Systemic Practice in Inpatient Psychiatry

Working with ideas from systemic psychotherapy can be challenging in medicalised contexts where the emphasis is on ‘illnesses’ which are said to exist within an individual. Such systems can often obscure the power dynamics which impact on an individuals experience of distress. During my work in an inpatient psychiatry service I was able to consider these issues and how they impacted on the people with whom I worked. The following is a taken from a reflective essay written during my training as a clinical psychologist.

Trust, choice and power; reflections on systemic practice in an acute inpatient mental health service

Systemic practice can involve work with individuals, families and professional teams. Psychologists practicing in this way are concerned with how the relationships between people, in the systems in which we live and work, impact on our wellbeing (AFT, 2009). In the context of severe psychological distress, the systems that are most influential are primarily inpatient mental health wards and community mental health teams. When these services function well, they help to promote recovery from psychological distress and improve psychological wellbeing. When they function poorly they can be counter-therapeutic and even abusive to service users (AFT, 2009). It is important for psychologists working within these services to understand the importance of trust, choice and power in the relationships between staff and service users, to help facilitate recovery from psychological distress (Laugharne et al., 2011). Social constructionism is central to post-modern systemic practice and posits that the language we use constructs the reality between us (Dallos & Stedmon, 2006). Psychologists will often attempt to bring these discourses into consciousness for staff and service users in order to develop a collaborative understanding of a person’s distress (Dallos & Stedmon, 2006). Through this collaborative understanding psychologists can begin to address the issues of trust, choice and power in their work with an individual and/or professional team.

Here I describe my work with Michael (pseudonym), a person whom I was asked to see on an inpatient mental health ward as part of my training as a clinical psychologist. The focus of the essay is on the fifth session with Michael, which led to a change in our understanding of his distress. This session highlighted how the service in place to help Michael was functioning poorly and how an understanding of systemic theory helped me engage with Michael collaboratively and to facilitate a collaborative relationship between Michael and a ward staff member. This essay is separated into four sections. Section One considers the context of inpatient mental health services, where my work with Michael took place. In Section Two, I will summarise Michael’s story from our first four sessions together. In Section Three, I will describe how my understanding of Michael’s experience changed during our fifth session using Kolb’s model of experiential learning (Kolb, 1984). In Section Four, I will reflect further on how systemic practice has informed my work with Michael and consider the broader implications for my practice as a clinical psychologist.

Section One: language, certainty and policy in mental health services              

Mental health care has undergone radical changes since de-institutionalisation occurred in the mid-20thcentury (Laugharne et al., 2011). However, the current system of mental health care still has a long way to go with gaps in service provision and long waits to access mental health services (DoH, 2014). In addition to this, there are specific problems in the way that mental health systems conceptualise psychological distress as a ‘mental illness’. The British Psychological Society (BPS) advocates a move away from the description of psychological distress as an ‘illness’ to one that describes it as part of the spectrum of human experience (DCP, 2011). Johnstone (2000) suggests that the use of diagnosis provides the foundation of medical language that we use; words like ‘patient’, ‘illness’, ‘treatment’ and ‘prognosis’ shape our assumptions about psychological distress and how it should be helped; with ‘hospitals’, ‘doctors’, ‘wards’ and ‘medications’.

Institutions often maintain power by controlling knowledge and language (Foucault, 1972). Systemic practitioners are often critical of medical, pathologising language for this reason and for the impact on the individual (White and Epson, 1990; Hoffman, 1993). Often the role of a systemic practitioner in the context of a mental health ward is to show that the way language is used to describe a person, their problem or ‘treatment’ can create an unhelpful reality for the service user. In some cases, this reductionist approach ignores the individual’s experience, perseveres for most of the life course and leads to disempowerment of the individual concerned (Pitt et al., 2009). On the ward in which I worked with Michael, service users almost always have been given a diagnosis or are subsequently given one after they are admitted; Michael was given a diagnosis of ‘paranoid schizophrenia’.

The staff working with Michael were from a variety of professional backgrounds that primarily encompassed support workers, mental health nurses and psychiatrists. Their understanding of psychological distress differed according to their profession, but generally they conceptualised Michael’s distress as an ‘illness’ and his experiences of persecution as a ‘symptom’ of ‘paranoid schizophrenia’; this did not reflect the reality of his situation, from his perspective. Michael viewed his experience in the context of the discrimination that he had experienced prior to admission, which I describe in Section Two. The staff team functions as part of a wider system that is influenced by powerful forces such as the staff members’ personal and professional experiences, the local organisational culture and the mental health system. (Boyle, 1990).

During discussions with numerous staff members, they expressed some certainty about Michael’s presentation, describing it as an ‘illness’. This certainty about understanding can be self-protective but can hinder our ability to help a service user (Amundson, Stewart & LaNae, 1993). I was aware of this in my own practice, as the pursuit of certainty in therapeutic work can lead to inflexibility and rigidity (Amundson, Stewart & LaNae, 1993). This was not always the case, as until the end of the 1970s, a systemic therapist would lead the session from a position of expert knowledge (Dallos & Stedmon, 2006). However, more recently there was a move away from an idea of certainty to one of usefulness or fit (Mason, 1993). A systemic practitioner will no longer go to a session to prove or disprove a hypothesis, but will instead explore ideas and meaning. They are able to use their training, expertise and beliefs, but are comfortable with not knowing what the problem is (Krull, 1998).

As professionals working to aid recovery, it is important to avoid establishing unhelpful patterns of certainty, where by we are unknowingly doing the same thing over and over again (Watzlawick, 1978). If we feel able to understand too quickly then the opportunity for further dialogue is reduced and the opportunity for poor understanding is increased (Anderson and Goolishian, 1988). I will describe how I considered these ideas of language and certainty in mental health services, in Sections Three and Four.   It is important to consider some context to mental health policy and legislation that is germane to Michael’s experience. Michael was admitted onto the ward as an informal patient, as he chose to seek help and was not detained under the Mental Health Act (1983), thus meaning Michael had the right to refuse proposed care and treatment, including medication. If Michael has been detained under the Mental Health Act (1983) and refused medication, he could be forced to do so by staff members and deemed to lack capacity under the Mental Capacity Act (2005). The implications of this will be considered more in Section Four.

Section Two: my work with Michael                                                                                 

Haley (1963) suggested that at the beginning of therapy, the therapist has power and often sees the complaints of the service users through the eyes of their own experience before selecting what information will be explored. In the first part of my work with Michael, I used a CBT-based approach that considered systemic factors in Michael’s life (family and work place) and systemic concepts, understanding of trust, choice and power. I chose a way of working that I thought would allow a wide variety of information to be explored whilst acknowledging the inevitable power imbalance in our relationship (Foucault, 1972). When I first met Michael, he had been in the inpatient Mental Health Service for two weeks. The consultant psychiatrist had asked me to meet with him to help him understand what has happened in the past, how things were at present and what he may be able to do to stay well in the future. In our first four sessions, Michael and I spoke about what happened before his admission to inpatient mental health services.

Michael engaged in the discussions that we had and was willing to discuss the difficult experiences from his past. I was aware that Michael’s experiences could have led him to feel persecuted during our sessions. Lawlor et al. (2014) found that openly discussing an individual’s experience of persecution whilst collaboratively addressing any issues, lead clients to feel understood and less ‘paranoid’. With this in mind, my work with Michael was based around collaboration, openness and shared decision-making. As a result, our formulation was a shared activity and not something that is done by the therapist for the service user (White and Epston, 1990). Michael and I began to create a shared understanding of his experiences prior to admission, thinking about what Michael was able to learn from these experiences to enhance his recovery and to keep him well in the future. This is my understanding of Michael’s story at that the end of session 4:

Michael is young British man; his family are originally from Iran. He spoke about how he had begun a new job in the months before coming into hospital. This job was in a new town which was not familiar to him and he had moved away from his immediate support network. Michael experienced racism from co-workers and people in the local town shortly after beginning the job. He found this situation distressing and felt increasingly concerned that others were attempting to hurt and upset him. Over time, Michael felt “weak” and “low in mood”. He began to neglect his wellbeing including paying less attention to his diet (eating more junk food) and his physical wellbeing (he stopped going to the gym to exercise). Michael was also struggling to sleep at night. This led to further distress and an increasing fear that people were trying to hurt him. Michael was jumping to conclusions about his experiences and began to feel increasingly isolated and unsupported. He returned home for a family event and had a disagreement with his uncle, during which they got into a fight and the following day he became angry with his sister and attempted to strangle her. Michael said he experienced this anger because he didn’t feel like anyone trusted him and that he was “not being listened to”. Michael had felt mistrustful of a number of people and was hoping to be able to trust his family to support him. He felt disempowered by his colleagues and his family and became very angry. Michael felt guilty about what had happened with his sister and wanted to consider what he could do to “feel better”.

Section Three: a change of understanding

During the first four sessions with Michael, I had briefly considered the impact of language (Johnstone, 2000) and certainty (Amundson, Stewart & LaNie, 1993) in the context of trust, choice and power but my primary focus was utilising CBT to explore Michael’s experience prior to admission and how he can keep himself well in the future. In session four, my approach changed and I focused more on the systemic factors mentioned above. I will use an adapted version Kolb’s (1984) four-stage model to describe my interaction with Michael (Part One) and my interaction with the staff members (Part Two). I have titled the four parts of this model: ‘Describing my experience’, ‘Reflection on observations’, ‘Considering trust, choice and power’and ‘Application of ideas’.

Part one: working with Michael

Describing my experience. Michael was distressed when he arrived to session five, which took place on the ward. In Michael’s account he spoke about how another service user had threatened him and was bullying him. Michael had reported this to staff and felt that they were not dealing with his concerns and were not protecting him. Michael said that the ward staff “had their favourites” in reference to the other service user and perceived that as the reason for their inaction. Michael reported that the service user who was bullying him had been entering his room without his permission and was leaving objects in the room and as all of the rooms are locked, the other service user would have had to have a key to Michael’s room in order to do this. Earlier that day, Michael had asked a staff member if the keys that service users had could be used to open other rooms on the ward. The staff member said that they couldn’t. Michael did not believe this and then attempted to open another door with the key that opened his room door and was able to unlock it. This confirmed his belief that another person had access to his room and he asked the staff member to test the other keys to see if they could open his door. The staff member refused to do this and asked Michael to return the key that he had for his room, as he had been given a master key in error. Michael refused to return the key. He was particularly distressed because immediately before the session as three staff members had approached him with the psychiatrist asking Michael to return the key. Michael did not return the key and was informed that if he continued to refuse the police would be called.

Reflection on observations made. There was a noticeable change in Michael’s presentation, compared to the previous sessions. He was more distressed, appearing anxious and angry. From hearing Michael’s account, I was unsure if another service user had entered his room but understood how his belief that this had happened would be distressing for him. The master key had been given in error and the staff members’ response had exacerbated Michael’s distress. I wondered why the ward staff did not test the other service user’s key to determine if another person had access to Michael’s room. I had a number of other unanswered questions but my initial concern was to help Michael consider how he might respond to this situation in a way that would be helpful for him and could improve his relationship with the staff. Dallos and Stedmon (2009) suggest that reflection in the session is primarily about a therapist listening to their body and noticing their emotional experience. When I heard Michael’s account, I felt angry because of how he had been treated, particularly because it was replicating his experiences of persecution and discrimination before his admission to the ward.

Considering trust, choice and power. The trust between Michael and the staff had been compromised and there appeared to be a mutual distrust. Michael no longer trusted that the staff would look after his best interests. In this instance, Michael was given only two choices: to return the key or not and he was made aware of the consequences if he refused. He felt like his only options were to ignore what he believed was right, and hand back the key or to follow with his values and hold onto the key for longer. In addition, he was told that if he returned the key, the staff will have to allow him access to his room until a new lock was fitted, which would take some time. There was an inherent power imbalance between the staff and Michael, which is perpetuated by the use of labels associated with diagnosis. Although his admission was informal, there is an expectation that Michael would generally do as staff asked as he was seen as ‘unwell’ and needing ‘treatment’. In this sense, Michael was effectively disempowered by his perceived ‘illness’ (Johnstone, 2000; Pitt et al., 2009).

Applying these ideas. Although my relationship to Michael was different to other staff members, I was aware that this incident might have impacted on the trust that Michael had for me. I decided that shared decision-making in relation to the incident could help to address the issues of trust, choice and power within the relationship between us (Hill & Laugharne, 2006). I began by helping Michael to explore the options that he had in this situation, to consider the possible outcomes of these decisions and whether he may need more information. Figure One shows the result of our shared considerations of these options. We began by considering the two options that Michael had been given and what the potential outcomes of each of these would be. I have added my understanding of how Michael’s experience of trust, choice and power would be impacted by these decisions. We considered another possible option of compromise between the staff and Michael, which I refer to as Option Three. At this point it was unclear how long it would take for a new lock and key to be fitted. Michael and I decided that I could support him in managing this decision by establishing if ‘Option Three’ was a possibility. My next step was to speak with a staff member who could provide me with more information as Michael stated he was too angry to speak to them.

screen shot 2016-03-14 at 12.19.55

Fig 1. Diagram representing the shared-decision making process in relation to the decision to return the master key to staff, or not.

Part Two: working with staff

Describing my experience. Following the session with Michael, I visited the nurse’s station and asked a staff member whom if they were aware of the current situation with Michael. She said that she was aware and agreed to discuss it briefly with me. I informed her that I had spoken to Michael about his experiences and that I had agreed to get more information about what might happen next. The staff member informed me that they were planning to call the police if Michael did not agree to hand back the key. I asked if Michael was to hand back the key what would happen next and was informed that a staff member would give him access to the room for around two weeks until the lock was changed. I then asked the staff member how they knew that it would be a two-week wait and they said they were not sure that this was the case. I then asked the staff member if they could find out for certain how long a replacement lock would take and she referred me to the member of staff managing the ward. I spoke to this staff member and they told me about their concerns for Michael, stating that “there is no choice, he has to give the key back”. I asked if they would contact the company whom replace the locks in order to determine if it could be facilitated sooner. They agreed to do so and when he got in touch with the company, he was told that the lock could be replaced immediately and thus ‘Option Three’ then became a possibility; Michael could hand over the key to the staff and a new lock and key would be fitted that same evening.

Reflection on observations made. The staff on the ward were very busy and this made it challenging to consider the situation with Michael in greater detail. This is evidence of the influence of wider systems on i.e. organisational culture and low staff numbers on their response (Boyle, 1990). The staff member told me that Michael had “no choice” but to give back the key and located the problem of the situation within Michael. I saw this as evidence of certainty and an attempt to understand the situation with Michael too quickly (Anderson & Goolshian, 1988). It was my impression that the staff were concerned about how the situation might reflect on their professional conduct and this may have resulted in their reluctance to collaborate with Michael, which may be further evidence of the broader systemic factors, such as individual blame for mistakes that are made, that might have influenced their approach to Michael (Boyle, 1990). When I offered to support the staff member with finding out more information and in communicating this to Michael, they responded well. Through this interaction, it became clear that Michael’s experience was based in the reality of the situation. I felt angry that the staff had been concerned about their own professional reputation and it was my opinion that they had used their power to attributed Michael’s actions to his ‘mental illness’ (Foucault, 1972).

Considering trust, choice and power. I was aware that the issues that I was considering between Michael and the staff in relation to trust, choice and power were also relevant to my interaction with the staff. There had been a mistake on their part (giving Michael a copy of the master key) and this may have resulted in a fear of being blamed, which led to the initial response of insisting that Michael returned the key. I did not want the staff to perceive me as punitive or blaming them for their actions. The staff member who I spoke to was distrustful of Michael and this manifested in a lack of willingness to collaborate. It could also be that the staff did not trust me because I had spoken to Michael about his experiences in detail. My understanding of this was that the staff were operating from a position of certainty and in the knowledge that Michael was ‘unwell’, ‘paranoid’ and could not be reasoned with (Amundson, Stewart & LaNae, 1993; Watzlawick, 1978). I considered how I might challenge these assumptions in a way that did not lead the staff to feel they had no choice or had to respond to me as member of the team who may be seen as more senior or powerful.

Applying these ideas. I informed the staff that I was willing to support both them and Michael. I decided to act as a mediator between the two, although I was aware that this brief intervention might not lead to sustainable change. I arranged briefly to meet with Michael and the staff member whom I had been speaking with. In the meeting I was able to facilitate clear, considerate communication between Michael and the staff member. In this way they were able to begin to develop mutual trust. Michael agreed to give back the key and was assured that his lock would be changed. Following the interaction, Michael thanked me for my help to which I informed him that the staff member was the one who had done the work. Michael then thanked the staff member for their help. I had a discussion with the staff member informing him of how there was some mutual mistrust with Michael and how Michael’s experiences are understandable in the current context, particularly given what happened prior to admission. I also spoke to the staff member about how Michael’s label of ‘paranoia’ could limit our openness to collaborative discussion and decision-making. Following these interactions, I summarised how I understood the escalating patterns of mistrust between Michael and the staff team.

screen shot 2016-03-14 at 12.21.15

Fig 2. Escalating patterns of mistrust, adapted from Dallos and Stedmon (2006).

Section Four: follow-up and further reflections

Michael’s experiences prior to admission were reinforced by what was happening on the ward just before our fifth session. Before admission, Michael felt that people were trying to hurt him and that no one was listening to him. The issues of trust, choice and power were central to Michael’s experiences and became a current reality on the ward. This gave Michael, the staff member and me, opportunity to explore the meaning and possible reasons for this. Amongst other things, I have become more aware of how disempowering medical language can be and how the pressures from the wider system of influence can lead to a need for certainty.

The following week when I returned to meet with Michael, I was informed that his relationship with the staff continued to deteriorate. Unfortunately, but not surprisingly, Michael’s increased ‘paranoia’ continued to be viewed as a function of his ‘illness’ rather than a rational response to situational factors and he was asked to change his medication because of this deterioration. He refused and was then detained under a section of the Mental Health Act (1983) and forced to take the medication. By the next session, one week later, Michael’s relationships had deteriorated further and he had been moved to a more intensive inpatient mental health ward, the Psychiatric Intensive Care Unit (PICU). Michael was subsequently given less choice and felt increasingly powerless in the decisions that were made, which resulted in increasing mistrust and more expression of his distress through angry outbursts whilst in the PICU. Over the following three weeks, the work we did was limited by sedation and fatigue resulting from medication side effects and our relationship ended with Michael after eight sessions when he was moved to another mental health unit.

Through this piece of work, I was able to consider how trust, choice and power are linked to our use of language and how the need for certainty and can have a harmful impact on a service user through disempowerment (AFT, 2009; Pitt et al., 2009; Amundson, Stewart & LaNae, 1993). I was able to use collaborative decision-making in an attempt to address these issues and to help promote recovery (Hill & Laugharne, 2006; Laugharne et al., 2011). Through my change in understanding about Michael’s presentation, I moved away from a CBT-based approach to one that focuses on the wider systems and allowed me to consider the wider factors that influenced the actions of Michael and the staff members on the ward (Boyle, 1990). I was sad to learn that despite the work that I did, there was a continued deterioration in the relationships between Michael and other staff members. Through this work, I became more acutely aware of how powerful organisational cultures and mental health legislation can be (Boyle, 1990). At times, I felt disempowered by the mental health system and found it challenging to be one of only a few voices considering the influence of issues such as trust, choice and power on a service user. I used my clinical supervision to reflect on this and to consider how I might continue to work in these challenging services.

In consideration of what would I might have done differently, I have considered possible reasons why there was no long-term change in the relationship between Michael and the staff members. I suspect that it is the lack of consistency in application of systemic thinking and the lack of availability of time and training for staff members that led to continued deterioration in the relationships. It is very difficult to facilitate significant changes in the face of powerful factors such as organisational culture (Boyle, 1990). In addition, I often struggle with the idea of not knowing as an appropriate position and struggle with my own need for certainty as a trainee clinical psychologist and someone who is currently learning how to work as a therapist. This challenge can be even greater within the context of adult mental health services because clinical psychologists are often the only professional voicing and alternative narrative in a powerful system. Sometimes challenging common discourses can be difficult when you are perceived as the voice of opposition and dissent.

There are some limitations in the approaches that I used here. For example, I decided that issues of trust, choice and power were most important for Michael, which is a potential problem as this may not have been the priority for him and he may have chosen to use different words (Haley, 1963). Primarily, the ideas are based largely on broad theoretical concepts rather than scientific research, which make it difficult to apply them meaningfully and consistently to a specific case. In relation to the ideas of medicalising language, there is evidence that some people find this helpful and gain reassurance in being given a label for their ‘mental illness’. Often in opposition of the dogmatic application of diagnosis I can become dogmatic in my assertion that it is often useless and unhelpful. In addition, although I acknowledged that certainty is protective, it can also be helpful. Certainty in an approach is related to confidence which could undoubtedly be reassuring for some people, particularly if they are distressed an trying to make sense of what has happened or is happening to them. Systemic therapists can sometimes be guilty of criticising other professionals that take an expert position, even though family therapists most commonly took the expert position during before the end of the 1970’s. It may be that this criticism is both hypocritical and unfounded; perhaps psychologists should be willing to take a more expert position, as psychiatrists often do, so that we are more commonly able to occupy positions of leadership and influence in mental health services. It may be that is what is required to facilitate large-scale changes in organisational cultures that could allow a difference experience for people like Michael.


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