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Moving psychotherapy into communitysettings: Alexis Brook's life's workMannie Sher aa The Tavistock Institute of Human Relations , 30 TabernacleStreet, London, EC2A 4UEDirector, Group Relations Programme andPrincipal Consultant, Organizational Development & ChangePublished online: 04 Jan 2010.

To cite this article: Mannie Sher (2009) Moving psychotherapy into community settings: AlexisBrook's life's work, Psychoanalytic Psychotherapy, 23:4, 303-306, DOI: 10.1080/02668730903368117

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Moving psychotherapy into community settings:Alexis Brook’s life’s work

Mannie Sher

Director, Group Relations Programme and Principal Consultant, OrganizationalDevelopment & Change, The Tavistock Institute of Human Relations, 30 Tabernacle

Street, London, EC2A 4UE

For 6 months after I joined the Adult Department of the Tavistock Clinic in October

1971, Dr Alexis Brook was a member of the Department whom I knew only

vaguely. However, I gradually warmed to him as we drank our coffees in the staff

common room. He was the Head of another Intake Team down the corridor, but his

friendly, warm chats in the common room about human nature, politics, a lively

interest in ordinary matters, like his strong objections to the type and colour of roof

that was being installed on the houses across the street, made me wish to work with

him. I must have mentioned this to my supervisors, Judith Stephens and Jane

Temperley, who worked in Alexis Brook’s Intake team, because some time later

Alexis asked me to join the Community Unit. This Unit was important for the Adult

Department because it carried psychoanalytic psychotherapy to the outside world

as an outward-looking community-based approach to mental health problems. This

was Alexis’s forte – introducing psychodynamic work into community-based

clinics and departments, and in the case of this particular workshop, to general

practice. Alexis already had a wide reputation for his methods of enlarging

psychological understanding of patients and relationships between patients and

their professional carers in ophthalmology, general psychiatry and social work.

Alexis explained the purpose of the Unit as part of a project of psychotherapy

attachments to general practice. These attachments, he said, were different from

normal secondments; they were experimental. The project attempted to answer the

question: ‘what contribution could a psychotherapist, spending three hours a week

in a general practice, make to the mental health of patients attending that practice?’.

It was clear, he often said, that the psychotherapist would not simply transport a

method of work from the psychotherapy consulting room to general practice. A new

role and a new method of work would have to be devised to optimize the

opportunities presented by the presence in the practice of a psychotherapist.

In 1998, Jan Wiener and I published a book: Counselling and psychotherapy

in primary health care (Wiener & Sher, 1998) in which we describe the evolution

of the primary care service and how it reflected the volume of work and the nature

of medical problems experienced. It was recognized that primary care structures

would have to adapt. Without losing sight of the fundamental principle that

the interests of the individual patient were paramount, doctors were influenced

by new organizational theories that portrayed families as systems and asserted the

ISSN 0266-8734 print/ISSN 1474-9734 online

q 2009 The Association for Psychoanalytic Psychotherapy in the NHS

DOI: 10.1080/02668730903368117

http://www.informaworld.com

Psychoanalytic Psychotherapy,

Vol. 23, No. 4, December 2009, 303–306

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interdependence of the diverse parts of the primary care system. This meant that

doctors who had previously worked with patients holistically now found their

work fragmented by operational systems that were much larger and more difficult

to control. The dual burden of viewing marriages and families as systems, while

at the same time being just one part of a larger primary health care mechanism,

proved stressful for doctors. They felt they were becoming small cogs in a vast

machine and that their traditional models of medical practice were becoming

outmoded.

By the early 1970s a few group practices – mainly in inner London boroughs

– took advantage of the training offered by the Tavistock Clinic under the

direction of Alexis Brook and Jane Temperley to deepen their understanding of

their patients’ psychological difficulties and their role in boosting their patients’

psychological well-being. Psychologists, psychiatrists and social workers in the

Adult Department of the Tavistock Clinic were approached by Alexis and Jane to

join the Community Unit and be seconded to GP practices in north-west London

for one or two sessions per week.

Alexis would stress the quite specific aims of the attachments. These were to:

1. Offer referring GPs opportunities to discuss the referral they were

intending to make before making them (unlike written referrals that GPs

traditionally made to psychotherapy clinics). This immediately gave a

consultative role to the psychotherapist, because out of these discussions

between GP and psychotherapist a number of options could then follow.

2. With a deeper understanding of the patient’s problem or illness, the GP

would be enabled to continue working alone with the patient. This step

had echoes of the Balint approach, but was also different from it, because

it involved psychodynamic psychotherapists being onsite and working

directly with patients. Another possible useful outcome of this initial

discussion between GP and psychotherapist, would be that the

psychotherapist’s regular attendance at the practice, would mean that

almost immediate consultation opportunities were on hand for the GPs as

they themselves worked at a deeper emotional level with their patients.

3. Discussions between GP and psychotherapist could lead, where appropriate,

to the psychotherapist actually seeing the patient for a diagnostic interview,

i.e. to extend the joint understanding of the patient’s condition so that a more

informed decision could be made about possible courses of action. These

included the following:

4. The psychotherapist might see the patient in the surgery for one, two or three

more sessions that would be either an extension of the diagnostic process or

would constitute a form of brief psychotherapy.

5. The patient might be referred to a psychotherapy clinic for medium to

long-term psychotherapy – individual, family, couple or group.

6. The patient might be referred to other forms of specialist or community help.

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The Community Unit Workshop was the second main arm of this initiative. It

was led by Alexis Brook and Jane Temperley and it met once a fortnight and was

attended by all the attached psychotherapists and two people from each of the

practice surgeries in the project – one GP and one other, a nurse or a social

worker – a workshop of between 10 and 12 people – at which cases of shared

care – a GP and a psychotherapist plus others – were presented for discussion.

These workshops were real treats. Three of the most memorable statements

that I recall Alexis making often, which in many ways gave the workshop its

character, were: (1) the idea of shared care rests on the premise that the patient

will receive a better level of care than when the two carers of different disciplines

and skills work alone; (2) that the carer is unable to deliver a high standard of care

if they themselves are not contained within a professional caring framework;

(3) and this one I remember vividly because he used his hands to describe a

psychodynamic intervention with hard-to-reach patients so often found in general

practices – ‘an intervention of the sort we offer patients in general practice means

that their lives will proceed either like this (raises his hand a few inches and

moves it to the right), and if they do not receive it, their lives will proceed like this

(lowers his hand a few inches and moves it to the right).

What were the benefits of the type of attachment pioneered by Alexis?

First, it was agreed by GP and the attached workers that the benefits of

collaboration far exceeded the price we had to pay for it. We were trying to

develop new ways of working in which psychotherapists could work in primary

health care. This required modification of therapeutic skills more appropriate to

the setting of a specialist clinic. We were all gratified to witness the adaptation of

our skills, and provided we could withstand the expectations, external and

internal, to produce magical cures, we also observed the patients’ responses to

their doctors with enhanced psychodynamic understanding.

By establishing close working relationships, in which experiences were

shared, and feelings freely expressed, we believe we managed to avoid the

traditional split functions of the medico-psychotherapeutic team, where each

member has a rather limited view of the patient and his family. We believe we

had a more balanced effect on one another; that our respective roles were

reinforced, rather than undermined.

Second, in actively working together in this way we presented to patients a

model of a successfully integrated medico-psychosocial system that offered

better therapeutic opportunities to patients than when parts of the system

operated separately. Patients brought and explored their emotional problems in

the relatively non-threatening setting of their local general practice. We found that

attending to what lay behind the symptoms of the patient often resulted in a

reduction of the number of attendances at the surgery. If a psychotherapeutic

intervention was carried out early enough formal referral often became

unnecessary.

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Third, through the careful structuring of the project by Alexis and Jane, the

attachments to general practice provided opportunities for lively discussion of

case material. These discussions were absolutely crucial to the establishment of

agreed goals of treatment.

Fourth, the development of a relationship between the general practitioners

and the psychotherapists allowed them jointly to share and begin to understand

the anger, despair, fears and psychological pain experienced by patients and by

themselves too. The setting of general practice allowed for confused or fearful

patients to return with reduced apprehension at a time of their own choosing.

Fifth, we believed then that the attachment of psychodynamically-trained

workers to general practice should be officially recognized and lead to the

employment of counsellors and psychotherapists in general practice. This has

come about and today, over 30 years later, Alexis Brooks’ vision of introducing

psychologically-trained workers into general practice means that almost

two-thirds of general practices in the UK have attached counsellors,

psychotherapists and mental health workers. The benefit this brings to so many

thousands of patients was a dream that Alexis would be proud to witness today.

Reference

Wiener, J., & Sher, M. (1998). Counselling and psychotherapy in primary care.London: Macmillan.

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