Containment lost: the challenge to child psychotherapists posed by modern CAMHS

Abstract

The paper is an examination of some emotional challenges facing child psychotherapists working in modern CAMHS following the introduction of the NHS internal market for commissioning and providing services. Its introduction has brought the loss of organisational containment for all CAMHS clinicians. The meaninglessness in work reported by clinicians is a clue to this loss. This loss is especially difficult for child psychotherapists because of their particular investment in the apprehension of meaning in symptoms and other presentations by patients. The paper proposes that meaninglessness is itself a clue to the ascendancy of what Freud called the death instinct, and that this is inherent within the internal market model. Because service design and delivery is predicated upon it, the internal market model structurally determines that clinicians are bound to senior management in a way that leaves child psychotherapists open to professional life-threatening dynamics associated with the death instinct. The −K (Bion) world of CAMHS is thus deathly, leaving child psychotherapists vulnerable to self-destruction. We have lost a workplace in which our approach flourished conferring on us the identity of a discipline structurally favoured, because of the help we provided through this approach to patient and clinic work. This loss of identity brings the dangers of containment lost. This situation leaves child psychotherapists emotionally vulnerable and is akin to Satan’s loss in Milton’s Paradise Lost.

Keywords:

• Containment
• death instinct
• envy
• identity
• internal market
• meaninglessness
• CAMHS
• NHS
• CYP-IAPT

Acknowledgments

I am grateful to child psychotherapists and other colleagues who have allowed me to use the content of our work. Without this work and their permission writing this paper would not have been possible.

Notes

1. An example of a CAMHS team that is attempting to wrest back meaningful work from a sense of this form of alienation is described by Shuttleworth, Britton, Keenan and Kyriakos in their chapter for Psychoanalysis, The NHS, And Mental Health Work Today (2017) edited by Alison Vaspe.

2. As examples of these surveys please see: Edwards, N., & Marx, C. (2016). The morale maze. Nuffield Trust comment, 27 October 2016. https://www.nuffieldtrust.org.uk/news-item/the-morale-maze.

Health and Care Professions Council. (2015). Report highlights powerless as indices of low morale due to no devolved decision making.

New Savoy Conference Wellbeing Survey. (2016). Division of clinical psychology. British Psychological Society. http://www.bps.org.uk/networks-and-communities/member-microsite/dcp-leadership-and-management-faculty/news/dcp-and-new-savoy-conference-wellbeing-survey.

NHS Staff Surveys. https://www.nhsstaffsurveys.com/Section/1003/Past-Results.

Nuffield Trust (2015). Health leaders’ panel survey 6: Footprints, financing and staff morale. Nuffield Trust.

Royal College of Nursing Evidence to the NHS Pay Review Body 2017–18 September 2016. https://www.rcn.org.uk/-/media/royal-college-of-nursing/documents/005803.pdf.

UNISON evidence NHS Pay Review Body 2017–18 September 2016. https://www.unison.org.uk/content/uploads/2016/10/UNISON-NHS-PRB-Submission-2017-18.pdf.

Unite Psychologists’ survey highlights NHS mental health funding crisis. October 2016. http://www.unitetheunion.org.

Young Minds. (2012). Staff morale in CAMHS has dropped to its lowest ever. Young Minds Magazine, 118, Winter 2012, pp. 24–27. Highlights the lack of clinical control over the design of clinical services.

Young Minds. (2014). Devastating cuts leading to children’s mental health crisis. http://www.youngminds.org.uk/news/blog/2480. Again highlights the lack of clinical control over the design of clinical services and that devastating cuts have leading to a crisis in children's mental health services.