Working with Isabel Menzies-Lyth

This paper was written as part of a celebration of the life and work of Isabel Menzies-Lyth arranged by Susan Maciver for APPCIOS (The Association for Psychodynamic Practice and Counselling in Organisational Settingson) 6th March 2021.  Julia Segal is very grateful to both APPCIOS and Susan Maciver.  It is the version sent to the publishers;  in the published version, IML is replaced by Isabel Menzies Lyth (an improvement made by the editors.)

Author: Julia C Segal MA FBACP

Psychodynamic Practice 

Individuals, Groups and Organisations

Volume 27, 2021 – Issue 4

DOI: 10.1080/14753634.2021.1980899.


This is a personal account of being supervised by Isabel Menzies-Lyth (IML) (1917-2008) when the author was beginning a career as a counsellor for people with multiple sclerosis, when counselling itself was finding its place in society in the early 1980s.  Isabel Menzies Lyth was a sociologist born in Scotland, the only woman amongst those who founded the Tavistock Institute of Human Relations.  An analyst, herself analysed by Wilfred Bion, she is best remembered for a paper she published in 1959:  ‘A case-study in the functioning of social systems as a defence against anxiety. A report on a study of the nursing service of a general hospital’ The paper describes the huge debt owed to her by her supervisee.

Isabel Menzies-Lyth: Some personal reflections

Isabel Menzies-Lyth (1917-2008) was a sociologist born in Scotland, the only woman amongst those who founded the Tavistock Institute of Human Relations.  An analyst, herself analysed by Wilfred Bion, she is best remembered for a paper she published in 1959,  ‘A case-study in the functioning of social systems as a defence against anxiety. A report on a study of the nursing service of a general hospital’  which probably appeared on the reading list of every psychoanalytically-influenced training for the following 40 years.  It was enormously influential, although unfortunately, many of the problems she highlighted can still be observed today.  She was somewhat irritated that her many later studies received less attention: an interesting and often entertaining collection of these can be found in two volumes of her works, Menzies-Lyth (1988) and (1989), along with an interview about her life and work.  There is a brief biography of her on the Melanie Klein Trust website as well as in Wikipedia.  

This paper is a very personal account of my own supervision by her.  I wrote it for a workshop organised by the Association for Psychodynamic Practice and Counselling in Organisational Settings  (APPCIOS) in March 2021.

I read Isabel Menzies Lyth’s paper on nurses when I was  a temporary nursing assistant in Fulbourne mental hospital in Cambridge in 1970.  I was 20, a student studying social and political sciences.  Hanna Segal gave it to me when I talked to her about the hospital and about Goffman’s Asylums.

It was mind-blowing.  I’d been brought up on stories idealising doctors and nurses: the idea that nurses could envy the attention given to patients, and the way hospital hierarchies pass responsibility up and ‘foolishness’ down, were both astonishing and revelatory; particularly as I was meeting real nurses in the hospital, where the distinction between patient and staff sometimes blurred.  There was a male nursing assistant who told me not to feed one of the patients who was always hungry because she had cancer and it would just ‘feed the cancer’.  The idea that one could make sense of such ideas was amazing.

At the time there was much discussion about whether psychoanalysis was simply for those who could afford it;  of whether and how the insights could be used for the benefit of the rest of society.   As an ex-maths student, I knew about ivory towers and how they might need tearing down; but I liked the idea of psychoanalysts in the consulting room with patients producing (‘pure’) creative ideas which could be ‘applied’ in the ‘real world’.  Then, as now, there was a sense that psychoanalysis itself was under threat, partly by the many attempts to help larger numbers of people at less cost, often without acknowledgement of any debt to psychoanalysis.  There were also accusations arising partly from internal disagreements: for example, that analysts were dismissive of external events and external reality, and that a preoccupation with psychic reality could lead to failure to notice or acknowledge physical causes of illness.   (In 1979, when I trained with Marriage Guidance in Manchester, I had to be very careful not to let too much overtly psychoanalytical thinking escape my lips.)   Isabel Menzies was a social scientist who was also a psychoanalyst, trying to combine the two worlds, against some opposition from both sides.    I used her work in my adult education teaching and in my books on the ideas of Melanie Klein, (Segal J.C. 1985, 1992) to combat the idea that psychoanalysis was simply something for the privileged.

In 1983 I began work with a self-help charity, Action and Research for Multiple Sclerosis (ARMS) run by and for people with MS (hereafter: pwms), where I was to be the counsellor on the team at a small research unit and at the same time had a role in the wider organisation, setting up counselling for pwms and members of their families all round the UK.  Isabel Menzies-Lyth very generously offered to supervise me, for free, as far as I remember;  she was retired by then but I think she was as interested in working with me in my setting as I was in working with her.  I drove for monthly supervisions from London to her house in Iffley, outside Oxford; sometimes she picked me up from the station. 

We sat by her fire, in her beautiful house, looking out over the garden, and she gave me tea and biscuits while we talked.

Heroic staff

Perhaps the most significant contribution she made to my own life was her warning that charities put staff under enormous pressure to work ‘heroically’; never to think of themselves and their own needs.  She told me how staff often found themselves denying the reality of any threat to their lives, particularly in reference to people working in danger areas overseas,  but also in terms of overtime, of the pressure to always ‘give’ more and ‘never count the cost’.

Her wise advice enabled me to insist that, as I had children who needed me, I would work the hours I was paid, but no more, and no amount of reproachful comparisons made me change my mind.   Thirty years later I suspect I was the only person in the NHS with this contract, and the one with the most work satisfaction and least stress.  (Fortunately I did not want promotion.)

This ‘heroism’ was part of a wider problem.  Isabel Menzies Lyth saw the temptation to deal with anxieties by splitting ‘them and us’: staff versus patients;   ‘workers’ versus ‘recipients’ of the charity’s aid, and  how this split could lead to all risks and all needs being attributed to ‘them’ while staff somehow imagined that they were invincible, with no needs, in no danger (I understand the fire brigade currently have been very reluctant to wear masks in response to Covid. Perhaps they see themselves as not only brave but also invincible?) .  Isabel Menzies Lyth saw this as a defence against recognising how much we all shared: and this became a focus for my work. 

Illness makes people feel they are not good enough, that they are ‘bad’, not only physically but also morally, psychologically and socially.  Staff too were anxious about whether they were good enough.  People work in the health service in order to make people better:  multiple sclerosis (MS) threatens staff because people with MS do not get better – over a very long period of time.  The them/us split defended against the anxiety that actually, we were just the same as the patients, just as vulnerable in a war zone.   In the case of the MS Unit, staff told me that they had all, in the first months of its existence, found themselves experiencing MS symptoms and worrying that they themselves had got MS, perhaps ‘caught’ it, though they knew this wasn’t how MS worked.  One of the difficulties staff had with MS was the fact that it was so easy to identify with those who had it because they were the same age as the staff; often young women, mostly from not very different backgrounds.  The desire to believe ‘it won’t happen to me’ can in many situations be bolstered by an unconscious tally of ways in which the patients differ from ‘me’: class, colour, age, social status, income.  With MS this didn’t work.

Within the Research Unit itself, Isabel Menzies-Lyth helped me to develop a strategy to reduce the chances of staff envying our patients the hour-long counselling sessions, the interest, the ‘being listened to’ which I was going to supply.  I started by offering one-to-one sessions with all the staff in the Research Unit at the same time as I took on clients already on a (small) waiting list.  Although they seemed to greet me with some relief, as someone who could ‘take over’ difficult patients, it was clear there was also ambivalence.  Some staff had become very attached to several of their needier patients, while ‘holding’ them, ostensibly until a counsellor was appointed, and they had mixed feelings about passing them over to me.  I was firm that I saw these colleagues as competent to continue the support work they were doing: I did not want too great an idealisation of my own capacities but was able to offer them something on the lines of the supervision counsellors are required to have, whereby we talked about what went on between the patient and the professional, and I learnt about the pleasures and pains of their work.  The one person who caused me difficulties in the team was an administrator who always refused to talk to me in this way.  She saw counselling as ‘just talking’, and nothing could persuade her I was worth as much as the other professionals when my salary went up alongside theirs.

In a different context I heard nurses complaining bitterly about how the counsellor on their ward would have no contact with the nurses; I do not know if they were motivated by envy, but I think they had a point.  Some conversation would have helped to reassure them that the counsellor knew what she was doing, that she was not encouraging patients to complain about them behind their backs, that she was interested in them and valued the work they were doing.  In turn, this would have helped the nurses to value the work of the counsellor.  Other professionals can have a highly significant role in emotional support of patients, and counsellors on a ward can enhance and support these capacities.  Isabel Menzies Lyth was emphatic on the need to work with the team, and I think she saved me from the backbiting that could have come my way.


Isabel Menzies Lyth was always interested in families and family organisation as well as professionals.  Family members too split responsibilities under pressure of anxiety.   One of the things patients complained about was the way their families tried to ‘protect’ them, to keep bad thoughts or feelings away from them,  and how this ‘keeping in cotton wool’ excluded them from decision making and ordinary family transactions. 

I ended up with approximately one third of my sessions being for family members of pwms.  With Isabel Menzies Lyth’s help, I saw the MS as a family project; I focused on how much was shared when one person had MS; how all family members were affected, and how splitting and denial happened around many issues:  Can I do this or can’t I? (I say yes, s/he says no);  Am I just ‘making it up’ or is it real?  Am I a good daughter or a bad one?  Do I want to die or don’t I ?  Do I want them to die or don’t I ?   Many very disturbing feelings arise in the face of a long-term, deteriorating chronic illness like MS.  It is not like a broken leg; there is some evidence that animals shun their fellows who demonstrate neurological damage, whereas they will go towards and help an animal which is injured.  Humans do find MS symptoms disturbing.

I encouraged couples to see how much they shared,  and could share, even though what they needed to share was not always the best part of themselves.  They shared anxieties about their own goodness or badness, their future, who was to blame;  their hatred of the MS, resentment of what it had done to their own lives.  One man was ashamed of his secret enjoyment of having his (disabled) partner in his power.  They also shared feelings of hope and vigour and capacities for living.  Keeping their feelings from each other often meant keeping loving feelings at bay as much as more angry, resentful feelings.  Sometimes it was  hard to disentangle the mix.  Sometimes there was just too much shame involved; often it was felt as protectiveness. 

A gung-ho patient might be held back by a partner who was desperately aware of the risks involved; but unable to explain this outright, they might find excuses; sometimes either or both might  be very afraid of having a proper fight about the real issues,  (‘because s/he’s ill’ or ‘they have so much on their plate already’)  so they remained hinted at, avoided, hidden – and each alone with their fears.   

‘Keeping in cotton wool’ is a reflection of the belief that pwms are less emotionally capable; but it works to actually diminish their capacities to contribute as well as putting extra strain on a partner who has taken over more responsibility than they need.

Hanna Segal had told to me that the difference between Kleinians and other analysts was that Kleinians were more concerned ‘not to leave people alone with their fears in the middle of the night’:  she had also said ‘if it comes to your mind when you are with a patient, it will have come into theirs already’;  which was both hugely reassuring and also scary.  I needed Isabel Menzies Lyth to help me put this into practice until experience demonstrated just how true it was.

Counselling as a profession

At the time counselling was not a recognised profession and was struggling to establish itself.  It was also a time when patients were beginning to find their voice and to challenge the medical profession.

There were many volunteers in the Charity who offered support, face to face, informally, over the telephone, through small ARMS branches which provided physiotherapy and dietary advice and sometimes a hyperbaric oxygen tank.  I was to help to bring professionalism, but I was to work with volunteers who could not be alienated.  These volunteers had widely varying beliefs about counselling : I had to persuade them that their branch should employ someone with proper training and supervision, to do something they often thought they could do best because they had the experience; because they were people with MS themselves or members of their families. 

ARMS had been set up because pwms found no place within the MS Society of the time, which was dominated by a group of people who could be dismissive towards anyone who was not a doctor.  In a challenge to these doctors, patients could be idealised as ‘the REAL experts’. Unfortunately MS is in fact different for everyone, and nobody can really be an expert on someone else’s MS. The CEO of ARMS  knew this, and he had found doctors who would work with patients, as well as other professionals including me.  I was new, and I was definitely not an expert.  (I was told off by my boss for emphasising this too much: he wanted me to be respected, while I was afraid of being idealised and denigrated at the same time.)   I needed to show that people with MS and their families were valued while not colluding in an anti-professional culture. I was also to contribute to research on counselling people with MS and to spread the word about what I discovered.  I’m still doing this.

Support givers

The roles, experiences and training of the existing informal ‘counsellors’ varied enormously across the country.  Some were people with MS or members of their families who had set up the branch and were ready to offer advice to anyone new who came along: many both sensitive and caring; others seemingly more interested in evangelising.  There was one older man who offered bracing advice on army lines, priding himself on not listening to anyone moaning or talking about what they had lost.  There were Christians who wanted to use their own experience to convert others; there were people who believed in whatever was the most recent snake oil.  (Coca cola and one of the anti-depressants was a cure which was being pedalled by a lovely young woman who attributed her own sudden improvement to this combination; others believed in vitamin C or yoga or yoghurt.)  IML helped me to define a role of ‘support giver’; someone who would be there for informal support, who could be given some training and validation by the organisation, but who would be distinguished from a professional counsellor.   I offered a training which consisted mostly of helping people to see how others’ points of view might differ from theirs.

There was also a telephone counselling service which had its own supervisors. They made it very clear at the beginning that  I could learn from them but not teach them anything.  They all had MS, there was a good vetting process and they had been running a very successful system for several years.  I did indeed learn from them and IML helped me contain my frustration at being forbidden to offer them anything. 

One of the main issues for this disparate group of people was the question of what you could or could not say to people; particularly to recently diagnosed people: did you tell them about symptoms they didn’t have yet? Would they be terrified and never come back? There was an example of someone who had been asked about their bladder when they had never had a bladder problem, who was totally freaked out by it.  At the time there was no internet.  Should you ask about sexual difficulties? If you did ask, clearly this raised the problem in the mind of the pwms and gave them something more to worry about; if you didn’t they might never know that the marital problems they had had for years might have been caused by MS rather than failure of love. 

This dilemma is one which faces therapists all the time.  Do you talk about something which is obvious but as yet unspoken, or do you keep quiet, on the basis that ‘the client hasn’t mentioned it, so it’s not their problem, it’s only mine’?  This can apply to disabilities, gender appearances, obesity.  (I always think of Melanie Klein’s first paper, on talking to her son about where babies come from.  She didn’t talk about the role of the father on the grounds that he hadn’t asked; Dr Anton Freund pointed out she needed to listen to the unconscious questions as well as the conscious ones.)  It is, I think, very Kleinian, to consider that talking about apparently unmentionable things is worth doing; clearly it requires tact, but it was one of the ways in IML was steadfast and supportive.

There was a general agreement amongst the telephone counsellors that they should not discuss sexual symptoms – until one week one of the original members turned up and mentioned in passing that ‘of course I ask about sexuality: it’s so important! No-one has ever complained, they’re often really grateful’. 

The more general question of ‘being positive’ remained an issue throughout my time at ARMS.  When I started at ARMS I was not allowed to talk about MS as causing loss; this was not ‘positive thinking’.  To be fair, it was probably the only way in which MS was ever presented at the time, on posters, in adverts raising money for the MS society;  as representing a ‘terrible loss’ which should evoke pity.   IML’s support was invaluable.  She helped me to hold onto a view of this as a defence against the monstrous fears which arose on first discovering any loss, and which would gradually dissipate if they were allowed to be thought through and brought into contact with reality.  When, however, they were cut off too soon  they remained at an unrealistically monstrous level.  

Taking people through their ‘worst fears’ was something I could do.   Beliefs that ‘you shouldn’t moan’; ‘you shouldn’t feel sorry for yourself’ or ‘bad feelings are dangerous’; that ‘negative feelings will stop you getting better’; ‘it’s mind over matter, so the only way to fight the disease is to only have happy and positive thoughts’….  Many of my clients felt such ideas as a huge pressure.  I could feel their relief when they stopped blaming themselves for ‘bad’ or ‘negative’ thoughts, and it was a great relief for me too when I saw, repeatedly, how unrealistic people’s hidden fears were.  In my last book, The Trouble with Illness, (Segal, 2017) the distillation of 35 years working with IML as my internal supervisor, I wrote about the bad press which ‘grief’ is given; how nobody likes it and nobody wants to recognise how long it hangs around for, partly because they have no idea what it does, or what is for. 

It is clear that there is a more nuanced message, that MS does cause losses, but it doesn’t destroy everything, and much can be salvaged if a grief reaction has caused losses to be greater than need be.  Sadly, this message does not seem to sell books. 


There was a specific question I remember asking IML.  The issue of suicide came up quite often with my clients.  They often spoke of ‘not wanting to be a burden’.  In their anxieties about current or future dependence some wanted to take control by ending it all.  Seeing clients often only for a few sessions,  I felt I couldn’t truly understand their suicidal impulses, and I looked to analysts for some kind of short cut.  I also worried about handling my own attitude to suicide; the need to remain neutral to allow clients to explore their own feelings without mine intruding; the discussion around the right to take one’s own life and the fact that clients wanted to know how I felt about it.  My manager informed me that here were also rules within the NHS about what a counsellor could and could not do or say or keep quiet about, in connection with self-harm.  Some clients evoked in me a strong sense that the world (as well as themselves) would be better off without them;  with others I had an equally strong feeling in the other direction.  Rather than just feeling guilty, I knew I needed to use these counter-transference feelings to help me explore the clients’ feelings, both conscious and unconscious, but I needed help for this.

IML was initially reluctant to tell me much: she insisted there was no general rule; that each individual had their own phantasies about suicide, there was no ‘one size fits all’.  However, she then described someone who was certain they would go on living after they’d killed themselves.  In phantasy they were killing an internal parent figure; they themselves would then be free of this persecuting person and would be able to live on.  The real impact of the suicide on others and the self was totally denied.  This was a powerful idea.  It suggested there might be a hidden desire to punish someone (for not caring enough, perhaps?); that death was not perhaps seen as the aim of suicide or as the end of life.  People who said they thought their families would be better off without them might consciously be certain this was true, but might also have other, less altruistic motives and beliefs; which they might be totally unaware of.  The question was, how could I use this in a counselling session?

I picked up the denial of the impact on other people.  An assertion:  ‘I’m just a burden; they would be much better off without me’ could be followed up by focussing on these others rather than on the person themselves.   ‘Who would be better off?  Have you known anyone who lost someone by suicide?  How did they feel about it?’  Or I sometimes asked the straightforward question,  ‘Who would care (if you killed yourself?)’  This was powerful.  It sometimes led to ‘Well, X wouldn’t care!’  which changed the conversation.  More commonly people ended saying, for example, ‘I can’t do it while my mother’s alive’. 

I was no longer paralysed by their feelings about their situation or their desire to die: I did not have to explore these nor admit I was afraid I would feel the same in their situation; nor discuss my own, perhaps idealisitic, view of the way people live on in others’ minds after they die, and the implications of this for the importance of the way they die.  It took away the fear that I might unwittingly be heard as either encouraging them or judging them or expressing my own opinion about ‘the right to die’. It gave me something real and less threatening to offer.  They did know that families and friends could be devasted by suicide.  I could empathise with their desire to end it all and the frustration caused by recognising that this would not be pain-free for other people.  I helped them put a time on the suffering: I did not accept ‘She’d soon get over it.’: ‘How soon?’ was easy to ask.  Together we could face the mixed feelings towards these others, and the awareness that their suicide would cause suffering, perhaps for future generations.   

I didn’t lose any clients to suicide, though I worked with more than 300 people who had MS. 

Mind and body

IML also talked about her study of girls with scoliosis.  She had linked this with the way they sat, pulling their arms across their bodies in depression and misery.  She wanted to show that the physical bone distortion was a result of this depression, and that depressed teenage girls needed psychotherapeutic help. A pilot study convinced her that the bend in the spine followed the child’s ‘handedness’, and this confirmed her hypothesis.  She was regretful that she had been unable to persuade the doctors that this was something worth pursuing.  Empathising with troubled teenage girls can be very painful and complex, for doctors as well as parents, with no certainty of outcome.

 She never tried to explain MS in psychological terms, for which I was grateful; she never questioned the physical basis of MS.  

The idea that their MS was ‘all in the mind’ was very common amongst my clients – and amongst psychotherapists of all kinds too.  IML helped me to see this as a defence against powerlessness (how much better if someone could get rid of their MS just by ‘sorting out their mind’).  It was something I looked for when people first came to me; did they think counselling could cure them?  In a group for psychotherapists and counsellors, seeing it as psychological seemed to be one way of reassuring oneself that ‘it won’t happen to me’ (since ‘I’m taking care of my mind, I’m a psychotherapist’);  and it offered a way of making sense of a senseless set of symptoms.   PwMS seeking a diagnosis often felt they were being told they were imagining their symptoms or were ‘mad’, when a doctor said they could find no physical reason for their symptoms.  This was in the days before wider use of MRIs, and neurologists (perhaps) thought patients would be reassured to hear the verdict: ‘there’s nothing wrong that we can see’ .   IML would have seen this, I think, as a diagnosis which relieved the doctor more than the patient.  I would explain to clients that the way I saw it was that there was the MS which went so far, and there might also be a bit ‘added on’ by the mind; but the basic MS was a ‘given’ which counselling could not remove. 

In the 1950s doctors had argued that there was an MS personality, ‘childish’ and ‘dependent’, which caused MS.  The stereotype in 1983 seemed to be ‘manipulative’ (whispered in a hushed voice).  The clients I saw did not seem childish or manipulative even if they were dependent, and we discussed one or two who were in terms of the way the illness was pushing them back into a kind of powerless dependency which they had suffered as children.  Illness and weakness do not always evoke pity or a desire to help; they can also evoke anger or a desire to attack or punish someone who is not ‘pulling their weight’.  Many patients felt themselves that they were useless; some felt this meant they had no right to ask for any kind of respect.  Some were too afraid, or physically too weak to stand up for themselves psychologically or physically. Not fighting is one way of living with imbalance of power; in particular, with bullying and oppressors. 

The importance of clients’ history of dependency became more and more clear in our supervisions, and again, became part of the bag I carried with me, to help me understand the impact of MS on my clients as rapidly as possible.  Those who struggled with their mothers, for example, found it hard to ask for help from those mothers, even when they desperately needed it.  I did a lot of work around people’s relationships with those they depended on, both in the past and the present, and the leakage between the two.  I still do this.  I am a strong believer in the insights of (some of) the ten commandments, particularly ‘Honour thy father and thy mother’.  Life is much better if one can do this.  I eventually developed a concept of ‘Mature Adult Dependency’ to contrast with a (feared) childish kind of dependency rooted in more paranoid-schizoid anxieties.

We talked too about the ways families split up tasks under the pressures of p-s anxieties; internal conflicts becoming expressed as external ones.  The desire to get away from the MS conflicts with the desire to care, to stay put.  Children and adults can be afraid that total sacrifice of the self is required, and therefore the only way to save one’s life is to escape;  within a family children sometimes divide this between them, so one gets away and another feels they cannot.  The split between ‘patients’ and ‘parents’ was the topic of my first ARMS book: ‘My mum needs me’, or ‘Helping Children with ill or disabled parents’, where I wrote about the fact that MS does not disqualify people from being parents: in particular,  parents who are capable of helping their own children.  Illness does not make everyone totally narcissistic and self-obsessed. I found parents were often feeling terribly guilty about the imagined impact of their MS on their children; once we had reduced this guilt they could find out what the MS actually meant to the child themselves – and this was not anywhere near as disturbing for the parents as their imagined fears had been. 

Summary: Counselling

IML valued counselling and helped me to explore its possibilities:  how to work with clients in five weekly sessions while remaining aware that some changes might require long-term support.  Working on phantasies around dependency could lead to increased emotional or practical support from friends and family.  Understanding the way illness affected other people as well as the patient themselves brought beneficial changes in attitude and behaviour.  Understanding the conscious (and sometimes unconscious) fantasies which people used to make sense of their symptoms and their situation led to changes in these fantasies.   It was clear that everyone had a different set of beliefs about MS, about what it meant to them and to others, and many difficulties caused by the MS came down to clashes of meaning and experience. 

I could also see the role played by the ARMS research unit itself in providing a ‘home’ for pwms and their families, where they felt they had a team devoted to them, who knew their history and cared about them and were easily accessible to help, for example, to prevent secondary disabilities if new symptoms arose.  Unfortunately, once we became absorbed into the larger organisation of an NHS hospital, patients had to go back to their doctor for a new referral every time: regardless of the many reasons why this was a bad idea.   All I could do was to make it clear that my support did not end after five sessions; that I would remain available to them in the future, as long as I could, and that (hopefully) other counsellors would be there if I was not.  Eventually my post was reorganised out of existence entirely. My clients’ difficulties could not be cured, solved and dismissed in a few weeks, as could those of the physiotherapists: measuring our ‘outcomes’ was not so simple, though it was possible (and I did it).  But neurological patients are a problem for an outcome-orientated service because they do not get better and nor do they die.  They remain as a reproach to a healthcare system which paradoxically seems to demand easily measurable ‘successes’ in situations where ‘living with losses’, and tolerance of ‘failure to cure’ would be more appropriate. 

Vol 2 of IML’s selected essays

I looked through Vol 2 of IML’s selected essays (Menzies Lyth 1989).  I had forgotten she studied chocolate and sweets; her paper evoked memories of my own childhood.  In this volume we see Menzies working to spread ideals of humanity and care in many different settings.  She not only wanted to improve the lot of babies in care, of patients in hospital, of firemen, of adolescents who have been taken away from their families; she wanted to improve life for those who cared for them too, both professionally and informally; for nurses and mothers; firemen’s wives as well as recruitment officers and staff in institutions.  Learning her craft through the war years, she had a conviction that organisations, that hierarchies, that society could be arranged in such a way as to improve lives; but that if we did not take care, primitive, dangerous and frightening anxieties would be allowed to constrain good intentions, good impulses.  Unfortunately, it is clear that this is true.  The NHS is constantly being undermined.  She felt it was regularly ‘reorganised’ in a way which enabled politicians to feel they were ‘doing something’ while seldom addressing the serious needs and concerns of patients and staff.  

She set out to find out what it was which led to babies being warehoused in nurseries which failed to observe or concern themselves with psychological development; to patients being treated as ‘the liver in bed 9’; to good nurses leaving and the fire brigade struggling to fill its vacancies.  She found answers in the anxieties involved; in difficulties people have dealing with their own and other’s losses, with grief, with failure.  She saw behaviour determined by attempts to avoid and deny guilt or distress rather than work them through,  not only in staff but also in those they worked with and were supposed to care for.  She saw that defensive rules prevented staff from using their practical and emotional capacities in a more satisfactory way. 

Now we have the test and trace system which relies on a set of rigid questions which do not bring about the desired objective of getting people to agree to self-isolate when they do not feel ill.  We have nurses who have been moved around to treat covid patients as if one nurse or one task was the same as another.  We have a 111 telephone system which asked a set of questions which didn’t pick up patient’s breathless weakness when their oxygen levels were dangerously low. (Michael Rosen describes this in his book about having Covid (Rosen 2021.) Treating people as automata does not satisfy anyone.  But listening for unspoken anxieties, recognising emotions, empathising with patients, with babies, with adolescents too, is painful and requires a belief that grief processes can be utilised for growth of maturity.  In order to get people to self-isolate we may have first to understand what is stopping them – but this means we have to hear their frustrations and their personal circumstances which may be distressing.  We may have to observe the unfairnesses of a society which underpays workers, a social security system which does not work for the most vulnerable.  This takes time and needs to be paid for.  You cannot ask all this of people working for peanuts in a call centre.  They cannot afford to care. And so we have a system which wastes the money which is poured into it.

IML was very aware that many of her projects had not brought about the changes she wanted.   She knew that change took time and regretted that consultants were seldom given time to continue to work alongside staff after they had made their reports.  But her work, and her supervisions, encouraged others, not only me.  My post as counsellor on a rehabilitation team was eventually lost, but she encouraged me to write up my work and I was able to publish books and papers including The Trouble with Illness (Segal 2017) and Helping Children with Ill or Disabled Parents, (Segal and Simkins, 1992) which were aimed at the general population.  Isabel Menzies was and continues to be, an inspiration for all of us who are working to integrate the insights of psychoanalysis into our culture in a way which enables us to use them for the benefit of the whole population; to increase emotional understanding and with it, the capacity to care for each other and ourselves.

Isabel Menzies Lyth was not just a psychoanalyst, though she was this and she had the insights, the understanding and the language to talk of unconscious phantasy and internal objects (though she used this sparingly because she didn’t just talk to analysts about these ideas).  But she had a wider view.  I went to her because she was interested in the organisations people worked in, in their settings and in applying psychoanalytical ideas outside the consulting room.  She was as interested in the impact of multiple sclerosis on the minds of my clients as she was in the way mental states affected people’s physical bodies.  She helped me to observe and think about the ways both unconscious phantasies and the realities of physical illness affected relationships, within the family and outside it, within the health system.

I am very grateful to her for all she taught me, both directly and indirectly; for her warmth and support and the inspiration which has sustained me throughout my working life.  I am so glad her work lives on; and I know she would be too.


Goffman, Erving (1961) Asylums. Essays on the social situation of mental patients and other inmates.  Anchor Books, USA, (2017) London and New York, Taylor and Francis.

Menzies Lyth, I  (1959) ‘A case-study in the functioning of social systems as a defence against anxiety. A report on a study of the nursing service of a general hospital’  InMenzies-Lyth, I. (1988) pp 43-89;

Menzies Lyth, I. (1988) Containing Anxieties in Institutions.   London, Free Association Books.  Selected Essays Vol I

Menzies Lyth, I. (1989) The Dynamics of the Social. Selected Essays Vol 2.   London, Free Association Books.

Rosen, Michael; (2021) Many Different Kinds of Love, Ebury Publishing. quoted in The Guardian 13 March 2021:

Segal, J.C. (1985)  Phantasy in Everyday Life, Pelican Books. Reprinted Karnac Books 1995, 2005 London, and Aronson USA 1996.   Translated into Romanian (2017), Editura Trei.

Segal, J. C. 1992. 2nd Edition 2004.  Melanie Klein:  Key Figures in Counselling and Psychotherapy. London, Sage Publications.   Hardback and paperback    Translated into Polish, Mandarin, Japanese, Korean

Segal, J.C. (2017) The Trouble with Illness.  How Illness and Disability Affects Relationships. Jessica Kingsley, London, UK  

Julia Segal and John Simkins. (1996) Helping children with ill or disabled parents; A guide for professionals.  Jessica Kingsley, London, 1996  (Previously published as My Mum Needs Me, (1993) Penguin books.)

About thetroublewithillness

I've been a counsellor for people with physical illnesses for a long time now, and learnt a lot about what it's like living with your own or someone else's illness. I want to pass some of this on.
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