The patient, a beautiful woman with the bleakest of backgrounds mentions to me, by the by, that her husband occasionally beats her up. She shrugs.
Of course, it’s not uncommon for patients to relate disturbing material. The kind of patient seeking, and eventually getting, therapy within the NHS often has a grim history. It can be deeply upsetting to listen to the litany of neglect and abuse, but it’s familiar. It’s a question of listening to the patient and perhaps making links between these early experiences and their adult difficulties. Easy! (It isn’t). Where I get confused is when I start wanting to act instead of think. “Get out of there, quick!” I felt like saying. “There are refuges!” I think this is probably what she wanted me to say and do too.
I have begged my own analyst for advice, hated him for not giving it to me, spent years thinking, “If only he’d told me what to do!” Sometimes, exasperated, I construct a viewpoint for him from shreds of ambiguous interpretation.
But from the other side of the couch, I now see how difficult it is to maintain a therapeutic (instead of “someone’s forthright friend”) stance in the face of real life crisis. As a therapist, I should listen for the unconscious meaning in the communication, not suggest strategy (that’s the forthright friend’s job)—but it is HARD!
It’s also debatable. I’ve been in a supervision group with someone who is a psychiatrist (prescribing drugs) as well as a psychoanalyst (peering into the unconscious) and he is very dismissive of the strict therapist’s stance I’ve been taught. “Tell your suicidal patient you need to be sure she’s not going to do anything silly over the weekend,” he said to one trainee. This kind of intervention would get you practically turfed out of some training institutions. We’re meant to say, “I think you’re telling me this because you need me to worry about you”; not “Don’t do it!”
If someone is a danger to themselves or others they can be sectioned under the Mental Health Act, and a therapist would automatically report concerns to a supervisor. A patient in some other kind of danger would also be flagged up and you can always try to get your message across by saying something like—“And I wonder if you need me to tell you to go to the police?”
But danger is difficult to define—fantasies about murder and suicide are common. Therapists would be flailing around at police stations all the time if they took everything literally. So, as my patient talks calmly, I find myself awash with horror while she seems blank.
Instead of screaming, “Go to the police!” I stick to my training and wonder why she is saying this now, to me, today, in this particular way, what she is doing to me in saying it. I try to remember that this isn’t a police report. She wants me to know she feels trapped and defeated, that home is not a safe place. My job is to think with her about how she has brought the domestic atmosphere of her early life with her into adulthood. Ideally (and let’s not hold our breath), we’ll gain enough understanding for lasting change to occur.
At the end of the session I felt completely helpless, baffled and frightened. It took me hours to understand that it was these very feelings she had unconsciously communicated to me. Shouting about going to the police wouldn’t have helped her. It probably would, however, have scared her out of therapy.
My supervisor’s view? “Bear the uncertainty.” It’s about not leaping into the material but bearing not knowing what to do; bearing not knowing how the situation will develop. I’m trying.
The below is a response to this column published as a letter in the October issue of Prospect.
Anna Blundy's column displays a troublingly insouciant approach to the assessment of risk in her clients: and an attitude to suicide prevention which places the profession she seeks to enter beyond the pale of mental health services generally.
Other clinicians, working in crisis services, A&E, and as well as psychiatric settings, are taught from day one to response to disclosures of suicidal thoughts, by clarification, risk assessment, advice and—where necessary—intervention. This approach has been repeatedly restated in governmental suicide prevention programmes, which now reach out as far as receptionists in A&E and doctors' surgeries, and appear to be successful.
Her account of a dismissively heretical psychiatrist who would be "turfed out of some training institutions" for advocating even minor intervention to reduce risk speaks volumes about those institutions, and raises questions about the training they provide.
Stephen Potts, consultant psychiatrist, Edinburgh
The following is a response by Anna Blundy to Stephen Potts's letter
I am in no way trying to represent Kleinian therapy or therapists—I should be very clear that I am simply drawing from my own experience of training in the hope that it might be informative and, ideally, entertaining. I'm not writing a manual or attempting to pass my own musings off as universal truths.
I am (genuinely) sorry if Mr Potts feels my tone is insouciant, but my approach most certainly is not. As he very rightly says, the NHS is very clear indeed about reporting suicide risk to supervisors immediately and I would always report suicidal thoughts in a patient to my seniors. Everyone, including myself, takes suicidality very seriously indeed. I have written at length on suicide in this very magazine and specifically focused on how brilliant the NHS is at dealing with seriously ill patients.
The point I was trying to make, though clearly Mr Potts is not a fan of my writing style (my aim is to make these extremely complex issues accessible and enjoyable to read about) is that Kleinian psychotherapists try to work with, understand and interpret the material brought by a patient rather than react to that material. The idea is that this reflection can be as helpful, if not more helpful, than concrete action.
There are a great many different ways of communicating suicidal thoughts, and a Kleinian psychotherapist would not always leap to section a patient who was, for example, having dreams about suicide. They would, I assume, intervene with a patient who was making plans to end his or her life. In both instances supervisors would be alerted.
However, Mr Potts points out a difference in approach which I was attempting to underline myself (he may feel crassly). A great many psychiatrists (and I am working on anecdotal evidence of which Mr Potts now forms a part) do feel that the strict Kleinian approach to psychotherapy is too much based in interpretation linking back to early life, and that a more active here-and-now approach to improving the patient's immediate circumstances is greatly preferable.
The two schools of thought are very different indeed. Psychiatry is not psychotherapy. Most psychiatrists are not psychotherapists and vice versa. However, both professions share the same goal—the desire to improve the mental health of patients seeking treatment and, extremely obviously, to protect them from harm where necessary.
