Setting up the Willesden Centre for Psychological Treatment

SUMMARY

The Willesden Centre for Psychological Treatment is a new facility built and funded by the Mental Health Unit in the London District of Brent. The unit was opened for clinical work in June 1985 and is a joint enterprise providing facilities for out-patient psychology services for Brent and a base for psychotherapy resources that were previously located at Shenley Hospital. Shenley is a large Victorian mental hospital situated about 20 miles from London in Hertfordshire and is the designated hospital for acute in-patient psychiatric services for Brent. In the first part of this paper I give an overview of the history of the negotiations that took place to bring about the opening of the Centre and then go on to make some general comments about the nature of the negotiating process itself.     

“Transferring” and transference

This paper is part of my research into psychotic transference and is also related to the psychotic aspect of any adult or infantile patient in analysis. In my research, I studied the origin of the concept of transference in Charcot's time before Freud, and the transformation of this concept in psychoanalysis. Freud thought that psychotic patients were not able to establish a transference relationship, but some of his early papers show the opposite. In fact, Freud himself and then several other analysts were able to develop a personal experience regarding the possibility of contact and transferring feelings and delusional experiences in a therapeutic context – individual, group, or institution. I provide some clinical examples in this paper, as well as some theoretical, personal views regarding intrapersonal and interpersonal transference. Like Freud and Melanie Klein, I believe that transference starts with life, but that in psychoanalysis it has a particular meaning.     

Bearing Witness in Israel/Palestine: Finding My Voice

This article traces my evolution as a political activist in relation to the Israeli–Palestinian conflict over the past decade, and describes the ways my activism has become integrated into my professional life. I discuss my journeys in Israel/Palestine with delegations of the Compassionate Listening Project, highlighting disturbing stories of injustice and abuse and inspiring stories of interfaith cooperation and nonviolent peace work. My focus is on the emotional impact of becoming the bearer of stories of unbearable human experience that I felt compelled to bring back and share. I reveal my struggles with continuing to speak and write publically about the injustice that I witnessed. In the course of standing up to both internal and external attacks on bearing witness, I have discovered a stronger therapeutic voice with my patients as well.     

Cohabitation and the negative therapeutic reaction

Borderline and psychotic patients especially, but not exclusively, show genuine motivation towards achieving insight and change and then suddenly behave as if these have never been desired. When this shift occurs after a helpful interpretation it can be thought of as a negative therapeutic reaction. Patients can feel taken over by perceptions which drive them to think and behave in ways they later disagree with. These observations have led the author, along with colleagues at the Willesden Centre for Psychological Treatment, to recognise a situation of internal cohabitation of two autonomous minds in the one body which is a development of but not identical to Bion's concepts of psychotic and non-psychotic personalities. Some of the psychoanalytic literature on the different modes of mental functioning are reviewed and problems of appropriate conceptualisations are discussed. Clinical examples are presented to illustrate that differentiating the genuine negative therapeutic reaction from reactions to poor interpretations is facilitated and leads to further understanding of the patient's psychotic personality if the psychotherapist can hold in mind both the patient's and the therapist's psychotic and non-psychotic personalities.     

Altruism and the Resolution of the Transference Resistance: Partners in Clinical Psychoanalysis

ABSTRACT

The article is devoted to the central place of altruism in clinical psychoanalysis and psychotherapy. Using an experiential-subjective perspective, I demonstrate how I overcame an inhibition in utilizing altruism in my theoretical and clinical work, which then reduced barriers against working with the experience of vitality, closeness, and creativity for my patients and myself. I then could follow the importance of resolving the transference resistance against consolidating the experience and functioning of the self or person. At this time, altruism has also become a subject of interest in several fields that deal with human and animal behavior such as evolutionary science, social biology, and anthropology. Psychoanalysis, with its special subjective and experimental perspectives, can make valuable contributions in these realms of knowledge and research.     

Commentary on “Night Cries: A Rural Tragedy” by Tracey Moffatt and Discussion of “States of Exile and Marginalization” by Gillian Straker

This is an excerpt of the work that I presented in Sydney last May at the International Association for Relational Psychoanalysis and Psychotherapy Conference “From the Margins to the Centre: Contemporary Relational Perspectives” in my capacity as discussant of Gill Straker’s work, which included the viewing of the film Night Cries by Tracey Moffatt. I focused on the relationships that are characterized by abuse of power, by inequalities that define interpersonal relationships, and by the type of trauma that ensues from them and on the ways and possibilities to find a way out, a method to reconcile with the victims.     

Getting in Tune: Songs of My Experience in Psychoanalytic Training

I use the metaphor of music and dance to explore cognitive, affective, and liminal elements of my training experiences in the New York University Post doctoral Program in Psychoanalysis. I highlight experiences with supervisors and patients, which shaped the development of my identity as an analyst, and the emergence of my analytic voice within a relational paradigm.     

The Development of a Personal View of the Psychoanalytic Field

This paper summarizes the development of my professional identity as psychoanalyst and psychiatrist. It describes the influences on my dedication to the study of severe personality disorders, namely, the training experiences I had under the guidance of Ignacio Matte-Blanco, in Chile; the research team of Jerome Franck at Johns Hopkins; the work in the Psychotherapy Research Project of the Menninger Foundation under Robert Wallerstein, my personal working relationship in New York, with Edith Jacobson, Margaret Mahler, the introduction to British Psychoanalysis by John Sutherland, and to French analysis in sabbatical times in Paris. I conclude by a brief overview of my theoretical orientation, combining ego psychological, object relations, and Kleinian approaches in the development of a synthesis that inspired my present research on the psychoanalytic psychotherapy of severe personality disorders.     

Response to Irene Cairo,Rogelio A. Sosnik,and Eyal Rozmarin

I have based my response on several central points put forward by my discussants. This has provided the opportunity to explore different frames of reference. I focus on the validity of some notions such as identity or belonging to a stable institution. Also I discuss the different viewpoints concerning how we construct our sense of belonging, proposing that in order to belong to a relationship, it is necessary to continually work at this relationship. I also state that representation is distinct from presentation and that each of them has a different logic. This is also true for identification and the relationship between two or more others. My view is that the concept of otherness and presentation cannot be included in the hypothesis of transference–countertransference. It needs another one name, Interference. As these are unfamiliar concepts, it is clear that sometimes they are likened to more established ones. Using Eyal Rozmarin's remarks about how a feeling of intimacy was created at a dinner party with friends, I challenged the validity of this concept of intimacy in the construction of relationships. I also emphasized the importance of tolerance of others as Irene Cairo suggested. I feel strongly that our work with patients is not difficult but rather challenging and stimulating.     

I Am a Mystery to Myself

Throughout my lifetime I have had a vague sense of my identity. There were no distinct memories or stories from my childhood and adolescence to provide me with the recognition, much less an appreciation, for who I was in the world. It wasn’t until I entered psychotherapy that revelations about my family life came into understanding. This was not from any recollecting of actual events but from the indirect observations of families where being engaged with each other had occurred. Through psychoanalysis, reading a variety of psychoanalytic thinkers, and by taking up my own writing I was encouraged to discover myself, even at the cost of the sorrow of never having that encouragement in growing up, the cost that comes with the exploration. Where no childhood home was to be found a new one was to be created instead.     

My Perspective on Psychotherapy Integration: An Outsider Who's Out of It

My rejoinder is a response to two commentaries on my SEPI keynote in 1997: commentaries written by Goldfried and Cullari. Instead of grappling with the ideas I presented, both respondents were distracted by my satirical beginning. In my talk I proposed a method for studying psychotherapy integration. I am not pessimistic about the potential for integration, nor am I pessimistic about psychotherapy. But I am a skeptic, and science is driven—and indeed advance—by skepticism. In fact, psychotherapy integration requires that its advocates be skeptics. I still do not know what psychotherapy integration is, and remain confused. I can only conclude that I am not only an outsider, but out of it.     

Die Wiederherstellung der Zeit in der ambulanten Psychotherapie mit Psychosekranken

In psychoanalytic psychotherapy with psychotic patients, a disturbance in time experience quite frequently turns out to be central to the psychotic experience as a whole. These patients experience disruptions in the flow of time that lead to a loss of temporal continuity. This loss of temporal structures causes damage in thinking functions: Relations like causality, finality and others which imply a temporal dimension, cannot be established any more. Parts of treatment histories serve to demonstrate the reconstruction of temporal continuity by the patient in psychotherapy. Object-relation-theory and Piaget’s experimental psychology provide the frame of reference for the understandig of the mental processes involved. At the beginning of the psychotherapy the patient experiences being together with the therapist and being separated from him as two discrete conditions of existing which have no links. The periodical reappearance of being together in combination with the awareness of the therapist’s continuous ongoing care encourages the patient to remember and to envisage the meetings with the therapist. The reliability of the alternation seems to stimulate a specific mental activity which creates connections allowing for transitions between the different conditions — in the sense of Winnicott’s transitional phenomena. Transitional phenomena which sometimes are quite concrete things bridge the gap between presence and future. Narrating serves as a link to the past. Through these creative ego-activities temporal continuity is regained providing the basis for strucured thinking and — very important — for the perception of one’s own personality and its continuity over time, thus generating a sense of identity. This process of reconstructing time is interesting in itself, because it sheds light on the psychodynamics of the restitutional processes after a psychotic illness. Moreover, it allows for hypotheses about the development of the inner time dimension in early childhood.     

The Paradox of Holding and Recognizing and the Local Moving Along of the Therapeutic Process

In an attempt to provide a first incomplete answer to the question raised by the editors as to “what cures traumatized patients,” I join my voice to that of the many authors who associate therapeutic action with the process of affect regulation that develops within the analytic dyad. I believe that we are yet to find effective ways of describing the therapeutic process so that the fundamental elements can be reflected upon and studied by therapists. This is especially important when we are working with severely traumatized patients. One of the challenges we are facing today has to do with the way in which therapists communicate such experiences to each other. In our reflections, it all depends on the level at which we situate ourselves, if the therapist places himself/herself at the local level of the interactive process he/she needs to learn to stand in the uncertainty of the security and change paradox relying on the intersubjective process itself. With traumatized patients the challenge in psychotherapy almost always involves the ‘treatment that hurts’ paradox.     

“A Place to Enter and in Which to Feel”: Reply to Cath,Levine, and Peltz

In this response, I clarify my argument for the utility of affectively organizing and containing work in the treatment of a traumatized child. I find myself in agreement with many of the comments of Peltz regarding the vitalizing aspects of the work and Levine’s discussion of scaffolding to promote development. I delineate my thinking in response to Cath’s queries about transference, Oedipal themes, and the value of interpretation.     

Rituals of Madness in the Practices of Place

While completing a PhD in literature with a focus on the practices of physical and linguistic spaces, I was also working and sleeping (on call) at a dilapidated house in a poorer part of Bristol in case I was needed by one of five paranoid or clinically psychotic residents. I gave out medication in the morning, then went home to study in a small rented room. I began to see ritual everywhere - in my professors' routines; my own habits; the behaviours of the mentally ill patients. This paper is the story of a number of madnesses and the problems with reading ritual performance in everything we do.     

On psychoanalytic figures as transference objects

One of the tasks that analysts and therapists face at a certain stage in their career is how to develop a way of psychoanalytic thinking and practising of their own. To do this involves modifying or overcoming the transferences established during their training or early career. These transferences are to one's teachers or training analyst, investing them with authority and infallibility, and to received theory, which is treated as though it were dogma. The need to free oneself from such transferences has been discussed in the literature. There is, however, another kind of transference that the developing therapist also needs to resolve, which has received little attention. This is the transference made on to a key figure in the psychoanalytic tradition. Such a psychoanalytic figure will be seen as the originator of or embodiment of those theoretical ideas to which one becomes attached, and/or as standing behind one's training analyst or seminal teachers who become a representative of that figure. The value of an investigation of one's relationship to a psychoanalytic figure is that it is an excellent medium for revealing one's transference, as the figure in question is not a real person but only exists through his/her writings. The body of the paper consists of an extended example of such an analysis, that of my own transference on to the figure of Winnicott. In this example I illustrate how my evaluation of Winnicott's ideas changed from seeing them as providing answers to all my clinical questions to no longer satisfying me in some areas of my work. This change in my relationship to Winnicott's theory went hand in hand with a modification in my transference on to the figure of Winnicott, from seeing him as endowed with authority and goodness to an appreciation of him as a still sustaining figure but now with limits and flaws. In the final part of the paper several questions arising out of my analysis are posed. Can the pull of writing such an account in terms of dramatic rupture rather than gradual and partial change be avoided? Should my account be regarded purely as a form of self‐analysis or does it have anything to say about Winnicott himself and his theory? And do some psychoanalytic figures attract more intense or sticky transferences than others?     

Psychoanalytic aspects of inpatient treatment

This paper looks at the experience of inpatient hospital treatment at the Cassel Hospital and how formal psychoanalytic psychotherapy, with its emphasis on the transference and the inner world, fits into that context and orientates itself to some of the realities of the setting. It outlines how psychotherapy and nursing can work to inform and enrich each other, and what is psychoanalytic about the overall work. A bridge of understanding is built using the patients' perceptions of, adjustment to and conflict about the inpatient setting, and the affective impact of the processes on patients and staff alike. Two clinical examples of severe child abuse family cases are given, the first of Munchhausen syndrome by proxy, the second in which a baby sibling had been killed. They show how in-depth psychoanalytic work with mother and child and individual psychotherapy of the child can be combined with psychotherapy of the parents and intensive work in the therapeutic community. Such a combination can contribute, even in cases of severe pathology, to the development of the relationship between mother and child and promote successful rehabilitation in the outside community.     

HAROLD SEARLES: LIFELONG WORK OF A MASTER CLINICIAN

Harold F. Searles was one of the most gifted and innovative clinicians of psychoanalysis. His clinical work arouses interest on its own merit, as well as for the ways in which it shaped his highly innovative thinking. We can only imagine what special processes were developing in Searles’s inner world under the everlasting impact of his experience with psychotic patients and from his life in general. Searles focused extensively on how the psychotic individuals’ mental distortions impacted their capacity to form personal relationships in general, and the role of the analyst and countertransference in treatment. This unique viewpoint helped him sustain a creative commitment to psychotic patients, regarded by many as unsuitable for psychoanalysis.     

Now and Then

I describe my development as a psychoanalyst from my dream of psychoanalysis as a revolutionary movement battling against ignorance and fixed beliefs to finding in Freud's theoretical framework a reliable, scientific base from which I could pursue my own thinking. I trace the evolution of my thinking through my experiences on the training and at my first post-training job in an antenatal department. I give an account of the culmination of my analytic development in my work at Brent Adolescent Centre where my husband, Moe Laufer, and I developed our theory of developmental breakdown in adolescence. Here we pioneered work and research with adolescents in analysis and at the walk-in center.