to distribute them to the staff team. Interested staff sent their details to the first author who arranged a meeting at which the purpose of the interview was explained again, and the participant was asked to re-read and sign the consent form. It was stressed to each participant that they were free to ask any questions and could withdraw at any time during the research.
Six qualified nurses and two nursing assistants working in an NHS assessment and treatment unit took part in the study. All had worked directly with at least one patient who had a learning disability and complex mental health needs for a minimum period of 6 months. Three were women and five men aged between early twenties and late fifties.
Unfortunately, it was not possible to check why some staff volunteered whilst others had not. The participants who did take part suggested it could have been that other members of staff may not have felt confident enough to take part in research. This may help to explain why the majority of participants were qualified nurses as they would have most likely undertaken research themselves and so more familiar and confident with taking part in this research process.
Interviews aimed to elicit the participant’s conscious and unconscious reactions to their work using ‘free association’. Free association refers to whatever comes to mind when a person is asked to think and talk about a particular issue: analysis focused on why certain aspects came to the forefront rather than others (Malan 1979). Thus, each interview began by asking the participant an open-ended question about their experiences and went on to explore their response in detail.
In line with this methodology an attempt was made to interview the participants twice, this had a dual purpose of giving the interviewer a chance to listen to the first interview and identify particular aspects of the participant’s account that they thought would be interesting to explore further. It also gave the participant a chance to reflect upon the account they had provided in the first interview. Five participants expressed a willingness to do this. However, this was difficult to facilitate because of time constraints and shift patterns. As a result, one participant was interviewed on one occasion for 105 min and three participants were interviewed twice. In the second interview, participants built on their first account and appeared to be more relaxed with the research situation. Interviews lasted between 30 and 105 min.
Analysis involved transcribing, coding and listening to the accounts many times for tone and affect, informed by notes made during and after each interview in a reflective journal. The interviewer’s reactions (first author) to the data were conceptualised as transference and countertransference and explored in-depth with a qualified psychodynamic psychotherapist (second author).
Results and discussion
The participants’ accounts are summarised under four headings. (i) What may have influenced the way they shared their experiences; (ii) organisational; (iii) patient issues they described as affecting their work; and (iv) the coping strategies they employed as a result. Each section discusses how they relate to previous research, and psychodynamic interpretations of the participants’ experiences are suggested when relevant and appropriate.
Factors influencing the way participants shared their accounts
Participants often began by saying they felt they had not had enough experience or training in working with people who have a learning disability and complex mental health needs. This appeared to indicate anxiety about their ability at work.
‘We just didn’t have a clue’. (Adam)
Participants also explained that they felt powerless.
‘It depends who is in power at the moment how we are treated … Consultants have complete power. We have nothing’. (Susie)
Nevertheless, participants wanted to focus on their positive experiences of work.
‘I try not to be pessimistic … and look at it positively’. (Tim)
This contrasted with more hesitant responses when invited to share negative feelings or experiences of working with patients.
‘I do know … what you’re after definitely, (pause) erm, (pause). Oh God, that’s a hard one … I don’t know. Do I ever get annoyed? (Pause) So hard erm … it’s a hard one … I can’t really answer it’. (Ann)
Staff appeared to find it a little easier to express their negative experiences and feelings about organisational factors.
‘I was never angry, I was never, (pause) I was [sic] angry with the situation, but never with the people you’re dealing with’. (Zak)
Participants’ anxiety and uncertainty, their sense of powerlessness and their desire to be positive influenced what participants shared with the interviewer (first author) and how they shared it.
Such feelings of uncertainty may be linked to the difficulties staff experience on an emotional as well as on a practical and theoretical level when working with patients (Dunn & Bolton 2004). It would appear that participants cope with such feelings using intellectual rationalisation, a psychological defence mechanism (Malan 1979). As a result, participants believe on a conscious level that the uncertainty they feel is because of a lack of knowledge that could be eradicated with training, and this probably holds some truth. However, this view prevents further exploration of these feelings of uncertainty. Such rationalisation is bolstered by researchers also concluding that staff simply need more training (Hastings 1995). There is evidence to suggest that more training does not always eradicate such feelings of uncertainty (Main 1957) and psychoanalysts argue that staff may benefit from exploring such feelings (Hodges 2003) rather than trying to eradicate or avoid them, particularly when working with patients who have complex mental health needs.
Some level of anxiety may have been generated by the research interview itself, but participants’ anxiety appeared high even when this was taken into account. Participants may have attempted to protect themselves from criticism by focusing on the more positive aspects of their job. Concern to appear positive and not express negative feelings in relation to the patients may also be linked to the belief that it is not professional to have negative feelings and that these emotions should be managed rather than expressed (Hochschild 2003). As a result, the safe way for staff to express negative feelings was to project and displace them onto the organisation.
Organisational issues
The organisational issues that participants identified as affecting their experiences were staffing issues and patient heterogeneity.
In relation to staffing, participants valued having a consistent group of people to work with as this helped the shift to run more smoothly. When there were insufficient staff, participants often worked overtime to cover the shift, keep the service safe and supplement their wage. Coincidentally, during the research, such overtime by permanent staff was banned, with temporary staff employed from a pool of ‘bank’ staff instead. Bank staff was described as having experience of general care work, but little if any training or experience with people who have learning disabilities.
‘So we get the most stressful things that happens to the staff some days is to realise there’s only two of us that know what we’re doing, and the rest are bank … it’s heart breaking … and that stresses the staff out a lot worse than … a fight, … and they are not empowered to do anything about it’. (Susie)
The other organisational issue participants raised was ‘patient mix’. This term described caring for a range of patients who differed in age, gender, cognitive ability and mental health needs. Participants commented that at times the patient mix could be so diverse it became very difficult to manage and provide care for all patients: one described it as a ‘ticking time bomb’ (Adam). Participants regarded such patient mix as one of their biggest problems, over which they had little control.
‘It is the main reason for the problems on here is the mix …. They don’t consider who they already have got in. … no control … how can I describe it? They can bring in anyone they want and they do. … We might pretend we have (power and control) but we have nothing. (Susie)
Staff shortages within learning disability services are nothing new (Hatton et al. 1995), but they generate stress and uncertainty for staff as they do not know who they will be working with. Deciding whether or not to do overtime was described as the only way participants could control when and who they worked with, control that was removed during the research. Objections to the change in overtime may have been influenced by the loss of additional earning, but were also interpreted to indicate loss of power and control. Such disempowerment was exacerbated by bank staff whom participants did not trust. Participants did not merely want more staff; they wanted permanent staff who are able to do the job satisfactorily.
The participants’ feelings of powerlessness over the patient mix may have added to the stress attributed to the complexity of their work. Staff appeared to cope with such feelings by engaging in the psychological defence mechanism of denial (Malan 1979): they sometimes tried to pretend that they had power. Acknowledging on a conscious level that they have no power was possibly too painful.
Patient issues
Most participants described experiences of patients targeting them, verbally or physically at one time or another.
‘She’d also know things that pushed my buttons. … that was really tiring, ‘cos she would just be on you and you knew, you’d trip up before she would if you weren’t careful ‘cos she was that good at it … she’d have a subject that she knew I couldn’t, I wouldn’t, I was weak on and she’d always manage to trip me up ….’(Adam)
Participants did not voice negative feelings in response to such behaviours explicitly, but their tone and language suggested that they found this difficult.
Accounts of being targeted were interpreted as evidence that participants felt emotionally and physically attacked by such patients. Feelings of being targeted may also be evidence that patients were projecting unwanted emotions such as vulnerability and helplessness onto the staff, making participants feel that the weakness was within them. The specific emotion that became projected onto each participant appeared to be different, because of the unique nature of the interactions between staff member and patient. Participants appeared to find this experience difficult to manage because it felt so personal. They also appeared to find it difficult to talk about except in rather clichéd phrases such as having their ‘buttons pushed’, a phrase commonly used in reference to the behaviour of patients labelled as having a borderline personality disorder (Mavromatis 2000). The significant point is that participants appeared to experience having their ‘buttons pushed’ as both real and unpleasant: a weakness in them rather than a projection from the patient.
Coping strategies
When asked about how they responded to such emotional experiences, participants reported viewing it as a sign of the patients’ illness and responded in terms of seeking to understand the reason behind the patients’ behaviour. Participants also said that they would talk to their colleagues about this if they were finding it particularly difficult. However, because of time pressures and events occurring within their service frequently, this type of informal support appeared at times difficult to obtain and provide to each other. Participants also spoke of using ‘time out’ when they moved away from the patient area, although this also appeared to be difficult in practice. Perhaps because of a lack of opportunity to discuss their work with other team members and/or to leave the situation physically, participants engaged in a number of what was interpreted as more individual psychological coping strategies. For example, participants reported displacing their emotions about work onto other things.
‘Take it out on the motorists on the way home’. (William)
Participants also spoke about building a harsh exterior.
‘We’re all soft … but you’ve got to kind of present this sort of fairly harsh exterior. … It’s just like developed over the years’. (Zak)
When participants were asked to describe how they felt about their work, they struggled to access these feelings. Apparently reluctant to discuss emotional reactions to patients, participants often responded to questions about how a particular incident or situation made them feel by saying that it was ‘part and parcel’ of their job to deal with difficult patients. The use of such strategies was interpreted to indicate that participants possibly did not have many opportunities to discuss their emotional feelings during work time. Participants appeared to find it more acceptable to express emotional reactions about the organisation.
‘It’s not patient related, it’s more sort of organisational, and, a lot of the organisational stuff annoys me and that will stay with me, but the patient stuff never does’. (Zak)
Another explanation for why participants did not discuss the emotional impact of their work with patients who have a learning disability and complex mental health needs often was because they appeared to believe that expressing such feelings was forbidden.
‘You’re not supposed to say things … like that but no.’(William)
Participants also appeared to view being emotionally affected by their work as negative, a sign of personal weakness.
‘that’s the one area where I am weak in my emotions’. (Adam)
When exploring further why participants appeared to find it difficult to talk to the interviewer (first author) about their emotional reactions, it became apparent that they considered thinking about their work in detail a significant risk.
‘we’d all crack up (laughs). We’d all end up in a mental home’. (Ann)
This helped to explain why participants appeared ambivalent about talking to someone outside the service about their feelings.
‘They don’t really want formal support, they don’t like it, they’re suspicious …‘Why have you come to see me?’…. ‘There’s nothing wrong with me.’… but if you came … and made a relationship with the person and they got used to seeing you, and you came in every week you most likely do a wonderful job … to break the barriers down’. (Susie)
As a result participants valued the ability not to think about their work.
‘it’s being able to, erm, switch off, you’ve got to be able to switch off … you’ve got to be able to switch off … you’ve got to switch off’. (Adam)
This appeared to be particularly salient for painful and traumatic events.
‘(the female patient) pinned me up against the wall before …. Oh God, I can’t remember, I think someone talked her down, I can’t remember, … I’d forgotten about it until someone mentioned it to me … I thought ‘God, I’d forgotten about that’… you don’t want to think about those time, you think back, how could I have managed it differently, how, what did I do wrong, did I not pick up the signs as quickly as I should … did I not see it coming … Yeah, I can’t remember … I don’t know … it was for only a few seconds but it’s, ‘Bloody hell’ you know, your feet are dangling and you’re like ‘Oh bloody hell’… yeah it was horrible, oh yeah, so but I’d completely forgotten about it until someone mentioned it, … To be honest that one I can’t really remember’. (Adam)
Nevertheless, participants were aware that their emotional reactions could be informative.
‘If you’re not in touch with your emotions you won’t be in touch with other people’s, … that’s the key, being in touch with your emotions’. (Mark)
Participants appeared to be concerned that using such strategies in the long-term ran the risk of them not being able to switch their feelings back on.
When asked how they coped with their work, participants did talk about their need for a range of practical and psychological ways of coping, in similar vein to previous staff research about the emotional demands of working with patients who have complex mental health needs (Mavromatis 2000). This is confirmed by the few, yet intense, emotions participants did share during this research, although participants did not appear to be comfortable discussing their emotional reactions with the interviewer (first author). It is possible this was because they did not know the interviewer well enough to feel safe. However, the interviewer felt during the interviews that participants wanted to forget about incidents, as illustrated by the excerpt recalling a physical attack. This strategy of forgetting was interpreted as a defence mechanism used by participants both during their working day and during the interviews that protected them from remembering the pain and fear of the incident (Freud 1914). During such accounts, the interviewer also felt that the participants were indirectly expressing a wish not to discuss such events and feelings any further, so did not probe further. The interviewer felt she was experiencing unconscious projections from the participants concerning their fear of being blamed and held responsible for such incidents.
Participants rarely mentioned a need for more training nor a need to talk to someone about their emotional experiences with their patients. When they did participants appeared ambivalent, which the interviewer linked to their fear of looking weak and difficulty asking for emotional support. However, staff can find supervision very helpful when working with patients with complex needs (Evans 2006). In view of this, the interviewer felt that participants could benefit from opportunities to reflect upon the emotional impact of their work. This might reduce their need to repress and deny their more negative feelings about patients with complex needs, and thus avoid responding to unconscious negative countertransference (Book et al. 1978). For this to be successful, the person offering the support would need to visit regularly to become a trusted confidante.
Summary and clinical implications
Participants did not appear to find it easy to talk directly or in much detail about their emotional reactions to working with patients who have learning disabilities and complex mental health needs. This appeared to be because it was too emotionally painful and/or because participants did not feel safe enough to disclose them in an unfamiliar research situation. When they did talk about it participants described using a range of coping mechanisms. These included talking to their colleagues and taking time out, although these strategies were difficult to implement consistently because of lack of time and staff. Participants also engaged in more individual psychological strategies: ‘trying to switch off’ and not ‘thinking about it’. Participants appeared to have developed these strategies to help them manage painful and anxiety provoking experiences, influenced by their belief that having negative feelings about patients was bad. As a result when these feelings were inevitably experienced, participants tried to manage them by either repressing and/or projecting them out onto the organisation.
Organisational factors appeared to be a very real problem for staff. However, when the participants commented upon such factors, the authors felt that participants were also communicating their emotional reactions about other aspects of their work such as not feeling safe and not feeling valued. If visiting professionals wish to attempt to provide support, this dual understanding of the interaction between organisational and individual issues may help them appreciate the difficulties staff face and experience in relation to their patients but rarely feel safe enough to express explicitly.
In response to a recent (June 2011) TV exposé of brutal practice in an English private hospital catering for similar patients to those studied here, many commentators have focussed on two issues: person-centred planning and closure of all institutions in favour of single-person community services. With regard to person-centred planning, researchers have struggled to identify exactly what it is and question whether it has the effects claimed for it (Claes et al. 2010). With regard to institutional closure, history does not support the idea that this in itself prevents abuse. From research into US services, Trent (1994) concluded that: ‘Both institutions and communities can be inhumane and exploitative; each mirrors the world around us.’ (p.277). With regard to English services up to 1950, Thomson (1998) observed: ‘There was a belief that problems could be solved by administrative reorganization. Questions of resource and finance were either evaded or relied unrealistically upon reallocation of patients from hospital to community.’ (p. 294). Our evidence indicates that an essential resource is skilled support that enables staff to acknowledge and work with their emotions.
Professionals intending to support staff would be unwise to try to alter or remove the defence mechanisms that help staff to manage difficult working environments. It may be more appropriate to try and understand why staff need to utilise them, and explore what can be performed to ameliorate those conditions. Once that has been achieved, it may become possible to develop a safe environment where staff may begin to examine their emotional experiences. When such discussions become the currency of a service, staff may then start to use their emotional reactions to help deepen their understanding of their own and their patient’s inner world.
Conclusion
Staff working with patients who have learning disabilities and complex mental health needs report intense emotions. However, these intense emotions appeared to be either displaced onto organisational issues or repressed rather than being consciously acknowledged as being in response to the difficult interactions they had with their patients. This appeared to happen, as staff perceived experiencing such intense feelings as personal ‘weaknesses’. Staff would benefit from sensitive support that normalises such emotions within a psychodynamic framework. This would allow staff to use these emotional reactions as a therapeutic tool rather than something to be displaced or denied.
