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.     

BLAME,MORAL STANDING AND THE LEGITIMACY OF THE CRIMINAL TRIAL

I begin by discussing the ways in which a would‐be blamer's own prior conduct towards the person he seeks to blame can undermine his standing to blame her (to call her to account for her wrongdoing). This provides the basis for an examination of a particular kind of ‘bar to trial’ in the criminal law – of ways in which a state or a polity's right to put a defendant on trial can be undermined by the prior misconduct of the state or its officials. The examination of this often neglected legal phenomenon illuminates some central features of the criminal law and the criminal process, and some of the preconditions for the legitimacy of the criminal law in a liberal republic.     

Enhancing CBT Consultation With Multicultural Counseling Principles

The use of multicultural principles to enhance cognitive behavioral therapy (CBT) for individuals of marginalized backgrounds has received increased attention in light of the heightened national awareness of systemic oppression and racialized violence directed towards Black, Indigenous, and People of Color. However, there has been less of a focus on applying such principles to consultation for skill development. If ethical guidelines are expected to influence the behavior of clinicians in session, guidance is needed to indicate how and where and when clinicians should receive training in implementing culturally responsive CBT. Individual reading and reflection are necessary but are not sufficient in acquiring new clinical skills. Consultation is recommended and strongly suggested when clinicians are working with new populations or delivering a new treatment, or even using a new modality. Consultation can also be useful when adopting a new approach or stance to therapy. For practicing clinicians who have not developed these skills, additional consultation can and should be used to address this gap. Moving forward, integration of cultural responsiveness into standard consultation will ensure that these skills are seen as a core competency, rather than an optional additional skill that may be (or not be) elected. This paper presents core experiences that may be integral to a CBT consultation model that aims to enhance providers’ ability to provide CBT in a way that is culturally responsive to their clients. These recommendations attend to both content and process within CBT consultation and reflect guiding assumptions for helping clinicians to develop the ability to practice CBT in a culturally responsive manner, including (a) normalizing discussions of cultural identity and oppression, (b) an emphasis on cultural self-awareness, (c) emphasizing culturally informed CBT case conceptualization, and (d) skill development in applying cultural elements to CBT interventions.     

‘You were not born here,so you are classless,you are free!’ Social class and cultural complex in analysis

The unconscious impact of differences in culture and social class is discussed from the perspective of an analyst practising in London whose ‘foreign accent’ prevents patients from placing her within the social stratifications by which they feel confined. Because she is seen by them as an analyst from both ‘inside’ and ‘outside’ the British psycho‐social fabric and cultural complex, this opens a space in the transference that enables fuller exploration of the impact of the British social class system on patients’ experience of themselves and their world. The paper considers this impact as a trans‐generational trauma of living in a society of sharp socio‐economic divisions based on material property. This is illustrated with the example of a patient who, at the point of moving towards the career to which he aspired, was unable to separate a sense of personal identity from the social class he so desperately wanted to leave behind and walk the long avenue of individuation. The dearth of literature on the subject of class is considered, and the paper concludes that not enough attention is given to class identification in training.     

The explosion of the present and the encapsulation of time: Transference phenomena in the analysis of a psychotic patient

The paper deals with some basic problems concerning the experience of time and space in the psychoanalytic treatment of psychotic patients. Whereas borderline patients tend to distort the experience of time and space under emotional pressure, the concepts of time and space seem to dissolve in acute psychotic states of mind. Sometimes this manifests itself in an explosion of the present, where the past is ubiquitous and the future is perceived as the end of all times. The case of a 48 year‐old patient with the external diagnosis of ‘paranoid–hallucinatory schizophrenia’ is presented to illustrate that the main task is to recreate a structure to contain the experience of space and time. Such a development may occur if primitive psychotic anxieties can be taken up and metabolized. A near‐psychotic decompensation before the first break and the development of a transference psychosis in the second year of the analysis are depicted in detail. Subsequently some developments became visible which helped the patient to better tolerate catastrophic fears of loss. This included the formation of a structure which the patient called ‘hibernation’ enabling her to psychically survive without falling apart. By retreating into her ‘time capsule’ she managed to overcome breaks and to delay her fears of fragmentation until they could be taken up and worked through in the transference. The creation of a structure like the patient's ‘time capsule’ is considered to be an attempt to construct the experience of time and space. It prevented a collapse of her internal space thereby enabling further steps towards thinking and symbolization. In conclusion, some theoretical and clinical aspects are discussed including the role of the countertransference.     

Expression,Truth, Predication,and Context: Two Perspectives

Abstract

This paper considers the challenge to understanding another that comes from the view that language is, in Cristina Lafont’s phrase, ‘world‐disclosing’. If different speakers understand and refer to the world from different holistically structured worldviews, it seems to follow that there can be no mutual understanding unless there is significant overlap between ‘worlds’. Gadamer’s hermeneutics, I claim, blocks this consequence while maintaining that language is indeed world‐disclosing. By holding that language is a medium in which the distinction between interpretation and object of interpretation is paradoxically both maintained and overcome, Gadamer shows us that the interpreter always thinks the object of interpretation as both transcending and immanent in her worldview. Mutual understanding becomes a matter of mutual recognition of such worldview‐(but not language‐) transcendent objects. Truth and meaning may on this view be characterized as ‘objective’, while retaining a significant element of relativity.     

Working with chronic and relentless self‐hatred,self‐harm,and existential shame: a clinical study and reflections (Paper 2 of 2)

This second of two papers focuses on the shame which emerged in the first 14 years of analysis of a woman who was bulimic, self‐harmed, and repeatedly described herself as ‘feeling like a piece of shit’. To explore this intense and pervasive shame I draw on Jung's and Laplanche's emphasis on experiences of unresolvable, non‐pathological ‘foreignness’ or ‘otherness’ at the heart of the psyche. Images, metaphors, elements of clinical experience, and working hypotheses from a number of analytic traditions are used to flesh out this exploration. These include Kilborne's use of Pirandello's image of shame as like a ‘hole in the paper sky’ which, I suggest, points to a crack in subjectivity, and reveals our belief in the efficacy of the self to be illusory. Hultberg's observations on shame as having an existential mode (function) are also explored, as is the nature of analytic truth. Using these ideas I describe my patient's process of finding some small but freeing space in relation to her shame and self‐hatred. Through enduring and learning from her shame in analysis she realized that it was part of a desperate unconscious attempt to draw close to her troubled father and so to ‘love him better’.     

CONVERSATION ANALYSIS AND PSYCHOANALYTIC PSYCHOTHERAPY RESEARCH: QUESTIONS,ISSUES, PROBLEMS AND CHALLENGES

Understanding the talk of the ‘talking cure’ remains a central goal of researchers in psychoanalytic psychotherapy. Here, we consider whether conversation analysis (CA) can provide techniques to understand better the conduct of the psychoanalytic therapeutic interaction. Following discussion outlining the participant‐oriented nature of this qualitative methodology we consider reasons for the emergence of CA‐informed studies of psychoanalytic psychotherapy. Amongst other aims, CA focuses on uncovering the process and procedures which make the therapy encounter a distinct form of ‘institutional life’. For psychoanalytically‐oriented researchers, CA can refine their skills of attention and engender sensitivity to understanding material in sessions. Using examples from segments of talk between a training therapist and client we highlight both the advantages of, and constraints on, employing CA as an aid to understanding psychotherapeutic sessions by considering contrasting conceptions of temporality in conversation analysis and psychoanalysis. In the former participants are oriented towards the ongoing production of sequential understandings and local ‘context’ in an unfolding present, in the latter participants aim to enhance the emergence of the remote past into the present of the therapeutic interaction. While recognizing the research benefits of CA methodology concluding comments raise questions regarding the potential complementarity between our dispositions towards the close monitoring of the activity and the feelings of fellow humans.     

Medical psychotherapy consultation: psychoanalytic psychiatry for the patient and professional

An NHS Mental Health Trust Medical Psychotherapy Consultation Service using psychoanalytic psychiatry to help the patient and professional is described. The Consultation Service established in 2000 is offered to secondary acute and community mental health teams and primary care. The service was evaluated as a basis for regional and national development. Between 2006 and 2013, 87 consultations from 210 were sampled to ascertain demographic and diagnostic profiles and outcomes of the consultation process. We conducted an online survey of local consultant psychiatrists’ views about the service, and undertook a thematic analysis of the free text comments. We also conducted a survey of members of the Royal College of Psychiatrists’ Medical Psychotherapy Faculty to ascertain whether similar consultation services existed elsewhere in the UK and had been evaluated. The Leeds model of psychoanalytic consultation – a ‘consultation sandwich’ – is described. From a psychoanalytic perspective, the work of consultation is seen as an extension of the dynamic field of the analytic situation. This paper develops the concept of a bastion – an omnipotent reserve in and between the patient and professional derived from adhesive identifications leading to stuck relationships. The adhesive identification in the patient and professional acts like a ‘grievance glue’ – a mutual manifestation in a last bastion of painful limitations not faced, losses not grieved.     

Chickens or eggs? A follow‐up case study exploring links between physical and psychological impact of Tourette's syndrome and sexual abuse

This follow‐up case study highlights the complex relationship when working at the interface between physical and psychological symptoms. The paper draws upon conversations between an ex‐client and myself, held seven years after the end of our six year therapeutic relationship. Conversational interviews, based upon social constructionist beliefs, led to an unexpected exploration of the client's subsequent diagnosis of Tourette's syndrome (given several years after the end of therapy) and evolved into a struggle to reach a shared understanding of how she now makes connection between her problem with eating in public, her neck and facial tics, and childhood sexual abuse. Our research relationship provided both of us with a rare opportunity to reflect upon how she had made meaning of her counselling and its outcomes. The paper draws attention to the impact of counselling and therapy discourses concerning sexual abuse on the work we did at the time and asks how that work might be different today. It also helps us understand the layers of complexity and ambiguity contained within the client's stories. This multi‐layered case study represents the overlap and ‘messiness’ that mirrors the ‘lived experience’ of the persons involved, and provides an example of how co‐constructed research conversations can evoke stories that create meaning as they are told.     

FINE'S MCTAGGART,TEMPORAL PASSAGE,AND THE A VERSUS B‐DEBATE

I offer an interpretation and a partial defense of Kit Fine's ‘Argument from Passage’, which is situated within his reconstruction of McTaggart's paradox. Fine argues that existing A‐theoretic approaches to passage are no more dynamic, i.e. capture passage no better, than the B‐theory. I argue that this comparative claim is correct. Our intuitive picture of passage, which inclines us towards A‐theories, suggests more than coherent A‐theories can deliver. In Finean terms, the picture requires not only Realism about tensed facts, but also Neutrality, i.e. the tensed facts not being ‘oriented towards’ one privileged time. However unlike Fine, and unlike others who advance McTaggartian arguments, I take McTaggart's paradox to indicate neither the need for a more dynamic theory of passage nor that time does not pass. A more dynamic theory is not to be had: Fine's ‘non‐standard realism’ amounts to no more than a conceptual gesture. But instead of concluding that time does not pass, we should conclude that theories of passage cannot deliver the dynamicity of our intuitive picture. For this reason, a B‐theoretic account of passage that simply identifies passage with the succession of times is a serious contender.     

Supervisory countertransferences and impingements in evaluating readiness for graduation: Always present,routinely under‐recognized

Utilizing detailed, in‐depth material from supervisory hours from around the world (explored in End of Training Evaluation groups), this paper shows that supervisors are subject to multiple, diverse and, at times, ongoing intense countertransferences and impingements on their ability to evaluate candidates’ progress. Multiple external and internal sources of these impingements are explored. It is suggested that supervisory countertransferences and their manifestation in parallel enactments remain under‐recognized, their impact underappreciated, and the information they contain underutilized. It is argued that the recognition, containment, and effective use of the parallel process phenomena and supervisory countertransferences are essential in order to evaluate candidates’ progression and readiness to graduate. Common signals of such entanglements in the supervisor's evaluative function are identified. Three remedies, each of which provides a ‘third,’ are offered to assist supervisors in making effective use of their countertransference: self‐supervision, consultation, and institutional correctives.     

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.     

State of mind assessments

This paper describes state of mind assessments as undertaken by child psychotherapists. It considers the similarities and differences with an assessment for an ongoing child psychotherapy treatment intervention and is described here as a ‘package’ that is offered to the family, child and young person and also the referring colleague. It is suggested that the consultative aspect has more weight in a state of mind assessment. The stages of the assessment are outlined and include the initial consultation with the referring colleague, a meeting with parents, three sessions with a child or young person and feeding back to parents with further consultation to the referring colleague. The meaning of the request at any particular time is explored and influences the stance and the approach to the assessment by the therapist. A summary of a case example illustrates the different stages outlined here. The thinking and approach described may be particularly useful to trainees and those starting out as child psychotherapists in child and adolescent mental health services.     

CHARACTER,PSYCHOANALYTIC IDENTIFICATION,AND NUMERICAL IDENTITY

Identification figures prominently in moral psychological explanations. I argue that in identification the subject has an ‘identity‐thought’, which is a thought about her numerical identity with the figure she identifies with. In Freud's psychoanalytic psychology character is founded on unconscious identification with parental figures. Moral philosophers have drawn on psychoanalysis to explain how undesirable or disadvantageous character dispositions are resistant to insight through being unconscious. According to Richard Wollheim's analysis of Freud's theory, identification is the subject's disposition to imagine, unconsciously, her bodily merging with the figure she identifies with. I argue that this explanation of identification is not adequate. Human character is held to be capable of change when self‐reflection brings unconscious identifications to conscious self‐knowledge. I argue that for self‐knowledge these identifications must be an intelligible part of the subject's self‐conception, and that Wollheim's ‘merging phantasy’ is not intelligible to the subject in this way. By contrast, the subject's thought that she is numerically identical to the figure she identifies with does provide an intelligible starting‐point for reflecting on this identification. This psychoanalytic account provides a clear conception of identification with which to investigate puzzle cases in the moral psychology of character.     

An outline explanation of how therapy heals

Therapists are unable to provide a comprehensive account of therapy as an intelligible activity. This is at least partly due to the unresolved problem of explaining how phenomenology is even possible. An alternative to providing a comprehensive account of therapy is to take the fact of phenomenology for granted and provide just an outline account of how therapy heals. One way this can be achieved is to set therapy in the context of medical anthropology which will facilitate a view of therapy as just another healing ritual. Insight into how healing rituals heal is provided in this paper by a long and in-depth look at the so-called ‘paradox’ of the placebo effect. This will reveal the so-called ‘placebo effect’ as a misunderstood, modern example of healing ritual self-healing. In fact, the single term ‘placebo effect’ will be abandoned and replaced by the two concepts of ‘SMCH’ (‘specifically modified consultation and health care’) and ‘RMH’ (‘response to modified health care’). These two concepts provide an outline explanation of how all healing rituals heal and so provide an outline explanation of how the healing ritual of therapy heals, also. At least one problem arises out of explaining therapy as healing ritual self-healing, namely that this conception conflicts with the idea in therapy circles that, in therapy, it is the relationship that counts. Nonetheless, it will be maintained that the purpose of therapy is healing, that the healing that is achieved is self-healing and that its fulfilment is not dependent upon one-to-one relationships. Finally, it will be argued that the further development of therapy requires a better understanding of what aids and obstructs psycho-emotional self-healing.     

Containment,curiosity and consultation: an exploration of theory and process in individual systemic psychotherapy with an adult survivor of trauma

This paper describes an individual therapy from the author's private practice. On referral, the client came to therapy requesting help with her 8‐year‐old daughter. Within the assessment, a single episode of trauma was revealed. Further therapeutic conversations told of multiple memories of trauma. The main therapeutic work has now ended, the contract being left that the client can continue to request appointments if she wishes. I show how systemic therapy from Post Milan and Narrative models, including practices from other orientations, has been useful and name three key practices as being crucial to the work, containment, curiosity and consultation. I suggest parallel processes operating between myself and my client as well as between the therapy and consultation. Distinct phases in the therapy recovery are identified. The discussion will consider themes of containment, curiosity and consultation.     

Basic‐Know And Super‐Know

Sometimes a proposition is ‘opaque’ to an agent: (s)he doesn't know it, but (s)he does know something about how coming to know it should affect his or her credence function. It is tempting to assume that a rational agent's credence function coheres in a certain way with his or her knowledge of these opaque propositions, and I call this the ‘Opaque Proposition Principle’. The principle is compelling but demonstrably false. I explain this incongruity by showing that the principle is ambiguous: the term ‘know’ as it appears in the principle can be interpreted in two different ways, as either basic‐know or super‐know. I use this distinction to construct a plausible version of the principle, and then to similarly construct plausible versions of the Reflection Principle and the Sure‐Thing Principle.     

Heidegger and the Supposition of a Single,Objective World

Christina Lafont has argued that the early Heidegger's reflections on truth and understanding are incompatible with ‘the supposition of a single objective world’. This paper presents her argument, reviews some responses that the existing Heidegger literature suggests (focusing, in particular, on work by John Haugeland), and offers what I argue is a superior response. Building on a deeper exploration of just what the above ‘supposition’ demands (an exploration informed by the work of Bernard Williams and Adrian Moore), I argue that a crucial assumption that Lafont and Haugeland both accept must be rejected, namely, that different ‘understandings of Being’ can be viewed as offering ‘rival perspectives’ on a common subject‐matter. I develop this case by drawing on an alternative account of what a Heideggerian ‘understanding of Being’ might be like.     

THE SORROW THAT DARE NOT SAY ITS NAME: THE INADEQUATE FATHER,THE MOTOR OF HISTORY

Although the following essay is literary‐philosophical, it arose from a practical interest. I have been struck by how widespread today is the complaint about the ‘inadequate father’. Of course a father may be inadequate in diverse ways, either absconding, absent and weak, or overbearing, bullying, and tyrannical, or some combination of these. Further, I am not restricting the term ‘father’ to its narrow biological sense, but using it rather as a metaphor for any institution or structure which an individual or a group feels should have been in place to guide, direct, and protect them in important situations, but did not do its job properly. Consequently they are willing to concede they are not all they could have been, but they insist it is not their fault, rather the fault of the ‘father’ who should have done his job better. This ties in with the fashionable appeal of ‘victimhood’. Everybody today seems to want to cast themselves as a ‘victim’, for reasons similar to those mentioned above. If you are a ‘victim’, then there must be an ‘oppressor’– and some ‘parent’ organization that should have guided, directed, and protected you against the oppressor, but again did not do its job adequately. It is striking how many individuals and groups around the world today choose to perceive themselves, and to present themselves to others, as ‘victims’; it has indeed become a preferred characterization of our age, for it carries with it a rhetorical advantage that trumps all others. If you are able to cast yourself as a ‘victim’, and have others accept this, you disarm and neutralize criticism, not only of what you are, but of what you are currently doing – because the latter can be presented as a just ‘compensation’ for what you have suffered. As with guilt, there is no built‐in quota or statute of limitations. This rhetoric was not as common thirty or forty years ago. There is an added factor here in America and the New World generally where, according to a whispered criticism, as our ancestors crossed the ocean, they experienced a ‘drop in civilization’. Life here was initially without some of the structures and institutions which had evolved over thousands of years in the Old World, which could thus be presumed there but here were absent. As we won with difficulty our independence, we unconsciously repudiated much of the ‘higher culture’ of the colonial master, throwing out the baby with the bathwater. As the ‘economic bubble’ of having won the Second World War has gradually dissipated, we discover we are handicapped by an absence of the forms of maturation and self‐realization that arise in and are necessary for dealing with prolonged peace. In our ‘ideology of liberty’, our adults become essentially grown children, unschooled in anything higher, and thus have particular difficulty assuming the responsibilities of parenthood. They are forced to fall back upon a military style of giving orders, because on this side of the water, ‘final causes’ in the form of commonly admired or agreed on goals for striving are not in place. In this sense there is an absence of the ‘adequate father’. Further, as ‘American Culture’ expands through publicity and the media, we spread the same disease. There is another relevant factor, the ‘celebrity‐liberationist’ lifestyle that has been diffused into the general population since the 1960's and has become a default secular ethic of our time, replacing the traditional Judeo‐Christian decalogue. The former is invoked as a justification for aggressively seeking fame and fortune, and making no attempt to conceal this; rather than worrying that such an attitude will cause offense, it is worn proudly and defiantly in the hope that others will identify with it, thereby branding the performer a cultural hero. This popular strategy towards fulfilment itself rests on a metaphysic of ‘expressive individualism’, a position that holds that the supreme ethical imperative to which other obligations must be subordinated is for each to bring forward their hidden noumenal core, the only source of value, into phenomenal appearances where it may be admired and benefit others and such that creation will for the first time be complete. This change in Western culture made possible by greater affluence and security represents a trickle‐down phenomenon and democritization of the awe reserved for the artist revered as a genius during the nineteenth century, now spread to the entire population. Anything that constrains this expansion, which interrupts or limits this transfer, is to be rejected as parental abuse, psychological repression, or cultural imperialism.