Review of Infant Mental Health papers

The paper of the Change Process Study Group of Boston addresses an unsolved conceptual problem: How does one codify intersubjective states? The transfer of concepts from infant research to the adult therapeutic dyad is more than an analogy in that certain primitive aspects of mind appear in infancy, but persist throughout life. The regulation of consciousness is one salient example. The adult therapeutic dyad and the mother–infant dyad can be viewed as self-regulating dynamic systems that are also self-reparative. The concept of implicit relational knowledge is offered as an alternative way of thinking about internal object relations. © 1998 Michigan Association for Infant Mental Health     

When the Frame Doesn't Fit the Picture

I reconsider the function and construction of the psychoanalytic frame from an intersubjective, relational perspective. The analytic frame is meant to create and stand for, both practically and symbolically, a therapeutic structure with clear and safe boundaries in which the process of therapy unfolds. From my perspective, the establishment of the frame is, at the same time, an integral part of the process itself and reflects conscious and unconscious aspects of both patient and analyst. I explore this paradox and its implications for both practice and theory. In theorizing the functions of the frame, I draw on Goffman's frame theory, Bateson's anthropological and ethological studies, Ferenzci's perspective on the elasticity of technique, and a number of contemporary relational theorists. Several clinical vignettes are presented as illustrative of a new perspective on the analytic frame as cocreated and contextual, reflecting the variability of the psychoanalytic situation and the uniqueness of each dyad.     

Relational dynamics between psychotherapy clients and clinic administrative staff: A pilot study

Extensive empirical research has established therapeutic alliance as one of the most stable predictors of psychotherapy outcomes. Nearly all the contemporary empirical literature on therapeutic alliance focuses on the therapist-client dyad without attending to the relational experiences many clients in outpatient clinics have with administrative staff. Literatures from the fields of social work, psychiatric nursing and milieu therapy suggest there are more systemic relational and environmental dynamics that impact treatment beyond the therapist-client dyad, although these issues have been considered primarily in inpatient settings. A relational ecology framework has been developed drawing upon relational psychoanalysis, attachment theory and symbolic anthropology to help conceptualise the broader relational dynamics beyond the therapist-client dyad that may impact a more systemic therapeutic alliance in certain outpatient contexts. In an initial cross-sectional pilot study with a sample of clients (N = 107) receiving psychotherapy at a community mental health clinic in the Northeastern United States, the present study found client ratings of both (a) the therapeutic alliance with their therapists and (b) their alliance with administrative staff each significantly positively predicted client ratings of treatment. Thus, ratings of administrative alliance predicted client ratings of treatment over and above the effects of the therapist-client therapeutic alliance. These findings provide preliminary support for further investigation of the relational ecology of outpatient psychotherapy and suggest that client experiences of relational and environmental dynamics with administrative staff may be important contributors to psychotherapy outcomes. Limitations of the present study and implications for future research and practice are discussed.     

Black client,white therapist: Working with race in psychoanalytic psychotherapy in South Africa

In post‐apartheid South Africa we speak about race extensively. It permeates our workplace, weaves a thread through the fabric of our professional and personal lives, as well as our private conversations and public interactions with others. From within psychoanalytic theory, the thread weaves through the unknown content of our racialized unconscious. When there is a focus on race in the South African psychoanalytic context it largely takes the form of the struggle to articulate the complexities of working with difference, as Swartz notes, or the struggle to map out issues of race. Such struggles are not localized in South Africa, but strongly reflect a much broader struggle within the global psychoanalytic community, as mirrored in the expanding focus on race. Although the consulting rooms seem far removed from the ongoing political tensions that have recently emerged in South Africa, psychoanalytic psychotherapy remains a space of meaningful engagement with the other, and where the therapeutic dyad is one of racial difference it permits an encounter with our racialized unconscious. This article seeks to document the experience of my black client and my white response to her racial pain and struggle; in doing so, I describe the racial ‘contact’ between us and within us that triggers a racialized transference and countertransference dynamic, which contains the space for racial healing for both of us.     

From relation to the field: Modes of unconscious fantasy elaborations1

Abstract

Relational and field theories have much in common, despite divergent foundations. In this paper, several areas of divergence are selected, including the structure of the field as a relational matrix or as an unconscious joint fantasy of the couple; the fate and form of insight; and the nature of the unconscious as relational or ubiquitous. Differences in cognitive and attentional sets are identified and linked to different modes of insight. Using a clinical vignette, these divergences will be illustrated with an attempt to compare and contrast the two approaches through a discussion of how each lens highlights, expands, or forecloses different features of the analytic process. A mode of conceiving the unconscious as unstructured and multiple in potential is offered to reconcile divergent assumptions in therapeutic action. A consideration of Sandor Ferenczi’s clinical emphasis on relaxed technique, elasticity, and especially mutuality suggests that he would have been a field theorist were he among us today.     

Dissociative Collusion: Reconnecting Clients with Histories of Trauma in Couple Therapy

This paper introduces the concept of “dissociative collusion” as a helpful theoretical and clinical tool for understanding and working with clients with histories of trauma in couple therapy. The paper describes ways to diagnose and treat dissociative collusion based on the integration of an object relations approach, a relational approach, and a narrative approach. Dissociative collusion, a unique version of the well‐documented “couple collusion,” describes relational unconscious dynamics where split‐off aspects of one or both partners are mutually dissociated in a complementary fashion that becomes a part of the shared unconscious and is reenacted in destructive ways. The dissociative collusion concept is especially relevant to couple therapists who work with clients with histories of trauma, who frequently use dissociation as a primary defense mechanism. We suggest that the challenge and goal for couple therapy with this population are to help them reconnect and better oscillate between dissociated self‐other configurations. A case of couple therapy of a wife who had been a victim of childhood sexual abuse and her husband who displayed frequent use of dissociative defenses is presented.     

The Problem of Thinking in Black and White: Race in the South African Clinical Dyad

Race, as it presents itself within the clinical dyad as an aspect of the relationship between therapist and patient, has scarcely been written about from an experience-near perspective within the South African context. This paper focuses on the difficulty of speaking and writing about race. It contends that race as a construct and as an aspect of subjectivity has the potential to interrupt the therapist’s capacity to think, in Bionian terms, and to prevent entry into the reverie that is crucial to the creation of an analytic third. Written through a relational psychoanalytic lens and drawing on the concepts of the normative unconscious and the anti-analytic third, the paper refers to clinical vignettes to illustrate the collapse in thinking and the progression to beginning to think, anew, about the race-nuanced, intersubjective space between patient and therapist.     

The unconscious and consciousness of the memory: A contribution from neuroscience

Abstract

By integrating data from general psychology and perinatal clinical psychology with neuroscience and psychoanalysis, the author discusses the relations between memory and consciousness, the aim being a unitary definition of the concept of unconscious. Nobody has a brain that can be the same as any other person's: the biology of memory lies in neural networks that have been constructed in the brain of that specific person by their experience. From the fetal stage, each brain progressively learns its own individual functions during its relational neuropsychic development. The author underlines how the continuous emotional biological work of the brain, together with a person's entire relational life, produces the construction of the whole functional and individual mindbrain. The whole construction is memory and this is unconscious; indeed it may be the true unconscious. From the continuous silent work of the mindbrain of a person, some forms of conscious level may emerge in his individual's subjectivity: some functioning of mindbrain makes what an individual person can consciously remember. The unconscious is only what appears in some form in an analyst's consciousness, at some specific moment in his relationship with a patient, and which the analyst translates into some form of his verbal interpretation.     

The Therapist’s Needs: Beyond Mutual Recognition

Abstract

As early as 1965, Harold Searles argued that therapists’ needs for healing and growth are part and parcel of their work with patients. Since then, the relational movement has corroborated this idea by articulating the healing function of treatment for both patient and clinician. In this article, the authors examine therapists’ needs that have been overlooked or those that have not been considered fully in the literature. Using various ideas related to the concept of what the authors call therapeutic freedom, this article argues that clinicians must strive to adopt a therapeutic vision that aims to loosen their own ties to safe, familiar modes of engaging with patients, particularly in moments of enactment or impasse. The authors elucidate these ideas with case material from their clinical work and show how embracing various forms of therapeutic freedom results in a type of mutual surrender on the part of both patient and therapist, creating opportunistic conditions that generate therapeutic action and new possibilities for the dyad.     

Relational ecologies of psychotherapy: The influence of administrative attachment on therapeutic alliance

There is now vast and multi-faceted empirical literature on the impact of relational dynamics in psychotherapy, and relationality is a central theme within contemporary psychoanalytic theories. Yet, there is virtually no literature addressing the relational dynamics around outpatient psychotherapy that influence the wider therapeutic alliance, that is the relational dynamics that unfold between clients and administrative office staff in making initial contacts and appointments, completing paperwork, negotiating payment, discussing insurance coverage, working through crisis calls, and the myriad of other forms of interaction which serve to form the relational ecology of psychotherapy. Milieu therapy or the use of supportive and structured therapeutic environments has been given significant attention in inpatient settings; however, administrative relational factors or administrative staff characteristics have seemingly been ignored in outpatient psychotherapy and psychoanalysis literatures. Many outpatient clinical practice settings involve multiple levels and dimensions of relationality between clients, administrative personnel, and therapists which shape the potential for secure continuous containment and various forms of attachment to psychotherapeutic space. In this paper, we describe several clinical illustrations of relational dynamics between clients and office staff which influence therapeutic alliance and outline the contours of our emerging idea of administrative hospitality based on relational psychoanalysis, attachment theory, symbolic anthropology, and stigma research. In doing so, we draw on our collective experience working in several outpatient clinics and insights from our current context in an urban outpatient training clinic which emphasises psychodynamic practice. Our goal is not a comprehensive analysis of the relational ecology of psychotherapy but to offer an initial exploratory account of some of the administrative relational dynamics in and around outpatient psychotherapy which go beyond the therapist-client dyad. The anthropological concept of liminality is connected to relational psychoanalytic theories to describe the important dynamics of transitional space in an overall process of relational transformation.     

Recognising the role of emotion in the classroom; an examination of how the psychoanalytic theory of containment influences learning capacity

This paper begins with personal reflections about my work in school which began over forty years ago, outlining how the different roles of teacher and therapeutic practitioner have contributed to my interest in the role of emotion for children’s capacity for learning in the classroom. I suggest that focusing too heavily on achievement risks losing sight of the experience of the individual child and argue that a psychoanalytic framework informs us of the significance of relational aspects of teaching and learning. My aim is to alert educationalists to the complexities of the classroom context, particularly the conscious and unconscious elements at work there. I have chosen to examine containment, as one aspect of the psychoanalytic, developmental framework, as a way of thinking about relational influences in the classroom and the importance of the relational context of learning. These case studies relate to my workplace, an Infant and Nursery school with a high British multi-ethnic population, where I am employed as a teacher/therapeutic practitioner. Two brief child studies are included to illustrate this examination. The first, Hamzah, concerns a young child entering formal learning without the expected relational skills and therefore unable to connect with staff and children in any meaningful way. The second, Isa, demonstrated well developed relational skills but at times found it difficult to manage his feelings when his needs took second place to the requirements of the curriculum.     

Commentary on Paper by Ellen F. Fries

In Perchance to Sleep: Minding the Unworded Body in Psychoanalysis, Ellen F. Fries masterfully articulates the complexities of right-brain to right-brain, body-to-body interactions between herself and her patient. Her work highlights the dominance of the nonverbal implicit self over the verbal, explicit self and provides an excellent example of clinical work in which she thoughtfully attends to the unspoken, bodily based communication that takes place within the therapeutic dyad. In this discussion, I offer perspectives from Sensorimotor Psychotherapy on the impact of early attachment on the procedural organization of action sequences that reflect and sustain the implicit self, and embody unconscious relational expectations. The following topics are addressed: (a) Physical actions that provide avenues of exploration into the implicit self, especially actions such as reaching out, making eye contact, or maintaining an upright posture that are abandoned or distorted when they are ineffective in eliciting the desired response from attachment figures; (b) Body-oriented interventions that target the involuntary physical spasms that Fries' patient experiences, which are associated with unresolved physiological arousal originally stimulated in the face of trauma; and (c) The nonverbal manifestation and negotiation of enactments that emerge from the body-to-body dialogue between the implicit selves of patient and therapist.     

What Changes in Therapy? Who Changes?

SUMMARY

A central component of therapeutic change involves facilitating the capacity to move and be moved by the other. Another way of saying this might be that change entails experiencing a greater freedom of relational movement. The question of who and what actually changes in the process of therapy is the focus of the three vignettes that follow. They highlight, among other things, the recognition and acknowledgment of mutuality as an essential force within the relational matrix and the ever-changing landscape that this creates. Each of these examples of a change process bears, as well, a particular stamp of its own, and thus speaks to the unique personality of every therapeutic dyad.     

The concept of the 50-minute hour: Time forming a frame for the unconscious

Abstract

The 50-minute hour is a feature of psychoanalytic work that is most commonly discussed in the context of case reports. This paper examines it as a concept. The author starts by describing the origin of the 50-minute hour and its development as an element of the psychoanalytic setting or framework. Next, he considers the significance of the clock as a relational factor in the session and reflects on the alienness of the time of day to the unconscious, and the consequences of this alienness. He then uses a clinical example to illustrate the phenomenon of the stretching effect of time in analytic sessions. Finally, the author demonstrates how cleverly the 50-minute hour excises the time needed for unconscious processes from our accelerated present; he shows that it challenges the social convention of time, and has a structuring effect in that it “times” psychic processes.     

A fundamental change in vision: where black lives matter

Using the lens of clinical work, the author, a white supervisor, plots her concerns about unconscious racism in the training of a black supervisee. Years later this supervisee brings a distressed black trainee nurse to supervision who is struggling with relational difficulties while suffering from unconscious racism in her hospital. Supervisor and supervisee grapple to offer the patient treatment on both fronts. The author explores the underlying presence of ‘white privilege’ and ‘unconscious racism’ which finds a global audience as a result of the killing of George Floyd – an event which also had implications for the long-term supervisory partnership. Links to Jessica Benjamin’s concept of ‘doer and done to’ are made, as well as discussion of a gradual change of vision in the supervisor herself. The author also makes use of insights gained from consultancy work in a multi-racial company and two Channel 4 UK television programmes that feature workshops on unconscious racism in a mixed secondary school in the London Borough of Sutton.     

On Attacking and Being Attacked in Group Psychotherapy

Verbal attacks are unavoidable within long-term psychotherapy groups. This article examines the inherent therapeutic value of potentially destructive exchanges. Group leader attempts to objectively define and regulate “attacks” are critiqued. A case example illustrates how leader interventions using induced feelings can enhance the therapeutic process and subsequent relational repair. Leader difficulties in identifying with the relational positions involved (attacker, victim, bystander) are explored, and a framework is offered for illuminating unconscious, dissociated, or unformulated emotional communications. It is argued that leader resistances may inadvertently promote and maintain group members’ damaging tendency to direct aggression toward rather than away from the self. Instead of being avoided or controlled, verbal attacking can be considered meaningful developmental progress and leveraged clinically to promote emotional maturation within the group.     

Anxiety, signal anxiety, and unconscious anticipation: neuroscientific evidence for an unconscious signal function in humans

A central tenet of psychoanalysis, and arguably of any comprehensive theory of mind, is the existence of a psychological unconscious. Years of clinical investigation into the nature of unconscious processes have facilitated the development of psychoanalysis as a clinical method. Empirical investigations of unconscious mental processes, however, have lagged behind clinical inquiry. With few exceptions, attempts to understand unconscious processes using rigorous experimental controls have remained sequestered in scientific domains other than psychoanalysis, where they have proliferated recently. In view of this recent upsurge of research on unconscious processes outside of psychoanalysis, efforts to integrate such knowledge into general theories of psychopathology and clinical investigation are critical. In this paper, an interdisciplinary approach is taken to the study of one aspect of unconscious mental functioning--what Freud originally termed signal anxiety. Signal anxiety is examined using information from cognitive psychology and learning theory, psychophysiology, behavioral neuroscience, and psychoanalytic theory. Though the original concept of signal anxiety is supported by recent research, it is concluded that signal anxiety is probably best thought of not as the affect of anxiety but as a subset of unconscious mental processes that have a signal function of anticipating danger. Such unconscious anticipatory processes are a general feature of the mind that includes responses to both real and imagined (neurotic) appraisals of a situation. The neurophysiological structures and processes associated with unconscious anticipation in humans are just beginning to be understood.     

The “death of freud”; and the rebirth of free psychoanalytic inquiry

The relevance of Grunbaum's recent critique of psychoanalytic theory is explored as it relates to relational/interpersonal theories. Griinbaum finds no scientific evidence for repression, the cornerstone of psychoanalysis. I argue that studies demonstrating the effects of motivated, unconscious processes are beginning to emerge in psychological research. This research, as well as interpersonal theory, refers to these processes as dissociated, not “repressed.”; I agree with Griinbaum that scientific validation of psychoanalytic theories of the mind, personality, and change cannot be gleaned from case studies alone. In relational theories the analytic situation is admittedly “contaminated”; with the analyst's participation by its very nature. There is beginning to be support for some relational hypotheses, but measures to validate these hypotheses are only now being developed. Grunbaum's criticisms have come at a time when the convergence between relational theories and theories in social/clinical psychology makes it more likely that relational hypotheses will be articulated in a more precise manner by researchers, if not by analysts.

The issues of the difficulty of measuring unconscious processes and the quest for knowledge seemingly beyond human limitations are addressed. Psychoanalysis is not only less than scientific, but more encompassing, in that it is also a creative activity that cannot be understood through science alone.

Science is not enough, nor art: In this work patience plays a part [Goethe].

The most beautiful and deepest experience a man can have is the sense of the mysterious.... To me it suffices to wonder at these secrets and to attempt humbly to grasp with my mind a mere image of the lofty structure of all that there is [Albert Einstein, quoted in Pagels, 1985].     

Fantasy,defense, and the representational world

This paper discusses the manipulation of mental representations, particularly in relation to the psychoanalytic concepts of conscious or unconscious fantasy. A distinction is made between the unconscious phenomenal (experiential) aspect of representations and the nonexperiential, quasi-structural aspect. The concept of the representational world is described and elaborated, and its development is seen as a consequence of the infant's interaction with itself and the external world. Processes such as identification and projection can be seen in terms of changes in self and object representations, and the same is true for all the mechanisms of defense. The content of unconscious wishes is transformed, by use of such mechanisms, into representations that are acceptable to consciousness. Major transformations of unconscious representational content occur in the process of creating unconscious (preconscious) fantasy, and further transformations are frequently needed before such (preconscious) fantasies are permitted access to consciousness. The concept of projective identification is considered in the light of the ideas put forward in the paper.