Fear, loss and disconnection: the emotional impact of the Covid-19 pandemic upon staff working in mental health services and how the organization can help - a psychoanalytic perspective.

This paper describes the work of a psychoanalyst working within NHS mental health services in the UK . The central contribution of a psychoanalytic approach within psychiatric care in offering a committed attempt towards understanding the patients' presentation, rather than treatment primarily aimed at symptom control, is described. Beyond this, the specific contribution of psychoanalytic ideas in establishing a containing framework for staff, and how this strengthens the capacity of the organisation as a whole to contain anxiety and to metabolize complex projective processes is outlined. Examples are given with clinical illustrations of activities which enhance this capacity in ordinary times.The author then turns to the impact of the covid-19 pandemic upon staff and patients, describing how fear, threat and experiences of multiple losses have permeated all areas of our lives and activated primitive defences. The pandemic starkly revealed profoundly disturbing questions about our assumptions and habits, adding to the intensity and multi-layered quality of the anxieties evoked . Urgent attention has been drawn to our deeply problematic relationship with the natural world, our own habitat, and indefensible social inequities have been crudely exposed. Staff have been caught between their own fear, the need to contain increased disturbance in their patients, already struggling with fragmented and disordered states of mind, and pressures from an organisation under intense strain. The capacity of mental health staff to act as containers for their patient's distress has been profoundly challenged and compromised.This paper outlines how the pandemic has highlighted the crucial role of the organisation as a container for anxiety and in supporting staff to do their work in mental health care. In order to strengthen this capacity during the crisis, the author describes how ideas derived from psychoanalytic principles were developed into guidance for NHS Mental Health Trusts during the early days of the pandemic . This guidance was adopted nationally by the Royal College of Psychiatrists and is summarised in this paper.

Parity of esteem within the biopsychosocial model: is psychiatry still a psychological profession?

In recent years, the Royal College of Psychiatrists has been engaged in activities to ensure parity of esteem for mental health within the National Health Service, seeking to bring resources and services more in line with those available for physical health conditions. Central to this has been the promotion of psychiatry as a profession that takes a biopsychosocial approach, considering all aspects of the patient's presentation and history in the understanding and treatment of mental disorders. However, there has been a drift away from considering the psychological aspects of the patient's difficulties in recent years. This potentially has profoundly negative consequences for clinical care, training, workforce retention and the perception of our identity as psychiatrists by our colleagues, our patients and the general public. This editorial describes this issue, considers its causes and suggests potential remedies. It arises from an overarching strategy originating in the Royal College of Psychiatrists Medical Psychotherapy Faculty to ensure parity of esteem for the psychological within the biopsychosocial model.

Understanding the impact of the COVID-19 pandemic on psychiatric trainees and what can help.

The COVID-19 pandemic has increased rates of psychological distress and burnout in healthcare staff. How can we understand our experiences of the pandemic? We reflect on the experiences of psychiatry trainees in two north London mental health trusts. From a psychoanalytic understanding, states of extreme anxiety can lead to a manic defence and functioning in the paranoid-schizoid position. This position is derived from object relations theory and is characterised by binary thinking, splitting, projection, defensiveness and 'knee-jerk' decision-making. This can affect our perceptions, responses to others, relationships and ability to function and, therefore, our clinical practice and well-being. We consider the importance of recognising these processes and of organisational containment and having space to reflect. This supports functioning in the depressive position, a state of mind where we can tolerate anxiety, address difficult realities and develop new ideas. We hope these understandings are helpful to our colleagues in all professions.