No Going Back: Psychodynamic Perspectives on Community Living for People with Learning Disabilities was the title of a day organised by Hertfordshire Partnership University Foundation Trust, Hertfordshire University and the Association for Psychoanalytic Psychotherapy in the NHS on the theme of community living for people with learning disabilities. Report by David O‘Driscoll and Georgina Parkes.
Research has shown that for the majority of service users the change from long term institutional care to community care has been positive. But it would be wrong to say that this has not been without its challenges and problems.
The emphasis on the day was on the psychodynamic approach. As the organisers we believe that having an understanding of some of its key concepts will bring greater understanding of a person’s behaviour. The majority of delegates were from Hertfordshire Partnership University Foundation Trust (HPFT) but some came from as far away as Bristol, Manchester and Derbyshire.
Tom Cahill, HPFT Chief Executive, opened the day with a historical account of how services have developed in Hertfordshire from the impersonal wards of the long stay hospitals to the exciting future development at Kingsley Green.
Portrayed as happy
The key note speech was by Professor Jan Walmsley, an independent researcher and teacher with an honorary position at the Open University. She gave an overview of where we are now after the long stay institutions closed and people moved into community services. While there have been many positive developments, Professor Walmsley pointed out that in most of the literature people with learning disabilities are still portrayed as happy and smiling, which leaves us wondering how people can express their sad or difficult feelings. She quoted Valerie Sinason, “The new beautiful community homes provide an even more disconcerting backdrop for communications of despair.”
Self advocate, Carole Lee, spoke about what it was like receiving services in a community setting, including her mental health experiences. Carole was positive about the help she received from the Trust’s specialist learning disability psychotherapy service after her mother died. In fact, she provides training with David O’Driscoll to the local bereavement service Cruise on working with people with learning disabilities.
Carole received a CBE for her work on the 2001 Government White Paper, Valuing People, as part of the self advocate team.
She gave an account of complaining about a member of staff and how, as a result, the staff team completely changed their attitude to her.
Professor The Baroness Sheila Hollins spoke about her role as a learning disability professional, the mother of a child with a disability and now as a politician. She is a former professor of Psychiatry of Learning Disability and President of the BMA and Royal College of Psychiatrists. Now, as an independent cross bench peer in the House of Lords, she makes good use of her role to advocate for people with learning disabilities, putting her hand up and asking, what about people with learning disabilities?
She talked about the stigma people with learning disability face including more subtle forms such as how to respond to articulate people.
Baroness Hollins founded and chairs ‘Beyond Words’ publishing a series of accessible picture books. She described how she uses these books in therapy and how she set up book clubs in her workshops.
Challenging setting
An entertaining and optimistic view of working in a forensic setting, Rampton National High Secure Hospital for people with learning disabilities, was presented by Jon Taylor, Consultant Forensic Psychologist and Psychotherapist. Dr Taylor has set up a therapeutic community based on Maxwell Jones’s original ideas. He talked about the challenges of this approach in such a setting, for example, staff swapping shifts because they did not want to attend groups and listen to the often painful topics under discussion. Significant improvements included staff being less afraid of change, feeling less cut off and a reduction in criminal thinking and hostility.
A state-of-the-art overview of what we know about the practice of psychodynamic psychotherapy with people with learning disabilities, and how to adapt practice,was given by Professor Nigel Beail, clinical psychologist at the University of Sheffield and Head of Psychological Services with Barnsley NHS Trust. Professor Beail’s presentation was based not only on his research but on his clinical work as a psychoanalytic psychotherapist. He talked about the client directing all their efforts to maintaining their own psychic equilibrium which is dysfunctional by the time they reach therapy.
Listening and observing
The purpose of therapy is to disturb this and ultimately bring about change. Professor Beail discussed the basic techniques of listening and observing, information giving and education which are not often part of traditional psychoanalytic techniques, as well as exploring, reflecting, confronting and attending to the counter transference. Interpretations need to be given in clear, open and undemanding language (for example, using words of less than two syllables if possible), not given with a question and the present discussed before current or past experiences. Behaviours and emotions need to be linked and spelt out to clients, ie. when you do this you feel like this.
Professor Beail talked about the evidence base which, though thin, shows positive outcomes. There is still a preference to evaluate challenging behaviour therapy models and a resistance to use psychodynamic models.
The evaluation forms showed a general theme of wanting more, more time for each speaker, more discussion and more events like this. People found it useful and helpful in their work and inspiring. One person gave emotional feedback that the day had helped him to find a way forward in his job. “I had a lump in my throat”, he wrote. “Thank you for an inspiring day”.
Another wrote: “I work in residential care and do not fully understand your language but found the day interesting, insightful and motivating. A very good day.”
And another said: “Should be delivered to every psychiatry trainee at the beginning of their training and every year after that. Please, please persevere and do it again.”
We are hoping that a major outcome of the conference will be an opportunity to develop a postgraduate short course on psychodynamic thinking at the University of Hertfordshire Centre for Learning Disability Research. The day will go some way to cementing the position of psychodynamic work in Hertfordshire.
David O’Driscoll is a psychotherapist and Dr Georgina Parkes is Consultant Psychiatrist with Hertfordshire Partnership University Foundation Trust.
