Chapter 3 – Referral for Psychodynamic Psychotherapy: Processes and Considerations




Abstract




For the patient, a referral to psychodynamic psychotherapy services is a highly meaningful and intensely personal experience. It offers potential to uncover the deeper issues behind whatever is troubling them and to explore areas of their emotional life beyond their conscious awareness. It is a bold step for the patient to cross this threshold, involving painful realisations and profound readjustments to their understanding of themselves and others. Alongside these challenges are the potential gains of improved mental health and function and the achievement of lasting changes in their relationships. This chapter will outline some of the issues important to consider in making and progressing such a referral.





Chapter 3 Referral for Psychodynamic Psychotherapy: Processes and Considerations



Jo O’Reilly



I find it useful to suppose that there is something I don’t know but would like to talk about


Bion [1]

For the patient, a referral to psychodynamic psychotherapy services is a highly meaningful and intensely personal experience. It offers potential to uncover the deeper issues behind whatever is troubling them and to explore areas of their emotional life beyond their conscious awareness. It is a bold step for the patient to cross this threshold, involving painful realisations and profound readjustments to their understanding of themselves and others. Alongside these challenges are the potential gains of improved mental health and function and the achievement of lasting changes in their relationships. This chapter will outline some of the issues important to consider in making and progressing such a referral.


The context within which the service is working determines the task and the available responses to a referral. This chapter will focus upon the referral processes from the perspective of a psychodynamic psychotherapy service for adults, located within an NHS Mental Health Trust.


For the referrer, the underlying reasons for making a referral may vary considerably. The psychodynamic psychotherapy service is a means to access expertise in understanding complex clinical presentations and the impact of unconscious factors in clinical care. In this context a broad approach to considering referrals is indicated, which seeks to provide a response in keeping with the underlying request. A model described as referring to and referring away will be introduced to consider both conscious and unconscious factors in the referral process. Clinical examples will illustrate the main points raised.



Risks and Potential Benefits of Progressing to Consultation


Not all referrals received into the service will progress to a consultation. It is an important part of the task from the outset to consider what a psychodynamic consultation may mean for the patient.


The offer to meet with a therapist may well be the first encounter for the patient with a psychoanalytically informed approach to their lives, relationships and sources of emotional distress. Perhaps this will be the first time that links have been consciously made between past experiences and present difficulties. For others it may involve a revisiting of issues that have been uncovered and partially processed in previous treatments. For some recent events may have revealed the emotional residue of past hurts or traumas that have lain relatively dormant until that point. The consultation is almost inevitably a powerful experience. The quality of sensitive attention paid by the therapist is likely to resonate with early experiences of nurture, longing, attunement and deprivation. It is likely that a strong transference response will be elicited which will shape their experience of the therapist. The focus upon the underlying issues behind the surface presentation means that intense feelings may emerge and deep suffering be revealed; sadness, grief, anxiety, relief, rage, shame, confusion and gratitude may all be expressed in what is often a profoundly moving experience. The patient may never have been listened to, or challenged in this way; although the full detail of what was said may be lost, the emotional experience is rarely forgotten.


At the same time, it is important to recognise that the psychodynamic consultation is an active intervention and not a neutral experience. Long-standing ways of seeing oneself in relation to others will be challenged and the patient’s defensive organisation against threat and intolerable psychic pain will be mobilised. However sensitively this is handled, it is inherently a destabilising and ‘invasive’ process into the internal world of the patient [2]. Learning is always painful and anxiety provoking as it exposes what you do not know. Bion wrote ‘if there aren’t two frightened people in the room … then there was not much point in turning up to find out what you already know’ [3]. Each consultation is a unique encounter; in approaching the unconscious neither therapist nor patient knows what will emerge and to an extent this is likely to be disturbing for both parties.


Bion also wrote of the ‘emotional storm’ created when two characters meet, which captures [4] the intense and immediate impact of one person upon another during a therapeutic encounter. Many patients referred for psychodynamic psychotherapy struggle with emotional closeness and the anxieties this can provoke. The intimacy of the psychodynamic consultation is likely to bring this to life and may uncover the very sources of fear and distress underlying the need for their defences. It is the responsibility of the service, along with the referrer, to consider whether to offer the consultation or whether there may be other responses that may be less disturbing and more in the patient’s best interests.



The Clinical Context


The context within which the work is undertaken necessarily informs the task. An NHS psychodynamic psychotherapy service located within a mental health trust is embedded in a network of mental health services. The task here is multifaceted and includes:




  • The provision of a psychodynamic consultation and treatment service to patients, many of whom may have required psychiatric care and may have significant psychological vulnerability and social disadvantage. There will potentially be access to other psychological therapies, such as cognitive behavioural therapy (CBT), trauma-focussed or mentalisation-based treatments. A range of mental health teams and crisis services may provide containment and support during therapy if required



  • To apply a psychodynamic perspective to emotional distress, complex presentations and countertransference responses, thus developing clinical understanding as the basis of treatment for patients under the care of GPs and mental health teams. This is likely to involve case discussions and supervision rather than direct patient contact



  • To provide a training role to a range of staff, from medical students, trainee psychiatrists, to honorary staff such as group and individual psychotherapists in training. This will to an extent shape the range of treatment vacancies available



  • To increase the overall capacity of the organisation to contain anxiety and emotional distress. Working with disturbed states of mind means projected states of distress disturb staff and may adversely affect clinical care through unprocessed countertransference reactions. Such processes inevitably arise in mental health care and need to be metabolised and understood. This maybe addressed through reflective practice and clinical panels within the organisation.



Referring To and Referring Away


Psychodynamic psychotherapy services within the NHS tend to require referrals from colleagues, such as GPs, psychology services, mental health staff or other health professionals, rather than patients referring themselves. This immediately raises the question of whether the wish for treatment is driven primarily by the patient’s own concerns or by the concerns of the referrer. This requires careful consideration as psychodynamic psychotherapy places considerable demands upon the patient who needs to be committed to the process of change and able to withstand the emotional turbulence this entails. There is anecdotal evidence that referrals from clinicians with little experience of psychotherapy may do better than those from referrers who themselves are very enthusiastic about its potential benefits.


In practice there is a spectrum of reasons driving referrals to psychodynamic psychotherapy services. At one end of the spectrum there may be a patient seeking to explore their underlying developmental issues in order to better understand their current difficulties and whose situation indicates this is a potentially realistic and timely endeavour. This scenario could be seen as referring to a service which seems likely to be able to provide the type of treatment required. Other referrals may originate from an experience of being disturbed in some way by a clinical encounter or difficulty in the relationship between the patient and the clinician. Such countertransference reactions can powerfully impact upon clinical care and the role of the psychotherapy service may be to address this difficulty rather than necessarily take the patient on for treatment. At the extreme this may be a wish to refer away if the clinical contact has become unbearably disturbing with limited space to process complicated projections.


Most referrals fall somewhere between these positions, hopefully arising from some shared and realistic understanding and agreement between the patient and the referrer. How best to respond may be indicated by where on this spectrum the driving forces behind the referral lie. This is illustrated in the examples below.


Helpful predictors of outcome for referrals include the pattern of previous engagement with services, along with evidence of the patient’s capacity to reflect about themselves and to consider their own contributions to their difficulties. It is also important for psychotherapy services to resist omnipotent beliefs they may be able to offer some kind of special treatment that will be able to change entrenched and unproductive patterns of relating to services. For Mr A, a further referral will almost inevitably provide further fuel for the process of continuing complaint and grievance and there is little to suggest he will be able to use the consultation in a constructive way. The escalating complaints suggest an ongoing dependence on projecting inadequacy into services with nothing to indicate an ability to tolerate any self-scrutiny; the need for change for Mr A is firmly located in the external world and he continues to relate to services on the immovable assumption that they will be deficient and negligent. A helpful and realistic response may be to offer a consultation to the GP and others involved in his care to recognise and understand the nature of the pressures they are under, the role they are being allocated and the limits of what they can do.


In contrast, Mr B has shown he can engage in treatment towards making positive changes and is able to face painful realities about himself, suggesting psychodynamic psychotherapy may be a helpful process.





Factors to Consider When Proceeding with a Referral


Patients referred for psychodynamic psychotherapy tend to have long-standing difficulties. Childhood adversity and abuse are very common in their histories. Difficulties in establishing and maintaining supportive and nurturing intimate relationships in adult life are often a painful consequence of these experiences. Psychodynamic psychotherapy is primarily a relational treatment, whether offered in groups or individually, shedding light upon the unconscious determinants of these difficulties as they are revealed in treatment within the transference relationship/s. This means treatment also faces the patient with precisely the situations that they find most difficult, raising intense anxiety about trust, authority figures, personal boundaries and the risks of exposing vulnerability to another. Past trauma may resurface vividly during the treatment. The individual’s attitude, defences, resources and psychological frailty in relation to these experiences determine whether they can withstand the emotional strain of treatment. It is important to resist the simplistic view that long-term developmental difficulties point towards the need for a long term and hence psychodynamic therapy, as this may not be realistic for the patient.


The process of exploration requires a capacity for open self-scrutiny to consider the ways in which one may be unconsciously contributing to the difficulties. Childhood adversity may result in a very wide range of psychological difficulties and supportive or symptom-focussed treatments such as the support of a multidisciplinary team, CBT or counselling may be more in keeping with the clinical presentation than psychodynamic psychotherapy.



Mr C ‘I couldn’t engage in the group at all at the time. All I could see were the school bullies looking at me. I was straight back in that playground. After the treatment for PTSD and anxiety I know now that the fear was coming from me and wasn’t about the others in the group, so I would like to give it another try.’


Childhood abuse, disrupted attachments and boundary violations can elicit powerful countertransference reactions and difficulties containing anxiety within clinicians and clinical teams. Referral patterns may both indicate a need for support for the team in processing projected disturbance and run the risk of unintentional repetition of patterns of rejection and broken relationships. It can be enormously helpful for the psychotherapy service to see beyond the referred patient at these times and to respond to the underlying distress in the team behind the referral.



Ms D had experienced severe childhood violence and multiple separations from her parents and subsequent parental figures. Her adult life was characterised by involvement in abusive relationships, a highly chaotic lifestyle and self-harm in relation to feelings of rejection and frustration. This occurred despite the best efforts of mental health services. While it seemed clear her childhood experiences of neglect and abuse continued to be re-enacted in her relationships in adult life, it was also apparent that her low tolerance of frustration and distress meant psychodynamic psychotherapy would be too anxiety provoking for her to manage currently. It was thought that the risk of repeating another experience for her of feeling rejected and unwanted if seen for a consultation was high and this was shared with the referring team. It was agreed that the ongoing containment and support of the community mental health team, with supervision from the psychotherapy service to help to process the countertransference responses and contain anxiety in the team would be a more helpful intervention.

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Jun 6, 2021 | Posted by in PSYCHOLOGY | Comments Off on Chapter 3 – Referral for Psychodynamic Psychotherapy: Processes and Considerations
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