Loss and change in primary care: Working with organisational anxiety

This paper will consider the identity of an inner voice that is experienced by everyone, but in very different ways. However, when working in the transference with psychotic patients the boundaries of personal identity and the question of choice and volition are so compromised by the illness that the phenomena are so to speak ‘writ large’. This allows the issues to be brought out with great vividness and intensity and it is the struggle with this that has led me to reconsider the identity of the inner voice in a way which I have found useful for the rest of my clinical work.

Prior to 1985, my clinical work with patients with psychotic illnesses was undertaken in the in-patient psychotherapy ward at Shenley Hospital that I was responsible for. With the movement of psychotherapy resources out of Shenley to set up the Willesden Centre, our ability to continue with this work was very compromised because the Centre is entirely an out-patient resource. However, a number of us persevered and gradually worked out ways to be able to continue to offer treatment to patients who had psychotic illnesses. This involved the establishment of a case-manager system to enable the therapist to work in the transference. This evolution has occurred in a specialist workshop that I have been running at the Willesden Centre since 1986.