Last week I attended the Royal College of Psychiatry annual Medical Psychotherapy conference, hosted in Exeter. This was an interesting meeting and I thought it would be a useful exercise to describe some of the meetings and discussions that took place, together with a few of my own reflections on the conference.
Below are presented some very brief notes on each of the presentations I was able to attend, followed by my own reflections to conclude.
Paradigms, Possibilities and Projections in Primary Care
This was the opening plenary session, following on from an introduction and welcome to the meeting. It was led by Dr J Stern (Consultant Medical Psychotherapist), Mr B Rock (Clinical Psychologist with interest in psychoanalytic models of treatment) and Dr W Brook (Salaried GP, Hackney, London, with an interest in the psychological and cultural aspects of medicine).
The presentation focussed on the experience of working with the City and Hackney Primary Care Psychotherapy Consultation Service. The goal of the service was to provide psychologically informed assessment services to primary care teams within the City and Hackney area. Offered services included – assessment services, consultation and joint clinical assessment with GPs. The assessment service was able to offer up to 16 sessions of, weekly, psychotherapy before on-ward referral or other advice was offered. Clinical liaison advice was offered for discussion of complex cases, joint consultation services were also offered although, it seems, these were rarely utilised by GPs.
The service seemed to target those individuals with complex needs whose support requirements fell outside the remit of the plethora of other services on offer – for example those not considered to be requiring secondary care input, but whose complexity was felt to be greater than could be provided for in primary care.
Quantitative targets were discussed and achievements highlighted, together with some interesting clinical vignettes to describe some examples of clinical case discussion.
Question and answer discussion towards the end of the session focussed primarily on the generalisation of lessons learned from the service – described as being bespoke for the Hackney area, how much could its practices be transferred to other primary care areas? For me this presentation highlighted an important issue around the boundaries of clinical care in mental health – how do we best meet the needs of those whose needs are sufficiently complex as to fall outside of mainstream service provision?
Plenary 2 – Forensic service provision
This second session focussed on the experience of providing care within a forensic setting. The first talk focussed on developing evidence relating to the treatability of Antisocial Personality Disorder, the second talk presented a clinical case seeking to demonstrate the need for long-standing supportive care for those with complex needs receiving care within forensic settings.
Questions in this second plenary were limited – owing partially to the speakers running late, but also I think as many of the topics covered in the talks were not controversial to the audience – that personality disorder could be considered a disorder of attachment, for example.
Parallel Workshops – Containment, Capacity and the Complex Personality Disorder. The therapeutic use of mental health law
Following lunch on the first day there was an opportunity to join one of five workshops – I attended a group discussion on the use of mental health law in complex mental health cases.
The workshop focussed on a tension that exists between the provision of client centred psychotherapy; where the individual expresses a willingness to consider, and work towards, change; together with the role of the mental health act, where treatment can be enforced and the risk of coercion presumably increases.
Following on from this the question arises – should psychotherapy be provided to people who are admitted to hospital under the mental health act? If community treatment orders are used can engagement with a psychotherapist, or therapeutic community, be part of that order? How can the role of therapist and registered clinician be handled, is it appropriate for a therapist to act as registered clinician?
Discussion focussed on the need to provide care and that if psychological therapy is deemed necessary how can this be withheld from an individual detained under the act? How can this best be handled in forensic settings where many people will be detained under various forms of the mental health act?
Uncertainty and Economic Life: Denial of Reality in pursuit of the phantastic – Prof D Tuckett
This final plenary session on the first day sought to review the applicability of psychoanalytic principles and approaches to understanding economic systems. The speaker, David Tuckett, is the director of the Centre for the Study of Decision-Making Uncertainty, University College, London.
The presented material was drawn largely from work discussed in Prof Tuckett’s book – Minding the Markets: An Emotional Finance View of Financial Instability. I personally found this presentation somewhat difficult to follow – however my understanding of the proposed thesis was that financial decisions are made in a context of uncertainty and therefore at risk of being biased by emotional factors impacting on decision makers. These factors can be recognised, but are often noted only retrospectively following an error. The implication was that an alternative manner of considering financial situations was necessary, that adequately considered personal narrative and emotional contribution to decision making.
Early evening session
The first day concluded with three lectures in a 90 minute session from 5 ‘o’ clock.
- Truth and Reconciliation in Northern Ireland – Lord John Alderdice
- Redemption and forgiveness: narratives and therapy with offenders – Dr Gwen Adshead
- Resettlement for prisoners from Guantanamo – Polly Rossdale, Deputy Director, Abuses in Counter terrorism, Reprieve
Day 2 – Group analysis plenary session
This session focussed on the work of the institute of group analysis and the role of group analysis in the development of varying fields of clinical practice.
- Group analysis – from its roots to now
- An historical overview of the practice of group analysis
- Group work in therapeutic communities, prisons and with prisoners with personality disorder
- Psychologically informed planned environments
- An overview of work taking place to develop institutions where those leaving secure settings can receive appropriate support on return to the general community
- Supervision in groups training
- Overview of training available for those offering supervision to group therapies
To me – this seemed a somewhat unusual plenary session as many of the audience members were trained in group analysis and experienced in taking part within group discussions. Indeed this comment was raised from the floor – with the criticism that much time in the conference had been spent on the provision of information with precious little space for reflection.
Plenary session – Contemporary practice
This was the final session of the second morning, but also the final session that I attended for a number of reasons. It sought to explain the work that was taking place within the Devon Personality Disorder Psychotherapy service. The talk included the difficulties that had been faced by the group and hopes for future development and continued work.
I found this to be an interesting conference for a number of reasons – the plenary sessions and workshops were obviously of interest in their own right, but there was another theme of interest to me that ran throughout the conference.
The medical psychotherapy faculty of the Royal College of Psychiatrists represents a very broad church – in theory encompassing practitioners from a variety of theoretical backgrounds including psychoanalytic and cognitive for example. However this conference seemed to consist entirely of those with a psychoanalytic background. This was pleasant, in that it was nice to share ideas with those from a similar theoretical background. However for me there was a somewhat hidden aspect to the conference. Medical psychotherapy as a profession is in crisis – there have been a large number of services reduced or dropped from commissioning and the employment of medical psychotherapists is far from settled, with many leaving the NHS to enter private practice.
For me I am concerned by this loss of talent from the mental health services. However this difficulty was not addressed at all during this conference. It was difficult not to see this as a form of wilful denial of difficulty? This absence of discussion around how to best approach developing novel research to support service users to me was deeply depressing. I am also concerned that the absence of reflective space in general within the conference served to compound my concerns – the continuous presentation of information perhaps giving an illusion of industry?
I continue to maintain that psychoanalytically informed understanding can benefit the care of those experiencing mental distress. I am aware this is a minority view – however in my experience the use of psychoanalytically informed formulations often seems to be an acceptable means of addressing the nature of distress for those with the most complex issues. I accept however that there is a need to develop the evidence base for these approaches – we need to turn attention to outcome measure research and to working with service users to ensure that we offer them the best possible support and care, when they require it.