THE PATIENT'S OBJECTS IN THE ANALYST'S MIND

In every analysis, the analyst develops an internal relationship with the patient's objects—that is, the people in the patient's life and mind. Sometimes these figures can inhabit the analyst's mind as a source of data, but at other times, the analyst may feel preoccupied with or even invaded by them. The author presents two clinical cases: one in which the seeming absence of a good object in the patient's mind made the analyst hesitate to proceed with an analysis, and another in which the patient's preoccupation with a “bad” object was shared and mirrored by the analyst's own inner preoccupation with the object. The use and experience of these two objects by the analyst are discussed with particular attention to the countertransference.     

PROBLEMS OF INTERNALIZATION: A BUTTON IS A BUTTON IS—NOT

Analysts hope to help the patient internalize a relationship with the analyst that contrasts with the original archaic object relation. In this paper, the author describes particular difficulties in working with a patient whose defenses and anxieties were bulimic, her movement toward internalization inevitably undone. Several issues are considered: how does the nonsymbolizing patient come to internalize the analyst's understanding, and when this does not hold, what is the nature of the patient's subsequent methods of dispersal? When the patient can maintain connection to the analyst as a good object, even fleetingly, in the depressive position, the possibility of internalization and symbolic communication is increased.     

Lost in translation,found in translation: A case study of working psychodynamically in an interpreter-assisted setting

Effective use of psychotherapeutic treatment in interpreter-assisted settings is well established; however, there has been little discussion of the use of psychodynamically informed treatments in such settings. The literature suggests that therapy facilitated by interpreters is not conducive to psychodynamic approaches due to the presence of a third person, the perceived lack of intimacy, and the difficulties of working with translated material. However, transference, countertransference and other unconscious communications and responses necessarily occur in every therapeutic setting, including triadic therapy using interpreters. This article describes a short-term (12 session) psychodynamically oriented intervention with a 52-year-old Cantonese-speaking man suffering from depression. A female, Chinese-born interpreter assisted in every session. The integral role of supervision in supporting a containing relationship between the therapist and the patient and the difficult emotional responses experienced by the interpreter is highlighted. The article attempts to trace some of the unconscious communications that occurred during the therapy and demonstrates the feasibility of working psychodynamically in an interpreter-assisted setting.     

Freud

The author explores the evidence-base and selection criteria for a short-term supportive dynamic approach for patients whose psychological mindedness and quality of object relationships is low. Illustrating this approach with a case example he outlines the central features of Supportive Dynamic Therapy. He describes a psychodynamic conceptual and developmental framework that can be used to guide the therapist's interventions and responses, and modulate the patient's anxiety. A dynamic focus presented in the form of a central issue is shown to have a significant function both in containing the patient's anxiety, and in giving shape to the therapist's efforts to support the patient's ego-strengths and adaptive abilities. The therapeutic work can be seen to result in an alteration in the trajectory or reiterating pattern of the patient's life.     

The search for evidence: Psychoanalytic practice and the male imaginary

In this paper, I will attempt to discuss the future of psychoanalytic practice in the wake of the National Institute of Health and Clinical Excellence’s (NICE) embrace of ‘evidence’-based practice. In 2005, NICE, whose task is to regulate the provision of health care across the National Health Service, adopted positivistic evidence-based protocols as the sole proof of the effectiveness of psychotherapy. Despite the success over the past 40?years of psychoanalytic and humanistic therapies in primary care and psychotherapy departments of psychiatric hospitals, NICE insists on restricting therapy, to those who can claim effectiveness as a result of using the data from client questionnaires commonly described as ‘outcome measures’ and it has gone on to promoting new modalities many of which have been imported from the States. As a consequence, most of the provision of psychotherapy in the public sector currently, whether as part of the National Health Service or the voluntary sector, has embraced evidence-based practice’ and many training organisations are promoting it, which will, in time, have an effect on private practice. I use some of the threads of the work of the feminist psychoanalyst Irigaray and others to understand this turn to positivistic science and how it can be understood as an instance of the retrenchment of the ‘male imaginary’ and a re-installation of the values of detachment and mastery. I query whether there are some problems within current theory, practice and institutionalisation which interfere with the emergence of a more progressive psychoanalytic practice.     

To whom does the unconscious belong? The interface between the private and the social dimension in psychotherapy practice

This paper explores how ‘the social unconscious’, namely the influence of society and politics, impacts upon clinical thinking and practice. The author argues that insufficient attention is paid to the influence of the psychosocial dimension and there is a methodological awkwardness in knowing how to conceptualize it. Furthermore it is argued that psychodynamic practice, with its emphasis on the exploration of the individual psyche, tends to disregard social engagement as a criterion of mental health.

Three clinical examples are cited to demonstrate how the influence of politics and society can enter the psychotherapeutic dialogue. A methodology is then proposed using Bion's formulations about binocular vision, to examine the patient-therapist pair from the perspective of a small work group in society.     

Sibling rivalry at work; from family to groups

Sibling relationships are ambivalent. They are full of love and hate, and therefore, our most basic wish cannot simply be to get rid of our siblings. Many of the conflicts we find ourselves in, either with friends or within institutions, may need a complex and subtle understanding of sibling dynamics. The famous Controversial Discussions that nearly destroyed the Institute of Psychoanalysis in the early forties could be partly attributed to the unacknowledged and unconscious dynamics of the sibling transferences that swirled around Melanie Klein, Anna Freud and Freud. One of the tasks of therapists is to explore how we all must live within a society, with our contemporaries. This difficulty involves observing that sometimes in therapy we are part of the nursery quarrel itself, rather than superior. And so in adult sibling conflict within an institution, there may be a need for an outside moderator, like a parent, to sort out the quarrel; for when sibling passions are revived at work or in the consulting room, they can knock one sideways with the unmeditated quality of the encounter.     

Erotic Transference and Its Relationship to Childhood Seduction

The phenomenon of an erotic transference has long been a difficult, if not mysterious, process within clinical psychoanalysis. Traditionally, the development of an erotic transference has been viewed as a negative clinical event fueled by the analyst's countertransference reaction. A much neglected dimension, the relationship between childhood seduction and the development of an erotic transference, will be introduced and examined. In three clinical cases our data suggest that actual sexual abuse in childhood is a causal factor in the manifestation of an erotic transference in the clinical interaction of an analysis.     

Self-Disclosure and Vulnerability

Abstract

Based on the theoretical assumption and clinical observation that projective identification is a natural, constant element in human psychology, clinical material is used to illustrate how projective identification centered transference states create situations where acting out of the patient's phantasies and conflicts by both patient and therapist is both common and unavoidable. Because they are more obvious, some forms of projective identification encountered in clinical practice are easier for the analyst to notice and interpret. Other forms are more subtle and therefore difficult to figure out. Finally, some forms, whether subtle or obvious, seem to create a stronger pull on the analyst to blindly act out.

In some psychoanalytic treatments, one form of projective identification might embody the core transference. In other cases, the patient might shift or evolve from one level of this mechanism to another. Some patients attempt to permanently discharge their projective anxiety, phantasy, or conflict into the analyst. There is a patent resistance to re-own, examine, or recognize this projection. Some of these patients are narcissistic in functioning, others are borderline, and many attempt to find refuge behind a psychic barricade or retreat (Steiner 1993). In other forms of projective identification, the patient enlists the analyst to master their internal struggles for them. This occurs through the combination of interpersonal and intra-psychic object relational dynamics. This “do my dirty work for me” approach within the transference can evoke various degrees of counter-transference enactments and transference/counter-transference acting out.

Another form of projective identification, common in the clinical setting, is when a patient wants to expand the way of relating internally, but is convinced the analyst needs to validate or coach the patient along. This is why such a patient may stimulate transference/counter-transference tests and conduct practice runs of new object relational phantasies within the therapeutic relationship. Over and over, the patient may gently engage the analyst in a test, to see if it is ok to change their core view of reality. Depending on how the analyst reacts or interprets, the patient may feel encouraged to or discouraged from continuing the new method of relating to self and object. The patient's view of the analyst's reactions is, of course, distorted by transference phantasies, so the analyst must be careful to investigate the patient's reasoning and feelings about the so-called encouragement or discouragement. This does not negate the possible counter-transference by the analyst in which he or she may indeed be seduced into becoming a discouraging or encouraging parental figure who actually voices suggestions and judgment.

All these forms of projective identification surface with patients across the diagnostic spectrum, from higher functioning depressive persons to those who are more disturbed paranoid-schizoid cases. Whether immediately obvious or more submerged in the therapeutic relationship, projective identification almost always leads to some degree of acting out on the part of the analyst. Therefore, it is critical to monitor or use the analyst's counter-transference as a map towards understanding the patient's phantasies and conflicts that push them to engage in a particular form of projective identification.     

Working Experientially and Somatically with Couples

SUMMARY

Working experientially and somatically with couples is a powerful method of accessing, exploring, and transforming both intra-psychic issues and interactional patterns. In this article, a number of methods of working experientially will be described, along with their underlying rationale. Basic assumptions about the nature of couple's difficulties and the role of the therapist also will be explored along with an integrated approach to assessment that provides a solid basis for these dramatic interventions.