Consultation, training, service development, supervision, and direct treatment for individuals, parents and couples
Psychoanalysis or ‘the talking cure’ is a productive response for most disturbances affecting quality of life. Much of the contemporary discourse around treatment seems to centre on ‘skills’ or ‘tools’ to manage symptoms arising from inner disturbance. While skills or tools may be helpful, for many they can have a limited effect and usually only in the short-term. In addition, many of these techniques are readily available in books or online. Symptoms have something to say, and psychoanalysis provides a way to put words to the unspoken; disrupting the drive of the symptom and putting it to work.
My rooms are in Carlton North and Croydon.
Medicare rebates are often available for psychotherapy.
In a health service context, symptoms can manifest beyond the client presenting with 'complex needs'. Individual workers and teams can experience a range of difficulties including confusion, anxiety, reactivity, splits, frustration and chaos. This is most pronounced in those working with clients described as complex or severe and personality 'dis-orders'. Where workers and teams struggle to formulate their work, the treatment can be compromised, which may be reflected in a deterioration in the client. Consultation is a leadership and reflective process embedded in workers’ experience and allows individuals and teams to navigate their work, delineate their roles, sustain their practice, develop formulations and treatment plans, and manage risk. Consultation works best when the various elements of the system are represented in the discussion.
Clients and systems
Identified complex clients can lead to complex service systems.
'Complex and severe' clients can sorely test the capacity of services and give rise to significant medico-legal issues. Around one individual, a wide range of services can be represented, including clinical mental health, primary health, non-government welfare, child protection, housing, disability, justice, private, education, and financial. In addition, family and carers can have an important presence in client’s lives, and should have a seat at the table wherever possible. Delineating roles, arriving at shared formulations, treatment planning, and risk management can be especially challenging for systems working with clients identified as complex. Different elements of the system can have strongly held and competing beliefs, sometimes due to their role, and sometimes due to a marked difference in their experience of the client. However, consultation brings all these elements together and leads to a clarity of thought and purpose for the team. As the team settles into their shared work with increasing confidence, the client frequently begins to stabilise; the chaos diminishes, the risk lowers, and there is more fruitful engagement.
The form of consultation
Consultation is rarely a one-off meeting; it usually consists of a range of activities. It is not exclusive to, but can include:
· Inter-service case meetings
· Reflective practice meetings and supervision
· Primary consultation to the client and client’s family
· Case formulation
· Treatment planning and documentation
· Report writing
Benefits of consultation
Consultation can have a wide range of benefits for the clients, the workers, the teams around the client, and the worker’s organisations. These are some of the benefits witnessed from consultation:
· Containment and stabilisation for the client
· Formulation and treatment planning
· Risk management
· Role clarity
· Improved collaboration and working relationships
· Family/carer inclusiveness
· Professional development for staff
· Improved staff morale
· Sustainable practice
· Cost effective practice
Primary consultations to families or carers either as part of wider consultation work or as work just for the family or carer are also available. We can learn much from families, and they are often at their wits-end and needing some support and guidance. Where families are involved, it is important that they are included in the systemic work as part of the stabilisation process.
A range of foundational and advanced training packages on 'Borderline Personality (Dis)order', risk management and complex clients for health and welfare workers and their organisations are available. Each workshop will be tailored to the specific work setting.
One or two-hour information session on Borderline Personality Disorder
This in-service is suited to a wide range of organisations encountering BPD in their everyday work including GP surgeries, community health, welfare, forensic, disability etc.
Half day workshop on Borderline Personality Disorder
Workshop focusses on what is BPD and how to work with BPD
One day foundational workshop on Borderline Personality Disorder
This workshop covers an understanding of BPD, self-harm and risk. It covers foundational principles for working with BPD and is experientially oriented
Two-day advanced workshop on BPD
This two day workshop covers the foundation day with a second day aimed at practice. Workers have ample opportunity to put into practice the learning from day one.
Half-day or one day risk workshop for complex and severe clients
Decreasing tolerance of risk can lead to increasing severity in the client. This workshop focusses on the principles and structures underpinning an evidence-based risk-tolerant approach to complex and severe presentations.
Working with so-called complex and severe clients sometimes places severe strain on organisational structures and systems. The best interests of the client and the organisation can seem at odds. This conflict can manifest around issues such as risk and duty of care, with organisations taking up increasingly risk-averse treatment approaches as the client becomes increasingly severe. In addition, while Recovery-Oriented Practice has extensive face-validity, there is increasing evidence this model may work counter to best practice for clients presenting with personality disorders. Often training and supervision for staff can provide a path toward containment and stability for the client -- although sometimes the systems and structures around the workers will also need careful and considered change. This change in systems and structures better supports the needs of the client group, and frees the organisation from the ultimate responsibility for the safety of the client. These systems have been shown to be highly effective and are supported by the NH&MRC Guidelines on Borderline Personality Disorder.
Service Development can take many forms but at its most comprehensive is a ‘top down, bottom up’ approach and can include:
· Presentations to the executive
· Risk assessments
· Protocols around risk management
· Treatment planning
· Front end assessment and planning
· Recovery-oriented practice for BPD and complex clients
· Train the trainer
Workers, teams and organisations in the health sector are exposed to significant client and systemic unprocessed and disturbing material in everyday operations. This can have lasting unanticipated negative impacts. Often this material is considered ‘noise’ that simply needs managing or controlling, while secondary organisational effects begin impacting on morale, treatment quality, and cost. When managed well, however, this material can provide important input for the evolution and improvement of the services provided both organisationally and in the direct treatment. Supervision provides a space in the individual, team and organisational working life to reflect, process and integrate material into the treatment. It can generate an interest in the work which is sustaining for workers.
The Benefits of supervision:
· Formulation of client and the work
· More thoughtful treatment
· Sustainable practice
· Professional development
· Organisational flexibility
Supervision can be provided to:
· Organisational teams
· Multi-service case teams