Growth in emotional intelligence. Psychotherapy with a learning disabled girl

This paper describes the once-weekly psychoanalytic psychotherapy of a girl, called Ellie, aged eight at the start of her treatment. Ellie had a learning disability and displayed difficult behaviour at school and at home. In her therapy, Ellie grew in emotional intelligence, more in touch with and able to express her feelings. Her behaviour improved and so did her capacity to learn. In the therapy there were certain limitations to progress and this is discussed in terms of how Ellie's disability affected the basic achievements of emotional development, including a mind with a solid ‘reality ego’, able to contain anxiety, and able to maintain depressive functioning. The importance of parallel parent work, to share observations and understanding of the child's functioning is discussed. Difficulties for both child and parents in dealing with the pain of difference and how this limits emotional intelligence are discussed. The author hopes that this paper will encourage the offering of psychoanalytic psychotherapy to children and young people with learning disabilities, who are significantly more likely to suffer from mental health problems than their peers.     

FLEXING THE FRAME: CONTEMPLATING THE USE OF MULTIPLE PORTS OF ENTRY IN PARENT–INFANT PSYCHOTHERAPY

Multirelational interventions are well described in the psychoanalytic parent–infant literature. Daniel Stern (1995) originally suggested and described five “ports of entry” that may be employed to access the multiperson parent–infant clinical system. Other authors have elaborated and extended Stern's original list of ports of entry. The impact of using multiple ports of entry on the psychoanalytic frame, however, is largely neglected in the parent–infant psychotherapy literature. Danielle Quinodoz's (1992) four facets of the psychoanalytic setting are used to structure a discussion of how the multiplicities associated with parent–infant psychotherapy may impact the frame. The article argues strongly for a necessary flexing of the psychoanalytic frame to establish therapeutic alliances. A fifth facet, that of psychoanalytic mindfulness, is offered as a counterbalance to the risks associated with excessive flexing of the frame, particularly in relation to Quinodoz's fourth facet of “refraining from ‘doing.’” This article relies on case material to illustrate the issues under discussion. Further engagement and debate are invited.     

Challenges of patient‐led mental health services to psychoanalytic clinicians

This paper considers implications to psychoanalytic psychotherapy of the British Government's decision to implement a patient choice agenda for state‐funded mental health services in England and Wales. It places the patient choice agenda in the context of consumerist society and argues that the complex nature of psychoanalytic psychotherapy leaves it more vulnerable than other psychological therapy modalities to compete in the current reality of ‘consumer’‐led public mental health, which, in turn reflects a profoundly changed social context from that to which psychoanalysis traces its roots. Unless psychoanalytic clinicians recognize and find ways to adjust to this context they will jeopardize the survival of psychoanalytic psychotherapy in an increasingly market‐orientated model of mental healthcare provision in the public sector, eager to promote more ‘consumer friendly’ psychological therapy models.     

Clinical Commentary

This paper describes a lengthy period of psychotherapy with a child. This treatment began only after a prolonged contact with other child and adolescent mental health services during which the child's difficulties, which had initially seemed to be ordinary behavioural problems, had proved puzzlingly intractable to a variety of interventions. Subsequent psychotherapy revealed a profound disorder of development which lay bath the Surface presentation. In a climate where Asperger's syndrome is often felt to be untreatable, this paper argues that some children, at least, can benefit from psychotherapy and can be helped towards real mental growth. Asperger's syndrome in children bears some striking similarities to narcissistic personality disorder as described in the adult psychoanalytic literature and this paper discusses some of the theoretical and clinical implications of the innate origins of Asperger's syndrome.     

An overview of the treatment of severe narcissistic pathology

This paper provides an overview of narcissistic personality disorders as they present clinically along a spectrum of severity ranging from the best functioning forms of pathological narcissism to the most threatening to the patient's psychosocial and physical survival. It proposes a general interpretive psychoanalytic stance with all these clinical syndromes that range from standard psychoanalysis to a specific psychoanalytical psychotherapy for the most repressive and life threatening conditions that may not respond to standard psychoanalysis proper. This general psychoanalytic approach is placed into the context of related developments in contemporary psychoanalytic understanding of pathological narcissism and its treatment.     

Lines of advance in psychoanalytic psychotherapy

Freud's 1919 paper is taken as a starting-point to review how far we have advanced towards fulfilment of his prophetic remarks about the need to develop psychoanalytic psychotherapy for the masses. A glance is taken back to some of the circumstances and characters involved in Budapest where the paper was given at the 1918 congress, where there was much talk about the need to do something about the war neuroses. Similar pressures led to the founding of the Tavistock Clinic and Cassel Hospital in the UK, long before the start of the NHS. The pressures of both world wars advanced the applications of psychoanalysis; the next wave of pressures may come from NHS changes and entry into Europe. The history of psychoanalytic psychotherapy in the UK is also considered via looking briefly at the history and development of psychoanalytic publications, of the Tavistock Clinic, of psychoanalytic training, of child psychotherapy and the emergence of adult (non-medical) psychotherapy. There have always been tensions between exponents of the pure gold of analysis and the needs of its wider applications. More flexible arrangements and boundaries are necessary if we are to spread psychoanalysis beyond London and to fulfil Freud's own hopes about the large-scale application of psychoanalytic therapy.     

Love in the counter-transference: The uses of the therapist's excitement

SUMMARY

The psychoanalytic tradition has always had difficulty with the question of the therapist's sexual feelings toward the patient. This paper traces that difficulty: from Freud's original struggle to replace moralism with a psychoanalytic mode of understanding, to the more recent literature on countertransference which still seems particularly averse to the possibility of the therapist's sexual experience. By way of a discussion of a psychoanalytic psychotherapy, I argue for the sometimes central therapeutic role of the therapist's experiencing, and then containing, excitement.     

The role of the body as the medium in child psychotherapy: snapshots of therapy with an 11-year-old,severely abused,multiply placed girl

In Victoria, Australia, children with a history of abuse and severe attachment difficulties, and who have experienced multiple carers and placements, have been traditionally viewed by mental health services as unsuitable for psychoanalytic psychotherapy. A number of factors, including the lack of integrated, long-term case planning; unstable residential placement; and the belief that psychotherapeutic treatment will be of an extended duration, have influenced the decision not to provide individual psychotherapy for these children. Currently, the movement within mental health services is towards responsive and briefer treatment models. The child psychotherapist is challenged to re-think theory, technique and practice. This paper identifies contextual constraints that have led to these children being precluded from accessing psychotherapy. An alternative model of intervention is discussed and illustrated with clinical material. The contributions of Alvarez, Trevarthen, Schore and other writers are drawn on to underpin the clinical work. This model involves a change in technique and role and the use of a time-limited intervention. Intrinsic to the model is the understanding of the child's psycho-biological experience of trauma and disrupted attachment. The child's experiences are conveyed in the pre-verbal, gestural domain to enable history to be given voice.     

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 Never Land – loss of an idealized pre-birth place and the gain of a thinking mind

This paper describes the main themes in the psychotherapy of a severely epileptic girl, over a period of eleven years, aged 16 at the time of writing. For most of the therapy the girl lacked an ability to differentiate between herself and others, and therefore there was little development of rudimentary Oedipal conflicts. Her severe physical and mental impairments were inextricably linked to this fundamental problem in the process of separating: the physical problems compounding the emotional, and the emotional compounding the physical. Her mother's illnesses were significant factors. Throughout the girl's life she was subject to extreme medical interventions. The paper draws upon psychoanalytic models of mind and body integration, including notions of the 'biopsychosocial dysregulation' model of illness. The clinical material describes the girl's use of the dolls to populate a Peter Pan Never Land, with its many static perspectives, denying growth and the difference between the generations, although therein was the beginning of the use of symbolization. As the child's awareness of her physical impairments grew, so did her despair at her own and her mother's hopeless physical condition. However, she became more able to express her outrage, but with the life-saving awareness of a therapist who was not also ill. This led to the girl's increased ability to acknowledge differentiation between self and other, further painful awareness of her disabilities, losses and possible death, as well as those of her ill mother and, gradually, an ability to acknowledge the passing of time and an appreciation therein of a healthy separate thinking part of her that could use symbolization and allow for some separateness and some emotional growth.     

Psychotherapy as one form of rehabilitation provided by the Finnish Social Insurance Institution

One of the several methods whereby patients in Finland may receive subsidised psychotherapy is as a component of rehabilitation, in order to improve a person's working and functional capacity. The Finnish Social Insurance Institution has carefully documented and monitored the effects of this intervention on patients. It is well known that it is difficult to measure the success of psychotherapy, but it appears that the results of psychotherapy (mainly psychoanalytic) are good, both according to the patients' own assessment and as indicated by the changes in the their functional capacities. More than 80 per cent benefited and about one third became free of symptoms of functional deficiency. The neurotic group appeared to have derived the greatest benefit from therapy.     

From Passive Psyche to Dynamic Dasein

This article is a study in contrasts between Freudian psychoanalytic metapsychology, shaped by the physical–mechanistic scientific model of the Helmholtz School of Medicine, and Boss's Daseinanalytic psychotherapy, formed by the human science model derived from the Heidegger's analysis of Dasein. It begins with Binswanger's initial attempt to replace the Freudian metapsychology with Heidegger's analytic of the human being as an active agent in the world. Following this path, the article shows the radical new direction Boss gives to psychotherapy by shifting the focus of therapy from the analysis of an abstract and disembodied psyche driven by forces toward an analysis of the person as a free and responsible agent engaged in the world. Although Boss maintains a high regard for Freud's great achievement, I suggest that he failed to appreciate fully the true magnitude of his new contribution and, due to his hermeneutic of generosity toward psychoanalysis, underestimated the reciprocal influence between Freud's metapsychology and his therapeutic advice and techniques. It is my basic contention that a radical shift of a psychotherapy's philosophical anthropology transforms the entire theory, as a whole, in all its dimensions.     

The role of psychoanalytic assessment in the management and care of a psychotic patient

The pressure on mental health services to move patients on quickly, and the emphasis on the recovery model, can encourage a superficial assessment of the patient's difficulties. The author argues that a narrow definition of the medical model based on the presence or absence of symptoms ignores the deeper psychic structures that govern thinking and behaviour over time. A psychoanalytic assessment can offer a dynamic picture of deeper psychic structures in the patient's internal world. This is particularly important with psychotic patients who may successfully use denial and rationalization to cover up their underlying psychopathology. The developmental perspective inherent in the psychoanalytic view can also give a picture of the patient's propensity to repeat certain aspects of his/her psychopathology. In addition, a psychoanalytic approach may shine some light on the relationship between relapse and risk behaviour.     

Psychoanalytic aspects of inpatient treatment

This paper looks at the experience of inpatient hospital treatment at the Cassel Hospital and how formal psychoanalytic psychotherapy, with its emphasis on the transference and the inner world, fits into that context and orientates itself to some of the realities of the setting. It outlines how psychotherapy and nursing can work to inform and enrich each other, and what is psychoanalytic about the overall work. A bridge of understanding is built using the patients' perceptions of, adjustment to and conflict about the inpatient setting, and the affective impact of the processes on patients and staff alike. Two clinical examples of severe child abuse family cases are given, the first of Munchhausen syndrome by proxy, the second in which a baby sibling had been killed. They show how in-depth psychoanalytic work with mother and child and individual psychotherapy of the child can be combined with psychotherapy of the parents and intensive work in the therapeutic community. Such a combination can contribute, even in cases of severe pathology, to the development of the relationship between mother and child and promote successful rehabilitation in the outside community.     

Revisiting ‘What works for whom?’: A qualitative framework for evaluating clinical effectiveness in child psychotherapy

This paper describes a framework for evaluating the effectiveness of child psychotherapy used by child psychotherapists in an inner city Child and Adolescent Mental Health Service (CAMHS). The Hopes and Expectations for Treatment Approach (HETA) involves using the assessment for psychotherapy that normally precedes treatment to derive a baseline from which to generate a set of hopes/expectations as regards the effects of the treatment on the part of parents and the psychotherapist, to be revisited one year after the start of the psychotherapy and/or at its completion. The Strength and Difficulties Questionnaire, for parents and schools, was also administered before and after the treatment. The characteristics of the first 30 children referred for psychotherapy over a particular time period are described. Of the first 15 children in this group to complete one year of individual psychotherapy, all showed change or significant change in the areas concerning parents' and therapists' hopes at the end-of-year review, as rated by parents and psychotherapists. A case of a child with conduct disorder is used to describe how the assessment generated a psychoanalytic formulation, how the therapist's understanding was fed back to the parents, and how the parents' and therapist's hopes and expectations were derived and recorded. This case illustrates powerfully the impact of trauma in the parents' backgrounds on the internal world of the child, and how the method provides a useful bridge between parent and child work. Feedback from the psychotherapists, the parents and the referrers using the framework is reviewed, and in conclusion the paper argues for the framework's value in promoting good practice in the treatment and management of complex cases and in enhancing awareness of the nature and scope of the psychotherapy process.     

Book reviews

Wilfred Bion is regarded as a psychoanalytic purist and his austere portrayal of the analytic aim and attitude is often considered to make impossible demands on patient and analyst alike. Not surprisingly, the applicability of Bion's theory and recommended practice to once-weekly psychotherapeutic work is often questioned. Bion is thus ambivalently regarded by psychotherapists as the embodiment of an analytic ideal, whose developmental theories are important, but whose practical utility is doubted, especially in the context of the typical therapeutic setting. This paper seeks to challenge these assumptions by presenting the once-weekly therapy of a woman with attenuated mentalizing capacity and a tendency to destructive acting out. The therapy was guided by the application of central concepts, models and ‘technical’ principles emerging from my understanding of Bion's work. The aim of the paper is to demonstrate that Bion's utility is not confined to formal psychoanalytic settings and that his work may be usefully applied in more modest psychotherapy contexts.     

ANALYTIC MIND USE AND INTERPSYCHIC COMMUNICATION: DRIVING FORCE IN ANALYTIC TECHNIQUE,PATHWAY TO UNCONSCIOUS MENTAL LIFE

Developed from established psychoanalytic knowledge among different psychoanalytic cultures concerning unconscious interpsychic communication, analysts' use of their receptive mental experience—their analytic mind use, including the somatic, unconscious, and less accessible derivatives—represents a significant investigative road to patients' unconscious mental life, particularly with poorly symbolized mental states. The author expands upon this tradition, exploring what happens when patients unconsciously experience and identify with the analyst's psychic functioning. The technical implications of the analyst's “instrument” are described, including the analyst's ego regression, creation of inner space, taking mind as object, bearing uncertainty and intense affect, and self‐analysis. Brief case vignettes illustrate the structure and obstacles to this work.     

Light and color in a void: The analysis of a special needs child

This clinical report comes from the five year, four day a week analysis of a male child. What is special is that this treatment is of a child with marked mental retardation. I have retained this nomenclature because that is how Ricardo's parents described his mental capacity. What they meant was that he was greatly impaired in his cognition and this could be seen in Ricardo's severe cognitive, social, behavioral, and relational improprieties. I have privileged the function of psychoanalytic understanding and the role of transference to bring about modifications in this child's internal world. And I have considered the patient's psychotic mental state to be in need of psychoanalytic treatment not withstanding his psychosis's connection to his cognitive handicap. I have also added information I have received after the analysis, information that demonstrates continued integration coming from the analytic process. Owing to Ricardo's limited mental capacities, this article advances clinical information that is not often found in analyses of children. There are possibly many other children like him who nonetheless would benefit from dynamic psychoanalytic understanding. On the other hand, I shall not discuss this matter theoretically, even though some theoretic considerations are necessary. Clinical practice and the transferential relation are this report's principal material.     

Searching for the enriching sense of otherness: The psychoanalytic psychotherapist as a meaning-bearing other

Abstract

This paper is a theoretical and clinical examination of the patient's search for the otherness of the therapist as a prerequisite for change and development in relational psychoanalytic psychotherapy. A basic assumption is that being in a relationship as well as being a personal self, is to be understood, as being with a “meaning-bearing other”; that is, someone who allows for the possibility of meaningful thoughts and feelings, either through an actual communicative presence or as a consciously, prereflective, or unconsciously imagined communication partner. The term “meaning-bearing other” is used to differentiate distinct, although often synchronic, modes of relatedness. The need for intersubjective “depth”—that is, to discover the otherness of the other, and for oneself to be recognized as an experiencing subject—is regarded as a main motivational force. Winnicott's, as well as Sullivan's developmental approaches, Mitchell and Aron's views on psychoanalytic interaction, and Heidegger and Gadamer's phenomenology and hermeneutics are used as theoretical points of reference for the present discourse. The theoretical points of view are examined and discussed through excerpts from twice-a-week psychotherapy with a six-year old girl.     

Day,Night, or Dawn: Commentary on Paper by Steven Stern

It was in the years immediately following World War II and through the 1950s that the psychoanalytic establishment officially defined psychoanalysis as a subspecialty of psychiatry, and it was in that context of the professionalization of American medicine that they codified the distinction between psychoanalysis and (psychoanalytic) psychotherapy. In this commentary on Steven Stern's “Session Frequency and the Definition of Psychoanalysis,” I deconstruct a series of binaries that was built into the analysis/therapy distinction and that has plagued our discipline. It is argued that psychoanalysis identified itself with the culturally “masculine” and heterosexual values of autonomous individuality (the intrapsychic), while it split off all that was relational and social (interpersonal), marked as “feminine,” homosexual, and “primitive,” onto psychotherapy, which it then devalued. The paper then examines the implications for practice and psychoanalytic education.