SUPERVISION WITH ISABEL MENZIES LYTHbjp_1166 152..155

Anna Motz

abstract In this paper the author describes two separate experiences of workingwith Isabel Menzies Lyth, first between 1987–1988 and then from 2002–2005. Sherecollects Isabel’s seminal role as staff group facilitator on a long-term rehabilitationward at Littlemore Hospital, the McKnight Unit, where the author worked as anursing assistant. She describes how Isabel’s insights and interpretations in thatgroup introduced the staff to a new way of thinking, and shed light on complexethical and clinical dilemmas. She discusses the powerful, sometimes surprising,impact of Isabel’s psychoanalytic understanding of psychosis, and of the anxietiesthat the staff team faced in this work. She then describes the experience of fortnightlysupervision with Isabel, some 15 years later, when the author had qualified as aclinical psychologist and was working in a forensic unit with mentally ill offenderpatients. The paper is a personal recollection of Isabel’s enduring insights and adescription of her keen intellect, sensitivity and compassion in practice.

Key words: Isabel Menzies Lyth, Peter Agulnik, forensic, McKnight Unit, Little-more Hospital, supervision

I was lucky enough to have known Isabel on two occasions, about 15 yearsapart, and both were tremendously significant.

On the first I learned from her directly, as a nursing assistant on theMcKnight Ward in Littlemore Hospital in Oxford, totally naïve to psychiatryand psychoanalysis. In this dark and imposing Victorian hospital ward, underthe care of inspired consultant psychiatrist, Dr Peter Agulnik, I worked withmen and women diagnosed with chronic schizophrenia, many of whom hadnot responded to drug treatment, and who also had histories of violence.Many also required physical care so that I learned how to bathe, shave, anddress elderly men as well as attending to the needs of the few femalepatients.

An equally challenging aspect of the work was listening to what seemedinitially to be nonsensical babbling but turned out to be meaningful utter-ances by people whose minds had been assaulted by serious mental illnessand trauma. The task was complex and, at first, rather frightening. The

anna motz is a Consultant Clinical and Forensic Psychologist with the ThamesValley Forensic Mental Health Service and psychotherapist in training at the Tavis-tock Clinic. She has extensive clinical experience with perpetrators and victims ofviolence and with the staff teams who work with them. She is the author of ThePsychology of Female Violence: Crimes Against the Body (Routledge, 2008, secondedition) and Managing Self Harm: Psychological Perspectives (Routledge, 2009) andis Past President of the International Association for Forensic Psychotherapy.Address for correspondence: Wenric Ward, Littlemore Mental Health Centre, Sand-ford Road, Littlemore, Oxford OX4 4XN. [ApMotz@aol.com]

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© The authorJournal compilation © 2010 BAP and Blackwell Publishing Ltd, 9600 Garsington Road,

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physical care alone was daunting, presenting me with unexpected intimaciesand requests for contact; the patients’ psychic needs equally powerful.Alongwith the other nursing assistants and students, I had somehow to learn tounderstand what I was supposed to do in my new role, and how to managemy complicated feelings that arose out of the confusion and fear of thisunknown territory.

At the weekly staff meeting I first encountered an elegant woman, quite atodds with the shabbiness of the environment. She was wearing very smartshoes and carrying a matching handbag, invariably arriving on the dot of oneo’clock and leaving at the dot of two o’clock, without so much as a ‘hello’ or‘goodbye’. This was Isabel, whose name meant very little to me at the time.I wondered who she was, and why so much anxious excitement surroundedthis staff support group. Twenty years later I vividly remember lookingforward to the weekly meetings and the lively discussions where Isabel’sobservations and questions catalysed decisions. One of these involved thepanic we were feeling about whether or not to administer medicationsecretly to a paranoid patient, who refused to take medication that couldprevent him from having a stroke. Should we put this in his daily egg withouttelling him, as he would certainly refuse if he knew? Isabel reminded us ofour nursing duties and raised the important question of whether this mancould realistically be considered to give informed consent. What were ourduties of care? Actually, we realized our ‘ethical stance’ was a way of avoid-ing our responsibility. Isabel’s well-placed questions and comments allowedus to discover what we already knew. She allowed us to talk about our fearsthat his life rested in our hands – poignantly so as his family had more or lessabandoned him.Although we could fulfil our mindless tasks without dissent,this decision brought up central issues of terrifying responsibility andrequired us to recognize that helping him to stay alive was our primary taskand obligation.

On another occasion an elderly patient had died on the ward of naturalcauses; he was very popular, a long-term patient. To our surprise, when wediscussed this in the staff group, Isabel told us to expect a lot of sex on theward. She was right, of course, as the trade in sex for cigarettes went throughthe roof over the forthcoming weeks, and heavy flirtations with one anotherpreoccupied the staff. No wonder we were all listening to her with suchinterest.

With Isabel’s clear vision and direct, no-nonsense but compassionateobservations we became increasingly able to explore our concerns, namelywhat on earth we were supposed to be doing with such profoundly ill people.We began to think about the humanity of our patients, and the terrific impactof the work on us.We began to air the secrets we all knew about. Isabel madethis possible, and showed us that nothing is more dangerous than a secreteveryone knows. We debated whether we were a home for patients with nohope for another life, or a rehabilitation ward, as Peter Agulnik passionately

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argued, with space for taking on responsibilities, including employment inthe hospital gardens. Isabel’s incisive comments forced us to discover howcalling the ward a home was a lie, possibly borne of a wish, but certainly away of avoiding our difficult task of helping chronically ill patients to get outof bed, get dressed, go to work and lead a more productive and bearableexistence. The same applied to calling them ‘clients’, not patients; it was apolitically correct euphemism and a way out of facing up to painful truths.Isabel later said to me: ‘You can change the words but you can’t change theideas. This hospital is not a home, it is a hospital where some people live.’

Ultimately Isabel helped us in the McKnight Unit to be clear about ourtasks, our roles and responsibilities and also to do the painful work ofacknowledging to one another how frightening, intimidating and, at times,disgusting, some of our duties were. She worked with us to as we unravelledour avoidance strategies that included frequent coffee and tea breaks hidingfrom the patients wandering the corridors of the McKnight Unit.We learnedto face the hate, as well as the love, that we felt for these patients.

Fifteen years after my first encounter with Isabel, I returned to Oxford, asa newly appointed Consultant Psychologist, on a former rehabilitation ward,now a secure forensic unit, and Isabel agreed to supervise me. She deeplysupported the work with forensic patients and was not appalled by theviolence, seeking instead to understand it. I found my new role and whatseemed to me to be the therapeutic vacuum within this unit difficult tounderstand, but felt I should as I was now a Consultant Psychologist. Thiswas a term which Isabel found most misleading and unsatisfactory, she said:‘Anna, but why do they call you a Consultant? Do you consult? And towhom? That is quite mad.’ And I who had been so proud of this new title wasable to see that, of course, as part of the team I could not be a consultant toit. Supervision was rich and sometimes quite humbling. Isabel asked whetherI thought the unit needed a psychology consultant as a status symbol or didI have real responsibility? This was a most profound question and onethat I continue to ponder.

After all this time, I was impressed to see that Isabel was as clear, vigorousand engaged as ever.Within a few minutes of our first supervision session wewere hard at work, piecing together the structure and purpose of the organ-ization I had joined. I fell at the first hurdle when she asked: ‘Who is incharge? You need to know who is in charge and have crystal-clear bound-aries and structures.’ She lamented the fragmented nature of the manage-ment structure in the health services of today, with off-site managers, and thegreat contrast with the Royal National Orthopaedic Hospital where man-agers, doctors and nursing sisters had been present, running the wards, withthe roles and boundaries unambiguous, where, she explained, the motherslooked after the children and the nurses looked after the mothers.

I recall vividly that Isabel’s starting point was to ask me what I could do,what my role was in relation to the ward and the team. She stressed the

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importance of working with groups, not individuals on the ward, eitherpatients or staff. This, she explained, was essential if we were to understandwhat goes on with psychotic patients in psychotic institutions. She felt pas-sionately about the plight of the nurses whom she described as ‘in thewilderness’ like the patients who were similarly abandoned, without a thera-peutic programme or a structured daily routine at that time. She helped methink this through and develop such a therapeutic programme; she offeredpieces of clinical wisdom about the formation and the timing of therapeuticgroups to maximize attendance.

By gently pointing out the numerous muddles, confusions and ineffici-encies in the structure of the unit, my role and the greater system of theclinic, Isabel helped me to answer her most vexing and central question:‘How can these patients get better?’

She was deeply in touch with why the patients needed to use violence tobe heard, in a ward and a system where chaos prevailed and no one personhad ultimate responsibility or authority. Likewise she understood the fear ofthe nursing staff when anything had the potential for danger, plastic forks,lighters, parts of the furniture, and the patients’ own bodies, remarking that:‘Everything becomes a weapon, but nothing actually is’ – nothing else hasthe potency or force to provide a sense of power and control. This was oneillustration of her remarkable compassion and lack of sentimentality. Sheargued passionately for Reflective Practice groups for all the wards, insistingthat doctors attend Community Meetings, and encouraged me to set upregular meetings for the management team, groups for nursing students andsupport workers, and to become clear about our primary task.

Despite her physical frailty in later years, she remained a lively, elegantand vital presence, sitting in her special chair in her beautiful living room inIffley, leaning forward as she heard about a new management system thatoutraged her – because it alienated staff from their work, damaged patientcare and, quite simply, didn’t make sense.

Isabel’s penetrating and deceptively simple questions and passionateengagement with patient care stay with me. I believe that, in the course ofour work, if we can continue to remain sensitive to unconscious processeswithin ourselves, the patients and our organizations, we can keep her insightsand work alive. As Isabel herself stated, in the debate with the Bishop ofOxford in December 1997, ‘Facing the Void’, although she was not a con-ventional believer, she hoped: ‘The form in which I will survive is in theminds of people whom I have loved and who love me, and people where Ihave done something to contribute to their lives’.

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