BION, BECKETT AND BOB

BION, BECKETT AND BOBbjp_1204 444..450

John Gordon and Gabriel Kirtchuk

abstract We worked with Bob Hinshelwood for many years and begin our paperwith an account of what we experienced as the essence of his approach in applyingpsychoanalytic understanding, especially an awareness of the ubiquitous effects ofprojective identification, to individual, group and organizational dynamics in mentalhealth settings. This takes the form of a juxtaposition of some ideas and responsestriggered by contact with patients expressed by Bion, Samuel Beckett and Bobhimself. They all conveyed what it feels like when ‘bits of identity’ are passed aroundthrough unconscious interpersonal interactions. We then introduce the forensic psy-chotherapy context in which we work and try to apply what Bob helped us to see.Contact with severely mentally ill patients, who have committed catastrophicassaults, is work on the countertransference edge where patients’ deficit in thecapacity for symbolic communication and subsequent resort to action – sustainedstreams of projective identifications – evoke the maximum emotional impact in staff.We conclude with an example of a reflective practice group for beleaguered, oftenfrightened, staff who desperately need but also attack – much as their patients do –what Bob called the attempt to build a reflective space which is so vital to survivaland effective work.

Key words: communication by action, forensic patients, organizational dynamics,forensic psychotherapy, reflective practice groups

In Experiences in Groups, Bion referred to the essential subjective compon-ent of interpretations in group treatment and based this contention on thecentral role of projective identification in groups:

The analyst feels he is being manipulated so as to be playing a part, no matterhow difficult to recognize, in somebody else’s phantasy . . . I believe ability toshake oneself out of the numbing feeling of reality that is a concomitant of thisstate is the prime requisite of the analyst in the group. (1961, p. 149)

john gordon is a Consultant Adult Psychotherapist in a Forensic PsychotherapyDepartment and at the Cassel Hospital, a specialized personality disorder service. Heis a psychoanalyst (British Psychoanalytic Association), a group analyst (Institute ofGroup Analysis), Honorary Lecturer at Birkbeck College, University of London andHonorary Senior Lecturer at Imperial College Medical School. He is interested inthe application of Bion’s thinking on psychosis to clinical work in groups, and hismost recent contribution, ‘Some neglected clinical material from Bion’s Experiencesin Groups: A prototypal interpretation’, will be published in Bion Today (ChrisMawson (ed.), Routledge and The Institute of Psychoanalysis). Address for corres-pondence: [[email protected]]gabriel kirtchuk is a Consultant Psychiatrist in Psychotherapy/Forensic and head ofa Forensic Psychotherapy Department. He is a psychoanalyst (British Psychoana-lytical Society), Honorary Senior Lecturer at Imperial College Medical School andLead Clinician of the National Forensic Psychotherapy Training and DevelopmentStrategy. Address for correspondence: [[email protected]]

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If you can figure out the role you have been cast in, you might find out aboutthe state of the patient–director’s mind and core self–other scenarios.

Bion’s patient, Samuel Beckett (2009, p. 277) ‘. . . was down at Bedlam thisday week & went round the wards for the first time, with scarcely any senseof horror, though I saw everything, from mild depression to profounddementia’. In Suffering Insanity, Bob (Hinshelwood, 2004) gives a differentpicture of Beckett’s response precisely from the perspective of the partBeckett might have been playing in a schizophrenic patient’s phantasy:‘. . . like a hunk of meat. There was no-one there. He was absent’. Thisdevastating destruction of the human being, the end result of psychoticattacks on his own mind, personality and relationships, is the only remnantof the schizophrenic’s self-experience – now more a non-self non-experience– externalized and residing in Beckett’s receptive reaction.

Bob has also applied Bion’s insight at the group and institutional level,looking respectively at the unconscious passing on of disowned bits of iden-tity between members of small groups (Hinshelwood, 1989) and at theunconscious role played by a Consultant Psychotherapist in the phantasystructure of a large group, the mental hospital (Hinshelwood, 1987a).We relyon these creative interconnected responses to contact with psychic turbu-lence in our own work in a National Health Service Forensic PsychotherapyDepartment, where every day we and our colleagues try to make contactwith severely mentally ill patients who have often perpetrated horrificassaults and, therefore, require care and treatment within a secure setting.

In a moment, we are going to describe how we have tried to develop ourexperiences with Bob in the work of a forensic psychotherapy department:our variation on the theme of the role of a psychotherapy department in thewider forensic service. To introduce this part of our presentation, and toplunge you into the forensic world – into its intrinsic impacts on mentalhealth staff, we should like to quote, from Beckett again, and then from theessential forensic text, Oedipus Rex.

In Malone Dies, Beckett (1956) describes a character:

But Lemuel was made of sterner stuff, in this connection, and far from being astickler for the statutes seemed to have little or no acquaintance with them.Indeed the question might have arisen, in the mind of one looking down uponthe scene, as to whether he had all his wits about him. For when not rooted tothe spot in a daze he was to be seen, with heavy, furious reeling tread, stampingup and down for hours on end, gesticulating and ejaculating unintelligiblewords. Flayed alive by memory, his mind crawling with cobras, not daring todream or think and powerless not to, his cries were of two kinds, those havingno other cause than moral anguish and those, similar in every respect, by meansof which he hoped to forestall same. Physical pain, on the contrary, seemed tohelp him greatly. And one day rolling up the leg of his trousers, he showedMacmann his shin covered with bruises, scars and abrasions. Then producingsmartly a hammer from an inner pocket he dealt himself, right in the middle of

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his ancient wounds, so violent a blow that he fell down backwards, or perhapsI should say forwards. But the part he struck most readily, with his hammer, wasthe head, and that is understandable, for it too is a bony part, and sensitive, anddifficult to miss, and the seat of all the shit and misery, so you can rain blowsupon it, with more pleasure than on the leg for example, which never did youany harm, it’s only human. (pp. 267–8)

Forensic patients, whether psychotic or personality disordered, characterist-ically communicate through action rather than through the medium ofwords; they are ‘out of their minds’, out of touch with themselves, and socannot symbolically represent their mental states. Consequently, mentalhealth workers may only become aware of what is going on in their patientsthrough paying attention to their own feelings, reactions and experiences. Inthe forensic setting, the hammer-blows to staff minds, through impact, areubiquitous; and the fear of assaults on heads is constant.

The emotional position of the member of staff in the maelstrom of suchimpacts and anxieties is captured in the words of Creon, in Seneca’s rougherversion of Oedipus:

I saw Plague, the killer of us all.Then the dreadful shrieks of Horror and blind Fury filled the air.There Grief stood, tearing at her hair.Disease, hardly able to stand at all,stumbled forward.Age,bowed under its own small burden,looked around for a place to hide from Fear,menacing us with its frightful form.I saw each wretched creature.The blood stopped still in my veins,and like a spike stuck into the earth,I could not move.1

(Rutenberg, 1998)

We believe that emotional contact with forensic patients creates a double-barrelled counter-dread in staff of psychic obliteration plus exposure tohorrific psychopathic sadism in all its invasive, perverse and violent forms.Consequently, our starting point in considering the role of a forensicpsychotherapy department is that staff – including psychotherapists – uncon-sciously inhabit the world of Oedipus Rex and that the oedipal situation in itsmost primitive, concrete form represents the central forensic drama whichintrudes into the professional work and can make it blind or ‘murderous’towards human relating between staff and patients and within the multi-disciplinary team. This is, of course, an extreme form of ‘suffering insanity’and doing work on that experience – increasing our awareness of, thinkingabout and trying to understand our patients’ disorganizing, painful and

446 BRITISH JOURNAL OF PSYCHOTHERAPY (2010) 26(4)

frightening impacts and effects on us – a task which we learnedfrom Bob during the many years that we worked in his PsychotherapyDepartment.

Subsequent to this apprenticeship with Bob, we both eventually con-tinued our psychotherapeutic work as members of a very small Psycho-therapy Department within a large forensic psychiatry service. With ourcolleagues, we have developed a range of interventions which takesaccount of our position both as individual psychotherapists and as adepartment (sub-group) in the unconscious phantasy structure of the hos-pital which Bob had studied in his 1987 paper. For it is only by takingdetailed account of the possible perceptions, expectations, rivalries andanxieties which, often entirely out of awareness, one department, ward orprofessional group may have in relation to others working in the sameorganization, that one’s own interventions have a chance of being effec-tive. These interventions included ward community meetings; interpersonaldynamic consultations, a structured approach to eliciting the predominanttransference–countertransference scenarios dramatized (as Bob put it inWhat Happens in Groups [Hinshelwood, 1987b]) between patients andstaff on the wards; reflective practice groups; and training in individual,group and organizational dynamics which has recently been developed toM.Sc. level. In Psychic Assaults and Frightened Clinicians: Countertransfer-ence in Forensic Settings (Gordon & Kirtchuk, 2008) we and our collabor-ators described these interventions in depth and Bob, in his usual style,contributed a challenging Foreword.

In the next part of our paper, we would like to focus on the role ofreflective practice for staff – what Bob (Hinshelwood, 1994) called thestruggle for a reflective space – in the context of a particular form of psy-chopathology and its effects on patient–staff interactions within mentalhealth settings. The value, even the indispensability, of reflective practice asa group modality of supervision and work discussion emerges clearly onlywhen one realizes that the nature and extent of patient impacts on differentmembers of staff may vary enormously, depending on a staff member’sauthority, gender, profession as well as many other idiosyncratic character-istics. Only in the group context can these differences become evident to allconcerned and their meanings explored.

As we have mentioned, most psychiatric patients, especially those suffer-ing from psychotic illnesses, personality disorders or combinations of thetwo, have a deficit in their reflective functioning. They find it difficult, pos-sibly most of the time or perhaps only during acute phases of the illness andmoments of intense emotional arousal or pain, to represent their feelingsand thoughts to themselves and to use words to communicate their states ofmind to others. Instead action on bodies, the patient’s own or, in the case offorensic patients, others’, replaces thinking and reflecting on their mentalstates, perceptions and experiences.


Both the deficit in reflective function and its replacement by action con-tinue in the treatment setting. In fact this setting is precisely one in whichpatients’ deficit and action meet and clash with the staff’s provision ofcontrol (incarceration) and care. Since communication under conditions ofsymbolic deficit and the action mode takes the form of sustained projectiveidentification, sometimes including physical impact and, most usually, thebreaking of boundaries, staff in turn may automatically resort to reactionrather than thought. Or patients may interpret carefully considered staffinterventions as actions; for example, an injection becomes a blatant intentto humiliate and hurt rather than an expression of emotional concern for thepatient’s delusional terror. Under these circumstances, the effective exerciseof professional roles, which depends on a complex, creative integration oftreatment and control while engaging with patients, is a major challenge.

As individuals and as members of multidisciplinary teams, professionalsneed a regular opportunity to stand back and think about their turbulentinteractions with patients. The central task of reflective practice is to reflecton the work to restore lost meaning through coherent individual and teaminterventions. Reflective practice is not pastoral support, free association orabreaction. The emotional impacts on individual members of staff, parts ofthe staff group and the team as a whole may be openly and honestlyexpressed, but the objective is to use this material in the service of under-standing what is going on in the patients’ minds – something they cannot dofor themselves – in order at least to avoid being sucked into maladaptivereactions and at best to develop coherent team interventions.

The reflective practice group meets weekly. It is multidisciplinary, and theregular presence of senior clinical and managerial members of the team isessential. A dedicated room should be available. The activity must be sanc-tioned and supported by the management unit as part of clinical governance.Finally, the reflective practice facilitator should have a professional train-ing in the psychodynamic and/or systemic approach, similar to that of aConsultant Forensic Psychotherapist, and should have access to regularsupervision.

An Example of Reflective Practice

To illustrate the process of working with communication by impact, we willconsider a reflective practice group for the multidisciplinary team on asecure forensic ward. The group was usually attended by a ConsultantForensic Psychiatrist and members of the nursing staff, and on this occasionseven nurses, including the ward manager, were present. The consultant hadnot sent apologies, but the group facilitator, beginning to work within hisown mind on the impact of the absence of a significant figure, recalled fromanother meeting that he had agreed to cover for a colleague who alsoworked on the ward and was on leave for two weeks. The consultant had


expressed considerable apprehension over having to be responsible for allthe patients on the ward during this period.

Talk in the group was desultory, and the atmosphere appeared simultan-eously tense and fatigued.After a while the facilitator gathered from severalcomments that things had been very difficult on the ward, especially withtwo patients on observation. One of these patients had been particularlythreatening. But it was impossible, beyond a general sense of unease anddisruption, to get any clear description of what had been happening, how thework had been for individual nurses or what they were feeling about thework.

The facilitator tried several times to indicate his awareness of how hard ithad been while also commenting on the prevailing silence in the group.There was little response to his comments until, eventually, a nurse who hadpresented himself from the start of the reflective practice group as a spokes-man for the nurses sharply said: ‘Why should we talk to someone who onlycomes for 20 minutes a week? Spend two or three hours on the ward andyou’ll understand what it’s been like’!

This statement felt like a punch to the facilitator, who realized that nowhe might know something of what the nurses had been feeling over theweek. Since his 45 minute presence for reflective practice had been minim-ized by over half, it seemed that he represented for the team the absentconsultants (both the one on holiday and the one who regularly attendedthe group). This loss had not been registered – loss rarely is explicitlyattended to and thought about in forensic settings – but the facilitator hadexperienced it in the shape of his ongoing feeling in the reflective practicesession that something fundamental was missing in the nurses’ presenceand communications.

Paradoxically, the facilitator could simultaneously identify both with theabsent consultants and with the staff who were missing them. The ‘punch’represented the feared reaction of patients to this loss with which staff hadbeen anxiously coping, and which was now conveyed directly through itsimpact on the facilitator.A further aspect of this emotional situation, involv-ing unconscious responses to the loss of a significant figure as anticipated inthe facilitator’s initial private associations, is that reflective practice – super-vision in group form – mobilizes what we all feel to some extent when‘super’-vised: that a superior figure is looking down on us, probably at thebehest of management, to monitor and criticize our work.Accordingly, theremay also be reflected in the material a wish to attack, get rid of and ‘murder’this hated persecutor, which makes any ‘loss’ extremely complicated. This iswhy it is so vital for senior staff to attend reflective practice and to offerexamples to their teams of presenting honestly and openly their struggleswith the work. It also shows why the reflective practice facilitator must betrained to take and to understand the ‘punches’ of his colleagues.


In the event, the facilitator was able to say that he appreciated the directcomment of the nurse; that he understood that its aggressive punch wasrelated to a picture of him as uninterested and probably critical, but that italso conveyed the depletion of important staff during the week and feelingsof anger about additional difficulties which had to be endured over thisperiod. The ward manager and several other members of the group becamevery active in reassuring the facilitator that the remark had not been meantas aggressive, that they really appreciated and valued the reflective practice.The facilitator commented that, ultimately, it was only through frank com-munication such as they had just shared that the value of reflective practicewas to be found.

Note

1. Reprinted with permission from Oedipus of Lucius Annaeus Seneca, © 1998 byMichael Elliot Rutenberg, published by Bolchazy-Carducci Publishers, Inc., Mun-delein, IL 60060, USA.

References

Beckett, S. (1956) Malone Dies In Beckett, S. Three Novels: Molloy, Malone Dies,TheUnnamable. New York, NY: Grove Press.

Beckett, S. (2009) The Letters of Samuel Beckett 1929–1940, Fehsenfeld, M.D. andOverbeck, L.M. (eds). Cambridge: Cambridge University Press.

Bion, W.R. (1961) Experiences in Groups. London: Tavistock.Gordon, J. & Kirtchuk, G. (eds) (2008) Psychic Assaults and Frightened Clinicians:

Countertransference in Forensic Settings. London: Karnac.Hinshelwood, R.D. (1987a) The psychotherapist’s role in a large psychiatric institu-

tion. Psychoanalytic Psychotherapy 2: 207–15.Hinshelwood, R.D. (1987b) What Happens in Groups: Psychoanalysis, the Individual

and the Community. London: Free Association Books.Hinshelwood, R.D. (1989) Communication flow in the matrix. Group Analysis 22:

261–9.Hinshelwood, R.D. (1994) Attacks on the reflective space: Containing primitive

emotional States. In: Schermer, V.L. and Pines M. (eds), Ring of Fire: PrimitiveAffects and Object Relationships in Group Psychotherapy, pp. 86–106. London:Routledge.

Hinshelwood, R.D. (2004) Suffering Insanity: Psychoanalytic Essays on Psychosis.London: Brunner Routledge.

Rutenberg, M.E. (1998) Oedipus of Lucius Annaeus Seneca. Mundelein, IL:Bolchazy-Carducci Publishers.


BION, BECKETT AND BOB

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