Editorial

In part 2 of this special issue we continue our series of papers from the celebration events for the centenary of the Tavistock Clinic.

Exploring the theme of inequalities, the first paper in this issue is entitled ‘Pandemic: challenges in care and recovery’ by Dinesh Sinha. It has long been known that economic disadvantage is linked to higher rates of mortality and poorer access to healthcare (Black, 1982). More recent evidence has suggested that industrialised societies with the greatest income differentials (such as the UK and USA) have the poorest health and social development (Wilkinson & Pickett, 2009). The COVID-19 pandemic, which delayed the Tavistock centenary celebrations, has highlighted once again the inequalities in health within our society. Using the lens of everyday sadism, Sinha identifies corrosive and deliberate counter narratives to the themes of care and courage in this period. He describes how the pre-existing silos of separation between the privileged and dispossessed have prevented survival and wellbeing in the wider society. He cautions health and social care workers about the possible lapse into masochism and bravery as defences against exhaustion and the guilt of having survived when thousands of our colleagues have not. He highlights the need for awareness of our own feelings of guilt and aggression, so that they do not vitiate our capacity to care. Sinha suggests that the process of recovering from the pandemic is not just about the restoration of physical wellbeing but also the creation of healthier conditions in society that actively mitigate the scourge of everyday sadism.

The next paper, ‘Under fire in the consulting room’ by Carine Minne, describes her work with patients at the Portman Clinic. The clinic traces its history back to 1933, when the ‘Psychopathic Clinic’ was founded by Edward Glover at the West End Hospital for Nervous Diseases. It was established as the clinical arm of the Institute for the Study and Treatment of Delinquency (ISTD), earlier founded in 1931 as the Institute for the Scientific Treatment of Delinquency. The Institute had been inspired by the work of Dr. Grace Pailthorpe, a psychiatrist and psychoanalyst, who worked in Birmingham and Holloway Prisons. There, she became interested in the personality of women prisoners and in 1932 published Studies in the Psychology of Delinquency.

In her article Minne uses clinical vignettes with patients such as a woman who was convicted of infanticide. She illustrates situations when the therapist realised there was a sudden unexpected rise in the ‘temperature’ of a patient’s mind. She likens this to the ignition of a fuse and discusses why this may have occurred. Minne relates this ‘ignition’ to possibly premature interpretations, or a failure to notice how anxious the patient was in the presence of the terrifying object-therapist and also, patients’ unexpected responses to external interferences during a session.

In 1948, on the creation of the National Health Service, the Psychopathic Clinic formally separated from the ISTD and became part of the NHS, renamed as the Portman Clinic. In 1970 it moved to its current premises on Fitzjohn’s Avenue, next to the Tavistock Clinic. In 1994 the two clinics joined together to form an NHS Trust and then, in 2006, a Foundation Trust. For detailed descriptions of the history and development of the Portman Clinic, see Fishman and Ruszczynski (2007), Saville and Rumney (1992), and Shapira (2016). Today the Portman Clinic works with both children and adults suffering from problems arising from delinquent, violent or criminal behaviours, or paraphilias (disturbing and damaging sexual behaviours or experiences) either legal or illegal.

In another of her case examples Minne reports on her work with a man with a life threatening sexual perversion. Like many of the patients seen at the Portman Clinic, his behaviour can be understood as a compulsive need to act out an earlier unprocessed trauma. The focus of the treatments at the Portman Clinic tends to be on the clinician’s affective experience of being with patients like this, who, by enacting their conflicts and impulses, create disturbed and disturbing states of mind in those around them, including their clinicians.

Minne describes how these situations unfolded during the sessions and reflects upon how they might have been diffused differently. She emphasises how best to maintain a psychoanalytic stance but also how to clinically judge when a session must be terminated in order to protect both patient and therapist from inadvertently ignited exploding ‘bombs’. Minne stresses the importance of supervision and consultation with colleagues in managing this disturbing work.

The next paper documents the history and work of the Fitzjohn’s Unit, formed relatively recently in 2000. David Bell and Birgit Kleeberg provide a history of the development and work of this specialist service which delivers psychoanalytic psychotherapy for adults suffering from more complex and/ or serious disorders. The paper describes the patients treated in the unit, many of whom have been unwell for decades. Using a variety of clinical vignettes the authors go on to illustrate the model of care and also more general considerations such as the nature of the psychoanalytic attitude and the relation of psychiatry to psychoanalysis. They conclude by considering the position of this work within the wider context of mental healthcare policy and provision in England and Wales. Huge shifts in the cultural and political landscape over the life of the Fitzjohn’s Unit have resulted in the domination of the nomothetic perspective and the consequent industrialisation of healthcare provision. The authors describe how the Fitzjohn’s Unit has been swimming against this current, trying to preserve and develop a different way of thinking about mental illness, human subjectivity, and culture in general.

We conclude this special issue with a paper by Lydia Hartland-Rowe, entitled ‘“When I nod my head, hit it”: Leadership and followership in the orchestral environment’. The paper explores the parallels between leading and following in music settings, and leading and following in other organisational settings. Hartland-Rowe draws on literature from a range of sources exploring organisational life in the orchestra including organisational psychology, music education, social semiotics and sociology, and with reference to psychoanalytic and systems psychodynamics frameworks makes links between experiences of leadership and followership in the orchestra and work in the NHS. The modern NHS may be too large, too complex, and too pressured a system for an ideal model of leadership and followership to hold. But Hartland-Rowe describes the merit in identifying spaces where this way of approaching a shared task can be effective, and links this way of working to the psychoanalytic stance of ‘not knowing’. She concludes that, like the orchestra when it is working collaboratively and with agreed structures for leadership and followership, perhaps we can transfer this capacity into our work in the wider organisation and system where we, like the orchestra, face the need to perform.