"Without being in psychoanalysis I would never have dared to become pregnant": psychoanalytical observations in a multidisciplinary study concerning a woman undergoing prenatal diagnostics

As is well known, Freud described the clinical practice of psychoanalysis as the 'loam' of his cultural-theoretical work, an assessment which is shared by many psychoanalysts up to the present, including the authors of this paper. The complex interplay between unconscious phantasies on the one hand, and the real experiences arising from the new possibilities opened up by prenatal diagnostics on the other, is described with reference to a report of an intensive, long psychoanalysis with an analysand from a family burdened with a genetically transmitted illness (haemophilia). The holding and containing function of the analyst enabled this analysand, despite traumatic experiences with the miscarriage of a healthy child triggered by a prenatal diagnosis and the later abortion of a haemophiliac baby, nevertheless to have the courage to go through another pregnancy and give birth to a healthy girl. The intensive clinical investigation of the unconscious phantasies, conflicts and traumas around the prenatal diagnostics proved to be not only therapeutically fruitful for the analysand, Ms F. It also facilitated insights into those individual chances and risks which appear to be an integral part of the opportunities presented by todays prenatal diagnostics and, through them, it lead to a cultural-critical look at the ambivalence of medical-technical progress. These insights, which are only attainable through psychoanalysis, can represent a distinctive contribution of psychoanalysis to a multi-disciplinary dialogue with medical practitioners, geneticists, ethicists and health policy-makers. By referring to a large EU study on 'Ethical Dilemmas due to Prenatal and Genetic Diagnostics', this paper gives a practical example of such a discussion. Ms F. was psychoanalytically interviewed as part of this study, 16 years after the conclusion of her analysis. The summary of these interviews, which is set against the account of the treatment, offers an impressive insight not only into the long-term effects of a psychoanalysis under very particular personal circumstances, but also into the lasting consequences of decisions made in the context of prenatal diagnostics. Finally, the results of the individual case study are brought together with the clinical outcomes of the EU study, and some considerations are formulated concerning the protective and risk factors facing women during and after prenatal diagnostics. The paper is an appeal to psychoanalysts, with their specific competence in dealing with unconscious phantasies and conflicts and their high level of professionalism in dealing with traumatised patients, to get involved in fresh dialogue with prenatal diagnosticians and their patients.     

Formal Defensive Aspects of Cognition and Modes of Thinking Exemplified by Freud's Case History of the Rat Man

Autoerotic gratifications are necessary for children suffering from a disturbed mother relation, and constitute symptoms of the same (jactatis capitis, extreme masturbation, etc.). The origins of the autoerotic functions go as far back as the foetal stage (thumbsucking). In the habits of so-called normal human beings, they also have an important stabilizing function to psychic autonomy. We are accompanied by primary and sublimated autoerotic functions all through our lives, which offer comfort and satisfaction during the different vicissitudes of life. Freud's monistic drive theory seems more plausible to me than his later dualistic theories. In accordance with the former, man can regress from object-libidinal cathexes into autoerotic positions when feeling psychically or physically threatened, and during normal conditions when asleep, sleep constituting a normal narcissistic state.     

The unconscious

A discussion of the unconscious leads naturally to Freud and to a theory on subjectivity we may designate as de-centred. The unconscious reminds us that not only do we not know ourselves. In the core of our subjectivity, we have to acknowledge the notion of otherness. Re-reading Freud's text, The Unconscious, from 1915, the current author emphasises the character and function of the unconscious as radically different from what we know about conscious processes. This allows for the concept of the preconscious, which the author links to Winnicott's intermediary area and Green's tertiary processes. Taking as point of departure Freud's differentiation of word presentation and thing presentation, the author points to Freud's introduction of the term thing-cathexies of the object as designating the primal psychic representation. The Freudian perspective is broadened, encompassing the notion of otherness as discussed by Laplanche and Aulagnier. Concluding the paper, the author draws some implications for psychoanalytic technique, focusing especially on transference.     

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.     

On creating a psychoanalytic mind

The term process knowledge is introduced to highlight a particular way of analyzing that centers on how our patients gain knowledge. It is suggested that analyzing with heightened awareness to process knowledge is crucial for the patients' capacity for self-analysis, and differs from helping patients primarily gain knowledge of their unconscious fantasies and conflicts as the primary curative factor in psychoanalysis.     

A 9-YEAR-OLD WITH CONVERSION DISORDER, SUCCESSFULLY TREATED WITH PSYCHOANALYSIS

This paper outlines the successful psychoanalytic treatment of a latency-aged boy with severe conversion disorder. Details of clinical treatment are presented. As no tested treatment has yet been found that reliably treats chronic conversion in children, this case is of importance in demonstrating the usefulness of psychoanalysis as treatment for severe psychopathology. The patient's unconscious fantasy constellations that gave rise to this syndrome are highlighted.     

Further developments of the concept of fantasy

After the Isaacs' seminal work on the nature and function of unconscious phantasy (1948), several authors (mostly in the British Society) have reflected on the topic and tried to extend the concept of fantasy. In this paper I shall examine the contributions of Winnicott, Gaddini, Joseph and Anne Marie Sandler that aim at broadening this psychoanalytic concept. The authors that I have considered share a focus mostly on the early stages of child development. Both Winnicott and Gaddini belong to a line of thinking that explores the vicissitudes of the primary emotional development of the infantile self (in the mother‐infant relationship) involving the earliest processes of holding and bodily and kinaesthetic fantasy that form the bodily integrity of the person. The Sandlers focused mostly on the concept of the past unconscious understood as a place of primitive vicissitudes with a deficit in figuration where the process of repression is missing. The present unconscious phantasy (that is located in the here and now) has the function of rendering the past unconscious phantasy partly accessible; otherwise it would remain unknowable.     

Reflections on Klein's radical notion of phantasy and its implications for analytic practice

Analysts may incorporate many of Melanie Klein's important contributions (e.g., on preoedipal dynamics, envy, and projective identification) without transforming their basic analytic approach. In this paper I argue that adopting the Kleinian notion of unconscious phantasy is transformative. While it is grounded in Freud's thinking and draws out something essential to his work, this notion of phantasy introduces a radical change that defines Kleinian thinking and practice and significantly impacts the analyst's basic clinical approach. This impact and its technical implications in the analytic situation are illustrated and discussed.     

Sabina Spielrein: out from the shadow of Jung and Freud

Abstract: Since the 1982 publication of Aldo Carotenuto's book, A Secret Symmetry: Sabina Spielrein Between Jung and Freud, there has been renewed interest in the life and work of Sabina Spielrein. She was Jung's first psychoanalytic case at the Burghölzli Hospital in 1904, and was referred to several times in The Freud/Jung Letters. Spielrein recovered, enrolled in medical school, and went on to become a Freudian analyst. Her most famous paper, published in 1912, ‘Destruction as a cause of coming into being’, was referred to by Freud in 1920 in relation to his Death Instinct theory. In the few Freudian publications on this controversial theory since 1920, Spielrein's contribution is consistently omitted. Jung also neglected to refer to her ‘Destruction’ paper in his early 1912 version of ‘Symbols of transformation’, even though he had edited her paper and had promised to acknowledge her contribution. He did refer extensively to Spielrein's first paper, her medical thesis, ‘On the psychological content of a case of schizophrenia’, published in 1911, as yet unpublished in English. In her paper Spielrein sought to understand the psychotic delusions of Frau M, a patient at the Burghölzli, much in the style of Jung's ‘Psychology of dementia praecox’ (1907). The purpose of this paper is to explore to what extent Spielrein's Frau M paper, and its companion ‘Destruction’ paper, make an original contribution to both Jung and Freud's emerging theories on the possible creative versus destructive outcomes of neurotic or psychotic introversion, culminating in Jung's concept of the ‘collective unconscious’ (1916) and Freud's concept of a ‘Death instinct’ (1920).     

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.     

Working psychodynamically and psychosocially with women who have been raped

In this paper, I analyse aspects of the experience of some female University students who have been raped drawing on a Kleinian psychoanalytic perspective and Layton’s concept of ‘normative unconscious processes’. I suggest that Klein’s writing provides a theoretical basis for thinking about the projective and introjective processes that may be at play between perpetrator and ‘victim’. Here, I focus upon Kleinian conceptualisations of castration anxiety, fragmentation, envy, greed and guilt. In terms of ‘normative unconscious processes’, I explore how castration anxiety (in a more symbolic sense of powerlessness), fragmentation, envy, greed and guilt may also operate within social discourses around sexual violence. Specifically, I draw upon Freyd’s concept of DARVO and Payne’s Rape Myth Acceptance Scale which both explain ‘victim blaming’ in terms of the social reversal of the positions of perpetrator and ‘victim’. I illustrate this social process with reference to representations of rape within the mainstream media. My hypothesis is that, although the ‘psychic’ and the ‘social’ are two contrasting positions theoretically, it is possible to draw on both of them to make sense of the experience of working with rape clinically.

The clinical context of this paper is my work as a psychodynamic counsellor at a modern London-based University. I draw on composite case studies of women who have been raped, drawing on both ‘psychic’ and ‘social’ perspectives. I seek to explore how the ‘psychic’ and the ‘social’ can be integrated in different ways depending upon the clinical situation. I suggest that they can be mutually enriching ways of working. Through approaching how the ‘psychic’ and the ‘social’ might interrelate from a clinical viewpoint, I conclude that the idea of ‘working psychosocially’ is of most use when approached as a flexible concept that different clinicians may draw on in different ways with different patients.     

Candidate progression in analytic institutes: A multi-center study

This study documents the criteria for graduation and for awarding credit for training cases used by thirteen institutes of the American Psychoanalytic Association (APsA). At the time of this study, these thirteen institutes were training 63% of all candidates enrolled at institutes of the APsA. Questionnaires were sent to the progression committee chairperson (PCC), a junior candidate and a senior candidate, and a recent graduate at each institute. Each participant also had a follow-up semi-structured telephone interview. Return rate was 100%. 92% per cent of the institutes reported that in order to receive credit for cases, the patient needed to be in treatment for some minimum amount of time (average 18.3 months). Many PCCs were skeptical about writing down the criteria for credit, stating that this made candidates overly focused on the time requirement. 85% per cent of PCCs felt that graduation from the institute was based primarily on obtaining credit for cases. Few required a terminated case and only one felt that classroom work was an important factor. 47% per cent of candidates felt that the need to keep patients in treatment to receive credit for cases affected their treatment of patients and only 46% of candidates could state the minimum time requirement used by their institute. These results indicate that graduation from institutes of the APsA depends primarily on receiving credit for cases, that case length is an important criterion for awarding credit and that this method of evaluating candidates may not be the best way to support educational objectives.     

The state,the institution,and the patient: A three-way collison at the crossroads as a hospital fights closure

This paper recounts the story of a National Health Service hospital which was almost closed for financial reasons in 1990. After a political campaign carried out in the full glare of publicity, the Hospital was reprieved. The account is based on the author's conversations with members of staff. The story of the staff, the patients, the Hospital, and the political struggle are woven together by common themes which are highlighted by reference to the Oedipus myth.     

The Role of Psychoanalysis in the Conflict of Interpretations

This paper describes how the temporary illness of the analyst affects the analytic work when it breaks the habitual analytic setting and exposes the analyst to countertransference reactions. The illness stimulates different meanings and reactions in the analysand. The paper describes how the fostering of the habitual analytic work helps the analysand to make use of the event, i.e., to integrate it into the transference. In the light of the patient cases, it would seem that corporeality is the key: the crucial question is what it means not only to the analyst him/herself but also to the analysand, that the analyst's body remains unchanged, secure, living and stable and does not require any particular attention.     

Reading Susan Isaacs: toward a radically revised theory of thinking

The author views Isaacs's (1952) paper, The nature and function of phantasy, as making an important contribution to the development of a radically revised psychoanalytic theory of thinking. Perhaps Isaacs's most important contribution is the notion that phantasy is the process that creates meaning, and that phantasy is the form in which all meanings - including feelings, defense 'mechanisms,' impulses, bodily experiences, and so on - exist in unconscious mental life. The author discusses both explicit formulations offered by Isaacs as well as his own extensions of her ideas. The latter include (1) the idea that phantasying generates not only unconscious psychic content, but also constitutes the entirety of unconscious thinking; (2) the notion that transference is a form of phantasying that serves as a way of thinking for the first time (in relation to the analyst) emotional events that occurred in the past, but were too disturbing to be experienced at the time they occurred and (3) a principal aim and function of phantasy is that of fulfilling the human need to get to know and understand the truth of one's experience. The author concludes by discussing the relationship between Isaacs's concept of phantasy and Bion's concepts of alpha function and the human need for the truth, as well as the differences between Fairbairn's and Isaacs's conceptions of the nature of unconscious internal object relationships.     

Elasticity of Technique: The Psychoanalytic Project and the Trajectory of Ferenczi's Life

The object of this paper is the Elasticity of Psychoanalytic Technique in the work of Sándor Ferenczi. The author sustains that this can be considered neither as an ultimate arrival point nor as a particular stage of Ferenczi's clinical–theoretical body of work, but rather as an ensemble of affective qualities, attitudes and values, which he gradually developed through experience, signalling a paradigm shift in the history of psychoanalysis. The following areas will be explored: the new sensitivity demonstrated by Ferenczi concerning the relational and communicative factors present in the analytic session, his subtle and acute attention to the participation of the analyst's own subjectivity in the therapeutic process, and how these enduring elements of Ferenczi's technique anticipate several significant future developments in psychoanalysis.     

Unconscious fantasy (or phantasy) as clinical concept

A clinical phenomenology of the concept ‘unconscious fantasy’ attempts to describe it from a ‘bottom‐up’ perspective, that is, from the immediate experience of the analyst working in session. Articles of psychoanalytic authors from different persuasions are reviewed, which taken as a whole would shed some light on how the concept of unconscious fantasy takes shape in the analyst's mind during the session with the patient. A clinical phenomenology in three steps is described. Each step is illustrated by clinical material. Current controversies around the concept of unconscious fantasy (or phantasy) are still trapped in the discussion about if and how they are really unconscious. The strategy to describe from a ‘bottom‐up’ perspective the process of how the analyst's mind embraces the idea that an emerging phenomenon in the relationship with the patient can be defined as ‘unconscious fantasy’, allows us to elude the question as to whether or not we believe that unconscious fantasies exist at all, since we are neither required to assert or deny such a prior existence in order to describe the process of elaboration which, in the end, does formulate a fantasy as fantasy.     

A reassessment of psychoanalytic education: Controversies and changes2

To understand the many controversies surrounding psychoanalytic education, it is necessary first to understand the unique role played by education in our field where control of educational structures remains the most important measure of professional success for the majority of psychoanalysts. To keep debate about educational policy focused on the task of strengthening the intellectual basis of psychoanalysis, it is also necessary to understand that forces affecting education arise from at least three different domains which can too easily become confused with one another: 1) the domain of knowledge‐ intellectual, scientific and clinical; 2) the domain of the organized professional community; and 3) the domain of local institutional politics. The authors explore controversy arising within and among each of these domains. They also explore the major alternatives proposed to the Eitingon model of psychoanalytic education, arguing that excessive authoritarianism in education arises not from the existence of hierarchical structures per se (as suggested by the ‘French model’), but from two other factors: the condensation of all important professional functions into the single ‘monolithic’ position of the training analyst, and the lack of agreed upon methodology for determining the validity of theoretical propositions. The solution lies not in obliterating all gaps in expertise and status by doing away with hierarchical structures altogether, but rather in strengthening the intellectual, scholarly and research context within which psychoanalytic education takes place. We must attempt to relocate our experience of a gap where it belongs: not between those who are training analysts and those who are not, but between what we feel we already know about mental life and what we do not yet know.