Psychoanalytic Psychotherapy

Published by Taylor & Francis (Routledge)
Print ISSN: 0266-8734
Publications
Three system levels: Relating neural architecture, mental architecture and behavioural architecture.
Three illustrations of different modes of attending to propositional and implicational meanings: (a) attention to propositional meaning within the central engine; (b) attention to meaning within the loop generating verbal expressions of propositions; and (c) attention to implicational meanings within the central engine.
The complexity of a mental disorder such as depression is such that a way of interlinking the neural, mental and interpersonal levels is needed. This paper proposes that a theoretical framework which distinguishes, and relates, macro-theory and micro-theory at these levels can serve this purpose. The 'Interacting Cognitive Subsystems' approach to mental architecture is used to show how, via the detailed specification of mental processes and representations, a macro-theory of mental architecture contributes to our understanding of depressed states. In the account advanced by Teasdale and Barnard depressed states are seen as being maintained by an abnormal version of a dynamic dialogue between two qualitatively distinct types of meaning: one is referentially specific, propositional meaning, the other consists of holistic schemata rich in latent content and is called implicational meaning. In depressed states with ruminative and avoidant thought patterns, the mental function of attention is seen as being directed preferentially at propositional meanings. There is a corresponding neglect of attention to implicational meanings. The paper concludes with a brief discussion of how this approach can address transdiagnostic issues and how it may suggest new strategies for therapeutic interventions.
 
Although the need for psychoanalytic research is increasingly acknowledged, many psychoanalysts remain resistant to the performance and findings of this research. Objections to research include a continuing mistrust of research tools and approaches, combined with a belief in the effectiveness of psychoanalytic treatments based on clinical lore and individual experience. Furthermore, as psychoanalytic literature continues to function within its own separate domain, even well-read psychoanalysts can be sequestered from central scientific conversations occurring in the larger literature about mental health. In part due to these factors, few adequate studies of psychoanalytic treatment approaches have been performed. The lack of efficacy research has added to the marginalization of psychoanalytic treatments. Fortunately, in recent years groups of clinicians and researchers have begun to study psychoanalytic treatments, particularly approaches to specific disorders. In this context, this issue provides a welcome addition to the literature in the trailblazing work and papers of Lemma, Target, & Fonagy and Gelman, McKay, & Marks. They have developed an exportable and specific psychoanalytic psychotherapy, which has been employed in the UK's National Health Service Improving Access to Psychological Therapies (IAPT) programme. Work on manualized treatments, such as the Dynamic Interpersonal Therapy of Lemma et al., has allowed psychoanalysts to better clarify and illustrate their treatment approaches. Thus psychoanalytic research, in addition to assessing efficacy, can potentially lead to the development of more effective and rapid relief of symptoms, in a broader population of patients.
 
This paper was written for presentation at a symposium of trainers when the author was a trainee in psychoanalytical psychotherapy. The original title was `Good Supervision: a consumer's guide'. The author drew not only on her own experience of being supervised but also on that of colleagues in training. It was found that it was essential to conceptualise the experience in terms of the triangular relationship between student, patient, and supervisor. Primitive feelings are evoked by the supervisory process and some of these are described. Characteristics of supervisors and the supervisory process and how these are felt to help, or otherwise, are discussed.
 
In this paper I consider the uses of the transference and countertransference dynamics in the assessment process. Patients referred to an NHS Outpatient Psychotherapy Department are discussed. In the Department the assessor will usually not be the patient's therapist. In this situation I suggest that the transference relationship is not the sole or central focus of interpretation, unless the transference is manifested as a resistance to the exploration of the patient's unconscious conflicts underlying the presenting symptoms and difficulties. However, the transference relationship and countertransference responses alongside the patient's history form the basis of the assessor's understanding and dynamic formulation.
 
The author outlines an approach to assessment, or as she prefers to call it, psychoanalytic consultation, in the Health Service. This involves giving the patient an experience of the analytic process, which they can then assess in a way, while the assessor gains information about a number of categories that can be thought of hierarchically, which inform the advice given the patient and the referrer about management and treatment. The safety of the patient is paramount, as psychoanalytic psychotherapy is a powerful and disruptive treatment. However it is argued that, on the whole, `suitability for psychotherapy' should be on the basis of exclusion rather than involving the patient passing a sort of `suitability test'. The latter may enable public psychotherapy services to deny the incompleteness of what they are able to offer.
 
This paper describes the clinical analysis of process notes from individual therapy sessions of twenty girls between 6 and 14 who had been sexually abused. Factors were identified from the material which could facilitate the future therapy for girls, particularly how their experience was that of losing a containing maternal object and then the subsequent trauma of sexual abuse.
 
Recent reports suggest that many patients view their admission to a psychiatric acute unit as an unrewarding, distressing or undermining experience. Whilst it could become genuinely therapeutic, in the sense that it could be an opportunity for self-reflection, personal exploration or change, it is often endured as a traumatic event in one's life that should best be forgotten. This paper explores a psychodynamic understanding of this multi-personal environment in which transference phenomena develop and are usually `acted out'. The admission process is examined, as well as the importance of understanding the support and attachment to fellow patients, staff-patient tensions, and relationships between staff and management. Issues about violence and fear, locked wards, and reflective interventions on a unit are discussed, focusing on how to maximise therapeutic opportunities. The multi-disciplinary ward-review is also scrutinised in this light.
 
For as long as man has been on this earth, envy and greed have performed a duet of destruction. Indeed, these terrifyingly complimentary emotions have been at the root of the worlds' great conflicts and can be seen featuring as a point of origin in what are euphemistically referred to as 'crimes of passion'. In biblical accounts, both were sighted amongst the seven deadly sins. An impressively awesome curriculum vitae indeed. In this paper I should like to explore the role of envy and greed in the formation of anorexia nervosa, where it would appear that the destructive nature of this powerful duo have been turned inwards against the body itself. Analytical theorists make much of the difficulties evoked by the Oedipal situation. These particular theories are explored at length and applied to anorexia nervosa. In attempting to understand how this painful stage of development impacts upon this client group, the difficulties posed and the coping strategies employed to alleviate them are both examined. A further avenue discussed is the particular challenge anorexia nervosa sufferers pose to those of us who would seek to engage them in therapy. Anorectic difficulties in engaging and accepting therapy are explored and understanding is sought as to how we might begin to make progress with this most intractable of illnesses. I would like to illustrate these issues by utilizing my experiences of working clinically with a client suffering from an enduring eating disorder.
 
Participants assigned to verbal and to art therapy groups and drop-outs. 
Hamilton Rating Scale of Depression.
The primary aim of this randomized controlled clinical trial was to compare the outcome from two types of short-term psychodynamic psychotherapy. The participants were thirty-nine women with depression. Half of the participants (n = 18) received art psychotherapy and the other half received verbal psychotherapy (n = 21). Data was collected before and after psychotherapy, and at a 3-month follow-up using self-rating scales and interviewer-based ratings. Results showed that art and verbal psychotherapies were comparable, and at follow-up, the average participant in both groups had few depressive symptoms and stress-related symptoms. The conclusion was that short-term psychodynamic art therapy could be a valuable treatment for depressed women.
 
This paper is concerned with two years' work with a woman who initially was suffering from panic attacks and who was 82 when we started. There is an introduction making reference to some work being carried out with patients suffering from such attacks. The complaints and symptoms of my patient are then described, followed by a personal history incorporating the onset of these. The treatment which is described was unavoidably unorthodox, taking place in the patient's own home and combining group and individual approaches. An account is given of changes in her thinking, arising out of her treatment, and culminating in her thoughts and fears as her life drew to an end .
 
This paper addresses the organizational resistance to psychoanalytic thinking within the public services. The paper begins with a look at Freud's proposal that resistance to psychoanalytic theory is provoked by his assertion that sexual impulses underlie much of human activity. The author suggests that similar unconscious resistance to psychoanalytic thinking is present in organizations today, but that which we in the modern world find more unacceptable than sex as such is to be confronted with our own essential vulnerability. It is argued that because psychoanalytic therapy makes us aware of the limits of our ability to control our emotional experience, it evokes resistance at the individual and organizational level. Therapies that promote mastery and control are more acceptable because they allow these defences to be maintained and sometimes reinforced. The consequences of this in terms of loss of creativity are explored.
 
This paper traces the development of the concepts of transference and counter-transference over nearly a hundred years, from the origin of the concepts to current understanding of them. Clinical material will be given to illustrate some of the ideas held today.
 
There are types of non-visual hallucinatory experience which occur in the psychoses other than those which have a critical and derogatory content. Wish-fulfilment plays an important part in the formation of the content of these hallucinations. In others, `persecutory' anxiety also occurs. A comparison is made between hallucinatory and dream content. An hypothesis is presented to account for the perceptual quality of these hallucinatory experiences. The therapeutic implications of these considerations concludes this presentation.
 
Paula Heimann asked a famous question: “Why is the patient now doing what to whom?”, and said “The answer to this question constitutes the transference interpretation”. In the individual setting, sometimes the answer is obvious, but more often it is obscure. Only a complex and painful integration in the mind of the therapist of manifest verbal and non-verbal material, with subtle countertransference feelings and the `atmospherics' of the session, can point to a possible description of the unconscious internal relationship indicated by Heimann. When this work takes place in a group setting, it is further complicated by the conscious and unconscious currents intrinsic to group interaction. Furthermore, the many patients now treated in formal group psychotherapy experience severe problems with their identity, ranging from the identity diffusion and rigidities of Personality Disorder to the fragmentation and confusion of more psychotic patients. Such additional factors must be confronted if a response, let alone an answer, can be given to Heimann's question from the group perspective. An account of a group session shows how the author considers Heimann's question in his clinical practice, and, by means of this question, approaches the application of psychoanalytic concepts to groups.
 
The suicidal person is tortured by an internal dilemma to do with unbearable feelings of separation and loss which seem to be insoluble. The suicidal act is an attempt to resolve this by creating a phantasy in which the intolerable pain associated with a grievance is projected and obliterated by murdering the body that has become identified with it. This type of assault on the self reveals a major confusion between mind and body, affecting the capacity to think and resulting in two-dimensional, rather than three-dimensional, thinking, which can permeate therapeutic efforts, at both individual and systemic levels, in the way these patients are managed by their carers. It is suggested that a safety-net made up of mindful carers, based on a triangular principle, can provide a symbolic or mental space, and a containment for the patient's intolerable states of mind, which can be analogous to an ego-function that is lacking internally, and works well if the net can manage to function as a healthy parental couple. Two case studies are presented as an attempt to illuminate some of the dynamics and difficulties in maintaining the safety-net.
 
One of the curative factors of psychotherapy is that the patient internalises, on the one hand, the therapist's attitude towards himself; and, on the other hand, he/she creates channels and the means to elaborate unmet needs in his/her internal experiential world. I consider the internalisation process in this study in the framework of a gradual symbolisation-reflectiveness process, using the tripartite model of Charles Peirce to conceptualise symbolisation and apply it to an understanding of the evolving psychic process. My aim is to analyse the organisation of symbolisation-reflectiveness in the psychoanalytic psychotherapy of my patient Thomas, illustrating this with material from the sessions. Thomas's central conflict was connected with early unprocessed separation experiences in the mother-child relationship. These separation experiences manifested themselves as inexplicable panic attacks during the therapy. In the potential space created by basic trust, Thomas was able to integrate feelings of panic within himself by means of his capacity for symbolisation and integrative reflection. The panic was shared, and this enabled him to assess and work through feelings and associations connected with it in the therapy dialogue. I describe sessions from the first, third and fifth years of therapy, which illustrate the integration of Thomas's emotional world in the treatment relationship and the internalisation of his feelings of need through the evolving symbolisation-reflectiveness. The session material illustrates these phenomena and shows how the therapist assists the developing symbolisation-reflectiveness.
 
In the author's view, closeness between patient and analyst enables the patient to gain insight into the pain of separation and thus to tolerate it, but at the same time brings up, paradoxically, a sense of separateness difficult to deal with. A distinction is made between separation and separateness. Through clinical material, the author tries to show that while analysis can help patients to come to grips with the pain of separation, it has limited effect on the profound core of affects which have to do with fear of death and emptiness — the affects pertaining to separation. Ognuno sta solo sul cuor della terra trafitto da un raggio di sole: ed è subito sera. —S. Quasimodo
 
This Special Issue of Psychoanalytic Psychotherapy draws together papers presented at the British Psychoanalytic Council (BPC) Psychoanalytic Psychotherapy NOW conference ‘Getting to grips with society’s ills: a psychoanalytic perspective’, held in London on 5 October 2013. Inspired by the work of the Joseph Rowntree Foundation (JRF), a British social policy research and development charity that funds a UK-wide research and development programme addressing the root causes of social problems, the conference sought to explore psychoanalytic perspectives on some of the key problems in today’s society identified by the JRF: the rise of individualism, consumerism and a decline of community; a decline of values; drugs and alcohol; families and young people; inequality and poverty; institutions, apathy and a democratic deficit.
 
Psychologically Informed Planned Environments (PIPEs) are an additional stage in the Offender Management Personality Disorder Pathway. The author describes the context, the impact of the work on both offenders and staff, and discusses the importance of paying close attention to the psychological process level from both a service and an organisational perspective. It is argued that the group analytic understanding of group and individual process is an important element of the psychological containment within PIPE for both offenders and staff. The group analytic focus on the here and now relational level linking to the historical context and the unconscious group and individual process provides a structure and concept for understanding the intrapersonal, interpersonal, group process, psychosocial process and the organisational context and its impact. Reference is made to the necessity of addressing the environment offender's move onto following their PIPE experience.
 
A triptych of clinical cases binds together a new frame for understanding the relationship vacuum that lies at the heart addiction to drugs. Beginning with a case anecdote about an amphetamine user who was troubled with an underlying psychotic condition, and much taken with David Bowie’s song Space Oddity, the case draws attention to the emptiness in which the client's social relations were conducted. Bion's thoughts on the challenge of linking drug addiction and psychosis are refracted in his personal copy of Rosenfeld’s (1965) book Psychotic States, where Bion made copious notes in the margins and coined the term ‘concentration for annihilation’. Some of these notes throw new light on Bion's approach to working with psychotic fixation which he derived from working with clients using drugs as well as those who were suffering psychotic states. Particular attention is given to one of Bion’s clients whose repetition-compulsion appeared to create what we might think of as a ‘psychotic vacuum’. In the final case study the life and death of Lucy Cameron is cause for reflection. Lucy’s poem ‘The Space’ draws attention to the devastating psychotic vacuum created by substance misuse.
 
In this opinion piece, I explore some of the social and cultural factors that contribute to the creation of feelings of shame in those members of society who are vulnerable or disadvantaged in various ways. I suggest that a ‘blame and shame’ attitude has become pervasive in today's political culture, reassuring the comfortable and privileged that they deserve their own success and allowing them to blame the disadvantaged for their own misfortune. Those who feel that they must become invulnerable in order to succeed therefore project their own vulnerable child onto the vulnerable in our society and attack and condemn in others what they most fear in themselves.
 
The 2009 National Dementia Strategy exhorted the National Health Service to raise the profile of dementia in the UK and to make the diagnosis in 75% of sufferers within a few years. While this aspiration is commendable in the sense that ideologically it is an attempt to improve things for dementia sufferers, it is likely to have other consequences which may not be so well understood or considered. Raising expectations in a vulnerable population is fine if those peoples’ lives can be improved even a little by making a diagnosis. It is, however, a lot to ask services to deliver at the same time that the country is experiencing one of the worst economic crises of our generation. This paper sets out what a pathway into dementia diagnosis might look like using a psychodynamic framework, including giving a dementia diagnosis and offering aftercare. The author considers some of the thoughts and feelings in the sufferers, carers and the staff who offer the service; the challenges posed by a diverse group and how to deliver best practice. The services described are from within community psychiatric settings: those used to delivering not only dementia diagnoses, but also managing delusions, hallucinations and mood disturbances associated with dementia. Mental health services do not exclusively provide memory clinics and the author is not extending these observations to services delivered by neurologists or physicians in medicine for the elderly.
 
This paper describes an approach to working with couples where one partner has a dementia, which is currently under development at the Tavistock Centre for Couple Relationships. This draws upon video-based methods that have been used with parents and children, as well as in psychoanalytic couple psychotherapy, to develop an intervention to assist emotional contact, communication and understanding in couples living with dementia. Our approach includes the person with dementia and their partner, focussing upon the relationship between them and using shared involvement in everyday activities as a basis for enhancing emotional contact. Evidence is reviewed of the need for such an approach, which aims to foster the resilience of the couple's relationship and strengthen their capacity to manage the emotional challenges of the situation. The importance of services holding a relational view in their delivery and the economic and humanitarian consequences of a neglect of this in dementia-care settings are also discussed.
 
In this paper, I draw on Freudian and Lacanian psychoanalytic theory to consider the notion of perversion and fetishisation within the context of contemporary UK public mental health services which have been subject to New Public Management restructuring. Offering an organisational case example based on clinical experience within an expanded NHS mental health service, I explore how services that are subject to neo-liberal regulatory and performance management systems sponsor a perverse organisational solution to the anxieties and difficulties of dealing with psychologically distressed patients. I conclude that theorising the unconscious dynamics of perversion and fetishism may provide an opportunity to rethink governmentality, offering a potentially fruitful means of addressing recent political concerns about the negative impact of a ‘target culture’ on public sector health services.
 
The author explores the development of female violence and its typical expression in acts of aggression directed towards the woman's own body and those of her children. She explores the societal resistance to confronting the disturbing reality of maternal abuse in the light of commonly held, cherished beliefs about femininity in general and motherhood in particular. The hidden nature of female violence, so often enacted in the private, domestic realm, is evident in the clinical case material presented. The author presents a model of the psychology of female violence described as ‘crimes against the body’.
 
At a time of considerable organisational change within Probation Services, the authors describe a new initiative to offer psychoanalytically-informed clinical supervision to frontline probation officers, linked to the development of a care pathway for offenders with personality disorders. An analysis of feedback forms from supervisors during the first months of this project highlighted the typical countertransference challenges of probation work. In subsequent months, concerns about organisational change were increasingly evident in supervision, possibly amplifying existing concerns about risk, formulation and management of countertransference responses. The complexities of offering containment and supervision to probation officers, at a time when they were anxious about the security of their organisational ‘container’, are explored.
 
There is growing concern about how people respond to a fast-changing world in the context of economic decline. Symptoms of distress such as depression and anxiety are reaching epidemic proportions alongside the breakdown of family stability. This paper considers how psychoanalysis can enter the debate about these concerns and whether psychoanalytic theory and practice in the UK has concentrated too much on the individual to the exclusion of the wider family and the community. © 2014 The Association for Psychoanalytic Psychotherapy in the NHS.
 
In this paper, I have reported how a woman with a long history of paranoid schizophrenia was able to use psychoanalytic psychotherapy in the NHS to work through a delusional belief of having her father's child. As a result of the therapy she was able to recover a reflective function and to represent herself, again, as a non-psychotic person. I have described the clinical framework of the therapy as based on the psychodynamic developmental therapy and the mentalization model, as developed by Fonagy and Target (19964. Fonagy , P and Target , M . 1996. Playing with reality: I. Theory of mind and the normal development of psychic reality. International Journal of Psychoanalysis, 77: 217–233. [PubMed], [Web of Science ®]View all references), which posits that the development of a core or psychological self is not a given and can occur only through early object relationships with a caregiver who enables the child to integrate two modes of functioning, the psychic equivalence and the pretend modes. If the care-giver is abusive or unable to acknowledge or think about a piece of reality the child will not be able to do so on her own and, as a result, will experience the unthinkable thought in a psychic equivalence mode. In the clinical setting, the role of the therapist is, first, to acknowledge the reality of the patient's internal world and eventually enable her/him to think about the unthinkable thoughts.I have emphasized, also, the technical importance of balancing interpretation of unconscious strivings with ego-supporting communications.I propose that this framework can be used to enable some people suffering from severe and incapacitating mental illness to lead more satisfactory and fulfilling lives through the exploration of delusional formations and the recovery of a non-psychotic part of their selves.
 
This paper uses the example of setting up a community-based adolescent psychotherapy and counselling service to explore the difficulties and anxieties that can arise when psychoanalytic practitioners venture out of the consulting room to become involved in planning and organizing services. Emphasis is placed on the complications of such a task in a climate of rapid change, when levels of anxiety, fuelled in many different ways, can threaten the viability of the task one is engaged in. The author argues that in a political climate that is generally not very supportive of psychoanalysis, it is possible none the less for psychoanalytic ideas to have an important impact on how psychological services can develop, and this in itself can challenge many of the preconceptions about psychoanalytic practitioners that one can be confronted with when one leaves the comfort of the consulting room.
 
This paper argues for the widening of perspective in the understanding of the functioning of the analytic process. By focusing on the complementary half of the bi-directional communication from one unconscious to another - the half that remains outside the analyst's conscious understanding or experience - it advocates that the conceptualization of the work we do can be enriched without recourse to changes in technique. Refusing to lose sight of the fact that the analyst's unconscious is, unbeknownst to him, constantly conveying messages to the analysand who then responds in accordance with these communications. This can only deepen our appreciation of the analysand's internal world and of the process of analysis. A selection of writings by psychoanalytic, philosophical and infant psychology authors as well as clinical material is enlisted to support the argument.
 
In this paper Segal gives brief summaries of her 19875. Segal , H. 1987. Silence is the real crime.. International Review of Psychoanalysis, 14: 3–12. View all references paper ‘Silence is the real crime’ and her 19956. Segal , H. 1995. “From Hiroshima to the Gulf War and after: socio‐political expressions of ambivalence.”. In Psychoanalysis in Contexts: Paths between Theory and Modern Culture, Edited by: Elliot , A and Frosch , S . London: Routledge. View all references paper ‘From Hiroshima to the Gulf War and after: socio‐political expressions of ambivalence’, to show the effect of psychotic factors in the background to September 11. She analyses the symbolic significance and psychological impact of September 11 and in a 2005 Postscript discusses the ensuing war on Iraq.
 
This paper examines some issues related to the Tavistock (Bionian) and Group-Analytic (Foulkesian) approaches to group therapy, in the context of an out-patient group which met weekly over thirty-two months. Reference is made to theories and models within the frameworks of Psychoanalysis and Group-Analysis. To conduct this group was a part of the author's training at the Institute of Group Analysis; although the group met at the Tavistock Clinic (‘next door'). The author had previously trained for four years in Child & Adolescent Psychiatry at the Tavistock; and he negotiated this unusual set-up with the Tavistock Clinic's management, becoming the first Institute trainee to run such a group at the Tavistock. The author had two supervisors simultaneously; hence there was a constant tension between the two theories throughout the history of the group. The Tavistock's supervisor played an active part in the early stages, especially during the process of setting-up the group; his role progressively changed to that of overseeing the work. On the other hand, supervision at the Institute was ninety minutes weekly for three years, in a small group of up to four trainees. In contrast to usual Group-Analytic practice, on the advice of the Tavistock's supervisor, eleven patients were invited to join the group without meeting the conductor beforehand. In contrast to usual Tavistock practice, on the advice of the Institute supervisor, one group member was seen, after she had left the group, for individual psychotherapy by the conductor. Being ‘caught up in the middle', the conductor himself was stretched to breaking-point. But he survived, and every one of the eleven members with him.
 
Top-cited authors
Peter Fonagy
  • University College London
Alessandra Lemma
  • University of Essex
Mary Target
  • University College London
Valerie Sinason
Andrzej Werbart
  • Stockholm University