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611 especially when this is focused on his psychiatric prob- lem. An anxious patient tends to be afraid of offending the doctor and forfeiting his chance of help, while one who doubts the doctor’s ability or willingness to help, or believes he has been brought at someone else’s instigation, is apt to be angry-either overtly with the doctor, or (that being feared) in the more covert form of inability to cooperate (either in treatment or in supplying diagnostic information). He may even dis- play that intense form of guilt-based hostile resistance only too familiar to those who treat obsessional and depressed patients by psychotherapy.23,24 When a doctor practises psychiatry, then, he not only deals directly with people who are inevitably antagonistic, but he does so in circumstances in which their hostility is aimed directly-even purposely-at himself." 23 And, if the patient is to be helped, this situation cannot be avoided since it provides the essen- tial setting for both diagnosis and treatment. 1 7,20 (The consequences of failure to meet the emotional needs of hostile patients-even during the ordinary work of a mental hospital-are clearly shown by evidence 26 that patients are more likely to kill themselves if the staff responds in an unsympathetic, retaliatory way to their difficult, demanding, behaviour.) Hence, the doctor’s dilemma in psychiatry is that he either avoids effective contact in self-defence, or invites an onslaught that, unless he has been properly prepared to deal construc- tively with it, may make him so anxious, angry, or guilty that he can hardly cope with his own feelings— let alone benefit the patient.11 A SOLUTION This does not mean that the student or doctor is necessarily as severely disturbed as his patients (or even that he is more so than the average person), but it does mean that to work competently with patients who are psychiatrically ill, or have disordered personalities, he must himself be more than usually free from inner conflicts. The more psychiatrically ill his patients, the more emotionally healthy the doctor himself must be— hence the need for most students and doctors intending to do this work to undergo some degree of personality change 27; and, for this reason, effective psycho- therapy must be made available (as required, and to the extent required) for the student himself as an integral part of the process of instruction.17 ,20,22 Such a purpose cannot be achieved merely by giving the student an " understanding " of the reactions of his patients-or even his own-for this is just what he is not yet ready to tolerate. Accounts of apparently suc- cessful attempts to do so usually reveal that the teacher is, in fact, a competent psychotherapist and has helped his students by leavening the instructional process with a considerable therapeutic component. 6 What the student needs is not " insight " into, but emancipation from, his own maladaptive responses. When genuine psychotherapy is not available, antagonistic feelings are likely to remain unresolved and perpetuate the hostile stalemate. It is clear, then, that the salient obstacle to effective psychiatric education will not be overcome until competence in psychotherapy is no longer an optional extra,28 but the very keystone of psychiatric practice and teaching. Requests for reprints should be addressed to A. C. W., Chil- dren’s Hospital, Department of Child and Family Psychiatry, Langhill, 117 Manchester Road, Sheffield S10 5DN. REFERENCES 1. Whitehorn, J. C. Am. J. Orthopsychiat. 1946, 16, 400. 2. MacCalman, D. R. Br. J. med. Psychol. 1953, 26, 140. 3. Hill, D. Br. med. J. 1960, i, 917. 4. Turrell, E. S. in Teaching of Psychiatry and Mental Health; p. 14. Geneva, 1961. 5. Walton, H. J., Drewery, J., Carstairs, G. M. Br. med. J. 1963, ii, 588. 6. Wolff, H. H. J. psychosom. Res. 1967, 11, 87. 7. Tredgold, R. F. Lancet, 1962, i, 1344. 8. Ellis, J. Br. med. J. 1963, ii, 585. 9. Royal Medico-Psychological Association’s Memorandum to the Royal Commission on Medical Education. Br. J. Psychiat. 1968, 114, 1435. 10. McLeod, J. G., Walton, H. J. Lancet, 1969, ii, 789. 11. The Place of Dynamic Psychiatry in Medicine. Report of Society of Clinical Psychiatrists. Ipswich, 1970. 12. Krapf, E. E. in Teaching of Psychiatry and Mental Health; p. 9. Geneva, 1961. 13. Horder, J. Proc. R. Soc. Med. 1967, 60, 261. 14. Education in Psychology and Psychiatry. Report of Royal College of General Practitioners. London, 1967. 15. Eron, L. D. Cited by Lin, T-Y. in Teaching of Psychiatry and Mental Health; p. 23. Geneva, 1961. 16. Report ofRoyal Commission on Medical Education. H.M. Stationery Office, 1968. 17. Woodmansey, A. C. Br. J. Psychiat. 1967, 113, 1035. 18. Carstairs, G. M., Walton, H. J., Smythies, J. R., Crisp, A. H. ibid. 1968, 114, 1411. 19. Walton, H. J. ibid. p. 1417. 20. Woodmansey, A. C. Br. J. med. Educ. 1967, 1, 183. 21. Br. med. J. 1969, iv, 448. 22. Fakhr El-Islam, M. Lancet, 1968, ii, 1184. 23. Woodmansey, A. C. Int. J. Psycho-Analysis, 1966, 47, 349. 24. Woodmansey, A. C. in Proceedings of 22nd Child Guidance Inter-clinic Conference. National Association for Mental Health. London, 1966. 25. Woodmansey, A. C. Br. J. med. Psychol. 1969, 42, 353. 26. Flood, R. A., Seager, C. P. Br. J. Psychiat. 1968, 114, 443. 27. Balint, M. The Doctor, his Patient and the Illness. London, 1957. 28. Hill, D. Br. med. J. 1969, i, 205. Medicine and the Law Handling of Mental Patients THE trials of five male nurses at Farleigh Hospital for the mentally subnormal, Flax Bourton, Somerset, have now ended. The juries found three nurses guilty on some charges in the first trial, failed to reach a verdict in the second case, and acquitted the nurse in the last case. All the nurses faced allegations-made by student nurses, and supported by some other members of the hospital staff-of using unnecessary physical violence against patients. The nurses pleaded not guilty, but, in the first two cases, main- tained that physical restraint was needed to control the violent patients. Other patients needed the stimulus of what a psychiatrist at the hospital described as horseplay (e.g., throwing plastic skittles at patients), and understood that they were not being attacked. In his summing-up in the first trial, the judge advised the jury to allow for the fact that mentally subnormal patients often needed rough handling: they had the physical strength of an adult, but the mental capacity of a child. On the other hand, certain acts-such as kicking, kneeing in the groin, and striking over the neck with a broom handle-were not acceptable. None of the patients was capable of giving evidence, so the jury had to judge between the claims of the witnesses and of the defendants. The second trial, where no verdict was reached, involved another nurse at Farleigh, again accused of ill-treating patients. In the final case, another nurse was found not guilty of beating-up a patient who had been try- ing to associate with the nurse’s daughter. As a result of the trial, nurses at Farleigh are to circulate a petition among all nurses in mental-subnormality hospitals, asking the Secretary of State for Social Services to define the way in which nurses are allowed to handle patients.

Medicine and the Law

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especially when this is focused on his psychiatric prob-lem. An anxious patient tends to be afraid of offendingthe doctor and forfeiting his chance of help, while onewho doubts the doctor’s ability or willingness to help,or believes he has been brought at someone else’s

instigation, is apt to be angry-either overtly with thedoctor, or (that being feared) in the more covert formof inability to cooperate (either in treatment or insupplying diagnostic information). He may even dis-play that intense form of guilt-based hostile resistanceonly too familiar to those who treat obsessional anddepressed patients by psychotherapy.23,24When a doctor practises psychiatry, then, he not

only deals directly with people who are inevitablyantagonistic, but he does so in circumstances in whichtheir hostility is aimed directly-even purposely-athimself." 23 And, if the patient is to be helped, thissituation cannot be avoided since it provides the essen-tial setting for both diagnosis and treatment. 1 7,20 (Theconsequences of failure to meet the emotional needs ofhostile patients-even during the ordinary work of amental hospital-are clearly shown by evidence 26 thatpatients are more likely to kill themselves if the staffresponds in an unsympathetic, retaliatory way to theirdifficult, demanding, behaviour.) Hence, the doctor’sdilemma in psychiatry is that he either avoids effectivecontact in self-defence, or invites an onslaught that,unless he has been properly prepared to deal construc-tively with it, may make him so anxious, angry, orguilty that he can hardly cope with his own feelings—let alone benefit the patient.11

A SOLUTION

This does not mean that the student or doctor is

necessarily as severely disturbed as his patients (or eventhat he is more so than the average person), but it doesmean that to work competently with patients who arepsychiatrically ill, or have disordered personalities, hemust himself be more than usually free from innerconflicts. The more psychiatrically ill his patients, themore emotionally healthy the doctor himself must be—hence the need for most students and doctors intendingto do this work to undergo some degree of personalitychange 27; and, for this reason, effective psycho-therapy must be made available (as required, and to theextent required) for the student himself as an integralpart of the process of instruction.17 ,20,22

Such a purpose cannot be achieved merely by givingthe student an " understanding

" of the reactions of his

patients-or even his own-for this is just what he isnot yet ready to tolerate. Accounts of apparently suc-cessful attempts to do so usually reveal that the teacheris, in fact, a competent psychotherapist and has helpedhis students by leavening the instructional process witha considerable therapeutic component. 6 What thestudent needs is not " insight " into, but emancipationfrom, his own maladaptive responses. When genuinepsychotherapy is not available, antagonistic feelings arelikely to remain unresolved and perpetuate the hostilestalemate.

It is clear, then, that the salient obstacle to effectivepsychiatric education will not be overcome until

competence in psychotherapy is no longer an optionalextra,28 but the very keystone of psychiatric practiceand teaching.

Requests for reprints should be addressed to A. C. W., Chil-dren’s Hospital, Department of Child and Family Psychiatry,Langhill, 117 Manchester Road, Sheffield S10 5DN.

REFERENCES

1. Whitehorn, J. C. Am. J. Orthopsychiat. 1946, 16, 400.2. MacCalman, D. R. Br. J. med. Psychol. 1953, 26, 140.3. Hill, D. Br. med. J. 1960, i, 917.4. Turrell, E. S. in Teaching of Psychiatry and Mental Health; p. 14.

Geneva, 1961.5. Walton, H. J., Drewery, J., Carstairs, G. M. Br. med. J. 1963, ii, 588.6. Wolff, H. H. J. psychosom. Res. 1967, 11, 87.7. Tredgold, R. F. Lancet, 1962, i, 1344.8. Ellis, J. Br. med. J. 1963, ii, 585.9. Royal Medico-Psychological Association’s Memorandum to the

Royal Commission on Medical Education. Br. J. Psychiat. 1968,114, 1435.

10. McLeod, J. G., Walton, H. J. Lancet, 1969, ii, 789.11. The Place of Dynamic Psychiatry in Medicine. Report of Society of

Clinical Psychiatrists. Ipswich, 1970.12. Krapf, E. E. in Teaching of Psychiatry and Mental Health; p. 9.

Geneva, 1961.13. Horder, J. Proc. R. Soc. Med. 1967, 60, 261.14. Education in Psychology and Psychiatry. Report of Royal College of

General Practitioners. London, 1967.15. Eron, L. D. Cited by Lin, T-Y. in Teaching of Psychiatry and

Mental Health; p. 23. Geneva, 1961.16. Report ofRoyal Commission on Medical Education. H.M. Stationery

Office, 1968.17. Woodmansey, A. C. Br. J. Psychiat. 1967, 113, 1035.18. Carstairs, G. M., Walton, H. J., Smythies, J. R., Crisp, A. H. ibid.

1968, 114, 1411.19. Walton, H. J. ibid. p. 1417.20. Woodmansey, A. C. Br. J. med. Educ. 1967, 1, 183.21. Br. med. J. 1969, iv, 448.22. Fakhr El-Islam, M. Lancet, 1968, ii, 1184.23. Woodmansey, A. C. Int. J. Psycho-Analysis, 1966, 47, 349.24. Woodmansey, A. C. in Proceedings of 22nd Child Guidance

Inter-clinic Conference. National Association for Mental Health.London, 1966.

25. Woodmansey, A. C. Br. J. med. Psychol. 1969, 42, 353.26. Flood, R. A., Seager, C. P. Br. J. Psychiat. 1968, 114, 443.27. Balint, M. The Doctor, his Patient and the Illness. London, 1957.28. Hill, D. Br. med. J. 1969, i, 205.

Medicine and the Law

Handling of Mental PatientsTHE trials of five male nurses at Farleigh Hospital for the

mentally subnormal, Flax Bourton, Somerset, have nowended. The juries found three nurses guilty on somecharges in the first trial, failed to reach a verdict in thesecond case, and acquitted the nurse in the last case. All thenurses faced allegations-made by student nurses, and

supported by some other members of the hospital staff-ofusing unnecessary physical violence against patients. Thenurses pleaded not guilty, but, in the first two cases, main-tained that physical restraint was needed to control theviolent patients. Other patients needed the stimulus ofwhat a psychiatrist at the hospital described as horseplay(e.g., throwing plastic skittles at patients), and understoodthat they were not being attacked. In his summing-up inthe first trial, the judge advised the jury to allow for the factthat mentally subnormal patients often needed roughhandling: they had the physical strength of an adult, butthe mental capacity of a child. On the other hand, certainacts-such as kicking, kneeing in the groin, and strikingover the neck with a broom handle-were not acceptable.None of the patients was capable of giving evidence, so thejury had to judge between the claims of the witnesses andof the defendants. The second trial, where no verdict wasreached, involved another nurse at Farleigh, again accusedof ill-treating patients. In the final case, another nurse wasfound not guilty of beating-up a patient who had been try-ing to associate with the nurse’s daughter. As a result ofthe trial, nurses at Farleigh are to circulate a petition amongall nurses in mental-subnormality hospitals, asking the

Secretary of State for Social Services to define the way inwhich nurses are allowed to handle patients.