Consultation in adolescence: Hurried,terminable, interminable1

The physiological ambivalence displayed by adolescents towards dependence on adults is an obstacle, at least initially, to a course of psychotherapy. A consultation is often the only thing that can be offered to start with, and constitutes an essential stage even for those teenagers who go on to prove themselves able to benefi t from therapy or analysis. The way this fi rst meeting is handled is therefore crucial. The author investigates the diffi culties and paradoxes of this consultation, the particular nature of the ‘time’ of the consultation compared to that of therapy, and the different internal attitude this requires of the analyst. She thus identifi es two separate confi gurations‐a hurried consultation and an interminable consultation‐which can result when the consultation fails in its primary objectives. Both are connected with possible collusive elements in the professional linked to specifi c adolescent angst. The very detailed account of a consultation shows the ‘journey’ made by a 14 year‐old starting from her urgent request to be freed from a symptom experienced as an incomprehensible obstacle, to her gradual development of curiosity towards herself and towards her own mental and emotional make‐up, resulting in her acceptance of therapeutic treatment, which would initially have been impossible.     

Power cut in the countertransference

This paper is an attempt to describe and understand a certain type of defence that I shall call a 'power cut' because of its crippling and anti-relational nature. I will take extracts from a baby observation to show how this type of defence can be adopted from the beginning of life, followed by vignettes from my work with a young child and an adult patient which addresses the particular kind of difficulty the analyst has to face with patients who resort to such a defence. I am arguing that while defending from another, the patient is able to destabilize not only the connection between himself and this other, the analyst, but also that between the analyst and the analyst's internal world. I understand this as the violent re-enactment of the patient's uncontained and split off primitive experience. I see recovery from 'power cuts' as the main challenge for the analyst who is helping the patient to recover from an early failure in containment which has led to defective splitting. Only when the unthinkable experience of 'power cut' can become an experience that can be lived through and converted into a deintegrate, may integration be achieved.     

Language and Intersubjectivity: Multiplicity in a Bilingual Treatment

This paper explores the psychodynamics of analytic work conducted between a French patient and an American analyst who are both bilingual in French and English. The depth of the patient's early traumatic relational history is initially bound and cloistered in French, her mother tongue. The author argues that through the symbolization of a series of initially dissociated enactments a transitional space is created in the treatment, facilitating the integration of the patient's (and analyst's) early French-speaking selves. Language is considered as a container for both dissociative and associative forms of multiplicity, as it serves to mediate an external and internal intersubjective expansion both between and within patient and analyst.     

Psychoanalytic attitude as a step in the transference/countertransference relationship

When the psychoanalytic treatment process reactivates the "primary oral conflict" in the patient, the author recommends that the analyst put off transference interpretations in favor of reacting with the "analytic attitude". Only after the relationship between patient and therapist has been restabilized, can the elaboration of the early conflicts be considered. The concept of the analytic attitude is essentially a synthesis of "holding" and "containing" functions.     

Commentary on ‘The arms of the chimeras’ by Béatrice Ithier

In this Commentary I will first of all summarise my understanding of the proposal set out by Béatrice Ithier concerning her concept of the ‘chimera’. The main part of my essay will focus on Ithier's claim that her concept of the chimera could be described as a ‘mental squiggle’ because it corresponds to Winnicott's work illustrated in his book ‘Therapeutic Consultations’ (1971). At the core of Ithier's chimera is the notion of a traumatic link between analyst and patient, which is the reason she enlists the work of Winnicott. I will argue, however, that Ithier's claim is based on a misperception of the theory that underpins Winnicott's therapeutic consultations because, different from Ithier's clinical examples of work with traumatised patients, Winnicott is careful to select cases who are from an ‘average expectable environment’ i.e. a good enough family. Moreover, Winnicott does not refer to any traumatic affinity with his patients, or to experiencing a quasi‐hallucinatory state of mind during the course of the consultations. These aspects are not incorporated into his theory. In contrast (to the concept Ithier attempts to advance), Winnicott's squiggle game constitutes an application of psychoanalysis intended as a diagnostic consultation. In that sense Winnicott's therapeutic consultations are comparable with the ordinary everyday work between analyst and analysand in a psychoanalytic treatment. My Commentary concludes with a question concerning the distinction between the ordinary countertransference in working with patients who are thinking symbolically in contrast to an extraordinary countertransference that I suggest is more likely to arise with patients who are traumatised and thus functioning at a borderline or psychotic level.     

Another language,another place: To hide or be found?

The author examines some specifi c features of the analytic encounter when both patient and analyst are émigrés from the same cultural and linguistic background. This can result in splitting processes that operate silently and are diffi cult to reach, but can also provide rich material, as they offer the couple the opportunity to work through the pain and the guilt over what is lost—ultimately the lost mother—murdered and betrayed. Working through the split faces the analyst with important technical considerations, bearing in mind that the shared cultural identity can conceal itself in the more undifferentiated features of the couple's psyche and be projected on to the setting. As such, it needs to be put to analytic scrutiny if the treatment is to avoid a stalemate. These are specifi c cultural defences deployed in the problematic existential encounter with the foreigner other within oneself. Using clinical material from two cases, the author shows how the couple's access to a dual linguistic signifying system can enrich the analytic dialogue, but can also result in enactment. Careful monitoring of the transference-countertransference relationship is essential to the progress of the analytic work.     

Thoughts on medication and psychoanalysis: a lay analyst's view

The issues involved in split analytic treatments-where a second person manages the patient's medication-are discussed from the point of view of a developmentalist and lay analyst. Case material is presented to illustrate the interplay of medication with other elements of the psychoanalytic situation. Medication and its effects, it is argued, should be accorded no special status apart from other interventions and enactments in an analysis. Some see medication and psychoanalysis as parallel processes, two separate and unintegrated theoretical systems, and recommend shifting back and forth between models of the mind or becoming "bilingual"; against this view, it is argued that anything the analyst does will affect the patient's thoughts, fantasies, and even physiology in individual ways, and only attention to analytic material can reveal what an intervention means in a specific case. Success in split treatment depends on a collaborative therapeutic alliance among patient, analyst, and consultant. Because there is as yet no theory that bridges psychoanalysis and psychopharmacology, analysts must talk of these matters as incompletely synthesized and regard them as part of the challenges that make psychoanalysis the exciting, impossible profession it is.     

The compulsion to confess and the compulsion to judge in the analytic situation

In this paper the author shows that human beings have two quasi‐instinctual primitive tendencies – namely, the compulsion to confess and the compulsion to judge (to condemn or to absolve). These compulsions are originally unconscious and become conscious during the course of the analytic process. The compulsion to judge is a natural consequence of the compulsion to confess. These two tendencies are intensified by the analytic situation. The patient has a compulsion to confess to the analyst and to himself, and likewise the analyst has a compulsion to confess to himself and to the patient. The patient therefore has a compulsion to judge himself as good or bad and to judge the analyst as good or bad while, on the other hand, the analyst has a compulsion to judge himself as good or bad and to judge the patient as good or bad. The task of analysis is to make both patient and analyst conscious of their compulsions to confess and to judge (to condemn or to absolve). The compulsion to judge in the analyst, particularly if unconscious, may give rise to mistakes in diagnosis, technique, treatment, and the assessment of analysability. The requirement of analytic neutrality in the analyst constantly conflicts with his compulsion to judge. If we are profoundly involved in our patient's dramatic conflict, we are bound to pass a judgement (condemnation or absolution); however, when we judge, we are not neutral and therefore become incapable of intellectual consciousness of the patient's conflict. Conversely, if we do not judge, we are neutral, but are then relatively uninvolved in the patient's conflict and are hence virtually unable to achieve emotional consciousness. The author attempts to show that neutrality cannot and must not be a preconstituted attitude in the analyst, but can and must be a point of arrival following a profound, intensely felt existential experience based on an attitude of non‐condemnation and non‐absolution.     

Impervious and intrusive: The impenetrable object in transference and countertransference

The author describes an internal object that he calls the ‘impenetrable object’ which has two characteristics: being impervious to the projections from the patient and being intrusive, i.e. projecting into the patient. It arises out of an early relationship with a mother who may be generally disturbed or traumatized so that she is unable to take in or tolerate the child's projections and may use the child as a receptacle for her own projections. He links the concept of an impenetrable object with other concepts such as Williams's ‘reversal of the container–contained relationship’ and Green's ‘dead mother’. If such an object dominates the patient's internal world, it can lead to severe difficulties in the analytic process. Interpretations may be experienced as violent projections from the analyst which the patient has to ward off and the analyst may enact an impervious or intrusive object in various ways. The author describes a case in which such dynamics played a significant role. He argues that intensive work in the countertransference is required to detect subtle enactments and allow a shift in the analyst, which in turn can enable change in the patient. He gives clinical material that demonstrates such work by the analyst and illustrates the shift from an impenetrable object to a more permeable one in the patient's internal world.     

Self‐disclosure,trauma and the pressures on the analyst

This paper argues that self‐disclosure is intimately related to traumatic experience and the pressures on the analyst not to re‐traumatize the patient or repeat traumatic dynamics. The paper gives a number of examples of such pressures and outlines the difficulties the analyst may experience in adopting an analytic attitude – attempting to stay as closely as possible with what the patient brings. It suggests that self‐disclosure may be used to try to disconfirm the patient's negative sense of themselves or the analyst, or to try to induce a positive sense of self or of the analyst which, whilst well‐meaning, may be missing the point and may be prolonging the patient's distress. Examples are given of staying with the co‐construction of the traumatic early relational dynamics and thus working through the traumatic complex; this attitude is compared and contrasted with some relational psychoanalytic attitudes.     

Psychotherapy in the aesthetic attitude

Abstract: Drawing upon the writings of Jungian analyst Joseph Henderson on unconscious attitudes toward culture that patients and analysts may bring to therapy, the author defines the aesthetic attitude as one of the basic ways that cultural experience is instinctively accessed and processed so that it can become part of an individual's self experience. In analytic treatment, the aesthetic attitude emerges as part of what Jung called the transcendent function to create new symbolic possibilities for the growth of consciousness. It can provide creative opportunities for new adaptation where individuation has become stuck in unconscious complexes, both personal and cultural. In contrast to formulations that have compared depth psychotherapy to religious ritual, philosophic discourse, and renewal of socialization, this paper focuses upon the considerations of beauty that make psychotherapy also an art. In psychotherapeutic work, the aesthetic attitude confronts both analyst and patient with the problem of taste, affects how the treatment is shaped and ‘framed’, and can grant a dimension of grace to the analyst's mirroring of the struggles that attend the patient's effort to be a more smoothly functioning human being. The patient may learn to extend the same grace to the analyst's fumbling attempts to be helpful. The author suggests that the aesthetic attitude is thus a help in the resolution of both countertransference and transference en route to psychological healing.     

The Dignity of Creating: The Patient's Contribution to the “Reachable Enough” Analyst

Through the defining power of words, the phrase “difficult-to-reach” patient reflects the extent to which the analyst inverts the patient's will to change and makes the analyst the subjective agent of treatment progress. If making a constructive contribution to another person's life engenders a sense of creative agency, the traditional dichotomies of analyst/helper who gives and an empty patient who receives may not be useful. I trace the evolution of a 23-year-long psychotherapy from a parent–child dynamic through to more uncertain relational terrain in order to illustrate how the analyst's own evolution may have clashed with the patient's ambivalence toward change and endings. I raise questions of how the dignity of making a creative contribution to the “reachable enough” analyst's life may enable the patient to work through gratitude, attain a sense of belonging, and terminate with good conscience.     

Workers,groups and gangs: consultation to residential adolescent teams

This paper discusses how the internal worlds of adolescents who are looked after in residential care homes impact upon workers and generate complex dynamics within teams. This is especially so regarding internal parental objects and couplings, which inevitably include those of abandoning, abusive and ambivalent parental figures. Versions of these are projected and enacted between adolescents and workers, workers and managers, team and consultant. Conceptual thinking about groups and gangs is drawn upon to help illuminate the emotional phenomena encountered in team consultation meetings as described in the paper. Clinical material is given of working in the transference as consultant to the team, in order to illustrate processes of containment and the opportunity for thinking to take place. In this, there is movement between different states of mind within the team. The paper seeks to demonstrate a way of consulting to residential teams working with looked after adolescents and to show how this can mediate some of the enactments by workers and teams of projected states and transferential phenomena. Associated with this, there can be a deepening of the team's understanding of the emotional experience of the adolescents in their care.     

The Things We Carry: Finding/Creating the Object and the Analyst’s Self-Reflective Participation

I reflect on the interaction between the analyst’s dedicated attention to the patient’s internal object relations and the analyst’s self-reflective participation. Our stops and starts of attention to the patient’s internal objects and our own is in some sense one of the most important elements of our personal participation. I suggest that the patient’s and analyst’s needs for privacy and the illusion of privacy in the presence of the other, undertheorized within relational theory, is not at odds with an emphasis on valuing the patient’s capacity for a “read” on the analyst. Needs for privacy and the illusion of privacy held by patient and analyst need to be integrated into any psychoanalytic theory and form part of the basis of intimate regulatory systems between two people.     

THE EXTERNAL OBSERVER AND THE LENS OF THE PATIENT-ANALYST MATCH

A focus on the match between patient and analyst places attention on the dynamic effect of the interaction of character and conflict of both participants on the process that evolves between them. Match is neither a predictive nor static concept. Rather it refers to an unfolding transaction that itself shifts and changes during the course of analytic work. The treating analyst's perception of the effect of this match is by necessity limited by the analyst's own blind spots and other countertransference phenomena. Reporting the analyst's clinical experience to an analytically trained observer, external to the dyad, may broaden the analyst's perspective. Using the lens of the match, a colleague in the role of supervisor, consultant or peer can provide feedback from which the analyst may acquire insight. As a result of this process, the influence that the participants' similarities and differences have upon each other becomes clear to the analyst. This awareness, in turn, may lead the analyst to appreciate the effect of the analyst's stance of distance or closeness and to evaluate whether at this phase of treatment it is beneficial or detrimental to the analytic process. Clinical illustrations of the effect of the external observer's feedback in relation to the patient—analyst match are provided.     

Sadism,Penetration, and the Negotiation of Desire: Commentary on Paper by Csillag

The author takes up Csillag’s idea of sadism as the wish to penetrate in the context of a patient who withholds from his analyst. With such a patient, the analyst has to bear the strain stemming from a lack of both satisfaction and recognition–the feeling of not having an impact. The defenses against sadism are examined along with the absence of intentionality in both clinical cases presented, an absence that places sadism in the realm of something that is unconscious or preconscious. Alternative views are offered on the enactment between Csillag and her patient with a focus on the unspoken negotiation of desire and (drawing on Fairbairn) the analyst’s attempt to breach her patient’s closed system of internal objects.     

Reflections on the setting in the treatment of adolescents1

The author focuses on the signifi cance of the setting for the development of the psychoanalytic process, especially in the case of adolescents who request analytic treatment. Her main goals are to specify: a) how the setting is confi gured with this type of patients; and b) to what extent it contributes to the creation of an inner space that may internalize a fi gure with reverie‐a good object that will metabolize the bad and thus enable identifi cation. The setting, which is considered the necessary context for analytic work, is defi ned as bearing two facets: that of the analyst, which must be constant and stable, and that of the adolescent, which will progressively change provided that the analyst maintains a fi rm context that contributes to make the adolescent feel contained and accepted. It is such a feeling that will enable the unfolding of the analytic process. The author emphasizes the importance of the presence of the analyst (his or her voice, the manner of his or her speech, and so on), and the need for the analyst to comply with the rules he or she has established together with the patient. She presents a clinical case to illustrate this conceptualization.     

The analyst's anxieties in the first interview: Barriers against analytic presence

To answer the questions: why don't more people enter analysis and how do we get more people to do so? Attention is drawn to anxieties in the analyst that become obstacles to the initiation of analysis. The main focus of the paper is how to understand why analysts, irrespective of patient characteristics, seem to have resistances against embarking on analysis. Being a meeting between strangers the consultation activates strong emotional reactions in both parties. One way of coping is defensively to diagnose, assess and exclude instead of being present as an analyst. The analytic frame of a consultation is ambiguous, and a secure analytic function is needed in order to meet the openness and unpredictability of this frame. A fragile psychoanalytic identity is seen as central to analysts' failure to create an analytic practice; it takes years to develop and maintain a robust analytic function, and analytic work continues to cause disturbing emotional reactions in the analyst. Analysts' vulnerable identity is also linked to the history of psychoanalysis that has fostered an ideal of analytic practice that is omnipotent and impossible to reach. Therefore it is no wonder that attempts to reach a convinced recommendation of analysis can become diverted in the process of consultation. Confronting these inner impediments in order to strengthen the analytic identity is suggested as a better way to get more analytic patients than to keep looking for so‐called analysability in patients.     

Addressing parts of the self

In this paper the author addresses the problem of framing an interpretation that properly takes account of the degree of splitting and projection the analyst encounters in a patient at a particular time. If the patient has needed to split off and project unacceptable parts of the self, the analyst has to consider how useful it is to describe this situation to the patient, who may no longer be in contact with the disavowed parts. The disadvantage of this situation is that an interpretation that refers to different parts of the personality may make sense intellectually, but may in fact reinforce the patient's defensive structure. The author describes one case in which such a situation prevailed, and contrasts this with a second case in which a greater degree of integration had developed, with accompanying internal conflict and pain. In this latter case it seems paradoxically more appropriate for the analyst to include, in his interpretations, references to the struggle between different parts of the personality.