What's it like to train as an Analyst? A Clinical Psychiatric Perspective

Clinical Placement in Psychiatry

My blog, 'What's it like to train as an Analyst?', is back! A glimpse into the trials and tribulations of training as an analyst, or not so quite dramatic but it has been an interesting journey so far. For the next few weeks, I will give you an insight into my five-week placement at a psychiatric hospital in Uganda. The experience of working in a psychiatric clinic or hospital is an integral part of training as a #JungianAnalyst at ISAPZurich. A placement or a series of placements in a psychiatric establishment lasting three months must be completed before the final exams, however, a one-month placement, must be completed before the end of the initial exams.

The initial exams are referred to as Propaedeuticum Exams which are taken by Training Candidates, i.e. students who are studying analytical psychology theory and have completed at least three semesters. This point in my training is a significant milestone. Providing I pass the exams and placement, I will be promoted from Training Candidate to Diploma Candidate status, i.e. an analyst-in-training who can provide psychoanalytic services under the supervision of a Supervising/Training Analyst and is on the path to certification as a Jungian Analyst, on 24 May by an ISAP Promotions Board.

I am looking forward to seeing clients or patients under supervision. I feel ready. I am not learning anything new in lectures and seminars which indicates to me that I am ready to apply my theoretical learning to actual work as an analyst. It is an exciting stage in my life. I wonder what kind of analyst I will make, hopefully, an effective one. Opening a practice in Zurich is a little daunting. I am a black man in a country that is not particularly welcome to non-white people so it will be interesting to see how my practice develops over time. The training at the Diploma Candidate stage is much less about theory, and more about gaining practical experience, developing client casework, and supervision.

I have completed 5 propaedeuticum exams during the Autumn 2022 semester and will complete the remaining 3 exams when I return to Zurich for the Spring 2023 semester. My placement is at Butabika Psychiatric Hospital in Uganda. I started on Monday 26 February and finish on Friday 31 March.

Butabika Hospital, Kampala, Uganda

I decided to do part of my placement in Uganda where my family is originally from. I chose Butabika because I visited the hospital a few years back to see a family member who was admitted as a patient. They swore me to secrecy and not to tell anyone of their admission to the psychiatric hospital. Mental health issues remain a stigma in Ugandan society and culture. Despite their acute suffering, they did not want anyone to know that they were being treated for depression. I visited my relative nearly every other day during my two-week stay in Uganda. The hospital was clean, and fairly well run. The care given to the patients was professional and delivered as well as they can, given the financial and resource constraints. When I found out that I was required to gain experience working in a psychiatric clinic as part of my training, I knew immediately that I wanted to do it at Butabika.

The objectives of the placement are to obtain an understanding of the mental health services offered at Butabika, to gain practical experience in 1:1 and group psychotherapy, and to identify the common mental health issues encountered by the hospital staff. The work is full-time, from 9 am to 5 pm, and varies in terms of my role and responsibilities depending on what happens during the course of the day, and anything can happen! I have to prepared at all times.

Butabika Psychiatric Hospital

Butabika is a Ugandan national referral hospital for mental health that opened in 1955. The hospital's bed capacity is 550 patients, however, it handles between 800 to 1,000 patients at any one time and operates a busy outpatient department with daily contact with 350 clients per day in both the general and mental healthcare areas. Butabika Hospital is the only National Referral Mental Health Institution in Uganda. The hospital provides general and specialized mental health treatment and is a teaching hospital for a broad range of mental health specialists, from nursing to postgraduate students.

Butabika Hospital also provides specialist advice to the Ugandan Health Service Commission and policy-making bodies. The hospital is an important platform for research into mental health trends in Uganda and approaches to address mental health issues. The hospital also serves as the psychiatric teaching hospital for Makerere University College of Health Sciences for both undergraduate and postgraduate training, especially for the degrees of Bachelor of Medicine and Bachelor of Surgery (MBChB), Master of Medicine in Psychiatry (MMed Psych) and Doctor of Philosophy (Ph.D.) in Psychiatry.

Butabika Hospital is also the location of the School of Psychiatric Clinical Officers (SPCO), a school administered by the Uganda Ministry of Health, which trains high school graduates to become Psychiatric Clinical Officers. It is the only school of its kind in eastern Africa. The SPCOs provide well-needed support to the team of psychiatrists and clinical psychologists. There are simply not enough mental health specialists to provide the service to the patients. In my 'meet and greet' with the head of nursing, she informed me that the hospital has 1,079 admissions on that particular day, over twice the maximum capacity the hospital is equipped to handle. This brings immense operational challenges for the staff keen to provide the necessary services: patients often experience long waiting times as they attempt to access the service and once accessed, there are often further delays to accessing acute care and 1:1 psychotherapy.

The view from the Staff Library, Butabika Hospital, Kampala, Uganda (spot Africa's largest lake, Lake Victoria, in the background!)

I felt anxious yet excited about the placement at Buta Bika. I arrived in Uganda the day before my start date and had hardly any time to prepare for the week ahead. I was thrown into the deep end from day one. I observed and participated in two 1:1 therapy sessions with my supervisor and observed a group therapy session. The individuals are inpatients facing serious addictions to substances, drugs, and alcohol combined with traumatic personal experiences. Butabika is well known for its drug and alcohol treatment centre. The inpatient ward is overwhelmed with the number of people who require rehabilitation and therapy. They are mostly young people indicating a significant health problem in the country.

Hysteria

Later in the week, I observed potential patients being assessed by psychiatrists in the outpatient area. It was interesting to me that an individual, 'Patient A', reported experiencing symptoms of Conversion Disorder or Functional Neurological Symptom Disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM): the DSM is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common language and standard criteria. Conversion Disorder was a term introduced in DSM to replace the older term Hysteria. The symptoms associated with hysteria have long been the subject of psychiatric study, particularly by the founder of psychoanalysis, Sigmund Freud. Freud and his colleague, Josef Breuer, a physician, studied patients with hysteria and published their findings in an 1895 paper entitled Studies on Hysteria. They proposed that hysteria was caused by emotionally charged ideas, usually sexual, which had become lodged in the patient's unconscious mind as a result of some past experience, and which were excluded from conscious awareness by repression (Shorter Oxford Textbook of Psychiatry, Harrison et al, 2018).

The assessment of Patient A unraveled a history of fainting at home and at school and other personal difficulties. Essentially, conversion disorder is a repression of emotions that convert into physical symptoms such as fainting, seizures, abnormal body movements, slurred speech, sensory loss, or disturbances such as visual, olfactory, or hearing disturbances. Hysteria was a common mental health issue, particularly among women in the late 19th and early 20th centuries. Freud adopted the word 'conversion' to refer to the process whereby a hidden, unexpressed emotion is transformed into physical symptoms, which he further summarised in the phrase, 'hysterics suffer mainly from reminiscences'. The theory also led to Carl Jung's idea of the #Complex, an autonomous, highly emotionally charged ideas, impulses, thoughts, feelings, attitudes, memories, associations, fantasies, expectations, tendences that are typically unconscious and which contributes to a person's behaviour. The complex exerts a strong, usually unconscious influence on the individual's attitude and behaviour. The notion of the complex was so important to Jung's theory of the psyche that he initially called his psychological theory, Complex Psychology, however, this did not stick and eventually came to be called Analytical Psychology.

The clinical features of conversion disorder are divided into four subtypes: with motor symptoms, with sensory symptoms, with seizures or convulsions, and mixed). The predominant symptom in Patient A is convulsions. The psychoanalytic understanding focuses on the idea that the 'hysteric' avoids the unwanted responsibilities from the symptoms and obtains relief from the conversion of the mental distress generated by a #Neurosis or inner conflict into physical symptoms such as fainting thereby allowing the conflict to remain unconscious. I was surprised to hear from my colleagues that conversion disorder is very common in girls' schools in Uganda. I observed another patient, Patient B, come into the hospital and reported the same symptoms as Patient A, both patients are young girls at school and report significant unresolved anxiety and stress from their home and school life. Hysteria is considered a declining problem in developed countries, however, some studies suggest an incidence of 5 - 50 per 100,000 people per annum. The hospital's psychiatrists and clinical psychologists suggest there is ample evidence that the mental condition remains a problem in a developing nation like Uganda.

In summary, conversion disorder is a conversion of emotional distress into physical symptoms. The person affected by the disorder finds it difficult to process adverse events. In some cultures, the condition is sometimes seen as a 'possession' state, so it is often unaddressed and sufferers of the condition do not present themselves to mental health practitioners.

Epidemic Hysteria

Both patients reported that other school girls are fainting. It is contagious, it acts like an outbreak, and it is greatly misunderstood by school authorities. Conversion disorder often spreads within a group of people as an 'epidemic'. This spread happens most often in closed groups of young women, for example, in a girls' school, nurses' home, or convent. Conversion disorder is two to three times more common in females. The epidemic starts in one person who is highly suggestible, histrionic, and a focus of attention in the group. Gradually, other cases appear, first in the most suggestible, before spreading. The symptoms are variable, but fainting and dizziness are common. Part of our action plan is to address the patient's symptoms, to inform and educate the school authorities about the condition and encourage the schools to change any related problematic issues facing school girls. If there are family related issues, the same approach is taken. The patient must be encouraged to face the source of their emotional distress. This is a massive cultural issue that will take time to resolve. Social factors appear to be major determinants of the onset and development of conversion symptoms.

Treatment

For conversion disorders seen in psychiatric care or services, sympathy, positivity, reassurance and suggestion of improvement are often sufficient, together with immediate efforts to resolve any stressful circumstances that provoked the reaction (Shorter Oxford Textbook of Psychiatry, Harrison, et al, 2018). The hospital will provide the patients with a brief course of psychotherapy, to help the patient express their feelings and to channel them into a constructive resolution. Attention is also paid to the external circumstances that provoked the problem and to finding ways to reduce the symptoms. Symptoms which have lasted less than a year indicate the patient is likely to recover quickly. The likelihood of recovery reduces if symptoms have lasted more than a year and are likely to persist for many years.

As a psychoanalyst in training, I couldn't have asked for a better week. I was fortunate enough to experience a mental condition that greatly influenced the development of psychoanalysis. An interesting coincidence that has enriched my understanding of the psychiatric assessment process and Conversion Disorder.

I'll be back in a few days with another update on my progress on the clinical placement.