‘Characters’ in psychoanalytic and interpersonal therapy: A comparison

In this paper the author considers how the therapist might listen to the characters talked about by his or her patients. In psychoanalytic therapy the emphasis is on listening to the patient's characters as though they are located in psychic reality and as representatives of the transference relationship, whereas in interpersonal therapy (IPT) the patient's characters are taken as inhabiting the realm of external reality. It is argued that clinical thinking in IPT would be enhanced by taking more account of psychic reality, which will make clearer the quality of external reality in which the patient's characters are located. It is also argued that both therapies share an interest in enabling the patient to find characters which can serve as holograms of previously unexpressed affective experience.     

Plea for a Balanced Conception of AD/HD and Its Diagnosis and Treatment

AD/HD may be overlooked as well as too zealously and concretely overdiagnosed. When this condition is properly identified, it is most fruitfully understood in a balanced manner that is integrated with an appreciation of its inevitable shaping influence on the patient's perceptions, self-experience, and psychodynamic constellation, including central unconscious fantasies. This exploration is necessarily multifaceted: the patient's internal experience of states of distractibility, impulsivity, and hyperactivity, their incorporation in unconscious fantasies, and their employment in the service of both self-punitive urges and defenses against the “unpleasure” (Brenner, 1982) associated with psychic conflicts. Psychoanalysts are in a unique position to grasp these complex relationships. Familiarity with diagnostic issues, the developmental impact of AD/HD, common difficulties such patients present in treatment, and typical countertransference responses will enrich their psychoanalytic work. Interrelationships between AD/HD and the patient's psychic world are presented as they arose in the analysis of a child and an adult.     

Mind the baby: The role of the nanny in infant observation

The influence of nannies and other significant caregivers on a child's psychological and emotional development may be profound and if unrecognized may contribute to psychopathology in adulthood. However, the significance of the nanny has been relatively neglected within the psychoanalytic literature. In this paper I will discuss the impact of early caregivers other than the biological mother on the psychic development of the child, and the role of the nanny within the family dynamics as a figure attracting powerful unconscious phantasies and unwanted projections. These ideas will be illustrated by a detailed account of a year‐long observation of an infant who had a succession of several different nannies in her first three months before her parents employed a more permanent nanny. It is proposed that the baby's emerging attachments to her two primary caregivers, mother and nanny, developed in parallel and influenced each other, with observable impact on her behaviour and developing personality. The paper concludes with a review of the place of infant observation within psychoanalytic training and how the experience of witnessing the earliest infant‐caregiver relationships in an extra‐analytic setting both refines understanding of developmental theory and builds a foundation for psychoanalytic practice.     

Tactics and empathy: Defences against projective identification

In this paper the author argues that interpretations made when the analyst has not done the emotional work of recognising and bearing what kind of object she has become in the patient's psychic reality will be experienced as empty tactics – even lies – rather than interpretations of integrity. However, interpreting from a position of bearing the truth of the patient's perception will be technically difficult and indicate turmoil as the analyst struggles to take in the patient's view of her. If the analyst avoids integrating her own picture of herself with the patient's picture (despite giving voice to the patient's picture) the split inside the analyst will be felt and intensify the patient's need to split. Vignettes demonstrate how the analyst, believing she is trying to understand, may become a projective‐identification‐refusing object and the issue of the analyst's disclosure of her countertransference is examined. Ultimately, the author argues, a capacity to receive and bear projective identification requires empathy with both patient and analyst‐as‐patient's object, engaged in a process about which both are ambivalent.     

On Digital Consciousness and Psychic Death

This paper describes states of consciousness in some disturbed or traumatized patients in which time is not experienced as being linked to future or past. The patient's experience in this state is “digital” rather than continuous, making it difficult for him to have an inner sense of continual “aliveness” and to link analytic sessions together. In extreme cases, his world may be experienced as a succession of moments interrupted by little blanks or psychic deaths. The experiential, developmental, and neurobiological aspects of these states are explored with an emphasis on implications for psychoanalytic treatment.     

New interpretative styles: Progress or contamination? Psychoanalysis and phenomenological psychopathology1

Psychoanalysis has started to recoup, often quite implicitly, a more phenomenological stance, ever since psychoanalysts have started working with borderline and psychotic patients. As many of these patients have commonly been through traumatic experiences, psychoanalysts have been using an approach that questions the role of traditional psychoanalytical interpretation and pays more attention to the patient's inner conscious experiences; this approach is characteristic of a specifi c form of contemporary psychiatry: phenomenological psychopathology, founded by Karl Jaspers in 1913 and developed into a form of psychotherapy by Ludwig Binswanger, with his Daseinsanalyse. If what we could call a phenomenological ‘temptation’ has been spreading over psychoanalysis, so too has a psychoanalytical ‘temptation’ always been present in phenomenological psychopathology. In fact, even though this branch of psychiatry has led us towards a deeper understanding of the characteristics of psychotic being‐in‐the‐world, its therapeutic applications have never been adequately formalised, much less have they evolved into a specifi c technique or a structured psychotherapeutic approach. Likewise, phenomenological psychotherapy has always held an anaclitic attitude towards psychoanalysis, accepting its procedures but refusing its theoretical basis because it is too close to that of the objectifying natural sciences. Psychoanalytic ‘temptation’ and phenomenological ‘temptation’ can thus be considered as two sides of the same coin and outline a trend in psychoanalytic and phenomenological literature which points out the fundamental role of the patient's inner conscious experiences in the treatment of borderline and psychotic patients.     

Selecting a patient or initiating a psychoanalytic process?

The defences provoked in the analyst by the anxieties associated with the difficult tasks of ‘assessment’ and ‘selection’ for psychoanalysis can result in a tendency to think in terms of ‘hurdles to be cleared’ by potential psychoanalytic patients, rather than ‘opening the gates’. This can result in a diminution of the analyst's capacity to enlist and sustain a psychoanalytic stance. Only within a psychoanalytic frame can a meaningful psychoanalytic process unfold, at all stages of a potential patient's movement from their first contact through to, possibly, entering into an analysis. The author illustrates the value of this thinking by describing the work of the London Clinic of Psychoanalysis where there has been a shift of emphasis in psychoanalytic consultation towards working with individuals on their potential to initiate a psychoanalytic process, and away from the sole aim of ‘selection of a suitable patient’. In this paper, the author notes that when institutional culture and practice supports psychoanalytic identity, this makes it more possible to recognize and articulate the anxieties provoked by the ‘emotional storm’ inevitable in psychoanalytic consultation, and the draw towards unhelpful enactment that may otherwise obscure the initiation of a psychoanalytic process that may or may not result in analytic treatment. Illustrative case material from the Clinic is presented.     

Psychoanalytische Überlegungen zur Pädophilie

Following the long psychoanalytic tradition in the treatment of paedophiles, in a first step this article tries to define structural components of sexual delinquency that on the one hand correlate with the psychoanalytic model of psychic structures and on the other hand are consistent with the clinical experience of forensic psychotherapeutic practice. In a second step different levels of severity in the structural psychopathology of sexual delinquents are described by taking advantage of the object relationship theoretical conception of personality organisation. Finally, in a third step the psychodynamic features of these patients are highlighted, which have frequently been found and described in the clinical psychoanalytic literature on paedophilia including traumatising mother relationship, narcissistic object choice, inadequate triangulation, self-permuting drive, simulation and disturbance of identification.     

Distinction between mental pain and psychic suffering as separate entities in the patient's experience

Abstract

Mental pain and psychic suffering are herein defined as two separate concepts in psychoanalysis. The concept of mental pain lies at the core of psychoanalysis; it was introduced by Freud and was further elaborated by a number of investigators, mostly by Bion. Mental pain refers to a pain that the patient reports as being impossible to describe in words, and lacking any associations, whereas psychic suffering can be both named and described by the patient. Mental pain is derived from non-tolerance on the part of the psychic apparatus when it is harmed by very painful emotions. In contrast to psychic suffering, mental pain resists elaboration and transformation by dream-work. How to address and transform the patient's mental pain is a major challenge facing the analyst in his clinical work because mental pain may halt or slow the progression of the analytical process. To overcome this hindrance, the work of the analyst is focused on helping patients to modify their mental pain into psychic suffering, that is, to reactivate in the patient the chain of transformations that generates thought. The analyst is also challanged with the mental pain of the patients because he has himself to tolerate the mental patient induced by counter transference. Suggestions for the analyst on how to deal with the mental pain of the patient during psychoanalytic therapy are proposed.     

Clinical applications of Matte Blanco's thinking

Ignacio Matte Blanco (1908–1995) left very few specific indications about the applications of his theoretical notions to his interpretative style. The author shows how he uses Matte Blanco to formulate some of his own interpretations. The first part of the paper uses clinical vignettes to illustrate some of Matte‐Blanco's concepts. Their theoretical vocabulary is thus made explicit. Then two psychoanalytic sessions are discussed at greater length, together with one from a therapy, so that the use of Matte‐Blanco's notions can be seen clearly, allowing for a fresh perspective on areas of psychoanalytic theory, particularly dreams, psychopathology viewed according to the proportions of asymmetrical and symmetrical functioning in the patient's bi‐logical mental system, the multidimensionality of the unconscious, the structural unconscious, the emotion‐thought relationship, projective identification, resistance, and negative therapeutic reaction. The practical consequences of all this are elaborated, particularly the ensuing possibility of ‘thinking with the patient' in the session. This enables the patient to introject a form of mental functioning in which the asymmetrical mode is not invaded by the symmetric mode (a parallel can be seen here with the Bionian concept of dialogue between the psychotic and non‐psychotic parts of the mind).     

A psychoanalytical phenomenology of perversion1

After stating that the current tasks of psychoanalytic research should fundamentally include the exploration of the analyst's mental processes in sessions with the patient, the author describes the analytical relation as one having an intersubjective nature. Seen from the outside, the analytical relation evidences two poles: a symmetric structural pole where both analyst and patient share a single world and a single approach to reality, and a functional asymmetric pole that defines the assignment of the respective roles. In the analysis of a perverse patient, the symmetry‐asymmetry polarities acquire some very particular characteristics. Seen from the perspective of the analyst's subjectivity, perversion appears in the analyst's mind as a surreptitious and unexpected transgression of the basic agreement that facilitates and structures intersubjective encounters. It may go as far as altering the Aristotelian rules of logic. When coming into contact with the psychic reality of a perverse patient, what happens in the analyst's mind is that a world takes shape. This world is misleadingly coloured by an erotisation that sooner or later will acquire some characteristics of violence. The perverse nucleus, as a false reality, remains dangling in mid‐air as an experience that is inaccessible to the analyst's empathy. The only way the analyst can reach it is from the ‘periphery’ of the patient's psychic reality, by trying in an indirect way to lead him back to his intersubjective roots. At this point, the author's intention is to explain this intersubjective phenomenon in terms of metapsychological and empirical research‐based theories. Finally, some ideas on the psychogenesis of perversion are set forth.     

Conflict in psychoanalysis and in life

Abstract

Unconscious conflicts are at the center of Freudian psychoanalytic inquiry, in the psychoanalytic situation as well as in the theory of personality and pathogenesis. The core dynamic formulation, intrapsychic conflict resulting in new psychic formation, is addressed in the paper in the following steps.

First, the development of the concept of conflict throughout the history of Freudian psychoanalysis is reviewed. Next, the analytic and synthetic aspects of conflict theory are explored and the role of conflict in the development of personality organization and pathogenesis is clarified. Then, the contemporary extensions and elaborations of structural theory are presented.

To illustrate analysis focused on conflict, clinical material covering the phases of psychoanalytic process is highlighted. From the beginning stage of analyzing the patient's initial diffuse state of indifference and “weirdness”, analysis proceeds to address primary and secondary symptoms of impotence and exhibitionism and underlying passive-phallic personality organization with conflict around aggression. This leads to the patient's sense of mastery over previously enslaving and “immobilizing” internal turmoil.     

Thoughts on autism with special reference to a paper by melanie klein

The article begins with a brief exploration of the various aspects of adolescent's psychic qualities as these are described in Greek mythology. It is argued that myths are an integral part of the way that adolescence is perceived and myths play an important role in adolescents' psychic and external world, as well as in their mythological thinking. Connections are made with the attraction towards the creation of myths about adolescence in ancient and contemporary societies. Three clinical vignettes from adolescents' psychoanalytic psychotherapy are presented in an effort to support the idea of the value and importance of mythology in adolescence in the clinical practice. Through the clinical material, we try to explore how psychic and developmental disturbances, which might lead to psychopathology, are reflected in family and personal myths and also in the mythological thinking of adolescents.     

The interface of family disturbance and individual patienthood

Abstract

This paper addresses the need to approach understanding the individual patient's psychopathology from the vantage point of two etiologic systems: psychoanalytic object relations theory and family systems theory. The complementarity of these approaches is emphasized. It is suggested that the processes of internalization and projection are bridging concepts and that marital relationships provide a unique research context.     

Full and empty spaces in the analytic process2

In this paper the author discusses two categories of patients which differ in terms of the impact they have in the countertransference. On the one hand, there are patients who create an empty space in the analyst's mind. The response they provoke is a kind of depressive feeling that remains after they leave. The patient may bring dreams and associations, but they do not reverberate in the analyst's mind. The experience is of dryness, a dearth of memory, which may‐at times‐leave the analyst with a sense of exclusion from the patient's internal world. At the other extreme, there are patients who fill the consulting room. They do that with their words, dreams and associations but also with their emotions and their actions. The experience is that the analyst is over‐included in the patient's world. They have dreams that directly refer to the analyst and the analyst feels consistently involved in the patient's analysis. The pathway through which the analyst can understand both these types of patients is via the countertransference or, to put it another way, the analyst's passion. In ‘Analysis terminable and interminable’ Freud suggested that the bedrock of any analysis is the repudiation of femininity. The author believes this statement may be viewed as lying at the crossroads of the discussion about the limits of the theoretical and clinical psychoanalytic formulations which she refers to. In the examples presented the author relates the repudiation of femininity in its connections to the gaps implicit in psychoanalytic understanding.     

The Psychotherapeutic Utility of the Five-Factor Model of Personality: A Clinician's Experience

This article summarizes experience using the five-factor model of personality, operationalized by the NEO Personality Inventory (NEO-PI), to facilitate psychotherapy treatment with 119 private-practice, outpatient, psychotherapy patients and their family members over a period of 2 years. Trait theories such as the five-factor model implicitly challenge the premises of much clinical theory, yet they can be useful to clinicians, as they provide a detailed, accurate portrait of the client's needs, feelings, proximate motives, and interpersonal style. I suggest that: Neuroticism (N) influences the intensity and duration of the patient's distress, Extraversion (E) influences the patient's enthusiasm for treatment, Openness (O) influences the patient's reactions to the therapist's interventions, Agreeableness (A) influences the patient's reaction to the person of the therapist, and Conscientiousness (C) influences the patient's willingness to do the work of psychotherapy. Fundamental questions raised by the five-factor model about the nature of psychopathology and psychotherapy are discussed.     

What is the function of faith and trust in psychoanalysis?1

Unlike other concepts such as ‘illusion’, ‘capacity to tolerate frustration’ and ‘libidinal investment’, the concept of faith has not yet found a well‐defined position in psychoanalytic theory. Bion focused on faith and placed it in an unusual context: scientific work. Through the Act of Faith a researcher can give some consistency to certain ideas, hunches or intuitions that may appear during observation, though he cannot represent them by existing theory. Through the Act of Faith an analyst can ‘see’, ‘hear’ and ‘feel’ those mental phenomena, the reality of which leaves no practising psychoanalysts in doubt, even if they cannot represent them by current formulations. In this paper, the author aims to expand Bion's proposals into the clinical and therapeutic fields. In the first part, the author examines how faith and trust overlap, and how they depart from each other, and he gives an example. Faith possesses an igniting and driving force which trust doesn't possess to the same extent. In the second part, the author looks at F as a psychic function of the analyst, which aids him in supporting a depressed and hopeless patient while waiting for the return of the patient's desire to live. In the final part, he focuses on F from the patient's point of view and studies the transformations of F that may occur during an analysis.     

An Independent Theory of Clinical Technique

The history of Independent analysis in the British Psychoanalytical Society is reviewed. The Independent Tradition, as an approach to psychoanalysis, is distinguished from the organisational grouping in the British Society that is the Independent Group. The Independent Tradition emphasises what differentiates human beings rather than how they exemplify general principles. This derives from Freud through Ferenczi. Ferenczi's stress on the quality of the patient's experience, on the need for analysts to be aware of the effect on themselves of the analytic process, and on the need for restraint in interpretation are all characteristically Independent aspects of analytic technique. Later Independent thinkers have developed these themes further. Especially important is Enid Balint's idea that theory mediates the analyst's creative imagination. The analytic setting infuses ordinary human interaction with psychoanalytic awareness, and another function of theory is to imbue with psychoanalytic understanding the use of everyday language. Independent clinical technique is primarily a way of listening. Regression is accepted, and free association valued as being in itself a vehicle of psychic growth. A central idea is that the analyst is an analytic object to be made use of by the patient. Several clinical examples illustrate the functioning in practice of these concepts.     

Disintegration of the self and the regeneration of ‘psychic skin’ in the treatment of traumatized refugees

This paper presents a tentative understanding of the characteristics of the extreme traumas, elsewhere called ‘complex PTSD’, that some refugees and asylum‐seekers bring into therapy. It suggests that these kinds of traumas suffered during adulthood may involve a disintegration of the self and a loss of ‘psychic skin’. This conceptualization is derived from the treatment of a refugee who survived multiple extreme traumas and with whom efforts were made in therapy to identify a complex methodology making use of supplementary therapeutic tools in addition to individual psychotherapy. The case demonstrates how the disintegration of self implies not only a deep somato‐psychic dissociation, but also a loss of intrapsychic and interpersonal space. In the treatment this was worked through via repetition of the victim‐aggressor dynamics at multiple levels. In the end, the therapeutic context was structured like a set of concentric layers, creating a ‘bandage’ over the patient's wounds whilst his ‘psychic skin’ was able to regenerate. The conditions triggered by extreme traumas in refugees challenge some of the cornerstones of individual psychoanalytic technique, as well as the idea that individual therapy may be thought of as existing in an environmental vacuum.     

The Dwelling Places of Self-Experience

Instead of dichotomizing psychic life as either intrapsychic or interpersonal, I suggest we think in terms of a continuum of self-experience from the most private or interior to the most public or exterior. I articulate four “domains”—phenomenologic, intrapersonal, interpsychic, and interpersonal—that constitute this spectrum of self-experience. Each domain lends a specific quality to one's internal life, and together (but in varying proportions) they constitute the psychic dwelling place unique to a given individual. This article illustrates how the variability among our patients in their habitual dwelling places may explain their diverse responses to differing analytic stances, interpretive approaches, and indeed, different analysts. A clinician's awareness of his or her own personal proclivity toward a more interior or more exterior orientation helps promote optimal contact with the patient's psychic life.