A psycho-analytical approach to the assessment of a psychotic patient

SUMMARY

When approached from a psycho-analytic point of view, psychotic states reveal a wide variety of patterns. Some of these are so complex and so rigid in their organisation as to render the patient quite unsuitable for formal psychotherapy. Others are more benign and accessible to a psycho-analytic approach.

The attempt to assess whether a psychotic patient might benefit from psycho-analytic psychotherapy can be facilitated by the use of certain psycho-analytic concepts which provide “ground rules” for decoding psychotic communication, for understanding the psychotic patient's experience and how it has come about.

This paper represents an attempt to show how the psychoanalytic approach to such understanding can help in the management of the case and open the way for psycho-analytic psychotherapy within the N.H.S. Although extremely limited in its provision of skilled psychotherapy, the N.H.S. provides an extremely rich potential for effective understanding, care and treatment of the psychotic patient if the psycho-analytic approach is sufficiently well understood and implemented.     

The NICE guidelines are misleading,unscientific, and potentially impede good psychological care and help

NICE guidelines have been given the authority to determine what psychological therapies can be provided within the UK National Health Service. This also has implications for private practice. The guidelines are based on a medical model and consider psychotherapy as analogous to a drug. Psychological thinking is discouraged by this approach. A large amount of psychotherapy research evidence is ignored by NICE, particularly the persistent finding that differences in effectiveness between therapies are minimal and elusive. Differences between the skills of therapists are a more significant factor. Practice-based evidence, and learning from the patient's feedback (both conscious and unconscious) may be a better approach. For most forms of psychological distress, none of the main psychological therapies studied in randomized controlled trials can be considered to be clinically effective, even though they facilitate some degree of statistically significant change.     

On the nature and standing of psychoanalytic psychotherapy

In this paper, I offer some reflections on the standing of psychoanalytic psychotherapy in the National Health Service (NHS), with special reference to contemporary forms of evidence-based thinking. I consider what may follow when a narrow view of science or psychotherapeutic practice becomes conventional wisdom and assumes dominance. I place stress on the potential loss to NHS psychology and psychiatry if psychoanalytic psychotherapy becomes increasingly marginalized on the one hand, or overly standardized on the other.     

Brief psychodynamic psychotherapy in adolescent depression: Two case studies

In this paper the authors outline the basic principles of a manualized, brief psychodynamic approach that was evaluated as part of an outcome study within the National Health Service researching the effectiveness of two different forms of psychotherapy for major depression in childhood/adolescence: Focused Individual Psychodynamic Psychotherapy and Systems Integrative Family Therapy. As well as describing some of the difficulties encountered in short-term dynamic psychotherapy with adolescents, the authors present therapeutic work with two adolescents with major depressive disorder who were both seen as part of the research study. The authors depict some of the challenges and unavoidable difficulties which emerged during the therapy, arising from the needs of the research programme.     

The search for evidence: Psychoanalytic practice and the male imaginary

In this paper, I will attempt to discuss the future of psychoanalytic practice in the wake of the National Institute of Health and Clinical Excellence’s (NICE) embrace of ‘evidence’-based practice. In 2005, NICE, whose task is to regulate the provision of health care across the National Health Service, adopted positivistic evidence-based protocols as the sole proof of the effectiveness of psychotherapy. Despite the success over the past 40?years of psychoanalytic and humanistic therapies in primary care and psychotherapy departments of psychiatric hospitals, NICE insists on restricting therapy, to those who can claim effectiveness as a result of using the data from client questionnaires commonly described as ‘outcome measures’ and it has gone on to promoting new modalities many of which have been imported from the States. As a consequence, most of the provision of psychotherapy in the public sector currently, whether as part of the National Health Service or the voluntary sector, has embraced evidence-based practice’ and many training organisations are promoting it, which will, in time, have an effect on private practice. I use some of the threads of the work of the feminist psychoanalyst Irigaray and others to understand this turn to positivistic science and how it can be understood as an instance of the retrenchment of the ‘male imaginary’ and a re-installation of the values of detachment and mastery. I query whether there are some problems within current theory, practice and institutionalisation which interfere with the emergence of a more progressive psychoanalytic practice.     

Mirror mirror on the ward: who is the unfairest of them all? Reflections on reflective practice groups in acute psychiatric settings

Consultant psychiatrists in medical psychotherapy, adult psychotherapists, child and adolescent psychotherapists and clinical psychologists increasingly complement their direct therapeutic activity with applications of their psychotherapeutic thinking in acute mental health work through facilitating reflective practice groups for staff working in mental health teams. The authors offer their reflections on facilitating National Health Service reflective practice groups using the metaphor of a mirrored dialogue between patient and professional, and professional and institution as a basis for informing the development of reflective practice for colleagues. Their reflections are based on working on three acute in-patient wards, in a crisis resolution team and in community mental health teams. They describe the practicalities of setting up and facilitating reflective practice groups, and offer insights into some of the issues that arise in reflective practice groups. They conclude that these groups are mutually beneficial in forging links between psychotherapy professionals and professionals working in other disciplines and areas of mental health. Facilitating these groups often requires a challenging adaptation of technique, which will not suit all psychotherapists, as well as a wider understanding of organisational dynamics and the interplay between clinicians and management.     

Sexual abuse as a theme in group-analytic therapy

The group-analytic approach, which emphasises the individual in a network of group relationships, is described with reference to the subject of sexual abuse in childhood. Three different National Health Service psychotherapy groups run by the author provide contrasting examples of how the theme, originating in an individual participant, was manifested in the dynamics of the group-as-a-whole. The therapeutic significance to the individual and the group is explored.     

Comments on “A neurobiological model for near-death experiences”

the recipient of a National Service Research Award (Public Health Service Grant IF32 CAOF234) from the National Cancer Institute.     

Curious bedfellows: Psychoanalytic understanding and old age psychiatry

SUMMARY

The author outlines an approach to assessment, or as she prefers to call it, psychoanalytic consultation, in the Health Service. This involves giving the patient an experience of the analytic process, which they can then assess in a way, while the assessor gains information about a number of categories that can be thought of hierarchically, which inform the advice given the patient and the referrer about management and treatment. The safety of the patient is paramount, as psychoanalytic psychotherapy is a powerful and disruptive treatment. However it is argued that, on the whole, ‘suitability for psychotherapy’ should be on the basis of exclusion rather than involving the patient passing a sort of ‘suitability test’. The latter may enable public psychotherapy services to deny the incompleteness of what they are able to offer.     

Negative relationships between abilities

Abilities are usually assumed to exist in a “positive manifold.” Experimental manipulations of physiological variables, however, suggest that negative relationships exist between certain of the neural processes contributing to simple perceptual-motor vs. perceptual-restructuring tasks. First-order correlative evidence of this phenomenon cannot be obtained because the between-individual differences in general ability level tend to exceed the behavioral effects of the intra-individual opposition between neural processes. Also, since statistical removal of the “g” variance induces bipolarity in the remaining variance, the second-order negative correlations are necessarily regarded as artifactual. A combined correlational-experimental approach is suggested to overcome this difficulty. This work was supported in part by the Dementia Praecox Research Project, Worcester State Hospital, and research grant HD 02557 from the National Institute of Child Health and Human Development, U. S. Public Health Service.     

European developments

The British National Health Service is 50 years old. The provision of many services has changed considerably through this time in ways that reflect shifts in organization and philosophy. The provision of psychotherapy has been particularly sensitive to these changes in ways that have made it more widely available but also shaped its content. As the pace of change continues to accelerate, some implications of the most recent shifts in philosophy for clinical practice are considered.     

Translational research: how social psychology can improve psychotherapy

In an effort to generate innovative treatments, the National Institute of Mental Health has made translational research for alleviating mental illness a major funding priority. Although translational research is a powerful approach for moving basic science findings into novel treatments, it remains ambiguous and rarely implemented in psychology. The current article describes conceptual and methodological issues involved with translational research, including considerations about time frame, scope of hypothesis tested, dose of treatment, contraindication, and sampling. Translational concepts and methods are illustrated with areas of social psychology that are promising for translation into solutions for pressing questions in psychotherapy research.     

Transference and countertransference in an applied setting — education

This paper offers an overview of current clinical approaches to psychoanalytically informed work with parents by child psychotherapists. The analysis is based on practice at the Tavistock Clinic and on broader knowledge of trends in work with children and families within the National Health Service. A brief history sets the scene. Four varieties of approach are described, with clinical examples. The particular sensitivity of child psychotherapists to infantile features in the personality is highlighted, and it is argued that this, together with their broad clinical experience, provides a proper basis for psychoanalytic psychotherapy with parents. Such work significantly extends and enriches the clinical contribution of child psychotherapists and has involved a shift in professional identity. It also raises ethical issues which are discussed.     

Best linear composites with a specified structure

Least squares linear composites of predictors for estimating several criteria are derived, satisfying the restriction that the composites have an arbitrary specified intercorrelation matrix. These composites are compared with the usual unrestricted regression composites. An illustrative example is provided. The derivation depends on a general result, given in an appendix, about best-fitting orthonormal transformations.This research was done while the author was a Fellow at The Center for Advanced Study in the Behavioral Sciences. The investigation was supported by a Public Health Service fellowship, 1 F3 MH-28, 495-01 (PS), from the National Institute of Mental Health. Preparation of the paper was supported in part by Grant MH 07722 from the National Institute of Mental Health, Public Health Service, for work done at Carnegie-Mellon University.     

Exploring the bio-psycho-social

The United Kingdom Council for Psychotherapy (UKCP) was formed to provide a professional body for all psychotherapists in the UK. It maintains a register of trained practitioners who abide by the ethical standards ratified by UKCP, which includes psychotherapists working in all the modalities recognized by UKCP irrespective of their primary professional training. In the absence of statutory registration, there is no fully representative list of UK psychotherapists, but the UKCP register is probably the nearest thing to it. The UKCP board recognized that a survey of registrants would provide a snapshot of the state of UK psychotherapy, which would be valuable in understanding the contribution of psychotherapists to health services in the UK.

A questionnaire was designed, and sent out to all 4005 practitioners registered by UKCP in December 1997. One thousand three hundred and thirty-one questionnaires were returned, a response rate of 34 per cent. The respondents were representative of all registered psychotherapists in 1998 in those characteristics that are published in the paper register, or that can be inferred from it. The respondents were aged 51 years on average, predominantly white (97 per cent described themselves this way) women (69 per cent) practising in London and the South East of England (55 per cent). All the respondents described themselves as being influenced by psychotherapeutic approaches rooted in psycho-analysis. Ninety-five per cent of respondents had another profession previous to psychotherapy. This was most commonly teaching (27 per cent), social work (22 per cent) or counselling (21 per cent). Only 11 per cent of respondents were psychologists.

The contribution of UKCP registrants to the National Health Service has never previously been estimated. A breakdown of the diaries provided by respondents in this survey suggests that UKCP registrants may contribute as many as 44,760 hours of psychotherapy per week to the British National Health Service and other health sectors. Assuming that a whole-time-equivalent psychotherapist works 37 hours per week, this means that UKCP registrants may provide the equivalent work to health service organizations, both public and private, of more than 1,311 full-time psychotherapists.     

The preventive and therapeutic effects of two school mental health programs

In 30 classrooms randomly assigned to experimental conditions, effects on mothers' reports of behavior symptoms were compared for (a) a parent education program; (b) an in-school program of consultation, counseling, training, and referral; and (c) control classrooms. A sample of 426 families were followed for 30 months from the child's entry into third grade. A simple unweighted count of the number of symptoms reported in a home interview had adequate validity, good reliability, low reactivity, and intrinsic significance. Both programs had significant preventive and therapeutic effects on boys but not on girls. Effects were immediate in the upper middle class families, delayed in the lower class families.The larger study on which this article is based was initiated some years ago by Professor Glidewell and his colleagues, and represents a pioneering research effort in the field of community psychology. The present article was prepared by the authors in response to an invitation from the Editor to report important and still timely aspects of the original study that were not previously published in archival sources. We are grateful to Professor Glidewell and his colleagues for giving us this opportunity to make their findings more generally available to community psychology researchers.This work was supported by research grant M-592 from the National Institute of Mental Health, U.S. Public Health Service, and the St. Louis County Health Department.     

Dynamic interpersonal therapy in an NHS tertiary level specialist psychotherapy service

We describe the introduction of dynamic interpersonal psychotherapy (DIT) into an National Health Service (NHS) tertiary psychoanalytic specialist psychotherapy service. Training in DIT began as our contribution to Improving Access to Psychological Therapies and primary care services, supporting the training and supervision of their DIT practitioners. We then discovered DIT could be a valuable treatment within our own tertiary NHS service for patients with complex presentations. Currently fighting for survival, like many NHS psychoanalytic psychotherapy services nationally, we have adopted a manual-guided, psychoanalytically based therapy to broaden our tertiary clinical psychoanalytic service and accommodate trends in mental health service provision, whilst protecting the quality and integrity of our psychotherapy. DIT helped us continue providing relevant and beneficial psychoanalytic and psychodynamic services to individual patients despite limitations of the financially challenged NHS, NICE guidelines and Payment by Results. We outline the progress and outcomes for patients with complex mental health presentations, include individual case discussion and our experience of using the DIT approach within a traditionally longer term psychoanalytic psychotherapy service.     

Book reviews

Institutions represent both the conscious and unconscious aspects of the interacting members. Psychotherapists need to address their unconscious position in the institution as well as the conscious aspects of their work. This paper describes the possible relevance that psychotherapy may have at the unconscious level. The notion of the ‘social defence system’ is extremely useful in finding one's way in the engulfing emotional attitudes, and for tolerating the often dismaying sense of irrelevance that psychotherapy appears to attract. The social defence system of a prison and a mental hospital are considered in this light and some thought are devoted to the changing state of the National Health Service at present.     

A computational procedure for tau correlation

Thetau coefficient is defined, and a computational procedure for tied ranks is described. The procedure maintains continuous computational checks, saves labor, and particularly facilitates the use oftau with large samples. It is also shown howtau correlation may be applied toQ-sorts with any shape of forced distribution or with unforced distributions.The procedure described was developed in connection with research at the Counseling Center, University of Chicago. The research is supported by a grant (PHS M 903) from the National Institute of Mental Health, of the National Institutes of Health, Public Health Service.     

Childhood depression: A place for psychotherapy

Pharmacotherapy and psychotherapy are the two dominant mental health treatment modalities, but they are often taught and practised very separately leading to polarisation which may fragment treatment delivery. This paper presents results from a small qualitative study of interfaces between these modalities as described by medical and non-medical professionals practising in the National Health Service (NHS) and explores whether this polarisation maps to the Kleinian ‘P/S’ (paranoid/schizoid) and ‘D’ (depressive) positions, the ‘P/S’ position of omnipotence and dominance of one model over the other shifting the attention away from a more realistic ‘D’ position of integration and concern for the patient. The challenges to the integration of pharmacology and psychotherapy are examined in reference to cultural, organisational, relational and intrapsychic issues. Finally, clinical implications of an integrative approach are considered.