Abstract
A most difficult part of psychiatric practice is the treatment of patients with limited capacity to contain their feelings and actions. These patients, such as those with severe borderline personality disorder, may experience insufficient containment during psychotherapy, resulting in actions which are harmful to themselves and others. The therapist, dealing with the patient's distorted reality, may be inhibited by the lack of support for the patient in the outside world. The situation may be compounded in work with children and their families where uncontained destructive actions and emotions define the dynamic situation. As discussed in its introduction, this excellent book is about the treatment of such patients who are children, parents and adolescents, with ‘psychosocial nursing and psychoanalytic psychotherapy within the therapeutic milieu of the inpatient hospital community’.
The Cassel Hospital is one of a small number of specialist services in the UK for people with a severe personality problem. It offers a multi-dimensional approach to management. Each patient or parent has an individual psychoanalytic psychotherapist within a milieu which encourages appropriate boundaries, interaction and involvement of patients with each other. Engagement with the milieu and with the realities and practicalities of living is facilitated by psychosocial nurses, as is learning for children by educational therapists. Staff counter-transference and organizational dynamic issues are addressed through supervision and meetings.
The seven main chapters encompass theoretical and clinical material. There is clear discussion of the contributors' largely object-relations theoretical understanding of the patients and the therapeutic process. The patients, their psychotherapy and engagement with the therapeutic milieu, together with the internal experience of the therapeutic staff, are clearly presented. This is conveyed through various clinical situations and over different age groups. There are for example, chapters on psychotherapy in families where Munchhausen syndrome by proxy has occurred. The intensity and therapeutic difficulty of working with perpetrating parents is presented in a way which conveys the nature and importance of the therapeutic relationship and the need for a containing environment. The complexity of containment of the patient's projections and the value of the therapeutic team for this task is well illustrated. In a subsequent chapter there is a rare in-depth presentation of the child's perspective through her therapy of this syndrome, something often lost in preoccupation with the adult perpetrator and the horror of the family dynamic. There are further chapters on inpatient work with children and their parents, outlining the treatment of abused children and the work of the educational therapist. There are three comprehensive chapters on work with adolescents, particularly those with severe borderline disorder. These present the therapeutic dilemmas of working with severe disturbance in this age group, of keeping in mind the developmental issues and of providing appropriate containment in the therapeutic process.
The book is a collection of individual clinical papers which relate to each other. The authors, from a variety of primary professional and academic backgrounds, have training and experience in psychoanalytic psychotherapy. There is repetition through some of the chapters, perhaps a function of them being separate contributions with different authors. There is a useful introduction which informs the reader of the nature of the institution and its aims. The hospital is participating in a multi-centre follow-up study of the inpatient treatment of children and families. There are impressive changes described in the course of therapy and initial follow-up of this group of young patients and it is obviously important to understand their future development. As pointed out, there is a paucity of funding allotted to mental health services for children and adolescents and yet one would hope that appropriate input at this stage of development would, apart form benefiting the individual, forestall a lifetime of trauma, expensive interventions and transmission of difficulties to a future generation.
I experienced a degree of angst in reading this book. I was reminded of the degree to which current psychiatric teaching and thinking has moved away from areas most pertinent to the management of this extremely disturbed and disturbing group of patients and that equivalent facilities are not available to such patients in our community. But it is important to be reminded of how things might be and this book does so in a readable, instructive and involving manner. It provides a significant contribution to the understanding of an important group of patients. Attempts to achieve significant change for such patients requires informed treatment which adequately addresses their internal dilemmas and their problems in negotiating their external world.