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Time-limited psychotherapy in the community mental health team

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Brendan McMahon, MSc, BA (Hons), SRN, RMN, Cert Psychodynamic Psychotherapy.

Clinical Nurse Specialist in Dynamic Psychotherapy, Southern Derbyshire Mental Health and Community Trust

This paper describes how a clinical nurse specialist carried out short-term focal psychotherapy in a community setting. It is asserted that such therapy has an important therapeutic impact, given appropriate assessment procedures, and that liaison between colleagues can ensure better care.
This paper describes how a clinical nurse specialist carried out short-term focal psychotherapy in a community setting. It is asserted that such therapy has an important therapeutic impact, given appropriate assessment procedures, and that liaison between colleagues can ensure better care.

The author is a nurse psychotherapist in Southern Derbyshire. Based in Derby Psychotherapy Department, where the post involves teaching, supervision and other activities, most of the author's clinical work takes place in the community mental health team (CMHT), which serves two small towns. Typically, the work involves long-term individual and group psychotherapy. Referrals come from GPs, consultants and colleagues in the CMHT, or are made directly to the psychotherapy department, and are allocated by geographical sector. Most treatment is individual therapy, with about 14 patients in weekly therapy at any time, and around 80 assessment appointments performed a year.

Psychotherapy in community practice
Practising therapy in this setting has several advantages. Many patients, particularly those with with difficult child-care arrangements, find it easier to attend the team base than the central psychotherapy unit. It is also possible to have useful discussions with occupational therapy and nursing colleagues who may have already seen the patient, instead of having to rely on often sketchy referrals. This can help identify inappropriate referrals and save the patient from having to endure an unnecessary assessment. Examples of patients that would be suitable for referral for psychotherapy are shown in Box 1.

It is important to distinguish those patients who would not benefit from psychotherapy from those who would so the community team can direct them to other, more appropriate, services Examples of patients who generally would not benefit from psychotherapy are shown in Box 2. Referrals are often received via informal discussions with colleagues. If this happens, of course, the referral needs to be formally documented.

Informal communication channels work well if the patient's health or social situation changes for one reason or another while awaiting assessment and/or therapy or when they need professional input from another health-care worker in addition to psychotherapy. Success depends on all disciplines having a clear understanding of colleagues' expertise, what services they offer and what they are particularly good at.

The author is trained in analytic psychotherapy, and the model used is long-term psychodynamically oriented therapy. Based on the clinical and theoretical work of Sigmund Freud, Melanie Klein, Donald Winnicott and others, this approach is founded on the belief that psychological symptoms, anxiety, depression and the like are rooted in unresolved emotional conflicts, of which the patient themselves may not be aware.

Neglect, deprivation or abuse, for instance, may produce conflict between love for the parent and anger towards the (same) parent who hurt the child so much: it is almost as if the individual has two mothers, or two fathers, one good and the other bad. The resulting tension can be so painful that it is 'repressed', pushed into unconsciousness - in a sense forgotten. But it does not disappear. It continues to produce sadness and stress, and can even interfere with the ability to form relationships with others, which may lead to despair, self-harm, and even suicide (Freud, 1915a).

In psychotherapy the patient is able to become aware of his or her unconscious conflicts in a safe environment, and so begin to master them. One of the ways resolution is achieved is through what therapists call the transference (Freud, 1914). Whatever feelings the patient may have about their parents are re-experienced in the relationship with the therapist, who becomes a kind of symbolic parent (Freud, 1914).

The therapist does not, of course, hurt the patient in the way that the real parent did, but he or she may still be experienced as hurtful or withholding because of the power of the original experience. This phenomenon allows buried childhood emotions to be expressed, which can be a moving experience for both the client and the therapist, and enables the client to give up the symptoms, build more satisfactory relationships, and get on with his or her life.

This is a simplistic account of what happens in psychotherapy. There are many difficulties in the way people protect themselves from emotional pain in various ways, and are reluctant to give up their defences. Sometimes these resistances cannot be resolved, due either to the patient's problems, the psychotherapist's problems, or, more commonly, their joint problem in just being together. This is because transference is inherently ambivalent and necessarily involves both love and hate (Freud, 1915b). But usually therapy helps.

Short-term focal psychotherapy
Psychoanalysis, as taught by Freud and practised by his successors, was and is a lengthy process. Analysts see their patients four or five times a week. Analytic psychotherapy, though it usually involves seeing the patient once a week, can also take years.

And there are good reasons for this. Years of complicated hurt cannot be put right quickly, if at all. But in recent decades clinicians have experimented with shorter therapies and, on the basis of research and clinical experience, have reached the conclusion that analytic therapy can produce significant improvement in much shorter timescales than was originally thought (Strupp and Binder, 1984). Much of the pioneering work in this field has been carried out by Davenloo and Malan (Davenloo, 1978; Davenloo, 1980; Malan, 1976; Malan, 1979).

Psychoanalysis is expensive, and is not generally available in the NHS. The real cost of shorter-term therapies is difficult to assess, since it depends on a comparison with whatever other form of intervention would be necessary if psychotherapy was not offered.

The author's own clinical experience leads to the belief that short-term therapy can break patterns of dependency that have often been established for many years. The work done by brief dynamic psychotherapy indicates that such interventions can reduce the need for future input (Aveline, 2001).

Patient assessment
To be effective, such short-term therapies, like all others, have to be based on accurate assessment (Coltart, 1988).

A therapist has to be able to identify a basic conflict which might respond to short-term work, and the number of sessions offered, which might range from two to 30, needs to be specifically geared to that assessment. Because psychotherapy, by definition, opens up issues of which the client may not have been fully aware on assessment, it might prove necessary to offer further or alternative forms of therapy.

The patient may become aware of new problems, or depths of dependency on the therapist, which cannot be worked through speedily. The complex nature of psychic reality can undo the most careful assessment.

It can be difficult to understand the reality of this outside the context of a specific therapeutic relationship. An example of such a therapeutic relationship is described in the following case study.

Case study
Jane Green's GP referred her to the author, as the CMHT's clinical nurse specialist in psychodynamic psychotherapy. The referral was at the request of the practice's counsellor, who had seen her five or six times. When referred for counselling, Mrs Green, who was in her early 30s, had been suffering from depression and anxiety, associated with a poor self-image. She considered herself to be ugly and stupid, whereas on any objective assessment she was articulate, intelligent and attractive. She was married with one child, and her main reason for seeking help was that she did not want her difficulties to affect her relationship with her young son.

Her problems went back a long way. She was adopted as a baby, and never really felt wanted by her adoptive parents. Her family was obsessed by dieting, and Mrs Green was told from a young age that no one would ever love her if she was overweight. In adolescence she rebelled in self-destructive ways, by abusing alcohol and solvents. She was also promiscuous, in a desperate attempt to gain the affection she was not getting at home. This led to abuse and damaged her self-esteem still further. As a young woman she joined the police service and met a young man, who she married. He was a supportive husband and things went fairly well until the birth of her son, which revived memories of her own childhood.

This was the reason why she sought counselling and, ultimately, why she was referred to the community mental health service. It was felt that Mrs Green required more exploratory work than the counsellor's schedule allowed for. Mrs Green had found the counselling helpful, which was a positive sign that she might benefit from further therapy.

During Mrs Green's first therapy session, it appeared that her principal problems were to do with a lack of love in childhood. At a deeper level was a feeling of profound rejection because of being given up for adoption by her biological parents. These experiences of loss became the principal theme of therapy, and short-term psychotherapy seemed appropriate because of the clarity of the focus and because her general level of functioning was high.

She was a committed mother and partner, active in her local church and in various social campaigns, and a more integrated and effective person than she considered herself to be. She was offered 20 sessions of time-limited dynamic psychotherapy.

Therapy focused on her poor self-image, and on the parental forces which had shaped it. The depth of her self-hatred, which surfaced quite early in therapy, was marked, though it diminished as the weeks went by. It became possible to relate her preoccupation with body weight to the lack of love she had experienced in childhood, and she gradually became less worried about how she looked.

The crucial session was about three-quarters of the way through, when she was able to say that 'Everyone I have ever loved has left me' and collapse into despair. After this her mood improved radically, she found a new job and began to face the future with hope and a degree of confidence.

She used her therapy well. In the author's view, a transference occurred in which the therapist became the 'good father' that she felt she had never had. When therapy finished she was effectively symptom-free, but will probably always be vulnerable to loss and rejection. Given the severity of the presenting psychopathology and the relatively short-term nature of the therapy, the outcome seemed satisfactory. The therapy took place a few years ago, and Mrs Green has not been subsequently re-referred, which suggests that she has maintained her gains.

Dynamic psychotherapy, which has from the outset been based on qualitative, clinically based evidence, attempts to identify the nature of the relationships which have shaped the client's experience often in pathological ways, and to help him or her to understand and mitigate their effects. While it is impossible to do justice in a paper of this length, it is hoped that this paper gives some idea of its therapeutic potential.

Essentially time-limited psychotherapy is effective when assessment indicates that a clear focus exists, and when the client is able to work with the issues. In such circumstances the therapeutic gains can be considerable.

- The author would like to thank Mark Aveline at Nottingham Psychotherapy Unit and Steve Buller at the Derby Psychotherapy Unit, for their assistance in the preparation of this paper.

Nurses in psychotherapy
Information on nurses in psychotherapy can be obtained from:

Derby Psychotherapy Unit,
Temple House,
Mill Hill Lane,
Derby DE23 6SE.

Tel: 01332-364512

Aveline, M. (2001) Very brief dynamic psychotherapy. Advances in Psychiatric Treatment 7: 373-380.

Coltart, N. (1988)Diagnosis and assessment for suitability for psychoanalytic psychotherapy. British Journal of Psychotherapy 4: 127-134.

Davenloo, H. (ed.). (1978)Basic Principles and Techniques in Short-Term Dynamic Psychotherapy. New York, NY: Spectrum.

Davenloo, H. (ed.). (1980)Current Trends in Short-Term Dynamic Therapy. New York, NY: Aronson.

Freud, S. (1914)Remembering, Repeating and Working Through: Further recommendations on the technique of psycho-analysis II). London: Hogarth Press/Institute of Psycho-analysis.

Freud, S. (1915a)Repression. London: Hogarth Press/Institute of Psycho-analysis.

Freud, S. (1915b)Instincts and their Vicissitudes. London: Hogarth Press/Institute of Psycho-analysis.

Malan, D. (1976)The Frontiers of Brief Psychotherapy. London: Plenum Books.

Malan, D. (1979)Individual Psychotherapy and the Science of Psychodynamics. London: Butterworth.

Strupp, H., Binder, J.L. (1984)Psychotherapy in a New Key: A guide to time-limited dynamic psychotherapy. New York, NY: Basic Books.

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