Turning the Tide

The Psychoanalytic Approach of the Fitzjohn's Unit to Patients with Complex Needs

Rael Meyerowitz, David Bell, Rael Meyerowitz, David Bell

• Publisher: Routledge
• Year: 2020
• eBook ISBN: 9781000149760
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Since it was founded in 1920, the Tavistock Clinic has developed a wide range of developmental approaches to mental health which have been strongly influenced by the ideas of psychoanalysis. It has also adopted systemic family therapy as a theoretical model and a clinical approach to family problems. The Clinic is now the largest training institution in Britain for mental health, providing postgraduate and qualifying courses in social work, psychology, psychiatry, and child, adolescent, and adult psychotherapy, as well as in nursing and primary care. It trains about 1,700 students each year in over 60 courses. This important volume traces an impressive range of descriptions, all clinically based, of the work of the remarkable Fitzjohn's Unit, which has about 60 patients under its care at any one time. The book also evokes a clear sense of collective commitment, one that has lasted over seventeen years, since its beginnings as an experimental project that was set up by David Taylor in 2000.

CHAPTER ONE
Finding a way in: the work of the Fitzjohn's Unit

Birgit Kleeberg

The young woman spoke slowly, with long gaps interrupting her sentences, which left me trying to hold on to fragments. Although she made a great impression on me, I struggled to remember what she had said.

She avoided meeting my eyes. She spoke of mood swings, of feeling confident, then very low. She told me she used to cut herself, but that was years ago.

I said coming here felt dangerous. She laughed and admitted to feeling extremely anxious.

A bit later I commented that she avoided looking at me and said that she may feel that she needs to shield me. Then she did look at me and I found encountering her gaze difficult. It was as if the connection, once established, could not be broken off again. Our eyes were locked together. I felt she had got right inside me.

I suggested that she was anxious about what she would do to me and what I would do to her. She told me she had broken up with a boyfriend yet again; it was the third relationship she had ended this year. She said she “hurts people”. She told me that she did not regret having gone to the ward when she was hearing voices telling her to cut herself, as it had led to her getting some help.

When she had first sought help, she thought the problem could be taken away completely and, while she still wished for it, she now did not think it likely.

I thought she was serious about wanting my help and yet felt we had not covered much ground. I felt I was being too abrupt when I told her we had to finish, as if I was dropping her into the void. What was strange was that our first meeting felt simultaneously so intense and yet so thin. I felt relieved that I would be able to think about this disquieting experience with my colleagues in the staff seminar.

With this account of my first assessment meeting with a young woman whom I shall call Ms K (whose progress I shall trace throughout this chapter), I hope to take you straight to the heart of the work of the Fitzjohn’s Unit. It shows how an extreme, disordered psychic situation can begin to be talked about by the psychotherapist and the patient. It also already points to the importance of the structures that provide containment for the therapist, helping her recognize unconscious aspects of what has been going on between her and her patient.

The history and approach of the Fitzjohn's Unit

The Fitzjohn’s Unit began life in 2000, evolving as part of the clinical services of the Adult Department of the Tavistock Clinic and embedded within the department’s psychoanalytic culture. It was started as an experimental project by David Taylor who was succeeded as the unit’s consultant by David Bell in 2002. Not long after that Mrs Edna O’Shaughnessy, a distinguished senior psychoanalyst, was invited to join the unit as its external supervisor. There had, for some time previously, been a broad recognition that a significant group of patients were particularly disadvantaged by the limitations of the generic treatment model of the service, which offered once-weekly psychotherapy for one year. These individuals tended to suffer from more serious levels of pervasive and long-term disturbance. We recognized that, after a year’s treatment, we had only just begun to make any significant contact with them and that, in some cases, ending the therapy then risked losing even the small gains we had made. It was therefore decided to develop a specialist unit that could address these patients’ problems in a more appropriate manner, and over the following year or two we developed the model that has become the foundation of our work.

We created a specialized service where patients receive twice-weekly sessions of individual psychotherapy for two years with an experienced psychotherapist, followed by group psychotherapy for a further number of years. This model was adopted and adapted from one used at the Cassel Hospital, an inpatient therapeutic community for more disturbed patients, where both David Bell and I had previously worked at different times.

I explore in more detail later in the chapter what can be achieved in the first phase of individual psychotherapy. As far as the latter part of the treatment—the group—is concerned, its aim is to continue the developmental process begun in the individual therapy. In addition, the group provides an opportunity for its members to learn something about themselves as reflected through the perceptions and observations of others, their fellow patients, who can speak to them far more directly—and often bluntly—than a therapist ever could. It can help to reveal their social strengths as well as the recognition of the pressures that their problems create for them in new relationships—how these difficulties come to be re-enacted, but also tackled. We think that it is helpful to enable our patients, as far as is possible, to determine their own discharge and thus to face and work through an ending in a manageable way. It is for this reason that the length of time they are able to spend in the group is more flexible than it is for the individual therapy. (See chapter 7, Maxine Dennis’s chapter on groups, for further elaboration of this work.)

In 2003, the Government published a document, Personality Disorder: No Longer a Diagnosis of Exclusion, highlighting the plight of patients with long-term disorders arising from profound character problems who were excluded from mental health services (on the grounds that they did not suffer from illnesses, as such) (NIMHE, 2003). This proved to be strategically very useful in the development of the Fitzjohn’s Unit, in that it provided incentives for other services to refer this group of patients to us for help.

While encouraging the referral of patients with features of personality disorder, we also attempt to retain a broader remit in terms of the types of patients we accept. Unlike most personality disorder services, we do not insist that our patients meet “official” diagnostic criteria for personality disorder. Our broader inclusion criteria thus give us a unique place among other local services, and this is increasingly appreciated by referrers and patients alike.

David Bell is well known for his long-standing interest in working with more disturbed patients. For some years he ran a psychosis workshop in the Adult Department at the Tavistock Clinic, where staff and trainees would come to discuss their work with the most difficult of patients. He brings the benefit of his considerable experience, as both a psychiatrist and a psychoanalyst, to the management of the challenging and risky situations that we face in the unit. While conducting a large proportion of the assessments in the unit, he will often take on the assessment and case management of patients who require particularly close liaison with psychiatric and other personality disorder services.

As the chair of the weekly unit meetings, where complex management issues are discussed, he takes the lead and assumes responsibility for concerns about how to deal with risks and crises in treatment. He may, for example, agree to meet with a patient who has acted in a threatening way towards his or her therapist, in an attempt to assist the patient either to return to therapy in a different frame of mind or to come to terms with the possibility that the therapy may no longer be viable.

By representing the work of the unit, both internally within the trust (to the board of governors, for example) and externally (by establishing links with the heads of other services), David Bell enables us to provide better, longer-term care for our patients. Clinicians from other services within the Tavistock and Portman NHS Trust are encouraged to bring complex cases for discussion in the unit meeting. We are also approached to consult to mental health services from other trusts, such as an inpatient team struggling to manage a particularly difficult patient. Occasionally an invitation will be issued to the team to come to our unit meeting to present the situation that they are struggling with. The ensuing discussion then also provides a learning opportunity for all the members of our own unit.

Having worked in the unit from its inception, I joined David Bell as co-manager in 2005. We have developed a model of sharing the responsibility of leading the unit between two people, which has worked very well. It is the only clinical unit in the adult service that is managed in this way. This again leans on our experience at the Cassel Hospital, where we had learnt the value of a “couple”—either psychotherapist and primary nurse, or consultant and senior nurse—working together to contain various levels of disturbance.

There is another weekly meeting, the staff seminar, led by Mrs O’Shaughnessy, who does not attend the unit meeting. This forum is only for those who have patients in treatment and therefore is not open to outside visitors. David Bell made a decision not to attend this seminar so that it could proceed unconstrained by the consideration of management issues. Highly valued by the staff group, the staff seminar provides a space to think together freely and creatively. An important feature of the seminar is that clinical work is presented and discussed in an open and trusting manner, centring on the material brought and eschewing any judgement of the therapist. When something is missed or has gone wrong in a session, there is an understanding that this might have happened to anyone working with the patient. At the end of a seminar, the presenting therapist will frequently be told, “We’re right behind you”. This expression has now been adopted as a kind of wry mantra as it seems to capture and acknowledge both the reality of being on one’s own with the patient and the solidarity provided by the group.

It is the structure provided by these two different meetings— the unit meeting and the staff seminar—that has enabled us to create and maintain strong staff morale, perhaps one of the most critical factors necessary for containing the high levels of disturbance created by the nature of our work.

The clinicians on the unit are all qualified, experienced psychotherapists, many of whom had their psychotherapy training in the Adult Department. A substantial number are psychiatrists and/or psychoanalysts; some have a background in philosophy and literary studies. We also provide an advanced two-year clinical training for qualified psychotherapists who wish to learn about working with more disturbed patients. As honorary psychotherapists on the unit, they are each assigned a patient for whom they provide psychotherapy. They are offered supervision and some theoretical seminars, attend all meetings, and contribute greatly to the life of the unit. The diversity of the staff group, who come from different countries of origin, intellectual and professional backgrounds, and schools of thought within psychoanalysis, makes it a rich and rewarding environment in which to work.

How people become our patients

Referrals to the unit come from a number of sources, regularly from GPs and psychiatrists based in local mental health, but also from psychology, the Improving Access to Psychological Therapies (IAPT) programme, and student counselling services. The large majority of patients referred proceed to assessment. However, the term assessment is perhaps not quite right, as it might suggest a kind of examination, a test to be passed or failed. When conducting our assessments, we are, in fact, not looking to the patients to prove themselves. Our default position is that the patient can be helped unless there are very good reasons that make it unwise to proceed—for example, if we feel that the risk of deeper engagement outweighs the likely benefit. The assessment consultation provides the foundation on which all subsequent engagement is built. As described in David Bell’s Introduction, the approach foregrounds the way in which the patient relates to us, as only this can provide the basis for an adequate assessment of what the patient is seeking and to what extent she or he can tolerate the therapeutic process.

As shown in my account of my first meeting with Ms K, it often becomes possible to talk to patients quite directly about matters they well may have been aware of but never believed could be talked about so openly. When this happens, there is often a palpable shift in the atmosphere. This kind of emotional contact can be very fleeting, but it provides an important indication of a patient’s capacity to form a therapeutic alliance. One might expect that someone’s availability for understanding, the capacity to be interested in his or her own mind, requires the person to be relatively less disturbed, but this is not necessarily the case. It is not unusual to find that very disturbed patients, including some who would be classed as psychotic, respond well to attempts to understand them and go on to make good use of psychotherapy. (For a more detailed account of our approach to assessments, see Bell & Kleeberg, 2013.)

Returning now to Ms K, the staff seminar group noted that, on the one hand, she was quite amenable and tried to please the assessor. On the other hand, there was a more hostile, perhaps paranoid state of mind. This became more evident in the second assessment meeting in which she described how friends had trashed her room and vomited in her bed. It seemed that her deeper fears were managed through projecting them outwards, locating them in someone else. There was also, however, some awareness of—and guilt about—the harm that she believed she caused to others and herself.

From the consultation, it was clear that the patient experienced a deep terror of being trapped in a tormenting world of deteriorated inner objects that had been damaged by her attacks. This brings to light how what we might describe, from the outside, as “depression” can be lived as an internal, largely unconscious experience. As well as being depressed, Ms K also felt persecuted by paranoid fears which she knew about and which I took up right from the start. The transference was prematurely intense and lacking in depth—what we might call a borderline or psychotic transference (Bion, 1957). In the initial discussion, we thought that Ms K was too claustrophobic and anxious to tolerate twice-weekly sessions, so she was put on the waiting list for once-weekly psychotherapy. After a six-month wait, she began her therapy with me.

Inevitably, because of limitations on our resources, patients have to wait—often for many months—before they can begin psychotherapy. Some patients find this too difficult and drop off the waiting list. This was, we thought, partly a result of first being invited into the intimate and disturbing contact of the assessment, but then feeling left to manage on their own. We therefore decided to ensure that all patients on the waiting list are seen by the assessor, at varying intervals according to need, usually every four to six weeks. This enables a continuing containment, which can help them manage and so sustain their interest in having psychotherapy.

As is perhaps already clear, the patients are not only disturbed but also disturbing, so we have found it helpful to insist that no individual clinician in the unit take full or exclusive responsibility for any patient. When difficulties threaten to lead to a breakdown in the relationship between patient and therapist, the assessor becomes a case manager and can thus step in to give another view of the situation in order to help the patient to remain in therapy. We have found that this separation of responsibilities between the psychotherapist and the person who helps to manage crises makes for a much better structure. We therefore, as far as possible, try to ensure that the psychotherapist offering treatment is not the same person as the assessor (though, as in Ms K’s case, this is not always possible).

Keeping assessor and therapist separate serves as a particular resource for the patient. For example, the assessor also carries out the review, which usually takes place a few months after a patient has completed his or her individual psychotherapy. This meeting aims to help patients reflect upon what has been achieved and whether or not they are interested in entering the second phase of the treatment programme, the group psychotherapy. The conclusion of the group treatment marks another juncture where they might again touch base with the assessor. Despite our limited resources, this structure enables us to provide a continuity of care that is an essential part of the approach of the unit.

Many of our patients are concurrently being managed by local mental health services, something w...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Contents
• SERIES EDITORS' PREFACE
• ACKNOWLEDGEMENTS
• ABOUT THE EDITORS AND CONTRIBUTORS
• FOREWORD
• Introduction: against the tide
• 1 Finding a way in: the work of the Fitzjohn's Unit
• 2 Looking both ways: the role of the administrator in the Fitzjohn's Unit
• 3 The emergence of emotional meaning: a journey through delusional symptoms
• 4 The progress of sorrow
• 5 The mine/d field of the internal world: the importance of the setting in work with borderline patients
• 6 Beginning in the dark
• 7 The group as an object
• 8 Supervision and consultation: tuning in to psychotic communications in frontline mental health settings
• 9 "A quandary of borders": theoretical and clinical thoughts on the borderline predicament
• REFERENCES
• INDEX