Contemporary Developments in Adult and Young Adult Therapy: The Work of the Tavistock and Portman Clinics

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'Nature dictates that as individuals we are conceived, are born, and then at some point later die. The shape of the arc that we follow, involving growth and development with eventual decline, is something that we might all like to influence. It has been argued that the same basic curve, however, is followed by societies, civilisations and indeed organisations. How does an organisation influence its trajectory? How do organisations avoid the pull towards conservatism and protectionism associated with the developmental plateau found at the top of the curve?.... I think that in this book Professor Alessandra Lemma has given us something of an insight into this process within one organisation, the Tavistock and Portman NHS Foundation Trust. ... The work of the Trust is now broad. Training and education makes up almost half of the activity, while Child and Adolescent mental Health Services over half of the clinical work. Professor Lemma has, in this first volume, broadly focused her attention on our work with Adolescents and Adults ... She has clearly selected her authors for their quality and supported them with similar care. All of this is evident in the chapters that comprise this book, and in the description of an organisation struggling to evolve in a manner that links it inextricably to the communities and society within which it is situated as much as to its own history.' - From the foreword by Dr Matthew Patrick, Chief Executive, Tavistock and Portman NHS Foundation Trust

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1: Talk talk: theories and practices for turbulent times

ePub

Andrew Cooper

Only by changing our institutional world can we change ourselves at the same time, as it is only through the desire to change ourselves that institutional change can occur.

David Harvey (2000, p. 186)

Mental health: hard labour

Stability or closure of our identities is an illusion. Too much change and transformation is intolerable. We seek closure as a refuge from the anxiety and mental turmoil it creates in us. We do this via the stories we tell about ourselves and others. These narratives structure our world, supported by and giving shape to powerful conscious and unconscious feeling states. But the stability of these emotional structures is illusory. They protect us at the same time as they limit our possibilities and freedom of thought and action. This is not a new paradox, but for individuals and organiza-tions—especially those devoted to alleviating mental suffering—it is given fresh significance by the times. The political, intellectual, and policy culture we inhabit ceaselessly demands innovation, transformation, and renewal. Thus it promotes one side of the paradox and demotes the other, the necessity of illusions, the need for a place to rest and think.

 

2: A plurality of just answers

ePub

Bernadette Wren & Ellie Kavner

Multiple identities and tribal loyalties

With the introduction of a more competitive, outcomes-oriented, and micro-managed NHS political economy, many mental heath institutions have become ideological battlefields where struggles for disciplinary primacy are being waged daily. In our workplace, rival modalities—articulating competing theories about and remedies for troubled behaviour relationships and inner worlds—are often seriously out of sympathy with each other. Many staff express anxiety about the way one model may gain favour over another within the NHS, and a fierce determination to defend time-honoured principles and practices in their clinical and teaching work.

With backgrounds in clinical psychology (BW) and social work (EK), we are two systemic psychotherapists working in an NHS institution, the Tavistock and Portman Trust, facing a future full of uncertainty. How and where we will be working in another five or ten years’ time is unpredictable. But, whatever is to come, we think there are a number of related risks attached to our adherence to the often sharp boundary marking that informs the working practices in our own and other mental health services.

 

3: Time-limited psychodynamic psychotherapy for adolescents and young adults

ePub

Stephen Briggs & Louise Lyon

This chapter discusses processes involved in articulating and evaluating a model of time-limited psychodynamic psychotherapy for young people, developed in the Adolescent Department in a multidisciplinary team working in a specialist service for young people with mental health difficulties. Time-limited therapeutic approaches are increasingly deployed in contemporary mental health practice, which recognizes an increased role for psychological therapies. These therapeutic modalities are largely—if not entirely— time-limited and focus on short-term relief of symptoms and problem behaviours. In contrast, this model of time-limited psychodynamic psychotherapy has at its core a treatment that focuses on the emotional and relational aspects of the adolescent developmental process. It aims to be relevant for contemporary practice in mental health services, to be replicable and evidence-based and usable within current resource availabilities. It aims also to provide a critical perspective to therapeutic modalities for adolescents that are symptom-oriented and practices that are diagnostically and risk-management-led, particularly through connecting the psychological processes of therapy with the social contexts for contemporary adolescents through the devel-opmentally focused approach. The model is in a state of evolution, and the discussion here will, first, identify some key contexts for the development of time-limited psychodynamic psychotherapy and, second, illustrate aspects of the model, including the role of audit, manualization, and the relationship between process and outcome. An illustrative case example is used to closely follow therapeutic processes in this approach for young people of different ages and hence at different points in the adolescent process.

 

4: The Young People’ s Consultation Services: a model of engagement

ePub

Linda Young & Frank Lowe

The adolescent process

As many writers, scientific and literary, have identified, adolescence is a turbulent period of profound change. The physical transformation initiated by the onset of puberty is but one of many, albeit one that is particularly striking and momentous. Any of us can observe how profound the change is when we look at a class of 11-year-olds, chronologically at the same age but, in terms of their physical development, very variable, ranging from those who are still pre-pubertal to those girls whose bodies are taking on a more adult, sexual form and who are beginning to menstruate, and boys who are growing taller, with voices breaking and increasing body hair. We know they will all need to negotiate these physical changes over the next few years, as we did ourselves in our own adolescence. Within this context of individual variability, puberty begins around the age of 10 and persists for approximately five years (Coleman & Hendry, 1999).

But there are other processes to be negotiated during this adolescent period. Along with the more overt physical changes prompted by increases in sexual and growth hormones are increases in sexual and aggressive drives, with accompanying and often highly charged and conflict-laden phantasies. The mental and emotional life of the adolescent takes on new dimensions that are challenging, exciting, and fearful. During puberty the girl comes to be able to carry a baby and the boy to impregnate a woman; both have the strength to cause physical damage to another in a way not possible during childhood years. These physical changes bestow a particular significance to sexual and aggressive phantasies, perhaps held unconsciously towards forbidden figures such as parents or siblings (see Blos, 1962, 1967; Klein, 1922; Waddell, 1998).

 

5: Complexity in primary care

ePub

Brian Rock & Anca Carrington

In recent years there has been an unprecedented investment in mental health within primary care and through the Improving Access to Psychological Therapies (IAPT) programme. This has led to the establishment of services primarily offering cognitive behavioural therapy to those people with common mental health problems—that is, mild to moderate anxiety and depression. Lord Layard, the architect of the IAPT programme, made a compelling financial case for such investment—around 173 million in the first three years—because he was able to demonstrate how such provision would enable those people unable to work and requiring incapacity benefit to return to work, thereby becoming more productive in society and more fulfilled in their lives.

IAPT has done what it says on the tin, so to speak, enabling thousands of people to access psychological help who would have not been able to meet the threshold criteria for secondary care services. If you imagine the stepped care model as a pyramid, with the more complex, specialist services/interventions provided closer to the apex, then IAPT services have strengthened the foundation in primary care and aimed to improve links with secondary/tertiary services.

 

6: Treatment continuity in discontinuous worlds

ePub

Carine Minne

Long-term continuity of treatment for forensic patients: a luxury or necessity?

In this chapter, I present the case of a very ill young man who, in addition to the usual psychiatric treatment, was provided with long-term continuity of psychoanalytic psychotherapy during the ten years he spent moving from a high secure psychiatric setting and eventually back to the community. The provision of such long-term psychotherapy for patients suffering from serious mental disorders can be misconstrued as a luxury. The NICE Guideline (2009) that maps out treatment for patients in forensic psychiatry settings has, for example, recognized the need to lengthen interventions, but these can remain disrupted as the patient moves between clinical teams and may, accordingly, be concerned with short-term goals of “treating crises, symptoms of distress … rather than core personality disorder psychopathology” (Warren, 2003). Furthermore, the economic considerations on public health-care spending have focused the attention away from what the patient fully requires to what is cost-effective. Published research has substantiated the need to reconsider the treatments typically given to severely disturbed patients; a meta-analysis of studies of the phenomenon of psychopathy found longer-lasting treatments more effective, albeit this included anything over as little as one year long (Salekin, 2002). The paper also indicates that recidivism in cases where continuous care is absent costs significantly to the community.

 

7: Picking up a log from both ends: couple work in the Tavistock tradition

ePub

Joanna Rosenthall

The idea of a couple coming together to produce a child is central in our psychic life, whether we aspire to it, object to it, realise we are produced by it, deny it, relish it, or hate it.

Ron Britton (1989, p. xi)

The history of “Tavistock” couple work started in the period following the Second World War. The new leadership at the Tavistock wanted to establish the clinic’s place in the newly established NHS, which involved major reorganization. According to Henry Dicks, the changes evoked resistance from the old guard, who felt that “playing with innovations like group therapy and other ‘ perversions’ of Freud’s technique was a very dangerous ‘ deviation-ism’” (1970, p. 6).

One of these “perversions” was psychoanalytically informed couple work, which was split between two organizations: the Marital Unit in the Tavistock Clinic, which had opted into the NHS, headed by Henry Dicks, and another grouping emerging from the Family Welfare Association, called the Family Discussion Bureau, later the Institute of Marital Studies, now the Tavistock Centre for Couple Relationships (TCCR). While the present-day Couples Unit in the Tavistock and Portman NHS Trust and the TCCR are separate bodies situated in different organizational contexts, they both have their roots in the “Tavistock Family” and share the philosophy of developing clinical work with couples using a psychoanalytic approach.

 

8: Treating the untreatable: the evolution of a psychoanalytically informed service for antisocial personality disorder

ePub

Jessica Yakeley

People tend to define and categorize themselves and others on the basis of appearance and behaviours. While attitudes towards certain types of appearance (such as skin colour) or behaviours (such as homosexual acts) have become more tolerant, other sexual and aggressive behaviours have become less acceptable to today’s society, which is more likely to react with punitive and ostracizing measures in the name of public protection than attempt to analyse the complex underlying dynamics and motivations of the person involved. It is as if the individuals behind the behaviours have been lost from view, and, more specifically, their minds and the complex contents and processes within are forgotten or dismissed as simply bad.

The field of mental health has not escaped the myopic tendency to focus on the most obvious behavioural manifestations of human activities at the expense of the much more uncertain endeavour of exploring the mind. Mental illnesses and disorders of personality are diagnostically categorized on the basis of observable symptoms, signs, and behaviours, regardless of aetiological theories. Antisocial personality disorder (ASPD) is a syndrome affecting approximately 1% of the male population (Coid, Yang, Tyrer, Roberts, & Ullrich, 2006; Torgensen, Kringlen, & Cramer, 2001) that is defined largely by behavioural criteria, particularly those emphasizing criminality. This is one reason why many people with a diagnosis of ASPD have contact with the criminal justice system, where their behaviours are punished, but may have little or no contact with the mental health system, as they are thought undeserving or unsuitable for treatment. Their plight has been exacerbated by the constant reorganization of community and forensic psychiatric services, with a primary focus on treating mental illness rather than personality disorder. Such fragmentation of service provision mirrors the disrupted lives and chaotic inner worlds of these difficult patients, and those who do seek treatment often find themselves being referred from service to service—a repetition of their early attachment history.

 

9: Where Internet was, there ego shall be: community and well-being in the digital world

ePub

Richard Graham

Over the past 20 years rapid developments in technology have radically changed the ways individuals communicate or form groups and communities: they can now spend almost half of their waking time online, communicating with each other. There is now an unprecedented capacity for any individual with access to the Internet to be in contact with a multitude of others and communicate ideas and beliefs to an entire world. However, while this creates a powerful opportunity to promote change, without a stable capacity for judgement there is a risk of causing harm as well as improving a sense of well-being. This chapter aims to explore the opportunities afforded by the digital revolution in promoting contact between individuals and establishing communities that can have a therapeutic effect. The emphasis is thus both on mental well-being and mental distress and how these may be attended to in online communities.

This chapter describes how psychoanalysis afforded a deeper understanding of mankind’s group behaviour, which led to an appreciation of how communities can function. The work and ideas of Wilfred Bion are explored, particularly those that emerged when he worked as an Army psychiatrist during the Second World War and observed how a community can be mobilized to find solutions to its own problems and consequently improve its sense of well-being. The latter part of the chapter describes how the Tavistock and Portman NHS Foundation Trust, recognizing the opportunities of the digital world, has established a partnership with an online well-being service, Big White Wall, to promote the well-being of its members, through the facilitation of its community activities and positive relationships.

 

10: Dynamic interpersonal therapy (DIT): developing a new intervention for depression

ePub

Alessandra Lemma, Mary Target, & Peter Fonagy

D“epression”, a patient said, “… feels like wearing a beautifully embroidered black veil. I know I can’t see things clearly through it, but I don’t know that I could reveal myself to the world without it.” This comment captures vividly the complexity of depression: it is a disabling condition, and yet the relationship an individual may have with it—that is, its function in the patient’s psychic economy—may make the patient fearful of change and hence resistant to being helped.

Depression is a common and often complex condition that typically manifests early in life: 40% of depressed people experience a first episode by age 20 (Eaton et al., 2008). It interferes with social and occupational functioning, is associated with considerable morbidity, and carries a significant risk of mortality through suicide (Ustun, Ayuso-Mateos, Chatterji, Mathers, & Murray, 2004). Incomplete recovery and relapse are all too common. Following the first episode of major depression, people will go on to have at least one more episode (Kup-fer, 1991), and the risk of further relapse rises sharply, to 70% and 90%, after the second and third episodes, respectively (Kupfer, 1991).

 

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