What contains the containers? An organisational thematic analysis within an NHS Trust investigating what supports staff in their work with people attracting a borderline diagnosis

Woodgate, Christopher

Abstract

People diagnosed with borderline personality disorder experience a ‘double dose’ of suffering. The chronic emotional pain and inner turmoil that is the result of their condition, compounded by stigma and prejudice at the hands of NHS staff they approach for help (Bodner et al., 2015; Dickens, Lamont & Gray 2016a). Interventions at an individual staff level have proven ineffective, with researchers suggesting further research might better target organisational and structural levels (Dickens, Hallett & Lamont, 2016b, p.125).

This insider research (Brannick & Coghlan, 2007; Crociani-Winland, 2018) builds on my experience working in one NHS Trust, across a variety of roles over an 8 year period. It takes a broadly ethnographic approach to a sequence of eleven interviews with staff working with borderline patients across the Trust, though in different teams, roles and having different professional socialisations. Interviews were analysed at individual and organisational levels, using a psychodynamic ontology (Armstrong, 2005; Hinshelwood & Skogstad, 2000; Hollway & Jefferson, 2013) & thematic analysis (Braun & Clarke, 2012) to provide a ‘binocular’ psychosocial synthesis (Richards, 2019). Data were triangulated with researcher observation and counter-transferential material. New knowledge is presented about what supports staff and teams to remain relationally connected to borderline patients, rather than detaching or becoming overwhelmed, when prejudice and stigmatisation become more likely.

Findings
At the individual level, the concept of therapeutic-level ‘containment’ was operationalised from theory and applied to the interview material. This was contrasted with the less therapeutically informed ‘coping status’, to form a continuum of containment. Higher level, therapeutic ‘containment’ was found to exist relatively independently of organisational factors, while lower level ‘coping status’ was strongly supported by organisational factors.

Contained staff relied on a superordinate process to sustain therapeutic-level relationships with patients. This process involved: 1. the capacity to manage inter-psychic proximity- the ‘empathic adult’ position’, and 2. the capacity to tolerate relational pain, attacks and not knowing- ‘negative capability’ (Bion, 1984). This key process was supported by a number of factors: a history of personal therapy, or experience of therapist-led group supervision; staff actively working to achieve ‘managed hope’; control over exposure to patients through informal spaces & supervision, and transitional frameworks drawn from professional socialisations (Bell,1990 [Main, 1966]; Winnicott, 1953).

At the group level, some teams were traumatically organised, while others functioned better. Interestingly, teams could be traumatically organised while seeming to cope well internally, through the use of social defences such as ‘barricading’, that pushed disturbance back out into other teams and patients. Traumatic team organisation could be mitigated by the organisation via managers, supervisors and wider organisational culture, through: reduced caseload sizes; providing theoretical frameworks; not passing on trauma from higher levels in the organisation, and giving staff control over exposure to the work through informal spaces, balanced with access to expert supervision.

This research suggests that Trust implementation of a manualised, time-limited intervention to help overwhelmed care coordinators was an organisationally containing act, supporting staff ‘coping status’ and protecting patients from the extremes of staff stigma & discrimination. However, insufficient funding meant the programme did not give staff sufficient time to reflect on feelings generated by the work. In this way, the programme functioned as a psychosocial bridge between social policy and staff internal functioning, inadvertently codifying emotionally dissociated ways of relating to themselves and others that discouraged therapeutic-level relationships. These treatment priorities may express and import a wider, market based culture of narcissistic self-reliance, where value is not attached to inner experience. In conjunction with atheoretical systems of diagnosis, such short term, manualised interventions may lead patients to lose hope in the possibility of change, potentially increasing their risk of eventual suicide (Paris, 2004, 2019). Longer term, relational therapies underpinned by psychosocial formulations and ‘containing practice’ are needed if meaningful and humane treatments are to be achieved for this group.

Citation

Woodgate, C. What contains the containers? An organisational thematic analysis within an NHS Trust investigating what supports staff in their work with people attracting a borderline diagnosis. (Thesis). University of the West of England. Retrieved from https://uwe-repository.worktribe.com/output/7107239

• Thesis Type: Thesis
• Deposit Date: Feb 22, 2021
• Publicly Available Date: Sep 27, 2021
• Public URL: https://uwe-repository.worktribe.com/output/7107239
• Award Date: Sep 27, 2021