The Making of a Psychotherapist

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In the first part of the book - 'Personal Qualities' - we are reminded that Psychotherapy means 'Healing the Soul', and that the healer has a moral responsibility for the state of his own mental health as well as the patient's. The second part - 'Professional Dilemmas' - discusses ethical values, and the author's conviction that moral amorphism has caught hold of the psychotherapy movement.

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1. The traditions and practice of psychotherapy

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Psychotherapy means healing of the soul. Until the eighteenth century, the power to heal the soul was the prerogative of the “holy man”. When someone was in spiritual distress, he approached a saint within Christendom, a Sufi within Islam, or an Arahat within Buddhism. What these holy people did when someone approached them in spiritual distress was to give the sufferer new understanding, a new line of thought that could then lead to an inner decision. Such a decision might either be to act in such a way as to alter the direction of habitual tendencies or, through reaching a deeper understanding of one’s own personal sorrow, to be able to accept it. The following extract fromThe Path of the Buddha (Morgan, 1986) will illustrate my point:

Kisa Gotami lost her only child and became almost mad with grief, not allowing anyone to take away her dead child in the hope that it might revive again through some miracle. She wandered everywhere and at last came into the presence of the Buddha. Buddha understood the deep sorrow that so blinded the poor mother, so after giving her comfort he told her that he could revive the child if she could procure a handful of mustard seeds from the house of one where no death had ever taken place. Hope came to her and she set forth from house to house asking for a handful of mustard seeds. She did receive, everywhere, the seeds with profuse sympathy. But when it came to asking whether there had been any death in the family, everybody universally lamented the loss of a mother or a father or a son or daughter, and so on. She spent hours travelling in search of the precious seeds that promised the revival of her son, but alas, none could give them to her. A vision arose before her and she understood the implication of the Buddha’s hint. She understood that death is inherent in life which is the source of all suffering, all delusion, [pp. 22-23]

 

2. The psychotherapist's education

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I follow Fairbairn (1958) in saying that emotional contact is what people most deeply yearn for and what fundamentally gives meaning to a person’s life. Men and women derive their deepest satisfactions—in their work, hobbies, domestic life, and guiding aspirations—when they tap into the reservoir of emotional contact. Such contact, however, is only effectively made through a signal emitted from the true self of another. I therefore contend that the only interpretations that are effective are those that proceed from the true self of the psychotherapist. I am conscious that such a bald statement may be more acceptable to the reader if it is expressed negatively, that is, that interpretations that proceed from the false self cannot touch the emotions of the patient.

The requirement in many psychotherapy trainings that the would-be psychotherapist undertake personal therapy for himself is to assist him in reaching a knowledge of his true self and also to assist him emotionally to do so. The development of a person’s emotional capacities is clearly central to any psychotherapy training, and without it all intellectual striving to master concepts becomes a hollow endeavour.

 

3. The analyst's inner task

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Iam sitting in my consulting-room and there is a knock on the door. I open it, and standing there in the doorway is a middle-aged lady with grey hair.

I shake her by the hand and I notice that she is wearing a red dress and black shoes. She pauses hesitantly and then rushes rather quickly to an armchair and sits in it. As I take my own seat, I detect the scent of Chanel No. 5. I had not met this woman before, but I have now touched her, seen her, heard her, and smelt her. These perceptual facts can be explained in terms of my sensory receptors and their link through the central nervous system to my brain. So I touch her, see her, hear her, and smell her, but I also feel her. I also know that she feels me. There is an interpersonal psychic experience whose physical correlate would be similar to two blind people feeling each other all over until each one begins to “know by feeling” the other.

The communication of feelings

When this woman came into my consulting-room, I received a very accurate feeling representation of her which became encoded in my inner affective representational life. But my problem is that I am not in touch with this inner representation. There is a barrier between my ego and this representation. This means that I have affective knowledge of this woman in my consulting-room, but I do not have conscious awareness of it. To illustrate from my own experience that such a psychic registration does indeed take place, I will relate an experience that occurred some years back.

 

4. Imagination and curiosity of mind

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This chapter is based on two papers, one entitled “The Imagination required in our Environment” and the other “Curiosity of Mind”. These topics are here linked together: both are states of mind that I believe have equal value, imagination being the producer of creative thought and feelings, and curiosity being a mental attitude. The previous chapter dealt with the importance of a psychotherapist being guided by his feelings. What I want to explore further are those elements that transform proto-feelings into feelings—elements that are intrinsic parts of the mental structure that forms personality. These elements are closely interwoven with feelings and, like feelings, can be developed through education. For a student of psychotherapy, two of the most important transforming elements are, I believe, the imagination and curiosity of mind.

Imagination is the psychotherapist’s instrument of understanding. It may sound strange to say this, but I think it is true that it is through the imagination that one human being makes contact with another, and through the imagination that the psychotherapist makes emotional contact with the patient. It is the mental faculty the psychotherapist most needs to cultivate, after such character traits as integrity and trustworthiness.

 

5. Mental pain and moral courage

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This chapter is based on two papers, one entitled “Pain” and the other “Moral Courage”. I have already touched upon mental suffering in my discussion of the Invention Model of education and in the conclusion to the previous chapter—it is, in fact, inevitably touched upon many times. And, because I believe that no psychotherapist can be effective unless he can reach his own feelings, moral fortitude is an essential quality in a psychotherapist if he is to endure the pain that reaching those feelings entails. In other words, moral courage is needed to deal with mental pain.

It is a universal truth that all animals seek to avoid pain, and mankind is no exception to this general principle. Human beings have found the means to relieve physical pain, so that today we have extremely effective drugs that can prevent the patient from being exposed to the full intensity of certain illnesses. In addition, the duration of these illnesses is often very much reduced. It also seems to be the case that a person’s health benefits from this alleviation of pain. There does not seem to be any accompanying constituent to physical pain that is essential for the physical well-being of the organism.

 

6. Self-esteem in analyst and patient

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This chapter explores the following interwoven themes: the problem of unconscious resistance in the analyst, the analytic process as the third term in the analytic endeavour, and the disparity between inner identity and declared role. In order to develop these themes, I start by relating a case of mine where I was seeing a couple experiencing difficulties in their marriage.

The husband was a stockbroker and the wife looked after their two daughters at their home outside London. The husband had been in a stockbroking firm since leaving school. It was a firm that his uncle was in, and he had been taken into the company on the old boy network. He was liked by his uncle and by his two cousins, who were also partners. My patient was not an adventurous man, and I doubt whether he ever made a fortune for any of his clients, but he served them well, distributing their money across a range of investments that produced a steady capital growth together with a moderate income. There had been occasions when some of his peers murmured that Harry was not bringing in much new business, but his uncle always assuaged their grumbles by saying that Harry had a gentlemanly style of approach which was very gratifying to many of their elderly and more traditional clients, “… and that is where the wealth of this country still lies”, he would say with an air of authority that was not to be disputed. For almost twenty years, Harry found shelter from the harsh realities of business in the contemporary world. Then his uncle died. A new chairman was appointed from outside the firm, and the organization was swept with a new broom. Each partner had to bring in a minimum amount of new business each year. Harry no longer met a comforting smile from his uncle, only an abrupt scowl from the efficient new chairman.

 

7. Transference

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This chapter is based on three papers, respectively entitled: “The Erotic Transference and Boundaries”, “The Negative Transference”, and “Countertransference”. They are here combined under the one general heading.

Interpreting the transference is the single factor that most clearly differentiates psychotherapy that has been derived from psychoanalysis from other therapies. One would expect, therefore, that this would be clearly understood by all psychotherapists and also that it would be at the very centre of any psychotherapist’s education, yet I think that it usually falls into second place. It is also not well understood—at least, it is not understood emotionally. At the most simple level, the transference constitutes those feelings that the patient has towards his psychotherapist. It is difficult to talk about the feelings that one person has towards you. Nearly all conversations that we conduct in our social lives avoid this particular area of expression. To get at why it is awkward and difficult is not quite so easy, but some understanding of it may come as we proceed. Let it remain as a fact that it is something that is exceedingly difficult for us emotionally, and for this reason the psychotherapist as well as the patient will try to avoid it.

 

8. Modes of cure in psychotherapy

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In the world of psychodynamic psychotherapy, there are many different schools of practice, and among these schools are competing theories and values, each with their passionate disciples. I believe that, from all of them, two theories can be distilled that concern what it is that cures a patient of his psychological illness. These two theories I will call “Cure through Understanding” and “Cure through Knowledge”.

The patient who comes to the psychotherapist is in distress and it is the task of the psychotherapist to understand the patient’s inner difficulties. What follows is an account of a man who came to me for treatment and my attempts at understanding him.

Understanding the patient

Stuart was in his mid-40s and, although a man of many talents, had never persevered sufficiently with any of them to have capitalized on his undoubted capabilities. He was therefore only moderately successful, with a foot in several camps. He was the kind of man who is very entertaining at parties; he also had a marriage that was crumbling. Stuart had a younger brother, Tony, who had contracted polio as a baby and had been left severely paralysed. When they were children, their mother devoted her attentions to Tony, and, to make things as easy as possible for her, Stuart had felt obliged to present himself as someone who never had any problems. As he did well at school and made many friends, all seemed well. “Stuart’s always all right,” was the catchword at home. He also presented himself to me as being someone with few worries.

 

9. The seductive psychotherapist

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I once came across the following situation. Let us call the psychotherapist, Joseph, the patient, Patrick, and the patient’s wife, Virginia.

Joseph had a reputation for being a kind and empathic psychotherapist. Patrick went to see him because he was suffering from severe obsessional symptoms. He had a fear of going blind which frequently reached panic proportions. In the initial interview, Joseph learned that Patrick was a librarian and was happily married with three children. In fact, his family seemed to be the happiest aspect of his life.

I will outline what began to take place, without going into the full details of this therapy. Patrick began to drop hints that he was not as happy with Virginia as he had made out in his initial interview. For instance, he let it drop that, when he came home at night from work, Virginia did not cook him a meal; that once, when they had planned to go out with the children and he arrived home a little late, Virginia had not waited for him but had just driven off; that when he got home and went to the fridge to get the beer that he was looking forward to, Virginia had already given it to a friend of hers. In addition to this, he began to hint that Virginia had homosexual leanings and wanted to spend more time with her friend, Fiona, than with himself. Every time that Patrick dropped one of these hints, Joseph was quickly on to it and got him to express the angry feelings he had towards his wife. Each time this happened, Joseph felt pleased that he was beginning to get Patrick to express his hostile feelings towards his wife. A situation developed where the marriage became more and more turbulent, and it also seemed that Virginia was spending more and more time with Fiona. As things worsened, Patrick’s distress deepened to the point that Joseph felt that it was necessary to give him more substantial support. He suggested that Patrick take a firmer line with Virginia, and he increased Patrick’s sessions from twice to three times a week. Eighteen months later, the marriage had broken up. Virginia had left to pursue her affair with Fiona, and an acrimonious legal case, which ended in divorce, soon followed.

 

10. Mimesis in narcissistic patients

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In this chapter, I intend to study one mode of action which is characteristic of narcissistic patients. I have called this mode of action mimesis. Natural historians use the term to describe the way in which one animal copies another; art historians use it to describe ornament that mimics materials or forms of a previous age. In both cases, although the essence of the two substances is different, the secondary qualities are similar. The purpose of the mimicry is deception—the Asilid fly mimics the bee in an attempt to avoid its predators; the laminex tabletop in a canteen displays the grain lines of wood, so diners feel they are eating fine food while seated at a wooden table.

The mode of investigation

The transference is the instrument that a psychoanalyst uses to investigate the inner structure of the personality. The transference means the emotional structure of relating that the patient adopts towards the analyst, and it is the instrument that the analyst uses to research the inner structure of the personality. Such usage only makes sense if we claim that the structure of the relationship between patient and analyst reflects a relationship between different parts of the self in the inner world.

 

11. Narcissism

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This chapter is based on two papers, entitled “Narcissism and Feelings” and “Narcissistic Patients, The Problems for a Psychotherapy Unit”. Each paper examined different aspects of narcissism, so the text of each has been retained in order to develop these aspects fully. There is inevitably some overlap and repetition of material between sections, and some material repeats text written earlier in this book.

Narcissism and feelings

It is possible for me to feel better for several different reasons. I may be very distressed because a close friend of mine has died, but if another friend takes me out to dinner, or I go out on a boat on the Harbour when it is bathed in perfect sunlight, I may feel better. A sympathetic friend may talk to me, and I will be able to speak to him about the circumstances that led up to my friend’s death. On the other hand, I may feel dejected, not because a friend has died, but, for no reason that I can identify, I might just feel down. If this state of affairs goes on for some time and I cannot discover in any way what the reason for it is, I may decide to approach a psychiatrist.

 

12. An analysis of greed

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Looking harassed, Mummy bustled into the kitchen. The three children were lolling around waiting for her. It was tea-time.

She opened the biscuit tin. “Heavens,” she cried, “where have they all gone?” and looked accusingly at Tom, Mary, and Jane. Tom rushed over, looked in, and exclaimed, “There are heaps there still”. “It was full when I left. Where have they all gone, where have they all gone?”, his mother wailed.

Greed inhibiting the therapeutic process

For four years, I had been conducting the analysis of a woman I shall call Mary. She was a left-wing sociologist living in Brixton, a suburb of London south of the Thames, and she came to see me in Hampstead.

She was very poor and had scraped together the fees to see me by approaching a variety of people she knew who had done very well in their professions. Mary hated the fact that they (and this included me) were capable of earning their own living, whereas she was not. In this, I saw the dragon of envy and made interpretations about it, but they had no substantial effect. Her life structure did improve, however, and she reached a stage where she could pay my fees out of her earnings. She asserted herself more and allowed herself to be exploited less. She got a couple of lectureships, the responsibilities of which she handled extremely well, although she went through an inner torture over the delivery of the lectures. Her emotional life, however, was empty.

 

13. The origins of rage and aggression

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It is a mistake to think that psychoanalysis has one theory. Psychoanalysis is a clinical methodology that encompasses a wide range of theories, and nowhere is this more evident than when psychoanalysts start to discuss the cause of aggression. At its most simple, there are two theories.

The first states that aggression arises when a human being’s basic needs are frustrated. This theory is based upon the homeo-static theory of motivation, which states that the organism has a built-in tendency to equilibrium, to homeostasis—that when inner tension arises, the organism is programmed to reduce that tension through incorporating food or water or finding an object that will satisfy a sexual need. Aggression arises when one of these needs is frustrated; aggression is therefore a reaction to frustration. The second theory states that aggression is a basic instinct in man. In summary, then, those who support the second theory say that man is a savage creature by nature, whereas those who support the first theory believe that man is essentially benign and only becomes savage when frustrated of his basic biological needs. I believe that both theories are wrong.

 

14. The autonomy of the self

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This chapter is based on two papers written in response to Brian Muir’s “The Enigma of the Self” (1993), which is a critique of Kohut. I have expanded various points that Brian made and taken them forward in my own way, so hopefully the reader need not have read his original paper to understand my arguments.

It is possible for me to be so engrossed in myself that another person is only perceived to the extent to which he impinges upon me. With such an orientation of mind, I shall try very hard to avoid any such impingements. However, there are a lot of human beings around, and, try as I might, it is difficult to avoid them. As Fairbairn pointed out, I find—much to my annoyance—that there is something in me that drives me towards human beings.

When I was a baby I was driven, faute de mieux, towards a breast. It was an unwelcome discovery when two eyes appeared behind that breast. “What”, I cried and bawled. “That breast is mine, it belongs to me, it has no right to attach itself to those two eyes.” So I put in a complaint to the Babies’ Rights Commission.

 

15. A question of conscience

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This chapter is based on two papers, “Conscience and the Superego” and “Conscience and the Good”, in which I examine that part of a person’s inner emotional agency that we call conscience and its integration in the personality.

I begin with a simple statement. It is this: that when a patient follows his conscience, his ego is strengthened. It was very surprising for me when I realized that. It was an unexpected discovery, and yet I think it is an ancient truth, a truth that predates psychoanalysis by more than a couple of millennia. This truth was stated with stark clarity by Plato in The Gorgias. I need now to explore and go a bit more deeply into what I mean when I say that the patient decides to follow his own conscience.

When I say that a patient follows his own conscience, I am talking about a particular action in his inner emotional life that has external repercussions on those people with whom he is emotionally engaged. The kind of action I am talking about is a psychic action. I need now to give you an example.

 

16. Psychotherapy and religion

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I believe that the psychotherapy movement is experiencing a period of severe crisis, a crisis that is similar to and with the same roots as the crisis that is evident in organized religion throughout the Western world. I wish therefore in this chapter to start by presenting the view that the contemporary psychotherapy movement (i.e. the movement that has developed since the days of Freud) developed as a reaction to the dominant attitudes within organized religion. From there I want to go on to examine what I call traditional religion and its categories. I then go on a brief excursus into the symbolic nature of the sexual and, from there, to an examination of conscience and its formative role in mental health. This leads naturally to an examination of the great religious teachers as illuminators of conscience, and then to my view that the crisis in the psychotherapy movement lies in the philosophical nominalism that underpins it. I shall end by trying to adumbrate the hazy outline of a solution—a solution that lies in the development of a concept of the Good within the sphere of human intimacy. I should add that the reader may notice certain similarities between this chapter and the previous one in viewpoints argued and concepts presented. However, the excision of such overlap in either chapter would have resulted in a dilution of what I am trying to say.

 

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