The British Journal of Psychiatry (2001) 178: 478
© 2001 The Royal College of Psychiatrists
Psychodynamic thinking and the community mental health team
K. Bhui
Department of Psychiatry, St Bartholomew's and The Royal London School of
Medicine and Dentistry, Queen Mary & Westfield College, University of
London, Mile End Road, London El 4NS
EDITED BY MATTHEW HOTOPF
I read with great interest Thornicroft & Susser's
(2001) editorial on
evidence-based psychotherapeutic care in schizophrenia. It called for
evidence-based interventions being implemented in the face of resource
limitations and a remedy to the absence of implementation plans for
well-established effective interventions such as family therapy. However,
Thornicroft & Susser dismiss psychodynamic approaches. Although the
general view is that people with schizophrenia do not benefit from intensive
psychoanalytic psychotherapy, there are some heroic efforts by analysts such
as Herbert Rosenfeld (1987). In
particular, such approaches do address the imperfection of our models of
mental disorder.
One thing the psychodynamic way of thinking can offer members of the
community mental health team (CMHT) is understanding of complex mental states
from the patient's perspective, and new ways of understanding those that fall
outside of our management strategies. There is no doubt that the delivery of
psychoanalytic psychotherapy to people with schizophrenia, on an intensive
basis, will not be resourced, nor will the symptom outcomes necessarily be
better. Therefore, the cost cannot be justified. However, part of the problem
that faces CMHTs is the long-term nature of their work with little reward in
terms of symptom improvement and recovery for those with enduring severe
mental illness. This can be frustrating and de-skilling for staff,
particularly if they have a limited range of therapeutic models. I have worked
in an assertive treatment team for the people with severe mental illnesses and
one for homeless people with mental illnesses. Staff retain curiosity and
capacity to think and question their formulations about patients in a
psychodynamic way. Their work continues to be fresh and motivating. This is
particularly welcome in light of Wykes et al's
(1997) finding that CMHT staff
are not uncommonly depersonalised and therefore unable to empathise with their
patients. At a time when there is a movement to ensure good human
relationships as well as therapeutic relationships with patients, dismissal of
the relevance of psychodynamic thinking in the healthy functioning of a CMHT
is premature. This is one area of CMHT functioning that warrants further
research, as suggested by Thornicroft & Susser.
REFERENCES
Rosenfeld, H. A. (1987) Impasse and
Interpretation. Therapeutic and Anti-Therapeutic Factors in the Psychoanalytic
Treatment of Psychotic, Borderline and Neurotic Patients. London:
Tavistock.
Thornicroft, G. & Susser, E. (2001)
Evidence-based psychotherapeutic interventions in the community care of
schizophrenia. British Journal of Psychiatry,
178, 2-4.[Free Full Text]
Wykes, T., Stevens, W. & Everitt, B. (1997)
Stress in community care teams: will it affect the sustainability of community
care? Social Psychiatry and Psychiatric Epidemiology,
7, 398-407.
