The creativity of metaphor in the unconscious

The second day of the College of Psychiatrists’ Winter Conference opened with an absorbing presentation by Dr Jonathan Sklar, Training Analyst with the British Psychoanalytical Society and former Consultant Psychotherapist. He spoke on the ‘creativity of metaphor in the unconscious’.

Dr Sklar discussed ideas around the uses and functions of metaphor in language which transfers understanding and knowledge in the unconscious.

In his presentation he examined these metaphors while exploring how patients deal with profound trauma. He encouraged clinicians to listen deeply to patients, who may be communicating through metaphor.

“For many patients the psyche-soma is holding the anxiety as the mind cannot bear it,” he suggested.

Another compelling presentation was that of Prof Gwen Adshead, Consultant Forensic Psychiatrist and Forensic Psychotherapist with the Southern Health NHS Foundation Trust, UK. She spoke to delegates about her work with male violent perpetrators with mental illness at Broadmoor Hospital, UK.

Those admitted to the hospital had typically been exposed to four or more types of childhood trauma, such as severe physical abuse, neglect, witnessing violence, and being in care, Prof Ads- head said.

Patients often had a history of mental illness, but not always, and sometimes committed acts of bizarre, catastrophic violence, she said.

The men participated in group therapy, individual therapy, occupational therapy, and received medication.

She revealed how she created a ‘Thursday Group’ for men who had killed someone close to them and discussed how group therapy could benefit such individuals.

Prof Adshead said her work had shown her that people who kill are not all the same. They can mourn and be appalled at themselves and struggle with shame and guilt.

“They need people to listen and witness; to offer radical empathy,” she said. “Accepting responsibility for violence is essential to risk reduction in the future and for better mental health.”

After her presentation, Prof Adshead was joined onstage by Dr Paul O’Connell, Consultant Forensic Psychiatrist at the Central Mental Hospital, Dublin; and Mr Mark O’Connell, author of A Thread of Violence and columnist for The Irish Times.

The session took the form of a conversation about their personal experiences on the controversial topic of ‘talking to murderers’.

Prof Adshead spoke about her recent book The Devil You Know: Stories of Human Cruelty and Compassion while Mr O’Connell detailed his encounters with Malcolm MacArthur, who was convicted of murdering two people in 1982, and how he came to interview and write a book about the criminal.

The three spoke about the topic of remorse and the need to develop an alliance with patients in order to have meaningful conversations about their actions.

Following this segment, a discussion was held on the Mental Health Bill 2024

and the significant issues of concern for psychiatrists (see news feature, p10).

College President Dr Lorcan Martin provided an overview of its activities in relation to the Bill. He said a working group had been established and key areas of concern identified. A meeting with Department of Health officials was scheduled to take place on 18 November, outlined Dr Martin.

Dr Joanne Fegan, Consultant in Old Age Psychiatry, provided an in-depth overview of the College’s concerns and a broader discussion was held involving members.

The main areas of concern included the potential for delayed treatment of people admitted involuntarily; the timing of psychosocial assessments; Ministerial regulations concerning care plans; the powers of the review board and the impact on consultant time and patient care; the broad definition of a mental disorder; and the inspection of all community mental health services, including the Child and Adolescent Mental Health Service (CAMHS), in the context of the ongoing and acknowledged under-resourcing of such services.

Potential solutions to these concerns were outlined, while more positive aspects of the proposed legislation were also noted.

For many patients the psyche-soma is holding the anxiety as the mind cannot bear it

Music and medicine

The afternoon session began with a presentation on music and medicine from Dr Carina Freitas, Consultant Child and Adolescent Psychiatrist, CAMHS.

She discussed the role of history and music in healthcare and highlighted evidence-based music interventions.

The first record of music therapy was found in the Lahun Papyri, a collection of ancient Egyptian texts from 5,000 BC. Music was used widely in Egyptian temples to help calm the spirit and elevate the mind, Dr Freitas explained. However, it wasn’t until the 1980s that arts in health emerged as an academic discipline. In 2019 the World Health Organisation (WHO) released a report on the evidence supporting the role of art in improving health and wellbeing.

Music can be used in illness prevention, health promotion, and in management and treatment, Dr Freitas remarked.

Furthermore, she noted how listening to familiar music can induce a healing environment and reduce pain and anxie- ty in children during medical procedures.

University of Limerick Professor of Music Therapy, Prof Hilary Moss, presented on how music therapy in healthcare set- tings can make an important contribution to health and wellbeing within mental health services.

Prof Moss said that the evidence base for music therapy for mental illness needed to increase, but noted that more evidence is emerging all the time.

The conference closed with a presentation by Mr Christopher Bailey, Arts and Health Lead with the WHO.

He told delegates about his work in the area of transgenerational trauma and the arts. He discussed his work in trauma recovery internationally, including in Ukraine.

In two years, the WHO will be publishing a report on creative expression as a health behaviour, he informed delegates.