The Tavistock Clinic: where Sigmund Freud continues to influence nurses
Influenced by the Vienna-based ‘new psychology’ approach 100 years ago, the Tavistock Clinic – aka the ‘Tavi’ – in London is renowned as a psychodynamic hub where nursing staff apply their skills
Influenced by the Vienna-based ‘new psychology’ approach 100 years ago, the Tavistock Clinic – aka the ‘Tavi’ – in London is renowned as a psychodynamic hub where nursing staff apply their skills to help people who are facing a mental health crisis
On a corner of Belsize Lane in leafy north London, Sigmund Freud sits attentive and thoughtful, hands in waistcoat pockets, immortalised in bronze by the Croatian sculptor Oscar Nemon.
A few metres away is the Tavistock Clinic, where nursing staff apply their extensive skills in psychodynamic and social-systemic approaches to help adults, children and families who may be facing crisis.
The roots of the Tavistock – the ‘Tavi’ – date back 100 years to the First World War. Influenced by the ‘new psychology’ emanating from Vienna and elsewhere in mainland Europe, neurologist Dr Hugh Crichton-Miller developed pioneering psychotherapeutic approaches to treating shell-shocked soldiers, which he believed would also work with civilians.
The Tavistock Square Clinic for Functional Disorders opened in 1920 in central London and was among the first outpatient psychotherapy clinics in Britain. It moved to its north London home in 1967, later merging with the Portman Clinic and is now the Tavistock and Portman NHS Foundation Trust.
Working across age ranges
Marcus Evans was the first nurse to work at the Tavistock after training there as a psychoanalytic psychotherapist in the mid-1990s. Today, there are various nursing teams, nurse specialists and nurse consultants working across the age range.
Antonia Carding heads the Camden Adolescent Intensive Support Service (CAISS). She and the other nurses in the multidisciplinary team come with a background in acute child and adolescent mental health services (CAMHS), which she believes gives all of the nurses added insight into the distress young people can experience and when intervention is necessary.
‘Initially, we provide a consultation service around the case and think about whether we can offer an intervention’
‘We work with any young person aged 11 to 18 who either presents in crisis or is already being seen in a CAMHS and their package of care is not holding things,’ she says.
‘An example might be someone who’s receiving psychotherapy in Camden CAMHS, but they may be self-harming more, or there’s suicidal thinking, or they’ve attempted to kill themselves. There may also be complex family issues that mean things at home are not going well.’
The team was set up to reduce the number of young people presenting to emergency departments and consequently transferring to adolescent psychiatric units.
‘Initially, we provide a consultation service around the case and think about whether we can offer an intervention,’ Ms Carding says.
She explains the various strands to the team’s work. ‘One is working intensively with young people and their families at home, which can mean going in daily.’
Another is joint assessments in the emergency department with paediatric liaison colleagues to decide whether a young person is safe to be discharged with a package of care.
‘What we do is help a young person thrive – getting back to school, having a social life and some kind of enjoyment’
Alex Duckworth is one of the CAISS nurses. He says the young people the team sees come from a range of backgrounds.
‘We represent the diversity of Camden borough. We’ve got kids you would think of as being quite deprived socio-economically, then some who come from more wealthy backgrounds.’
Nearly all are suicidal or have tried to hurt themselves in some way, she says, and some have eating disorders.
‘A lot of the young people I see describe inconsistent or inadequate parenting,’ says Mr Duckworth. ‘They don’t feel they can talk to their parents about what’s going on or they don’t feel contained by a lot of the things around them. That’s mostly what they have in common.’
The team’s approach is flexible in the way it responds to need, deploying different approaches and drawing in other agencies as appropriate, Ms Carding says. ‘What we do is help a young person thrive – getting back to school, having a social life and some kind of enjoyment.’
Evidence so far suggests the CAISS is proving successful in supporting young people in crisis. The team always responds within 24 hours and the average length of intervention is five months. It has no waiting list. But crucially, in its first year of operation, it brought about a 40% reduction in inpatient admissions in Camden.
‘Most of the children who come to us have experienced quite significant early trauma’
The work can be challenging, not least, says Jonathan Creedy, another CAISS nurse, because the child or young person is always at the centre of a wide network – family, school, social worker, other agencies. ‘That’s the tricky bit,’ he says. ‘Keeping the communication clear between everyone and making sure everyone’s on the same page.
‘But what I like about the job is building relationships with the young people, getting to know them and what makes them tick – and then being able to help.’
Included under the auspices of the Tavistock and Portman NHS Foundation Trust is Gloucester House, an independent special school for children with social, emotional and mental health needs. Kirsty Brant is the school’s lead nurse and clinical lead.
‘Most of the children who come to us have experienced quite significant early trauma,’ she says. ‘The majority have also been excluded or are at significant risk of exclusion from mainstream schools. They’ve often had lots of multi-agency involvement over the years, or are in families that have fallen through the gaps.’
‘Nursing enables a real flexibility and creativity, a willingness to try things out, with a core of doing what’s in your patient’s best interests’
In many ways the school functions like any other – it follows the national curriculum – but there’s a heavy therapeutic focus.
‘Different elements might be group therapy, targeted nursing interventions, individual psychotherapy, family work or work with parents,’ says Ms Brant.
‘But interweaving through everything is the therapeutic milieu – things which are being paid attention to all the time, such as the children’s relationships with each other, with adults, the projected processes between the child and the team.’
She adds: ‘The richness of the information we can gather from being all one team and spending so much time with the children – that’s difficult to get in a different sort of service.’
Even though the context for her work is therapeutic education, Ms Brant says her nursing identity and experience are essential for the role she does. ‘It’s something about the shop-floor nature of nursing – a model of getting stuck in.
‘Nursing enables a real flexibility and creativity, a willingness to try things out, with a core of doing what’s in your patient’s best interests.’
Sharing knowledge is crucial
The Tavistock Clinic has a long history of sharing knowledge and understanding about its clinical interventions, and it offers an extensive range of training programmes. It also reaches out to others in the NHS to encourage more reflective approaches to practice.
Psychotherapist Claire Shaw, head of nursing for adult and forensic services and lead for nursing development and research, says: ‘We try to find ways of linking up with nurses outside the Tavistock to say: “If you have protected time to stop and think, and a framework for understanding, it makes your work more interesting and satisfying”. It helps with understanding and resilience.’
An example is Nursing in Mind – a monthly, three-hour event run by the Tavistock to examine the complexities of contemporary nursing and which promises a ‘restorative, stimulating and developmental learning opportunity’.
‘The work nurses do is important,’ Ms Shaw says. ‘We have contact with people often at the extremes of their states of mind, and the contact we have is usually prolonged.
‘So part of this is about valuing the nursing role. There are things that can make it all a bit more bearable, so that you’re likely to go back the next day feeling more valued and more interested.’