Psychoanalytic thinking in primary care: The Tavistock Psychotherapy Consultation model

Abstract

This paper describes the conceptual underpinnings, structure and operations of a novel service, the City and Hackney Primary Care Psychotherapy Consultation Service – a service set up partly with the aim of addressing the needs of patients who present with ‘medically unexplained symptoms’. As part of the Tavistock and Portman NHS Trust, this service moves its clinical base, staff members and daily work, as well as the foundations of psychoanalytic thinking that define the Trust's work, into the heart of a community, and provides psychoanalytically informed clinical practice and consultation to patients and general practitioners in the City and Hackney, one of London's (and the UK's) most deprived and ethnically diverse boroughs. The authors describe the psychoanalytical underpinnings of the model, the design and structure of the service, patient demographics and preliminary outcome data, as well as an example of consultation work with general practitioners. The authors propose that psychoanalytic applications have a place in primary care and that psychoanalytic thinking can help general practitioners and patients alike, even when the clinical interventions offered are not solely based on psychoanalytic technique or therapeutic approaches. The paper concludes with thoughts about the model, its origins and its future.

Keywords:

• applied psychoanalytic psychotherapy
• medically unexplained symptoms (MUS)
• primary care
• consultation
• general practitioner (GP)

Acknowledgements

We would like to acknowledge Philip Stokoe for the conceptualisation of the service model and for supporting the implementation of the service in its first year. We are grateful to Marilyn Lawrence for her encouragement to write this paper.

Notes

1. The Tavistock Clinic has had a long and influential history working in primary care, and developing and promoting psychoanalytic and systemic thinking and practice. The pioneering work of Michael and Enid Balint has profoundly influenced medical practice in primary care and continues to influence the work of GPs (Balint, 2000). The work of Alexis Brook and John Launer merits special mention for extending psychoanalytic and systemic knowledge and practice, respectively, from the consulting room to medical and community settings (Elder, Majid, & Stern, 2009; Launer, Blake, & Daws, 2005).

2. See Rock and Carrington (2012) for more details of this programme, our service and the stepped care model that frames its delivery.

3. See http://www.elic.org.uk/index.php/City/MentalHealth for further details.

4. The impact of the changes for GPs in taking up a much greater commissioning role within the major reorganisation of health and social care remains to be seen. Concerns about the dilution of the clinical role of GPs have been expressed about the present changes (RCGP letter, n.d.), as well as about past changes (Elder, 2009).

5. HoNOS PBR refers to the scales that are being developed to form the classification underpinning Payment by Results (PBR) for mental health in England.

6. Cohen (1977, pp. 26–27) illustrates the visibility of these magnitudes in concrete terms: an effect of 0.5 is as visible as the difference in height between 14- and 18-year-old girls, while an effect size of 0.8 is as the difference in height between 13- and 18-year-old girls.

7. Please note that, owing to data availability constraints, this data covers a slightly different period compared with the data in the remainder of this paper.

8. Each case has been disguised to protect confidentiality.

9. Two further cases were discussed and the meeting ended with a request for a follow-up with this practice and group of GPs.