The Flash in the Bedpan

A Flash in the Bedpan? The APP Chair’s Blog

Jeremy Clarke

Ever tried, ever failed, no matter. Try again, fail again, fail better.

First, let’s pick up the bedpan. Aneurin Bevan famously said: ‘the sound of a dropped bedpan in Tredegar should reverberate around the Palace of Westminster’. What did he mean? Essentially that he, and not the BMA, was now in charge. Whilst the clinician would remain directly responsible for ‘first doing no harm to the patient’, the elected Minister of the day is accountable for the NHS as a whole. Thus, ‘regulation, regulation, regulation’ – often in response to ‘scandal after scandal after scandal’ – and a plethora of managerial levers (targets, outcomes, cost controls) – in the name of delivering a tax-funded universal service, fairly and equitably for all.

Rule number one for APP, therefore, as a professional discipline trying to survive in this kind of system, let alone thrive, is to be politically savvy. I’ve studied closely some of those who are. Over the past decade as (former) National Adviser to IAPT (2008-2013), I have been on the inside of a radical experiment – the first attempt anywhere in the world to ‘realize the mass public benefit of evidence-based psychological therapies’.[1] When I was appointed by the Royal College of Psychiatrists to lead the 2nd National Audit (2013) I was able to evaluate independently the results of this failed experiment. Likewise, as an expert member of the NICE committee for its Depression guidelines in 2009, and 2020 (forthcoming), I have seen how evidence-based medicine operates to the advantage of some kinds of treatments at the expense of others. Those interested can follow this story in a recent special issue of our Journal that I edited.[2] Rule number two, based on these observations, and in the words of a young Al Pacino, remembering what his father taught him in Godfather II, is: “keep your friends close, and your enemies closer”.

It was Freud who first articulated the vision of universal access to therapy, free-at-point-of-need at the Budapest Congress in 1918[3], which we feature at the heart of APP’s mission statement. Let’s remind ourselves of what he said to take stock of where we are now:

at some time or other the conscience of society will awake and remind it that the poor man should have just as much right to assistance for his mind as he now has to the life-saving help offered by surgery; and that the neuroses threaten public health no less than tuberculosis …

[Note to Freud: the Time to Change and Heads Together campaign against stigma towards mental health, led by the Young Royals, has awoken the conscience of UK society to the scale of unmet need]

When this happens, institutions or out-patient clinics will be started, to which analytically-trained physicians will be appointed …. Such treatments will be free. It may be a long time before the State comes to see these duties as urgent… Probably these institutions will first be started by private charity. Some time or other, however, it must come to this.

[Note to Freud: it did. Lord Layard and myself took a business case to the Treasury ahead of the government’s 2007 Comprehensive Spending Review and additional investment to the tune of £300M was agreed for IAPT services; with a further £400M by the Coalition; and a further £600M by the current government – plus, a package worth £1.25 billion for CYP-IAPT. All these treatments are free.]

We shall then be faced by the task of adapting our technique to the new conditions…. We shall need to look for the simplest and most easily intelligible ways of expressing our theoretical doctrines… It is very probable, too, that the large-scale application of our therapy will compel us to alloy the pure gold of analysis freely with the copper of direct suggestion …

[Note to current and future APP members:as we all know, cognitive-behavioural therapists have won the race to capture IAPT. They are now today’s incumbent NHS talking therapists. Dynamic Interpersonal Therapy, our own adaptation, came in 6th … out of 6!]

This brings us to the Flash. At the time that Freud was inventing psychoanalysis the phrase ‘a flash in the pan’ was associated with the Californian gold rush. When the prospector was sifting through his pan of mud and gravel he would spot something that glistened, but often it was not gold. Hence, also, ‘all that glisters is not gold’. It is tempting to see some parallels with what I call the NICE/IAPT axis, especially now that we are seeing the over-promotion of ‘digital therapies’ as the new panacea for ‘curing depression and anxiety’.

But there is an older origin to the phrase. In this version the pan refers to a priming pan for a flintlock pistol in which a small amount of gunpowder is ignited that then sparks the explosion of gunpowder in the barrel that then fires the bullet. Sometimes there would be a flash but the pistol wouldn’t fire: hence it was only a flash in the pan. There is a difference between these two kinds of failure – something that turns out not to be what you were looking for, and something that doesn’t work the way you want it to when you expect and need it to. I want to use this distinction here to underline Rule number 3: Ever tried, ever failed, no matter. Try again, fail again, fail better.[4]

Writing in our journal at its inception Enid Balint described a group of non-medical professionals she set up in 1948. She and Michael Balint then invited GPs to form similar such groups, whose aim broadened from helping practitioners to work more effectively with couples to helping doctors work more effectively in family practices. It was Michael Balint, seeing the opportunity presented by the NHS, who judged that psychoanalysis’ social mission, to date, had failed:

The original idea clearly delineated by Freud: psychotherapy for the masses, became completely lost … It is a justified charge against us analysts that we are so little concerned about it, and only a fair consequence that the therapy of the masses is passing more and more into other hands and will eventually be solved — rightly or wrongly — without us.[5]

As Freud had surmised, and the social historian Elizabeth Danto has documented[6], the first wave of psychoanalytic polyclinics, in Berlin, Vienna, London, Paris and elsewhere, were founded as charitable projects prior to the welfare state. This meant they depended on support from wealthy philanthropists but struggled to get funding or backing from local or central governments, and presented a potential rivalry with established medical professional bodies in the emerging field of mental health (e.g. psychiatry and psychology). By 1938 most of the clinics had either been closed or been taken over. The point here, that I will elaborate on later, is crystal clear: in the case of Berlin it was the rise of fascism and antisemitism under Hitler that caused this first ‘failure’ of psychoanalysis’ early social mission.

In an editorial in our Journal in 2010,[7] Alessandra Lemma (then the editor) and Malcolm Allen (then the CEO of the BPC) paid a generous tribute to me for my role in managing to “keep alive in the minds of all constituencies the important contribution of applied psychoanalysis to a modern healthcare system”. They were drawing attention to our need to persuade NICE & IAPT of our relevance and ongoing value, and to work with leading mental health charities such as Mind, as well as the Royal College of Psychiatrists and British Psychological Society, and with UKCP and BACP, to exert influence. But on behalf of whom? And to what purpose? Notwithstanding the plaudit, my earlier efforts failed to impact IAPT and we came close to being dropped again by NICE. So to champion applied psychoanalysis in a modern healthcare system today how do we learn to fail better?

The first lesson, I think, is related to what we mean by “applied”. When Freud used this term in his 1918 speech he contrasted it with “pure”, using the following famous analogy:

‘The large-scale application of our therapy will compel us to alloy the pure gold of analysis with the copper of direct suggestion’.

I take it that what Freud would have thought was ‘pure gold’ was insight. I think this also was what Michael Balint first had in mind when he developed what he called ‘the flash technique’ with GPs in his Balint groups. Enid Balint describes it, interestingly, similarly to how, in my view, Betty Joseph used the concept of ‘here and now’:

a moment of mutual understanding between a doctor and his patient … communicated by the doctor to his patient. It was not an understanding about the patient’s past about which the doctor was very likely completely aware, but was usually about something in the patient’s current life and which was reflected in the relationship with the doctor for a brief time.[8]

The applied model that we came up with for IAPT was DIT (dynamic interpersonal therapy). It too encourages working in the ‘here and now’ relationship through a lens that is sharpened both by limited time and by what is called an IPAF (interpersonal affective focus). It is one amongst a family of brief dynamic models (see also e.g. PIT [psychodynamic interpersonal therapy]; ISTDP [intensive short-term dynamic therapy]; SET [supportive-expressive therapy]) … the search for ‘gold’, in other words, goes on! But the point I want to make is a different one. My own engagement with brief therapy was in a GP practice on Coldharbour Lane in Brixton, a short walk away from the Maudsley hospital. I worked in the practice as a counsellor.[9] Mostly, I could offer 6 sessions. But what made a difference between whether a patient could benefit or not was their 6 minutes before with their GP: those 6 minutes. So, as well as a collaboration that is largely lost in IAPT, here there is a sifting process, and time and care taken sorting through the mud and the silt of ordinary lives. If APP is still to be relevant today (e.g. for dynamic work with groups, couples and families, as well as with individuals across the age range) it will need to revisit this question of how to support and sustain this kind of ‘down to earth’ dynamic work in its own setting and context.

The 2nd lesson I draw, therefore, relates to our modern healthcare system. So let us assume for a moment we have a pistol that works. When we take aim and pull the trigger we can rely on firing a shot. So what is our target? Who are we wanting to influence? Who do we need to work with in order to have a voice? Who do we want to take out?! Healthcare today is at least as competitive as it is collaborative. But if we are to keep social justice at the heart of our endeavour, how are we making a difference, for example, to people on welfare benefits? These, after all, were the original target group for IAPT when we made our promise to the Treasury to help them get back to work. One of the reasons that I parted company with IAPT as adviser was my insistence we were failing on this promise (NB: never a wise move when successive governments have invested in it coming true).

Fortunately, and thanks serendipitously to the arrival in 2010 of Lord Freud (Sigmund’s great grandson) as minister for welfare reform at the Department for Work and Pensions, while IAPT abandoned people on social security and switched focus to patients with long-term physical health conditions, I was seconded to DWP. There I was able to persuade David Freud and Norman Lamb that we needed a more joined up approach to mental health and welfare. A team of researchers based at Durham University and LSE[10], with myself, have just completed an evaluation of a 3-year pilot in Greater Manchester, Working Well.Our results are very exciting. Whereas IAPT gave itself a target of getting 5% of ‘harder-to-help’ people back into employment (and missed it), we gave ourselves a target of 20% into sustained employment, which we exceeded. On the back of this success we have launched a new consensus statement, led by BPS, UKCP, BACP and BPC. It argues for an end to sanctions for people with mental health issues as evidence shows they don’t work. It calls for a guarantee of access to support that makes a genuine difference – which must go well beyond IAPT’s current offer. It looks towards an integrated, community based team, who can deal with complexity.

Finally, I come to a 3rd lesson. Looking back at the papers published in our journal from that inaugural Psychoanalytic Psychotherapy NOWconference, there were very forward-looking contributions from Matthew Patrick, Mary Target, Peter Fonagy and Malcolm Allen. There was also a moment, a ‘flash’, related as Matthew Patrick said to “now, which does actually mean right now”. I had asked for Malcolm Allen to include in his own keynote, where he set out a reform and renewal agenda, that we must grasp the nettle – he called it a ‘deal breaker’ – of confronting a deeply institutionalised homophobia within psychoanalysis. It is ingrained in our culture, our trainings and, in the cautionary tale of the Berlin Polyclinic, in our traumatic history as a community of practice.[11] The audience responded to Malcolm’s brave call with a spontaneous ovation. We had lit a spark. To ignite a new passion for using psychoanalytic ideas across our publicly funded services today we must be more inclusive.

How? We rightly pride ourselves on what we call structural change, facing up to ‘the truth’ or ‘psychic reality’, as a defining feature of our clinical work. But only rarely do we give proper credit to those in leadership positions when they similarly confront a need for long-overdue institutional change. We followed up PP NOW with a special edition of our Journal on the subject of psychoanalysis and homosexuality.[12] Ten years on we have set up an LGBT+ network for psychoanalytic psychotherapists, the UK’s first, hosted by Albany Trust, supported by Tavistock Relationships, APP, Association of Child Psychotherapists, BPC, IGA, UKCP and BACP, as well as the Tavistock and Portman NHS Foundation Trust. This is indeed welcome change.

If YOU are interested and have ideas about how to achieve ‘universal access’ to psychoanalytic interventions; using applied psychoanalysis to address social injustice; and making our discipline more inclusive, I would like to hear from you. Your Association Needs Your Help!

[1] Clark, D.M. (2018) Realising the Mass Public Benefit of Evidence Based Psychological Therapies: The IAPT Program Annual Review of Clinical Psychology 14:9.1-9.25

[2] Clarke, J. (2018) Guest Editorial: The Social and Interpersonal Origins of Depression Today Psychoanalytic Psychotherapy Vol 32, No. 2 95-101

[3] Freud, S. (1919) Lines of advance in psychoanalytic therapy. Standard Edition 17.

[4] Samuel Beckett (1983) Worstward Ho

[5] Balint, M. (1947) On the psychoanalytic training system. In Primary Love and Psychoanalytic Technique. London: Tavistock 1965

[6] Danto, E. (2005) Freud’s Free Clinics: Psychoanalysis and Social Justice, 1918 – 1938 New York: Columbia University Press

[7] Alessandra Lemma and Malcolm Allen (2010) Psychoanalytic Psychotherapy 24(1) 1-2

[8] Balint, E. (1985) The history of training and research in Balint groups. Psychoanalytic Psychotherapy 1(2) 1-9 See also: Balint, E. & Norell, J.S. (1973) Six Minutes for the Patient: interactions in general practice consultation London: Tavistock Publications

[9] Other brief therapy influences include: working with HIV/AIDS in the counselling service at Terrence Higgins Trust in the late 1980s; helpline support at London Lesbian and Gay Switchboard; student counselling at LSE.

[10] APP’s Education Trust (our charitable arm) gave a small amount of seed-corn funding to support initial workshops at Durham University’s Centre for Humanities Engaging Science and Society, and LSE’s Centre for Philosophy of Natural and Social Science (Karl Popper’s old department). This was where we designed our blueprint for a more integrated, personalised approach than IAPT can offer, more suited to helping people who have chronic and long-term depression, in addition to social support needs, such as dealing with financial debts; domestic violence; drug and alcohol abuse; squalid housing conditions – all made worse by austerity.

[11] I suspect few APP members know about what happened when the Nazis took over the running of the Berlin Polyclinic, putting Felix Boehm in charge, turning it into the German Medical Society for Psychotherapy led by the Nazi doctor Matthias Goring, with Carl Jung as deputy. The deal Boehm made with the Nazis involved the clinic being used as a triage centre, sending those who were found to be homosexual to the death camps, a practice that Danto thinks Ernest Jones knowingly turned a blind eye to. Next in line, as we know, were Jews.

[12] Jeremy Clarke and Alessandra Lemma (2011) Psychoanalytic Psychotherapy vol. 25(4).

Leave a Reply