‘On Learning From The Patient’ details a variety of techniques developed by psychoanalyst Patrick Casement to increase sensitivity to conscious and unconscious client communication in therapy. Casement is critical of too rapidly seeking to interpret client discourse, and elaborates (with clinical examples) methods of simulating client subjectivity. Therapists can use these methods to avoid too readily calcifying their understanding of a particular case, through overly rigid adherence to theory and technique. Casement argues for a tenuous theorising, rooting understanding in the experience and interpretation of the client, rather than in an analyst’s previous case experience or theoretical orientation. As Casement points out, transference is a two way process, with the client as likely as the therapist to receive and respond to unconsciously expressed expectations and judgements. Thus he recommends an ongoing awareness of the uncertainty of interpretation, and a negotiation of understanding with the client as the process of analysis continues. Casement seeks to move psychoanalysis from hierarchical interpretation towards negotiated understanding; altering its ‘way of intervening’ (Cheston, 2000), while retaining its way of ‘way of knowing’ (object relations theory), and ‘way of being’ (relatively impersonal relationship).

Casement usefully outlines a number of mental tools for the psychotherapist.

Internal Supervision begins as an interojection of the insights and criticism provided by the analysts own clinical supervisor during psychoanalytic training. Internal supervision manifests as an ability to step back from feelings and even insights in a session, and examine multiple possible understandings.

Unfocused Listening allows the analyst to examine the processes revealed by the generalities  rather than the specifics of a client’s talk (for example unconscious symmetry), and to ponder a variety of potential interpretations before intervening: A way of both being in and observing the therapeutic conversation, simultaneously.

Interactive communication includes a variety of techniques for assessing the client’s state without direct communication, such through an awareness of the dynamics of countertransference, projective identification and through non-verbal processes.

Trial Identification is the ability (developed through the analysts own analysis) to identify with the client (or others in their lives), and to use this selective identification to preview and review interventions, or simply understand the clients perspective (in the session, or in their outside relationships).

As a reminder of the power inequalities inherent in dyadic psychotherapy, On Learning From The Patient is valuable. By repeatedly providing examples of therapy being derailed by interpreting too readily or didactically, Casement reminds psychotherapists to listen to their client’s reactions; to remain constantly wary of slipping into established roles that mirror a client’s (or the therapists own) past experience, a “countertransference response to the familiar”.

The tools Casement has developed are breaks on the wheels of interpretation, ways of outthinking our natural tendency to predict, or to assume understanding. Casement’s text is full of small but brilliant insights – for example that clients unconsciously use their therapists own unresolved issues, “countertransference resonance” (concordant or egosyntonic material) as a tool to communicate, and their therapist’s mistakes as tools to engage in (potentially constructive) recapitulation. On Learning From The Patient includes many detailed examples of how transference, projection and countertransference play out in theory and practice.

The cases outlined provide concrete exemplars for Casement’s theoretical approach, demonstrating the results of his own failures to understand client communication, as steps on the pathway to developing inner resources of understanding and “not knowing”. These cases are as important in demonstrating ‘what not to do’, as in pointing out useful analytic techniques.

However the book’s underlying assumptions – that a therapist should never provide solutions, that “reassurance never reassures” since “corrective emotional experience” leads to a “false self”, the curative role of lengthy recapitulation / catharsis of trauma etc – remain those elements specific to (and often criticised in) psychoanalysis.

Of particular importance in psychoanalytic psychotherapy is the analyst’s assessment of countertransference; and their ability to divine the difference between neurotic (illusory) and diagnostic (somatically or empathically introjected) unconscious communication (Jacoby, 1984). Casement’s tools could be employed as ways of understanding how elements of a therapists own emotional response to a client resulting from unresolved identification, projection, prejudices or misapplied experience (or indeed or ‘indirect countertransference’ from supervision or elsewhere).

In common with other practitioners from RJ Lang to Oliver Sacks, Casement advocates a meaningful examination of what at first seems unintentional, irrational or even nonsensical client communication. He advocates remaining open to the metaphorical, “primary process” communication of client experience.

Casement’s definition of ‘mutative interpretation’, provides a prototype for genuinely reflective, timely, and transformative interpretations.

Casement’s articulation of the psychotherapeutic relationship as one of holding, is appealing. All therapists should aspire to provide the level of loving, non-directive containment (in Klienian term’s ‘reverie’) he models: A way of supporting and empathising without colluding; of keeping client’s focused on their experience without compulsion, and of receiving and transforming a clients suffering, without rejection. Casement demonstrates a healthy model for client therapist interaction, and a series of techniques which may help us remain sensitive and receptive in the face of clients suffering, projection and testing.

Although Casement emphasises humility in client interpretation, his case examples still demonstrate a pursuit of interpretation that non-psychoanalytic therapists might find troubling. Research into eyewitness testimony (Loftus, 1996) has demonstrated the liability of memory and interpretation, and even subtle cues from a practitioner have been shown condition and elicit trained responses from a client (Kanter, Kohlenberg, Loftus, 2002). Integrating research like this into the process of negotiating interpretation with the client, could mollify the (even in Casement’s modified form) prescriptive nature of analytic interpretation.

Similarly, Casement reaches or references many useful understandings, but fails to tie these into the broader background of contemporary research. One example is the ‘interactional viewpoint’, that client discourse responds to consciously and unconsciously communicated therapist expectations (Casement, 1995, pp 56). Such ‘Demand Characteristics’ (Whitehouse, Orne, Dingles, 2002) are an important area of research within experimental psychology as a whole. Neglecting this research allows Casement to erroneously assume that a single ‘real’ lived experience exists to be uncovered (if an analyst can be sufficiently open to the origins of conjecture, respectful of client individuality, and open to learning); rather than countless emergent performative identities (or client / patient social scripts).

In conceptualising identity as a truth to be carefully protected, rather than an experience to be negotiated through the theatrical encounter of the session, Casement leaves untapped a well of potential solutions to the problem of the intersubjectivity of the analytic discourse; tools for the evaluation of countertransference material – for example research into the processes of modelling in social learning (Anderson & Berk, 1998), or ‘reactance’ as a model of resistance from motivational interviewing (Miller & Rollnick, 1991).

Casement (citing Bion) advocates entering each new session absent the “desire” (to cure), the “memory” (of previous sessions) and “understanding” (of theory). While we can assume he doesn’t mean to suggest that such selective knowing is literally possible, he does seem unaware of the extent to which implicit biases and heuristics pre-consciously configure our understanding (Gigerenzer & Todd, 2000). Applying research from behavioural economics / thinking, judgement and decision making could help to develop techniques which more explicitly monitor (and exploit) the nature of such universal cognitive foibles.

Casement’s emphasis on client subjectivity mirrors the concept in Person Centred Counselling that the client is the expert on their own life (Bott, 2001). In fact, Casement’s approach (with its belief in an intrinsic drive towards growth, it’s emphasis on learning from the client and a client directed therapeutic process, and its sensitivity to accurately reflecting client communication) could be broadly characterised as person centred psychoanalysis, yet frustratingly this link is never explicitly made; leaving another perspective on the intersubjectivity of the therapeutic alliance unexamined.

Finally, the concept of the internal supervisor relies on a supervision process that is relatively undeveloped in Casement’s ‘phases’. Others have articulated more sophisticated models of the development and internalisation of understanding in supervision (Page & Wosket, 1994), and building on this work might have helped deepen the conceptual and technical aspects of ‘internal supervision’.

Perhaps unnecessary is the books early emphasis on geometric metaphors (taken from the work of Matte Blanco). Although these tools are conceptually illuminating, they connect only tenuously with the theory and praxis Casement employs. They may serve to discourage the casual reader, and perhaps offer a pseudo-scientific veneer that adds little to the elucidation of Casement’s ideas.

While some of Casement’s client treatments seem nothing short of miraculous (particularly his successes with a seductive obese client, and with a catatonic psychotic client), I was troubled by a number of moments during the book’s case histories, where he appeared to significantly neglect client welfare.

In one case Casement repeatedly interprets a client’s communication as referencing her desire to end therapy (he believes prematurely), after “only six months”. Casement never explicitly questions whether he is serving his own need (to retain his client) rather than his clients “flight into health” (Casement, 1995, pp 40). These exchanges seem (to my ‘trial identification’ of Casement’s client), circular and persecutory.

A more worrying example of client welfare in jeopardy is the case of a woman who had experienced severe scalding and surgery as a child. This client explicitly requested Casement hold her hand as she re-experienced the trauma of her childhood surgery, and he ultimately refused – not wanting to take on the role of the “good mother”, for theoretical reasons; despite the client losing trust in him and approaching psychosis. Although Casement relates a successful outcome to the case, this seems an inordinate risk and rejection, solely on the basis of (Winnicottian) theory. Had the client abandoned treatment, she would have been left defenceless against this reopened (or reconstructed) wound. Indeed this kind of intensive recapitulation can potentially lead to retraumatisation (Faris & van Ooijen, 2012); as well as the creation of real seeming, though wholly artificial memories (Ofshe & Watters, 1996). Casement’s approach to the case demonstrates a worrying absence of healthy, safe containment (extending far beyond his avowed mistake in initially offering to hold the clients hand).

Casement provides a convincing argument for a less certain, more humble psychoanalysis. Although his clinical experiences are largely unsupported by reference to research, they are never the less convincing articulations of his techniques. Tools like internal supervision, trial identification and unfocused listening serve as concrete means of working against our innate tendencies to judge, to behave according to imposed patterns and to impose our understanding. Casement reminds therapists of the two way nature of transference – clients can respond not only to their own projections, but to their therapist’s projective material and inaccurate interpretations. On Learning From The Patient seeks to open us to client communication, to dissolve certainty, to acknowledge and learn from our mistakes, and to make us aware of our own contribution to the dyadic congress of the session. If we can absorb its techniques and humility perhaps we can become more capable containers and advocates of the client’s truth.

 

 

References

Andersen, S. M. & Berk., M. (1998). The social-cognitive model of transference: Experiencing past relationships in the present. Current Directions in Psychological Science, 7(4), pp 109-115.

Bott, D. (2001). Client Centred Therapy and Family Therapy: A Review and Commentary. Journal of Family Therapy. vol 23, pp 361-377.

Casement, P. (1995). On Learning From the Patient. UK: Routledge.

Cheston, S.E. (2000). A New Paradigm for Teaching Counseling Theory and Practice. In: Counselor Education and Supervision. Vol: 39. 4.

Faris, A., van Ooijen, E. (2012). Integrative Counselling and Psychotherapy. A Relational Approach. UK: Sage.

Gigerenzer, G., Todd, P.M. (2000). Simple Heuristics That Make Us Smart. USA: ABC Research Group

Kanter, Kohlberg & Loftus (2002). Demand characteristics, treatment rationales, and cognitive therapy for depression. Prevention & Treatment, Vol 5(1).

Loftus, E. (1996) Eyewitness Testimony. USA: Harvard University Press.

Mario Jacoby (1984) The Analytic Encounter: Transference and Human Relationship. USA: Inner City Books.

Miller, W.R. & Rollnick, S. (1991) Motivational Interviewing: Preparing People to Change Addictive Behavior. USA: Guilford Press.

Ofshe, R., Watters, E. (1996) Making Monsters: False Memories, Psychotherapy and Sexual Hysteria. USA: University of California Press.

Page, S. Wosket, V. (1994) Supervising The Counsellor: A Cyclical Model. UK: Psychology Press.

Whitehouse, W.G., Orne, E.C., Dingles, D.F. (2002) Demand Characteristics: Towards an understanding of their meaning and application in clinical practice. Prevention & Treatment, Vol 5(1).

Pychoanalysis privileges the intrapersonal (and even the transpersonal) at the expense of the interpersonal. D.W. Winnicott wrote that ”There is no society except as a structure brought about…by individuals”, a philosophy later mirrored by Margaret Thatcher in her infamous proclamation, “…there is no such thing as society. There are individual men and women, and there are families.”

In object relations, there is no material connection between human psyches – only a kind of modelling, continually confirmed or conflicted by reality. Recent research suggests a deeper interrelation, demonstrating inter-brain sychronisation during social interaction.

The significance of the developmental triad in the work of Klein and Winnicott, excludes not only the innate developmental factors we now know to be significant in the formation of personality – genes, epigenetic heritable changes in protein synthesis, intrauterine environment, exposure to cognitive stimulation in early life etc) but also the social factors examined by social psychologists like Albert Bandura: Those aspects of personal development that rely not only on the context of the immediate family, but wider community, society, culture, subculture, religion etc.

Daniel Costigan once said ‘demand characteristics collapse the wave function of personality’. The developmental theory adhered to (whether it be Winnicott’s emphasis on the literal transitional object as a totemic referent for the development of individuation, or Klien and Bion’s emphasis on the breast as container for emotional and symbolic development), delimits the expression and formation of the client in therapy (and the therapist in training).

Robert Anton Wilson called such perspectives ‘reality tunnels’, specific matrices of belief and salience which attend to some stimuli at the exclusion of others. All perspectives or models are reality tunnels, necessitating a delimited collection of information in order to avoid the ‘map as big as the territory’ described in Borge’s beautiful story ‘On Exactitude in Science’.

In that Empire, the Art of Cartography attained such Perfection that the map of a single Province occupied the entirety of a City, and the map of the Empire, the entirety of a Province. In time, those Unconscionable Maps no longer satisfied, and the Cartographers Guilds struck a Map of the Empire whose size was that of the Empire, and which coincided point for point with it. The following Generations, who were not so fond of the Study of Cartography as their Forebears had been, saw that that vast Map was Useless, and not without some Pitilessness was it, that they delivered it up to the Inclemencies of Sun and Winters. In the Deserts of the West, still today, there are Tattered Ruins of that Map, inhabited by Animals and Beggars; in all the Land there is no other Relic of the Disciplines of Geography.

Jorge Luis Borges, Collected Fictions, Translated by Andrew Hurley Copyright Penguin 1999

It seems almost certain that Borge’s story was influenced by the writings of Alfred Korzybski, who famously remarked, “The map is not the territory”. Korzybski, whose work prefigured that of post-structuralists like Foucault, Lacan and Jean Baudrillard, was the founder of General Semantics. General semantics attempted to develop methodologies for making explicit the ways in which language and discourse shapes how we think. Korzybski influenced Robert Anton Wilson, and the beat iconoclast William S. Burroughs studied his theories. Korbinski’s goal of abstracting consciousness to remove the power of reactive thought / emotion is embodied in contemporary cognitive and behavioural therapies. For example in the diffusion techniques that are a central part of Acceptance and Commitment Therapy. Ironically, as with so many techniques of liberation, Korzybski’s work has been subverted to obtain goals diametrically opposed to those of it’s creator.

Psychoanalysic theories of personality which account for later / higher emotional development that provided for in the oscillating dynamics of paranoid schizoid / depressive positions as outlined by Klein, have an inevitable appeal. One such model was cooked up by the transpersonal psychoanalyst Stanislav Grof, who in attempting to build a non-ethnocentric, cogno-centric psychology, situated both a diathesis for psychological distress and a foundation for higher states of awareness / unity in birth trauma and interuterine distress. Expanding on Otto Rank‘s ideas, Grof termed these experiences perinatal matricies. While his model is certainly speculative and pseudoscientific – such labels are equally applicable to both transitional phenomena and ‘the breast’ in object relations. Grof’s insight into pre-birth trauma and its impact on functioning comes from analysis of the shamanistic, meditative and psychedelic experience. His perinatal matricies 1 – 4, represent these experiences as related to the ‘consecutive stages of biological birth’ as follows (articulated in his book ‘The Transpersonal Visions).

1: Gestation – related to experiences of physical connection with the mother (which serve as prototypic attachment), ‘oceanic’ and ‘cosmic identifications’, in other words a continuity with the universe (as might be experienced at higher levels of Daoist or Hindu meditative practice); chemical disruption of this stage of development, is experienced as a threat to life. Severe disruption of this first stage of development is in Gofman’s system associated with deep emotional identifications of the hellish or heavenily.

2 – The contraction of the uterus – associated with the pain and electrochemical stimulation of the birthing – results in inevitable trauma. Traumatic contractions result in trauma that will manifest later as aggressive, submissive and helpless patterns of relating. This is linked with later depression and inferiority as well as compulsive and addictive behaviour and even psychosis (if deepened with later childhood trauma). They are also associated with clean / unclean splitting and fixations, e.g.: OCD.

3 – The birth canal – pressures and electrical discharges – resulting in foetal anxiety, pain and potential suffocation trauma – if unmitigated by strong parental or substitutive containment experiences, this can result in neuroticism and persecutory religiosity.  This is related to sadistic, masochistic and aggressive sexual and scatological ‘deviations’ and positions.

4 – Early natal (Death / rebirth) – new stimuli both comforting and distressing – excessive imposition of environment can result in later feelings of failure. The end of one existence (an aquatic, comforting and constricted one), is replaced with another (with more intense sensory experiences and individuation). Adequate early natal comfort emphasises feelings of connection to nature and aliveness and divine redemption. Painful early natal experiences (rooted in illness, cutting of the chord or circumcision for example) can result in later somatic problems (e.g.: autoimmune disorders).

These matricies imply a treatment model which addresses primitive traumatic experiences and allows for ‘non-ordinary’ states of consciousness (e.g.: experiences of the transpersonal and transcendental, communicative psychosis etc). They also provide a more coherent explanation of what Freud described as thanatos, a severely maladaptive drive toward destruction or death.

Grof also outlined a matrix of transpersonal experience of transcendence of self (collective and extra-collective consciousness and identification), of time, and the experience of the mythological realm. This later experience relates to Hindu and Daoist ideas of collective divinity (atma-brahmin).

Grofs model is certainly outre, but it demonstrates how arbitrarily fixated psychoanalysis has always been on the period of early infancy and its supposed phenomenological content. Real development occurs on a continuum from conception to death, and there is no reason to assume unconscious processes begin at birth, and solidify in latency. The problem of course is, as with all ‘depth psychology’, no theory can hold a greater claim to hermeneutic validity than any other. The very best we can hope for, as practitioners or supplicants of psychotherapy, is to find a model that describes and enables us.

‘Hello, my name is Gareth, and I’m a graduate.’ I picture myself staring down at a little red and white name tag, unable to meet the eyes of the others – the failures, the graduates. ‘It’s been…’ I pause, I can’t say it out loud, ‘Go on,’ someone tells me gently, patting my arm. ‘… three years since my last graduation, but I think about returning every day. Even though I know it won’t go anywhere, even though…’ My voice cracks up, I cover my mouth with a shaking hand. I shouldn’t be ashamed, but I am. Everyone here understands.

I left school in 1999, right as the dot com bubble burst. Like many of my class mates, I coasted in the dead zone of early naughties minimum wage work. I made sandwiches  built websites, phoned farmers to question them on behalf of some wax faced European bureaucracy. I did courses, oh did I do courses. I dropped out of great courses in video game design, computer programming, and even an open university arts degree. I fumbled my way through a worthless FAS course in web design.

Finally, I scrambled onto the good ship education, finding a berth on the lower deck of a pre-college social studies course in NCI (don’t look for it, the ladder fell away behind me), attending Trinity as a mature student as soon as they’d have me. I was twenty three. Finally! Finally I could pursue my lifelong dream, I would unscramble the mental mysteries, I would become a soul surgeon, a thought tinkerer, I would become a psychologist.

College stretched for five years (four year degree, including a year out when a bad relationship kicked me into a funk). It was wonderful. I helped run a radio station, start a music magazine, and co-created Ireland’s first internet TV show. Then I graduated, right as the great recession hit, in 2009. Two strikes. I now had a first class honors degree, but no money for a masters (which might possibly get me into a doctoral program, but almost certainly wouldn’t get me a job in my field). What to do?

Since I couldn’t continue my studies I decided to pursue writing, because that’s just the kind of practical person I am. This quickly turned into performing standup comedy, making weird video things and producing radio programmes. The standup was eye opening – when it goes right, standing on stage in command of an audience is like mainlining love from a talent syringe. But try as I might, I couldn’t make it pay – nor could I afford to do the one thing that would give me a chance of progressing in it, an Edinburgh show. My own gig ‘Marshmallow Ladyboy Jesus’ pulled in a regular audience – but it wasn’t getting me any closer to being able to pay for luxuries, like pants. During this time I became involved in ‘the arts’ helping to run the collective arts centre Exchange Dublin, Open Learning Ireland and a number of other unpaid bits and bobs. So 2011 hits and I start to freak out a little. How am I to eat in this brave new future of massive social inequality and Europe wide austerity? Money isn’t important to me – eventually escaping Ireland is. So I tangentially peruse my degree, starting a two year diploma in psychotherapy (beginning, borrowing, stealing the substantial fees – which are still much less than a masters). This course will qualify me for an income. An income! An income which I can eventually use to pay for a masters, to get onto a PHD or D.Clin Psych, and perhaps some day, I think naively, around 2019 I can begin my productive working life.

Hah! Turns out the course I’ve selected is far from ideal – it’s two years part time (rather than three, as is the norm), which may lead to all sorts of certification problems down the road as psychotherapy becomes better regulated. It’s also in a quirky no-mans land of pseudo-science, lacking even the respectable intellectual veneer of psychoanalysis. Most importantly, its graduates don’t seem to be finding clients. So I change courses, switching to another faculty that has a three year (oh wait, no I later discover, a four year) diploma course. Meanwhile I finally get a radio show funded (hallelujah!), and consequently have to sign off the dole and onto a back to work enterprise scheme. Now I have a hard deadline for not being able to afford luxuries like fancy haircuts and medical bills. About six months remain. Fingers crossed, I await my next radio funding application – if I get it, and it’s by no means assured, my income for next year could possibly be as high as nine or ten grand, before tax.

I finish my sob story and finally look up. The other faces are blank, hopeless. One or two are teary. Some of them have jobs – in call centres, accounting firms, in the blood sanded arenas of marketing and sales. They’re the worst off, their eyes have that already dead look you see in cattle being funneled to slaughter. One or two are grinning slightly, they’re younger, more hopeful, they’re on springboard courses in ICT or biotechnology, they’re sure this won’t happen to them.

I’m two years into a four year diploma in psychotherapy; which will eventually allow me to work (maybe even for money, depending on when they bring in regulations, and whether I get grandfathered, and I never did get on with him). It won’t allow me to travel – since the qualifications don’t. There may be a possibility of doing a distance masters after this course (which would only be an additional two or three years, finishing around 2018). I’ll be thirty eight.

Options? Now that I’m building client hours, I could apply to a D.Clin Psych programme in Ireland – but they generally require research experience and a year of unpaid work for a clinical psychologist (a highly sought after form of middle class servitude). Even if I was lucky enough to get on one, D.Clin courses are generally four years (although they are paid). Not an option is a clinical psychology doctorate (three years, which you pay for – no funding available). That leaves a research / applied psychology masters (which could possibly, maybe, get me into a doctorate), but which again, I can’t afford. Yikes. How do I escape Ireland? How do I begin to earn a living wage if I stay? How do I overcome the gravity well of arts graduate unemployment. Rock, meet hard place.

Playing and Reality (Winnicott, 1971) represents a compendium of papers published during Donald Winnicott’s career as a paediatrician and psychoanalyst.  The book offers an overview of Winnicott’s theories relating to the development and use of the internalised evaluations of ourselves that lie at the heart of the object relations approach. These essays outline the role developing internal objects (initially internalised representations of physiological aspects of caregivers, later obtaining affective and thinking aspects) play in child and adolescent development, and how they relate to the concept of play – both as a way of exploring the external universe, and a means of counterfactually denying the failure of omnipotence.

Each chapter outlines or elaborates on a specific element of Winnicott’s thinking. Chapter 1 explains the use of a symbolic transitional (substitute mother / breast) object (a favourite blanket or the like) as a midway point between infantile omnipotent egocentrism and individuation / instrumentalism (and later empathic relation with others). Thus Winnicott seeks to outline an area of experience / fantasy linking interpersonal reality with intrapersonal reality – a point where a persistent relationship develops with a physical object (linked to direct oral-erotic stimulation), which provides the possibility for real relationships with individuals and with society. Winnicott sees this transitional object (TO) as the first visible instance of symbolic (representative) reasoning (literally the transformation of an internal object into the illusory need fulfilling aspects of an external one) and thus key to a variety of intellectual developments; as well understanding later developmental problems.

Although Winnicott’s approach has psychodynamic theory at its heart, the object relations system that he (in common with Melanie Klien) pioneered gives rise to a radically altered conception of interpersonal relationships as key to the development of the individual. Although the emphasis remains on early developmental experience – where Freud situated innate drives and universal conflicts at the heart of individuation, Winnicott puts the parent child relationship.

The concept of the ‘good-enough mother’ (Winnicott, 1971, pp13) has been an influential aspect of Winnicott’s thinking. In common with the idea of ‘graduated failure’, it represents an acknowledgement of the inevitability of imperfect parenting, while simultaneously emphasising the need anticipating role of the maternal relationship, and the frequent importance of ‘reparenting’ in psychodynamic therapy. This represents an entirely different way of thinking about the client – not so much as an individual to be helped to develop the capacity for insight through the analyst’s skilled interpretation, but as a person in need of (organic) ‘corrective emotional experiences’ (Summers, 1999, pp183), which will facilitate healthy ‘dethronement’ (Adler, 2006) through the ‘real relationship’ (Duqette, 1993) of the analytic encounter. Thus development is no longer exclusively the domain of infancy, the oedipal triad and the physiological progression of the stages of sexual development; but a lifelong process of adjusting to decentration, of engaging with others as necessary elements of our introjected developing selves.

Winnicott’s examples of the use of day-dreaming / ‘fantasying’ (Winnicott, 1971, pp28) provide a fascinating account of the neurotic’s defensive preoccupation with an imagined alternate life (a creative denial) ‘rigidly fixed in a defensive organisation’, blocking potential real behaviour and change. This behaviour is rooted in childhood separations (what we might think of today as attachment disorder), necessitating dramatic defensive re-working. Fantasying links in with Winnicott’s idea of the realm of ‘illusion’ as a defensive formation – but also a place of motivation and creation. However, Winnicott goes on to explore distinct degrees of delusion / dissociation and their symbolic significance. For him dissociative omnipotent ‘fantasying’ lacks the symbolic productive aspects of dreaming, and as such shares the obsessive imposed quality of compulsive thoughts in OCD. Winnicott sees such extreme disabling dissociations as caused by the failure of ‘scaffolding’ containment offered by the primary caregiver.

Winnicott’s conception of the play space of therapy, dovetails with Erving Goffman’s idea of the ‘script’ of the social encounter (Goffman, 1959). To Winnicott, all progress in the therapeutic encounter occurs in the liminal play space. He describes this playing as like the playing of children – unrelated to erotic stimulation. Playing is neither inside nor outside the individual – and therefore, like the transitional object and the ‘subjective object’, occurs at the intersection of self and other – a ‘potential space’.  In play, the child takes aspects of their internal fantasy life ‘dream material’ and projects them onto real world objects (toys etc) – in a creative symbolic manipulation of meaning.

Playing has positive outcomes – growth, group integration and communication. In fact to Winnicott, psychoanalysis is a form of play, and play is a form of psychotherapy.
Winnicott describes the diagnostic use of play observation in a variety of case studies – but it’s here that his tendency to interpret in line with theory, rather than the evidence of observation takes over. For example with the boy Edmund – who displays a stammer, difficulty with toilet training and insecure attachment, Winnicott takes his play with a piece of string as symbolising both his attachment and disconnection from his mother – ‘it was clear that the string was simultaneously a symbol of separateness and of union’ (Winnicott, 1971, pp58). This tendency to see patterns is useful, but when over applied approaches pareidolia. I’m not suggesting that children’s play is never symbolic, but rather than any play at all would lend itself to interpretation (and indeed to Winnicott, the process of play is essentially symbolic).

Winnicott describes unobserved play as communication with the self (the observing ego), but this is fallacious both because it presumes an understanding of infant phenomenology, and infant unawareness of being observed. We might postulate, if infants exist in this liminal space of subject-object enmeshment, do they not in a sense always assume themselves to be observed?  Winnicott’s need to validate play as therapeutic, in the context of object relations theory, fixes it in the hermeneutic structure of psychoanalysis.

Winnicott sees play as part of the process of individuation – an infant moves from ‘merged’ omnipotence towards objectivity (Freud’s reality principle), through the mothers ‘scaffolding’ (to apply Lev Vygotsky’s term), and later containment and processing of projected experience to allow the infant to re-introject. Eventually the ideas of others can enter into the play space, as autonomy develops making socialisation possible.

Winnicott saw unstructured playing as creative and therapeutic; moving away from the necessity of ‘indoctrinatory’ interpretation in his play sessions (Winnicott, 1971, pp63), to avoid creating reactance or inducing conformity.

For Winnicott, play occurs neither inside (subjective) nor outside (objective) – but in space of transitional phenomena, and initially in the transitional object – the first symbolic instrument and plaything. This object is a symbolic representation of the infant-mother union, and at the same time acknowledges their separation, tying an external symbol to a mental representation. It is an external object that requires the support of real maternal affection for its continued internal significance. Prolonged maternal absence destroys the meaningfulness of this object. This traumatisation results the development of defences against ‘unthinkable anxiety’, and a breakdown of ‘continuity of existence’ (Winnicott, 1971, 130) for the infant.

Culture is an expansion of this inter-subjective ‘potential space’ between self (inner reality, unconscious and dreams) and world (related to as a drive satisfying object), ‘continuity and contiguity’. Its appreciation, for Winnicott, requires a sound base of world reliability. This is significant because Winnicott sees life as not merely the absence of neurotic symptoms, but a real engagement with playful creation (of the external world through continued fantasy of object destruction).

The deprived child, with his impoverished capacity for play, displays an impoverished capacity for culture, a ‘compliant false self’ – this is the space of religious indoctrination, of Catholic guilt. As Dylan Moran jokes, ‘Catholics don’t need twitter, they have constant internal updates – you’re fatter than you were thirty seconds ago’. Thus, cultural appreciation is rooted in the final stage of infant separation; ‘Male’ individuation, accompanied by a provision of space by maternal object. This tentative moment requires both presence and a toleration of separation (both in childhood, and in the therapy room). Ultimately reliability / identification / love allow for freedom. Winnicott is particularly amusing about culture and the failure of caregivers to provide a proper and timely access to cultural heritage. ‘What… are we doing’, he asks ‘when we listen to a Beethoven symphony, or making pilgrimage to a picture gallery, or reading Troilus and Cressida in bed?’ Why, being middle class of course.

Winnicott argues that searches for ‘self’ in creative work are doomed to failure (Winnicott, 1971, pp73), since the discovery of self requires ‘non-purposive’ activity. In practice this exhibited in his therapy sessions with a tolerance for ambling digression, without imposed interpretation (primarily given in response to client request).  Withholding interpretation allowed clients own creative space to act (prefiguring Casement’s emphasis on ‘negative capability’, Casement, 1995). Winnicott advocates space for unstructured sessions, which allow crises to emerge, and clients to communicate by impact.

This can seem problematic to a modern reader – since Winnicott stretches sessions to fit client’s needs on request (often to several hours), and compensate for missed sessions: Both violations of boundaries that seem inviolable today. However the fluid space of Winnicott’s therapy room – full of toys and art supplies, where clients are free to roam around, draw or remain silent, is appealingly open and creative. Winnicott suggests that this unstructured approach, this space for creativity and ‘formless experience’, allows ‘unintegrated states’ to emerge, which through reflection by the therapist bring on the real work of the session (Winnicott, 1971, pp82) – the reintrojection of disowned parts of self.

Aspects of Winnicott’s chapter on ‘creativity and its origins’ were the parts of the book I found most compelling. Winnicott argues for the essentiality of ‘creative apperception’ to life, and the deathliness of ‘compliance’. For Winnicott, creativity is a universal faculty of life (not merely artistic creation) – a faculty which can be diminished (hidden) or damaged by illness or repression. To be creative is to retain the capacity to suffer – and it is those who are unable to sacrifice their own creativity who suffer most under tyranny. In common with Foucault, Winnicott claims that modernity made possible the individual (Foucault, 1995) – alienated from identification with community and nature. Creativity is embodied in ‘healthy looking’ and ‘deliberate doing’ – active engagement rather than passive participation in life. Thus Winnicott normalises and universalises ‘the creative impulse’, placing it at the heart of healthy life.

“Compliance carries with it a sense of futility for the individual and is associated with the idea that nothing matters and that life is not worth living”
Winnicott, 1971, pp87.

The Self Seers (Death and Man), Egon Schiele

Winnicott goes on to discuss the schizoid to whom, ‘reality remains to some extent a subjective phenomenon’. This is a state not sharply delineated from health – nor from schizophrenia, one in which a ‘fay’ individual is unable to fully connect with consensual reality. These individuals feel dissociated, detached from both the ‘real’ world, and the ‘dream’ symbolic universe.

To understand early breakdowns in creativity (in Bionian terms –K activity) – we need to examine both the individual and their early environment (primarily their parenting). Hence Winnicott offers a space for the social in psychoanalysis. Graduated failure (the good enough mother) makes possible the trauma of loss of omnipotence. Reliable environment is key, to trust that allows the creation of internal objects that match reality (‘subjective objects’).

Winnicott’s subsequent discussion of the bisexual (transsexual) nature of humans, and his identification of aspects of male and female is less productive; and includes outdated ideas like the centrality of anal sex to homosexuality (Winnicott, 1971, pp 105). Winnicott discusses the male and female aspects existing within people of either sex. He identifies how traumatised clients sometimes split off one of these two components of self – triggering for example a fixation on young girls in an effort to excite the immature disavowed female component of an older man. For Winnicott the ‘male’ component in both men and women is associated with drives, ego-separation, doing, and Freud’s ‘erotogenic’ stages, while the female component relates directly to the breast / mother and is responsible for the sense of ‘being’. A failure of maternal containment (the ‘good’ breast) at the omnipotent stage of infancy is thus responsible for envy and ‘lobsided’ gender development.

Winnicott distinguishes object relating from object use. Object relating alters the self, obeying the pleasuring principle (seeking on some level erotic excitement), using projection and identification to imbue another with meaning. This evolves into object use, obeying the reality principle, a shared reality / environment which allows interaction with the real world. To transfer from object relation to object use, the infant in the process of recognising their own lack of omnipotence must destroy the object (this is an illusory potential destruction). If the object survives the destructive impulse, love results (although the creative destruction persists, and must persist to allow an interface with the real). If the destruction is not contained (for example by the mother’s retaliation or withdrawal), then the developing individual can fail to proceed to a relationship with external / shared reality. This process occurs too in analysis, when clients engage in hostile transference – attempting on some level to destroy the analyst, who must persist to allow them to engage in object use. Although Winnicott humorously notes, ‘when the analyst knows that the patient carries a revolver, then, it seems to me, this work cannot be done’.

Thus we see the necessity of maintaining boundaries and reliability in psychotherapy, and of failing to be a perfect need satisfying object – in order to become a real one. Here Winnicott differs from Klien, since envy doesn’t begin until the object is external (used), and occurs later in development than the infant’s attempt at destruction. The film ‘We Need To Talk About Kevin’, depicts this failure of containment / mirroring by a schizoid mother and it’s horrific impact. For Winnicott, the maternal resistance of infant aggression teaches the infant that aggression is intolerable, and thus uncontainable.

Winnicott identifies the importance of identification in the maternal gaze (mirror). The complete absence of reflection (whether because of maternal defence or preoccupation) diminishes creativity, forcing the infant to replace apperception (of self) with perception (Winnicott, 1971, pp149).  The therapist’s role too is to return the patients glance, to see them ‘as they are’.

 Despite my reservations about the phenomenological claims of Winnecott and Klien alike, the attention they pay to the meaning symbolic objects and play have for children is worth replicating.

Winnicott’s focus on disabling dissociation is significant too – especially at a time when digital media provide a ubiquitous defensive utility, casually and socially acceptably employed on a near constant basis; while cultural individualisism precludes functional ‘dethronement’. Understanding how clients employ fantasy could help them to manifest more actively and rewardingly – although it is also likely to provoke extreme dissonance as they come to fully realise the extent of the disconnect between lived and imagined life. I felt a sense of strong recognition when Winnicott’s fantasying client described listening to talks rather than music, as a dissociative techniques (Winnicott, 1971, pp 43).

While I feel Winnicott at times goes too far in his interpretation of infant play – his ideas about the importance of unstructured creative play at the heart of the psychodynamic encounter are invaluable.

Winnicott’s emphasises delaying interpretation (paralleling Rogers, and prefiguring Casement) to encourage transference. Interpretation is useful to ‘let patients know the limits of my understanding’, rather than to provide the answer that will heal. Winnicott points out that interpretation can be defensive. Since his treatment approach is rooted in transference, he finds difficulty in treating client’s who can’t use cross identifications (introject / project); since they can’t transfer feelings held towards others or aspects of themselves onto the therapist.

Winnicott’s emphasis on a meaningful utility for depression is encouraging. For example with one adolescent client ‘Sarah’,  he views her depression as buried rage provoked by the threat of loss of a ‘good person’ in her life, mirroring the failure of her ‘good enough mother’ in infancy (her primary narcissistic wound). Here, testing to destruction of the object failed, setting up a pattern of testing in later relationships (e.g.: of her boyfriend).

Winnicott’s papers are a product of the time they were published, and as such contain a variety of social evaluations that are problematic today, from worries about potential homosexuality to evaluations of the ‘good family’ and the ‘backward girl’ (Winnicott, 1971, pp 26). It’s interesting to note that he describes a failure in the case of a boy who grew up to ‘waste his time’ and use recreational drugs. Given the date of this chapter’s initial publication (1969), it might be worth contextualising in the countercultural revolution of the time.

Winnicott references sessions extending beyond the traditional hour (Winnicott, 1971, pp 43), it would have been interesting to see more discussion / explanation for this.

Winnicott claims that fantasying and dreaming are distinct in that fantasying lacks a creative / symbolic component. This seems conjecture, rooted in Freudian theory (about the essentially symbolic work of the dream) rather than client experience. In his back and forth with his unnamed female fantasist, Winnicott’s interpretations arguably produce / shape the clients performance (as symbolic dreamer), rather than allowing her true experience to be expressed.

The mother looms large in Winnicott, it would be interesting to hear his theories applied to more modern families. For while he talks about the female aspect of men and the male aspect of women, and his breast is often allegorical, he does speak about the unique relationship between mother and infant in a way that seems to ignore alloparenting and exclude contemporary gay and mixed families.

 

Winnicott (like Freud), makes the claim that we never completely accept ‘objective’ reality – even in adulthood resorting to illusory experiences (like religion and art) to relieve the dissonance between reality and fantasy (desire) (Winnicott, 1971, pp18). This is a strong ontological claim – something that Alan Watt’s called the ‘fully automatic model’ (Watts, 1996, pp76). Here, reality is assumed to be a) objectively perceivable and b) essentially meaningless, with meaning being a kind of conciliatory illusion. Certainly meaning is subjective – but that is not to say that meaningless experience is any more real, more ‘true’. Indeed we can conceive of meaning (and meaning making) as a perceptive faculty, certainly one with adaptive utility, shaped by adaptive processes; what Herbert Simon called the blades in the scissors of ecological rationality (Gigerenzer, 2002). Meaning serves a variety of objectively useful purposes: without a comprehension of meaning, any theory of mind (contextualised assessment of another’s motivation) disappears. Meaning underlies volition, hedonia, existential purpose – so what is this objective reality, to which the deprivation of meaning would allow apperception? It is not the domain of the physical universe – which is merely ‘one damn thing after another’ without the meaning making construction of theoretical models. If this is the case, then it can be assumed that meaning / experience / ‘illusion’ is normally concordant with a valid interpretation of reality. Winnicott unconsciously evokes Simon’s ideas himself, when he talks about the ‘good enough environmental provision’ being essential to genetic expression (Winnicott, 1971, pp 187).

Winnicott makes strong claims about the importance of the transitional object – citing for example the lack of a ‘true’ transitional object / overlong breast feeding as the origin of significant attachment difficulties in later life (Winnicott, 1971, pp 9). However, the causal relationship he posits is never demonstrated conclusively in any of Winnicott’s ‘just so’ case studies. Since correlation is not equal to causation, we cannot be sure whether the lack of weaning described is symptomatic of an attachment disorder, nor whether its cause is the mother’s interpersonal difficulties, or some combination of (heritable dysfunction) in infant and maternal sociability or something else entirely. We cannot be certain whether the transitional disruption is cause or symptom (except in so far as it would fit Winnicott’s system for it to be causal).

The strong claim as to the importance of the literal transitional object lies at the heart of Winnicott’s description of the development of object relations, and yet it seems largely hypothetical – never subjected to empirical testing (at least in this volume).  At times he’s forced into mental gymnastics to squeeze observed infant behaviour into his model – differentiating the observation (that infants do in fact appear to relate to others, even in the ‘merged’ stage of development), from hypothesised internal ‘infant experience’ (Winnicott, 1971, pp175) – without demonstrating a source for his phenomenological presumption.

The need to describe all phenomena at the level of the individual becomes problematic and necessitates baroque theory – the separation of the ‘merging’ mechanism from later identification mechanisms for example, or the link between object use and the continual ‘destruction’ of an internal object. What’s missing here is some perspective on the utility of various levels of description, and an acknowledgment that many phenomena are only meaningful on a social level (e.g.: language, culture). This is most visible when Winnicott discusses his belief that societies healthy growth develops out of the collective actions of individually healthy members. Winnicott gives as an example, the possibility that racial tensions in the United States are rooted in bottle fed white envy of black breast feeding (Winnicott, 1971, pp192). The impact of culture and history in the shaping of group and inter-individual relations is erased. Even if we take the family as the only unit of social impact, we can see the influence of culture – for example of child rearing practices on infant attachment in Northern Germany (Grossman et al, 1985). Alas, Winnicott (prefiguring Margaret Thatcher) believes ‘there is no society except as a structure brought about…by individuals’ (Winnicott, 1971, pp190).

Again, when addressing the symbolic uses of the transitional object, Winnicott purports to understand the phenomenological experience of the infant – in perceiving the breast as part of self, created out of desire (Winnicott, 1971, pp17), and thus integral to disillusionment of omnipotence. This is a fascinating conjecture – but unammenable to disconfirmation, and thus, neither evidence nor explanation. A more convincing case study involves a child defensively employing the imagery of string to combat separation anxiety / maternal depression (Winnicott, 1971, pp23), and in this example we see clearly the diagnostic utility of examining the symbolic weight of the transitional object for the individual child – still, this is far from a confirmation of the ubiquity and transitional / phenomena Winnicott posits for the TO. Later he suggests that for infants the mothers absence is assumed to be literal death (because of cognitive deficits in object permanence) (Winnicott, 1971, pp29), but this is to assume an understanding of death that is unlikely in the infant.

Winnicott is at his strongest dealing with play, culture, the liminal space between self and other. He’s weakest when describing the origins of self /object relations, or discussing adolescence. Winnicott believes adolescent groups take issue with social inequalities because of their seduction by individuals with ‘delusions of persecution’ into provoking actual persecution. His view of adult maturity, where jobs lessen guilt because of their social contribution (rather than their attendant social approval); and where the ‘long term view’ (for example privileging defence spending over education) is objective reasoned wisdom, rather than the conservatism of age, resource protection, cognitive inflexibility and the fear of death. Ultimately he is a thinker very much of his era, erroneously individuating and culturally stymied as often as he is insightful.

Winnicott’s key contributions are containment, graduated failure, the importance of play and the play of the psychotherapeutic encounter. His relative reluctance to interpret and informal therapeutic style have been influential, as has his focuses on the meaningfulness of symptoms and on the transference as a means of understanding.

Arguably, Winnicott overemphasises initial parenting experiences, and underemphasises later socialisation’s impact on current functioning. The dubious evidence for his infant phenomenology call into question the theoretical basis for object relations as a whole. However the processes of projection and introjection he outlines, and the narcissistic wounds he identifies in childhood offer avenues into understanding the developmental process underlying dysfunction.

We must be careful however, not to pursue to dogmatically psychoanalysis’s historic witch hunt of the inadequate mother, as the basis for chronic emotional dysregulation and neuroticism. Neglect and abuse can come from all quarters, and resilience factors can protect the infant and developing child from many of its worst impacts.

References

Adler, A. (2006) The Collected Clinical Works Of Alfred Adler. Volume 12. The General System Of Individual Psycology. Overview and summary of classical Adlerian theory and current practice. USA: Alfred Adler Institute.

Casement, P. (1995). On Learning From the Patient. UK: Routledge.

Duquette, P. (1993) What Place Does the Real-Relationship Have in the Process of Therapeutic Character Change? Jefferson Journal Of Psychiatry. Vol 11, 2.

Foucault, M. (1995). Discipline and Punish: The Birth of the Prison. UK: Vintage.

Gigerenzer, G. (2002). Bounded Rationality: The Adaptive Toolbox (Dahlem Workshop Reports). USA: MIT Press.

Goffman, E. (1956). The Presentation of Self in Everyday Life. New York: Doubleday.

Grossmann., K., Grossmann, K.E., Spangler, G., Suess, G., Unzner., L. (1985). Maternal Sensitivity and Newborns’ Orientation Responses as Related to Quality of Attachment in Northern Germany. Monographs of the Society for Research in Child Development.Growing Points of Attachment Theory and Research. Vol. 50, No. 1/2, pp. 233-256.

Summers, F. (1994) Object Relations Theories and Psychopathology: A Comprehensive Text. USA: The Analytic Press.

Watts, A. (1996). Myth and Religion: The Edited Transcripts. USA: Tuttle Publishing.

Winnicott, D.W. (1971) Playing and Reality.  UK: Tavistock Publications.

John Marzillier’s autobiographical account attempts to convey what the experience of therapy ‘is really like’. Rather than elucidating case histories, he has provided a fictionalised, novelistic memoir of cases spanning his four decade career. Marzillier began working as a behaviourist and became during practice a cognitive therapist, and finally a ‘psychodynamic narrative therapist’. The book’s title relates to the uniqueness and importance of the ‘real relationship’ (Duqette, 1993) between therapist and client.

The Gossamer Thread provides an insight into the experience of therapy for the psychotherapist. It does so without any attempt at objectivity or summation, rather it represents the particular and unique experience of one practitioner, deeply rooted in his own autobiography.

The author points out the liability and unreliability of his (and his clients) memory of events, arguing that this no obstacle to understanding the uniqueness of individual perspective. Perspective, the way in which we view our histories and positions in the world, is open to change, and it is this change Marzillier suggests is key in psychotherapy (Marzillier, 2010, pp8). Marzillier emphasises the contiguity between normality and disorder – the continuum along which anxiety and depression run, laid down by social norms and expert discourses. Marzillier himself utilised ‘electrical aversion therapy’ with gay clients (in the 1960’s). His experience as an influential participant in a rapidly changing discipline (clinical psychology), made him keenly aware of ambiguity and ethnocentricity of diagnosis and mental illness.

By ironically reflecting on his own imagined competence as a new behaviourist practitioner, Marzillier demonstrates the man behind the curtain of psychotherapy (Marzillier, 2010, pp29). This is especially pertinent given the popularity of behavioural approaches in the treatment of autistic spectrum disorders (Rosenwasser & Axelrod, 2001), and cognitive behavioural approaches to depression (Leichsenring, 2001) today.

It is noteworthy how much more of himself Marzillier required as a practitioner of psychoanalysis, and how much more emotionally challenging the process seemed (Marzillier, 2010, pp169). Marzillier also notes the higher requirements on the client in psychoanalysis, the ability to tolerate the pain of unconscious exploration, reflexivity, commitment to long term treatment, trust in the practitioner (Marzillier, 2010, pp135).

Too often in accounts of psychodynamic work, the duration disappears, the months of work without progress becomes dissolved by the relatively brief narrative description of the case. Marzillier bucks this trend, demonstrating the slow progress of re-parenting a closeted narcissistic client. Here he introduces an interesting concept from self psychology (Kohut, 2009) (a sect of psychoanalysis that seems to mirror object relations with different terminology) – ‘Selfobjects’, external ‘objects’ that the narcissist cannot separate from their internal function or perceive as separate to themselves, a defense against unbearable emptiness / disillusion (Marzillier, 2010, pp177).

Marzillier argues for the utility of brief psychodynamic therapy (Marzillier, 2010, pp200) – as a means of rapidly approaching insight for the prolonged grief of his patient (rather than the relief of suffering, as in CBT).

Having been educated right when ethology / behaviourism was being superseded by the cognitive revolution in psychology (Marzillier, 2010, pp69), and at a time when psychoanalysis was gaining popularity in Britain (despite its dismissal within academic psychology), Marzillier is in a unique position to highlight the arbitrary way in which intellectual fashions choose to focus on specific aspects of personality or cognitive function. This parallel’s my own experience, studying psychology at a time when cognitive science is being integrated (somewhat tortuously) with neuroimaging.

Marzillier argues for the need to shape psychotherapy to the individual client, and to continually critically evaluate the assumptions behind theory and practice and the origin and meaning of client distress. He also demonstrates the importance of relationship over methodology in addressing the needs of clients (which can vary significantly from their presenting problem) (Marzillier, 2010, pp24). I share Marzillier’s dislike of the value laden conception of personality disorder (and psychological disorder in general), rooted in a syndromal disease model that lack construct validity (Clark et al, 1997). I found Marzillier’s reference to the work of Jerome Frank on the ritual of psychotherapy (as more important than the technique / theory) fascinating, as it relates to Erving Goffman’s theories on the dramaturgical aspects of everyday life (Marzillier, 2010, pp25).

Despite his later disavowal of behaviourist treatment approaches, Marzillier describes a number of successes in treating phobias, anxiety disorders and the like with behavioural approaches (Marzillier, 2010, pp32), and later similar success with social phobias, teaching social skills with feedback (Marzillier, 2010, pp52). Given the irresolute nature of outcomes in psychodynamic psychotherapy, it’s hard not to find this attractive. Similarly, last year I studied ‘choice theory’ (Glasser, 1998), a cognitive approach to behavioural change rooted in needs and contemporary relationships; and I find it challenging not to apply any of these techniques to client work. However, as Marzillier goes on to demonstrate, clients differ enormously, and simple techniques are not necessarily universally applicable (Marzillier, 2010, pp44, pp57). Focusing too intently on specific symptoms or (frequently misapplied) diagnosis can professionalise the clients identified disorder (Marzillier, 2010, pp47), providing a (toxic) identity as well as a sense of learned helplessness. Marzillier argues for a therapeutic approach rooted in aspects of a variety of techniques – the anxiety / depression reduction of cognitive therapy, the use of transference and the working alliance of psychodynamic therapy (Marzillier, 2010, pp188)

Another issue which arose for Marzillier was his client’s reluctance to take ‘trained’ learning into the real world (Marzillier, 2010, pp60). This is an issue I’ve found myself as a client of therapy – it’s a great deal easier to come to an insight than to apply it in practice. There are several important take home messages here: One, for behavioural therapies to work they need to be as ecologically valid as possible, even taking place in the real world. Two, a great number of client’s core issues are disguised by their surface problems. Three, as I discovered during the course of my own undergraduate thesis, experimental power requires large, homogenous groups of participants (Marzillier, 2010, pp61).

Although Marzillier later disavowed simple behaviourism (Marzillier, 2010, pp75), his practical approach to the difficulties of clients – informed by cognitive and behavioural accounts – is appealing. For example with one client ‘Angie’, his focus on cognitive factors (‘vicarious traumatization’) helps to elucidate the origin of violent fantasies and ultimately remove their severity (through self monitoring and curtailing avoidance) (Marzillier, 2010, pp78). He’s never averse to trying to help a client resolve their difficulties, rather than to simply accept them or endlessly ruminate upon their origins.

I found a number of Marzillier’s reflections on the psychotherapeutic process enormously insightful; ‘avoidance prevents… anxiety from going away’ (Marzillier, 2010, pp77), ‘significant change always entails a significant loss’, (Marzillier, 2010, pp92), aggression can be expressed through gratitude (Marzillier, 2010, pp156), passionate love is ‘the archetypal narcissistic illusion’ – the projection of what’s missing in oneself into the other person (Marzillier, 2010, pp260), cognitive appraisal (negative thinking) affects how you feel (Marzillier, 2010, pp93) and negative feelings that persist become depressed mood. Never having studied CBT, I found the detailed description of a variety of cognitive distortions and schema underlying depression informative.

For Marzillier, work with a variety of clients demonstrated that core beliefs (schemas / metaphysical beliefs) were difficult to mollify with cognitive techniques (Marzillier, 2010, pp111), and more amenable to emotional challenge from within, from a place of safety in therapy. There’s an intrinsic issue with any kind of cognitive therapy – and it is that the most useful, cheering belief may not be true, and whether true or untrue may not be good for the individual to hold, or the community to be subjected to (as for example in the destructive behaviour of narcissists). Marzillier’s own issues with cognitive therapy arose as much out a disillusioning of his idealisation of his mentor, Aaron Beck, during an embarrassing tennis game, as through rigorous methodological critique (Marzillier, 2010, pp 127)! Problem solving is useful in some circumstances, the important thing is to tailor the treatment to the client’s needs (Marzillier, 2010, pp157).

Marzillier’s commentary on the normality of depression and disorder (even amongst practitioners) is heartening – like Jung’s concept of the wounded healer (Burns & Burns, 2009), it allows a place for our damaged humanity.

Marzillier notes the utility of illness – the function of disorder within the family dynamic, both as identity and escape (Marzillier, 2010, pp 47). I find this a useful adjunct to the idea of the ‘identified patient’ (Agazarian, 1999) – rooting disorder in the family and social system, rather than ignoring the environment in which suffering emerges. Specifically, the power of obsessive compulsive routines to control those around the client is something I’ve witnessed in group psychotherapy.

Marzillier’s difficulties in not offering practical help to his clients when he begins practicing psychoanalsysis (Marzillier, 2010, pp145), mirror my own. This links in with his frustration at the avoidance implicit in the orthodox Freudian analysis he receives as a client, which fails to penetrate a surface relationship and is allowed to become a cursory exercise (Marzillier, 2010, pp195).

The chapter on boundaries ‘getting too personal’, is informative in showing that boundary violations can be as much about wanting to do something to help the client (unconsciously treasuring their approval) as taking advantage of them (Marzillier, 2010, pp 239). In the subsequent chapter Marzillier focuses on ‘the unanswerable question’ of what drove one of his clients to suicide – highlighting impulsivity, life history of failure and conflict, and inescapable patterns of negative feeling and thinking. Again the theme of unwillingness to disappoint the client, to disillusion them, arises (Marzillier, 2010, pp251).

It’s useful to note that Marzillier takes three to four sessions to decide whether to see and how to treat a client (Marzillier, 2010, pp 242). After which he offers a written formulation (essentially a case study) to his client (both psychoanalytic and cognitive aspects) and discusses potential treatments. This emphasis on disclosure and informed consent has impacted on my psychotherapeutic practice.

Writing a book like this, so deeply rooted in subjective life experience, skipping forward and backward through memory is inarguably inexact and inscrutable. However, this kind of ‘romantic science’ (to use Oliver Sack’s phrase) (Wasserstein, 1988) has the capacity to include aspects of the lived experience of the practitioner that more rigid / theoretically driven accounts leave out.

It was fascinating reading about Marzillier’s encounter with the ‘desk drawer problem’ in scientific research – where studies that fail to find an effect (rather than serving to demonstrate the lack of one) rarely have an impact.Interesting too, was his experience of parallel process in the supervision relationship (Marzillier, 2010, pp158).

The books weakness is Marzillier’s relatively privileged clinical position – he generally doesn’t work with (or write about) about intellectually or physically disabled, extremely socially deprived or at risk clients, geriatric, children or adolescent clients: Essentially excluding most ‘front line’ clients of publically provided psychotherapy today.

Marzillier’s self deprecating description of a career in psychotherapy is deeply entertaining. His points about the arrogance of applying evidence based therapies regardless of the uniqueness of the client in question are well made. By charting his own course from behavioural to cognitive and finally psychoanalytic therapy, Marzillier makes a convincing case for developing a therapeutic practice that suits the individual practitioners style of relating; and finding value in a variety of techniques. Finding a way of working he could ‘identify with’ was most important in his development as a therapist (Marzillier, 2010, pp211). Marzillier rejects the systematisation of technique as costly and time consuming (Marzillier, 2010, pp99), and his own career reflects the truth that pioneers have the freedom to make mistakes, and hence the freedom to grow and develop. His experience evidences the importance of allowing therapists to learn ‘on the job’, in a scenario where their developing learning can be put into practice as they become ‘agentic’ practitioners (Bandura, 2001).

I share the author’s distrust of ‘doctrinal’ aspects of psychoanalytic orthodoxies (Marzillier, 2010, pp 212), and other rigid forms of therapy. Marzillier successfully argues for the importance and utility of finding meaning in suffering allied with change (Marzillier, 2010, pp213). The advantage of ‘time to listen’ (in long term, private therapy) provides Marzillier with an open ear to client’s evaluations of their own problems, and the underlying problems they sometimes conceal (Marzillier, 2010, pp217).

Marzillier has built a therapeutic methodology that seeks to combine the best elements of the various aspects of his training background. The book is convincing in its invocation to build a toolkit with which to as Marzillier puts it, citing Yalom, ‘create a new therapy for each patient’ (Marzillier, 2010, pp220); to operate from an unknowing place, but an empowering one – respectfully focusing on the avowed problem (Marzillier, 2010, pp223) without blinding oneself to deeper causation, providing containment (Marzillier, 2010, pp 248) without constriction. All this is demonstrated by Marzillier’s treatment of ‘Cordelia’, a client who presents with panic attacks, later revealed to be stemming from deeper problems (Marzillier, 2010, 227).

The book finishes by focusing on the importance of the personal factor in psychotherapy (Marzillier, 2010, pp260), of the personality and humanity of the practitioner; and the utility of providing a ‘secure base’ even when cure is impossible.

References

Agazarian. Y.M. (1999) Phases of Development in the Systems-Centered Psychotherapy Group. Vol. 30 no. 1 82-107.

E.I. Burns, L. Burns. (2009) Literature and therapy: A systematic view. Karnac Books: UK.

Bandura, A. (2001) Social cognitive theory: an agentic perspective. Annual Review of Psychology. 2001;52:1-26.

Clark, L.A., Livesley, W.J., Morey, L. (1997). Special Feature: Personality Disorder Assessment: The Challenge of Construct Validity. Journal of Personality Disorders: Vol. 11, No. 3, pp. 205-231.

Duquette, P. (1993) What Place Does the Real-Relationship Have in the Process of Therapeutic Character Change? Jefferson Journal Of Psychiatry. Vol 11, 2.

Falk, L. (2001). Comparative effects of short-term psychodynamic psychotherapy and cognitive-behavioral therapy in depression: A meta-analytic approach. Vol 21(3), 401-419.

Glasser, William. (1998) Choice Theory. USA: Harper Collins.

Kohut, H. (2009) The Analysis of the Self: A Systematic Approach to the Psychoanalytic Treatment of Narcissistic Personality Disorders. USA: University of Chicago.

Marzillier, J. (2010) The Gossamer Thread. Karnac Books: London

Rosenwasser, B., Axelrod, S. (2001). The Contributions of Applied Behavior Analysis to the Education of People With Autism. Behavior Modifaction. Vol: 25: 671-677.

Wasserstein, A.G. (1988) Toward a Romantic Science: The Work of Oliver Sacks. Annals of Internal Medicine. Vol 109(5):440-444.

The psychoanalyst D.W. Winnicott was one of the pioneers of the ‘object relations’ school. Broadly object relations (an enormously diverse area, underlying modern approaches like family systems theory and transactional analysis) situates the primary parental bond as the source of the individual’s ability to contain threatening feelings, and understand themselves as a subjective participant in an ‘objective’ consensual reality. I’m not entirely convinced by object relations accounts of child development – which rely heavily on untestable assumptions about the infant experience. However, I do find Winnicott’s approach to play and creativity exciting.

Winnicott argues for the essentiality of ‘creative apperception’ to life, and the corresponding deathliness of ‘compliance’. For Winnicott, creativity is a universal faculty of life (not merely the domain of artistic creation) – a faculty which can be diminished (hidden) or damaged by illness or repression. To be creative is to retain the capacity to suffer – and it is those who are unable to sacrifice their own creativity who suffer most under tyranny. In common with Freud and Foucault, Winnicott claims that modernity made possible the individual – alienated from pure identification with community and nature, and hence capable of reflection and creativity. Creativity is embodied in ‘healthy looking’ and ‘deliberate doing’ – active engagement rather than passive participation in life. Thus Winnicott normalises and universalises ‘the creative impulse’, placing it at the heart of healthy life.

“Compliance carries with it a sense of futility for the individual and is associated with the idea that nothing matters and that life is not worth living”

Winnicott, Playing & Reality

[Note – the first time I wrote out that quote, I substituted the word 'mothering' for ‘nothing’, psychoanalytically inclined readers can go ahead and half a field day with that one]

Winnicott goes on to discuss the schizoid, to whom ‘reality remains to some extent a subjective phenomenon’. This is a state not sharply delineated from health – nor from schizophrenia, one in which a ‘fay’ individual is unable to fully connect with consensual reality. These individuals feel dissociated, detached from both the ‘real’ world, and the ‘dream’ symbolic universe.

Its worth noting here that labeling is a huge issue in mental health, and that personality disorders are syndromal – that is to say classified based only on underlying symptoms, rather than any understanding of ‘disease process’. It’s probably more meaningful to this of personality disorders as states / conditions, or even positions, rather than fundamental to the structure of self – since in many cases they can alter greatly over time, and are amenable to treatment.

According to Winnicott, to understand early breakdowns in the capacity for creativity (in Bionian terms –K learning) – we need to examine both the individual and their early environment (primarily their parenting). Hence Winnicott offers a space for the social in (traditionally individualist) psychoanalysis. The ‘graduated failure’ of the ‘good enough mother’ makes it possible for infants to tolerate the trauma of losing the illusion of their own omnipotence. Thus, a reliable infant environment is key to the development of trust that allows the creation of internal objects that match reality (‘subjective objects’) – and it’s absence can create the kind of schizoid dissociation, or incapacity for a real creative engagement with the world, we’ve been discussing.

Winnicott argues that searches for ‘self’ in creative work are doomed to failure (Winnicott, 1971, pp73), since the discovery of self requires ‘non-purposive’ activity. In practice this exhibited in his therapy sessions in a tolerance for ambling digression, without imposed interpretation (primarily given in response to client request).  He allowed sessions to overrun by hours, and his treatment room was full of toys and art supplies! Clients would physically wander round the treatment room, fall asleep or draw a picture. This can seem problematic to a modern reader – especially since Winnicott stretched sessions to fit client’s needs on request, and added sessions to compensate for missed sessions: violations of boundaries that seem inviolable today. Winnicott often let his clients without interpretation – allowing them their own creative space to act (prefiguring Patrick Casement’s emphasis on negative capability, and paralleling Carl Roger’s person centred approach) and crises to emerge and be communicated by impact. As with Irving Yalom and even Freud, we see an informality and humanity that has been (perhaps inevitably) lost as psychotherapy has professionalised and become more concerned with protecting clients from exploitation.

I’ll write more on the construct of ‘the schizoid personality’ in a future post.