Response to ‘Containment lost’ by Andrew Briggs

This is a response to Andrew Briggs’ paper presented to the ACP Conference in June 2017. Briggs’ paper, sobering, pessimistic and challenging, looks at the emotional pressures on child psychotherapists in Child and Adolescent Mental Health Services (CAMHS) as a result of the imposition of the internal market in the NHS. He posits that this has caused the loss of organisational containment, not just for child psychotherapists, but for all those clinicians who work in CAMHS. Briggs writes that this loss of containment is evident in clinicians’ experience of meaninglessness in their work and that this meaninglessness may lead to the despair of the death instinct. For Briggs, this goes along with the loss of professional identity as a once favoured discipline. He compares this fall from grace to Satan’s as described in Milton’s Paradise Lost. If, as he suggests, there has been a strong sense of being the favoured discipline, then maybe a dependence had grown in the profession whereby this loss now feels like a terrible abandonment. The author of this response sees hope amidst the despondency being forced upon workers in the NHS and makes the case for us to engage and resist in a number of practical ways.     

The Clinical Advantage of the Death Instinct

Abstract

The death instinct has been debated, devalued, criticized, and ignored by various analysts and analytic schools. Nevertheless, it remains a viable part of Kleinian theory. This paper explores the advantages of the concept from both a clinical and theoretical perspective. Due to their self-destructive ways, certain patients seem to create difficult and destructive transference-countertransference patterns. Clinically, they need a period of intrapsychic and interpersonal containment, followed by analysis of the death instinct in its clinical manifestations, followed by the working through of primitive states of paranoid-schizoid loss and persecution. Case material, focusing on the analysis of the death instinct, is used for illustration.     

Mutilation of self and object: the destructive world of the paranoid-schizoid patient and the struggle for containment and integration

Using case material, I have described the three overlapping phases of treatment that occur with some borderline, narcissistic, or psychotic patients. These patients are dealing with paranoid-schizoid experiences of the self and the object. In this part-self, part-object world, many shifting, opposing, and contrary states of feeling and thought occur. Acting out is the first phase of analytic treatment. This is an externalization of persecutory anxiety, primitive guilt, and phantasies of annihilation. Projective identification, splitting, and denial are common and tend to make for difficult transference and countertransference problems. During the middle phase of treatment, pathological superego states and manifestations of death instinct color the analysis. The death instinct reacts defensively to the sadistic superego. Technically, the destructive internal conflicts created by these two elements must be clarified and interpreted in the transference. Flexible analytic management and containment are crucial supplements to ongoing interpretation. If these chaotic patients are able to stay in treatment for a period time, the acting out and the superego/death instinct phase gradually give way to phantasies of loss. This is still a paranoid-schinoid perspective of loss, making it persecutory experience. Although depressive anxieties do enter the picture, these still involve pathological anddestructive states of guilt and all-or-nothing threats of abandonment and attack. A case was presented in which the patient managed to continue into the third stage of analytic treatment, long enough to benefit frominternal, structure change. In this final stage, the patient "O" was able to acknowledge, work through, and integrate her prior feelings and phantasies of loss, persecution, and abandonment anxiety into more manageable and reality-based depressive functioning.     

Revisiting ‘What works for whom?’: A qualitative framework for evaluating clinical effectiveness in child psychotherapy

This paper describes a framework for evaluating the effectiveness of child psychotherapy used by child psychotherapists in an inner city Child and Adolescent Mental Health Service (CAMHS). The Hopes and Expectations for Treatment Approach (HETA) involves using the assessment for psychotherapy that normally precedes treatment to derive a baseline from which to generate a set of hopes/expectations as regards the effects of the treatment on the part of parents and the psychotherapist, to be revisited one year after the start of the psychotherapy and/or at its completion. The Strength and Difficulties Questionnaire, for parents and schools, was also administered before and after the treatment. The characteristics of the first 30 children referred for psychotherapy over a particular time period are described. Of the first 15 children in this group to complete one year of individual psychotherapy, all showed change or significant change in the areas concerning parents' and therapists' hopes at the end-of-year review, as rated by parents and psychotherapists. A case of a child with conduct disorder is used to describe how the assessment generated a psychoanalytic formulation, how the therapist's understanding was fed back to the parents, and how the parents' and therapist's hopes and expectations were derived and recorded. This case illustrates powerfully the impact of trauma in the parents' backgrounds on the internal world of the child, and how the method provides a useful bridge between parent and child work. Feedback from the psychotherapists, the parents and the referrers using the framework is reviewed, and in conclusion the paper argues for the framework's value in promoting good practice in the treatment and management of complex cases and in enhancing awareness of the nature and scope of the psychotherapy process.     

Gender/ed identities: an overview of our current work as child psychotherapists in the Gender Identity Development Service

Abstract

This paper is adapted from a presentation first given at the 2017 Association of Child Psychotherapists (ACP) Conference. We hope to give a feel of our work as psychoanalytic child psychotherapists working in a Tier 4 national assessment service for gender variant children and connect with our colleagues working therapeutically with these families in Child and Adolescent Mental Health Services (CAMHS) and other settings. Gender variance does not have a single cause, or straightforward developmental pathway; rather it is a complex interplay of multiple factors, akin to sexuality in the diverse manifestations and ‘tributaries’ taken. This paper is given as a plea for complexity, to counter the current intense focus on gender identity and the consequent reductionism this can lead to. To this end, three case studies from the clinic, taken from Under Five, Latency and Adolescent phases of development, are explored. The complexity of the cases is then discussed, followed by parallel issues of development, divergence and difference. These three ‘average’ cases from the Gender Identity Development Services (GIDS) serve to demonstrate the need for child psychotherapy as part of multi-disciplinary thinking about gender variance and how attention must be maintained to each unique story and process of identity development; as well as our clinical task to establish and encourage depressive functioning and secondary processes where possible.     

Aims in parent work: a brief qualitative survey

Child psychotherapists’ views of the treatment aims of parent work in a community Child and Adolescent Mental Health Service (CAMHS) were explored. Parent work undertaken by the child psychotherapy team in one calendar year was analysed. The parent worker was asked to describe the primary aim of the work for each case. The resulting thematic analysis found that the main aims of parent work were: increasing empathy with the child; decreasing enmeshment; and containing anxiety. Linking with Alvarez’s notion of a hierarchy of interpretative approaches, the study’s findings suggest that there are parallel ‘levels’ of intervention in parent work, where therapists work in ways appropriate to the parent’s psychological functioning.     

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.     

The death instinct

The death instinct has always been a controversial concept, insufficient to account for actual dying, and usually taken to be fused with aggression. After dislodging it from the shadow of aggression in order to evaluate its function, the instinct turns out to be one of the components that form the death motivation. Human beings develop a complex motivation for death, one that is more than biology (instincts) or physics (entropy). It includes (a) the death instinct, the primary analogue; (b) sequellae of the universal experience of object-loss, with identification and fantasies of a restorative reunion; (c) guilt over hostile attitudes toward the lost object, with depression, longings for atonement , and self-punishment; (d) compliance with reality, like that of old age or grave sickness. Examined in light of the complementary series of Freud's aetiological equation, the death instinct turns into a precondition of the composition motivation. Death motivation is a comprehensive concept, since patients express various of its aspects during their psychoanalyses , and it facilitates a metapsychological understanding and refines the accuracy of interpretation.     

College Student High-Risk Drinking as a Maladaptive Serious Leisure Hobby

The role of occupational therapy in community child and adolescent mental health services (CAMHS) multidisciplinary teams is not well documented. This qualitative study investigated the perception of occupational therapy practice held by community CAMHS workers in the Perth, Australia, metropolitan region. Eight mental health community CAMHS professionals took part in semi-structured interviews. Three themes emerged which included team membership, the nature of the work, and the team and occupational therapy. This article focuses on the third theme. Findings suggest a limited understanding of the scope of occupational therapy practice. Implications for occupational therapy in CAMHS are discussed.     

Concentric circles of containment: a psychodynamic contribution to working in pupil referral units

This article aims to reflect on the lessons learnt from using a psychodynamic approach to offering onsite therapeutic child and adolescent mental health services (CAMHS) in four pupil referral units (henceforth referred to as PRUs). The PRUs cater for six- to 16-year-old children and adolescents permanently excluded from mainstream schools. The work takes place in an inner London borough. The approach described evolved over five years through practice-based evidence of what worked well in each particular setting. This was viewed both in terms of sustaining families' engagement in the therapeutic process, and also effectively supporting child and adolescent mental health services and education staff in their respective tasks. The model which gradually evolved owes much to Bion's concept of containment as the necessary foundation for emotional growth and genuine learning. It also draws on ideas from psychoanalytic consultation and open systems theory. The importance of work discussion groups in this setting will also be evident. Some links are made to relevant Buddhist concepts and metaphors.     

The unwelcome child and a lack of acceptance of new ideas

Ferenczi’s idea of the unwelcome child and his death instinct is used as a background for discussing the treatment of adult patients who do not expect to be received and understood and who turn their aggression back upon themselves, destroying their will to live. When these patients enter analysis, they are very difficult to reach because they have internalized an obstructive object (Bion, 1958). Further, I have linked the unwelcoming of a child to the hatred of the new idea. The paper highlights the deadening defenses that arise in response to awareness of premature separateness between mother and baby, inevitably experienced by an unwelcome child. Coming alive involves suffering the pain of the original loss. To avoid this pain, patients reject anything new, and become stuck in monotonous, seemingly lifeless, patterns where new ideas and new ways of being threaten the static order. This includes the threat that relationship with the analyst brings.

     

Thanatos and massive psychic trauma: the impact of the death instinct on knowing,remembering, and forgetting

The connection between massive psychic trauma and the concept of the death instinct is explored using the basic assumptions that the death instinct is unleashed through and is in a sense characteristic of traumatic experience, and that the concept of the death instinct is indispensable to the understanding and treatment of trauma. Characteristics of traumatic experience, such as dissolution of the empathic bond, failure to assimilate experience into psychic representation and structure, a tendency to repeat traumatic experience, and a resistance to remembering and knowing, are considered as trauma-induced death instinct derivatives. An initial focus is on the individual, on how death instinct manifestations can be discerned in the survivors of trauma. Next the intergenerational force of trauma is examined; a clinical vignette illustrates how the death instinct acts on and is passed on to the children of survivors. Finally, the cultural or societal aspects of trauma are considered, with an eye to how death instinct derivatives permeate cultural responses (or failures to respond) to trauma. Because trauma causes a profound destructuring and decathexis, it is concluded that the concept of the death instinct is a clinical and theoretical necessity.     

Negotiating time: the significance of timing in ending inpatient work

This paper discusses work with young people during their stay on an NHS psychiatric inpatient unit, especially focusing on the end of treatment and the appropriate timing of discharge into the community. When approaching the end of an admission, various factors are considered that seem particularly relevant to the decision of when a young person may be ready to leave and cope with the transition back to life outside the unit. Indications of medical stability, in patients where this has been an issue, is a factor of prime importance. Other important factors include family functioning; the availability of adequate ongoing local CAMHS support for the child and family; suitable school provision; and the identity of the child within a peer group. The reality of NHS resources and the demand for inpatient beds is another pressing consideration. The young person's own motivation emerges as crucial at this stage – towards the end of treatment – not only in terms of what is said, and therefore evident verbally, but also through signs of internal shifts in the child that indicate a capacity to re-engage with life outside in a lasting way. Decisions about when to stop are taken with all this in mind and when the decision does not seem straightforward, it can provoke considerable anxiety in the multi-disciplinary team. Clinical material from psychotherapy with a young adolescent boy with anorexia nervosa is used to illustrate some of the dilemmas.     

PSYCHOANALYTICAL PSYCHOTHERAPY: Psychoanalysis and psychotherapy: A long and troubled relationship

The extended, inconclusive debate over distinguishing psychoanalysis and psychotherapy has been muddied by two underlying issues. The scientifi c identity that psychoanalysis claimed, leading it to affi rm that it was more than a treatment modality, was in confl ict with the actual therapeutic mission it assumed. Psychoanalysis was further hampered in those discussion by its internal confl icts over doctrinal purity; deviations for psychotherapeutic ends were vulnerable to the charge of dissidence. More recently, the debate has been clouded by the fact that newer candidates, by and large, can anticipate careers primarily as psychotherapists, driving a wedge between generations within institutes. The course of the debate and the problems encountered in it are affected by the formal relations between the psychoanalytic establishment and the health-care industry, including government agencies. In the long run, it appears to make little difference whether psychoanalysis is offi cially recognized as a mental-health treatment, as in Germany, or attempts to maintain its independence, as in the UK. Finally, as the debate appears to be winding down, the fate of dynamic psychotherapy is also in the balance. If in the past psychoanalysis seemed at risk of losing its specifi c identity, today dynamic psychotherapy is in danger as well.     

Life and death in Freudian metapsychology: A reappraisal of the second instinctual dualism1

In this paper we re‐examine the second instinctual dualism hypothesis introduced by Freud in Beyond the Pleasure Principle. We suggest that the life instinct hypothesis as something opposed to the death instinct does not seem to fit into this theory easily. On the other hand, death instinct turns out to be an internal necessity of Freudian metapsychological theory from the beginning of Freud ’s metapsychological writing. We shall argue, based on the ideas formulated in Beyond the Pleasure Principle and in later metapsychological texts, that Freud could not wholly justify the existence of an opposition and a symmetry between the two classes of instincts. Even though up to his last works Freud held on to this instinctual dualism, again and again his arguments lead to the idea that the life instincts should be regarded, ultimately, as death instincts.     

Lost in the crowd: Conformity as escape following disbelief in free will

Belief in free will is founded on the idea that people are responsible for their behavior. People who believe in free will derive meaning in life from these beliefs. Conformity refers to succumbing to external pressures and imitating others’ behaviors. Sometimes, conformity involves a loss of self-awareness, which reduces perceived meaninglessness. We tested if disbelief in free will increases perceived meaninglessness and if people subsequently become more conformist to address this negative existential perception. We conducted three studies to test this hypothesis. In Study 1, experimentally induced disbelief in free will resulted in perceived meaninglessness. In Study 2, perceived meaninglessness correlated with conformity. Finally, in Study 3, perceived meaninglessness mediated the relationship between disbelief in free will and conformity, especially under high self-awareness. We conclude that perceptions about meaning play a central role in the relationship between disbelief in free will and conformity.     

The autistic dialogic style: a case of Asperger's syndrome

This paper explores the idea of possible proto-experiences of the prenatal child in the context of Bion's model of container/contained. The physical configuration of the embryo/foetus contained in the maternal uterus represents the starting point for an enquiry into the unborn child's possible experiences of its state of being contained in a container. The paper takes into consideration the sensory dimensions of auditory, tactile and kinaesthetic levels of awareness of the prenatal child in relation, respectively, to the maternal voice and the uterine environment. The author's hypothesis is that concrete prenatal experiences of containment may have their mental counterpart in the development of a proto-mental container and memory, the existence of which can be observed in the newborn infant. It is also suggested that prenatal proto-experiences of containment may prepare the child for further postnatal realisations of the pre-conception of containment and represent the experiential basis for the encounter with the breast. Observations of newborn babies in an obstetric ward, as well as the observation of a prematurely born child, seem to confirm the idea that the intrauterine experience of container/contained plays a role in the child's prenatal development. The meaning of prenatal thumb-sucking is explored in terms of the model of container/contained at a part-object level. An observation of the play of a three-year-old child offers material for further thought about the meaning and function of the introjected configuration of container/contained for the development of a sense of identity and symbolic thinking. The clinical case of an autistic child who survived a threatened miscarriage shows how the emotional containment in psychotherapy allowed the formerly inaccessible nameless dread to re-emerge and be represented and shared.     

Shifting landscapes of counselling identities in Aotearoa New Zealand

ABSTRACT

The professional identity of counsellors and guidance practitioners in Aotearoa New Zealand is currently under review as a result of the passing of legislation regulating health professionals and the proposed introduction of national registration of counsellors. In this paper I explore this debate, and examine the professional identities claimed by counsellors, counselling psychologists and psychotherapists. The current discussion in this country is both informed by and provides an illuminating lens on professional identity issues in Australia, the UK and the US. An alternative construction of professional identities that are localised and dynamic, yet distinctly of Aotearoa New Zealand, is proposed.     

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.