Containment lost: the challenge to child psychotherapists posed by modern CAMHS

The paper is an examination of some emotional challenges facing child psychotherapists working in modern CAMHS following the introduction of the NHS internal market for commissioning and providing services. Its introduction has brought the loss of organisational containment for all CAMHS clinicians. The meaninglessness in work reported by clinicians is a clue to this loss. This loss is especially difficult for child psychotherapists because of their particular investment in the apprehension of meaning in symptoms and other presentations by patients. The paper proposes that meaninglessness is itself a clue to the ascendancy of what Freud called the death instinct, and that this is inherent within the internal market model. Because service design and delivery is predicated upon it, the internal market model structurally determines that clinicians are bound to senior management in a way that leaves child psychotherapists open to professional life-threatening dynamics associated with the death instinct. The ?K (Bion) world of CAMHS is thus deathly, leaving child psychotherapists vulnerable to self-destruction. We have lost a workplace in which our approach flourished conferring on us the identity of a discipline structurally favoured, because of the help we provided through this approach to patient and clinic work. This loss of identity brings the dangers of containment lost. This situation leaves child psychotherapists emotionally vulnerable and is akin to Satan’s loss in Milton’s Paradise Lost.     

Well-suited partners: psychoanalytic research and grounded theory

Abstract

Research is a ‘core activity’ of ‘central importance in improving mental health and social care’ (NIME, CAMHS National Conference, 2005 CAMHS National Conference. January 2005. Research in CAMHS Conference Handbook January,  [Google Scholar]). This paper examines the philosophical issues confronted when considering psychoanalytic clinical research. It is argued that a well-suited partnership can be formed between psychoanalytic clinical research and Grounded Theory. The methodological issues encountered when using Grounded Theory to analyse qualitative clinical data are explored. The well-suited partnership formed between Grounded Theory and psychoanalytic clinical research has the capacity to provide explanatory mechanisms, findings that are translatable to routine clinical practice, and to discover new ways of grouping young people so that they are alike in the most significant aspects of their mental health presentations. This makes further clinical trials more reliable. Psychoanalytic clinical findings are used together with a range of material from different sources to develop concepts and theory that are readily accessible to the wider professional community. Illustrations will be provided from the author's doctoral research into Risk-Taking, Dangerous Behaviour.

Selon l'Institut National de la Santé Mentale en Angleterre [NIME], la recherche est une “activité fondamentale” d'une “importance cruciale pour l'amélioration des soins en santé mentale et dans le cadre social” [Colloque National des Services de Santé Mentale pour Enfants et Adolescents, 2005]. Dans cet article, l'auteur étudie les problèmes auxquels sont confrontés les chercheurs en clinique psychanalytique. Il affirme qu'un partenariat tout à fait opportun peut être établi entre la recherche clinique psychanalytique et la théorie inductive ancrée dans le réel (“grounded theory”). Il explore les difficultés méthodologiques que soulève cette théorie inductive appliquée à l'analyse des données cliniques qualitatives. Ce partenariat tout à fait opportun entre la théorie inductive et la recherche clinique psychanalytique est capable de fournir des mécanismes explicatifs et des résultats qui peuvent être mis en application dans la pratique clinique ordinaire; en outre, il permet d'envisager de nouveaux regroupements par catégorie basés sur les aspects les plus significatifs de la pathologie présentée par les jeunes. Les contrôles cliniques complémentaires sont alors plus fiables. Les observations cliniques psychanalytiques sont associées à un éventail de matériel de sources différentes pour développer des concepts et des théories à la portée de tous les intervenants de ce secteur. L'auteur illustre ses propos à partir de sa thèse de doctorat de troisième cycle portant sur la prise de risque et les comportements dangereux.

Mots-clés: Recherche clinique psychanalytique, méthodologie de la théorie inductive ancrée dans le réel (“grounded theory”), philosophie de la science, psychothérapeute d'enfants, spécialiste de Niveau 3 des Services de Santé Mentale pour Enfants et Adolescents, refuges

Riassunto: La ricerca è ‘attività principale’ di ‘importanza centrale per il miglioramento della salute mentale e dell'assistenza sociale’ (NIME, CAMHS National Conference, 2005). Questo articolo esamina le questioni filosofiche che si incontrano quando si considera la ricerca clinica in campo psicoanalitico. Si sostiene che un buon rapporto di partnership possa essere stabilito tra la ricerca clinica psicoanalitica e la Grounded Theory. Vengono esplorate le questioni metodologiche che si incontrano quando si usa la Grouded Theory per analizzare dati clinici qualitativi. Il rapporto di partnership che si stabilisce tra Grouded Theory e la ricerca clinica psicoanalitica ha la capacità di fornire meccanismi di spiegazione, risultati che sono traducibili nella pratica clinica di routine, e di scoprire modi nuovi di raggruppare i giovani in modo che siano simili per gli aspetti pi[ugrave] significativi della loro presentazione in salute mentale. Tutto ciò rende pi[ugrave] affidabili ulteriori prove cliniche. I risultati clinici psicoanalitici vengono usati con una serie di materiali di origini diverse per sviluppare concetti e teorie che siano facilmente accessibili alla pi[ugrave] ampia comunità dei professionisti. Verrà fornito del materiale dal lavoro di dottorato di ricerca dell'autore sul comportamento di rischio e sul comportamento pericoloso.

Parole chiave: ricerca clinica psicoanalitica, metodologia della Grounded Theory, filosofia della scienza, psicoterapia infantile, Tier 3 Specialist CAMHS, rifugi

Forschung ist eine ‘zentrale Aktivität’ von besonderer Wichtigkeit in der Verbesserung von psychischem Wohlergehen und Sozialfürsorge’ (NIME, CAMHS Nationalkonferenz 2005) Dieser Artikel untersucht philosophische Fragestellungen, mit denen man konfrontiert wird, wenn man psychoanalytische klinische Forschung in Betracht zieht. Es wird argumentiert, dass eine gut funktionierende Partnerschaft zwischen psychoanalytischer klinischer Forschung und grounded theory hergestellt werden kann. Es werden die methodologischen Fragen, auf die man stösst, wenn man grounded theory benutzt, um qualitative klinische Daten zu analysieren, exploriert. Die gut funktionierende Partnerschaft zwischen ‘grounded theory’ und psychoanalytischer klinischer Forschung hat die Fähigkeit, Erklärungsmechanismen und Ergebnisse bereitzustellen, die routinemässig in klinische Praxis übersetzt werden können, und neue Arten der Gruppierung von jungen Leuten zu entdecken, sodass sie sich in den signifikantesten Aspekten ihrer Präsentierung ähneln. Weitere klinische Versuchsreihen werden dann mehr verlässlich. Es werden klinische Ergebisse zusammen mit einer Reihe von Materialien von verschiedenen Quellen benutzt, um Konzepte und Theorien zu entwickeln, die für die weitere professionelle Gruppe leicht zugänglich sind. Es werden Illustrationen aus der Doktorarbeit der Autorin über das Eingehen von Risiko und gefährlichen Verhaltensweisen gegeben.

Keywords: Psychoanalytische klinische Forschung, Methodologie der ‘grounded theory’, Wissenschaftsphilosphie, Kindertherapeut, Kinder-und Jugendpsychiatrischer Dienst, Zufluchtsorte     

Users of secondary school‐based counselling services and specialist CAMHS in Wales: A comparison study

Background: The increasing prevalence of mental health issues in young people has contributed to a rise in the provision of school‐based counselling services in the UK. Between 2008/09 and 2010/11, data were collected from users of secondary school‐based counselling services in Wales. Aims: To identify the characteristics of users of school‐based counselling services in Wales – including demographics, referral pathways, presenting issues, and predominant issues – and how they compare to users of specialist CAMHS in Wales and Welsh secondary school pupils in general. Method: Data were collected on 10,687 episodes of counselling. School counsellors completed a client record sheet after each counselling episode and submitted these to their Local Authority. Collated results were then compared to matched data from Welsh specialist CAMHS and Welsh secondary schools data. Results/findings: A typical user of a secondary school‐based counselling service in Wales was female, of white ethnicity, and from the ‘middle’ school years. There was a marked under‐representation of users from BME backgrounds. Users were most often referred by school staff, and the most common presenting issues were family‐related, anger, and behaviour‐related. Conclusions: There was a higher proportion of females accessing school‐based counselling services than males. This was in direct contrast to data from specialist CAMHS and possible explanations for this are discussed. The under‐representation of BME populations suggested that there were some equality issues associated with accessing these services. Implications for practice: Future research should explore equality issues associated with young people from BME backgrounds accessing intervention services.     

‘Who owns my pain?’ An aspect of the complexity of working with looked after children

This paper underlines the difficulties of working with looked after children and their carers. The author discusses a particular approach to respond to the complexity of looked after children's emotional difficulties, and their impact on the network of professionals making decisions about their life in care. As their own parents are no longer in a position to take responsibility for them, their trauma and past abuse make for a lack of clarity amongst this network when establishing the responsible role in loco parentis. In order to provide effective therapeutic work with these children, it is crucial to consider their disturbance as affecting the network around them. Enabling the network to understand and process powerful feelings around the child enhances its self-reflective function, so crucial for thinking about the child's needs and emotional development.     

Working with the complexities of adolescent mental health problems: applying time-limited adolescent psychodynamic psychotherapy (TAPP)

This article discusses the application in a CAMHS setting of a distinctive intervention for adolescent mental health difficulties, time-limited adolescent psychodynamic psychotherapy (TAPP). TAPP has been developed specifically for working with adolescents and the characteristic developmental and psychosocial complexities they present to mental health services. It is widely recognised that supporting the developmental process in adolescence is central to therapeutic interventions and the therapeutic aim of TAPP is to enable recovery of the capacity to meet developmental challenges. The key factors of TAPP are described, including the formulation and working with a developmental focus, the therapeutic stance, working with transference and counter-transference, working with time limits, and the emphasis is placed on engagement of adolescents in therapy in TAPP. The experiences of introducing and developing TAPP in the CAMHS service are discussed with two brief and one extended case examples and this leads to a discussion of the kinds of outcomes achieved. It is concluded that TAPP is a key and relevant intervention for adolescents in complex and vulnerable situations; further work will be undertaken to continue its application in these settings and to formally assess outcomes.