Becoming dependent again: The fears of some elderly persons and their younger therapists

In this paper I shall be discussing only a few of the many aspects of dependency in later life that cause difficulties for some elderly persons and for their younger therapists. I shall be particularly emphasising the fear of dependency in both partners in the therapeutic relationship, and the central role that this fear can play in both bringing the elderly person to the mental health professional for help, and in interfering with the provision of help.     

APP conference summary

This is an account of the extended assessment of a 22-year-old man who was initially sent for a court report, having been accused of setting fires. He had a history both of delinquency and, importantly, of childhood asthma. Although he proved unable to engage in psychotherapy, some management was provided, such as Winnicott advocates in cases of delinquency. This paper explores the symbolic meanings and functions of the patient's delinquent acts, drawing upon theoretical concepts from Freud, Aichhorn, and Deutsch. Of particular importance is the link between this patient's delinquency, his asthma, and the unresolved mourning for his dead mother which he carried not simply for himself but for his whole family.     

The aim of psychoanalysis

The changing aims of psychoanalysis are discussed with reference to Money-Kyrle's paper on the subject. The theory of dammed-up libido, the theory of moral conflict and the theory of misrepresentations and perversion of reality which he described, all imply different aims. It is argued that, in addition, the theory of projective identification leads to a radical change in the aim of treatment which can now be formulated in terms of helping the patient regain lost parts of the self.     

Cases to cases: A study of psychotherapy

The background to the study was a research project on psychotherapy (279 subjects) in the context of the Finnish Student Health Service. Patients were divided into three groups by duration of treatment. For each group, a hypothetical case was constructed. The hypothetical case in relation to short-term treatment (less than six months) is someone whose temporarily disturbed mental balance is supported by the therapist. The hypothetical case in relation to medium-term treatment (one to two years) exhibits recovery through release from self-objects. The hypothetical case in relation to long-term treatment (two to five years) was marked by the partial working through of object relationships.     

The psychotic wavelength

In this paper I have endeavoured to draw attention to what is meant when we refer to a patient as psychotic. It is argued that it is not enough just to be ordinarily sensitive to our patients; we need to tune into the psychotic wavelength with all its implications for understanding and management. Illustrative case-histories are presented from everyday psychiatric work.     

Audit in psychoanalytic psychotherapy with children and adolescents

The importance of multidisciplinary audit in child and adolescent psychiatry, including the work of child psychotherapists, is discussed. Research is highlighted which shows that certain groups of children in particular benefit from psychoanalytic psychotherapy. The problems related to auditing psychoanalytic psychotherapy are discussed, and a possible method of audit based on peer review of notes, which takes into account both inner and outer change, is presented.

A patient is discussed whose notes have been audited using the audit form. It is suggested that this form of audit has good educational potential as well as ensuring a high standard of patient care.     

Loss and change in primary care: Working with organisational anxiety

This paper will consider the identity of an inner voice that is experienced by everyone, but in very different ways. However, when working in the transference with psychotic patients the boundaries of personal identity and the question of choice and volition are so compromised by the illness that the phenomena are so to speak ‘writ large’. This allows the issues to be brought out with great vividness and intensity and it is the struggle with this that has led me to reconsider the identity of the inner voice in a way which I have found useful for the rest of my clinical work.

Prior to 1985, my clinical work with patients with psychotic illnesses was undertaken in the in-patient psychotherapy ward at Shenley Hospital that I was responsible for. With the movement of psychotherapy resources out of Shenley to set up the Willesden Centre, our ability to continue with this work was very compromised because the Centre is entirely an out-patient resource. However, a number of us persevered and gradually worked out ways to be able to continue to offer treatment to patients who had psychotic illnesses. This involved the establishment of a case-manager system to enable the therapist to work in the transference. This evolution has occurred in a specialist workshop that I have been running at the Willesden Centre since 1986.     

The undesired selves of repressors

Previous research has shown that prototypes of familiar categories are preferred over novel exemplars of familiar and unfamiliar categories. The present research demonstrates a reversal of this effect by simply inducing an exploratory mindset. Specifically, participants were asked to judge the attractiveness of dot patterns that represented prototypes of familiar categories, exemplars of familiar categories, or exemplars of novel categories. An exploratory mindset was manipulated by asking participants to imagine the stimuli as stars (versus as peas). Results show that participants in the exploration condition preferred exemplars of novel categories (thereby reversing the classical prototypicality effect), whereas participants in the control condition preferred prototypes. The role of mindsets and familiarity in attractiveness ratings is discussed.     

Surviving as a personality disorder service

Personality disorder services working along psychotherapeutic lines gained appeal with Health Care Commissioners following the publication of the National Institute for Health and Clinical Excellence (NICE) guidelines for Borderline & Antisocial Personality Disorders and the emerging successful application of psychoanalytically derived approaches. In parallel to this creative development, the economic downturn has faced the National Health Service (NHS) with considerable challenges in its ongoing survival. The potential for creative pursuit often then sits in competition, juxtaposed with the need to survive. We examine the impact of this dynamic upon the therapeutic efforts of a newly established personality disorder service. We suggest that both conscious and unconscious aspects stirred up within such encounters are demanding of the need for development of a capacity within each to bear contact with unfamiliar experiences. Through attention to that development, both patient and clinician may further enliven and enrich individual and collective identities, such that the potential to survive creatively is actualized.     

Self-representing dreams

SUMMARY

Certain dreams are particularly striking for the way they represent themselves and the manner in which they are told within a psychotherapeutic relationship. Within such a dream is contained a picture of the dream's function and significance as part of the transaction between patient and psychotherapist. This phenomenon illustrates the nature and function of unconscious phantasy, the relations that hold between phantasy and mechanisms of defence, and the manifestations of phantasy within the transference.

Three examples are given of self-representing dreams which have been reported and re-enacted by trainee psychiatrists in psychotherapy supervision.