The dynamics of escalation and untoward incidents: an immersive psychoanalytic observation of the acute in-patient setting

This paper is concerned with two main issues in the acute psychiatric setting: the dynamics in play when the working relationship between patients and staff (in particular nursing staff) is disturbed or suddenly fractured by... [ view full abstract ]

This paper is concerned with two main issues in the acute psychiatric setting: the dynamics in play when the working relationship between patients and staff (in particular nursing staff) is disturbed or suddenly fractured by escalation or an untoward incident; and the way in which the individual psyche of the patient and the wider staff or institutional dynamic interact to potentiate or de-escalate untoward incidents. The paper introduces a planned psychoanalytic observation of the adult acute in-patient psychiatric setting, designed to investigate the dynamics of escalation and untoward incidents in the setting. My doctoral research, currently underway, aims to evaluate both psychoanalytic observation as a research method, and the concept of ‘unconscious dynamics’ in the psychiatric setting. The research design is based on an innovative, ‘immersive’ form of psychoanalytic observation which has its roots in the immersive traditions of ethnographic fieldwork as well as the specifically psychoanalytic focus on affect and its vicissitudes. All the interactions on the ward – those between patients, between staff and patients, and between staff - will be observed, with a particular focus on ‘micro-interactions’, behaviours that might initially be almost imperceptible or apparently unrelated  but which may nevertheless cumulatively promote an environment of impending escalation. Data analysis will be contextualized within what is already known about the broad general factors that promote untoward incidents, aggression and violence in the acute setting, and what is seen as best practice in mental health care. The intention is to contribute to the debate on the precipitants and reduction of untoward incidents in the acute setting, by achieving a deeper understanding of these precipitants; and to have practice relevance by contributing both to the opportunities that nursing and other staff have to process their work experiences, and to the development of a more reflective and humane ward culture.