n e w s , a n a l y s i s , o p i n i o n f o r t h e psychoanalytic c o m m u n i t y i s s u e 7 AUTUMN 2011

A future New review Working in Psychosis and strategy for supports a forensic psychoanalytic the BPC psychodynamic setting approaches 2 5 therapies 8 11 which we hope will be well attended The strategy for growth combined by many BPC registrants and other with the moves towards CHRE/PSA psychoanalytic practitioners. And finally, accreditation creates the need for A blueprint the BPC is moving towards a position significant changes to the structure of the statement that is expected to be adopted organisation: at the levels of constitution, by the November Council meeting. governance and management. The BPC Together these developments will give Council already feels too large and meets for growth the pathologisation model the quiet too infrequently to function properly as retirement it now deserves, and hopefully a high-quality decision-making body; allow for a new dawn of scientifically this can only get worse as we expand. In By Malcolm Allen rigorous, psychoanalytic exploration of addition, accreditation is bound to require psychosexuality – at last reclaiming the major changes to the way we do business. movement’s original home ground. Our staff and management functions will also need to be re-organised around these STRATEGY CONFERENCE A new sense of purpose is in the air. This is also a necessary precondition to new imperatives. This change process will in October representing A number of existing BPC member start to seriously address the issue of be a major focus of work over the coming all the member institutions are exploring the option diversity for the profession, not out of months. institutions of the BPC of a merger. The BPC is in discussion anxiety about ‘political correctness’, but unanimously signed off a bold, forward- with the Association for Psychoanalytic A because a profession that is not able to The work of the Future Strategy Working looking plan for expansion. Central to Psychotherapy in the NHS (APP) and the engage with – and reflect – the diverse Group, led by Helen Morgan and Alexa this ambitious blueprint is a capacious Association for Child Psychotherapists nature of contemporary demography isn’t Walker in partnership with the Executive, view of the profession the BPC now (ACP) with a view to creating a more going to carve out much of a place in the laid the basis for the decisions taken at aspires to work for. It seeks to champion united and powerful campaigning force modern world. The decision that the BPC the Strategy Conference. The group is the whole of the psychoanalytic and for our approach. We are re-opening a will develop a ‘realistic action plan’ in this now turning its attention to questions of psychodynamic sector, moving beyond the conversation with the Institute for Group area is vital; and the words are important. implementation, and in particular the limited appeal to ‘frequency’ as the Analysis (IGA) to explore the possibility We have to move beyond easy rhetoric major challenges around promotion and ultimate litmus test of what does or of developing a closer relationship. Our and abstractions, and start to think about advocacy. This is to be the subject of a doesn’t constitute psychoanalytically- Registration Committee is now working what practical, incremental steps we can major Search Conference on Saturday, 28 based work. harder than ever with a queue of take that will begin to make a tangible April 2012. organisations seeking BPC accreditation. difference. In its place, a statement that aims In the meantime, we have been attracting In the face of the major challenges and to capture the broad principles new affiliate member organisations, The Strategy Conference spent time setbacks being experienced recently, underpinning psychoanalytically- including our first international affiliate: considering the complex question of especially in the NHS, a new spirit of informed work will be the grounds for the South African Psychoanalytic regulation, especially the government’s determined realism has begun to show membership of the BPC. A statement Confederation. proposals around ‘assured voluntary itself. That old boiler of a philosopher, of the BPC’s new strategic vision and regulation’ that the Council for Friedrich Hegel, put it well: ‘Only when the draft statement of principles, with Regulatory Health Care Excellence the dusk starts to fall does the owl of the latter expected to be ratified by a ‘There is talk of (CHRE), to be renamed the Professional Minerva spread its wings and fly’ November BPC Council meeting, are both Standards Authority for Health and published inside. a “psychoanalytic Social Care, will be responsible for. The conference supported the view that the Malcolm Allen is CEO of the BPC The statement of principles provides a spring”.’ BPC should provide a form of regulation basis for eligibility for psychodynamic and registration for the profession, and organisations whose members train One area where the ‘psychoanalytic will work towards accreditation from and work at lower frequencies than is spring’ is really making itself felt is the CHRE/PSA, though the final traditionally the case with our existing homosexuality. For a long time, a quiet decision membership to become BPC member consensus has been growing within on the institutions. Accrediting lower-frequency the BPC’s constituency that does not application trainings was already agreed in 2008, view as useful or even relevant the will be providing they were attached to existing pathologisation of same sex relationships made member institutions. Now an organisation that has been promoted in the past. when based on a twice-weekly or once-weekly However, this has been implicit rather the full model can join the BPC in its own right. than explicit, and has not been articulated implications in a forthright way across the community, are Taking a cue from recent events in let alone beyond. It has been thought to clear. We are the Middle East, there is talk of a be too ‘sensitive’, on the odd calculation expecting CHRE ‘psychoanalytic spring’. Growing numbers that deference to past orthodoxies was to publish their of people within the psychoanalytic more important than our relationship latest thinking community acknowledge that the with the gay and lesbian community, on the scheme massive challenges we face will not especially potential trainees and patients. in December, be overcome by recycling yesterday’s An irreversible change is now in train. following a series solutions. Conversations are taking place of consultative at all levels and in all organisations The last Psychoanalytic Psychotherapy workshops held over about the need for radical and innovative NOW conference organised a lively break- the summer and early measures to maintain the future of out session on the issue which attracted autumn. The target psychoanalytically-informed work. significant numbers of participants. start date for the Previously unthinkable ideas are taking The next edition of the APP’s journal scheme is July 2012. shape and galvanising new energies. Psychoanalytic Psychotherapy is devoted Rigid thinking and calcified ways of to the subject. A special conference on doing things are being questioned. psychoanalysis and homosexuality takes place on Saturday, 21 January 2012 2 NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1 NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1

The BPC’s new strategic vision

THE FOLLOWING statement of the BPC’s strategic vision was agreed by a special Strategy Conference held on Saturday, 1 October 2011.

The broad aims of the British Psychoanalytic Council (BPC) are: • to support and sustain a viable psychoanalytic/dynamic professional community • to build an effective professional organisation serving the professional needs of that community • to maintain and expand the availability and attractiveness of psychoanalytically-informed work to a UK population with diverse needs.

To achieve these aims the BPC has agreed the following strategic objectives for the next 2 – 3 years.

1. The BPC will seek to redefine and realign the profession around a 2.2. The BPC will work towards an application for accreditation from trajectory of growth the Professional Standards Authority for Health and Social Care (currently the Council for Regulatory Health Care Excellence), 1.1. The BPC will develop a formulation of the theoretical basis and though the final decision on the application will be made when the boundaries of eligibility for membership of the BPC. full implications are clear.

1.2. The BPC agrees the principle of accepting eligible psychodynamic 2.3. The BPC will work on proposals around its governance and organisations as BPC member institutions whose members procedures that are deemed necessary to secure accreditation train and work at lower frequencies than existing BPC member from the CHRE/PSA in the light of the emerging scheme. institutions. 2.4. The BPC will play an active part as a stakeholder in the process of 1.3. The BPC will develop a realistic action plan that starts to credibly developing the CHRE/PSA’s accreditation scheme. address the long-standing issues of equality and diversity within the profession. 3. The BPC will shape a strategy for the promotion of psychoanalytically-informed work 1.4. The BPC will develop a realistic action plan to establish the BPC as a truly national organization rooted in the nations and regions of 3.1. The BPC, using the focus of the planned Search Conference, the UK. will develop a strategy for the promotion and advocacy of psychoanalytically-informed work in all sectors to enable our 1.5. The BPC will conduct purposeful discussions with like-minded registrants and member institutions to compete more effectively psychoanalytic/ dynamic organizations with a view to achieve within the contemporary market. greater organisational cohesion in the short term. 4. The BPC will work with its member institutions to help rethink and 1.6. The BPC will continue to build collaborative relationships with reorganise the training of the future profession bodies such as United Kingdom Council for Psychotherapy (UKCP) and British Association for Counselling and Psychotherapy (BACP) 4.1. The BPC, using the focus of the planned Training Conference, that also represent psychoanalytic/psychodynamic practitioners. will work with member institutions to develop a comprehensive and diverse training infrastructure throughout the UK, capable 1.7. The BPC will develop a scheme to enable and encourage individual of training future generations of psychoanalytically-informed and group affiliates, especially from relevant fields such as therapists. psychiatry, government, NHS, universities, etc. 5. The BPC will refocus our information and other services to support 1.8. The BPC will agree to give high priority to communicating the profession effectively to our own registrants the importance of the BPC’s strategic mission and objectives. 5.1. The BPC will refocus its information and other member services with a view to enable our registrants and member institutions to 2. The BPC will provide an appropriate form of regulation for the compete more effectively within the contemporary market. profession

2.1. The BPC will continue to act as the voluntary regulator for the profession of psychoanalytic and psychodynamic psychotherapy and counselling, maintaining a professional register. NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1 3

BPC chief executive moves on

Malcolm Allen, the BPC’s chief executive ‘Malcolm has been an outstanding CEO. for the past five years, is to become the Our community does not easily take new Dean of Postgraduate Studies and to being ‘led’ by a non clinician. It is a Director of Education and Training at the testament to his skill and intelligence Tavistock and Portman NHS Foundation that he has earned such a degree of Trust. He will start the new post at the admiration and gratitude. Above all he beginning of January 2012. has demonstrated how a professional organisation can play an important part Malcolm said: ‘I am immensely looking in the promotion of the psychoanalytic forward to meeting the challenges of the project. His contribution can be measured new post at the Tavistock. But I will be in the wide range of working relationships leaving the BPC with great sadness. The he has developed both within the BPC last five years has been amongst the most and beyond. For myself it has been an A proposed formulation richly rewarding of my professional life, inspiring partnership and it goes without and I have enjoyed massive support from saying that we shall miss him greatly. of the theoretical basis every section of the BPC constituency. I believe that together we have achieved ‘Whilst managing our sense of loss I do that defines the BPC a huge amount, and that with the new also believe that no organisation depends strategic vision in place, the BPC is poised on one person and I feel confident that we and its boundaries for a new wave of growth and success. shall make another good appointment so I am proud to pass on that legacy to my that we can continue the work Malcolm successor.’ has made such a creative contribution to.

The following describes the five broad principles that would have to Julian Lousada, Chair of the BPC, writes: ‘The consensus that the recent BPC be shared by any organisation joining the BPC as the basis for clinical ‘One of my first acts as Chair of the BPC Strategic Council achieved is in no practice. It is an attempt to define only what is necessary and sufficient as was to be a member of the panel that small way an illustration of Malcolm’s a statement of the basic criteria, and does not aim to be a comprehensive appointed Malcolm Allen. Quite simply achievement in helping our community description of psychoanalytic/dynamic practice. The formulation is this was probably the best decision I and collaborate and develop.’ intended to cover psychoanalytic and psychodynamic work with children, the BPC Executive have made in the past adults, couples, families or groups. five years.

1. The centrality of unconscious but will always indicate the need for processes in the model of the mind the therapist to respect the potential employed within the approach to transference dynamics by behaving in a clinical practice. This includes paying well-boundaried and relatively neutral close attention to the potential for way with low levels of personal disclosure. Psychological Therapies symbolic meaning revealed in dream and fantasy as indications of an internal 4. The specific symptoms which may in the NHS emotional life that can be understood. lead a patient to seek treatment are regarded as manifestations of 2. A model of psychological internal psychic distress. Thus the development that recognises the aim of the work is to take the presenting key contribution of early childhood symptoms seriously and, as well as directly experiences in shaping characteristic addressing them, to engage with and patterns of emotional distress, psychic explore the internal dynamics to which The 5th annual New Savoy conference arrives at a conflicts and anxieties, and the defences they point, with the ultimate aim of instituted to manage these.DRAFT From this developing psychological capacities and time of significant change in the NHS commissioning derives the ability to work appropriately resources and becoming able to face life’s landscape. Psychological therapy services will need with patients’ needs, anxieties and challenges with greater flexibility and to understand this landscape if they are to navigate defences. freedom. the NHS efficiency drive intact, and expanded, in 3. The centrality of the therapeutic 5. The approach to clinical practice line with the government's promise to invest a further relationship as a primary means will include the therapist’s £400M. Who and what should guide the clinical of promoting psychic change. commitment to maintaining an open- This leads to a focus of attention minded, emotionally available and commissioning decisions in the new GP-led NHS? on the transference and counter- self-reflective attitude as a means of transference as a fundamentally facilitating the exploration, articulation important means of identifying and and containment of the full range of the processing relational patterns as they patients’ experience. become dynamically activated in the Thursday 24 and Friday 25 November 2011 therapeutic relationship. The way these The titles ’patient’ and ‘therapist are used Savoy Place, London, WC2R 0BL are worked with may vary depending as generic terms and are not meant to on a number of factors including the preclude other preferred terms To book your place please visit intensity, frequency and type of work http://www.healthcareconferencesuk.co.uk/psychological_therapies or for further information contact kekerryrry@[email protected].

B+W Add 20.indd 1 10/27/2011 12:40:21 PM 4 NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1 NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1

PIPES and Therapeutic Communities It seems from Nick Benefield’s article Letters to the Editor that the wheel is being reinvented; than I was surprised reading Nick Benefield’s none of the experience and knowledge article on ‘PIPES and personality gained from the once thriving therapeutic disorder’ that there was no mention community movement is being drawn Psychotherapy services in the NHS by the use of NICE guidelines, despite of therapeutic communities. I gather upon for this initiative. Can I refer him to objections from some clinicians (such PIPES aims to create something the considerable body of writing covering I read the article ‘Psychotherapy services as myself) that within secondary and similar to that provided by therapeutic the theory and practice of therapeutic in danger’ on the BPC website with great tertiary care there are no guidelines for communities; a therapeutic environment communities, including the International interest and wanted to share some of the the ‘complex, severe and enduring’ client in which serious psychological work can Journal of Therapeutic Communities and ‘dangers’ that I have noticed within the group that we have to work with. be done. Therapeutic communities I the book Dealing With Deviants by Stuart NHS Trust I currently work for. know of dealing with people diagnosed Whitely, Denise Briggs and Merfyn It seems to me that these changes with personality disorder were the Turner I am not trained as a psychoanalytic significantly disadvantage psychodynamic Henderson Hospital, closed down by the psychotherapist, instead having therapies and therapists (including those previous government, and a therapeutic Catherine Wilson gained a Practitioner Doctorate in such as myself who are informed by this community in Grendon Underwood Senior Member, BAP Jungian Analytic Psychotherapeutic and Counselling model and appreciate the consultation and prison. The Cassell Hospital, still in Section Psychology from the University of Surrey. supervision required to work in this way). existence as far as I’m aware, works with However, I highly value this way of It is also very worrying for those clients dysfunctional families including those working and have reasonable knowledge who benefit from psychoanalytically struggling with personality disorders. Nick Benefield responds: and experience in this model. I therefore informed practice. I fear that this trend, As Catherine Wilson will have noted really value the relationships I have if carried to conclusion, would all but Research projects carried out at the from the article, PIPEs are not a model formed with the psychoanalytic/dynamic eradicate these therapies from the NHS, Henderson, and no doubt elsewhere, of treatment but rather the development therapists who work within the same by the removal of analytic work offered showed positive results in treating of conditions in which more focussed NHS Trust as I. During my training one directly by analysts, and by the removal this difficult patient group. When I psychological work can be supported. of the four psychoanalytic departments of their ability to consult/supervise those worked at the Henderson I saw how The objective is to establish the setting in the Trust provided a placement for me of us whose work is often informed in this individuals changed positively over the in which relational work is more likely where I received the opportunity to work way. six to nine months they stayed there. to take place. They are not watered down and be supervised with both individuals I, and other members of staff, would versions of the therapeutic community and analytic groups. Subsequently to Whilst a psychologist rather than even years after come across previous (TC), which is a complex model of social qualifying, the same department allowed psychoanalyst, I feel that pluralism is residents of the Henderson now leading therapy with a long history dating me to join a supervision group where I needed, especially to work with complex fulfilled productive lives, grateful for the back to the early years of the 20th could continue to reflect on my work with cases, and that many need the approach experience which changed their life. century. PIPEs are not, as she seems the aid of an analytically trained therapist that psychoanalytic thinking offers. I am to suggest, an attempt to create a TC and the other group members. I have also extremely concerned over the way things The mental health provision for the Royal ‘lite’ model of treatment. Therapeutic benefitted from consultation on complex are going. Borough of Kensington and Chelsea communities are not referred to in the cases/organisational dynamics and the used to provide therapeutic community article precisely because it would confuse ability to refer clients who might require a I hope that this information will, in day centres individually tailored for a the concept of environment rather than more ‘in-depth’ therapy than I myself am some way, be useful to future attempts to range of mental health problems. That intervention. The TC is an established able to provide. redress this balance was dismantled in the 1990s in favour model of treatment. PIPEs provide of the latest fashions in mental health more psychologically informed and However, over recent years I have Dr Roly Fletcher where buzzwords were ‘user involvement’ supportive conditions in residential and noticed that posts, within these already Chartered Counselling Psychologist (ignoring the fact that therapeutic custodial settings where psychological under-resourced departments, are communities have genuine, meaningful treatments are more likely to be taken up, not being filled when members leave. user involvement), and ‘directions of supported, and the process of change in More worrying still, the Trust recently change’ with apparently no clear idea of the individual sustained. To achieve this implemented a ‘redesign’ of its adult what ‘direction of change’ to go in. we need to improve the ground on which mental health services and those these models are planted. The wider work psychologists who ‘survived’ the process on Enabling Environments (EEs) by the were told that we were receiving ‘too Royal College of Psychiatrists, with the much supervision’. Our supervision development of PIPES, aims to create arrangements have now been limited and better environmental conditions, and I am no longer allowed to participate in organisational cultures in which TCs and the additional monthly psychoanalytic many other psychological treatments can supervision group I used to benefit from. grow and be shown to be effective.

More worrying still is the general attitude The closure of TCs in recent years relates within the Trust that seems to favour the to the many changes in health and cognitive-behavioural model (using NICE social care policy, and in particular the guidelines to support this). Within the increasingly economic and evidence eye next year the Trust is to implement the applied to public service commissioning. ‘Payment by Results’ model of working (as However, their demise has as much to advocated by the Institute of Psychiatry do with a failure in communication and I believe), with the related ‘clustering’ of understanding in our relationship to clients at assessment and standardised the non-psychotherapy world as with an interventions that this entails. Having attack on psychotherapeutic work per se. seen the draft interventions proposed for each cluster, psychoanalytic/dynamic Whilst this matter cannot be debated therapy is nowhere to be seen. The here, I raised many of these issues in my interventions are heavily weighted Maxwell Jones lecture 2005, and it might towards CBT and its off-shoots such as be helpful that we consider these issues IPT, mindfulness etc. It is not clear, but I afresh through future articles in New have heard talk that the psychodynamic Associations therapies will be offered as ‘second line treatments’ for those who do not benefit or do not wish to be pushed into CBT. As mentioned, this thinking is justified NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1 5

New review supports psychodynamic therapies

By Nick Midgley compared to systemic family therapy, be reflected in empirically-supported depressed children appeared to recover treatment guidelines. more quickly when receiving family • In samples that can be assumed to eighteen, thereby enabling more refined therapy, whilst improvements for those OR MANY YEARS have lesser degrees of difficulty, either questions to be asked regarding the receiving individual psychodynamic psychoanalytic and because of the setting or selection nature of the current evidence and gaps therapy appeared to be slower but psychodynamic therapies criteria, short term and even minimal requiring further exploration. more sustained, with some young have been considered to interventions were shown to be people continuing to improve after lackF a credible evidence base, and have effective. consistently failed to appear in lists of Using a systematic search strategy, we the end of treatment. A similar ‘empirically supported treatments’. Partly identified 34 separate studies that met pattern of more gradual improvement, • When children present with more this has been due to a degree of reluctance criteria for inclusion, including nine but with improvement continuing marked difficulties, e.g. with conduct among psychodynamic practitioners to randomised controlled trials (RCTs), beyond the end of treatment, was disorder or severe emotional disorder, support the kind of empirical research the so-called ‘gold standard’ of outcome found in a study of children with the intensity of the treatment may be that would help to establish such an research. Full details of our findings are emotional disorders, giving some important. evidence base; whilst other approaches reported in an article in the Journal of evidence of a possible ‘sleeper effect’ in • There were some indications of – especially cognitive behavioural therapy Child Psychotherapy (volume 37.3), which psychodynamic therapy. potential adverse affects. One study comes out in December 2011. But overall, – appear to have been more active; but • Certain children appear to be suggested that if psychodynamic child our review of the research literature partly it is due to the fact that the more responsive to psychodynamic psychotherapy was offered without suggests that there is some evidence to research which has been done has not treatment than others. Where age parallel work with parents, this support the effectiveness of psychoanalytic been gathered together and widely groups have been directly compared, could be counter-productive. Another psychotherapy for children and young disseminated. younger children appear to benefit study suggested that for adolescents, people, although many of the studies more than older ones, with the receiving more intensive therapy reported in our paper are small-scale, In the field of psychodynamic treatment likelihood of improvement during (three to five times per week) rather often lacking in carefully selected control of adults, the situation has finally begun treatment declining with age. than once weekly therapy did not groups, thus making it difficult to draw to change over recent years, with the However, there are also studies improve outcomes, and that more any firm conclusions with confidence. publication of a series of important that suggest that older children and intensive work could, in some cases, reviews and meta-analyses culminating adolescents can also benefit from add to the adolescent’s sense of ‘stigma’. Although the evidence base for in the landmark publication of Jonathan psychodynamic therapy. Shedler’s paper on ‘The efficacy of psychodynamic psychotherapy with One positive message taken from this • Certain disorders appear to be psychodynamic psychotherapy’, children and adolescents is still at a review is that the amount of research more responsive to psychodynamic published in the American Psychologist relatively early stage in its development, investigating the efficacy and/or treatment than others. Children (2010). This paper brought together the these studies have begun to give some the effectiveness of psychodynamic with emotional or internalising evidence from a number of randomised tentative indications about who is likely to psychotherapy with children and disorders seem to respond better than controlled trials, showing that effect benefit most (or least) from psychodynamic adolescents has increased decade by decade those with disruptive/externalising sizes for psychodynamic therapies are child psychotherapy. Key conclusions from from the 1970s through to the present disorders. at least equal to those of other forms of the review included the following: day. Indeed, fourteen of the 34 studies treatment long regarded as ‘evidence- • Although there are relatively few • Children and adolescents with included in the review had been published based’, and that patients who receive such studies of psychodynamic therapies disruptive disorders are more difficult in the last seven years. This is a promising treatment not only appear to maintain with children and adolescents to engage and more likely to drop sign that we are beginning to gain some their therapeutic gains after treatment compared to those focusing on the out of psychodynamic treatment; understanding of ‘what works for whom’ ends, but in many instances continue to treatment of adults, those that exist but where they have engaged in in regard to psychodynamic treatments improve after treatment ends. indicate that this treatment can be treatment there is some evidence that for children and young people effective for a range of childhood it can be effective. Whilst the situation may have changed disorders, as measured by well- • There is a particularly strong evidence in relation to the treatment of adults, Nick Midgley is a Child Psychotherapist validated, standardised research base emerging for the treatment research examining the efficacy and Program Director of the MSc in instruments. of children and young people with and effectiveness of psychodynamic Developmental Psychology and Clinical • Where direct comparisons have been depression. One RCT conducted by treatments for children and adolescents Practice at the Anna Freud Centre / made, psychodynamic treatment of Trowell et al. (2007) was so sufficiently has lagged behind. In 2004 Eilis Kennedy University College London. Nick was children and adolescents appears to well-designed, with impressive was commissioned by NHS London to awarded the Early Career Achievement be equally effective to comparison findings, that it led to psychodynamic undertake a systematic review of the Award by the BPC in 2010 treatment being identified as an literature, and in 2010 (with further treatments, with mixed findings evidence-based treatment in the NICE support from the Association of Child across studies - some suggesting guidelines on child and adolescent Psychotherapists) I joined her to update psychodynamic therapy is more, some depression in the UK. References and revise the review. In conducting less, and some equally effective as such a systematic review of the other forms of therapy. • There is also a range of studies that Midgley, N. and Kennedy, E. (2011). Psychodynamic psychotherapy for children and adolescents: a research, our intention was to provide • There are some indications that suggest that psychodynamic work critical review of the evidence base. Journal of Child as complete a picture as possible of the psychodynamic treatment may have is effective with children who have Psychotherapy, 37(3): 1-26. experienced abuse, maltreatment existing evidence base for individual a different pattern of effect to other The online version of the paper can be found at: psychodynamic psychotherapy for treatments. For example, when and trauma, although the group is http://www.tandfonline.com/doi/abs/10.1080/007 children aged between three and too diagnostically diverse for this to 5417X.2011.614738 6 NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1 NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1

Asylum: one step beyond

By David Morgan

How can those of us in the psychological professions hope to bring any internal asylum or respite from suffering to people in such extreme states of deprivation and trauma? David Morgan seeks some answers.

S FOR MANY, the scene in The plight of those earlier dispossessed above social welfare, and we also saw the so colleagues are being trained in quicker the film adaption of Ken vulnerable people continues even more spring uprisings against the kleptocracies treatment methods because time is money. Kesey’s One Flew Over the extensively. Those in need of asylum, be in Egypt and Tunisia and Syria, plus NHS Direct, that five-minute phone Cuckoo’s Nest when the it for psychological or economic reasons, the rather pathetic riots in London that refuge that amplified what the NHS could Anative American chief, who has been under the present global economy have disturbed our holidays. All this anger is offer, and the excellent Sure Start are incarcerated for many years in an asylum, even greater problems now. The need about one thing, as Pankaj Mishra in The being or have already been dismantled. tears a water fountain from its mounting for safe places, where the lost can get a Guardian said: ‘extreme and seemingly Both offered refuge for the troubled and and hurls it through the hospital wall sense of identity or belonging, apparently insurmountable inequality’ between the were in fact a pre-emptive strike on future then lopes his way to freedom, seduced has no place in an economy driven ‘haves’, the ‘have-mores’ and the ‘have- more expensive interventions. me. The filmic images of institutionalised by market forces. The people who are nothings’ in our society. In a market human beings constrained by authority unable to function as part of society due economy there is no asylum for the have- made me passionate about the need for to psychological illness, or because they nots. ‘The truth is we revolutionary action to free the oppressed. are dispossessed and outside our cultural are all asylum In those days Laing saw asylums as norms, or cannot keep up with the need Protesters everywhere are driven by the repressive institutions and psychosis as for economic striving, are not too different conviction that the power structures of seekers.’ more of a spiritual journey than a from the much maligned category of corporate and government work together disturbing psychiatric meltdown. The ‘asylum seekers’, now a term of abuse in to screw the broad middle and working What I really want to get across is the closure of the large mental hospitals many quarters; though asylum, as we all classes. A few people, it seems, those self- asylum we all need to have and the hope during Thatcher’s government apparently know, originally meant nothing other satisfied bankers, have got rich while a we have of finding it both internally following the theories of Italian than a place of safety. Why, then, does majority remain poor. and externally. I believe it used to be a psychiatrist Franco Bassaglia, although society now hate those who seek or need backdrop of our society, and even recently questionable under that government, safety? Are they reviled because they The most vulnerable victims of this under the last government the importance seemed a good thing, and the espousal of make us aware of our own vulnerable inequality are children in trouble, the of care for the underprivileged existed. ‘Care in the Community’ a progressive position? Our own struggle with life and aged the physically and mentally ill. In The truth is we are all asylum seekers. step. Bassaglia was even quoted by the death anxieties? India, Pankaj says, hundreds of thousands The longing for respite from life and then health minister. of farmers have committed suicide despite death anxieties, whether generated in their society being more successful than our internal world, or all too apparent in The true intention of that government’s ‘ “Community ever before. And now in this country it crumbling external worlds whether from policies soon became clear. It had nothing Care” was in is our turn, of course: the educated and socio-economic or political causes is, I to do with placing people back into society aspiring middle classes worry about our believe, a fundamental human drive. but was an excuse to close refuges, to save many cases futures, or our children’s. A child’s failure money. The ‘Community Care’ that was “community to get three starred A’s can feel like the The number of bankers I have assessed set up to ‘contain’ patients was in many beginning of sinking down through (privately, of course!) who feel they cases ‘community neglect’, leading to a neglect”.’ the social order to Skid Row. In other have lost their souls to the machine massive increase in suicide and the tragic quarters this sense of helplessness leads to they created has increased. One man cases of the unwell and dispossessed As with the destruction of the old denouncing the corruption in politicians, dreams he is being pursued by living enacting their anxieties on others. mental hospitals, when the Berlin Wall businessmen and bankers, a corruption dead zombies and a man in a taxi cab is crashed down along with the repressive that leaves us helpless without a voice. helping him escape from their threat, Like Cameron’s pre-election slogan of communist dictatorships behind it, there We have a condition of prosperity without to make him one of them, but the taxi the ‘Big Society’, the real aim of ‘care was some hope that the removal of the equality, wealth without peace. is very, very slow, he screams at the in the community’ was a cynical one, physical emblem of control and authority driver, presumably me the analyst, to go to encourage an espousal of charitable could bring greater freedoms. Perhaps in Lest I appear a hypocrite, I admit that I quicker but he doesn’t, keeping up the community values as a cover for saving some respects it has, but its effect has also benefited from house price increases, but same plodding pace. This is a man who money at the expense of the most been to reduce choice and to demonise like everyone else I too face an uncertain worked seven days a week, used cocaine, vulnerable. societies with ideals other than the future where the idea of meaningful prostitutes etc., and had panic attacks on pursuit of profit. What profit can there professional work for my children, doing Sunday night. The panic attacks were There followed at that time a lack of ever be in providing asylum? what I was able to, where they might help perhaps the justifiable alarm of this man’s care for the mentally ill, who were then others, is becoming a scarcity because beleaguered soul. dumped into the care of the community: a We can see the worldwide effects of this sickness is not a profitable business. I public driven to earn more money to shore relentless market-driven society in our never thought I would attend a meeting From my perspective, achieving the up flagging mortgages, who had no time newspapers. In India tens of thousands in the NHS where the patients were capacity to bear uncertainty and the or mental space to manage such complex demonstrate against the ruling elite, in described as products but this has come terrors of life depends on having safe problems in their midst. Israel there are demonstrations for social to pass. Child psychotherapy is now places both outside and, of course, inside. justice, in China cyber critics blame their beleaguered because it takes a long time, My profession as a psychoanalyst working government for putting wealth creation at times with very disturbed and unhappy NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1 7

people is mostly focused on trying to course compare these middle class fears as a psychologist. It seemed that my One of the fundamental reasons why help restore or create for the first time an with the monstrously deprived people in academic tools of insight and empathy so many doctors become cynical and internal capacity to bear uncertainty and my group, but I knew I had frissons of could be nothing against the powerful disillusioned is precisely because when the loss without too many psychotic defences, anxiety that related to theirs daily, and drive I felt: the need either to turn away abstract idealism has worn thin they are such that very frightened and troublesome to my guilt I knew that compassion could and shut my eyes and ears, or to become uncertain about the value of the actual lives people can attain some feeling of respite fluctuate. a one-man charity centre for this group. of the patients they are treating. This is from mental torture. This is in my view a The Bleeding heart. The Champagne not because they are callous or personally really important form of personal asylum. The pressing concerns of these people socialist. This was a dilemma that can inhuman: it is because they live in and But I remain mindful of the fact that can involve housing, clothing, food and never be easily resolved. accept a society which is incapable of although my domain is that of mental other basics. But they also have other knowing what a human life is worth. torture, there is an external world of needs too; more human, social and hard It’s important to get help, contact social torture too. to administer, they needed help and a workers to deal with acute problems of For ‘doctors’ let us read us all. I believe feeling that others could retain a sense of homelessness and neglect, all the while it is only through fighting for a society The conflict brought about in trying to them as human even in the face of some trying to keep the therapeutic space as a which is truly committed to providing work with people whose loss of identity of their experiences of rape and torture. place where thinking and managing the asylum in all respects, social and mental, and dispossession is both mental and The strongest impulse of many of those sense of helplessness is valued. The sense for our most deprived that we individually societal was brought home when working brought into contact with them was to of helplessness was on both sides, they and collectively affirm the worth of with groups of refugees and asylum turn away. I could sense my own pressing who had experienced such loss and abuse human life. We let our care institutions seekers. Their awful helplessness that one need to shore up my own sense of security and me who felt torn about what resources crumble at our peril. Remember please: assumes to bear can be unbearable, all in the face of their reminder of the were needed and could be used. I learnt a We are all asylum seekers that they may have dear they may have traumatic possibility of loss. lot from that group of patients. lost – family, dignity and home – leaving the therapist feeling helpless, fat and ‘Having to take How can those of us in the psychological This article is based on a lecture given at privileged. professions hope to bring any internal St Anne’s College, Oxford, as part of the in the profound asylum or respite from suffering to people Children in Troubled Worlds Conference, Our task as therapists is supposedly to in such extreme states of deprivation 23 September 2011: A Step Beyond. Asylum. enable traumatised individuals to manage loss and terror and trauma? I learnt very painfully and David Morgan is a psychoanalyst and their psychological symptoms, anxiety, of others is very personally that there is a drive in me, member of the BPAS and BPA. depression, chronic fear and constant risk which I think we witness constantly in of breakdown, when our own position at demanding.’ all our hate-filled responses to people times can feel precarious. I remember at in need, to turn away and to reject. the height of the then soaring Thatcherite Since I have always needed inspiration to Having to take in and identify with the interest rates and, as for many at the time, keep my hope alive and find ways to work profound loss and terror of others is very my mortgage was a constant persecutory with the hopeless, I turn to writers like demanding, and I think there is always presence. It can be difficult at these John Berger: a drive to push out the bad feelings times to process enormous need while The poverty of our century is unlike that of through rejecting and demonising those simultaneously experiencing our own any other. It is not, as poverty was before, who fill us with terror, thus repeating for struggle to keep body and mind together. the result of natural scarcity, but of a set of them all their experiences of rejection I was lucky in that I had some private priorities imposed upon the rest of the world and cruelty. We all have to find our own patients at the time; thus I subsidised by the rich. Consequently, the modern poor ways of fighting the battle to keep hope Subscribe my work and paid the mortgage which are not pitied [have no asylum no way out and compassion alive for both our work the NHS salary no longer covered. The no representative]… but written off as trash. and ourselves. I find that it is through the to New Associations risk of homelessness was not a real The twentieth-century consumer economy collegiate experience of thinking with threat, but I was aware there was little has produced the first culture for which a others and reading that sustains me, and Stay informed of the latest issues financial cushion for many to fall back beggar is a reminder of nothing. recent reading brought me this, from John affecting your profession by subscribing on. That time, as now under the present Berger again: to New Associations. In my countertransference at that time government, felt like a win or lose society: An annual subscription of three issues with refugees and asylum seekers, I felt if you failed you went to the wall. There costs just £10*. were scenes of home repossessions, dispossessed and exiled from my identity including that of a young unemployed Send £10 per subscriber and include architect next door to me. 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The best defence

By Gwen Adshead

Although social defences are necessary to manage anxiety in institutions, they are problematic in two ways. First, the defence may not contain the anxiety, especially if it is chronic or extreme, leading to dysfunctional acting out as the anxiety grows. Second, both the defences and the acting out can impair an individual’s capacity to perform their task. Gwen Adshead discusses how institutional defences operate in forensic settings..

REUD IS CREDITED with required respite from their intolerable from unconscious fear alone, but from what they have to say is usually very first describing how people difficulties, and the need to offer conscious fear of the patients, who have disturbing to hear, and staff may not defend themselves from treatment and cure to patients suffering been identified as highly risky people. The know what to say. Some patients engage overwhelming anxiety from illness. That these aims were not emphasis on security measures means in an unconscious symbolic re-enactment throughF the use of beliefs, values and compatible either went unrecognised or that nursing staff are being encouraged of either their abuse or the offence, so that attitudes that unconsciously work to was not accepted by the hospital staff. to provide a personally supportive the nurse ends up feeling either like a relieve anxiety. Interest has increased in relationship to patients, while at the same victim or a perpetrator of abuse. how groups of people deal with anxiety, Residential forensic settings: time being suspicious of the danger they and whether social groups too use the demands of care pose. Patients may relate to nurses as defences; even groups as large as In forensic psychiatry, care is principally significant parental figures from a businesses and organisations. delivered through the medium of long Unconsciously, staff fear the madness in patient’s past; especially since the nurse stay residential care at different levels of the patients, envy their care, and hate the is someone who both cares for the patient In 1959, Isabel Menzies commenced security. High secure hospitals typically hopelessness that their situation seems and controls them, much like earlier a ground-breaking study which has offer care for at least five years, medium to provoke. Defensive manoeuvres to attachment figures. Nurses can find influenced health care staffing and secure care for two to five years; although keep these feelings out of consciousness themselves on the receiving end of rapidly training. She utilised a psychoanalytic these numbers are averages in both cases include distancing themselves from oscillating attitudes from the patients approach to help hospital staff to think there may be people, patients and staff, the patients as much as possible (for (either needy or hostile) which leave them about nurse training and retention by who stay much longer. instance by withdrawing into the office feeling bewildered and deskilled. For viewing their difficulties of student nurse or kitchen); rubbishing attempts to help example, a patient with a persecutory allocation as the ‘presenting problem’. This means forensic staff live cheek by the patients, and seeing patients as either and abandoning past care-giver will She discovered that this ‘actual problem’ jowl with patients for hours of days of ‘all good’ or ‘all bad’. The latter is clearly engage in a hostile way to a nurse who arose because a third of nurses were not weeks of years. Staff in these settings an example of splitting, and represents offers support in a kind and concerned completing their training, due to high will spend more time with patients than both a manic defence against the reality way. The nurse experiences a hostile levels of anxiety and distress. Others with their own families; and their units of what the patients have done, and a cruel rejection and abandonment, just as the frequently took time off due to minor and hospitals can become like enclosed identification with the hopelessness of patient experienced in the past, and may illnesses. She concluded that nurse communities of both staff and patients. their position. Perhaps the most common be tempted to either abandon the patient, absences, and the organisational processes In one case known to me, both a patient form of institutional defence is found in or respond aggressively, much as the past that structured their training and and his primary nurse had entered policies and procedures that support either care-giver did. If they do so (and even employment, were unconscious defences the hospital at the same time 23 years a collusive or a punitive stance towards the best of us may), the re-enactment has against distress and anxiety entailed in previously: they had both ‘grown up’ patients, as demonstrated in the findings taken place. It is essential that all staff general nursing care. together in a high security hospital. of two public inquiries into the work of learn to understand this process to prevent high secure hospitals. further damage to the patient. Menzies also concluded that these social defences operated to help both individual ‘Forensic staff Additional demands Second, the conflict of purpose that Bott and organisation avoid the experience of will spend more There are three other problems peculiar described in the old style asylums is even anxiety, guilt and uncertainty. However, to work in forensic residential institutions, more intense in forensic institutions. these defences were ineffective: staff time with patients which give rise to particular anxieties Are the staff there to help the patients still felt anxious and distressed, but the than with their and defences. First, the vast majority of feel better or behave better? How can social defences meant that they were not forensic patients not only have severe they work towards patient recovery allowed to know their feelings or express own families.’ treatment resistant mental illnesses, and discharge when it is not at all clear them. No attempt was made to enable but also suffer from moderate or severe that their recovery is welcomed by the individual nurses to confront their Forensic nursing staff therefore have to personality disorders. Patients with society? Without care, patients will be anxieties and distress, and they were manage the emotional demands of long personality disorders may not only institutionalised and hopeless, and the therefore unable to develop a capacity to term care for people with severe mental relate in immature and fragmented ‘nursing’ purpose will be gone; but even bear these anxieties more effectively. It illnesses who do not recover quickly. ways; socially, they also elicit care from with the best care, patients may be so was inevitable that staff would drop out of However, they also have to try to make professional carers in hostile and toxic damaged that they continue to pose training. Menzies later wrote, ‘Unless staff therapeutic relationships with patients ways. In outpatient settings, staff may unpredictable risks to others. The conflict know what they are doing, there is little who have committed horrifying and respond by distancing themselves from between the need to ‘care’ and the need to hope of doing it effectively.’ disturbing acts of violence. Normally, the patient; in forensic settings, this may protect others is a crucial one for forensic such people are shunned by others; not be possible. nursing staff, and it leads to a multiplicity Elizabeth Bott, who applied Menzies’ instead, forensic nurses have to try to of unconscious behaviours that allow thinking to a psychiatric setting, found care for them, and nurses are faced with Caring for forensic patients entails avoidance of thinking. a number of conflicting aims of the task this challenge each time they enter the listening to accounts of both their offences of the organisation: a need to control the hospital. We can imagine, using both and their personal backgrounds. Since Finally, an anxiety that all forensic madness that society could not tolerate, Menzies’ and Bott’s formulations, that the majority of forensic patients have professionals try to keep as far from a need to provide care for people who staff have to defend themselves not been childhood victims of extreme abuse, Continues on page 10 NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1 9

On the edge of nameless dread

By John Gordon

To get in touch with forensic patients, staff members must develop a method to get in touch with themselves and to reflect on their findings. John Gordon offers an example of what happens.

WORK IN A VERY SMALL present as impacts on the psychotherapist- psychotherapy department in a consultant. Here is an example of what very large forensic psychiatry may happen. service. There are about two and Ia half whole time equivalent posts, one a I came onto the secure ward of a forensic whole time Consultant Psychiatrist in hospital where several weeks previously Psychotherapy/Forensic, and three or four I had arranged to meet regularly with other part-timers, mainly analysts. We’re multidisciplinary professionals to discuss a drop in an ocean of hundreds of patients their work. We had agreed the time and and even more staff. In describing our place, but on the first two occasions I had clinical interventions, we have found myself alone for fifteen minutes. the other a smaller rehabilitation section highlighted a psychoanalytic compass When I went out of the appointed room where they had been telephoned by the with which to orient ourselves: the to ask at the nursing station whether charge nurse on the acute ward where countertransference responses to working people were planning to come to our the group takes place – to respond to an with patients in an atmosphere redolent of reflective practice, I was informed that it emergency. The spokesman, increasingly gave way to anger and then to a classical Greek tragedy1. In effect, staff hadn’t been put in the diary for that week. joined by his incredulous co-responders, despairing cynicism which reconfirmed members are in the position of Creon as Eventually my appearance outside the told us that, arriving on the ward, they for many that no one could be trusted in he faces the situation in Thebes after glassed-in nursing office would be noted, had been directed by the nurse in charge such a dangerous setting. But this event Oedipus’ murder of Laius: and members of the staff would file into to the reflective practice room where seemed to show that even members of our room. they were expecting to find a dangerous, your own professional tribe would not be I saw Plague, the killer of us all. aroused patient causing chaos and possibly watching your back. On the contrary, they Then the dreadful shrieks of Horror and Shortly after this inauspicious ‘launch’ severe damage to their colleagues. They might deliver you into the hands of the blind Fury filled the air. of the group, I was sitting with the could not believe their eyes to find four enemy. There Grief stood, tearing at her hair. Consultant Psychiatrist, a nurse and a people sitting in silence around a table, Disease, hardly able to stand at all, health care assistant. The Consultant, a and we could not believe what we were Many succeeding reflective practice stumbled forward... regular attendee and major force behind being told. meetings were spent in trying to identify I saw each wretched creature. the initiation of the group, was wondering this dangerous enemy as... thinking The blood stopped still in my veins, aloud to his nurse colleagues whether about their work at all. Whether it was a and like a spike stuck into the earth, any more of their peers intended to ‘The hammer- deceptive senior colleague, a manager or I I could not move.2 come. They were at a loss, commented blow impacts myself who might be held responsible for that the ward was ‘very busy today’, and forcing them to attend reflective practice; Forensic patients, whether psychotic or we all lapsed into a perplexed, helpless on staff minds even an unconscious and disowned part of personality disordered, characteristically silence tinged with annoyance at what and the fear of one’s own mind advocating the usefulness communicate through action rather than was pretty clearly emerging as resistance and survival value of thinking creatively words; they are ‘out of their minds’, out to, if not outright sabotage of, the assaults on heads under pressure to ‘make the best of a bad of touch with themselves, and so cannot reflective practice. I was not particularly are constant.’ job’3: this object could not be perceived symbolically represent their mental states. surprised by this reluctance which I as authoritative, helpful and caring Consequently, mental health workers may had experienced many times in forensic Eventually, the ‘response team’ joined us but only as treacherous, attacking and only become aware of what is going on in and other staff groups – including ones at the table; we continued for a while to destabilizing. Through dramatizing the their patients through paying attention to which I belonged as a participant grin at each other trying to absorb the latter quality, we began to understand to their own feelings, reactions and rather than a facilitator. But I had never implications of what we had just witnessed how the charge nurse had reflected this experiences. In the forensic setting, the experienced what was about to happen in ; and then some of these implications negative internal presence, patently hammer-blow impacts on staff minds and this reflective practice group. began to be spelled out, both in this corrupt, unworthy of loyalty and respect the fear of assaults on heads are constant. meeting and others that followed. For and mandating fight/flight. And at a To get in touch with their patients, Suddenly the door opened and six male reflective practice had suddenly been subsequent meeting we found out more therefore, staff members must develop a staff members burst into the room. Their energized by our joint experience. The about the anxieties which maintained method to get in touch with themselves faces showed utter perplexity while we members of the ‘response team’ expressed such an ominously malevolent image of and to reflect on their findings. Reflective were startled and stared as they stood, their sense of having been utterly betrayed authority. practice, consequently, becomes a key silently towering over us for what seemed and lied to by a senior colleague. How intervention in order to provide staff forever. Finally I asked what was going could they have been set up in such a I arrived to find a number of group with a mental seatbelt to sustain their on. To our collective amazement, one of serious and frightening way by members members already present, passing around researches into their patients’ dismantled the arrivals managed to stammer that of their own profession? This sentiment and laughing over a brochure on the minds by attending to those fragmented they had just been called by the nurse in was seconded in spades by those who had remnants which can still be glimpsed in charge – this ward was divided into two already been in the meeting. Amazement their own minds, and which often also geographically separate areas, one acute, Continues on page 10 10 NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1 NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1

The best defence On the edge of nameless dread

Gwen Adshead, continued from page 8 John Gordon, continued from page 9 consciousness as possible is the fear of table. The main theme of the meeting ‘minds’ of forensic patients, including identification with these violent and cruel was that managers only came to the inchoate and unmetabolized emotional patients. Those who work with forensic ward to criticize, otherwise you never saw states, are externalized and dispersed patients may have unresolved feelings of them. And if a patient complained about though their interactions with staff on the hatred and cruelty that they long to act you, the investigation would be arduous: ward, just like the real damage they have on, but cannot; they may wish that their a third degree. Examples from group already wreaked in the external world. capacity for cruelty and violence was members’ experiences were given. As I And among the emotions which some cared for in the same way as the patients. was listening I found myself trying to patients may never be able to tolerate, and This may be especially true for those decipher the, for me, upside down writing others become psychotically depressed staff members who have actual histories on the cover of the brochure, which had or acutely suicidal when they approach , of childhood victimisation. Professionals ended up at the other end of the table is persecuting guilt: a constituent of the like ourselves may be drawn to this work from where I was sitting. It dawned on NEMESIS INFERNO which turned up in because we also unconsciously long to be me that this was an advertisement for a our reflective practice group cruel, or seek revenge for past hurts, or are theme park roller coaster, and the name of unconsciously anxious about our capacity the ride emerged: NEMESIS INFERNO!!! for destructive anger. Whatever the I said that I thought this was exactly John Gordon is a Psychoanalyst and Group reason, a variety of defensive acting out what they feared reflective practice Analyst. He is Honorary Senior Lecturer behaviours by staff may be driven by the was; and that by demonizing it – helped at Imperial College Medical School and anxiety that we psychologically resemble immeasurably by the nurse in charge Buckinghamshire New University and the patients. whose deception had legitimized their Former Consultant Adult Psychotherapist (and his) continuing rebellion against at West London Mental Health NHS Trust Something understood: attending – it was possible to protect taking care of the carers themselves as a team from anxiety that The forensic residential setting represents open engagement in the group could only Notes a place of containment and safety, for the reveal humiliating individual inadequacy, 1. Gordon, J. and Kirtchuk, G. (Eds) (2008) Psychic patient and for society. Physical security failure and probably worse qualities in Assaults and Frightened Clinicians: Counter- transference in Forensic Settings. London: Karnac is paramount; however, it is also evident themselves. They believed that contacting Books. that psychological security is important, their feelings about the work would References 2. Rutenberg, M. E. (1998) Oedipus of Lucius not only to manage the seriously damaged contaminate their ability to continue to Annaeus Seneca. Wauconda, Illinois: Bolchazy- and traumatised offenders residing Adshead, G. (1998) Psychiatric staff as attachment care for their patients. Carducci Publishers Inc. figures. British Journal of Psychiatry, 172: 64-69 within, but also to assist the staff in this 3. Bion, W. R. (1979) Making the Best of a Bad Job. most demanding task of both caring for Bott, E. (1976) Hospital and society. British Journal We are still riding the roller coaster. But In: Clinical Seminars: Brasilia and Sao Paulo and and containing potential violence. of Medical Psychology that is what working in secure forensic Four Papers. Abingdon: Fleetwood Press. Freud, A. (1963) The ego and the mechanisms of settings is. The proto-constituents of the If we understand that social defence defence. London, Hogarth systems act to make organisations feel Henderson, S. (1974) Care eliciting behaviour in psychologically secure, and to make man. Journal of Nervous and Mental Disease, 159: 172-181 individual staff members the carriers of intolerable anxiety, then this might assist Hinshelwood R.D. (2001) Thinking about institutions: milieux and madness. London, Jessica us to put in place structures and policies Kingsley that help them reduce destructive acting Kahn, W. (2005) Holding fast: the struggle to create out. This in turn will allow care-giving a resilient care giving organisation. London, Brunner organisations the chance to become Routledge more resilient. The extent of the anxiety Lowdell, A. & Adshead, G. (2008) The best felt in forensic institutions should not defence? Institutional defences in forensic care. In Aiyegbusi A. & Clarke Moore, J. (eds) Therapeutic be underestimated, as unconsciously relationships with offenders. Jessica Kingsley, pp indicated by the sign in the canteen in a 53-68 forensic unit: ‘This building is alarmed’ Main, T. (1977) Traditional psychiatric defences against close encounters with patients. Canadian Psychiatric Association, 22: 457-466.

Gwen Adshead is a forensic psychiatrist Menzies, I. (1961) The functioning of social systems and psychotherapist. She trained at as defence against anxiety: a report on a study of nursing. London, Tavistock Publications st George’s Hospital, the Institute of Psychiatry and the Institute of Group Miller, E. & Gwynne, G. (1972) A life apart. London, Tavistock Analysis. She has worked at Broadmoor Hospital, setting up and running Norton, K. (1996) Management of difficult personality disorder patients. Advances in psychodynamic groups for offenders. Psychiatric Treatment, 2: 202-210 Gwen has research interests in attachment Sarkar, S.P. (2005) The other 23 hours: special theory applied to forensic populations; and problems of psychotherapy in a ‘special’ hospital. moral reasoning in antisocial men and Psychoanalytic Psychotherapy, 19: 4-16 women. Watts, D. & Morgan, G. (1994) Malignant alienation: dangers of patients who are hard to like. British This article is based on a chapter written Journal of Psychiatry, 164: 11-15 with Amanda Lowdell. Whittle, M. (1997) Malignant alienation. Journal of Forensic Psychiatry & Psychology, 8: 5-10 NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1 11

we engage the family well from the have offered supervision and training beginning our outcomes are far better here in the UK, and there are plans to Psychosis and and families will more readily contact us publish the Danish manual of supportive at early signs of relapse. Family meetings psychodynamic psychotherapy in English are not instead of individual work, but in the near future in the ISPS book series. this early involvement with key family I have myself recently concluded that psychoanalytic members means that conflicts over psychodyamically informed family therapy confidentiality are very rare. The rapid with psychosis is fully compatible with response to the patient and their family NICE guidelines in the area.5 approaches: (and friends) in their home for as long as it is needed with a focus on slowly helping It is important to emphasise how all in finding words where none existed fascinating the work is for those with a for the key family issues (rather than psychodynamic approach (as well as often some hope? an exclusive focus on symptoms) is the challenging). There is such a wealth of hallmark of the Finnish Open Dialogue opportunity to study psychodynamic approach,1 which is an evolution of the mechanisms and theories of psychosis, By Brian Martindale Finnish Need-adapted approach pioneered and to be creative in the way one works by psychoanalyst Yrjö Alanen.2 The Open with the patients and their families. Dialogue outcomes with psychosis are Richard Lucas6 and Murray Jackson7 have some of the very best in the world. But written books that demonstrate this. I will are created in an attempt to try to steer HAVE BEEN DISMAYED in their publications do not have the word give one brief clinical example, that can clear of personal realities that are just recent months to hear of the loss psychodynamic in them and I regard be enjoyed at many levels. too painful, overwhelming or otherwise of so many psychoanalytic this as another example of the success of ‘unwanted’. psychotherapy posts in the NHS. ‘hiding in the jungle’. A man with a steady deterioration in IOak trees take a long time to grow and functioning over some time was admitted, For a long time in my career as a only a short time to cut down, and this and revealed no signs of psychosis to the consultant psychiatrist in psychotherapy, article is written in the hope that it might ‘The psychosis ward staff following their direct questions our psychotherapy services regarded encourage some medical and non-medical to him. The staff wanted to discharge him psychosis as a contraindication to field has psychoanalytically-trained practitioners, as someone with a personality disorder. psychoanalytic psychotherapy. I have rather than leave or have to leave the exciting growth In a non-directive informal meeting undergone a radical conversion (greatly NHS, to consider seeking employment in with a staff person with a psychoanalytic influenced by Scandinavian colleagues potential for the psychosis services where they might be training (that fact unknown to the as well as the late Murray Jackson and able to utilise and develop their skills. psychodynamic patient), the patient started to mention others), and for six years I worked full the computer chip behind his eye and the time as a consultant psychiatrist within Most psychoanalytic psychotherapists minded.’ messages that Tony Blair sent to him on an early intervention in psychosis (EIP) who work as such in psychological the news each evening. The therapist said service. EIP services were one of the major A more local example of jungle life therapy services must feel very exposed to the patient that he was aware that he developments in the mental health field was illustrated in the work of an ISPS3 and vulnerable at present, and need had not mentioned anything of this to initiated by the last Labour government UK research group trying to identify every help they can be given to survive. the ward staff in the last two weeks. The in the late 1990s. For me, there were psychoanalytic psychotherapists currently However, with certain provisos, I consider patient immediately said, ‘Of course not, three crucial features: the relatively low working with psychosis, and finding the psychosis field as possibly having they would think I was crazy.’ an exciting growth potential for the case loads for the core staff, the explicit quite a number of psychologists who have increased emphasis on ‘psycho-social’ obtained CBT training but who ‘quietly’ psychodynamically minded. In doing so I encourage the BPC to make sure it has interventions in guidelines, and above all use their earlier psychodynamic training I am mindful of a distinguished French a good space for psychoanalytic psychosis the expectation that patients should be and understandings in their daily clinical colleague who, in a debate about the practitioners in its publications and offered three years of treatment within work without formally ‘coming out’. psychotherapy field, remarked that it conferences was much easier to hide/survive in the the service. This frame makes for the jungle: the psychosis field is certainly that possibility of a relatively substantial period There is of course a relative dearth of psychotherapeutically informed work. of English-language modern RCT at the moment. By referring to hiding in Brian Martindale is Consultant research to satisfy formal advocacy and the jungle, I am also hinting at what I Psychiatrist in EIP to the Northumberland With more than six years of experience commissioning of psychoanalytic therapy regard as the necessity for a completely Tyne and Wear NHS Foundation Trust, now of fulltime work in a EIP service, in psychosis, but it is important to note different style / technique compared and a psychoanalyst and currently chair of I would emphasise first of all the need the work of Danish psychoanalyst Bent to those used with other problems if ISPS and Honorary President of the EFPP. for all ‘psychosis’ practitioners to become Rosenbaum and his colleagues who have the psychodynamically minded are to [email protected] frequently succeed in relating to patients, very comfortable at working in a very published promising controlled trial 4 families and even colleagues in psychosis flexible style, both in the setting in which outcome studies of a year of individual services. I will touch on this later. they meet the patient and his family weekly supportive psychodynamic therapy and friends, and in the way in which for psychosis, as well as the cohort studies Notes UK readers may not be aware that in all they relate to the patient and his family. of analysts Yrjö Alanen and Johan Cullberg 1. Seikkula, J., , Aaltonen. J., Alakare, B., of the Scandinavian countries, it was Outcomes depend significantly on the from Finland and Sweden respectively. Haarakangas, K., Jyrki Keränen J,. Lehtinen, K. (2006) Five-year experience of first-episode psychoanalyst psychiatrists who played professional’s capacity to engage and nonaffective psychosis in open-dialogue approach: leading roles in developing first episode sustain engagement with very scared Many of the people I have mentioned have Treatment principles, follow-up outcomes, and two been key contributors to the ISPS, which case studies. Psychotherapy Research, 16(2): 214- psychosis services (mistakenly known and suspicious young people, often with /228. low self esteem and a long complex has a lively and large UK membership as EIP or early intervention services in 2. Alanen, Y. (1997) Schizophrenia: Its Origins and the UK, as few services are yet resourced problematic relationship with authority of whom a reasonable number have a Need-Adapted Approach. London: Karnac. to do all the sophisticated community figures. It is vital that right from the psychodynamic background. The ISPS was 3. ISPS stands for International Society for the work needed to reach people much beginning there is a tuning into what is founded 55 years ago by psychoanalysts Psychological Treatments of the Schizophrenias and other Psychoses, www.isps.org earlier). Although it would be an error to going to be experienced as helpful and interested in psychosis, and in the last unhelpful by the patient and the family. two decades has become a multi-modality 4. The Danish National Schizophrenia Project: generalise, there is some truth in stating prospective, comparative longitudinal treatment that a far larger percentage of mental Otherwise one may not get a second organisation offering a range of ‘products’ study of first-episode psychosis. The British Journal health professionals in Scandinavia chance for a long time when the situation that support psychological approaches of Psychiatry (2005)186: 394-399 believe that it is the slings and arrows may have become even more serious. and in which psychoanalytic practitioners 5. Martindale B, and Smith J, 2011 Psychosis: Psychodynamic work with families. Psychoanalytic of outrageous fortune that contribute have less of a need to hide amongst Psychotherapy Volume 25, Issue 1, , pages 75-91 their colleagues of different hues. The far more to severe mental illness than Much of my engagement work and that of 6. Lucas. R 2009. The Psychotic Wavelength: A biological factors, and hence there is a my colleagues occurs in patient’s homes, organisation is also a vehicle for sharing Psychoanalytic Perspective for Psychiatry. Karnac more natural acceptance of psychosis sometimes over quite a long period of what is going on in other parts of the Books being an unconscious and dynamic way time. I have become convinced that when world. For example both Bent Rosenbaum 7. Jackson, M. & Williams, P. 1994. Unimaginable Storms: A Search for Meaning in Psychosis. Karnac in which a new reality or new realities and his late colleague Lars Thorgaard Books. 12 NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1 NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1

stretching the boundaries, or creating a An homage to Tony Parker, and to News In Brief firm setting within which analysis could psychoanalysis in the NHS take place? Or was he redefining the parameters of analytic space? How do we Janet Low writes: conceptualise borderline states, and what Earlier this year, I discovered Tony Parker. New BPC Affiliate Members from those of a control group; that the implications does that have for therapeutic I was handed his seventeenth book, Life amygdala in these patients does not aims and technique? After Life (1990): twelve monologues by The BPC welcomes the Anna Freud communicate with the prefrontal cortex men and women held within the British Centre as its third Affiliate Member in in the usual way, so that a borderline The findings from neuroscience – penal system, each of them convicted September. The AFC is internationally patient swings from one intense emotion supporting Gabbard’s definition of of murder. How each person accounted renowned for its innovative clinical to another, without having the capacity borderline pathology in terms of affective for his or her crime was both a shock (it services for children, and for its training to think about the feelings; and about dysregulation – added weight to some seemed to just pop out of their story) and and research programmes. an opioid deficiency in such patients, serious technical dilemmas: how does deeply moving (as they grappled with the meaning that when they use opiates they one work in the transference, when the responsibility for what they had done). I Another exciting development is do not get the more usual ‘high’ that drug- attachment to the therapist can stimulate couldn’t put it down. the application by the South African takers seek, but rather the opiates merely hyperarousal? Psychoanalytic Confederation to become bring their responses up to a normal level. The simplicity of Parker’s work is that the BPC’s first International Affiliate. Professor Gabbard showed how at least What came across strongly was Glen he lent his ears (‘a national treasure’, seven different therapies are effective Gabbard’s spirit of optimism, creativity according to Anthony Storr, who should The Anna Freud Centre and South in allowing the internal chaos of these and humanity in the face of profound know about ears, having been a famous African Psychoanalytic Confederation patients to mediate, but said that long- technical difficulties. Controversially, Jungian analyst in his time) and invited join the North West Institute of Dynamic term change in the neural physiology he argued that the establishment of a people to tell their story. He sometimes Psychotherapy and the Institute of Group could be brought about only by long-term working treatment alliance – the single worked for as long as two years to Analysis as BPC Affiliates. work, which would take a lot of effort – as most important factor for mediating accumulate what he needed and then anyone with such patients in their practice therapeutic change – is possible with to find the key to cut the mass of words Peter Fonagy, chief executive of the knows very well. this refractory patient group. He then into a pithy monologue. He taped the Anna Freud Centre, said: ‘The BPC is demonstrated this in action, playing conversations and transcribed them, and the key strategic organisation for 21st- Gabbard moved seamlessly between himself in a compelling video-taped listened to and read them over and over century psychoanalysis in this country. findings from neurobiology, psychiatry, dramatisation of two consecutive sessions again. This hard work paid off with lucid, All those who want to have their say and clinical psychology and psychoanalysis with a borderline patient, in which the simple, compelling stories, each one influence decision-making in relation to to paint a rich and multi-layered picture audience enjoyed the ‘main course’ Gwen touching a truth. development of the profession in the UK of both the brain and the internal world Adshead had promised, and was still left must belong and be active within the of this challenging and troubling group with appetite for more. His twenty-two books give truthful BPC’ of patients. He made a compelling case glimpses not only of convicts (with whom for modifications in technique with these This was a stimulating and inspiring he began his work), but also lighthouse patients, whom Freud had originally conference in a lovely space, and keepers (Lighthouse, 1975), miners Conference report: Glen Gabbard, deemed unsuitable for analytic work. beautifully organised. Full credit should (Redhill, 1986), people living on the Understanding and Treating One was left wondering if Gabbard’s be given to the South of England Heygate Estate in Elephant & Castle (The Borderline Personality Disorder success with this rigid, intractable patient Psychotherapy (SOEP) committee – Prof People of Providence, 1983), denizens of group derived in part from his freedom Paul Williams (BPAS), Sally Saunders Kansas (A Place Called Bird, 1989), the This was an inspiring and immensely to adapt his technique to what his patient (LCP), Penni Swinden (LCP) and Jackie people of Russia in a time of cataclysmic valuable conference on several levels. can manage at any given moment. His Charbit-Middleton (BAP) – who provided transition (Russian Voices, 1991), citizens Professor Glen Gabbard (Professor of inspired advice – quoting Fred Pines – an excellent example of BPC collaboration of Belfast (May the Lord in His Mercy Psychiatry and Brown Foundation to ‘strike while the iron is cold’, so the in Hampshire. Keep an eye out for details Be Kind to Belfast, 1993), single mothers Chair of Psychoanalysis; former Joint patient will be able to think about what he of the next SOEP conference in 2013 (In No Man’s Land, 1972), and even Studs Editor-in-Chief of the International says, was particularly resonant. Terkel (1997). Before he died in 1996, Journal of Psychoanalysis) and Dr Jan Harvie-Clark (BPA, Chair of he had begun to interview GPs as his Gwen Adshead (Consultant Forensic He emphasised neuroplasticity, building Outreach) next group and was planning to tackle Psychotherapist at Broadmoor Hospital) his case that psychotherapy can Astra Temko (Child and Adolescent psychoanalysts after that. proved an irresistible draw for 250 potentially modify earlier neurobiological Psychotherapist, Candidate, BPA) delegates to the inaugural South of mechanisms. He showed that, in the same Of course, there were those who criticised England Psychotherapy Conference at way that neural circuitry affects how we Parker’s work on the grounds that Winchester University on 18 June. think, how we think can impact upon Collected Writings of D.W. Winnicott listening isn’t really work. It was too easy, neurological structures. Indeed, Gabbard they said anyone could do it. His response Many in the packed auditorium had shifted fluidly between neurobiological The Winnicott Trust is planning a was to invite them to go ahead and try. travelled a long way to participate. It and psychoanalytic paradigms. In a ‘Collected Writings of D.W. Winnicott’. If was an unusually diverse and welcome clinical vignette, he described asking you have access to materials – unpublished I’ll take up the challenge! I don’t suppose audience for a psychoanalytic conference. his suicidal borderline patient, who had documents, correspondence, videos or it’s easy, but I do think it worthwhile. I Many were not psychotherapists; a good returned after missing her weekly face- audio – that you wish to be considered for propose to pay homage to Tony Parker number were psychiatrists, most of them to-face session, ‘What did you think I was inclusion or for use in preparing it please by listening to psychoanalysts whose young to middle-aged. thinking when I was waiting for you to contact the General Editor, Dr Elisabeth work touches on the NHS. From where come?’ On a neurobiological level, the aim Young-Bruehl: [email protected] I stand, psychoanalysts seem a little bit As important as all this is, it was the is to quieten the amygdala by activating like the lighthouse keepers he wrote content of the conference that made it the prefrontal cortex; in more familiar Original documents donated will become about doing a vital, lonely and risky job, so memorable. Dr Gwen Adshead set language, to promote reflectiveness or, part of the Winnicott Archive at the clinging on between a rock and a hard the scene, urging young psychiatrists not citing Bion, alpha function. As Gabbard Wellcome Institute for the History of place, little known, barely understood, to ‘let the psyche go’ in their work. She put it, ‘The therapeutic frame is an Medicine in London. A website is also and about to be wiped out by the creeping modestly described her brief, erudite envelope within which a way of thinking being set up where visitors can subscribe commodification of medicine and health and stimulating talk, ‘How to do things is imposed upon unbearable affect states to a newsletter and contribute to a happening all around them. with words: psychotherapy for complex which cannot be borne by one person alone.’ discussion group. problems’, as ‘merely the hors d’oeuvre’ If you would like to be part of this for Professor Gabbard. His ideas raise questions in the The Trust also welcomes financial support project, or know someone who might, current debate about what constitutes for this important scholarly project. Please please get in touch. You can track the Gabbard’s masterly presentation on psychoanalysis versus psychoanalytic contact the Chair of Trustees, Dr Lesley progress and get more information at: Borderline Personality Disorder used psychotherapy – is it frequency of Caldwell, University College London, at http://homagetotonyparker.blogspot.com PowerPoint to drive home his hypothesis: sessions, use of the couch, interpretation [email protected] [email protected], 020 8455 4549 the way brain pathways are different of (or ‘in’) the transference, or the mode among his specific group of patients of therapeutic action? Was Gabbard NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1 13

Relational psychotherapy

By Jean Knox

N HIS EXCELLENT discussion of Affect regulation Adam’s mind, but between them, but the therapist also session frequency in the last issue The non-verbal patterns of relationship offered a tentative helps the patient to gradually make his of New Associations, Jeremy and communication between therapist invitation to Adam or her own sense of his or her own past Holmes suggested that most and patient have been extensively to imagine what experience. The patient’s own sense of Ipeople would agree that the key features described and thoroughly researched it might feel like to be in five times a self-agency plays a vital role, both in of psychoanalysis ‘include working with by the relational/attachment models of week therapy, to which Adam responded relationship with the therapist and in transference and making interpretations psychoanalysis by, among others, the by mentalizing – reflecting on his own terms of making sense of his or her own rather than suggestions and Boston Change Process Study Group. conflicting feelings about separateness emotions and memories. I think that the encouragement,’ the latter being what These ‘non-interpretive mechanisms’ and independence. example Jeremy Holmes gave illustrates most people think of as the hallmarks of in the intersubjective dynamics of the importance of the patient’s agency supportive psychotherapy. He went on to the clinical process operate at a far A mentalizing approach in psychotherapy very well – when invited to consider what argue that there is therefore nothing deeper level than suggestions and requires a therapist’s intuitive ever- five times a week therapy might feel intrinsic to frequency that makes it encouragement, and contribute to a good shifting perspective-taking that does like, Adam replied that the gap between quintessentially psychoanalytic, and that outcome in any psychotherapy as much as not attempt to pin the patient’s mind sessions give him a sense of resilient the hierarchy which regards four sessions the verbal exchanges between therapist down with definitive interpretations. independence, a response that conveyed a week as the gold standard is arbitrary and patient. They depend as much on The therapist’s focus of attention on the his capacity to make his own mind up and may not reflect real and fundamental tone of voice, facial expression and the meaning-making process itself is more of about what he needed and to survive on differences between therapies of different rhythm of the dialogue as on what is an implicit attitude than being directly his own. intensity. actually said. Together these provide the and explicitly stated. The evidence I experience of affect regulation, through have touched on strongly supports the The co-construction of interactive I entirely agree with Holmes’ conclusion the processes of on-going emotional view that what makes effective clinical patterns and self regulation plays a that low intensity work can be mutative, regulation, heightened affective moments practice is the co-construction of meaning crucial role in the therapeutic potency of but would like to highlight some of the and disruption and repair. between therapist and patient, rather than psychotherapy. It depends on patterns of relational processes that evidence shows the meaning being determined by the emotional interaction between therapist to effective in psychotherapy – it is not therapist’s interpretations. and patient, which are implicit patterns just interpretation or working with ‘It is not just of collaborative turn-taking and repair of transference that make psychotherapy Self-agency ruptures and misunderstandings that are of any intensity effective in bringing interpretation Language is itself a form of action and fundamental to all human interaction, about real and lasting psychic change. or working with reaction, with its own communicative whether verbal or nonverbal. They are For example, Wallerstein found in rules which have been identified the major guarantors of intersubjectivity, his original study that, among other transference across cultures, races and languages. of shared understandings, which are factors, corrective emotional experiences that make In the study of conversations, it is the fundamental to a relational model of correlated with a good outcome, but response of the hearer to the previous the mutative nature of psychotherapy, interpretation by the therapist or insight psychotherapy turn, and the production of the next whatever the frequency of the sessions. on the patient’s part actually showed no effective.’ turn in the conversation, rather than Indeed, each therapist-patient dyad needs such correlation with outcome. Shedler, the interpretations of an outside to find the rhythm of interaction that in his recent meta-analysis, found that In addition, neuroscience studies are observer, which provide the evidence best facilitates the patient’s development the therapist’s facilitation of a positive providing further evidence for the for what meaningfulness is. From this of affect regulation, mentalization and working alliance was important, as well importance of non-verbal aspects of perspective, psychotherapy is a two-way agency, and there is no one pattern of as verbal exploration of the patient’s relationship in human psychological and conversation, whose successful outcome frequency that works for everyone emotions and thoughts about self and emotional development; much of this actually depends on the patient having discussion of interpersonal relationships research is described in a recent book an opportunity to repair the therapist’s and relationships with early caregivers. by Ruth Lanius and colleagues, The misunderstandings and other disruptions Jean Knox is a Training Analyst with the It seems to me that this kind of research Impact of Early Life Trauma on Health between them. This therapist-patient SAP and BAP. Her book Self-Agency in shows us how important the unconscious and Disease: the hidden epidemic (2010), turn-taking is a cooperative meaning- Psychotherapy: Attachment, relational experience with the therapist is, as well as in the extensive research of a making effort on the part of therapist Autonomy and Intimacy was even when this is not interpreted. number of other authors, such as Allan and patient that is far removed from published in December 2010. Schore and Jaak Panksepp. the patient as a passive recipient of the In a recent book, Self-agency in analyst’s interpretation of his or her psychotherapy: attachment, autonomy Mentalization unconscious. Too didactic a form of References and intimacy (2010), I have suggested interpretation can become a way for the At first sight, mentalization might seem Knox, J. (2010) Self- that there are three fundamental to be the capacity that most depends on therapist to tell the patient what is ‘really’ Agency in Psychotherapy: processes that underpin the change in going on in his or her unconscious, rather Attachment, Autonomy the explicit verbal exchanges between and Intimacy. New York psychotherapy, namely affect regulation, therapist and patient. But it also has than facilitating the patient’s gradual London; WW Norton mentalization, and the development of ability to relate to, fully experience and implicit, automatic relational aspects Lanius, R.; Vermetten, self-agency. In many ways, these function that are just as important and underpin find what his or her own memories, hopes E.; Pain, C. (2010) The under the radar, as it were, depending on and fears actually mean. Impact of Early Life empathic imitation of gesture and the Trauma on Health and the implicit intersubjective dynamics of turn-taking that is so fundamental in Disease : the Hidden the clinical interaction, rather than on In an intersubjective, relational approach, Epidemic. Cambridge human communication. The example University Press conscious understanding. Jeremy Holmes gave in the last issue the therapist and patient co-construct illustrated this well – he did not make a a sense of the meaning of the patterns definitive statement about what was in of communication and relationship 14 NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1 NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1

22 November 2011 JANUARY MARCH Diary JUNG AND ALCHEMY SAP, 1 Daleham Gardens, London NW3 21 January 2012 3 March 2012 NOVEMBER Speaker: Bob Withers PSYCHOANALYSIS AND HOMOSEXUALITY: Depression: A Psychoanalytic Contact: 020 7435 7696, MOVING ON Perspective 11-12 November 2011 [email protected] Resource for London, 356 Holloway Road, 23 Magdalen Street, London SE1 The Red Book Two Years on London N7 Workshop Leader: Stephen Crawford 13-15 Arundel Street, London WC2R 24 November 2011 Speakers include Malcolm Allen, Nicola Contact Mayra Angulo, 020 7378 2054 Speakers include Paul Bishop, Christian ISSUES OF ‘RACE’ IN SUPERVISION Barden, Jeremy Clarke, Peter Fonagy, 9 March 2012 Gaillard, Sonu Shamdasani, Murray 120 Belsize Lane, London NW3 Leezah Hertzmann, Trudy Klauber, TEMPORALITY IN THE UNCONSCIOUS – Stein, plus clinical panel Speaker: Frank Lowe, chair Helen Morgan Alessandra Lemma, Julian Lousada, Contact: 020 8938 2285, A Matter of Time: From Churches to Contact: 020 7435 7696, Paul Lynch, David Morgan, Sculpture [email protected] [email protected] Bernard Ratigan, Mary Target 112a Shirland Road, London W9 Contact: BPC, 020 77561 9240, 24-25 November 2011 Speaker: Gregorio Kohon 12 November 2011 [email protected] Contact: [email protected] ‘COULD IT BE MAGIC?’: Identifying the Psychological Therapies in the NHS dynamics of change in Couple Therapy Savoy Place, London 23 January 2012 17 March 2012 TCCR, 70 Warren Street, London W1T www.healthcareconferencesuk.co.uk Paternal function and thirdness in Witnessing the Unspoken Speakers: David Hewison, Mary Morgan psychoanalysis and legend 120 Belsize Lane, London NW3 Contact: Matt Williams 020 7380 1975, 26 November 2011 B20, Birkbeck, Malet Street, London WC1 SAP Annual Lecture: Wendy Bratherton [email protected] Changing Minds in Therapy: Speaker: Rosine Perelberg The Way Forward Contact: [email protected] Contact: 020 7435 7696, 12 November 2011 Friends Meeting House, 91-93 Hartington [email protected] Internet Pornography: Grove, Cambridge CB1 28 January 2012 Working with Client Preoccupation Speaker: Margaret Wilkinson FACING SEXUALITY 17 March 2012 WPF, 23 Magdalen Street, London SE1 Contact: 020 7435 7696, 18 Holyrood Park Rd, Edinburgh EH16 Psycho-somatic? Hysterical? Physical? Workshop Leader: Jenny Riddell [email protected] Speaker: Brett Kahr Contact: 020 7378 2054, Contact: 01728 689 090, www.confer.uk.com 23 Magdalen Street, London SE1 [email protected] Workshop leader: Mary Pat Campbell 26 November 2011 28 January 2012 Contact: 020 7378 2050, 13 November 2011 Real and Illusory Space in the Mind [email protected] of the Mother The Developmental Model in TOPIC OF CANCER Post-Jungian Psychology: The LCP, 32 Leighton Road, London NW5 Friends Meeting House, 43 St. Giles, Contribution of Michael Fordham 17 March 2012 Speakers include Helen Bender, John Oxford OX1 SAP, 1 Daleham Gardens, London NW3 Speaker: Gerry Byrne Nature crisis: Rethinking Woods, Martin Schmidt, Sue Saville Speaker: Elizabeth Urban psychoanalysis for the environment Contact: 020 7435 7696, Contact: LCP, 020 7482 2002, Contact: 020 7435 7696, The Eden Project, Cornwall [email protected] [email protected] [email protected] Speakers: Phillip Derbyshire, Greg Garrard, Stephen Gee, Paul Kingsnorth, 15 November 2011 DECEMBER FEBRUARY Murdered father; Dead father Sally Sales, Joe Suart, Paul Zeal Contact: 01707 649788, B01, Clore Management Centre, 1 December 2011 4 February 2012 Maya Centre Charity Event [email protected] Torrington Square, London WC1 The Transcendent Function in Speaker: Rosine Perelberg Free Word Centre, 60 Farringdon Road, Adolescence 29 March - 1 April 2012 London EC1R Contact: [email protected] Friends Meeting House, 43 St. Giles, The Initial Psychoanalytic Interview Speakers: Melissa Benn, Jill Dawson, Oxford OX1 and the Treatment Process 17 November 2011 Margaret Drabble, Helen Simpson, Speaker: Marica Rytovaara Marriott Paris Rive Gauche Hotel Ethics, Self-Deception & Sarah Waters the Corrupt Physician Contact: 020 7435 7696, EPF Annual Conference Contact: Free Word, 020 7324 2570, 120 Belsize Lane, London NW3 [email protected] www.epf-fep.eu [email protected] Speaker: Glen O. Gabbard FORTHCOMING 10 February 2012 Contact: Jane Vogler 0208 938 2606, 3 December 2011 Working Through in the www.tavistockandportman.ac.uk Understanding and working with 12 May 2012 abuse in couple relationships Countertransference Revisited BPC TRainees’ conference TCCR, 70 Warren Street, London W1T TCCR, 70 Warren Street, London WC1 18-19 November 2011 West Yorkshire Playhouse, Leeds Organizational and Social Dynamics Speakers: Judith Siegel, Christopher Speaker: Irma Brenman Pick Contact: [email protected] Ambassadors Hotel, 12 Upper Woburn Clulow, Damian McCann Contact: 0207 380 1975, Place, London WC1H Contact: Joanna Bending 020 7380 1970, [email protected] Speakers: Kathleen Pogue White, [email protected] Michael Rustin 11 February 2012 Contact: 020 7736 3844, [email protected] 3 December 2011 Mothers, Infants, and Maternal WINNING AT ALL COSTS: A PSYCHOLOGICAL Mental Illness EXPLORATION OF SPORTING GREATNESS 19 November 2011 Friends Meeting House, 91-93 Hartington The Unspeakable and The Unbearable SAP, 1 Daleham Gardens, London NW3 Grove, Cambridge CB1 BAP, 37 Mapesbury Road, London NW2 Speaker: Ian Williamson Speaker: Elizabeth Urban Speakers include Jean Knox, Julian Lousada, Contact: 020 7435 7696 Contact: 020 7435 7696, Janine Sternberg, Joscelyn Richards [email protected] 3 December 2011 Contact: 020 8452 9823, Adult Love and its Roots in Infancy [email protected] Anna Freud Centre, London NW3 25 February 2012 Speakers: Lisa Appignanesi, Bernard Jung and Gender Identity 19 November 2011 Barnett, David Morgan, Anna Furse, SAP, 1 Daleham Gardens, London NW3 Destroying the Knowledge of the Speaker: Jean Thomson Need for Love Estela Welldon Primrose Hill Community Centre, Contact: www.freud.org.uk Contact: 020 7435 7696, 29 Hopkinson Place, London NW1 [email protected] 9-11 December 2011 Speaker: David Morgan RON BRITTON TODAY Contact: 0207 978 1545, Cruciform Building, UCL, London WC1 [email protected] Speakers: Ron Britton, Liana Chaves, Peter Fonagy, Mary Target, David Taylor, David Tuckett www.ucl.ac.uk/psychoanalysis/ NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1 15

Psychoanalysis and homosexuality: moving on The Divided Brain and its Importance for the Understanding of Mind – Ref: CPD/27 Half-day Conference – Saturday 5th May 2012 A one-day conference co-hosted by The Anna Freud Centre, Iain McGilchrist, Psychiatrist and author of the ground-breaking book: The Master and Association for Psychoanalytic Psychotherapy in the NHS, his Emissary: The Divided Brain and the Making of the Western World, argues that British Psychoanalytic Council, the two hemispheres of the brain have not merely different skills, but wholly different Tavistock and Portman NHS Foundation Trust, and perspectives on the world. He will be presenting this argument at the conference and Tavistock Centre for Couple Relationships Helen Morgan, Senior Member, British Association of Psychotherapists will explore the implications for psychoanalytic work in a response. Fee: £40 (Trainees: £35)

Beyond Words – Art and Image in Psychotherapy – CPD/3 Saturday 21 January 2012 Six seminars, covering a range of topics related to creativity and image-making from a Jungian perspective. Each workshop will begin with a talk by a Jungian Analyst, Resource for London, 356 Holloway Road, London N7 followed by experiential and clinical discussion groups, with the opportunity for participants to bring images from their clinical practice. Aimed at professional therapists and arts therapists who want to deepen their thinking about the area of images and art For some time, much of the psychoanalytic community in the UK has been in relation to analytical therapy. Fee: £350 conspicuously silent on the issue of homosexuality, and by extension on the area of sexuality in general. There has tended to be a de facto retreat from the Weekend Course: The Foundations of Psychoanalytic pathologisation model that was promulgated in the past, but with little in the Theory & Practice – Ref.INT/4 way of explicit articulation or theorisation of a new consensus. A movement that Aiming to provide an understanding of key theoretical concepts, this course helps once made the fearless exploration of human sexuality its very hallmark has participants explore how psychoanalytic ideas can be applied both directly when become a little coy. working with patients and also in understanding the underlying dynamics in the work place. Weekends include theoretical seminars, small group discussions and experiential But an irreversible change is now in train. Earlier Psychoanalytic Psychotherapy groups. Suitable for those interested in exploring psychoanalytic ideas or considering NOW conferences have highlighted the need to deal with this issue in a more further training. Four weekends: February, March, and May & June 2012. Fee: £780 direct and forthright way. A special edition of the journal Psychoanalytic Psychotherapy published in December 2011 is devoted to the subject. And the Infant Observation – A Jungian Approach – Ref. INT/12 British Psychoanalytic Council (BPC) is adopting a position statement. The experience of observing an infant from birth to two years old is invaluable in This conference seeks to define and explore the current state of mind within understanding the unfolding of the self. By reflecting on participants observations in a the psychoanalytic community on this subject, ranging across some of the group, we endeavour to build up a picture of the developing inner world of the infant and key scientific questions to what changes need to be made to ensure that the their relationships. Joining the course is possible at the beginning of any term. Seminars profession fully opens up to gay and lesbian trainees and patients. In so doing, are held in South and West London. Fee: £690 it is hoped to allow for a new dawn of psychoanalytic thinking on its original home ground of psychosexuality. For further information and application forms, please contact Sandra Pereira: Tel. 020 8452 9823 or via [email protected] Outline programme

9.30 – 9.45am Welcome and introduction: Malcolm Allen

9.45 –11.15am Plenary A scientific theory of homosexuality for psychoanalysis Chair Alessandra Lemma Paper Peter Fonagy Discussant Nicola Barden

11.45am – 1.15pm Breakout sessions 1. Scientific discussion continued Bernard Ratigan in conversation with Nicola Barden 2. Creating a gay-friendly profession Paul Lynch and Jeremy Clarke 3. Exploring the complexities of conscious and unconscious NA sexual orientation in the clinical relationship Leezah Hertzmann and Mary Target 4. Clinical perspective: the uncertain patient New Associations is published by For insertion of advertising David Morgan the British Psychoanalytic Council, materials contact Contribute to New Associations Suite 7, 19-23 Wedmore Street, Leanne Stelmaszczyk, We welcome your ideas for articles, London N19 4RU [email protected] reviews, and letters to the editor. 2.15 – 3.35pm Plenary Training curricula and training practices – Tel. 020 7561 9240 In particular we are looking for what needs to change? Fax 020 7561 9005 Design Studio Dempsey reviews of cultural events, books Presentation Paul Lynch www.psychoanalytic-council.org Designers Mike Dempsey, and films with psychoanalytic [email protected] Stephanie Jerey and the BPC interest. If you would like to propose Respondents Illustrations Leanne Stelmaszczyk a topic for a longer article (up to Three issues of New Associations Printer Advent Colour 1200 words) please contact Janice 3.50 – 5.00pm Plenary Next steps are published each year in March, Cormie: janice@psychoanalytic- July, and October. Views expressed in New Associations council.org Chair Helen Morgan under an author’s byline are the Panel Julian Lousada, Trudy Klauber, Jeremy Clarke, Subscriptions views of the writer, not necessarily Deadlines: The next issue of Bernard Ratigan UK annually (3 issues): £10 those of the BPC. Publication of New Associations will be published Overseas annually: £16 views and endorsements does not in February 2012. The deadline for constitute endorsement by the BPC. article proposals is 23 December Editorial Board © 2011 British Psychoanalytic 2011. Contributions and letters to The New Associations Editorial Council. No part of this publication the Editor should reach us no later Booking details at www.psychoanalytic-council.org Board is currently being convened. may be reproduced, stored or than 20 January 2012. Details will be posted on the transmitted in any form or by any BPC website. means without the prior permission Managing Editor: Malcolm Allen of the publisher. ISSN 2042-9096 16 NEW ASSOCIATIONS ISSUE 7 AUTUMN 2 0 1 1