Medical Psychotherapy Faculty and Royal College of General Practitioners Joint Conference

Medical Psychotherapy Consultation and Medicine

Mourning Cure; Becoming Curious Friday 20th April 2012

2.00pm

Aims of this Workshop 1. To describe medical psychotherapeutic consultation in relation to psychiatric practice and general practice. 2. To describe consultation from a psychoanalytic psychotherapeutic perspective with an emphasis on the mourning process for patient and professional. 3. To demonstrate the role of medical psychotherapy consultation in the interface between psychiatry and primary care services.

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4. To use an example of a medical psychotherapy consultation to go beyond the descriptive formulation to show the use the patient is making of professional help.

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Medical Psychotherapy Faculty and Royal College of General Practitioners Joint Conference

Medical Psychotherapy Consultation and Medicine

Mourning Cure; Becoming Curious 1. Consultation as an interface between psychotherapy and psychiatry The medical psychotherapist who is invited to consult offers: a) Recognition of the impact of past life events and childhood history on the current presentation.

b) Assessment of the psychological capacities of the patient (psychological mindedness, curiosity, location of the problem).

c) Knowledge of psychological treatment options and their availability. d) An opinion on psychological treatment priorities.

e) A perspective on the impact of the patient’s problems on the staff and organisation. f) An opinion on particular areas of clinical impasse: eg: discharge, engagement, disruption, enactment, diagnosis and risk management.

g) Reflective practice regarding a particular patient within a team. h) Links with other agencies (eg: a Personality Disorder Service).

i) Access to psychological therapy for the patient.

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k) A facilitated forum (e.g: chairing a professionals meeting) to discuss a particular case or issues surrounding a case in a team/across teams.

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j) A space for the psychiatrist to discuss current or past cases.

Medical Psychotherapy Faculty and Royal College of General Practitioners Joint Conference

The decision making process in consultation includes: a) Recognition of the limitations in the use of consultation on the basis of a referral letter: is a ‘piece of paper’ enough to give a sense of the dilemma? b) Whether or not to see the patient, or, more often, when to see the patient? c) How to make contact with the professionals if the patient is not to be seen: who to see and in what setting? d) How to engage effectively with professionals involved: ie: how to relate to their process – professionals meetings, CPA reviews; etc? e) How to arrive at an agreed formulation with professionals which is robust, credible and includes recognition of the use the patient makes of professional relationships. f) Modifying the consultation approach for different diagnostic groups and different situations; ie: holding a model which is sufficiently flexible to adapt to different patients relating with different clinicians in different clinical contexts. Problems encountered in consultation include: a) Perception of avoidance of the problem by not seeing the patient for assessment for therapy immediately (eg: because we fear the patient). b) Giving the irritating impression that only psychotherapists think. c) Negotiating the perception of arrogance (omnipotence). d) Negotiating the perception of having very little to offer (impotence). e) Losing sight of the patient in one’s attention to the professionals.

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f) Question of RMO responsibility and authority.

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Medical Psychotherapy Faculty and Royal College of General Practitioners Joint Conference

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Consultation from a psychoanalytic psychotherapeutic perspective

Consultation is a conversation with a colleague or colleagues about a patient. Each colleague brings their own experience to this conversation: one is initially more closely involved with the dilemma the patient offers than the other. Our usual understanding of the way we use our clinical skills and training is in our direct work with patients. Consultation frequently though not invariably includes direct contact with the patient but can solely involve indirect work with the professionals through the conversations about the patient with colleagues. My approach to consultation is to shift my focus from the patient and their psychopathology to the interplay between the patient and the professionals involved with them (an application of the therapeutic approach of psychoanalytic psychotherapy). The constellation of transference-countertransference affects between the patient and professional are therefore crucial in a psychoanalytically orientated consultation. One way of considering the problem that is brought to consultation by colleagues about a patient is to think of it in psychoanalytic terms as the past presenting in the present. The unconscious is timeless so the past is repeated in the present but the problem will often be apprehended through a lens which turns a blind eye to the past and emphasises the present with an anxious eye to the future, the problem is happening now but worse, the problem is going to happen. 

The problem that happened (That is: the patient has failed to develop; the professionals are failing). The unconscious past: the child failed to develop; the parents failed.

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The problem is happening now (That is: the patient fails to recover). The unconscious present: the failure in development. The problem is going to happen (That is: all of the above suffused by professional anxiety of death, suffused by professional shame, guilt and recrimination).

From a psychoanalytic point of view the unconscious past is alive and enacted in sometimes deadly behaviour in the present. If the past is not remembered and used to inform the present the past will be repeated in the future.

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The unconscious past/present projected forward as a judgement of failing.

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Medical Psychotherapy Faculty and Royal College of General Practitioners Joint Conference

What we do not remember we are doomed to repeat (Freud). What underlines all of these ‘happenings’ are differing degrees of anxiety within the professionals involved. In listening to the narrative presented by colleagues about the patient I try to discern the nature and degree of professional anxiety. Quite often anxieties associated with the past, present and future happenings co-exist, but I think one type of anxiety tends to predominate and this emphasis will influence on what is being asked of the consulting psychotherapist. 

If, for example, there has been a prolonged situation between the patient and the psychiatric team which has come to feel chronic the request for help has more of an ‘end of the line’ feel. While there isn’t any urgency, the pressure to secure relief from a deadening burden may inhibit creative thought between the psychotherapist and the psychiatric team.

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If we are invited to consult about a clinical situation where there are more acute anxieties (more often surrounding tensions within the team than to do with concerns about risk) the pressure to intervene may well make it difficult not to see the patient, to plan, to make space, not to do rather than think.

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If there are anxieties surrounding some form of dangerous enactment this may inhibit the psychotherapist from becoming involved. The psychiatric team have a role in providing containment for the psychotherapist.

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In each situation the psychotherapist attempts to discern who the key players are in relation to the problem, (who should be involved in the consultation including those not present) and what the anxieties are and where they are located temporally.

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In practice the initial meeting usually sets the scene in relation to these questions and it is usually possible to decide whether to proceed to: a) Further meetings with the team, or with the team and someone not initially present b) Further meeting with a team member

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d) No ongoing contact needed.

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c) Meeting with the patient prior to further team meetings (consultation ‘sandwich’: professional-patient-professional)

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Medical Psychotherapy Faculty and Royal College of General Practitioners Joint Conference

The role of the consultation as an interface between psychotherapy and psychiatry Consultation provides a vehicle for clinical partnership.

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Consultation can offer a space to explore the tensions and splitting which can arise from theoretical differences in approach to mental disorder.

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Consultation offers a structure for containment of patients who have been diagnosed with personality disorder.

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Consultation creates an opportunity for psychotherapists to learn from contact with acute psychiatric work.

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Consultation can help to keep colleagues informed about psychological approaches.

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Consultation can facilitate referrals in both directions by enhancing our direct working knowledge of each other’s paradigms.

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Consultation can provide a forum in which we can share our limitations with colleagues as opposed to engaging in treatment rivalry which can be counterproductive.

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Consultation (particularly ‘in-reach’ into wards) challenges the ivory tower view of psychotherapy and brings the psychotherapist into contact with levels of psychological disturbance which will inform their day to day therapeutic work.

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Consultation can offer a foundation for outreach work in the transition into a residential therapeutic community.

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Consultation provides a platform for research into combined pharmacotherapy and psychotherapy in personality disorder.

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Medical Psychotherapy Faculty and Royal College of General Practitioners Joint Conference

Some examples of different settings in which consultation can be used. Being invited to think with a multidisciplinary team about their work in the patient’s regular treatment setting (eg: professionals meeting in the GP surgery, CMHT, ACS, CRHT or in patient unit).

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Being invited to a ward by the team to think about a specific patient; such an invitation may relate to a management impasse or a request for an opinion before recommending a referral for a residential placement. Occasionally, the team want to discuss the impact of a (most often) borderline patient on team relationships to facilitate future management.

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Being invited to see the patient in their regular treatment setting as part of an assessment or as a prelude to supervision of the professional working with the patient in that setting (may be primary, secondary or tertiary care).

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Inviting colleagues to chair a meeting of other professionals on behalf of the patient.

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Thinking with a referrer about their referral; by letter, phone or face to face contact.

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Seeing a colleague (colleagues) to talk about a case from the past to reflect retrospectively on what happened.

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Seeing a colleague (colleagues) to talk about a case in the present.

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Seeing a colleague (colleagues) to think about past/present work to help to inform future management strategies.

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Seeing colleagues to discuss handover of a patient between other professionals and to consider their different approaches.

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Liaise with colleagues in the course of psychotherapy (psychotherapist using professionals meetings or CPA reviews, etc).

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Ongoing consultation in the form of reflective practice groups in CMHT, ACS, CRHT or in patient unit.

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Formulation groups focused on case management (see 5 below).

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Balint groups focusing on the dynamics of the patient-professional dilemma.

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Medical Psychotherapy Faculty and Royal College of General Practitioners Joint Conference

5.

Formulation

The formulation is used to offer an integrated biological psychological and socio-cultural perspective on the patient’s problems. The psychoanalytic approach to formulation includes the transference and countertransference dynamics between patient and professionals. Close attention to the pattern of relating between the patient and the professional may offer a clue to what is being enacted or repeated from the past in the present. For example, people who have suffered abuse will tend to repeat patterns of abuse in later care giving relationships. 

Predisposing, Perpetuating and Precipitating factors.

The early relationships from childhood are the predisposing factors (unconscious and acted out in destructive and self destructive behaviour). The perpetuating factors are the maintenance of destructive patterns of relating in current relationships. The precipitating factors include breakdown of the equilibrium in the maintenance of destructive patterns of relating with a need to use professional help to contain these patterns. The consultation process has to include a formulation which gathers childhood history as part of the process to hold at the back of one’s mind to inform present management. 

Professional factors (the impact of help offered to the patient).

The experience of the professionals has to be incorporated in the formulation, using the impact of help and ascertaining whether the patient tends to use help to aid or impede change for the better. This can then be brought to the patient who may or may not benefit from the link.

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Dr James Johnston Consultant Psychiatrist in Psychotherapy Medical Psychotherapy Lead Leeds and York Partnership NHS Trust

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The formulation offers a vantage point on the management from an external or third position which can offer a different perspective on the management and care of the patient for the professionals.

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