Restoring Dyadic Connection in the Face of Multiple Disruptions: Accounting for Vicissitudes in the Therapist’s Capacity for Reflective Functioning

This article describes the working method of our study group comprised of former Chestnut Lodge Hospital therapists and focusing on understanding therapeutic work with severely disturbed adolescents. Using process material from one therapy session, the therapist’s commentary on her feelings and reactions in the session, and the group’s discussion of the work, we explore factors disrupting the therapist’s moment-to-moment capacity to maintain a theory of her own and the patient’s minds. We then discuss what allows her to refind her theory of mind in the face of the patient’s aggressive nihilism and her own sense of loss. Salutary factors included the therapist’s empathy for the patient’s shared sense of grief, the patient’s offering the therapist cues to his inner state, and the dyad’s capacity to tolerate the therapist’s vulnerability in the patient’s presence.     

When the Tree Falls and No One Hears It: On Being Dropped and Learning to Hold

This case study focuses on a student therapist’s reflections upon a premature termination that occurred in her work with an adolescent male patient. The therapeutic process is traced back to the beginning of treatment, and the article delineates the extent in which the patient’s early interpersonal experiences influenced the development of the therapeutic alliance. The author addresses several themes that evolved throughout the treatment, including the patient’s experience of unpredictability and instability and his inconsistent understanding of time, and the ways in which these experiences ultimately influenced the treatment’s ending. The article describes the therapist’s development as a clinician over the course of the treatment, focusing on the various experiences that helped her consolidate a dynamic understanding of the holding environment.     

From Dead to Alive: Desire,Dissociation and Passion in the Analytic Dyad

When patients present in a deadened state, the analyst may feel a sense of futility and shame in his efforts to have impact. This may cause him to withdraw and contribute to an enactment in which both participants purge themselves of wanting anything from the other, sapping the treatment of purpose and aliveness. The author presents a model in which the analyst can reawaken his desire for recognition and connection and utilize it to introduce the patient to his or her own dissociated longings. This involves fortitude on the therapist’s part, since he must withstand the rejection that had caused him to withdraw in the first place, and also be sensitive to the patient’s fear of retraumatization. But if the analyst can do this, he can not only break through the impasse, but enliven the patient and infuse the treatment with a sense of purpose and hope.     

To Be Saved and Not Saved: The Ongoing Challenge of Working in the Depressive Position: Reply to Commentaries

In this response to the generative commentaries by Stefanie Solow Glennon and Steven Cooper, I address issues taken up by the two discussants, including the analyst’s challenges to both work in and help her patient work in the depressive position, and to envision a sense of psychic future. I also explore questions related to Relational notions of therapeutic action, in the context of a recent panel in Psychoanalytic Dialogues that considers whether Relational psychoanalysis has gone too far in the direction of relationality and away from privacy, contemplation, and reverie.     

Typical-Atypical Interactions: One Patient’s Experience of Weight Bias in an Inpatient Eating Disorder Treatment Setting

Abstract

This article examines one patient’s experiences with weigh bias in an inpatient eating disorder treatment setting with a focus on interactions between the patient and her primary therapist. These therapeutic interactions had multiple unintended consequences, including bolstering feelings of denial, modeling of disordered behaviors, and disrupting the therapeutic alliance. Additional instances of weight bias with other treatment professionals, including an inpatient nutritionist and psychiatrist, are briefly discussed. The article ends with several brief recommendations for how clinicians can more skillfully approach issues of weight and size in the therapeutic alliance in order to resist size-related oppressions rather than reinforce them.     

Psychosomatik in der Dermatologie

Psychosomatic dermatology deals with skin disorders that are substantially influenced by psychosocial causes, sequelae or circumstances or in which these are important in the selection of therapy for the particular patient. In this context, skin diseases have been recognized in a biopsychosocial model for holistic medicine. In a wider sense, psychosomatic dermatology embraces every aspect of intra- and interpersonal problems relating to skin disorders and psychosomatic trigger mechanisms and/or ways of coping with skin disorders. A distinction is made between primarily psychic conflicts, psychosomatic diseases and somatopsychic aspects. Approaches to treatment take account of the doctor (doctor’s–assistant)–patient relationship, compliance factors, the dermatosis patient’s quality of life and the psychosocial health of the dermatologist, and also steps that can be implemented in the context of the practice management and basic psychosomatic treatment including referral for special psychotherapy     

Therapist Self-as-Context and the Curative Relationship

This article discusses how the way the therapist relates to his or her personal responses to client material during the session contributes to making the relationship with the client an effective tool for treatment. Ideas from third wave behavior therapy are used to describe aspects of therapist involvement in the relationship and modes of therapist awareness of inner responses. In two vignettes, negative client reactions to an intervention bring problematic therapist material to the fore. Both cases highlight how the stories the therapists spun about themselves as professionals and persons could easily have limited their effectiveness in responding to the material. The vignettes also illustrate how clinicians can overcome personal meanings and judgments to access a more productive mode of interacting with the feelings a critical incident in the relationship evokes in them. It is argued that observing their own content from a psychological distance makes it possible for clinicians to use their feelings without getting caught up in them. These same feelings may then help the therapist perceive how the incident relates to the client’s daily life problems. The therapist’s engagement in a sense of self-as-context is described as a therapeutic stance that provides the psychological distance needed to help overcome alliance ruptures and other potential gridlocks and which may transform the therapist’s inner response to client content into a tool for addressing important client issues.     

Identification with the aggressor and the ‘normal traumas’: clinical implications

Ferenczi's (1933) surprisingly unknown concept of identification with the aggressor – an abuse victim's ‘eliminating’ her own subjectivity and ‘becoming’ precisely what an attacker needs her to be – has radical implications for our understanding of analytic technique. Its very frequent occurrence also forces us to broaden our understanding of what constitutes trauma. Ferenczi saw the experience of ‘traumatic aloneness’ or ‘emotional abandonment’ as the key element of trauma, since this is what enforces the traumatic responses of dissociation and identification with the aggressor. Identification with the aggressor operates in the analytic relationship in both patient and analyst. This has various consequences, including the structuring of the relationship through unconscious collusions – mutually coordinated, defensive identifications designed to help both participants feel secure. This view of the analytic relationship has clinical implications in at least four areas: the understanding of the patient's free associations, which may reflect the patient's compliance with the analyst's wishes rather than the contents of the patient's own unconscious; the need for some kind of mutuality of analysis; the traumatizing potential of the analyst's authority; and the tendency of some patients to take blame and responsibility reflexively, as a way of protecting the analyst.     

Addictive states of mind

This paper explores the meaning of the pregnancy of the therapist as a challenge to the maintenance of the setting for therapy. The patient I shall describe was born ‘black’ in a ‘white’ family and was thus a challenge to her father's sense of paternity and her parents as a couple. She was the visual evidence of an infidelity. The problem had been denied in various ways, going as far as the attempt to deny her very existence. The therapist's pregnancy signified a betrayal of the ideal of a stable setting which was compounded by an earlier absence through illness. This ‘breaking of rules or promises' was then the setting for a re-working of the patient's story.

Setting, it is argued, can helpfully be seen as the mental space created by the partnership within the therapist between maternal and paternal relating to the ‘baby’ of the therapy. This enables a sense of negotiation and relationship in the creation of setting, which can include disruptions and other babies. At the same time the therapy had to work with a fundamental issue of illegitimacy or lack of belonging and the therapist's response to this. The ‘rules' of setting are a means to ensure a place to belong or attach to, but this work emphasized ‘setting’ and belonging as issues of relationship supported and enabled by our rules of engagement, but not reducible to them.     

不只是“谈话疗法”：精神分析治疗中的非言语维度

精神分析治疗在很长一段时间里被视为“谈话疗法”,其治愈机制是将潜意识的内容意识化,语言解释在其中发挥关键作用。自20世纪末开始,越来越多分析师强调非言语交流在治疗中的作用。非言语交流不仅能够为咨访双方提供更丰富的交流形式,还能通过互动中的“相遇时刻”,实现对患者过去经验的重组,改变其有缺陷的内隐关系知晓。非言语交流和语言交流能够在治疗中发挥互补作用,未来的精神分析心理学要继续加强对非言语领域的研究。     

‘Mr K’ – A successful case of analytic oriented therapy documented empirically: the role of the therapeutic relationship and reflexive self-awareness

A successful case of analytic treatment over the course of 250 sessions is described from different perspectives, including considerations from the two-year follow-up. The therapeutic alliance and the patient’s experiencing were evaluated. Pre-treatment diagnosis was validated via diagnostic interview. Symptoms and interpersonal problems were assessed at intervals. Data were analysed using two different time-series analyses. Aspects of agency with regard to mentalizing capacity were assessed with the Metacognitive Assessment Scale. We obtained the following main results: (1) Symptoms and interpersonal problems improved continuously until the end of treatment. Symptom severity fell to below the clinical cut-off. This successful outcome remained stable at the two-year follow-up. (2) The therapeutic relationship improved during the therapeutic process. (3) The patient’s capability for reflexive self-awareness, operationalized as experiencing, decreased. (4) The metacognitive mastery of the patient increased. The following conclusions were made after combining the empirical data with the clinical observations: (1) Mr K improved clinically in terms of symptoms, self-regulation and interpersonal problems as a result of his gaining affect control. (2) The patient’s experiencing does not capture a positive outcome in all cases. (3) Aspects of agency (i.e. metacognitive mastery) deserve further attention in psychoanalytic treatments.     

不只是“谈话疗法”：精神分析治疗中的非言语维度

精神分析治疗在很长一段时间里被视为“谈话疗法”,其治愈机制是将潜意识的内容意识化,语言解释在其中发挥关键作用。自20世纪末开始,越来越多分析师强调非言语交流在治疗中的作用。非言语交流不仅能够为咨访双方提供更丰富的交流形式,还能通过互动中的“相遇时刻”,实现对患者过去经验的重组,改变其有缺陷的内隐关系知晓。非言语交流和语言交流能够在治疗中发挥互补作用,未来的精神分析心理学要继续加强对非言语领域的研究。     

‘Making Room for the Other(s)’: A consideration of psychodynamic counselling with women with Asperger’s Syndrome

This paper explores psychodynamic therapy with young women with Aspergers Syndrome through the use of a composite case study. It seeks to make sense of a female patient’s obsession with a figure from celebrity culture – ‘Tom’ from ‘Britain’s Got Talent’. The potential use of ‘Tom’ by the patient as an idealised object, an autistic object, a transitional object and a transformative object is considered. Drawing on Rosenfeld’s concept of pathological narcissism and Meltzer’s concept of ‘aesthetic reciprocity’, the paper seeks to make sense of both the defences that the patient utilises and the impact of the deficits she has experienced. Attention is given to the development of the therapy through the use of play and work in the transference. Gradually, the patient becomes more able to tolerate separateness and in doing so becomes more connected to her own internal world and the feelings of others. In so doing, she becomes more aware of her actual social marginalisation and gains a greater sense of awareness of her diagnosis.     

The Strangeness of Passing: Commentary on Paper by Christopher Bonovitz

Christopher Bonovitz gives us a rich landscape of the theoretical, historical, and relational aspects of his work with his mixed-race patient. In my response I explore what seems missing: a stronger sense of the patient as a person, more of her own history in her family, more of the clinical back and forth with her therapist, a sense of what is being played out in the transference, and particularly what “passing” is for her. I show how his choices about how to think about her story and how to tell it are oversaturated with awareness of identity and race at the expense of the basic human relationship. In the face of such racial anxiety, there is a pull to rely too strongly on countertransference as a way to gain privileged access to knowledge about the other. I attribute many of these problems to the inescapable power of race in our culture. Furthermore, I address the themes of hatred, silence, secrecy and transgression as they relate to the history of transgenerational trauma for this patient and invite our broadening our awareness about how they play out in the therapeutic process. We are faced with the difficult, yet the essential task of holding and living out the patient's anger and outrage at the racial hatred that has been endured.     

How a Kleinian Analysis Also Tells a Relational and Intersubjective Story Commentary on Paper by Meira Likierman

Dr. Likierman narrates her case in ways that differ dramatically from the usual discourse of relational analysts, and she frames her work with constructs that derive primarily from contemporary Kleinian theory. Yet I believe that if we listen closely to her clinical material, we can see how she and her patient live out a deeply relational/intersubjective process—intersubjective in both Stolorow, Brandchaft, and Atwood's (1987) broad sense and Benjamin's (1995) more developmental point of view.

I suggest is that there is real mutuality in their relationship, a reciprocal, unconscious, taking in of the mind and role of the other—a mutual change in which, paradoxically, both parties seem more real and, more deeply than ever, to express themselves. Ultimately, I think we can see that analyst and patient have “enacted” a slightly subversive, yet vital, mutual dance into and through precisely the paradoxes that Likierman recognizes as “forbidden” territory in the therapeutic relationship.     

‘I am not crying. I am rubbing my eyes’: Annie and the hollow object

This article explores the relationship between the development of severe eczema and asthma in an eight-year-old girl and her difficulties with experiencing psychic pain and conflict. The author focuses on the transference dynamics that preceded and surrounded the psychosomatic reaction in the session. The observations in this case may explain why patients, despite feeling taken over by intense physical sensations, can display flatness and superficiality of affect giving the appearance that they are emotionally ‘hollow’. The author proposes that these patients experience an emotional sense of emptiness in themselves and in their objects that is the result of a very early defence of dissociation caused by overwhelming anxieties of annihilation that are lived out in and through the body. The appearance of a psychosomatic symptom during the session can follow the emergence of sudden and intense raw hostile feelings towards the primary object, accompanied by a sense of danger and profound anxiety, as the hated object is also desperately needed for the subject’s own physical/emotional survival. The analyst can contribute to triggering these episodes by failing to contain the patient’s projections, which may lead to the patient feeling forced to re-introject unprocessed and unbearable ‘psycho-physical’ emotions. This article discusses the different degrees – and forms – of symbolic functioning in connection to this girl’s experience of her eczema and asthma and their manifestation in the transference relationship to the therapist.     

How Therapy With Victims of Political Trauma Repairs the Third—Commentary on Gómez and Kovalskys’s Work in the Context of Postdictatorship Chile

In this discussion I use the concept of the moral Third to designate the position in which we experience the world as lawful because repair is possible. Repair takes place through acknowledgment of harming and consequent suffering. This form of acknowledgment, coupled with social recognition, is considered by the authors to be a crucial part of the therapeutic work with victims of collective trauma, especially of torture by the Pinochet security police. In relation to Gómez’s case, I discuss how the moral Third, the representation of a lawful world, is shattered by attacks on the victim’s family. Further, the witnessing function is reversed and perverted in torture, where the torturer presents a blank face and denies the very suffering he is inducing. The experience of betrayal becomes the core issue which the therapist seeks to address through the attachment relationship itself. In relation to Kovalskys’ case I consider how the moral Third of the activists, the belief in the possibility of a world in which all can live, is attacked in order to affirm the paranoid view that “only one can live.” The lived experience of this traumatizing attack is that the child becomes imbued with the sense of not deserving life, of having gained life at the expense of the other. Helping the patient to testify publicly to her personal history and truth becomes part of the healing process in the context of collective trauma.     

Clinical Practice With Cases of Extreme Traumatization 40 Years After the Military Coup in Chile (1973–1990): The Impact on the Therapists

This paper presents our clinical experience with patients who were severely traumatized by the systematic violation of human rights during the military dictatorship in Chile (1973–1990). The lack of recognition of trauma of sociopolitical origin encapsulates the traumatic experience and forces it to remain as part of the present. Clinical vignettes of two therapeutic processes—mother and son—are presented: The mother was detained; sexually tortured; and, as a result of this, gave birth to the torturer’s son. Her therapeutic process is an account of her ambivalence towards her son, of how his origins were kept a family secret, and of how this secret was unconsciously transmitted. The young man’s therapeutic process centers on the transgenerational transmission of trauma and how the torturer–tortured dynamic seeps into the relationship with the analyst. The impact on the analysts’ subjectivity in working with extreme trauma is described.     

Race,power and intimacy in the intersubjective field: the intersection of racialised cultural complexes and personal complexes

This paper presents work with a biracial young woman, in the context of a predominantly white Jungian training organisation. The patient's relational difficulties and her struggle to integrate different aspects of her personality are understood in terms of the overlapping influences of developmental trauma, transgenerational trauma relating to the legacy of slavery in the Caribbean, conflictual racial identities, internalised racism, and the British black/white racial cultural complex. The author presents her understanding of an unfolding dynamic in the analytic relationship in which the black slave/white master schema was apparently reversed between them, with the white analyst becoming subservient to the black patient. The paper tracks the process through which trust was built alongside the development of this joint defence against intimacy ‐ which eventually had to be relinquished by both partners in the dyad. A white on black ‘rescue fantasy’, identified by the patient as a self‐serving part of her father's personality, is explored in relation to the analytic relationship and the training context.