On the nature and standing of psychoanalytic psychotherapy

In this paper, I offer some reflections on the standing of psychoanalytic psychotherapy in the National Health Service (NHS), with special reference to contemporary forms of evidence-based thinking. I consider what may follow when a narrow view of science or psychotherapeutic practice becomes conventional wisdom and assumes dominance. I place stress on the potential loss to NHS psychology and psychiatry if psychoanalytic psychotherapy becomes increasingly marginalized on the one hand, or overly standardized on the other.     

A systematic review of the effectiveness of psychoanalysis,psychoanalytic and psychodynamic psychotherapy with adults with intellectual and developmental disabilities: progress and challenges

Objectives: This systematic review aimed to critically appraise the literature on the efficacy and effectiveness of psychoanalysis, psychoanalytic and psychodynamic psychotherapy in adults with intellectual and developmental disabilities (IDD). Method: A systematic search of electronic databases was carried out. The methodological quality of the studies was assessed using a quality assessment tool and comparisons were made with a review of the quality of research on the effectiveness of cognitive behavioural therapy (CBT) for people with IDD. Results: The search yielded 13 papers which provided evidence for the effectiveness but not efficacy of psychoanalytic and psychodynamic psychotherapy; but none were found for psychoanalysis. The quality of the research was generally poor compared to the current research on the effectiveness of CBT. Conclusions: Positive outcomes have been indicated for psychoanalytic and psychodynamic psychotherapy with people with IDD. Larger scale, more controlled research is necessary to advance the evidence base.     

Medical psychotherapy consultation: psychoanalytic psychiatry for the patient and professional

An NHS Mental Health Trust Medical Psychotherapy Consultation Service using psychoanalytic psychiatry to help the patient and professional is described. The Consultation Service established in 2000 is offered to secondary acute and community mental health teams and primary care. The service was evaluated as a basis for regional and national development. Between 2006 and 2013, 87 consultations from 210 were sampled to ascertain demographic and diagnostic profiles and outcomes of the consultation process. We conducted an online survey of local consultant psychiatrists’ views about the service, and undertook a thematic analysis of the free text comments. We also conducted a survey of members of the Royal College of Psychiatrists’ Medical Psychotherapy Faculty to ascertain whether similar consultation services existed elsewhere in the UK and had been evaluated. The Leeds model of psychoanalytic consultation – a ‘consultation sandwich’ – is described. From a psychoanalytic perspective, the work of consultation is seen as an extension of the dynamic field of the analytic situation. This paper develops the concept of a bastion – an omnipotent reserve in and between the patient and professional derived from adhesive identifications leading to stuck relationships. The adhesive identification in the patient and professional acts like a ‘grievance glue’ – a mutual manifestation in a last bastion of painful limitations not faced, losses not grieved.     

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.     

Cultural function and psychological transformation in psychoanalysis and psychoanalytic psychotherapy

Cultural experience of silence and individual vicissitudes between talking and being silent infl uence the way individuals form an alliance and pursue the analytic process. This is of relevance both for the patient and for the psychoanalyst/therapist. The author describes a patient, whose silent phase occurred in the fi fth and sixth year of intensive psychoanalytic psychotherapy. She suggests that a) the silence functioned as a protection of a space for the core self and promoted inner transformation and psychologicaldevelopment;b)thesilenceinvolvedatransference-countertransference matrix with projective identifi cations of the patient's internalized mother- and father-related objects that caused a tenuous balance between maintaining and erasing the relationship between the patient and the author; c) the silence phase was highly infl uenced by the author's own cultural background and what she brought into the relationship of tolerance of being silent in the presence of another, and understanding of the many complex functions of silence. During the silent phase the patient moved from simply describing and naming her affects and inner experiences or expressing them as somatic processes, to being able to internally access and verbally convey her own affects and experiences in the therapeutic alliance. This process involved both affect desomatization, affect differentiation, and affect verbalization.     

Thoughts about the internalised speaking object: psychoanalytic psychotherapy with children of delayed verbal development

This paper discusses the meaningful effects of intensive psychoanalytic psychotherapy on language development in children with verbal delay or disorder. Three clinical cases of children aged five to seven are presented; two of these display significant verbal delay and one exhibits unusually high verbal abilities. Following Meltzer, the author explores the concept of the ‘internalised speaking object’ – a good object speaking to the child, which has been internalised. This internal model is essential for the child’s development of language and speech. At times, these children experience this internal object as a persecutory object which must be warded off and avoided. Even more so, when the external object addresses the children verbally, language itself becomes a persecutor and they experience a fear of disintegration. During such times, the therapist must find new and creative ways for communication. The author describes his therapeutic efforts in dealing with these difficulties which stem both from the lack of a reciprocal verbal communication and from the therapist becoming a persecutory object to the child, and demonstrates the manner in which he facilitated gradual shifts in the patient, from an anxious and defensive position into a more relaxed one. These efforts set in motion a process of internalisation of a speaking object by the child and the development of internal language, that is, thinking along with expressive verbal language. The article furnishes some evidence to support the idea that verbal development relies significantly on establishing good, strong and healthy early object relations.     

Structural models of psychotherapy groups and their effect on inpatients with borderline personality disorders: Patients' perceptions

This research compares the way in which various group structural models affect self-understanding, interpersonal relationships and catharsis in hospitalized patients with borderline personality disorders. Each of the models is characterized by a different combination of group focus and leadership style. Three psychotherapy groups were chosen as paradigms: the dynamic psychotherapy group; the therapeutic games group, and psychodrama group. Sixty three inpatients with borderline personality disorders participated in the study. The one-way ANOVA yielded significant differences between the group models. Results of the post-hoc t-test showed that the dynamic and the games groups were perceived by the patients as more beneficial than psychodrama.     

A successful trial utilizing the Leuzinger-Bohleber methodology for evaluation of psychoanalytic treatment: Preliminary report

Utilizing audio-recorded psychoanalytic interviews of both patients and their analysts, group discussions of these interviews, and the application of questionnaires commonly used in psychotherapy research, the authors investigate the potential use of the Leuzinger-Bohleber methodology as an objective evaluative instrument to assess the quality of psychoanalytic treatment. Preliminary study results were obtained through interviews conducted with seven analysts and their respective patients, three of whom were treated with psychoanalysis (three or more sessions per week, for a duration of no less than one year) and four with psychotherapy (one or two sessions per week, for a duration of no less than one year). Patients were found to be eager to participate, and no adverse experiences were reported by analysts, patients or the research team. In addition to the interviews, further data were obtained through review of mailed-in questionnaires completed by 21 patients. The authors present both preliminary observations regarding the methodology as a whole, as well as the detailed results of one specifi c case subject treated with psychotherapy. Review of study fi ndings supports the utilization of this methodology as an evaluative instrument which may ultimately advance current knowledge of the process and outcome of psychoanalytic treatment.     

Supportive interventions and nonsymbolic mental functioning

The author aims to show how supportive interventions are the analyst's most relevant therapeutic means to helping patients with a feeble symbolic system transform nonsymbolic episodes and reestablish symbolic mental functioning. Symbolic and nonsymbolic modes of mental functioning are first outlined. Supportive interventions are redefined as an analyst's effort at improving a patient's nonsymbolic mental functioning, by using principally pragmatic or interactive aspects of communication to deal with her or his patient's nonsymbolic in-session experiences. These interventions are psychoanalytic when transference focused, in so far as they foster the symbolization and transformation of more primitive (nonsymbolic) layers of the transference. Some probable mechanisms underlying the effect of supportive interventions on nonsymbolic functioning include the modification of mental procedures. Supportive interventions also help restore symbolic mental elaboration through the gratification of a basic ego or self-need, bringing about a temporary relief from psychic pain, with increased affect tolerance and a renewed capacity to use symbols. This soothing effect accounts for a missing link in Bion's model of the elaborative effect of the analyst's reverie.     

The elephant tied up with string: a clinical case study showing the importance of NHS provision of intensive,time-limited psychoanalytic psychotherapy treatments

Prof. Richard Layard's influential advocacy for greater provision of ‘evidence-based’ psychological therapies, based in part on an economic rationale, has lead to greatly increased provision of cognitive behavioural therapy (CBT) and short-term therapies for depression, through the Increasing Access to Psychological Therapies (IAPT) initiative, whilst longer-term psychodynamic treatments are under threat, criticised as lacking an evidence base. This paper argues for the continuing provision of intensive thrice-weekly psychoanalytic psychotherapy treatments, time-limited to two years. It does so by describing such a treatment within an NHS psychotherapy department with a patient with a long history of severe personality pathology, including significant levels of perversity. The paper describes the patient's difficulties and his movement through the treatment, focussing on his difficulties making genuine emotional contact, his destructiveness of such contact, his acting out in the treatment, his perversity and the vital working through of the ending. The shifts the patient made are described, and follow-up information on the patient is given. The paper discusses the unique benefits of time-limited treatment and intensive psychoanalytic treatments for this ‘hard-to-help’ group of patients, and the economic rationale that can be made for such treatments.     

Dynamic interpersonal therapy in an NHS tertiary level specialist psychotherapy service

We describe the introduction of dynamic interpersonal psychotherapy (DIT) into an National Health Service (NHS) tertiary psychoanalytic specialist psychotherapy service. Training in DIT began as our contribution to Improving Access to Psychological Therapies and primary care services, supporting the training and supervision of their DIT practitioners. We then discovered DIT could be a valuable treatment within our own tertiary NHS service for patients with complex presentations. Currently fighting for survival, like many NHS psychoanalytic psychotherapy services nationally, we have adopted a manual-guided, psychoanalytically based therapy to broaden our tertiary clinical psychoanalytic service and accommodate trends in mental health service provision, whilst protecting the quality and integrity of our psychotherapy. DIT helped us continue providing relevant and beneficial psychoanalytic and psychodynamic services to individual patients despite limitations of the financially challenged NHS, NICE guidelines and Payment by Results. We outline the progress and outcomes for patients with complex mental health presentations, include individual case discussion and our experience of using the DIT approach within a traditionally longer term psychoanalytic psychotherapy service.     

The talking cure: Wittgenstein's therapeutic method for psychotherapy,by John M. Heaton

This paper offers an outline of the challenges particular to intersubjective approaches to psychoanalytic psychotherapy in South Africa. Past experiences of deeply entrenched and racialized divisions between communities continue to shape the negotiation of power in therapeutic spaces, and affect participants’ capacity to engage freely with the exploration of unconscious communication. Examples are given of the ways in which race, class and gender difference may complicate, hinder or enrich intersubjective psychoanalytic psychotherapy. Some suggestions are made about the kinds of reflective work that need to be undertaken by psychotherapists in order to assume fully the burdens of history and to appreciate fully the opportunities offered by a society in transformation.     

Child psychotherapy: Converging traditions

In this paper I outline some of the ways in which I believe the psychoanalytic traditions in North America and in Great Britain are influencing each other. I identify points of convergence and divergence at this moment in the evolution of psychoanalytic theory and technique. I then point out some of the implications of relational perspectives in child psychotherapy as this perspective is developing in the United States.     

Dissatisfied psychotherapy patients: A tentative conceptual model grounded in the participants' view

Usually, between 5% and 20% of psychotherapy patients are dissatisfied with their treatments. This naturalistic study explores seven clearly dissatisfied patients' view of the therapeutic process and outcome. Interviews at termination of psychoanalytic psychotherapy and at a 1.5-year follow-up were analysed to create a tentative conceptual model of patient dissatisfaction using grounded theory approach. At the core of the model is an experience of abandonment by a therapist felt to be insufficiently flexible, a therapy lacking intensity, and links missing between therapy and everyday life. Dissatisfied patients lacked confidence in their relationship with the therapist, described their therapists in negative terms and concluded that their therapies lacked direction. They wanted more response from the therapist. Paying greater attention to the patient's emerging dissatisfaction may prevent lasting disappointment, unnecessary continuation of fruitless treatment, and probably increase efficiency.     

Making a case for case studies in psychotherapy training: A small step towards establishing an empirical basis for psychotherapy training

The evidence debate in psychotherapy pays little attention to developing an evidence base for training practices. Understanding effective training requires an examination of what makes training work. This article examines the role of case studies in psychotherapy training. This has not been articulated explicitly or researched systematically in spite of its cardinal importance. An analysis of the role of case studies in psychotherapy training is presented. Reading, watching, or hearing about cases can offer novice psychotherapists access to a closed world; access to psychological theory in action; access to whole courses of therapy; access to different approaches; access to significant moments; access to the therapeutic relationship; access to a wide range of client types; access to working in different contexts; and the opportunity of identifying with therapists and clients. Writing or presenting cases offer students the opportunity of: learning to integrate information into a relevant whole; being in the ‘hot seat’; learning to give appropriate feedback; assessing the validity of interpretations, inferences, and interventions; adapting methods to suit the client; and learning to collaborate with other professionals. The paper presents directions for future research into psychotherapy training, specifically proposing an international survey of training practices at psychotherapy training institutions.     

Psychodynamic psychotherapy for children with disruptive disorders

Findings from a clinical project aiming to make psychodynamic psychotherapy more effective for children with disruptive disorders are summarised and discussed. In this project a supportive expressive model was used and the therapists worked with both children and parents. Nine boys aged 6 – 10 years were treated; all were reported to function better socially after therapy, but improvements were less marked in those boys who in addition to the initial diagnoses of ODD or CD had ADHD. Collaborative meetings with school teachers were associated with more positive effects.     

The patient,the nurse,his life and her mother: Psychodynamic influences in nurse education and practice

Using the film The Cook, the Thief His Wife and her Lover (from which this paper's title is borrowed) as a powerful illustration, the paper examines some of the unconscious processes which form part of everyday life for nurses working in the community, particularly on the wards of our hospitals. It is an attempt to describe some of these processes and to understand the conditions that promote them. With acknowledgements to the pioneers in this sort of work, such as Main, Menzies-Lyth, Trist, Bamforth and Jaques, the paper looks at the ethology of institutions and at activity that takes place on the boundaries between self and other, between the inner world and external reality, and between various levels in the hierarchy.

The paper identifies some of the ‘routines’ which grew up in nursing (and those which have replaced them), the unconscious purpose of which is to safeguard the emotional and psychological integrity of the nurse, through creating a distance between herself and her patients. The paper argues against removing these necessary defences until more helpful alternatives are in place. To fulfil this aim, it recommends that clinical supervision and support seminars should become a regular part of all nurse-training programmes, and should continue throughout the professional life of the nurse.