Psychoanalytic Psychotherapy in the Kleinian Tradition

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This set of papers, from members of the British Association of Psychotherapists, demonstrates the vitality of the 'Kleinian tradition' in work with adult patients. It is a picture of work from outside the inner circle of Kleinians in London. And it thus indicates how the concepts have fared in their transport into everyday psychotherapy.

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1. Recollection and historical reconstruction

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Philip Roys

Writing in 1937, Freud commented that “the work of analysis aims at inducing the patient to give up the repressions … belonging to his early development and to replace them with reactions of a sort that would correspond to a psychically mature condition. With this purpose in view, he must be brought to recollect certain experiences and the affective impulses up called by them which he has for the time being forgotten” (Freud, 1937, pp. 257-258).

That such recollection is central to psychoanalytic psychotherapy there can be no dispute, but there are different points of view about what precisely might be recalled and how this should be achieved; in particular, historical reconstruction tends to be approached differently by contemporary Kleinians and those of other orientations.

In this chapter, I intend to explore contemporary Kleinian technique in psychoanalytic psychotherapy, with particular reference to the question of historical reconstruction. I shall suggest that it is possible to delineate a distinctively Kleinian approach to historical reconstruction which follows from the Kleinian account of the development of mind and of its functioning.

 

2. On the persistence of early loss and unresolved mourning

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Susan Lipshitz-Phillips

In this chapter, I discuss the impact of early loss and the ways in which the personality can be constructed to keep in touch with, to commemorate, or, on the other hand, to deny such experiences, using both clinical and literary examples.

Psychoanalytic theory of psychic reality shows that reaching adulthood does not necessarily coincide with reaching maturity. Individuals remain constrained by, and live in, their past in various ways. As Freud (1920g) described it, the powerful force of the repetition compulsion refuses to allow later experiences to modify earlier, often disappointing ones. He recognized, in Beyond the Pleasure Principle, that the individual felt obliged to “repeat the repressed material as a contemporary experience instead of, as the physician would prefer to see, remembering it as something belonging to the past” (Freud, 1920g, p. 18). And he understood that the compulsion to repeat painful experiences was an attempt to keep them alive, perhaps to control them, and could be used psy-choanalytically as a communication. When a traumatic experience breaks through the protection that the mind usually employs, the person deals with the breach in order to continue functioning, by resorting to their usual defences. This is particularly likely when they suffer loss and bereavement

 

3. Interrelationships between internal and external factors in early development: current Kleinian thinking and implications for technique

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Jessica Sacret

In this chapter I want to explore, in a necessarily somewhat schematic way, some of the issues implicit in current theoretical developments in the Kleinian literature and to elaborate some of their implications. More specifically, I want to focus on the relationship between internal and external influences in psychic development, insofar as these are highlighted in the discussion of issues underlying the understanding and treatment of patients whose therapy seems to present particular difficulties by virtue of the predominance in the personality of what has come to be known widely in the literature as a “pathological organization” of the personality (Spillius, 1988). For example, Joseph (1975) has described “patients who are difficult to reach”; Steiner (1993) uses the notion of the “psychic retreat”; and Rosenfeld (1971) has elaborated the concept of “destructive narcissism”. Others in the Kleinian tradition have also written on the subject of this now well-documented albeit diverse phenomenon.

 

4. ‘Turning a blind eye”: misrepresentation and the denial of life events

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Mary Adams

A patient, Mr H, would often preface what he was going to say with the comment: “I know this is not really the case, but….” He would then describe to me his own view of things that he knew other people would consider untrue. He was a bright young man in his mid-twenties, highly articulate and already successful in his career. However, he felt endlessly tormented by his view of the world, driven to violent rage by it, and unable to give it up. He seemed caught in a claustrum world where his only pleasure was in sadism and triumph. It was a world constructed to defend against the kinds of emotional experiences—painful or joyful—that were out of his control. It was a way, ultimately, I believe, of defending against unresolved oedi-pal guilt.

For the first two years of Mr H’s life, as well as looking after him and his older brother, his mother was caring for her dying sister. Extreme rivalry for the mother’s attention developed between the two brothers, which persisted throughout their teens and led to worrying physical violence between them. Although guarded about this, Mr H described “whole holidays being ruined” by the viciousness of their fights. Tragically, during Mr H’s adolescence his father became ill with a degenerating illness and remained in a nursing home until his death.

 

5. Tolerating emotional knowledge

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Stanley Ruszczynski

The primary task of psychoanalytic clinicians is to listen to and observe everything that is going on in the consulting-room: in the patient, in the therapist, and in the relationship between the two. This is usually referred to by the concept of the total situation of the transference (Joseph, 1985; Klein, 1952). This primary task also requires that from time to time we say something to our patient about what we have heard or observed. This usually comes in the form of a description, which, if we have listened and observed sufficiently acutely, will inevitably include meaning or interpretation. Understanding or insight may emerge. This clinical stance has long informed clinical practice. Freud recommended that we listen to our patients with free-floating attention; Sandler advocates free-floating responsiveness; Bion tells us to listen with negative capability, with no memory or desire; Betty Joseph promotes a detailed tracking of every moment in the session; Dennis Carpy and Irma Brenman-Pick (amongst others) describe, respectively, the necessity of tolerating and then working through in the countertransference.

 

6. Psychoanalytic psychotherapy for chronic depression

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Noel Hess

Depression is undoubtedly among the commonest of the complaints that bring our patients to us for help and from which they seek relief. We do also know that “depression”—or what our patients may call depression—can conceal a myriad underlying pathologies and can be of many and varied types, in both depth and severity. Perhaps the most important diagnostic judgement in determining the particular kind of depression with which a patient presents has to do with the degree to which the depression has infiltrated the structure of the personality. At one end of the spectrum is the presentation of a previously well-functioning patient, with the capacity to form and sustain relationships, who has managed some level of personal, professional, or material achievement, but who is suddenly felled by a depressive episode. This may be apparently inexplicable or, more usually, related to an experience of external loss, such as death. We know that mid-life is a time of particular vulnerability for such episodes (Jaques, 1965), when underlying omnipotence and narcissism (often quite hidden in the personality) are severely challenged by the reality of ageing, loss, and death.

 

7. Notes on a case of paedophilia

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Jean Arundale

Since the 1970s psychoanalytic psychotherapy has had to focus on the structure and dynamics of sexual perversions for a number of reasons: not only in order to understand and treat the overt sexual deviations, child sexual abuse, and the various types of antisocial and criminal behaviour appearing in consulting-rooms, but also because the close link between perverse states of mind and psychotic states has gained recognition. Perverse functioning is now seen as a feature in the borderline and narcissistic personalities, and the presence of unintegrated perverse areas can be found in many different patterns of psycho-pathology (Bion, 1959; Meltzer, 1973; Rosenfeld, 1971a). Furthermore, Glasser (1978) has pointed out that towards the end of many analyses—even those of neurotic personalities—perversions emerge, particularly in creative people. The psychoanalytic theory of polymorphous perverse sexuality suggests that perversions are ubiquitous and capable of unconsciously infiltrating all human relations. Thus, investigations in this area can reveal, writ large, problems of the widest relevance in object relations theory.

 

8. When is enough enough? The process of termination with an older patient

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Evelyn Katz

The subject of termination is a complex and problematical one, theoretically, clinically, and technically. At the simplest level, all therapies come to an end one way or another, sooner or later. However, there is all the difference between the precipitate, premature termination and interruption of a therapy for external reasons or due to therapeutic impasse, and a planned ending arising naturally as part of the evolution of the therapeutic process. In the latter, therapist and patient may be engaged in a painful but rewarding process which forces both to face and work through yet again issues of separation, loss, and mourning and all their underlying phantasies.

Schachter (1992) tells us that according to numerous surveys, in only 50% of cases is there a termination that has been mutually agreed upon and, by implication, that experiences of mutually satisfying endings are relatively few in the lifetime of a therapist. Indeed, most endings belong in the murky area between the two extremes mentioned previously, and for the most part termination stirs up many anxieties for patient and therapist alike. Despite the repeated experience and working-through of separation and loss associated with the breaks between sessions, weekends, and holidays, the patient faces the undeniable fact of having to bear the final separation alone, and to mourn the loss of this “strange” relationship without the help of the therapy he* has come to rely on. While he might look forward to his independence and freedom from the therapy, he also has to struggle with the regressive pull to perpetuate the comforting relationship of dependency inherent in the therapeutic relationship. On the other hand, the therapist has to contain anxieties about the timing of the termination and whether a “good-enough” therapeutic outcome has been achieved. The well-documented phenomenon of an apparent relapse or the recurrence of symptoms in the terminal phase may be alarming to both therapist and patient and lead both to question not only whether it is the right time to end but whether it was right to have begun in the first place.

 

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