Welcome to the penultimate issue of 2022, which commences with a theoretical paper entitled ‘Mentalizing the modern world’ by Chloe Campbell and Elizabeth Allison. Mentalization-based treatment (MBT) is a key part of the new integrated offer for people with severe mental health problems, as set out in the NHS Long Term Plan. However, this paper takes a somewhat different perspective, turning attention away from MBT and instead applying the concepts of mentalizing and epistemic trust to the relationship between social systems and individual subjective experiences. This focus draws our attention to societal contributors to mental health difficulties. The authors suggest that we may be able to identify the mechanism for the observable relationship between psychopathology and socio-economic alienation and inequality in the disadvantaged individual’s experience of a broader social context that fails to take into account the subjective richness of the individual minds of those with diminished economic value or social capital, as is the case in highly unequal social systems such as the UK. They propose that the experience of being mentalized and openness to epistemic trust may be the mechanism by which individual experiences of psychic distress, perception of self-agency and perceptions of others, are both influenced by and shape wider social phenomena and social change. They go on to consider some implications for legitimacy and the social contract when reduced co-mentalizing brings about an ‘epistemic mismatch’ in relation to social communication. They conclude that the impact of social inequalities and the breakdown of political legitimacy on mentalizing, epistemic trust and psychopathology means that optimal individual outcomes cannot always be achieved without adaptation of the wider social environment. This draws our attention to the possibility for improvements in the mental health of the population by reducing inequalities within our society.
The next paper, by Andrew Howe, Merryn Jones, Chris Bowden and Kevin Lu presents evidence for the effectiveness of Therapeutic Community (TC) treatments. ‘The importance of relationships in therapeutic communities: a systematic critical case study’ describes the experience of a service user who undertook a course of treatment at a TC day service. The importance of relationships within the TC model has previously been described theoretically but has not been clinically demonstrated in the literature. Using electronic patient notes, outcome measures, review letters, staff reflections, and a post-treatment interview, the authors show the importance of relationships within TC care. This case study is congruent with the findings from a recent RCT that showed significant improvements in satisfaction and lowered levels of aggression and self-harm for people with a diagnosis of borderline personality disorder treated in TCs when compared to those who received ‘treatment as usual’. This case study emphasises the importance of relationships to TC work beyond any specific therapeutic modality. The authors conclude that relationships are central to therapeutic community (TC) treatments and the process of change that is facilitated.
Mattia Beggi and John Gordon author our third paper, ‘The interpersonal dynamics consultation in a therapeutic community for borderline patients: containing relationships at the coal face’. The Interpersonal Dynamics (ID) consultation is a structured method of group reflective practice which helps staff to mentalize transference and countertransference dynamics with patients. The authors present a detailed ID consultation for a woman in an inpatient TC for people with severe personality disorders. The paper demonstrates how this method can shed light on the way that a patient’s internal world can become externalised interpersonally with staff in the treatment setting. The resulting enactments are discussed in relation to psychoanalytic theories and concepts, such as Bion’s theory of containment and Ogden’s interpersonal definition of projective identification. The authors describe how their patient population use the psychological defences of splitting and projective identification and conceptualise them as living in a space between the Kleinian paranoid-schizoid and depressive positions. They argue that the ID consultation functions as a container for staff and patients by bringing together and integrating the parts of the patient that are split off and projected into different staff members. Furthermore, they describe how the ID consultation can be an invaluable triangular space that facilitates the move from difficult dyadic subjective experiences with patients to triadic objective perspectives and from passive reactions to responsive thinking and understanding.
Our final paper is ‘Therapeutic encounters at the onset of the COVID-19 pandemic: psychodynamic therapists’ experiences of transition to remote psychotherapy’ by Katrin Ahlström, Camilla von Below, David Forsström and Andrzej Werbart. In early 2020 the COVID-19 pandemic crippled many parts of society as it spread throughout the world. Overnight, social distancing and lockdowns forced entire populations to change their way of life. For psychotherapists, this meant that in-person sessions were no longer possible and many switched to different forms of synchronous remote communication such as telephone, online audio or video link. This study explored psychodynamic therapists’ experiences of forced transitions to remote working. Five therapists were interviewed at the beginning of the pandemic and again at a one-year follow-up. The data were analysed by applying thematic analysis with a phenomenological approach. The study suggests that initially the therapists struggled with technical and safety issues. The loss of the therapy room and of access to non-verbal nuances contributed to impaired contact with the patients and resulted in more superficial conversations. The therapists reported that the very nature of psychodynamic psychotherapy was affected, even if telepsychotherapy also provided some new opportunities. One year later many of these difficulties remained, but the therapists had developed better coping strategies and were more able to maintain the therapy focus. The authors conclude that one implication of this study is that remote working should be included in psychotherapy training and supervision.