IMPORTANCE OF PSYCHODYNAMIC EDUCATION OF PSYCHIATRIC NURSES WORKING WITH THE ACUTE PSYCHOTIC PATIENTS
Sladana Ivezic'
Key words:
milieu therapy, nurse training
ABSTRACT
Therapeutical milieu is important as environment for the process of emotional reeducation of psychiatric patients. Nurses are a part of the therapeutical milieu and have interpersonal potential as a curing factor. Working with an acute psychotic patient a nurse becomes the object of many intensive reactions based mostly on the patients projective identification. Projective identification brings about intensive counter-transference reactions and can be used also as a curative factor through a process of corrective internalization. That is why it is very important that the nurses are able to recognize this mechanism and to handle it. The author thinks that the education in Balint groups helps the nurses to understand better the behaviour of psychotic patients, decreases their feelings of frustration and anxiety, and improves their mental health.
INTRODUCTION
There are many reasons for psychodynamic education of nurses in psychiatry. Within the British National Health Service (NHS) it is now well established that the demands of caring for others can be extremely stressful. Among the caring professions nurses are a particularly high risk group, primarily because of the "hands on" nature of their work (Kunkler, Whittick, 1991). It is known that the interpersonal relations between the staff and the patients influence the patients psychic condition and withdrawal of symptoms as well as the worsening of their psychic condition (Sullivan,
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1953; Freeman, Cameron, 1958; Arieti, 1974; Searles, 1965). Studying the importance of the staff-patients interaction, Ludwig (1971) observed that it can lead to the antitherapeutical complementarity when the nurses are uneducated and not supervised. He states that a long exposition to the emotional reactions of the patients with no possibility of understanding these reactions can cause the reactions in the nurses he calls staffphrenia, manifesting in apathy, boredom, declining enthusiasm, minimal personal contribution in the patients treatment and reduced expectation in effects of the treatment, compensatory paranoia and depression. The therapeutical milieu consists of both the staff and the patients, their interaction having a therapeutical potential. The therapeutical milieu is very important in the process of emotional reeducation of psychiatric patients (Gunderson, 1978; Mesnikoff,1964; Searles, 1965). Being a part of the therapeutical milieu, the nurses have an important role in this process. The fact is that the nurses-patients relations are unavoidable and behaviour of both these parties leads to many and complex emotional reactions.
Reasons for psychodynamic education of psychiatric nurses
Therefore I think the psychodynamic education of nurses necessary for two reasons: 1. theoretical and practical knowledge about the psychodynamics of the staff-patient relation should improve and protect the mental health of the nurses, and 2. the interpersonal relations are a curing factor in the therapeutical milieu regardless of the type of treatment. Working with an acute psychotic patient a nurse becomes the object of many intensive transference projections, based mostly on projective identification. The condition of an acute psychotic patient is characterized by regression, loss of ego function, loss of ego boundaries, existence of primitive defence mechanisms (negation, projective identification, omnipotence), loss of capacity for reality testing, increased anxiety, even panic, etc. In transference very intensive emotions - from very negative ones to positive ones, from aggression to love - can be projected. These transference reactions cannot be avoided and it is necessary to train the nurses to recognize them and to handle them in order to improve their self-confidence and to minimize their feeling of anxiety. This results in an increase of the therapeutic efficiency and prevents the use of the defence mechanisms similar to those used by the patients. Countertransference reactions of the nurses are provoked by their patients pathology, they are not the result of theu- own unsolved problems only. This is the view about counter-transference similar to Winnicotts (1958).
The importance of projective identification in education
In work with the acute psychotic patients, due to the intensity of mutual reactions, it is very important to analyse the feelings towards patients, for countertransference reactions for they can be very intensive, especially those based on projective identification, and nurses can feel guilty and ashamed because of their feelings. An open discussion about their feelings can be of great help. Countertransference feelings can be discussed only in a milieu which respects the importance of psychodynamic factors. According to Brown (1980), supervision of the staff, with special attention paid to their feelings toward the patients, is the essential element of an effective hospital treatment of borderline patients. The importance of projective identification, which can be usually observed in acute psychotic patients, should be emphasized, because it brings about intensive countertransference reactions and, also, it can be used as a curative factor through interpersonal experience. Projective identification (Ogden, 1979; Ogden 1983) is an intrapsychic and interpersonal process, it is used as a transference, defence mechanism and way of communication. Projective identi-
fication is the exchange of the intrapsychic and the interpersonal, thus the fantasies of one person communicate with those of another and influence them. This process has three phases. One projects his/her aspects on another person with the intention of getting rid of undesired aspects of himself or protecting himself from an imagined inner danger. In the second phase the projector forces the recipient to accept himself in accordance with projectors projections. In the third phase the recipient modifies projective feelings in a more mature way and offers them to the projector to be rein-temalized through introjection and identification. This can result in psychological growth of the projector; if not, the feelings remain unchanged in a pathologic way through negation, omnipotent idealization or further projective identification, which results in status quo of the patients pathology. For instance, a patient may project his hostility on the nurse accusing her of having bad intentions towards him and he tries to "convince" the nurse of that. In the situation of pressure and "really bad" behaviour of the patient, who experiences the nurse as his true enemy, such a projection may provoke the nurse to really hostile behaviour or makes her hide her hostile feelings. This serves the patient as a definite proof of the nurses animosity and justification of his projection. If the nurse is able to understand, through empathy, the patients condition and his inability to behave differently, she will not have nor show hostility. In that case she will not reject the patient and she will make possible the process of corrective experience or corrective internalization to take place. In this way the patient has a chance to internalize a milieu that is benign and modifies his "bad" object representations. The patients use of projective identification often provokes strong countertransference reactions, but at the same time it is a chance for him to moderate it in a more mature way in the interpersonal relations. According to Kemberg (1965), the patients use of projective identification often creates strong countertransference reactions in his therapist and caretakers, and the staff members are therefore prone to experience themselves as though they were actually such awful creatures the patient fantasies them to be. Having such feelings, the staff members are susceptible of dealing with their anger about being made to feel ill at ease with themselves by acting out toward the patient. When this occurs, the hospital milieu serves only to recapitulate the pathological patterns of relating that brought the patient to the hospital, and therapeutic stalemates may ensue.
All this shows that it is important that the nurses recognize the mechanism of projective identification and understand countertransference feelings caused by this mechanism in order to be able to contribute to the process of corrective internalization. To acquire psychodynamic knowledge for a better understanding of the nurse-patient relationship I consider the continuous education in Balint groups very suitable. The aim of these groups is to offer psychological education close to self-observation and the observation of the others in a way that theoretical knowledge alone cannot give. Training in Balint groups enables a better understanding of the patients difficulties as well as the nurses reactions to them. In Balint groups with the nurses conducted in my institution a lot of attention is paid to the feelings the patients evoke in relations, having in mind that their better undestanding increases spontaneity in communication, expands it and offers greater opportunity for improvement of interpersonal relationship.
CONCLUSION
It is important to educate the nurses exposed to intensive emotional reactions and unpredictable behaviour of the acute psychotic patients which they very often can
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not understand. In this context recognizing and deahng with process of projective identification is of the utmost importance. The process of education should enable the nurses to understand and handle better these situations for two reasons: to reduce their feelings of frustration and anxiety and to improve their mental health, with the final aim to enable them use the interpersonal relationships as a curing factor in treating psychiatric patients.
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