Fostering Independence: Helping and Caring in Psychodynamic Therapies

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FOSTERING INDEPENDENCE

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FOSTERING INDEPENDENCE Helping and Caring in Psychodynamic Therapies A. H. Brafman

First published in 2011 by Karnac Books Ltd 118 Finchley Road, London NW3 5HT

Copyright © 2011 to A. H. Brafman.

The right of A. H. Brafman to be identified as the author of this work has been asserted in accordance with §§ 77 and 78 of the Copyright Design and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. British Library Cataloguing in Publication Data A C.I.P. for this book is available from the British Library ISBN: 978 1 85575 828 5

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CONTENTS

ABOUT THE AUTHOR INTRODUCTION

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INTRODUCTORY NOTE TO CHAPTER ONE Dogma vs. doubt

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CHAPTER ONE Infant observation

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INTRODUCTORY NOTE TO CHAPTER TWO The role of intuition

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CHAPTER TWO Winnicott’s therapeutic consultations revisited

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INTRODUCTORY NOTE TO CHAPTERS THREE AND FOUR Who should ask?

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CHAPTER THREE Increase or not increase?

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CHAPTER FOUR Touching and affective closeness

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INTRODUCTORY NOTE TO CHAPTERS FIVE AND SIX Flexibility

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CHAPTER FIVE Child analysis: when?

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CHAPTER SIX Tailor-made therapy for the child: new developments in Winnicottian work with young people

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INTRODUCTORY NOTE TO CHAPTERS SEVEN AND EIGHT Feet on the ground

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CHAPTER SEVEN Letter to a young psychotherapy trainee

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CHAPTER EIGHT Memorizing vs. understanding

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INTRODUCTORY NOTE TO CHAPTERS NINE AND TEN Helping? Yes, but how?

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CHAPTER NINE Holding, containing, interpretations: a question of timing?

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CHAPTER TEN The setting: what makes therapy work?

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INTRODUCTORY NOTE TO CHAPTER ELEVEN Adolescents

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CHAPTER ELEVEN Working with adolescents: a pragmatic view

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INDEX

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ABOUT THE AUTHOR

Dr A. H. Brafman worked as a Consultant Child and Adolescent Psychiatrist in the NHS until his retirement. He is a qualified psychoanalyst of adults and children, and gave seminars on Infant Observation for trainees of the British Psychoanalytic Society and other training institutions. For many years he ran a weekly meeting for under-fives and their parents at Queen Mary’s Hospital, Roehampton, London. He has published three books based on his work with children and parents: Untying the Knot (Karnac, 2001), Can You Help Me? (Karnac, 2004) and The 5–10-Year-Old Child (Karnac, 2010), as well as a series of papers on various clinical topics. For several years, under the sponsorship of the Winnicott Trust, he ran weekly clinical seminars for medical students at the University Hospital Medical School, Department of Psychotherapy.

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After many years of practice as an analyst of adults and children, I came to realize that my work was based on a principle of which I was not consciously aware. Even though the feedback on the quality of my work (from colleagues and the patients themselves) was, on the whole, positive, I had had no more than a handful of patients who saw me for more than five years. It now struck me that, more from a personality trait than any considered scientific parameter, my clinical work aimed at helping the patients to deal with their problems themselves, rather than to foster situations of dependence. I saw some patients who knew exactly the nature of their problem and were, therefore, ready to leave when they found how to improve their situation, and then many others who came to see the appointments with me as a long-term, openended relationship. Most of these latter ones saw me as a trusted source of support in a world where they had no other similar person to turn to, but a few others had an unconscious need to build a situation of dependence. Predictably, each of these groups brought to life a different type of therapeutic relationship and, as the analyst involved, I discovered that they aroused very different reactions in me. ix

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Patients needing a relationship of dependence seemed to achieve little change in their lives and their analytic sessions were almost indistinguishable from each other. Winnicott wrote many papers and books on the work with this group of patients, and his account of the analyst’s emotions through the many years of work with this specific group of patients is simply unsurpassable. He described some of these patients as psychotic, but I saw and heard of patients in this group who would not be thought of as strictly psychotic. However much we read about this type of patient, in practice, only time and clinical experience help us to identify them and understand the feelings they produce in us. The majority of the patients who seek psychodynamic help create a pattern of sessions where progress is clearly detected. Not that each session shows movement forward, but a longer-term view gives evidence of improvement. I believe that the therapists’ (I am using analyst and therapist as interchangeable designations) experience of this pattern of psychodynamic work is greatly dependent on their personality and preferred rhythm of work. In other words, some of us will experience these patients as more challenging in so far as their sessions raise issues and questions that are difficult to predict, and, therefore, they demand a greater effort to decide how to react, while those patients who regress to a relationship of dependence will be more challenging to those other therapists who find themselves feeling impatient, or bored, or, as Winnicott described, hating the patient. My conclusion is that each therapist must aim to discover what type of patient he feels more comfortable to work with. Only by respecting his personal preferences will he manage to find satisfaction and pleasure in his work. This discussion of the analyst’s likes and dislikes contains an implication that should be made explicit. “Countertransference” is a concept that has been interpreted in many different ways over the years. At present, most trainees are taught that they should consider their emotional reactions to the patient as countertransferential. No doubt this makes life much easier for the trainee or the therapist, in so far as they have an easy formula to fall back on whenever struggling with uncomfortable feelings or when finding themselves unable to understand the patient. This is a regrettable formulation. It is simply wrong to pretend that patients have feelings, but therapists do not. I follow Paula Heimann’s (1950) definition of

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countertransference, where an analyst’s emotions while seeing his patient have to be scrutinized, and only if he concludes he is experiencing feelings which do not match his image of himself should he go on to consider the possibility that these are the result of the patient’s projections. But, beyond this, to treat the therapist’s feelings as automatically synonymous with those of the patient’s deprives the trainee or the therapist of a valuable opportunity to learn about himself as he follows his performance in the clinical encounter. Working with patients who need an open-ended relationship of dependence requires a way of thinking that is not part of every therapist’s endowment, and this raises the strong possibility that some of the analyst’s feelings are not the result of the patient’s projections. It is still possible to ascribe feelings of impatience or irritation to the patient’s low self-esteem, but I believe a therapist in such a situation should also consider his own preferences, his likes and dislikes. The papers in this book describe a number of clinical problems and I focus on both patient and therapist. Like all my colleagues, I insist that no two patients are alike, that we must always seek and respect each patient’s individuality, but I am very aware that speaking to a patient I am always drawing parallels with other patients (and people in general) I have met. I want to believe that I retain the capacity to analyse these associations and take them as cues to help me to formulate questions and comments that may advance my understanding of the patient in front of me. Perhaps an example will clarify this argument. A student told me of an interview with a mother who complained of a “clinging three-year-old child” and was able to admit that she, the mother, was over-anxious when attending to this child. I asked the student what questions she had asked the mother, and she could not remember this, simply saying that she had helped the mother to continue her account. I said it was very important to bear in mind the possible reasons for this mother’s feelings and behaviour, since only then would we know what questions to ask her. This required going through previously met similar situations and drawing on what had been learnt from them. A brief list of situations that might be relevant to understand this mother’s feelings and behaviour would be (a) this was an only child, (b) the mother had lost an earlier child, (c) because of her age or some hormonal deficiency, she

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would not contemplate another pregnancy, which turned her child into a special possession, (d) the child had suffered from some severe illness at birth or soon after, (e) she might have “gone off” sex, or become terrified of another pregnancy, and the child’s behaviour was a useful “shield” to keep her partner at a distance, etc. But I have met the argument that in a “proper analysis” one does not ask questions and, instead, one accepts the patient’s communications as the relevant material for analysis. I cannot agree with this technical parameter, since I believe it can lead to misunderstandings. When the therapist takes the patient’s words exclusively as “transference material”, this leads to an apparently logical sequence, but I have met many examples where this misguided short-circuiting led to the therapist having no clear knowledge of the patient’s actual life. In line with these principles, the papers in this collection discuss a number of clinical problems and they aim to enable clinicians to approach each patient with a keen, inquisitive, open mind and proceed to identify the conscious and unconscious emotional experience of that one particular patient. Indeed, easier said than done! But an attempt is made (a) to describe a number of characteristics in the patient’s presentation that may help the clinician to formulate his questions in order to understand that particular patient’s problems and, gradually, to decide on what therapeutic intervention to make, and (b) to focus on how the practitioner has to combine knowledge and intuition in order to optimize his clinical skills. I believe that a patient approaches a therapist (doctor, psychoanalyst, psychotherapist, counsellor, social worker, psychologist, etc.) only if and when he has a problem. We have jokes portraying patients seeking professionals for a variety of other, supposedly funny, reasons, but, in real life, this does not happen. There are times when the patient finds it difficult to define the precise nature of his problem, but this only increases the importance of discovering why that person came to consult the therapist. Quite often these are people who suffer from a very painful problem: loneliness. If previous generations might have sought the help of a priest or other reliable figure in their family or community, in our times a therapist is frequently the chosen, if not the only available, port of call. I have found colleagues who disputed the importance of establishing why

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the patient has knocked at our door; they argue that this is a doctor’s way of thinking, “the obsession of establishing a diagnosis”. In fact, many of these colleagues also object to my using the word “patient”. Yes. I am a doctor, and I believe in the importance of defining a “diagnosis” before embarking on any kind of therapy. Whether these words are used or not, entering into a therapeutic contract without first establishing what is the patient’s problem and how we will know that our work has been helpful raises the delicate question that we may be keeping the patient in therapy for needs of our own. To practise any type of psychodynamic psychotherapy, a good professional training is most important. Since the second half of the twentieth century, there has been a major multiplication of training courses in psychotherapy and, predictably, each one has very different teaching standards and selection procedures. It is impossible to choose any one of these training establishments as “the best” one, since opinions and criteria will always differ. What I find regrettable is that this growth and diversification has led to a number of, so to say, simplifications: rather than broader and varied theoretical formulations, a move to a reduced number of principles and rules. The result is an apparent clarity of theoretical and technical formulations, but this comes at the cost of a very reduced capacity to recognize, let alone deal with, complex clinical situations. Equally important for a competent therapist is a particular type of personality: ideally, this should be someone able to listen and to know which questions need to be asked before a full understanding of the patient’s problem is reached. A capacity for empathy is vital, but also the ability to scrutinize one’s intuitive, spontaneous responses to the patient’s self—a point that is made several times in the text that follows. Therapy is a demanding type of work. Because it involves a very close emotional relationship, it constitutes a continuous test of one’s capacity to recognize and respect the boundary between oneself and the patient. There will always be times when it becomes difficult to reconcile the daily struggle of personal and family commitments and the performance of professional duties. This is why I believe that therapy should be the exclusive domain of people who are able and devoted to helping others. Indeed, therapy is still “work” and a source of income, but it requires not only the sense of responsibility to carry out a professional task, but the

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emotional drive to understand and seek to alleviate the pain of an other. But this has to include the capacity to recognize the point at which this help is no longer required, when the focus must change to enabling the patient to recognize his new abilities and move on to an independent life. To make explicit an implication of my argument: formal training, however thorough and meticulous, cannot create this capacity to both care for an other and yet not to cling to that other. Training will help a caring person to recognize his private emotional needs, abilities, and limitations, so that he can conduct more effectively the therapy of the patient. If we have a trainee who lacks this capacity (quite often it is a need) to care and help, we find someone who learns theories and techniques and embarks on an apparently competent practice, but close scrutiny will show how cold, distant, and hollow his work is. Carrying out his work, a therapist has no machines to help him decide what to make of the patient’s words and behaviour. Some psychologists and other professionals choose to turn to questionnaires and tables as tools to reach the goal of understanding the nature of the patient’s problem. The argument goes that this ensures scientific standards, since personal interpretations are excluded and results can be validated by a second opinion on the findings obtained. I do not believe in the validity of such an approach, since there is no guarantee that the patient gives true, accurate answers to the questions. Furthermore, there is no real substitute for a live, face-to-face interchange to enable the professional to adapt his usual interview pattern to the unfolding of the patient’s account of his present and past life. I see our discipline as part of the humanities, not a science. However well trained, a therapist cannot eliminate his human characteristics, his likes and dislikes, his way of dressing, his style of speaking, and so many features of his self that are bound to affect the patient facing him. It is more productive to learn how to deal with these features than to pretend they can be ignored or that they do not influence the patient’s experience of the therapeutic encounter. These are all issues that influence a question that always baffles students, since they believe it only aims at teasing them: when does the session start? It is not rare to find patients who seem to start the session long before they enter the therapist’s room, but for the therapist the session starts the moment the patient rings the bell or,

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if the work involves a shared waiting-room, it starts when the therapist first sees the patient. Why? Because each one of us forms impressions of the patient’s state of mind as soon as we first see him. Should these impressions be ignored? We have learnt from our teachers that each session must be considered as starting from a clean slate: indeed valuable advice, but we all know that our visual and auditory perceptions have been registered. To classify these initial impressions as belonging to countertransference experiences is a dogmatic assumption that achieves the same effect as trying to dismiss or ignore them: both lead to a feeling of knowledge and security, but this is illusory, since they are decisions reached irrespectively of what is actually unfolding between patient and therapist. These initial perceptions deserve careful and detailed scrutiny; indeed they can originate from our preconceptions or prejudices, but they may also stem from our intuition, from our knowledge of that particular patient and from our clinical experience in general. Only paying attention to what further material the patient describes will help us assess the value of those initial impressions.

Reference Heimann, P. (1950). On counter-transference. In: P. Heimann & M. Tonnesmann (Eds.), About Children and Children-No-Longer: Collected Papers 1942–1980 (pp. 73–79). London: Routledge, 1989.

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INTRODUCTORY NOTE TO CHAPTER ONE

Dogma vs. doubt

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eing Jewish, I was brought up on the philosophy of “on the one hand we have . . . but on the other hand . . .”, that is, a reluctance or incapacity to accept dogmas. As I became involved with seminars where trainees presented their observations on the first year of a baby’s life, this attitude of mine proved to be not only justifiable, but central to teaching students to respect their interpretations of what they saw, but always to subject these impressions to a detailed and careful scrutiny. Not surprisingly, I found that each student’s account of his observations could lead one to identify the theoretical group to which his personal analyst belonged. However, I was shocked to see the extent to which this pattern of learning meant relinquishing or ignoring any influence that their previous training and work should have led them to take into account. Only persistent questions would sometimes lead them to put aside the theories they were being taught and bring their own, private experience into practice. An interesting example came up during one of the frequent discussions regarding the influence of inborn instincts and of environmental inputs on the development of the child’s personality. A trainee described a six-month-old baby playing in a 1

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playpen, while his mother talked to him and helped him with various toys. The little boy was sitting up and, suddenly, trying to pick up a toy, he lost his balance and fell on his side. His face expressed his surprise and his lips and eyes were clearly showing his hesitation on how to react. His mother bent down, smiling and uttering words such as “Poor thing! You didn’t expect that, did you?”, in a tone of voice that showed amusement, but also a wish to comfort him. Virtually instantly, the baby’s face was illuminated with a broad smile. The other trainees smiled, enjoying this heart-warming sequence. After some minutes, I turned to another trainee and asked how a similar sequence would unfold with the baby he was observing. “Nothing like that! His mother or his nanny would virtually jump in fear, trying to rescue him, and it is certain that the baby would burst out crying in terror!” We all laughed, since this contrast between the behaviour of each baby seemed so plausible and convincing—but convincing of what? Little room for discussion, since the evidence of the adult’s input as a determinant of each baby’s reaction to his fall appeared too obvious. But what to do with what these students were learning about the role of the inborn instincts? And, equally important, if, years later, one of those babies happened to be seen by a professional, how would they hypothesize what had been that child’s earliest experiences? However cynical it might sound, only one answer existed to this question: the expert would follow his favoured body of theories and put these forward to postulate that child’s early experiences. Another baby was found to have great difficulties with breastfeeding and the mother complained of feeling pain because of the baby biting the nipple. The student who was having a Kleinian analysis explained, “Clearly, this baby operates under a powerful hostile, oral instinct.” Suddenly, at a subsequent visit, the baby was found to be feeding quietly and efficiently: the mother had been seen by a breast-feeding counsellor, who helped her to position the baby at the breast. It was sad to find that this datum had no influence on the trainee’s views on inborn instincts. It is experiences like these that have led to the writing of this paper. We have now many decades of psychoanalytic theorizing, but it is regrettable that the human need for certainties has consistently led to professionals adopting their favourite theories and ignoring any finding that might introduce a doubt about their

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validity. In other words, we have to accept that when postulating human psychological development, we rely on views that stem from hypotheses; there is little or no room for certainties. These past few decades have led to a passion for statistical analyses, and we often find colleagues quoting these figures as evidence to substantiate their views. Indeed, some are more credible than others, but, fundamentally, they describe a hypothetical human being, never allowing for certainty when considering a particular individual. Facing the one-to-one consulting room encounter, we can only rely on our experience, our knowledge, preconceptions, and prejudices; therefore, it is most important that we should avoid dogmas and put each of our views under careful scrutiny, continuously assessing the patient’s input to the situation.

CHAPTER ONE

Infant observation*

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y definition, a psychoanalytic theory of human development attributes considerable importance to infancy and childhood. However psychoanalytic theories may vary in their choice of emphasis, they all see infancy and childhood as crucial phases in human development. There has always been controversy about constitutional endowment (e.g., instincts) and the relevance of actual environmental experiences, but very few analysts have turned to the infant or the child with a view to discover what light this might throw on analytic theories. Hartmann (1950) and Heimann (1966) have pointed out the extent to which one’s chosen frame of conceptual reference will colour one’s observations. This is borne out, for example, in Anna Freud’s (1953) paper on her lectures to medical students on the development of infants and in Klein’s (1952) paper on the observation of infants. Kestenberg (1977) gives an amusing account of how various analytic theorists might interpret a particular vignette on infant observation, and her description is a vivid warning to those who

*First published in 1988 in International Review of Psycho-Analysis, 15: 45–59.

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wish to observe infants. Psychologists and paediatricians have been making such observations in recent years and an important series of findings has been published. Bowlby (1969), Lichtenberg (1981), and Peterfreund (1978) seem to be lonely voices in our world, attempting to attract the attention of analysts to the significance to our formulations of emotional development of recent discoveries regarding the infant’s neurological and cognitive development. On the whole, analysts seem to consider such research work as fascinating, but rather running in parallel to our theories. Freud’s renunciation of the seduction theory (1897) led analysts to concentrate their attention on the patient’s “internal world” and only “psychic truth” is seen as relevant. True, time and again, writers will refer to the importance of the patient’s real parents and his real experiences but, in practice, only the patient’s psychological elaboration of these stimuli is seen as relevant. Stern’s (1985) distinction between the “clinical infant” and the “observed infant” is particularly clear and helpful. The “clinical infant” represents the construct based on a particular body of theories that will lead a worker to conceptualize what the infant is, was, or might have been; something along the lines of what some analysts call “the child in the adult”. This is a dramatically different picture from the infant as observed. Because of the obvious lack of verbal report, only the infant’s behaviour can be noted: cognition, discrimination, learning, memory, affects can only be inferred and, at times, subject to verification and testing as to plausibility or correctness of any hypotheses raised to explain particular behaviours. Ainsworth, Bell, and Stayton (1974), Brody and Axelrad (1970), Bowlby (1969), Kris (1951), Mahler (1969), Robertson (1962), Spitz (1950), and Winnicott (1957) are some of the analysts who observed the development of infants and/or children, each from his or her own theoretical position. Curiously, the findings of each research team seem to have been used only by those who adhered to their theoretical postulates: transitional object, and separation–individuation are examples of the few concepts that have crossed theoretical borders. Bick (1964) seems to have been the first analyst to include the observation of babies in the training of child psychotherapists and, later, analysts. As mentioned above, infants and children had been

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observed before, either in formal research (e.g., Spitz, 1950) or in other settings such as, for example, the Hampstead Nurseries (Burlingham & Freud, 1965). Hampstead analysts have published important papers on work with both children and parents (Hellman, Friedman, & Shepheard, 1960) but, as with other papers on child analysis (Joseph, 1966; Klein, 1932, 1961), the infant/child depicted represents what Stern (1985) called the “clinical” infant. Bick’s pioneer work represented a new departure. If Bick was influenced by her Kleinian theories, Ernst Freud’s valuable papers (1967, 1975) were closely linked to his Freudian theoretical framework. The curricular discipline of infant observation (Spillius, 1981) has moved toward a fact-finding stance, aiming to teach the student to recognize his data before formulating a theoretical interpretation, rather than following the opposite path, in Procrustean fashion. This paper proposes to describe and discuss the author’s view of infant observation as a curricular discipline of the analytic training offered by the British Psychoanalytical Society. Even if these views broadly reflect trends and procedures adopted by other colleagues, details and interpretations are the sole responsibility of the author.

How it is organized First-year candidates are divided in groups of two to four students and each group is allocated to a seminar leader. Because the British Psychoanalytical Society has three groups with distinct theoretical orientations, when the students are chosen for each seminar leader, consideration is given to the analytic groups to which each of them belong. In practice, this distribution does not present much difficulty. The students meet their seminar leader towards the end of July and they discuss their future work together. Students arrange an initial meeting with both parents, when they can discuss their future visits. The students are usually advised to tell the parents that they have to observe the development of a normal baby for the first year of his life, as part of a training they are starting in psychoanalysis. In practice, this straightforward and truthful statement satisfies most parents. Difficulties arise mostly when the observer is

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ill at ease with his role in visiting the family: this can lead him to search for reassurance that the parents “really” accept his visits and the parents can become confused about what is expected of them. The initial visit, where student and parents discuss the possibility of being visited, and the first formal observation probably depict the student at his most spontaneous. As his attendance at the seminars exposes him to the seminar leader’s views and comments, his observations are likely to be influenced by the teacher’s interests and theoretical viewpoints. This is part of the process of learning, and the preservation of the individual style of the student will depend on a complex interaction between the teacher’s flexibility and the student’s resilience and confidence in himself and in his teacher. The student will visit the family weekly until the end of the first academic year, and seminars are also held weekly for the same length of time. Subsequently, visits continue at increasingly longer intervals, and it is a matter of personal interest that dictates when the visits come to an end. A recent development has been the demand that students should write papers on the infants they have observed. The student is free to choose a topic of his own interest, and the only stipulation made is that the paper should contain illustrative material from the observations. The main purpose of this paper is to help the student to organize his experience and his growing involvement with the analytic training around a theme and, at the same time, to practise the skill of writing a paper. At present, these papers are stored and, subject to scrutiny of the issue of confidentiality, they can be consulted within the premises of the Society. Discussions have been held regarding the publication of particularly outstanding papers, but no decision has yet been reached on this.

What is observed Somehow, fathers are seldom found at home by the observer. The number of people present at each visit seems to depend on the mother’s lifestyle and social class. It is probably typical of our present conditions of life in a capital city that grandmothers are seldom present. Fathers will always take one or two weeks off work

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after the birth of the baby, but then the mother is left to her own resources during daytime. Those who live near relations may have their help, but otherwise mothers can only count on the occasional help of friends and neighbours. If the baby is a first child, the observer finds the mother struggling with her new role in considerable isolation. If there are other children, the mother may have added difficulties, but then she can count on her previous experience. Most mothers sense that the observer would prefer to watch the babies being fed and bathed. Sometimes, the student will mention such preference, but this is usually unnecessary. It is possible that mothers can identify with an observer’s position, but they may also be aware that feeding and bathing are activities which show up quite dramatically the baby’s progress and the mother’s increasing confidence in her maternal abilities. If there is conflict, again these activities being demonstrated to the observer would represent an opportunity of sharing the problem with an outsider, as well as the hope of obtaining help from him. The observer has to watch for movements, sounds, words, all the multitude of minute details that constitute the interaction between mother and baby. There is a large literature describing, analysing, and debating what can be observed in a mother–baby pair, but in our training we have taken the view that we do not concern ourselves with issues of reliability, concordance, duplication, quantification, etc. We assume that our student is observing and reporting phenomena through a highly subjective perspective (see, for example, Anthony, 1968). We have, therefore, adopted the technique used in analytic supervision: we accept the account of the mother–baby interaction as a sequence of events occurring as if independently of the observer’s presence (i.e., we assume it is representative of what happens at other times when the observer is not there), and we use the observer’s reactions as a guide to his understanding of the emotional atmosphere of the observation. Situations will occur where the observer’s presence and interventions obtrude into the mother–baby relationship, and this poses the problem of how the seminar leader should react. Our analytic tradition maintains that the supervisor must leave it to the student’s analyst to study any departure from his supposed “proper” role. However, the infant observation seminar leader is still left with the

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problem of helping the student to differentiate between events that can be considered characteristic of the mother–infant dyad and those which are possibly the result of his interventions. I consider this differentiation very important, since infant observation offers a unique opportunity for the student to learn how his presence influences the events in which he participates and, conversely, how he is affected by them. According to what each seminar leader considers significant, observations will focus on specific aspects of the unfolding events. Some reports will describe the baby’s movements in minute detail, while others will emphasize the mother’s utterances; some will make explicit the observer’s interventions, while others will record very little of what the observer says or does. In my seminars, I insist that the observer should detail his own participation in the encounter, but the main focus of the report still remains the activities of the baby and the mother, how they relate to each other, and how each of them relates to the observer.

How it is reported We stress that the student must make some notes immediately he leaves the family home. This is the only way in which he may recall and record the rich and complex experience he has undergone in any amount of detail. It is not enough to have a record of gross patterns or of adjectival appraisals of events. We assume that the emotional charge of the mother–infant interaction is such that the student is likely to be influenced by his emotional reactions to the events he has watched; furthermore, much of what the student witnesses can be so foreign to him that he is bound to resort to interpretations of events in order to make them understandable. If, therefore, we want to have access to an account which may approximate what “actually” happened between mother and baby, we must demand that the student should record his observations in as much detail as possible before it is reduced to an interpretative account of remembered affective resonances, which is what happens when an observation is recorded after a long interval. The student is expected to expand the notes made after the visit into a more coherent account that can be understood by others. It is

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always best to request that this final report should be typewritten. This makes it easier for others to read it and it also means less paper being used, which facilitates storage. I ask each student to post his report to all the participants of the seminar, so that by the time we meet for the weekly seminar, we have all read the reports and had time to think about what we consider relevant for more detailed discussion. On the whole, students can see the advantage of such procedures and they tend to co-operate with this. Each seminar is taken up by one student presenting his observations. If there are any crises that necessitate urgent discussion, time is made for this at the beginning of the seminar. Usually, as the student will have accumulated two or three observations since his last report to the seminar, only one is read in detail, while the material of the others is taken up according to the degree of importance of particular events observed. The students are encouraged to interrupt their colleague’s account if they want to ask questions or make comments—initially, they find this difficult, probably due to the fact that these seminars represent the first activity that those students share together and they do not feel sufficiently confident in each other to raise doubts or questions.

Crises The observation of any family will bring about situations where the observer feels emotionally involved to the point where his anxiety is increased. This is an integral part of the exercise and can usually be contained within the ordinary discussion of the seminars. However, there are occasions where the seminar leader has to ensure that the student’s working capacity is not impaired. The initial process of choosing a family deserves careful attention. Students are always advised not to consider visiting families that present the probability of social meetings. Families of colleagues can create difficulties over confidentiality. Families from a social background that is too close or too foreign to that of the student should also be avoided, if at all possible. The former can treat the student as a close friend and, because of a natural tendency on the part of the student to identify with the configuration of problems the family are struggling with, delicate situations can arise.

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For example, a student in his early thirties who has a child of just over one year of age can easily become over-involved in the struggles of a family where the father is a young doctor trying to reconcile the duties of medical house-jobs with his new family role and the mother is torn in her wish to support her husband and yet feels left behind, unprotected in learning to cope with the newborn. The opposite extreme, a family whose background is too distant from that of the student, is equally (if possible) to be avoided. For example, a foreign student brought up in a comfortable middle-class family will experience great difficulties when visiting a typical working-class family: their witticisms may be interpreted literally and the student may try to compensate for his sense of bewilderment by seeing the family as being sick or impoverished—the result can be a misplaced attitude of sympathy with its consequent danger of condescension. A more unusual case occurs when the student develops early and strong feelings about the family. One example was an expectant mother who told the prospective observer that she intended to bottle-feed the baby: the student felt intense disapproval for what she considered a planned deprivation for the baby. Another example was a mother about to deliver the first child after a series of unsuccessful pregnancies, where the student declared a particular interest in observing the development of the relationship between this mother and her “surviving” child. Such feelings of revulsion or interest clearly arise from experiences that are not related to the particular family with whom the student will be involved for the following year. The context of the seminars on infant observation does not allow for a proper exploration of such feelings. The last example is particularly complex, since the seminar leader may also be interested in the research possibilities of observing the development of a “survivor” child. Such temptation should be resisted. The seminar leader has no knowledge of the student’s previous life experiences and there is a real danger that the teacher’s research interests may expose the student to traumas he may not be equipped to cope with. Once the observations get going, crises usually have to do with issues related to the observer’s role. Each family has its own lifestyle and there is no end to the list of unusual situations that families can create: they range from the painful to the hilarious.

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Deciding what is pathological, what is cultural, and what is idiosyncratic to that individual or family is the bread-and-butter of these seminars. But, from time to time, a student will panic or feel stuck over some issues; on the whole, this reflects a conflict over the student’s concept of what he “is expected to do”. Indeed, when the student reports such a conflict to the seminar, he is to be congratulated for his capacity to detect the clash between his impulse to react actively and promptly to a situation and his awareness of being in a new role that may call for a more considered reaction. Real danger exists when the student comes with a fait accompli report of having neglected his role of observer. An example of the former situation was a student being asked to let the mother watch him tiling a wall in his bathroom: the situation did not allow for a categorical “no”, so he promised an answer by a date that would allow him to discuss the issue at a seminar. An example of a trainee behaving inappropriately was that of a female student who took her impeccably dressed two-year-old along to her weekly visit to a mother whom she saw as messy and uncaring towards her baby.

The role of observer Unfortunately, it is easier to define the observer’s role by stating what it is not than by saying what it does involve. The observer should not criticize, advise, counsel, prescribe, antagonize, reassure, praise, congratulate, support, intrude, impose upon, distance himself in a rejecting manner from a family member, voice opinions, take sides, behave in a cold clinical fashion, pretend not to have feelings—these are some of the elements of the role of observer. It is not difficult to show that it is virtually impossible to visit a family for about one year and sustain each and all of these injunctions. The list must be respected and followed with an attitude of good sense. Literal adherence to these precepts quickly reveals an overt compliance that usually fails to hide underlying, more powerful feelings. Most of the items in the above list represent attitudes that should characterize ordinary human relationships. It must be remembered, however, that each participant will, often, have a

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different interpretation of a particular interaction. No observer will prevent an anxious mother from interpreting some utterance or silence on his part as an expression of a particular view she dreads or longs for. It would be naïve to expect our students to prevent all such eventualities. What is important is the student’s capacity to perceive and assess a mother’s behaviour and consider the possible connection between this and some intervention of the observer. This often happens only at the seminar where these observations are discussed, and the student gradually learns to appreciate (1) the impact his participation has on the family, and (2) how an anxious person can (mis)interpret contributions meant to be “neutral”. The expression “like a fly on the wall” is sometimes used to describe the observer’s role. To my mind, this is an adaptation of the “mirror” metaphor used by Freud to depict the analyst’s stance toward his patient. The opposite extreme might be represented by heeding Winnicott’s recommendation to the “good enough mother”: that she should, could, or need only be herself. Unfortunately, students soon find it impossible to adopt either extreme. They find themselves dropping off the wall or feeling quite worried by the possibility of “being themselves”. The very fact of being in training is taken as synonymous with adopting some new image and avoiding attitudes they associate with their previous social and professional image. Each student will approach the family in his own typical way that will colour his discussion with the parents of the arrangements for an initial visit and the subsequent observations. A dramatic instance of this personal style comes when the observer first meets the baby with one or both parents. There is always a point where the parent asks the observer whether he/she wants to hold the baby, and this sequence can summarize much of what follows in the course of the visits. Predictably, it is only the later events that enable us to recognize the richness of meaning of these early interactions. However, as each of these events is reported to the seminar, it is difficult to isolate what exactly is part of the personality of each parent, what belongs to their relationship as spouses now faced with the presence of this stranger who wants to observe their private lives, what reflects their adaptation to the new role of parenthood, and what, in fact, is part of the student’s personality and his/her adaptation to the role of observer.

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A point that is often discussed is the information that the observer should give the family. With regard to their private lives (married? children? country of origin?), it is best to leave the students to decide what makes them feel most comfortable. I would argue that the truth is always best, since secrecy or deception only lead to constraints to spontaneity that may affect the quality of the work, but some students find it necessary to preserve their privacy and this point of view should be discussed in detail. Usually, the student will understand his reasons for defining “privacy” in this manner (e.g., identifying with parents imagined to be under threat of an invasion to their privacy); occasionally, the situation cannot be resolved, and this has to be noted (e.g., a medically qualified student who did not reveal this status to the family and gradually displayed many indications of strong feelings against them). I would like to attempt a description of how I see the observer’s role in positive terms. The student should have an attitude of warm and sympathetic concern for the parents and the infant. He should be able to appreciate that these parents are struggling with an experience which mobilizes very powerful emotions—not only fear, ambivalence, anxiety, jealousy, disillusionment, etc., but also pride, happiness, a sense of fulfilment and achievement, hope, determination, and love. Above all, the parents are not dealing only with feelings, but they have now a real human being they have produced and whom they have to look after. That the parents are willing to share with the student this multitude of emotions demands that he should give them some feedback to indicate that he is aware of what they are going through; this response need not be in words: as long as the student does comprehend how the parents feel, he will smile, or make a gesture, or even find the right words (right for those specific parents) to convey his understanding. This point can be illustrated by referring to the situation where the mother asks the observer if he would not agree that the baby is putting on weight. Students dread this question! One actually answered, “Oh, it is difficult to see with so many clothes on . . .” They are afraid of “ignoring the mother’s anxiety”, they try to guess what is the unconscious fantasy behind that question, they check and doublecheck what they really think about the baby’s progress. If the observer can grasp the multiple determinants of this question, he will make some gesture and mumble or say clearly some words

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such as “I guess so”, or “I’m sure he is!”, which is just about as much as the mother needs and longs for. Besides concentrating on the details of what goes on around him during his visits, the observer must have some appreciation of what his subjects are going through and what they expect of him. When he manages to grasp what they are feeling, he is less compelled to do or say “the right thing”. Indeed, there are many occasions when he cannot grasp what is happening, and this is when we expect the observer to be able to keep himself from saying or doing anything to cover up his lack of understanding. Perhaps we should make explicit the difference between the student’s role in infant observation and that when meeting his first analytic patients. Facing his training cases, the student is conscious of his patient’s expectation and need of some feedback from him, in order to alleviate the problems that brought him into analysis; if the student cannot understand what is happening in the analysis, he becomes anxious because his self-esteem is affected and he is aware of disappointing his patient’s hopes and needs. Under normal circumstances, this constellation does not apply to infant observation. It is we, the training establishment, who expect the observer to preserve his perceptual skills and develop his comprehension of what unfolds in front of him, while continuing to sustain an attitude of warmth and concern: the parents want him to be a participating guest with whom they can share their struggles and their achievements. Parents learn quite early that the observer will refuse to give them direct opinions or advice and they do not mind this, as long as they perceive that the observer values their efforts. Indeed, there are families where conflicts, anxieties, and needs become manifest during the observer’s visits; at times, these parents turn to the observer for help and such pressures have to be recognized and looked into. We may conclude that the parent(s) is treating the observer as if he were the baby or some other object of the parent’s life, but it is wrong to assume that the observer is, ab initio, such a transference figure. It follows from this that it is incorrect for the observer to assume that his thoughts or feelings reflect, by definition, elements of his subjects’ internal world. Another way of stating the complexities of the observer’s attitude to the parents is to say that, having established that he is visiting the family because this is a requirement of his course, and

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having obtained the parents’ agreement to this, he has then to help the parents to see him as someone who is valuing his experience, if not enjoying it, and not simply a student performing a chore. In Bick’s words (1964, p. 558), “he would be a privileged and therefore grateful participant observer”. If the student cannot manage this, there is bound to be trouble with one or more of the participants of the observation.

What is discussed Although we speak of infant observation and we stress the importance of the student’s role as an observer, both students and seminar leaders are aware that their discussions are part of a psychoanalytic training. The students are eager to discover the connections between their observations of the infant and the theories of human psychological development they are learning in other areas of the curriculum. For their part, the seminar leaders are also influenced by the particular framework that guides their work. It is important to preserve the principle that these seminars should not become a situation where the students discover only the connection between what they observe and the seminar leader’s chosen theoretical framework. This is only one of the goals of the seminars; we also want to help the student to understand the richness of the events he witnesses and to prevent him from taking isolated details or sequences to signify the evidence for some theoretical concept he is interested in. A third objective is to help the student to see the links between psychoanalytic concepts of several schools of thought and the child and parents they are observing. However easy it is to describe each of these three areas, in practice it can be difficult to separate one from the other, since, for example, when the seminar leader stops a student’s account to discuss a particular sequence, he is implicitly conveying what issues are important to him. Still, being aware that we have three different objectives will help the teacher to recognize misunderstandings if and when they occur. Even as they start their training, most of our students have a reasonably good idea of what various analytic schools postulate regarding early stages of child development. However, they often

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have a preconception that psychoanalytic concepts refer to emotional pathology. This leads them to evaluate what they observe along the spectrum of normal/abnormal, “common” being synonymous with normal, and “bad” or “not quite good”, or “never met before” leading them to consider the presence of pathology and, therefore, something explicable by a psychoanalytic concept. Often, significant events are reported which are passed over as irrelevant because they are taken as commonplace and unimportant. An example is that of the mother who says that the baby would not stop crying when she picked him up, so that she went on to give him the breast and, because the crying went on, she decided to wind the baby. “Surely, that is a natural thing to do?” is the usual way of dismissing the sequence. The word “natural” can lead to quite a long discussion, but it is important to make explicit this mother’s capacity to see the baby as a separate being and to take his crying as a sign of distress which she wants to remedy, and how she interprets each failed attempt at relieving him as her not having quite discovered what the baby is distressed about, rather than feeling persecuted because of attributing to the baby an intention to reject her ministrations. At the opposite extreme is the situation where a student claims that a certain datum signifies that the baby is experiencing a particular impulse or unconscious fantasy. It is important to help the student to argue this proposition, rather than just accepting, dismissing, or correcting his assertion. Psychoanalytic concepts are explanatory hypotheses, and it is our duty to the student to help him to find the explanation that best suits the data of the observation he reported. If we simply agree to the link he has made, or, instead, give him the interpretation that we favour, we will miss an opportunity to teach the student how to make sense of the real life events he is observing and gradually discover the psychoanalytic concept that most satisfactorily explains his findings to himself. Families where there is an older sibling present many opportunities where there is enough material reported for the recognition of the child’s unconscious fantasies. Similarly, it happens sometimes that a parent will give enough information for us to form an idea of their unconscious feelings and impulses. Such opportunities can be taken up and the student helped to recognize their importance.

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On the whole, the first few seminars are taken up by discussions of situations where the student has experienced some difficulty. The mother asks the student to hold the baby while she goes to the kitchen: what should he do? The student was asked whether he has children of his own: should he answer this? The family have decided to stop the visits: how to deal with this? The father invited the student to go out for a drink: should he accept? The student is asked whether his reports are read out to others: what to say? These common and apparently simple questions can take up considerable time in the seminars. Very few situations demand or allow a definite clear-cut instruction. Usually, it is necessary to explore the meaning of the problem within the context, as far as it is known, of the family’s background and its present life, before the student can decide how to proceed. A more delicate element on these occasions is the understanding of the student’s reaction to the problem. It is definitely not correct to postulate axiomatically that his feelings are countertransferential: such an interpretation can be misleading, if not dangerous; it deprives the student of a fuller comprehension of his feelings and can lead him to believe that his contribution to the situation is irrelevant, and this can lead to its repetition. An example was a student’s intense reaction of protest and horror when a mother “force-fed” the baby by tricking him into opening his mouth. Discussion in the seminar showed that the observer had never seen a baby learning to ingest solid food: the students in the group who had previous experience with children thought nothing of this mother–baby interaction. The observer could then reassess his account and recognize that the impulses he had attributed to the mother belonged to his own previous experiences, the exploration of which did no longer have place in the seminar. If the “countertransference” version had been adopted, the observer would continue to believe that this was an uncaring mother feeding a baby badly in need of an ally to protect him against the mother, and, worse, he would not appreciate that his life-experiences could affect the interpretations he made of the interactions he observed. As in other teaching situations, helping the student to understand his work does not necessarily lead to changes, even when these are necessary; conversely, it can be difficult to explain a situation and help the student to preserve what is his own individual

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style. One example is the student mentioned above who informed the seminar that she had decided not to tell the family that she was a doctor; the other students and the seminar leader were worried by the creation of a lie that might create difficulties. But the particular student could not agree with this, and the notion of deception coloured her further observations, even if never convincing the person who most needed to appreciate it. Another example is the request for the observer to hold the baby: this can produce complex reactions that are often related to the student’s own feelings about having or not having a baby. Before arriving at a recommendation about how to proceed, it is important to explore how at ease or otherwise the student feels when holding the baby. In spite of the apparent difficulties of these issues, most students cope quite well with these discussions and eventually find an answer that incorporates a better understanding of the new situation to that behaviour which they find ego-syntonic. Eventually “problems” seem to disappear from the scene and seminars are taken up by a consideration of what is happening with the baby and between him and the mother. There is universal agreement about the baby being an individual in his own right, and much discussion will focus on this issue, trying to isolate the baby’s own experience of a situation from what is the parent’s interpretation of it. One mother will say her breasts are painful and decide to wake the baby up, in the hope that he will suckle and alleviate her pain. Another mother will say that the baby’s cry or movement means that he is hungry and she will, therefore, pick him up and put him to the breast. A third mother will say that three or four hours have gone since the last feed and that she should now feed the baby. When the observer witnesses one of these interactions during the hour he is in the house, he will attribute affects and wishes to each participant, since he cannot otherwise produce what would seem a coherent account of events. Whether he sees the sequence as harmonious or resulting from conflict, it is natural that he should use adjectives and adverbs to give life to his story. From this point of view, the observer is in the same position as the parent(s) in his need to make sense of what he perceives. It is only after we can isolate the observer’s contribution to his account and the parent’s interpretation of the baby that we can

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begin to delineate what constitutes the baby’s individuality. This comes across in his way of dealing with himself and his world, that is, his sounds, movements, his capacity to cry and to stop crying, how he responds to being picked up, touched, spoken to, put down in the cot, shifted positions, how he deals with his fingers when they go into his mouth, how he uses his eyes, and many other such actions that are mostly not noticed, even if they invariably lead to some modification of the parent’s approach to the child. It is the fact that it is virtually impossible to observe a baby in isolation that makes it so difficult to grasp those data that we can take as elements of the baby’s constitutional endowment. Winnicott’s dictum that there is no such thing as a baby, only a baby and his mother, was meant to illustrate the infant’s total dependence on his environment for his survival. However, this formulation also implies that the infant is under the continuous influence of the people around him to shape and alter his behaviour. There is considerable research to show that mothers can recognize their baby’s crying and identify some of the messages contained in it, but by the time we observe these interactions, the baby has already been exposed to the waiting and the attention that his parent has given him and this will have influenced his subsequent behaviour. The converse is equally true, and research has also shown how a baby will influence his carer. The goal of our observations to identify the features that constitute that infant’s individuality is ever present, but seldom rewarded. It is far easier to depict the interaction between the baby and his carer(s) and the way in which they influence each other. We can always repeat what parents are continuously doing, that is, pick up some movement or sound and attribute definite qualities, intentions, or meaning to it and trying to establish that this is peculiar to this child, but only the passage of time can help us to recognize which of these actions are built into a pattern and which are modified or even disappear forever. It is only as the infant grows older that we can pick out sequences that appear reasonably convincing with regard to connections made by the child between his needs, parts of his body, and elements from his environment. However, again we have to contend with the issue of what constitutes sufficient evidence, and it is well known how different analytic schools will interpret the same piece of behaviour in very different ways.

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What is gained We should not expect infant observations, as a curricular discipline, to provide us with results comparable to the formal observational studies undertaken by research workers. Even if we can hope that some of the reports produced by our students would substantiate points of theory in our psychoanalytic psychology, this should not be seen as the main objective of this discipline. Primarily, the rationale that underpins infant observation as a training course is the education of the student. I would like to discuss some of its advantages in detail, under separate headings, though, in fact, these overlap to a considerable extent.

The student Interest in children It might be expected that the close contact with a baby, parents, and possibly older siblings would lead students to develop an interest in children which, for example, could make them wish to train in child analysis. Strangely, this does not seem to happen. Those students who like children (and this does not seem to be linked to their having children of their own or not) can enjoy and obtain great and evident pleasure from following the baby’s development. Though the majority of students will show their intellectual curiosity in learning of various meanings discussed around the observations, this exercise is still seen as self-contained. Emotional involvement with various members of the family will depend on individual characteristics of the student, but, for most of the students, the main interest lies in working with adults and learning about adult psychopathology. Some will transpose findings on to the notion of “the child in the adult”, and it can then be seen that, in fact, they are usually doing the exact opposite: they try to understand the baby in front of them by resorting to what they have learnt about reconstructions and hypotheses on adult psychopathology, what we have referred to earlier as the “clinical infant”. In spite of these comments, all students value the opportunity of taking part in a live family situation, where they gain a firsthand view of what goes on around the child and form a very vivid idea of the interactions which will, one day, be translated into the

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“internal world” of the child and adult. It is difficult for students to articulate what they gain from the year’s observations, but they always report the sense of marvelling at having shared in such a novel and rich experience.

Normality/pathology Over the months, the observer gains a vivid notion of how behaviour or statements that one day appear to represent gross pathology will later result to have meant normal events in a developing person or relationship. Social and cultural characteristics are fertile ground for examples. In one family, a mother panicked over her baby’s minor symptom and the child spent the night in a hospital under observation: the seminar discussed the mother’s threshold of anxiety, her feelings toward the baby, the repercussions of the event in the baby’s development. Several months of further observations failed to elicit a single clue to indicate consequences of the episode.

Concept of time Virtually every student will witness situations where the mother’s delay in responding to the baby’s crying will produce considerable anxiety and an urge to deal with the baby. On the surface, this might appear to be only an identification with the child and a sense of rivalry with the mother, as if the student “knew best” what the baby needed. Another possible meaning of this interaction is the student’s disbelief in the baby’s capacity for dealing with (internal or external) stimuli. This was particularly clear when one student stayed in the baby’s room after the mother had put the baby in bed, half asleep: after a few minutes, the baby cried, and the student had to make enormous efforts not to pick him up or to call the mother back. He was astonished to find that gradually the baby quietened down and fell asleep peacefully. Such situations are, in fact, of great help to make the student understand that if a child (or, later on, his patient) shows distress or discomfort, this is not, in itself, justification for him to intervene. We usually describe this issue by referring to the capacity to wait, and infant observation presents to the student many opportunities to discover that each person has his

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own concept of time and his own individual capacity to deal with stimuli and regain a state of equilibrium.

Change, development Sleep patterns, feeding behaviour, kinds of crying, degree of demands, body sensations (colic, pain), body functions (vomiting, teething, bowel movements) offer the best possible lesson one might wish for to learn about change and development. Whether it is a question of the mother’s reported view of the child or the actual witnessing by the observer of these issues, the degree of change that can take place from one week to the next is so dramatic that it should teach any student that humans change in themselves and both influence and are influenced by those with whom they live. The identification of a typical pattern that will characterize the individual or a particular relationship is something we definitely believe in, but in practice these constant changes illustrate how difficult it is to pick out the pattern we are after.

Affect experienced or presumed? The wish to recognize the affect and the unconscious fantasy of the infant/child is ever present in these observations. If observer and seminar leader put forward different interpretations over some particular behaviour, it is impossible to prove or disprove either view, but a similar impasse can also occur between mother and observer as, for example, in the situation of the baby crying when falling asleep. If, logically, it is equally impossible to show the student that he is right or wrong, these situations allow the point to be made that, correct or incorrect, the adult’s interpretation of the baby’s affects and needs is what will determine his approach to the baby. From that point onwards, infant and parent are involved in an interaction where they have to adapt to each other. By the time the student observes the infant and his parents, he will often manage to make sense of the way in which they react and adapt to each other; the parents’ attitudes and utterances to each other, to the baby, and to the observer will allow us to understand their experiences, but it is extremely difficult to understand and conceptualize the infant’s experience without resorting to our own preconceptions.

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Self-control As mentioned above, infant observation visits teach the student how to keep himself under control. His role is so complex that, by comparison, the analytic stance is almost simple. The student is part of very intimate situations and he is exposed to challenges and invitations that he cannot accept or reject without considerable tact. He will watch situations where the child gets hurt or makes demands, and he cannot afford to make the parent feel displaced, nor that his child is neglected by the observer. Marital issues will be referred to or will, sometimes, be displayed in front of the observer. All in all, these visits are excellent training for the student’s future work, where he has to show his participation in an interaction without necessarily doing anything active to achieve this.

Giving and taking Most students feel embarrassed or guilty because they cannot see that the family is getting anything out of their visits. They will become over-apologetic or too self-effacing; sometimes they will put endless questions to check if they are really wanted in the house. More serious is the over-compensation for these feelings by becoming intrusive and over-active. When this happens, it is only after a long period that these students believe that the parents value their visits and their participation in the life of the family. It is true that the student’s feelings are linked to his own personality, but these seminars cannot be a forum to discuss this, though the family usually achieves better results in improving the student’s selfesteem than any seminar leader could ever do.

Comparison with other students Besides the advantages of following closely the development of three or four families, the student also gains from discussing his own work and the work of his colleagues. The intimate forum created at this earliest stage of their training helps each student to gain in self-confidence and it also represents a unique opportunity to carry out extensive and intensive work in a particularly challenging discipline within a reasonably protective environment.

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How participant is the observer? In the course of his visits, the student has many opportunities to discover the importance of his presence in the home. Some students can become too anxious, lest they are inhibiting or embarrassing one or both parents, or even interfering with the care of the baby: if, for example, a mother talks to the observer while feeding her baby, the student’s anxiety can be quite intense and he may find it difficult to decide how to respond to her. At the opposite extreme, we may find students who believe that their presence exerts no influence on the family and, consequently, that any emotion they experience is entirely caused by the conflicts in or between various family members. In the context of an exercise focused on an understanding of the development of the infant and his parents, it is important to help the student to differentiate between the various factors that influence his perception/interpretation of the events he is observing. This is a very delicate task that can create difficulties between students and seminar leaders; nevertheless, it should not be shirked, since infant observation is probably the best situation in the analytic training for the student to appreciate the complex and subtle pattern of mutual influences between worker and subjects. It is only when the student can appreciate his contribution to the situation that he can interpret the rich interaction between the infant and his carers. When the student cannot comprehend the contribution he brings to his position of observer, his reports and his interpretations will usually contain an unconvincing blend of comments and descriptions that seldom allow the infant or the parent to come alive to the other seminar members.

The training Capacity to learn and change The first year of the analytic course is taken up by lectures and seminars where the student will be seen only a few times by each individual member of the training establishment. When a class happens to be large in numbers, this makes it even more difficult for the teachers to gain a convincing picture of the capacities of each particular student. In most cases, lecturers can evaluate the student’s dedication to the training and his attitude to colleagues and

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teachers, but only in exceptional cases will more serious emotional difficulties become manifest in this setting. By the second year, when the student starts his analytic cases under supervision, his performance will be observed over a long period, but in the first year, infant observation seminars represent the only setting where the one analyst follows closely the work of a candidate for the whole academic year. The visits to the family will show the progress of the student from a beginning where he presents himself at his most naïve to his gradual overcoming of inexperience and anxiety, finally to summarize his experience in a paper that combines what he learnt in the work with the family, what he gained from the seminars, and also from his other activities at the Institute of Psychoanalysis. The seminar leader is, therefore, in a privileged position to observe the progress made by the student over the first year of his training, and his reports play an important role in the evaluation of the student’s capacity to relate to his subjects, his peers, and his teachers; above all, the student’s capacity to learn from experience and to change.

Relating to the child and adults The infant observation visits represent our only opportunity of learning how the student copes with more than one person at a time. The kind and level of conflicts to which the student is exposed during these visits is quite different to what pertains in the one-toone situation in analysis. Seeing his analytic cases, the student can utilize the concept of transference to cope with many situations that might, otherwise, baffle him. Similarly, a student can learn the meaning of concepts such as projection, introjection, identification, etc., without necessarily being able to grasp the emotional experience the patient is going through. Such a difficulty can appear in striking manner during infant observation visits, when a student is seen to make sense of the events unfolding in front of him by resorting to analytic concepts he has adopted. This represents a kind of false learning, which makes it difficult for that student to perceive precisely those interactions that can, in fact, be described with particular analytic concepts. In such cases, the challenge for the seminar leader and other members of the training establishment lies in establishing whether this false learning is the result of

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inexperience and anxiety, or whether it reflects a character disturbance that may not be amenable to change.

The family I do not want to close this section on the advantages gained from the infant observation visits without making explicit my conviction that these visits are helpful to the families visited, particularly to the mothers. Most of the families visited in London are isolated from relatives and friends; most observers will report visits on end where the mother is found alone with the child or children. Not surprisingly, these mothers form strong and close bonds to the observers, and often a student (particularly male ones) will become aware of an increasing sense of unease in himself during his visits. Because of her isolation, the mother’s experience of her changing self-image from nurturing mother back to a sexual woman can lead her to see the observer as a source of feedback regarding her self-image and self-esteem. When the student succeeds in keeping to his role through retaining his concerned interest and never taking a colluding or critical stance, there is no doubt that he will help father and mother to work through these individual and marital developmental issues. Somehow, students find it difficult to see this, and invariably begin their observations feeling like intruders; in part, this feeling stems from the idea of gaining entrance to the intimate relationships between infant and parents, but the belief of “getting more from the family than they get from me” persists for a long time and it is important to help the student to recognize how, in fact, his presence is valued. This will help the student’s self-esteem and it will also allow him to understand better how each parent sees him.

Summary A distinction was drawn between observation of children, as described in child development studies, and the psychoanalytic observation of infants by students in training. Technical and theoretical aspects of the seminars and of the students’ work were discussed. Unfortunately, only seldom is it possible to identify

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characteristics of the individual child. The main gains for the student are an appreciation of the mutual influences between infant and parents, as well as between worker and subjects, a vivid experience of the concept of development and of the importance of waiting before acting or forming interpretations of his data. The role of observer was described and comparisons made with that of the analyst. It was stressed that the seminar leader should not simply accept or correct the student’s interpretations, but, instead, help him to find the analytic concepts that best make sense of his findings. These seminars, extending over a whole academic year, give the training establishment a unique assessment of the student’s ability to relate to his subjects and of his capacity to learn and to change.

References Ainsworth, M. D. S., Bell, S. M., & Stayton, D. J. (1974). Infant–mother attachment and social development: socialization as a product of reciprocal responsiveness to signals. In: M. P. M. Richards (Ed.), The Integration of a Child into a Social World. London: Cambridge University Press. Anthony, E. J. (1968). On observing children. In: E. Miller (Ed.), Foundations of Child Psychiatry (pp. 71–123). Oxford: Pergamon. Bick, E. (1964). Notes on infant observation in psychoanalytic training. International Journal of Psychoanalysis, 45: 558–566. Bowlby, J. (1969). Attachment and Loss. London: Hogarth Press. Brody, S., & Axelrad, S. (1970). Anxiety and Ego Frontiers in Infancy. New York: International Universities Press. Burlingham, D., & Freud, A. (1965). Infants Without Families. London: Allen & Unwin. Freud, A. (1953). Some remarks on infant observation. In: Indications for Child Analysis (pp. 569–585). London: Hogarth Press, 1969. Freud, S. (1897). Letter to Fliess, no. 69, 21 September 1897. S.E., 1: 259. London: Hogarth Press. Freud, W. E. (1967). Assessment of early infancy. Psychoanalytic Study of the Child, 22: 216–238. Freud, W. E. (1975). Infant observation—its relevance to psychoanalytic training. Psychoanalytic Study of the Child, 30: 75–94. Hartmann, H. (1950). Psycho-analysis and developmental psychology. Psychoanalytic Study of the Child, 5: 7–17.

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Heimann, P. (1966). Comment on Dr Kernberg’s Paper. International Journal of Psychoanalysis, 47: 255–260. Hellman, I., Friedman, O., & Shepheard, E. (1960). Simultaneous analysis of mother and child. Psychoanalytic Study of the Child, 15: 359–377. Joseph, B. (1966). Persecutory anxiety in a four-year-old boy. International Journal of Psychoanalysis, 47: 184–188. Kestenberg, J. S. (1977). Psychoanalytic observation of children. International Journal of Psychoanalysis, 4: 393–407. Klein, M. (1932). The Psychoanalysis of Children. London: Hogarth Press. Klein, M. (1952). On observing the behaviour of young infants. In: J. Riviere (Ed.), Developments in Psychoanalysis. London: Hogarth Press. Klein, M. (1961). The Narrative of a Child Analysis. London: Hogarth Press. Kris, E. (1951). Notes on the development and on some current problems of psychoanalytic child psychology. Psychoanalytic Study of the Child, 5: 24–46. Lichtenberg, J. D. (1981). Implications for psychoanalytic theory of research on the neonate. International Journal of Psychoanalysis 8:35–52. Mahler, M. (1969). On Human Symbiosis and the Vicissitudes of Individuation. London: Hogarth Press. Peterfreund, E. (1978). Some critical comments on psychoanalytic conceptualizations of infancy. International Journal of Psychoanalysis, 59: 427–441. Robertson, J. (1962). Mothering as an influence on early development. Psychoanalytic Study of the Child, 17: 245–264. Spillius, E. (1981). Description of infant observation seminars for first year students (unpublished notes). Spitz, R. A. (1950). Relevancy of direct infant observation. Psychoanalytic Study of the Child, 5: 66–73. Stern, D. N. (1985). The Interpersonal World of the Infant. New York: Basic Books. Winnicott, D. W. (1957). On the contribution of direct child observation to psychoanalysis. In: The Maturational Processes and the Facilitating Environment (pp. 109–114). London: Hogarth Press, 1965.

INTRODUCTORY NOTE TO CHAPTER TWO

The role of intuition

I

ntuition is a word not frequently found in psychodynamic writings. This follows from a point of view that considers intuition an unreliable tool when trying to understand the interaction between patient and therapist. Rycroft (“The present state of Freudian psychoanalysis”, in Psychoanalysis and Beyond, pp. 52–57) formulated this question in a very lucid and convincing manner: What I am suggesting is that one of the unresolved contradictions in Freud’s thinking is between psychoanalysis conceived of as a natural science—objective, detached and intellectual—and psychoanalysis conceived of as an intuitive, receptive mode of relating to others; and that awareness of this contradiction combined with failure to resolve it is part of the contemporary “malaise” of psychoanalysis. If an analyst conceives of himself as only a scientist, he will apply theory to his patients and risk seeing only what he already knows. If, on the other hand, he conceives of himself as only a “freefloating attention”, existing “in a state without memory or desire”, as André Green recommends he should—or displaying Keatsian Negative Capability, “being in uncertainties, mysteries, doubts”, as another analyst, Bion, has recently advocated—he risks not being able to express what he discovers in terms comprehensible to others.

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Faced with this dilemma, it is hardly surprising that some analysts cling defensively to the theoretical model Freud constructed when wearing his “natural scientist” hat, while others form coteries and sub-schools in which they pursue the implications of Freud’s more muted, less publicized subjectivism.

In “Psychoanalysis and the literary imagination” (pp. 261–277 in same book), Rycroft focuses more explicitly on symbolism and the role of intuition: . . . the embarrassing, unscientific nature of symbolism arises from the fact that symbolic interpretations can be arrived at intuitively and, as Freud himself put it, intuition “is exempt from all criticism and consequently its findings have no claim to credibility” (Freud, S. in Standard Edition, vol. V, p. 350). Although this is a very respectable scientific opinion, it is hardly applicable to the subject of symbolism, since symbolism is a form of metaphor and, as Aristotle said, “a good metaphor implies an intuitive perception of the similarity in dissimilars”. [in Poetics, Chapter 22]

I consider intuition a central, vital element in the therapeutic encounter. This statement tends to be more acceptable when the word “empathy” is used to replace “intuition”, but, when focusing on the therapeutic encounter, the two words can be seen as virtually synonymous. However, “empathy” has acquired a coat of psychodynamic respectability in so far as it can be explained in psychoanalytic language as the result of a projective identification, where the therapist sees himself in the patient’s self. By contrast, “intuition” is seen as a gratuitous product of the therapist’s self, as if unrelated to the patient under the focus of his attention. Whatever concept is chosen, as long as the intuitive idea is subjected to a careful analysis, I see it as a valuable tool in understanding the communications of a patient. Winnicott’s account of his Therapeutic Consultations represents a precious piece of evidence about the importance of intuition. Time and again, he grasps the content of a child’s unconscious feelings on the basis of evidence that might not be picked up by another therapist or reader. Whether this is explained by referring to Winnicott’s capacity for empathy or, instead, to his intuition, I believe is not important. I am stressing this point because I see the

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ability to grasp the content of a patient’s unconscious feelings and thoughts as the main tool in the process of our therapeutic work. We do have professionals who do not have this ability, and their work shows a mechanistic, mathematical, cold quality of deductive thinking, where the underlying theoretical postulates can be seen more clearly than any valid connection with the patient’s behaviour or utterances. The paper “Winnicott’s therapeutic consultations revisited” describes a series of interviews applying his approach. I have, subsequently, published (Untying the Knot, 2001) a further collection of similar cases. Some of my interviews involve not only the child, but also his parents. This widening of Winnicott’s technique follows from my experience that the parents’ account of their individual histories gives me a clearer grasp of the basis on which they interpret the child’s development, and this is an important datum to understand their interaction with the child. This joint meeting allows the child to hear the parents’ view of his problems, and it also helps the parents to hear their child’s account of his life and his problems. Many times have I found parents reacting with great surprise at what their child told me. “I never knew he thought that!” and “I didn’t know he could answer so many questions!” were some of the comments. What I learnt is that most parents and teachers (and therapists!) tend to give answers, explanations, and advice to the children addressing them. It is, unfortunately, rare to find people who will, instead, ask the child for the reason behind his comment, complaint, or question. I was seeing a ten-year-old boy and his parents, who were unhappy with his behaviour and felt very frustrated at the boy’s apparent withdrawal from them: he refused to answer their questions and never volunteered any communication. At one point, the father told us his memory that when the boy was four years old, “he came to me one day and said ‘I know God created the Earth’. I said this was good. After a while, he asked, ‘Do you want me to tell you how it is I know?’ I said yes, and he explained ‘Because there was no ground for anyone to stand on, so only a God could have done it’.” The father carried on speaking, as if this episode had no particular significance and went on to tell us once again how impossible it has always been to get his son to speak about anything at all. I said that this story was most remarkable

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considering the boy’s young age, and added that if the father’s reaction at the time was similar to the one he had just demonstrated, there was a good chance that the boy felt that his father gave no special attention to his thoughts and ideas, perhaps concluding that there was no point in getting himself heard.

As we often learn from our daily life, it is not common to find someone who is actually interested in hearing the extent of our thoughts. On the whole, people want a succinct statement of what is desired or expected from them, so that they can decide how to respond. To ask questions risks not only longer encounters, but the possible emergence of difficult or even embarrassing issues. In a diagnostic interview it is essential to discover the relevant questions that will lead patient and therapist to information that could clarify the presenting picture. And most of the time it is the therapist’s intuition that can guide him to identify the points in the patient’s account that require more detailed probing. This principle clearly applies to ongoing, long-term therapy, but it is particularly important in the context of a diagnostic consultation. These therapeutic consultations demonstrate how important it is to help the parents to understand how their unconscious experience of the child’s difficulties leads them to deal with the child in a manner that, contrary to their intentions, ensures the continuation of the problem. If the parents can take this understanding into account and change their approach, there tends to be a quick resolution to the presenting problems. If, instead, they are unable to change, this indicates the importance of offering some form of individual psychotherapy to the child.

CHAPTER TWO

Winnicott’s therapeutic consultations revisited*

W

innicott described in his book Therapeutic Consultations (1971) how a diagnostic assessment of a referred child developed into a fruitful therapeutic intervention when he was able to discover the unconscious fantasy that underlay the child’s symptoms. Because these were children who were, essentially, developing normally, he used the word “knot” to depict the obstacle the child had met. Any conflicts the parents might have were not explored in that context. This work presents cases in which child and parents are seen together for the diagnostic assessment. The child’s feelings about his world and his difficulties are explored through a variety of techniques, including drawings. In the same interview, an analytic enquiry into the parents’ history and also their views of the child reveals how the child’s fantasies and the parents’ past experiences interact and create a mutually reinforcing vicious circle. In other words, the “knot” involves all of them. If the child’s unconscious fantasy can be verbalized and if the parents are able to approach the child in a manner that acknowledges the child’s real

*First published in 1997 in International Journal of Psychoanalysis, 78: 773–787.

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needs, the “knot” disappears and normal development can be resumed. I still remember Winnicott presenting therapeutic consultations at Scientific Meetings. Everybody agreed that his stories were fascinating, but quite a few colleagues whispered that “it was not really analysis”. I cannot imagine that Winnicott needed such a reminder, but by the time he published the book that became so famous (Winnicott, 1971), he made it quite explicit that his work represented an application of his psychoanalytic knowledge to the field of child psychiatry, almost as if to pre-empt this kind of criticism. Winnicott was a great believer that a psychoanalytic treatment widened the horizons and enriched the knowledge of all caring professions. He also thought that psychoanalysis, as a scientific psychology, was a vital element if one wished to understand and help people. I am sure that Winnicott saw his consultations as a further proof of the therapeutic value of psychoanalytic theories. My work with children and adolescents has shown me how right Winnicott was. In the course of the past twenty-five years, I interviewed many children and adolescents in my NHS and private work. I gradually developed the approach to be presented here, seeing children together with their parents. I believe psychoanalysis constitutes the main influence in my thinking, even though, like so many colleagues, I was influenced by group work, family therapy, etc. My view of people and the world leads me to give great importance to each individual’s right to independence and self-reliance, and there is no doubt that the work with children and their families makes us continuously aware of the pressures people exert on each other whenever there is a conflict between dependence and independence. We have many theories of infant development, but whatever the concepts we choose to adopt, essentially what we see is a human being born in a state of total dependence who needs his parents’ help to become truly independent. To achieve this independence, the child needs not only to mobilize his genetic endowment, but also to have parents who can enable him gradually to disengage from them. When we have late adolescent or adult patients in treatment, we assume that they should have reached a stage of emotional and social development where we can treat any indication of emotional

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dependence on their parents as a sign of some underlying psychological conflict. But when we see children or young adolescents, we have to take into account that their state of dependence is not just psychological, but factual, and when we embark on a one-to-one treatment, we must clarify the role of the parents vis-à-vis our therapy, since the patient is only too aware of our first-hand knowledge of their parents as real people. From a psychoanalytic perspective, it is quite logical to offer individual treatment to a child or adolescent who has a problem, but other schools of thought would consider this situation quite differently. Family therapists consider the child’s symptom as a sign of family pathology and address themselves to the whole family. It is interesting to note that one of their founding fathers, Ackerman (1973), wrote quite early on that the child as an individual was being neglected and pointed to the difficulty that workers found in making contact with the child as the probable main cause for this: I suspect he might still say the same if he were writing today. Selvini Palazzoli, Boscolo, Cecchin, and Prata (1974) follow family dynamics theories, but they concentrate their work on the parents. The Palo Alto (Haley, 1971) and other American teams based their work on Bateson’s theories, where the parents represent the fundamental factor in determining the child’s development. The “interactional” view of relationships is found in other approaches and it is worth noting that Bowlby (1958) seems to have been the first to use the word “interaction” to describe the relationship between mother and baby. Winnicott also followed this view (1964) when he stated that one should always consider “mother and baby” and not an isolated baby at the earlier stages of development, but Bowlby’s attachment theory has been developed by Main and Cassidy (1988) and Ainsworth, Blehar, Waters, and Wall (1978). The interactional view of baby–mother has led to valuable research and therapeutic interventions in the field of infant psychiatry (Cramer et al., 1990; Sameroff & Emde, 1989; Stern, 1995). A psychoanalytic view of these family-directed approaches has been presented by Dare (1988). Coming back to the world of those who value “subjective experience”, we have Anna Ornstein (1984). She engages the child in play and aims at understanding the child’s unconscious conflicts, much along Winnicott’s lines. Her explanatory system comes from

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the school of the psychology of the self, though I sense a close parallel with Winnicott’s ideas about stages in the development of the concept of an object. Ornstein sees the parents separately, in order to evaluate their experiences and views of the child, so that she can then best translate to them what she learnt from the child when seen in the one-to-one play setting. Ornstein’s view of the parents’ role is different from Winnicott’s. He thought the child could not improve if living in a non-supportive environment, while a “good enough” mother/parents would allow the child to sustain the improvement that he had brought about. But Winnicott, apparently, did not see them as the object of his work, while Ornstein considers the parents as a fundamental source of support for the child, and she tries, therefore, to discover how best to help them to understand their child. Should the therapist be successful in establishing empathic contact with the parents and help them understand their troubled child in depth, she has achieved two interrelated goals: the parents, instead of responding to the child’s manifest behaviour in a way that further aggravates his condition, can now tune in and respond on the level of the child’s subjective experiences; they have been helped to recognise their own therapeutic potential. [Ornstein, 1984, p. 361]

Can there be a better result? This view of the parents’ role is also found in the work that Selma Fraiberg undertook with infants (1980). This pioneering project has originated what is now called infant psychiatry and Fraiberg’s views have influenced most of the present practitioners. She concentrated on uncovering the “ghosts in the nursery”: the parents’ past experiences were explored and linked to the way in which they were treating their infant. Fraiberg was very insistent that the baby must be present during the meetings, since this allowed the therapeutic team to gain close knowledge of the mutual influences between infant and parents. Tavistock Clinic workers have made important contributions to this field of work, covering brief interventions as well as the longer-term infant–parent psychotherapy (Daws, 1989; Hopkins, 1992). Helping the child in a psychodynamic framework, we think of “deep”, “early” conflicts, long-term work, and transference relationships, but the parents are usually seen as extraneous to this

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work. Whatever form the contact with the parents takes in each particular case, the analyst/therapist considers the child’s symptoms as a compromise formation between his impulses and the environment in which he lives, and, because the impulses cannot be eliminated and the environment is not the analyst’s brief, he concentrates on helping the child to find more ego-syntonic solutions to his conflicts. With his Therapeutic Consultations (1971), Winnicott demonstrated that children’s symptoms can respond to a brief intervention. Winnicott’s fundamental findings in this work were: (a) that the uncovering of the child’s unconscious anxiety led to the disappearance of the symptom and (b) that this uncovering could occur in the first interview with the child. Winnicott acknowledged the existence and importance of the parents, but he did not include them in his field of work. Winnicott described the quasi-magical ambience that was created in his encounters with children and we have accounts of observers testifying to the degree of intimacy established between the child and Winnicott, where everybody else appears to be excluded from their awareness. Experience has shown me that when parents share this interaction, they do not significantly affect the contact I make with the child and, equally important, they can learn a great deal about their child’s feelings and thoughts. Indeed, not all parents react in the same way, but this is precisely one of the points that I want to emphasize: it is important to assess the parents’ capacity to change their perception of the child. Without any doubt, Winnicott has been the most influential analyst in my work. I have mentioned other workers whose findings and theories led to changes in my professional development, but it is Winnicott’s passionate interest in the child that touches me most powerfully. I happen to have a capacity to make contact with children and, using words, toys, or drawings, I somehow manage, in most cases, to find some common language to grasp what the child wants to express. But I see my role as one of helping the child express his anxieties in a manner that both he and the parents can recognize, put words to. It is rare for me to think of transference in this work, and I see my presence as existing only until the parents can resume their effective parenting of the child. To make a play on words, not a “transitional” object, but a “transitory” one.

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To make explicit a point which is usually ignored: I believe it is an important part of the assessment process that the consultant should establish whether the child’s symptoms have a dynamic basis or whether there is an actual or possible physical substratum to them. If organic pathology is found, this does not preclude dynamic help, but it should be investigated and treated accordingly. Seeing a child who has progressed normally along most of his developmental steps, I feel justified in assuming that the presenting symptoms result from a developmental knot and that the child’s unconscious fantasy that created that knot for the child is kept in place by a parallel knot in one or both parents’ psyche, whether the child’s problem was originally “caused” by them or whether they have been unable to help the child to sort out a knot of his own creation. Fraiberg refers to this when she discusses, with Central European exuberance, cases of a baby “at the centre of treatment”, his growth held back by his parents’ conflicts. As the parents change, the baby’s “strong developmental currents which are present throughout the early months of life” are set free: “Undo the impediments to forward movement and the baby takes off! It’s a little bit like having God on your side” (Fraiberg, 1980, p. 53). I have another assumption that guides my work: I believe fantasies, however deeply buried in the unconscious, start off from an actual experience. This view leads me to probe child and parents regarding situations, events, and experiences that might be relevant to explain how the knot was formed and now holds them up. An explanation about the clinical accounts that follow: I have found that these reports come across as no more than interesting stories. They have a beginning, a middle, and build up towards a revealing dénouement, but they are seen as almost contrived: this is because it is virtually impossible to depict the fumbling along with predictable and unpredictable questions, the pursuit of that key finding that, I believe and hope, will bring light and cohesion to the mass of information collated in the interview. My thesis is that the questions derive from the theoretical preconceptions and personal experiences that guide my thinking. The material I obtain stems from the information given by the various members of the family, but the flow of the interview is very influenced by my questions, and these follow from my assumptions about individual and relational factors that result in and maintain the child’s problem.

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I prefer to start my investigation by seeing child and parents together. This has the advantage that all information is shared knowledge. Children take it for granted that the parents have already spoken to me, but they always accept my addressing them as if it was their account that mattered to me. In many cases, the child’s account contains information the parents had not been aware of. This is the point at which one or both parents will correct the child and, when this happens, I point out that it is not so important to establish who holds the truth, but that accepting and exploring the disagreement may lead us to understand the extent, and the consequences, of the probable misunderstanding. It is rare to find a parent who cannot tolerate being “shown up as wrong” and, when this happens, it is an important diagnostic and prognostic factor. Most parents accept my request and sooner or later they can understand that they are “discovering” things about their children that had not occurred to them before.

David David was a nine-year-old with a long history of educational and behavioural difficulties. For some months now, the boy had complained of an intense abdominal pain that did not respond to medication and the GP referred the boy to me just before embarking on investigations for physical causes of this persistent pain. The boy could speak quite freely about his life, but he seemed rather unable to grasp the implications of his experiences. In spite of his apparent self-assurance, his mother pointed out that he can, at times, break down and cry bitterly, saying, “I’m a dummy, I will never learn, I want to kill myself!” She could recognize that this showed him to be insecure, and, accordingly, the family had fallen into a pattern: the boy had trouble falling asleep because of his “tummy pains” and/or nightmares, and every night one of his parents ended up lying beside him, comforting him for hours. As I explored the boy’s night-fears, he told me of watching horror films and emphasized a recent one which prompted the remark, “It’s his (pointing to his father) fault!” before recounting the film in detail. Father was fascinated and shocked at how accurately the boy remembered the film and the mother’s looks made it obvious how she felt about her husband’s obsession with horror

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films. They had known that such films kept the boy awake, but apparently only the flow of our conversation made them aware of a link that had not occurred to them before and the father asked his son, “Is that when you get your tummy pain?” and the boy answered “Yes.” The ensuing silence was very moving and I could now ask the boy, “So, how do you know when you feel fear or when it is pain?” And with a sad voice he said, “I don’t know, really.” Follow-up information six weeks later was that since our meeting the boy had been sleeping normally; twice he complained of nightmares, but a few minutes “chatting” had enabled him to resume sleep. Rightly or wrongly, I did not ask whether they had stopped him from watching horror films, but my guess is that the parents had tackled that problem with each other. However, I did have to enquire about the tummy pains: the mother had forgotten them!

Comment David seemed to have understood that his pains were an expression of his fears, but for the circle to be broken the parents also needed to grasp that their protective behaviour confirmed the boy’s belief that something serious was happening. Because of his learning and behavioural difficulties, David had undergone a series of tests and investigations, and this was the main source of the parents’ anxiety and consequent incapacity to be firm with the boy. While David struggled with the fears sparked off by horror films, he saw the parents’ protective attitude as confirmation that such threats were real. However, even if the present crisis was overcome, I was left with the impression that David would require further support at some later point.

Daniella This was a thirteen-year-old referred because of ME. She had been seen by paediatricians and immunologists, but her symptoms of physical and emotional fatigue had not lifted for some eighteen months. It turned out that her father had been presenting similar symptoms for three years and he had cut down his work considerably. He looked very depressed, and recounted a life of struggle to achieve a successful position as a lawyer. The mother came from a

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humble background, an only child, and she had also struggled to carve a position for herself: in fact, after years of “just being a mother” and helping the husband in his work, she was due to start college only days after our meeting. The decision was probably linked to her husband’s unresolved illness, but this was not made explicit. The discussion came back to physical symptoms time and again. When I focused on the girl’s school life, it emerged that she had achieved a remarkable success as a dancer. I was given a story of exceptional achievements, all of which were cut short by the ME. But to my surprise, the girl told me that all along she “didn’t want to be big-headed”, so that she “made herself think that the others were better” than she was. To me, this clearly meant that her reaction to success pre-dated the ME. But how could I discover what other factors might have played a role in this? My understanding of Daniella’s account was that she did not feel entitled to enjoy her success and, because of my findings with other patients with similar anxieties, I decided to ask her to make a drawing of how she saw her family (Figure 1). I called Daniella’s attention to the sequence of ages and the apparent “gap” between her sister and herself. “Oh, my Mum wanted more children, but she lost them—she had one or two miscarriages.” I asked, “Does that mean anything to you?” and she began to cry: “Yes, I think about them . . . my parents had to accept me . . . not that

Figure 1.

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I am taking their place, really, but it’s that they might be here, in my place.” The parents were totally stunned; they had never known that the girl had such feelings. I made some comments about success and how difficult it is to accept it when one feels that this is being achieved at somebody else’s expense. At one point I asked the girl whether she was afraid of going to school or whether she was afraid of leaving home: very emphatically, she said, “Leaving home! I love school!” and this led to a discussion about the girl’s sensitivity to any problems unfolding at home and what the mother saw as the girl’s “natural” impulse to pacify or comfort anyone she felt was distressed. The father’s ME had only been mentioned at the beginning of the interview and no further reference was made to it, even if it was so clear that this played an important role in Daniella’s behaviour. Following this meeting, the girl’s symptoms quickly lifted and I had a letter from her, some weeks later, proudly describing how she had managed to regain her former level of practice and exercises in ballet.

Comment Daniella and her parents were convinced that daughter and father shared the same illness. If it was true that Daniella tended to identify with other people’s pain, it could be assumed that she had identified with her father and his ME. What the interview revealed was Daniella’s identification with her mother’s earlier pain. Considering the mother’s decision to resume her studies, it seems plausible to infer that she had gone through considerable conflicts regarding her support for her husband’s condition. This would suggest that Daniella might have juxtaposed her mother’s recent distress with her earlier feelings over the miscarriages. Seeing that Daniella was able to recover after this meeting, it is possible to imagine that her parents had now focused on each other’s distress, thereby allowing Daniella to move on.

Joanna This is a lovely, amusing case. Joanna was a precocious two-and-ahalf-year-old, whose mother had worked for many years as a

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nanny. The little girl had an astonishing memory and a rich vocabulary, which delighted both parents and her nursery teachers. Suddenly, she developed a phobia of baths. As soon as her mother tried to put her into the bathtub, the girl went into a panic, crying painful tears. Her mother tried all the tricks she knew and also all kinds of advice she collated from friends and professionals, but after several months of stalemate, she asked for a referral to a child psychiatrist. But this charming child simply refused to engage in conversation with me. She played, most competently, with various toys, but only gave me the odd monosyllable in answer to all sorts of questions I asked. At some point, she found the felt-tip pens and proceeded to make a drawing on a piece of paper (Figure 2).

Figure 2.

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I noticed that she first made horizontal lines with wings in the middle of the page in red and then an encircling line in light green, after which she proceeded to make innumerable criss-crossing lines of varying colours. So, what was this about? She wouldn’t answer me! I told her that I had noticed the first line and the “containing” one: no comment. After further attempts, I asked her if she would tell her mother if I left the room. Mother was surprised, but Joanna beamed. After a couple of minutes, the mother called me back: she had been instructed to tell me that the drawing represented a fish-tank and that the first red line showed a goldfish. And this information had reminded the mother of a goldfish Joanna had won at a fair not long ago. As it happens, the goldfish had died and the girl was upset, but neither parent thought much of this. Joanna was following her mother’s account, standing near her. I said I now understood the mystery: Joanna was afraid she might die in the bath, just as the goldfish had. The mother was incredulous, but Joanna smiled gently and now sat on her mother’s lap, resting her head on her bosom. She made no comment and when her mother asked me what she should do next, I said that probably nothing more needed to be done, since Joanna’s behaviour showed very clearly that she had understood what had gone on. They left and a few days later I heard from the Health Visitor that from the moment they got home, the little girl had had no further difficulties with her daily bath.

Comment I thought there was no question of relevant preceding pathology interfering with the parents’ capacity to help their child, but the mother’s presence at the interview helped me to elucidate the precise nature of the child’s unconscious anxiety regarding her baths. Joanna’s mother must have gone through many different emotions in trying to get the daughter into her bath, and I believe that many times her impatience or exasperation were seen by Joanna as signs that she, mother, wanted to kill her. It is conceivable that Joanna might have blamed herself for the death of the goldfish and she was, now, projecting this image on her mother. Joanna’s understanding of her anxiety and her mother’s insight into what prevented Joanna from entering the bath seem to have led to the disappearance of the phobia.

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Eve Eve was a three-and-a-half-year-old who was referred by the Health Visitor for night and day-time wetting. An older brother came to the meeting, but sat away in a corner. The mother was the youngest child of a large family and looked pale and worn and anxious. She had worked for an international organization, but now stayed at home. The father had a lighter face, with an easy smile; he had a brother and sister, both older than him. He now worked as an artist. Eve was a pretty blonde girl, who quickly made herself at home. She went straight for the toys on a table. She picked up an elephant and brought it to show me, but refused to answer my questions, only making unintelligible baby noises, I thought provoking me in some way. She then picked up a bear, held down its ears, and brought it to me, saying, “Teddy has no ears.” As I began to speak to her parents, Eve held each animal in one hand, turned them upside down and made sure we all saw that she was comparing their underneaths. She then placed each animal next to a doll, both snuggling up into her sides. She stayed watching them for a bit, quite tenderly, making her baby noises. Eve had become dry by the age of one and a half when the family went on a summer holiday at the seaside. They described several amusing incidents and, because Eve had resumed bedwetting at that time, they were keen to establish any relevant events that might explain the wetting. An au pair had left them to have a baby at that time, and they finally agreed that she had gone in August and the holiday had taken place in September. Eve now slept in nappies and was reluctant to use the toilet during the day, so that often she got herself wet. From Eve’s play with the animals and the story of the au pair, I believed I knew the nature of the problem, but I needed evidence to justify my interpretation. I asked Eve to draw, but she refused. I asked the father to help but he claimed not to know what to draw. Then he drew a music stand, but suddenly Eve interrupted and asked him to draw a fish (Figure 3). 1.

(almost centre page) Eve gave him the green felt-tip and when he finished, she got the blue pen and filled it in, carefully, meticulously.

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Figure 3.

2. 3.

4.

5.

(bottom left) Now Eve gave him the yellow pen and again she filled it in. (top right) Eve hesitated and picked up the purple pen: father drew “a different” (flat) fish, describing it. Eve said, “This is the cross Mummy fish”; we all laughed and Eve pointed to number 2, saying this was “grumpy”. (bottom right) Eve asked for a Daddy fish. He said this would also be different—when Eve saw the long sword, she was surprised. She asked where the mouth was and father explained it did not show because of the sword. Eve was clearly embarrassed. She was silent and then asked for a baby fish. Father did a minute smudge just above number 3 and Eve objected, demanding something bigger (showing the size with her hands)—she gave him the green pen, he drew it (far left, middle) and she now filled it in.

I was now aware of time running out; I knew what I wanted to say, but I was not sure whether the parents would agree with the

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“evidence” I could present for my comments. So, I decided to talk directly to Eve: I told her that her mother was right, the nanny’s pregnancy was important and it had affected Eve. I called her attention to the fact that she had filled in only the female fish, that is, she knew that something was inside the nanny’s body and her examining the underneath of the animals showed that she knew that boys and girls are different, but her “teddy has no ears” probably meant she felt she had something missing. It sounds like too much, but Eve’s reaction was to pick up a rabbit puppet and make it kiss me, then she did the same to her mother, on whose lap she now lay down. Not surprisingly, both parents were shocked and asked me what the relevance was of what I had said. I explained that she was afraid of the toilet, not knowing what would come out of her. “But she has no problem with the poos!”, said her mother. I could only answer that perhaps it was “the front” she feared, as she seemed aware of the difference between boys and girls: luckily, the mother confirmed this, saying this is a subject that Eve has commented on. The parents wanted to have a definite prescription to help Eve. I said this was probably not necessary, as I believed that it was their knowing of her worries that she needed. But they decided to make a chart, based on which Eve might get a reward—I suggested they should discuss, bargain with Eve about what this reward might be. Eve now told me that she wanted to take the drawing away. As I wanted to keep it, I had to face hard bargaining: she finally accepted borrowing the rabbit puppet as an exchange for the drawing! When I saw the family again two weeks later, I was told that Eve had not wet herself since our meeting.

Comment The only relevant factor I could find in the parents’ personal histories was the fact that, prior to their own children, they had no experience of looking after children. It was quite striking that all the details of Eve’s play, which we would see as a transparent statement of her unconscious fantasies, meant nothing to them. They were caring and devoted parents, but I thought they would not know how to help a child overcome a “childish” conflict, though it seems that after the interview they were prepared—and able—to

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help Eve overcome her wetting. I should mention that only very rarely would I comment on the unconscious meaning of a parent’s contribution, hence my silence on father’s choice of a “Daddy fish”.

Penny Penny was six when referred for constipation and occasional overflow. As soon as they came into the room, Penny nestled into her mother’s lap, thumb in mouth and fingers covering her eyes. I asked her some questions, but she remained silent. Her mother took over: she told me about Penny’s successful school life and happy family life. When the mother was telling me about Penny’s older siblings, she mentioned that the middle girl had been difficult as a child and Penny interjected that her sister had screamed a lot. I asked if she remembered it and she pointed out that she was not there at the time. When school matters were exhausted, I asked about what problem brought them to see me. Mother said, “Penny refuses to go to the loo”, and described the history of constipation and increased doses of laxatives. It emerged that the oldest girl had had the same problem and the GP had said she would grow out of it, which she did. But now, with Penny, his advice had not worked, and mother demanded referral to the paediatrician; after a further six months with no results, she accepted a new approach. Several times mother indicated that she “had been too carefree about toilet training” and father’s comments suggested that he also had trouble with discipline issues. I invited Penny to make drawings, but she refused. Her parents told me that Penny enjoyed playing with Plasticine and I offered her a game of felt shapes to be placed on a board, which she accepted, sitting down on the floor to play with it. I asked the parents for information about themselves. Father was the middle one of three children; he told me of a chequered career in which his artistic gifts played a dominant role. Mother was the youngest “of a very large family”; she failed her eleven-plus examination (in those days, this meant “low self-esteem”) but went on to build a career working with computers. What came across was a picture of an ordinary, middle-class family, bringing up their three normal children.

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We moved to a discussion of Penny’s problem. While describing her constipation, the mother mentioned that she had also had difficulties with bowel motions and it was then the father’s turn to indicate that he had also had similar problems. The mother recounted sitting in class, desperately wanting to go to the toilet and feeling unable to ask the teacher, and then finding she had messed herself. Her mother used to give her Syrup of Figs every morning, and the mother stressed her sense of revolt at being forced into the problem she dreaded. She was afraid of returning home and would go to one of her older sisters for help. I do not know when this symptom was overcome, but she said she was in her early twenties when she could forget about bowels. The father began a humorous account of playing football and being reluctant to stop, but his tone changed when he came to describe his father hitting him and putting a suppository into his anus. He remembered his sense of revolt and helplessness, both towards his father and the effect of the suppository. I think it was just before the mother’s account that the father composed a bee (Figure 4, top left). Penny said this was not quite right and made her own bee (left, just below father’s bee). While her parents were describing their own experiences, Penny made two birds, one she called an ostrich (middle, right) and the second was “a flying bird” (top, right). She then copied a pram from the toys’ box (middle, bottom) and then she made a flower and also a baby. I again asked Penny to draw, but she refused, and somehow we ended up with the father drawing himself “having an accident” (Figure 5). We all laughed at the lines showing the smell coming out and “people running away”. I asked if the mother would draw herself: she refused, and it was the father who drew her (Figure 6). She laughed and decided to do her own picture (Figure 7). When the parents finished their drawings, I sat on the floor beside Penny and asked her about the pictures. I asked about the little figure, “You know what that is.” “A little child?” she confirmed and went on to take the mother figure from the pram and put the child in it (Figure 8). The parents found this amusing. She then put the bee (her own) on the flower (Figure 9).

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Figure 4.

Figure 5.

Figure 6.

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Figure 7.

Figure 8.

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Figure 9.

Here, I thought I had recognized the fertilization theme, but Penny did not seem to know about this. Her mother told me that Penny had a book on bees and only the previous week she had seen a queen bee mating outside their window and had called her sisters to see it. I asked Penny if she knew where babies grew, “Inside mummies’ tummies”, “And how do they get there?” Penny was silent and mother explained Penny did not know about conception or insemination. I said that the idea of babies was on Penny’s mind, considering her putting the baby inside the pram and the bee on the flower. “How do the babies come out of their mummies?” “From the bottom, of course!” answered Penny. I voiced my wish that Penny would make a drawing of a pregnant woman, but in the event it was father who obliged. He started a drawing (not reproduced), but “it went wrong—she is too pregnant, might have quadruplets!” said the father. He turned the page and drew another woman (Figure 10), “again too big” and Penny protested as well.

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Figure 10.

Now (Figure 11), he drew each bit asking for Penny’s comment; she voiced approval until he drew the back: “Her bottom is too big,” she said, and he tried to correct it, though Penny still complained. At this point, I made a comment such as “Do you see what she is getting at?”, but even before I voiced it, both parents noticed something had happened. Penny had an embarrassed expression,

Figure 11.

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she moved towards her mother, circled her chair, climbed on her lap and again put her thumb into her mouth and closed her eyes. There was a long silence and it was mother who said, “It is not only babies that come out of bottoms.” Penny curled up even more. Her father could understand what had happened, but he voiced his scepticism about what was being inferred from the drawings. I explained that an older child might put into words or express in drawings their muddle about the insides of their bodies, but at Penny’s age this was more difficult. But as we discussed this point, Penny came down from her mother’s lap and built “a pregnant lady” (Figure 12), which she proudly showed her father. He was amused until I called his attention to the perfectly flat bottom: “This was just a meaningless coincidence!”, and remained unconvinced, even when I showed him other round shapes Penny might have used. The parents asked, “What next?” and I voiced my belief that the problem had been resolved. They demanded some concrete prescription and I suggested making a chart that would lead to a reward that Penny would find meaningful. When I saw the family again, Penny was very happy that she had not had further bowel troubles and her parents had given her

Figure 12.

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a nice present. But this was the only family I ever met where, besides the words of thanks—and disbelief—I found that the mother said, very sadly, “I only wish someone had helped me like this when I was Penny’s age . . .” When I checked for news with the referring paediatrician and the family doctor some time later, I was told that Penny had not presented any more problems.

Comment Perhaps nothing needs to be added. Considering each parent’s earlier experiences, it was not surprising that they could not grasp that “discipline” is not synonymous with intrusion and domination, or that “firmness” does not necessarily mean insensitivity and tyranny. Particularly with regard to sphincter functioning, it is understandable that they could not see that Penny was trying to find out what was happening with her body. This case shows more clearly than any other how the various unconscious fantasies of parents and child can come together to compose a self-perpetuating pattern.

Discussion I think of the work I have reported here as a continuation of Winnicott’s therapeutic consultations: not simply because these are brief interventions or diagnostic interviews which turn out to have a therapeutic result, but because of the primary focus residing in the understanding of a child’s anxieties. A child who struggles with a “problem” is bound, sooner or later, to feel disappointed that his parents cannot help him to overcome it. Indeed, in many cases, the parents’ response is such that the child can interpret their attitudes as a sign of disapproval or condemnation. This means that on top of feeling defeated by the symptom, the child now has to contend with feeling unloved, if not unlovable. The damage to the child’s self-image and self-esteem can take serious proportions and lead to regrettable, long-term consequences. Winnicott’s therapeutic consultations freed the child from his symptoms and, one hopes, this led to a healthier interaction between

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child and parents. What I have added is the parents’ piece of this complex picture. Most parents want their children to grow as happy and independent beings; when the child develops a symptom that they cannot help the child to overcome, one or both parents will find themselves struggling with their own conflicts, trying hard to overcome their frustration and to preserve their self-esteem. The joint approach here described can offer child and parents a better opportunity to discover the obstacle that holds them up. Of course, we can find parents who will tell us, “My child has a problem: deal with it!”, but this is a matter for assessment, not to be taken for granted ab initio. The beauty of a full assessment lies precisely in determining the needs and capacities of each member of the family, so as to ensure that the child is best served—whatever treatment(s) we come to recommend. Fundamental to each diagnostic and therapeutic approach is the question of how the child’s symptom is conceptualized. Putting it simply, for the sake of brevity, Winnicott based his therapeutic consultations on the assumption that the symptom indicated a hitch in the child’s development as an individual: his intervention was founded on his psychoanalytic views on symptom formation and his personal techniques to make contact with the child. What I have described in my cases follows from the assumption that the child’s moves along his developmental growth represent steps in a process where he gradually disengages himself from his parents. Correspondingly, the parents are seen as the primary agents responsible for enabling that child to become independent. In this view, for example, a bed-wetting or a phobic child will suggest parents who are not enabling the child to accomplish that step of self-control and self-confidence that will, perforce, make him less dependent on his parents. However, I am not saying that every symptom of a child stems from some parental conflict or shortcoming. I believe very strongly that we have children who do not possess the required equipment to develop as well as we would like them to do. We are not all born with the same genetic endowment, and this is why I would stress the need to make a careful assessment of the child’s capacities, much as we have to assess the parents. My therapeutic “successes” occur when child and parents are caught up in a mutually reinforcing vicious circle that sustains the child’s symptoms against a background of

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otherwise normal development. If the child has a problem that requires treatment in its own right, it is most important to make this available. In such situations, the parents may well have become caught in a series of adaptations to the child’s difficulties, and it is then obvious that we should try to help them with this. I cannot give you information about follow-up that might convince you that my approach produces long-term benefits. Cramer, Stern and their teams are trying hard to find such evidence for the work they undertake. But I would suggest that if we accept that I cannot convince our analytic superegos or those involved with the strict laws of scientific evidence that these children have gone on to develop normally, then we may derive considerable comfort from the knowledge that these children and parents seem to have moved on to a far more satisfactory and symptom-free life.

References Ackerman, N. (1973). Child participation in family therapy. Family Process, 12: 403–410. Ainsworth, M., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, NJ: Lawrence Erlbaum. Bowlby, J. (1958). The nature of the child’s tie to his mother. International Journal of Psychoanalysis, 39: 350–373. Cramer, B., Robert-Tissot, C., Stern, D. N., Serpa-Rusconi, S., De Murait, M., Besson, G., Palacio-Espasa, F., Bachmann, J.-P., Knauer, D., Berney, C., & D’Arcis, U. (1990). Outcome evaluation in brief mother–infant psychotherapy: a preliminary report. Infant Mental Health Journal, 11: 278–300. Dare, C. (1988). Psychoanalytic family therapy. In: E. Street & W. Dryden (Eds.), Family Therapy in Britain (pp. 23–50). Milton Keynes: Open University Press. Daws, D. (1989). Through the Night: Helping Parents and Sleepless Infants. London: Free Association Books. Fraiberg, S. (1980). Clinical Studies in Infant Mental Health. London: Tavistock. Haley, J. (1971). Changing Families. New York: Grune & Stratton. Hopkins, J. (1992). Infant–parent psychotherapy. Journal of Child Psychotherapy, 18: 5–18.

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Main, M., & Cassidy, J. (1988). Categories of response to reunion with the parent at age six. Developmental Psychology, 24: 415–426. Ornstein, A. (1984). The function of play in the process of child psychotherapy: a contemporary perspective. Annals of Psychoanalysis, 12/13: 349–366. Sameroff, J., & Emde, R. N. (1989). Relationship Disturbances in Early Childhood. New York: Basic Books. Selvini Palazzoli, N., Boscolo, L., Cecchin, G. F., & Prata, G. (1974). The treatment of children through brief therapy of their parents. Family Process, 13: 429–444. Stern, D. N. (1995). The Motherhood Constellation. New York: Basic Books. Winnicott, D. W. (1964). The newborn and his mother. In: C. Winnicott et al. (Eds.), Babies and Their Mothers (pp. 35–49). Reading. MA: Addison-Wesley, 1986. Winnicott, D. W. (1971). Therapeutic Consultations in Child Psychiatry. London: Hogarth Press.

INTRODUCTORY NOTE TO CHAPTERS THREE AND FOUR

Who should ask?

R

ecent years have seen the publication of a number of papers approving the decision of a therapist to touch his patient and in some of them there is a virtual recommendation of the usefulness of this practice. Of course, since the early days of psychoanalysis practitioners have been strongly urged to keep a physical distance from their patients: contact is to be established exclusively by the use of words. An apparently unrelated issue is the number of weekly sessions a patient should have. I believe there is a link between these two topics and this is why I have brought them together here. It is enormously important that a therapist should have a clear idea of how he defines his role in the therapeutic contract. Any long-term therapy will present multiple occasions when a therapist struggles to make sense of a clinical situation. The fact that such experiences are not rare illustrates the argument that the therapist is not omniscient and he should recognize his limitations and wait for further developments, rather than resort to stratagems that might produce a false sense of understanding the patient, of feeling in control of the therapeutic encounter.

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It is particularly at these difficult phases of the therapy that the therapist must bear in mind how he defines his role. The patient comes to his therapy because he has a problem and seeks help: in any form of psychodynamic psychotherapy we will inform the patient that he has the right to voice his thoughts and express his feelings without first scrutinizing their validity or their propriety. This approach is based on the assumption that such freedom will allow the therapist to gain access to the patient’s conscious and unconscious needs and wishes. But do we then move on to give similar rights to the therapist? Certainly not. By offering professional services to the patient, the therapist takes on the responsibility to gauge the patient’s needs and abilities and, most importantly, he then proceeds to decide on the best way of helping the patient. The model here is that of doctor and patient. The latter is free to express his thoughts, feelings, and impulses, but the doctor/therapist has to bear in mind his responsibility to preserve ethical standards and aim at a carefully considered analysis of clinical parameters that enable him to put into practice what he considers the best way of helping the patient with his problems. But at some point of the therapy the patient may voice his wish to touch the therapist or, on other occasions, he may raise an argument that they should change the number of weekly sessions. How should the therapist respond? It is important to remember that these are a minimal sample of wishes that a patient may express. He may wish to have sessions lasting more than the usual fifty minutes, or he may request having to pay lower fees, much as he may decide to undress during a session or to demand to use the therapist’s chair during his session. The therapist’s job is to help the patient to understand why he comes to formulate such wishes. If it happens that the therapist believes that any of these changes to the usual parameter of sessions is useful, beneficial for the ongoing work, then it is the therapist who should suggest them. Accepting changes simply because the patient voiced his wishes goes against the whole philosophy of the work. If an appropriate discussion of such wishes takes place and the therapist can eventually agree to the patient’s views, this is a different issue. In principle, however, it is the therapist who is responsible for prescribing and implementing the ideal parameters for the therapy of a particular patient. And the therapist will only succeed in achieving this goal when he is very clear about the definition of his role in the therapy.

CHAPTER THREE

Increase or not increase?*

A

patient being seen in twice weekly psychotherapy asks to increase the number of weekly sessions: how should one respond? Thinking about this question, it struck me that before it can be answered, it is necessary to discuss a number of other issues, particularly how the initial decision is reached regarding the number of weekly sessions recommended to a patient. When I started my psychoanalytic training in 1960, psychotherapy was just beginning to be recognized as a valid therapeutic method. Analytic training involved five weekly sessions of fifty minutes each and trainees practised this pattern after qualification. Psychotherapy, by contrast, involved less weekly sessions and, predictably, discussions followed attempting to define what differentiated psychotherapy from psychoanalysis. The importance given to the transference relationship seemed to be the most often quoted difference. The argument went that psychoanalysis led to a transference regression that helped the patient to obtain insight into the early origin of his problems, now brought to life again in the

*First published in 2008 in British Journal of Psychotherapy: 197–208.

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analytic relationship. Psychotherapy, instead, did not aim at fostering this regression, and, to some extent, the dialogue between patient and therapist was supposed to be more reality-orientated, perhaps focusing more on the patient’s present life and, implicitly, offering him the support he needed to resolve his problems. This differentiation was based on the definition of transference as a phenomenon that gradually appeared in the course of the patient’s relationship with the analyst and only eventually, with intensive, careful ongoing work, developed into the transference regression that allowed the understanding of the patient’s early years of life. A totally different perspective appeared when it was argued that transference was present ab initio, in therapy much as, the argument went, in the infant at birth, who already had images of, and relationships to, his objects. In a fascinating way, under the influence of this new definition of transference, “transference relationship” acquired a different meaning and gradually came to be seen as virtually synonymous with the relationship between patient and therapist. In other words, there was no longer the differentiation between the patient perceiving the therapist as a real individual and experiencing him as the product of the projections of his early objects. Over the years, new psychotherapy training institutions were founded and, predictably, theoretical frameworks and corresponding technical practices multiplied. If some were overtly anti-psychoanalytic, others followed the psychoanalytic model very closely. These developments involved political implications and they occurred at a time when British society demanded that social and health professionals had their work regulated and monitored by official institutions. The creation of two separate organizations (United Kingdom Council for Psychotherapy [UKCP] and British Psychoanalytical Council [BPC]) to cover the psychodynamic world illustrated the many differences that now existed between practitioners. Those psychotherapists who followed more closely the psychoanalytic model eventually adopted the title of psychoanalytic psychotherapist. However, my personal impression is that, looking at the actual clinical approach of psychoanalysts and psychoanalytic psychotherapists to their patients, it might be difficult to guess the original training of the particular professional. In fact, some psychotherapists now argue that the title “psychoanalyst” should

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not be restricted to members of the International Psychoanalytic Association. This suggests that an underlying hierarchical distinction between these many professionals has persisted. But leaving aside the theoretical and technical framework followed by the professionals, the question is still there: why FIVE sessions per week? Why FIFTY minutes each session? Over the years, I have heard many answers to this question, but, within the British psychoanalytic community, these figures have a dogmatic quality and the official training in the British Psychoanalytical Society still involves five weekly sessions of fifty minutes each. But every now and again one hears of departures from this rule. Discussions about the dissemination of psychoanalytic training in other countries will suddenly mention that a smaller number of weekly sessions is accepted as valid. Then someone will let it escape that his sessions only last forty or forty-five minutes. And reactions of horror were provoked by the news of Lacan’s way of conducting the analyses of his patients—apparently stopping the session when he thought appropriate. Whatever views are held about Lacan’s approach, it must not be forgotten that his trainees went on to reproduce his techniques, leading one to conclude that they felt their analyses had been beneficial. Or is there some other explanation? It is not only Lacan’s analysands who “copied” their analyst. Most of my colleagues went on to treat their patients in precisely the same way their analyst had conducted their analyses. Curiously enough, they also tended to deal with patients’ fees in precisely the same way they had been treated. There are exceptions, and, anyway, most analysts eventually develop their own style, but I believe the point is still valid: the analytic relationship produces in the trainee a degree of identification with his analyst that can last for quite long periods. In practice, we have a large number of therapists offering their patients exactly the same scheme (number of sessions, use of the couch, arrangements regarding holidays, mode of greeting and parting at each session, charging patterns, etc.) they had encountered during their training analyses. And whenever I questioned their practice, the answer was usually “This is how I like to work”. No discussion possible . . . It is understandable that a professional should work within the same parameters of the training he received: presumably, this gives him a degree of familiarity, comfort, and safety that can only feel

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positive in its experiential perspective. Some practitioners may have experimented with other techniques and found that a particular scheme of work allows them to function at their best: in this case, the pattern of work would be the result of a process of conscious, deliberate self-scrutiny and experimentation that led to a recognition of personal preferences. However obvious it is that each professional is entitled to follow the techniques he feels comfortable with, this does not entitle him to tell every patient that this is the treatment pattern he needs. I can respect that ideal therapist who would tell his patient that he “might well be able to benefit from 1–2 therapy sessions per week, but if you wish to have therapy with me, you would have to attend for 4–5 weekly sessions, because this is how I work”, but I have only heard of one psychoanalyst who works in this manner. Rightly or wrongly, many practitioners do not appear to differentiate between their personal style of working and the patient’s needs. Turning to the patient, how can he know the number of sessions he needs per week? Nowadays we have many people who come for a consultation and tell us exactly the number of weekly sessions they want to have. Usually this figure is justified by what they have learnt or heard about therapy, though quite often the painful reality of available financial means comes to be an added constraint that influences their argument. Nevertheless, whatever views the patient has about the frequency of sessions he wants, it still is the therapist’s duty to evaluate the number of sessions the patient needs (Klauber, 1971). Perhaps this approach I am arguing for has to do with my medical training. Doctors are taught that no therapy should be considered until a clear diagnostic evaluation has been carried through. The idea of subjecting patients to a Procrustean couch is unacceptable. Indeed, there are doctors who prescribe drugs or other treatments they favour for reasons that others might consider unjustifiable. But, in principle, the consultant has to approach his patient with an open mind and investigate what exactly that patient needs: only then will he be equipped to discuss with the patient what helping programme they will actually embark on. I write this at a time when (regrettably) most NHS and academic services offer a strictly limited number of sessions and there is no possibility of providing the appropriate helping scheme that would match the

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original assessment of the patient’s needs. In practice, the consultants in these services can only evaluate whether a particular patient can benefit from the therapy scheme that the institution can offer. But when seeing a patient privately, there should not be any constraints on establishing the best therapeutic scheme to be embarked on. As a matter of fact, it is important to remember that sometimes we will see patients who require no more than words of reassurance, rather than further interviews. I would suggest a rough classification of patients that might help us to discuss our problem. Essentially, we have patients who struggle with a well-defined conflict and we have others who have generalized existential conflicts. In each of these groups we can find patients who can work with insight, and others who require a different approach, where insight may occasionally occur, but the main therapeutic input seems to be the continued availability of the person of the therapist—this is what has come to be called “holding” or “containing”. If we then focus on each of these groups: 1.

2.

When a patient comes to the consultation complaining of an apparently simple, well-defined, self-contained conflict, we need to establish whether he can work with insight. If this is found to be the case, there is a good possibility that one or two weekly meetings for a relatively short period will help the patient to take over his own care. Further discussion with some of these patients presenting a well-defined, simple complaint can come to reveal that they experience other, more subtle, difficulties, composing what I call existential problems, that is, doubts and anxieties affecting their vision of themselves and others in their world. Other patients who approach us already describing these wider, deeper conflicts would, of course, be included in this group. If we establish that these patients can work with insight, we can assume that they are likely to benefit from our therapeutic input and that this will lead to a mutually agreed end. Of course, actual change depends on many factors that are not influenced by the consulting room experiences, but, on the whole, patients who can achieve insight tend to see therapy as a temporary, self-limited source of help and not an integral part of their daily life. However, the next challenge

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for the analyst/therapist is the decision of how many weekly sessions to recommend. Most professionals have a clear idea of their preferred pattern of work, but my clinical experience has been that it is very difficult to evaluate at the initial diagnostic consultation how the patient will respond to the actual, regular, therapeutic interviews. For the sake of brevity, however, I prefer to consider the patients in this present group as likely to need at least two weekly sessions—whether the final decision is to embark on two or more sessions will depend on a multitude of factors that will vary from patient to patient and, needless to say, on the number of sessions the professional happens to have free at that point in time. The actual number of sessions that is the ideal, most beneficial for each particular patient, will only be discovered after some time of regular work. If we establish that the patient cannot work with insight, we face a difficult challenge. Do we recommend some alternative therapy, for example, cognitive–behaviour therapy, Alcoholics Anonymous, etc.? The decision will depend on how the professional defines his work. Many will claim that without the capacity for insight, the prognosis is impossible to establish and analysis or psychotherapy is not recommended, since they believe that change is contingent on the patient understanding the nature and, one hopes, the origin of his problems. Others, however, will still recommend analysis or psychotherapy, arguing that the transference relationship will help the patient to develop more effective ways of seeing himself and relating to the world. The latter group of professionals will argue that long-term, intensive therapy will offer the patient “holding” or “containing”, and that this constitutes valid, effective therapy. For this group of patients, I do not believe it is possible to determine the ideal number of weekly sessions. Many patients in this group are keen to embark into analysis or therapy, and it is interesting to note that most of these will inform us at the initial meeting of having been in therapy previously with one or more therapists. How should one interpret this information? Of course, it is unwise to make generalizations, but I have found that many of the patients in this group will wish to stay in treatment ad infinitum.

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I find it puzzling that so many psychodynamic practitioners appear to believe that their therapy can help all patients. The argument that “holding, containing” the patient within a good transference relationship is undoubtedly beneficial to him has become a justification to take into therapy any patient who is willing to undertake it. It might be useful to consider how these concepts came into being. Winnicott saw psychological pathology as the result of maternal deprivation and argued that the analyst’s “holding” constituted a new, therapeutic, maternal provision that helped the patient to develop his potentials. Bion attributed pathology to inborn, instinctual disturbances that affected the infants’ experience of their mothers’ ministrations: when the analyst’s responses did not contain an identification with the patient’s negative projections, the patient could experience the analytic situation as a “containment” of his conflicts and this would represent a positive therapeutic input. These are very different theories, but both imply that insight is not the only benefit that analysis/therapy can offer. With the passage of time, these theoretical postulates have led to the argument that when the analyst/therapist provides good mothering (under the name of holding or containing), the patient can be helped to improve self and object-relationships. Each conceptual view of pathology and therapy implies a different definition of the therapist’s role. The professionals who do not believe that pathology is the exclusive result of early mothering will investigate the possibility of other causative factors that might be responsible for their patients’ psychopathology. It is no coincidence that these are also the therapists who draw a sharp distinction between a therapeutic alliance and a transference neurosis. I see this group of analysts/therapists as much closer to our forefathers, who argued that transference was a kind of relationship that appeared after a period of analysis. When the therapist worked on the initial indications of transference, this could lead to a “proper” transference neurosis. But they always emphasized the significance of this being accompanied (and differentiated) from the therapeutic alliance, where the analyst was seen as a real person. I suspect that the patients Winnicott described as regressing to a state of dependence were those who could not sustain the picture of the analyst as a real person. However interesting and important it is to explore Winnicott’s contribution to this development, this is best left for

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another discussion, although we have to note how much his findings have influenced following generations of professionals. If the patient is found ab initio to treat the analyst as no more than a projection of his internal objects (what is called “an early transference”), this constitutes an important diagnostic datum, suggesting a probable psychotic level of mental functioning. There is general agreement that psychotic patients have a poor prognosis when considered for psychodynamic therapy. The same applies to others presenting serious psychological disturbances (e.g., Asperger’s syndrome, addictions, manic–depressive illness, personality disorders, etc.), and yet we can find that some of these patients are keen to embark on psychodynamic therapy and may often want to continue having it for extremely long periods of time. I believe that even when both patient and therapist are happy with the progress of the work, i.e., there is improvement in some areas of the patient’s life, the prognosis for change of the basic pathology is very doubtful. It is wise to consider therapy with these patients as being of an experimental nature. This is a brief and highly personal classification of the patients who consult us about psychodynamic therapy. I only hope it is helpful. In our work we often find ourselves caught up in passionate arguments over “the best” way of helping a patient. These disagreements are always expressed in sophisticated language that supposedly characterizes a scientific pronouncement, but the element of personal belief, of idiosyncratic choice, that is, not just knowledge, but also faith, is very prevalent. I can only claim that my description of patients comes from my personal work experience. Another example of this area where elements of the framework of therapy are implemented for reasons that are definitely not scientific is the question of how long each session should last. Fifty minutes? Forty? My analyst gave me fifty-minute sessions and I put this into practice without much thinking. All these many years later, when I am asked about it, I can only answer that my biological clock functions on the basis of spending fifty minutes with each patient. Regarding diagnostic assessments, I discovered that I needed between one and a half to two hours for each consultation. Curiously enough, as I got older, I found that the initial five minutes that I left between one patient and the next had become ten minutes. But I would not be able to apportion degrees of

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importance for this change between my needing less money, requiring more resting time, or whatever other factors. I was certainly very surprised to learn of analysts who left no interval whatsoever between patients: both the analysts and their patients still quoted having sessions of fifty minutes, but I could not see how this was possible. Coming back to the number of sessions, the most important factor to me is the distinction between the therapist’s preferred pattern of work and the clear definition of what the patient needs. The best example of the unusual factors that influence the decision of what number of sessions to have each week came from a friend of mine who told me that her analyst informed her that he only worked seeing his patients five times per week. She pointed out that her medical job included a twenty-four shift in her hospital, which only allowed her to attend for four sessions. After considerable discussion, she agreed to his demand that she had to pay for the fifth session, but after a few weeks she decided to quit. She did not mind paying for the session, but she found it intolerable that the analyst should repeatedly refer to presumed unconscious factors that led her to miss that fifth session. I gave above a thumbnail sketch of how many weekly sessions I would recommend to various types of patients. Perhaps I should repeat my arguments in different words. Patients with limited problems that do not affect significantly their general life of work and leisure and are able to make use of insight can usually benefit from one weekly session for a reasonably limited time. Patients who, whatever their initial complaint, have problems that affect their self-image, self-esteem, and their relationship to significant people in their world, but are able to take a second look at their experiences (i.e., gain insight) will require, and should be able to benefit from, a higher number of weekly sessions. It probably makes no significant difference whether patient and therapist embark on two, three, four, or five sessions each week, since, at the start of therapy, it is impossible to gauge the patient’s ability to work in therapy, or his precise needs. In practice, factors related to the patient’s private life—place of residence, work commitments, financial means, domestic circumstances (e.g., a young child at home)—and also the number of hours the therapist has free in his weekly schedule will determine the number of sessions.

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I have come to feel comfortable with seeing most of these patients for a maximum of three weekly sessions, but I am aware of the fact that many colleagues still see some patients for four or five sessions each week. However, my discussions with them gave me the impression that very few of their patients had developed the “regression to dependence” that was, historically, the predominant justification for these intensive therapy schemes. Conversely, I have seen and heard of patients seen less frequently who showed the characteristic features of a regression to dependence. It seems, therefore, that such regression is linked more to the individual patient’s psychopathology than to the number of weekly sessions he attends. The conclusion regarding the number of sessions offered presumably is that it follows personal preferences, and that the diagnosis of a regression to dependence depends on the therapist’s chosen conceptual framework. Those analysts who give each patient only the number of weekly sessions that they believe he needs probably face their most difficult challenge when they meet one of that large number of patients who, whatever their presenting complaints, seem quite incapable of using interpretations as a key to understanding and change. They deserve help, and there is nothing wrong with accepting them for analysis or psychotherapy, but I strongly hope that the professional is properly aware of these patients’ abilities and needs. I have never worked out the reason why some of these patients seek and accept therapy, when so many others with precisely the same psychopathological features will never see a psychodynamic practitioner. Leaving aside financial issues, it is just possible that the explanation lies in these patients’ desire to find a reliable person they can talk to, as distinct from those other patients who are not able to confide in anyone and who may seek doctors who will prescribe drugs, or, sadly, give up hope and remain locked in their isolation. Indeed, these differences imply the presence or absence of hope, and this is a significant diagnostic element, but it does not seem to affect the prognosis of treatment. I have come to think of patients in this group as people who see the analyst/therapist as an indispensable part of their life. It is, surely, significant to find that if one analyst decides to bring their analysis to an end, these patients will move on to another analyst they can trust. Earlier in my career, I thought this moving to another analyst was proof positive that the

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first analyst had failed to help the patient, but, gradually, I came to understand that these were patients who could not find valid substitutes in their life to fulfil the role of an analyst. Of course, we can construct hypotheses along the lines of early maternal deprivation or an exaggerated force of some instinct to explain this type of behaviour, but, from a pragmatic point of view, it is very important that the analyst/therapist has a clear understanding of the needs and abilities of patients in this group, as this is bound to influence how the therapist defines his role. To make explicit the point of this paragraph: these are patients who decide the number of weekly sessions they want and if one analyst is not prepared to concur with the demand, they will seek another professional who is willing to oblige. In the end, it may be very difficult to establish the reason why an analyst/therapist chose to see his patient for three, four, or five sessions each week. Assuming he agreed with my arguments, the final decision would still belong to the category of “this is what I believe is best for the patient”, unless he said that the number of sessions was dictated by his personal style of work. But what about the patient? Most patients I have met referred to the number of weekly sessions they had as a figure put forward by their analyst/therapist, and tended not to correlate this frequency to whatever results they believed they had obtained. But I have also seen a specific group of people who had four or five weekly sessions that left me with the impression that they saw the therapist as an absolutely vital presence in their lives. These are the patients who suffer during weekend or holiday breaks and, in fact, any kind of absence (i.e., real or experienced) of the therapist. Put under the microscope, what we find is that they do not value the therapist for the verbal pronouncements he makes, but rather because he fills a gap, a void, that the patients can only cope with through the physical availability of the therapist. Some of these patients lead a life of actual or experiential isolation, though others appear to lead active social and/or professional lives. But it is the therapist who occupies a unique position in their lives. I would like to mention two contributions to this question. Gedo has published many papers on the relevance that the number of weekly sessions has on the characteristics of the analytic relationship. He is clearly in favour of the patient being seen four or five

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times per week, arguing that this ensures the development of a rich, deep and meaningful transference relationship (see Gedo & Cohler, 1992). In May 1996, the American Psychoanalytic Association organized a debate on “the relevance of frequency of sessions to the creation of an analytic experience” (Richards, 1997), and this report gives a vivid, convincing picture of how different analysts can give dramatically different interpretations to the same clinical material. Certainly, the number of weekly sessions did not appear to most discussants to be the crucial factor in determining the characteristics or the efficacy of the therapy. It would be quite fascinating to discover whether this debate did lead any of the participants to change their approach to the issue of frequency of sessions! What is so difficult to accept in this question is the simple fact that only that professional who saw the patient actually knows the patient and went through the experience of meeting and assessing him: by the time he reports his findings, this account is already coloured by the theoretical framework that guides his work and it is then unavoidable that listeners will respond from the perspective of their own frame of reference. This is the reason why I am quoting Gedo’s views and those quoted by Richards: our work does not seem to be suitable for duplication tests that give the stamp of “scientific evidence” to other matters. As the number of trainees increases, we see a multiplication of teaching techniques and, regrettably, we find that many schools adopt precepts that depart from the early parameters that valued flexibility and attempted to use analysis or therapy as tools to increase our understanding of our fellow human beings. We now find students being taught rules that, indeed, make their lives easier, but produce a greatly impoverished learning opportunity for both therapist and patient. One example: I found a group of trainees that had been instructed to see their patients for three consecutive days. I was puzzled, and asked the reason given for this rule: “We were told that this would increase their separation anxiety” was the answer. Clearly, here was a group of teachers/practitioners who did not believe in teaching their students to recognize this anxiety if and when it arose, but instead instructed them to schedule their sessions in a particular manner and, furthermore, dictated the type of interpretation they should give, whatever material their patients gave them. This episode reinforced my suspicion that

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many of our trainees are not given the opportunity of exploring their patients’ individual psychopathology, but simply taught rules to be applied indiscriminately. These new trainings have also introduced new parameters regarding the frequency of sessions. I do not know when and where it was first established that a training analysis involved five sessions per week, but this has certainly remained the practice followed by the British Psychoanalytic Society, though I understand that some Societies affiliated to the International Psychoanalytic Association now adopt four weekly sessions as the rule. Is this a matter for discussion? If so, it must surely be very carefully separated from the issues I have been discussing in the present paper. Training requirements consult one set of parameters, where, on the whole, the trainee’s psychopathology is not the main issue, while clinical practice should involve a very detailed and careful assessment of the patient’s needs. We can now, at last, come to the question: how to react when a patient wants to increase the number of his weekly sessions? Occasionally, this will happen in therapies where the therapist had originally recommended a higher number of weekly sessions that the patient was unable or unwilling to accept, and these are easy cases to resolve; in fact, the therapist may take the patient’s request as a true compliment to the quality of his work! We cannot, however, ignore the fact that when the therapist has no free hours, that patient’s request (whatever the context) has a simple, prompt answer: “Sorry, not possible”. I have never heard of a therapist who would, in these circumstances, refer his patient to another colleague with a higher number of free hours. We have analysts/therapists who will simply give the patient the extra hour without much discussion, whatever the reason claimed. It is also true that when the patient is caught in some unexpected crisis, an extra session is obviously in order, since both patient and therapist see this as part of the emergency, not the start of a new pattern of attendance. When the request is for a change of pattern, this should be submitted to very careful and extended scrutiny before being agreed to. Whatever else this request means, it must contain a statement that “You think x sessions is enough for me, but in fact I believe that I really need x plus one (or two or three)”. The therapist may, in fact, have made a mistake in his original recommendation, but, if this is

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the case, surely he should be the one to suggest the increase in the number of sessions? If the therapist is, however, certain of the adequacy of his prescription, he is on firm ground to explore what underlies the patient’s request. In many cases, the patient may be testing out precisely the therapist’s reliability in assessing his needs, and, in this case, if the therapist agrees to the extra session/s, this is bound to be taken by the patient as a statement that (a) the therapist was uncertain of the correctness of his assessment and (b) he does not really believe the patient has sufficient resources to cope with his problems without further therapeutic input. Both hypotheses can have serious consequences, as they undermine the patient’s confidence in the therapist and in himself. Another instance that calls for careful discussion arises from the patient’s increased dependence on the therapist. This situation will require the therapist to consider very seriously his views on the therapy he wishes to practise. The patient’s request probably involves not only an increased number of weekly sessions, but also a wish for an open-ended therapy. In line with the classification I proposed earlier, this may indicate a patient who wants therapy “forever” and the therapist should consider carefully whether this is a kind of therapy he is happy to engage in. If the patient can pay a good fee and the therapist has free hours in his schedule, he may be very tempted to agree to the patient’s request, but we can also have a therapist who is happy to see this patient for the x weekly sessions they had been holding, but who is not at all tempted to undertake a schedule of more weekly meetings and an open-ended engagement. The truth of the matter is that, at the time of the patient’s request, neither the patient nor the therapist really knows for certain which course of action will bring more benefit to the patient in the long run. But it is important that the therapist considers very carefully how he wishes to proceed, since any eventual disappointment is bound to affect his self-confidence and the quality of his work.

References Gedo, P. M., & Cohler, B. J. (1992). Session frequency, regressive intensity, and the psychoanalytic process. Psychoanalytic Psychology, 9: 245–249.

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Klauber, J. (1971). Personal attitudes to psychoanalytic consultation. In: Difficulties in the Analytic Encounter (pp. 141–159). London: Maresfield Library, Free Association Books, 1986. Richards, A. K. (1997). The relevance of frequency of sessions to the creation of an analytic experience. Journal of the American Psychoanalytic Association, 45: 1241–1251.

CHAPTER FOUR

Touching and affective closeness*

I

came to England to pursue my analytic training and my psychoanalytic life has unfolded in this country. My analyst, supervisors, and lecturers were all unanimous in teaching that analysis was a process based on words. Of course, as the years went by, we took on board the relevance of non-verbal material, of the personality and style of the analyst, the importance of a diagnostic assessment of the patient’s pathology, the elements that presumably differentiated between psychotherapy and “proper” analysis. Needless to say, opinions varied and each of us gradually developed his own brand of working with patients. However, curiously enough, “touching the patient” was usually considered one of the things that “only Dr Winnicott” did with his patients. Touching was one of the unusual things that he provided to those patients who had “regressed to dependence”, and his accounts were treated with puzzlement and an implicit sense of condemnation. I am sure that it was the enormous respect and admiration that Winnicott commanded in the

*First published in G. Galton (Ed.), Touch Papers: Dialogues on Touch in the Psychoanalytic Space (pp. 15–28). London: Karnac, 2006.

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British Society that precluded overt criticism of his approach to these particular patients. Not many other analysts came forward to inform the world that they treated similar patients or resorted to such technical parameters. Margaret Little proved the exception, but then, she had been analysed by Winnicott, and this was seen as confirmation that “touching” constituted a technique that characterized the analyst’s therapeutic preferences, rather than being exclusively part of a patient’s conscious or unconscious needs. Balint’s Basic Fault was published in 1968, and touching the patient was mentioned by him, but, as far as I know, this was treated in the same way as Winnicott’s procedures: highly idiosyncratic views and definitely not procedures to be adopted by all analysts. Pedder (1976) and Casement (1982) published papers discussing the issue of touching the patient, but their papers did not lead to many other analysts of the British Society writing about this topic. I believe it is fair to say that the general ethos of the British psychoanalytic scene still considers “touching the patient” as wrong, or, at least, dangerous. Apparently, this is not the case in other analytic societies, even though not that many papers have been published on this issue. Psychoanalytic Inquiry published an issue (2000) on this subject of “Touch in the Psychoanalytic Situation”. Casement’s “Some pressures on the analyst for physical contact during the re-living of an early trauma” (1982) was taken as the basic statement for discussion by a number of distinguished analysts. There was general agreement that this was a most important paper and each author praised Casement’s work. But several of the papers made it clear that they saw this as a not-too-convincing exposition, clearly written by an orthodox Freudian British psychoanalyst, who appeared defensive and apologetic over his dealing with the patient’s wish to hold his hand. The discussion papers were presented by authors who have published articles and books advocating the importance of feeling free to touch the patient, all criticizing what they saw as a prejudiced adoption of Freud’s “rule of abstinence”. Contrary to this supposedly Freudian condemnation of touching, they argued that some patients have special needs for physical contact and, provided care was taken to respect the precepts of professional ethics, they

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saw no reason not to satisfy these needs. To someone coming from a Latin culture (Brazil) it is quite amusing to read discussions that include handshaking as an example of “touching the patient”. This brought back memories of my first analytic sessions in London, when I shook hands with my analyst and took off my jacket and shoes before lying down on the couch. After some interpretations about the unconscious, transferential meaning of such behaviour, I got the message and adopted proper behaviour best suited to a patient undergoing analysis in Britain: shoes on (so that was the reason for the mat at the end of the couch!), jacket on, and no handshakes. Hardly work facilitating insight into the unconscious! But, justice to my analyst, it was her room and we were no longer in my home country . . . However, I remain unconvinced that I was expressing any particular unconscious need. I would like to mention some experiences that have influenced my views on the issue of touching. 1.

2.

Many years ago, I saw a man in his mid-thirties for a consultation. We discussed his problems, I agreed that he would benefit from having analysis or psychotherapy, and I recommended he should have at least two or three sessions per week. He came to see me for another two meetings, but he then sent me a letter, informing me that he did not intend to come for further sessions. He told me that he was seeking an analyst who would give him that precise kind of analysis that Winnicott had given Guntrip and some other patients. He was convinced that he had experienced early traumas and now wanted an analyst who would help him to regress to that period of his life, someone who would not hesitate to offer him emotional and physical holding if this became necessary. As he had concluded that I was not that type of analyst, he thanked me for my efforts but he now wished to seek a more suitable analyst. He was correct in his assessment: I did not believe his complaints suggested any early traumatic experiences. During our analytic training, we had the privilege of having clinical seminars with Dr Lois Munro, an exceptionally gifted analyst. She was in charge of the Clinical Services of the London Clinic of Psychoanalysis and very active in teaching activities. One evening, when discussing the relationship between patient

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and analyst, she told us the story of a student analyst who reported in supervision that he had agreed to a female patient performing fellatio on him. We were all duly horrified and there was unanimous outrage at such a practice. Apparently, the student argued that the patient had been experiencing enormous anxiety and gradually came to put into words her conviction that only an intimate physical exchange would soothe her panic. Dr Munro did consider that the patient’s psychopathology had some relevance to give rise to this occurrence, but she gave much more importance to the analyst’s neglect of the responsibilities of his position. Obviously, fellatio can hardly be seen as an example of the kind of “touching the patient” under discussion, but this episode still depicts an analyst believing that using his body was more effective than his words, under the conviction that this is what would meet his patient’s needs. Over the years, I have had patients who expressed a wish for physical contact and I have also supervised students whose patients sought such close physical proximity. In one case, a young female patient wormed herself over her analyst’s chair to lay her head on the analyst’s lap. Another patient many times came very close to me and occasionally touched me on the arm or the leg; this particular female patient would always claim that having physical, if possible sexual, contact with me was her idea of bliss. There was also one day, early in my analytic work, when a female patient stood up to leave the room, but instead, with great pain and anguish, came close to me and embraced me. I made some would-be-fatherly movements with my arms, trying not to come too close to her and still not embarrass and hurt her by refusing any response. But I had a shock when I felt that I was getting an erection. Neither at that moment, nor subsequently, did I attribute this unexpected erection to the patient’s psychopathology: I had no doubt in my mind that it was linked to the fact of this particular young woman being very attractive. Subsequent experience has confirmed, time and time again, that young, good-looking women invariably move male professionals to respond to them in a dramatically different way to their ordinary manner with patients who are not so attractive. Indeed, this can happen in any sphere of life, but it is particularly dangerous for analysts

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to ignore their feelings of attraction or repulsion towards a patient: it is a serious mistake to write these off on the basis of attributing them exclusively to countertransference. Rodman’s recent (2003, pp. 397–398) biography of Winnicott recounts the case of Corky, a woman who had developed the type of regression that Winnicott judged justified a number of departures from ordinary analytic technique. The patient took several overdoses and, when she could not attend for her sessions, Winnicott would see her at her home, often taking his secretary with him, so that she could do the patient’s shopping and attend to other domestic chores. However, it seems this patient had had many pregnancy terminations and when Winnicott was unable to continue her analysis, Masud Khan took over her treatment and, apparently, developed a sexual relationship with her. No doubt, this says something about Khan’s attitude to his patients, but the patient’s compliance makes me wonder whether her multiple physical demands when seeing Winnicott might also point to a similar capacity to sense her object’s needs and expectations, which she could then satisfy. In other words, how can we, as outsiders, ever establish whose needs are being met in such complex and private interactions?

Let us assume there is a point where the patient expresses, verbally or in gestures, the need or the wish to hold the analyst’s hand. There are only two possible alternatives: either the analyst does hold the patient’s hand or, which is the same, indicates his willingness to do this, or else he uses words to indicate his interpretation of the patient’s verbal or non-verbal communication. Whether this becomes an isolated incident or the beginning of a pattern, only further developments will reveal. Whether the patient expresses some deep, early, physical longing or, alternatively, there are sexual elements in this move, again, only further developments will reveal. My thinking in this matter is very influenced by my views on the issue of physical violence. Whatever the patient’s age, at the point where the analyst is attacked, his reaction is fundamental in establishing what is to follow. This has been my experience over children’s physical violence, in ongoing analysis or in their ordinary, daily, family life. The first time a child moves a limb in such a way

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that pain is inflicted on parent or sibling, it is possible that this results from frustration and hostility. But it is equally possible that this is still some spontaneous, accidental movement quite devoid of such emotions. However, the parents’ response to this gesture will be experienced by the child as a pointer to the link between that movement and certain affects and impulses: and this may become the beginning of a pattern of behaviour. As a matter of fact, this combination of action and reaction is what characterizes any interaction between two people. If the encounter continues, these behavioural expressions quickly become the expected response that influences each party’s contribution to the interaction. Two important points have to be made in the context of the analytic encounter. One, each patient has his own conscious and unconscious needs, and two, each analyst has (or should have) a clear notion of how he defines his therapeutic role. The issue of “touching” takes us to that classical question raised by the behaviour of drunk people: is their behaviour caused by the drink or is it that the drink brought to the surface behaviour that was dormant? In my own personal case, I have long been aware of a conscious and unconscious compulsion to help others, but I have learnt that this need has never taken me to the position of creating or fostering a situation of dependence on me. This may well be the reason why I have never managed to keep in treatment patients who wish to remain in analysis forever. In all my years of analytic practice, I never had a patient who regressed to an emotional position that necessitated any other than the ordinary tools of analytic practice. Is this a case of blindness? Is it a professional shortcoming? I prefer to think that this follows from my understanding of my professional self and I can only hope that I have not failed any of my patients because of this. Regarding the patient’s needs, ideally, we should have access to a laboratory where we could start one patient in simultaneous analysis with two different analysts. If this patient were to plunge into a deep regression, would he come to voice a wish for physical contact with both analysts? And, if so, would both analysts respond in the same way? And what difference would each response make in therapeutic and prognostic terms? The possibility that this hypothetical regressed patient might express a wish to be held only to one of the two analysts is, clearly, quite disturbing.

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To a large extent, the controversy over touching or not the patient has been influenced by Freud’s recommendation of the rule of abstinence. Many of the authors who discuss this point emphasize the contradiction with Freud’s earlier putting his hand on the patient’s forehead. Freud’s journey from this technique, imported from hypnotism, to what became the talking cure may parallel his views on having the patient lying down on the couch. But Freud made it explicit that this position was chosen to cater for his dislike of having the patient staring at him during the session, that is, a choice made for the sake of the analyst’s comfort. As is well known, over the decades lying on the couch has become a dogma, and endless justifications are put forward to implement this rule. I have, in fact, taught students and explained to patients that this position enabled the patient to concentrate on his own thoughts and feelings without the interference of various perceptions of the analyst’s movements. Is this the full answer? As the years went by, I came not to be bothered by the patient’s lying on the couch or sitting on the chair opposite me—and each patient made his own choice. I believe a similar pattern has occurred over many other issues where patient and analyst are involved: for whose sake is a particular point adopted or denied? My main objection to the arguments recommending touching as a regular technical parameter is the claim that this responds to a patient’s needs. When touching is undertaken as the therapist’s concept of the appropriate technical step, then I respect his setting out to use physical contact with all or most of his patients: this is his own, private, personal view of his therapeutic tools. Bio-energetics is now quite a widespread technique that adopts this principle of physical touching as a basic parameter. As happens with every single technique put to the public, there will always be people in pain who will believe this is the help they need. However, this is not the same as finding arguments in the patient’s psychopathology to justify the adoption of touching as an alternative to talking, in order to bring fulfilment to “the patient’s needs”. If a diagnosis is made that the patient will benefit from touching, this should be implemented without the patient having to ask for it. We find patients who claim to NEED more time than the fifty minutes we allot them: will our colleagues who respond to the patient’s need to be touched also grant the patient the time

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span they ask for? We have patients who desperately beg to have a session on a Sunday morning: how to respond to this need? And the patient who asks to be granted a long break from analysis: do we accept this? Another example: when I trained in the 1960s, many analysts smoked and allowed their patients to smoke. Presumably, it was universally accepted that smoking was a need to be gratified: so, are analysts now prepared to allow patients to smoke during their sessions? The challenge, clearly, lies in the assessment of the unconscious meaning of these wishes, requests, or demands. The acceptance of touching is justified by arguing that it stems from early privations: conceivably, smoking might be seen as the result of early oral frustrations; do we then allow the patient to smoke? Insight (2003), a publication of the International Psychoanalytical Association, printed a fascinating survey of the views of seven analysts on the issue of “Telephone analysis”. The present trend of spreading analytic knowledge to students who live too far away from training centres has led to some most unusual arrangements. I had heard of supervision sessions and group seminars being conducted on special communication equipment, under the justification of the geographical distance between the place of residence of trainees and the senior analysts involved. But I had never considered telephone conversations with patients as a major issue. I discovered now that some analysts did agree to conduct analytic sessions over the phone. I am mentioning this survey because, even though patients’ needs and wishes are considered and agreed to, I found no reference to early or primitive needs. Analysts seemed to accept that work commitments of their patients might make it impossible for them to attend their consulting rooms and were prepared to embark on an arrangement that allowed the patient to continue his work with the analyst. I think telephone analysis contains a parallel to the question of touching the patient. In both cases, a patient’s wish leads to the analyst’s acquiescence, but one is justified by the practicalities of modern living and the other is explained by the primitiveness of the patient’s needs. Clearly, not much intellectual ingenuity would be required to postulate “early” anxieties and impulses determining the request for regular telephone contact, and, yet, these were not considered necessary before agreeing to the patient’s request.

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What will lead the analyst to consider that a patient’s wish represents an early, primitive, developmental need that was not fulfilled during the patient’s infancy or, instead, a statement that what the analyst normally offers is not sufficient? At the time when Freud, Balint, and even the early Winnicott were writing about regressed patients, the analyst saw himself as a professional trying to help his patient. Gradually, a change occurred and many analysts were no longer “the mother in the transference”, but came to see themselves as “the mother” who now tried to put right the failures of the patient’s real mother. This change occurred with the increasing prevalence of the teaching that the analysis of the transference was the main tool of analytic work and, furthermore, that early conflicts had primary significance in the patient’s material. Not surprisingly, many or most of the patient’s wishes were now seen to stem from early developmental deprivations. I believe that this is the reason why several authors have taken up the patient’s need for physical contact as representing a consequence of their earliest experiences. Arguments have been published emphasizing the extent to which the contact between the baby’s skin and the mother’s skin is a vital step in the organization of the baby’s awareness of his body, his body self. Orbach (2003) emphasized this point quite forcefully in her arguments to justify, if not to prescribe, the physical contact between patient and therapist. But oral experiences are also most important in the infant’s growing awareness of the other: so, how should we respond to a patient’s wish for oral contact with the analyst’s body? Research has now shown that the foetus is influenced by the mother’s heartbeats: if the patient wants to rest his/her head on our chest, should we oblige? The concept of “trauma” also deserves attention in the present context. Casement (1982) emphasizes his patient’s traumatic experience: seriously scalded when eleven months old and submitted to surgery at seventeen months of age. During this intervention “the patient was holding her mother’s hand until the mother fainted”. His paper discusses events as “she was reliving this experience”. Some of the colleagues who contributed to the symposium mentioned above argued that, at this point in time, we must adopt an interactive, relational, interpersonal view of the analytic encounter, that is, in what way had Casement contributed to bring the patient

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to that situation? Clearly, this is an argument that will not allow for a compromise solution. Each interpretation of his patient is entirely dependent on the analyst’s preconceptions. Personally, whenever I heard stories of patients being helped to regress, for example, to the point of the primal scream, I wondered about the therapist’s powers of persuasion. It has not been established that we retain retrievable true memory traces of these earliest experiences. In other words, we do not know when exactly each individual manages to register his life experiences in a way that these memory traces are available for future translation into words. In fact, I am one of those who believe that we are forever rewriting our history. In the case of Casement’s patient, I would assume that she was not expressing her memory of the events surrounding the burns and the surgery, but, rather, trying to make sense of her mother’s account of those events. Children feel puzzled when informed of events in their own life that they cannot recall. Depending on their age when told of such happenings, some of these accounts can be experienced as traumatic. On the basis of this assumption, the issue then would be not so much “holding hands”, but, rather, helping the patient to understand the feelings underlying her mother’s words and what feelings these words had brought out in her, whatever the age when she first heard them. I would like to relate two further stories: In a clinical seminar during our analytic training, Michael Balint asked each student how we started and finished our sessions. We all saw our patients in the main building of the Institute of Psychoanalysis, and this meant that all our patients were met in the same waiting-room and then taken to each student’s assigned room, which was on one of two floors. The result of this exercise was rather surprising. We were twelve students, but it turned out that we had not a single example of two of us doing the same thing. Some preceded the patient in the route from waiting room to consulting room, others invited the patient to go first; some shook hands with the patient in the waiting-room, while others barely nodded their head towards the patient while standing at the door. We had a variety of formulae whereby each of us indicated it was time to finish the session. Some of us would stand up and allow the patient to leave the room, while others opened the door to let the patient out. The account that caused general surprise was that of

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the student who left the analytic room first, letting the patient organize his/her things and find his/her way out. None of this would ever be known if it had not suddenly become the focus of a discussion. It would be quite fascinating to discover how each of our patients interpreted our behaviour! These “rituals” seem quite trivial, but this seminar remained a dramatic example that what happens between patient and analyst is only, exclusively, known by the two of them. We can take it for granted that not always will each of them interpret events in the same manner as each other. If words are questioned, it can be quite difficult to agree on what they meant, but when non-verbal communications are considered, the difficulties are much worse. Another interesting example that I place in the same category is that of a very eminent analyst who wrote extensively about the analysis of seriously ill patients. His papers demanded the strictest adherence to orthodox “boundaries”. He argued that analysis was a verbal process and that primary attention had to be given to the analysis of the transference. I met a colleague who consulted this analyst for supervision of an extremely difficult case. At one point, my colleague told him that this patient was panicking at the analyst’s impending long holiday. He had tried all kinds of interpretations about separation anxiety, envy, disillusionment, hatred, punishment, but the patient remained anxious and, clearly, suicidal. The senior analyst discussed these interpretations, but eventually suggested that my colleague might give his patient a photo of himself. Obviously, my colleague was surprised and mentioned the supervisor’s insistence on the exclusiveness of interpretations in the analysis of any patients. “Oh, well . . . you don’t really think that we put on paper all that we do in the consulting room, do you?” was the reply. Perhaps, along similar lines, there may be many analysts who might admit to episodes of touching their patients? It is a simple fact that the vast majority of practitioners do not recount or publish the details of their clinical work. Considering the accounts of touching that I have read, I am left with the impression that some analysts consider the actual or possible touching the patient an exceptional event and try very hard to explain the reasons why they did or refused to do this. Other analysts, however, seem to argue that here is a significant, valuable, effective, technical paradigm and, accordingly, present theoretical

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justifications that would give legitimacy to their technique. I want to make it explicit that I do not have doubts about the sincerity of their arguments or the ethical correctness of their practices. However, I would strongly urge any of my students never to touch their patient. I do not consider shaking hands a type of “touching”, and if some exceptional circumstance leads to the analyst’s body touching the patient’s body, again I would not see this as anything more than an accident. If an example is called for, we have situations where patient and analyst have to climb stairs to reach the consulting room. If whoever is in front trips up and is about to fall, I would take it for granted that the person behind should hold the one in front and prevent his/her getting hurt. However, if the patient asks the analyst to hold his/her hands, I believe this has to be treated in the same way as any other request, that is, considering its meaning in the context of the analytic situation. If the patient says “You cannot imagine how I am feeling . . . I do wish you would let me hold your hands!”, I would see this as an attempt to gauge the analyst’s repertoire of communication abilities. The request can only arise because the patient has learnt that this is an analyst who does not use his body as an instrument of understanding or making contact. Agreeing to hold hands immediately signifies a new departure and I would argue that it may be very difficult for the patient to put into words his interpretation of the analyst’s behaviour. We like to urge the analyst to be consistent, and I agree that there is a difference between consistency and rigidity. Nevertheless, any departure from the analyst’s normal posture poses the danger of the patient (1) questioning his motives, and (2) wondering what other departures may come to take place. If, however, we have an analyst who does believe in physical contact in the work with a patient, then the issue of “the patient asking for it” surely should never arise. It is for the analyst to decide the moment when he touches or holds the patient’s hands, head, or other body parts. It is important to remember that touching is not a common part of British mores, and this heightens the possibility that any touching may be misinterpreted by the patient. All things considered, I repeat my advice to any students: a patient’s request for touching is a matter for understanding, not for obliging.

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I would like to conclude with another story. Mrs Eva Rosenfeld, a most admired analyst, was in analysis with Melanie Klein in the 1940s. One day, she reported having heard that a close relative had been killed by the Nazis. Mrs Rosenfeld was very distressed, indeed. The session came to the end and, as Mrs Rosenfeld got up from the couch, trying to get control of her balance, Mrs Klein suggested she should sit for a while in the waiting room and have a cup of tea that she offered to prepare. I have always seen this as a most convincing example of the fact that whatever the transference makes of us, patient and analyst, we remain human beings. There is no harm in demonstrating our human solidarity with the pain of another person, but this makes sense when done spontaneously, not under the guise of psychodynamic conceptualizations. In other words, I do not think that it is important to touch a patient to show him/her that we care for his pain. If we do share it, our voice and demeanour will convey it and if we don’t truly share it, our touching will still feel “technical”, not spontaneous.

References Balint, M. (1968). The Basic Fault. London: Tavistock. Casement, P. (1982). Some pressures on the analyst for physical contact during the reliving of an early trauma. International Review of Psychoanalysis, 9: 279–286. Insight (2003). Telephone analysis—in Insight. International Psychoanalytical Association, 12(1): 13–32. Orbach, S. (2003). The John Bowlby Memorial Lecture 2003. British Journal of Psychotherapy, 20(1): 3–26. Pedder, J. (1986). Attachment and new beginning: some links between the work of Michael Balint and John Bowlby. In: G. Kohon (Ed.), The British School of Psychoanalysis (pp. 295–308). London: Free Association Books. Psychoanalytic Inquiry (2000). Touch in the psychoanalytic situation. 20(1): Special Issue. Rodman, F. R. (2003). Winnicott: Life and Work. Cambridge, MA: Perseus. Rosenfeld, E. (1963). Personal communication.

INTRODUCTORY NOTE TO CHAPTERS FIVE AND SIX

Flexibility

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he two papers in this section illustrate a principle of enormous importance: the need for flexibility in deciding how best to help a child. Indeed, this is equally important when dealing with adult patients. No therapist is likely to describe his approach to psychotherapeutic work as rigid. And yet, we do have professionals who apply the same technical parameters to every patient they take on. When they argue that, for better or for worse, this is how they like to practise their skills, or that this is how they work at their best, I can respect their decision. But often this brand of rigidity is justified as being the best way of meeting the patient’s needs, and I consider this a type of blindness or self-delusion that is unacceptable. Each patient has different needs, and the constraints of life conditions impose a series of restrictions that deserve to be taken into account. It is understandable that when recently qualified, each professional will tend to apply those techniques that his training taught him. Many psychotherapy trainees have a long previous history of involvement in closely related fields of work, and these will manage to practise with some degree of flexibility, but for many years now we have had trainees with no professional experience in 93

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this field of work. It is this group who tend to adopt the principles taught in their specific training as dogmas to be put into practice in a very rigid manner. A recent development in the public health field is the issue of over-specialization. This can be seen with particular clarity if we focus on surgeons. We find a puzzling categorization of their approach to patients that is probably more closely linked to personality factors than strict clinical views: some doctors will be known as interventionists, while others are considered as less rigid regarding the therapy they prescribe. There is a similar division between doctors who will always prescribe the same (medical or surgical) intervention and others who are known to be more flexible. The usual pragmatic manner of describing this is the reference to some doctors as having their prescriptions totally predictable. In other words, a general practitioner who believes his patient needs “treatment x” will always refer that patient to the specialist he knows will recommend “treatment x”. Similarly, those patients who believe “treatment x” is what they need will consult that specialist known to prescribe this. I once was consulted by a patient who, after two interviews, told me in a considerate, apologetic manner that, however competent he thought I seemed to be, he had read papers by Winnicott and Guntrip and he wanted to have therapy with someone who followed the techniques described by those two analysts; he was sure I was not one of them. It is not rare to find patients who come to see us after deciding the exact number of weekly sessions they want to have. Similarly, many parents will reach such decisions before approaching a therapist for help with their child. Ideally, the initial evaluation of a child’s problems should establish a careful assessment of the ideal therapy for that child. This is to be followed by an appraisal of what child and parents can realistically invest in the therapy and, perhaps the most difficult step, how the therapist can find a compromise between the parents’ proposal and his personal views on what therapeutic scheme he would like to apply. Perhaps only rarely will it be possible to implement the ideal recommendation, but in the context of the present argument, I do believe that the therapist should approach child and parents with enough flexibility to ensure that they obtain the help they need.

CHAPTER FIVE

Child analysis: when?*

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sychoanalysis is usually seen as a therapy for emotional problems, but psychoanalysts also consider it a research technique and a theory of psychology. Similarly, “child analysis” is seen as a therapeutic technique, though analysts consider it important for two other reasons: (1) the light it throws on our theories of emotional development, and (2) the role it can play in the training of a psychoanalyst of adults. Each of these roles deserves attention in its own right.

Training In June 1970, the European Psychoanalytical Federation organized a symposium on “The role of child analysis in the formation of the psycho-analyst”; the papers given by René Diatkine, Anna Freud, and Hanna Segal were published in 1972 in the International Journal

*First published in L. R. de la Sierra (Ed.), Child Analysis Today (pp. 29–44). London: Karnac, 2004.

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of Psychoanalysis and are well worth re-reading. Diatkine focused on the treatment of children by analysis and discussed many of the problems encountered in clinical practice. Diatkine seldom used the word transference, but he stressed how “from the very beginning of the cure the psychoanalyst should be for the child the source of both pleasure and aggression and that this ambivalence should not cease to develop thereafter”. The analyst is, therefore, a helpful figure for the child to introject. This is quite a different picture from the usual one of the “neutral” analyst or the image of the analyst who is no more than the transference construct created by the projections of the child. Discussing the role of the parents, Diatkine writes, “Everyone agrees that a psychotherapeutic approach of the parents is necessary, except, of course, when one treats exclusively the children of psychoanalysts themselves, whose own analysis should suffice” (p. 149). And if it does not suffice? This can be a serious clinical problem. But he stresses that the real parents “can play a most important restorative or traumatic role, but they are not the original ‘objects’ of the child, for the elaboration of object relations begins very early” (ibid.). Another illuminating comment is worth quoting: “If the parents’ mental functioning has a structuring effect upon the psyche of the child, one must not forget that the child in turn structures his parents and that this essential aspect of reciprocity should not be neglected” (p. 150). Diatkine is discussing analysis as therapy. He appears to take developmental theory for granted, and his frequent comparisons between the analyses of children and adults focus on the similarities and differences in terms of theory and technique, rather on the issues taken up by Anna Freud and Hanna Segal. Anna Freud gave a forceful paper that is still very topical. She saw the child as a live field of research and she believed that the child analyst had a unique opportunity to observe how the child utilized his inborn potential to adapt to pressures from the external world. Anna Freud argued that “child analysis . . . was the only innovation which opened up the possibility to check up on the correctness of reconstructions in adult analysis” (p. 153). And yet, “analysts of adults remained more or less aloof from child analysis, almost as if it were an inferior type of professional occupation”. After listing the reasons usually given to justify why five times per

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week analysis is not feasible with children, Anna Freud commented: “It was difficult not to suspect that most analysts vastly preferred the childhood images which emerged from their interpretations to the real children in whom they remained uninterested” (p. 153). She found that training students who had not analysed adults before, with only their own personal analysis as a model of procedure for adults, had, if anything, less than the average analyst’s difficulty to accept a technique in which free association is non-existent; in which transference is shared with the parents; in which there is a minimum of insight on the patient’s part, coupled with a maximum of resistance; where the patient’s treatment alliance is unstable and precarious and needs parental assistance in times of stress; where action takes the place of verbalization and where the analyst’s attention cannot be concentrated on the patient exclusively but needs to be extended to his environment. [p. 154]

Anna Freud wanted a training institute where each trainee would see adults, children, and adolescents, since she considered the analysis of children and of adults as of equal importance in the training of a psychoanalyst. Segal thought this was a deserving ideal, but she pointed out that this was unlikely ever to be achieved. In our institute in Great Britain we had for years lectures on child analysis and clinical seminars, which were compulsory for all students. Unfortunately, we are going through one of our periodic great upheavals and reorganization, and I find to my horror that the child has been thrown out with the bath water: the course of child analysis for the ordinary candidate has disappeared, I hope only very temporarily. [p. 160]

She listed her minimal requirements: first, full integration of theory of psychoanalytic knowledge derived from the analysis of children in teaching; secondly, baby and child observation; and thirdly, attendances at lectures and clinical seminars on child analysis irrespective of whether the candidate is treating children himself. [p. 160]

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She adds her hope that exposure to these experiences might encourage candidates to see a child case in analysis. Sadly, to this day, Segal’s comment that many people might find her “minimal requirements already far too ambitious” still remains a true reflection of prevailing attitudes. I have quoted rather extensively from these papers because it is important to reflect on what, more than thirty years later, has changed. “The child in the adult”, “the baby part of the adult”, and other such expressions have become fashionable. Those who have had children or adolescents in analysis continue to put forward arguments to convince other analysts that they should experience first-hand the analysis of a child. Although not a single analyst would say a negative word about child analysis, the vast majority of analysts, nevertheless, feel more comfortable working with adults. I share Anna Freud’s view that analysts prefer to work with the “reconstructed child”, that conceptual organism that we postulate underlies an adult’s pathology. I was very surprised when I first discovered students observing babies and trainees analysing children who told me that these children represented the nearest they had ever come to a child. I now know that this is far more common than I would ever have guessed. If we consider training, aiming at widening the experience of a future analyst of adults, I subscribe to Segal’s “minimum requirements”, but I would add a different suggestion. When I started my analytic training, because my medical course had not included any long-term placement in psychiatry, I had to spend a whole year working part-time in a mental hospital. So, why not demand something similar from those candidates with no experience of children? “Infant observation” sounds a reasonable option, but, in practice, candidates are influenced by the theoretical views of their training analysts and seminar leaders. To discover how children think, feel, behave, and speak, it would be much more effective for candidates to spend a number of sessions at a nursery and/or infant school. Not supervised or monitored, and with no reports to present, but simply observing at close quarters children living and playing together. I am sure that our candidates would have a great deal to learn from the children and the class teachers. I am sure we will continue to preach, like Anna Freud and Hanna Segal over thirty years ago, that “child analysis is good for

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you”. Nevertheless, I am not convinced that analysing a child is the best way of persuading analysts that our developmental theories are soundly based or the ideal way of making them familiar with the psyche of a real child. In fact, I am not convinced that analysing a child is such an additional benefit for the work with adult patients.

Research From Freud onwards, we have made sense of adult psychopathology through our theory that links it to early infantile development. Both instinct and object-relations theories postulate phases that the child goes through to achieve adulthood. Normal and abnormal psychological functioning are seen as the result of conflicts and failures that can, supposedly, be resolved by our psychoanalytic techniques. In the paper quoted earlier, Anna Freud described the aims of therapy of the child very succinctly: [as with adults] to include the undoing of repressions, regressions and inadequate conflict solutions; to increase the sphere of ego control; and, added to this, as an aim exclusive to child analysis: to free developmental forces from inhibitions and restrictions and enable them once more to play their part in the child’s further growth. [p. 154]

It follows from these postulates that the observation of infants and the analysis of children should give us the opportunity of putting our views to the test. In practice, we find that the theoretical framework adopted by each worker determines his observations, descriptions, and interpretations. This can be clearly seen in reports on infant observation, where the students appear concerned, above all, with learning the teacher’s preferred mode of interpretation of the findings. Considering child analysis as a research tool, perhaps we should turn to Anna Freud again: “Transference itself as a concept has changed its nature from a manifestation spontaneously arising in the patient’s consciousness and behaviour to one purposefully introduced into the situation by the analyst’s interpretation” (p. 152). This is a perfect example of how

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one and the same clinical datum can be interpreted in fundamentally different ways depending on the analyst’s theoretical bias. Reading clinical accounts of child analysis or child psychotherapy cases, whatever the pathology of the child, the same mechanisms and concepts so familiar from adult analysis are put forward to explain the behaviour and/or utterances of the child. I would like to find an account where the analyst wrote that interpretation “x” might explain the content of the child’s material, but it would NOT explain why this was expressed in that particular manner. This might lead us to study and research non-dynamic factors that are relevant to an understanding of some of the children seen in the consulting room. Schacht described the analysis of a four-year-old boy, Julian, in Psychoanalysis in Europe (1992). Because Julian made frequent and vicious attacks on children at his nursery, transfer to a school for handicapped children was considered. Similar destructive behaviour occurred at home, and his mother also reported that he compulsively dug, with his hands, deep holes in the garden. After he repeated this action at the analyst’s house, Schacht linked this behaviour to his unconscious fantasies about his mother’s body and also to the demolition of a barn where he used to play. Julian also attacked the analyst (“without warning tore my hair, tried to throw things in my face and once even scratched my eyes in such a dangerous way that I became deeply frightened and angry”) (p. 68). Schacht quoted many examples of Julian’s compulsive repetition of words and actions. For example: “Julian kept asking me in a monotone ‘what’s that?’, ‘what’s that called?’ and so on—endlessly. With unusual patience I gave him answers and explanations” (p. 65). Later, she wrote, “As an aside he told me that there had been a bird’s nest at home and he had destroyed it. Babies had been growing in it, tiny babies. He had squashed them all. He burst out laughing” (p. 75). Schacht’s moving account of an extremely difficult analysis focuses on the discussion of a particular technical parameter (seeing the child in another room during a limited period of regression) that proved very useful. Most interpretations quoted centred on Julian’s conflicts with his younger sibling and their mother and how these had affected his developing sense of self. Progress was noted, though there was also (p. 69) a reference to continued violence at home.

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The material I have quoted reminds me of similar children I have seen. Some of them had psychotherapy and I was profoundly disturbed when, many years later, I saw them turning up as adult psychiatric patients. Searching back for features I had missed that might have alerted me to more serious pathology, I found, for example, repetitive behaviours (echolalia, perseveration, rituals, tics, endlessly repeated games and constructions, etc.), concrete thinking (learning by rote, not grasping symbolic meanings in ordinary interactions, reacting to drawings and toys as animate beings), incapacity to empathize with objects (treating people as things, lack of awareness of how the other feels) and an odd balance between affects and overt behaviour (manic reactions, panic attacks, frozen/detached appearance: if one can consider uncontrollable anxiety as an explanation, the degree of the reaction still begs an explanation). Some of these features can be seen in the description of Julian and, if it is true that at times Schacht’s interpretations did appear to bring relief and change in his behaviour, I wonder whether this boy’s difficulties could be remedied through his analysis. I am sure that he gained immensely from the help Schacht gave him, but it would be most interesting to learn how he progressed into adolescence. My suspicion is that even when relief can follow insight or some interaction that proves helpful, these children may still have some inherent tendency, weakness, or incapacity that persists throughout their lives. Joe was a child I observed in a group of children with developmental problems. He was three-and-a-half-years-old when referred because of his odd behaviour, toilet training difficulties, and language delay. It became clear that he presented an autistic-like picture, and later on the diagnosis of Asperger’s syndrome was chosen, so as to take into account his obviously high intelligence level and competence in certain areas. One day he came into the room making gentle, sinuous movements with his hands. Someone commented that this movement had been named by Joe the previous week as “the spider”. Joe smiled and stopped the movement. But his mother explained that the same movement might at other times be incorporated into other games he happens to be playing. For example, they could become a flying aeroplane. The following week, Joe again made the movements with his hands, but he now gave them names: they had become Thunderbird One and Two.

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Joe’s mother told us of an occasion when Joe complained about a hissing noise produced by a bus; she explained that this was produced by the brakes. But soon another bus came, and it had a huge advert on its side depicting a snake: Joe pointed to it, said “snake”, and added the hissing noise. She thought this was funny, but she became quite perturbed when he now pointed to each bus that went by and made the same hissing noise, each time saying “the snake” and, of course, refused to climb into any of them. The difficulties of caring for children like Joe can be seen from an example where, when it was time to leave our weekly meeting, Joe lay down on the floor and raised his arms. Mother said, “No, I won’t carry you, you are too heavy”, explaining this often happened in shops or streets. I said that perhaps Joe wanted some comfort and suggested holding him a bit on her lap: she gave it a try and only seconds later he was willing to walk out normally. Six months later, Joe had a new ritualized movement: he lifted his shoulders and shook his head. His mother linked this to the time when he had eczema and she had checked his back a few times. Joe greeted me warmly as ever and asked me for the time, a request he repeated only a few minutes later. His mother commented that this happened quite often, but added that Joe had no concept of what the answers he received might actually mean. A further six months later, Joe’s vocabulary had increased, and his manner of approaching adults and children was absolutely normal as far as accepted manners are concerned. His play could appear normal even if he always played on his own (he might accept other children playing alongside him, but he never actually played with them), but every so often he would come up with a non sequitur that made us wonder about his grasp of the words he could absorb. His mother found it remarkable that he could, out of the blue, come up with a sentence he had heard months earlier when watching television. And yet, in spite of all these indications of Joe’s difficulties in relating to those around him, one day he made some drawings on the blackboard. First, he called them diplodocus and tyrannosaurus rex. Then he made another huge, prehistoric-looking figure with a baby figure next to it: he called them Joe and mother. Then he began to draw a father; that was obviously too big and would drown the other two, so he stopped and told me to wipe it all off. Then he repeated the same drawings, but now they were father and his sister and Joe proceeded to draw himself and mother at the other end of the blackboard. Good, solid, orthodox Oedipal material. Joe was placed in a small class for children with special needs and, four years later, he is starting to attend ordinary classes. He seems to do well

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in mathematics and can read well, but a new teacher commented, “Talking to Joe is like having an echo chamber; he repeats what I say”, and his contact with the children appears formal and stilted. He still cannot engage in mutual play and occasionally experiences anxiety he cannot control.

I could give many more examples of this bewildering mixture of words and behaviours that do contain meaning and others that do not appear to have it. There is no doubt that Joe can learn, but it can be difficult to assess whether he can grasp the rationale behind each new piece of learning. So, we speak of stereotypes, ritualistic behaviour, concrete thinking, incapacity to symbolize, and many other descriptive concepts, but my point is that when we have children like Joe in analysis it is not enough to interpret the content of their communications. We should also try to explore whether there is, in fact, any logic that determines whether or not they can grasp the meaning of each new piece of learning. Having observed Joe and other children like him, I am left with the impression that they can acquire new knowledge and build on some skills, but each child seems to have a number of impediments that appear not to respond to educational or therapeutic input. Surely, these are the children who would make child analysis a most valuable research instrument. Our dilemma is that once we adopt the theory that maternal (environmental) input during the child’s growth through his developmental stages determines adult psychopathology, we have locked ourselves into the straitjacket of believing that obstacles, impediments, shortcomings, failures, inhibitions, etc., can all be removed by “effective” analytic therapy. Personally, I do not believe that we are all born with the same endowment and the same potential for development. Analysis of children gives us a golden opportunity to gain some idea of the difference between what we could term an “emotionally determined” symptom and a manifestation of some intrinsic fault in the child’s mental/psychological/emotional makeup. The fact is that such an organic fault is definitely not a contra-indication for analysis, but we should use this analysis precisely to sharpen our understanding of the interplay between endowment and learning. Interpreting the content of the child’s material can be useful, but we must keep an open mind with respect to other aspects of the child’s communications if we are to take advantage of the analysis as a research enterprise.

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Therapy The European Psychoanalytical Federation has held several meetings to discuss child and adolescent analysis. In 1991, Campbell read a paper on the frequency of sessions (1992), giving very helpful guidelines to the problem of diagnosis and choice of treatment. Campbell surveyed the literature, quoted the results of a questionnaire that our Psychoanalytic Society sent to qualified analysts, and he also interviewed senior child analysts in the Society. I would like to quote from this paper the link made by Ross (Bernstein, 1957) at the American Psychoanalytical Association annual meeting in 1957 between Anna Freud’s diagnostic categories and the treatment modalities she recommended: 1. Conflicts between the child’s primitive wishes and their frustration by environmental forces could be treated by counselling or therapy of the parents to correct over-severity or excessive leniency. 2. Conflicts between the child’s primitive wishes and the parents would become internalized conflicts after identification with the parents and include the compulsive, over-aggressive, delinquent and over-conforming child. After the age of 6 or 7 years, once- or twice-weekly treatment was considered to be insufficient to modify the superego. 3. The presence of truly internal conflicts between male and female identifications, activity and passivity, and love and hate, indicate the need for analysis. [Campbell, 1992, p. 106]

The two key concepts underlying this formulation are (a) that symptoms result from conflict between instinctual impulses and a restricting influence that comes from the environment or, later, from the superego, and (b) that the level of intervention is dictated by the assessment of the child’s internal world. It follows from this that, when the child is very young, the parents are counselled or treated “to correct over-severity or excessive leniency”, but, as the child develops further and internalizes the conflicts with the parents, it is the child who becomes the focus of treatment. But what about the parents? Campbell wrote that “it is often difficult to recommend what the child needs (my italics) because of the parents’ motivation and pathology”. This view is probably what led the discussants in the

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1957 American panel to accept “that therapy was advisable for parents when their child underwent psychotherapy or psychoanalysis”, much as Diatkine said more than ten years later. I believe Campbell reflects the predominant view on child and adolescent analysis in our Society when he goes on to write, “when the recommended five-times-weekly frequency is unmanageable by the parents it is still worth working with a child on a once-weekly basis if the parents can support this”. I want to discuss two aspects of this statement: (a) the treatment of the child, and (b) the role of the parents. We seem to have developed in our psychoanalytic world something akin to what is found, for example, in medicine. Some surgeons are known to be interventionists and others are considered conservative in their approach. This means that the treatment eventually offered to the patient is virtually predictable when one knows whom one is consulting. Of course, this also works the other way round, when the patient is determined to obtain a particular treatment and consults several sources until he finds someone who will recommend the treatment he wants. In the field of child analysis, it is well known that many analysts wanted their children to have analysis because they believed this would ensure their normal psychological development. This attitude duplicates the determination of other parents who will only allow their children to have once weekly sessions. Similarly, some colleagues argue that children should have “good analysis”, that is, five, or, at least, four, sessions per week, while others are convinced that this is unnecessary and that children can benefit from less frequent sessions. What concerns me is how rare a true assessment of “what the child needs” has become. Virtually all analysts and therapists see children for a diagnostic evaluation, but so often this becomes the beginning of the kind of therapy practised by that professional. In my experience, it is very rare to hear that the child was best served by a therapy that required the services of another professional. However, I suspect this cannot be changed: it seems to be a manifestation, in our psychoanalytic world, of the curious blend of knowledge and faith that affects all human beings. In other words, deciding “what the child needs” comes to depend on highly personal views and, at best, we can only aim to discuss this as much as possible among ourselves.

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Turning to the parents: what do we want to evaluate? Our family therapy colleagues found a way out of considering different alternatives by claiming that both the parents and the child are involved and all need treatment together. When we decide to take the child into treatment we may well recommend that one or both parents have therapy for themselves, but, in practice, we try to ensure that the child’s treatment is not jeopardized. I would like to look at the parents’ role in a different way: considering that they have helped the child to develop normally in so many other areas of his life, why is it that they now cannot help the child with his presenting problems? One answer might be that this results from the child having internalized parental figures that can no longer be affected by the real parents, but how do we establish that the parents can cope with a child who overcomes these conflicts? If a parent is unable to shift his perception of the child, can we really count on his co-operation with our treatment? Conversely, if the parent(s) is able to treat the child differently, to what extent can we involve them in the child’s treatment? When training is considered, we search for a child whose parents are prepared to co-operate with the required number of attendances. “What the child needs” is still respected, but I think we are entitled to take into account the trainee’s needs as well. But when there is no question of training involved and we have to decide which treatment to recommend, our diagnostic evaluation should also establish how much we can count on the parents for help. Not only “will they support treatment?”, but “would they be able to benefit from knowing in what way their own conflicts are involved in the child’s problems?” In The Motherhood Constellation (1995), Stern describes his work with what is now called parent–infant psychotherapy, and he reassures readers that this is not a new “blame the mother” therapy (p. 21). I met similar criticisms when trying to justify work involving both children and parents (Brafman, 1997, 2001). If we can establish the reason why the parents treat the child in a manner that perpetuates the child’s problems and we help the parents to understand the child’s feelings, this can be beneficial to all of them. This is not “blaming the parents” but seeing them as a source of help for the child. Because we have developed a theory of the psychopathology of the individual, we have come to consider, implicitly or explicitly,

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that therapy of the individual is the only area to which we can devote our therapeutic efforts. Of course, many will argue that oneto-one therapy is what we have been trained in. This is fair enough, except when we discuss “what the child needs”. Then, we must differentiate between treating and conducting a full assessment. I have quoted Diatkine on the mutual influences that child and parents exert on each other, and this is a point of view now adopted by many other workers. But he did not pursue his argument to its logical conclusion. It is in the literature on parent–infant psychotherapy that we find this approach put into practice. Fraiberg (1980), Ornstein (1984), and now Daws (1989), Hopkins (1992), and Stern (1995), have demonstrated how, given the right help, parents can influence the development of their children in a positive way. This is achieved when the parents can change the way in which they treat the child. I have been able to obtain similar results with older children and adolescents (Brafman, 1997, 2001), even when the presenting symptoms seemed quite serious. I am not arguing that we have better and quicker ways of helping children than giving them analysis. I rather want to emphasize the importance of a careful and detailed evaluation of the patient brought to us. Only then will we know precisely “what the child needs” and how we can best provide for this. In the worst possible scenario, we have parents who bring the child to us and have no capacity or wish to change their way of seeing the child. We may well decide that, even in these circumstances, we must do what we can to give the child a positive emotional experience. But when we find parents who are able and willing to become involved in the child’s treatment, we should consider whether the child should be seen on his own and the parents by another therapist, or whether we should see them together, so that they can learn about each other and develop different ways of relating. Quite often, joint meetings are a valuable step to ensure a subsequent individual analysis that makes sense to the child and the parents. Whether we like it or not, there is no doubt that a full analysis is an onerous commitment for any family. Furthermore, not many children or adolescents are able to accept attending for sessions four or five times each week. I believe we do ourselves a disfavour if we recommend analysis to a child or adolescent for no other reason than

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that child and parents are willing to accept it. I feel that, in the end, we should make sure that full analysis is given only to those children whose needs cannot be met by other therapeutic interventions.

References Bernstein, I. (1957). Panel: indications and goals of child analysis as compared with child psychotherapy. Journal of the American Psychoanalytic Association, 5(1): 158–163. Brafman, A. H. (1997). Winnicott’s Therapeutic Consultations revisited. International Journal of Psychoanalysis, 78: 773–787. Brafman, A. H. (2001). Untying the Knot: Working with Children and Parents. London: Karnac. Campbell, D. (1992). Introducing a discussion of frequency in child and adolescent analysis. Psychoanalysis in Europe, 38, Spring: 105–113. Daws, D. (1989). Through the Night: Helping Parents and Sleeping Infants. London: Free Association Books. Diatkine, R. (1972). Preliminary remarks on the present state of psychoanalysis of children. International Journal of Psychoanalysis, 53: 141–150. Fraiberg, S. (1980). Clinical Studies in Infant Mental Health. London: Tavistock. Freud, A. (1972). Child analysis as a sub-speciality of psychoanalysis. International Journal of Psychoanalysis, 53: 151–156. Hopkins, J. (1992). Infant–parent psychotherapy. Journal of Child Psychotherapy, 18: 5–18. Ornstein, A. (1984). The function of play in the process of child psychotherapy: a contemporary perspective. Annals of Psychoanalysis, 12/13: 349–366. Schacht, L. (1992). The elasticity of the setting. Psychoanalysis in Europe, 38: 63–80. Segal, H. (1972). The role of child analysis in the general psychoanalytical training. International Journal of Psychoanalysis, 53: 157–161. Stern, D. (1995). The Motherhood Constellation. New York: Basic Books.

CHAPTER SIX

Tailor-made therapy for the child: new developments in Winnicottian work with young people*

W

innicott was twice a president of the British Psychoanalytic Society and he was equally prominent in the medical and paediatric worlds: but if his colleagues treated him with respect, there was also a thinly disguised position of antagonism. We had no Winnicottians. Now, so many years after his death, Winnicott is becoming increasingly popular. Italians love him, Spanish analysts study him, in Latin America and France meetings and courses are being organized to spread his theories and techniques. Indeed, increasing numbers of professionals are keen to be recognized as Winnicottians. I think there are several Winnicotts now mobilizing the attention of the psychodynamic community. The one I most admire is the paediatrician who became a child analyst. Winnicott saw an enormous number of children and, above all, he knew how to engage them. As Clare Winnicott wrote (1977): “Readers will sense Winnicott’s own enjoyment in his play with the child. He perceives and

*Presented at a Conference, “The good-enough Winnicott”, 29 October 2005, organized by The Winnicott Clinic of Psychotherapy and The Freud Museum.

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accepts the transference, but he does much more: he brings it to life by enacting the various roles allotted to him”. He could express complex and profound experiences and views in a deceptively simple manner. It is important to remember that Winnicott had a deep artistic vein: he painted, he played the piano, and his writings often contain the touch that only poets can bring to life. But, much like Freud, Winnicott wanted to be seen as a scientist, and this is what probably led him to emphasize the conceptual elements in his findings. My impression is that Winnicott is being adopted as a gifted prescriber of theories and techniques. Much as happened to many of Klein’s formulations, there is a concrete and rigid element attached to what were meant to be explanatory concepts and I want to believe that this is not how Winnicott put his ideas into practice. We are now at the stage where biographers and commentators try to grasp the enormous richness of Winnicott, the man, the doctor, and the analyst. I want to focus on only one aspect of his work: trying to help children in distress. I would like to describe what I consider the main characteristics of “Winnicott’s approach” and then present what I have built on this foundation. 1.

2.

3.

Winnicott sought, above all, to understand the child’s experience of his problem. However obvious this may seem, it is very different from the goal pursued by the majority of professionals. Diagnosing a child as a case of “ADHD”, “depression”, or “obsessive–compulsive disorder” gives the professional the justification to implement what he considers the appropriate treatment for the condition, but it says nothing about the child’s conscious and unconscious perception of his life experiences. Even if listening to the parents’ account of the child’s problems, Winnicott gave primary importance to the child’s own formulation of his problem. He left us many descriptions of his style in approaching the child and the “squiggle game” has become a trademark of Winnicott’s work, but he was equally at home with toys or any other way the child chose to engage with him. Individual long-term treatment for the child was recommended if the child’s needs demanded this, but particularly so

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if the parents could not offer the child the support he needed. My impression is that even while maintaining a warm, friendly contact with the parents, he made no formal assessment of their psychopathology. He seemed rather to assess how much they would support or hinder the child to overcome his problems. Winnicott was very flexible in framing his help to the child. Often, what is called “a proper psychotherapeutic process” may mean no more than that therapist’s preferred mode of working, but this certainly never applied to Winnicott. One-off therapeutic consultations might be followed later by infrequent, “on demand” sessions and, if necessary, regular, longterm therapy would be recommended. He took careful account of the social needs and capacities of each family. At no point can one imagine Winnicott trying to “score points”, aiming to aggrandize his role in the therapeutic endeavour. The child’s improvement was his sole goal. I particularly like Winnicott’s description of the child relating to him as someone they had already met. I believe I am addressing the same point when I say that the child comes ready to open up and give the therapist all clues necessary for him to recognize what the child is struggling with. This specific kind of trust probably originates from the child seeing the therapist as a found-again ideal object, and it creates a very striking sense of closeness. Reading Winnicott’s account of his meetings with children, people will have different reactions. I suspect that his idiosyncratic rendering of the child’s unconscious feelings will puzzle some readers. Personally, I have come to believe that what words a therapist chooses to formulate his understanding is not really so important. Adults, but mainly children, seem to be far more preoccupied with gauging the therapist’s understanding their feelings or not, so, sometimes, an apparently “correct” interpretation is ignored, while a clumsy sentence may be experienced by the patient as true and helpful. And, time and again, Winnicott can be seen to tune in to the child’s feelings whatever words he chooses to convey this understanding. His work was truly tailor-made to fit each child’s needs and abilities.

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My contribution I like to start a clinical assessment by seeing child and parents together. After inviting them to make themselves comfortable, I address the child and try to engage him in conversation. I ask whether he knows who I am, why is he coming to see me, what difficulties he is experiencing and, depending on his age, I will ask about details of his daily life at home, at school, etc. It does not, usually, take very long to gauge the child’s capacity to communicate with a stranger, but I also discover each parent’s attitude towards the child: do they interrupt him? Correct him? And how does the child react? When I feel satisfied that I have a good idea of the child’s experience of himself in the world, I suggest he might do some drawings while I speak to the parents: children are quite happy to comply. While the child draws, I ask each parent to give me a thumbnail picture of their individual history, to serve as a background for me to understand the child’s problems. This history and the ensuing account of how each parent sees the child’s problems give me a reasonable picture of whatever contribution they might be making to the persistence of the child’s problem. I believe that, by the time we see the child, whatever started “the problem” has led to the creation of a mutually reinforcing vicious circle, where the child and the parents confirm, time and again, what they have come to expect of each other. There is no point in searching for what is cause and what is effect: the challenge is discovering the child’s unconscious fantasy that perpetuates the problem and, correspondingly, what factors in the parents lead them to treat the child in a manner that his fantasies are confirmed. If we find that the parents are not prepared or not able to change their behaviour once the child’s unconscious fantasy comes to light, then we have to focus our therapeutic input on the child alone. But it is important to remember that not all children’s problems are of a psychodynamic nature. The consultant has to be extremely aware of the importance of picking up any organic, physiological, nonpaychogenic problem that requires specialized attention. Indeed, all these problems will also lead the parents to find ways of adapting themselves to the child’s abilities and needs, but the consultant has to be very careful to identify what is psychodynamic and what is

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physiological: both require appropriate attention, but they demand very different approaches. The advantage of adopting this interactive model is that when parents understand the true nature of the child’s problems and are able to change their approach to the child, they can be recognized as effective therapists who can help the child. With younger children, we are often consulted over problems related to body functions like eating, sleeping, and control of bowel and urinary sphincters. I believe these bodily activities are very powerfully influenced by the family’s ethos. Some children will achieve sphincter control with minimal parental input, but other children require laborious “toilet training”. Needless to say, each parent has his own thoughts and feelings regarding the body’s functions and these will inevitably influence his/her approach to the child; furthermore, this training process also mobilizes the parent’s views on what “education” and “discipline” mean. Some parents see toilet training (or table manners) as a crucial step to living with peers and, therefore, feel justified in using whatever techniques will help the child to achieve continence (or good eating manners). Other parents, however, see “disciplining” as an infringement of the child’s right to independence and are loath to impose rhythms or routines on their child. We also find parents who see excretion as eliminating poisons and will give medicines or impose punishments until the child excretes those dangerous substances. But I firmly believe that similar considerations about the parental input to the child’s development apply to many other details of daily living, such as sleeping, or how a child treats other children and the adults around him. What makes our work so immensely difficult, but also so fascinating, is the need to differentiate between what is part of the child’s inborn endowment and what results from what that child’s unconscious processes have made of these external and other internal stimuli. Winnicott and most child therapists focus their helping programme on exploring the child’s unconscious fantasies and helping him to achieve a better, more realistic view of himself and of the people around him. But I have found that if we can identify the parental contribution to the child’s problems and proceed to help them to obtain a clearer understanding of the child’s experience, they can modify their approach to the child, thereby breaking the

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vicious circle, what we might call “the knot”, that previously perpetuated the child’s anxieties and symptoms.

Drawings I have a special interest in drawings. Creating images can allow the child (or the adult) to express thoughts and feelings that they might not manage to formulate in words. This may be linked to unconscious defence mechanisms, but I believe that it is also a question of “language”. I have found that some people have a personal, idiosyncratic ability to represent perceptions or fantasies in images. In fact, I have also found that some persons have precisely the same ability to translate feelings, thoughts, and experiences into musical language. In principle, I will invite children to make spontaneous drawings. Most of them will ask what they should draw and my standard answer is “anything you like”. If they cannot do anything without a definite suggestion, I will say something like “your family”, or “yourself”, or “something you like to do”, or I will remind them of something they have said during our conversation and suggest they depict that. If the child is completely unable to draw spontaneously, I will then suggest we play “squiggles”. I have still to find a child who does not join this game. When I feel I have “worked out” the child’s unconscious fantasy, I try to find the words to convey this to the child. In most cases, one or both parents will have come near our table by then, so that they can both see the pictures and hear the child’s words. When both child and parents can see how they had “misunderstood” each other, we have a discussion covering what had been happening and attempting plans for the future. If this is not the case, we will arrange a follow-up appointment to continue with our investigations.

Clinical examples Robert This eleven-year-old boy was complaining of hearing shouts, echoes, and voices in his head. He had a fourteen-year-old brother,

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and both boys were doing well in their schools. Both parents came to the interview with Robert. Father was an industrialist and mother was a teacher. Robert was aware of how worried his parents were by the symptoms he complained of. He told me about his school and general social life, and, in a rather hesitant way, he described his “voices”. He came to mention that only seldom did the voices haunt him when at school, and when this happened he discovered that he could try to ignore them and they would stop. I asked what happened when they appeared at home, and he became clearly self-conscious, looking up to his parents. To my surprise, his mother said it was quite all right that he should say whatever he wanted. Robert indicated that life at home was rather tempestuous and mother took over, telling me that she had frequent and passionate clashes with her husband. They disagreed over how to bring up the children and the husband always demanded she should heed his injunctions. This had led to two crises when mother had actually moved out of the house for rather short periods. I turned again to Robert, and he told me in detail how the voices tended to plague him mostly at home in the evenings. He could not fall asleep and invariably ended up sleeping on his mother’s bed. I asked the parents what led them to agree to this arrangement, and father shrugged his shoulders, barely muttering that his wife was very protective of Robert. For her part, the mother explained that she was very worried because a friend’s brother developed aural hallucinations and psychosis in his late teens and also because an older sister of hers “was always a depressive” and had committed suicide aged twenty-six. It seemed obvious to me that Robert had found a way of comforting his mother and ensuring she did not leave him. The question then became how to help him. I thought it was the mother who needed to gain some insight into her anxieties, while we could afford the time to put Robert through a test. If this did not work, we could always look for new solutions. They had told me that up to one year ago the two brothers shared double bunk beds and that Robert had resented being “promoted” to have his own room. I emphasized Robert’s reported discovery that, given time, the voices disappeared: a development that only failed to work when he was on his mother’s bed. I recommended, therefore, that Robert should

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sleep in his brother’s room for a period of time and they could then report to me on the results of this change. The mother telephoned me two weeks later and said that the crisis seemed to have been resolved. She added, however, that she was struggling with feelings of helplessness and self-doubt, and this led to our arranging a series of meetings to discuss these problems. Needless to add, Robert’s voices disappeared and his nighttime behaviour returned to normality. We agreed that Robert might need individual help later on, but this would depend on his further development.

Joanna This was a two-and-half-year-old whose mother had worked for many years as a nanny. Joanna had a rich vocabulary and “an astonishing memory”, which delighted both parents and her nursery teachers. Suddenly, she developed a phobia of baths. As soon as her mother tried to put her into the bathtub, the girl went into a panic, crying painful tears. Her mother tried all the tricks she knew and all kinds of advice she collated from friends and professionals, but, after several months of stalemate, she asked for a referral to a child psychiatrist. But this charming child simply refused to engage in conversation with me. She played, most competently, with various toys, but only gave me the odd monosyllable in answer to all sorts of questions I asked. At some point, she found the felt-tip pens and proceeded to make a drawing on a piece of paper (see p. 45). I noticed that she first made horizontal lines with wings in the middle of the page in red and then an encircling line in light green, after which she proceeded to make innumerable criss-crossing lines of varying colours. So, what was this about? She wouldn’t answer me! I told her that I had noticed the first line and the “containing” ones, but . . . after some further attempts, I asked her if she would tell her mother if I left the room. Mother was surprised, but Joanna beamed. After a couple of minutes, the mother called me back: she had been instructed to tell me that the drawing represented a fishtank and that the first red line showed a goldfish, and this information had reminded the mother of a goldfish Joanna had won at a fair not long ago. As it happens, the goldfish had died and the girl

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was upset, but neither parent thought much of this. Joanna was following her mother’s account, standing near her. I said I now understood the mystery: Joanna was afraid she might die in the bath, just as the goldfish had. The mother was incredulous, but Joanna smiled gently and now sat on her mother’s lap, resting her head on her bosom. She made no comment and when her mother asked me what she should do next, I said that probably nothing more needed to be done, since Joanna’s behaviour showed very clearly that she had understood what had gone on. They left, and a few days later I heard from the Health Visitor that from the moment they got home, the little girl had had no further difficulties with her daily bath.

Max The parents of this eight-year-old boy had divorced and, though they agreed on the timetable for his contact with his father, there remained considerable animosity between the parents. Max started to present behaviour problems at school and he was clearly depressed. However much each parent loved Max, and even if very aware that their clashes made Max feel insecure and unhappy, neither of them was able to change their attitudes to each other. During the diagnostic consultation, Max made a drawing that showed how torn he felt between his parents and their expectations. I saw the parents a few times on their own and it was clear that they could not change their feelings and help Max. Fortunately, they agreed with my recommendation that Max should have openended individual psychotherapy.

Summary I hope these examples show how, when seeing a new case, I try to gain a picture of how the child and each parent see the problems that brought them to see me. Once this evaluation is achieved, it is important to assess the capacity each of them has to gain insight into their feelings and change their approach to the others. It is rare to find parents who truly understand the child’s experience of the situation. In a sense, this is quite normal: in any relationship we

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have to expect that each participant has his own, private, ideas as to what the other one feels and thinks. But when a child is involved this takes on a special dimension, since the child can only function in line with his age. There are many things that can surprise or produce fear in an adult for a few moments, that is, until reason is brought into action, to put things in a more realistic dimension, but they can trigger off feelings and thoughts in a child that can gain overwhelming proportions. And it can be virtually impossible for the parents to find the way to what interpretation the child has put on that initial experience. Considering the examples given above, with Robert it was not difficult to perceive how intimately his symptoms were linked to his perception that the mother resented and dreaded any closeness to her husband. He was also afraid that she might again leave the home. Whatever first led him to experience and complain of “voices, noises in his head”, he must have sensed that these complaints produced in his mother a mixture of tenderness and anxiety that kept his symptoms in place. Fortunately, his mother had enough insight into the situation to request further help for herself. In Joanna’s case, her mother must have gone through many different emotions in trying to get her daughter into the bath, and I believe that many times her impatience or exasperation were seen by Joanna as signs that she, mother, wanted to kill her. It is conceivable that Joanna might have blamed herself for the death of the goldfish and she was, now, projecting this image on her mother. Joanna’s understanding of her anxiety and her mother’s insight into what prevented Joanna from entering the bath led to the disappearance of the phobia. Max and his parents were caught in a painful conflict that made the boy unhappy and depressed. As the parents were not able to change their feelings towards each other, it was important to provide Max with the opportunity to have his individual psychotherapy. Follow-up information was that his feelings and behaviour had improved considerably. Each time I present these and similar cases, I am asked to explain why it is that one or two interviews should be sufficient to produce such dramatic results. Sometimes, people say that these cases have the appearance of “magic”, other times someone will say

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that it is not anybody that can carry out such interviews. I believe that these therapeutic consultations can be effective when one aims to elicit the child’s unconscious ideas that underlie the presenting symptoms, and I have found, time and again, that the moment the child understands the real nature of his fear, the symptom will disappear. This is even more so when the parents can also change their approach to the child. But this is not magic; it must, rather, show that, given the right kind of help, the child’s own resources come into play and restore normal functioning. This is what we call resilience, and I do believe that this is what enables the child to come to a consultation and give the consultant all the clues he needs to find his way to helping the child.

Reference Winnicott, C. (1977). Introduction. In: D. W. Winnicott, The Piggle: An Account of the Psychoanalytic Treatment of a Little Girl. London: Penguin, 1991.

INTRODUCTORY NOTE TO CHAPTERS SEVEN AND EIGHT

Feet on the ground

M

y bringing these papers under the description of “feet on the ground” appears to have a touch of irony, but that is not my intention. It is safe to assume that most of those learning or practising therapy have a good level of intelligence and this will ensure their ability to use their knowledge and imagination to formulate hypotheses to make sense of the emotional experiences they encounter in this field of work they have chosen. Formulating these views with a language that characterizes scientific findings is an attempt to put them forward as facts, and, predictably, this meets the needs of many students and qualified professionals who do not feel comfortable with uncertainty or doubt. My “letter” to the new psychotherapy student discusses some of problems trainees are likely to meet as they embark on this training. The emphasis is on helping the trainee to recognize that psychotherapy involves a wide and complex range of issues, not all of which will be found in other areas of work. Urging them to keep their feet on the ground refers to showing them that many of these difficulties are part and parcel of this particular field of work and not the result of any personal emotional shortcoming. When much 121

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of present day teaching points to a patient’s pathology to explain the trainee’s anxieties, I prefer to help the trainee to scrutinize what belongs to the patient, what is an intrinsic part of the psychotherapy setting, and what, in fact, stems from his personal feelings. “Memorizing vs understanding” was written having in mind colleagues devoted to teaching. I tried to share my realization that . . . learning demands the existence of a previous “not-knowing”, where the new datum will fill a gap or explain a quandary. When this is not present, an intelligent student is well able to memorize what he is supposed to absorb, but this will only be translated into actual learning when that awareness of a gap is experienced by the student.

It is not so common to find lecturers who seek to establish a live dialogue with their students and, sadly, many teachers will often misinterpret the motive behind questions put to them by the students. In an ideal world, a teacher would try to establish whether their students have truly grasped what they wish to convey. It is this goal that would demand that they had “feet on the ground”. The observation of infants and discussions on child development can offer a clear picture of the difference between what is learnt from lectures or textbooks and what originates from a close contact with infants and young children. In another paper (Caldwell, 2002), I expressed my disappointment at this discovery: Whatever the reason, all trainees can put forward endless theories of early development, but only a few actually welcome the opportunity of coming close to a baby. In practice, those who feel comfortable with children and actually want to work closely with them move towards trainings specializing in work with children, while those who come to analytic or psychotherapeutic trainings are mostly interested in seeing adult patients. They clearly feel more comfortable dealing with the “conceptual infant” (Stern, 1985) than with real babies. Infant Observation, sadly, becomes no more than one of the disciplines leading to their desired qualification. [p. 69]

I cannot emphasize enough the richness of the material we meet, whether observing infants, teaching students, or seeing our

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patients—provided we keep an open mind and, to use another body metaphor, keep our feet on the ground, making sure that our understanding of what we see or hear can be confirmed by further scrutiny of what we are involved with.

Reference Caldwell, L. (Ed.) (2002). Infant observation—what do you see? In: The Elusive Child (pp. 59–69). London: Karnac.

CHAPTER SEVEN

Letter to a young psychotherapy trainee*

D

ear Colleague,

I am pleased to learn that you have started your psychotherapy training. You have been looking forward to this moment for a long time and I can imagine how proud you are. Congratulations! It is kind of you to ask me for some views on the work ahead of you. Very much as you requested, these are highly personal views. I have no wish to give you a comprehensive, textbook-like view of psychotherapy, since I am sure your lecturers are bound to give you plenty of reading lists. I will rather describe some of the answers I give to questions that come up when I see psychotherapy students. Psychotherapy is always defined as a “talking therapy”, but, for practical purposes, you should remember that “talking” is the patient’s share, while your major responsibility is rather to listen and to learn how to hear what the patient is trying to convey to you.

*First published in 1999 in The Psychotherapy Review, 1(1): 16–22. This is an abridged version of the original publication.

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This is not as easy as it may sound and, over the years, a number of formulae have been devised to help people in your position to feel comfortable when facing patients. Many of these formulae have become clichés that can be misleading: they may help you in the short term, but they interfere with your spontaneity and block your capacity to discover your own way. I will discuss some of these “rules” further on. First, though, I want to make some comments on one of the two main protagonists of the psychotherapeutic encounter: you. Freud once recommended that the analyst should behave like a “mirror”, reflecting back to the patient his own material, without allowing personal factors to influence his work. His argument was correct: the patient does not consult you in order to learn of your ways of coping with the problems of living. Your experiences, feelings, views, social or ethical or of any other nature, are your concern—you must remember that when the patient comes to you he is in a vulnerable position, highly suggestible to your influence. This is what led Freud to urge the analyst to concentrate on helping the patient to find for himself the solutions to his problems and never to allow his own prejudices to influence the patient. However, this recommendation does not mean that all therapists are interchangeable, or that the therapist should attempt to behave like some automaton, pretending to be anonymous. Quite the contrary: your personal appearance, every minute detail of your behaviour, is an important factor in your interaction with your patient. What you do counts just as much as what you don’t do; what you say is just as significant as how you say it; your physical presence is just as important to your patient as your emotional stance and your professional intervention. Your patient wants to meet you as you really are and not someone trying to impersonate a particular character. However, the real difficulty here is that it is virtually impossible for anyone to feel self-confident enough to behave spontaneously when in the position of a trainee, a beginner. In other words, I am only telling you what you should aim at: if you bear this in mind, you will find it easier to use your self-criticism in a constructive way. There has always been considerable discussion about what are the “therapeutic factors” in psychotherapy. Essentially, some argue that what counts is what you say to your patient, and others say that

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it is your attitude to your patient that will lead to his improvement (or otherwise!). Whichever view you follow, you should assume that, irrespective of what you say to your patient, your attitude to him will make an enormous difference. Any patient will accept his therapist making a mistake or saying something irrelevant, puzzling, or even incomprehensible, provided he can perceive that the therapist is saying this in good faith, with good intentions. Conversely, even if you proffer the most indisputable revelation about him, no patient will cope with this being put forward in a spirit of malice or sarcasm or contempt. In other words, if you treat your patient with respect, tolerance, patience, and a genuine wish to be helpful, you will be given time to find the words that you may consider important to voice.

What makes them come to you? The patients you will see as part of your training will be chosen by one of your senior colleagues. Depending on where you work, they will be described in different ways, for example, using a psychiatric diagnosis, naming a symptom, describing some psychodynamic conflict, etc. Whatever the language used, the consultant’s formulations represent the summary of what he thinks is the patient’s problem and why he believes he can benefit from therapy. As you have been working in that department, you are likely to understand what is meant by that formulation, but you will find that meeting the patient is quite a different story. Broadly speaking, you will meet three kinds of patients: (1) those who know precisely what bothers them and who want to discover whether you can help them to overcome it; (2) patients who seem more preoccupied with the personal interaction with you, who will enquire about you and soon make it clear that it matters to them how you see them, what you make of them; and (3) others who appear oblivious to who or what you are and who behave as if they did not really know why they came to see you or what might be the purpose of such meetings. You will soon find that each patient presents features of more than one of these groups. But this classification should prove helpful in your first contacts. Patients of each of these groups will arouse

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a different reaction in you. At the risk of oversimplifying a complex situation, let us look at each of them. 1.

2.

These patients lead a life that is mostly satisfactory; they have an active personal, family, and social life, but they become aware of having met some stumbling block that creates difficulties for them. This can be experienced in activities or in relationships, but the relevant point here is that the patient feels able to cope with his day-to-day life, except for this one area. One example is the successful lecturer who is appointed to direct a department and then finds himself clashing with the Head of the College. It might be argued that therapy should probe his relationship with his father, his attempts to contain his aggressive impulses, his feelings about success and responsibility: in practice, patients in this first group will stay in therapy only until they understand the nature of their present conflict and find a way of resolving it. This is not due only to a defensive wish to refuse looking into other conflicts, but to the fact that these patients feel, on the whole, competent and fulfilled. Here, in this group, are the patients who bring to life the concept of transference. The problems they report pervade most areas of their daily lives; they may well have managed to build a reasonably successful family, social, and professional life, but they feel dissatisfied, they experience a sense of having achieved success “in spite of” themselves. Or they can be patients who have ground to a halt in one or more areas of their life—not that they stop working, indeed, they usually keep going, discharging their obligations, but they describe a loss of “joie de vivre”. This is not necessarily the same as depression, though it is often diagnosed as such. It might be more accurate to describe it as an existential crisis, a point when the person questions the validity of what he has done or what he is. The typical university student who breaks down during or shortly after his studies belongs to this group, and so do young adults who reach the “thirties” landmark and become unable to feel justified in continuing work, relationships, or even their attitude towards life, as up to that point. Most patients in this group are able to discuss your comments, that is, they can understand the words and respond in

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line with what you meant to convey, but sooner or later you will notice that there is another level of communication operating between you: the patient is reacting to the emotional content he attributes to your comments. This can be very disconcerting, as you are bound to be trying hard to be objective and dispassionate in your work. Suddenly to be challenged (explicitly or otherwise) as harbouring critical, or even supportive, feelings towards the patient may lead you to feel that you have to defend or justify yourself or even to correct the patient. Instead, you should recognize that these are patients for whom it is important to assess how they are seen, people whose selfesteem is low and who hope to build it up on the basis of obtaining positive feelings from you. From all points of view, it is best that your patient finds friendship, devotion, and love in his life outside the consulting room: here, he is best served by meeting professional competence. The work with the patients in this group will teach you the concept of transference and help you develop your personal style when giving a transference interpretation: here you have a patient who knows who you are and yet experiences and voices feelings which are directed at who you seem to be. You have to find the words and the manner to voice your understanding of both these levels of relationship. It is not as easy as it sounds, but because this group of patients can grasp the difference between factual reality and emotional reality, you should have the opportunity of improving your personal style of work. Incidentally, this relationship that the patient has to who you are is what is called the therapeutic alliance, while the relationship to whom they imagine you to be is the transference proper, sensu strictu. This is the most difficult group of patients that are likely to come your way. In ordinary language, you would say that their lives have come to a halt. Some of them will be called psychotic, others inadequate or immature personalities, others will attract more abstruse diagnoses. But the common denominator between them is that they become unable to keep up with their day-to-day life commitments, they tend to require help from both the medical and the social services departments. Some will be on drugs, others will attend day centres or

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hostels, or even require hospitalization; others manage to sustain some kind of independent life, but this tends to be limited in scope. Clearly, these patients need help and it is likely that a few of them will be able to benefit from individual psychotherapy, but it is difficult to decide the precise technical parameters of such therapy. Sadly, these patients seldom manage to utilize understanding to bring about a change in their lives and it is this puzzling finding that makes this group of patients so difficult to help. As a professional who decided to learn psychotherapy, it is likely that you believe in the curative effect of insight. You will find that many patients in this third group can articulate words of apparent insight into their problems. But, even if the patient believes in the truth of his utterances, he cannot work on these apparent truths to achieve any change in his views of himself and of his world: he can learn how to accommodate to harbouring those feelings, but not to alter them in any effective way. However, do bear in mind that working with some of these patients can be very rewarding as a learning experience, but you will need to approach them with a different set of expectations than you might bring to the work with the other two groups.

What are you supposed to say? You are not the only student to worry about this: it is a universal anxiety that persists for quite a few years. You know that you have become a more experienced therapist when this same question turns into “considering these various things I could say at this point, what is the relevance of each of them?” This now means that (a) you find several alternatives to choose from, and then (b) you are able to differentiate why each option occurs to you and what would result from your voicing it or not. Being a student, you are probably quite content when you find one thing you might say, but I believe this does not so much result from your capacity to be or not to be a therapist as from trying to guess “what you are supposed to say”. This is a highly crippling thought. If we accept that you cannot eliminate it, perhaps we can identify the reasons for its presence: first, your normal self-criticism and your presumably

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long-held idea of what a therapist is supposed to do are bound to make you deride most of the possible interventions that come to your mind. Being a student of a new discipline tends to make you oblivious of the value that experience in other fields (including your own life!) has in enabling you to understand this person now turning to you for help. This view results from an awareness of your inexperience in this new field, but it also stems from your idealization of the figure of the analyst/therapist: the combination of these two factors can reduce you to an embarrassed silence. Second, your own therapist or analyst. Like all trainees, you must be in some form of therapy, and it is inevitable that you should attempt to guess what your own therapist would say if he was in your place. But, as you face your patient, the attempt to guess what your therapist might do only leads you to a bout of self-mortification, and it takes your mind away from what your patient is saying. Third comes the setting in which you see your patient. If you are part of a group, you will soon find yourself imagining their reaction to what you report. This is a phase where everyone wants to score points and I am sure you are no exception. The group leader should help you out, but otherwise you may find yourself feeling trapped. The best way of escaping this impasse is to acknowledge that your colleague may be right, but remind him that only you were in the room with the patient. Putting it simply, being a beginner is an unavoidable condition, and trying to guess “what you are supposed to say” to your patient is part of your present predicament. You cannot be spontaneous in the first stages of your learning and it is actually good that you should aim at modelling yourself on those professionals you respect, but the lesson to learn from these complex situations is that you must try to identify your mistakes—and learn from the experience. Whether your “mistakes” are called such by colleagues or teachers is not as important as is the capacity to use self-criticism and a rather elusive blend of modesty and self-assurance.

When does the session begin? Here is an issue that demands two, apparently contradictory, answers. On one level, meeting your patient in the waiting-room,

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bringing him/her to your room, offering him/her a chair are steps that call for your behaving in a civil, courteous manner, as in any other social encounter. The first time you meet your patient, you should do your best to put him/her at ease; some brief statement about who you are might be appropriate, though your state of anxiety and self-consciousness might preclude your managing to do this. But in any case, greeting the patient when you first see him and saying some form of “good-bye” when he leaves underlines the fact that, whatever roles a therapeutic contract imposes on you, both you and the patient remain two adults who have to treat each other with the respect and consideration that you would use in any social situation that brought you together. There are a number of issues that you will have to discuss with your patient in your first meeting, for example, fees, timetables, holiday arrangements, length of each session, procedure over missed sessions, etc. Of course, the setting in which you see the patient may add other issues or make some of these examples superfluous, but it is important to treat these questions in a matterof-fact manner, that is, as if no feelings were attached to them. Your NHS patient might argue that he needs much more than the one session per week that you offer him, and this must not lead you to apologize that your consultant or your caseload does not allow you to offer him more. When such issues are raised, you should discuss them with your patient as any two adults about to enter into a contract. If your patient is unable to do this, you will know that he cannot cope with a situation where ordinary everyday logic applies, and you must treat this as an important diagnostic finding that calls for appropriate technical steps. However, on another level, you must pay great attention to every detail of your patient’s behaviour from the moment you meet, since this will help you to build a picture of how he deals with a new situation, a stranger, and particularly a stranger who is in a special situation. It is not only you who is aware of being a student; your patient also knows that a senior practitioner has put you in charge of undertaking his long-term treatment and this is bound to affect his attitude to you. Whether you feel that his attitude is fair or unfair, appropriate or not, justified or otherwise, is quite immaterial: what matters, at this point, is that this attitude throws light on how this patient looks at his world, how he deals

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with people he meets, and, particularly, his expectations as he meets someone who purports to wish to help him. Your objective is to understand your patient, not to correct or give him explicit reassurance, but to use every step of your encounter as a clue to make sense of the patient’s relationship to you and to the people in his world. If you can show the patient that his comments deserve respect and that they can help both of you to understand his feelings and his behaviour, this will represent the most effective reassurance you can give him. There will always be situations that may take you by surprise. One example is the patient asking you about the use of toilets; another common one, when you ask your patient to lie on a couch, is his asking whether he should take his shoes off. You must be quite clear in your own mind about what you wish your patient to do and state it, simply, matter-of-factly. If you feel it is important to discuss such requests, then you have to find a way of keeping apart (a) the clarification that your patient requests and deserves, and (b) your belief that the request contains emotional elements that should be discussed. The fact of your being a therapist still does not justify your speaking to him only in the language of “interpretations”. Those who are familiar with the idea that the therapist is trying to put into words what he believes is the content of the patient’s unconscious thoughts and feelings accept quite happily the classical shorthand, “I think you are telling me that . . .”. However, at the beginning of therapy, it is best that you should first acknowledge the patient’s explicit communication. What follows is essentially a matter of individual style, but you should say a few words to explain that you can discern in his words a meaning of which he may not be aware. This is not an apology, but a sign of respect for the patient’s reality-testing and for his capacity to consider that his words might have conveyed a meaning different to that which he had meant to express. Incidentally, this capacity is the essential prerequisite to benefit from insight-directed psychotherapy. Not that the patient has to say “Amen” to each of your interpretations: some of them may be put to him prematurely or in the wrong phrasing, while others can be plainly wrong. But if you establish that your patient cannot consider that his words may convey something different to his conscious conviction, then this points to your revising the parameters of the therapy you are offering him. He

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may well benefit from some form of psychotherapy, but not from those techniques that aim at giving him insight into his problems.

What are the qualities required of a therapist? Many years ago, the British Society of Psychoanalysis held a meeting to discuss this topic. Many opinions were voiced, but, essentially, these were a series of adjectives, meant to define the ideal, no, the essential, attributes to be expected of any candidate. Honest, responsible, reliable, trustworthy, truthful, respectful, consistent— these commanded general approval. Most analysts protested when one of them said she also expected a candidate to be intelligent (she was accused of being elitist), but the audience was taken by surprise when another analyst (Paula Heimann) said that she believed all the attributes put forward should, in fact, be expected of any decent human being. By themselves, they said nothing of a candidate’s aptitude to become an analyst. You will meet many therapists treating psychotherapy as a set of rules, much along the model of earlier books on the significance of dream symbols. The implication of these rules is that, provided you can follow them, you will become a good psychotherapist. You will meet rules such as “everything the patient says must be interpreted as a reflection of his feelings for you”; “all the people in a dream indicate parts of the patient”; “your feelings during the session indicate what the patient is feeling or what he is trying to make you feel”; “patients experience week-ends and other breaks in the therapy as separations that arouse resentment and fear of losing you”; “the patient cannot cope with his bad feelings and will project these on you: this is why he experiences you as a critical figure”; “the patient’s feelings for you are determined by his earliest experiences”; etc. It is quite natural that a student should turn to these rules to help him with the anxieties of his inexperience, but eventually you will find your colleagues separating out into two groups: one will continue to use these formulae, while the other will notice that their patients do not fit so perfectly into these supposedly universal rules. The essential quality required of a psychotherapist is that of empathy, but, ideally, he should also have a need to help others. On

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its own, the need or wish to help others is not enough to make a therapist. Empathy, as you know, is the capacity to put yourself in somebody else’s shoes, but this implies the capacity to retain a clear awareness of the distinction between self and other; if this is lacking, even if there is an appearance of understanding, it will soon be clear that the therapist is seeing himself in the patient. Some patients sense this and take flight, but others may have met such a relationship earlier in their lives and they can become attached to the therapist, with an increasing and crippling dependence on him. A therapist needs to gain some gratification from the experience of helping another person. You will find that being a therapist represents a heavy burden and it can often be a painful occupation. If it is true that it may bring you better remuneration than some other occupations, it certainly will never make you rich. It is said that a training analysis is really meant to help you discover why you want to be an analyst: this is a fundamental question you should attempt to answer before you decide to adopt psychotherapy as your career.

What are you aiming at? As you are part of a formal training, I assume that you intend to take up psychotherapy as your main career. Many people in your position have joined the courses run by hospitals, clinics, and services that are offering some psychotherapy training experience to people working in the helping professions. A large proportion of these professionals are exploring “how it feels” to be with a patient in a psychotherapeutic endeavour. Not all trainees go on to become full-time or even part-time psychotherapists, and I would urge you to suspend this decision for a time, if at all possible. Once you set qualification as your goal, every mishap feels like a catastrophic failure. You can get to the point where, if your patient misses one session, you become fearful that another period of weeks (months?) will be lost before you find a new training case! This is a dangerous thought, as you can find yourself treating the patient with the awful mixture of placation and resentment that we have towards another person felt to have “power” over us. Feeling insecure in your

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position, it is easy to believe that the patient is trying to control or overpower you. Perhaps it is impossible to forget that you are not just trying to help the patient, but also pursuing a training that means a great deal to you. And yet, you should try to allow yourself to savour the psychotherapeutic encounter as if this was, all by itself, your single objective. When with the patient, it is vital to push aside all preconceptions, assumptions, anxieties, wishes, goals, etc. Different authors have described this attitude in their own way, and my favourite one came from Dr Hans Thorner, who compared a session to the opening of the curtains to reveal a stage where the action was totally unknown. If you believe you can predict the action, you are bound to compare what comes your way with that which you anticipated would happen. Similarly, if you listen to your patient while thinking of your supervisor, you are bound to interpret the patient’s words as confirmations or denials of the supervisor’s comments. All such assumptions and comparisons take your attention away from concentrating on what the patient is actually saying. Counsel of perfection, no doubt, but you will only approximate this ideal if you keep an eye on the occasions when you deviate from it. There is something just marvellous to be gained from a psychotherapeutic encounter. You will feel enormous excitement when you hear your patient say “oh, yes . . . that makes sense . . . funny, when you say it, I can see that I’ve known it all along . . . and yet, I had not really seen it like that at all”. It is the pleasure of finding that the theories you believed in are really correct, that it is possible to help someone without interfering with their lives or giving them advice based on your preconceptions. You will be pleased with your capacity to understand and make sense of what the patient tells you and you will enjoy your patient’s appreciation. A good psychotherapeutic experience will help you understand how people think and feel. You appreciate the value of work that does not carry a demand for gratitude and/or dependence. It is the patients in the first of the groups I described earlier that are more likely to help you achieve these discoveries, and I hope you will find some of these patients before long. The patients in the second group tend to embark on a protracted therapy, developing a transference relationship that will take you through the vicissitudes of

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such therapies, where the occasional good session is followed by days or weeks of trying to find your way in a fog of multiple possible meanings. This is a valuable learning experience, but it can become very taxing for those who are not contemplating a career in psychotherapy. I hope you will not be given patients from my third group. They are the bread and butter of those who work in hospital wards, hostels, or day hospitals, but they can lead a psychotherapy trainee to feel total despair of his capacity to make sense of the patient. There are other patients who do not fit this classification, but it is unlikely that they will come your way: perverts, addicts, confidence tricksters, gamblers, etc. But these patients share with those of my third group the characteristic that, even if they come for therapy, they profess their disbelief that this can help them and leave you with the wish to explode and ask them the obvious question “why, then, do you come?”. It is pointless to ask this, as they would be unable to answer it in any satisfactory way, and it is probable that they will interpret your question as your informing them that you have reached your limit of tolerance. Patients in this last group should be seen by you as part of your acquiring increasing experience in this work. One of my teachers, Dr Julius Rowley, a wise and knowledgeable analyst, taught me that with these patients you must not hope to change them, that you can only relax, do your best and learn from the experience. You may think this is a cynical opinion, but I assure you that this makes clinical sense and, furthermore, such a posture can at times be quite helpful to these patients.

So? As you can see, I have put more emphasis on what you should not do or say than on what you should. This is because I believe that if you understand your patient, you will find the right way of conveying this to him, while if you do not understand him, it is unlikely that any advice, from me or anyone else, will enable you to hide or disguise this. Nobody expects you to understand the patient all the time, and you will find that your patients are usually able and willing to give you time to work out how to help them.

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In practice, the sense of urgency in finding something relevant to say to your patient will mostly originate from yourself. Only practice and growing self-confidence will make you believe that your patient can accept your not having something useful to say, as long as he can feel that you are concentrating on him and trying to help, and he will glean this more convincingly from your attentive silence than from shallow or inane remarks meant to disguise your feeling lost. If you find that the patient has stopped and expects you to say something, while you cannot quite grasp the meaning of what he has said, you can always ask him to clarify or enlarge on some point he has made. Seeing your first patient is bound to make you feel terribly excited—and enormously scared. If you are afraid that you will make your patient pay the price of your inexperience, congratulations: this means that you can recognize the impact that your actions can have on another person and this augurs well for your capacity to learn from your experiences and, all going well, do good work as a psychotherapist. This is one of those occasions when it is healthy to be aware of your fears and proceed with caution, care, and, yes, with confidence and optimism as well. Good luck! Do let me know how you get on! Yours sincerely, A. H. Brafman

CHAPTER EIGHT

Memorizing vs. understanding*

U

niversity College Hospital, now the Royal Free and University College School of Medicine, has a long tradition of giving clinical medical students the opportunity to see selected patients for weekly individual psychotherapy for periods of about one year (Shoenberg, 1992). Predictably, this scheme attracts students who already have an interest in this kind of work. Peter Shoenberg, the present consultant in charge of the Psychotherapy Department, thought of extending this project by offering to those students attending the department during their four weeks’ placement in psychiatry a series of weekly meetings where issues related to psychotherapy would be discussed. This project was sponsored by the Winnicott Trust (a charitable organization devoted to the teaching of Winnicott’s ideas and the propagation of his writings, teachings, and beliefs. I am grateful to the Trust for their support and to Peter Shoenberg for his invaluable advice and encouragement) with the intention of helping students to understand the psychoanalytic view of the influence of early emotional development on the behaviour of the adult. *First published in 2003 in Psychoanalytic Psychotherapy, 17(2): 119–137.

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Not surprisingly, it was found that there was considerable variation in the level of interest that students showed in these seminars. For many, the psychiatric placement was just one more subject they had to go through in order to achieve their medical qualification, and this led to their wanting to learn just enough to produce answers to exam questions. A few, however, found the discussions interesting, and they participated in the meetings with an obvious wish to learn. The focus on the patients’ emotional state seemed to offer a theoretical baseline to their own innate capacity to make contact with human suffering. The present paper describes the author’s experience with these students, who were seen for one hour on each of the four weeks’ placement. Because of the psychoanalytic orientation of our department, I initially thought I should teach the students the psychoanalytic theories linking adult psychiatric pathology to an individual’s early development. I compiled a list of the relevant concepts that I believed the students should learn and they were encouraged to report to our meetings a patient they had seen, whom they would like to discuss in more detail. Eventually, I discovered that no two groups are the same. I was surprised to find that many of the students were meeting each other for the first time at my seminars: there is a difference between a group of students who have been working together and those who have not. Perhaps in a “lecture” setting this is not important, but when an open discussion is invited, there is an understandable fear of self-exposure. Only towards the latter meetings will students show some spontaneity and voice their opinions during our discussions. Sadly, the small number of meetings meant that by the time some degree of familiarity developed, we had come to the end of the series. The list of concepts that I mentioned contained a brief definition of each one. I thought that most of the concepts on the list represented words they had heard and used in discussions with friends and colleagues, for example, transference, projection, identification, unconscious. And yet, time and again, I found that they had no idea how these concepts related to their actual contact with psychiatric patients. They could define countertransference, denial, defences, etc., much as other educated youngsters, but they did not know what the concept was supposed to explain. I had the strong impression that my list of concepts had not been of any help. But only very

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recently did I recognize the reason for this. It may be that, as with all things obvious, this can be missed or, perhaps, it is a question of putting words to something we have known all along. It is this “discovery” that I would like to describe, as it is the main point of this chapter.

Case 1 A twenty-five-year-old young woman was admitted, under section, following an overdose. The student found her depressed and angry, demanding to be discharged, as she saw no reason to remain in hospital. She had only recently started a new job, which she was keeping down with difficulty. She lived with a boyfriend, but, as with other relationships, she spoke of dissatisfaction and resentment. She had minimal contact with her family. She denied the use of hard drugs, but she was a heavy smoker and drinker, besides occasionally using recreational drugs. Part of her history was an account of becoming depressed, rebellious, and using these drugs at age fifteen, after her father left the family and her mother brought in a man whom she later married. Asked about the overdose, she said that she had been finding life just too difficult. I asked the group for comments. They thought the story sounded quite straightforward. Her overdose, the repeated changes of boyfriends and jobs, her lifestyle and her demeanour when talking to the student, all were manifestations of her depression. I asked what they meant by “depression” and I was given a list of textbook features of depressive illness. The group certainly thought the depression was the cause of her difficulties. This reminded me of an earlier meeting with another group, when depression was being discussed. Most of the students had voiced opinions similar to those just quoted, but one of them, Julia, said that she had never seen anyone “depressed” until she started at medical school. Her colleagues were surprised, or, more correctly, horrified. She explained that she had seen many people who were unhappy, sad, disappointed, perhaps feeling disheartened because of some painful experience, but never had any of them thought of using the word “depressed” to describe how they felt. The other students tried to persuade her of the importance of recognizing a

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psychiatric condition when it is present. Julia insisted that, however much she could agree to a psychiatric condition named “depression”, most of the depressed patients she had seen described experiences that were no different from those she had met in her ordinary social life. To Julia, depressive affects were the effect of a person’s life experiences. Having considered the reported affects congruous with the related experiences, she saw no need to invoke a medical condition to explain them. I did not quote this experience to the group under discussion. To return to the recent group: when I stopped my questions, they focused on the patient’s wish to be discharged. Most of them were prepared to accept the consultant’s opinion, but, suddenly, one of them, Walter, voiced his doubt as to whether there was, really, anything wrong with the patient. “I think it’s only fair she should feel depressed after all that has happened in her life—I can easily see myself feeling exactly the same!” The other students now agreed with him. Perhaps because of the patient’s age, they could feel that “there, but for the grace of God, go I”. However, I realized that their argument—first opting for “depression”, then, like the earlier student, Julia, choosing “life experiences” as the cause of the patient’s problems—would hold for a patient of any age. And it was now that I spotted the point that had eluded me so far. Whether they opted for “depression” or for “painful experiences” as the cause of the patient’s condition, they were putting forward the explanation that helped them to make sense of their findings: they saw no need to ask further questions or, therefore, to find any further explanations. What I have called my “discovery” was the realization that just giving the students definitions of my psychodynamic ideas was a simple, but futile exercise. These are very intelligent people, well able to absorb and memorize no end of ideas and definitions, which they then recite and comment on. But listening to the description of cases they had seen, brought home to me how new theories are only absorbed into true knowledge when the person is aware of a question, a gap, that the new theory is able to deal with. Julia and Walter were, essentially, saying they believed that their patients were behaving in a congruous, logical manner, that is, they saw no need for further explanations. The suggestion of an unconscious content is, fundamentally, a hypothesis that aims to throw light on

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something seen as illogical or puzzling. Clearly, this can only make sense if and when the patient and/or the doctor recognizes feelings, ideas, or behaviours that do not fit what they see as ordinary logic.

Case 2 Tasmin, one of the students, reported: “During my oncology placement, a young woman was admitted with lung cancer in its final stages. There was a lot of interest in her because the case had only been spotted when already far advanced. My colleague and I were told to clerk her. When we came near her bed, her husband was also there. He got very aggressive and took us to a nearby room, where he spoke with great anger about our wanting to ask her questions at that point. We were embarrassed and scared. But he suddenly began to cry, very painfully. We stayed there with him for a while.” Another student thought this was a natural, understandable sequence: (1) the husband was upset and this is why he was so violently aggressive; (2) being students, no particular contribution could be expected from them; (3) the students themselves had to accept the fact that, because of their limited knowledge and experience, they could not but be seen as unwelcome intruders. Here, then, the “closed case” that did not beg for any further enquiries. In line with my “discovery”, instead of voicing my interpretation of the husband’s behaviour, I tried to raise a point that could not be explained by their comments. I said that the husband could have simply told them to clear out and leave his wife alone: how would they explain his actually taking them off to another room? They were clearly thrown off balance. Eventually, they said it was possible the husband did not want to let the wife know the extent to which he wanted to protect her, in case that gave her a measure of how serious was her condition. I brought forward another gap in their answer. If this was the case, how would they explain his staying with them and not just speaking his mind and returning to his wife? They were plainly intrigued, not quite knowing why such a question arose. Well, perhaps he was too upset himself? they asked. I could only agree with this assessment. But,

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once we agreed that the husband was saying “what about my pain?”, here was a golden opportunity to ask the students whether they thought he was aware, conscious that this was a motive behind his calling them away from the wife’s bed. No, they recognized: if present, this wish was definitely unconscious. I do believe that the concept of an “unconscious” had now acquired a totally different meaning for them. Before Tasmin had told us of her case, we had been discussing the students’ feeling of having to conform to the role imposed on them. One of them considered himself “a good communicator”, but he had no doubt that any patient could only resent his coming to ask them questions when they could expect no particular benefit to accrue from that exercise. Another student said that he had seen patients who seemed quite pleased to have the opportunity of talking to a young student. As the group argued over these views, I suggested that whatever a particular patient might come to feel, the student’s view of himself in that situation affected his assessment of the patient’s actual response. The students found this difficult to accept. Intellectually, it made sense, but they could not match it with any experience of theirs. It was the account of the crying husband that made them see the validity of my argument. Seeing him as “very aggressive”, I suggested, followed from the premise of the students seeing themselves as unwelcome intruders. In spite of this, the husband must have attributed some human warmth to the students, since he had treated them as people with whom he could share his pain—the fact that they “stayed together for a while” was evidence that the husband had valued their intervention and help. Somehow, students do not seem able to grant themselves the supportive, therapeutic role that some patients see in them, and I believe this follows from their evaluation of their abilities and, particularly, from their feelings when approaching each patient. It was against this background that we could discuss the definitions for self-image, projection, transference–countertransference. When the student has an image of himself as an intruder, he is bound to project this on the patient, and it becomes virtually impossible for him to evaluate any projection or transference that the patient might be displaying to him. This affects his capacity to scrutinize his experience and spot any countertransference feeling.

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Personal involvement? It is useful to consider the question of the students’ view of how they approach their patients. I have found striking similarities between our medical students and those training in psychotherapy or psychoanalysis: (1) they seem to dismiss as irrelevant or inappropriate all knowledge accrued prior to the present training; (2) they adopt a posture and put forward answers which they believe are expected of them as part of their new training; (3) it is very difficult to get them to express what their “previous self” actually made of whatever patient or situation they are discussing. Sometimes, I try to bypass these difficulties by asking them to tell me the kind of opinion about a patient which, I take for granted, they would quite naturally voice to friends. They understand exactly what I mean and, with some embarrassment, they will sometimes tell me of views that, quite obviously, they had assumed were not appropriate to be held by a conscientious student. I thought this was a deliberate or unconscious attempt to practise a new professional role: a student trying to mimic “a doctor”, much as a psychotherapy trainee wanting to behave like “a therapist” or “an analyst”. But one day, one of the medical students pointed out that the key problem involved is the student’s “personal feelings”, or, to put it in different words, the need “to be objective”. He quoted a lecturer who had told the class that “feelings only cloud your thinking” and should, therefore, be avoided. This comment brought back a memory from my own student days. An eminent surgeon told me that he tried hard to avoid getting involved with his patients. He could not avoid examining them, but he had learnt that any deeper contact led to his feeling impeded in his surgical skills. He decided that his “job was to eliminate the patient’s disease and this demanded (he) keep his involvement restricted to theatre”. At the time I was horrified, but I came to respect his argument: it is absolutely vital that each of us should learn how we can work at our best. As a policy resulting from selfknowledge, my teacher’s “confession” could not be faulted. However, to transform this stance into a universal prescription, I consider a perversion of the doctor’s role vis-à-vis his patients. I asked the students what they thought of that advice. They were evenly divided. Some did believe it was best to sustain an

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objective view of the patient and concentrate on facts, but others thought this was difficult, if not impossible, and one of them quoted psychological texts discussing the concept of perception and its relation to objective reality. This was an animated discussion, and they could only agree on the “advisability” of not allowing one’s feelings to cloud one’s view of the patient, since all of them could admit to experiencing feelings of some kind whenever meeting their patients. At this point, I could bring in my argument that since we cannot eliminate feelings just because of wanting to do so, perhaps it is best to take account of these feelings and explore the possibility that they might help us to make sense of our meeting with the patient. The secret would, therefore, lie in learning to make use of the feelings, rather than simply acting on them or, conversely, pretending they do not exist. This is an extremely important issue and not simply because “we have to take stock of the countertransference”, a fashionable precept at present. Rather, I prefer to argue that we can only gauge what truly constitutes the patient’s typical reaction to us and, perhaps consequently, to those around him, if we take stock of our own contribution to that encounter. We cannot speak of what the patient is “projecting” on us, until and unless we consider the possibility that he may be reacting to a feature of our own attitude towards him. There is no question of telling the patient what we feel about him or giving information about our personal life, but rather an awareness of the feelings the patient arouses in us when we approach him, trying to display an attitude of genuine interest in him.

Case 3 A petite, blonde student reported her interview with a man in Casualty a few days earlier. This was a man in his mid-thirties, whose sister had brought him back to London from abroad because of his suddenly developing a state of agitation and paranoid ideation. After some conversation with the pair, the nurses directed the patient to a side-room for a more detailed interview with the psychiatrist. The psychiatric Senior House Officer invited the student to join them, but, before reaching the side-room, the SHO

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was called away and the student found herself moving to the room with the patient. The patient went into the side-room and the student followed him, but she was surprised to find him turning round and shutting the door behind them. At this point of the account, the students in the seminar immediately voiced their concern about the situation being described. The student smiled and reassured us that she was quite aware of the dangers to which she had exposed herself: furthermore, her specialist registrar had already ticked her off. As it turned out, the patient had shown further evidence of intense anxiety and paranoid feelings, but at no point had the student felt personally threatened. The next day, when taken to the Consultant’s ward round, she found that the patient had absconded and, when brought back, had demanded that the young student should sit near him. The students voiced their ideas about what might have happened between the patient and their colleague. They all agreed that some kind of non-verbal communication had taken place between them, but how were we to explain that the meeting had followed a course which none of us might have anticipated? I suggested that, in spite of his psychotic ideation, the patient had perceived the student in front of him not as a persecutor, but an ally. Correspondingly, she must have conveyed to the patient that she saw him as a person in distress and not a potential aggressor. The students thought this was intellectually plausible, but, nevertheless, too speculative. They saw the course of the meeting resulting from a combination of good luck and factors linked to the personality of their colleague, and not from attitudes and interpretations they could adopt themselves. A particular difficulty posed by cases like this is that we, the teachers, want to emphasize principles, attitudes, utterances, postures that can (or should) be adopted by any student in that particular situation. Often, as described, students interpret such interactions if not fortuitous, then as totally dependent on personal factors. This, sadly, turns a teaching situation into an apparent exercise of praise, where the other students may admire or even envy their colleague, but they feel implicitly criticized or belittled. This is particularly disheartening, as it appears to point to the limitations of learning and self-improvement.

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Case 4 A nineteen-year-old Art student was brought to A & E after jumping from a fourth floor. The psychiatric SHO saw her together with the medical student and, when he could not visit the patient the next day, he asked the student to see her in the ward. The patient was a foreign girl, whose parents had come to pick her up to take her back to their country. The girl had jumped from the window of the hotel room where the parents were staying. When the student arrived at the patient’s bed, the parents were just leaving. She sat and talked to the patient and, very much in passing, she told us that she “was holding the girl’s hand”. When the family returned, the patient sadly asked the student not to leave, but the family had made it clear that she had to go. At this point of the account, I stopped the student and I asked the group how they imagined their colleague had felt. “Relieved, surely!”, they said. In fact, she said, “No, I was quite upset.” She explained that she believed the patient had turned to her for protection and she was afraid that, being left alone with her family, the patient might again feel compelled to attempt suicide. We had a rich, lively discussion about medical ethics and human, moral solidarity. The reporting student still felt guilty, but she had to accept the limitations imposed by the age and position of the patient. It is easy enough to say that our student felt identified with the patient, but I would argue that, much as the student in Case 3, she was able to present herself to the patient as a human being meeting another. Indeed, there are points in their behaviour which deserve further discussion, but we have to acknowledge that there is something positive in their spontaneity, their capacity to trust their intuition and empathy. Surely, it is valuable that their capacity to see other people with an attitude of acceptance and goodwill is not abandoned because they now work in a medical setting.

Ordinary human warmth: is it really wrong? Why is it so rare to find examples of this kind of contact between student and patient? I hope I am being influenced by the size of the sample of students I have met and that, in fact, this is more common

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than I imagine. Nevertheless, I cannot avoid a suspicion that, as teachers, we tend to foster a brand of professionalism that leaves little room for spontaneity and ordinary human warmth. This is not entirely our fault, since, as I have mentioned, we have many students who want to learn facts, who prefer to deal with patients with this particular brand of “objectivity” that spares them from any emotional involvement. But it is important for us to show them that there is a problem here and to help them to make a considered decision as to how they want to develop their medical identity. In a paper presented to the 42nd annual meeting of the American Academy of Psychoanalysis on “Teaching psychotherapy to medical students” a Canadian colleague, Dr S. R. Fleming (1998), summed up this argument in a concise and poignant statement. “By senior years, many medical students have a personal and professional investment in content over process, objectivity over subjectivity, knowing over understanding, naming over wondering, diagnosing over empathizing to a degree that the latter are all devalued”. Occasionally, a student turns up who is able to use critical judgement to evaluate his/her experiences in the course. One day, a student said it was all very well for psychiatrists and psychoanalysts to emphasize the importance of exploring the patient’s life experiences, but the fact was that the ordinary doctor, on the whole, did not have the time to pursue this. A forceful young woman replied that the way in which a doctor treated his patient did not depend on the time he had available for his consultation. She recounted sitting in at a gynaecological clinic when a patient was seen who complained of heavy periods; the consultant had enquired about her private life, her work, and her general situation in life, and the consultation was over in no more than ten minutes. She added that the patient left feeling much happier. On another occasion, she was at a different consultant’s clinic, and when a woman came in with precisely the same complaint of heavy periods, the doctor was interested “only in her womb”. She concluded, “but the consultation lasted no less and no more than the same ten minutes: clearly, it is not a question of time, it all depends on the kind of doctor who deals with the patient.” I am sure that every single student knows full well that this colleague is stating a fact that matches what they have learnt from their own private experiences when turning to doctors for help. I

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find it, therefore, most disturbing that when looking at such situations from the doctor’s perspective, they are quite prepared to adopt and preach standards that they would have criticized when in the position of the patient. Sadly, I suspect that my teaching has not converted many students to adopt a warmer, kinder attitude to their patients. Explicitly or implicitly, they firmly believed they were following a prescribed ethos, aiming to achieve a professional stance that they perceived around them during other classes. Nevertheless, every now and again, there was a student who delighted in finding that his/her instinctive moves towards a patient in pain were supported and reinforced by a teacher.

Case 5 A young woman discussed a twenty-four-year-old man who had been referred to the psychiatric liaison team because of severe depression. He had come to Britain from an African country when a revolution led to the break-up of his family: his father had been killed, some of his siblings had gone to America, others had stayed behind with their mother, and he was the only one who came here. In spite of having been here for eight years, his English was still poor. The patient told the student that he had had abdominal problems all his life. About one year ago, however, he had severe rectal bleeding. He was admitted, and Crohn’s disease was diagnosed. He was discharged after one week, but a fortnight later he had to be readmitted and he had now been in the same surgical ward for the last nine months. The student had not read the patient’s notes and she could only recount what little information the attending nurses had given her. The patient had had part of his bowel removed and he was being fed through a gastric tube, which was due to be removed a few days later. She did not know why he had other tubes going into the right side of his upper abdomen and the patient could not explain the reason for this, either. The surgical team had requested the consultation because of the patient’s intense depression, which had not responded to any amount of explanation or reassurance. As the group of students discussed the case, various suggestions

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were put forward: the patient might be afraid of the further course of his illness, he might be feeling lonely and missing his family, he might be wishing for an end to his pains and, who knows?, he might be wishing he was dead. I asked the students to try to find words that would describe the experience of the patient when in such an uncertain and painful situation. The young woman who had clerked him came to suggest that perhaps he felt “he had lost part of himself”. After further discussion, I said that this was quite probable. I suggested that a more accurate description might be that he had lost a part of “his self”, that is, he could no longer recognize the continuity between his present situation and what he had learnt was his self in the past. Some students could not agree to my formulation, but the young woman decided to go back to the patient. Instead of the cold, detached, depressed man she found earlier, she was surprised to see that he received her with a warm, welcoming smile. She apologized for not having stayed with him long enough earlier on and asked him if he had perhaps thought of other things he might want to tell her. She described his response as “if (she) had opened a Pandora’s box”. His eyes filled up with tears and he told her of his experiences throughout the crisis that had broken up his family and the world he had known. He had witnessed murder, rape, plundering, arson, fights with all kinds of weapons, blood-letting in most disturbing ways, and he had been forced to face all this only too aware of his helplessness and his total incapacity to offer support or comfort to those around him. This was a sensitive and gifted young medical student. Her knowledge of psychodynamics was nil, and her experience of psychotherapy non-existent. But her heart could recognize what was happening, and this helped her to find the words to say to the patient: he had lost family and country and he had now lost part of his body as well. The patient now burst out crying and, true to his background, he moved his hands and held the student’s hands. She accepted this, trying hard not to cry herself. The patient’s depression improved after the student’s visit. His Crohn’s disease will continue to require appropriate treatment, but, in view of his response to the student, he will be offered the opportunity of one-to-one psychotherapy.

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The psychiatric patient: a special challenge Every new group represents a different experience. The students have been through several placements and some of them will already have seen psychiatric patients in various settings. My meetings are listed as “Psychotherapy seminars”, and, yet, each group arrives quite unclear about what to expect. I introduce myself and explain that in the brief space of four meetings I would hope to convey to them how an analyst or psychotherapist looks at psychiatric problems. I apologize for not trusting myself as a lecturer, and ask them to help me by voicing questions they may have about my subject and perhaps recounting some experience they have had with patients. Somehow, it is rare to find a student who has a question waiting to be asked. Each beginning is quite hard work! I have often tried to define what is the main lesson that I would like the students to take away with them from these few meetings. As mentioned earlier, the initial objective was to convey to the students the psychoanalytic theory of the influence of early experiences on the emotional development of the individual. I found that the students could understand the substance of this theory, but there was a definite hollowness in their comments about it. They could learn my “lesson”, but some of them seemed to believe the theory, while others could not quite accept it: and yet, both groups appeared not to know where and how to fit the new data. This led me to change the goal of my “message”. I decided to teach the meaning of some psychoanalytic concepts. Again, I discovered that they could easily learn my definitions, but these were only new data to be added to a gallery of other information coming their way. Gradually, defining concepts took a secondary place and I aimed at contrasting the psychiatric notion of disease with the dynamic view of mental phenomena. This formulation seemed to encompass the previous ones, while, I hope, conveying the language and techniques adopted by psychodynamic practitioners. Because my arguments coincided, in time, with the different views of psychiatric nosology the students met at other lectures, this appeared to make better sense to them. I noticed a subtle change in the students’ reaction when I found myself concentrating more on the emotional impact they experienced when interviewing psychiatric or other severely ill patients. This examination of their emotional experience

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as a step towards understanding the patient’s predicament proved particularly meaningful. It had the additional benefit of giving me the opportunity of bringing into the picture analytic concepts I wanted them to learn about, but now in a context that had a definite dimension of reality. This is the notion I tried to define by stressing the difference between a hollow learning by rote and an intellectually and emotionally meaningful understanding. Two main problem areas appeared very often in my discussions with the students. One relates to the concept of mental illness and the second refers to the student’s self-image. Psychiatric patients appear to pose a specific problem for many medical students: are they really ill? Patients seen in other specialities are very aware of their illness and the need for medical/surgical intervention: the student can well accept that the patient should be distressed, anxious, fearful, or even unperturbed. Both patient and student can discuss “the illness”, and the student will see the patient’s emotions not as defining the kind of person he is, but as a response to his illness, the doctors, the hospital, or whatever—and, usually, not directed at the student. Both patient and student are very aware of the fact that only experienced doctors will provide effective help to affect the illness. In other words, the student is not usually seen as a potential ally or enemy, but only a feature of the patient being treated in an academic setting. This helps the student to cope with his sense of inexperience and, more importantly, he can assume that ordinary courtesy and respect should ensure a smooth, perhaps even cordial, meeting with the patient. This is not the case in psychiatry. Here, the patient’s behaviour, words, feelings are taken as diagnostic data, and this often makes students doubt the validity of their perceptions. Students can accept that the fact of the patients being seen in a psychiatric ward indicates that they are ill, but students cannot but take into account a number of features that affect their assessment of the patients’ condition. Some patients are seen in a hospital that has become “fashionable” for artists and rich people to seek help for addictions and other problems; other patients behave and speak as “ordinary, normal” people, and others argue that they have been hospitalized in an unfair and unjustified manner. From the patient who ignores the student to the opposite extreme of the patient who tries to enlist the student’s support to release him from the ward, the student

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quite often finds his position challenged and his personal feelings mobilized. Focusing on the patient, we can discuss the issue of “insight” into illness, but many students will often wonder about the appropriateness or fairness of the patient being in a hospital— and, correspondingly, about their role in the interview. When asked about the patient’s reaction to their approach, most students find it virtually impossible to consider the patient’s behaviour as anything other than a response to their presence. Hence, reactions like the ones described above in the case studies. It is those psychiatric patients showing total self-absorption and paranoid ideation that best help to illustrate what is “a response” or, alternatively, an intrinsic feature of the patient’s state. Some of these patients will simply ignore the student and others will respond as if they were hostile intruders: virtually every single student takes either of these attitudes as valid, appropriate responses to their lack of experience and knowledge. In other words, the manner in which the patient treated them is not seen as indicative of any pathology in the patient. It is quite difficult to get them to recognize that they were not treated as individuals in their own right: that their personality, attitude, and self-image were totally ignored by the patient, in view of his unconscious need to protect himself from every single stranger. We will speak of transference, projection, internal world, or, conversely, of psychotic features, but I have found that while most students “learn” these concepts, they quite often will continue to believe that the patient was justified in ignoring or attacking them. The turning point, when understanding falls into place, occurs if the student can accept that, whatever he thinks of his own abilities, to the patient he is a total stranger: he is being treated in the same way as the patient would treat any other person coming near him. Therefore, whatever characteristics he attributes to this stranger are the result of his own mental processes. Most students have heard about projection, transference, and countertransference. They will usually define transference as “what the patient feels about you—something from his past is seen in you”, and countertransference as “what you feel about your patient”. I definitely cannot accept this formulation where one’s feelings are, axiomatically, taken as originating in the patient. I hope that the clinical examples I quoted will have illustrated my rationale for objecting to this equation. I find it most important to show

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students that how they experience their role vis-à-vis the patient influences how they will interpret the patient’s response. A student who believes he has nothing to offer to a patient is primed to interpret the patient’s words and attitudes as a response to a youngster’s pointless interference. The dogmatic assertion that the student’s sense of bafflement, incompetence, embarrassment, or guilt stem from the patient’s projections deprives the student of an opportunity to work on his self-esteem and improve his self-image, making him better equipped to scrutinize what legitimately belongs to the patient. This approach is anchored in an interactive view of emotional experiences. Each participant in any encounter will influence his partner in ways that are very difficult to identify. When students doubt that this might apply to medical practice, I invite them to bring to mind a visit to their general practitioner. If they enter the consulting room and find that their usual GP is away and they are being seen by another doctor, “How long does it take (you) to know whether this doctor wants to hear your story or just give you a prescription?” Every single student responds with a smile of familiarity and occasionally one of them will quote an immeasurably brief space of time. They know only too well how deeply and forcefully such a perception influences their approach to that doctor. This is a useful first step to their recognizing the relevance of understanding their contribution to the clinical encounter before working out the meaning of how each patient treated them. Only when they can recognize their approach to a patient will they be properly equipped to evaluate the patient’s contribution to the interaction. The same reasoning underlines the importance of taking into account every impression or feeling they experience towards each particular patient. Students tend to dismiss any feeling towards a patient, when they believe they are being “judgemental”, and attempt to overcome this by trying to guess “what would a doctor make of this now?” Sometimes, this “reluctance” of the student is interpreted as a sign of his unconscious difficulty in accepting mental disturbances. This may well be the case, but, before such a “defensive” reading is put forward, it is important first to consider the role of inexperience and lack of knowledge. There seems to be a contradiction in arguing that the student’s feelings will affect his patient and then, at the same time, that he

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must note the patient’s utterances and behaviour as diagnostic data for an evaluation of his pathology. This is only an apparent contradiction, since being aware of his feelings, however they may affect the patient, represents the essential baseline against which to evaluate the patient’s response. The challenge of a clinical assessment (particularly a psychiatric one) lies in establishing what exactly is relevant in all that the patient can reveal to us. The doctor must be aware of what precisely he is setting out to explore and identify when approaching his patients. Whether questions arise from “intuition” or from “clinical expertise”, what we decide to ask is the main key to what we come, in fact, to elicit from the patient. Predictably, when a student is articulating questions listed in a form, he obtains no more than the data matching his questions. When seeking the pointers to a psychiatric diagnosis, this is clearly the way to achieve it, but it is unlikely to give the patient the opportunity to voice his anxieties. Here lies the crucial point demonstrated by the student (Case 5) who explicitly sought to give the patient the opportunity to voice what he wanted to say. A psychotherapist takes it for granted that his approach to his client aims at eliciting what troubles the patient and, sadly, only a rare therapist will be concerned with the psychiatric diagnosis of his patient. These two approaches are, clearly, complementary, but a medical student can find it difficult to give equal importance to the patient’s private anguish and pain and to the search for data that will help him to establish the nosological entity that is supposed to describe the patient’s condition. I am aware of the fact that much of what is written above might convey the idea that each action of patient and/or doctor is, by definition, a response to the other’s input. This is definitely not what I believe. We have to assume the existence of a mutually influencing pattern, but the challenge of a diagnostic evaluation lies precisely in the unravelling of what exactly is the patient’s response and what, instead, is an inherent feature of his being or of his state. A published account of a patient seen in a Casualty department (Foxton, 2002) demonstrates some of the points made here. Police officers brought a “violent man” to hospital and the nurses called the doctor on duty to sedate him. When he approached the patient, the man kept shouting he should “F—- off”. The doctor wrote that

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this was an “angry” man, definitely not a mental patient requiring sedation. Whatever police officers and nurses might think, he argued that this man was only angry. Suddenly, the man saw the doctor’s tie and he “let rip”. “The gates! Cambridge! The coat of arms!” And out comes the most intensely paranoid delusory system about Cambridge medics that I had ever heard.” And now the doctor prescribed Haloperidol. The fact that the doctor was treated the same way as all the other people who had previously approached the patient was, obviously, not seen as an important diagnostic datum. I would argue that, much as my medical students feeling that they approach a patient on the orders of a senior psychiatrist, the doctor felt used by police and nurses as their agent. It was, therefore, not surprising that he saw the patient’s behaviour as showing justifiable anger: to the police, the nurses, and himself. Only the “paranoid delusory” outburst helped the doctor to recognize that behind the apparently justifiable “anger” there was a severe paranoid psychotic episode. A very similar pattern can be seen when children are brought to a doctor because of temper tantrums. It is usually quite easy to find justification for the child’s outbursts in some feature of the parents’ attitudes, but it is infinitely more difficult to establish what feelings the child is harbouring and why they are being expressed in this manner. Nevertheless, both aspects have to be elucidated if appropriate help is to become possible. I always remind students that a safe rule of thumb is to assume that if they have a patient seeing them, there must be a reason for this. They find this very difficult to accept. With patients carrying a recognizable physical disease, students have no problems, but psychiatric patients very often bring to the fore this anxiety that some personal emotional or social problem is being “medicalized”. As mature members of society and as medical students, they are prepared to grant the doctors the knowledge and the probity to admit to hospital only those patients who are “definitely ill”. And yet, time and again, they find “psychiatric patients” who strike them as showing reasonable, plausible reactions to traumatic life situations. When these impressions hit them simultaneously, students can feel very confused and doubt the fairness or appropriateness of their task of clerking the patient.

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Summary I have tried to illustrate my experience that medical students can find certain difficulties in dealing with psychiatric patients that are not frequently experienced in other medical disciplines. While other patients are seen to harbour a well-defined cause for their pathology and, particularly, for being hospitalized, psychiatric patients will sometimes be seen as “normal people” going through some personal crisis that, in the students’ experience of life, should not warrant the diagnosis of a medical condition. Because of the educational setting in which these patients are met, students may listen to what their seniors are teaching and memorize concepts and their definitions without, necessarily, comprehending the rationale for these. In the specific field of psychotherapy, this problem becomes even more difficult to spot, since so many psychoanalytic concepts have become part of everyday language. Projection, unconscious, transference, and others are used very often, even though the meanings and implications of each concept may elude the user. I put particular emphasis on my finding that, fundamentally, learning demands the existence of a previous “not-knowing”, where the new datum will fill a gap or explain a quandary. When this is not present, an intelligent student is well able to memorize what he is supposed to absorb, but this will only be translated into actual learning when that awareness of a gap is experienced by the student. This is why I believe that simply giving definitions of concepts does not equip the student to grasp where to fit in the new datum. Another point made in the paper is a discussion of the relevance of trying to help the students to become aware of the feelings that patients bring out in them. This is especially important in psychiatry, where patients can sometimes produce a strong emotional impact on the student. Most students see such feelings as a sign that they are becoming personally involved, or being judgemental, and, therefore, they try hard to dismiss or deny these impressions. Because these feelings will influence the student’s approach to the patient and, in a more subtle way, his capacity to assess the patient, it is important to discuss how any emotional reaction to the encounter with the patient must be acknowledged and scrutinized.

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I have argued that to categorize, ab initio, these feelings as “countertransference” is not only wrong, but it deprives the student of an opportunity to learn about himself and his approach to patients.

References Fleming, S. R. (1998). Teaching psychotherapy to medical students. Unpublished paper presented to the 42nd Annual Meeting of the American Academy of Psychoanalysis. Foxton, M. (2002). Bedside stories: you don’t have to be mad to be admitted here, but . . . Guardian, 13 June, 2002, G2, p. 15. Shoenberg, P. (1992). The student psychotherapy scheme at the University College and Middlesex School of Medicine. Its role in helping students to learn about the doctor–patient relationship. Journal of the Balint Society, 20: 10–14.

INTRODUCTORY NOTE TO CHAPTERS NINE AND TEN

Helping? Yes, but how?

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hese papers focus on technical parameters that were originally put forward to explain specific findings. But, with the passage of time, their use was widened to the point where they are now applied to psychodynamic work with all patients. I find this a regrettable development, and I argued how important it is to bear in mind how these concepts came to be formulated, in order to preserve their use exclusively with patients who actually justify their application. The patients who experience distress at any change of the analytic setting happen to be the same patients who led our teachers to put forward the concepts of holding and containing. At a clinical seminar, Winnicott commented how after each patient left his consulting room, he went round making sure that the next patient would find the room exactly as he/she had left it after their previous session. One of my patients came to see me for four weekly sessions for nine years, but stopped the analysis two weeks after I moved from a house to a flat, claiming that this new environment was totally unacceptable. These are the patients who develop that specific relationship to the therapist that Winnicott called a “regression to dependence”: because they were so intensely and closely 161

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attached, not only to the person of the analyst, but also to every detail of the environment of their sessions, he postulated that this transference pattern has its origin in the earliest days of the infant’s life, when the infant had a relationship of total dependence on the mother. From my own work and consulting the available literature, I was struck by the fact that these patients attend their sessions faithfully and often react intensely to any breaks in the work, but, as the months and years go by, they do not appear to show significant changes in their lives or in their emotional structure. Some of these patients will stop their analyses without the analyst managing to fathom out the precise rationale for this decision, but soon enough they return to therapy or find another analyst with whom to continue their so-called analysis. I came to think of these patients as people who need analysis “for life”. If one analyst happens to die or, in other cases, decides to stop the analysis, these patients will soon find a substitute analyst. Describing this type of patient as someone who needs “to regress to dependence” does not yet explain why this analytic engagement should proceed with little change in the patient’s needs and abilities; nor does it explain the analyst’s rationale for continuing to see the patient for so many years. Dr Lois Munro, a senior analyst of the British Society of Psychoanalysis in the mid-twentieth century, told me of a very senior educationalist who would attend for sessions three times a week: she “ranted non-stop for fifty minutes, with no pause for any significant comment” from the analyst; she then left and resumed her life, discharging most efficiently her social and professional obligations. I asked her what she made of this therapy, and Dr Munro shrugged her shoulders and said, “She certainly seems to need this support and I feel it would not be fair to let her down and stop it.” The opposite example came from Dr Charles Rycroft, another eminent British analyst, who described in a study group his work with a similar patient and told us of stopping the analysis after six years. He was asked what had led him to decide it was time to stop. He paused, considered his answer, and said, “I guess I had had enough.” One final quote comes from Dr Julius Rowley, also a senior member of the British Society. I was telling him about the work with a very difficult patient and my sense of incompetence, seeing there was no progress. “You better accept”, he said,

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“this man is not going to change—you better sit back and enjoy the experience, just learn from it what you can.” When psychic pathology is equated with the quality of early mothering and analysis is defined as a new opportunity to supply or correct the earliest mothering input, the analyst will have a clear picture of how he should proceed in the analysis of these patients. His chosen theoretical framework enables him to list the qualities that early mothering failed to offer that patient, thereby leading to the presenting clinical picture, and this formulation defines how that analyst sees his role in the ensuing analysis. If, instead, the patient’s clinical presentation is not interpreted as an exclusive result of early mothering, the analyst faces the challenge of finding alternative explanations. Personally, I have come to give greater weight to personality traits that do not truly allow us to decide with any certainty between structural or environmentally determined features. Some of these patients will recount memories of their early upbringing that show strong feelings about one or both parents, but I tend to see these not so much as valid historical data as hypotheses the patient has built in order to explain his position in the world. In these two papers I try to trace the origin of these concepts and argue about the importance of a careful assessment of a patient’s psychopathology before embarking on long-term treatment. There is no doubt that we find patients who will “regress to dependence” and require the particular techniques described by Winnicott, Bion, and Balint, among others, but the vast majority of the patients we see do not have these psychopathological traits and needs. Most of the patients that consult us see the “setting” as far less important than what they perceive as the analyst’s competence. These patients seek a clear understanding of their difficulties and they can be helped by interpretations of the unconscious feelings that create their problems. Once they obtain this improvement, they promptly proceed to resume their life—away from the analyst. However, dealing with patients who “leave us in the dark” most of the time can indeed lead us to invoke the presence and value of offering them holding or containing, but, ideally, the therapist should help himself to decide whether these are the patients he wants to work with.

CHAPTER NINE

Holding, containing, interpretations: a question of timing?*

A

s time goes by, the words “holding” and “containing” are used with ever increasing frequency in clinical discussions. Is there a difference between them? They certainly seem to be used as if they were synonymous. For example, Casement (1985, p. 133) writes: In more human terms, what is needed is a form of holding, such as a mother gives to her distressed child. There are various ways in which one adult can offer to another this holding (or containment). And it can be crucial for a patient to be thus held in order to recover, or to discover maybe for the first time, a capacity for managing life and life’s difficulties without continued avoidance or suppression.

“Holding” and “containing” seem to have become something like a mark of excellence to describe a laudable posture on the part

*First published in 1999 in Scientific Bulletin of the British Psycho-Analytic Society, 35(9): 67– 73.

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of the analyst/therapist towards his patient. In the past, an analyst was considered “good” if he quoted a successful interpretation of his patient’s material. This still rates highly enough, but the failure to produce “a good interpretation” is usually forgiven or even thought to be not so important, as long as the therapist is showing his patient tolerance, patience, emotional support—qualities which are now taken as “holding” or “containing” the patient’s anxieties. So, what is the relationship between these concepts? How did they come into existence? And how did they acquire their present meaning? “Holding” was originally linked to regression, but this association seems to have been left behind. I thought it might be useful to identify what has changed and how relevant these changes are. Let me tell you about an interesting and pertinent concept that I believe describes what has happened. Main (1999) put forward the concept of “hierarchical promotion” to describe a process that can be found in many areas of our daily lives. A new action, idea, or belief is utilized to deal with a specific problem. When it is transmitted to the next generation of practitioners, through ever-sosubtle changes in the way it is conveyed, it gradually acquires the status of an indispensable, unquestionable idea or procedure. It is striking how only an outsider or the occasional sceptic will question the rationale of applying that particular concept or procedure to the situation where it is now being employed. Main described how one day he discovered that new members of staff at the Cassel Hospital (of which he was the Medical Director) were instructed about the “week-end rule”: all in-patients were supposed to leave the hospital at week-ends and return to their homes. If a patient refused to go back to his place of residence, this indicated negative feelings towards the treatment he was having there. Such a rule was a barely recognizable distortion from the initial idea, adopted some years earlier, when Main had initiated a discussion about ways with which to deal with the degree of regression and dependence that hospitalization created in the inpatients. Main had then proposed that patients should be allowed to go home for week-ends in order to help them sustain/rebuild their contact with their lives outside the hospital setting. Main pointed out that this “promotion” of an appropriate solution into a procedure that is followed blindly can be found in many

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different settings. It is sad to find that the world of psychoanalytic concepts gives us many examples of this process. Who will now discover when transference interpretations became the shibboleth of “good therapy”? I recently discovered that some students are being instructed to see their patients on three consecutive days, so as to heighten their exposure to “separation anxiety”, another present-day fetish of some therapies! Countertransference is another concept that has had its original meaning diluted and virtually lost through its indiscriminate use. To state the obvious, but to begin from the beginning, we should remember that psychoanalytic concepts have been created in order to explain clinical findings. Freud’s “talking cure” led him to recognize the role of (1) the uncovering of the unconscious meaning of a symptom, and (2) the influence that past events had on the patient’s present life. When patients were eventually found whose reaction to supposedly correct interpretations did not fit the analyst’s expectation, this called for an explanation. The other relevant and related finding was the patient’s attaching more importance to the analyst’s person (i.e., his behaviour, attitudes, feelings, etc.) than to his verbal interpretations. “Regression” was the concept that could explain both these clinical phenomena, but this made sense only within the framework of interpreting psychological functioning as resulting from the succession of phases of increasing sophistication. This is an essential element of a dynamic view of psychological phenomena. “Maturity” is usually defined as one (a) having a clear sense of self and other, (b) relating to the world on the basis of shared logic of words and behaviour, (c) having reached the level of genitality, (d) being independent, but not asocial, and (e) being able to ask for and to accept help without feeling diminished, humiliated or intruded upon. It follows from this definition that any sign of deviation from these standards can be defined as “regressing to a less mature stage of development”. What stage exactly is postulated will depend on the particular scale of steps under consideration, for example, instinctual phases or levels of object relating. But I want to repeat the caveat that these interpretations follow from the adoption of our specific psychoanalytic model of psychological functioning: if new findings are automatically explained by these theories, we can run the danger of believing that our theoretical framework can explain any and all findings when meeting our patients.

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From its earliest days, psychoanalysis was supposed to rely on “interpretations”, making the unconscious conscious. Freud’s initial putting his hand on the patient’s forehead was quickly abandoned, and he went on to stress how the analyst had to conduct his work without allowing any intrusion of his personal prejudices or his physical persona. By the time Ferenczi put into practice techniques that involved more than just spoken words, the question arose whether he was dealing with patients with special needs or whether he allowed his own feelings to influence his clinical judgement. Freud expressed his disapproval of this departure from the “rule of abstinence”, and warned Ferenczi against his experiments. Balint (e.g., in The Basic Fault, 1968) discussed the consequences of this disagreement and charted the inhibiting effect it had on the majority of analysts. Nevertheless, more patients appeared who seemed not to respond to interpretations alone, and each analyst had to find his way to understand these patients and devise ways in which to help them. There is general agreement that the main “disturbance” that first points to this regression is the point where, instead of the analyst’s words being taken at face value, they are taken as expressions of his feelings about the patient. Two different languages are now being used: literal and metaphorical, child and adult, rational and irrational, “normal”/neurotic and psychotic. At this point, a fundamental choice has to be made: does the analyst continue to see his words as the one and only contribution he makes to the patient? Or does he now give equal value to his silence and general non-verbal, physical presence? I suspect that what analysts have written about this issue may well not correspond to what the patient or an observer might conclude about actual events, but we must restrict our discussion to published material. Essentially, we have Winnicott, Balint, and Little arguing that the analyst has to adopt a different technique when seeing these regressed patients, while Bion appears to see no need for the analyst to change his stance towards the patient. As I understand Bion’s text, his original formulation about “containing” aims at explaining the general characteristics of the communication patterns in the analytic situation. “Container” and “contained” were concepts he put forward to describe how one party projects into the other those mental contents that he cannot

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cope with. He wrote (1962, p. 90) that he took this formulation from Melanie Klein’s theory that . . . the infant projects a part of its psyche, namely its bad feelings, into a good breast. Thence, in due course, they are removed and reintrojected. During their sojourn in the good breast they are felt to have been modified in such a way that the object that is re-introjected has become tolerable to the infant’s psyche. . . . From (this) theory I shall abstract for use as a model the idea of a container into which an object is projected and the object that can be projected into the container: the latter I shall designate by the term contained. The unsatisfactory nature of both terms points the need for further abstraction.

Bion appears to extrapolate from Klein’s mother–baby dyad to propose a model of relationship that transcends the patient–analyst couple and is applicable to any pair. In fact, he developed this model into elements of his theory of thinking. And yet, time and again, we find that these concepts are linked (1) to the features of the earliest phases of the child’s development, and (2) to portray what happens between patient and analyst. If Bion believed he was unravelling the complexities of thinking processes in general, we now find many analysts defining their role as “containers” of their infant/patients projections into the parent/analyst. The shorthand reference is to “the analyst acting as the container”. I want to stress the implication here that the analyst’s physical being and his general non-verbal contribution to the encounter is depicted as not relevant. Winnicott adopted a totally different approach to the regressed patient. Like Bion, he made the link with earliest phases of development, but he defined the analyst’s role as involving more than his verbal utterances. “Holding” was Winnicott’s word to describe a particular attitude of support, care, non-intrusive and non-demanding attention that the analyst would offer his patient when the patient had regressed to a position of dependence. He compared this to the mother’s nurturing of her baby and, as we all know, he put forward a rich and complex network of concepts around his vision of the earliest mother–infant relationship. Perhaps the word “compare” does not convey the directness of the link Winnicott made between the two dyads of patient–analyst and baby–mother. For example, he wrote in Playing and Reality (1971, p. 131):

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. . . at some point the baby takes a look around. Perhaps a baby at the breast does not look at the breast. Looking at the face is more likely to be a feature. What does the baby see there? To get to the answer we must draw on our experience with psychoanalytic patients who reach back to very early phenomena and yet who can verbalize (when feel they can do so) without insulting the delicacy of what is preverbal, unverbalized, and unverbalizable except perhaps in poetry.

Winnicott’s accounts of this work aroused considerable opposition, but it was the actual physical contact with the patients that produced the strongest reactions. I suspect it was the enormous respect that Winnicott commanded in the analytic community that led to a general silence over these technical approaches, rather than cruder condemnation. But, from the special provision to a regressed patient, Winnicott gradually extended the concept of “holding” to define the ideal analytic setting and a technique to help patients with special needs (Abram, 1996, pp. 183–189). But another analyst in the British Society was also reporting regression and physical contact: Balint. He emphasized (1968) that when the analyst’s words are no longer seen as expressions of ideas, but, instead, of his personal feelings, then this indicated that the patient seeks, needs, a relationship with an object. Balint linked this to a basic fault, a mental condition where the analyst’s physical presence becomes more important than any words he may use. But note that Balint’s argument refers to a position of regression and not to the “ordinary” patient’s relationship to his analyst. Balint was certainly not the only analyst who focused on the needs of the regressed patient and it is interesting to note his survey of the conceptualizations that other workers had put forward to define this aspect of the psychopathology of patients. Focusing on the characteristics of the analyst’s contribution during phases of regression, Balint wrote (1968, pp. 167–168): Several other authors tried to describe this sort of object relationship or, more correctly, environment-patient relationship, using other terms. Anna Freud (“War Years”) used ‘the need-satisfying object’; Hartman (1939) ‘the average expectable environment’; Bion in a paper to the British Psycho-Analytical Society (1966) contrasted the ‘container’ with the ‘contained’. The most versatile inventor of such

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terms seems to be Winnicott, who used (1941) the ‘good enough environment’, then talked about the ‘medium’ in which the patient can revolve like an engine in oil, then (1949) came his ‘ordinary devoted mother’, in 1956 the ‘primary maternal preoccupation’, then (1960) the ‘holding function’ of the mother, while in 1963 he borrowed the term ‘facilitating environment’ from the American literature and used it as part of the title of his last book (1967). Margaret Little called it the ‘basic unit’ (1961), while M Khan proposed (1963) the ‘protective shield’ and R Spitz ‘mediator of the environment’ (1965), while M Mahler preferred (1952) ‘extra-uterine matrix’. Any one of these terms is correct. Each describes one or the other aspect of this non-omnipotent relationship that I have in mind.

The word “omnipotent” refers to Balint’s view that the repeated interpretation of the patient’s utterances as references to the person of the analyst conveys, fosters, and reinforces an image of power, immense significance, and omnipotence of the analyst. During these phases of regression, Balint considers it vitally important that the analyst should recognize that it is his attitudes and behaviour that most fit the patient’s needs and capacities. But, as I understand his text, Balint is, initially, not linking this relationship to a model of early infancy: rather, he seems to identify two different modes of mental functioning, much along the lines of Bion’s “container– contained”. For their part, Winnicott and Little see the patient as having regressed to that state of mental functioning that characterizes the stage of psychological development of an infant. From this, it cannot but follow that the analyst will be seen as a similar or improved version of the patient’s original mother. However, even if Balint first stressed the patient’s mode of communicating, he eventually also pointed to the same notion of a trauma, injury, lack, loss, defect, fault, or whatever else, acute or protracted, that the person suffered during his earliest, preverbal phase of development. This means that this one point comes to be central to all the formulations we have been discussing. From the moment we decide that the patient’s disturbances result from an environmental failure that interfered with his development, we cannot but proceed to debate whether this can be counterbalanced, remedied by some special input from the analyst. Bion (1962) opted for an apparently different solution: following Klein, he focused on the innate characteristics of the patient. As in other formulations, the

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timing of the disturbances is located in earliest infancy, but it is the child’s instincts and the manner in which these are dealt with that are seen to be of primary importance. It could be argued that from the moment Bion raises the importance of the mother’s reactions to the child’s projections, for example, the state of reverie, we are back at the model followed by the other authors. Nevertheless, reading Kleinian texts, it can be difficult not to conclude that the patient’s psyche is given exclusive importance when describing the progress of the interaction with the analyst/mother. I believe these formulations contain two fundamental assumptions that I would like to discuss: first, the link between the clinical setting and the early mother–infant couple, and second, the specific or general applicability of these concepts. Two recent discussions highlight the main views on these points. The Psychoanalytic Department of University College Hospital held a meeting between André Green and Daniel Stern to discuss their views of Stern’s work with infants (2000). Stern is one of several analysts who have been observing babies and trying to establish their actual abilities. Green was very forceful in his assertion that such work has nothing to contribute to psychoanalysis. He argued that analytic theories are entirely based on hypothetical reconstructions of early psychological development on the basis of work with older patients. The observations of Stern and others can only tap on the perceived behaviour of the infants - how, in fact, the infant experiences impinging stimuli, what conscious and unconscious constructs he builds on these, remain beyond our reach. This means that until such time as we can discover what psychic elaboration the infant or the preverbal child makes of himself and his objects, we can only rely on whatever hypotheses are put forward to explain the child’s reactions. Authors like Trevarthen (1979), Emde (1988) and Tronick (1998) present very convincing interpretations of the infant’s behaviour during interactions with their mothers, but for those who give primary importance to the unconscious perceptions and fantasies of the individual, we still need a bridge to bring together these two worlds. An alternative short-cut can be found with many of those who practise “infant observation”, where the infant’s behaviour is axiomatically interpreted along the lines of our adult-based theories, an approach which is vitiated by the fact that it applies self-fulfilling premises.

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Interestingly enough, Stern and colleagues have just published (1998) the findings of their study group on “Non-interpretative mechanisms in psycho-analytic therapy”. They argue that interpretations of the patient’s unconscious are not the only important factor in the therapeutic interaction between patient and analyst. They put this relationship under the microscope and produced a list of new concepts. “Now moments” are emotionally charged exchanges that are not strictly part of the transference–countertransference relationship. If these “now moments” are seized therapeutically, they can create “moments of meeting”. They also focus on the “shared implicit relationship”, where patient and analyst learn of each other on the basis of minimal, mostly non-verbal cues. Note, however, that these concepts describe the interaction between the analyst and any of his patients. But Stern’s study group goes on to draw a parallel between these relational concepts and the early development of the child. The paper quotes relevant research literature showing how, from very early days, infant and mother operate within a “mutual regulation model”. “Ongoing regulation involves the repetition of sequenced experiences giving rise to expectancies and thus, becomes the basis of implicit relational knowing” (original italics). Stern’s conceptual formulations are very interesting, but I suspect they will hit analysts and therapists as old acquaintances in new clothes. If we focus, first, on the present, actual interaction between analyst and patient, I cannot imagine that anybody will question the accuracy of Stern’s formulations, but seeing our “ordinary neurotic patients”, these findings are simply taken for granted. When it comes to the regressed patients we have been discussing, I have quoted Winnicott and Balint to show precisely how important they consider these phenomena. If we now turn to the link that Stern makes with early mother–infant relationship, I think that Green’s arguments over this hypothesis has the support of many analysts. I imagine that analysts who follow attachment theories will welcome Stern’s findings, but they do not bring us closer to knowing exactly how the infant or child experiences the interaction with their carers. Developmental psychologists feel justly very proud of the advances that recent research has brought to the understanding of the emotional development of the child. We now have more and

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more analysts (our British Society has Peter Hobson and Peter Fonagy) doing this work and the Winnicott Foundation has been supporting Lynne Murray for many years in her research into this area. But we still seem quite far from the day when research on early infantile development will add to, or correct, some of our psychoanalytic formulations. For the moment, I suspect analysts will look at these research findings and ignore them, or find confirmation for whatever theory they already follow; equally sad is the fact that non-analysts will never take them as evidence that might lead them to give credence to analytic theories. Our therapeutic efforts with ordinary, neurotic patients tend to confirm the validity of our theories. When, however, we come to patients we consider “more seriously disturbed”, I believe we should undertake a long-delayed review of our experience with them. If we were to see the patient’s utterances and behaviour not as the result of some earlier developmental disturbance, we would have to find some alternative explanation for this. I think we should consider the possibility that someone can have different levels or modes of thinking, speaking, relating to the world that are caused by some other factor than the dynamics of their earliest nurturing experiences. We often find cases where we are at a loss when trying to make an accurate aetiological diagnosis, but this is not sufficient reason to justify the axiomatic choice of the early mother–infant model. My argument is that as long as we interpret all pathology as the result of some form of impingement or omission during the earliest phases of the patient’s development, we will remain stuck in a tight set of self-fulfilling hypotheses. I would like to quote very brief vignettes of some cases: I saw a patient who demanded “a full analysis” but I was determined to keep her in three sessions per week therapy, sitting opposite me, as I thought her mental equilibrium was rather brittle. She went on to another analyst who did give her the five sessions per week she wanted—and she soon had a major psychotic breakdown. Presumably, she was considered recovered by the time she stopped her analysis, but when I met her quite some years later, she was precisely the same agitated, anxious, high-pressured, and unhappy person I had first met in my consulting room. I have seen a young woman who presented frequent incursions into psychotic thinking but retained a reasonable grasp of everyday

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reality. She was in her mid-forties when I saw her, but her first analysis started when she was six years old. She had been through eight different analysts, staying for over fifteen years with one of these. In spite of a couple of hospitalizations and periods of medication, I felt that none of the professionals (obviously including myself!) had ever achieved any qualitative change in her mode of experiencing herself and the world. More significantly, I have seen many young children with diagnoses like autism, Asperger’s syndrome, pervasive developmental disorder, and various other language and/or behaviour disturbances. Some of these had psychotherapy, others went to special schools, and some managed to attend normal schools with some additional specialized teaching. It happens that I followed quite a few of these children for very extended periods, and if their progress into adolescence and adulthood demonstrated a wide range of degrees of adaptation, they retained the essential feature(s) of their original presenting clinical picture. We do not have many accounts written by patients who went through periods of serious regression during their analyses, but both Guntrip (1975) and Little (1985) have paid tribute to the dramatic help they obtained from Winnicott. In practice, each one of us has to decide how he will deal with a patient who makes it clear that our interpretations alone do not suffice to bring understanding, relief, or any kind of improvement. How should we respond? Do we depart from strict interpretations and introduce new technical parameters? This can be a difficult decision, since it involves not only theoretical factors, but also very significant personal ones. It is perfectly obvious that departing from strict, verbal interventions and deliberately introducing non-verbal parameters will never work if the analyst/therapist does not feel comfortable putting this in practice. Conversely, if these non-verbal parameters feel comfortable to the analyst, then he must carefully analyse his motivations when introducing them into the analysis. Personally, I have come to think of what, for the sake of brevity, we may call psychotic thinking, as a mode of experience that cannot be altered. If the patient cannot recognize this experience as abnormal (i.e., ego-alien), he is beyond the reach of our words, but if he is aware of its nature, we can help him to recognize how, when, and why these ideas and experiences appear and how they affect

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him—this will usually help the patient to overcome the anxiety which tends to appear as a response to the psychotic experience. I do not feel comfortable over having physical contact with a patient and this obviously determines my clinical stance, but I take serious notice of the patient’s perception of my body expressions and I do adapt my verbal contributions to my assessment of the patient’s mode of functioning at each particular moment. I believe that it is the duty of each analyst or therapist to make a careful appraisal of his patient’s level of intellectual/emotional functioning at each step of the treatment. I do not believe it is correct to treat all and every word and behaviour of a patient as if they originated from one and the same kind of psychological operation. Of course, with our “run of the mill”, “ordinary” patient, this is not so important, but we forget caution at our peril. However, this attitude of caution, of responsible appraisal of the patient’s needs and capacities, of respect for his feelings and wishes, of considered and measured responses to the patient, I see this as part of responsible professionalism. The attributes I listed earlier on as usually seen to be part of “holding/containing” (tolerance, respect, patience, kindness) should really be in place at all times, irrespective of the patient’s pathology. I think it is very important that we return to the original meaning of Winnicott’s “holding”, i.e., a specific technical stance that belongs to a well-defined pathological state. I find Balint’s theories and recommendations equally helpful, as they also refer to this state of regression that calls for special technical parameters. Bion’s original notion of container and contained makes good sense and is clinically helpful in the same way that Mrs Klein’s “positions” (paranoid–schizoid and depressive) are illuminating and useful, in helping us to understand a patient’s mode of experiencing himself in the world. When these concepts are literally translated into renderings of the patient’s earliest mothering experiences, they simply fail to convince me. At the risk of repeating myself, I would like to make explicit my argument about the link between the analytic “now” and “early infancy”. I find it intellectually unsatisfactory to adopt reductionistic arguments, since they easily lead us to cross the boundary between reasoning and belief. But, specifically in the context of our regressed or seriously ill patients, this axiomatic translation into

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phenomena that supposedly occurred in earliest infancy can blind us to other important data. The nature vs. nurture mysteries are not solved by a blanket adoption of the “environmental factors” (i.e., mothering) and, furthermore, the patient’s life does not stop with the onset of Oedipal conflicts (whichever be the age at which this is attributed), and he remains vulnerable to all kinds of impingements. Turning to the technical side of our discussion, if one must refer clinical findings to theoretical constructions we have built over the decades, at least I would make the plea that they are reserved for professional discussions: when I hear or read an interpretation where the analyst refers to him/herself as parent, I find myself wondering whether the patient accepts this as a cue to insight or, instead, an idiosyncratic language of the analyst that he has to learn to live with. In summary: “holding” should be treated as a technical parameter belonging to a specific clinical picture; “container–contained” is a useful concept to define one view of object-relating, but neither “holding” nor “containing” should be watered down into a pseudoscientific disguise for not knowing what to do with our patient. Interpretation is a concept best reserved for that one particular kind of communication where the analyst/therapist decides that the patient is able and ready to benefit from hearing what the analyst has understood of the unconscious content underlying the patient’s communications. I believe that the therapeutic action of analysis involves more than the analyst’s interpretations, but I prefer to see the analyst’s contributions to the interaction as preparatory work for the eventual interpretation which can help the patient to gain insight into his difficulties.

References Abram, J. (1996). The Language of Winnicott. London: Karnac. Balint, M. (1968). The Basic Fault. London: Tavistock Press. Bion, W. R. (1962). Learning from Experience. London: Karnac. Casement, P. (1985). On Learning from the Patient. London: Tavistock Press. Emde, R. (1988). Development terminable and interminable: 1. Innate and motivational factors from infancy. International Journal of Psychoanalysis, 69: 23–42.

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Green, A., & Stern, D. (2000). Clinical and Observational Psychoanalytic Research: Roots of a Controversy. London: Karnac. Guntrip, H. (1975). My experience of analysis with Fairbairn and Winnicott. International Review of Psycho-analysis, 2: 145–156. Little, M. I. (1985). Winnicott working in areas where psychotic anxieties predominate: a personal record. Free Associations, 1(3): 9–42. Main, T. (1999). The ailment. In: J. Johns (Ed.), The Ailment and Other Papers (pp. 12–35). London: Free Association Books. Stern, D. N., Sander, L. W., Nahum, J. P., Harrison, A. M., Lyons-Ruth, K., Morgan, A. C., Bruschweilerstern, N., & Tronick, E. Z. (1998). International Journal of Psychoanalysis, 79: 903–922. Trevarthen, C. (1979). Communication and cooperation in early infancy: a description of primary intersubjectivity. In: M. M. Bullowa (Ed.), Before Speech: the Beginning of Interpersonal Communication (pp. 321–349). Cambridge: Cambridge University Press. Tronick, E. Z. (1998). Interventions that effect change in psychotherapy: a model based on infant research. Infant Mental Health Journal, 19(3): 277–279. Winnicott, D. W. (1971). Playing and Reality. London: Tavistock.

CHAPTER TEN

The setting: what makes therapy work?*

I

n recent years, the psychoanalytic setting has come to be regarded as a fundamental element of the work, perhaps even the most important factor in bringing about a positive therapeutic result. I do not agree with such a view, and I would like to discuss some of the points involved in this issue. When I went through my training, the word “SETTING” was not really heard that often and it meant no more than a reference to the physical arrangements involving analytic therapy. It has now become the subject of conferences and, in fact, most discussions on analysis or psychotherapy will, sooner or later, contain a reference to “THE setting”. This follows from the present extreme importance being attached to the concepts of a facilitating environment, management, holding, or containing, and the analytic setting is considered a central ingredient of these. The index to Freud’s twenty-four volumes in the Standard Edition (1943–1974) does not contain the word “setting”, neither is

*First published in 2008 in Scientific Bulletin of the British Psycho-Analytic Society, 44(5): 17–24.

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it listed in Spillius’s (1988) two volumes on Mrs Klein’s work. Rycroft’s Critical Dictionary of Psychoanalysis (1968) does not have an item on “setting”, nor is the word found in Laplanche and Pontalis’s dictionary (1983). The index to Balint’s The Basic Fault (1979) does not list the word either. I do not know who first used the word “setting” as a distinctive feature of psychoanalytic therapy and I imagine the word appears in many papers of the first half of the twentieth century, but I suspect it was Winnicott who first used it with the meaning that came to be invested in our days with such profound importance. At the International Psychoanalytical Congress in Marienbad in 1936, a symposium was held on the theory of the therapeutic results of psychoanalysis. The predominant view depicted the analyst acting as an auxiliary superego. He helps the patient to develop a transference relationship in which he can be shown that the analyst does not copy the original objects. He does not praise or attack, but interprets the patient’s defences, eventually helping him to recognize the nature and strength of his instincts and, thereby, develop a better functioning ego. All revolved on the work carried out by the analyst; I could not find any reference to the setting as such in which the analysis took place. Glover (1937) focused on the development of the transference and suggested that the analyst might be seen as “a better composite family figure, that is to say, the analyst who endures the patient’s projections and is, in course of time . . . introjected” (p. 129). It is interesting to note that he then adds that this explanation even if “correct enough, is rather a self-satisfied explanation on the part of the analyst and depends a little on his enthusiasm for his own interpretations” (ibid.). Bibring (1937) suggests an explanation that might be considered an earlier version of the “setting”. He sees the patient gradually developing a transference relationship where he makes the analyst “an external representative of his super-ego” (p. 175). In this way the rôle of the omnipotent authorities of childhood, who are endowed with magic and can be protective or terrifying, is ascribed to the analyst. The analyst plays at first either part alternatively, according to the situation. This extraordinarily unstable situation is counteracted by the analyst’s actual attitude, as evinced

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by his analytical activity and by the creation of the so-called analytical atmosphere. That is why the patient has the constant certainty, even though it may often be disturbed by anxiety, that the benevolent and understanding relationship of the analyst to him, beyond considerations of blame or punishment, will never be interrupted. [ibid., my italics]

Coming to more recent times, screening the many quotes in Abram’s The Language of Winnicott (1996), it becomes clear that the all-important analytic setting is, in fact, part of Winnicott’s original conceptualizations. He was working with severely ill patients who did not respond to the customary analytic techniques that relied on interpretations. He built a body of concepts that involved theoretical constructs and new therapeutic techniques. He described these patients as psychotic, but he also defined them as having “regressed to dependence”. “Interpretations” as such were no longer the main tool of work, since these patients needed the analyst to act, concretely, as the source of the nurturing they required. Winnicott wrote that they needed “management”: the holding, containing, or facilitating environment that infants needed if they were to mature into independent people. Rodman (2003), in his analysis of Winnicott’s work, focuses on the period between 1945 and 1952 as particularly relevant to this problem: The principal point of controversy was whether psychoanalytic work must be limited to verbal interpretations or whether, as Winnicott claimed, it must also include what he called ‘management’. Management encompasses all those deeds and gestures other than verbal interpretations that give comfort to the patient in time of need and which, according to him, address the failures of parental figures in the first part of life and facilitate the process of understanding that is embodied in verbal interpretation. Management might include the offering of a cup of tea, an arrangement for a friend of a patient to provide care during a break in analysis or even the holding of the patients’ hands during a deep and devastating reliving of trauma, as was the case in his analysis of Margaret Little.

Phillips (1988) described Winnicott’s changing theories and techniques when considering psychotic patients. “His new ideas

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about early development and psychosis as an ‘environmental deprivation disease’ necessarily involved modifications of the classical psychoanalytic technique Freud had invented for the analysis of neurotics” (pp. 87–88). Phillips argues that Winnicott’s views are stated most clearly in his 1949 paper on “Hate in the counter-transference”. The analyst of a psychotic patient must be prepared to bear a strain without expecting the patient to know anything about what he is doing, perhaps over a long period of time. To do this he must be easily aware of his fear and hate. He is in the position of the mother of an infant unborn or newly born. [p. 198]

Phillips continues, In this new model of the analytic setting, devised for the psychotic patient, the setting is not symbolic of the mother’s care as it would be with a neurotic patient, it IS the mother’s care. It cannot represent something that never existed. The earliest experiences of the psychotic patient—the mothering that should have facilitated the processes of integration, personalization and realization—’have been so deficient or distorted that the analyst has to be the first in the patient’s life to supply certain environmental essentials’. [pp. 87–88]

This is a very lucid description of Winnicott’s proposal of infant development theories that might throw light on the psychopathology of the particular type of severely ill patients he was treating. After finishing our training, some of us organized a study group, and one evening (in 1965) Winnicott came to talk to us. At one point, he told us that after each patient left his session, he would go round the room and ensure that the next patient would find the room arranged precisely in the manner that he had left it at his last session. We all felt quite daunted by such a demanding yardstick of good clinical practice! It happened that a couple of days later I had supervision (of one of my child cases) with Hanna Segal and I told her this story. She did not mince her words: “Pernicious rubbish!” she said, “What is the point of pretending to a patient that nothing happens in your room from one session to the next?” Winnicott was telling us about the importance of preserving the continuity of the analytic setting. To Segal, this was a deception, a collusion with a patient’s denial of the realities of life.

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Brearley discussed this question in a paper on “Neutrality and setting” that he presented in March 2008. He focused on the physical setting, which . . . is mine and expresses me, not as a whole, but in my work . . . Since it is, in my case, in the basement of my home, issues of my family, of wealth, of cars, of care of the garden etc become inevitable. Similar issues arise in relation to situations in which a patient happens to know of one’s previous career.

(Brearley had been a famous professional cricket player.) He emphasizes how unavoidable these facts are: the challenge lies not in ignoring or disguising them, but in deciding how to deal with them in the ongoing therapeutic work. Brearley is endorsing Segal’s stance, but let me quote an opposite view. Kahr’s book The Legacy of Winnicott (2002) contains a chapter by Langs in which he depicts very clearly the two fundamental meanings of the word “setting”. In what he calls a “preWinnicott” phase in his professional life, he describes thinking of “setting” as the traditional image of the analyst’s work: consulting room layout, timetable, analyst’s reliability, consistent appointments, etc. He followed his teachers, associating this with the notion of the neutral analyst, sometimes described as no more than a mirror to the patient, reflecting only that which the patient wanted to see in him. But after reading Balint and Winnicott, Langs felt that his professional world suffered a major change. And Winnicott wrote of the holding environment, the way that the analyst safely holds the patient as a mother holds a child . . . [he was] telling me, directly and by implication, that the analyst’s management of the setting is a way of holding and even healing the patient. [pp. 17–18]

His is a passionate endorsement of Winnicott’s views and, as can be recognized, this is the ever more dominant meaning being attributed to the analytic setting. Winnicott had written about psychotic patients, but Langs, like so many other analysts, now refers to “patient”—no longer exclusively psychotic ones. In 1995, I wrote a brief discussion paper on the “Contract for therapy”, in which I listed some of the issues related to Langs’ “preWinnicott” phase. I mentioned the question of having a waiting

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room available because I had heard a colleague’s account of demanding his patient should ring the front door bell only at the precise time for the session. If the patient travels by public transport, is this fair in a cold climate? But it happens that my colleague did not have a waiting area in the part of his house where he saw his patients! Does this matter? Seeing patients without any interval between them, especially if they cross each other when arriving or leaving the consulting room, breaches the most elementary rules of privacy and confidentiality. And yet, we have colleagues who work in this way. Does this matter? I remember visiting Masud Khan’s consulting room and finding that not only was his central heating on, but he also had two heaters working full force. I was shocked by the ghastly heat in the room and, very politely, voiced my surprise. He dismissed this with a curt “Sorry, I like to work in a very warm atmosphere.” I felt great sympathy for his patients. Can an analyst smoke during sessions? There was a time when some analysts (male and female!) would knit during sessions and we have all heard of analysts taking notes during the session. And what about answering the telephone? A different example: the patient was a doctor whose work involved a twenty-four-hour hospital shift each week. The analyst demanded seeing her for five sessions each week and refused to compromise over that day when she had to be in hospital. Believe it or not, for a time she agreed to pay for the fifth, non-existent weekly session, but what she eventually found unacceptable was hearing every single week her analyst referring to the unconscious meanings of “the session you failed to attend”. It took me many years to understand the lesson of these stories. It is so obvious that we tend to ignore it. The arrangements of the consulting room and the practical details of his work pattern are just as much a clue to the analyst’s identity as a human being and a professional as his way of dressing and his whole approach to the patient. The setting is organized to suit the analyst’s needs, capacities, and wishes. As Green (1975) describes, in a classical analysis the patient, after the surprises of the beginning, ends by assimilating all the elements of a situation which allows the analysis to proceed . . . The elements of the setting provide

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material for interpretation only when there are occasional modifications. [p. 10]

Once the setting is taken for granted, patient and analyst can get on with their work: it is the analyst’s interpretations that will count in this relationship. The analyst still has to discover how he defines his approach to understanding and helping each individual patient. Whatever his personal style, some adaptation will take place when working with each one of his patients, however difficult it is to establish precisely how they influence each other. The British analytic scene was certainly influenced by Strachey’s arguments (1934) on the role of interpretations in psychoanalysis. He gave great importance to the analyst’s position of a source for new, healthier, more benevolent identifications, but the main therapeutic element was the “mutative interpretation”. But over the second quarter of the century, Mrs Klein was developing her views on the importance of the child’s endowment and his earliest years. During those years, other analytic authors also published their work with what they called regressed patients. These were no longer those earlier patients, where regression meant a development that allowed transference to develop, that is, the analyst to be experienced not only as a real professional, but also as a representation of earlier objects. Clearly, more disturbed patients were now taken on for analysis and there was the gradual discovery that many of the patients previously considered neurotic were, in fact, more seriously disturbed. Balint described them as having a “basic fault” and he gives an interesting list (1979, p. 16) of the various concepts coined by various analysts to describe this specific pattern of relationship. In the present context, I will choose as the main feature of these states the fact of the patient losing the capacity to utilize words as the main element in the analytic relationship. Following our theories of development, it is easy to postulate regression to a preverbal phase of development. If the analytic intercourse cannot take place exclusively through the use of words, what should an analyst do? Let me quote Heimann (1956): . . . [the patient] re-experiences his old conflicts with their attendant persecutory and depressive anxieties. But repetition turns into

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modification, because the analytic relationship provides not merely a stage on which the patient re-enacts his past experiences. This time the patient’s emotional object, the analyst, does not react by responding emotionally to his wishes and fears, as his original objects did. In this new emotional setting in which the patient repeats, the analyst contributes, in the form of interpretations, the perception and consciousness of what is happening in this setting. This combination of contact with an object together with conscious insight into what this contact unconsciously signifies distinguishes the transference from the original relationship. [p. 111, my italics)

This is a continuation of Strachey’s arguments and a quite explicit statement that the analyst’s contribution to the analysis is in the form of interpretations, not actions. On another occasion, during the discussion of a colleague’s paper on therapeutic results at the British Psychoanalytic Society, someone stressed the importance of the analyst being honest, straightforward, reliable, and respectful: Paula Heimann reacted forcibly that these were attributes she would expect from any decent human being, so that possessing these qualities was not relevant in defining the nature of the analyst’s therapeutic role. Not many years later, Bion (1962) introduced his new concept of the “container”, writing that he took this formulation from Melanie Klein’s theory that . . . the infant projects a part of its psyche, namely its bad feelings, into a good breast. Thence, in due course, they are removed and reintrojected. During their sojourn in the good breast they are felt to have been modified in such a way that the object that is re-introjected has become tolerable to the infant’s psyche. . . . From (this) theory I shall abstract for use as a model the idea of a container into which an object is projected and the object that can be projected into the container: the latter I shall designate by the term contained. [p. 90]

As I understand him, Bion still advocated no departures from the usual parameters of analytic technique, meaning that the analyst’s contribution remained restricted to his interpretations. In a way he is confirming but reformulating Heimann’s views, now phrasing them in something of a supposedly physical form and language that, as time came to show, proved immensely attractive to later

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analysts. What I also find extremely important here is the equation of the analytic situation with that of the earliest infant–mother dyad. Whatever disagreements have existed between Kleinians and followers of Winnicott in terms of technique, the underlying conceptualization that underpins the clinical work of both groups is this equation of the patient–analyst and infant–mother dyads. In his 1954 paper on regression, Winnicott wrote (note the word setting): Psychotic illness is related to environmental failure at an early stage of the emotional development of the individual . . . the setting of analysis reproduces the early and earliest mothering techniques. It invites regression by reason of its reliability . . . [it] can only be relieved by specialized environmental provision interlocked with the patient’s regression. [p. 16]

In 1956, in “Primary maternal preoccupation” (PMP), Winnicott describes PMP as an “illness” and refers to mothers who can produce autistic children as being those who do not develop PMP. He uses here the word setting, provided by the mother for the baby to develop: “The mother who develops this state that I have called ‘primary maternal preoccupation’ provides a setting for the infant’s constitution to begin to make itself evident, for the developmental tendencies to start to unfold” (p. 303, my italics). In The Basic Fault (1979), Balint endorses Winnicott’s views on the importance of the setting: Since the basic fault, as long as it is active, determines the forms of object relationship available to any individual, a necessary task of the treatment is to inactivate the basic fault by creating conditions in which it can heal off. To achieve this, the patient must be allowed to regress either to the setting, that is, to the particular form of object relationship which caused the original deficiency state or even to some stage before it. [p. 166]

These views are fascinating from an intellectual point of view. They come from analysts who combine clinical experience with a rare capacity for creativity, weaving concepts and arguments that command admiration and awe. These analysts saw patients who seemed unable to benefit from the usual analytic techniques. They

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had the inspiration and the courage to put into practice new techniques and they managed to find theoretical constructs that could justify their experiments. But, however tempting it is to adopt these concepts and techniques as guidelines, it becomes very easy to forget the precise cases in which they were felt to be necessary and appropriate. Quite often, we find theories turned into dogmas that are then applied more widely than originally intended. There is no doubt that the analyst’s work becomes far easier if there is one specific formula he can adopt in his practice. I have been discussing the “setting”, but a similar process occurred with the question of “transference interpretations”. Freud, Strachey, and many others wrote about developing, building, the transference relationship and the importance of timing the transference interpretation so that the patient was able to make good use of it. But we now have analysts and therapists who feel they have failed if found to have said anything to the patient that is not exclusively “a transference interpretation”. As it happens, I found that already in 1959 Balint (Thrills and Regressions, Chapter Twelve) noted and criticized the fashion that the analyst should only give “transference interpretations”. If some rationale is required for such a view of the transference, perhaps the justification for this approach is the theory that patients come into analysis or therapy with an already established transference. Indeed, we have some patients who present the features of a transference relationship right from the beginning of therapy, but this is far from a universal finding. But, as is well known, we do have theories of infant development that postulate that the infant is equipped right from birth with images and fantasies of the world he is born into. So, which came first: the clinical finding or the theory of infant development? I suspect this is another example of a theory of the child’s earliest development put forward to explain findings in the analysis of very specific types of patients. Whether the developmental theories are accepted or not, surely it is not logical or justifiable that these theoretical postulates and clinical parameters should be taken as axioms into which to fit all patients. In other words, is it really true that all patients need an immutable nurturing “setting” from which they benefit? Is it really true that all patients can only be helped by the use of transference interpretations? Is there really no difference between psychotic

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and neurotic patients? Or between regressed and non-regressed patients? I would like to focus on two points that I consider particularly relevant. One is the importance of the clinical assessment, the evaluation of each patient’s actual needs and abilities. The other is the juxtaposition of the analyst with the figure of the patient’s earliest objects. It is one thing to learn Freud’s, Klein’s, Winnicott’s, Bowlby’s, Mahler’s, or any other infant development theory. But it is rather dangerous to turn any of these into a universal model of development that explains the psychopathology of all patients. This can only lead to the patient being seen as the infant in one’s favoured theory and, almost inevitably, define one’s position as the new good maternal object who will help the patient. We have come to accept as a given the attribution of central importance to the earliest phases of an individual’s development, but, what about his later years? Do they really exert no influence? And, equally important, how do we interpret the actual conscious emotional position of a patient at the time when they come to see us? The temptation is to translate all clinical findings into those early patterns of development, but I see this as a mistaken over-simplification. It is a reductionistic position that may help us to achieve some degree of clarity over the patient’s relationships to his objects, but it can also mean that we lose sight of the patient in front of us, seeing instead some construct that we feel comfortable with. A similar reasoning applies to the question of diagnosis. Winnicott saw autism and psychosis as resulting from deficient mothering, but has this been proved correct? This theory implies that we all have the same inborn psychological endowment and potentials. Indeed, I have heard and read many psychodynamic assessments that seem to adopt this view and, perhaps predictably, go on to argue that, given the “right” analytic provision, all patients can achieve equal benefits. The assertion of the therapeutic importance of “the setting” seems to be based precisely on this assumption. However, how many patients do, in fact, regress to that state of dependence discussed by Winnicott and Balint? How many of us do really take on such patients? How can we ever establish how different analysts would assess the same patient? This is not a question of recognizing, as early as in the diagnostic interview, that

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particular patient who will regress to dependence, whether he is seen as psychotic, or as a personality disorder, or borderline psychotic. It is useful to remember that Margaret Little saw two eminent analysts before entering analysis with Winnicott: she wrote (1985) that they failed to recognize her needs. This suggests that a patient can only regress to a state of dependence when given the appropriate response from the analyst. But does this “appropriate response” depend only on professional competence, or are there other, more subtle, factors that influence this development? I suspect we will never discover the full answer to this question. Only patient and analyst know what exactly happens between them. We, the outsiders, will only learn of that interaction that each of them allow us to know and, predictably, we will probably choose to believe in the version of the person we trust more. Hardly a situation open to scientific scrutiny! Perhaps I should attempt to describe my picture of the type of patient who, I believe, gave rise to the problems we are discussing. This is a person who, consciously or unconsciously, needs and wants a person, a place, or a haven that he can trust and rely on for sameness, reliability, and open-ended availability. Psychiatric diagnoses such as psychosis, personality disorder, autism, etc. are not necessarily the main factor to help us identify them. Many of these patients lead active and reasonably “normal” lives, but they carry a deep sense of unhappiness and isolation. If, after a few sessions, they feel comfortable with the analyst, they will attend sessions punctually and there is usually no shortage of material to discuss in sessions. These patients seem to have an extraordinary sense of observation and they will notice and react to any change, however small, in the analyst or in the room. They may attempt to reduce the physical distance between themselves and the analyst and occasionally this may take the form of trying to touch some part of the analyst’s body—our literature contains now many examples of the forms that this move can take. They have a sharp sensitivity to words or actions that they experience as critical; the word “paranoid” can be applied here, but we should note a loss of the capacity to distinguish between reality and fantasy, so that words are interpreted literally. An example: one day I had to cancel a session of one of these patients. He felt I had cancelled him and we had weeks of bitter complaints and accusations; even when I was “forgiven”,

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every so often this episode was brought up as evidence of my capacity to discard him. But perhaps the most striking feature of these analyses is that even though the patient attends his sessions and perhaps even reports elements of progress in his life, the analyst has a repeated impression that he does not know what use the patient makes of his interpretations. At times, the patient ignores the analyst’s words, and at other times he makes it clear that the analyst has said something valid and important, and yet there is no significant change that can be attributed to those “important” interpretations. Gradually, the analyst comes to experience a sense of discomfort and puzzlement, since he cannot link his own verbal contributions to the patient’s responses. The patient attends regularly and clearly values the analyst’s availability, while the analyst feels increasingly frustrated that his interpretations seem to carry no weight. It is, then, plausible to imagine that the patient is relating to an image of the analysis that clearly transcends the actual content of the analyst’s interpretations. I believe it is this situation that Winnicott has described so vividly in his papers. It is a plausible hypothesis to argue that the patient is being kept in the analysis by his attachment to a situation (i.e., not just the person of the analyst) that provides for his emotional needs. Non-analysts might describe this as addictive behaviour, but once the analytic situation is conceptualized as a repetition of the earliest infant–mother dyad, it is not surprising that we find holding or containing as descriptions of the observed events. When this situation arises, it is very important for the analyst to decide how he wants to proceed. Coming to the conclusion that the patient is holding on to the setting of the analysis, he can learn from Winnicott an explanation of his feelings and guidance on how to proceed. However, there is no question that each and all of Winnicott’s technical parameters do not have to be copied! For example, I would not allow a patient to touch or hold me, let alone reciprocate the gesture. Looking at the wider picture, I am sure that there are many analysts and therapists who would not feel comfortable to work with this type of patient. I firmly believe that we are not equally able to work with every single patient, and I think it is important to work only with those patients that we feel comfortable with—otherwise, we will not be working at our best.

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It is part of our profession that we should decide which patients we feel able and willing to work with, whatever the reasons for this view. If one analyst may argue that a particular patient is not suitable for analysis in the sense of the techniques that he employs with “ordinary” neurotic patients, there will always be another analyst willing to take the opposite view and take on that same patient. This clinical dilemma has been beautifully portrayed by Green (1975): “I personally do not think that all patients are analysable, but I prefer to think that the patient about whom I have doubts is not analysable by me”.

References Abram, J. (1996). The Language of Winnicott. London: Karnac. Balint, M. (1959). Thrills and Regressions. London: Hogarth. Balint, M. (1979). The Basic Fault. London: Tavistock. Bibring, E. (1937).Contribution to symposium on the theory of the therapeutic results of psychoanalysis. International Journal of Psychoanalysis, 18: 165–184. Bion, W. R. (1962). Learning from Experience. London: Heinemann. Brafman, A. H. (1995). Contract for therapy. Newsletter of the British Association of Psychotherapists, Autumn: 28–32. Brearley, M. (2008). The analyst’s neutrality: cold or containing? Bulletin of the British Psychoanalytical Society, 44(9): 1–10. Freud, S. (1943–1974). Standard Edition. London: Hogarth Press. Glover, E. (1937). Contribution to symposium on the theory of the therapeutic results of psychoanalysis. International Journal of Psychoanalysis, 18: 125–132. Green, A. (1975). The analyst, symbolization and absence in the analytic setting (on changes in analytic practice and analytic experience). In Memory of D. W. Winnicott. International Journal of Psycho-analysis, 56: 1–22. Heimann, P. (1956). Dynamics of transference interpretations. In: M. Tonnesmann (Ed.), About Children and Children-No-Longer (pp. 108–121). London: Tavistock/Routledge, 1989. Langs, R. (2002). D. W. Winnicott: the transitional thinker. In: B. Kahr (Ed.), The Legacy of Winnicott (pp. 13–22). London: Karnac. Laplanche, J., & Pontalis, J.-B. (1983). The Language of Psycho-Analysis. The International Psycho-Analytical Library, London: Hogarth Press.

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Little, M. I. (1985). Winnicott working in areas where psychotic anxieties predominate: a personal record. Free Associations, 1(3): 9–42. Phillips, A. (1988). Winnicott. London: Fontana Press. Rodman, F. R. (2003). Winnicott: Life and Work. Cambridge, MA: Perseus Books. Rycroft, C. (1968). A Critical Dictionary of Psychoanalysis. London: Nelson. Spillius, E. (1988). Melanie Klein Today. The New Library of Psychoanalysis, London: Routledge. Strachey, A. (1934). The nature of the therapeutic action of psychoanalysis. International Journal of Psycho-Analysis, 15: 127–159. Winnicott, D. W. (1949). Hate in the counter-transference. In: Collected Papers: Through Paediatrics to Psycho-Analysis (pp. 194–203). London: Karnac. Winnicott, D. W. (1954). Metapsychological and clinical aspects of regression within the psycho-analytical set-up. In: Collected Papers: Through Paediatrics to Psycho-Analysis (pp. 278–294). London: Karnac. Winnicott, D. W. (1956). Primary maternal preoccupation. In: Through Paediatrics to Psycho-Analysis (pp. 300–305). London: Karnac.

INTRODUCTORY NOTE TO CHAPTER ELEVEN

Adolescents

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here seems to be general agreement that adolescents are the most challenging patients to treat. It is often difficult to make a precise assessment of their problems and it is only the exceptional adolescent who actually wants to have analysis/therapy, however worried he/she may be about their life situation. For the therapist, it is a problem to find the exact attitude that will win the adolescent’s confidence and ensure he/she continues to attend the sessions. When attendance is secured, it may still involve missed sessions and occasions when the therapist has to decide whether to wait for the patient to make contact or whether it is important to involve family or other resources. This can be very taxing when the adolescent has been exposed to drugs, violence, or other life-threatening situations (suicidal feelings is an example). But we do find adolescents, whatever their psychopathology, who become attached to their therapy and this leads the analyst to watch very carefully what role he plays in the patient’s life. Should he maintain contact with the patient’s family? How to respond to the approach of a family member? And should a medical professional and/or a medical institution be available? We will find therapists who have 195

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strong feelings about such issues, and in such situations it is extremely important to explore with great care what role they are playing in the adolescent’s life. It is a painful, sad finding that the most severely disturbed adolescents tend to have a poor or non-existent relationship with their family. When they establish a trusting relationship with their therapist this is, clearly, a blessing, but it is a double-edged one. The therapist must be extremely cautious of such a relationship where he is felt to be the one and only source of emotional support for the patient. The following paper attempts to describe a developmental view of adolescence and a detailed view of the problems that can be found when they seek psychotherapeutic help.

CHAPTER ELEVEN

Working with adolescents: a pragmatic view*

Some definitions of adolescence

F

rom a socio-biological point of view, we have childhood and adulthood: adolescence is the time in between the two. Biology considers hormones and other physical features to characterize the stage of development of each individual, and society has adopted yardsticks that have varied over the years and in different cultures to determine the rights and duties of each person according to his chronological age. In the psychoanalytic world, following Freud’s instinct theory, we speak of childhood, latency, adolescence, and adulthood. Latency is seen as a period of quiescence, when instinctual drives that dominated the child’s development through the oral, anal, phallic, and genital phases of childhood subside and we find a child who appears not to be under pressure from his instinctual urges. Puberty marks the resurgence of instinctual drives and leads to a

*First published in I. Wise (Ed.) Adolescence (pp. 41–65). London: Karnac, 2000.

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growing individual who struggles with his unconscious instinctual impulses and tries to accommodate the pressures from his environment and from his developing physical endowment. In other words, his early identifications with his parents and his present dependence on them produce child-like feelings and urges, while his widening horizons and growing independence lead him to rebel against them. Adulthood signifies the achievement of some balance between instinctual drives and the forces of reason, that is, a sense of becoming a responsible social being. Jones (1922) put forward the idea that “in the second decennium of life” the individual recapitulates the developments he passed in his first five years, adding that the form of his infantile development “to a great extent determines” how he negotiates adolescence. This formulation has been followed by most, if not all, later analysts. Anna Freud (1958) gives a most sensitive and comprehensive view of adolescence. She discusses in detail the adolescent’s attempt to leave childhood behind and to achieve independence from his parents. This leads to quick changes “from one pathological posture to another”, and this is very different from the adult whose pathological picture can be recognized and worked with. The difficulty of engaging adolescent patients in treatment is compared by Anna Freud to patients in mourning or in love: because their libido is invested in a real person, available or just lost, little libido is left to invest in the analyst. After a detailed analysis of various defence presentations, Anna Freud stresses it is normal for a youngster to waver in his struggles with his impulses and the constraints of his conscience; there is reason to worry only when he becomes fixed in his behaviour and feelings. Mahler (1963) postulated a stage of child development that she called the “separation–individuation” phase. This describes the progress a child makes from being at one with his mother towards creating some distance from her and establishing his own sense of a separate self. This development is strongly influenced by the mother’s capacity to tolerate and to foster the child’s independence. In childhood, this occurs during the toddler stage, when the child is physically able to move away from his mother. Following up on the idea that adolescence would represent a second attempt at this move from dependence toward independence, Blos (1967) described adolescence as “the second individuation process”. Blos

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emphasized how treating an adolescent helps one to observe the alternating and interacting pictures of his view of childhood and of the present world around him, though now within very different individual, family, and social conditions. Klein’s paranoid–schizoid and depressive positions (Segal, 1964) do not constitute developmental phases sensu strictu, but emotional configurations which occur at all stages of the individual’s life. The paranoid–schizoid position is seen as a more primitive structure, which, upon certain achievements by the individual, can become the depressive position, but, whatever his age, the person can oscillate between one and the other. This being so, adolescence was not seen as a developmental phase as such, but, rather, another period of life where these two fundamental positions play a role in characterizing the youngster’s relationship with his internal and external objects (see, for example, Harris, 1965, also in Spillius, 1988, pp. 158–167). More recently, however, Anderson and Dartington (1998) define adolescence as a developmental stage where the individual tries to leave behind his “infant and childhood longings” and moves to adulthood through a complex process of changes that they compare to the work of mourning. Erikson (1965) followed Freud’s formulations, but he introduced the social environment as a most important factor in the understanding of adolescence. He stressed the role of the adolescent in society and described this period leading up to adulthood as a “moratorium”, a time when the individual takes stock of his achievements and failures and of what is expected of him, before achieving his full adult role in the family and in society at large. Society also makes allowances to give the youngster time to find his way through the turmoil of late adolescence (e.g., the years spent at university can be seen as a “moratorium”). Erikson warned that: “. . . the danger of this stage is role confusion. Where this is based on a strong previous doubt as to one’s sexual identity, delinquent and outright psychotic episodes are not uncommon”. Laufer (1976) defined the “three developmental tasks of adolescence” as “the change in the relationship to the oedipal objects, the change in the relationships to contemporaries and the change in attitude to his own body”. He later (1978) wrote: “I would say categorically that illness in adolescence always contains some abnormality in sexual development and functioning”, that is, he

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considers “adolescence pathology to be a breakdown in the process of integrating the physically mature body as part of the representation of oneself” (original italics). Winnicott (1989), in his incomparably rich and colourful language, depicts this period of conflict and change as fundamentally one of individual growth. While the adolescent is invariably seen as a rebel, struggling to find his way to independence, Winnicott stresses the vital importance of the adults who accept the challenge and fight back, supporting the youngster in his turmoil. Much as Anna Freud in the paper quoted earlier, here is also the wise emphasis on time: only the passage of time (p. 72) allows processes to unfold and reach their goal, in this case for the adolescent to become an adult. With all our emphasis on the adolescent as an individual, it is important to emphasize the fact that a person’s adolescence also signifies a major challenge for his parents: they have to “let go” someone who has taken up vast hours of their life and they have to find a new modus vivendi, counting on each other to satisfy needs that had long been covered up by preoccupations with their “child”. Anna Freud (1958) puts this quite poignantly: . . . it may be [the adolescent’s] parents who need help and guidance so as to be able to bear with him. There are few situations in life which are more difficult to cope with than an adolescent son or daughter during the attempt to liberate themselves. [p. 276]

At a time when therapies focus either on the individual or on the family, it is well worth remembering this warning that when taking an adolescent into analysis or psychotherapy, we must also consider his parents’ capacities and needs. The price of neglecting this will often be our losing our patient.

Three stages of adolescence 1. EARLY. Here, we have a child who finds his body changing in multiple ways: size, hair distribution, voice pitch, growing sexual organs, etc. A girl has to learn how to cope with her periods, much as a boy has to adapt to his capacity to ejaculate; finding her breasts

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developing in size can be a source of conflict, as can the boy’s eventual comparisons of his penis with the penises of other boys and men. Soon they discover that not only are other youngsters attracted to them, but they also experience feelings of attraction and/or revulsion towards others around them, which can be accompanied by body sensations they have to make sense of, perhaps even before they learn to label these as “sexual”. When does this process of change begin? Most authors quote the age of twelve years as marking the beginning of adolescence, but there is immense variation in different individuals and populations which has to be taken into account. Furthermore, the individual’s notion of where his development stands may be quite different from what those around him will assume to be the case. Even as we think of “delayed” or “premature” adolescence, it is important to explore the adolescent’s experience of his position. His ability or otherwise to voice his views about the changes taking place in his body and the way in which the world now treats him will enable us to reach an understanding of his unconscious relationships to himself and to his objects. This is part of any good therapy, but, on another level, we should remember that during these early (teen- or pre-teen) years, the child/adolescent is likely to arouse sympathy and warmth whenever he/she voices discomfort, anxiety, or fear, or behaves in ways which are considered to depart from the “ordinary” and move towards the pathological range of reactions. As he grows older, this sympathy gives way to far more complex responses from his environment. If this interest/sympathy is welcome, at times the early adolescent is likely to experience varying degrees of shame when coming in contact with family and strangers, since his/her own conscious and unconscious feelings of strangeness vis-à-vis his/her body are experienced as what “everybody” else feels about him/her, that is, not about his/her body, but about him/her as a person. This is a point to be remembered: to the adolescent, his body is (unconsciously experienced as) his self. 2. MIDDLE. In English, the expression “teen years” describes this period of change from the “childish” early adolescent to the eventual near-adult. These are years when the youngster has to fumble his way through disentangling those values of his earlier life that he can continue to adopt from those he wants to discard. In other words, separate his parents’ principles, beliefs, rules, mores,

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etc., that have constituted his “education”, from what he now discovers himself impelled to adopt on the basis of his new (physical and emotional) capacities and of his interactions with peers. Conceptually, we would be considering his object representations— the result of his interactions with parents and other early objects —and how these now influence and are influenced by the adolescent’s new experiences with his parents and others. If, in early adolescence, the youngster’s attempts at self-assertion were seen as a “cute”, charming kind of awkwardness, now similar (from the adolescent’s point of view) manifestations of selfconfidence are taken as acts of rebellion and defiance and gradually give rise to clashes and battles. The parents accuse the youngsters of wanting to dominate them, while the youngsters accuse the parents of wanting to squash them and treat them as children. An outsider will recognize that these power struggles are, in a sense, inevitable: each one of them is trying to cope with an unconscious (and sometimes conscious) ambivalence regarding the disengagement that will enable the adolescent to become independent and self-sufficient. Understandably, this phase acquires extra poignancy in one-parent families: Oedipal conflicts are brought to the surface, but we must not lose sight of the social significance of that parent being left to live on his/her own. In practice, as long as adolescent and parents go on fighting, the clinician can believe there is hope of some positive resolution. On the other hand, prognosis is more guarded and pathology is more likely to develop when these roles are reversed (i.e., a parent breaks down and the youngster has to assume the role of carer) or when adolescent and/or parent(s) abandon their battles and write each other off. When this disengagement/disowning occurs, serious crises can develop. Most times, the adults manage to deal with the resulting feelings of failure and guilt by covering them up with selfjustifying anger or contempt. For the adolescent, however, the experience of being written off by one or both parents can be very traumatic. Not only does he lose their protection, but most times he will take upon himself the blame for the breakdown of the relationship: the resulting blend of guilt, resentment, and despair can lead to destructive relationship patterns which are repeated with increasing erosion of self-esteem and, quite often, danger to life.

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But during the middle phase of adolescence, whatever the youngster feels, he is still dependent on the parents: in our society, at least, he will be living with the parents and relying on them for food, money, schooling, etc. Over the last few decades, we have seen a dramatic change in these patterns as the use of drugs and sexual customs that used to characterize the late phase of adolescence are practised by ever younger adolescents. Predictably, parallel changes have affected the structure of the family: unemployment, job shortages, the need for both parents to work, new views regarding pregnancy, marriage, and family obligations, all combine to create a blurring in the transition from middle to late adolescence. From a practical point of view, having to work with an adolescent, we must investigate and take into account not only any possible gap between his emotional and his physiological stage of maturity but also the actual family and community environment in which he lives. 3. LATE. These are the years when the adolescent goes to University, finds employment, leaves home to pair up with one or more peers or, if he still lives at home with his parents, becomes increasingly able to reach a modus vivendi where confrontations occur less frequently than situations of mutual tolerance and perhaps even amicable togetherness. But, as he finds his way to recognizing the various components of his sense of self, the adolescent can also experience powerful feelings of isolation. Having left behind the sense of self-in-the-family developed up to that point, he may seek the company of peers to achieve some new sense of belonging. In a sense, this is a normal process, but we should differentiate between the youngster who is reasonably self-sufficient and seeks others of his age out of a desire to socialize from another who needs company to escape from his loneliness. Some adolescents learn to disguise this sense of isolation through various stratagems, but, in fact, this is a type of depression, and when it sets in, the adolescent can feel quite abandoned and reach a degree of despair that often leads to self-destructive behaviour. Another common solution for such crises is the pairing up with someone who is felt to be able to offer the protection, company, and love longed for. This often takes the appearance of sexual behaviour and, indeed, this is how the adolescent will usually present it, but we must remember the possibility that sex is being used as an attempt to deal with a

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much wider and deeper sense of estrangement from the self and the objects that had represented sources of emotional security. 4. “LATER”. Most societies will consider the eighteen-year-old as a virtual adult, though the celebrations for the twenty-first birthday represent a more realistic appraisal of the person’s degree of maturity. Nevertheless, we all meet people older than this who still appear to be struggling with the conflicts we associate with adolescence. Astor (1988) coined the expression “adolescent state of mind” to describe such individuals, which is more accurate than simply saying they are “emotionally immature”. Many years earlier, Bernfeld (1923) described a specific kind of male adolescent, “the protracted type”: they retain adolescent characteristics well beyond the usual chronological time parameters for this and show “tendencies toward productivity whether artistic, literary or scientific and a strong bend toward idealistic aims and spiritual values”.

Conceptualizing the findings Within a psychoanalytic framework, all schools appear to agree that adolescence represents a developmental stage where the person moves from dependence on the parents to the independence that characterizes adulthood. This progression has been juxtaposed on the similar developmental process that leads the infant to grow from birth to latency: it follows from this that adolescence is seen as a “second chance” in the pursuit of self-sufficiency and independence. The basic premise for this formulation is the theory of unconscious mental representations of the child’s objects; psychoanalysis sees “adult behaviour . . . as an elaboration or evolution of infantile behaviour, and complex ‘higher’ forms of behaviour can be interpreted as elaborations of simple, primitive behaviour patterns and drives” (Rycroft, 1968). It is this assumption that underlies the interpretation of the adolescent’s behaviour as resulting from his relationship to his “early objects”. But recognizing in the adolescent’s behaviour and account the features that justify this interpretation should not blind us to taking into consideration that the circumstances of the adolescent’s life are dramatically different from those present in his early childhood. When a twelve-year-old is described as behaving like a toddler, this

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signifies an emotional regression, which may well indicate the presence of some pathology. Even if we interpret our patient’s feelings and behaviour along the lines of his earliest object relationships, we must still note how he experiences his life with his actual, present parents. It is this that helps us to evaluate his capacity to distinguish between the reality of their present attributes from the images of the parents that he has internalized in his earlier years. Understanding the meaning of the patient’s feelings, words, and behaviour should not preclude the assessment of his capacity to perceive the reality of the world in which he lives. Ideally, one should choose a body of theory after one has gained some clinical experience. In practice, theories are learnt from lectures and books before approaching the patients, and this cannot but lead to one’s experiences being interpreted already within that body of theory one has learnt to follow. However, it is useful to remember that theories were constructed in order to make sense of clinical findings, and this should help us to scrutinize the various theories available until we find the one that best makes sense for us of our observations. Instinct theory, object relations, attachment, Kleinian, and ego psychology are not necessarily mutually exclusive theoretical frameworks, and they should be used with the main objective of helping us to understand and formulate what we observe. When conveying our findings to others, it becomes important to make sure that our formulations can be understood. I believe, however, that if we have reached a correct understanding of the patient, our formulations are likely to be coherent and comprehensible (whether they command agreement or not!), whatever theoretical framework we adopt.

Meeting the patient There has been a multiplication of walk-in services for adolescents, and these will always be sought by the youngster himself: though administrative procedures will vary from centre to centre, the therapist is bound to see the patient on his own for their initial meeting. When private therapists receive the referral of an adolescent by letter or any other means, they have to decide whom they will meet first. Clearly, before learning the details of a case, there is no way of

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guessing which technical approach will bring best results, and the therapist can only follow his preferred manner of work. Personally, whatever the age of the adolescent, I prefer to meet initially the youngster and both his parents, since this helps all of us to know exactly why and how we are proposing to proceed. A useful (for me) rule of thumb is that the younger the adolescent, the more important it will be to see him together with the parents; late adolescents, on the whole, prefer to be seen alone and, usually, their parents are quite happy to see the therapist also on their own. But I have found that it is quite useful for the therapist to make it explicit to the adolescent and to both parents that he reserves the right to call for joint interviews if he believes this is necessary. Many analysts choose to refer one or both parents to another colleague, so that they can restrict their involvement to the individual work with the adolescent. In such cases, one should be very clear about the rationale of this approach, and I believe this must be discussed very carefully with the parent(s). Often enough, the first contact with the analyst comes from parents who request an appointment and explicitly ask to meet the analyst without the presence of the adolescent. I am usually willing to accept this, though I make a point of informing them of my usual way of working; this helps us to discuss their request, rather than my having simply to accept or deny the parents’ wishes In some instances the adolescent does not wish his parents to be seen, and this poses a more difficult problem. I will always agree to see the adolescent on his own, in the first instance, but, before or during the interview, I will insist that I should see the parents— preferably together with the adolescent him/herself. Of course, confidentiality has to be preserved, but there are a number of issues (e.g., fees) that have to be discussed with the parents and, besides any practical considerations, it is always useful to learn from each parent how they see their child’s problems. If, during the meeting with the adolescent, it becomes clear that there are problems (e.g., drugs, pregnancy) that may require informing the parents or the family doctor, this should be discussed in detail with him. Occasionally, it can happen that the adolescent forbids the consultant from contacting anybody else: the consultant may decide that, whatever dangers he perceives in the adolescent’s situation, he will agree to the patient’s request, but it is then extremely important that

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he makes careful and detailed notes about this. Ideally, such a decision should be discussed with a colleague, but this is not always possible, which makes it imperative that the consultant writes down his arguments for reaching his conclusion. Delicate and painful issues of confidentiality are at stake, but then the analyst is also responsible for the patient’s care. Weighing up the pros and cons of stepping out of a strictly analytic posture can be an extremely delicate problem. A nineteen-year-old who had been in analysis for nearly two years became involved with drug addicts and I was told of their experiments with various drugs, including heroin. This was an intelligent and sophisticated youngster, but he lived virtually on his own, with few relations alive. He always attended punctually for his sessions, but one day he did not turn up. I telephoned him, and when I had no reply, I contacted the police. They gained entrance to the flat and found the patient in a nearly comatose state. He recovered well, but then sent me a letter stating that he could no longer trust me. I wrote to him explaining my decision and I tried to persuade him to return and discuss the situation. He refused. A few weeks later, one of his relatives contacted me to say that the patient had died of a drug overdose. A twenty-year-old patient complained of persistent headaches. This was after one year of analysis and all kinds of interpretations had made no impact on the headaches. He consulted the health services of his university, who decided this was a psychogenic complaint. As the headaches continued unabated, I insisted on a second opinion. The physician who saw the patient immediately asked for various tests and found a brain tumour. The patient was operated upon, but died after a few days.

The first meeting must make the adolescent feel that here is a professional who is able, willing, and, in fact, determined to give him the opportunity of being heard and, one hopes, understood. This is not an easy task, since we must assume that the youngster is very sensitive to how adults react to him as a person and, for example, he may resent firmness as much as he may be suspicious of kindness. Perhaps the key attitudes to show are respect and interest, but the atmosphere one generates out of one’s experience and personality are equally significant, though more difficult to define. The therapist, however, has to use this first interview to assess the

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seriousness of his patient’s problem. It is not always possible to reach in one session a clear idea of the nature and gravity of what brings the youngster to us, but we must establish whether any urgent issues demand prompt attention or whether we can take our time for an extended diagnostic evaluation of the case. Over the past few decades, there has been what can only be called a glorification of the notion that the therapist should concentrate on the “here and now” of the meeting with the patient. It is really debatable whether this is such a universally applicable proposition, but when it is put into practice during an assessment interview, the results can be truly regrettable. The consultant should have a clear idea of the problem areas he wants to explore in conducting his evaluation of each individual patient’s needs, and this is particularly important when seeing adolescents. When the consultant takes the stance that whatever the patient says and does reflects the “psychic truth” of his relationship to the interviewer, he will assume a receptive, non-active, not probing posture, and this may interfere with his capacity to question or challenge the adolescent’s communications. An assessment interview places a serious responsibility on the consultant that is very different from that situation where the patient is being assessed for his suitability for longterm therapy. It is a simple fact that we have no way of deciding when a patient is telling us the truth or when he is opting for deception or evasion, but in ongoing therapy this is not such a major difficulty. However, when seeing an adolescent for a diagnostic evaluation, it becomes extremely important for the consultant to voice any suspicions that he is not being allowed to obtain a proper knowledge of the patient’s situation. If we are meeting the adolescent together with his parent(s), we must respect his right for privacy and it is, therefore, useful to stress that he should feel free not to answer any questions we ask (this right applies to the parents as well). We can add that there may be things he would prefer to tell us in private, and that we intend to see them on their own in due course. It is impossible to cover all eventualities to be explored in an initial assessment, but two main indications of serious pathology should be mentioned: psychosis and self-destructive behaviour. Some youngsters may volunteer sufficient information for us to recognize the presence of one of these, but usually we will have to

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formulate appropriate questions so as to elicit pointers to either diagnosis. Self-cutting, eating compulsions, suicidal impulses, use of drugs, involvement with dangerous company or activities, or perverse or risk-taking sexual practices are behaviours which will usually only be revealed in private, away from the parents’ presence. Nevertheless, if a reference to any of these activities emerges in front of the parents, it is most important to explore the attitudes (overt and covert) of each parent (a) to what their child has said, and (b) to the particular subject itself—what each parent thinks, for example, of body weight, use of marijuana, etc. I am not suggesting going through a questionnaire on anti-social behaviours. I have in mind situations where the adolescent makes a reference to some “objectionable” activity and one or both parents dismiss this as, for example, the youngster trying to call attention on himself or his pretending he is a more active member of some crowd than they “know him to be”. For the consultant to accept such an assertion without comment may appear to be his choosing which of them he really believes; in other words, a kind of taking sides. It is preferable to suggest they leave out, at least for the moment, whether the adolescent’s claim is fact or fiction, and request each parent to explain his/her attitude about that particular behaviour. If we have, for example, an adolescent who feels tormented by a compulsion to experiment with drugs and we find the parents speaking about drugs in some dismissive, contemptuous way (“oh, today’s kids are determined to experiment with just about anything! It’s a phase they all go through!”), this will give us a live demonstration of why the adolescent feels unprotected, as if some insurmountable barrier existed between him and his parent(s). A depressed fifteen-year-old told me of going to boarding school because his “parents wanted to get rid of (him)” and gave me examples of his friends avoiding him. On the whole, he said, he felt “bored” and I suggested he meant “hopeless”. When I met him with his parents, he restricted his account to his troubles with various teachers. When he finally managed to voice his sense of isolation and depression, his father snapped “Oh! He doesn’t mean it! He just needs to discover a passion for some subject! School is boring, I never liked it, either! In the 1960s, everyone was having sex with everyone, I didn’t like it, so it’s no surprise he doesn’t want to mix with anyone!” As the discussion proceeded, it became clear that the boy’s father felt quite incapable of

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any proximity with the boy, choosing to be involved all hours in his own work. Subsequent regular individual therapy brought forward the boy’s difficulties in developing his gender identity.

It can happen that a parent tries to use the consulting-room environment to extract a confession from their child. The consultant has to be very sensitive to the adolescent’s feelings: some youngsters may, indeed, welcome the opportunity to get across to their parents what they have been struggling with, but others may choose to limit what they want to say. In such situations, I usually point out that we are not in a courtroom and I try to get everyone to concentrate on the feelings that influence their living together, rather than on an apparent pursuit of “the full truth”. We must remember that, whatever their unconscious motivations, most parents view these interviews as an opportunity to obtain guidance as to how best to help their child. Even if we have already formed an opinion about the adolescent’s problems, any advice to the parents must take into account how each parent perceives their child’s present situation. We have to evaluate the extent to which they can distinguish between their own feelings, beliefs, and prejudices and those of the adolescent’s. This is not a question of exploring moral views (and very often the consultant will be asked what he thinks, for example, of the use of cannabis. One father demanded I should confirm his view that coffee was a damaging drink in view of its high content of caffeine), but an attempt to evaluate the capacity of each parent of perceiving and experiencing the adolescent as a separate human being and not simply a part of themselves. This is a vital element in the assessment of the framework against which we have to make sense of the adolescent’s behaviour, especially if we consider that the parents’ level of object relationships will have affected the whole of the adolescent’s emotional development. The parents should, therefore, not be seen only as “sources of information” about the adolescent: their personal and marital history, characteristics, and needs should be explored with due attention. I raise this issue by turning to each parent after the adolescent has given me his picture of “the problems” and the parents have also voiced their interpretation of these problems. I ask them to give me some idea of their own individual backgrounds, “so that I can understand his problem within some

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kind of context”. Usually, parents smile, puzzled and embarrassed, but, however reluctant they purport to be, they tend to recognize the importance of seeing their son not just as “another problem child”, but as a member of their family and part of their past and present lives. My emphasis on assessing the capacities of each parent follows from the assumption that, whatever theories we follow in terms of the causation of mental/emotional problems, it is an indisputable fact that the adolescent and the parents live together and they influence each other in multiple, helpful and harmful, ways. A proper evaluation of the adolescent’s needs must establish how each parent will react to any changes in his behaviour: whatever conclusions we come to will influence our choice of treatment to recommend. 1. Psychosis. When a psychotic illness has progressed to the point where the patient has lost insight into the abnormality of his experiences, this is quite easy to recognize and the referrer and both parents will be able to notice this is the case. However, when the adolescent reports with considerable fear and anxiety of experiences which feel real even if known to be abnormal, or when he recounts experiences which are clearly illogical and yet he appears to consider them normal, then this poses a more difficult diagnostic challenge. Such psychotic ideation can be no more than the temporary result of complex individual and/or family dynamics (or, at times, the result of the use of drugs), but it can also indicate the initial stages of a psychotic illness. Depending on the age of the patient, the manner in which he responds to his psychotic perceptions (some adolescents can become agitated and threaten to harm themselves or others), and the circumstances of home life, it may be necessary to consider admission to an in-patient setting or referral to a psychiatrist who may decide to put the patient under medication. If the adolescent appears to retain sufficient insight into his misperceptions and demonstrates a good capacity to cope with upsurges of anxiety, urgent and intensive therapy can be embarked upon, but, in such a case, it is vital to ensure that the parents feel effectively supported in their task of looking after the adolescent. In some cases, our assessment may reveal that one or both parents are very intimately involved in the patient’s life (one mother would sit

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for hours into the night discussing with her son his anxieties and also his feelings about the psychotherapy session earlier in the day). It is then important to establish (i) to what extent the parent’s psychopathology makes it difficult for him/her to tolerate the adolescent becoming involved/dependent on the therapist, and (ii) whether the patient’s needs are perhaps not sufficiently met by the therapy sessions. However difficult it is for the therapist to disentangle these two possibilities, it is most important that he evaluates this with care and determination, since otherwise there is a danger of the therapy being terminated without him being consulted. If the parent(s) find it difficult to cope with their situation, it is very useful to have a working relationship with colleagues who can undertake a supportive role in the therapeutic programme by seeing the parent(s) and helping them to co-operate with the adolescent’s treatment. 2. Self-damaging behaviour. This presents a different diagnostic challenge. Only seldom will parents be aware of their child’s selfdamaging behaviour. If a youngster allows his parents to know that he feels depressed and/or suicidal, we must note the positive element of his belief that others can help him. Sadly, most selfdestructive behaviour is carried out in private, as part of a conviction of being someone not worth helping or of not trusting the world to wish or to be able to help him. Isolation, loneliness, and hopelessness are the key features in these situations. The youngster feels fear, shame, self-loathing, and despair, but when he comes to see us, we have to search for any remaining flicker of hope, which, when present, may be expressed in terms of a challenge as to what motivates our involvement, a “what is it to you?” attitude. The distinction usually drawn between the patient who comes to see us of his own volition or is forced to come to see us can be, in practice, misleading. It is better to assume (even if we are later proved wrong) that only in exceptional circumstances can an adolescent patient be forced to see a professional. If he is there with us, this may well mean that some minimal degree of ambivalence is still lurking somewhere in his mind. The challenge here is how to convey to him that we have picked up his ambivalence without making him feel exposed; it is a question of finding a way to help him to attend again, even it appears to be, as it were, on his terms. We may come to recognize that no regular treatment is possible at

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this point and that we have to be content to plant a seed in his mind that might enable him to return to us at some later point. Adolescents who are cutting themselves or exposing themselves to life-threatening situations (e.g., drugs, unprotected sex, dangerous company) can arouse considerable anxiety in the consultant, and yet, regrettably, many of these patients are reluctant to accept offers of therapy. These are situations where the consultant can only rely on his intuition and empathy; some patients can respond positively to a blunt confrontational statement of the kind, “You are really in a mess and I think you better admit it”, while others may rather respond to a “gentle” argument leading them to acknowledge the despair and loss of hope underlying their behaviour. But the consultant must not forget that an adolescent involved in risktaking activities is struggling with very low self-esteem: he longs for an outsider’s proof that he can be valued, wanted, and loved. And yet, any word or gesture that he perceives as promising to give him such help can arouse (a) a suspicion that the therapist is being moved by his own feelings and needs, rather than recognizing that he, the patient, is nothing like the person the therapist imagines him to be, (b) guilt that he is accepting help from a stranger, rather than turning to his parents, friends, or relations, and (c) terror that he may eventually disappoint this stranger who wants to help him. This situation, where the consultant is in constant danger of having his motives questioned, creates an experience of considerable self-consciousness. In practice, the therapist is on guard, lest he is suddenly accused of holding prejudices or harbouring some messianic needs, either of which are likely to be felt like attacks on the person of the therapist, rather than comments about his professional motivations. But these challenges result from the adolescent projecting on the therapist the opposite poles of his self and objectrepresentations: total love and total condemnation towards someone who is seen, at the same time, as a loved and a despicable person. Only slow and consistent work on this dynamic configuration may lead the patient to take stock of his view of himself and the world around him, but this requires that the adolescent embarks on, and stays in, therapy. Eating problems present a different kind of challenge. Even if they have become a common feature of middle-class occidental society, they quite often constitute the presenting symptom of

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severe underlying pathology. It is prudent to recognize all variations of eating problems as part of self-damaging pathology, but particularly in the case of anorexia nervosa, we have to bear in mind the physical condition of the patient. These are patients who require the therapist to have close links with a medical colleague, who can supervise the conditions of the patient’s metabolism. The same precaution applies to those patients who are referred for help with their emotional problems, but who are under medical care for conditions such as diabetes, asthma, epilepsy, rheumatic diseases, coeliac disease, etc. Many of these patients experience their illness as an attack from their bodies on their self: the body is seen as an enemy, a persecutor that the youngster wants to defy and dominate. At times, they will stop taking the drugs or following the diets required to keep their illness under control, and this forces us to consider them as involved with self-destructive behaviour. During adolescence, these psychosomatic problems become telescoped together with issues of gender identity and the impossibility of achieving total independence and “normality”, since the illness is seen to inflict on him the need to depend on doctors and drugs. A sixteen-year-old girl was referred because of “eating problems”. Both the patient and her parents spoke at great length about diets, weight, and multiple clashes over these issues. There was no doubt that the young woman was unhappy and depressed. They were quite happy to accept the offer of individual psychotherapy to help the patient with her problems. But detailed questioning about the girl’s physical development had brought out the information that she had still not had any periods. The family accepted a referral to a paediatric endocrinologist and this revealed that the patient had a serious congenital malformation of her ovaries. Psychotherapy was embarked upon, but appropriate medication was also given to the patient.

All authors agree on the importance of sexuality for the adolescent, but we must never forget that often adolescents will use sexual feelings and activities as a means of expressing anxieties that belong to other areas of their sense of self in the world. The danger for the consultant or therapist is to neglect these deeper anxieties (that may involve feelings over living and dying) and focus on sex in a manner which the youngster may interpret (i) as a blindness to other anxieties or (ii) as the result of a moralistic attitude which he

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probably experiences from parents and also from his own conscience. Either way, the adolescent will feel disappointed and helpless.

Frequency of sessions The therapist makes life easier for himself if he only works under one fixed scheme of therapy sessions. If, however, he varies the frequency with which he sees his patients, depending on the severity of their pathology, he has to develop and follow his diagnostic criteria for such decisions: no easy task. The consultant should be able to decide what he considers the ideal treatment modality he would recommend for that particular patient. Once he puts this forward, he has to decide whether he is prepared to accept some counter-proposal from patient and/or parents, or whether he will refuse to take responsibility for the patient unless his recommendation is accepted. There is no end of (conscious and unconscious) reasons why patient and/or parents will dispute the consultant’s advice, but in the end it is the consultant who has the final word about his further involvement in the case. I believe each practitioner is entitled (expected, in fact) to know the conditions under which he works at his best, and if this involves the number of sessions he gives each patient, so be it. But he should make this reason explicit, rather than imply that such conditions are being put forward for the benefit of the patient. Campbell (1992) reviewed the literature on the criteria utilized by various analysts to establish the frequency of sessions in analytic work with adolescents. Most papers published in the psychoanalytic world focus on the “suitability for psychoanalysis”, which is not necessarily synonymous with determining which helping programme best applies to a particular patient being seen. Campbell’s survey is written with sensitivity, and is clearly based on wide experience of work in different settings, which brings the advantage of not stemming exclusively from clinical work with children of families who want and can support (financially and emotionally) their child’s visits to a private professional. He quotes Laufer’s (1991) argument that adolescents in danger of a breakdown, or who present a tendency to serious acting-out, should be seen in full

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psychoanalysis; this view is supported by Yorke (1965). In contrast to these authors, Berman (quoted in Sklansky, 1972) lists “psychosis, borderline states, severe delinquency, hypochondriacal complaints, exclusive cathexis of peers and hostile or seductive involvement with parents, loss of control or severely rigid control of impulses” as contra-indications for psychoanalysis. Clearly, issues of diagnostic definitions are involved here, but it is far more difficult to establish the role of the consultant’s personal style and bias on the final choice of treatment. Discussions about frequency of sessions involve complex and conflicting arguments over what are effective and, perhaps, legitimate ways of helping a patient with emotional and behaviour problems. The nature of the work we practise does not allow us to submit the same patient, at the same point of his life, to two different treatment modalities. We cannot, therefore, but accept the consequences of the fact that, with each particular patient, we put into practice the approach we believe to be the best we can offer him. This makes for considerable difficulties when it comes to comparing views expressed by professionals who follow different theoretical and technical schools. Campbell’s paper is exceptional in his description of how he does his best to adapt his idea of what the adolescent would ideally need to what the adolescent is prepared/able to accept (p. 110). This is an approach with which I strongly agree. If the analyst presents himself from a basis of knowledge, sympathy, and seriousness, his flexibility, his preparedness to mould his views to the reality of the patient’s abilities, cannot but reassure the adolescent (or a patient of any age) that here is someone who is interested and cares enough for him as to allow him to establish his own timing in developing the relationship of trust which may bring him some eventual benefit. This is not the same as saying that we allow the patient to dictate the number of sessions we are to have, but rather that a serious discussion can be held about this, where patient and analyst express and justify their viewpoints until a compromise can be reached to the satisfaction of both of them. It should be noted that an adolescent who promptly and eagerly accepts the assessor’s recommendation may be giving an early warning of an all-or-nothing type of attachment, which is based on faith and a very limited capacity for reality testing: just as quickly

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as he can (apparently) surrender into compliance, he can shift to paranoid anxieties and take flight without warning. This should be recognized as a psychotic transference in a patient who cannot develop a working alliance with the therapist. I would agree with Campbell, Laufer, and Yorke that an adolescent who presents psychotic anxieties and shows poor capacity for self-control by endangering his life through serious acting-out should be seen as many times per week as possible. Whether this comes to be five, or four, or any other number of sessions each week, the objective is to endeavour to help the adolescent to bring his pathological ideation, wishes, and impulses into the treatment room. But the success or failure of any therapy contract depends on too many factors when we are dealing with a disturbed adolescent, and I have tried to discuss some of these. In practice, to my mind, working with adolescents demands flexibility and a preparedness to be alert not only to the fluctuations of the therapeutic relationship, but also to other factors which may be playing a role in the youngster’s life. Helping the parents or a school, when the adolescent allows us to do so, can be of great importance in securing the continuation of the one-to-one work with the adolescent. If, however, we are seeing a late adolescent who does not allow us to contact anyone other than himself, then this can create situations of great anxiety for the analyst: he cannot but try to work through these with the patient.

Technique Much has been written about the features that characterize a psychoanalytic treatment and in what way psychotherapy should be conducted. Now we speak of psychoanalytic psychotherapy, and this appears to signify a treatment where the patient is seen for less than four or five sessions each week, but the therapist conducts his therapy as if he were seeing his patient four or five times per week. When seeing adolescents only once or twice a week, the therapist is likely to go through painful moments, since these are patients who experience peaks of anxiety and impulsiveness precisely at a time of life where the capacity for self-control is one of their main problems. Similar crises can occur even when the adolescent is being

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seen five times per week, but when sessions are less frequent, the therapist is likely to feel more anxious, for example, by blaming himself for taking on that patient under such “misguided” conditions. Analysts and therapists, like any other member of the helping professions, are entitled to reassess their findings. As treatment progresses, the therapist may decide that his patient requires more or less sessions than those being followed and, when this happens, he should make this the subject of an open discussion. This reassessment is quite different from the ordinary, frequent occurrence of experiencing sudden, intense, powerful feelings when seeing an adolescent in crisis. When a therapist is seeing an adolescent once or twice per week, it can happen that the youngster describes situations and feelings which make the therapist experience intense feelings that lead him to an impulse to argue, advise, or admonish. Some will say that this is a countertransference response: the therapist is identifying himself with the patient’s unconscious image of a parental figure who has let him down and now tries to make up for this by blaming the adolescent for doing something wrong. This formulation leaves out the possibility that the therapist might hold a belief that the “truly helpful” way of helping a patient is by giving him the ideal effective therapy of four or five times per week analysis. Both possibilities must be seriously considered. When we manage to separate out the patient’s anxieties from the therapist’s value systems, we can proceed to interpret the adolescent’s material more correctly: in this case, irrespectively of the frequency of sessions that has been decided upon. A disturbed adolescent in pain arouses very powerful feelings in us, but it is always prudent to consider that a proportion of these feelings originate in us. Particularly during the phase where a therapist is learning to work with adolescents, it is important that he scrutinizes his feelings carefully before deciding that they stem from the patient’s projections. This advice is based on my conviction that however moved we may be by the distress of an adult patient, this cannot compare with the intensity of feelings we experience when trying to help a child or an adolescent. And there is the additional factor that the younger the therapist, the more prone will he be to imagine himself in the position of the youngster. Only if he

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analyses his feelings with great care will he be able to recognize what belongs to the patient and what is part of his own professional development. An automatic countertransference interpretation can be a convenient short-circuit that may spoil a valuable learning opportunity. A frequent argument in work with adolescents refers to the type of interventions that the therapist/analyst is supposed to make. There are analysts who argue for strict transference interpretations, but these tend to be the analysts who make the same prescription for the analyses of children and of adults. Other analysts are prepared to accept that work with children involves other interventions than only transference interpretations. When it comes to adolescents, I think one experiences difficulties which are linked to their developmental stage: they do not play with toys or drawings as younger children do, and they do not see the therapist as strictly a professional as adults will do. Because of their conscious and unconscious struggles to disengage from their parental figures, and because of their changing views of language as a means of communication, adolescents will one minute treat the therapist as a “mate” or older friend who can understand what they feel without their having to try too hard to convey it to him, only the next minute to treat him as another parental figure who wants to criticize, preach, indoctrinate, dominate, or take over their selves. A perfectly correct transference interpretation can, sometimes, be experienced as a complaint or a seductive move. In other words, some adolescents can understand words as signifying shared symbols, much as they can suddenly take words quite literally. Personally, I try to formulate my interventions as if they were part of a dialogue: not between equals, but aiming to make the adolescent feel that it is his view that I am interested in. Instead of putting forward a statement purporting my idea of his unconscious feelings, I would invite/provoke him to explain or reconsider a statement of his that might lead him to arrive at the same interpretation I might have given myself. A nineteen-year-old young man had amassed a long series of initial successes that were promptly followed by failures. One day, he quoted something I had said two sessions earlier, commenting that he was surprised at being able to remember it. A bit later, he mentioned an

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older man with whose family he had lived for several years: he felt that man had given him enormous encouragement in dealing with life. Later, the patient mentioned a friend to whom he was very attached for a long period; he said this was a charismatic figure whose company made him “feel great”. When he embarked on another long account of his compulsive attempt at making himself accepted, clearly without believing he would succeed, I reminded him of his words about those two men and asked whether they represented sources of some special power. He beamed. “Oh, they really made me feel a winner!” I then asked if remembering my words had any particular significance and he laughed “I guess it reminded me of them . . .”

There is no doubt that it is quite difficult to make an adolescent engage in long-term therapy, but provided this is what the analyst believes the youngster needs, he can only treat each meeting as if there was to be a next one at the previously arranged time. The adolescent is, by definition, watching every word and every move of the analyst for cues to gauge how he sees him. The closer the analyst sticks to his professional stance and shows his interest in the fact that the patient has come to see him, the better the chances that the patient will also stop and consider the meaning of his presence in that room. With luck, he will eventually recognize that his attendance signifies that he has allowed an element of doubt to seep into his previous conviction that he and his world were hopelessly lost; some adolescents take flight at this point, but some decide to look further into what they have made of their lives.

Summary This chapter presents an overview of the issues involved in the psychoanalytic/psychotherapeutic approach to adolescents. Some of the key theoretical conceptualizations of the adolescent phase of development are presented, and technical problems of working with these patients are considered in detail. More dramatic clinical pictures, for example, psychosis or self-destructive behaviour, are considered in more detail. In view of the adolescent’s actual dependence on his parents, the importance of assessing each parent’s view of the patient is emphasized. This influences the therapeutic programme which comes to be recommended and, whenever necessary,

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provision must be made to ensure the parents’ needs are also cared for. Because seeing adolescents in treatment tends to produce, quite often, intense emotional reactions in the analyst, particular emphasis is placed on the need to differentiate countertransference responses from those stemming from the therapist’s personal life experiences.

References Anderson, R., & Dartington, A. (Eds) (1998). Facing Out. London: Duckworth. Astor, J. (1988). Adolescent states of mind found in patients of different ages seen in analysis. Journal of Child Psychotherapy, 14(1): 67–80. Bernfeld, S. (1923). Über eine typische form de mäninlichen pubertät. Imago, IX. Blos, P. (1967). The second individuation process of adolescence. Psychoanalytic Study of the Child, 22: 162–186. Campbell, D. (1992). Introducing a discussion of frequency in child and adolescent analysis. Psychoanalysis in Europe, 38: 105–113. Erikson, E. (1965). Childhood and Society. London: Hogarth Press. Freud, A. (1958). Adolescence. Psychoanalytic Study of the Child, 13: 255–278. Harris, M. (1965). Depression and the depressive position in an adolescent boy. Journal of Child Psychotherapy, 1(3): 33–40. Jones, E. (1922). Some Problems of Adolescence. Papers on Psycho-Analysis. London: Baillière, Tyndall & Cox. Laufer, E. (1991). Personal communication, quoted in Campbell, D., as above. Laufer, M. (1976). The central masturbation fantasy, the final sexual organization and adolescence. Psychoanalytic Study of the Child, 31: 297–316. Laufer, M. (1978). The nature of adolescent pathology and the psychoanalytic process. Psychoanalytic Study of the Child, 33: 307–322. Mahler, M. (1963). Thoughts about development and individuation. Psychoanalytic Study of the Child, 18: 307–324. Rycroft, C. (1968). A Critical Dictionary of Psychoanalysis. London: Penguin. Segal, H. (1964). Introduction to the Work of M. Klein. London: Heinemann.

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Sklansky, M. A. (1972). Indications and contraindications for the psychoanalysis of the adolescent. Journal of the American Psychoanalytic Association, 20: 134–144. Spillius, E. (1988). Melanie Klein Today, Part 2: Mainly Practice. London: Routledge. Winnicott, D. W. (1989). Adolescence: struggling through the doldrums. In: The Family and Individual Development. London: Karnac. Yorke, C. (1965). Some metapsychological aspects of interpretation. British Journal of Medical Psychology, 38: 27–42.

INDEX

Abram, J., 170, 177, 181, 192 Ackerman, N., 37, 59 affect, 6, 10, 20, 24, 84, 101, 142 aggression, 96, 104, 128, 143–144, 147 Ainsworth, M. D. S., 6, 29, 37, 59 Alcoholics Anonymous, 68 American Academy of Psychoanalysis, 149, 159 American Psychoanalytical Association, 104 Anderson, R., 199, 221 anger, 100, 141, 143, 157, 202 Anthony, E. J., 9, 29 anxiety, xi, 11, 14–16, 23, 26–28, 39, 42–43, 46–47, 57, 67, 74, 82, 86, 101, 103, 114–115, 118, 122, 130, 132, 134, 136, 147, 153, 156–157, 166, 174, 176, 181, 201, 211–213, 217–218 depressive, 185 paranoid, 217 psychotic, 217

separation, 74, 89, 167 unconscious, 39, 46 Asperger’s syndrome, 70, 101, 175 Astor, J., 204, 221 attachment, 135, 162, 167, 191, 195, 205, 215, 220 theory, 37, 173 autism, 101, 175, 187, 189–190 Axelrad, S., 6, 29 Bachmann, J.-P., 37, 59 Balint, M., 80, 87–88, 91, 163, 168, 170–171, 173, 176–177, 180, 183, 185, 187–189, 192 behaviour, xi–xii, xiv, 2, 6, 14, 20–21, 23–24, 33, 38, 41–42, 44, 46, 73, 81, 84, 89–90, 99–101, 103, 112, 116–118, 126, 132–133, 139, 143, 148, 153–154, 156–157, 167, 171–172, 174–176, 191, 198, 203–205, 208–214, 216, 220 see also: sexual 223

224

INDEX

Bell, S. M., 6, 29 Berney, C., 37, 59 Bernfeld, S., 204, 221 Bernstein, I., 104, 108 Besson, G., 37, 59 Bibring, E., 180–181, 192 Bick, E., 6–7, 17, 29 Bion, W. R., 31, 69, 163, 168–172, 176–177, 186, 192 Blehar, M. C., 37, 59 Blos, P., 198, 221 Boscolo, L., 37, 60 Bowlby, J., 6, 29, 37, 59, 189 Brafman, A. H., 106–108, 138, 192 Brearley, M., 183, 192 British Psychoanalytical Society, 7, 65 Brody, S., 6, 29 Bruschweilerstern, N., 59, 173, 178 Burlingham, D., 7, 29 Caldwell, L., 122–123 Campbell, D., 104–105, 108, 215–217, 221 case studies Corky, 83 Daniella, 42–44 David, 41–42 Eve, 47–50 Joanna, 44–46, 116–118 Joe, 101–103 Julian, 100–101 Max, 117–118 Penny, 50–57 Robert, 114–116, 118 Casement, P., 80, 87–88, 91, 165, 177 Cassel Hospital, 166 Cassidy, J., 37, 60 Cecchin, G. F., 37, 60 cognitive–behaviour therapy, 68

Cohler, B. J., 74, 77 conscious(ness), ix, xii, 62, 66, 80, 84, 99, 110, 133, 144, 172, 186, 189–190, 201–202, 215, 219 see also: unconscious(ness) countertransference, x–xi, xv, 19, 83, 140, 144, 146, 154, 159, 167, 173, 182, 218–219, 221 see also: transference Cramer, B., 37, 59 D’Arcis, U., 37, 59 Dare, C., 37, 59 Dartington, A., 199, 221 Daws, D., 38, 59, 107–108 De Murait, M., 37, 59 depression, 42, 110, 115, 117–118, 128, 141–142, 150–151, 176, 199, 203, 209, 212, 214 see also: anxiety illness, 141 manic, 70 development(al), 5–7, 12, 23–26, 28–29, 35–38, 40, 45, 58–59, 68–69, 74, 83, 87, 99–101, 115–116, 140, 167, 171, 174–175, 180, 187, 189, 196–199, 201, 204, 210, 214, 219–220 child/childhood, 1, 17, 22–23, 28, 33, 36–37, 58, 99, 103–104, 106–107, 113, 122, 169, 173–174, 182, 188–189, 197–198 cognitive, 6 emotional, 6, 95, 139, 152, 173, 187, 210 psychological, 3, 17, 105, 171–172 social, 36 theory, 96, 99, 182, 185, 188 Diatkine, R., 95–96, 105, 107–108

INDEX

ego, 99, 104, 175, 180, 205 super-, 59, 180 -syntonic, 20, 39 Emde, R. N., 37, 60, 172, 177 empathy, xiii, 32, 134–135, 148, 213 Erikson, E., 199, 221 European Psychoanalytical Federation, 95, 104 Fleming, S. R., 149, 159 Foxton, M., 156, 159 Fraiberg, S., 38, 40, 59, 107–108 Freud, A., 5, 7, 29, 95–99, 104, 108, 170, 198–200, 221 Freud, S., 6, 14, 29, 31–32, 80, 85, 87, 110, 126, 167–168, 179, 182, 188–189, 195, 197 Freud, W. E., 7, 29 Freud Museum, 109 Friedman, O., 7, 30 Gedo, P. M., 73–74, 76 Glover, E., 180, 192 Green, A., 31, 172–173, 178, 184, 192 Guntrip, H., 81, 94, 175, 178 Haley, J., 37, 59 Harris, M., 199, 221 Harrison, A. M., 59, 173, 178 Hartmann, H., 5, 29 Heimann, P., x, xv, 5, 30, 134, 185–186, 192 Hellman, I., 7, 30 Hopkins, J., 38, 59, 107–108 Insight, 86, 91 instinct, 2, 5, 73, 99, 104, 150, 167, 172, 180, 197–198 inborn, 1–2, 69 theory, 197, 205 International Psychoanalytic Association, 75

225

International Psychoanalytical Congress (Marienbad), 180 intervention, 9–10, 14, 23, 38–39, 57–58, 87, 104–105, 126, 131, 144, 219 surgical, 94, 153 therapeutic, xii, 35, 37, 108 verbal, 175 introjection, 27, 96, 169, 180, 186 intuition, xii–xiii, xv, 31–32, 34, 148, 156, 213 Jones, E., 198, 221 Joseph, B., 7, 30 Kestenberg, J. S., 5, 30 Khan, M., 83, 171, 184 Klauber, J., 66, 77 Klein, M., 2, 5, 7, 30, 91, 110, 169, 171–172, 176, 180, 185–187, 189, 199, 205 Knauer, D., 37, 59 knot, 35–36, 40, 114 Kris, E., 6, 30 Lacan, J., 65 Langs, R., 183, 192 Laplanche, J., 180, 192 Laufer, E., 215, 221 Laufer, M., 199, 217, 221 Lichtenberg, J. D., 6, 30 life, ix, xii, xiv, 1, 7–8, 12, 16, 18–20, 33, 40–42, 59, 64, 70–73, 79, 81–82, 88, 93, 106, 110, 115, 128–131, 141–142, 146, 149–150, 157–158, 162–163, 165, 167, 177, 181–182, 191, 195–196, 198–202, 204–205, 211, 213, 216–217, 220–221 daily, 34, 67, 112, 128–129 family, 25, 50, 83 professional, 128, 183

226

111 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 711 8 9 20 1 2 3 4 511 6 7 8 9 311 1 2 3 4 5 6 7 8 911

INDEX

Nahum, J. P., 59, 173, 178

Palacio-Espasa, F., 37, 59 paranoid, 146–147, 154, 157, 190, 217 –schizoid position, 176, 199 parent(s), 6–8, 14–18, 20–22, 24–26, 28–29, 33–51, 55–59, 84, 94, 96–97, 104–107, 110–119, 148, 157, 163, 169, 177, 181, 198, 200–206, 208–215, 217–221 Pedder, J., 80, 91 Peterfreund, E., 6, 30 Phillips, A., 181–182, 193 Pontalis, J.-B., 180, 192 Prata, G., 37, 60 Procrustean, 7, 66 projection, xi, 27, 46, 64, 70, 96, 118, 134, 140, 144, 146, 154–155, 158, 168–169, 172, 180, 186, 213, 218 negative, 69 projective identification, 32 Psychoanalytic Inquiry, 80, 91 psychotic, x, 70, 129, 147, 154, 157, 168, 174–176, 181–183, 187–188, 190, 199, 211, 217 see also: anxiety

object, 6, 16, 38–39, 64, 83, 96, 111, 169–170, 172, 180, 185–186, 189, 201–202, 204, 213 emotional, 186 external, 199 internal, 70 relations, 69, 96, 99, 167, 170, 177, 187, 205, 210 objective/objectivity, 17, 22, 31, 136, 145–146, 149, 152, 205, 217 Oedipal ideas, 102, 177, 199, 202 Orbach, S., 87, 91 Ornstein, A., 37–38, 60, 107–108

regression, x, 64, 69, 72, 79, 81, 83–84, 87–88, 99–100, 161–163, 166–171, 173, 175–176, 181, 185, 187–190, 205 Richards, A. K., 74, 77 Robertson, J., 6, 30 Robert-Tissot, C., 37, 59 Rodman, F. R., 83, 91, 181, 193 Rosenfeld, E., 91 Rowley, J., 137, 162 Royal Free and University College School of Medicine, 139 Rycroft, C., 31–32, 162, 180, 193, 204, 221

social, 115, 128, 142 school, 43, 50 Little, M. I., 80, 171, 175, 178, 181, 190, 193 London Clinic of Psychoanalysis, 81 Lyons-Ruth, K., 59, 173, 178 Mahler, M., 6, 30, 171, 189, 189, 221 Main, M., 37, 60 Main, T., 166, 178 Morgan, A. C., 59, 173, 178 mother, xi, 2, 8–10, 12–16, 18–21, 23–24, 26, 28, 41–47, 49–51, 54, 56–57, 69, 87–88, 100–102, 106, 115–118, 141, 150, 162–163, 165, 172–173, 177, 182–183, 187, 189, 198, 211 –baby, 9–10, 19, 37, 169, 171 good enough, 14, 38 grand, 8 –infant, 10, 169, 172–174, 187, 191 Munro, L., 81–82, 162

INDEX

111 2 3 4 5 6 711 8 9 10 1 2 3 4 5 6 7 8 9 211 1 2 3 4 5 6 7 8 9 30 1 2 3 4 5 6 7 8 911

Sameroff, J., 37, 60 Sander, L. W., 59, 173, 178 Schacht, L., 100–101, 108 Segal, H., 95–98, 108, 182–183, 199, 221 self, xiii–xv, 25, 32, 38, 69, 84, 87, 100, 135, 145, 147, 151, 167, 198, 201–204, 212–214 -absorption, 154 -assurance, 41, 131 -confidence, 25, 28, 76, 126, 138, 202 -conscious, 115, 132, 213 -contained, 22, 67 -control, 58, 217 -criticism, 126, 130–131 -delusion, 93 -destructive, 203, 208, 212, 214, 220 -doubt, 116 -esteem, xi, 16, 25, 28, 50, 57–58, 71, 129, 155, 202, 213 -exposure, 140 -image, 28, 57, 71, 144, 153–155 -knowledge, 145 -mortification, 131 -reliance, 26 -satisfied, 180 -scrutiny, 66 -sufficient, 202, 204 Selvini Palazzoli, N., 37, 60 Serpa-Rusconi, S., 37, 59 sexual, xii, 28, 82–83, 199–201, 203, 209, 213–214 behaviour, 203 identity, 199 relationship, 83 Shepheard, E., 7, 30 Shoenberg, P., 139, 159 Sklansky, M. A., 216, 222 Spillius, E., 7, 30, 180, 193, 199, 222

227

Spitz, R. A., 6–7, 30, 171 Stayton, D. J., 6, 29 Stern, D. N., 6–7, 30, 37, 59, 60, 106–108, 122, 172–173, 178 Strachey, A., 185–186, 188, 193 subject(s), 16, 26–27, 29 subjectivity, 32, 149 experiences, 37–38 symbol(-ism), 32, 101, 103, 134, 182, 219 Tavistock Clinic, 38 Thorner, H., 136 transference, xii, 16, 27, 39, 63–64, 69–70, 74, 81, 87, 89, 91, 96–97, 99–100, 110, 128–129, 140, 144, 154, 158, 162, 167, 180, 185–186, 188, 217 see also: countertransference interpretation, 129, 188, 219 neurosis, 69 regression, 63–64 relationship, 38, 63–64, 68–69, 136, 180, 188 unconscious, 81 Trevarthen, C., 172, 178 Tronick, E. Z., 59, 172–173, 178 unconscious(ness), ix, xii, 18, 32–34, 39–40, 50, 71, 80–81, 84, 86, 110–111, 113–114, 119, 133, 140, 142, 144–145, 154–155, 158, 163, 167–168, 172–173, 177, 184, 186, 190, 198, 201–202, 204, 210, 215, 218–219 see also: anxiety, transference conflict, 37 fantasy, 15, 18, 24, 35, 40, 49, 57, 62, 100, 112–114 relationship, 201 University College Hospital, 139, 172

228

111 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 711 8 9 20 1 2 3 4 511 6 7 8 9 311 1 2 3 4 5 6 7 8 911

INDEX

Wall, S., 37, 59 Waters, E., 37, 59 Winnicott, C., 109, 119 Winnicott, D. W., x, 6, 14, 21, 30, 32–33, 35–39, 57–58, 60, 69, 79, 80–81, 83, 87, 94, 109–111, 113, 139, 161, 163, 168–171, 173, 175–176, 178, 180–183, 187, 189–191, 193, 200, 222 Winnicott Clinic of Psychotherapy, 109

Winnicott Foundation, 174 Winnicott Trust, 139 world external, 96 internal, 6, 16, 23, 104, 154 psychoanalytic, 104–105, 197, 215 psychodynamic, 64 Yorke, C., 216–217, 222