An exploratory study of psychodynamic therapists’ working with people with multiple sclerosis

There is little published on working psychodynamically with chronic illness and even less on the clinical insights of therapists working with people with multiple sclerosis. The objective of this study was to consider therapists’ reflections on the impact of multiple sclerosis on the internal worlds of clients with multiple sclerosis. I would also like to think about the challenges multiple sclerosis presents and how these challenges are worked with therapeutically. Finally, the impact of my multiple sclerosis diagnosis upon the research interviews was considered. Twelve counsellors / psychotherapists who had experience of working with clients with multiple sclerosis were interviewed. Data was analysed thematically and the findings revealed a number of significant themes. Denial appeared significant both for those with multiple sclerosis and those therapists working with them. Therapists also identified that people with multiple sclerosis hold a range of conscious and unconscious feelings in relation to their multiple sclerosis. Also, the meanings and impact of multiple sclerosis are broad and idiosyncratic. Therapists also faced a number of challenges in their work with people with multiple sclerosis: powerful countertransference feelings which could disable the therapy, embodied countertransference, the tendency to make generalisations, the physical reality of multiple sclerosis and its impact upon continuity, therapists’ unconscious phantasy and associations which if unaddressed could impact their ability to work with illness and the pressure multiple sclerosis placed on therapeutic boundaries. Therapists within the study recognised the need to work with both the physical reality of multiple sclerosis, as well as its psychological impact while at the same time keeping themselves open to powerful countertransference feelings and using them in the service of the therapy. The study has implications for theory, practice and future research.     

Trauma, Regression, and the Intensive Group Experience

Ferenczi contributed a theory of trauma and regression that has application in the contemporary practice of group therapy. This article seeks to present an extension of these seminal ideas in the form of interventions based on therapist induced regression. The Intensive Group Experience (I.G.E.), a time extended group format found to be necessary for extensive emotional reliving and working through of trauma is described. A clinical case example is then discussed in detail and concludes this report.     

Links among theory, research, and practice: cornerstones of clinical scientific progress

Discusses how explicit links among clinical theory, research, and practice are necessary if a clinical discipline is to survive in the managed care marketplace of today. Robust links among theory, research, and practice enable the elaboration of a systematic body of clinical knowledge that is practical in its deployment, effective in its methods, and compelling in its rationale. Moreover, theoretical advances are increasingly necessary, in that they allow scientists to categorize and prioritize the growing amount of empirically derived information, determine how pieces of multilevel data fit together, identify knowledge gaps, and set priorities for future studies. As shown by some of the articles in this special section, evolving theories of behavior have several characteristics in common; namely that they are developmental, transactional, contextual, adaptational, multilevel, and multidetermined. Concerns may be raised, however, as to whether current research methods are fully adequate to test these newer, more complex, multilevel theories or the clinical phenomena they seek to characterize. To address these difficulties, as well as to increase the pace of scientific advances that may result from propitious links among theory, research, and practice, I offer several recommendations to clinical psychology in general and to clinical child psychological research in particular.     

Trauma,Healing and The Reconstruction Of Truth

The author analyzes recent developments in trauma theory, made necessary especially after the massive psychic traumas following World War II and the Shoah. The theories of Freud and Ferenczi are analyzed, especially, their different views of reality and their clinical attitude. When working with survivors of any trauma (from incest to genocide) it is necessary to reconstruct the historical details as carefully as possible, with the appropriate timing. Psychoanalysis is therefore viewed as an ethical and political practice similar to testimony, allowing the reconstruction of truth within the community and interrupting the cycle of the death instinct from one generation to the next.     

Is second order practice possible?

This paper looks at the difficulties in applying second order ideas to therapeutic practice. It considers, first, what second order ideas are and how they relate to one another, second, what second order practice looks like, and third, the problems these ideas create when trying to apply them. It is argued that their pure application is impossible given our strong moral beliefs, but that there are good ethical and aesthetic reasons for taking such ideas as far as we can.
'There are always people who possess a theory they cannot act on.'(Leih Tzu from The Book of Leih Tzu)     

The hyperreality of clinical ethics: A unitary theory and hermeneutics

Medical ethics nowadays is dominated by a conception of ethics as the application of moral theories and principles. This conception is criticized for its depreciation of the internal morality of medical practice and its narrow view of external morality. This view reflects both a lack of interest in the empirical realities of medicine and a neglect of the socio-cultural value-contexts of medical ethical issues, including the creative development of a broader philosophical framework for a practicable medical ethics. Several alternative approaches and conceptions have been proposed. The unified clinical ethics theory, developed by Graber and Thomasma, is an interesting attempt to synthesize these alternative approaches. It correctly identifies as the crucial problem the present disconnectedness of medical ethics from theoretical philosophy as well as the practice of medicine. In this paper, however, it is argued that the unitary theory should take more serious attention to the hermeneutic character of medicine as well as ethics. This implies that the unitary theory must in fact transform itself into aninterpretive clinical ethics theory. The theoretical characteristics and practical consequences of an interpretive theory of medical ethics are discussed in the present paper.     

Childhood and Trauma

In this paper, I follow the evolution of the concept of trauma within psychoanalytic theory, and some of the effects of this evolution. Starting out from the point where Freud gives up the theory of trauma as the cause of neurosis in 1897, and the alleged reasons for such a change, I analyze the theoretical and clinical consequences of this change within psychoanalysis. I proceed to develop Ferenczi's ideas on trauma, their relevance to present-day psychoanalytic theorizing and practice, as well as for the understanding of the psychic processes in children, tracing the development of some of these ideas in contemporary psychoanalytic thinking.     

A critical examination of Michael Polanyi's conception of skills

In this paper I will consider some of the main issues in Michael Polanyi's discussion of ‘Skills’ from Chapter 4 of his book Personal Knowledge published in 1958.The concept of ‘skill’ features prominently in psychological theories of human performance in activities such as games, gymnastics, swimming and dance; such theories are often applied to other spheres of human activity in which issues about skill acquisition arise. It is not surprising to discover that skill theory is considered to be essential to the study of human movement and physical education. Physical education teachers in schools have consistently maintained that ‘skill acquisition’ is a major objective for the P.E. curriculum — see Kane 1974. Yet concepts such as ‘skill’, ‘ability’ and ‘know-how’ are constituent features of practical knowledge therefore the notion of ‘skill acquisition’ on its own will not do as a curriculum objective since all instances of skill and practical knowledge are specific to their contexts, namely, to different practical activities. If particular activities are valued in schools in the pursuit of children's learning and education it seems necessary to clarify the epistemological features of such activities in order to understand what it means to teach them and what it means for children to learn and know-how to perform them successfully. It is in these respects that the concept of ‘skill’ in different human activities should attract the interest of physical education students. In order to draw attention to major features of Polanyi's thesis on the nature of ‘skill’ I shall consider the relevance of his ideas about skill and knowledge in relation to human action theory. I suggest that misconceptions may arise in teaching and learning theories relating to ‘playing soccer’ if the basic underlying ideas about ‘skill’ in human activities are inconsistent with ideas about human action or, say, practical reasoning. It is this issue that is not, in my view, attended to by Polanyi in his discussion of ‘skill’. Thus, if my criticisms of Polanyi's ideas are shown to be valid it will be necessary, by implication that is, to exercise caution before any attempt is made to use his thesis as a basis from which to formulate ideas about teaching skills and skill acquisition. The extensive use I make of quotations from Polanyi's writings is necessary because it is towards Polanyi's use of language in his explanation of ‘skills’ that much of my criticism is directed. It is hoped that what follows may provide students of human movement and physical education with an insight into Polanyi's view of ‘skills’ in particular and to issues related to skill theory and human action in general.     

Healing the wounds of our fathers: intergenerational trauma, memory, symbolization and narrative

This paper explores the history of psychoanalytical approaches to intergenerational trauma, both from the Freudian and from the Jungian schools, and addresses the need when we speak of intergenerational or transmitted trauma to better define the nature and the different categories of trauma with particular reference to extreme and cumulative traumas such as those experienced by the survivors of the Nazi death camps and the Russian gulags. Therapy with survivors and with their children requires a particular adaptation of analytical technique as what is at stake is not so much the analysis of the here and now of the transference and countertransference dynamics which indeed can in the early stages be counterproductive, but the capacity of the analyst to accept the reality of the trauma with all its devastating and mind-shattering emotions without losing the capacity to imagine and to play metaphorically with images, essential if the patient is to be able to create a space for representation.     

Immigration,Belonging, and the Tension Between Center and Margin in Psychoanalysis

Immigration is in the unconscious of the unconscious of psychoanalysis. Immigration as a dramatic instance of the always precarious social and political registers of human living. Immigration as the movement of people from one place to another, across regions and national borders and oceans, by choice or necessity. Immigration as movement across other types of social boundaries, always defining an outside and a way into a desired inside. Immigration as an inverted reflection of our deep need to belong. This paper reflects on immigration as a clinical reality and as a clinical metaphor. It uses the notion of immigration to question the perceived, often if not always illusory settledness of the analytic practice, and its tendency to privilege a sense of well-inhabited center vis-à-vis the margins we all travel through and persist in. My aim is to join Veronica Csillag in deliberating a more uncertain and daring potential for our theory making and practice.     

A Mixed Bag: The Realities of Psychoanalytic Practice

For a variety of reasons, psychoanalytic training is done in somewhat of a vacuum. It teaches a theory and a way of practicing that does not always translate well to day-to-day private practice work. The clinical realities of psychoanalytic practice prove the psychoanalytic method to be one that provides help to a wider audience than classical psychoanalytic training programs might suggest. The psychoanalytic approach offers the analyst many special opportunities to work with and help a wide variety of patients. Analysts who accept both the limitations as well as the wide application and broad benefits of the psychoanalytic approach may have a more fulfilling experience than their training experiences might foster. At the same time, the analyst's level of therapeutic skill, the patient's diagnosis, and many multiple external factors create different limitations in the practice and outcome of psychoanalytic work. Extensive case material is used to show the broad range of patients who are helped by the psychoanalytic method. The clinical material also shows the less than perfect, but often good enough outcomes of these difficult cases with often severely disturbed patients.     

The Misuse and Use of Science in Family Therapy

The wish to adopt ideas and metaphors from science can have a constricting effect on thinking about family therapy theory and practice. We describe three examples from the recent literature. The two problems describe: (a) borrowing the prestige and certainty of scientific ideas and metaphors and using them as cultural representations of reality, and (b) embracing certain philosophically comprehensive systems of thought. We then recommend some appropriate borrowing from the natural history tradition of science, and give some examples of ways in which that tradition has widened rather than narrowed the range of ideas that are used in family therapy.     

Jungian metapsychology and neurobiological theory

This paper deals with brain research and depth psychology. Because brain research is becoming significantly more sophisticated and increasingly able to assay the neurobiology of subjective (i.e. mental) events in vivo , it is suggested that any school of depth psychology will probably not survive as a mainstream treatment modality if its theory and practice is found to be in frank variance with the findings of the modern neurosciences. Jung's psychology is compared to Freud's and shown to be reasonably consonant with such findings. Historical highlights of Jung's non-reductive way of conceptualizing and working are presented and put in the context of more recent scientifically defensible concepts (emergence, supervenience, complexity theory) from the fields of both philosophy of science and philosophy of mind. These concepts postulate a hierarchical model of reality which permits an exploration of the mind/brain relationship without resorting to reductionism or dualism. A sense of the present struggle is conveyed between the proponents of these and more traditional scientific concepts. Finally, the nature of mind/brain confluence is elucidated by examples from the areas of learning, memory, and the capacity to symbolize in order to illustrate how clinical practices and observations familiar to experienced depth therapists and also in agreement with Jungian theory are compatible with neuroscientific findings. A research suggestion is offered.     

Causal theories of the moving spotlight

This paper brings together the Sarvāstivāda (a major school of Abhidharma Buddhism) and Miller's (2019) moving spotlight theory to see how presentness is explained in terms of causation. The paper argues that a causal theory of presentness like Miller's encounters a dilemma: causation is either synchronic or diachronic, but neither is safe in the presence of the challenges. On the one hand, if causation is synchronic, how does a causal chain extend over time so that the wave of causation (and hence the spotlight) can move at all? On the other, if causation is diachronic, then a present moment has a temporal extension enough to accommodate a cause and its proximate effect. The paper proposes a synchronic notion of causation that counters the first challenge. This can be done by bringing together the Sarvāstivādin grasp-production model of causation, some Stoic ideas about causation, and some Armstrong's metaphysics.     

Boundaries in the practice of humanistic counselling

The multifaceted concept of boundary is used to describe the ground rules, quality and type of therapeutic relationship in a humanistic form of counselling that develops some of the principles of Carl Rogers and blends them with principles from psychodynamic practice. The concept of boundaries is first discussed in relation to its usages and practical consequences. An analysis of some core principles and assumptions about boundaries that guide the communicative psychotherapy approach of Robert Langs leads into a comparison with person-centred counselling. The aim is to develop a middle path for humanistic practice along more formal lines, involving a more fluid understanding of relationships and precise use of counselling principles. This also involves finding aspects of agreement between the psychodynamic and humanistic styles of working, by omitting some concepts and practices and identifying areas of common ground. Several comments on practice are made by comparing the two perspectives. The concept of boundary enables counsellors of all schools to think about points of similarity and difference. Finally, the notion of boundary itself is critiqued, and intersubjectivity is proposed as a potentially more meaningful term.     

Some brief considerations on the relationship between theory and practice

The present crisis in models of training and in psychoanalytical education in general can be linked to the gulf that has come to be created between analytical theory and clinical practice. The paper(1) examines the historical facts that have led to this split and suggests the need to return to the models of Freud and Jung. Both these fathers of depth psychology stressed the dangers inherent in the dogmatic use of theory and both insisted that theory must always spring from and be able to account for clinical practice rather than vice versa, as is so often the case today. The paper also looks at how theory should be taught in our analytical institutes in order to ensure that what we transmit to our candidates is not knowledge in the form of dogma but rather a way of proceeding that will enable them to think creatively about their clinical practice and thus produce new knowledge, essential if depth psychology is to remain relevant to our post-modern culture.     

From disconnection to connection: 'Race', gender and the politics of therapy

Person-centred therapy typically fails to address structural dimensions of inequality such as 'race', gender and class. In this paper, I explore why this is, and what can be done about it - at the levels of theory, practice and the organisation of services. Drawing on person-centred theory and practice, I discuss theoretical and practical resources that can inform a critical therapeutic practice that both attends to the individual and connects with social contexts. Focusing on the intersectionality between gendered and 'raced' positions mobilised within any therapeutic intervention highlights the inevitability of working across various dimensions of structural difference and power. Rather than obscuring these, I illustrate how a direct engagement with them can enhance person centred theory and practice. In particular, I highlight the role of racialised and gendered conditions of worth (Chantler, 2004) together with concepts of minoritisation and intersectionality (Batsleer et al., 2002). I also indicate ways forward for inclusive counselling services.     

Reclaiming the Idea of Truth: Some Thoughts on Theory in Response to Practice

This paper examines the idea of truth, its place in therapy and in the history of systemic theory. Beginning with some practice fragments, the theory exploration considers the idea of truth in the modernist frame, the paradox of the modernist metaphor in describing the activity of therapy, and the peculiarities of the idea of truth in the earlier systemic therapies. Postmodernist and social constructionist ideas are then explored, and meaning is identified as the concept which currently occupies the place of an idea of truth in systemic discourse. It is argued that meaning as a concept is insufficiently attached to an idea of (external) reality or to an understanding of the relationship of the individual to knowledge of her/his experience of the world. Reclaiming the idea of truth as an emotional and social process has more potential to meet the complexities of human experience in thinking about the process of therapeutic change.     

A Synthetic Approach to Bioethical Inquiry

This paper attempts to sort out some of the current tensions and ambiguities inherent in the field of bioethics as it continues to mature. In particular it focuses on the question of the methodological relevance of theory or ethical principles to the domain of clinical ethics. I offer an approach to reasoning about moral conflict that combines the insights of contemporary moral theorists, the philosophy of American pragmatism, and the skills of rhetorical deliberation. This synthetic approach locates a proper role for moral theory in the practice of clinical ethics, thus linking abstract philosophical ideas about morality, humanity, suffering, and health to specific deeds, actions, and decisions in the concrete lives of particular individuals. The aim of this synthetic approach of bioethical inquiry is a rapprochement between theoretical knowledge in moral philosophy and the contextualized, relational, and practical understanding of what morality demands of us in our daily lives. I argue for a conception of bioethical inquiry that takes morality to be a study of certain practical, socially embedded concerns about matters of right and wrong, good and evil, as well as a study of the moral theories by which these actual concerns can be explored and critically evaluated.