Being ordinary in extraordinary places: Reflective practice of the total situation in a total institution

This paper examines a ‘Foulkesian type’ Balint group for psychiatry trainees set in a high secure forensic hospital. Within a Balint group, group processes and dynamics are not examined. Deviation from this format is construed as resistance, and destructively getting in the way of the primary task.

This paper reports on a case‐based reflective practice group operating on a more Foulkesian group analytic model and argues that the revised principles of method proposed here – paying attention to context; group processes; and creating an atmosphere where group curative factors are in play – can help trainees to sustain an emotional reservoir for their patients. Further, these principles do not get in the way of the primary task but can add to an understanding of the individual transference and counter‐transference issues, and can place these in context within the organization and society. This is particularly important in total institutions such as forensic units.

Clinical material from this group is used to support this claim.     

Development of the concepts of transference and counter-transference

SUMMARY

This paper traces the development of the concepts of transference and counter-transference over nearly a hundred years, from the origin of the concepts to current understanding of them. Clinical material will be given to illustrate some of the ideas held today.     

Assessing the risk of self-harm in adolescents: A psychoanalytical perspective

SUMMARY

This paper explores the way psychodynamic factors can be used to extend and improve the quality of the assessment of adolescents at risk of self-harm. Conventional risk factors are clearly of value to identify those young people who require admission or other interventions. However, a consideration of the internal and external factors and their interaction, as manifest in the transference and in a consideration of the history and present circumstances, allows shape and depth to be added to the assessment. In this way an assessment can be a therapeutic intervention in its own right, and can play a part in reducing the risk. This approach is described and illustrated with clinical examples.     

Anorexic and bulimic states of mind in the psycho-analytic treatment of anorexic/bulimic patients and psychotic patients

SUMMARY

This paper discusses the relationship of bulimic and anorexic states of mind, and their interchangeability as manifested in the transference. The anorexic making bulimic-like greedy demands upon his/her objects. The bulimic showing all the qualities manifestly presented by the anorexic, an appetiteless approach to possibilities and peculiar searches in a non-specific fashion for satisfaction. Clinical material for discussion is presented from the analysis of three patients — one of whom was psychotic.

The paper attempts to show how in the transference in the true anorexic and bulimic, attacks are directed towards the awareness of the meaningful and intended specificity and function of all objects, so that any specific function can be mis-directed or nullified by the patient. The paper shows how some of these characteristics can appear as well in the treatment of borderline cases and affect the countertransference of the therapist.     

Alchemy and the erotic transference: A Jungian approach

Abstract

In The Psychology of the Transference Jung showed a series of pictures which he discovered in an ancient alchemical text, the Rosarium philosophorum. He connected these to the effects of the transference in psychotherapy. This may seem an unnecessarily obscure way of looking at the transference, yet it makes remarkable sense. Although alchemy is often considered the sole province of Jungian analysis, it can also be seen as illuminating a psychodynamic approach to counselling. Written from a post-feminist viewpoint, a critical approach is taken to certain key Jungian terms. The paper is illustrated with two clinical examples.     

Braving the erotic field in the treatment of adolescents*

Abstract

The psychoanalytic literature on erotic transference and countertransference in adolescence is notably sparse, despite the centrality of the developing sexual body/mind. Erotic feelings in the consulting room with an adolescent can feel taboo, causing the analyst to avoid the immediacy of these feelings. Excessive timidity on the part of the analyst can limit the growth of the capacity for containment of sexual feelings and yield what I term ‘erotic insufficiency’ in our work with adolescents. I offer clinical material from a period of erotic transference and countertransference with a 12-year-old boy to consider these ideas. Further, I suggest that the very terms ‘erotic transference’ and ‘erotic countertransference’ can feel defensively remote and antiseptic. I suggest that ‘erotic field’ better captures the subtle, nuanced interplay of feelings.     

Seduction,date rape,and aborted surrender

Abstract

This paper clarifies the dual-layered nature of the “demon lover complex,” with its background of both pre-Oedipal trauma and Oedipal-level desire. It draws on an object relations understanding of the unconscious and dissociated addiction to an internal demon object that has derivations in the personalities of the actual parents, and in the internalization of these parents. The dramatic case of early trauma compounded by adult date rape trauma serves to illustrate how a “developmental mourning process” in treatment can resolve such trauma. It also illustrates how reparation with the mother that partially heals pre-Oedipal trauma cannot immunize anyone against Oedipal-level attractions to a “demon lover” father, as represented in a displacement, resulting in victimized behavior, and in an aborted surrender to heterosexual desire. However, this victimization can be resolved, as seen in the clinical illustration, when the psychoanalyst has an understanding of the mourning process in developmental terms, working with a natural interaction between mourning and transference evolutions in treatment. The case also demonstrates the transitional object role of the psychoanalyst who is involved with the healing of pre-Oedipal trauma through mourning.     

Emotion: Sensory Representation,Reinforcement, and the Temporal Lobe

Abstract

In this article emphasis is placed on the reciprocal relationships between reinforcers and the central representations of extrinsic stimuli. It is argued that an understanding of these processes will prove crucial in an understanding of how adaptive stimulus representations can be formed and how such representations can come to elicit emotions. It is proposed that the evolutionary origin of emotions, which are primarily Seen as energising signals of survival value, arose from the need to Sensitise an animal in the absence of appropriate signals of reinforcement. Evidence is provided that many of these functions take place in the primate temporal lobe.     

Psychodynamic counselling in an educational setting: Containing,transference and clientele

Abstract

The concepts of containing and transference, as well as the specific nature of the clientele, may, on a first approach, be used to differentiate psychodynamic counselling in an educational setting (PES) from the ‘pure gold’ of psychoanalysis. Further, it is argued that a realistic understanding of PES, given the constraints in which it operates, demands that the psychodynamic practitioner be prepared to cut her procedural cloth in accordance with the demands her clients place upon her. This makes PES a pragmatical practice rather than some lesser cousin of ‘orthodox’ psychoanalysis.     

Therapeutic and counter-therapeutic factors in acute ward settings

Summary

Recent reports suggest that many patients view their admission to a psychiatric acute unit as an unrewarding, distressing or undermining experience. Whilst it could become genuinely therapeutic, in the sense that it could be an opportunity for self-reflection, personal exploration or change, it is often endured as a traumatic event in one's life that should best be forgotten.

This paper explores a psychodynamic understanding of this multi-personal environment in which transference phenomena develop and are usually ‘acted out’. The admission process is examined, as well as the importance of understanding the support and attachment to fellow patients, staff-patient tensions, and relationships between staff and management. Issues about violence and fear, locked wards, and reflective interventions on a unit are discussed, focusing on how to maximise therapeutic opportunities. The multi-disciplinary ward-review is also scrutinised in this light.     

Holding in mind: Theory and practice of seeing children in groups

ABSTRACT The authors will describe their therapy group for children in a Child and Family Consultation Centre. They will discuss the rationale for this treatment. An account will be given of the group processes with special reference to different feelings as they emerge in the transference relationships. Issues concerning the dynamics of co-therapy will be addressed. The work on the ‘reflective function’ by Fonagy and Target, which the authors think is an important contribution to understanding the therapeutic process in the group, will be discussed.

What literature there is on group therapy for children suggests that it is an effective form of treatment. This article describes the way in which the children's issues come alive in group therapy and in this way can be addressed quickly, in comparison with individual therapy where the process is sometimes slower. It will be emphasized that structure and boundaries are essential for containment of children so that psychoanalytic reflectiveness can take place. This reflectiveness includes understanding of the group process as well as the inner world of the child.     

Book Reviews

Abstract

There are many brief, demanding, aborted cases that no one ever writes about. The typical psychoanalyst or psychoanalytic psychotherapist, however, has many outpatient cases that are shortlived, intense encounters with very disturbed patients. Rather than ignore these encounters as non-analytic or non-instructive, I think these cases add to our knowledge about the mind and its functions. In addition, it is unrealistic to think we can always help a very anxious and disturbed person to enter the treatment process with immediate success. It is more instructive to apply the analytic method and offer the patient what we can and have both analyst and patient learn as much as they can in the time they are able to stay together. Using case material, I show the Kleinian approach to working analytically with these difficult patients. Whether focusing on transference or extra-transference material, the analyst interprets the patient's internal phantasies and anxieties regarding the self and the self's important objects. This analytic stance tends to relieve the immediate anxiety and set the stage for potential self-reflection and the start of basic working-through processes.     

The application of self-psychology to short-term counselling

Abstract

This article explores how key aspects of Heinz Kohut's self-psychology can inform short-term counselling work. Initially a summary is offered of Kohut's developmental theory, his understanding of the nature and causes of psychopathology and his view of the analytic cure. The application of his ideas to short-term counselling is then discussed. Specifically, it is suggested that short-term therapeutic work based on self-psychology involves a stronger emphasis on the curative aspects of the selfobject transference between client and therapist, a more limited notion of the role of interpretation, and a different understanding of working through to that of long-term self-psychological analysis.     

On the Psychoanalytic Treatment of the Depressive Personality

In order to discuss the depressive personality we have first to distinguish between this clinical entity and other types of depressive psychopathology that might also be chronic. The character traits and psychodynamics of the depressive personality confirm that there is a special group of patients, who belong to a depressive disorder continuum. The particular technical problems that depressive personality present are: (1) the inability to enjoy anything and the consequences of this on the therapist's experience and interventions, and (2) the negative therapeutic reaction which threatens the analytic process and the therapist's competence. If we combine transference/extratransference interpretations with an "empathetic understanding" approach to systematic confrontation and interpretation, we can therefore justify the need for a slightly modified psychoanalytic technique in the treatment of the depressive personality.     

Chapter 7 The Gay Therapist's Response to a Gay Client Practicing Unsafe Sex

Abstract

The significance of psychoanalytic perspectives for brief psychotherapy is discussed in the report of a gay man practicing unsafe sex (known colloquially as “barebacking.”). The paper focuses both on understanding transference and counter-transference issues in work with this man.     

Le dégoût dans le trouble obsessionnel compulsif,mécanismes, évaluation,implications pour des pistes thérapeutiques

IntroductionAlthough considered a basic emotion, disgust has received little attention from research from the psychology of emotions compared to other emotions such as fear or sadness.Literature findingsMany empirical and experimental data suggest, however, that disgust plays a determining role not only in our ability to adapt to our environment but also in the maintenance and development of certain psychopathological states such as obsessive-compulsive disorders. The purpose of this article is to review the literature on the construct of disgust, including its two basic dimensions of disgust and disgust. A first part will be dedicated to the acquisition of disgust in the framework of evaluative and Pavlovian learning, we will then describe in detail the assessment tools available in the literature allowing to evaluate the different dimensions, then we will address the continuum. Experience of disgust, from normal disgust to pathological disgust, and will particularly target its role in dysfunctional obsessions of contamination and emotional distress.DiscussionIf, from a theoretical point of view, the understanding of the underlying mechanisms of pathological disgust reactions improves, the proposals for treatment to mitigate these reactions are rare. New approaches to care will be described to allow the development of empirically based psychological interventions.ConclusionThe recognition of emotional influences beyond anxiety in obsessive-compulsive disorder (OCD) stems from the fundamental importance of a dimensional approach to psychopathology and support. The accumulated data suggest that the inclusion of disgust in the theoretical models of OCD, in particular those with contamination concern, will thus improve our understanding and treatment of this disorder.     

Psychoanalytic Perspectives Concerning the Impact of Managed Care on Psychotherapy

Abstract

The impact of managed care insurance coverage on the psychoanalytic situation is explored, using case material to show the particular ways transference and resistance may differ or not differ under this special circumstance. Managed care shapes typical areas of anxiety such as fees, schedules, frequency, and termination into riper opportunities for transference and resistance exploration. However, the so-called reality factor of an external influence easily disguises these potentialities. The analyst may unwittingly act out countertransference feelings using this “reality factor” as a rationale. While managed care does shift the nature of the therapeutic relationship, the emphasis on interpretation of transference and resistance remains at the forefront of technique.     

The non-mirroring mother and the missing paternal dimension in a case of narcissistic disturbance

SUMMARY

Heinz Kohut (1971, 1972, 1977), has developed an innovative framework for understanding the dynamics and genesis of disturbances in the sense of self — broadly speaking, the area of narcissistic disturbance. He has emphasized the failure of the primary objects (in his terms ‘selfobjects’) to be available as responsive mirroring figures who can also be idealized. The role of oedipal conflict is specifically de-emphasized. In this paper a patient is described for whom the factors noted by Kohut were relevant, but as well as these, issues related to a failure to negotiate the oedipal position and a denial of the primal scene were also crucial. These phenomena are not described in Kohut's writings. For this patient, the exclusion or foreclosure of the ‘paternal dimension’ (Chiland 1982) left her with a fundamental defect in psychic structure with profound ramifications. In addition various features of the transference pointed to a failure of early communication via projective identification and maternal containment, of the kind described by Bion (1962). This process is compared with that subsumed by Kohut's concept of mirroring.     

The Understanding and Creation of Rituals: Enhancing the Life of Older Adults

ABSTRACT

We live in a rapidly changing culture, often with a loss of identity, community, and meaning. Rituals can give us a foundation, that sense of stability we need as we tackle the challenges and opportunities that confront us on a daily basis. Rituals must be grounded in understanding developed through particular attention to the meaning of the aging process in the context of the life span. The purpose of this article is to discuss the meanings of rituals and to present a simple method for creating rituals that can add meaning to the lives of older adults.     

Working Experientially and Somatically with Couples

SUMMARY

Working experientially and somatically with couples is a powerful method of accessing, exploring, and transforming both intra-psychic issues and interactional patterns. In this article, a number of methods of working experientially will be described, along with their underlying rationale. Basic assumptions about the nature of couple's difficulties and the role of the therapist also will be explored along with an integrated approach to assessment that provides a solid basis for these dramatic interventions.