Editorial

Viewing NHS Psychotherapy Services at the 50-year mark, we know how often our minimally-resourced clinics are faced with patients whose difficulties challenge the limits of our treatments. We often can provide only a fraction of what we may judge the patient really needs. This regularly faces us with clinical and ethical dilemmas. When is it right, even safe, to offer once-weekly, time-limited treatment to a deeply disturbed person who ideally needs the containment of a full analysis? Is it best to offer nothing or too little? The difficulty and discomfort for both patient and therapist of sustaining analytic work when little time can be given may make packaged, more ‘educational’ or cognitive treatments seem misleadingly attractive, though some would argue that the patient is thereby sold even shorter.

Three papers in this issue of Psychoanalytic Psychotherapy cause us to consider such important themes by their presentations of work with borderline and psychotic patients. Richard Lucas presents an unusual and impressive account of the NHS treatment of a manic-depressive patient in full analysis. The availability of a sufficiently containing structure and appropriate expert resources for this is almost unheard of. It is worth noting, however, that this treatment, though labour-intensive, is relatively inexpensive compared with in-patient treatment, and could quickly pay its way in selected cases if overall admission time was thereby shortened even fractionally. Judith Felman's thoughtful account of once-weekly work with a severely depressed self-destructive patient raises interesting questions about the limits of treatability. Felman uses her case to think about the clinical usefulness of the death-instinct concept. Penelope Garvey's paper is also about work with borderline patients, and her vivid case-material is used to think about Rosenfeld's work on narcissistic states.

Many patients in the NHS are treated in analytic groups, and contributions to Psychoanalytic Ps