LEARNING OBJECTIVES
After reading this article you will be able to:
describe key psychoanalytic concepts relevant to psychosis, including Bion’s distinction between psychotic and non-psychotic parts of the personality
recognise common countertransference and systemic reactions when working with psychotic processes
identify signs that clinicians or teams are becoming overwhelmed by psychotic projections.
Clinical work with severe mental illness, particularly on in-patient wards, is deeply rewarding but also psychologically immensely demanding. Psychiatric training rarely prepares clinicians for the emotional intensity and powerful unconscious forces they will encounter.
Engaging with these dynamics is essential for safe, effective care and for protecting the well-being of all involved. When such forces remain unrecognised, even the most experienced clinicians may become overwhelmed and unable to think clearly, leading to poor decisions, diagnostic errors and treatment failures. Opportunities to take meaning from symptoms which could deepen the understanding and meaning in the therapeutic encounter can be lost. Action can take the place of thought, and care can turn punitive or neglectful, unwittingly re-enacting the very abuse and abandonment that brought many people to the care environment in the first place. Staff risk burnout, moral injury and psychological or physical harm. Understanding unconscious psychotic processes is therefore not an academic exercise but a clinical necessity, vital to maintaining humanity in the most challenging work.
This article addresses a significant gap in psychiatric teaching and literature: the lack of attention to unconscious forces shaping care for those with severe mental illness. It outlines a psychodynamic understanding of these dynamics and presents composite clinical material drawn from my experience as a psychiatric consultant working in in-patient and community settings. Although most apparent in in-patient settings, where intensity and immediacy heighten pressures, these dynamics pervade all areas of clinical work (Evans Reference Evans2016; Gibbons Reference Gibbons2021). The case vignettes are fictional, and are inspired by, and synthesise, many clinical encounters from the author’s psychiatric practice. They aim to validate clinicians’ experience and illustrate how psychodynamic thinking can reduce risk, strengthen care and sustain those who provide it. Although these vignettes may seem extreme to those outside such settings, those working within them will recognise that they are, in fact, realistic reflections of what is routinely encountered in clinical care.
Words marked with an * are defined in Box 1.
Definitions
Psychotic states A normal part of mental functioning in which the capacity to distinguish between internal and external reality is severely compromised. Thought processes become dominated by splitting, denial and projection rather than integration and symbolisation.
Primitive Related to early, infantile, developmental experiences.
Splitting Division of experience, people, parts of the self or feelings into all-good or all-bad categories to avoid ambivalence, confusion or uncertainty.
Projection Primitive expulsion from the mind into the outside world of unwanted thoughts, feelings or parts of the self. These are then attributed to others.
Denial Primitive refusal to recognise a painful or threatening reality.
Projective identification A primitive process in which unwanted parts of the self are projected into another person, who is then unconsciously pressured to feel, think or behave in accordance with what has been projected. The recipient may temporarily identify with these projected aspects, blurring the boundary between self and other. When recognised and contained, this process provides valuable clinical information and forms the basis of countertransference understanding.
Countertransference This is the clinician’s conscious and unconscious emotional reactions to the patient, evoked by the patient’s projections. These responses are shaped not only by the patient’s communications, but also by the clinician’s own experiences, personality and current emotional functioning. Countertransference reactions are therefore both informative and complex: they reflect an interaction between two internal worlds. When recognised and reflected on, they become a vital source of diagnostic and therapeutic understanding, allowing the clinician to sense and contain what the patient cannot yet bear to experience directly.
Theory
Understanding the nature of psychotic experience
Psychotic states* are a fundamental aspect of human mental life. Under intense anxiety, the ordinary capacity to think and to distinguish inner from outer reality breaks down. Melanie Klein (Reference Klein1946) described this as the paranoid–schizoid position, a mode dominated by primitive* defences such as splitting*, projection*, projective identification* and denial*. Bateman & Fonagy (Reference Bateman and Fonagy2016) later conceptualised it as a collapse of mentalisation, in which the ability to reflect on mental states in oneself and others disintegrates.
Human beings move repeatedly between these mental states as anxiety fluctuates. As pressure rises, the fragile bridges linking thoughts collapse and reflective capacity is lost; when anxiety subsides, linking and coherence return. This oscillation is adaptive. In moments of psychic threat, thought can delay necessary action, so the mind suspends reflection and substitutes doing for thinking. The psychotic, non-mentalising state thus serves a short-term survival function by attacking the linking processes that make thought possible.
Psychic retreat: when psychotic functioning becomes entrenched
When pressure does not abate, defensive withdrawal may solidify into a psychic retreat, a mental enclave where painful reality is excluded. What begins as refuge becomes entrapment, and defensive withdrawal crystallises into mental illness. Contact with reality is lost and the mind is taken over by its own creations, leading to the symptoms of psychotic illness such as delusions and hallucinations. These states represent the farthest extension of the paranoid–schizoid position, in which defensive processes designed to avoid unbearable anxiety replace reality itself. The retreat offers safety but at the cost of growth (Steiner Reference Steiner2003). The delusional beliefs that develop within a psychic retreat serve a defensive purpose, they replace painful external reality with internal explanations that feel safer, more coherent and controllable. This explains the powerful pull psychotic symptoms exert and what can be their apparent resistance to treatment or external influence.
Entrenchment is most likely when symbolic functioning is compromised by organic illness, early deprivation or trauma that overwhelms the mind’s capacity to process experience (Gibbons Reference Gibbons2023).
The psychotic and non-psychotic parts of the mind
Wilfred Bion went further than Klein, proposing that every mind contains two coexisting systems: a psychotic part and a non-psychotic part (Bion Reference Bion1957, Reference Bion1962). This is not illness versus health, but two enduring modes of mental life. The psychotic part, a remanent from infancy, cannot tolerate dependency; it seeks to deny painful truth and attacks emotional reality. Thinking itself feels dangerous because it is relational. The capacity to think is developed in a containing relationship with another, and implies need and reliance on an external object (another person who is emotionally significant). To avoid this dependence, the psychotic part mounts attacks on linking in the non-psychotic part of the mind, fragmenting coherence and generating persecutory psychotic anxiety (Bion Reference Bion1957). The psychotic part of the mind gains pleasure and derives a perverse satisfaction (sadism) from these attacks.
The non-psychotic part, by contrast, represents the achievement of integration. It seeks truth, meaning and connection, and can bear anxiety, tolerate difference and seek help when needed. Under stress, the psychotic part may again become active, drawing the mind back into an earlier mode of functioning. In healthy mental life, these two parts exist in dynamic balance: the psychotic part provides short-term protection from psychic pain, while the non-psychotic part sustains contact with reality and supports growth. When this balance is lost, reality-testing weakens and coherence begins to fragment. As Money-Kyrle (Reference Money-Kyrle and Meltzer1978) observed, sanity may be ‘no more than a firm island [...] in a sea of chaos’ (p. 437).
Tuning into the psychotic wavelength
Richard Lucas (Reference Lucas2013), a psychiatrist and psychoanalyst, extended Bion’s ideas into clinical practice. He suggested that ordinary neurotic sensitivities operate on ‘wavelength 1’, whereas those overwhelmed by psychotic functioning operate on ‘wavelength 1000’. To work effectively, those offering care must tune into this psychotic wavelength. They need to hold in mind Bion’s two parts of personality, asking which part they are encountering at any given moment. Without this awareness, psychotic functioning may go unnoticed and the possibility lost of contact with the non-psychotic part of the person that is always there and available. As Lucas said ‘there is always a part of the individual we can talk to about how the psychotic part is operating’ (p. 88).
Lucas highlighted rationalisation, often overlooked in psychoanalytic literature, as a primitive defence central to psychotic functioning. The most common manifestations of psychosis, he argued, are not hallucinations or delusions, but the pervasive operations of denial and rationalisation, used by the psychotic part to ‘cover up its murderousness’ (p. 142).
In clinical work, the struggle between the psychotic and non-psychotic parts is continuous, not only in those receiving help, but also in those providing it. Powerful projective processes operate across this divide: the psychotic parts of both can collude in attacking thought, attempting to ‘convert, pervert or override’ the sane parts (Money-Kyrle Reference Money-Kyrle and Meltzer1978, p. 438). When those offering help unconsciously locate all sanity in themselves and all chaos in those they are caring for, the result is both false and dangerous, and opportunities for genuine contact and therapeutic understanding are lost.
Countertransference: clinicians, teams and the organisation
The primitive defences used in psychotic functioning, splitting, projection, denial and rationalisation are very powerful. Unprocessed and infused with extreme affect, they resonate with the clinician’s own psychotic functioning. They can therefore lead to particularly potent and dangerous countertransference* responses. This is the clinician’s conscious and unconscious emotional reactions to the projections* from the individual they are providing care for. These effects permeate not only individual clinicians, but entire teams, wider systems and whole organisations. When psychotic processes operate at an organisational level, the consequences can be profound and far-reaching. Teams fragment, institutional processes become destructive and the capacity to care breaks down (Gibbons Reference Gibbons2025).
This section explores these dynamics at three levels – the individual clinician; the clinical team and wider system; and the organisation as a whole – using hypothetical case vignettes to illustrate each of the countertransference responses.
The individual clinician
The risk of being overwhelmed by these countertransference effects increases when the clinician is meeting someone for the first time and/or alone. The risks are minimised when the clinician knows the person and their history, and when a third person is present. Each assessor can then rely on the other to check the reality of what they are being told, and to notice their own countertransference responses. This creates a containing space where thinking can be preserved.
Common manifestations of countertransference in clinicians include:
accepting the rationalisation of the psychotic part of the mind
overidentification with denial: disregarding the history
attacks on linking: mental confusion
attacks on symbolisation: concretisation of thinking
overidentification with sadism projected by the psychotic part of the mind.
Vignette: Accepting the rationalisation of the psychotic part of the mind
Helen, a medical student, met with Jamal, a man recently admitted to the ward, for an assessment on her own. She presented his history in the ward round. Why, she asked, were the ward team not supporting him in a prosecution he had started against the neighbour who was pursuing him, listening to his every move and banging on the floor and walls wherever he was sitting so that he had no peace? He had discussed it with his mother, but she was conspiring with the neighbour. The police, too, were involved in the conspiracy. As she recounted this history aloud, she began to realise that the reality might not be quite as described.
Understanding the dynamics
Helen had been pulled into accepting the rationalisation of the psychotic part of Jamal’s mind and lost contact with her own capacity to think and question. This part can be remarkably persuasive, presenting its distorted version with such conviction that the clinician’s own reality-testing becomes compromised. It was only when others were present that Helen could reconnect with her thinking. Without another person to provide an external anchor, the clinician can be drawn into the delusional system, temporarily losing access to their own non-psychotic functioning.
Vignette: Overidentifying with denial – disregarding history
Maya was brought into hospital after months of immobility, emaciated and with marked rigitity of her limbs, in the context of severe self-neglect. She had a previous diagnosis of an illness with predominantly psychotic functioning, with two episodes of psychosis clearly recorded. She was started on antipsychotic medication.
She was later seen by a temporary consultant psychiatrist. Under time pressure, the consultant felt provoked and irritated by his own confusion in contact with Maya, and in response decided she had primarily complex emotional needs rather than an illness that was psychotic in nature. He stopped her medication and changed the diagnosis on the electronic notes system.
Over the next 9 months, she deteriorated physically and mentally. The community team noted her decline, but attributed it to ‘acting out’. No medication was given, and no admission offered. When she was finally re-admitted, she was close to death. She was restarted on antipsychotic medication and recovered.
Understanding the dynamics
The psychotic part of Maya’s mind had successfully attacked the clinician’s capacity to think and to link past with present. Flooded with uncomfortable feelings, he changed the diagnosis in response to his immediate countertransference. Infiltrated by psychotic processes of splitting and denial, he became unreasonably confident in the new formulation and dismissed the history that contradicted it.
Vignette: Attacks on linking – mental confusion
Dr Roberts had returned from holiday refreshed. His first task was to review Sarah, a new psychiatric admission. During their meeting, he realised he could not concentrate. Within minutes he lost track of what he was saying and could not recall the purpose of the conversation. His mind felt ‘fuzzy’, and he was confused about why he was there. Once he left the room, his thinking recovered.
Understanding the dynamics
The psychotic attacks on linking in Sarah’s mind were projected into Dr Roberts. His thinking fragmented and he became unable to hold thoughts together. This temporal pattern of confusion during contact, and clarity before and after, is diagnostic of countertransference. His post-holiday clarity made the contrast more striking, allowing him to recognise this as a communication of Sarah’s psychotic functioning rather than struggles with his own mental state.
Vignette: Attacks on symbolisation – concretisation of thinking
At the end of a long day, Dr Lee, a calm and thoughtful consultant psychiatrist, saw Michael, referred for forgetfulness and suspected dementia. She tested his memory, found it reasonable, and discharged him, feeling rather irritated with the referral. Later that evening she felt uneasy and the next day she telephoned him to return to her clinic. On further questioning, he described delusional beliefs that he was dead and that suicide made sense to him. His apparent memory difficulties were a symptom of depression with psychotic features.
Understanding the dynamics
Dr Lee was tired and vulnerable after a long day. The balance of her own mind was tipped towards it’s psychotic part. She could not withstand further attacks on linking from Michael’s projections and her thinking concretised. She could ‘do’, but not ‘think’, taking the referral literally, forgetfulness equals dementia, without considering what it might represent. Symbolic thinking returned later, when reflective space allowed her non-psychotic part to reassert itself.
Vignette: Overidentification with sadism projected by the psychotic part of the mind
Aaron was very unwell, deluded and self-destructive. He accused staff of being abusers and cowered in his room, terrified of them. The team found it difficult to give him medication because this required restraint, which they felt would make them sadistic. As a result, Aaron remained unwell until transferred to a psychiatric intensive care unit (PICU), where he was given an injectable medication and stabilised.
Understanding the dynamics
In this situation, this internal sadistic violence from the psychotic to the non-psychotic part of the mind was projected outwards into the external world and enacted. The team had overidentified with Aaron’s projection of sadism. Unable to distinguish between feeling sadistic (a countertransference response) and being sadistic (an action), they became paralysed. Their capacity to think about what was therapeutically necessary collapsed until the projection could be recognised and contained.
The clinical team and wider system
When psychotic processes affect teams and networks, common manifestations include:
splitting of the system around the person: the ‘jigsaw’
collusion with psychotic functioning by ‘rationalisation’ within institutional processes
identification and enactment of psychotic functioning by the whole team.
Splitting of the system around the person: the ‘jigsaw’
In illnesses characterised by predominantly psychotic functioning, the mind becomes fragmented and these fragments are projected into the external world. Members of the multidisciplinary team, as well as family and friends, become containers for different, often conflicting, aspects of the individual’s psyche. This leads to splitting across professional, social and family networks.
When recognised and thoughtfully engaged with, this process can become a source of understanding, providing vital information about the person’s inner world. When unacknowledged, however, it becomes dangerous: each faction may identify with one fragment and turn against the others. Lucas likened the ward round to ‘assembling the pieces of a jigsaw puzzle where you do not know who will bring the most important piece’ (Lucas Reference Lucas2013, p.147). Only by bringing these pieces together can a coherent picture emerge. This insight underpins approaches such as Open Dialogue, in which the individual is understood within the context of their relational network and the focus of intervention becomes the system as a whole.
Vignette: The jigsaw 1
Yasim was brought to the ward by police. He appeared severely unwell and unkempt. On admission, he claimed to have no family, no friends and no home, and refused to give his name. He was cared for on the ward and started on antipsychotic medication. Gradually, he disclosed details of a brother, whom the team then contacted. The brother responded angrily, saying he could no longer cope. Their parents were ill and the situation had become unbearable for the family. However, he provided contact details for their sister, who agreed to attend a ward review to represent the family. As Yasim’s condition improved and his psychotic functioning receded, the weekly meetings gradually filled with family members, who began re-engaging with one another and planning for Yasim’s future.
Understanding the dynamics
When Yasim’s psychotic part was dominant, it had successfully attacked all links between thoughts, feelings and people. His claim to have ‘no family, no friends and no home’ was both a delusion and a psychic reality: the attacks on linking had severed his internal and external connections. His family system mirrored this fragmentation, the brother overwhelmed and rejecting, the sister anxious but isolated, the parents ill and unable to contain the distress. As medication began to work and Yasim’s capacity for linking was restored, the external system also began to reintegrate. This parallel process, internal reintegration reflected in external repair, is a powerful indicator of recovery.
Vignette: The jigsaw 2
Idris wanted to be discharged home from the ward. Everyone in the team agreed, as he appeared much improved compared with when he was admitted a month earlier. His discharge was therefore planned, somewhat hastily, for a Friday afternoon, prompted by his apparent enthusiasm to attend a distant family member’s birthday party over the weekend. Because of the rushed arrangements, and contrary to usual practice, his key worker had not been informed. When the key worker heard the news from Idris that morning, he was alarmed, saying Idris had seemed very unwell during their recent conversation.
The ward team initially dismissed these concerns. However, to be on the safe side, they postponed the discharge. Later that evening, staff discovered all the medication Idris had been given while in hospital hidden under his mattress. Soon after this discovery, Idris became acutely and manifestly unwell.
Understanding the dynamics
The non-psychotic part of Idris was communicating through the key worker, signalling that he was still unwell and that the psychotic part had deceived the team. The ward staff had identified with Idris’s psychotic part, his rationalisation, enthusiasm and apparent recovery, while the key worker remained in touch with the reality of his continuing illness. The split within the clinical system mirrored the split within Idris’s mind. In this instance, the key worker held the missing piece of the jigsaw.
Collusion with psychotic functioning by ‘rationalisation’ within institutional processes
Rationalisation and denial of psychotic functioning can be projected into institutional systems, for example mental health tribunals. These tribunals safeguard legal and human rights when someone is detained (‘sectioned’) under legislation such as the Mental Health Act 1983. During the hearing, evidence for detention is presented by the treating team and then cross-examined by the individual’s solicitor. The tribunal decides whether detention should continue; if it is deemed unwarranted, the section is lifted immediately and the person is free to leave.
Although essential to civil liberty, this process can be powerfully shaped by unconscious dynamics. The legalistic framework, combined with limited awareness of the countertransference evoked by psychotic functioning, may lead tribunals to identify with the rationalising psychotic part of the individual and oppose the non-psychotic part represented by the clinical team.
Vignette: identification with the rationalising psychotic part
Mark, a successful city lawyer, was admitted involuntarily in a manic state. From the outset, his forceful, persecutory rationalisations dominated the ward. He repeatedly threatened legal action against staff, claiming unlawful detention, and said he would report them to their professional bodies. Intimidated and fearful, staff found themselves unable to treat him effectively. Mark’s manic state was expansive and intrusive, he entered others’ spaces, propositioned people, appropriated belongings and engaged every visitor on the ward. He telephoned the police and ambulance services repeatedly, alleging wrongful imprisonment, and even obtained the consultant’s private phone number, calling it several times a day.
Two weeks after admission, Mark appealed his detention. At the tribunal, he presented himself immaculately: dressed in a suit and assuming the professional composure of the competent lawyer he was when well. Contrary to usual practice, the tribunal allowed him to cross-examine the consultant. Despite the consultant’s description of Mark’s recent disinhibited and chaotic behaviour, the panel accepted Mark’s rational, articulate presentation and concluded that he no longer required detention. The section was lifted, and he was discharged that afternoon.
The following week, police returned Mark to the ward after he behaved in a disinhibited manner in a restaurant. On readmission, he was clearly in a poor state.
Understanding the dynamics
The tribunal unwittingly identified with Mark’s rationalising psychotic part, mistaking manic logic and pseudo-sanity for genuine coherence. The non-psychotic part of the system, the ward team, was left silenced and shamed. The institutional process, intended to safeguard liberty, had instead become a vehicle for collusion with psychotic functioning.
Identification and enactment of psychotic functioning by the whole team
Herbert Rosenfeld, an analyst who worked alongside Bion, likened the internal functioning of the disturbed part of the mind to a powerful gang dominated by a leader, very like the Mafia. This gang threatens the healthy part of the psyche when it tries to elicit help, illustrating why it is so difficult at times to tip the balance towards health from destructive functioning (Rosenfeld Reference Rosenfeld1971).
When teams are overwhelmed, this ever-present and pervasive gang can be projected wholeheartedly into them (Bell Reference Bell2001). The whole environment can then function on the psychotic wavelength without recognising this is happening, working to its own delusional rules, disconnected from external reality.
Vignette: Team functioning on the psychotic wavelength
A mental health ward had suffered an in-patient death by suicide. The team were traumatised and had accessed no support to process the loss and shock. The consultant and ward manager had left the organisation following the internal inquiry. The team lost confidence and felt abandoned without the containment of clinical leadership. They were working with very unwell individuals and had become frightened of taking any risks in treating them, fearing that any intervention might lead to another death. There were no discharges and no admissions. There were frequent staff and patient assaults. They became fearful and ashamed of what was going on and felt there was no point in asking their managers for help. Instead, they reassured them that everything was fine.
The team took refuge in the nurses’ station, where they stuck paper up over the windows so they could not be seen and could not see out. A new doctor who joined the ward said the team felt like a ‘gang’ and she felt left out and paranoid. The gym instructor and the ward clerk, neither of whom was clinically trained, appeared to have most authority. Those receiving care remained untreated, overwhelmed by psychotic experience and disturbed. They spent much of the day and night banging on the doors and windows of the papered-up nurses’ station.
Finally, someone set fire to a rubbish bin. No serious damage was done, but this triggered an alarm and an investigation by senior management, who were appalled that the situation had become this bad. They believed they had neglected the ward and felt guilty themselves. The ward was closed temporarily to allow for a full assessment. During this time, the staff group were given space to reflect and process the previous trauma. The ward reopened 3 months later with new leadership, senior support for a weekly reflective practice group, regular senior management input and supervision for all team members.
Understanding the dynamics
The ward team had become paranoid and terrified. There was a loss of structure and healthy authority. Rosenfeld’s gang, the psychotic part of those receiving care, had been projected into the team so completely that the team itself began to function in a psychotic manner themselves.
The organisation as a whole
Organisational systems of defence
Isabel Menzies Lyth, a psychoanalyst who studied with Bion, first described ‘organisational systems of defence’ in her seminal study of nurses in a general hospital (Menzies Reference Menzies1960). She observed how organisational systems developed to defend against the life-and-death anxieties staff faced daily. These social defences allowed staff to ‘avoid anxiety, guilt, doubt and uncertainty’, but at the expense of carrying out their real task. Box 2 proposes some of the ways these organisational systems of defence manifest in mental health settings.
Common organisational systems of defence in mental health settings
Idealisation and omnipotent phantasy Collusion with the belief that omnipotent care can be provided irrespective of resources. New service initiatives become idealised as the ‘messiah’ coming to rescue the organisation.
Ritualisation and concrete thinking Ritualised form-filling without evidence of effectiveness (e.g, risk assessment). Belief that action is more important than reflection. Structural enshrining of unhealthy functioning.
Organisational collusion with the psychotic part Scapegoating, suspensions and complaints processes that enact psychotic attacks. Communication systems, particularly email, become vehicles for split-off aggressive functioning, allowing attacks on thinking and colleagues without direct contact.
Splitting of care needs Staff and patient needs are seen as opposing. Only patients are considered to need care, which must be unlimited. Staff care needs are denied and denigrated.
Denial of staff distress Staff ‘sickness’ covering up mental breakdown. Absence treated as administrative rather than recognising the psychological impact of the work.
Perversion of language ‘Cost improvement’ for ‘cuts’; ‘pursuit of excellence’, denying developmental struggles; language that obscures rather than addresses difficulties.
Collusion with concrete thinking and the devaluation of reflection in favour of action (‘doing’ activities) By privileging concrete doing over symbolic reflection, psychotic functioning is supported, enforced and enacted.
(Gibbons Reference Gibbons2025)
Vignette: Organisational collusion with psychotic functioning through the complaints process
A hospital’s Patient Advice and Complaints (PAC) service decided they could ‘nip complaints in the bud’ by coming weekly to visit in-patients on the acute psychiatric ward to ask if anyone had complaints about their treatment. Some patients said they were delighted to be asked and took up the offer with enthusiasm. After their visits, the consultant psychiatrist regularly received email complaints from the PAC team, many of which had delusional content. For example, in one the consultant was asked to stop the night staff from removing and replacing the patient’s organs while they slept.
Understanding the dynamics
With good intentions but no clinical training, the PAC service bypassed clinical thinking and accepted all complaints at face value. The psychotic part of the minds of the inpatients seized this opportunity: delusional beliefs were given institutional authority and treated as legitimate grievances. The consultant was left in the impossible position of responding formally to complaints rooted in psychotic functioning, while the PAC service unwittingly became a vehicle for attacks on reality.
Vignette: Organisational collusion with psychotic functioning through human resources processes
A mental health trust was facing a severe nursing crisis. Chronic staff shortages left in-patient wards reliant on temporary nurses unfamiliar with those being cared for and ward processes and procedures. Disturbance on the wards escalated, as did the financial strain on the trust.
On one acute ward, a young woman unwell with a bipolar illness stripped naked and ran around the ward in extreme agitation. She was eventually restrained by the four remaining permanent nurses, two of whom were men. Afterwards, she accused the male nurses of sexual assault. Both were immediately suspended pending investigation. The inquiry took 6 months to conclude there was no case to answer, by which time their morale and well-being had collapsed and both resigned, further depleting the ward’s containment.
Understanding the dynamics
The automatic suspension, without considering the young woman’s state of internal disturbance, the clinical necessity of restraint or the context of acute risk, represented a failure of thought. The organisation treated the accusation concretely, bypassing clinical understanding. The psychotic part of the mind successfully turned the system against the non-psychotic part of the mind represented by those attempting to help.
Recognising and managing the impact of psychotic processes on staff and teams
When clinicians and ward teams become penetrated and controlled by psychotic functioning, they may behave in ways that are uncharacteristic or irrational, often without realising what is happening. These effects can be subtle or profound, transient or enduring, and may lead to burnout. Signs include:
changes in behaviour: acting out of character or abandoning agreed management plans;
emotion dysregulation: feeling overwhelmed, fearful or angry; sending irritable emails; losing temper; or struggling to sleep;
difficulty separating from work: staying late, dreading the workplace, or losing pleasure in the job;
detachment and numbness: feeling disconnected, unable to empathise, as though watching from a distance.
Restoring thinking and resilience
The most effective protection against being overwhelmed by psychotic processes is space to think. Reflection is not a luxury, but the foundation of therapeutic care. Without it, teams enact the very disturbance they are trying to treat.
Reflection must be embedded in organisational life through:
regular and reliable spaces such as reflective practice groups, supervision, team meetings and risk panels;
supportive organisational frameworks that provide stability, review structures regularly, clarify boundaries, foster staff development and promote well-being.
Reflective practice groups
Creating and sustaining reflective groups can be difficult because of the very processes described: psychotic functioning in the environment attacks the non-psychotic spaces for thinking. Doing is privileged over thinking. Staff describe themselves as ‘too busy’ to attend. Groups are cancelled, poorly attended or gradually eroded by ‘more pressing’ demands, signs that the attack on thought is succeeding. These spaces must be actively protected by senior leaders through fixed times, stable locations and reliable facilitation. The moment when reflection feels impossible is precisely when it is most essential.
Complex case and risk panels
Multidisciplinary panels can contain anxiety and restore perspective when teams are overwhelmed. Including a psychotherapeutically informed clinician helps identify unconscious processes shaping the work. Such panels offer a containing function in holding anxiety and confusion until they can be returned in a more thinkable form.
The key question for any organisational response should be: ‘Does this intervention increase our capacity to think about the care, or does it defend us from having to think?’
Conclusion
Work with those dominated by psychotic functioning is challenging and deeply demanding. Yet when space for reflection is protected and privileged, this work is profoundly meaningful and provides an extraordinary window on the unconscious mind.
The power of the unconscious forces faced in mental health work must be recognised and acknowledged. Without this understanding, dangerous collusions with psychotic processes become inevitable. But with awareness, containment and structures for reflection, clinicians can preserve their capacity for thought and compassion and use these unconscious communications as a valuable therapeutic tool.
When overwhelmed, the psychotic pull towards hopelessness can lead staff to lose contact with the reality of how much they are able to help. The numerous people who have improved, often with remarkable transformations occurring over a short period, can be forgotten.
I will conclude with an excerpt from an article written by a psychotherapist in training, reflecting on her observations during a placement on an acute psychiatric ward:
‘The reality is that, for many patients on the ward, being sectioned turns out to be a solace. It is the only way out of a state of mind that has become unbearable: the last resort. […] When I started observing ward rounds I was shocked by the extremity of suffering […]. I had never seen seriously mentally ill patients close up. […] There was a broken and silent 20 year old who seemed almost catatonic following a suicide attempt. […] Yet within a month he had made an astonishing recovery. He was smiling, chatting […]. This is an experience repeated with patient after patient […]. I often see incredible transformations […]. It is so important for patients truly to be thought about, often for the first time’ (Blundy Reference Blundy2011).
MCQs
Select the best single option for each question stem:
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1 According to Bion, the psychotic part of the mind is characterised by:
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a acceptance of dependence on others
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b capacity for symbolic thought
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c attacks on emotional reality
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d ability to seek help when needed
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e tolerance of anxiety and difference.
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2 Lucas argued that the most common manifestation of psychosis is:
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a hallucinations
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b first-rank symptoms
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c delusions
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d rationalisation and denial
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e thought disorder.
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3 When assessing someone with psychotic functioning, it is essential to have a third person to reflect with in order to:
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a meet legal requirements
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b help notice countertransference responses and check the reality of what is being communicated
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c speed up the assessment process
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d complete documentation more accurately
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e prevent violence.
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4 The ‘jigsaw’ phenomenon as described by Lucas refers to:
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a the fragmented thinking within psychotic states
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b the projection of fragmented aspects of the patient’s mind into different people in the network, leading to splitting across the system
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c diagnostic tool for assessing psychosis
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d the way delusions are constructed
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e a treatment approach for psychotic disorders.
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5 According to this article, what provides the most important intervention to prevent staff being overwhelmed by psychotic processes is:
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a increased staffing levels
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b better medication protocols
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c reliably protected spaces for reflection and supervision
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d stricter ward policies
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e earlier discharge of patients.
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MCQ answers
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1 c
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2 d
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3 b
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4 b
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5 c
Acknowledgement
I am grateful to Jo O’Reilly, who provided advice and support in writing this paper and continues to be a valued partner in numerous creative endeavours.
Funding
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
None.
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