We are a small service, comprising 3.7 whole-time equivalent clinicians, providing a psychodynamic service for NHS Lothian. A psychodynamic approach focuses on how people relate to each other, and recognises how unconscious factors impact on people’s lives. Our main resource is focussed around psychotherapy teaching and training, particularly to trainee Psychiatrists.
Discussion with clinicians and a psychodynamic perspective
Although a psychodynamic approach can help some patients through seeing them in person; a psychodynamic perspective for clinicians can be of significant value for their work with a patient.
We are happy to speak with clinicians with a view to supporting them in making sense of a patient’s difficulties and their relationship with care.
This psychodynamic perspective can be helpful for professionals’ and teams’ understanding of why a patient may be struggling to make use of offered care, or is evoking anxiety in the team. This sort of input from us may be more useful to a situation than our seeing a patient directly, as a psychodynamic perspective for clinicians helps to preserve and support existing longer-term therapeutic relationships. It is often within these existing relationships (e.g. with GPs, Psychiatrists, CPNs) that change may take place over many years.
Please contact us by phone (0131 5376926) if you wish to discuss a patient in this way. Please consider this option before referring a patient to see us in person for a therapeutic consultation.
Therapeutic Consultation and other services
We also have a small service for seeing patients in person for a psychodynamic therapeutic consultation.
Depending on resources available, other potential services include Reflective Practice Groups, and consultation to services and organisations about systemic issues.
Psychodynamic Therapeutic Consultation
This information relates to referrals for a psychodynamic therapeutic consultation. This is a brief form of psychodynamic treatment, usually over 2 sessions. A psychodynamic approach focuses on how people relate to each other, and recognises how unconscious factors impact on people’s lives.
Through this interaction with an experienced psychotherapist, patients have space to talk and think about themselves, their relationships and their predicaments. A relational formulation of their difficulties is developed which is discussed with the patient. This provides ideas for the patient to begin to apply in everyday life. For some people, this experience can provide what they are looking for at this point in time and their care may be returned to their GP or referrer after consultation. If a psychodynamic therapeutic consultation is found not to be helpful or suitable, the patient will be helped to think about other approaches that are better suited to their needs.
Referrers receive a letter containing a formulation, a description of the consultation process and recommendations to the patient. We are happy to discuss formulation letters with referrers if this would be helpful.
A consultation also provides the opportunity the patient and the clinician to see whether further psychodynamic treatment is the right approach at the moment. The majority of our further treatment is provided by doctors in training who deliver psychodynamically-oriented therapy under weekly supervision with a senior colleague. We have more limited availability for individual psychodynamic therapy or group psychotherapy delivered by Adult Psychotherapists or Consultant Psychiatrists in Psychotherapy. If patient proceeds to further treatment this is usually for six months or a year. This may be longer in group therapy.
Who to refer:
This approach suits a range of patients who recognise that their relationship difficulties play a key part in their problems.
The therapist stance in psychodynamic work is: exploratory, non-directive, with a focus on the patient-therapist relationship and the relational context. A psychodynamic approach is not suited to patients who are looking for therapy that is problem / goal orientated, symptom focussed, or where coping strategies are taught.
Analysing the referrals we receive, coupled with the characteristics of the treatment we offer, the following are situations where a psychodynamic approach may be particularly suitable (but please see also referral criteria):
- Patients whose clinical presentation does not easily fall into a well-defined category
- People where it is felt that the ways in which they relate to offered care has interfered with their treatment
- People who are suitable for psychological therapy but have not benefited from other types of psychological therapies
- People for whom it is recognised that by virtue of severity and length of the adversity they have experienced, a longer therapy approach may be of benefit. The standard length for further treatment in the department is 6 or 12 months.
Criteria for referral for psychodynamic therapeutic consultation
Psychodynamic psychotherapy is an exploratory approach that brings to the surface underlying issues. This can help people gain insight into their difficulties, but can be unsettling and make people feel worse at times. Therefore, referral for a psychodynamic therapeutic consultation is suited to patients who:
- Are reasonably stable and can tolerate at least moderate distress
- Have some of their own resources, coping strategies and supports so they can manage between weekly sessions
- Want to explore deeper patterns and meanings in their lives
- Are interested and have some capacity to notice how they relate to people and how this may link with other problematic relationships
- Have some sense that they play a part in the organisation of their own lives
For patients who do not meet criteria 1 and 2, out-patient psychodynamic psychotherapy is likely to destabilise patients further. In those situations, another approach that is less probing and challenging would be better suited to the patient.
For people who do not have factors 3-5, psychodynamic psychotherapy is unlikely to be helpful and would be more likely to result in patients feeling disappointed and possibly frustrated by the approach.
Who not to refer:
Out-patient psychodynamic psychotherapy is not indicated for patients who:
- See their symptoms exclusively as purely physiological and are therefore resistant to the psychotherapeutic approach
- Have a psychotic illness (these patients are sometimes referred for assessment and formulation but this is usually done by tertiary services)
- Use drugs or alcohol heavily. Heavy substance use makes it hard for patients to think clearly in sessions and remember what is discussed with the therapist. Furthermore, it may be hard for patients to retain self-control between sessions, particularly as the sessions may bring to the surface unsettling ideas
- Severely harm themselves or have other severe forms of acting out such as serious violence towards others
Referral Pathway for psychodynamic therapeutic consultation
We accept referrals from NHS Lothian only. Please address referrals to ‘Psychotherapy Department’ – address is in Resources sections. We are happy to discuss patients beforehand by phone.
All referrals are reviewed against our referral criteria and if appropriate we will offer the patient a therapeutic consultation.
To help work out whether our service appears suited to your patient, please explore with them the factors described in criteria 1-5 and refer to these in your referral letter. Please also consult indications not to refer.
Please describe some background information in a referral letter. The following are helpful to know something about, but we are aware that not all will be possible or practical to obtain:
- Developmental history – including any childhood adversity
- Childhood/Education/Work
- Relationships – with peers/colleagues/family/partners
- History of psychosis
- Self-harm/Drug/Alcohol misuse/Eating disorders
- Current stressors
- How you respond to the patient
- How the patient responds to you
It is important to discuss the referral with the patient and to seek their opinion as to whether they want a psychodynamic therapeutic consultation. Talk to them about why you are referring them for this and why you feel it might be helpful. Mention how a psychodynamic consultation might help them to understand their repeated patterns of relating to themselves and others and that it may allow them to make connections between their experiences in the past and their current situations.
It is important to mention that longer term psychodynamic treatment may not be right for them at the current time.
Further information about a psychodynamic approach
A Psychodynamic approach is based on psychoanalytic ways of understanding personal and emotional development. The way we see and relate to the world develops through relationships made in infancy, childhood, and later life. Disturbances in these relationships can produce continuing vulnerabilities, and symptoms and relationship problems in later life. Symptoms have a meaning in the context of our lives, and difficulties in relationships often follow patterns laid down in earlier life. Psychodynamic thinking can be applied directly to seeing patients and indirectly to clinicians and teams working with patients.
Clinicians, and other people in caring roles, can offer a reliable and professional relationship, where old patterns may be repeated, but can be thought about and understood in a way that frees people to change (Royal College of Psychiatrists website, see useful links).
Further information about the therapeutic consultation sessions
Observations from therapeutic consultation that suggest further longer-term psychodynamic treatment is suited to patients
- The person is interested in exploring who they are and were
- The person can make some use of noticing and exploring their current thoughts and feelings as they emerge in relation to the therapist
- The person finds the relatively reserved and non-directive psychodynamic stance to be helpful, and not overly unsettling or destabilising.
This involves exploring patient’s relationships and development and making links between these. Psychotherapists derive formulations to help patients and referrers. There is a discussion with the patient as to whether further (longer-term) treatment – which would usually be with a doctor in training – is helpful at the current time (see Box 1).
Address and useful links
Psychotherapy Department, Royal Edinburgh Hospital, Edinburgh, EH10 5HF Tel: 0131 537 6926
https://www.rcpsych.ac.uk/members/your-faculties/medical-psychotherapy/psychotherapy-counselling-and-psychological-treatment-in-the-nhs– Royal College of Psychiatrists website information about Psychotherapy in the NHS
http://www.rcpsych.ac.uk/mentalhealthinformation/therapies/psychotherapy.aspx – Further information on Psychotherapy
https://sapp.org.uk/ – Scottish Association of Psychoanalytic Psychotherapists. Information about psychoanalytical psychotherapy and private therapy.
http://www.hdscotland.org.uk/# – Human development Scotland website (Formerly Scottish Institute for Human Relations). Information on other private psychodynamic services.
