Plädoyer für eine Direktausbildung zum Psychotherapeuten

The undisputed necessity of a reform of the Psychotherapist Act could open up the chance to reconsider the training of psychological psychotherapists and to completely renew the structure from the ground up. This article proposes that psychotherapy training should be designed based on the profession itself. Starting from the question of what a good psychotherapist needs to have learnt, a study curriculum is drafted which is structured towards this professional target from the very beginning. This direct training imparts psychotherapeutic competence based on a broad psychological, medical and social scientific education, encourages targeted social competences and enables clinical experience in advance. The training terminates after six years with a state examination and qualification for the profession of psychotherapist. Subsequently, qualified psychotherapists undertake a four-year in-house advanced professional education to an adult or pediatric and adolescent psychotherapist. After completing half of the study period, i.e. after three years, students decide on one of the scientifically recognized courses and subsequently the study course is partly procedure-related and mostly interprocedural. The study incorporates a practical year which accompanies the last four semesters as a half day practical training. Universities which want to offer this study course must be qualified to award doctorates and have a psychotherapy research walk-in clinic. They must also cooperate with recognized training partners who participate in the course of the study and professionally structure the four-year in-house advanced professional education.     

Das Ende der Analyse und die postanalytische Beziehung

In this article the author discusses two aspects of psychoanalysis which in contrast to other fields have received little attention in the specialist literature: (a) the end of the analysis and (b) the postanalytical relationship between analysand and analyst. The circumstances of this specialist lag are seen among others as being due to unresolved fears and demands still remaining in the unconscious mind for both sides of the analytical pair. In that the author turns against the metaphor of death as the end of an analysis it is apostrophied as a separation process and developed into aspects, such as objectivity, process of sorrow, loss suffering, gain of relief, return and departure as well as dialectically folded gain of autonomy. In this way separation and binding can be simultaneously understood as essential features of every psychotherapy. The postanalytical relationship patterns will be illustrated according to the various starting positions, therapeutic or training analysis relationship, in each case internal and external reality and again for both sides of the analytical pair. The author is also especially concerned with the practical consequences in the reacquaintance of trainee and trainer. The cooperation on the dissolution of the original fascination of psychoanalysis and its allure is promoted. Both are required to be successful but both must be transferred into the (new) reality, whereby the analyst, even against internal self-resistance, must offer help because the analysand will only gradually be freed from the fascination and allure and be able to mourn and also in time welcome this loss.     

The use of brief focal psychotherapy in the treatment of chronic pain

Material is presented from brief focal psychotherapy used in the treatment of four patients with chronic pain refractory to multiple forms of treatment. The value from therapy for each patient is described in terms of actual pain relief, in improvement in understanding the interpretation of past trauma into present bodily symptoms, and in subsequent ability to cope with the pain. Three reported treatment to have improved their pain; one reported an improvement in her ability to cope with it and consequent improvement in lifestyle. The place of pathological mourning in the aetiology of such pain is considered, together with a discussion on the constant finding of denial or displacement of intense anger towards important past figures and its manifestation in the transference. A discussion of the place of brief focal psychotherapy as a time- and cost-effective intervention in the treatment of chronic pain is presented.     

The psychotic personality: A psychoanalytic theory and its application in clinical practice

This paper presents and discusses aspects of Bion's theory of the psychotic personality. In particular, it focuses on the psychotic personality's attacks on the dependent and needy self. The paper considers how Bion's theory can be applied to understanding the schizophrenic patient. Examples are given to show its importance not only in analytic practice, but also within general psychiatry.     

The trauma of attempted suicide

Suicide is a traumatic event, one which may acutely recreate a previously-experienced traumatic situation. The person's capacity to think after a failed suicide attempt is affected by the use of defence mechanisms against persecutory anxieties and depressive pain, and there is a wish to turn a blind eye to the seriousness of the suicidal act. This includes the damaging effects on the person's relationships with others, and damage to his own psychic integrity.

The need to turn a blind eye to the consequences of a failed suicide attempt may also be mirrored by the therapist who assesses and treats the patient in the early hours after such an event. Suicide is associated not only with the pain of despair but also with a ruthless abandonment of life. It is a complex and difficult task for a therapist in the immediate aftermath of a suicide attempt to be able to keep in mind a concept of suicide that includes both the patient's role as the perpetrator of great violence against himself, in which death is the intended outcome of his actions, and at the same time recognise the patient's identification with an abandoned and cruelly treated object.

In this paper, we describe some of the psychodynamic factors that affect and influence the assessment and treatment of patients in the immediate period following a failed suicide attempt. We emphasise the importance of supervision in helping prevent destructive acting-out by the therapist when treating disturbed patients under such painful circumstances.     

The value of grandparents

This paper is a slightly revised version of a paper presented on 26 October 1989 as one of the Tavistock Open Lectures. The role of grandparents is discussed and the value of a supportive presence, both externally and internally, is emphasised, especially at birth and at times of mental illness. This concept is extended to the maternal or ‘grand’-maternal role adopted by agencies attempting to improve the quality of mental care, and its value is also visible in the transference in psychotherapeutic work.     

Knowledge,learning, and freedom from thought

This paper discusses the acquisition of knowledge by one generation from another, and the problems inherent in the process. The difficulties are seen as falling into three areas: (i) the difficulty of understanding the knowledge itself; (ii) the difficulty that a fact or a theory becomes an internal object subject to all the vicissitudes of object relations; and (iii) the difficulty of finding a training method that will enable the learner to assimilate knowledge and use it judiciously rather than to swallow it in an uncomprehending way. Examples are drawn from the history of ideas in general, and from the author's experience of therapeutic communities, particularly the Cassel Hospital. The danger of allowing a body of knowledge to become, in its passage from one person to another, a mere set of never-to-be-questioned beliefs is illustrated. The common frailties of both trainers and trainees are discussed and methods suggested for understanding and overcoming them.     

Different origins and meanings of acute acting-out in an inpatient psychotherapeutic setting

In this paper I describe four different sources of acute acting-out behaviour as may be observed in long-term hospitalised patients suffering from severe personality disorders. I hope to demonstrate that acute psychological distress does not happen in a vacuum, but that specific intrapsychic and interpersonal dynamics within the hospital setting are at the root of what appears overtly as nonspecific emotional and behavioural disturbance. I argue that the hospital team's correct insight into the factors underlying acute acting-out is crucial to the implementation of therapeutic interventions aimed to decrease the patient's disturbed state of mind.     

Remembering and repeating in multiple personality

This paper is a case-history of a student in his early twenties tortured by different personalities of different ages and sexes vying for control of his body. Guilt over an incestuous relationship with his mother is uncovered and understood in the context of his whole life. Confusion between memories of fantasies, memories of sleep dreams, memories of daydreams, and memories of actual memories are described, the elucidation of which lead to clearer thinking and memory, and more tolerance for the previously distorted affectladen situations of his past. Thus his belief that he was experimented on in an alien spaceship becomes the memory of an operating-room diagnostic experience.

A hypothesis is put forward that the separate personalities in the multiple personality are not simply the products of ego splits, but are at the instant they are formed a ‘doubling’ of the personality that is being copied. Immediately thereafter, splitting mechanisms create differences between the two separate personalities, using projective and introjective mechanisms. Integration of the various personalities, the ultimate goal in treatment, is made difficult by the patient's fear of loss of self through fragmentation, when the self is felt to be in danger of being intruded upon.