Audit in psychoanalytic psychotherapy with children and adolescents

The importance of multidisciplinary audit in child and adolescent psychiatry, including the work of child psychotherapists, is discussed. Research is highlighted which shows that certain groups of children in particular benefit from psychoanalytic psychotherapy. The problems related to auditing psychoanalytic psychotherapy are discussed, and a possible method of audit based on peer review of notes, which takes into account both inner and outer change, is presented.

A patient is discussed whose notes have been audited using the audit form. It is suggested that this form of audit has good educational potential as well as ensuring a high standard of patient care.     

Thoughts about the internalised speaking object: psychoanalytic psychotherapy with children of delayed verbal development

This paper discusses the meaningful effects of intensive psychoanalytic psychotherapy on language development in children with verbal delay or disorder. Three clinical cases of children aged five to seven are presented; two of these display significant verbal delay and one exhibits unusually high verbal abilities. Following Meltzer, the author explores the concept of the ‘internalised speaking object’ – a good object speaking to the child, which has been internalised. This internal model is essential for the child’s development of language and speech. At times, these children experience this internal object as a persecutory object which must be warded off and avoided. Even more so, when the external object addresses the children verbally, language itself becomes a persecutor and they experience a fear of disintegration. During such times, the therapist must find new and creative ways for communication. The author describes his therapeutic efforts in dealing with these difficulties which stem both from the lack of a reciprocal verbal communication and from the therapist becoming a persecutory object to the child, and demonstrates the manner in which he facilitated gradual shifts in the patient, from an anxious and defensive position into a more relaxed one. These efforts set in motion a process of internalisation of a speaking object by the child and the development of internal language, that is, thinking along with expressive verbal language. The article furnishes some evidence to support the idea that verbal development relies significantly on establishing good, strong and healthy early object relations.     

Acting,feeling and thinking: psychoanalytic psychotherapy with Tracey

This paper consists of a case study and commentary which formed a part of the inaugural lecture in a series entitled ‘Working with Psychosomatic Issues’*. The audience consisted of psychoanalytic, body psychotherapy and integrative practitioners. The presentation was divided into three parts, (1) an outline of philosophical themes that inform perspectives on health, illness and psychosomatic phenomena, (2) the case study reproduced below and (3) a summary of Winnicott's work (1960, 1966, 1988) on ‘the indwelling of the psyche in the soma’. The case study describes work with a young woman who harms herself through self-hitting and, in addition, expresses other physical manifestations of psychological distress. The core approach of the practitioner is psychoanalytic. The work is informed also by postmodern sensibilities and phenomenological themes.     

Politics in psychotherapy: Therapists' responses to political material

This paper reviews the psychotherapeutic literature that addresses the ways in which political material is engaged with by psychotherapists. The paper explores this in both the traditional and contemporary psychotherapeutic approaches. The paper concludes with a recognition of some of the challenges psychotherapy faces in developing politically sensitive approaches which draw upon the lessons learned across therapeutic theory.     

Concurrent individual and individual-in-a-group psychoanalytic psychotherapy

This paper's thesis is that concurrent individual-in-a-group and individual psychoanalytic psychotherapy can be conducted in conformance with psychoanalytic principles of treatment as well as can individual psychoanalytic psychotherapy alone. American psychoanalysts have shown little interest in group psychotherapy, probably because of earlier criticism that transference is diluted by the greater reality of the therapist in group psychotherapy. This is a misconception extrapolated from the mirror model of dyadic analytic technique. The criticism was formulated during a period when that model was prominent and there was little awareness that the actual personal relationship between patient and analyst played an important facilitating role in the dyadic analytic process, including providing a basis for investiture of transference. Also, the criticism was based on one-session-per-week group psychotherapy, whereas concurrent individual-in-a-group and individual psychoanalytic psychotherapy utilizes two group sessions plus one or two individual sessions per week, enabling a more intensive patient-therapist relationship. Concurrent group and individual psychoanalytic psychotherapy constitutes a contribution to the widening scope of application of psychoanalytic treatment.     

Lines of advance in psychoanalytic psychotherapy

Freud's 1919 paper is taken as a starting-point to review how far we have advanced towards fulfilment of his prophetic remarks about the need to develop psychoanalytic psychotherapy for the masses. A glance is taken back to some of the circumstances and characters involved in Budapest where the paper was given at the 1918 congress, where there was much talk about the need to do something about the war neuroses. Similar pressures led to the founding of the Tavistock Clinic and Cassel Hospital in the UK, long before the start of the NHS. The pressures of both world wars advanced the applications of psychoanalysis; the next wave of pressures may come from NHS changes and entry into Europe. The history of psychoanalytic psychotherapy in the UK is also considered via looking briefly at the history and development of psychoanalytic publications, of the Tavistock Clinic, of psychoanalytic training, of child psychotherapy and the emergence of adult (non-medical) psychotherapy. There have always been tensions between exponents of the pure gold of analysis and the needs of its wider applications. More flexible arrangements and boundaries are necessary if we are to spread psychoanalysis beyond London and to fulfil Freud's own hopes about the large-scale application of psychoanalytic therapy.     

Dream frequency in psychoanalysis and psychoanalytic psychotherapy

The authors examine data on dream frequency from 50 patients, half of whom were seen in psychoanalysis and half in psychoanalytic psychotherapy. Frequency, defined as the proportion of sessions where at least one dream is related, is analyzed statistically as a function of sex, age, and type of treatment. Also, treatment outcome is examined as a function of sex, type of treatment, diagnosis, and dream frequency. Psychoanalytic patients are found to have higher dream frequency than the patients in the psychotherapy group. Higher average dream frequency is correlated with a better treatment outcome in both patient groups.     

On the nature and standing of psychoanalytic psychotherapy

In this paper, I offer some reflections on the standing of psychoanalytic psychotherapy in the National Health Service (NHS), with special reference to contemporary forms of evidence-based thinking. I consider what may follow when a narrow view of science or psychotherapeutic practice becomes conventional wisdom and assumes dominance. I place stress on the potential loss to NHS psychology and psychiatry if psychoanalytic psychotherapy becomes increasingly marginalized on the one hand, or overly standardized on the other.     

Narcissism and childhood recollections: a quantitative test of psychoanalytic predictions

Different psychotherapeutic theories provide contradictory accounts of adult narcissism as the product of either parental coldness or excessive parental admiration during childhood. Yet, none of these theories has been tested systematically in a nonclinical sample. The authors compared four structural equation models predicting overt and covert narcissism among 120 United Kingdom adults. Both forms of narcissism were predicted by both recollections of parental coldness and recollections of excessive parental admiration. Moreover, a suppression relationship was detected between these predictors: The effects of each were stronger when modeled together than separately. These effects were found after controlling for working models of attachment; covert narcissism was predicted also by attachment anxiety. This combination of childhood experiences may help to explain the paradoxical combination of grandiosity and fragility in adult narcissism.     

The symbolic and concrete: Psychotic adolescents in psychoanalytic psychotherapy

Unique disturbances in symbolisation are characteristic of the pathology of schizophrenia. Drawing on the case vignette of a psychotic adolescent, the author discusses theoretical problems in the symbolisation process in general and then in psychosis, in particular the relation between 'concretism' as a thought disorder and other psychotic defences. The ability to symbolise on the one hand and to maintain sufficiently stable ego boundaries on the other hand are examined in their relation. The author's clinical experience supports her hypothesis that there is a close relationship between the impairment of the symbolisation process in the adolescent or adult psychotic patient and his/her inability to engage in symbolic play as a child. Special attention is paid to the role of early trauma and consequent pathology of object relations for disturbances of symbolic play in childhood. Regression to concrete thinking is understood as the chance of the psychotic patient to give some meaning to reality in an unreal, delusional world and as his/her last chance to communicate at all. Conclusions are drawn for psychoanalytic techniques in the treatment of patients who are deeply regressed in this respect. Special attention is given to the particular circumstances and challenges of adolescence and to providing psychoanalytic psychotherapy to adolescent psychotic patients.