The four papers in this issue of Psychoanalytic Psychotherapy are quite different in their subject matter, but seem to me to be linked in thinking about the creation of spaces, in different sensory modalities (auditory, visual, verbal and experiential) and in different settings (a child and adolescent mental health service (CAMHS), a community-based day centre, a research interview and a Balint group), where security, growth, exploration of ideas and creativity can be fostered in the minds and interpersonal spheres of the patients, clinicians, students and researchers under study.
The first two papers describe the work of non-verbal therapies – art therapy and music therapy, respectively – at a time when creative therapies are under threat within the increasingly financially constrained NHS, often due to the perception that they are not essential in the treatment of mental health difficulties. It is therefore heartening to publish accounts of on-going work of two of these treatments.
‘Going backstage: a psychoanalytically informed study with amateur musicians in adult mental health services’ by Lorcan Fingleton, John O’Connor and Greg Stynes is a very moving account of a qualitative study exploring the meaning of playing music in six men who attended mental health services and were amateur musicians. This paper addresses a little explored area, namely the therapeutic role of such music playing in the maintenance of mental health. Following a useful review of the literature on the psychological function of music and the growing evidence base for its effectiveness in ameliorating a range of mental disorders, the authors describe the results of the open interviews with the six participants that they conducted, in which they facilitated a free-association style of responses to elicit how their music playing had impacted on their mental health in both positive and negative ways. Fingleton, O’Connor and Stynes applied a psychoanalytically informed qualitative analysis to the transcribed interviews, which revealed four inter-related themes: ‘Left on the outside’; ‘Playing and linking’; ‘A beautiful gift to myself’; and ‘Frustrating play’. Drawing on the ideas of Freud, Winnicott, Fairbairn, Kohut and others, they discuss the role of music as a transitional object, the narcissistic and containing functions of music and its conceptualisation as an exhibitionist act.
Similar to the first paper, ‘The Vasarhelyi method of child art psychotherapy: an adjunctive treatment in childhood depression’, by Aisling Mulligan, Aynur Coşkunlu, Ezgi Tanıl, Anne Coffey and Dicle Buyuktaskin, starts with a useful overview of art therapies, and goes on to describe the Vasarhelyi method, which has been developed from psychoanalytic object relations theory. The therapy uses images for pictorial communication as a non-verbal language, where the image is a snapshot of the child’s inner unconscious, and can express the child’s anxieties and conflicts in a safe ‘empty space’ without the immediate presence of the therapist. The authors describe in detail the respective treatments in two CAMHS in Ireland of two children with this method, both of whom suffered with anxiety and depression, including suicidal thinking in one of them. They demonstrate how the treatment can be effective for children and young people with depression in mental health settings, as well as usefully applied as part of a multi disciplinary team, particularly for those children who do not respond to cognitive-behavioural therapy or where anti-depressant medication is thought to be unsuitable or ineffective.
I am pleased to publish another paper about gender identity, a topic that has exploded into the public consciousness in the last few years, but which remains controversial, stimulating debate regarding its aetiology and management, including within the psychoanalytic community, although psychoanalytic studies of transsexual and gender identity disorders are accumulating. ‘Falling outside of the ‘nice little binary box’: a psychoanalytic exploration of the non-binary gender identity’, by Mairead Losty and John O’Connor is a paper which does not address vexatious issues of causes or treatment but is focussed on the subjective experiences of individuals with gender identity issues, who have to negotiate integration of their identity at several levels: within themselves, within wider culture and society, but also within the gender variant identity community itself, where they may experience being on the edge of this population still in the main defined by a binary conceptualisation of gender. Non-binary gender identity refers to individuals who experience a gender identity that is neither exclusively male nor female, but is a combination of male and female or is between or beyond genders. Losty and O’Connor use a psychoanalytically informed qualitative research design to explore the internal world and object relationships of six young people who, to varying degrees, identify their gender identity as being ‘outside the binary box’. The conscious and unconscious material revealed through their qualitative analysis of the interviews reveals the participants’ struggles in developing their gender identity and their perceptions about how they are treated and viewed or not (being seen and unseen) within the society in which they live, results which may inform future studies of clinical and cultural responses to such individuals.
The final paper in this issue, ‘Balint groups in undergraduate medical education: A systematic review’ by Alice Monk, Daniel Hind and Helen Crimlisk, is about an area in which I have been involved for many years – the use of Balint groups as a method of teaching medical students about emotional aspects of the doctor–patient relationship. As is well known, Balint originally developed such groups for GPs, and participation in a Balint group for psychiatrists in training is also a mandatory part of the psychiatric curriculum. However, what is less well-known is that Balint experimented with these groups for medical students, and in the last 10 years, medical student Balint groups have been developed and delivered at an increasing number of medical schools in the UK and abroad. Training in communications skills and the promotion of whole-person medicine has been a central feature of medical school curricula in response to studies demonstrating a worrying decline in patient-centred attitudes and empathy in medical students as they progress through medical school, thought to be due to the dominance of a medical culture that promotes the biomedical mechanisms of disease rather than psychosocial determinants. Medical student Balint groups differ from other forms of communication skills teaching, however, in their focus on the emotions of both patients and medical students, who often become increasingly distant and detached from their emotional states to survive in the harsh working environments of today’s junior doctors. Giving permission to the students to explore in a safe space their relationships with their patients, and introducing them to the notion of countertransference, can be a liberating experience in an atmosphere in which emotional responses amongst health professionals are disapproved of or denied, and there is increasing evidence that participation in such groups increases empathy and resilience in medical students. This paper is important and timely in being the first systematic review of medical student Balint groups in the UK and abroad, and informs the Royal College of Psychiatrist’s current initiative to develop Balint groups at every medical school in the UK as part of their overall strategy to recruit more medical students into psychiatry.
Tavistock and Portman NHS Foundation Trust, London, UK
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