Who is allocated to psychoanalytic psychotherapy in a Tier 3 CAMHS setting?

At a time when Child and Adolescent Mental Health Services (CAMHS) are experiencing unprecedented levels of demand (Look Ahead, 2023), the need to determine which patients require which interventions has become increasingly salient. Closely related to this is the question of whether clinicians responsible for these decisions demonstrate consistency across the different professional disciplines working collaboratively. This qualitative study aimed to examine clinicians’ understanding of the allocation of patients to psychoanalytic psychotherapy within a Tier 3 CAMHS service, and to explore whether a patient profile could be identified for those considered suitable for this intervention. Data were collected through five semi-structured interviews with clinicians from a range of healthcare backgrounds, all of whom were members of the same multidisciplinary team (MDT). The data were analysed using thematic analysis. Six principal themes were identified: (1) Preliminary patient characteristics, (2) Going deep, (3) One size does not fit all, (4) Team process, (5) Clinical intuition versus guidelines, and (6) Issues of disagreement. The findings indicated a degree of consistency in the characteristics of patients allocated to psychotherapy, including those presenting with internalising difficulties, who had experienced complex relational trauma and were understood to require a novel form of therapeutic relationship in order to address these difficulties. Nevertheless, several clinicians reported uncertainty regarding the nature of psychoanalytic psychotherapy and expressed a desire for greater understanding of the intervention. In addition, the findings highlighted factors extending beyond the individual patient, including team dynamics and, notably, the impact of resource constraints on clinical decision-making. These findings have implications for understanding the functioning of MDTs within the current economic context of CAMHS and underscore the need for a more coherent and shared conceptualisation of psychotherapy in order to enhance clinician confidence in allocating patients to this intervention.