Borderline States, Madness, Psychosis, Reflective Practice, The Inner World, Ways of Being


chaosI am in the interesting position of having left a university faculty where we taught nursing and now working in nursing’s front line. Both organisations have to manage chaos. Or defend against their fear of chaos. It is barely worth noting that my creativity is your chaos. What i find liberating and exciting, you may find terrifying and anarchic. The skill is to find some way of allowing my creativity to live alongside your order-And to allow us both avoid killing each other! In the university there was a terror of anything that smacked of chaos. The faculty was closely managed and tightly controlled. Learning outcomes were set out. Aims and objectives clearly stated – for both staff and students.We could have stopped delivering education and moved to selling car tyres and very little would have needed to change. Instead of teaching our students how to take Blood Pressure we would teach them how to change a tyre. Instead of learning how to manage a disturbed patient, students would have been taught how to manage a difficult customer. The system was designed to take almost any content and deliver it. Thus as a lecturer one was expected to be able to teach almost anything – regardless of one’s specialist knowledge and training.This is akin to the early problems of student nurse training and retention-and is still expressed in the shift system.One is not expected to care what one teaches. No more than nurses are expected to care which patients we see.The aim is to teach a subject, not a group of students. Similarly the shift pattern in nursing means that my patient may not see me for three days or three weeks, depending on my off duty. All that matters is that are seen by someone..Both the university and nursing practice set out to control anything that is feared to be uncontrollable-or uncontrolled. Such as attachment.

Th word chaos has its roots in ideas of chasms and empty spaces; of sponginess, looseness and emptiness. (Going back further the image is of gums. Of a space waiting for teeth to fill them.) From this there is a sense that chaos is a potential space, waiting for something to occupy it. If we stay with the image of gums waiting for teeth to emerge, we have a picture of a baby moving away from the Breast and approaching more autonomy. Once I have teeth, the range of things I can eat expands hugely. It also signals a different relationship with the Breast. One that involves learning about my separateness from the Breast.If the  university discouraged separateness and autonomy, psychiatric services seem to have become overwhelmed by Need. After a very short time back in front line nursing, I’m struck by how nearly psychotic the service has become. The chasm seems to have become so al consuming that staff and patients have give up trying to find ways out of it. We all now live in its depths.Health is no longer defined by autonomy but by how far down in the chasmic depths one is.

If the university defended against a fear of chaos by rigid control, clinical work seems to have all but given up any hope of managing the chaos. (Hence the image of psychosis where the boundaries between fantasy and reality become utterly blurred. Am I spying for a secret agency or being spied on? Am I responsible for that tsunami or is it about to overwhelm me?) I recently attended a staff meeting in my clinical area.It lasted for about 30 minutes. 20 minutes was taken up by our manager telling us about our progress in filling in RIO,our data base .We had made progress here, had overtaken Team C there but were lagging behind in these areas.(This review had been conveyed to her by her managers.) I was taken aback .No mention had been made of the number of patients staff were supporting.That each team member does about eight hours unpaid overtime each week. That caseloads are dangerously high. No.All that mattered was that a data base was correctly completed.

There are many lessons here. My central point this time is how we manage chaos-or our fear of it. The university and the NHS management deal with it by trying to control the smallest details. The patents and staff manage it by psychosis .Neither seems a good solution. I will end this blog with quote form Winnicott,a psychoanalyst who understood many things. He writes

“It could be said that with human beings there can be no separation, only a threat of separation; and the threat is maximally or minimally traumatic according to the experience of the first separatings”.(Playing and Reality 1971)


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