I write this editorial as we are slowly emerging out of lockdown in London, horrified by the ravages of Covid-19 and realising how lucky I am with sustained employment in the NHS but not exposed to the life-threatening risks endured by those working at the frontline, some of whom have sacrificed their lives for their patients. Others working at this interface between life and death have been deeply traumatised by their experiences and find themselves disoriented and vulnerable as they allow their defences, which have been mobilised to protect them from being overwhelmed by the fear, pain, guilt and exhaustion of their endeavours to save the lives of others, to abate but then find themselves without a container in which these anxieties can be processed. Hence, the rapid wave of reflective practice forums, such as Balint groups, that have been offered by many psychotherapy services in the last three months to these frontline professionals, which they have eagerly accepted, generating requests for more of these interventions which create protected spaces to reflect upon and share their distressing and disturbing experiences with the help of psychotherapists and psychotherapeutically informed clinicians.
Although the first paper in this volume (the issue’s release in hard copy having been delayed in part due to the pandemic), ‘Psychic room to breathe. Themes emerging within a staff Balint group on an eating disorder inpatient unit’, by Dimitrios Chartonas, Anneka John-Kamen, Robert Freudenthal and Rachel Gibbons, was written before the outbreak, its subject matter is relevant in that it describes the benefits of a Balint group for staff working on an in-patient eating disorder unit with a patient population who also hover on the border between living and dying. The authors describe the staff’s conscious and unconscious preoccupation with mortality and their tendency to focus on the practicalities of keeping their patients physically alive at the expense of their own psychological survival.
The following papers may not convey the urgency of efforts to revitalise the psychic and bodily capacities of patients and staff injured by recent trauma, but nevertheless describe the application of specific psychological therapies – short-term psychodynamic psychotherapy (STPP) and art therapy, respectively – with patients diagnosed with ‘treatment resistant’ mental conditions or personality disorders whose lives may have been threatened by more distant childhood traumas and who also present with life-threatening behaviours of self-harm, neglect or other risky activities.
In ‘Short term psychodynamic psychotherapy (STPP) for clients with complex and enduring difficulties within NHS Mental Health Services: a case series’, by Javier Malda Castillo, Sophie Valavanis and Guillermo Perez-Algorta, the authors detail a small study conducted in an out-patient secondary mental health service in the NHS with a psychological modality that many psychotherapists working in the UK may not be familiar with, as it was developed by Davanloo, a psychoanalyst and psychiatric researcher in Canada, where it is more commonly practiced, most notably by Allan Abbass and his group. Nevertheless, it has a growing evidence base for its efficacy and effectiveness and as a result will be recommended as one of the interventions that may be used in depression in the forthcoming NICE guidelines for this mental disorder.
This study followed a quantitative case series design of eight patients with complex, enduring mental health difficulties, and evaluated the therapeutic effects and safety of receiving of STPP. Participant engagement in therapy was positive and at the end of treatment and follow-up, the patients reported clinical improvement. Although this study was limited by its small sample size, it nevertheless highlights the potential benefits of a short term focused psychodynamic therapy for patients who may have not reported improvement from previous pharmacological and/or psychological treatments and who are at risk of being designated ‘untreatable’, leading to despair and hopelessness that compounds their psychological distress.
The third paper is about art therapy, again a modality which I suspect many of our readers are not experts in, although it is also a NICE guideline recommended therapy, for the management of schizophrenia and psychosis. In ‘The function of the art object: art-psychotherapy theory and practice’, Liam Bierschenk draws from his experience of working with patients with a diagnosis of borderline personality disorder (BPD), as well as Bion’s theory of thinking, Steiner’s concept of the psychic retreat, and Fonagy and Bateman’s work on mentalization. He elucidates the fundamental assumptions of art psychotherapy, and from these constructs a hypothesis of art theory and practice that introduces the concept of the ‘art-psychotherapy object’. This is the totality of the triangular relationship between the creator, the artwork and the viewer, and acts as lens through which to view the art object. Bierschenk proposes that the art object serves one of several possible functions, and it is the task of the therapist to determine what that function is. One of these functions, he suggests, is of the art object acting as a defence against psychic metabolism and mentalizing of disturbing affects, for example, the artwork may serve the function of powerful feelings of envy and greed, which protects the patient against the realization of painful feelings of exclusion, separateness and emptiness. Bierschenk’s theory is complex but comes alive with clinical vignettes taken from a group he ran in a NHS therapeutic community day service for people with BPD, another patient population who may challenge professionals with their destructive impulses and behaviours which cannot be represented in the mind as this would risk them being overwhelmed with unbearable pain. This paper shows us, like the previous two, how psychoanalytically informed interventions, whether these are primarily aimed at patients or staff, can create therapeutic spaces where hope, creativity and connection can be nurtured, and what has been lost can be mourned.