An analytic approach in a psychiatric intensive care unit

SUMMARY This paper gives a psychoanalytic perspective on work in an Intensive Care ward of a general psychiatric hospital. It is a twenty-bedded locked ward, which had previously had limited medical input. Rigid adherence to a medical model had led to inappropriate reliance on the use of drugs, which can be shown to have perpetuated many of the problems, and in particular violent behavior. A psychoanalytic hypothesis, using the concept of idealisation, helps to make sense of the denial of the limitations of working within a medical model. My hypothesis is that violent behaviour in a ward setting gives rise to confusion of boundaries and defensive reactions against primitive fears. Fears of chaos and escalating destructiveness in behaviour can stimulate a wish for an ideal solution to cope with the violence. With idealisation, there is denial of the boundaries of an external reality: in this case, the limitations of pharmacotherapy. This encompasses denial of the toxic side-effects of medication. Chronic illness can be difficult to tolerate, and the frustration of the professional can lead to a displacement aggression towards the patient, enacted by toxic prescription of drugs. Clinical examples illustrate the resistances in staff to making changes in therapeutic approach. By illustrating this work, I hope to demonstrate the advantage of an analytic approach in psychiatry.