Stuckness in psychiatric practice
| Pages | 195-211 |
| Date | 29 August 2019 |
| Published date | 29 August 2019 |
| DOI | https://doi.org/10.1108/MHRJ-08-2018-0023 |
| Author | Peter J. Wilkinson |
| Subject Matter | Health & social care,Mental health |
Stuckness in psychiatric practice
Peter J. Wilkinson
Abstract
Purpose –The purpose of this paper is to introduce and explore stuckness as a felt phenomenon in
psychiatric practice in order to stimulate clinicians in mental health settings to be on the lookout for stuckness
and on the lookout for unexpected solutions to difficult clinical scenarios.
Design/methodology/approach –Signs of stuckness are looked at and then proposed causal factors of
stuckness in clinical practice are reviewed. These are divided conceptually into four main groupings: patient
factors, clinician factors, service factors and societal factors.
Findings –Although clinicians are encouraged to acknowledge when stuckness is present and to try to
address possible causes with their patients, clinicians are also advised to work on understanding stuckness
as a natural part of creative processes. It is suggested that services should draw on a psychoanalytic ethos to
support staff to tolerate and respond to stuckness better.
Originality/value –Feeling stuck with patients’partial recoveries or “revolving door”cycles is uncomfortable.
In stretched psychiatric services in particular stuckness may go unnoticed, and instead the difficulty of the
work with patients may inadvertently drive therapeutic mania or rejection of the patients, which can lead to
harm. This paper offers a simple scheme to use when thinking about stuck patients in the psychiatric setting
with the hope that this can stimulate clinicians to search for new creative solutions for patients.
Keywords Stuckness, Impasse, Psychiatric practice, Mental health services, Creative practice, Psychoanalysis
Paper type General review
Introduction
Clinical case conferences, where patients’histories and management dilemmas are discussed
with peers, are commonplace in psychiatric practice and training. A few years ago, while a Core
Trainee in Psychiatry, an invitation to present a patient case at a local forum spurred some
thinking about stuckness as I was feeling stuck with a number of patients at the time. Upon
exploring this with my supervisor, we wondered whether feeling stuck with patients might be a
key motivator behind choosing who to present to one’s colleagues. Why one is presenting
a given patient case out of many is often not voiced, though instances of rare or interesting
presentations, successes against the odds, or cases that arouse strong feelings such as anger
or anxiety may commonly find their way to theforefront of would-be presenters’minds, and stuck
cases will have a place in such a list. Indeed the intra- and inter-professional cross examination
afforded at case conferences can help clinicians get new ideas, to get unstuck with cases.
But what of stuckness as a subject in its own right? Might a dedicated exploration of stuckness
itself –itssigns, symptoms and causes –betterequip us to notice it and to wrestle with it so that we
might attempt to limit its influence over our work with patients? An initial exploratory presentation
on stuckness was assembled and deliveredlocally. The present paper is the result of those initial
forays and further thinking on the subject.
Defining stuckness
Stuckness is perhaps best understood in opposition to its antithesis –getting unstuck implies a
freeing from impingement, a lubrication of processes. In an essay exploring the ebb and flow of
artistic drives, artist Jonathan Harris (2014) likens residing in stuckness to the “off”phase of a
ornamental fountain –one can wait, certain that the next phase will be the upwards surge of the
Received 7 August 2018
Revised 20 May 2019
17 June 2019
Accepted 26 June 2019
The author would like to
acknowledge the input of his
former supervisor David Dayson
FRCPsych for the conversations
that kick-started this work, and
Andrew Dawson for discussions
and sharing ideas on the subject
of stuckness.
Peter J. Wilkinson is based at
the South Lanarkshire
Psychotherapy Service, NHS
Lanarkshire, Carluke, UK.
DOI 10.1108/MHRJ-08-2018-0023 VOL. 24 NO. 3 2019, pp. 195-211, © Emerald Publishing Limited, ISSN 1361-9322
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column of water, the dizzying flight back into creative activity. When things are stuck,
unstuckness may simply follow with the passing of time, but Harris also suggests that trying to
embrace childhood qualities like playfulness and exploration may be a more active route out of
stuckness. In a similar vein Robert M. Pirsig (1999) wrote of unstuckness as intrinsically linked
with intuition, creativity and invention, qualities that help us with what to do or where to look next
when we are stuck.
In clinical practice noticing and naming stuckness happens when we realise that things are not
moving forwards, perhaps that something significant has so far been eluding us, that we have
been shining our torchbeam of examination on the wrong alcove of our subject’s life.
The question is then one of what to do next. First, however, it must be stated that as clinicians we
are under pressure not to notice and to know stuckness. Arguably, the pressures that exist in
modern healthcare services can compel us to oversimplify patient encounters –we place on a
pedestal diagnosis, medication, risk assessment and documentation, sometimes at the expense
of understanding what it is that really keeps us and our patients stuck.
Signs of stuckness
Practising clinicians will already sense stuckness on a regular basis, even if it is not always named
as such or known consciously. The most obvious sign is a palpable dissatisfaction with a case not
progressing as expected, but there are more subtle signs: we might hesitate when discussing
strategies with patients; we later find ourselves frowning or scratching our heads; we are
suspicious that all is not as it seems, even that deception might be afoot; we ask colleagues for
their views; at intervals we take baffling cases to forums where the time is granted to explore the
complex lives of our patients in more detail. There are more uncomfortable personal associations
too: we feel unfulfilled at work; we feel frustrated, perhaps angry; work situations seem repetitive,
boring even; sadness and hopelessness can creep in (Kahn, 2012). Relationships with
colleagues may deteriorate; factions may develop within teams. Furthermore, with individual
patients who are stuck, we may find ourselves unconsciously employing maladaptive defences
against the dissatisfaction of treatment failure or partial recovery, both common occurrences in
psychiatric practice. As Tom Main (1957) pointed out in “The Ailment”, patients who get well do a
great service to their clinicians, but with patients who do not get better quickly enough for their
clinicians, overzealous therapeutic avenues are sometimes pursued in the service of the
clinician’s own anxiety, impatience, hatred, sense of despair or impotence, or to counter
the “guilt-by-association”that gets into staff working with certain patients. These defence-driven
directions are dangerous because of their tendency to propagate unchecked in busy and
increasingly stretched public healthcare systems. These signs of stuckness go unnoticed too
because to look at them asks for the uncomfortable work of self-examination.
We may do well to consider how, in the field of mental health, we are working in a current culture
and climate where “recovery”is often expected when it may not in fact be possible –severe and
enduring mental illness is incurable and personalities change over the lifespan, not discrete
treatment episodes. Whilst stuckness may be encountered in all areas of life and in all disciplines
of medicine, the juxtaposition of the desire for cure against the incurability of our “ailments”is
perhaps most pronounced in psychiatry, and therefore, our potency as would-be curers
is arguably most challenged. This disconcerting reality can regrettably drive our acquaintance
with stuckness further underground.
The impossible job
The purpose of shoehorning in Figure 1 at this point is to illustrate how, in a typical psychiatric
encounter such as the 30-minute outpatient appointment, a lot is going on, which only adds to
the difficulty in detecting and comprehending stuckness. The general psychiatric outpatient
appointment is a markedly time-limited interaction with a patient that is alive with multiple parallel
processes that dance back and forth in competition for primacy. Although clinicians can control
the direction of the conversation to an extent, and we can structure the encounter into time
segments used for specific purposes, it is important to acknowledge that many of the multiple
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