Exploring Silence in Psychoanalytic Theory and Clinical Work

Silence, as an element of the therapeutic encounter has been of interest in psychoanalytic theory from the early stages of its development. Theoretical views on the functions of silence have broadened considerably since the phenomenon was first examined, in line with developments of theory and technique. This literature review aims to explore silence in psychoanalytic theoretical literature and proposes three broad categories of silence in psychoanalytic psychotherapy, namely: silence as defence; silence as connection; and silence as withdrawal. From this review it appears that silences in psychoanalytic therapy may often be multidetermined in nature; it is suggested that there are limits to the extent to which these can, and possibly should, be understood. The implications of the theoretical understanding of silence for clinical practice are then explored, and the importance of each therapist finding their own way to incorporate silence into their work with each patient is acknowledged. Debate within the literature as well as research in this area are important to further understanding of this phenomenon.     

Taking Your Own Side in the Argument

This contribution is written in response to Helen Morgan's paper ‘Whiteness: A problem for our times’. A distinctive feature of her writing and thinking in this essay, and her new book, is how she moves easily and freely between psychoanalytic, sociological, political and psychological frameworks of understanding. In doing so her work exemplifies something that the psychoanalytic community has mostly been poor at achieving – a recognition of both its distinctive and unique potential to illuminate social and political processes, and a parallel acknowledgement of its need to enter into equilateral dialogue with other intellectual paradigms. Social and political life is historical, specific, local and complex, and not amenable to reductionist or universalizing modes of analysis and engagement. Through some examples I aim to add to Helen's very thoughtful and well researched paper, to show how psychoanalysis needs to respect other languages and methodologies for engaging with the world, render its own more accessible to non-specialists, and relinquish its tendency to assume the status of a ‘master discourse’.     

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.     

Maintaining the Tension Between the Classic Seduction Theory and the Role of Unconscious Fantasies: A Contemporary Reconsideration

This article describes the long-term psychoanalytic psychotherapy of a young woman who had experienced trauma during her childhood. The details of the trauma were unknown, as all memory of the trauma had been repressed. Past trauma is analysable through a prism of transference, dreaming and dreams, mental states and thinking processes that offer an opportunity to explore and analyse the influence of both reality and fantasy on the patient. The presented case describes a therapeutic process that strives to discover hidden meanings through the unconscious system and illustrates the movement from unconscious to conscious during exploration of the patient's personal trauma in treatment. The author discusses the importance of classical and contemporary psychoanalytic models of childhood sexual trauma through the discovery of manifest and latent content, unconscious fantasies and actual events of trauma. It is suggested that the complexity of trauma is clarified by the tension between these models and by the inclusion of aspects of both of them for a complete understanding.     

The Wish to Never End: Grappling with the Termination of an Infant observation And its Relevance to Clinical Work

This paper uses a psychoanalytic infant observation to highlight the significance of grappling with endings. It describes the termination of a two-year relationship with a child and his mother, who were observed weekly by the author. The content of the ending process is extrapolated to apply to infant observations in general, with implications for termination of psychoanalytic psychotherapy treatments with patients of any age as well as personal relationships. Transference and countertransference reactions and enactments evoked during the prelude to termination are considered. Vignettes from the infant observations illuminate important crossroads during the termination process. The paper also illustrates the resilient capacity that a child (and by extension the child part of an adult) can have to experience, process and bear the ending of a relationship, as well as to continue to hold that relationship internally. This glimpse into one child's, one mother's and one observer's experience of separating from each other demonstrates the ways primitive aspects of the psyche may be activated during a termination. Finally, Donald Meltzer's concept of three-dimensional interior space and Bion's idea of open-ended reality are applied, indicating how relationships that have ended may be contained within one's psyche, enduring beyond their ending.     

Gay Men and Suicidality: The Development and Nature of the Critical Superego

National research studies report elevated suicide rates amongst gay men, particularly those under the age of 26. Much of the current health and psychiatric literature on suicide tends to focus on the external world impacting on the suicidal individual. Although valuable, it is not enough to understand the specific circumstances that could contribute to gay men's suicidality. This paper focuses on the relationship between the external and internal dynamics at play in the suicidality of gay men, with particular emphasis on the development, influences, and nature of a cruel and punishing superego. The author provides some contemporary psychoanalytic theories on same-sex desire as a useful framework to understand minority sexuality. Some influential classic and contemporary psychoanalytic theories regarding suicidality and the development and character of a cruel and punishing superego are presented. The concept of internalized homophobia and the impact of heteronormative masculinity on the gay man's psyche are explored as drivers for suicidality. A composite case study from clinical experience with suicidal gay men in an NHS setting is presented to illuminate the discussion. This paper could add new perspectives and important dialogue for psychoanalytic psychotherapists working with this patient population.     

Social Media and its Impact on Therapeutic Relationships

In the current age of social media, the boundaries between the online and the offline, the personal and the professional, have become blurred and ambiguous. This poses significant challenges to the practice of psychoanalysis, which for a long time has been thought of as a technology-free and private space. This paper compares how social media impacts therapeutic relationships in the broader field of psychotherapy and in psychoanalytic psychotherapy in particular. Direct breaches in therapist privacy were found to be more frequent with non-psychoanalytic psychotherapists due to therapists’ higher online presence. Psychoanalytic psychotherapists, on the other hand, generally have a lesser online presence because of different views on therapeutic anonymity from other clinical orientations. The author suggests that this leads to different forms of virtual impingements: due to the absence of psychoanalytic therapists’ online presence, patients seek to re-create therapists (and, by extension, therapeutic situations) on a virtual level rather than discover something that was already ‘put out there’ by therapists. Virtual manifestations of anonymity, splitting, and solipsistic introjection processes are discussed with reference to John Suler's concept of the online disinhibition effect. Further recommendations for research on social media impact are discussed.     

Mourning through Poetry: Discovering the Lost Love Object and Symbolization of Desire

Deborah was referred to me for psychoanalytic psychotherapy following a suicide attempt and depression. We began a fascinating journey spanning more than 10 years. During therapy, many questions arose concerning the suicidal episode, which she could not register consciously. I tried to understand the reasons for her depression and the attempted suicide through the unconscious process in the therapeutic relationship and through the music and poetry that she brought to sessions. In this paper I describe the process of listening for the signifiers of semiotic and symbolic language, both metaphoric and metonymic, as revealed in poetry and music according to the theories of Kristeva and Lacan. The poetry enabled the patient to retrieve childhood memories, experience the movement from unconscious to conscious, and mourn through the experience of transference and countertransference in the therapeutic relationship. Also illustrated is the transition from singing the music to more symbolic language, turning the patient's sensory experience into language, and connecting her personal experience with the culture of her past. The patient's mourning and the lost love objects are discussed through the prism of classical and object relations theories.     

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.     

Psychoanalysis and CBT: From Rivalry to Hospitality in Psychotherapy Integration

Despite the many efforts to integrate psychoanalysis with CBT, many loyal therapists of each school have consistently refused to ‘open their gate’ to the other's influence. We explain this resistance as a way to preserve a strong professional identity through the Us–Them distinction. Any attempt to encourage loyal therapists to be influenced by the other school must guarantee that the other will not threaten their identity. We use Derrida's notion of hospitality to facilitate mutual influence between the schools while overcoming the other's threatening encounter. According to Derrida, hospitality, in response to the law of ethics, opens the home's threshold to the foreigner; in this law, the other is always welcome. At the same time, hospitality prevents a hostile takeover – by the law of politics, which ensures the owner's ongoing control over his house. By thus keeping the tension between openness and control over who enters, hospitality makes listening and learning between the psychotherapeutic schools possible. We discuss practical ways to put the concept of hospitality to work between the two schools, offer illustrations, and argue for this model's advantages.     

The philosophical and historical context of Bion's concept of reverie and its use as a rhetorical act in his theory of psychoanalysis

In this article, we seek to clarify the historical and philosophical roots of Bion's somewhat enigmatic concept of reverie. We also reflect on the rhetorical reasons for Bion's decision to introduce the concept into psychotherapeutic discourse. Although Josef Breuer and Sigmund Freud (1894) had used the term in their Studies on Hysteria, prior to Bion it had lost its independent significance and role in psychotherapeutic theories. We would contend that even if the concept reverie has become increasingly popular in recent psychotherapeutic discourse, the relative neglect of its history and philosophy have led to problematic ways of implementing the concept in both the theory and practice of psychotherapy. We start from Jean-Jacques Rousseau, moving on to Freud, William James, Henri Bergson and Gaston Bachelard. We present our view of why Bion considered reverie to be an indispensable tool in explicating certain psychoanalytic dimensions. We also reveal the kinds of historical and philosophical commitments that are embedded in the concept of reverie and append brief comments on the relevance of our analysis to the present state of psychotherapy and psychotherapy research.     

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.     

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.     

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.     

Online Psychotherapy: Transference and Countertransference Issues

This paper arises from the shift, following the start of the 23 March 2020 lockdown in Britain, from clinic-based to online psychotherapy within National Health Service (NHS) psychological treatment services. The paper draws on previously published observations about privately funded online psychotherapy. It also provides a snapshot of my own and my clinical psychology colleagues’ experience of providing clinic-based and online NHS-funded psychotherapy before and soon after the March 2020 lockdown began. I use these impressionistic data to illustrate transference and countertransference issues involved in online psychotherapy. In addition, I note problems relating to its setting or frame, and ways in which this form of treatment can obstruct empathic mirroring and the patient's experience of being contained. I conclude by noting limitations of this study based as it was on the immediate reaction of myself and my colleagues to the transition from providing clinic-based to online psychotherapy, not on interviews with patients about their experience of this transition nor on any measure of the relative effectiveness of online compared with clinic-based psychotherapy.     

INTRUDER IN THE NIGHT: CANCER AND THE 'I' WITHIN

ABSTRACT Little has been written about psychoanalytic psychotherapy with people who suffer from medical conditions such as cancer and as distinct from the well-established literature describing psychoanalytic theories and clinical work with those who have medical conditions which may be considered to have a psychologically-influenced causal basis.
In this paper, I will explore the nature and experience of cancer, its psychological impact upon the patient and also the therapist, and the patient's relation to the disease inside. I think about cancer as an unboundaried invader within the body which may temporarily dislocate the patient's ego, resulting in the 'I' of the patient feeling overwhelmed or threatened. The subject of this paper is the 'I' which perceives and relates to the cancer within. The aim of the paper is to work towards describing the principles and practice of a model of ego-supportive psychotherapy with cancer patients, its goal being to help the patient to strengthen, relocate or reinstate his/her vulnerable ego.     

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.     

The Double Session: Two for the Price of One or One for the Price of Two?

The double session is evaluated here as a treatment option in a once-weekly psychodynamic psychotherapy. The double session is defined as two 50-minute sessions back-to-back, a single 100-minute session. I discuss how the double session came to be chosen and practiced with one particular male client. I discuss previous literature on the use of the double session, elucidating the rationale, clinical thinking, indications and contraindications in these papers. I analyse my own clinical experience and thinking in the use of the double session in the context of the many objections; I attempt to argue positively and reflectively with this seemingly controversial adaptation of well trodden once-weekly work. I address therapists' resistance to the double session. Using other examples of extended session work I examine how the therapy can be enhanced by its intensity and I argue for further research and use of the double session in an endeavour to deepen and enhance once-weekly work.     

Young adults' ideas of cure prior to psychoanalytic psychotherapy

The study aims to explore systematically the ideas of cure among young adults prior to psychoanalytic psychotherapy. Forty-six individuals aged 18 to 25 years who applied for psychotherapy underwent the Private Theories Interview (PTI). Twenty distinct categories of ideas of cure were identified. Based on these categories, a theoretical model was constructed with the dimensions, Approaching-Distancing and Doing-Receiving. Individuals were classified into types using "ideal type analysis." Seven ideal types were formed: Processing and Understanding, Mastering Through Own Will and Action, Talking, Discordant Ideas, Incoherent Ideas, Getting It Out, and Avoiding or Placing the Solution onto Others. New hypotheses emerged concerning ideas of cure as an important factor for psychotherapy matching, thus potentially predicting premature termination, alliance, and outcome.     

Gender and perversion – what constitutes a “Bad Mother”

Summary Background: There is a need for reconsidering the conceptualisations of female perverse behavior, especially in connection with motherhood. Methods and findings: Based on case material obtained through psychoanalytic psychotherapy with female patients from a psychosomatic gynecological outpatient clinic, the characteristics of the psychic structure of these patients who presented symptoms of deliberate self harm and of misusing and mistreating their children, are outlined. Another common trait is the embeddedness of their perverse behavior in a generational chain of transmission. Female patients who mistreat their children had been victims of traumatising experiences in their own biography, inflicted by their mothers and directed towards their bodies. Discussion: Female perverse behavior, therefore, is fundamentally different from male perversion: the perverse act in women is aimed against themselves and/or their children. Currently used diagnostic statistical manuals lack categories to describe this symptomatology adequately. Further research is requested to understand a mother's perverse actions and thus develop treatment strategies, without marginalizing these patients. Accepted October 6, 2002; Published online December 9, 2002 Correspondence: o. Univ. Prof. Dr. Marianne Springer-Kremser Departement of Psychoanalysis and Psychotherapy, University of Vienna Medical School, Waehringer Guertel 18-20, A-1090 Vienna, Austria; e-mail: marianne.springer-kremser@akh-wien.ac.at