Psychiatric Bulletin (2003) 27: 77. doi: 10.1192/pb.27.2.77
© 2003 The Royal College of Psychiatrists
Psychiatric Bulletin (2003) 27: 77
© 2003 The Royal College of Psychiatrists
Consultant participation in therapeutic management
Oscar Hill, Emeritus Consultant Psychiatrist
Sir: The articles by Haigh (Psychiatric Bulletin, October 2002,
26, 380-382), Holmes (Psychiatric Bulletin, October 2002,
26, 383-385) and Davenport (Psychiatric Bulletin, October
2002, 26, 385-388) on the therapeutic management of the acute ward,
were timely. It is not easy to manage a busy ward in this fashion but with
determination from the consultant and a senior nurse, it is possible and very
rewarding.
Contemporary registrar training does not always prepare well for this role.
I was lucky to have the benefit of being Douglas Bennett's registrar in the
1960s when I was introduced to this style of management. I then went on to be
a co-therapist in an outpatient psychotherapy group with Heinz Wolff. Heinz
was a very active therapist and this is more what is needed in a ward group
where practically all the patients, if given the option, would rather not be
there. In any case, the purposes of the ward group are different from those of
outpatient psychotherapy. At their most basic they are a reason for the
patient to get out of bed in the morning and an occasion for recognising the
existence of each individual. It is important not to exclude a difficult and
disruptive patient. Often in the setting of the group, they can respond
remarkably well, which makes it a positive experience for all. The group is
also a highly efficient way of using staff time, when all the patients attend
the group. It is also possible to include patients on special observations,
which turns what is usually a tedious task into a therapeutic experience. It
is not easy to maintain the group culture against unwilling patients and some
unwilling staff and it is much easier if the group is a daily activity, well
established and up to the expectations of new staff and patients. The group
can also be a great learning experience, and I have never had any problems
about including medical students and student nurses. It is vital to have a
staff discussion after each group.
The main problem with the system is shortage of staff and staff who are not
very experienced or comfortable with the approach. I had the advantage of
having a gifted psychologist, Herbie Pillay, in the team, who offered specific
training sessions, which were undermined by the shift system and the shortage
of nurses. With the stripping of the inpatient service when priority was given
to the community services, I lost psychology, just as I had lost a designated
social worker. Because of the need to work as a team, the system works poorly
where there are multiple consultants on one ward.
Finally I would like, with the writers, to emphasise the importance of
staff groups and the particular importance of the consultant's participation.
In his or her absence it is very likely that the group will project their
problems on to the absent consultant, who will have his or her paranoid
suspicions about what is being said in the group.
