This chapter provides an introduction to psychodynamic theory as applied to settings outwith the specialist psychotherapy clinic, paving the way for the chapters that follow in Part 4. An individual’s internal world affects how they relate to others. Others may be unconsciously invited into playing old roles that are familiar to the individual (such as rejecting, not listening, criticising), even though these roles bring difficulty and distress to both sides. This chapter explores how these powerful but sometimes ‘invisible’ interpersonal dynamics may play out between service users and staff in settings where the human relationship is at the fore (such as schools, social service agencies, and hospitals). We also discuss splitting within a clinical team and other system dynamics. In circumstances where services and professionals can sustain a good-enough therapeutic environment in the face of unconscious invitations to repeat a problematic relationship, trust may develop between service user and service and many people are able to discover new ways of forming relationships. This depends partly on the capacities and current state of the person using a service, but also, crucially, on the capacity of the professionals and services to observe and be reflective about both sides of the relationship.

This chapter explores the complex area of working with patients who experience relational difficulties and who may function predominantly at a borderline level of psychological organization. These patients are influenced by early traumatic experiences, which can shape the therapeutic encounter. They often don’t have the kind of early experience that enables them to develop the capacity to recognise feelings and to know that they are not dangerous, that they are bearable, and will pass. Acts of self-harm are frequently a response to manage unbearable feelings. These and the experience of suicidal thoughts can be understood as a wish to get rid of these feelings. The nature of self-harm and what it evokes in the clinician are discussed. Individuals with these difficulties have often experienced a lack of a consistent and containing other and can enter crisis in response to experiences of rejection or threats of abandonment. This is important both during therapy but particularly when ending the therapy. If we understand what underpins the relational difficulties that these patients have, we can take them into account in the therapeutic work. Some adaptations of technique when working with patients with borderline level difficulties are considered.

This chapter provides a brief introduction to the relational dynamics underlying ‘multiple exclusion homelessness’ and an approach to working in this area. Adults experiencing multiple exclusion homelessness have often, during their developmental years, experienced multiple homes, disrupted attachments, un-forecasted endings, multiple and short-lived figures of support – all experiences that can lead a person to develop an understandable anxiety about trusting anyone to remain stable in their life. These dynamics may inadvertently be recreated in the person’s adult life through the impermanency of different organisations they are involved with. Multiple exclusion homelessness can be understood as a late emerging symptom of underlying difficulties in someone’s relationships with care. A psychologically informed approach for staff working in the homeless sector is outlined. The staff-service user relationship, while often viewed as important within mainstream services, is commonly seen as a vehicle through which treatments can be completed rather than as the treatment itself. By contrast, a psychologically informed service for people experiencing multiple exclusion homelessness understands that the reverse is often more accurate: that the tasks and activities are really just the vehicle through which a relationship can develop that carries the possibility of developing a sense of safety, trust, and continuity.

There are many ways of becoming depressed. In this chapter we highlight common developmental themes and therapeutic situations amongst people who experience depressing/depressed states. In particular, we expand on two common clinical constellations in some detail: the first a pattern to do with dynamics of loss and abandonment; and the second a tendency to harsh self-criticism, which leads to a devaluing of oneself and others. We use the phrase ‘depressing/depressed’ state to capture the dynamic nature of depression, as opposed to conceptualising depression as a passive state of affairs when someone ‘just is’ depressed. From a psychodynamic view, this is an active and dynamic situation, where an aspect of someone’s internal world is depressing in some way to that person, leaving them feeling depressed. This chapter approaches the external manifestations of depressing/depressed states not as a discrete ‘disorder’, but more as a ‘basic emotional response’ that signals that something is amiss in an individual’s world which requires attending to and addressing.

Psychoanalytic work is always under threat of degradation; for example, understanding is replaced by education, or subtle pressure on the patient to function in a different way (that is getting him to think or behave differently, give up his symptoms etc.). One of the most important locations of this degradation of growth-promoting thought takes place at the site of the transmission of knowledge from one generation to the next. The supervisee is on the one hand being taught and at the same time needs to discover for herself a way of doing things that truly belongs to her. This chapter discusses these tensions giving illustrative examples suggesting that supervising must join the list of the impossible professions.

A psychodynamic approach to anxiety is not disorder specific; anxiety can and usually is present to varying degrees in all patients that are seen for psychodynamic psychotherapy. This chapter aims to shed some light on some psychodynamic approaches to thinking about anxieties. Using theory and clinical examples we think about how difficulties in containing processes between caregiver and infant early in the infant’s life may predispose to the persistence of archaic anxieties. We go on to explore the nature of separation and loss in relation to anxiety and finally, we reflect on how internal conflict and the role of a critical internal object can bring about anxiety. The clinical examples illustrate how wider variation in anxieties may present in therapy and the last section focuses on how the therapist may experience and respond to these different anxieties.

This chapter is a summary of psychodynamic psychotherapy and includes elements of the theory and technique of psychodynamic psychotherapy. It starts with a brief description of what it is and drawing on work by Blagys and Hilsenroth. Seven key features of psychodynamic psychotherapy are described. There is a very brief outline of the various schools of psychotherapy in order to orient the reader. This is followed by brief practical sections explaining the differences between brief and long-term therapy, and between open-ended and closed therapy. Practicalities involved in combining therapy with psychotropic medication are discussed.