Editorial

It is hard to bring my mind to the, usually, pleasurable task of writing an editorial because I am preoccupied with the Strategic Review happening in the Trust where I work. It strikes me now, however, that a number of the papers in this issue touch on themes relevant to my own preoccupations, themes that many clinicians and managers have been grappling with for a long time, but seem to be at the fore for me and my colleagues right now.

Time, and how we think about it, is the common thread I will use to link the papers in my description of them here. We begin with a paper which is the second of three instalments, following the story of ‘Sam’s’ 14 year treatment. There is a spaciousness and generosity in Holloway’s writing, which must be, at least partly, to do with the length of treatment and thus the time this has afforded him to reflect on the work. A 14 year treatment in Canada contrasts sharply with what Australian Ruth Schmidt Neven explores in her book on time limited psychodynamic psychotherapy, reviewed here by Maria Papadima. She is enthusiastic about this book as a thoughtful approach to austerity that is adapted to reality, unlike the notion that we could endlessly offer more for less, which Papadima likens to the parable of the five loaves and two fish. She writes: ‘As UK child and adolescent psychotherapists working within chronically underfunded public services, our dilemma is stark: do we overstretch ourselves and offer more and more, trying and failing to magically multiply the resource that exists? Or do we adhere to rigid boundaries, sticking to the required hours and patients per day and reserving traditional child psychotherapy for a limited few?’ I agree with reviewer and author that the former, like all manic flights from reality, is doomed to failure through burnout, while the latter involves both practical and ethical problems for public sector clinicians.

The joy of working in the Journal of Child Psychotherapy is that we receive papers from therapists working in wonderfully varied contexts, allowing us to learn from experiences we are unlikely to know about otherwise. For example, as an NHS clinician, I don’t expect to be able to ever find out for myself how to adapt technique for a 14 year treatment, but I do feel I can take something from Holloway’s writing that enhances my practice, borrowing from his experience. However, I also welcome advice on how to use what we do have to best effect. Papadima tells us that this is exactly what Schmidt Neven does, through challenging some of our assumptions and their unhelpful sequelae. ‘By adhering to the belief that long term and open-ended treatment is the sine qua non of good quality child psychotherapy, while everything else is second best, not only does our existence within the current British public sector become threatened, which is a pragmatic reality; but more importantly, we risk feeling perpetually disappointed and frustrated that we are ‘not offering enough’.’

Jocelyn Catty’s paper ‘Out of time: Adolescents and those who wait for them’ explores the complex relationship between time and value in the context of risk. This paper comes out of a larger-scale project looking at waiting times in healthcare. Catty’s talent for bringing into sharp focus the most nebulous of phenomena is in full force here. Time management in the NHS is mind numbing, both because it is mundane, and because it demands magical thinking, as explored above. And yet, for those working with adolescents in crisis, time is also a highly charged entity, making it very hard to think meaningfully about it: but Catty’s paper does just that. With the following vignette we are plunged into the paradox of a nine-to-five crisis service, and the value beneath the apparent impossibility of it all. ‘One Thursday afternoon, a crisis team is slowing to a halt before the end of the working day, tidying up paperwork and making tea. A call comes in from a school nurse: she is sitting with a 14-year-old boy who says he is going to kill himself on Monday. I experience a shocking double-reaction: ‘he’s going to kill himself, we need to get him in [to see us]; oh fine, we’ve got till Monday’. The contrast is breathtaking. After painstaking discussion with colleagues, the boy’s mother, the school nurse and the boy himself, he is escorted home, with a CAMHS appointment booked for the next morning.’ Catty explains that an immediate emergency appointment would have risked undermining the family’s capacity to offer ordinary loving care, while waiting until Monday would have been provocatively laissez-faire. The Friday appointment is ‘just right’. It asserts that there is time – time to think, rather than react – and that time spent waiting can be borne. Also, this might signify the beginning of time being set to a rhythm of appointments offered at regular intervals, and all the associated benefits of this. As Catty writes: ‘Why the psychoanalytic offer of time is helpful in crisis situations, then, is surely that it allows a slowing of time, even in the midst of crisis. This is time in which the unconscious communication can be heard – in both the patient and the anxious professional.’ Catty tells us that the work of calibrating here is ‘painstaking’ and that even clinicians accustomed to this work are initially thrown to extreme responses.

The difficulty of thinking clearly about time is compounded by the conflation of patient need with organisational need, as Catty points out: ‘A patient who has presented to A&E and who has, if necessary, received appropriate medical attention, is no longer in an emergency situation: he or she is just in an emergency setting. One might say, in fact, that this is a problem of location rather than time’. This conflation also gets into the systems for measuring our work/time and this, in turn, can make it hard to resist what she describes as ‘the temporal demands exerted by clinical governance in the NHS and the insidious ways in which it values administrative tasks above the clinical encounter.’ I am painfully aware that even in non-crisis work, the systems set up to measure my work/time do not really map onto the way clinical work actually happens, so that I end up trying to reshape the work to fit the system, with a sense that the tail is now wagging the dog. The time wasted by all this is, of course, never factored into job planning, and so ever more deeply do we cleave from reality and find ourselves in Mad Hatter time.

Sarah Harris describes a piece of work in which anxiety about wasted time is a central theme. Here it is anxiety about whether we have time to wait for our patients to move into a state of mind and body that allows for more active analytic work. Her feeling of having a guilty secret, that actually nothing much at all is happening in the room, is made more acute by the relief felt by the network that someone is taking the boy off their hands. Harris is highly ambivalent when her employer extends the work beyond what felt like an obvious point of ending to her. She evokes the struggle of holding onto the value of ‘negative capability’, particularly when we are all so overworked and when doing what seems like ‘not much’ feels heinous. Yet, as the latter part of this paper shows, the investment of bearing while not knowing and apparently not doing really can pay off.

Phyllis Cohen and her colleagues describe a model of working with the most disturbed parent–child relationships in the context of court mandated supervised visits, in New York. This model, Building Blocks, which is grounded in psychoanalytic thinking, actually uses ‘an interdisciplinary group of mostly early career professional[s]’ to deliver the program; but they are supervised by ‘highly trained and experienced senior child and adult psychoanalysts and psychotherapists, with extensive experience treating trauma’. This is a model that would fit well within the NHS long term plan in relation to Psychoanalytic Child Psychotherapy becoming a supervisory resource for a larger number of lower banded clinicians who, we are told, will actually see young people. It is not dissimilar from the model we use at the Tavistock Outreach in Primary Schools Project, where assistant therapists in honorary (unpaid) posts are supervised by qualified child psychotherapists, who also offer parent work. Alongside adapting our technique to offer time limited psychotherapy, this may be another realistic way to stretch resources. Cohen and her colleagues describe the Building Blocks model as a form of ‘nested mentalization’, which resonates with the idea of the Russian dolls of containment. They quote Slade et al. (2017) describing the model: ‘We think of it this way: the supervisors and the team hold the clinician, baby, and mother in mind, the clinician holds the mother and baby in mind, so that the mother can herself hold the baby in mind. We refer to this as ‘nested mentalization’. This supervision and support insure[s] that the clinician will herself be able to remain authentic and reflective and not succumb either to shutting down or becoming dysregulated’ (p. 97).

Another way of helping psychoanalytic insight reach a larger number of children is for qualified child psychotherapists to offer Work Discussion seminars to allied professionals. This has long been a part of pre-clinical training but is relatively under-researched as a method of improving practice in other fields. Lida Anagnostaki and her colleagues in Athens have identified a particular dearth in the research on Work Discussion for nursery school educators. They describe their research into the experience of those facilitating groups in Greece, as well as the nursery educators attending the groups. The Work Discussion seminar facilitators and attendees were interviewed, to gain their view of how the seminars had impacted their work and what it had felt like to participate. The transcripts of these interviews were analysed by the authors using thematic analysis, to explore and contrast emerging themes. The results suggest that being in a Work Discussion group had an important impact on most nursery teachers, both on a professional and personal level, but that the experience was disquieting and uncomfortable to begin with for a number of interesting reasons.

The final three papers have quite a different feel. Graham Shulman, Yaakov Roitman and Tim Smith all make time to delve deep into different aspects of psychoanalytic thought, and each finds fertile seams to nourish us. Roitman takes us on an odyssey into the complex interrelation of a series of associations he has in a state of reverie during a session with a child. We might all discuss our countertransference, and even touch upon the significance of associations to art, literature, jokes etc. However, it is the way that Roitman follows his own line of dream-thoughts about a film, which emerged in a session, that is gratifyingly extravagant with time. In Poetic memories of Winnicott’s ‘Mirror role of the mother and the family’ and Tarkovsky’s film Mirror, Roitman reminds us that if we don’t take the time to amble after our dream-thoughts, we limit what we might have to offer our patients: ‘In this waking-dreaming, therapists are in a condition in which they are better able to be attentive to the patient’s ineffable experiences, so that they might freely and creatively create images and sounds to unconsciously think their patient’s unthinkable experience.’

Our special issue on the impact of the pandemic had a lively immediacy, which seems to have been well received. Here, Shulman has evidently used the passing time to carefully digest theories from Bick, Britton, Klein and other contemporary writers, in relation to how they can offer a deeper level of understanding on some of the experiences so vividly described by our authors at the time. This process has led to a well-formed formulation of exactly what is lost in the two-dimensionality of the ‘Screen Object’ and why the loss is so profound: ‘I suggest that at the most primitive psychic level, the internal physical surface and three-dimensional bounded space of the playroom is, and functions as, the material component of the skin. By this I mean that they function psychically for the child in a way analogous to that in which the mother’s body and bodily presence function for the infant in the most primitive phase of post-natal psychic life. I am proposing that this three-dimensional physically bounded space, materially delimited by walls, floor and ceiling, is necessary and integral to the holding and containing of the primitive inchoate and disparate unintegrated bodily experiences and parts of the personality. In this sense, the physical room is more than a ‘depository’ of the psychotic part of the self, and is more than a ‘background’, in the same way that the infant’s mother’s body and bodily presence do not function merely in a passive way or as ‘background’, but are integral to the primal process of establishment of a skin, internalisation of a containing space, and embodiment of the self.’ Shulman also reminds us of the way we struggle to view the phenomena associated with remote work as grist to the psychoanalytic mill, rather than noise to be filtered out.

Finally, Tim Smith discusses Bion’s autobiography, The Long Weekend, focusing on Bion’s depiction of sexual states of mind. As a profession, we are beginning to more deeply acknowledge the importance of owning our own particular, culturally situated, perspective on our clinical encounters, and this makes it a particularly interesting time to go back and think about the cultural and social context which one of our great psychoanalytic minds emerged out of. Smith is not reverential, but accompanies Bion through his painful lessons from experience. He is baffled by Bion’s treatment of sex at his English boarding school: ‘where he puts the topic front and centre, yet affords it a peculiar kind of censorship’ and is interested in the religious Edwardian social context and ‘the stifling impact this had on Bion’s creativity.’ Smith also argues that ‘the adolescent sexual states of mind Bion describes are still the kind that provoke much anxiety, disturbance and cause for concern in the public sphere today but also, invariably, although less widely acknowledged, privately within oneself. There is a propensity in all of us to blame our repression on the systems around us, rather than the forces within ourselves – something Bion does not deny but places at the foreground of his book.’ He notes that ‘Bion’s personal qualities of courage, his capacity to observe and his interest in the truth, helped to counterbalance the destructiveness that had led him to reject relationships.’

The final section of this editorial is written by my co-editors Maria Papadima and Rachel Acheson, who will honour the loss of their colleague Jo Bent-Hazelwood.

In reading this editorial and considering the matter of time, both our minds were brought to Jo Bent-Hazelwood, a friend and child psychotherapist colleague who died in late April of this year. Her death was a sharp reminder of how time is a limited resource in all our lives. It is poignant that Jo herself wrote eloquently on the subject of time in her paper ‘How Much Time Do We Need? Time and Psychoanalytic Psychotherapy in CAMHS’, which was published in the British Journal of Psychotherapy in 2020. In that paper, Jo examined the tensions that exist in the contrast between the model of work we are trained in, and the realities of what child psychotherapists can offer in the NHS. Her exploration is lively, hopeful, and creative, much like Jo herself. Her death is a loss to the profession as a whole, and most apparent to those who knew her at IPCAPA and worked with her. At the Journal, we will miss her as a peer reviewer and budding author, and we want to dedicate this issue, with the weaving theme of time running through it, to Jo’s memory.