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Malignant Alienation –a concept that has not yet arrived?

  • Darryl Watts (a1)
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Abstract
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This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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Watts, D. & Morgan, G. (1994) Malignant alienation: dangers for patients who are hard to like. British Journal of Psychiatry, 164, 1115.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Malignant Alienation –a concept that has not yet arrived?

  • Darryl Watts (a1)
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eLetters

Growing recognition of the importance of maligant alienation

Daniel M Beales, Specialist Registrar in Forensic Psychotherapy
20 January 2005

Watts (Psychiatric Bulletin, December 2004, 28, 459), in highlightingthe continuing importance and relevance of the concept of malignant alienation, perhaps doesn’t blow his and Morgan’s trumpets loud enough.

Davies (2004) has recently highlighted the importance of the concept in relation to institutional settings and Whittle (1997) has explored its relevance to forensic psychiatry. Graham et al (2004) refer to the conceptin relation to learning disability and Holloway (2002) emphasises its importance in the context of suicides and homicides by psychiatric patients.

It is perhaps more relevant than ever in relation to recent policy guidance concerning personality disorder and the challenge this presents in terms of training and service development (Snowden and Kane, 2003). This is especially so in the context of psychiatry’s difficulties in managing (both conceptually and practically) patients with co-morbid Axis 1 and Axis 2 pathology. Ranger et al (2004) illustrate this, in the same issue of the Bulletin in which Watt’s letter appeared, by detailing the extent of such co-morbidity in an assertive outreach team’s caseload.

From a personal perspective Watts and Morgan’s paper is one of the most influential papers I have been fortunate enough to have been introduced to during my training (I would put it in the same league as TomMain’s “The Ailment” (1957) and R.D. Hinshelwood’s “The Difficult Patient”(1999)). Watt’s letter will hopefully prompt all STSC Chairs and Clinical Tutors to see if their trainers and trainees are making use of it.

Watts suggests “the avoidance of the powerful negative feelings at the heart of the alienation process itself” might explain difficulties in staying with the implications of the concept of malignant alienation. Balint, or reflective practice, groups are an integral part of the College’s requirements for trainees’ psychotherapy experience and may provide a forum for such feelings to be explored. They may however only bea partial solution and represent the separating out of a core task that belongs to staff at all levels of seniority on an ongoing basis. Services may need to work towards cultures where such work can be acknowledged as integral to their healthy functioning and that address the inevitability of the patient-staff dynamics illustrated by malignant alienation.

References

DAVIES, S. (2004) Toxic institutions. In: From Toxic Institutions to Therapeutic Environments: Residential Settings in Mental Health Services, (eds. P. Campling et al), pp. 20-31. London: Gaskell.

GRAHAM, S., HERBERT, R., PRICE, S., WILLIAMS, S. (2004) Attitudes andemotions of trainees in learning disability psychiatry. Psychiatric Bulletin, 28, 254 -256.

HINSHELWOOD, R.D. (1999) The difficult patient: the role of 'scientific psychiatry' in understanding patients with chronic schizophrenia or severe personality disorder, British Journal of Psychiatry, 174, 187-190.HOLLOWAY, F. (2002) The 5-year report of the National Confidential Inquiryinto Suicide and Homicide by People with Mental Illness. I: Clinical practice. Journal of Forensic Psychiatry, 13, 131-137.MAIN, T. F. (1957) ‘The Ailment’. British Journal of Medical Psychology, 30, 129-145.

RANGER, M., METHUEN, C., RUTTER, D., RAO, B., TYRER, P. (2004) Prevalence of personality disorder in the case-load of an inner-city assertive outreach team. Psychiatric Bulletin, 28, 441-443.

SNOWDEN, P., KANE, E. (2003) Personality disorder: no longer a diagnosis of exclusion.Psychiatric Bulletin, 27, 401-403

WHITTLE, M. (1997) Malignant alienation. Journal of Forensic Psychiatry, 8, 5-10.
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