By Paul Jenkins, Chief Executive of the Tavistock and Portman NHS Foundation Trust
The 27th September marks the 100th anniversary of when the first patient, a child, was seen at the Tavistock Clinic. While inevitably more muted, due to Covid 19, than originally planned, it remains a good time to reflect on a 100 years of a unique tradition in mental health and its relevance for the next century.
In some ways, it is hard to imagine the world in 1920. It was a challenging time as the country emerged from the collective trauma of the First World War and the devastating impact of the Spanish Flu pandemic. It was a period before the NHS and at time when mental health care equated with long stay hospitals.
It was against this background that a group of clinicians led by Hugh Crichton-Miller set up the Tavistock Clinic. Informed by experience of using Freud’s theory of neurosis in the treatment of shell-shocked soldiers, the aim was to provide systematic major psychotherapy for people unable to pay private fees.
Much has happened in the last 100 years which has made the Tavistock synonymous with a distinctive tradition in thinking about and responding to mental distress, bringing together a range of different traditions such as psychoanalytic, psychodynamic and systemic thinking and increasingly marrying those with innovative interventions. Tavistock figures like John Bowlby, Isabel Menzies-Lyth, Wilfred Bion, Enid and Michael Balint and many others have made a profound contribution to both practice and social policy, in this country and internationally.
While a centenary is, in part, about looking back and celebrating the achievements and heroes of the past it is also a time to make the case for the relevance of our approach and areas of interest to the addressing of contemporary problems.
I want to highlight four areas.
The first is the importance of early years and attachment. Standing back from the day to day challenges of running children and young people’s mental health services, the importance of the first thousand days and the significance of difficulties in forming secure attachment, especially for those young people experiencing the greatest distress, is a clear priority for me in how we need to think about our response to the growing scale of mental distress in young people.
From John Bowlby, the father of attachment theory, onwards the Tavistock has seen such issues as of central importance. Today, as well as putting such concepts at heart of clinical practice we must advocate for the importance of a greater focus on early intervention and support for those groups, such as looked after children, where issues with attachment are bound, in many cases, to be more difficult.
Linked to these issues has been the Tavistock’s long-standing focus on the whole family and on the intrinsic challenges of parenting. There is no more difficult task in life than that of being a parent and, in my view, we are immensely neglectful, as a society, of an honest debate about the measures which would support what Donald Winnicott describes so honestly as “good enough parenting”. Family work should be at the heart of good care for children and young people.
The second theme relates to the uncertain boundary between physical and mental health. Interest in this goes a long way back into the history of the institution but has recently seen expression in the primary care services the Tavistock has run in Hackney and Camden. In a mechanistic health system, we can easily over focus on the physical symptoms of illness and distress without having the curiosity to explore the underlying causes. As colleagues in primary care often recognise, much of the distress they see in their surgeries has no real clinical name and medically unexplained symptoms are a major draw on NHS resources. We have created the same dilemmas at the end of life where the relentless desire to extend life is prioritised over the psychological acceptance of death and the provision of good palliative care.
My third area relates to the Portman Clinic and its work with forensic patients. Founded in 1931, it joined with the Tavistock in the 1980s. Over the years it has demonstrated the ability to work effectively in the community with patients who have been troubled by problems of criminality, violence, problematic sexual behaviours, or anti-social personality disorder and who often may have acted on their fantasies.
The work of the Portman has always highlighted for me the importance of a criminal justice system which addresses not just the consequences but also the causes of crime and can hold together a view of individuals as both perpetrators and victims. The work is very special, the insights crucial and is indicative of the values of other initiatives which the Tavistock has led, such as Family Drugs and Alcohol Courts, to deliver more compassionate models of justice.
The final topic I want to focus on is the contribution which the Tavistock family has made to understanding the unconscious dynamics of the workplace and of groups more widely. This has great contemporary relevance as we think about staff mental health in the wake of the pandemic with its focus on thinking systemically about what is going on in the workplace and not just focusing on individual distress.
The Tavistock has also been committed, since its earliest days, to a mission of teaching and education, based on a model of clinician educators. Over the years, many students have appreciated the impact of teachers whose teaching is grounded in the reality of clinical practice.
At its best the Tavistock has been an organisation which has been prepared to engage with some of the most difficult issues of the day, as has been the case, in recent years, in working through the public controversies surrounding what is the most appropriate care for gender diverse young people. These are uncertain times. However, the issues which have driven a century of clinical work and thought leadership at the Tavistock remain as valid in 2020 as they were in 1920. Working with others we must continue to make the case for their relevance.