Understanding,respecting and integrating difference in therapeutic practice

The purpose of this paper is to promote thought and discussion around how and why we treat patients in chosen ways. In the present climate practitioners are required to treat patients following NICE guidelines in which cognitive behavioural therapy (CBT) is the treatment of choice in the majority of diagnoses. This paper raises concerns that this may lead to an homogenization of treatment, loss of invaluable skills and understanding from other treatment approaches, and loss to the patient who may be best cared for by a combination of treatments and approaches, most notably patients presenting with complex pathology. This paper aims to present this as a general principle, and by way of example, will focus on coupling two specific treatment orientations, cognitive behavioural therapy with psychodynamic psychotherapy, with the specific diagnosis of obsessive compulsive disorder (OCD).

Methods: Clinical material is drawn from case studies from practice in secondary adult mental health care services within the NHS. All patients were referred to the psychological services for treatment for OCD and provided with 1:1 therapy with UKCP‐registered therapists. Details have been anonymized by describing fictitious cases re‐constructed from clinical material. A theoretical understanding is included which provides both an overview for integrating treatment for the specific example of OCD and is intended by extension to other diagnoses.

Results: Working with the commonalities of therapeutic approaches, and integrating specific skills of CBT and psychodynamic psychotherapy, appears to offer a viable mode of treatment for cases resistant to single‐orientation therapies.

Conclusions: Coupling the skills of different therapies can be effective in treating complex patients that are referred to the secondary mental health services. Conversely, restricting practice to single orientation therapies can lead to an impoverished care for patients and diminution of invaluable therapeutic skills which may become underused, undervalued and lost in the practice of mental health care within the NHS. Acknowledgement of the skills of others, valuing these and learning from each other can help to avoid the defensive reactions of practitioners, where each may defensively retreat to their corners of specialism. Respecting and sharing skills from different orientations, and acknowledging this in the NICE guidelines, is good for both mental health services and patient care and addresses the concerns raised by practitioners exemplified by Bateman (2000 Bateman, A. 2000. Integration in psychotherapy: An evolving reality in personality disorder.. British Journal of Psychotherapy, 17(2): 147–156.  [Google Scholar], p. 147) that ‘psychotherapy continues to be bedeviled by ideological schisms with practitioners apparently ignoring alternative conceptualizations and potentially superior interventions’.     

Digital technology is here to stay and the psychoanalytic community should grapple with it

Digital technologies have revolutionised our lives and are also gradually affecting the way psychoanalytic psychotherapists and their patients interact. The author claims that these changes need to be embraced responsibly and with an open mind by the profession and illustrates some of his own experiences with clinical material.     

Psychotherapy with an adolescent boy who refused medical treatment

In this paper we describe psychotherapeutic work carried out in a paediatric hospital to illustrate the important contribution of a psychoanalytically-oriented approach in a hospital context. The work concerns an adolescent boy who had undergone several surgical operations with the result that some of his natural orifices were obstructed and artificial ones had to be created. He was referred to us because he refused pharmacological and rehabilitative treatment necessary prior to further surgery and his eventual recovery. The boy's experience of loss of control of his life and the more primitive anxieties of not feeling safely contained in his physical and psychic skin emerged and were worked through in the psychotherapeutic relationship. The parallel work with medical staff reduced the risk of splitting and acting out by the patient and professionals. The approach adopted enabled this boy to resume his medical treatment and his developmental process.     

The development of a brief group intervention (Dynamic Interpersonal Therapy) for patients with medically unexplained somatic symptoms: a pilot study

The primary aim of this equivalence study was to compare the outcome of a brief group therapeutic intervention, based on the principles of dynamic interpersonal therapy (DIT) with an intervention based on cognitive behavioural therapy (CBT) in patients suffering from medically unexplained somatic symptoms (MUSS). Participants were 89 patients (aged 18 to 62) who were offered 20 sessions of either DIT or CBT, as central part of a treatment package, consisting of art therapy, psychomotor therapy, social therapy and physical therapy. Measurements were conducted at baseline, 10 weeks and 20 weeks, using self-rating scales measuring the level of anxiety and depression, the severity of medically unexplained symptoms and quality of life. Results showed that CBT and DIT were comparable. The conclusion was that it is recommended to design a larger scale randomised controlled trial to further elaborate the short-term and long-term effects of this novel psychodynamic group therapy for MUSS patients.     

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.     

The embodied analyst: from Freud and Reich to relationality

This paper presents the impact of clinical supervision on once-weekly psychoanalytically-informed training psychotherapy. The development of Oedipus complex theory is presented, culminating in Britton's work on the triangular space that opens up by working through the complex. The geometry of psychic space is described to highlight the importance of supervision, especially when training in therapy. The theme of spiders and cobwebs emerging from the clinical material provides a powerful metaphor for the tensions in psychic space. In the course of this training, the trainee therapist was at times less able to benefit fully from supervision, and thus the third position partially collapsed. Vignettes from anonymised clinical work are presented in the three ‘phases’ of this therapeutic process, illustrating the impact of the presence – and relative absence – of supervision.     

Of “sleep and dream: A psychoanalytic essay' by Joyce McDougall (discussion)

Abstract

The author describes experiences gathered during several years of teaching psychodynamic psychotherapy with psychologists and psychiatrists within a 2-year-training programme in Shanghai, China. Questions and problems of the reception of psychoanalysis – shame, sexuality, harmony, abstinence – as well as the possibilities and limitations of exporting psychoanalysis are discussed. The possible future development of psychoanalysis in China is also outlined.     

Editorial

With the aim of increasing knowledge about processes of change in psychodynamic individual child psychotherapy, sessions that could be called turning points were analysed.     

Types of sexual transference and countertransference in psychotherapeutic work with children and adolescents

The question of normal sexuality begins to arise in the treatment of severely sexually abused or sexually offending patients. The author suggests that it is an interesting and delicate moment during the process of recovery when less perverse, more normal sexuality appears mixed with, or even disguised by, the more habitual perverse fantasies. Writers in the adult field have drawn distinctions between perverse, eroticized and normal erotic transferences, and between Oedipal and post-Oedipal sexuality. Some have also distinguished between countertransferences in the analyst of an erotised versus a normal erotic nature. The paper discusses whether these distinctions could have any relevance for child patients. Freud and Klein have taught us much about the child's sexuality in relation to his interest in and attraction to his parents as sexual beings. But can we also detect some origins in earlier experiences in infancy of the child's later capacity to feel himself a sexual being capable of being wanted by an other? How might such a feeling of sexual self-worth differ from narcissism and from sexualised exhibitionism? The paper asks how therapists might deal with such problems and such possibly healthy developments.     

Psychodynamic psychotherapy for children and adolescents: a critical review of the evidence base

For many years psychoanalytic and psychodynamic therapies have been considered to lack a credible evidence-base and have consistently failed to appear in lists of ‘empirically supported treatments’. This study systematically reviews the research evaluating the efficacy and effectiveness of psychodynamic psychotherapy for children and young people. The researchers identified 34 separate studies that met criteria for inclusion, including nine randomised controlled trials. While many of the studies reported are limited by sample size and lack of control groups, the review indicates that there is increasing evidence to suggest the effectiveness of psychoanalytic psychotherapy for children and adolescents. The article aims to provide as complete a picture as possible of the existing evidence base, thereby enabling more refined questions to be asked regarding the nature of the current evidence and gaps requiring further exploration.