This March will see the publication of a timely and significant book illustrating the distinctive contribution psychoanalytic thinking brings to our mental health services. Psychoanalysis, the NHS, and Mental Health Work Today (Karnac, March 2017, part of their Psychoanalytic Ideas Series, edited by James Rose, former Chair of the BPC) features contributions from psychoanalysts, psychotherapists, organisational consultants, consultant psychiatrists, and a leading practitioner in the field of primary care.
Between them, they address a wide range of contemporary issues, including the complexity of work with traumatised individuals, including refugees; the wide-ranging psychoanalytic contribution to child and adolescent services; the impact on commissioning of a market culture skewed towards targets and quick wins; and the working conditions that can cause staff to neglect and abuse their patients, and/or become ill themselves.
Leanne Stelmaszczyk caught up with the contributing editor, Alison Vaspe, to find out what motivated the contributors to pull together such a publication and what the aims of its release might mean for the profession.
Leanne Stelmaszczyk: How did the book come about?
Alison Vaspe: I have worked therapeutically for many years with NHS staff experiencing psychological problems, most recently and most extensively as part of an in-house, psychoanalytically informed service in a mental health NHS Foundation Trust. Working so closely with the whole range of these staff – clinical and non-clinical managers; psychiatrists, nurses, and healthcare assistants; administrative and ancillary workers – brought home to me the importance of the emotional and psychological relationships, both intra- and inter-psychic, which keep the whole system working.
There was something very interesting to me about the quick response nearly all of these staff had to my psychoanalytic way of working with them. It was much easier to communicate on this level (including those you might have thought would be averse to a psychoanalytic approach) than I had found to be the case when working with general medical staff. Psychoanalytic thinking seemed to speak to the culture of these staff, even if many seemed to know nothing about it.
There seemed room for a book that could illustrate the distinctive psychoanalytic understanding required if the NHS is to continue to tackle the complex psychological problems that face our society. I hope to interest mental health workers across the board, not just the converted, so to speak, who are well aware of the potential of psychoanalytic treatment and of the various ways in which psychoanalytic thinking contributes to mental health work, in the form of supervision, reflective practice groups, Balint groups, organisational and managerial consultancy, and in thinking about the wider system, in a socio-economic context.
LS: What were the motivations for such an in-depth publication?
AV: Given the range of contributions, it seemed important to give the authors space, so that they could do justice to what was inevitably a selective approach of chapters covering these different aspects. When you have just one chapter on, for example, psychotherapy with adults, one on psychotherapy in Child and Adolescent Mental Health services, one by an organisational consultant, one by a Reflective Practice Group leader, and so on – well, it seemed to me that each one needed to be in-depth.
LS: How close do you think we are to realising Freud’s vision, which you quote in your introduction, of psychotherapy for all that need it?
AV: In 1918, Freud spoke in Budapest of his vision of psychoanalytic clinics that would be available to all, regardless of ability to pay. Thirty years later, after he moved to London but sadly too late for him to witness its beginnings, the NHS was established, with the Tavistock Clinic and the Cassel Hospital both in it from the start. With outreach from these centres to other areas, including GPs, social workers, probation officers, and in education, his vision was partially realised. It was certainly shared by psychoanalysts such as Bion, who in 1961, reflecting on his work in a military hospital, described how ‘[S]ociety, like the individual, may not want to deal with its distresses by psychological means until driven to do so by a realization that some at least of these distresses are psychological in origin… further insight may be needed before whole-hearted backing can be obtained for those who attempt in this way to deal with deep-seated springs of national morale’.
LS: If we understand that one in four will suffer from an episode of psychological illness at some point in their lives, what do you think are some of the barriers to society meeting the challenge of addressing that level of need?
AV: It is a challenge – and probably the main barrier is our difficulty in understanding, and/or wanting to understand, the complexity of the human mind, our vulnerability and need for ‘mature dependency’, as Winnicott put it. We have a social tendency to think of psychological problems in medical terms. Which of us has not had a patient telling us they wish they could suffer a broken arm or leg, rather than face the struggle to explain their need to take time off work for depression or anxiety? There is a shame attached to these conditions, which connote weakness – not to mention the shibboleth of madness. Hinshelwood put it very effectively when he identified the fear of madness as being akin to the fear of death: a fear of death of the mind, which goes back to our very earliest experiences.
LS: How can we today work on overcoming the pitfalls of what your Crichton-Miller quote (referencing the monocular vision of physicians on the one hand and psychotherapists on the other) speaks to? Is there a way of promoting or instituting better integrated services, as opposed to just paying lip-service to society’s accepted notion of the medicalised institute? Is this indeed still an issue, or is society at large slowly waking up to the idea of psychological specialism as independent from medicine?
AV: The NHS Forward View for mental health does address this question, in the vision of ‘No health without mental health’ and ‘Parity of Esteem’ between the two services. However, the reality of improving physical health among those suffering from mental ill-health – and, actually, vice versa, though there was little or no space in this book to address the relationship between physical illness or injury and the psychological suffering that frequently ensues – is not as easy as it may sound. One of the dedicatees of this book, the late Siobhan O’Connor, addresses both the importance and the difficulty, without a therapeutic relationship, of managing the physical health of women patients in a Psychiatric Intensive Care Unit. The context is her struggle to understand why levels of violence in women-only units seemed to be higher than in all-male or mixed units (reflecting her experience of another Government policy, of segregating the sexes). She provides a fascinating account of how she came to understand this, drawing on her own training and her private practice as a psychoanalyst.
LS: Why do you think it’s been so hard to promote and grow the psychoanalytic endeavour? Does it speak to the disavowal (as a psychical defence?) of society to address or face our own mental vulnerabilities?
AV: That is a complex question. I don’t disagree with your interpretation, but I think it is also important to note that as a society, for whatever reason, we seem to be obsessed with a need to break down complex issues into quantifiable units.
This issue is dealt with in the book by means of an interview with a key figure in the field of General Practice, Dr Clare Gerada MBE, by Marilyn Miller, a psychoanalytic psychotherapist with experience of senior management. The main theme of the chapter is ‘General Practice, Mental Health, and Stress’. They refer to the very damaging effects on staff of an organisational system that is characterised by, as Miller puts it, ‘a superficial culture, driven by market principles, and littered confusingly with archaic throwbacks, odd juxtapositions, and linguistic gimmicks.’
There is a lack of fit between this culture and the core psychoanalytic principles, involving the importance of emotional linking in the activity of thinking, of emotional and psychological containment, and of course the importance of unconscious forms of communication, that do not correlate to the concrete, rationalising tendencies of politicians and managers, who need to demonstrate value for money. As Judy Shuttleworth and her fellow authors point out in their chapter about mental health services for children, adolescents, and their parents, existing research methods can reflect and validate the disciplines from which they originated – whether from psychology or from medicine. Psychoanalytic practitioners have been suspicious of means of demonstrating effectiveness that are intrinsically suited to other forms of clinical reality. Ground is now being gained, however, as can be seen from the useful Overview of the evidence base on the BPC website.
One gap in the book, which I regret, is in the area of what research is being done in other fields – psychoanalytic supervision, consultancy, reflective practice groups, and so on. However, in this context I want to mention a very positive development, which is making real inroads into the quality of psychiatric input in mental health services. The Royal College of Psychiatrists’ ‘Learning from the Cradle to the Grave: the Psychotherapeutic Development of Doctors from the Beginning to the End of their Career in Medicine and Psychiatry’ (James Johnston, RCP OP 102, 2017) initiative gives grounds for hope in what can seem a very dispiriting scene.
My experience of working in the NHS has informed my private practice, just as my psychoanalytic training informed my work with NHS staff. Without this experience, I would be much the poorer. Psychoanalytic practitioners are working so hard to ensure unconscious life is thought about in the public sector. Their work benefits us all. I believe psychoanalytic work will continue, but as Siobhan O’Connor’s chapter in the book makes so clear, understanding very ill patients contributes to our understanding of those who may be less floridly unwell, and who can manage to see us privately.
Alison Vaspe trained as a psychoanalytic psychotherapist with the British Association of Psychotherapists (now the British Psychotherapy Foundation), before applying for membership as a psychoanalyst with the British Psychoanalytic Association. She has extensive experience of working therapeutically with NHS staff and students, including fifteen years at the South London & Maudsley Foundation Trust. She is now in full-time private practice in Hampshire.
Her new edited collection, Psychoanalysis, the NHS, and Mental Health Work Today, has just been published by Karnac. Its contributors include: Julia Britton, Tim Dartington, Clare Gerada, Richard Ingram, Amanda Keenan, Marilyn Miller, Turlough Mills, Carine Minne, Siobhan O’Connor, Christopher Scanlon, Judy Shuttleworth, Wilhelm Skogstad, Mike Smith, Joanne Stubley, and Kyriakos Thomaidis-Zades.