We are a small service, comprising 3.9 whole-time equivalent clinicians, providing a psychodynamic service for NHS Lothian. We are based at the Royal Edinburgh Hospital.
A psychodynamic approach focuses on how people relate to each other and how unconscious psychological processes can impact on people’s lives. From a psychodynamic perspective, symptoms have a meaning in the context of our lives, and present-day patterns in relationships may be influenced by past experiences and relationships. A substantial part of our resource is focused around psychotherapy teaching and training for doctors in the South-East Scotland deanery.
We welcome discussion with NHS Lothian clinicians about psychodynamic aspects of patient care.
Please note, we have a similar name to Psychological Therapies Services. Please follow this link for the main Adult Mental Health Psychological Therapies Services.
Case consultation and reflective practice for clinicians in NHS Lothian
- A psychodynamic perspective for clinicians 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 or other emotions in the team. This might include offering some time for the clinician to process how a particular clinical dynamic leaves a clinician feeling and reacting.
- This can help to preserve and support existing long-term therapeutic relationships (e.g. with GPs, Psychiatrists, CPNs) within which change may take place over many years.
- This kind of contact with a psychotherapist ranges from a single phone-call or an in-person meeting, through to longer-term regular Reflective Practice Groups for a clinical team, depending on what the clinician is looking for and what would be most helpful.
- Please contact us by phone (0131 5376926) or email reh.psychotherapyserviceadmin@nhs.scot if you are interested in discussing a clinical encounter in this way.
Psychodynamic therapeutic consultation for patients
- A psychodynamic therapeutic consultation is a brief form of psychodynamic treatment, usually over 2-3 sessions.
- A therapeutic consultation is exploratory and has a focus on the patient-therapist relationship and the patient’s ways of being in relationships (see box, below).
- A relational formulation of their difficulties is developed which is discussed with the patient. This provides ideas for the patient to begin to consider in everyday life.
- For some people, this consultation can provide what they are looking for now, and their care may be returned to their GP or referrer.
- A therapeutic consultation also provides the opportunity for the patient and clinician to consider whether further psychodynamic treatment is the right approach now.
- If it transpires through the course of the consultation that a psychodynamic therapeutic consultation is not helpful for a patient, the clinician will help the patient to consider if other approaches might be better suited to their needs.
- Referrers receive a letter containing a formulation, a description of the consultation process, and recommendations. We are happy to discuss formulation letters with referrers if this would be helpful.
| Therapeutic consultation – further information. (Adapted from the Royal College of Psychiatrists webpage).In this 2-3 session encounter with an experienced psychotherapist, patients have space to talk and think about themselves, their relationships and their predicaments. There is space to discuss: -What is happening in the patient’s life at the moment – how the patient goes about things and the part they play in things going right or wrong -What has happened in the past, and -How the past can influence how the patient is feeling, thinking and behaving right now. The ways a patient responds and behaves in sessions often mirrors the way they act in day-to-day life. The therapist may therefore comment on what happens in the sessions as they talk together. This can support a patient with a process of becoming more aware of how they relate to themself and to others. |
Further psychodynamic treatment
- Whilst the therapeutic consultation (usually 2-3 sessions) is with an experienced clinician, for patients going on to have further treatment, the majority are seen by doctors in training who deliver psychodynamically-oriented therapy under weekly supervision with a senior clinician. These doctors are seeing their first psychodynamic cases and therefore need to see fairly straightforward presentations.
- There is more limited availability for individual psychodynamic therapy or group psychotherapy delivered by Adult Psychotherapists or Consultant Psychiatrists in Psychotherapy.
- If a patient proceeds to further treatment this is usually for six months or a year. This may be longer in group therapy.
C.M. & A.P. 11-02-25
We welcome discussion with clinicians about a patient prior to a formal referral.
A psychodynamic consultation offers a space for a patient to start to consider how they relate to themselves and others and what might underly these patterns of relating. This can be a searching and challenging process, and therefore although it can be helpful for some patients, for others it may be overly unsettling.
It takes time – more than one meeting – for referrers to form a clinical impression about whether a referral for a therapeutic consultation might be helpful for the patient at the current time, and to explore the patient’s views.
If a referral is not right for a patient, it may still be helpful for the clinician to talk through an understanding of the patient’s psychological dynamics with a psychotherapist who is not directly involved in the patient’s care.
When making a referral, please mention to your patient that the referral would be for a psychodynamic therapeutic consultation, and that longer-term psychodynamic treatment may or may not be right for them at the current time.
Who to refer:
- A psychodynamic consultation may be particularly suitable when a person has found some benefit from previous psychological therapy, but continues to have some difficulties and is now likely to be able to build on previous work in a more exploratory, relationship-focused way.
- It is not likely to be a good fit if someone is seeking affirmation of their current position or a direct focus on symptom reduction.
- Please consider counselling or supportive approaches as a first line for patients with relatively recent onset of difficulties who would benefit from a non-directive approach.
Referral criteria
The following prompts are useful in predicting who is likely to do benefit from a referral, and who is unlikely to benefit (or may be unsettled / disturbed).
Does the person want what a psychodynamic consultation offers them?
- Is the patient actively curious about the relationship patterns they engage in, and in exploring who they are, and were?
Is the person likely able to make use of a psychodynamic consultation? 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.
- Can notice and reflect on how they relate to people, and how this might impact upon their current difficulties and symptoms.
- Have a sense that they play a part in the organisation of their own lives, as opposed to seeing their difficulties as mainly due to others’ actions.
- Can experience a two-way dialogue with the referrer as helpful, as opposed to only wanting to express their difficulties and be affirmed.
Factors 2-3 are important, as otherwise out-patient psychodynamic psychotherapy is likely to destabilise patients further. In the absence of factors 2-3, another approach that is less probing, more structured, and explicitly collaborative would be better suited to the patient.
Factors 4-6 are important, as otherwise 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:
- Are looking for therapy that is problem / goal orientated, symptom focused, or where coping strategies are learned.
- See their symptoms as purely physiological.
- Have a psychotic illness (these patients are sometimes referred for a 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.
How to refer:
We accept referrals from NHS Lothian clinicians only. Please send referrals by email or post:
- Email: reh.psychotherapyserviceadmin@nhs.scot Tel: 0131 537 6926
- Address: Psychotherapy Department, Royal Edinburgh Hospital, Edinburgh, EH10 5HF
All referrals are reviewed against the referral criteria above and depending on this, a therapeutic consultation will be offered to the patient. If a referral is not accepted, we would discuss this with the referring clinician and would ask them to communicate further with the patient about other possible avenues.
Additional information
Please describe some background information in the referral letter. The following are helpful to know something about, but we are aware that not all will be possible or practical to obtain:
How you respond to the patient and how the patient responds to you
Developmental history – including any childhood adversity
Childhood / education / work
Relationships – with peers/colleagues/family/partners
History of psychosis
Self-harm / drug use / alcohol misuse / disordered eating
Current stressors
http://www.rcpsych.ac.uk/mentalhealthinformation/therapies/psychotherapy.aspx – Further information on Psychological Therapists
https://sapp.org.uk/, https://www.hds.scot/ – Further information about psychodynamic therapy
