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Fostering Independence

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In a series of papers, the author addresses the needs of students, patients, and practitioners of psychodynamic therapies. The work of these professionals with children and with adults is discussed from a pragmatic point of view, stressing the importance of recognizing the needs and capacities of each individual patient. At the same time, the author focuses on the professional's role in the clinical interaction, emphasizing the need to identify and respect what leads him to the consulting room, and what he expects to obtain from this strenuous and demanding type of work.The evolution of psychodynamic theories has led to its being often defined as a new version of the patient's earliest relationship of dependence on a maternal figure. The author discusses the implications of such a formulation and argues that, however correct it may be when referring to a small number of patients, it is important that, for the majority of cases, the professional should aim to help the patient to find and develop his or her independence and self-sufficiency.

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Chapter One: Infant observation

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By 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 Hei-mann (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 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.

 

Chapter Two: Winnicott’s therapeutic consultations revisited

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Winnicott 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 needs, the ‘knot’ disappears and normal development can be resumed.

 

Chapter Three: Increase or not increase?

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Apatient 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 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.

 

Chapter Four: Touching and affective closenes

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Icame 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 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.

 

Chapter Five: Child analysis: when?

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Psychoanalysis 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 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.

 

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

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Winnicott 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 Winni-cott’s own enjoyment in his play with the child. He perceives and 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.

 

Chapter Seven: Letter to a young psychotherapy trainee

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Dear 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.

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.

 

Chapter Eight: Memorizing vs. understanding

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University 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.

 

Chapter Nine: Holding, containing, interpretations: a question of timing?<a href="#ch09f1"><sup>*</sup></a>

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As 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 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.

 

Chapter Ten: The setting: what makes therapy work?

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In 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 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 Pon-talis’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.

 

Chapter Eleven: Working with adolescents: a pragmatic view

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Some definitions of adolescence

From 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 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.

 

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