John Hughes – A couch up a Public Health Psychiatrist’s Sleeve

THE LETTER 12 Spring (1998) pages 99-105

Working psychoanalytically with non fee-paying patients in the public health sector presents certain problems. Many subjects have been patients of the psychiatric services for years, even decades, and as an analyst one is regarded: i) invariably, as yet another in a long line of medical practitioners, and ii) always, as a member of a support ‘team’. Very few patients would be familiar with or interested in the distinction between counselling, psychotherapy and psychoanalysis, being principally interested in alleviation of anxiety. However, despite these and other problems, results can be achieved, and perhaps the non-payment of fees is not such an insurmountable problem. I would suggest that it is the transference that provides the opportunities; and within the context of a public health setting, the absence of payment doesn’t seem to become an impossible obstacle in the development of the transference.

For just over three years I have been working with medical card patients, seeing each patient twice a week, at a public health ‘community mental health day centre’, a unit ancillary to one of Dublin’s Psychiatric hospitals. A consultant psychiatrist refers patients from amongst those who attend his nearby clinic. He selects those for referral on the basis of patients who are articulate and, in his judgement, have the desire and the potential to live without medication and the support of the mental health services. When patients are referred, they would generally be taking either anti-depressant or anti-psychotic medication. In most cases, by the time they are referred, patients are eager to end what they speak of as an unwelcome dependence on medication.

Patients are not ‘referred’ in the usual medical sense of the word; the psychiatrist would introduce the possibility of psychotherapy to the patient, leaving it to the patient to respond then or later with a request for a referral. Emphasis in this discussion is placed on how difficult it is to obtain psychotherapy in the public health sector. Patients often have to wait weeks…

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