Reviewer Dr Jane Martin
This is an unusual book. One unusual element is in the sub-title, since the application of psychoanalytic theory and practice to recovery from severe mental illness is decidedly out of fashion in today’s NHS. The author is a clinical psychologist by professional background. He is CEO of Threshold, a Belfast-based mental health charity, which aims to provide therapeutic living environments to facilitate recovery. In his introductory chapter, Kapur tellingly comments on how there is “no (psychoanalytic) training course in the UK to help mental health clinicians work with severe mental illness … I found those in most need got least psychoanalytic help.” Rather than following the usual analyst’s career path with the “worried well”, Kapur opted for what sounds like a modified and personally tailored Kleinian analytic training. This involved thrice weekly personal analysis, to equip him to do analytically-informed work with patients who suffer from severe mental illness. And yes, he calls them ‘patients’ (rather than ‘clients’ or ‘service users’), to emphasise the suffering that people with severe psychosis endure.
The kernel of Kapur’s argument is that mental health services and the clinicians who work in them must pay attention to the patient’s “state of mind” in order to truly promote recovery. He swiftly deals with the now rather wearisome debate between those (usually psychiatrists) who work from a starting point of diagnosis and a disease model of mental disorder, versus those (usually psychologists) who promulgate formulation as the preferred conceptual system. Kapur concludes that both can result in the patient feeling that something is being “done to” him/her. Instead, he suggests that scrupulous attention to capturing the patient’s state of mind can “synergistically complement diagnostic and formulation paradigms to help offer the patient a comprehensive understanding of his mental illness.” This, he believes, is possible by working clinically within a Kleinian model, drawn from the traditional psychoanalytic consulting room, but applied to a more systemic form of clinical practice within mental health organisations – public, private and third sector.
Kapur appears also to have no time for the familiar dialectic about medication versus psychotherapy. In a passing reference to medication, he makes it clear that he considers drug treatment necessary when patients suffer from severe mental illness that adversely affects their quality of life and can cause harm to themselves and/or others. My clinical experience of having worked for many years with people who are tormented by psychotic experiences is that ‘dynamic prescribing’ is possible and necessary. This is an approach whereby medication is used to reduce internal distress and disturbance, and, yes, to help manage risky behaviours, but is done with repeated consultation and negotiation with the recipient and kept under continual review. Crucially, the personal meaning of the psychotropic medication becomes one of the themes explored and/or kept in mind during any form of psychological therapy.
Destructive Processes In Psychosis
The opening chapter is something of a whistle-stop tour of the theoretical work of Melanie Klein and her followers, particularly Wilfred Bion, John Steiner and Herbert Rosenfeld. Kapur does an admirable job, in this and subsequent chapters, in helpfully relating Kleinian and post-Kleinian theory to what may be going on in some real life clinical situations. For those of us who are mental health workers, concepts such as Bion’s ‘attacks on linking’, Rosenfeld’s internal ‘Mafia gang’ and Steiner’s ‘psychic retreats’, all make sense when we think about some of the familiar dilemmas that can arise. For example, despite what we may think of as our best efforts, people nevertheless deteriorate, or reject our attempts to offer care and treatment.
This is risky territory for any clinician to opine or write about, because, done badly, he or she can be accused of blaming the patient for not getting better. Indeed, in clinical practice on inpatient wards, how often I have heard the damning verdict “Oh, Patient X is sabotaging his treatment.” But Kapur is alert to this trap. His attempt to describe the destructive struggle between the so-called psychotic and non-psychotic parts of the person’s internal world is analytical without blaming, compassionate without being patronising. He emphasises again and again the central importance of unconscious processes – often totally ignored in mainstream mental health practice. He describes how patients with psychosis are not actively choosing to behave in ways that thwart their progress towards recovery, but are caught in the midst of a tumultuous and overwhelmingly disturbing psychic battle. This internal battle can then be unhelpfully enacted externally with their peers and caregivers, with all of us playing our roles in a destructive drama, unless we are alert to what is happening.
The book follows a logical sequence of chapters, with sections on therapeutic community principles, group and individual processes, training, research, and organisational processes. The therapeutic communities chapter includes a description of the concept of the “therapeutic environment”. Kapur appears to believe that the therapeutic communities can sometimes be a tad naïve about the outcomes that can be expected from providing calm, emotionally containing environments, when the needs of people suffering from psychosis are so great. He claims that further, key “atmospheric” ingredients are required, which he goes on to describe. In this section, I liked his attention to the basic levels of need as being around good, safe housing and structured daily activities – he relates these to Maslow’s ‘hierarchy of needs’ and Bowlby’s concept of the ‘secure base’. It is refreshing to find, in a book about psychoanalysis, this level of attention to the importance of some areas of psychological ‘containment’, which are more usually the province of the social worker, or the occupational therapist. It made sense for me that his organisation, Threshold, is based upon what might elsewhere be described as ‘supported housing’. This led me to investigate Threshold’s website, where I discovered some exacting job descriptions and lengthy person specifications for current vacancies. These demonstrated meticulous attention to the detail of what is required from staff who aspire to work within this organisation.
For me, reading these job advertisements helped to illuminate the content of the second half of the book. Here, Kapur describes some aspects of the application of his Kleinian theory and principles to organisational consultancy, management and employment of staff. The book takes a rather unexpected swerve into more self-disclosure. The author relates his own experiences as CEO of Threshold, grappling with dysfunction within the organisation, seeking external consultancy which failed to grasp the complexity of what they were dealing with. It appears that Kapur has been on the receiving end, personally and professionally, of what sounds like a really hard time. It made me curious about the voices of his staff, who are rather absent from the book. Then, looking at their photographs on the organisation’s website, I was also curious about what kind of a book this might have been had it included more direct quotes or experience from the patients who live in Threshold housing. But perhaps that is another book.
Sandwiched between these two halves of the book is an important and welcome chapter on research. I was struck by how respectfully and gratefully Kapur writes of his research supervisor and mentor, Professor Peter Hobson. Having done my own psychotherapy training (as a trainee psychiatrist) with Professor Hobson’s father, Dr Robert Hobson, this chapter had particular personal resonance. Robert Hobson worked predominantly earlier in his career with patients suffering from psychosis, and established a psychotherapeutically oriented inpatient ward in Manchester, which must have been very different, indeed, from today’s overcrowded, under-resourced, tumultuous inpatient wards. As well as developing a school of psychotherapy now called Psychodynamic-Interpersonal Therapy (formerly the Conversational Model), Dr Hobson believed in evidence-based practice, long before the term was ever widely used.
Kapur opens his chapter on research with the somewhat wry observation: “Applying research findings in the real world of mental health and social care is rare.” He then gives a brief introduction to research methodology, explaining the challenges inherent in researching any psychological therapies. He goes on to review the findings of some existing studies on psychotherapeutic approaches to working with people with severe mental illness (most of these are rather old, reflecting the relative dearth of research in this area). He comes up with a list of “Research-Informed Guidelines” for effective approaches. He gives a reasonably detailed account of evaluations carried out at Threshold, and is appropriately modest in his conclusion, which is that “something in the Threshold atmosphere seems to be helping our severely mentally ill patients, and … we can be reasonably confident that after eighteen months they will improve and not deteriorate.” Kapur concludes the chapter with a report on his own doctoral research, conducted with Professor Peter Hobson. This includes some interesting accounts of techniques that attempt to capture and measure some of the processes proposed by Kleinian theory, as demonstrated in clinical practice. He ends with the confident statement: “It is possible to reliably operationalise and measure variables derived from a Kleinian theoretical framework.” Impressive.
The Introspective Quotient
I can do no better than to end this review with Kapur’s own words, in his concluding chapter, where he describes a recipe for good practice. He defines, in simple English, what is required to have a high “IQ” – in the sense of “Introspective Quotient”. This is to always pay attention to:
“Who is doing what to whom?”
“Who is putting what into whom and is it good or bad?”
“Is it me or is it you?”
I would predict that the book’s readership is likely to be limited to those who already have an interest in and some acquaintance with its theoretical framework, perhaps forensic psychotherapists, who work in a highly specialised field where Kleinian theory has been readily embraced and accepted. But I would recommend that those mental health workers who are open to different approaches to understanding severe mental illness and recovery may find something of value in it. I was curious about the voices of Threshold’s staff, and, importantly, about what kind of book this might have been had it included more experiences and direct quotes from the patients who live in Threshold’s supported housing, but perhaps that is another title.