Ordinary Unconscious Communication in the Therapist/Patient Relationship

ABSTRACT

In this article, I consider the ways in which unconscious communication between therapist and patient is omnipresent in psychoanalytic work. To consider unconscious communication between therapist and patient is to consider psychoanalysis, at its core. The phenomenon of unconscious communication between patient and therapist is a quotidian event. It defines its essential listening stance, with variations associated with different theoretical perspectives. I present several clinical vignettes to illustrate the phenomenon and consider some different theoretical perspectives that bear on the therapist’s uses of self in engaging the ways that one unconscious informs another.     

Languages of trauma; towards a phenomenological response

In this article, I explore the possibilities of a phenomenological perspective on trauma in psychoanalytic practice. I highlight the problem of interpretations that universalise experiences of trauma, provide explanations in terms of ‘causes’ and assume particular processes/stages of ‘recovery’ from it. The notion of trauma challenges dichotomies of ‘internal’ and ‘external’ worlds. Traumatic experiences always have a context – that of the immediate relational circumstances of the individual suffering from the trauma, including the wider social/relational context, and the person’s history. I argue for an attunement to the language and specificity of the meanings, verbal and non-verbal, conscious and unconscious, of the client’s suffering within the analytical relationship. This requires the therapist to avoid ‘ready-made’ interpretations from psychoanalytic theory and to be open to the poiesis of the speech, which emerges between therapist and client. My discussion of my reading of the Chilean documentary film, Nostalgia for the Light, which focuses on the traumatic experiences of those who survived Pinochet’s military regime (1973–1989), highlights how diverse responses to trauma are. The originality of the language of the film calls on us as therapists to discover new ways of listening and speaking to our clients’ suffering.     

Restoring Dyadic Connection in the Face of Multiple Disruptions: Accounting for Vicissitudes in the Therapist’s Capacity for Reflective Functioning

This article describes the working method of our study group comprised of former Chestnut Lodge Hospital therapists and focusing on understanding therapeutic work with severely disturbed adolescents. Using process material from one therapy session, the therapist’s commentary on her feelings and reactions in the session, and the group’s discussion of the work, we explore factors disrupting the therapist’s moment-to-moment capacity to maintain a theory of her own and the patient’s minds. We then discuss what allows her to refind her theory of mind in the face of the patient’s aggressive nihilism and her own sense of loss. Salutary factors included the therapist’s empathy for the patient’s shared sense of grief, the patient’s offering the therapist cues to his inner state, and the dyad’s capacity to tolerate the therapist’s vulnerability in the patient’s presence.     

The experiences of therapy from the perspectives of carers of people with dementia: An exploratory study

Design: Interviews were conducted with six carers of people with dementia about their experience of receiving counselling/psychotherapy. Interviews were conducted in the carer's own home, and data were analysed thematically using a narrative approach. Findings: Three themes were identified from the data: ‘Still doing the best I can’ (identified as losses and processes of personal growth); ‘Feeling connected and being understood’ (identified as attributes believed to be important within the therapeutic relationship); and ‘Wanting to share information’ (identified as sharing information with someone ‘neutral’). Carers placed emphasis on the age of the therapist and the amount of therapist self‐disclosure. Attending counselling and/or psychotherapy also helped the carer to find a ‘safe space’ to disclose and share concerns. Discussion: Carer loss and personal growth are explored, together with the importance of building therapeutic relationships and, for the therapist, seeking supervision when managing personal self‐disclosure. The theme of therapist self disclosure is explored together with the importance of therapists seeking supervision when managing personal self‐disclosure.     

Peter and the renegade ‘It was Georgie I loved best’

This article contains reflections on my last conversation with Peter Lomas. As a consequence of this interchange, I consider Peter's inheritance of Sandor Ferenczi's therapeutic legacy. Some critics of the work of both practitioners insinuated that their ideas and practice amounted to a form of ‘wild analysis’: I examine this mistaken attribution and argue that the creativity inherent in their therapeutic ideas and practice was wrongly perceived as ‘wild analysis’. I consider Peter's misgivings in relation to Winnicott's ideas about regression in therapy, predicated on idealisation of the mother–baby relationship and entailing undue idealisation of the therapist–patient relationship without due attention being paid to the role of the father. I muse upon Peter's love of football, seeing it as a metaphor for the practice of psychotherapy.     

Telepathic Entanglements: Where are we Today? Commentary on Paper by Claudie Massicotte

In this commentary, stemming from Freud’s conflictual interest in psychic phenomena, I examine current views of telepathy as reflected in controversial parapsychological research and theories of nonlocal mind. I hope to inspire readers’ curiosity about the possible existence of telepathic communication by proposing clinical examples and raising the feasibility of the impact of the therapist’s own predisposition and belief system. Finally I speculate about how findings from parapsychology research in combination with findings from neuroscience and quantum theory might influence the evolution of psychoanalytically based practice methods in the future.     

Therapeutic action in psychoanalytic therapy with toddlers and parents

Psychotherapy with toddlers and parents can focus on promoting attachment, facilitating development and improving interactions. Some techniques provide guidance to the parents, whereas others interpret to them their unconscious fantasies or ‘ghosts’ contributing to the child’s disorder. A recent paper introduced a psychoanalytically oriented technique, which emphasised the therapist’s interaction with the child in the presence of the parent(s). The child was addressed about his/her unconscious motivations in the session and the feelings towards the therapist. Also, the parent’s transference onto the therapist was seen as a vehicle that might further the therapeutic process and was accordingly addressed. The present paper analyses the therapeutic action in such treatments. Whereas work with the parents resembles that of ordinary psychodynamic therapy, therapeutic action is more difficult to conceptualise regarding the toddler, whose understanding of verbal interpretations and the therapist’s dialogues with the parent is more limited than that of an adult. However, a clinical vignette demonstrates a toddler’s precise and swift reactions to communications from mother or therapist. The paper investigates evidence from neuroscience and psychological research as to which communicative channels – beyond words – toddlers might perceive and comprehend. In addition, it is claimed that the countertransference is key to explaining how the therapist understands such communication.     

Discussion of “Taking the Sting Out: Manifesting Aggression and Containing Difficult States in a Relational Group Psychotherapy”

Ravit Raufman’s paper contributes to the bridging gap between relational approaches and group therapy. It is also important in its recognizing the (group) therapist’s aggression and suggesting how to use it in the service of the group development. In this review I focus on the dynamics of a group of women led by a woman to explain some of the phenomena that Raufman describes in her article, and I add some social unconscious ideas to enrich our understanding of that group.     

THE ‘OTHER 23 HOURS’: SPECIAL PROBLEMS OF PSYCHOTHERAPY IN A ‘SPECIAL’ HOSPITAL

In this paper, I describe and discuss the complexities of being a therapist in a maximum security forensic psychiatric hospital, working with patients who have committed acts of serious violence, and who also suffer from severe mental illness and personality disorders. I suggest that profound disturbances in the patient's inner world get played out in triangular disputes between the patient, the therapist and other professionals working in the hospital. I also describe how real events in the life of the institution impact on the therapeutic process, and the importance for the therapist of reflection on the ‘other 23 hours’ that the patient lives outside of therapy. Finally, I raise some ethical dilemmas that arise for therapists working in such settings, where the stated therapeutic aim is not only treatment but also the containment and prevention of future violence.     

Psychoanalytic Engagements With Death: Discussion of Martin Frommer’s “Death Is Nothing at All: On Contemplating Non-Existence”

In this discussion, I reflect on some historical, theoretical, and clinical implications of Martin Frommer’s thesis that death anxieties are best navigated via reaffirming attachments with that which is beyond the self. Frommer’s examples of active engagement with his patients in personal modes of discourse about shared existential concerns are considered in terms of the ethics and responsibilities of self-disclosure and the therapist’s own subjective reactions to the death anxieties. Frommer’s contribution is applauded as an exemplar of relational psychoanalytic therapy that incorporates and goes beyond Freud’s formulations of internal processes of identification with the deceased.     

When Time Stands Still: The Non-Interactive Interaction in the Psychoanalytic Encounter

This paper strives to shed light on the patient–therapist encounter at times and places where emotional life has stopped, both within the patient and in the therapeutic dyad. The term non-interactive interaction is coined to describe a manner of being together that does not possess the essential features of interaction: movement, encounter, and change. The paper explores the characteristics and effects of such dead areas in one’s soul and the various motivations for the therapist’s willingness to surrender himself to such areas, both those of his patient’s and of his own. Among these, the paper suggests, are the therapist’s love and dedication to his or her patients; his deep-rooted struggle to cope with and give life to some of his own deadened and traumatic self-states; and, perhaps most important, a mythical, hubris-like, valiant, and perennial urge to fight death. Two clinical examples are presented.     

Altruism and Boundary Violation

ABSTRACT

The desire to help others is a common motivation for becoming a therapist, and boundary crossings are an expectable part of psychotherapeutic work. However, progression to boundary violation is rare. The concept of an altruistic boundary violation is presented and illustrated with detailed clinical material drawn from the analysis of Mrs. A,¹ a generally ethical therapist, whose violation of the therapist/patient boundary with her patient, M, began as an altruistically motivated enactment and boundary crossing. In Mrs. A’s case, and arguably in all similar altruistic boundary violations, a specific fit existed between patient and therapist. The intense need to rescue this particular patient was fueled by Mrs. A’s history of early physical and abandonment trauma, which increased her vulnerability to overidentification with her traumatized patient. The stress of relocation to another city and closing her practice further magnified her susceptibility. The complex clinical, professional, ethical, and legal issues inherent in consulting on such a case are discussed. I describe my countertransference and my parallel enactment, an initial crossing of the boundary between the roles of supervisor and therapist.     

Inhabiting Mutuality—The Mutuality of Vulnerable States in Psychotherapy: A Discussion of “Did You Say He Has a Hitler Mustache?: Analytic Vulnerability and Destabilization in the Face of Trauma”

This discussion of Sandy Silverman’s clinical vignette explores the realm of mutual vulnerability in working in realms of trauma and dissociation, where internal bad objects threaten the physical and emotional stability of patient and therapist alike. I consider some ways in which therapist and patient alike can be helpful to one another when unbidden thoughts parachute in to the field of therapy, even as they resist being “seen” for what they are.     

A Child Therapist at Work: Playing,Talking, and the Therapist’s Inner Dialogue

The author reflects on his work with a child patient struggling with affect regulation, loss, and his adoption through a detailed process account of the treatment with a focus on the therapist’s inner dialogue in relation to the child’s play and words—how each affects the other. Drawing from his personal use of clinical theory stemming from multiple theoretical influences, the author shows how his associations, identifications, and tentative formulations inform his work and how the various transference/countertransference matrices influence his inner dialogue. Attention is paid to the movement from the therapist as an object within the patient’s closed system to a system that gradually becomes more open, in which the patient is able to take in the therapist’s own person as they come upon various ways to communicate and build a narrative together.     

Client self-image,therapist acting,and the establishment of the therapeutic alliance in a training context

This study examined how clients’ self-image and perception of therapist’s behavior are related to the therapeutic alliance, as well as how these variables change in the psychotherapy process in trainee-led psychotherapy. A total of 164 participants (M = 28.9 years) who attended two semesters of treatment at the Psychology Clinic of Umeå University completed the Working Alliance Inventory (WAI) to evaluate their perception of their alliance with the therapist. They also completed two questionnaires based on the Structural Analysis of Social Behavior (SASB) model to give insight into their self-image patterns and to analyze their perceptions of the therapist’s behavior. The results show that a positive self-image and positive perceptions of the therapist’s actions increased significantly over the course of the therapy, with a corresponding decrease in negative patterns. The alliance scores show that the therapeutic alliance gains significance over time and that it is influenced more by the perception of the therapist’s behavior than by the self-image. The self-image becomes relevant after the mid part of therapy, underlining the role of the therapist in co-creating the treatment relationship. The implications of these results are discussed, and so are directions for future research in other trainee-led settings and samples.     

‘Paralysed associations’: countertransference difficulties in recognising meaning in the treatment of children on the autistic spectrum

Children with autism can have a paralysing effect on the clinician’s capacity to associate freely: connections that seem obvious on reflection may be impossible to notice in the child’s presence. The author argues that this situation can be reached by more than one pathway, and that the degree of the child’s bodily and emotional cohesion is an important factor. Children may seek to immobilise the therapist’s thought processes through projective identification, whether to communicate their own experience of paralysis or because these thought processes are equated with a parental intercourse that produces a ‘baby’ (as described by Bion and Britton). Vignettes are offered to illustrate how the therapist may be nudged into overlooking this baby as well as a potentially growing part of the child that is identified with it, with important consequences for development. A second possible pathway appears to involve the much more primitive mechanism of adhesive identification, in which the child’s sense of continuing existence depends on sticking to the therapist’s surface and any movement can lead to a sense of bodily disintegration. In the clinical illustration, the therapist felt physically constrained and unable to recognise links in the material: it is suggested that this was in resonance with the child’s fear that movement, whether physical or mental, meant losing parts of his body and must be avoided at all costs. These levels can mask each other, and it seems essential to attend to both in order to avoid impasse or the overlooking of essential aspects of the child’s experience.     

What Can Be Given? What Can Be Found? A Therapist and Supervisor Consider What It Is to Hold and Let Go

This paper is a companion to Simone Hidary’s paper. It gives a supervisor’s perspective on the process of a student therapist’s development. The therapist was particularly interested in defining for herself the meaning of a holding environment.     

Therapist Factors Matter: A Systematic Review of Parent Interventions Directed at Children’s Behavior Problems

The present review systematically explored research examining the relationship between therapist‐related factors and the outcomes of parent interventions directed at children’s behavior problems. A systematic search of the literature was conducted with online scientific databases, parenting programs, web sites, and bibliographic references of the selected articles, according to PRISMA guidelines. A total of 24 quantitative studies met the inclusion criteria. Although some methodological limitations were identified with respect to the measurement of therapist factors, the reviewed research strongly suggests that the therapist plays a critical role in parent interventions directed at behavior problems. In particular, many parent outcomes are found to be related to the parent–therapist alliance, the therapist’s fidelity to the intervention, specific therapist’s in‐session actions, and the therapist’s personal variables. The parent–therapist alliance and therapist fidelity to the intervention consistently relate to changes in parenting practices, and alliance additionally relates to fewer perceived barriers to participation in treatment, more treatment acceptability, and greater parenting satisfaction and self‐efficacy. In addition, specific in‐session therapist interpersonal actions relate to parents’ engagement and satisfaction, while both the therapist’s interpersonal actions and more active skills relate to parent change. Therapist’s personal variables have been scarcely or poorly studied to date, but the results found justify the need to develop further research in this area. In conclusion, more attention should be given to the role of the therapist when implementing parenting programs directed at behavior problems, and more and better research is needed that can overcome the methodological limitations identified.     

Self-fulfilling prophecies in the clinical context: Review and implications for clinical practice

The expectancies a therapist and client bring into the clinical relationship can act as self-fulfilling prophecies. This article reviews the literature bearing on three types of self-fulfilling prophecies in a clinical context. First, I look at how the initial expectancies held by a therapist may bias the diagnosis and treatment of the client. Second, I look at the client's own self-expectancies for improvement and how they can enhance or impede progress. Last, I look at how receiving mental health treatment may be regarded as a stigma by others, resulting in negative social interactions for the client. For each of these domains, practical examples and implications are discussed, and suggestions are offered to therapists for how they can avoid or minimize damaging effects of negative self-fulfilling prophecies.