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About Casework
 
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Lacap
initially took its referrals from primary care
practices, and by 2004 had a base of some 42 GP
referring practices. On 1st January 2005 lacap published
its website, and now receives the majority of its work
through self-referral.
This media path does make a difference. We hypothesise
that entry by the the primary care path meant that
patients had already ‘medicalised’ the symptom, were
prepared then to address it to the authority of a
Doctor, and accepted a passage where lacap was a point
of termination for that symptom to be received. The GP
will have added screening.
Self-referral is different. The patient arrives without
‘screening’. There is little culture for
psychoanalysis in the UK, and you cannot expect the
patient to have any reference points beyond the demand
to lose the suffering in the symptom. The internet
offers the endless sliding along research pathways.
Master discourses such as the medical/psychiatric
discourse are drowned out by other noise. Quite where
lacap has fixed a point of addressee, as interlocutor,
as knowledge, for that patient in that cyberspace medium
cannot be controlled for.
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The
other classic control is to reference lists of
indications and contraindications for psychoanalysis.
But as the clinical openings at lacap are so diffuse and
varied, there is little chance of establishing work
according to a notion of ‘What is a standard
patient?’. What
we have experienced then is that lacap clinicians have
often found the clinical openings to be quite
‘left-field’; governed as they are by the nature of
self-referral through this medium. Symptoms are more
diffuse and less-organised. The demand can be
correspondingly vague, and desire can be low and
problematised by paranoia.
This does not need a wholesale re-writing of the
rule-book, but does call for work to be done to build
the analytic transference and stabilise the initial
wild-transference without assuming you represent
‘analytic authority’. (Bucketloads of ‘analytic
attitude’ and frustrating silence are appropriate for
the training organisation, but not for coal-face
therapy. You might also wish to consider this when
choosing your supervisor.) Most treatments then take on
the flavour of more standard work after this opening has
been transited in the first six or eight meetings, and
are ‘business as usual’. So, we are delighted that
retentions beyond six months remain at around 66%.
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You
are being asked to commit to a caseload that is a
minimum of six and a maximum of eighteen in the first
six months. After the first six months, you may ask for
new referrals to be made over to your offsite premises,
although you must still retain an onsite reception
capacity of a minimum of six patients. After six months
you may ask to receive volumes to a maximum of 30
patients.
Because lacap advertises its services, we cannot
guarantee your patient volumes; that will also depend to
a large extent on the amount of time-slots that you
place on the service front-end as available hours, and
the times that you hold open. Not surprisingly, the
demand for evening and weekend slots far outstrips those
for daytimes, and the fees are often higher. Pressure on
clinical room resources means that it is unlikely that
you can retain ‘open slots’ to build an ‘only high
fee’ practice. On the ground, those resource hours
will be taken by therapists accepting ‘standard fee’
rates.
Lacap
does not believe that the psychoses, the addictions or
the perversions are beyond the therapeutic remit,
although you will have to decide for yourself whether
your practice can address without risk to the patient,
& let us know.
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In
this sense, assessment is the assessment of the
clinician’s capacity to receive the patient, not an
assessment of the patient’s capacity to receive
treatment.
You will find that lacap does not oversee your
day-to-day practice, and is on the whole management-lite.
However, we cannot ignore that lacap is a
transferrential object in your clinical work, and we do
try to minimise that presence. But it is because lacap
does continue to function in the patient’s minds that
we do insist that emails are generated in lacap’s name
that ‘rubber stamp’ any variations that you agree
with the patient to the contract. In essence, the
patient is a lacap patient. If you cannot accept this
stricture, you cannot work here.
At the end of six months, you may ask at any time to
disassociate yourself from lacap, and for its part lacap
will be pleased to advise the patients’ that you are
receiving that your association has ended, and to
recommend that they continue their work with you
elsewhere. In the event that lacap is forced by concerns
to end its association with you, the patients will be
advised, and without recommendation that they retain
you. There is at all times clarity about when the
patient is with, or separate from lacap.
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