Developing a Psychosomatic Imagination in Medical Students and Psychotherapy Trainees

How can we help medical students and psychotherapy trainees to develop an awareness of the mind in relation to the body, so that both can develop a psychosomatic imagination? This is an exploration of some of the difficulties that medical students have in appreciating the role of emotions in illness and of the difficulties psychotherapy trainees have in considering the importance of the body in psychotherapeutic work with patients with physical symptoms. Student Balint discussion groups and student psychotherapy schemes give clinical medical students the opportunity to explore their own and their patients’ emotional reactions to illness and to learn about the interplay of emotions with the body in physical illness. The Royal College of Psychiatrists is now encouraging the development of such Balint groups and/or psychotherapy schemes in all UK medical schools. Psychotherapy trainees studying the effects of emotions in psychosomatic illnesses often have difficulty in learning how to interpret physical symptoms that occur in psychotherapy. They tend to want to see such symptoms as having symbolic meaning and find it hard to appreciate the medical logic of physical illness. It is important that some medical understanding of these conditions is also included in seminars on psychosomatic conditions.     

Psychic fragments and changing bodies: Theoretical and clinical applications of bodily reverie

Set from a relational body psychotherapy perspective, the article examines three somatic aspects of reverie: sensory (following Ogden’s work), resonance and somatic indwelling (entering and leaving someone else’s body). Tracing the place of reverie in the works of Winnicott, Bion, Ogden and Mindell, further developments to reverie are offered and demonstrated. The article suggests that the therapist’s body can be used not only as a diagnostic tool and selfobject in psychotherapy, but moreover as an active healing agent. This proposition is supported by theoretical arguments and case material.     

The System of the Dimensions of the Organism (SDO): A common vocabulary for body psychotherapy1

This is an article based on a presentation given at the United Kingdom Council of Psychotherapy (UKCP) conference 2004. Our modern attempt to re-include the body in psychotherapy brings with it the inevitable danger that we import the culturally dominant objectifying construction of the body into a field which may represent one of the last bastions of subjectivity, authenticity, and intimacy in an increasingly virtual world. The paper addresses the question how embodied subjectivity can be found within a relational matrix pervaded by disembodiment and self-objectification.

The ubiquitous objectification of the body in our culture and in the field of psychotherapy is illustrated in the paper. It is described as a manifestation of an underlying experience of dis-embodiment. Two ways of re-including the body in psychotherapy are then distinguished: one based on a “third-person” “medical model” stance and the other on a “first-and-second-person” “intersubjective-relational” model. By formulating these two contradictory and complementary ways of using the body in terms of the therapist's implicit relational stance, attention is drawn to what is considered an underlying paradox inherent in all types of psychotherapy. I am hoping that practitioners from across the approaches will be able to recognize and relate to both sides of the dilemma, and through this to both ways of re-including the body in psychotherapy.

As the medical model stance was the prevalent default position of what we may therefore call traditional body psychotherapy, and the relational one has become available only in the last decade, a case illustration is used to trace some of my own development as a therapist through the shadow aspects and pitfalls of an exclusive reliance on the first towards an integration of the two and to an appreciation of their necessarily conflicted co-existence in the paradoxical core of the therapeutic position.     

Being,having, and becoming bodies

Following on from my earlier paper ‘Body psychotherapy and social theory,’ and continuing the argument that body psychotherapy has a lot to learn from contemporary social theories of embodiment, I describe what might be called the ‘cutting edge’ of those theories and suggest how this work might be applied to body psychotherapy. The crucial argument is that, although the crude Cartesian split between mind and body is clearly inadequate, it is a mistake to see body psychotherapy as trying simply to close the gap and unify mind and body. The experience of ‘having’ a body is intrinsic to human experience, and a necessary component of ‘becoming’ a body.     

Accentuating the positive in adult attachments

This paper proposes that attachment theory, with its emphasis on stability and security, accentuates the positive aspects of affectional relationships and suggests a way to look at the process of adult psychotherapy. Attachment-based research has shown that positive attachment experiences are related to feelings of joy, comfort, and contentment throughout life. In contrast, experiences that are hurtful or traumatic, and especially if they are chronic or repeated, can have negative effects on thoughts and emotions as well as the body. In applying these findings to psychotherapy, the role of the therapist can be seen as providing a positive emotional experience within which to examine and gain a new perspective on the origins and development of distress. Through therapy, the opportunity to experience a relationship of secure attachment enhances psychological and physical well-being and the capacity to make and maintain lasting affectional bonds with others.     

Treating comorbid depression and avoidant personality disorder: The case of Andy

Major depressive disorder is among the most frequently diagnosed mental disorders and is often accompanied by other disorders such as anxiety or substance abuse. As a result of a complicated tangle of comorbidities, psychotherapy in such cases can become quite demanding. The present case study presents and discusses the challenges represented by a complex case of psychotherapy, focusing on ongoing modifications of the clinical hypotheses and therapeutic approach. This process is illustrated through the case of Andy, a 44-year-old man suffering from depressive disorder, social phobia, substance dependency, and an avoidant personality disorder. This case draws attention to the quality of the relationship and the flexibility and adaptation required from the therapist while depicting an integrative way of working therapeutically with complex cases.     

Structure of medical psychotherapy: program for academic formation

Starting from a general definition of psychoanalysis and with the aim of deepening our knowledge of the relationship between theory and practice, a scientific structure of psychotherapy is developed. The necessity of a training for doctors specialized in the field of psychotherapy has led us to design a training program consisting of three academic courses. This program, established by the Academy of Analytical Psychotherapy in a University Department of Psychiatry and Medical Psychology, introduces a new speciality in our country. In these three academic courses the theoretical aspects are covered (in a series of courses, seminars and lectures) as well as practical aspects (dealt with in sessions of individual and group psychoanalyses) and methods of evaluation at both individual and group levels. The model stated above can be considered the basis of a training program for doctors specializing in analytical psychotherapy.     

Couple therapy and relational body psychotherapy: Healing childhood wounds

This paper presents an approach to healing childhood wounds through the use of Imago relationship couple therapy in conjunction with relational body psychotherapy. Working with couples in crisis arouses powerful and confusing questions regarding the transference and counter-transference tensions within all aspects of the therapeutic triangle: intra-subjective in each member of the couple, their inter-subjective space, their interaction with the therapist and within the therapist herself. One of the ways of coping with these multifaceted dyads is the use of somatic cues in all three members of the triad. The paper provides three clinical vignettes, which illustrate some of the advantages of the combination of the two theories in relational couple therapy.     

Body psychotherapy and social theory

This paper argues and tries to demonstrate that, alongside neuroscience and relational psychotherapy, body psychotherapy can and should draw on a third important source beyond its own tradition: the social sciences and social theory of embodiment. After establishing and outlining the enormous body of relevant material, hardly used so far within our discipline, I move on to the theoretical underpinnings of this material, and in particular social constructionist approaches to embodiment. From this, I explore some of the fundamental theoretical approaches used in the social sciences, based on the work of Michel Foucault and of Maurice Merleau-Ponty, and try to show their implications for body psychotherapy.     

PSYCHOTHERAPEUTIC ENDS AND ENDINGS

ABSTRACT The paper proposes that the way therapists think about endings in psychotherapy is inseparable from the ends that they and their patients arrive at. At first, the question of how ends and endings relate would seem quite straightforward: determine the'criteria for termination', and we will know how to effect the ending. In fact, it turns out to be quite the opposite: grapple with the ending as a central organizing phantasy underpinning the therapeutic relationship, and gradually the ends emerge. Particular attention is given to'ending'as an archetype activated by the very nature of the therapeutic relationship.     

Fundamental Considerations in the Psychotherapy of an Identical Twin

Identical twins encounter unique psychological and maturational difficulties alien to the experiences of single children. A brief review of the literature on these points is presented, emphasising both the tormenting and gratifying aspects of a twin who has in the outside world another identical self that the world notices and confuses with him. Such aspects need to be taken into consideration when engaging an identical twin in analytical psychotherapy. 'Fallout' from psychotherapy can have repercussions on those close to the patient but in the case of identical twins the effects on the twin not in therapy can be disastrous. In particular, when psychotherapy-by-proxy ensues it appears possible for the co-twin to establish strong links to the analyst through his narcissistic relationship with his twin, which appear transferential in nature. A clinical vignette is presented which elaborates on the issues of twin transference and the fallout effects on the twin not in therapy. A question is put forward: whether it is realistic to analyse identical twins individually and not together when their narcissistic dependency and defensive hostility are paramount to internal processes. The author takes the view that a psychoanalytical orientation to the psychotherapy of an identical twin is the most recommended but cautions against individual psychoanalytical psychotherapy where the real drive is the assassination of the internal and external twin-object as a means to individuation from the twinship. The nature of this object - whether selfobject or transformational object - is tentatively discussed.     

Your own body of wisdom: Recognizing and working with somatic countertransference with dissociative and traumatized patients

This paper is intended as a contribution to the dialogue between body-orientated and psychoanalytic approaches to the psychotherapy of trauma. Therapists’ use of their own body awareness and somatic countertransference is central to body and movement psychotherapy but is rarely discussed in the psychoanalytic psychotherapy literature. Both phenomena have crucial roles in facilitating therapy, particularly with patients who have been traumatized. Both can provide critical windows into patients’ material and dynamics; similarly, the neglect of attention to either can lead to clinical ignorance and errors, no matter what the diagnosis of the patient in treatment. In work with traumatized or dissociative patients however the risks of not attending to somatic countertransference and body awareness include the vicarious traumatization of the therapist. Examples of body awareness and somatic countertransference are given, and their use is addressed. A model for the transmission of vicarious traumatization is briefly described that relates to dissociated kinesthetic mimesis.     

Considerations of verbal and non-verbal communication in body psychotherapy

Communication with others has both verbal and non-verbal aspects. This article describes theory about the use of language in body psychotherapy, ways of the psychotherapist relating to the client's language, and the psychotherapist using language with different therapeutic purposes in mind. Illustrative case vignettes are included. Links are made to current thinking in neuroscience and cognitive psychology. Language in the therapeutic relationship is discussed in terms of emotional regulation and spiritual awareness by combining verbal and non-verbal communications with intention, presence, contact and awareness.     

THE FUTURE OF PSYCHOTHERAPY IN THE UK: DISCUSSING CLINICAL GOVERNANCE

ABSTRACT 'Clinical governance' is a term coined to denote a requirement that all forms of clinical care should be governed by an attention to the quality of its delivery to the public. Clinical governance has been set as the future for the NHS by the NHS Executive. This paper draws together some of the themes of current discussions concerning clinical governance and other related issues for psychotherapy. Clinical governance has many facets but it can be defined as a commitment to evidence-based quality assurance in relation to clear national standards for practice, the delivery of evidence-based practice and the ongoing monitoring of standards. The paper provides a brief outline of clinical governance and indicates how it might be accomplished within primary and secondary care. A sketch is made concerning the possibility of there being local and national standards for various aspects of psychotherapy provision which is an additional requirement. The term'psychotherapy' is used to cover the full range of psychological interventions. Towards the end of the paper a critical overview of the standard paradigm of quantitative research is presented. This critical stance has been provided by two leading quantitative researchers who have called into question the applicability of the drug trial model for testing efficacy and finding the change-active ingredients of psychotherapy.     

Losing the Internal Oedipal Mother and Loss of Sexual Desire

This paper aims to examine how it might be possible to use psychoanalytic concepts to explore a deeper understanding of the difficulties with conscious and unconscious same gender sexual desires in psychoanalytic psychotherapy. The author explores how the loss of the unconscious oedipal mother can be manifested as a loss of sexual desire in a couple's relationship. The author suggests that the move from what is referred to as the longed‐for state of being in perfect harmony, to a more realistic state of imperfect harmony can bring about the recovery of an unconscious belief that one can possess the oedipal mother. The move from this fantasy state of merger to a more reality‐based relationship can induce feelings of abandonment and loss, particularly of sexual desire. The implications of this for the transference and countertransference, and the conscious and unconscious nature of erotic desires within the therapeutic relationship are considered. The importance of aspects of technique and the need for non‐pathologizing use of concepts to help clinicians more fully explore formulations and therapeutic interventions are examined. While this paper focuses on lesbian relationships, the relevance of the ideas presented here for other gender pairings is explored.     

The Birth and Death of Hope

I discuss the origins of the capacity to hope, its roots in the infant's experience of a loving and secure relationship with their caregiver. The infant's awareness of his or her own mental and emotional agency can gradually develop and so the capacity to channel desires and impulses, and to expect an attuned response. I suggest that the failure of this intersubjective developmental process gives rise to an enduring sense of hopelessness, an expectation that emotional needs and desires will never be met. The key role that play has in the development of hope is discussed from psychoanalytic and neuroscientific perspectives. The impact that a patient's persistent hopelessness has for psychoanalytic psychotherapy practice is explored, its function as a defence against any new, spontaneous relational experience which might activate trust and hope. Internal and external change and transference dependence are resisted as the patient fears becoming vulnerable to being abandoned or rejected by the analyst. I explore some socio-political aspects of hope and hopelessness, such as the belief that people deserve their success in society and the self-blame, shame and hopelessness that result from an experience of economic or social failure. I discuss the possibility that hope in human relationship and in our humanity can survive in the face of overwhelming catastrophe.     

ORCEIN POSITIVE HEPATOCELLULAR MATERIAL IN THE LIVER With Special Reference to Its Relationship with Human Lipofuscin

Histopathological relationship between orcein positive hepatocellular material (ophm) reported by SIPPONEN and human lipofuscin (hip) was investigated. Ophm was found to be very similar to hip of the liver as well as of heart muscle cell morphologically and histochemically, and it seems to be quite rational to consider that ophm may be a substance which belongs to the lysosome series comprising hip and prelipofuscin. Ophm has been discussed often from a view point of copper contents, which was considered to be one of its specific characters, but it has become clear that hip can also possess copper according to our Investigation and to some reports of other researchers. This fact throws a doubt on the significance of the specific relation between ophm and copper, as well as the usability of orcein stain for detecting copper in histological specimens.
Victoria blue stain is quite useful for the detection of hip including ophm, since it gives a blue color for it with a good contrast against red colored cytoplasm and nucleus. However, this can not be considered as a method for specific stain of copper either.     

Orcein positive hepatocellular material in the liver. With special reference to its relationship with human lipofuscin

Histopathological relationship between orcein positive hepatocellular material (ophm) reported by Sipponen and human lipofuscin (hlp) was investigated. Ophm was found to be very similar to hlp of the liver as well as of heart muscle cell morphologically and histochemically, and it seems to be quite rational to consider that ophm may be a substance which belongs to the lysosome series comprising hlp and prelipofuscin. Ophm has been discussed often from a view point of copper contents, which was considered to be one of its specific characters, but it has become clear that hlp can also possess copper according to our investigation and to some reports of other researchers. This fact throws a doubt on the significance of the specific relation between ophm and copper, as well as the usability of orcein stain for detecting copper in histological specimens. Victoria blue stain is quite useful for the detection of hlp including ophm, since it gives a blue color for it with a good contrast against red colored cytoplasm and nucleus. However, this can not be considered as a method for specific stain of copper either.     

Technological developments and applications in clinical psychology and psychotherapy: introduction

This article introduces a special issue on technological developments and applications in clinical psychology and psychotherapy. The question of why it is important to deal with such developments is raised. An overview of the individual topics and articles in the issue is given, and additional aspects are discussed. This is followed by an overview of possible advantages and disadvantages of technological developments as well as problems to be solved. Overall, the developments are still largely underresearched, but-if utilized-hold considerable promise in changing the field of clinical psychology and psychotherapy as well as training in the field.     

A study of significant moments of change in body psychotherapy

This article is based on research exploring significant moments of change in individual body psychotherapy. It involved semi-structured interviews with two body psychotherapists and two body psychotherapy clients. The research found that significant moments of change were identifiable. The participants gave precise and detailed accounts of the moment(s), and how the changes generalised to daily life. The longevity of the therapeutic relationship and the interactions during, and following the change moment were important for the change to stabilise.