Approaching the Transference Relation in Cognitive-Behaviourism: Applying a Lacanian Logic

Authors aiming to conceptualize a ‘cognitive countertransference’ continue to search for the most effective way to integrate psychoanalytic theory, and a coherent definition for such a concept. This paper first argues that authentic attempts at integration of the concept of transference into cognitive-behaviourism require a return to seminal work on Übertragung (transference) and Gegenübertragung (countertransference). References to these terms throughout the work of Sigmund Freud and Jacques Lacan are discussed in the context of the overall progression in the work of both theorists. With regard to two fundamental psychoanalytic concepts that underlie a Freudo-Lacanian understanding of transference – the unconscious and repetition – this paper subsequently explores how a Lacanian logic may inform the emerging ‘cognitive countertransference’ literature. This paper contextualizes such thinking within the ongoing psychoanalytic debate regarding the utility of the analyst's participation in the transference relation. Ultimately, this paper argues that a cognitive countertransference may be redundant in favour of an understanding of shared cotransference, or transference relation, which begets simple theoretical conclusions, and technical recommendations. Implications for cognitive-behavioural theory and practice are examined.     

Some Reflections on the ‘Teaching Attitude’ and Its Application to Teaching About the Use of the Transference: A British View

In this paper the author argues that psychoanalytic education is enhanced when (a) it attends seriously to the affective, relational and social processes that frame the experience of teaching and of learning, fostering a critical engagement with both, and (b) it engages candidates in exploring what they do (technique) in the context of the articulation of their model of working (theory). The features of the ‘teaching attitude’ that are relevant to psychoanalytic education are illustrated though a ‘teaching case study’ detailing the rationale, process and content for a curriculum on the concept of transference.     

‘Chaos,Through a Veil of Order’: The Dialectic of Theory and Spontaneity in Psychoananalytic Work

The theme of the paper is the quotidian debate about the role of theory in analytic practice. Based on examples from recent psychoanalytic publications, I argue that psychoanalytic theory may influence therapists as ideology, heuristics, or empiricism, or combinations thereof. Bion's eschewing of theory, and advocacy of an analytic stance ‘beyond memory and desire’ as a precondition for psychoanalytic creativity is questioned. Buber's advocacy of I–Thou relatedness is compared with the concept of mentalizing, and related to recent findings in developmental psychopathology. Parallels are drawn between the therapeutic relationship – bringing together theory and spontaneity in a hermeneutic enterprise – and the infant's use of security‐promoting care‐givers.     

A Couple's Unconscious Communication: Dreams

The author describes the process of a couple's psychoanalytic psychotherapy, conducted in co‐therapy, through the analysis of some dreams and their associations. The dream analysis will show the common and shared inter‐subjective dimension of the couple that emerged from the psychoanalytic psychotherapy setting. Central notions of this clinical work are those of inter‐phantasizing, common and shared dream space, and couple associative chain. But also the containing model of the psychic envelope can be considered as one of the bases of the theory of a couple's dream space. The author describes the process by which the partners of the couple, and more generally the ‘therapeutic new group’, were able to achieve the unveiling of a denial pact that allowed the couple to add to their family at the time of the birth of their first child with Down's syndrome; but also, and more fundamentally, what has allowed this young couple to cope with the trauma of this birth. The author finally shows how the group working‐through, within the setting of the couple's psychoanalytic psychotherapy, gave new meaning to sensations, feelings and affects of the couple.     

‘You Can Take it With You’: Transitions and Transitional Objects in Psychotherapy with Children Who have Learning Disabilities

This paper will consider what impact a learning disability may have on development and transition in a child's life. With reference to Hollins and Sinason's ‘Three secrets’ (2000), Alvarez's ‘Levels of psychoanalytic work’ (2012), and attachment theory, I will reflect on the development of the self when there is learning disability. The paper will go on to relate Winnicott's paper, ‘Transitional objects and transitional phenomena’ (1953) to the theory and practice of integrative arts child psychotherapy (IACP). In IACP, objects, play and creativity form a central part of the treatment. Drawing on clinical material from my long‐term treatment of two young people in particular, I will link the therapeutic effect of objects with Winnicott's ideas about creativity, aggression, motivation and the expression of self. In the paper I set out how, through the therapeutic use of objects and what I call, ‘object games’ we were able to address the children's experiences of trauma as well as the impact of their disabilities. I will describe the changes I saw in the internal worlds of my patients which in turn led to significant and positive changes in their relationships with self and with others. These changes came, over time, to allow them greater independence and self‐determination in everyday life.     

Persecutory Entrapment and Flights in and out of Situations: A Question of Survival

This paper considers the occurrence of entrapment, invasion and phobic functioning ‘in’ and ‘out’(side) the consulting room as well as states of mind connected with safety and survival. Patient and therapist set sail on a troubled analytic journey beset by dangerous, terrifying mother imagoes, a mafia gang and a watchful life-saving ally. It is an epic journey into the unknown that involves inter alia thrills, braving the elements and the antagonistic forces of Thanatos and Eros. ‘No one dies and no one is hurt’, but emotional storms are created in media res. The patient then takes many flights. Firstly, into the place of her worst ‘nightmare’ and secondly, into action and inaction. In reality, a truly secure space and object cannot be found – only a feeling of captivity and disintegration remains. The use and function of potent and evocative objects may be significant for the patient in terms of safeguarding against re-experiencing primitive disasters, while achieving (a retroactive) control and mastery over the original trauma and helplessness. The author navigates a wide range of psychoanalytic theory, finding correspondence between classical and contemporary psychoanalytic traditions.     

Time in Motion: Qualities of Temporality Within Psychotherapeutic Psychodynamic Counselling

Our relationship to time is both a developmental and a relational one; an inter- and intra-psychic experience. Exploring how the theories of Freud, Klein, Winnicott, and their successors offer explanations of how the psychoanalytic subject develops and sustains a concept of time and the factors that may hinder this, this essay suggests that different qualities of time, such as continuity, rhythm, repetition and interruption, can reveal themselves through the client's transferential and countertransferential relationship with the therapist. Using fictionalized clinical examples it explores how a bodily felt experience of time was thought about by the therapist/author using Laban movement analysis to support a client in ‘working through’ early material that felt stuck. The exploration of a client's perspective is brought in through the writings of the activist Passerini on her psychoanalytic treatment (cited by Baraitser in Enduring Time) and her experience of trauma's capacity to stop time. The essay also looks at how psychoanalytic ideas of temporality challenge the ‘recruiting’ of time by the wider culture to create more time-efficient late-capitalist subjects but by using ideas from movement studies and a Lacanian influenced time register it is suggested that cultural attacks on subjective experiences of temporality could be challenged within therapy. It is hoped the essay encourages the therapist to become alert to the manifestations of different temporal experiences within the therapeutic relationship and to develop a creative, embodied language with which to explore it with the client.     

Mentalization within Intensive Analysis with a Borderline Patient

The author discusses whether the concepts of mentalization are helpful within intensive, individual analytic work with a personality disordered patient. Child and adult technique within the widening scope of psychopathology can be thought of as building on developmental help, studied at the Anna Freud Centre from the sixties to reach ‘atypical’ children who could not use classical analysis. The first two years of work with Jenny, a young borderline woman, were anchored by developmental research on attachment and early parent–infant relating. Later, when her capacity to symbolize, tolerate and communicate affect had greatly improved, she could accept and use interpretations, and working in the transference was gradually able to be accepted as thinking and not only as action. The infantile modes of experiencing psychic reality hypothesized in mentalization theory are illustrated from the material, and the status of attachment within psychoanalytic theory is reconsidered. In the last section, how each psychotherapist specifically shapes the process of change will be discussed, building on the concept of ‘marked mirroring’.     

The Use of Benign Authority with Severe Borderline Patients: A Psychoanalytic Paradigm

Kernberg has suggested that work with severe borderline psychopathology requires limit‐setting interventions to mitigate the possibility of life‐threatening enactments. These actions constitute a deviation from the classical analytic stance of technical neutrality. Taking up these modifications, I argue for a re‐calibration of the analytic task with severe borderline patients predicated on the use of benign authority. Abandoning therapeutic equidistance, I propose a model based on interventions organized around ‘maternal’ and ‘paternal’ functions and the dialectical and generative intercourse between these two poles. Such engagement requires close attention to the countertransference, as enactments are inevitable. In this context I reflect on the way ‘action’ in psychoanalysis is considered pathological, as a countertransference enactment. Clinical vignettes are presented arguing for ‘actions’ based on limit setting and active emotional engagement as therapeutic in their own right, which is consistent with psychoanalytic practice. This realignment of the psychoanalytic project embodies the ideas that Gabbard and Westen introduced in ‘Rethinking therapeutic action’. They suggest that it is now more accurate to speak of therapeutic actions in psychoanalytic treatment, rather than the ‘single‐mechanism theories of therapeutic action’, which may have implications for psychoanalytic practice beyond the treatment of the personality disordered patient.     

Social Justice on the Couch: Collapse and Repair of Social Thirdness

How have the white, middle-class, Eurocentric ideologies and practices of the Western psychoanalytic canon prepared us to make meaning of the complexities of our pluralistic world? Psychoanalysis has been criticized for its predominantly decontextualized and depoliticized perspectives that emphasize universal intrapsychic unconscious dynamics. In the context of a sociopolitically critical view of psychoanalytic theory and practice, I will reflect on what it means to keep conducting ‘business as usual’ in an era where movements like Black Lives Matter, #MeToo, as well as the health inequities that became apparent due to the Covid-19 pandemic are clear warning signs that our world is deeply troubled by injustice. I will argue that psychoanalytic theory and practice is not immune from this injustice. I will also contemplate aspects of a socially just psychoanalytic vision that may reverse decontextualizing, depoliticizing, and prejudicial trends using the principle of social thirdness, which expands traditional views of thirdness to include the patient's and therapist's embeddedness in the larger sociopolitical currents that inform and shape their engagement with each other. Reflecting on themes such as race, sexuality, gender, and sex/gender nonconformity, both the collapse and repair of social thirdness will be described and illustrated with relevant clinical examples.     

BION,BECKETT AND BOB

We worked with Bob Hinshelwood for many years and begin our paper with an account of what we experienced as the essence of his approach in applying psychoanalytic understanding, especially an awareness of the ubiquitous effects of projective identification, to individual, group and organizational dynamics in mental health settings. This takes the form of a juxtaposition of some ideas and responses triggered by contact with patients expressed by Bion, Samuel Beckett and Bob himself. They all conveyed what it feels like when ‘bits of identity’ are passed around through unconscious interpersonal interactions. We then introduce the forensic psychotherapy context in which we work and try to apply what Bob helped us to see. Contact with severely mentally ill patients, who have committed catastrophic assaults, is work on the countertransference edge where patients' deficit in the capacity for symbolic communication and subsequent resort to action – sustained streams of projective identifications – evoke the maximum emotional impact in staff. We conclude with an example of a reflective practice group for beleaguered, often frightened, staff who desperately need but also attack – much as their patients do – what Bob called the attempt to build a reflective space which is so vital to survival and effective work.     

What it Means to Bleed: An Exploration of Young Women's Experiences of Menarche and Menstruation

As a topic of psychoanalytic inquiry, menstruation is surprisingly absent from psychoanalytic literature: menstruation as a part of female psychosexual development is in need of further empirical exploration. The research uses semi‐structured interviews with six young women to explore individual experiences of the menarche and menstruation. The data is analysed using narrative and thematic analysis and interpretations, made within a (broadly classical) psychoanalytic frame, drive the results. In this condensed version of the research, three central findings will be discussed: (1) the role of mother in negotiating the menarche; (2) the difficulty of irregular periods and the fear that something internal has ‘gone wrong’; (3) the link to ideas of mess, dirt and shame, potentially reflective of feelings about sexuality. The research concludes that menstruation is an area worthy of careful psychoanalytic consideration in theory and in clinical practice.     

How Much Time Do We Need? Time and Psychoanalytic Psychotherapy in CAMHS

The author considers what seem to be norms and values concerning session frequency and length of treatment in ‘traditional’ and current child and adolescent psychotherapy practice, and the impact of training expectations and models of training on identity and status as a child and adolescent psychotherapist. In the UK National Health Service, there is pressure to do more in less time: the norm is once-weekly work. Such an expectation does not sit comfortably with psychoanalytic theory and training, which remains rooted in higher frequency, longer-term cases. For trainees, this can lead to feelings of fraudulence and questioning whether less frequent therapies imply that the work is not psychoanalysis. The author explores, through a literature review, a case study and research material, how one might acknowledge the tension between these conflicting values about time; how psychoanalytic work in all its forms might be valued and be valuable for patients; and urges the need to feedback clinical experience into training structures and ongoing learning.     

Speaking Through Action,Acting Through Speech: Acting and Enacting in the Analytic Process

In this paper the author looks at the significance of different forms of action in the psychoanalytic situation. He traces the development of related concepts, going back to Freud's early concept of a ‘symptomatic act’ and the introduction of his concept of ‘acting out’ with the Dora case, through to more modern and complex ideas of enactment. He shows that acting out can have a defensive as well as a communicative function. Actions can be a way of ‘speaking’ to the analyst, of communicating things that cannot be thought or put into words. On the other hand, speech itself can become an action rather than a form of symbolic communication, a way of putting pressure on the analyst to fit in with a projective phantasy. Important theoretical contributions to the concept of enactment, by Sandler, Joseph, Feldman and Tuckett, are described in some detail. Looking at Freud's Dora from such a perspective, the author argues that an enactment developed between Freud and his patient. Detailed clinical material is presented to show how the author uses these concepts in his own analytic work. Finally, the relationship between enactment and containment is discussed.     

Analysis on Demand

In his book The Piggle, Winnicott describes a psychoanalytic process that began when his young patient was 2½ years old. He saw her for 15 sessions over a period of about 2½ years and he called this type of setting ‘psychoanalysis on demand’. He concluded that a child should either have analysis as daily sessions or be seen on demand. For an analysis ‘on demand’, the young patient needs a high capacity for continuity and linking to bridge the long intervals between sessions. The author examines in relation to the material of Winnicott's creative case presentation how this capacity was communicated to Winnicott by the small child (a kind of primary symbolization) and how these mostly preverbal communications were ‘heard’ (or not) by Winnicott.     

INTEGRATION IN PSYCHOTHERAPY: AN EVOLVING REALITY IN PERSONALITY DISORDER

ABSTRACT Psychotherapy continues to be bedevilled by ideological schisms with practitioners apparently ignoring alternative conceptualizations and potentially superior interventions. However, I argue here that there is evidence of a rapprochement , both in theory and in practice, between cognitive therapy and psychoanalytic therapy, especially within the domain of personality disorder, which may lead to the development of integrative psychotherapy. Cognitive therapy has begun to encompass an interpersonal approach within its theoretical base. Similarly, psychoanalytic therapy increasingly uses an interpersonal formulation of the process of therapy. The therapeutic alliance is emphasized equally and process research suggests that interventions, when given by experienced practitioners, are not as dissimilar as'brand-named' therapies imply. Continued refinement of process psychotherapy research could lead to true integration of efficacious therapeutic interventions. But translating research findings into practice will necessitate psychotherapists opening themselves up to each others' ideas.     

Community preceptors' views of their identities as teachers.

PURPOSE: Community physicians are increasingly being recruited to teach medical students and residents, yet there has been little research about how they think of themselves as teachers or what factors contribute to "teacher identity." Physicians who think of themselves as teachers may be more likely to enjoy teaching, to teach more, and to be recognized by students and other faculty as good teachers. Identifying factors that enhance teacher identity may be helpful for the recruitment and retention of high-quality community faculty. METHOD: Thirty-five experienced community preceptors were audiotaped in five structured focus groups in April 2001, answering a series of questions about their teacher identity. Responses were qualitatively analyzed for evidence of themes. RESULTS: "Feeling intrinsic satisfaction" was the most common theme that emerged from the tapes. Preceptors also identified that "having knowledge and skill about teaching" and "belonging to a group of teacher" enhanced their roles as teachers. "Being a physician means being a teacher," "feeling a responsibility to teach medicine," and "sharing clinical expertise" also emerged as important themes. Although a group of participants were interested in "receiving rewards for teaching," rewards did not need to be financial compensation. For some, genuine recognition for their efforts by the medical school, particularly in the form of faculty development opportunities, constituted reward and recognition for teaching. CONCLUSIONS: Community physicians described a variety of factors that contribute to their identity as teachers. Faculty development programs offer opportunities to strengthen teacher identity and foster relationships between teaching programs and community-based faculty.     

I am not a doctor,but… A reflection on training doctors in communication skills without being one

Over the last 15–20 years, the scope of medical education has broadened to include disciplines other than the biomedical. Many educators from the humanities and social sciences are thus currently teaching in the faculty of medicine. But how should we understand and communicate the position from which we - as ‘non-doctors’ - teach in this field? This article provides a reflection on how both doctors and ‘non-doctors’ in medical education seem to confirm and reproduce an underlying norm, namely that doctors are the most suitable teachers in medical education. I argue that these norms could and should be challenged. I provide examples of how a ‘gaze from the outside’ is fruitful and may be necessary in medical education, and highlight the potential strength of cross-disciplinary teaching that involves medical educators ‘within and outside’ medicine.     

The Psychoanalyst As Revolutionary

By comparing psychoanalytic transformational processes to political revolutions, the author advances the psychoanalytic project in several ways. The analogy extends British object relations theory by elaborating upon Fairbairn's (1952) observation that psychoanalysts arduously compete with their patients' devotions to their internal worlds. In essence, he argues, and by exploiting the ‘mutual but asymmetrical’ (Aron, 1991) intimacy of the psychoanalytic dyad, psychoanalysts foment change in individuals like revolutionaries alter governments. The comparison to political revolutions also highlights how changes in the behaviour of other persons in patients' lives are necessary for transformation. Clinical insurgencies, when successful, alter patients' intra-psychic structures, interpersonal relationships, and overall behavioural patterns. The paper includes two case examples, one a successful revolution and the other not, as illustrations.     

Training and disillusion in Counselling Psychology: A psychoanalytic perspective

In this paper, I argue * that Counselling Psychology's professional identification with pluralism poses significant emotional problems for trainees. An important factor in such problems may be the trainee's sense of disappointment and disillusion that the route to professional and personal self‐transformation will not be achieved via a set of universal theoretical principles and established clinical ‘rules’. I draw on recent psychoanalytic theory to suggest that the task facing trainees involves balancing pluralism, characterized as an ‘external’ third position, with an ‘internal’ third space indexing an awareness of subjectivity and intersubjectivity. Maintaining a dialogical‐dialectical perspective on these two positions allows for a creative space in which the trainee may be transformed from lay helper into professional counselling psychologist via a personal engagement with theoretical, clinical and academic material presented during training.