This paper examines a clinical case that demonstrates the utility of the Conversational Model of psychodynamic psychotherapy in the most acute settings. This is a discussion of ‘T’, a 10 year-old girl who attended an Emergency Department in acute mental health crisis. ‘T’ arrived to the ED highly traumatised, distressed and dissociated; unable to talk or tolerate any form of direct interview. She was able to offer valuable insights into her internal world through drawings, jokes and poetry. In this way, the engagement thickened, transforming what might have been a formulaic process into something genuinely therapeutic. The Conversational Model’s emphasis on working with that which is offered: the valuing of metaphor, analogical relatedness, empathic attunement and inter-subjectivity, was crucial to the success of this engagement.
Current practice in NSW dictates that almost all persons attending Emergency Departments be seen and treated within 4 hours. At a time when acute mental health services are increasingly pressured to ‘flow’ clients through their systems, the emphasis on genuine therapeutic engagement can suffer. The example in this paper demonstrates a brief engagement that has authentic clinical import and resonance, even in these difficult circumstances; albeit with a note of caution.
This paper aims to examine the utility of the Conversational Model within an acute, public mental health system setting. It also aims to offer an orientation to the Conversational Model’s key theoretical concepts and clinical practices, particularly the clinical engagement as a form of play or reverie.
