Introduction

It is of primary importance for organisations in the field of mental health to provide opportunities for clinicians of all backgrounds to reflect on their work. This enhances their ability to provide high quality care, supports staff in their work and can prevent burnout.

The General Medical Council recognises and supports this in their guidance for the reflective practioner, stating ‘Medicine is a lifelong journey, scientifically complex and constantly developing. It is characterized by positive, fulfilling experiences and feedback but also involves uncertainty and the emotional intensity of supporting colleagues and patients. Reflecting on these experiences is vital to personal well-being and development, and to improving the quality of patients care.’ [1]. There has been a real grassroots movement to create a variety of additional reflective spaces in the shadow of the COVID-19 pandemic, not only in mental health but also in physical health settings. This powerfully demonstrates their usefulness to staff when facing emotional distress.

There are many definitions of reflection and reflective practice; for the purpose of this chapter it is understood as a way of making contact with the emotional aspects of clinical work and finding the meaning of this experience in the context of the team. Reflective practice is often carried out in a group setting. It provides the participants with a safe space that is managed by a facilitator to explore the feelings stirred up by encounters with both patients and colleagues in work situations. Models of reflective practice vary, from psychoanalytic approaches, underpinned by the concept of the unconscious mind, to more cognitively informed paradigms.

Reflective practice can be provided in many settings including:

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  Supervision

  
  
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  Case-based discussion groups

  
  
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  Staff support groups

  
  
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  Reflective practice groups

  
  
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  Case discussion groups, including Balint groups

Balint groups have a special place in medical training, starting in medical schools and being the first mandatory component of psychotherapy training for all new psychiatric trainees. Recognising and attempting to understand and process the emotional complexities at work has been recognised to foster the developing doctor’s empathy and resilience [2].

This chapter is specifically focussed on psychoanalytically informed reflective practice including case discussion and Balint groups. It will consider the ways these models can be applied to psychiatric practice and illustrate their value using clinical examples.

The Theoretical Underpinning of Reflective Practice in Groups

Psychoanalysts have put forward a model of the mind which emphasises the importance of moving from the initially dyadic relationship between the baby and the mother towards recognising the painful reality of exclusion in psychological development [3]. This realisation is key to establishing the ability to be separate and to think for oneself. As the dyadic relationship is challenged by the presence of a third, usually a father and the baby experiences being outside in terms of the mother’s preoccupations, a triangular space becomes opened up in the mind where thinking can take place. The concept of reflective spaces is rooted in this idea of finding a ‘third position’ from which both oneself and others can be observed and thought about.

This observation by Freud speaks helpfully to the unconscious processes that occur between staff and patients within mental health organisations. These processes can powerfully increase anxiety and disturbance if they are not recognised and digested. Capturing and reflecting on the emotions engendered by contact with patients can become a lens through which the unconscious can be glimpsed.

Psychiatric breakdown can be a very painful and frightening experience, giving rise to unbearable feelings such as helplessness, dependence, avoidance of responsibility and shame. Defences against awareness of these feelings include projection and projective identification into the staff that work with them. Those processes are particularly potent with psychotic patients whose projections can threaten to overwhelm the clinicians’ mind. Due to the intensity of those experiences, recognising and understanding the countertransference often needs the presence of another, which can relieve the dyadic relationship between clinician and patient and create space to think. As patients are likely to see a number of professionals from the same team, discussing the effect of this phenomenon in the group allows for more thorough examination and multiple perspectives can emerge. This is then a valuable tool helping us to understand the experiences of our patients.

Without opportunities to reflect on those processes, the mind of the clinician can become controlled and trapped by powerful projections and may also react against the projective pressures. Responses from staff to such powerful communication may include:

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  Over-involvement or emotional detachment, driven by a disowning of one’s own emotional response

  
  
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  Identification with the patient as if they are of one mind

  
  
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  Taking action in a reactive way which can become a doing-to the patient rather than a being-with

  
  
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  Fragmentation of patients’ care which is seen as a sum of tasks rather than holistically considering all aspects of the presentation

  
  
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  Inability to maintain a perspective about risk, leading to risk avoidance or under-recognition of any threats to patient safety in treatment plans

We all have our own blind spots, likely to be linked to our reasons for choosing mental health as a profession. These are deeply personal and we are drawn to particular responses when facing powerful conscious and unconscious communication from patients as a result. Working in teams amplifies those phenomena potentially leading to conflicts and difficult team dynamics. To prevent possibly destructive enactments it is vital to develop an understanding and awareness of our own limits, vulnerability and tendency towards taking up a particular role within a team and towards patients.

Bion’s concept of containment [5] is particularly helpful while thinking about the impact of projections on staff. Containment describes the capacity of the mother to recognise that frightening and disturbing projections from her infant are attempts to communicate with her. She receives and thinks about them. In the process they are detoxified and rendered understandable and communicable. These can then eventually be returned to the infant who feels understood, held in mind and becomes calm. Bion postulated that with time the process of feeling contained leads to the infant internalising this capacity and becoming able to think about his emotional states and to manage them himself. There are clear parallels here to be drawn in terms of how patients project unbearable states of mind in mental health settings. The motivation is similar to the infants in that they are searching for a container which will accept the projections and think about them, transforming ‘raw bits of experience’ into thinkable form.

To be able to act as such a container, staff need thinking space to safely unpick the disturbing threads of their emotional response to patients, making use of their countertransference in a way that frees them up to support and to understand their patients more deeply. Thinking under the fire of powerful projections is hard work. There are times that both individuals and the team resist engaging with such a painstaking task.

Why Teams May Resist Reflection

Anyone that has tried to set up a reflective practice group in a mental health setting will be aware that it can be difficult. On occasion teams express their desire for the space but then find it difficult to attend or fully engage. Bion’s concept of basic assumptions [6] is helpful in terms of the theoretical underpinning of the team dynamics that help explain this. He proposed that groups of people continually engage in a cycle of working towards the primary task, and then disengaging with it due to the emotional challenges the work demands. This disengagement is marked by the group resorting to unconscious ‘basic assumption’ functioning. This is evidenced through three main ‘positions’ or dynamic patterns taken up by the group as a whole, dependence, fight/flight and pairing.

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  Dependence: if the unconscious assumption is that the group’s primary task is to fulfil the dependency needs, the group is passive and relies on authority to solve all problems

  
  
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  Flight/fight: if the unconscious assumption is it is only fight/flight that can preserve autonomy, the conflict with authority is prevalent, expressed through avoiding the challenges of the task

  
  
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  Pairing: if the basic assumption is a phantasy that pairing of powerful individuals will resolve the group’s problems, the group sits back and waits for the magic solution, avoiding engagement

While basic assumptions are more visible in therapy groups, less pronounced versions might be also observed in reflective practice groups and at times, can be accessible for discussion.

Winnicott’s concept of maternal holding and the holding environment [7] can be extrapolated to wider social environments, including those of psychiatric wards. For the mother to be able to provide a holding function which includes the ability to contain the baby’s primitive anxieties projected onto her, she needs her own containment as described by Bion. This function is usually provided by the father, extended family and the wider social environment around her. To enhance the ability of staff to contain their patients, they too need support from the wider organisation, rather like the paternal function described by Winnicott, and reflective groups is one of the ways in which this can take place.

Mental health teams are constantly under pressure from the patients, the organisation and their own members which can make it difficult to think and to create and maintain its reflective capacity. The team’s diversity (including ethnicity, age, gender, sexuality, religion, status, academic achievement and personality) creates a powerful mix which can become negatively amplified when the team is under pressure, leading to splits. Klein described splitting as unconscious mental phenomena in the infant’s mind of separating good and bad parts of the object driven by the fear of good ones becoming destroyed by the bad, toxic ones [8]. In this process experiences and people can be experienced as polarised, only good or bad. The potential to split can continue throughout life and can be seen in mental health care teams, for example; with good nurses and junior doctors but a bad consultant, a good female therapist and a potentially harmful male one. Yet, providing patients with a safe and containing environment demands cooperation and interdependence; it is a combined effort of admin staff, nurses, doctors, occupational therapists, therapists, psychologists and others which makes key contributions to the patients’ experience of health care. Reflective practice provides a setting where such splits can be noticed, thought about, understood and worked through in the best interest of patients’ care.

Organisations also play their role in staff’s attitude towards reflective practice taking a range of positions towards it, from actively promoting, scepticism or a degree of resistance seeing it as not a productive time. The latter might be for a variety of reasons and is likely to be linked to high levels of unprocessed anxiety within the organisation. Organisations might need support in understanding this link and in changing the organisational culture to embed reflective spaces so that staff feel supported to engage with them.

Setting Up a Reflective Practice Group: The Process

Related posts:

Chapter 3 – Referral for Psychodynamic Psychotherapy: Processes and Considerations Chapter 9 – Systemic Family Therapy Chapter 10 – Cognitive Analytic Therapy (CAT): Chapter 15 – Personality Disorder Chapter 16 – Complex Post-traumatic Stress Disorder Chapter 25 – Therapeutic Communities

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