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

A blog-series about what it's like to train as a psychoanalyst. My latest blog summarises my experiences, thoughts and feelings about working at a psychiatric hospital in Uganda. It was an exceptional experience and I am grateful to my supervisor, colleagues and staff for their support, advice, guidance, professionalism and friendship! A special thanks to Cathrin, a Systemic Psychotherapist in training who joined Butabika the day after I arrived, it was great to meet someone passionate about the care of others, and curious about psychotherapy and psychiatric care in Africa. Check out her instagram page and (Ex)Changing Perspective chats @cathrin.hmm

Return to Zurich

I completed my clinical placement at Butabika Psychiatric Hospital at the end of March after five weeks. I’m back in Zurich, preparing for my final Propaedeuticum exams in Psychology and Religion, Myths and Fairy Tales and Psychology and Dreams. Completion of the eight Propaedeuticum exams, an hour’s analysis with each of my Admissions Committee and a one-month clinical placement will enable me to meet the conditions to promoted to Jungian Analyst-in-training.

The promotion will allow me to see patients and clients for psychoanalysis and charge a fee for my services. The remainder of my training will mostly be based on patient or client casework. This is a significant milestone in my training and life. I feel ready to see patients, a realization firmed up in my mind since I returned to Zurich. Opening my very own psychoanalytic practice seems so unreal after years of reading psychoanalysis as a hobby and eventually entering professional training.

It is good to be back in Zurich. I arrived home to find a 'loveletter' from Credit Suisse telling me 'everything will be alright', I'm not so sure and already thinking of contingency plans to move my hard earned cash elsewhere or at least to a more secure Swiss bank.

Psychiatric Clinical Placement

Before I graduate from training, I must complete another two months of working in a clinical psychiatric setting. I've decided to finish my placement at Butabika. The placement exceeded my expectations. Sure, the hospital has tough challenges, far too many patients, too few clinical staff, and limited financial resources, however, the hospital's staff do their best in the circumstances. With just over 1,000 patients at any one time, there are a lot of psychopathology cases in a multitude of forms, valuable experience for any psychiatrist, clinical psychologist, or psychoanalyst.

View of Credit Suisse HQ taken on my first tram ride since returning to Zurich

At the same time, I also enjoyed being back in Uganda after such a long time, seeing friends and family, and experiencing the new restaurants, bars, and shops that have emerged since the last time I was here.

View from my cousin's home in Muyenga, Kampala

Uganda still has its socioeconomic problems and it was disappointing to see the Ugandan parliament enact legislation that will effectively criminalize the lives of LGBTQ people. I would hope the Ugandan government would have better things to do with its time rather than police the sex lives of its citizens. Speaking to a couple of individuals at Butabika who support the ban, it was interesting to hear their perspective, however, I also tried to explain the ludicrousness of the ban, highlighting the plight of black people in Western nations who are criminalized just for being black. There was some recognition and understanding of what I was saying, however, cultural indifference and opposition to sexual orientation other than heterosexual orientation remains worryingly popular even among people who are in helping professions. I have my psychoanalytic views of Uganda’s discriminatory beliefs but I think I’ll leave that for another blog.

Uganda is a deeply religious country, with a large percentage of the population practicing Christianity and Islam. 70% of the population identify as Christian and 30% as Muslim. Religion pops up in the workplace in unexpected ways. Some meetings at the hospital started with a Christian prayer. Patients are asked to state their religious affinities during the psychiatric placement, a seemingly unnecessary collection of data, but given the country’s religious fervour, the clinical assessment of patients and their religious affinities is an important part of gaining an understanding of the patient’s life history and psychosocial background.

City scenes from Kampala

A great deal of my placement involved the observation of the assessment, diagnosis, and treatment of patients. The hospital provides psychiatric care for children, adolescents, and adults so I was able to observe the psychiatric care process through the psychopathologies presented by clients as young as a few years to elderly adults. It has been fascinating but also very difficult to experience. Life in Uganda, a developing nation, is challenging for so many people. Financial poverty, lack of jobs, and poor education creates immense psychological suffering for people of all ages. The majority of people earn a living running microbusinesses. The country's wealth is disproportionately enjoyed by a minority of people but there is a growing middle class. The stark differences between poor and rich neighbourhoods is captured in the videos below which I took from the back seat of a car as I was driven from work to Kisementi, a well known shopping and entertainment district.

A drive past Kampala's microbusinesses

A drive through an affluent neighbourhood in Kampala

My main objectives of the placement were to obtain a good understanding of the mental health services provided at Butabika National Referral Mental Hospital, to observe and/or participate in one-to-one and group psychotherapy, and to gain an awareness and understanding of psychiatry and the treatment of psychiatric disorders, psychopathology, and other mental health issues. The internship was full-time, Monday to Friday, typically starting at 9 am and finishing at 5 pm. A total of 200 working hours were completed during the internship. I agreed on a specific set of objectives with my supervisor and set out below.

• Understand the admissions and referral process for adults, adolescents, and children.

• Observation of outpatient and inpatient care from registration, examination, and treatment.

• Understand the approach to assessment, diagnosis, and treatment of psychiatric and other mental health disorders ranging from alcohol and drug misuse to trauma, and schizophrenia.

• Observation and participation in meetings between patients and psychiatrists/psychologist.

• Participation in relevant support interventions for patients.

• Understand the hospital’s multidisciplinary approach to healthcare and the cooperation and collaboration between the hospital’s psychiatrists and external psychotherapists.

Given the large number of patients at Butabika, there was plenty of opportunity to gain experience and get involved in the treatment and care of patients.

Patient Assessment and Diagnosis

Butabika Hospital provides a free service to both inpatients and outpatients of all ages; children, adolescents, and adults. A patient’s initial contact with the hospital usually takes place in the outpatient ward. A psychiatrist screens the patient through a triage system which determines whether the patient is admitted to the hospital and treated as an inpatient, prescribing medication and treated as an outpatient, or no further action is required.

During the triage, the psychiatrist or psychiatric clinical officer obtains comprehensive information from the patient and any informants who accompany the patient, e.g. family members and/or friends. The psychiatrist uses a structured to a semi-structured approach which aims to identify the patient’s signs and symptoms to make a diagnosis and prognosis.

This approach is known as the psychiatric assessment or interview and it has three main goals: to make a diagnosis, to understand the context of the diagnosis, and to establish a therapeutic relationship with the patient. The psychiatric interview can be broken down into the following stages: preparation using a template provided by the hospital, collecting the information face-to-face with the patient, evaluating the information, using the information to make treatment decisions including prescribing medication e.g. antipsychotic drugs, recording and communicate the information collected and the conclusions drawn.

The hospital uses a classification system to enable clinicians to communicate with one another about the diagnoses given to patients, to aid patients and their families by allowing clinicians to provide a framework for them to understand their symptoms and difficulties and for proposed treatments, to understand the implications of these diagnoses in terms of their symptoms, prognosis, and treatment, and sometimes their aetiology. The hospital uses the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) published by the American Psychiatric Association https://www.psychiatry.org/psychiatrists/practice/dsm. DSM-5 is a criteria-based diagnostic system. Criteria are rules that describe or define a clinical disorder. They specify the type, intensity, duration, and effect of the various behaviours and symptoms required for the diagnosis. The DSM classifies mental disorders using a common language and standard criteria. I learned a great deal about the practice of psychiatry both from observing assessments and reading the corresponding description of mental diseases and symptoms in the DSM and other psychiatry textbooks.

The psychiatric assessment also establishes whether the symptoms and signs are organic or functional, neurotic or psychotic, and whether there is any comorbidity or dual diagnosis i.e. a patient is showing symptoms of more than one disorder; the disorders are distinct but causally related or disorders that are causally unrelated.

Information collected by a Psychiatrist or Psychiatric Clinical Officer (PCO) is grouped under the following headings: informants, history of the present condition, the reason for the referral, family history, personal history, past psychiatric and medical history, personality, mental state examination (appearance and mood, speech, mood, thoughts, perceptions, cognitive function, insight). An inpatient’s personal, psychiatric, and medical history may be further assessed by a Psychiatric Clinical Officer (PCO) during the early stages of their admittance to the hospital. The PCO presents the assessment to the psychiatrist during a ward round in the children, male and female wards. The psychiatrist asks the patient and their informants any further questions to refine or adjust the initial diagnosis, prognosis, and treatment plan. If the patient has also been referred to the clinical psychology team for psychotherapy, a clinical psychologist will also undertake an independent review of the initial psychiatric assessment.

The hospital treats children, adolescents, and adults with a wide range of mental health problems such as mania, depression, schizophrenia and other psychotic disorders, epilepsy, anxiety disorder, substance abuse, personality disorders, bipolar, trauma and stressor-related disorders, neurodevelopmental disorders, and psychosocial issues. The identification of a diagnosis comes from a collaborative effort with the patient. The psychiatrists and psychiatric clinical officers gather as much information as possible, are mindful of the patient’s need to be heard and understood, avoid jumping to conclusions, and maintain a balance of checklist questions and spontaneous free-form, open and closed questions. The hospital encourages clinicians to let patients reveal themselves freely and to listen. After listening carefully to the patient’s presenting problems, the psychiatrist selects which branch of the diagnostic tree to climb first i.e. they place the symptoms among the most pertinent of broad categories in the DSM-5 and then start narrowing down to the particular diagnostic prototype that best fits the patient.

I learned that in isolation, a single symptom, or even a few, do not by themselves constitute psychiatric illness. Two additional conditions must also be met before symptoms can be considered a mental disorder. First, they have to cluster in a characteristic way. Isolated symptoms of depression, anxiety, insomnia, memory difficulties, attention problems, and so forth are never by themselves sufficient to justify the diagnosis. Second, the symptoms must cause clinically significant distress or clinically significant impairment in social or occupational functioning. This caveat is an important aspect of the differential diagnosis for psychiatric disorders. It must always be kept in mind that it is never enough to identify symptoms. They must also create serious and persistent problems.

I also learned that with some patients, it may be so clear that the diagnosis is identified within a few minutes, but with others, it may take hours, weeks, months, or even years. The diagnosis is a hypothesis that requires comprehensive information to support it. I also learned that it is important not to rush into a diagnosis, but to ensure comprehensive information is collected, reviews are undertaken overtime before giving a final diagnosis and also to remain open to changing the diagnosis as new information is received. It is clear that if you rush into a diagnosis, serious mistakes can be made. It is also recommended to use the unspecified categories in the DSM-5 if a hypothesis is unclear and to always document your thinking in the patient’s file.

I also learned that psychiatric diagnosis depends completely on subjective judgments. Therefore, the more information the better. Especially since people aren't always the most accurate reporters about themselves. Whenever possible, the clinicians speak with family members and other informants and also where possible get records, both medical records and records of any previous psychiatric or other mental health treatments.

The hospital’s approach known as the ‘structure for the general psychiatric interview’ includes the capture of the following information:

• Personal details

• Source of referral and information source (names of informants, the relation of the informants to the patient)

• Chief complaints and their duration

• Presenting complaints and history of presenting complaints (diagnostic phenomenology)

• Past psychiatric history and past episodes of illness

• Past medical history

• Family history

• Personal/developmental and social history

• Mental status examination

  • Mood/Affect

  • Thoughts

  • Perception

  • Cognition

  • Physical examination

• Diagnosis giving reasons for it using the standard nomenclature for DSM-5 https://www.psychiatry.org/psychiatrists/practice/dsm:

  • Axis I, clinical mental disorders, and other conditions that may be a focus for clinical attention. At least two differential psychiatric diagnoses giving reasons for and against.

  • Axis II, personality disorders, intellectual disability.

  • Axis III, general medical conditions.

  • Axis IV, psychosocial/environmental problems.

  • Axis V, global assessment of functioning (GAF) score.

• Investigations, biological, psychological and social

• Management of treatment, outpatient or inpatient treatment, voluntary or involuntary admission, and why

• Bio-psychosocial approach for holistic care

• Treatment of medical illness, medication, and psychopharmacological interventions

• Psychological-psychotherapeutic intervention

• Social-environmental intervention

• Immediate, short term or long-term treatment

• Prognosis

Therapeutic Interventions

The clinical psychology team provides psychotherapy in one-to-ones and groups. There are just too many patients and too few clinical staff to provide one-to-one therapy. As well as therapy, the Clinical Psychologists use clinical assessments in the form of questionnaires to understand their patient’s needs and to design appropriate clinical interventions.

One-to-one psychotherapy

The major therapeutic concepts are cognitive behavioural, supportive psychotherapy, interpersonal psychotherapy, and counselling.

Group psychotherapy

Small, and large group therapy including family therapy.

MAT service provision

The hospital runs a medically assisted therapy for outpatients addicted to drugs and/or infected with HIV. The service is free and aims to help patients to abstain from or reduce drug use. The MAT clinic provides methadone to patients daily to alleviate withdrawal symptoms. The clinic also provides mental health assessment and treatment, and psychosocial interventions including counselling, family reintegration, and occupational therapy. A clinical psychologist provides psychotherapy using a range of techniques including cognitive restructuring, behavioural activation for depression, and emotional regulation exercises.

I observed the daily MAT services and group counselling sessions. When a new patient registers at the MAT clinic, a psychological assessment is carried out by a clinical psychologist which considers the following information including a Freudian psychoanalytic assessment:

• Name

• Age

• Date of birth

• Clinical interview (the chronological order of what happened during the interview, who was present, and the behaviour)

• Psychosocial history (childhood to adulthood)

• Development and medical history (any diseases while growing up. Medical conditions that affected them while growing up)

• Psychosexual history (Using Freud’s stages of psychosexual development. Oral, anal, phallic, latent, and genital stages)

• Behavioural examination (mood and mannerisms during the interview)

• Mental state examination (general appearance, mood affect, speech content, attention, thought process and thought content, cognition and intellect, judgement and insight)

• Psychological tests

• Summary of findings or recommendations (diagnosis and what can be done)

How do the patients respond to the setting given?

The patients generally cooperate with the clinicians. Some patients seek treatment voluntarily, however, some patients report that their family insisted that they come to the hospital and are co-operating under duress. Some patients leave before the end of their treatment. The patients are treated for some time before being formally discharged by the psychiatrist. The clinical psychologists can also recommend a discharge but ultimately, it is the psychiatrist’s decision whether to discharge a patient or not. The hospital wards are separated by gender and there is a separate ward for children. As patients show signs of recovery, they are transferred to recuperation or recovery wards prior to discharge.

Butabika Hospital Grounds

How do the therapists decide which therapy might be helpful for which patient? Are the patients involved in that process? Who is in charge of what (in the therapeutic process)?

Clinical psychologists are responsible for providing psychotherapy to patients. The clinicians use a range of tools to identify the patient’s signs and symptoms and their severity. For assessment, Clinical Psychologists use a wide range of tools, Beck’s Anxiety Inventory, Beck’s Depression Inventory (BD-II), Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), Millon Clinical Multiaxial Inventory-IV (MCMI-IV), Minnesota Multiphasic Personality Inventory (MMPI), PTSD Assessment Instrument, SRQ20 instrument (neurotic disorder, psychiatric disorders, substance abuse, and epilepsy), and HTQ-5 Harvard Trauma Questionnaire (for measuring torture, trauma and DSM-5 PTSD symptoms in refugee populations). The clinical psychologist reviews the patients file and determines the best modality for therapy i.e. one to one therapy which may include family members or group therapy. The hospital has only 5 clinical psychologists and a large number of patients so often the most effective way to provide therapy is through a short course of psychotherapy and/or group therapy.

The clinical psychologist digs deeper during the psychotherapy sessions, where necessary they meet the patient’s family at least three times and prepares the patient and their family for the transition to recovery. The clinical psychologist will also work with the patient to ensure they adhere to any recommendations, provide continued support and help post-recovery, and works with the family to ensure the patient is not stigmatized within the family and community. Mental health remains a ‘taboo’ in Ugandan culture. Patients are often stigmatized by Ugandan society as ‘mad’ for their mental health issues.

How do different professions cooperate and communicate?

The hospital operates a liaison approach or 'firms' with information communicated through the file. At each stage of the patient’s interaction with the hospital, the clinician involved is responsible for updating the patient’s file with notes. Each clinician is required to read the notes whenever they meet the patient to keep them informed of the patient’s progress.

Clinicians are put into ‘firms’ or clusters that oversee the management of patients. The clustering of the clinicians into groups enables a fair allocation of work across all the functional teams. Each firm is given a name based on colour, for example, the red team includes forensic psychiatrists, patients with criminal records, or prisoners, and orange includes patients with comorbid or dual symptoms. Each firm has a team of psychiatrists, psychiatric clinical officers, clinical psychologists, psychiatric nurses, and counsellors.

What struck you most during the internship? - What was the biggest challenge? - Where was your biggest aversion?

Overall, I enjoyed my placement at Butabika. The experience exceeded my expectations. The hospital is quite well-run, and clean and has highly motivated and committed staff. The hospital operates under limited financial funds, however, the staff do their best in the circumstances. I was pleasantly surprised to hear that the service is free. The hospital’s services are a lifeline for so many people suffering from mental health issues and problems. There is a lot of stigma attached to the patients at Butabika by Ugandan society and culture. However, the hospital is doing its best to destigmatize mental health and to provide a service that meets the needs of its patients. I was particularly interested to find out what kind of analyst I will be, and during this placement, I got a sense of how I would work with patients. I felt compassion and empathy for the patients I observed. It was important for me to do my internship in an African setting, to work with patients who look like me but also come from the same cultural background. I am confident that I have the necessary theoretical knowledge in psychoanalysis and feel ready to see patients. I also felt contained within myself, I wasn’t particularly averse to anything that I experienced. I remained open-minded, keen to learn and to support my colleagues in any way.

One-to-one psychotherapy and group therapy

I observed and participated in one-to-one psychotherapy and group therapy sessions. This allowed me to ask questions to the patient to clarify their situation, experiences, and symptoms. I observed several psychopathological symptoms including depression, trauma, psychosis, schizophrenia, and addiction.

Ward rounds

I regularly attended ward rounds led by psychiatrists. The purpose of a ward round is to review cases of recently admitted patients and to review existing ones. The outcomes of such reviews included a change of medication, transfer to another ward e.g. recovery, discharge, treatment plans, etc. I was able to observe the various mental health conditions, and treatment plans, and reviewed the files of patients.

Word Association Experiment

I was asked to carry out a word association experiment on a patient. The WAE is a psychoanalytic diagnostic questionnaire used to identify unconscious conflicts or complex. It is a useful way to identify the sources of a patient's mental state. The assessment gives a clinician information about the patient's unconscious conflicts which are subsequently treated psychotherapeutically.

Hysteria, Refugees and Returnees

I was particularly struck by the prevalence of ‘hysteria’ or conversion disorder/functional neurological disorder among young girls. The large number of young patients being treated for drug and alcohol abuse was also unexpected. I was even surprised to see among these patients, young Ugandans from the international diaspora like the UK who had come back to the country for treatment either voluntarily or on the insistence of their families. I was also struck by the patients who had been deported or repatriated from manual jobs in the middle east where they have experienced severe abuse which has left them with post-traumatic stress disorder. I created a register for refugees and returnees using Microsoft Excel which will enable the clinical psychology team to track and administer treatment plans to this cohort of patients.

Research

I was asked to research the psychoanalytic approach to treating personality disorders specifically, borderline personality disorders and anti-social personality disorders. This allowed me to learn more about personality disorders and the psychoanalytic approach to treating patients with such disorders.

Presentation on the clinical use of dreams in psychotherapy

There was a lot of interest in psychoanalysis from the clinicians. I was asked to do a presentation on psychoanalysis. It was clear that there was a lot of interest in dreams so I decided to do a presentation on the clinical use of dreams in psychotherapy. The presentation was attended by around 20 clinicians and lasted for around two and a half hours.

One-to-one psychoanalytic sessions

As well as observing one-to-one and group psychotherapy, I was allowed to have one-to-one psychoanalytic sessions with two patients admitted to the alcohol and drug addiction ward. These were sessions designed to explore the patient’s inner conflict in terms of their inner motivations and needs. The sessions lasted up to an hour and a half each.

Transference and countertransference

I was anxious before I started the internship but once I was at Butabika, I settled in quite quickly. The hospital gave me unlimited opportunities which helped to raise my awareness and understanding of psychiatric care. Generally, I felt ok throughout the internship, however, on one occasion, when I was observing a ward round at the male ward, I felt dizzy and lightheaded during the assessment process of patients experiencing schizophrenic or psychotic symptoms. Initially, I thought it may be a side effect of the anti-malarial tablets I was taking daily. However, on reflection, I thought it may be countertransference on my part. I felt more certain about this after I observed a couple of assessments in which I felt sleepy and tired. The sleepiness and tiredness did not feel like actual fatigue because I had a restful sleep the night before. I became more alert at other times during these assessments.

In my last blog, I talked about the prevalence of hysteria or conversion disorder among young girls in Uganda. Psychoanalytic therapeutic techniques can be used to resolve so-called conversion disorder symptoms, physical symptoms which are based on, or represent, unconscious symbolic meanings related to unconscious conflicts. But most of all, psychoanalysis treats personality disorders. Personality disorders are an area of interest to me. There are all kinds of them, borderline, anti-social, histrionic, and many more. The basic technique of the treatment is the analysis of the transference.

What is the transference? The #transference is the unconscious repetition in the here and now, of general conflicts of the patient’s past. The unconscious conflicts of the past tend to reproduce themselves in the psychoanalytic sessions with the analyst or the therapist. The unconscious conflict emerges if it is facilitated by a particular attitude of the psychoanalyst or therapist. The psychoanalyst asks the speak freely, something called free association everything that comes to their mind, without any control, without any suppression, as much as they can. Free association is a technique to facilitate the gradual emergence of deeper contents of the mind. The analyst listens to the patient’s free associations while at the same time observing the behaviour of the patient in the treatment session and observing their own emotional reaction to the emotional reaction that the patient gradually develops in the treatment situation, what is called the #countertransference.

Patients tend to repeat, under such circumstances, past conflicts, for example, a patient with depression who has a cold, unemotional mother or father, may very easily and soon experience the analyst as somebody who is cold and rejecting, or afraid that the analyst doesn't like him or her, so they feel rejected. In other words, the patient reproduces the past conflict all the time in their daily life because of the character distortions as a result of the past conflict. But the big difference is that here and now, in the therapy session, the emotional reaction will be explored with the patient and contrasted with the objectivity of the nature of the therapeutic relationship. So she or she will have the opportunity to gradually recognise the past origin of the behaviour that presently is inappropriate and learn how to understand it, and how to change it. The dawning of #consciousness permits an analysis of the personality and personality changes as a result of self-awareness. The conflict is no longer #unconscious and causing neurotic symptoms.

So why did I feel dizzy and empty when observing some of the psychotic and schizophrenic patients? Probably countertransference on my part, an emotional resonance with the patient’s illness and feelings. It helped me to understand transference in a practical rather than theoretical way and has paved the way for me to include it in my own psychoanalytic approach to treatment. In a way, it is a kind of compassion and empathy but at a deep unconscious level. Used in a psychotherapeutic way, transference is a great way to understand what it is like to be in a patient's shoes, to understand their history, experience their suffering and to develop a therapeutic alliance with the patient.

Concluding thoughts

Overall, I thought my internship was a success. I met the objectives that I set for myself, and I learned a lot about the practice of psychiatry and psychopathology in particular the psychiatric assessment process, symptoms, and treatment. It was interesting to observe and participate in mental health treatment in my country of origin.

My colleagues expressed a lot of interest in psychoanalysis. I was given the opportunity to present psychoanalytic techniques such as the clinical use of dreams in psychotherapy, complexes and the word association experiment, and the concept of transference and countertransference in the treatment of patients with personality disorders.

The hospital has expressed an interest in applying psychoanalytic techniques in the treatment of their patients with personality disorders. I would like to complete my remaining internship at the hospital (two months) with a specific remit to provide psychoanalysis to patients and support the hospital to implement psychoanalytic practices in their treatment plans for patients with personality disorders. I informed the hospital that I will draft some terms of reference for further discussion.

I hope to go back to Butabika in September or October this year for another 4 to 5 week stint. I also see myself spending more time in Uganda spending time with family, friends and seeing more of this beautiful country, known as, the pearl of Africa.

Entebbe International Airport, Entebbe, Uganda