The embodied analyst: from Freud and Reich to relationality

This paper presents the impact of clinical supervision on once-weekly psychoanalytically-informed training psychotherapy. The development of Oedipus complex theory is presented, culminating in Britton's work on the triangular space that opens up by working through the complex. The geometry of psychic space is described to highlight the importance of supervision, especially when training in therapy. The theme of spiders and cobwebs emerging from the clinical material provides a powerful metaphor for the tensions in psychic space. In the course of this training, the trainee therapist was at times less able to benefit fully from supervision, and thus the third position partially collapsed. Vignettes from anonymised clinical work are presented in the three ‘phases’ of this therapeutic process, illustrating the impact of the presence – and relative absence – of supervision.     

“My graduation is my mother's funeral”: Transformation from the paranoid-schizoid to the depressive position in fear of success,and the role of the internal saboteur

Abstract

Freud's conflation of neurotic and existential guilt is challenged in this paper. A study of fear of success in a female analysand is presented that illustrates the resolution of this syndrome through a mourning process in which the neurotic guilt of Melanie Klein's paranoid-schizoid position is transformed into the existential guilt of Klein's depressive position. An evolution within the depressive-position existential guilt is seen as the analysand mourns and separates from an internal mother and father, who are hostile to her developmental needs. This evolution involves the transformation of an idealizing transference, symptomatically enacted through gradations of vicarious living through the analyst, being profoundly transformed into the analysand's active creation of an identity in the world. Simultaneously, the internal world becomes alive in psychic fantasy. This transformation also involves the modification of an internal sabotaging psychic structure, which had been compelled by the dissociated punitive reaction of an internalized angry mother of separation trauma, employing the unconscious re-enactment of an early infant illness. Split-off envy and split-off self-sabotage become consciously owned through the grieving of existential guilt, as visceral experience is converted into symbolization.

Susan Kavaler-Adler. “Meine Graduierung ist das Begräbnis meiner Mutter”: Transformation von der paranoidschizoiden zu der depressiven Position in der Furcht vor Erfolg – und die Rolle des innerenSaboteurs.

Freuds Verschmelzung von neurotischer und existentieller Schuld wird in dieser Arbeit in Frage gestellt. Eine Studie der Furcht vor Erfolg bei einer weiblichen Analysandin wird dargestellt und sie zeigt die Auflösung dieses Syndroms durch einen Trauer-Prozess in dem die neurotische Schuld von Melanie Klein′s paranoid-schozoider Position in die existentielle Schuld von Klein′s depressiver Position umgewandelt wird. Eine Evolution innerhalb der depressiven Position und existentieller Schuld wird gesehen als die Analysandin trauert und sich von der inneren Mutter und dem Vater trennt, die gegenüber ihren Entwicklungsbedürfnissen feindlich eingestellt sind. Bestandteil dieser Evolution ist die Umwandlung einer idealisierenden Übertragung, symptomatisch inszeniert durch Abstufungen vikariierenden Lebens durch die Analytikerin und gründlich umgewandelt in die aktive Schöpfung einer Identität in der Welt der Analysandin. Simultan wird die innere Welt in psychischer Phantasie lebendig. Diese Umwandlung involviert auch die Modifikation einer inneren seelischen Struktur, die durch die dissoziierte strafende Reaktion einer internalisierten ärgerlichen Mutter eines Trennungs Traumas aufgezwungen worden war, wobei eine unbewußte Reinszenierung eines frühen kindlichen Traumas eingesetzt wurde. Abgespaltener Neid und abgespaltene Selbst Sabotage werden dem Bewußtsein zugänglich durch ein sich Grämen in existentieller Schuld so wie viszerale Erfahrung in Symbolisierung umgesetzt wird.

Susan Kavaler-Adler. “Mi graduación es funeral de mi madre”: La transformación desde la posición esquizoparanoide a la depresiva en el miedo al éxito, y el rol del saboteador interno.

La combinación de la culpa neurótica y la culpa existencial de Freud is puesta en duda. Se presentará un estudio sobre el miedo al éxito de una analizanda mujer para ilustrar la resolución de este síndrome a través de un proceso de duelo en el cual la culpa neurótica de la posición esquizo-paranoide de Melanie Klein se transforma en la culpa existencial de la posición depresiva de Klein. Como una evolución dentro de la posición depresiva la culpa existencial es vista mientras la analizanda hace el duelo y se separa de su padre y madre internalizados, quienes son hostiles hacia sus necesidades de desarrollo. Esta evolución involucra la transformación de una transferencia idealizada actuada sintomáticamente a través de gradaciones de formas de vida sustitutivas a través de la analista, para pasar a ser una de transformación profunda en la activa creación de la identidad de la analizanda en el mundo.Simultáneamente su mundo interno toma vida en la fantasia psíquica. Esta transformación también involucra la modificación de la estructura psíquica interna saboteadora, que había sido impuesta por la reacción punitiva disociativa de una madre enojada internalizada por el trauma de separación, empleando la reactivación inconsciente de una enfermedad de la infancia temprana. La envidia y el autosabotage escindidos se vuelven conscientes a través de la aflicción de la culpa existencial, así como la experiencia viceral es convertida en simbolización.     

Of “sleep and dream: A psychoanalytic essay' by Joyce McDougall (discussion)

Abstract

The author describes experiences gathered during several years of teaching psychodynamic psychotherapy with psychologists and psychiatrists within a 2-year-training programme in Shanghai, China. Questions and problems of the reception of psychoanalysis – shame, sexuality, harmony, abstinence – as well as the possibilities and limitations of exporting psychoanalysis are discussed. The possible future development of psychoanalysis in China is also outlined.     

Editorial

With the aim of increasing knowledge about processes of change in psychodynamic individual child psychotherapy, sessions that could be called turning points were analysed.     

Types of sexual transference and countertransference in psychotherapeutic work with children and adolescents

The question of normal sexuality begins to arise in the treatment of severely sexually abused or sexually offending patients. The author suggests that it is an interesting and delicate moment during the process of recovery when less perverse, more normal sexuality appears mixed with, or even disguised by, the more habitual perverse fantasies. Writers in the adult field have drawn distinctions between perverse, eroticized and normal erotic transferences, and between Oedipal and post-Oedipal sexuality. Some have also distinguished between countertransferences in the analyst of an erotised versus a normal erotic nature. The paper discusses whether these distinctions could have any relevance for child patients. Freud and Klein have taught us much about the child's sexuality in relation to his interest in and attraction to his parents as sexual beings. But can we also detect some origins in earlier experiences in infancy of the child's later capacity to feel himself a sexual being capable of being wanted by an other? How might such a feeling of sexual self-worth differ from narcissism and from sexualised exhibitionism? The paper asks how therapists might deal with such problems and such possibly healthy developments.     

Psychodynamic psychotherapy for children and adolescents: a critical review of the evidence base

For many years psychoanalytic and psychodynamic therapies have been considered to lack a credible evidence-base and have consistently failed to appear in lists of ‘empirically supported treatments’. This study systematically reviews the research evaluating the efficacy and effectiveness of psychodynamic psychotherapy for children and young people. The researchers identified 34 separate studies that met criteria for inclusion, including nine randomised controlled trials. While many of the studies reported are limited by sample size and lack of control groups, the review indicates that there is increasing evidence to suggest the effectiveness of psychoanalytic psychotherapy for children and adolescents. The article aims to provide as complete a picture as possible of the existing evidence base, thereby enabling more refined questions to be asked regarding the nature of the current evidence and gaps requiring further exploration.     

You can't miss what you've never had: Can you?: The challenges and struggles of single parenthood from a psychoanalytic perspective

The issue of the growth of single-parent families has been in the forefront of political, social and moral debate in recent years. Children from single-parent families tend to be over-represented in clinic populations. Yet this state of My being may be no more potentially pathological than the nuclear family, which can become conceptually idealized The aim of this paper is to look behind the statistics and examine the impact on children of life in a single-parent family, to explore how this may be managed, and to look for potentiating factors which can enable good-enough development to unfold. Case material is used to illustrate the theme.     

Report on ‘A conversation about unintegration,disintegration and integration’ with papers by Anne Alvarez and Edna O'Shaughnessy,chaired by Margot Waddell, 25 february 2005 1

This paper attempts to explore the nature and consequences of trauma in infancy by an exploration of a prototype of trauma when babies are born addicted to heroin. The trauma not only involves a painful withdrawal from the drug and invasive medical procedures carried out in isolation in a special care baby unit, but often also an ongoing cumulative trauma of the lack of availability of a receptive containing parent. The paper raises specific issues about these babies as well as about trauma in general. It examines current psychoanalytic, attachment and other theories about trauma and resilience, and includes an infant observation of a baby in a special care baby unit who was born addicted. A detailed case is presented, illustrated by sequences of drawings by an 11-year-old boy who had been born addicted. These show how the lack of containment of any sort in infancy had profound effects on the child's ability to process his emotional experience in any meaningful way. An attempt is made to evaluate the effectiveness of the psychotherapy using criteria derived from Mary Main's work on disordered/chaotic infants. This involves a shift from disintegration and a lack of resolution of any crisis towards the emergence of the possibility of a hopeful outcome.     

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.     

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.