Unexpected Gains: Psychotherapy with People with Learning Disabilities Edited by David Simpson & Lynda Miller. London & New York: Karnac Books. 2004. 236pp. £18.99 (pb). ISBN 1855759640

Unexpected Gains is a welcome addition to the literature on psychoanalytically informed work with people with learning disabilities. Many community learning disability services across the country offer counselling as part of their health provision. Very few of these services are audited and most are managed from within a psychology department.

This book describes the theoretical background of psychodynamic psychotherapy, illustrated by case examples showing work with children, adolescents, adults and carers. It gives a clear flavour of the clinical work of the Tavistock Clinic Learning Disability Service in London, which has been built on what appears to be a niche interest within the psychotherapeutic field. It also includes an attempt at using audit to quantify the psychological gains made by clients and gives brief details of a research project that will measure outcome in a more structured way.

Service users who have been helped through psychodynamic psychotherapy are vividly portrayed, as are the dilemmas and empathy of their therapists. It is not all roses: powerful, unpleasant feelings are given expression as the therapists try to understand and the service users struggle to make sense of years of pain, loss and lack of self-worth.

It would have been interesting to be told more about the duration of treatment and why it was stopped. Several treatment contracts appear to have ended after a year, which by any standards is a short duration for this type of intervention. Occasionally I wondered what was really being said in the room, although the extracts from the sessions clarified some of the confusion about what belonged to the therapist and what to the client.

Another unaddressed issue is why clients were referred. It would have been helpful if a profile had emerged of clients who might do better with psychotherapy at the Tavistock rather than locally. In addition, data on which services tend to refer more often could help to identify service gaps within and outside of London and to indicate whether successful referral depends on a ‘postcode lottery’.

Finally, information on what the Tavistock Learning Disability Service currently offers and whether funding is needed to access it are important omissions. It is of some concern that the clinic's specialist psychoanalytical team may remain a hit-and-miss opportunity for many people with learning disabilities and, indeed, for the services caring for them.

Unexpected Gains is an interesting and well-written book that can easily be read by (and recommended to) professionals in the field as well as lay people who know or care for someone with a learning disability. However, I wonder whether it will break into the market (and therefore awareness) outside the confines of the psychotherapeutic community.