NHS PSYCHOTHERAPY - PAST, FUTURE AND PRESENT

NHS PSYCHOTHERAPY - PAST, FUTURE AND PRESENT

Jeremy Holmes

ABSTRACT The paper considers whether the ideal of a `national psychotherapy service' is arealistic or desirable possibility. In its origins community psychiatry was inextricably linked withpsychoanalysis and group psychotherapy. Today the links between community psychiatry andpsychotherapy are much more tenuous, despite the evidence for the effectiveness of manypsychological interventions in psychiatric disorders. Future psychotherapies will explore thelinks between brain and mind, integrate the different psychotherapeutic modalities, consider thewider costs of not providing psychotherapy, and be more client responsive. How will this comeabout? Authority in the field depends partly on seniority, partly on evidence, partly on popularappeal, and partly on psychotherapeutic narratives which accurately reflect the needs of societyand those who suffer from psychological distress.

I will start with a credo, one which tries to balance psychodynamics with a kind ofsecular Buddhism which, I believe, is compatible with the values of psychotherapy. Theaim of psychotherapy is to help people live more fully in the present - but in order to doso we need to be aware of the past while not being depressively trapped in it, and lookforward to the future, without fearing its inherent unpredictability. But what does itmean to live more fully in the present? Freud frequently described neurosis as a `turningaway from reality'. To live in the present is to be in touch with reality. The underlyingpurpose of this paper is to discuss whether a national psychotherapy service is a realisticpossibility.

A title like `the future of psychotherapy' is vast, vague and, ultimately, frustrating.When originally considering it I started to think about psychotherapy's eternal verities -unchanging truths which would survive into the millennium: the idea of the unconscious,the importance of attachment, the relational self, transference, resistance, and envy.Looking back, I thought the whole corpus of psychotherapy might be described as `footnotes to Freud', rather in the spirit that Western philosophy has been dubbedfootnotes to Plato. Then suddenly I found myself switching to a futuristic post-Descartianvision in which the mind-body divide had been transcended, a cyberworld in whichpsychotherapy was conducted on the internet, and a utopian vision in which BCP couldlie down with UKCP, psychotherapy was equitably and widely available on the NHS, andevery GP used pens encouraging them

JEREMY HOLMES is Consultant Psychotherapist and Psychiatrist in North Devon. He is currentlychair of the psychotherapy faculty of the Royal College of Psychiatrists. His most recent book isHealing Stories: Narrative in Medicine and Psychiatry (with G. Roberts, OUP). His researchinterests include the clinical applictions of attachment theory, severe personality disorder, andintegration in psychotherapy. Address for correspondence: North Devon District Hospital, RaleighPark, Barnstaple, Devon, EX31 4JB. [Email: [email protected]]

British Journal of Psychotherapy, Vol 16(4), 2000© The author

mailto:[email protected]

448 BRITISH JOURNAL OF PSYCHOTHERAPY (2000) 16(4)

to offer their patients not just the latest antidepressant, but also cognitive therapy orpsychoanalysis.

In deference to my opening principle, I have decided to resist all such millennialmania and, mundanely, to concentrate on what I know about: psychotherapy in the NHS.I shall start with a brief historical survey, move to a personal blueprint for the future, andend by thinking about how the current balance of forces might be tilted in directionsfavourable to psychotherapy.

The History of NHS Psychotherapy

A doomsday scenario for the future of health care in the UK runs as follows. The veryrich would continue, much as at present, to have high-quality personalized private carepaid for at the point of delivery. The middle class would be protected by expensive buteffective health insurance, providing reasonable care along the lines of US `healthmanagement organizations' or the NHS in its heyday, while the poor would be offeredsecond-best treatment provided by barely trained professionals in dilapidated settings instate-funded schemes run at minimal cost.

This picture represents a return to the state of health care in Britain prior to theintroduction of the NHS in 1948. Here class and health care were inextricably linked, nomore so than in the field of mental health. This was based almost entirely on mentalhospitals, with the poor cared for in large Victorian institutions which offered little morethan sequestration of the mad from the rest of society, with treatment regimes varyingfrom the brutal to benign neglect. Meanwhile, the mentally ill middle and upper classeshad access to smaller, more genteel and comfortable retreats, but whose therapy was nomore effective, nor necessarily more humane.

War has proved to be a powerful stimulus to the development of publicly fundedpsychotherapy. In an attempt to treat 'shell-shock' and battle fatigue in the First WorldWar, outpatient treatment units were set up mainly by progressive intellectuals, offeringhelp for people suffering from neuroses in contrast to the psychotic disorders whichlargely filled the mental hospitals (Pines 1991). These were staffed by psychiatrists andpsychologists inspired by psychoanalysis which seemed to offer greater hope and deeperunderstanding of mental distress than any previous theories or therapies. The TavistockClinic and Cassel Hospital in London were both products of this yoking ofpsychoanalysis with humanitarian and socialist inspiration. The Second World Warsimilarly enabled psychoanalytic ideas to make inroads into conventional psychiatry withthe use of group and milieu therapy in military mental hospitals, and psychologicalmethods in the officer selection boards.

The fact that the two great leaps forward in publicly funded psychotherapy have bothtaken place in the aftermath of war is intriguing. This is partly perhaps because at suchtimes the need to deal with loss and grief is so great, but also because in war peoplebecome aware of the importance of `morale'. Morale is where psychology meets themilitary machine. Psychotherapy is able to draw out the connections between morale andself-esteem, good group relations, autonomy and interpersonal satisfaction, and to deviseways to enhance them.

At its inception the NHS was based on the socialist principle that medical care shouldbe available to the whole population according to need, free at the point of delivery, andfunded redistributively out of general taxation. Psychotherapy and psychoanalysis wereat this stage both politically and psychiatrically progressive, and

JEREMY HOLMES 449

began to make an impact on the crumbling mental hospitals with their authoritarian andanti-psychological philosophy.

By contrast the tradition of sceptical empiricism within British psychiatry continuedto rely on traditional psychiatric methods, especially the new antidepressant andantipsychotic drugs which, unlike their predecessors, were at least partially effective.NHS psychotherapy was essentially confined to one or two centres, mainly in London,such as the Tavistock Clinic, and was strongly psychoanalytic in orientation. Clinicalpsychology was beginning to establish itself as a discipline, championing scientificpsychotherapy as opposed to the unproven claims of psychoanalysis, and pioneeringbehavioural treatments especially for anxiety and obsessional disorders.

By the 1970s things had moved on apace. The first consultant psychotherapist postshad been established in psychiatric departments, and junior psychiatrists were at lastroutinely being trained in psychotherapy alongside the use of social and physicalmethods of treatment. The next decade saw a steady spread of psychotherapydepartments throughout the UK, with important centres being established in Manchester,Nottingham, Oxford, Birmingham and Newcastle. Edinburgh and Aberdeen both hadlong traditions of psychotherapy, and a centre was established in Belfast, but Wales andthe western half of England lagged behind. The emphasis in these centres was onpractising psychotherapy to a high standard, developing training at all levels, devisingmethods of psychotherapy such as brief therapies and group treatment that wereappropriate to a NHS setting with a catchment population as opposed to a purely client-based ethic, establishing good relationships with psychiatric colleagues and GPs, and onthe importance of research, especially in the field of evaluation.

Community Psychiatry

Social change is subtly charted in language. In the 1950s, community psychiatry wassynonymous with therapeutic community (TC), and, by implication, withpsychotherapeutic as opposed to an administrative or narrowly biomedical approaches topsychiatric treatment. The idea was to transform the anti-therapeutic mores of the mentalhospital - sequestered, static, rigid - into a place where psychological growth anddevelopment could take place, and from which the mentally ill would eventually emergeonce more to rejoin the wider community, free from stigma and constraint. Thetherapeutic community defined itself in opposition to the traditional mental hospital.Patients were to be encouraged to be active rather than passive: therapeutic work,domestic self-sufficiency, and involvement of patients in the day-today practical andpolitical running of the community were some of the means by which this was to beachieved. A collaborative atmosphere with more fluid boundaries between staff andpatients was encouraged. Expression rather than suppression of feelings was valued,through the use of various forms of psychotherapy, especially creative therapies such asart therapy, music therapy and psychodrama. Above all a `culture of enquiry' (Main, T.1989) was fostered, in which the community itself became a 'living-learning'environment, where, through large and small groups and individual therapy, patientscame to understand themselves and their difficulties better (Pullen 1999).


At this stage then psychotherapy and community psychiatry were inextricably linked.The leaders of the community psychiatry movement were mostly psychoanalyticallytrained. Psychotherapy and community psychiatry tended to be opposed to the use ofmedication in the management of mental illness, and both held to a utopian vision of carefor the mentally ill transformed through the use of humane, psychotherapeutically-informed communities, acting as models for the reform of other ossified socialinstitutions. The predominant psychotherapeutic ideology was psychodynamic, `behaviourism' being viewed with the same suspicion as psychotropic medication - as asinister means of social control rather than valid therapeutic tools.

Today, all this has changed. A complex set of social, political and technologicalforces - which include the advent of more effective psychotropic medication, the push tosave money in public services, and a general mistrust of institutions and the rise ofindividualism - has seen a recession of the therapeutic community movement, parallelingthe decline of the mental hospital generally as a required antithesis to the TC. Today,rather than creating a `good' alternative to the `bad' traditional institution, communitypsychiatry tries to do away with the institution altogether, basing itself in the `natural'community - however fragmented - as opposed to the fragile artefact of the TC.Community psychiatry is psychiatry in the community as it exists, rather than anaspirational community of psychiatry and its patients. While there have been great gainsin this change, there have also been substantial losses, one of which has been thedisengagement of psychotherapy and community psychiatry, to the detriment of both.

With the loss of the community as a place where container for disturbance can becontained and metabolized, there is a greater reliance on medication and a move to afunctionalist approach in which risk assessment and control take precedence overpsychotherapy and the search for meaning which characterized the TC. Despite itsopposition to the traditional mental hospital, contemporary community psychiatry is morefirmly based on a `medical model' than the TC. The most extreme example of thisdismantling of psychotherapy within psychiatry is seen in today's acute psychiatricwards, which have become barren places, atrophied parodies of the thriving therapeuticcommunities of the 1950s.

A Glimpse into the Future

Staying with the psychotherapeutic insight that phantasy - compounded of defensiveassumptions derived from the past and wishful visions of the future - is the mainimpediment to living fully in the present, let us move now to an ideal picture of futurepsychotherapy before returning to reality. What follows is a list of fairly modestobjectives for which I believe we should be striving.

A Psychotherapeutically-informed Psychiatry

I shall start with a clinical example taken from an acute psychiatric ward, which mayread like self-advertisement, but which is an attempt to illustrate the kind of psychiatry Ibelieve we should be trying to practise.

Anthony (who has willingly given me permission to talk about him) is a talented andintelligent young person whose life had been restricted by his illness, which started at theage of 19 when he had a major schizoaffective breakdown a few weeks

JEREMY HOLMES 451

into his first term as an trainee officer at Sandhurst and had to discontinue his armycareer almost before it had started. Now, 12 years on, he has made a reasonableadjustment, is married, has a steady clerical job. He takes a lot of pride in his role as apart-time fireman, although he tells me that oculogyric crises while climbing up a ladderin burning buildings are not much fun! He has had several short-lived relapses over theyears, in which hypomanic features seemed to dominate.

On the occasion I wish to describe he had been admitted to hospital on Section afterhe had decided to dispense with his normal medication of neuroleptics and lithium andtry a `holistic' approach, consisting of meditation, naturopathy and osteopathy. Hisadmission had been triggered by his wife who was worried by the fact that he had notslept for several weeks, had turned their front-room into a makeshift `shrine' and hadbecome increasingly peculiar and aggressive towards her.

One afternoon I was called to the ward because the staff were worried by hisirritability, restlessness, insomnia and grandiosity, and refusal to take any medication. Istarted with a rational appeal to him to return to the medicines which over the years hadenabled him to lead a relatively normal life. I immediately sensed that we were engagedin a battle of wills, with me cast as an authority figure hell-bent on imposing my wishes,while he was determined to resist me to the last. `How can you possibly know moreabout me than I know myself?' he argued. `I know what is right for me, and it has to bethe natural holistic way.' I tried to agree with him: `Of course, you are the expert onyourself. All I can claim to know about is psychiatric illness, and yours responds well toDepixol and Lithium.' He was not impressed. I tried another tack: 'You speak of holisticmedicine - but modern medicine and complementary medicine are two halves of thatwhole - you need both, to render unto Caesar and to God.'

Bringing God into the consultation was not a good idea. Anthony roundly told methat I had no authority over him, that was God's prerogative, and, what is more, he wouldprefer to see another psychiatrist. Desperate for a new angle I tried to understand ourinteraction in psychodynamic terms. I recalled that Anthony's unhappiness had startedwhen, at the age of 11, his parents separated and his mother remarried. I said: `Perhapsyou see me as like your step-father, someone who in your eyes has no genuine concernfor or legitimate authority over you. You long for a loving father - and a new consultant -who will value you and look after you.' This was said no doubt partly in retaliation for hisdevaluing of my efforts, but also in the hope of breaking through to the deeply deniedsadness which so often underlies manic experience.

There was a momentary pause, a slight glazing of the eyes, but Anthony remainedadamant - no pills under any circumstances. Since he was on Section we did have theoption of forcibly injecting him, but that was a last resort, and would have furtherjeopardized the fragile working alliance. We decided to wait.

Two days later he was much better, sleeping at night, and had resumed his habitualmedication. What had made him change his mind? Was it the interpretation? Or was itthe long talk he had with a medical student the next day - an able and friendly youngman, far less threatening than a consultant? In any case, I felt vindicated and pleased thata psychodynamic interpretation might possibly have helped with a pharmacologicalintervention. That is the kind of psychiatry I believe in. Psychodynamics had helped withcompliance, and the battle over compliance had helped me to understand him and hiscore conflict more clearly.


Psychiatry without psychotherapy is sometimes described as `veterinary', but I don'tthink that opprobrium - if it is one - is quite right. I am sure it is possible to practisepsychiatry successfully and humanely without any particular training or expertise in theminutiae of psychological therapies, and no doubt there would have been many differentways to persuade Anthony to take his pills. But psychotherapy's unique contribution isthat it provides a language with which to talk and think about relationships. Without thatbackground psychiatry relies either on a conventional doctor-patient relationship mode -a `medical model' - learned through the apprenticeship system, and/or on intuitiveexperience of relationships, derived from the practitioner's developmental history. Wherethose experiences have been felicitous, and the patient is non-problematic, all may wellbe well. Part of the `value added' of psychotherapeutically-informed psychiatry is that itsystematically trains practitioners to be self-reflexive in their practice. For psychiatrictrainees this starts with the Balint groups that have become an essential part of trainingfor all junior psychiatrists, and moves on to the supervision of individual casework, inwhich the therapist's own reactions and responses to the client are crucial. Thuspsychotherapy training is a safeguard against `reflexive breakdown' (Lear 1998),enabling the doctor to understand and work with painful or worrying feelings in thepatient and himself - which are an inescapable aspect of contemporary psychiatry,especially with patients suffering from personality disorders.

There is, of course, much more to psychotherapeutically-informed psychiatry thanusing psychodynamic understanding to help patients take their pills. All the majorfunctional psychiatric disorders can benefit from psychotherapy of one sort or another (Roth & Fonagy 1996). Effective treatments include cognitive behavioural therapy indepression, psychosocial interventions in schizophrenia, family and individual therapy inthe management of eating disorders. Recently evidence suggests that, even in theproblematic area of personality disorder, structured treatments in intensive outpatientsettings or therapeutic communities can be of significant benefit. The recently publishedNational Service Guidelines (NSF) (NHSE 1999) for mental health strongly supports theview that patients have a right to expect such treatments to be available in whatever partof the country they live. The NSF also places great emphasis on what it calls `training theworkforce' in which psychotherapy departments must play a central role. Expertise inpsychological therapies, whatever their modality, gives confidence to mental healthworkers, providing a framework and a theory and a guide to action, which are inthemselves therapeutically beneficial.

Social Accounting

The basis of my argument so far is that psychotherapy is not a luxury, like a meal out or aforeign holiday to be indulged in if and when surplus money becomes available, but anessential and integral part of psychiatric care. Currently the pressure on generalpsychiatry is so great that, when new funds do become available, they tend to be spent inways that appear to relieve the immediate stress, while investment in psychotherapy getspushed to the back of the queue. Recent health economic research in the treatment ofmental illness suggests how short-sighted this is (Chisholm 1998). Psychotherapyimproves outcomes in two crucial ways: patients are symptomatically improved and their`service utilization' - amount of psychotropic drugs consumed, numbers of visits to theirGP and hospital admissions, dependency on benefits - is reduced. If this is

JEREMY HOLMES 453

taken into account and the costs of psychotherapy and `standard care' are compared, thesums come out roughly equal: psychotherapy is expensive, but its cost is offset by thereduction in service utilization. Since psychotherapy patients are consistently madebetter when compared with those receiving standard care, psychotherapy is clearly agood investment, but only if total costs are calculated in this way - which at present theyare not.

Widening the Aims of Psychiatric Treatment

`Standard care' in psychiatry - i.e. psychiatry without specialist psychotherapy - aimsprimarily to alleviate the immediate symptoms of psychiatric distress, and it is relativelygood at doing this. Psychotherapy is more ambitious - its aims include strengthening thepersonality so that it is proof against further breakdown in response to stress, helping itssubjects to feel more autonomous and in control of their lives, and to be able to formmore satisfying intimate relationships. In our own study of personality disorder we havefound that standard care, despite consuming huge amounts of medical resources, doesindeed help to improve psychiatric status and symptoms over a two-year period, but thatsocial adjustment remains unaltered. Psychotherapy is often criticized for not being cost-effective (Holmes et al. 2000). Our research shows just how cost-ineffective `standardcare' can be, especially in personality disorder. Treatment must be effective before cost-effectiveness comes into the equation. To be effective psychotherapy needs to bedelivered by well-trained therapists working in a structured setting - often the antithesisof today's CMHTs and community psychiatry. .A similar story is to be found with familyintervention in schizophrenia, a research finding that is still very far from beingimplemented as part of standard care.

Integration in Psychotherapy

I am a passionate integrationist. I believe we are on the threshold of an integrativerevolution in psychotherapy as old paradigms are re-examined, and cross-fertilizationbetween different psychotherapeutic modalities and intellectual disciplines becomesincreasingly possible. I will pick out three aspects of integration. Firstly, there isorganizational integration of the different modalities and professions involved inpsychotherapy. With the advent of cognitive therapy and the rise of systemic therapiespsychoanalysis is no longer 'the only game in town', although I believe thatpsychodynamic thinking remains fundamental to any psychological approach. But thereneeds to be a range of psychological therapies available if the differing disorders,personalities and preferences of patients presenting in psychiatric settings are adequatelyto be met.

In my modest dream of the future each district mental health unit would contain amultidisciplinary Psychological Therapies Department, staffed by psychotherapists,psychologists, nurses and others, and offering the full range of treatment and training inthe different psychotherapy modalities. This ideal set-up involves a hub-and-spokesmodel in which psychological therapies retain their identity and separateness, offeringspecialist treatment for complex cases, while at the same time providing assessment,supervision and training to the community mental health teams on a sessional basis (Holmes 1998).


The second aspect of integration concerns the nature of the psychotherapeuticrelationship itself. Starting with Freud's insistence on differentiating psychoanalysis from`suggestion' and supportive psychotherapy, most modalities of therapy emphasize theirown supposedly unique features, flying the flag of difference in the market-place andhoping thereby to attract funding and admiration. In reality what goes on the consultingroom suggests there are as many overlaps and similarities between the different types oftherapy as there are differences. As cognitive therapists' treatments extend for longer andlonger periods they are beginning to become interested in transference; converselypsychoanalysts not infrequently deliver behavioural suggestions, and make Rogerian-style empathic and supportive comments. In my psychotherapy of the future thesesimilarities, as well as the limitations, of the different therapies will be openlyacknowledged and discussed and researched - as is already happening to some extent.

A third facet of integration is speculative but even more exciting. As traditionalacademic demarcations become more fluid, I believe there is a possibility of realtheoretical exchange between different disciplines. There are signs that this is alreadytaking place. We can now use magnetic resonance technology to track the progress ofpsychotherapy as it impacts in the brain (Gabbard 2000). Cognitive scientists arebeginning to take emotions seriously, moving from the brain as a computational system,to a mind that makes probabilistic assessments and judgements using feelings as a guide.When a hard-nosed neuroscientist like Dimascio says, `We think with our bodies' (Dimascio 1994), one can almost hear the erstwhile neurologist Freud purring withsatisfaction in his grave, remembering his dictum that `ultimately the ego is a body ego'.Attachment theory brings an observational and evolutionary perspective to psychotherapywhich can also help contribute to new paradigms in which we are discovering just howrelational the self is - how caregivers affect and modulate their charges' physiology, notjust their psychology, which may have profound implications for borderline patients, withtheir inherent difficulty in affect regulation. The body we think with is a relational body.In addition, the `new genetics', so far from being antipathetic to psychotherapy, suggestthat it is the environment (and for humans this is almost entirely the human and relationalenvironment) which switches genetic potential on and off. Millennial psychotherapy willbe collaborating both clinically and in research to deepen our understanding of theseprocesses.

Finessing the Future

Returning to the present, what are the forces ranged against psychotherapy, as well asthose which might propel it towards the modestly glorious future I have outlined? Inorder to succeed, psychotherapy needs all the skills of engagement, subtlety,accommodation, appropriate challenge, self-knowledge, ability to hang quietly onto corevalues, and acceptance of inevitable partial failure for the sake of eventual modestadvance, that are required in the therapy of a difficult borderline patient. Crucially,psychotherapy - which currently is still more of a presentiment than an establishedpresence in public life - faces what one might call the Blairite dilemma. Just as socialism,in claiming the centre ground of politics, has tempered its radical edge to the point atwhich it is almost unrecognizable, so psychotherapy, in wanting to enter the mainstreamof publicly funded medicine, may run the risk of compromising its core values. Again, itis rather like the struggle with a difficult

JEREMY HOLMES 455

patient in which the therapist is faced either with entering a collusive relationship thatmerely perpetuates the patient's problems, or issuing a challenge that risks breaking offthe treatment altogether.

However, it is possible to exaggerate the dangers of engagement; also, as well asbeing a struggle for survival, there is much to be gained by working within the NHSmarket-place. Understanding the role and constraints of time-limited therapies, learningto be appropriately directive, exploring the benefits and pitfalls of combiningpsychotherapy with medication, tailoring treatments to particular diagnoses, developingprotocols for different levels of therapy - all these have come out of the need to find formsof therapy appropriate to a publicly funded service. Nor do I think psychodynamic ideasare necessarily lost in the process. There is a Trojan Horse aspect which means that corevalues and psychodynamic principles can be held onto while exploring ways ofcontributing acceptably to general psychiatric culture, although a band of brothers andsisters in the core or hub or secure base of a psychotherapy department is essential if thisis to succeed.

I will end with some remarks about the nature of authority in psychotherapy - whatgives us the right to be listened to at all? This is relevant because in an institution such asthe NHS power and influence are the key to securing funds and shaping policy, and weneed to be sure of the authenticity of our voice and its demands. We need to be able tospeak with the entitlement of the healthy infant, rather than the despair of the abandonedchild, with the confidence of a benign superego that has a clear sense of what is right andwrong, not with the guilt-inducing whine of the ineffectual parent, with an ego that is intouch with things as they are, rather than a nostalgic turning away from reality.

In the world of psychology people draw on a number of different sources of authorityin justifying their claim to be heard, each of which can be used in the fight to strengthenthe position of psychotherapy. First, there is authority that comes with leadership andseniority. This has always played a crucial part in the psychoanalytic world, which hasremained until very recently something of a gerontocracy. At worst, what Klein or Segalor Winnicott had to say may be revered in its own right, irrespective of its validity orrelevance. But we need to hold on to these ancestral voices without uncriticallysanctifying them as sacred texts, immune to criticism or correction. Freud's novelistic andphilosophical insights may last in a way that his `scientific' contributions will be, and to alarge extent have already been, superseded.

Against this quasi-religious reverence for the elders and their pronouncements we canset today's new God: evidence-based medicine (EBM). The scientific method has thecapacity to challenge the self-evident but often erroneous convictions and beliefs withwhich we comfort ourselves as we go about our daily life. RCTs can confound oureveryday delusions and so represent the ultimate in `reality testing' which is a keyoutcome goal for both cognitive and psychoanalytic therapy. While the difficulties offitting therapy into the RCT paradigm and the limitations of the drug metaphor can meanthat EBM is used mischievously to denigrate psychotherapy, I believe that we shouldgenerally welcome EBM as a key - but not the only - basis for authority in our field.Sadly, with honourable exceptions, we lack the strong academic base for psychotherapyin this country which is needed to mount effective RCTs.

A third source of authority in the debate about psychosis is the other side of theseniority coin. Here authority comes from popular appeal. It was not just the power andbeauty of his prose and his charismatic personality which explained R.D. Laing's


extraordinary success in the 1960s and 1970s, but because he struck a political chord at atime of cultural upheaval in the West which meant that there was an audience hungry forhis message of liberation and critique of the psychiatric establishment. Similarly, theincreasing authority of the user voice in psychiatry today flows from a new paradigm,based around (sadly, often justifiable) mistrust of professionalism, and an increasingfocus on consumers as active shapers of the care they receive. Users are the key ally inthe battle for psychotherapy, since they consistently want a psychiatry that values `talk' inpreference to 'pills'.

Finally, we come to narrative, and its crucial role in medicine and psychiatry. Theetymology of authority links the notion of authorship in the sense of an originator orcreator, with that of one who has power over the opinions of others. The idea of narrativeor story is tantalizingly Janus-faced. On the one hand we need a healthy scepticism aboutstories: quacks and charlatans as well as genuinely self-deceiving doctors have alwaysjustified their nostrums by appeals to authority coupled with stories of individualinstances of miracle cures. It is just this pitfall that EBM aims to counteract - like mypatient Anthony, we have to learn to render unto the Caesar of evidence and the God ofstory. But if we abandon story and the individual case history, we throw away the verybasis of our discipline - stories are where we live as doctors, psychiatrists and, especially,as psychotherapists.

Advocates of narrative argue that with all the huge advances of modern scientificmedicine there has been a loss of 'meaning' in our work and in what has been offered tothe patient. But what do we mean by meaning? According to Quine (in Caper 1999, p.129) meaning arises out of connectedness - we look up a word in the dictionary and areoffered another set of words to which that word is connected, and they are in turn linkedto another set of words and so on until we reach a web of meanings that comprise anentire language. Meaning in this sense can be linked to both metaphor and story. Ametaphor shows us ways in which something is like something else. A story is a series oflinked intentions and actions: 'first this happened, then I did that, and the result was theother'. Basing his ideas on those of Bion, Hinshelwood (1999) has argued that inpsychotic experience this linking process breaks down. The bizarreness and lack of 'reality' of delusions and hallucinations mean that they cannot easily be connected to thelexicon of everyday experience. A narrow 'medical' approach in psychiatry runs the riskof mirroring this evaporation of meaning with its restricted view of all that is abnormalas illness. Narrative-based medicine tries to expand its range of meanings to includemultiple perspectives. The challenge of a truly psychobiological psychiatry, whichembraces psychotherapy as an equal partner to biological approaches, is to produce astory that is sufficiently subtle and nuanced, both at the level of brain function and at thelevel of meaning to carry its own authority.

Here again I believe the attachment perspective can provide a useful bridge betweenthe world of science and that of psychotherapy. In developing the Adult AttachmentInterview, Main (Main 1995) has shown that there are features of secure narrativeswhich can be used to distinguish them for those whose basis is insecure or incoherent.These include succinctness, coherence, emotional balance and selfreflectiveness, all ofwhich can, in a research setting, be reliably coded and used to differentiate betweensecure and insecure authorial styles. Although they themselves might not necessarilyformulate it this way, psychotherapists are people who are trained to tune into differentnarrative styles - both their own and those of their

JEREMY HOLMES 457

patients - and to identify inauthenticity, defensiveness, incoherence, evasion and all theother aspects of distorted or falsified stories, and to help their clients to move towards aself-authorship and personal authority that has the ring of truth.

If, in our struggle to secure a future for psychotherapy, our stories are incoherent, orif we cling anxiously to past glories, or deny present difficulty, or shy away from conflict,or try to bully the opposition into submission, we will not, and do not deserve to,succeed. But if we get the story right - plaiting together past, present and future into acoherent, subtle and aesthetically satisfying whole - then our desires will, at leastpartially, be realized.

References

Caper, R. (1999) A Mind of One's Own. London: Routledge.Chisholm, D. (1998) Costs and outcomes of the psychotherapeutic approaches to the treatment of

mental disorders. Mental Health Research Review 5: 53-55.Dimascio, D. (1994) Descartes' Error. New York: Basic Books.Gabbard, G. (2000) A neurobiologically-informed perspective on psychotherapy. British Journal of

Psychiatry (in press).Hinshelwood, R. (1999) The difficult patient: the role of `scientific psychiatry' in understanding

patients with chronic schizophrenia or severe personality disorder. British Journal of Psychiatry174: 187-190.

Holmes, J. (1998) The psychotherapy department and the community mental health team.Psychiatric Bulletin 22: 54-58.

Holmes, J., Harrison-Hall, A., Montgomery, C., Chiesa, M. & Drahorad, C. (2000) Stigma andquality of life in schizophrenia. In Stigma and Personality Disorder (Ed. A. Crisp) (in press).

Lear, J. (1998) Open Minded: Working Out the Logic of the Soul. Cambridge, MA: HarvardUniversity Press.

Main, M. (1995) Recent studies in attachment. In Attachment Theory: Social, Developmental andClinical Perspectives (Eds. S. Goldberg, R. Muir and J. Kerr). New York: Analytic Press.

Main, T. (1989) The Ailment and Other Essays. London: Free Association Books.NHSE (1999) The National Service Framework for Mental Health. London: HMSO.Pines, M. (1991) A history of psychodynamic psychiatry in Britain. In Textbook of Psychotherapy

in Psychiatric Practice (Ed. J. Holmes). Edinburgh: Churchill Livingstone.Pullen, G. (1999) Schizophrenia: hospital communities for the severely disturbed. In Therapeutic

Communities: Past, Present and Future (Eds. R. Haig and P. Campling). London: JessicaKingsley.

Roth, A. & Fonagy, P. (1996) What Works For Whom? London: Guilford Press.

NHS PSYCHOTHERAPY - PAST, FUTURE AND PRESENT

Documents

Transcript of NHS PSYCHOTHERAPY - PAST, FUTURE AND PRESENT