Turning the Tide: The Psychoanalytic Approach of the Fitzjohn's Unit to Patients with Complex Needs 9781782203322

Table of contents :
Cover
Half Title
Series Page
Title Page
Copyright Page
Contents
SERIES EDITORS' PREFACE
ACKNOWLEDGEMENTS
ABOUT THE EDITORS AND CONTRIBUTORS
FOREWORD
Introduction: against the tide
1 Finding a way in: the work of the Fitzjohn's Unit
2 Looking both ways: the role of the administrator in the Fitzjohn's Unit
3 The emergence of emotional meaning: a journey through delusional symptoms
4 The progress of sorrow
5 The mine/d field of the internal world: the importance of the setting in work with borderline patients
6 Beginning in the dark
7 The group as an object
8 Supervision and consultation: tuning in to psychotic communications in frontline mental health settings
9 "A quandary of borders": theoretical and clinical thoughts on the borderline predicament
REFERENCES
INDEX

Citation preview

TURNING THE TIDE

Tavistock Clinic Series

Margot Waddell, Jocelyn Catty, & Kate Stratton (Series Editors)

Recent titles in the Tavistock Clinic Series

(for a full listing, please visit www.karnacbooks.com) Addictive States of Mind, edited by Marion Bower, Rob Hale, & Heather Wood Assessment in Child Psychotherapy, edited by Margaret Rustin and Emanuela Quagliata Childhood Depression: A Place for Psychotherapy, edited by Judith Trowell, with Gillian Miles Consultations in Psychoanalytic Psychotherapy, edited by R. Peter Hobson Contemporary Developments in Adult and Young Adult Therapy. The Work of the Tavistock and Portman Clinics, Vol. 1, edited by Alessandra Lemma Couple Dynamics: Psychoanalytic Perspectives in Work with the Individual, the Couple, and the Group, edited by Aleksandra Novakovic Doing Things Differently: The Influence of Donald Meltzer on Psychoanalytic Theory and Practice, edited by Margaret Cohen & Alberto Hahn Inside Lives: Psychoanalysis and the Growth of the Personality, by Margot Waddell Internal Landscapes and Foreign Bodies: Eating Disorders and Other Pathologies, by Gianna Wiliams Living on the Border: Psychotic Processes in the Individual, the Couple, and the Group, edited by David Bell & Aleksandra Novakovic Making Room for Madness in Mental Health: The Psychoanalytic Understanding of Psychotic Communication, by Marcus Evans Melanie Klein Revisited: Pioneer and Revolutionary in the Psychoanalysis of Young Children, by Susan Sherwin-White Oedipus and the Couple, edited by Francis Grier Organization in the Mind: Psychoanalysis, Group Relations, and Organizational Consultancy, by David Armstrong, edited by Robert French Psychoanalysis and Culture: A Kleinian Perspective, edited by David Bell Reason and Passion: A Celebration of the Work of Hanna Segal, edited by David Bell Short-Term Psychoanalytic Psychotherapy for Adolescents with Depression: A Treatment Manual, edited by Jocelyn Catty Sibling Matters: A Psychoanalytic, Developmental, and Systemic Approach, edited by Debbie Hindle & Susan Sherwin-White Social Defences against Anxiety: Explorations in a Paradigm, edited by David Armstrong & Michael Rustin Surviving Space: Papers on Infant Observation, edited by Andrew Briggs Talking Cure: Mind and Method of the Tavistock Clinic, edited by David Taylor The Anorexic Mind, by Marilyn Lawrence The Groups Book. Psychoanalytic Group Therapy: Principles and Practice, edited by Caroline Garland Therapeutic Care for Refugees: No Place Like Home, edited by Renos Papadopoulos Thinking Space: Promoting Thinking about Race, Culture, and Diversity in Psychotherapy and Beyond, edited by Frank Lowe Towards Belonging: Negotiating New Relationships for Adopted Children and Those in Care, edited by Andrew Briggs Understanding Trauma: A Psychoanalytic Approach, edited by Caroline Garland Waiting to Be Found: Papers on Children in Care, edited by Andrew Briggs “What Can the Matter Be?”: Therapeutic Interventions with Parents, Infants, and Young Children, edited by Louise Emanuel & Elizabeth Bradley Young Child Observation: A Development in the Theory and Method of Infant Observation, edited by Simonetta M. G. Adamo & Margaret Rustin

Turning the Tide The to

Psychoanalytic Approach of the Fitzjohn's Unit Patients with Complex Needs Edited

Rael

by

Meyerowitz Foreword

Edna

& David Bell

by

O'Shaughnessy

First published in 2018 by Karnac Books 118

Finchley Road

London NW3 5HT

Copyright © 2018 by Rael Meyerowitz & David Bell. Foreword © 2018 by Edna O'Shaughnessy. All contributors retain the copyright to their own chapters. The

rights of the editors and contributors to be

identified

as

the authors of this

work have been asserted in accordance with §§ 77 and 78 of the

Copyright

Design and Patents Act 1988. All

rights reserved. No part of this publication may be reproduced, stored in or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. a

retrieval system,

British

Library Cataloguing in Publication

Data

A C.I.P. for this book is available from the British

Library

ISBN: 978–1–78220–332–2 Edited, designed, and produced by Communication Crafts Printed in Great Britain by TJ International Ltd, Padstow, Cornwall w .Karn cbo ks.com

CONTENTS

vii SERIES EDITORS' PREFACE ACKNOWLEDGEMENTS

xi

ABOUT THE EDITORS AND CONTRIBUTORS FOREWORD

by

xiii

Edna O' Shaughnessy xvii

Introduction:

against the

tide

David Bell1 1 Finding

a way in: the work of the Fitzjohn's Unit

21

Birgit Kleeberg 2

Looking both ways: the role of the administrator in the

Crispin

Fitzjohn's

Lane & Camilla Nicliolls

Unit 37

3 emergence of emotional meaning: The a journey through delusional symptoms Hiroshi Amino

45

4 progress of The Helen Barker

sorrow

59

5 mine/d field of the internal world: The the importance of the setting in work with borderline

patients

Ellie Roberts 6 Beginning

69

in the dark

Marcella Fok 7 group The

as an

85

object

Mxine Dennis 8

95

Supervision and consultation: tuning in to psychotic communications in frontline mental health settings Marcus Evans "A

9

quandary

113

of borders":

theoretical and clinical on

the borderline Rael

REFERENCES 155 INDEX

thoughts predicament

Meyerowitz

131

149

SERIES EDITORS' PREFACE

Since it was founded in 1920, the Tavistock Clinic has a wide range of developmental approaches to mental health which have been strongly influenced by the ideas of psychoanalysis. It has also adopted systemic family therapy as a theoretical model and a clinical approach to family problems. The Clinic is now the largest training institution in Britain for mental health, providing postgraduate and qualifying courses in social work, psychology, psychiatry, and child, adolescent, and adult psychotherapy, as well as in nursing and primary care. It trains about 1,700 students each year in over 60 courses.

developed

The Clinic’s philosophy aims at promoting therapeutic methods

in mental health. Its work is based on the clinical expertise that is also the basis of its consultancy and research activities. The aim of this Series is to make available to the reading public the theoretical, and research work that is most influential at the Tavistock Clinic. The Series sets out new approaches in the and treatment of psychological disturbance in children, adolescents, and adults, both as individuals and in families. This important volume, Turning the Tide, traces an impressive range of descriptions, all clinically based, of the work of the rather remarkable Fitzjohn’s Unit, which has about 60 patients under its

clinical, understanding

care at any one time. The book also evokes a clear sense of commitment, one that has lasted over seventeen years, since its beginnings as an experimental project that was set up by David Taylor in 2000. David Bell subsequently took over as Consultant in charge of the unit in 2002. The commitment is to a model of working therapeutically with extremely complex cases. The work is reminiscent of that of the Cassel Hospital, an inpatient unit where several members of the Tavistock Clinic’s current staff have previously worked. The Fitzjohn’s Unit is based in the Clinic’s Adult Department, and the fact that the staff group has survived intact all this time speaks for itself. For this is in spite of today’s treatment which runs strongly the other way, towards medication and psychiatric diagnosis. The unit’s work is based in psychodynamic thinking in a collective context of different professionals with degrees of expertise. The group is kept strongly together within a set of well-held boundaries, a tribute to its clinical and leadership: Edna O’Shaughnessy has, over the last 12 years or so, provided an external supervision seminar for all who work on the unit, and David Bell and Birgit Kleeberg have together the service. Although not offering psychoanalysis as such, the work is embedded in psychoanalytic thinking. The longevity of the mode of working developed over the years is self-evident. It does, indeed, run as the title suggests, against the tide, and very successfully so. This highly functioning hub of mutual learning and cooperation is, as this book attests, a developmental experience not only for the patients but for the staff too, as many who have had the good fortune to participate richly confirm. In this respect, there is one chapter in the book, on the role of the group’s administrator at the time, that offers insight into a further, and often overlooked or undervalued, form of holding, so crucial where complex needs are involved: that is, the coherence and the continuity provided by the administrative underpinning—no easy task in a setting of this kind.

collective

direction varying managerial

managed

One of the many, and now noteworthy, features of the unit’s

work is that it offers, within the NHS, an unusually long period of continuity of contact, both individually for two years and in a group of fellow patients—a “package of care” that is so crucial for those suffering the wide range of difficulties that are treated in the unit, from a broad spectrum of borderline symptoms

thereafter

and delusional states to chronic incapacity and social dysfunction. Very often, the psychotherapeutic model can offer a transition from a purely psychiatric way of thinking to a finding of meaning for patients, which is often such a significant step towards a greater capacity to manage their lives. Such a great range of complex disorders requires an equivalently strong and shared commitment on the part of the staff to offering and receiving a firm model of management and containment of the kind that, whatever the often immense stresses, the Fitzjohn’s Unit can provide. The following pages express the courage, and also the hope, that such a unit can instil in all its participants.

ACKNOWLEDGEMENTS

The editors would like to thank everyone who has had a hand in producing this book, which has had a long period.

gestation

Rael Meyerowitz wishes particularly to thank his wife, Tracey

Miller, for her support and technical, stylistic, and editorial help. As has been the case with many another endeavour, he could not have done it without her. There would have been no book whatsoever without our supervisor, Mrs Edna O’Shaughnessy, who has maintained consistently that the Fitzjohn’s Unit offers a unique and exemplary model of psychoanalytic work and urged insistently that we write about it! We wish to thank Margot Waddell in particular for all her help and particularly for keeping alive our belief in the project through times when there were serious snags and flagging spirits.

external

We are grateful to Oliver Rathbone, Rod Tweedy, and everyone

else at Karnac and to Eric King of Communication Crafts for their support throughout the project and for acting so speedily to it as a book. It is in keeping with the ethos of the Fitzjohn’s Unit that we regard not only the actual authors, but each and every psychotherapist,

produce

past and present, who has sojourned with us and taken on these troubled patients, as having contributed invaluably to this book. We hereby both celebrate their work and thank them for their efforts. Finally, this book is dedicated to all the patients who have come to the Fitzjohn’s Unit for help. It is our hope that they have benefited at least as much from us as we have learned from them.

ABOUT THE EDITORS AND CONTRIBUTORS

Hiroshi Amino was born in Japan, where he trained in and psychotherapy. He continued his psychotherapy at the Tavistock Clinic and later qualified as a psychoanalyst (member of the British Psychoanalytical Society and guest of the Japanese Psychoanalytical Society). He is a senior member of staff in adult services at the Tavistock Clinic and a consultant psychiatrist at an outpatient clinic for the Japanese community in London, and works in private practice. He is actively involved in supervision and teaching in England and abroad.

psychiatry training member

Helen Barker trained in medicine, psychiatry, and

psychotherapy psychotherapist

in Manchester. She completed the Tavistock Clinic training in psychoanalytic psychotherapy and has worked as an adult in the Fitzjohn’s Unit since 2008. She is currently training to be a psychoanalyst at the British Psychoanalytical Society. David Bell is the consultant psychiatrist for the Fitzjohn’s Unit and

the unit lead. He is a past president of the British Psychoanalytical Society. In 2012–13 he was Visiting Professorial Fellow at Birkbeck

College London. His interests include the psychoanalytic understanding of severe disturbance, such as psychosis and borderline states, psychoanalytic concepts, and critical appraisals of contemporary psychiatric practice. He is course lead and principal lecturer for the Tavistock course, “The Development of Psychoanalytic Concepts”. He is particularly interested in the relation between psychoanalysis and other disciplines—literature, philosophy, and socio-political issues—and has published extensively in these areas. His books include Paranoia (2003); Psychoanalysis and Culture (1999); Reason and Passion (1997); and Living on the Border (with Aleksandra Novakovic, 2013). He is a leading psychiatric expert in asylum and human rights.

culture,

Maxine Dennis is a consultant clinical psychologist and

psychoanalyst (member of the British Psychoanalytical Society). She is groups lead in the Adult Department of the Tavistock Clinic where she also runs a psychotherapy group and sees patients in the Fitzjohn’s Unit. She teaches and supervises on the Tavistock’s adult psychotherapy training and is a visiting lecturer at the University of Essex. Marcus Evans is a psychoanalyst and consultant psychotherapist

at the Tavistock and Portman NHS Foundation Trust with thirtyseven years’ experience in mental health as a practitioner, lecturer, and manager. He qualified as a psychiatric nurse in 1983 and took up senior nursing posts at St Giles Day Hospital, King’s College Hospital, and the Bethlem and Maudsley Hospitals. After training as a psychotherapist at the Tavistock Clinic, he became head of the nursing discipline and later was appointed associate clinical of the adult and adolescent departments, 2011–2015. He has taught outreach courses for frontline staff for the last twenty-five years in many mental health trusts. He was one of the founding members of the Fitzjohn’s Unit and has recently started working in the Portman Clinic. His passion is the application of ideas to the treatment and care of patients in mental health settings, and he is the author of Making Room for Madness in Mental

director psychoanalytic Health: The Psychoanalytic Understanding of Psychotic

Communications (2016).

Marcella Fok trained in medicine in Edinburgh and then in in London. She worked as an honorary psychotherapist in the Fitzjohn’s Unit in the latter stages of her psychiatry training. Guided by her interest, she completed a medical research doctorate on the epidemiology of personality disorder, at the Institute of Psychology & Neuroscience, King’s College London. She is now a consultant psychiatrist in psychotherapy at the Central and North West London NHS Foundation Trust and is also in private practice. She is currently training to be a psychoanalyst with the British Psychoanalytic Association.

psychiatry

Psychiatry,

Birgit Kleeberg is a consultant adult psychotherapist and

psychoanalyst (member of the British Psychoanalytical Society) and has co-managed the Fitzjohn’s Unit since 2005, having worked there since its inception. She initially trained as a medical doctor in South Africa and worked for some years in psychiatry in Namibia before coming to the Tavistock Clinic in 1994 to train as an adult psychotherapist. She has also worked at the Cassel Hospital and in the Trauma Unit at the Tavistock. She has contributed chapters to a number of edited volumes. Crispin Lane trained as a psychoanalytic psychotherapist with

the Lincoln Clinic and Centre for Psychotherapy and is now a member of the British Psychotherapy Foundation. He has worked in a number of psychotherapy settings in the NHS as well as in private practice. He was the first clinician to join the Fitzjohn’s Unit’s advanced clinical training for qualified psychotherapists; after completing the course, he found that the unit was such a fulfilling and absorbing place to work that he has stayed on as an honorary psychotherapist. Rael Meyerowitz was born in South Africa. He is an adult

psychotherapist and psychoanalyst (member of the British Psychoanalytical Society since 2004), having embarked on clinical training in mid-life, after an earlier career as an academic in a range of humanities disciplines and on several continents. In addition to working clinically at the Tavistock and in private practice, he teaches a variety of psychoanalytic subjects on the Tavistock’s

adult psychotherapy training, at University College London, the British Psychoanalytic Association and the British Psychotherapy Foundation, and elsewhere. Camilla Nicholls is a psychodynamic psychotherapist who worked in the NHS for five years, three with the Fitzjohn’s Unit in an honorary capacity while completing the unit’s advanced clinical training for qualified psychotherapists. She now works in private practice in London and Brighton. Camilla’s journalism has been published in national newspapers, magazines, and online. Edna O’Shaughnessy was born in South Africa in 1924. After the Second World War, she came to England to continue studying at Oxford. Questions that engaged her there were meaning and its representation, and the freedom (or not) to choose—both topics of continuing interest when she moved from philosophy to psychoanalysis in the 1950s. Her analytic training began with at the Tavistock Clinic. In the 1960s, she trained as an adult psychoanalyst at the British Psychoanalytical Society of which she is now a distinguished fellow, a training and supervising analyst, and a child analyst. For a while now she has not seen patients (a huge loss); however, she is still a supervisor, including for the Fitzjohn’s Unit staff seminar. During more than fifty years of psychoanalytic work, she has written many papers, now collected in Inquiries in Psychoanalysis (2014).

philosophy

children

Ellie Roberts is a consultant child psychotherapist (member of the Association of Child Psychotherapists), a lead clinician for the Oxford Health NHS Foundation Trust in Oxfordshire and and a training therapist for the Tavistock’s child training. She teaches on the Tavistock course, “Working with Children, Young People and Families: A Psychoanalytic Observational Approach”, in Oxford and Bologna. She also trained as an adult psychoanalytic psychotherapist at the British Foundation and spent several years seeing patients in an honorary capacity at the Fitzjohn’s Unit.

Buckinghamshire, psychotherapy Psychotherapy

FOREWORD Edna O’Shaughnessy

The patients seen in the Fitzjohn’s Unit suffer from complex problems of neurosis and psychosis and are prey to extremes of anxiety and distress. Their treatment is by the method of psychoanalysis, but with an approach adapted both to the and capacities of the patients and to the constraints of in the NHS. In regard to time, instead of the “for as long as it takes” of traditional psychoanalysis, therapy in the unit is for a fixed period of two years. Furthermore, frequency of sessions has been reduced to twice weekly, sometimes once, where that seems better suited to a particular patient. At the end of the two years, patients are offered the option of joining a group—a new way of ending treatment. Sigmund Freud long ago remarked on how “the extraordinary diversity of the psychical constellations concerned, the plasticity of all mental processes and the wealth of determining factors oppose any mechanization of the technique . . .” (1913c, p. 123). This is true for work with all patients and is especially true for patients attending in the Fitzjohn’s Unit. Their complex problems lead them to communicate from strange and even bizarre perspectives, which then need finding and understanding. This is not easy to do, and the therapeutic task is a stressful one for both therapist

anxieties working

and patient. Yet, as readers may see in the chapters that follow, in which members of the unit describe their work, their patients engage with them in diverse ways, often with great intensity, and bring their predicaments into the sessions. In this way patients come to be known and understood by their therapists and, if all goes well, are enabled to make some new psychic development of their own. Such work is always uncertain and difficult, and it needs to be done in a spirit of enquiry and exploration. Though we have had our share of failures, many Fitzjohn’s patients have found themselves moved and grateful for a primal experience of “being known and understood by another”—for some for the first time in their lives.

TURNING THE TIDE

Introduction: against the tide David Bell

It is a very great pleasure for me to introduce this book celebrating the work of the Fitzjohn’s Unit, which I have led for the last fifteen years. We have sustained within the unit our own particular approach to psychological suffering, one that is so divergent from the ever-increasing impoverishment in thinking and practice that typifies many approaches to mental today.

illness The Fitzjohn’s Unit is a specialist outpatient service offering

treatment to adults with severe and enduring mental health problems that usually take their origin from early on in life—that is, in childhood and/or adolescence. Such individuals largely do not benefit from brief treatments that focus on their symptoms. Instead, they require an approach that engages them as a whole person and a treatment of much longer duration that provides a context in which they can develop in their own way. The work of the unit is described in the chapters that follow.

The role of this introductory chapter is to set that work within a broader context—that is, to situate our approach within a of psychiatric practice and to describe what is meant by a psychoanalytic attitude to mental suffering.

framework

DAVID

BEL

Mrs C, a woman in her forties, was referred for an assessment for psychotherapy. She had suffered from chronic depression for over ten years and had already undergone a raft of treatments, to no avail. When invited to tell me of her difficulties at the beginning of the consultation, she gave me a detailed and in many ways very competent account of the illness, much of which consisted of going through a list of symptoms, how long she had had them, how her life was affected, etc.The atmosphere, however, was one of utter lifelessness: she talked only of her symptoms and not of herself, and it felt as if she was handing her “ill self” over to me, positioning herself as an object. I pointed this out to her, saying that she appeared to be wanting to give me a list of all the things that assailed her, to hand them over to me for diagnosis and recommendation for treatment, without having to participate in this process at all. Suddenly there was a change in the atmosphere. She started weeping and said, “I don’t think I have ever participated in anything in my life.” An important move had taken place: she had become much more alive, and, paradoxically, by talking of not participating, she was now participating in the interview in a way that was very real, but also quite disturbing to her. This brief vignette serves to characterize a number of features that are essential to the psychoanalytic attitude: an individual’s suffering cannot be properly characterized as an “illness”, for it is always the expression of a whole personality, and it is only through an engagement that foregrounds the relationship in the room that the psychopathology can be grasped as a dynamic structure that enables one to form an adequate assessment of the patient’s difficulties and what he or she is seeking, at both a and a less conscious level.

consulting conscious Psychoanalysis and psychiatry

Psychoanalysis and psychiatry occupy conceptual domains that do not map onto each other precisely, that are not symmetrical. Psychiatric theory and practice are informed by a large of conceptually distinct paradigms. Some of these paradigms

number

INTRODUCTION

can live more or less happily alongside each other, while others are in direct contradiction; some are entirely consistent with a psychoanalytic perspective, but others are, to varying degrees, opposed to the whole approach that psychoanalysis represents. If one thinks, for example, of the situation where a patient requires medication, much may depend upon the context within which it is given. Where this context emphasizes an understanding of the psychological development of the illness and its meaning within current personal and social circumstances, there is no with psychoanalysis. But where the illness is understood as a purely biological phenomenon, distinct from the person in which it manifests itself, where the person is viewed as a passive recipient of a pathological process (an object of this process, not a subject), then the contradiction with a psychoanalytic perspective is clear.1

contradiction

The Fitzjohn’s Unit started life in a psychiatric context very

different, if not categorically different, from the present one. That is, where we are now bears some relation to where we were then, but there has been an evolution of sorts—regrettably, not a one. Twenty years ago, there was much more general acceptance that psychiatric theory and practice are necessarily informed by a large number of conceptually distinct paradigms, as touched upon above. That is, differing models of mental though representing fundamentally different attitudes to mental suffering, had to cohabit, and this gave breadth and to psychiatry. A proper understanding of psychiatric involved considering the individual in relation to his or her current social context and psychological past, as well as to his or her existence as a biological being. Psychiatric training would involve acquiring a certain familiarity with these paradigms, thus encouraging a capacity to live with ambiguity—an essential quality for a psychiatrist. In our current world, this multifaceted richness is in danger of being completely lost, as one particular attitude to psychiatric illness is in danger of achieving hegemony.

developmental

illness, richness disorder competing Thus, when the unit began, the service was unusual but not

strikingly at odds with the general psychiatric context. Many referrers

recognized that some kinds of psychological disturbance require

long-term treatment and valued the kind of thinking, liaison, and continuity of care that we were able to offer. However, our service has increasingly come to be in conflict with other mental health care provision as services have been reduced, curtailed, and fragmented in response to cost-cutting measures, performance targets, and financial pressures. As a result, psychiatric liaison has become very difficult and sometimes impossible in a context where patients can only be provided with the required care if there is a crisis—a crisis that might have been averted if the previously existing structures of care had not been dismantled. The general recognition that many kinds of psychological

disturbance require long-term treatment and continuity of care has

been replaced by an attitude of short-termism, with catastrophic consequences. For example, until recently, day hospitals provided a non-toxic environment where patients could gradually develop interpersonal skills and receive emotional support in a structured context; this required stays of many months, often more than a year. However, these centres have been redesignated as “recovery centres”. The implication and expectation is that in a quite limited amount of time, measured in weeks, patients can recover from years of mental illness and return to ordinary living. This not only bears no relation to the reality of these patients’ difficulties, but also creates a tyranny for the staff. The patients are supposed to recover, and there are performance targets against which this will be judged. If they do not recover, the implied conclusion is that the service or staff have failed. What is missing here is any recognition that a great deal of the

care of those with enduring mental illness has more to do with damage limitation and providing forms of support and care—skills that are much less valued today. Day hospitals were often staffed by teams established over many years and composed of with high levels of skill. The de-skilling process, driven by financial pressures, has resulted in patients often being looked after by well-intentioned individuals who have virtually no experience of working with the mentally ill.

individuals

By perverse logic, some of these changes in health care are

presented as providing the patient with more freedom of choice. In reality, the “choice agenda” serves to make people believe they

have more freedom in order to mask the fact that they have less. Patients cannot choose a service that has been closed. Patients with these longer-term difficulties need to have

continuing contact with the psychiatric teams that had provided their

care in the past and would do so in the future. This ongoing provides a vital consistency of care. Many have told me what a relief it is to have this kind of continuity and not have to keep repeating their story to each new service or practitioner. Also, and perhaps most importantly, they feel a sense of containment from the knowledge that those looking after them now have known them at their worst. Here, the real understanding that patients are sometimes damaged by institutionalization has been perversely twisted into justification for closing down the that provide ongoing containment on which patients could depend.

contact

previously

services

Psychiatric liaison, which remains an important part of our

work on the Fitzjohn’s Unit, has become increasingly difficult to achieve in a context where services have been so radically cut and fragmented. Maintaining and indeed continuously expanding the unit in this changed climate has, I believe, been a very considerable achievement.

Nomothetic and ideographic levels of description The foregoing can be further elucidated by considering what is perhaps one of the most important tensions in the practice of psychiatry and within psychology in general—namely, that between the “nomothetic” and “ideographic” levels of description. The nomothetic seeks to group together objects that are similar into a single category (e.g., vegetables, forms of transport, infectious diseases), whereas the ideographic aims to capture the unique qualities of an individual case. When we characterize someone as depressed or as suffering from a psychosis, we are using the nomothetic level of description and we hope that classifying phenomena in this will be helpful in various ways, such as suggesting the likely course of the illness, prognosis, treatment, and so on. Or, when we

manner

suggest that a particular kind of mental state tends to be associated with specific forms of transference, we again give emphasis to the nomothetic characteristics they share. The ideographic, on the other hand, explores the individual, sometimes unique, qualities of any object. Clearly, there must be both levels of description for rational discourse to take place. Over time, however, and with increasing momentum, this

tension is being lost as our discipline is overtaken by the hegemony of

classifications and diagnostic labels. Patients are now shoe-horned into discrete categories and mental illness “clusters” with packages of care and prices attached (e.g., Lee et al., 2011), a model that serves the needs not of patients but of a market-oriented system dominated by the insurance and pharmaceutical industries.

pre-prescribed

This commodification of mental suffering pushes mental health

workers to treat patients not as individuals, but as the carriers of diagnostic categories. This has resulted in profound feelings of alienation and loss of morale among mental health workers. Staff morale, although one of the most crucial elements in health care, is largely absent from health policy, which tends to focus on “skill mixes” rather than on people. The psychoanalytic approach, by contrast, requires the

sustaining of this tension between the general and the particular, always

preserving an emphasis on the ideographic, whether at the level of the individual person or in the detailed discussion of a particular session. This approach thus finds itself increasingly at odds with the mental health system, and so its place has been reduced to a fraction of what it once was. I am not saying that the of psychiatric services is a direct result of the reduced of psychoanalysis, as such. It is due, rather, to the loss of the kind of psychiatric Weltanschauung in which this kind of thinking has a natural place.

impoverishment presence The psychoanalytic attitude

Implicit in much of the above is the distinctiveness of the approach, which characterizes a central core of the tradition and underpins all the work of the unit. It might

psychoanalytic Tavistock

now be helpful to examine in more detail some core elements of the psychoanalytic attitude. The term psychoanalysis covers a wide conceptual range but

can be encompassed within the following broad categories: a body of knowledge about the mind, a research method, and a way of treating mental disorder. It is useful to keep this broad frame of reference in mind because, in discussions of psychoanalysis in the context of psychiatry, it is easy to slip into thinking of it solely as a form of treatment for individual patients. This is an important misunderstanding, for it is as a direct consequence of its range that psychoanalysis has had so much to contribute to the and treatment of mental illness.

understanding Normality and abnormality

Psychoanalysis does not investigate the human condition from the perspective of “normality”; for all psychoanalysts since Freud, this has been a convenient fiction. The relation of the abnormal to the normal in psychoanalysis is more complex and more Careful study of the abnormal reveals what the normal hides, shows what is immanent in it. To paraphrase Freud, the neurotic speaks loudly about what the rest of us keep secret. It was his appreciation of what was revealed in delusions of being observed—an abnormal phenomenon—that led Freud to the depth and archaic qualities of the normal primitive Even within the most ordinary and most disregarded aspects of mental life (such as slips and symptoms), Freud finds profound and sublime aspects of the human struggle.

problematic.

appreciate superego.

In “Obsessive Actions and Religious Practices”, Freud (1907b)

showed the parallel between the strange private ceremonials and rituals of the obsessional neurotic and certain religious practices. Both centre on the need to keep separate good and bad, the sacred and the profane. Both have intense feelings of guilt, and ways of dealing with it, as central to their content. The difference is that obsessional rituals are idiosyncratic to the individual, whereas religious ceremonials are collective and stereotyped. Freud goes on to say (referring to the difference between neurotic symptoms

and the achievements of culture): “The divergence resolves itself ultimately into the fact that the neuroses are asocial structures; they endeavour to achieve by private means what is effected in society by collective effort” (1912–13, p. 73). This demonstration of the between the apparently bizarre or abnormal and so-called normality—the insight that the achievements of human culture and the manifestations of human neurosis have more in common than our narcissism would like to regard as acceptable—is typical of Freud’s thought.

continuities

Freud’s attitude to religion is symmetrical to his attitude to

psychiatric disorder. He showed considerable respect for the contradictory nature of both of these human creations: they are at and

one and the same time expressions of human problems of our attempts to resolve them; they display what is highest and what is lowest in our nature. Thus, psychoanalysis humanizes our to mental illness, serving as a useful brake on those culturally endorsed projective systems that seek to view those suffering from mental illness as fundamentally “other”, not like ourselves.

attitude

Ms T formed a precipitately idealized relationship with her whom she saw as different from the psychiatrists she had seen; they were “not interested in me but only in their theories”. In one session, the therapist made a mistake as to the age of her son. Suddenly the atmosphere changed, as she turned on him with scorn and contempt, saying that now she could see he was no different from anyone else; he obviously had never been listening to her at all. The atmosphere was now one of utter hopelessness. A few weeks later, she recounted that as a child she would escape from a very disturbing situation at home by “holing up” in some caves nearby and painting over all the cracks in the cave with “magic paint” in order to “stop the monsters getting in”.

psychotherapist,

One might say that she had, in the early phase of her therapy, used the magic paint of idealization to create for herself a kind of personal sacred space in the treatment—the cave of her childhood—where she could feel safe.The therapist’s mistake, however, opened a crack in the idealization, and now all the monsters could get in, as her attack on the therapist had made manifest.

And now a very different situation: When the emergency team visited Mrs X, a known patient with a history of psychotic illness, they found her in a terrified state. She had covered all the windows and doors with Sellotape. This was, she explained, to prevent the evil rays getting into her flat. These two examples, one of a more neurotic situation and the other more clearly psychotic, serve to show how, despite the gross differences in mental state of the two patients, the content of their preoccupations is very similar. Each patient worked to create an idealized retreat, a kind of personal religion, where they could find protection from destructive forces. In both cases, the destructive forces are felt to exist in the external world (the fantasied monsters in Ms T’s case, the evil rays in Mrs X’s case). The content of the preoccupations is thus similar for both patients, but the form it takes is quite distinct.

Historical continuity—a developmental perspective An important related feature of psychoanalytic explanation lies in its commitment to historical continuity. Freud’s Three Essays on the Theory of Sexuality (1905d) not only provided a model of sexual development and an understanding of the sexual perversions, but introduced a method of understanding disorder in terms of Disorder makes manifest certain aspects of mental life that, at a different developmental phase (e.g., in early childhood) might well have been normal. Although we never completely lose earlier ways of functioning, when these more archaic forms come to mental life they become the basis of psychopathology.

development.

dominate Psychoanalysis thus seeks to reveal the historical continuities

that underlie apparent discontinuities, whether this be at the level of general psychological development or more specifically. For example, those moments of change or transformation that occur in what we term a “breakdown” often present themselves as discontinuities in mental life. Part of the therapeutic task is to

impressive

show that there are continuities occurring, albeit at a less apparent level. This type of understanding not only imparts meaning to symptoms but goes further, as the following illustrates. Shortly after the death of his father, Mr D developed symptoms that were nearly identical to those his father had suffered. In the course of psychotherapy, it was possible to understand that this expressed his unconscious identification with his father and a way of keeping him alive. However, it was also a way of making himself suffer, thereby expressing the guilt at the painful realization that he had felt triumph arising from death wishes towards his father. At one and the same time, this kind of understanding addresses the meaning of the symptom and displays its causal structure and history.2 Tom Freeman (1981), a psychoanalyst who worked in a general

psychiatric setting, gives the following excellent illustration of an impressive manifest break in continuity characterizing a psychotic breakdown: A young man was admitted to hospital in an acute psychotic state. He said to the admitting psychiatrist, “If you look into my eyes I will betray you.” Freeman learnt from others close to the patient that this overtly psychotic phase had been preceded by an introspective depressive period in which the patient felt worthless and helpless, following a betrayal in love. In this melancholic state, all recriminations against the girl who betrayed him were directed not towards their real target, but towards himself. In other words, the young man, in a typically melancholic manner, identified with his girlfriend (it is he, not she, who is worthless), or, as Freud put it, “the shadow of the object fell upon the ego” (Freud, 1917e, p. 249). In this way, he also maintained his idealization of his lost love. In the next phase, however, a further transformation has occurred: the patient has “solved” his problem through a psychotic identification. He has become his girlfriend; it is he who is now the betrayer, and it is someone else who is the betrayed. The patient resists any restoration of the continuity between the and the psychotic phases because of the pain it would bring.

prepsychotic

Although there have been very significant theoretical and technical developments in psychoanalysis since Freud’s day, the general approach, as outlined here, has not altered.

Personality and illness: a problematic distinction Psychiatric diagnosis traditionally distinguishes between disorder and mental illness. This broad distinction is not without value in terms of forming a general appreciation of the patient and for the purpose of making rational plans for Moreover, this differentiation has some importance from an epidemiological perspective, particularly in terms of service planning, because the kind of service necessary for mental illness (which is generally expected to be episodic, although episodes may be very long) is different from that required for the management of personality disorder (where there is a reasonable expectation that difficulties will be enduring, even lifelong, given that they are functions of the whole personality structure). When it comes to the individual, however, the separation between “personality” and “illness” is more problematic.3 In psychoanalysis, illness is always understood in terms of a development resulting from the stresses of internal and external conditions. Inevitably, individuals have a kind of psychological “fault line” that, under the pressure of a toxic interaction between a sensitized internal world and particularly malign external is brought to the point of breakdown. This fault line, which is often the source of pervasive anxiety, may in other circumstances be managed well enough not to become manifest. A related issue here is that whereas, psychiatrically, one may speak of a patient as having more than one illness, from a psychoanalytic perspective all the patient’s symptoms are seen in a more unitary way, as an expression of his or her character.

personality

management.

personality

circumstances,

As discussed above (with a different emphasis), a breakdown

may apparently represent itself as an impressive discontinuity in psychic life but, when examined more carefully, may reveal, in bizarre and distorted form, conflicts and preoccupations that were part of the personality long before the breakdown. In fact, helping

the patient integrate his or her pre- and post-breakdown states is an important part of working analytically with such conditions, as is helping with the less welcome discovery that recovery from the illness is not the same thing as recovery from the difficulties that brought it about. These will continue to operate, though at a less manifest level, within the character structure of the individual.4 Mr A, an academic, suffered from a severe manic-depressive disorder. When manic, he felt himself to be in possession of a kind of that was both absolute and his alone; in this state, he believed that he was the object of considerable envy. When depressed, he felt himself to have been ejected from his epistemological paradise and, as an inferior creature, to be the object of everyone’s contempt. However, during his so-called “normal phases”, Mr A revealed to be still overwhelmingly and continuously preoccupied with his position relative to others (was he bigger or smaller?) or, more precisely, with his relative position or size in the eyes of his primary object. This obsession, which governed all else in his life, was kept hidden in his more normal phases but quickly became evident in his analysis.

knowledge himself

Symptoms versus structures From a psychoanalytic perspective, symptoms are the outward expression of deeper structures. Treatment, therefore, aims at understanding the underlying psychic structures as a more method of alleviating symptoms.

enduring

Mr B, a man in his early thirties, presented in an agitated, depressed state. It emerged that he was acutely bereft, having been abandoned by his girlfriend who had chosen his closest friend instead. His seemed to be a manifestation of an oedipal depression: he felt forced to watch the couple—his friend and his ex-girlfriend—in a state (as he saw it) of continuous pleasure, triumphing over him. Within a few weeks of psychotherapy with a young woman therapist, however, he was “cured”. He was back at work, functioning well, feeling happy in the world and very far from his depressed state.

disturbance

Indeed, he had a new girlfriend who had herself chosen him over her husband. His sessions were full of long accounts of the virtues of his new girlfriend, related in such a way as to make his therapist feel, as she put it, like an “irrelevant observer”. From a symptomatic perspective, the man is cured (an assessment based on a questionnaire or inventory of symptoms would find no evidence of depression), but looking at things more deeply, one can see that the basic structure remains unaltered. The psychic furniture has not changed: there are still three “chairs”, two occupied by a couple and the other occupied by a depressed, excluded party. In his present life, the last chair is now occupied by the husband of his girlfriend, and in his psychotherapy by the therapist, the “irrelevant observer”. The excluded person is, thus, the target of a projective which serves to rid the self of unbearable feelings of exclusion/ rejection, now located in a third party. Such a situation is, of course, inherently unstable.

system

This vignette serves to make a broader point: most patients tend to seek help at a point in their lives when there has been a breach in the ordinary defensive structures that protect them from psychic disturbance.5 Their most urgent aim is thus to restore their psychic equilibrium in order to be free of unbearable psychic pain. Thus, in the initial phases, the therapeutic situation is often used as an aid to restoration of the original structure, the status quo ante, and this is probably inevitable.6 Some patients will leave treatment at this point, having accurately perceived that continuing treatment will undermine their defensive structure and threaten them with a return of symptoms. It is only through managing the return of such symptoms within the therapeutic setting, however, that some real and durable protection against further breakdown can be provided.

The role of agency As described above, from a psychoanalytic perspective an is never only a passive recipient of illness but is always involved in the manifestations of his or her disorder. This trenches

individual

upon the problematic distinction between “illness” and “personality”, discussed earlier. However, there is here a further issue of some importance. Certain patients, because of the nature of their difficulties, will pressure others into treating them as if they really are passive recipients of an illness. This was well illustrated in the vignette with which I started this chapter. Mrs C, at least in the early part of the consultation, presented herself as a kind of passive object, but it was not too difficult to break through this self-objectification. There are patients, however, who firmly resist any alternative that tries to engage them in an active way—that is, they welcome self-objectification. Some psychiatric approaches can, unwittingly, collude with this objectification when they seek to treat the illness as if it really could be alienated from the rest of the personality. Here the language of “medical treatment” is based on a false

analogy with physical medicine. It suggests that an individual’s suffering is best considered within the logic of illnesses and their treatment as something done to them. It is as if, in just the same way that an antibiotic can attack a streptococcus, an can take out a “depresso-coccus” that has infected the patient or an anti-psychotic can “target” the psychosis, conveying a kind of biological specificity that, in reality, does not exist. There is no symmetry, as regards nosological categories, between infectious diseases and psychiatric disorders (see, e.g., Moncrieff, 2008, 2013). I am not, however, suggesting that medication is not helpful, only that the symptomatic relief it can provide should not be in this way, implying as it does that psychiatric disorders have no connection with the personality of the individual.

antidepressant

overvalued A multi-level approach

A particular strength of the Fitzjohn’s Unit approach is the of psychoanalytic thinking to the system within which patients find themselves. We attempt to be as sensitive to disturbances at different levels within the system as to disturbance in the patient. Although much of our work is with individual patients, this does not mean that we reductively locate pathology primarily or exclu-

application

sively in the individual. For psychoanalysis, causality is complex and multi-layered. Every breakdown takes place within the context of human relationships and is always determined by a combination of individual, group, institutional, and wider sociopolitical though at any given moment any one of these levels may be more significant than the others.

structures, The psychiatrist Arthur Crisp (personal communication)

conducted a simple study illustrating the systemic contribution to

psychiatric disturbance on a ward. The ward staff logged, on a daily basis, the number of events of acutely disturbed behaviour. Each incident, as it occurred, was, inevitably, attributed to the problems located in the individual patient. However, the log revealed a more systemic causal factor: the number of incidents was found to rise predictably as the day of the ward round loomed, reaching a on that day itself. The general tension and anxiety caused by the approaching round was a major—and until then unrecognized—factor in the disturbances erupting in individual patients.

maximum When our unit receives a referral, we need, at times, to

consider this broader context. In the same way that a child referred for psychiatric treatment can be understood as being the presenting symptom of a disturbed family, so a referred patient may be

better understood as the carrier of a disturbance that belongs to an institutional setting, so it might be more appropriate to intervene at that level (perhaps by a visit to the service that has referred the patient). It is not unusual, for instance, for a very helpful and detailed referral letter to end with words such as, “I am coming to the end of my work in this service” or, “the unit where this patient has been treated is currently being reorganized” (both indicating more systemic factors that will need consideration). Mr F was a 38-year-old Eastern European man who came from a very severely disturbed background, although he disowned his own knowledge of this. He was admitted to a ward in a hospital after a series of self-harming incidents, including cutting, overdosing, a serious attempt at drowning himself (requiring resuscitation), and throwing himself in front of a lorry while on leave from the ward (resulting in the amputation of his leg). This most recent incident led to his being transferred to a different hospital, which was now responsible for his care. The diagnosis was of “treatment-resistant depression”.

Mr F was referred to the Fitzjohn’s Unit, but, instead of an individual assessment, we decided to consider the broader perspective and offered a consultation to the ward. During the meeting with the ward staff, I learnt that Mr F had been an inpatient for over two years and that the staff’s capacity to manage him was nearing exhaustion. He was relentlessly negative, saying that he had nothing to live for, that his life was entirely meaningless. Ms L, his special nurse, saw it as her job to persuade him otherwise, but without any success. Special care was provided for the patient on a daily basis. In discussion, it emerged that there was a “politically correct” way of talking about him, as someone who was very ill, suffered, was and needed special care. However, during the consultation it gradually emerged that there was another much more negative view of him that was difficult to own. As it became possible to talk more freely, staff spoke of the hatred that was stirred up in them. The nurse who was “specialling” him described how all meetings were arranged by the team, never requested by the patient. The patient would reluctantly agree to come, but would always add, “If you think there is any point”. The staff felt extremely burdened with the dayto-day responsibility for keeping him alive and found it very difficult when the patient said he enjoyed being on the ward, that it was “like being in a hotel”. It also emerged that a number of the nursing staff worried more about this patient than about anyone else, and that this worry invaded their personal lives to the degree that even when they were not on duty they thought about him and phoned up the ward to make sure he was still alive. Each of them felt very alone with this worry, as if it were their own very personal responsibility. The crucial moment came when the senior consultant, Dr J, felt able to describe her distaste at a scene she was frequently exposed to when the patient’s wife visited the ward. The couple would caress each other in a sexually exhibitionistic way, in full view of the staff and patients; it was done just sufficiently to make it clear what they were doing, but not so much that it could be censured. We understood this in the following way: the very public, excited “intercourse” that was displayed by the patient and his wife made manifest the malignant type of intercourse that was taking place between the patient and the staff. That is, Mr F projected his wish to live into the staff, to the degree that they felt continuously responsible for keeping

damaged,

continuous

him alive, and, further, this had become a source of addictive for him. The excitement seemed to derive from at least two sources: from being rid of the burden of a wish to stay alive, but also from a perverse triumphant mockery of the staff, in whom that wish was now located.

excitement

Mr F belongs to that group of patients who project the wish to live, in this way, into other people. Although some patients feel relieved by this process, which may then allow others to help them, this was not so for Mr F, where there was a more malignant relationship. The more the staff owned Mr F’s wish to live, the more he was free of it—it was no longer his concern.7 It is typical of such situations that the staff’s capacity to cope is overwhelmed, as anxiety about these kinds of patients invades their personal life. I have known similar situations in which staff members could not even take a holiday for fear that this would result in a patient’s suicide. As we discussed Mr F’s situation further, we learnt that the patient’s wife had made a formal complaint against the previous hospital: he had been considered well enough by them to be given leave but then made a suicide attempt. We also learnt that six months previously there had been a successful suicide of one of the patients under Dr J’s care, resulting in an exhausting inquiry in which some blame was levelled at the ward team, unjustifiably in Dr J’s view. Thus, one can see how different levels within the system—the patient’s inner world, his relationships with staff, the recent history of the consultant and her team, the institutional setting, hospital procedures, and broader NHS policy—all interact to produce and maintain this very disturbing situation. In order to provide care for Mr F, it would be necessary that those looking after him be helped not to have to take full personal responsibility for whether he lives or dies. That is, although they may inevitably end up feeling responsible, it is important that this position not be supported externally.

appropriate

It is also very important in these situations that no individual

member of staff be psychologically isolated with the patient and that the team make sure that they regularly discuss their with him. This can help minimize the splitting processes—for

involvement

example, where one staff member is idealized and another denigrated, or one staff member is left holding unrealistic hopes for the future of the patient. (For the earliest but still one of the finest discussions of these processes, see Tom Main’s seminal 1957 paper “The Ailment”.) This more systemic approach was formerly embraced in many

quarters by mainstream psychiatry. However, the current context— particularly the marketization of health, which necessarily costs treatments in terms of individual patients—weighs very heavily against consideration of these systemic factors. Where staff members do become the focus of attention, it is

now less often in order to understand or appreciate their role in a system. Instead, they become the objects of blame, with accusations frequently being directed at individual members of staff. Without a multi-level understanding, supervision is in danger of into surveillance, where staff feel less supported and more criticized as untoward incidents are attributed to their individual failings. (See chapter 8, by Marcus Evans, for a comprehensive discussion of such situations.)

degenerating

Conclusion It is clear, then, that although the psychoanalytic attitude has not necessarily sat easily with certain forms of psychiatric thinking, it has until recently been able to maintain something of its in psychiatric institutes and in the teaching of social However, as I have discussed, the situation has transformed dramatically in England and Wales over the last decades. The change has not derived from any new discoveries, or even from anything internal to the mental health system, but, rather, from huge shifts in our cultural and political landscape over the last thirty years. Neoliberalism, which manifests itself as the penetration of the market form into all spheres of life, health care, has led to the near hegemony of a world-view in which society is (mis)understood as an aggregate of individuals, each seeking to satisfy his or her own needs (for further discus-

position workers.

increasing including

sion of this, see Bell, 1997, 2013). This results in the domination of the nomothetic perspective and the consequent industrialization of human suffering. Inevitably, what is lost is a more complex, ideographic understanding of the individual as a unique being whose suffering occurs within the narrative of his or her lived life and the human relationships that surround him or her. We in the Fitzjohn’s Unit have been swimming against the

tide, trying to preserve and develop a different way of thinking about mental illness, human subjectivity, and culture in general. It is possible—and only just possible—that with the increasingly critical evaluation of the role of medication in psychiatric together with the realization that the claims for the success of brief therapies have been grossly exaggerated, and perhaps the re-recognition that individuals are bio-psychosocial beings in their culture rather than diagnostic labels, the tide may be beginning to turn.

disorder,

embedded Notes

Parts of this Introduction have been adapted by permission from D. Bell, “Psychiatry and Psychoanalysis: A Conceptual Mapping”, in A. Lemma & M. Patrick (Eds.), Off the Couch: Contemporary Psychoanalytic Applications (pp. 176–193). London: Routledge, 2010. 1. Perhaps a word of caution is needed as regards the very term “biological”, as its use here is really a misuse. A biologist is always interested in the interactions between an organism and its natural environment. If the biologist wants to understand what is ailing a tree, she or he will examine the soil, the climate, the surrounding trees, etc. So, if a “biological” or “medical” made in a psychiatric context, is derived solely or entirely from material endogenous factors, then this, in fact, constitutes a parody, or even a of biology and medicine. 2. I am aware that I am touching on an important epistemological issue that cannot be dealt with here in any detail. For some, meanings and causes are entirely distinct phenomena, while for others it is the intertwining of meaning and cause that characterizes the human subject. It is this latter view which is consistent with psychoanalysis as discussed here. 3. In the psychiatric literature, there is a growing sense that that the between mental disorder and personality disorder (which underlies the differentiation of axes in DSM–IV) is questionable (e.g., Westen, Gabbard, & Blagov, 2006).

decision, perversion,

distinction

4. This commitment, to the restoration of continuity to that which appeared to be discontinuous, again manifests the developmental perspective, as above. 5. The popular term for this state is, of course, a “breakdown”, and in many ways this is quite accurate, as the cause of the disturbance is a in the capacity to maintain the defensive structure. The consequent state is usually of mixed anxiety and depression, and this was the usual diagnosis up to the 1980s, when, instead, many of these cases came to be diagnosed as suffering from depressive disorder. The phenomenology, however, remains the same although the label is different. 6. For an excellent discussion of the subtle but profound effects of this need for psychic equilibrium, see Joseph (1989). 7. Hanna Segal (1993), making use of clinical and literary material, an excellent account of this kind of triumph over the wish to live.

discussed breakdown

provides

CHAPTER ONE

Finding a way in: the work of the Fitzjohn's Unit Birgit Kleeberg

The young woman spoke slowly, with long gaps interrupting her sentences, which left me trying to hold on to fragments. Although she made a great impression on me, I struggled to remember what she had said. She avoided meeting my eyes. She spoke of mood swings, of feeling confident, then very low. She told me she used to cut herself, but that was years ago. I said coming here felt dangerous. She laughed and admitted to feeling extremely anxious. A bit later I commented that she avoided looking at me and said that she may feel that she needs to shield me. Then she did look at me and I found encountering her gaze difficult. It was as if the once established, could not be broken off again. Our eyes were locked together. I felt she had got right inside me.

connection,

I suggested that she was anxious about what she would do to me and what I would do to her. She told me she had broken up with a boyfriend yet again; it was the third relationship she had ended this year. She said she “hurts people”.

BIRGIT

KLEBRG

She told me that she did not regret having gone to the ward when she was hearing voices telling her to cut herself, as it had led to her getting some help. When she had first sought help, she thought the problem could be taken away completely and, while she still wished for it, she now did not think it likely. I thought she was serious about wanting my help and yet felt we had not covered much ground. I felt I was being too abrupt when I told her we had to finish, as if I was dropping her into the void. What was strange was that our first meeting felt simultaneously so intense and yet so thin. I felt relieved that I would be able to think about this disquieting experience with my colleagues in the staff seminar. With this account of my first assessment meeting with a young woman whom I shall call Ms K (whose progress I shall trace throughout this chapter), I hope to take you straight to the heart of the work of the Fitzjohn’s Unit. It shows how an extreme, disordered psychic situation can begin to be talked about by the psychotherapist and the patient. It also already points to the of the structures that provide containment for the therapist, helping her recognize unconscious aspects of what has been going on between her and her patient.

importance The history and approach of the Fitzjohn's Unit

The Fitzjohn’s Unit began life in 2000, evolving as part of the clinical services of the Adult Department of the Tavistock Clinic and embedded within the department’s psychoanalytic culture. It was started as an experimental project by David Taylor who was succeeded as the unit’s consultant by David Bell in 2002. Not long after that Mrs Edna O’Shaughnessy, a distinguished senior was invited to join the unit as its external supervisor. There had, for some time previously, been a broad recognition that a significant group of patients were particularly disadvantaged by the limitations of the generic treatment model of the service, which offered once-weekly psychotherapy for one year. These individuals

psychoanalyst,

THE WORK

OF THE FITZJOHN

’S UNIT

tended to suffer from more serious levels of pervasive and longterm disturbance. We recognized that, after a year’s treatment, we had only just begun to make any significant contact with them and that, in some cases, ending the therapy then risked losing even the small gains we had made. It was therefore decided to develop a specialist unit that could address these patients’ problems in a more appropriate manner, and over the following year or two we developed the model that has become the foundation of our work. We created a specialized service where patients receive twiceweekly sessions of individual psychotherapy for two years with an experienced psychotherapist, followed by group for a further number of years. This model was adopted and adapted from one used at the Cassel Hospital, an inpatient community for more disturbed patients, where both David Bell and I had previously worked at different times. I explore in more detail later in the chapter what can be achieved in the first phase of individual psychotherapy. As far as the latter part of the treatment—the group—is concerned, its aim is to the developmental process begun in the individual therapy. In addition, the group provides an opportunity for its members to learn something about themselves as reflected through the and observations of others, their fellow patients, who can speak to them far more directly—and often bluntly—than a therapist ever could. It can help to reveal their social strengths as well as the recognition of the pressures that their problems create for them in new relationships—how these difficulties come to be re-enacted, but also tackled. We think that it is helpful to enable our patients, as far as is possible, to determine their own discharge and thus to face and work through an ending in a manageable way. It is for this reason that the length of time they are able to spend in the group is more flexible than it is for the individual therapy. (See chapter 7, Maxine Dennis’s chapter on groups, for further of this work.)

psychotherapy therapeutic

continue perceptions

elaboration In 2003, the Government published a document, Personality

Disorder: No Longer a Diagnosis of Exclusion, highlighting the plight of patients with long-term disorders arising from profound problems who were excluded from mental health services (on the grounds that they did not suffer from illnesses, as such) (NIMHE, 2003). This proved to be strategically very useful in the

character

development of the Fitzjohn’s Unit, in that it provided incentives for other services to refer this group of patients to us for help. While encouraging the referral of patients with features of personality disorder, we also attempt to retain a broader remit in terms of the types of patients we accept. Unlike most personality disorder services, we do not insist that our patients meet “official” diagnostic criteria for personality disorder. Our broader inclusion criteria thus give us a unique place among other local services, and this is increasingly appreciated by referrers and patients alike. David Bell is well known for his long-standing interest in

working with more disturbed patients. For some years he ran a psychosis workshop in the Adult Department at the Tavistock Clinic,

where staff and trainees would come to discuss their work with the most difficult of patients. He brings the benefit of his experience, as both a psychiatrist and a psychoanalyst, to the management of the challenging and risky situations that we face in the unit. While conducting a large proportion of the assessments in the unit, he will often take on the assessment and case management of patients who require particularly close liaison with psychiatric and other personality disorder services.

considerable

As the chair of the weekly unit meetings, where complex

management issues are discussed, he takes the lead and assumes responsibility for concerns about how to deal with risks and crises in treatment. He may, for example, agree to meet with a patient who has acted in a threatening way towards his or her therapist, in an attempt to assist the patient either to return to therapy in a different frame of mind or to come to terms with the possibility that the therapy may no longer be viable. By representing the work of the unit, both internally within

the trust (to the board of governors, for example) and externally (by establishing links with the heads of other services), David Bell enables us to provide better, longer-term care for our patients. from other services within the Tavistock and Portman NHS Trust are encouraged to bring complex cases for discussion in the unit meeting. We are also approached to consult to mental health services from other trusts, such as an inpatient team struggling to manage a particularly difficult patient. Occasionally an invitation will be issued to the team to come to our unit meeting to present the situation that they are struggling with. The ensuing discussion

Clinicians

then also provides a learning opportunity for all the members of our own unit. Having worked in the unit from its inception, I joined David

Bell as co-manager in 2005. We have developed a model of the responsibility of leading the unit between two people, which has worked very well. It is the only clinical unit in the adult service that is managed in this way. This again leans on our experience at the Cassel Hospital, where we had learnt the value of a “couple”—either psychotherapist and primary nurse, or and senior nurse—working together to contain various levels of disturbance.

sharing

consultant

There is another weekly meeting, the staff seminar, led by Mrs

O’Shaughnessy, who does not attend the unit meeting. This forum is only for those who have patients in treatment and therefore is not open to outside visitors. David Bell made a decision not to attend this seminar so that it could proceed unconstrained by the consideration of management issues. Highly valued by the staff group, the staff seminar provides a space to think together freely and creatively. An important feature of the seminar is that clinical work is presented and discussed in an open and trusting manner, centring on the material brought and eschewing any judgement of the therapist. When something is missed or has gone wrong in a session, there is an understanding that this might have to anyone working with the patient. At the end of a the presenting therapist will frequently be told, “We’re right behind you”. This expression has now been adopted as a kind of wry mantra as it seems to capture and acknowledge both the reality of being on one’s own with the patient and the solidarity provided by the group.

happened seminar,

It is the structure provided by these two different meetings—

the unit meeting and the staff seminar—that has enabled us to create and maintain strong staff morale, perhaps one of the most critical factors necessary for containing the high levels of created by the nature of our work. The clinicians on the unit are all qualified, experienced many of whom had their psychotherapy training in the Adult Department. A substantial number are psychiatrists and/or psychoanalysts; some have a background in philosophy and studies. We also provide an advanced two-year clinical training

disturbance psychotherapists,

literary

for qualified psychotherapists who wish to learn about working with more disturbed patients. As honorary psychotherapists on the unit, they are each assigned a patient for whom they provide psychotherapy. They are offered supervision and some theoretical seminars, attend all meetings, and contribute greatly to the life of the unit. The diversity of the staff group, who come from countries of origin, intellectual and professional backgrounds, and schools of thought within psychoanalysis, makes it a rich and rewarding environment in which to work.

different How people become our patients

Referrals to the unit come from a number of sources, regularly from GPs and psychiatrists based in local mental health, but also from psychology, the Improving Access to Psychological Therapies (IAPT) programme, and student counselling services. The large majority of patients referred proceed to assessment. However, the term assessment is perhaps not quite right, as it might suggest a kind of examination, a test to be passed or failed. When conducting our assessments, we are, in fact, not looking to the patients to prove themselves. Our default position is that the patient can be helped unless there are very good reasons that make it unwise to proceed—for example, if we feel that the risk of deeper engagement outweighs the likely benefit. The assessment consultation provides the foundation on which all subsequent engagement is built. As described in David Bell’s Introduction, the approach foregrounds the way in which the patient relates to us, as only this can provide the basis for an adequate assessment of what the patient is seeking and to what extent she or he can tolerate the therapeutic process. As shown in my account of my first meeting with Ms K, it often becomes possible to talk to patients quite directly about matters they well may have been aware of but never believed could be talked about so openly. When this happens, there is often a shift in the atmosphere. This kind of emotional contact can be very fleeting, but it provides an important indication of a patient’s capacity to form a therapeutic alliance. One might expect that

palpable

someone’s availability for understanding, the capacity to be in his or her own mind, requires the person to be relatively less disturbed, but this is not necessarily the case. It is not unusual to find that very disturbed patients, including some who would be classed as psychotic, respond well to attempts to understand them and go on to make good use of psychotherapy. (For a more detailed account of our approach to assessments, see Bell & Kleeberg, 2013.)

interested

Returning now to Ms K, the staff seminar group noted that, on the one hand, she was quite amenable and tried to please the assessor. On the other hand, there was a more hostile, perhaps paranoid state of mind. This became more evident in the second assessment meeting in which she described how friends had trashed her room and vomited in her bed. It seemed that her deeper fears were managed through projecting them outwards, locating them in someone else. There was also, however, some awareness of—and guilt about—the harm that she believed she caused to others and herself. From the consultation, it was clear that the patient experienced a deep terror of being trapped in a tormenting world of deteriorated inner objects that had been damaged by her attacks. This brings to light how what we might describe, from the outside, as “depression” can be lived as an internal, largely unconscious experience. As well as being depressed, Ms K also felt persecuted by paranoid fears which she knew about and which I took up right from the start.The was prematurely intense and lacking in depth—what we might call a borderline or psychotic transference (Bion, 1957). In the initial discussion, we thought that Ms K was too claustrophobic and anxious to tolerate twice-weekly sessions, so she was put on the waiting list for once-weekly psychotherapy. After a six-month wait, she began her therapy with me.

transference

Inevitably, because of limitations on our resources, patients have to wait—often for many months—before they can begin Some patients find this too difficult and drop off the list. This was, we thought, partly a result of first being invited into the intimate and disturbing contact of the assessment, but then feeling left to manage on their own. We therefore decided to ensure

psychotherapy. waiting

that all patients on the waiting list are seen by the assessor, at intervals according to need, usually every four to six weeks. This enables a continuing containment, which can help them and so sustain their interest in having psychotherapy.

varying manage As is perhaps already clear, the patients are not only disturbed

but also disturbing, so we have found it helpful to insist that no individual clinician in the unit take full or exclusive responsibility for any patient. When difficulties threaten to lead to a breakdown in the relationship between patient and therapist, the assessor becomes a case manager and can thus step in to give another view of the situation in order to help the patient to remain in therapy. We have found that this separation of responsibilities between the psychotherapist and the person who helps to manage crises makes for a much better structure. We therefore, as far as possible, try to ensure that the psychotherapist offering treatment is not the same person as the assessor (though, as in Ms K’s case, this is not always possible). Keeping assessor and therapist separate serves as a particular

resource for the patient. For example, the assessor also carries out the review, which usually takes place a few months after a patient has completed his or her individual psychotherapy. This meeting aims to help patients reflect upon what has been achieved and whether or not they are interested in entering the second phase of the treatment programme, the group psychotherapy. The of the group treatment marks another juncture where they might again touch base with the assessor. Despite our limited resources, this structure enables us to provide a continuity of care that is an essential part of the approach of the unit.

conclusion

Many of our patients are concurrently being managed by local

mental health services, something we actively encourage, as we are not an emergency service and so cannot offer help in an acute crisis. It is important to maintain close liaison with these services, while at the same time protecting the psychotherapy itself from potentially damaging intrusions. Again, the person for this kind of liaison is not the psychotherapist, but the or sometimes another therapist on the unit. However, when the patient is discussed at a unit meeting, both the psychotherapist and the case manager are present—so the boundary between the

particularly

responsible assessor

two functions can perhaps best be described as a kind of “semipermeable membrane”.

A more detailed look at who our patients are An audit of cases referred to the Fitzjohn’s Unit over a two-year period (2011–2013) showed that the average age of patients was 40 years and 77% of them were female (Wood & Mills, 2015). The picture is of a patient group with long-standing serious difficulties, usually dating from childhood or adolescence (69%). The majority report having had problems within themselves and in their with others for as long as they can remember, and many have found social interaction unmanageably exhausting. Some feel they lose their sense of self when with others, and yet on their own they feel very alone and empty. Many say they don’t want to be alive, that they are unable to move forward and feel stuck forever in a “living hell”.

relationships

In addition to other diagnoses that they may have been given

over the years, a significant number of our patients have a of recurrent depressive disorder, but this label does no justice to the complexity and depth of their difficulties. What they from is ongoing and life-long and might more accurately be described as a depressive personality disorder. There is a history of abuse and severe trauma in a large proportion of our patients, and suicidality and self-harm are common features. The damage they inflict on themselves can take many different forms, such as restriction of food, binging and vomiting, cutting or burning themselves, overdosing on pain killers, or severe bouts of drinking. Some will have been diagnosed with bipolar disorder, others will have had periods of hospitalization under section during manic or depressive episodes.

diagnosis suffer

The majority of patients treated on the unit will have been

unable to sustain employment for many years, sometimes despite good academic achievements. Others manage to hold down jobs but may become troubled when they are promoted to positions that bring new stresses, the most difficult change often being one

that requires the patient to deal more directly with greater numbers of people. A few manage quite demanding jobs by cutting off from their disturbance—that is, they live in a kind of state. In such cases, when the psychotherapy progresses, defences can temporarily break down and work colleagues may become more aware of the patients’ difficulties. This, of course, needs careful managing. Our patients have usually had many previous therapeutic interventions—including medication, other forms of and psychiatric admissions—before they are referred to our service. This high proportion of failed previous attempts at treatment indicates a group of people who, because of the toxic transferences they form, find it difficult to establish a relationship. In some cases, this occurs within the context of having made a complaint against their local service. This is a special group, and the outcome is difficult to predict: some are able to work through the complaint and engage in a therapeutic process, while for others history unfortunately repeats itself. even in these situations—that is, where a complaint is made against our service—it remains very important to work with the patient to try to understand the nature of the complaint and the psychic reasons for making it. In some cases, there can still be a good therapeutic outcome.

themselves dissociated

psychotherapy,

constructive

However,

The most common ICD-10 diagnoses for our patients were

recurrent depression (F33), specific personality disorder (F60), and bipolar affective disorder (F31). Forty-three per cent of the cohort presented with some form of diagnosable personality disorder, 63% with serious affective disorder. The most common were between these two diagnoses.

comorbidities Assessment reports highlighted the presence of suicidality in

40% of the sample; PTSD, dissociation, a history of abuse, or severe trauma appeared in 46%; personality disorder, including paranoid traits, were detected in 33%; and self-destructiveness, self-hatred, and the risk of harmful behaviour to the self was manifested by 20%. In terms of psychoanalytic formulation, the most commonly observed qualities were suppressed anger, self-hatred, narcissism and grandiosity, and elements of dissociation, denial, or In half of cases, there was explicit mention of physical health problems, with a quarter having physical symptoms possi-

defensiveness.

bly related to mental health disorders, including eating disorders, and 23% presenting with what were apparently psychosomatic disorders. The frequency of comments relating to previous failed attempts at treatment (57%) indicates a population that finds it very difficult to establish a constructive relationship to sources of help or is particularly sensitive to inadequacies in the care Just over half the sample was unemployed. Just over half of referred patients were offered treatment; of these, a quarter were categorized as declining treatment.

provided. What change can psychotherapy bring?

Most services that make use of a psychoanalytic model are aware of the need, in many patients, for longer-term work, resources permitting. When the end of the two-year period of individual psychotherapy arrives, many Fitzjohn’s patients feel it has come far too soon. The findings of the Tavistock Adult Depression Study (TADS;

Fonagy et al., 2015), which has explored the efficacy of longterm psychoanalytic psychotherapy for patients suffering from chronic treatment-resistant depression, are illuminating.1 As the first fully randomized trial of managed long-term psychoanalytic psychotherapy, TADS provided important evidence for its efficacy. Although not identical, the patients included in this study have much in common with the patient population in the Fitzjohn’s Unit, in terms of diagnoses, chronicity, and their resistance to other forms of treatment. A crucial discovery that emerged from TADS was that many

patients only began to experience any robust improvement when they were into the second year of treatment. Having followed participants post-intervention, another important outcome of the study was that nearly half of patients who had been offered psychoanalytic psychotherapy were still seeing major two years after the therapy had ended. This is very much in contrast with other forms of psychological treatment. Thus, the study has confirmed and corroborated our clinical impression that when psychoanalytic psychotherapy works well, it sets in motion

improvements

a developmental process that continues to be active in the patient after the therapy has ended. I discuss the ways in which we understand the gains from treatment later in this chapter, but first I return to Ms K to provide a picture of what was achieved in her two-year psychotherapy. As was to be expected, Ms K was ambivalent about the therapy, both wanting to engage in understanding herself while at the same time fearing being trapped in something she could not escape. Nonetheless, she engaged well with the work, and after some months we increased her sessions to twice weekly. She missed many sessions, often around the times of my breaks, though always giving very plausible external reasons. Ensuring that I was the one who was left, not her, protected her from feeling abandoned. Over time she was able to bring more of her history, particularly in regard to her relationship with her mother, who had suffered difficulties conceiving the patient, her first child. The patient felt that her mother had “loved her too much”. From an early age, she was told by her mother that she was her favourite, and this had made her feel deeply guilty and anxious in relation to her less but steadfast father and her younger sister. At age 10, when her mother became depressed after the unexpected death of her own mother, Ms K felt that there was no point in going on living.

serious

successful

This dynamic pattern of relatedness, based on Ms K’s internalized early experience with a mother who was felt to be either too close (as when she told her she was her favourite) or too far away (as when her mother became emotionally withdrawn during her own episodes), was relived in her relationship with her therapist. She needed me to be very close, but then she would get panicky about feeling too needy and dependent and would miss sessions. At times she reported paranoid thoughts—for example, that a person in the lift who did not press the button for a particular floor was put there to watch her and to report back to me. This revealed her view and treatment of me in the transference as the intrusive mother who would not allow her to live her own life.

depressive

Her claustro-agoraphobic dilemma (Rey, 1986) also affected her relationship with her boyfriend, which continued to be tempestuous.

When she was staying with him, she tended to lose a sense of herself and her ability to work. She was a bright student, but she often failed to hand work in on time, as if, again, a proper, thoroughgoing with her studies felt like too much for her.

engagement As is evident in this material, the patients we see are heavily predisposed to developing serious psychological disorders, through

a combination of endowment or predisposition and disturbing experiences early in life. It is very difficult, maybe impossible, to disentangle one from the other. Sometimes the early trauma is very stark—for example, where there has been emotional, physical, or sexual abuse. Whatever their sources or origins, because these early developmental processes have not been worked through successfully, they continue to dominate the lives of these patients, leaving them limited in their emotional capacity and vulnerable to breakdown. Inevitably, the frightening and persecuting inner objects are transferred into the relationship with the psychotherapist, who may thus have to bear long periods of being experienced in a very negative manner. The therapist’s capacity to endure this requires considerable experience and can be of the utmost importance for the patient’s welfare. In this way, tormenting relationships can be relived and worked with in their present manifestation and over time, be modified.

gradually, At the same time, patients also develop a capacity to contain

their own disturbing states of mind, and this, in turn, creates a greater self-awareness and self-acceptance, together with a to see others as they really are. These psychological can bring about reparative wishes and an increased ability to consider another person not only as an object, but as a subject with his or her own history and experience. This leads to improved interpersonal relating, and, instead of a vicious circle, a more benign circle can develop.

capacity developments

As the therapy approached its final quarter, Ms K unexpectedly became pregnant. She was tormented by doubt as to whether to proceed with pregnancy or to have an abortion. Her boyfriend and her family wanted her to have the baby. She allowed the pregnancy to continue but again broke up with her boyfriend, as she felt threatened

by a sense of losing her own identity when she was with him. she maintained some contact with his mother.

Nonetheless,

While pregnant she was filled with an almost delusional belief that the child was doomed to repeat her own experience of unremitting suffering, that nothing could be done that would prevent her from passing the depression on from one generation to the next. In the final trimester of the pregnancy, there was, however, a rapprochement with the boyfriend. She felt he should be involved with the baby, and this showed her increased capacity to think of him as a separate person, with a mind and capacities of his own, someone who might make a real contribution. Nonetheless, in the staff seminar we noted the psychotic manner in which Ms K felt that being separate was akin to murder, and thus birth itself was linked with enormous danger. Of course, the other separation that was looming was the end of her psychotherapy. She was managing this through missing many sessions and, in so doing, avoiding having to engage with what was evoked by this separation. There seemed in her mind to be a confusing parallel between herself as the one who would give birth (thus causing a murderous and as the one who would herself be pushed out into the world by me when the therapy ended. In her identification with her own baby, this must have felt as if I were about to mount a similarly attack upon herself! She may also have stayed away because she feared that all I could do was to project my own depressive into her or her baby, and thus her terror of an intergenerational transmission of trauma and depression would be re-enacted.

separation)

annihilating feelings

Prior to the birth, Ms K moved to where her family lived (a long way from London). We agreed she would have a final session after the birth when she felt ready to come to see me. Our aims are modest. We do not expect very ill patients to emerge from therapy in a radically altered state. Indeed, it is often a major achievement—for the psychotherapist as well as the patient—to throw off the tyrannical idea that the patient should recover. Even individuals who are unable to change very much can find the experience of being understood and accepted as they are to be both profound and immensely valuable. Patients may realize that

they will always be ill, but they may nonetheless feel that has changed. Progress can only be measured in the patient’s particular terms.

something

When Ms K came to her final session some months later, I had the startling sense that my patient was the baby who had finally been born. There was a striking visual aspect to this, as she had cut her hair very short, giving her the appearance of someone newly born: instead of her baby, she had brought me herself as a baby. She felt greatly moved and relieved by the birth of her son. He was separate and different. I have no doubt that his being a boy was helpful to her in this regard. She had had some difficulty breastfeeding him and had changed to bottle-feeding quite soon after his birth, which her mother had disapproved of but she felt comfortable with. She had not suffered any major post-partum breakdown (I had thought severe post-natal depression a real possibility). Reparative feelings had been strengthened, and she was in the process of establishing a more mature relationship with her son’s father. She wanted them “to be a family”. We were, however, under no illusion that she was completely cured. She remained susceptible to paranoid and depressive anxieties and seemed relieved when I talked about the possibility of group in the future. I think it was important to her that I remained aware of her ongoing difficulties, while also being able to recognize the considerable development that had taken place. She said I had helped her more than she had ever thought possible.

psychotherapy

Note 1. The Tavistock Adult Depression Study (Fonagy et al., 2015) was the first fully randomized controlled study of a manualized long-term psychotherapy (LTPP) for treatment-resistant depression. The LTPP group received once-weekly psychoanalytic psychotherapy for 18 months with an experienced psychotherapist. The control or treatment-as-usual (TAU) group received interventions as directed by the referring clinician, mostly medication, with or without cognitive behavioural therapy. Improvements in depression were modest but comparable between the LTPP and the control group until termination of treatment, but important differences emerged from

psychoanalytic

24 months post-randomization, with the LTPP group mostly maintaining the gains achieved while the control group seemed to be at greater risk of relapse. At two-year follow-up, almost one third of the participants who received LTPP were still in partial remission, compared with only 4% of those in the control group. At that time, 44% of the LTPP group no longer met diagnostic criteria for major depressive disorder, compared with 10% of those receiving TAU alone.

CHAPTER TWO

Looking both ways: the role of the administrator in the Fitzjohn's Unit Crispin Lane & Camilla Nicholls

This chapter is based on an interview we conducted with the Fitzjohn’s Unit administrator, Ibironke Aboyade (Ibi). We are very grateful to her for her cooperation and, as will become clear, for much else besides. The Roman god Janus ranked coequal in the pantheon with

Jupiter and was unique in being ritually invoked at the beginning of each and every religious ceremony. He was clearly crucially significant. He was the god of beginnings and also of endings, of transitions, of birth and journeys and exchange. He is particularly associated with thresholds and doorways, the limina or from one space to another. He gives his name to the month of January, the temporal junction of the old and the new. Janus is invariably represented as having two faces, one aspect facing the other back. Ibi, the tutelary spirit of the Fitzjohn’s Unit, could be aptly seen as our Janus.

passageways forwards,

In addition to being the administrator for the Fitzjohn’s Unit,

Ibi’s job in the Adult Department of the Tavistock Clinic also involves working with the generic psychotherapy units, the Unit, and the Trauma service, so that she is answerable to about sixty clinicians and many more patients. She says that for her the Fitzjohn’s is most similar to the Trauma Unit, but that there is

Couples

CRISPIN

LANE

& AMILLAC

NICHOL S

a particular “feel” to Fitzjohn’s patients that is instantly This “feel” is partly attributable to her experience of these patients’ tendency, in the course of a conversation, to transform with bewildering rapidity from one tone and attitude to another that seems entirely cut off from the first. This may be linked to their capacity to disregard boundaries: should a patient intrude into Ibi’s fourth-floor administrative office, having ignored and bypassed the gatekeeper at ground-floor reception, demanding immediate access to their therapist or to see their file forthwith, Ibi will tend to understand immediately that this is “one of ours”. Sometimes, when a colleague in administration receives a call about a case, “you can tell immediately it’s a Fitzjohn’s patient by the expression on their face—they quickly want to pass it on”.

recognizable.

We are all aware of how certain front-line or “public-facing”

roles—for example, staff on the railways or in banks—may be peculiarly subject to high levels of uncontained, potentially levels of acting-out (this phrase signifies the performing of an impulse rather than managing and thinking about it). Often employees in these environments have the support of “zero-tolerance” signage, making it very clear that the grosser forms of verbal and even physical insult will entail refusal of service, and perhaps further sanctions besides. Receptionists in GP surgeries—and any GP will readily concede how valuable their receptionist is to their practice—frequently have to contend with people whose behaviour may become distorted under the pressure of pain and anxiety. Similarly, the very disturbed people we see in the unit are often felt to be quite as troubling as they are troubled and sometimes arrive with a history of having been difficult to manage during their psychiatric “careers”. However, there is no zero-tolerance policy in the Fitzjohn’s Unit; on the contrary, we hold rather a profound belief that difficult behaviour needs to be met with the creation of a space in which at least one person in the interaction can hold on to thinking and the search for meaning and Though Ibi has no specialist training, she is required, as she puts it, to “handle” patients; she says that she has had to learn to do it her way, that “it’s a personality thing”.

offensive

exclusion,

understanding.

As soon as any clinical referral to the Tavistock is made, there

tends to be a diffused transference to the institution as a whole

LOOKING

BOTH

WAYS

(often literally concretized in the patient’s impression of the building itself), which later becomes refined and condensed into the figures of the assessor and later the therapist. Ibi, as the first human agent with whom a patient is likely to have contact, will also be the focus of powerful projective processes. She will write and speak to the patient at the referral stage, liaise throughout the assessment and while the patient is maintained on the waiting list (when he or she will be offered regular “holding” consultations with the or lead clinician), and of course function as passage and filter throughout the treatment.

assessor

She will usually be the first person with whom any prospective

patient will have a substantial conversation, and, although this is meant to be practical in nature, it is often replete with meaning. Ibi is sensitive to these other layers and knows that the impact of the proverbial “first impressions” may be held in the patient’s mind for a very long time. The extent to which such first impressions may be modified or mitigated over time can be a barometer for any of change in the patient’s inner world. This obviously applies to the transference to the therapist, but many patients also report their dealings with Ibi in their sessions, and it is fascinating to see how their fantasied relationship to her can alter over time and as the therapy progresses.

indication

She has, on average, ten telephone contacts with the unit’s

patients per day—very conservatively, around two thousand calls per annum. Thus far she has prematurely terminated only one call because of a patient making it impossible to continue (she subsequently called the patient back within minutes and was able successfully to resume the contact). This is a remarkable statistic. Again, we should stress that Ibi has no dedicated training to help her in this challenging work; she has to rely on her own resources. In the above instance, the patient was unable to accept that his therapist was not immediately available and could not hear or take in Ibi’s assurance that she would get a message to the therapist as soon as practically possible. She made several attempts to explain the situation and to reassure him that she was trying to help, but the patient was not able to listen to her. One might even suggest that it was the reinstating of a boundary by means of the gap—that is, the brief silence between the first call being terminated and Ibi’s calling back—that seems to have helped the patient to recognize

that a real barrier existed and had to be acknowledged. In effect, this issued a useful challenge to his omnipotence which was, as is so often the case, a defence against his helplessness. Ibi explains that she frequently encounters the perturbing

lability of these patients during the course of a call, so that one moment a patient may be threatening to cut him/herself or jump off a bridge, and the next, “it’s like you’re talking to someone else entirely”. There is a guideline that administrative staff should not be on the phone with a patient for more than five minutes, but Ibi exercises her own careful judgement in order to find an moment at which to end a call without merely guillotining the contact.

appropriate

Henri Rey’s (1979) description of borderline or schizoid patients

captures accurately what it is like to encounter the immediacy and rawness of their emotional world. There is very little “as if” here. He says of these patients that . .. they rapidly and transiently form an identification with their objects, and experience a loss of their sense of identity with the self. . .. They are demanding, controlling, manipulating, threatening and devaluing towards others. They accuse society and others for their ills and are easily persecuted. This may be associated with grandiose ideas about themselves. In fact, their feelings are dominated by phantasies of relative smallness and bigness. When threatened by feeling small and unprotected and in danger they may defend themselves by uncontrollable rages and various forms of impulsive behaviour. [p. 204]

He goes on: “schizoid communication . .. often takes place at a level of ‘merchandise’, a sort of barter agreement in which the subject feels himself to be given ‘things’, made to accept ‘things’, and where ‘things’ are done to him” (p. 205). Thus, Ibi is involved in such transactional relationships with patients where the “things” to which Rey refers are actualized and reified as letters, telephone calls, negotiations over appointments, and so on.

necessarily

Another manifestation of the mode of relating that Rey focuses

on is the consequence of these patients’ exquisite sensitivity to humiliation and debasement. This takes the form of a ferocious reaction in which a grievance may be pursued with vengeful malignance because of the hatred provoked by a felt attack on a

wounded, helpless self. These are people who are prone to complaints, and, along with most of the therapists in the unit, Ibi has also received her share of grievances, threats, as well as complaints.

launching

These attacks are extremely upsetting: after all, one’s immediate

reaction to being the subject of a formal complaint is quite to worry that one’s job, one’s livelihood, may be under threat. Ibi says that one of the first callers she had to deal with in the unit was someone who, in short order and by turns, yelled at her and demanded her name in order to report her. She says, “I didn’t like that. I had done nothing to this woman”—the feeling of being dealt with so unjustly was obviously hard to bear. She adds, “I am beginning to understand the kind of patients they are, and I won’t put the blame on me or blame the clinician”. Neither, however, will she blame the patient. She has the capacity to create a space in which such an attack can be heard and held without or recrimination, a containing cordon that tends to forestall the escalation of acting-out.

understandably

retaliation In her position as the person facing both ways, as the

intermediary between patient and therapist, Ibi is the conduit through

which each partner in the therapeutic dyad communicates when not physically in a session together. To this extent, she can be seen by the patient as either the good and helpful “third” who allows and facilitates a channel through the uncertainty and frustration of separation, or as someone who debars and thwarts. She might be Saint Peter or Cerberus. Because she is pivotal in the transmission of information, she may be co-opted in the patient’s mind, during the assessment period, as the person who is really in charge and who actually determines the outcome of what is often experienced as an all-or-nothing audition.

readily

As clinicians who work with such patients know, issues of

admission and exclusion, in versus out, and the problematic of the claustro-agoraphobic dilemma are central to the experience. It feels impossible reliably to attain a safe space in which one is neither too close to the object nor too far away. patients are often fearful both of being intruded into and taken over and of invading the object and risking retaliation. At the same time, they are also terrified of being utterly alone in an empty void, a black hole that threatens them with total disintegration.

negotiation borderline Borderline

Given these dilemmas, some patients seem most comfortable while being maintained in a holding position on the waiting list, not yet in treatment proper but neither completely out in the cold. This attempt to perch atop the fence, in order to avoid the dangerous, split certainties of an untenable choice, can result in a preference for living in a kind of no-man’s-land. Paranoid-schizoid thinking is the primitive defensive mode of thought that cleaves the ego and the object into good and bad aspects that are then kept apart, as integration is felt to be too threatening to the survival of the good. To be sure, the no-man’s-land alternative can itself be a hazardous place which entails the risk of being shot at by both sides, but, like the central reservation of an eight-lane motorway, it can also serve as a comparative oasis of peace. There is another variation on these vexed efforts to adjust to

the problem of boundaries, one that is very different from the perimeter by crashing through it, but similar to the delicate balancing act of fence-sitting. This is exemplified by those patients who may arrive very early for their sessions and leave very late. They effectively create an extended transition from out to in and back again. Some patients, particularly after their appointments are over, are known to roam the corridors of the Tavistock, half lost and half delighting in their trespass, haunting the interstices. One patient would even come to the building and sit in the staff canteen at his weekly session time during the therapist’s break. He later explained that he had a routine to follow, even if his therapist was not there for the appointments.

ignoring

Of course, it tends to be the administrative staff who are called

upon to deal with these situations, as clinicians are loath to with their patients outside the frame of the session. As Ibi says, “Everyone rings Admin. Anytime anyone rings reception and they don’t know what to do with it, they put it through to Adult Admin.”

interact

So Ibi is a buffer, a hub, a channel. The evocation of the figure

of Janus is underscored when we recognize that patients can (and quite understandably) identify Ibi with the clinicians. She is readily treated as a therapist by a patient in distress: “They call you and tell you about their problems—they’ve called to cancel their session and they tell me about their problems.” She may also be felt to be obstructive and withholding in much the same way

readily

as psychotherapists are easily viewed by patients as remote and unresponsive. She may be used as a kind of transitional object, someone imbued with some of the qualities of the absent therapist, but standing at one remove. More than one patient has begun a by inveighing against Ibi, when it is clear that the real target of the grievance is sitting in the room with them!

session She is also liable to be seen by patients as someone like

themselves, a kind of sibling with whom they have a sense of alliance

and even complicity. She can be subject to pressure from patients who want to discuss their therapist with her. Interestingly, she stresses that it is not so much that she has to discourage the patient from interrogating her about the therapist, but more that she does not want to hear from the patient what they themselves have to say about the therapist. If she has to contact a patient on behalf of a therapist, to inform them of a rare cancellation, she can be put under considerable pressure to divulge the reason for this. As she reports, “‘due to unforeseen circumstances’ is not enough—they want me to explain everything”. The patient, of course, makes the unwarranted assumption that Ibi always knows why a therapist is cancelling. It can also happen that unit clinicians themselves “miscast”

Ibi in these roles, treating her either as a proxy for their patient or as a therapist colleague. Of course, it is her job to “represent” (in various meanings of the word) the patient to the therapist, and her careful and attuned ear makes it possible for her to pass on crucial elements of a patient’s communication (its tone and other “between the lines” subtleties); this means that clinicians receive far more than the bare bones of a message. However, any of us is momentarily liable to mistake the messenger for the source (and perhaps to feel like “taking a shot”), so Ibi also has to tolerate the occasional prospect of the clinician needing a moment to sort out this confusion in his or her mind. Alternatively, we may be subject to the passing fantasy of Ibi being a kind of co-therapist, forgetting that she is not in a position to know very much about any given patient—after all, she does not sit in the sessions with us. In summary then, Ibi is an essential member of the unit, far

more than merely an ancillary or some kind of janitor (though this is another word that is derived from Janus). Her tact and sureness of touch with patients, and her skill in dealing with provoking and

sometimes frightening situations, are functions of her personality and not, I repeat, the product of any formal training. We in the Fitzjohn’s Unit have been extremely lucky to have someone like her manning our phones, liaising with our troubled clientele, and even managing the stresses of the unit’s therapists. However, this should precisely alert us not to rely, in this regard, on mere good fortune or happenstance of character. There is a great need to provide ongoing support, education, and supervision to front-line administrators in mental health settings. Moreover, it would be sorely misguided to think that Ibi might simply be replaced with an iPad, or that there would be no serious degradation of patients’ experience of care if they were to encounter not Ibi’s particular, empathic voice and presence, but a digitized, robotic telephone menu. She very well reflects the culture of what we aspire to in the Fitzjohn’s Unit—to be human, not infallible, but above all responsive.

CHAPTER THREE

The emergence of emotional meaning: a journey through delusional symptoms Hiroshi Amino

Psychoanalysis can be viewed as a joint endeavour between a patient and an analyst, as a mutual search for the meaning of the patient’s life. The analytic experience can help to address a patient’s feelings of emptiness and loss of purpose, but the process can also feel disturbing, threatening, and even annihilating.

emotional

Freud gave unprecedented emotional significance to lives that

had hitherto been considered either meaningless or subject to divine or demonic influences. By introducing the concept of the unconscious and the specific mechanisms of its mental functioning, he first deciphered the meanings of hysterical symptoms and then of dreams (Freud, 1895d, 1900a). He postulated that the state of mind has its own logic and functions according to a process that is alien to the logic of consciousness. Reaching the real emotional meanings of symptoms and dreams can only be achieved by attending to the unconscious. However, any and understanding of emotional experience is subject to the enormous power of resistance mobilized by the overwhelming intensity of feelings such as pain, guilt, terror, fury, and along with the concomitant illusions and phantasies.

unconscious

recognition murderousness,

HIROSHI

AMINO

The dawn and development of mind A baby is born in an unprotected, exposed, and fragile state, both physically and emotionally. He might well feel vulnerable to apart at any moment. Winnicott (1947) famously said, “There is no such thing as a baby”—there is always a mother with the baby to nurture and protect him from any unbearable physical or emotional state. The baby needs to experience consistency in the way he is fed, held, and understood, again in both physical and emotional terms. The baby’s experience of being attended to and understood by his mother affects the baby’s ability to develop the capacity to digest emotional experiences as vital information.

falling

I would like to bring, as an illustration, a brief vignette from the

observation of a baby who was 12 weeks old: A baby boy starts wriggling and whining while incessantly moving his head and body. He lets out crying sounds. The mother holds him under both his arms in an upright position. He stretches both feet, as if standing. He grizzles and moves more frantically. He arches backwards all of a sudden, which surprises her. She quickly tries to support him and puts him on her lap in a lying position. He begins yawning from time to time. She says to him, “sleepy”, in a comforting manner and with a certain tone of voice. She adds, “It’s all right to fall asleep.” He still moves his head left to right and arches backwards. He continues to make similar sounds, each slightly different in intonation but basically like his mother’s way of saying, “sleepy.” He yawns more frequently. He buries his face in his mother’s chest while continuing to make the sounds, as if trying to intensify the presence of his mother. He gradually calms down and falls asleep.

comforting

The baby seems to be trying to soothe himself, to combat the

emotional loss of his mother that allowing himself to fall asleep represents. By producing a consoling sound that echoes his mother’s tone, he emulates the mother who intuitively understands his distress. The baby has not yet developed the capacity to internalize his mother securely; however, there is emotional meaning beyond the mimicry. One can see the dawning of the development of the baby’s mind as he recreates his mother’s function. The main purpose of the action seems to be to deal with overwhelming and

MEANING EMOTIONAL OF EMERGENCE THE

disturbing feelings, while attempting to internalize the experience of feeling understood and consoled by his mother (Shuttleworth, 1989). As experiences like those in the vignette are repeated over time, the baby can eventually internalize the mother’s ego and they will eventually become the baby’s own (Bion, 1962; Winnicott, 1945, 1960b). The experience of being understood, therefore, functions for the mind in essentially the same way as milk does for the body.

functions,

On subjective frustration Of course, things do not always go so smoothly in life. The that a baby may experience as a threat to his survival might necessitate his developing ways of protecting himself from physical and emotional turbulence. In order to survive, he might temporarily regard himself as the source of nourishment. One can see this in a baby who sucks his thumb when he feels physical or emotional hunger or is left alone with a disturbing experience (Isaacs, 1952). This relates to an illusory experience that he “is” his mother (Winnicott, 1945, 1951). The baby identifies his thumb with his mother’s nipple in his illusory experience and, based on his previous experience of being fed by his mother, tries to sustain the illusion that he is creating her nipple as he sucks his thumb. In this way, he can temporarily tolerate his frustration.

frustration catastrophic

If the frustration and deprivation is repeated, accumulates,

and feels too unbearable, a different psychic structure might have to be developed to protect himself from the pain, fury, and terror that threatens the sustaining of his emotional life. It is a psychic structure of this type that I would like to examine in the clinical material below.

Initial stages of psychotherapy Mr M was in his mid-thirties when he became my patient. He had come to the UK from a western Europe country when he was in his mid-twenties. He sought help due to a desperate conviction that

the shape and size of his jaw was “wrong”, and this was causing him unrelenting misery. Following assessment, I took him into twice-weekly psychoanalytic psychotherapy. Mr M’s belief led him to feel desperate and hopeless. He felt his life was meaningless. He had had numerous operations to change the shape of his jaw, claiming that the reason was not “cosmetic”. He told me he did not know why he was so preoccupied with his jaw’s shape, nor what compelled him to undergo multiple operations. In the meantime, Mr M described his mother as denigrating,

volatile, judgemental, and self-righteous. His father had died in his late thirties after a lengthy struggle with cancer. Throughout Mr M’s childhood, his father had received chemotherapy and treatment, with periods of remission. Mr M often the hatred he felt towards his father. From an early age, Mr M felt convinced that he too would die of cancer at a similar age and was preoccupied with his physical state. His belief that he was “inappropriate” because of his jaw, together with his fear of dying from cancer, led him to feel his life was irreparably and meaningless. Anyone who raised a question about these twin beliefs was met with utter contempt by him, as if they did not appreciate the absolute and undeniable “Truth” of his situation.

radiotherapy emphasized

miserable

On first meeting Mr M, my impression was that he was from

a different planet and was transparent, like a walking spirit. His sense of despair at his unavoidable fate struck me powerfully. Change seemed impossible. I often found myself feeling that there was an impenetrable barrier between us, which made me feel hopeless. It soon became clear that any attempt to create space to think

about Mr M’s deep-rooted conviction was conceived by him as deception and a twisting of what he saw as the truth. I was also struck by the way in which my initial sense that Mr M appeared transparent was gradually taken over by the feeling that it was I who was transparent. I found myself feeling as if he was through me, talking to something or someone behind me. The feeling was so powerfully convincing that I was tempted to look behind me, to see whether someone else was in fact there! I felt driven into a world where phantasy and reality were utterly confused.

looking

There seemed to be an oscillation between the sense of complete non-existence and a conviction about absolute truth, swinging back and forth in the room like a pendulum. I often wondered whether he or I actually existed physically. I wondered whose life he was living and through whose eyes he was seeing people, the world around him, and especially himself.

Clinical situation 1: rigidity and terror Some months into Mr M’s treatment, his rigid defensive armour became less formidable and it seemed possible to begin to what might lie behind it. He began talking about his girlfriend and her family, who questioned whether he intended to marry her. He found the suggestion disgusting and horrifying. I suggested to Mr M that he felt safe as long as things were kept separate and no links existed. In a dismissive manner, he asked me what “exactly” I meant. It felt as if he wished to remove any potential space in which his own thoughts might develop, killing off any curiosity and interest. He seemed to be refusing to take in any potential “milk” from me. For a while he glared at me with his piercing eyes. I felt as if my words were broken into pieces and dumped into a bin. When I kept silent, he angrily and contemptuously told me that he felt that I was making him think about things he had previously managed to put aside.

comprehend

instantaneously

This awareness seemed to lead Mr M to feel that his identity

was under tremendous threat. He emphasized that I had said original, that he had already thought about everything that we were discussing. He was condescending and defensive, and I thought he might be experiencing me as someone who aimed to impose my own thoughts upon him in order to control him. When I said this to him, marrying his association and my thought, it seemed to shake him to the core. He became panicky and confused, moving his body restlessly. He said he hated feeling that someone might influence his state of mind. It seemed as if his sense of self was slipping further away. He admitted, with panic and terror, that he did not want to feel influenced by coming to therapy. He then tried to correct himself by again saying that everything in fact

nothing

originated from himself. While he knew how miserable he was, his situation was immutable, and he wanted to be left alone. In this session, Mr M’s anxiety, panic, and terror had surfaced

overwhelmingly, as if contamination and impingement were experiences. Emotional contact seemed to be felt by him as if he was being intruded upon and taken over physically, resulting in somatic reactions. His ego function had temporarily broken down. Gradually, however, through his sense of being understood by me, he became able to put his experience into words and to stay with his disturbing feelings. I believe this was a demonstration of his growing ego strength. He was at the gateway of being able to take in at least some of what was being provided. As with the baby in the above vignette, he was not yet able to internally recreate my understanding of his feelings. However, his claim to possess the truth gradually gave way to an acceptance of the more ordinary truth that he needed other people for his development, no how disturbing he found the experience. What also seemed significant was Mr M’s basic confusion about who was who in the clinical situation, demonstrating his fragile identity. This was what gradually became clearer in the following sessions.

concrete

matter

Clinical situation 2: curiosity and interest After six months of therapy, I began to draw Mr M’s attention to how he jumped to conclusions whenever he faced something uncertain and distressing. He agreed, telling me that he often felt immediately convinced by whatever came to his mind. This, I felt, demonstrated a further development of his ego capacity to observe and become curious about his own state of mind. However, the awareness seemed to disturb him, and he quickly became distressed, and lost in the room. I suggested that his curiosity unsettled and scared him. Grimacing as he spoke, he told me about his constant and powerful curiosity about his father’s cancer his childhood and his later fascination with any television on the subject. I suggested that he harboured a desire to get to know his father from the inside. This, in turn, made him feel terrified, because to accept his close identification with his father would inevitably also entail having cancer. He said, in a rather

restless, during programmes

detached manner, that unless he became his father, he would not be able to understand what his father was. I then said that when he felt understood by me, he felt relieved but also terrified and confused because he felt as if I was right inside him. He looked stunned and scared while confirming that what I said was true. Mr M told me of his fear of anyone trying to come close to him, and he now appeared quite unsettled. We can see how Mr M’s need to believe in his possession of the truth became less dominant in the session. My about his terror of curiosity helped him develop the space to accommodate his burning childhood curiosity about his father’s cancer. He seemed to become less confused as to what it would mean for him to share emotions and to be understood. He became less inclined to believe that he would immediately turn into others or that others would become him. The fear that curiosity about and interest in himself might threaten his own identity seemed to lessen somewhat.

interpretation

There was evidence to suggest that his father and cancer were

used interchangeably in his mind, as if he could not differentiate between the two. Any attachment he might feel to his father would lead inevitably to him being contaminated by cancer. His preoccupation with cancer seemed, however, to have taken a more understandable shape.

Clinical situation 3: total identification The confusion about Mr M’s identity, an expression of his identification with his father, gradually became more as the therapy progressed. As my ability to demonstrate understanding of his emotions increased, the disturbing sense of the transparency of both patient and therapist in the room seemed to subside. I believe this related to his growing sense of acquiring an identity, separate from both his father’s and mine.

unconscious palpable

One year into Mr M’s treatment, he began to talk about his

conviction that he was carrying something fundamentally wrong and nasty inside himself. He recounted that his experience of his childhood home was of a place where everything felt dark and grim. All he remembered about his father was the cancer and his

fear of his father after chemotherapy. He grimaced in the session, as if he was touching upon something excruciating and He immediately swerved away, saying he had never thought about his father’s death; this seemed to return him to his that he was doomed to have the same terminal cancer as his father. I drew his attention to the way in which he had reverted to his conviction about the cancer and turning into his father, how this had occurred at the very moment that he had acknowledged the reality of his father’s illness and death. I added that he felt a mixture of loyalty and fear in relation to his father. This prompted Mr M to recollect that he had felt nothing after his father died. However, a couple of weeks after the death, he remembered feeling empty and vague, though he made no link to the death at the time. Instead, he started to feel he should dress in a white gown and keep his hair short, like his father’s after his chemotherapy, but had no clue as to why. He told me that one night, as he was passing a mirror, he was convinced that he had caught a glimpse of his . .. Here he appeared to lose his voice and was unable to say the word, “father”! After a pause, he said he had been stunned and immobilized by the experience. He repeatedly but unsuccessfully tried to say “father”. I also found myself feeling both stunned and intrigued. I suggested that he had made a concrete, physical attempt to become his father after his death, to rewrite reality. He looked shaken and told me he believed that he and his father had not loved but, rather, hated one another. As painful as it was, this felt as if he was trying to pull himself together. Mr M seemed to be starting the process of mourning his father. I think my interpretation of his retreat into his own world, in which he believed he had possession of the truth, helped him recollect significant experiences from around the time of his father’s death. What I found most striking was his concrete attempt to become his post-chemotherapy father, and thus to rewrite history. What was also intriguing was the lack of emotion about his father’s death and his unawareness of the links. These two phenomena are related to each other: he seemed to try to deal with the loss of his father by means of a concrete identification with him—that is, he became his father in order to keep him alive. He could apparently only do so

frightening. conviction

conscious

by destroying or disavowing his perception of his father’s death and creating his own reality. Nonetheless, he of course also knew intellectually that his

father had died. I think Mr M existed in two states of mind, one that acknowledged his father’s death and another that dismissed it and created another (false) truth. These states existed side by side, as if there was no contradiction, but at the cost of a “splitting of the ego” (Freud, 1940e [1938]). The loss of his father had not yet been acknowledged emotionally nor fully mourned. However, in the course of the therapy, the balance seemed to have shifted gradually towards the acceptance of the ordinary truth of his father’s death, which heralded the beginning of the digestion of this disturbing experience. I believe that Mr M’s inability to utter the word “father” in the session demonstrates the dawning awareness of a clash between the two parts of his ego, each of which carried a different truth. The massive and palpable emotional battle between them was a sign of his struggle to integrate his ego. He was in effect trying to take in some external nourishment, gradually relinquishing his belief that he possessed some ultimate truth, and moving towards mourning. However, this move inevitably caused emotionally catastrophic instability, and he tried to reinstate his equilibrium by retreating into the familiar world of mutual hostility.

Clinical situation 4: the meaning of the repeated surgeries The previous clinical material has given us a sense of how Mr M’s concrete identification with his father dominated his mental functioning and protected him from the devastating impact of his father’s death. Eighteen months into his therapy it became clear just how this concrete identification influenced the irresistible pull towards the repeated operations on his jaw.

powerfully

Mr M began talking about his sense that he did not have any

choice in his life. He added that he knew that no matter how many operations he had, he would never get what he wanted. This led him to utter despair, to saying that he felt he was gradually dying. He had of course witnessed his father’s gradual decline and death

during his childhood. Although he had hated his father and never wanted to be like him, he felt destined to travel the same path. I found myself intrigued again by the enormous power of this identification. He mentioned how his relatives and his father’s old friends had been shocked by how closely he had begun to resemble his father. I became aware that there must be a link between his desperate unconscious demand to become his father and the series of operations. Therefore, I wondered out loud whether the part of his own face that had not resembled his father’s might have been his jaw. He beamed at me with open interest and confirmed this, saying that his jaw had originally resembled his mother’s. After the series of operations, however, he thought that his face had become identical to his father’s, but he then quickly added (as if trying to brush off something frightening) that he had never wanted to become like him. Mr M became tearful and seemed pained, though he said he did not know why. It was as if he was actually feeling the loss of his father for the very first time. Here one again sees the dominance and the powerful pull of the

identification with his father. Although the reason for Mr M repeated operations was his desire to concretely become his father, he also carried the additional delusion that if he did to become his father, by appropriating his jaw, the reality of his father’s death would be erased. What seemed significant here was the link that I made between being pulled towards a concrete identification with his father and his desperation for the surgery; this stimulated his interest, and he came alive. What ensued was a further integration of Mr M’s ego, whereby he became more able to take in my understanding, to explore ordinary reality with and to relinquish delusion. Mr M’s belief in his possession of the truth gradually lost its power and domination. He experienced an actual sense of the loss of his father. The compulsion to actually undergo diminished following that session. The subsequent workingthrough was nevertheless a painstaking and slow process. He could easily revert to his wish to have more operations when he felt unsettled and lost, as if this possibility still offered him the promise of stability and safety.

undergoing manage

curiosity, operations

Further theoretical discussion: from delusion to ordinary reality At the beginning of his treatment Mr M claimed that he possessed in his mind an unassailable truth. Those who dared to question this were met with contempt and rage. The possession of this truth was intended to draw together his fragile and fragmented ego in such a way as to allow him to claim that he needed no one, no support—no external “milk”, as it were. He was the source of all knowledge about himself. He also desperately tried to take complete control of any communication, for instance, by asking me forcefully to account for “exactly” what I meant, thus trying to push back violently against any possibility of emotional What seemed like a question was an attempt to avoid rather than develop contact with me. This enabled him to be in charge of the relationship between us while I was also meant to carry all the emotional distress and tension for him. Therefore, for the sake of the development of his ego, it was more important to understand what was behind his interrogation and to put it into words than to blindly satisfy what he demanded (Stewart, 1992). As a result of this painstaking work and as the therapy progressed, Mr M’s concrete and delusional attempts to become his father via a series of operations became apparent.

connection.

Mr M was like a baby who severs the link with his mother’s

nipple. The connection with external reality is lost, and the baby forms the delusion that he produces the milk by himself. Thus, his thumb becomes the breast, the ultimate source of pleasure and The baby thereby develops the conviction that he already possesses everything to meet his needs. Mr M’s rigid beliefs became the foundation of a distorted rather than a temporary defence mechanism. In order to sustain his delusional system, he forced others to accept his thoughts as true. This perverse system became formidable, an unbreakable fortress against any external source of help, and caused hostility and hatefulness towards the external world, him to hate even his own perceptions and perceptual apparatus (Bion, 1957; Freud, 1911b, 1940e [1938]).

satisfaction. personality

leading

This was clearly demonstrated by Mr M’s rage against and

contempt for any questions raised about his truth. The very fact

that his own needs, curiosity, fragility—his very life—depended on his parents at the beginning of life felt threatening, repulsive, and even catastrophic. This relates partly to innate envy and partly to the experience of either early privation or unbearable deprivation, which can increase envy, hostility, and murderousness towards those upon whom he depends (Glasser, 1992; Rosenfeld, 1971). The acknowledgement of his dependency was thus severely hampered, resulting in the developmental arrest of his mind. This led to another problem. Ordinary curiosity and interest

are essential for the mind to develop. Yet, because these implied Mr M’s “not knowing”, they disturbed the belief that he possessed the truth. He therefore had to destroy these capacities at all cost, further hampering mental development. Klein (1930) has described how her autistic boy patient could not become curious about because of his utter terror of his own murderousness towards his mother, which damaged the development of his mind. Returning to Mr M, as the therapy progressed and he his pain, distress, and agony through being understood by me, what lay behind that rigid and brittle system came into focus. At first, he reacted to my interpretations contemptuously or angrily, but later it was overwhelming and annihilating terror that surfaced and became located in his body. As Mr M’s clumsy, delusion-based defence mechanisms—originally employed to his ego from falling apart—loosened their grip and his ego capacity broke down, his body became the theatre for his emotions. Later still, Mr M’s experience of being understood enabled him to re-develop his ego capacity, to relate to external sources, and gradually to break free from his belief in his spurious truth.

anything experienced protect Freud tells us that often “the patient does not remember

anything of what he has forgotten and repressed, but acts it out”

(1914g, p. 150). Thus, Mr M could not mourn the loss of his father but instead became him by identification through action, in the series of surgeries on his jaw. This also leads me to think about Freud’s remarks about melancholia or chronic depression, where “the shadow of the object fell upon the ego” (1917e, p. 249). The existence of this shadow implies, in the first place, that the ego and the object are separate, indicating a symbolic level of In Mr M’s case, however, something more primitive was happening: one might say that it felt as if the shadow of the object

representation.

completely took over his ego, and therefore he had concretely to embody his father in order to spare himself emotional loss. Following Klein’s (1946) ideas about schizoid mechanisms,

Henri Rey (1979) beautifully describes the concrete experience of a female patient who, in order to protect herself from the experience of losing of her father, believed that he was living in a house within her own body; this meant that she could not move lest she destroy him. Mr M resembled her in that he too created a delusional world in which he claimed to be the father, and this brought his emotional development to a halt. However, as the psychotherapy progressed, he progressively experienced “dis-delusionment” and curiosity was mobilized. This caused unbearable pain, so he again tried to retrieve the primitive fusion with his father. However, his longing also reinvoked the fear of being engulfed by his father. I believe that Mr M’s experience of witnessing his cancer-ridden father dying in pain and agony intensified his murderousness, which might in turn have caused him more terror at the prospect of his own death. In the latter stages of Mr M’s treatment, his total and concrete identification with his father was revealed. By resorting to delusion to deal with the unbearable feelings surrounding his father’s death, he found himself in an unresolved limbo between life and death which prevented him from having a life of his own. However, his growing ability to take in external resources and his capacity for curiosity led to the creation of an internal space, a theatre in which unbearable emotional experiences could be turned into meaningful scripts (Kleimberg, 2006). His actions—such as being dressed in a white gown, having his hair cut short, and later undergoing the operations—could finally be given emotional meaning.

devastating

development idealized

Conclusion My intention in this chapter has been to demonstrate how bizarre and meaningless actions—in this case, a series of unnecessary surgeries—can hold profound emotional meaning. In the more troubled patients with whom we work in the Fitzjohn’s Unit, the patients’ logic is often difficult to understand. It can often

seemingly

lead them to feel repeatedly misunderstood and terribly isolated. As the case of Mr M has shown, the more troubled the patient becomes, the more inflexible he or she can appear. Mr M, and patients like him, can feel attacked when they have to contend with ordinary logic and reality. However, in my experience, no matter how deeply troubled a patient might be, the primary wish to be understood is still there, waiting to be uncovered. The frequently painful process of treatment can, and often does, lead to a patient feeling relieved and to a freeing of the ego to develop in a healthy way.

CHAPTER FOUR

The progress of sorrow Helen Barker

"The progress of sorrow” is a quotation from the 1759 novel, Rasselas, Prince of Abyssinia by Dr Samuel Johnson, a novel that featured prominently in the psychotherapy of my patient, Mr E. This moral fable chronicles the adventures of Prince Rasselas who seeks to escape from Happy Valley when he becomes aware that his daily pleasures come at the price of self-deception. He becomes convinced that true happiness lies elsewhere and undertakes a pilgrimage to discover the best way to live his life. He is accompanied by his sister, the Princess, and the Imlac, who acts as their guide. With each new adventure they become increasingly disillusioned, encountering foolishness, despair, paranoia, and omnipotence where they had hoped to find solutions. When the Princess’s beloved companion is abducted, she is besieged by depression, guilt, and self-reproaches. It is only after many months of “the progress of sorrow” that their companion is returned to them by chance. Only then are they able to give up their relentless search and return to the city. Finally, they visit where they wonder if they have been so distracted by trying to find the best way to live that they have neglected life itself. The book ends with a final chapter, “The Conclusion, in Which Nothing Is Concluded” (Johnson, 1759).

poet-philosopher

catacombs

HELEN

BARKER

As Mr E described this story to me, I began to reflect on the parallels with psychotherapy. Many of our patients have constructed their own “Happy Valley” way of existing, creating an internal reality whose satisfactions have faltered over time. They enter treatment seeking a solution, setting off hopefully, but inevitably encountering problems and difficulties along the way. It is these vicissitudes of therapy that I want to address in this chapter, using Mr E as an example. In his case, we had to survive a prolonged period in which he was in the grip of powerful suicidal ideas. These are not the ordinary ups and downs of therapy but with a particularly destructive flavour, leaving both patient and therapist fearing for the outcome.

something

Some might argue that offering psychoanalytic therapy to some

of the disturbed patients referred to the Fitzjohn’s Unit is unwise, given the potential seriousness of the consequences. Are we idealizing a psychoanalytic approach without respecting the severity of the psychopathologies that our patients have to live with on a daily basis? Clearly a proper assessment is necessary before embarking on such therapy. However, even the most and thoughtful assessment process can only serve to signpost the difficulties ahead rather than to avoid them.

perhaps thorough

It is commonly accepted that psychoanalytic therapy is in any

case a troublesome process, one in which patients tend to feel stirred up and often complain of feeling worse rather than better, at least in the early stages. However, with patients like Mr E we are walking an even more dangerous line in which therapy can precarious defensive structures and can result in serious outcomes. Commonly we encounter self-destructive behaviour, self-harm, and ideas of suicide. Patients might be hospitalized or sectioned. They sometimes drop out of treatment, or stay to themselves and the therapist with ever-increasing spirals of sadomasochistic behaviour. We also have become familiar with having to continue to work with patients while a formal or complaint against the therapist or the department is ongoing.

destabilize

torment informal Sometimes these developments are quite minor and the therapy

can continue, but, at the other extreme, we have experience of events that become critical incidents and the continuation of the therapy comes into doubt. Reflection, judgement, and consultation with colleagues become essential in deciding when these vicis-

THE PROGRESS

OF SOR W

situdes are an expected part of therapy and when they are a sign that therapy is endangering the patient to such an extent that it is not safe to continue. At this point, some colleagues might consider adopting a more flexible approach to defuse a crisis situation, while others maintain an analytic stance wherever possible. Mr E is a 40-year-old man with a diagnosis of borderline

personality

disorder and a long history of depression and hospital admissions. In his teens and well into his twenties, he was on alcohol and drugs and, for some years, was involved in a criminal gang. He seemed to me to delight in relating stories in which he had been the recipient or perpetrator of violent physical attacks. He had once been present when a fellow gang member was shot in the head. Despite this, in his late twenties he managed to distance himself from the criminal gang and was able to go to university, gaining a first-class degree, followed by a scholarship for postgraduate study. He proved to be highly intelligent and was able to surround himself with supportive friends and mentors. He believed that he had successfully reinvented himself and knew that he must keep his violent past a secret.

dependent

It was in the course of his studies that he encountered Samuel

Johnson’s Rasselas and described how he, too, felt that he was on a relentless and ultimately futile search for a better life. He often wondered if he had chosen the right path or whether it would be preferable to return to his previous lifestyle, which, to his mind, had the benefits of making him feel powerful and excited. At the start of treatment, Mr E was working for a charity,

handing

out sandwiches to homeless people on the street. He readily identified with the homeless, particularly men who were alcoholic, drug dependent, and violent. However, Mr E himself had been brought up in a privileged, middle-class family with no apparent traumatic experiences. His stable history and attractive did not match his inner experience of catastrophe. He seemed drawn to the rough sleepers, with their very visible signs of and disturbance. Through his relationship with these men he was able to find recognition for and, at the same time, to disown the damaged parts of himself, which he could locate and care for at a distance. He was recognized and praised by his boss for being good at his job and working excessively long hours—indeed, for being over-conscientious to the point of exhaustion.

appearance damage

However, he often felt bullied and exploited by the organization and secretly felt he could run the charity better than his boss. He would also become angry with the homeless men when they complained to him about the choice of sandwiches and when they did not seem appreciative of his wish to help them. At these times, he felt humiliated and laughed at, and he had to contend internally with a persecutory and cruel superego that taunted and bullied him. When this became too much to bear, he would have fantasies of burning down the homeless shelter and attacking the homeless men as they lined up for their sandwiches. He then wondered if he would be safer in a prison, whether as an inmate or a prison guard. Naturally, all these aspects came to life in the transference as his therapy progressed. Mr E felt that he was a danger to others and was reluctant to

allow himself to become too involved in friendships or relationships. It emerged that he had three teenage sons, each from a relationship with a different woman, but had broken off contact with all of them. Shortly before starting therapy, and for the first time in many years, Mr E had started a relationship with a younger woman, who had become pregnant. At first, the couple were delighted and talked about moving in together. However, as the pregnancy and plans for a shared home progressed, Mr E became increasingly disturbed and convinced that his partner had an evil presence growing inside her, possibly an alien, which she needed to get rid of. He also felt that the baby would grow up to hate him, as he was sure his three estranged sons already did. He pressured his partner into having an abortion, which she reluctantly agreed to, evidently disturbed by his threats and talk of aliens. The couple separated shortly afterwards, and Mr E collapsed into a further bout of depression, tormented by guilty feelings and talking of turning himself into the police for being a murderer. Mr E started therapy in combative mood. He was openly

suspicious of me and my motives, feeling that I must be using his

therapy to make myself feel better and to enable me to feel superior to him. He actively challenged the psychiatric diagnosis he had been given, which he experienced as a damning judgement, and was sure that I would use this to consign him to the rubbish bin. He fought with me, using his intelligence but also with subtle refer-

ences to his physical strength, to try to demonstrate his superiority over me and to deny his own need for help and understanding. Gradually, over the course of many months, he became slightly

less convinced that I was actively trying to harm him, that my intention was to “abort” or convict him, and, instead, began to value the opportunity to talk and think. He could occasionally appreciate being helped and understood rather than relentlessly requiring others to admire his abilities to help them. He moved from a small studio flat where he felt isolated to a shared house owned by a “nice old lady” and felt better for the companionship. Imlac, the poet guide of Dr Johnson’s novel, says that “no

disease of the imagination is so difficult of cure as that which is

complicated with the dread of guilt” (Johnson, 1759, p. 66). My patient, Mr E, also had to contend with terrible guilt which proved to be a considerable obstacle to any recovery. He was assailed in particular by persecutory guilt over his girlfriend’s abortion. He saw himself as a murderer, and if the police and his estranged sons would not punish him, then he must take this role of punisher upon himself. Nothing good could be allowed to exist inside him. At this point in the therapy, whenever he felt understood by me and in danger of understanding himself, this would be attacked. He became severely depressed and began to drink heavily. Instead of the solution of his earlier life, when Mr E would

direct his violent impulses outwards, he started to tell me about his plans to kill himself. This became much worse when he was required to give evidence in court as a witness to a violent at work. He felt tormented by this and experienced it as if he was, finally and rightfully, being put in the dock. He became unable to work. Over the course of several months his condition deteriorated, and I felt considerable concern for him. At times, the bleakness felt overwhelming to us both, and I could find myself becoming convinced by his chillingly rational arguments that there was no hope for him and that the only logical solution was to kill himself. I began to wonder whether he would survive and whether it was wise to continue with a treatment that had provoked so much disturbance.

incident

It was at times like these that I particularly needed and valued

the “third position” of the staff seminar. This weekly meeting with

my Fitzjohn’s colleagues, each of whom has a caseload of equally difficult and disturbed patients, sustains a strong “work-group” mentality. The contribution of this seminar seems to be of a order from the benefit of supervision alone. I have treated other difficult cases with the support of weekly individual supervision and yet have found the experience in many ways more demanding, owing to the sense of isolation from colleagues and the absence of the sense of containment that the group mind can provide.

different

We are fortunate in Mrs O’Shaughnessy to have an external

supervisor whose independence creates a space for clinical alongside, but also outside of, the usual structures and of the department. A patient might only be presented once or twice a year but often becomes a presence in the mind and memory of the group, which seems to offer a particularly helpful type of containment. There is a sense of shared responsibility and with the patients in the unit which seems to be especially useful when a therapist feels alone and under attack from a disturbed patient in a session. In this way, the group becomes a sustaining object, providing vital support when the individual therapist feels under pressure. (See chapter 7, in which Maxine Dennis elaborates the idea of a therapeutic group’s nature and function in similar terms.) Gradually, over several months, Mr E’s state of mind became less violently despairing. Paradoxically, this occurred at the very point where he and I seemed to feel that there was nothing more to be done to help him. We had both accepted the hopelessness of his situation, the impossibility of repairing the broken relationships with his sons, and the reality of his doubts about the future. He reminded me of Winnicott’s patient who said, “The only time I felt hope was when you told me that you see no hope, and you with the analysis” (1960a, p. 152). Surprisingly, it was just then that a small degree of mourning (the progress of sorrow) became possible. He could allow himself to feel genuinely remorseful, rather than cruelly self-attacking, about the past. His persecutory guilt became a more depressive kind of guilt, with the possibility of something new emerging.

thinking hierarchies

familiarity

continued However, sorrow and mourning can themselves become

intolerable states of mind, and the more familiar, persecutory state can

exert a strong pull. In Mr E’s case, I was also aware of the excite-

ment caused by his masochistic hopelessness and reminded of the patients described in Betty Joseph’s (1982) paper “Addiction to Near Death”. Joseph writes: Some patients present “real” situations, but in such a way as silently and extremely convincingly to make the analyst feel quite hopeless and despairing. The patient appears to feel the same. I think we have here a type of projective identification in which despair is so effectively loaded into the analyst that he seems crushed by it and can see no way out. The analyst is then internalized in this form by the patient, who becomes caught up in this internal crushing and crushed situation, and paralysis and deep gratification ensue. [p. 452]

Joseph goes on to describe the “enthralled” state in which the patient experiences an intense excitement at being painfully without hope of escape or change. Having survived this bleak period of hopelessness, Mr E reacted by suddenly declaring himself cured and precipitously moving to another city, six months before the end of his therapy. Again, the timing seemed crucial, because it was at the very moment when there was a possibility of change that he felt compelled to evade this through a manic flight, in search of the next Happy Valley. I was the one to be left with any feelings of loss, disappointment, and rejection. The power to deprive us both of any further also seemed to deliver the excitement to which Mr E was so addicted. Though I had no further word from him, some months later I was contacted by a clinical service in another city where he had applied for three-times-weekly psychotherapy.

imprisoned

development

At the end of the novel, Prince Rasselas and his companions

find themselves back where they started, with more questions than answers. There is a conclusion in which nothing is concluded. Our patients may not be transformed in the way that they had hoped to be, and they may still find themselves struggling with on a daily basis. Although they may continue to live with a problematic internal world, being understood can bring benefit, including relief and the hope of an at least slightly changed perspective. John Steiner (1979) discusses the problem of treating borderline patients in his paper, “The Border between the Paranoid-Schizoid and the Depressive Positions in the Borderline

difficulties significant

Patient”. The patients he describes seem very similar to the ones we see in the Fitzjohn’s Unit. He concludes that, despite the caused by the preponderance of negative transference, fragmentation, and projective processes, therapy can be rewarding and worthwhile:

difficulties I believe significant deep analytic work can be done. This is, of course, not a claim that patients as disabled as this can be magically transformed by treatment, but even a modest change in internal structure seems to produce a real softening of the horrors with which they have to live. [p. 390]

Does this perhaps rather modest and limited claim for our success suffice? Surely we should be aiming for a more significant, lasting, and measurable change from this relatively intensive and expensive intervention? However, when we as become too focused on the goal of “cure”, like the travellers in Johnson’s tale searching for a better life, we can miss something valuable that has been present all along. Here we also find in the realm of John Keats’s “Negative Capability”, where he spells out the perhaps paradoxical advantages “of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason” (1899, p. 277). With the capacity to tolerate the pain and confusion of hopelessness and not knowing comes the possibility of a new perspective emerging.

therapeutic therapists

ourselves

The travellers in Rasselas are finally released from their futile

search for happiness when they spend time in the catacombs: “I know not”, said Rasselas, “what pleasure the sight of the can afford; but, since nothing else is offered, I am resolved to view them, and place this with my other things which I have done because I would do something” (p. 99). When they reluctantly visit this “mansion of the dead”, they are surprised to find unexpected meaning and a renewed appreciation of a more ordinary life. The catacombs are flooded by the inundation of the Nile, and the return to their old city, “contented to be driven along the stream of life” (p. 99).

catacombs

travellers

Returning to the current century and more modern concerns,

the results of the Tavistock Adult Depression Study (Fonagy et al., 2015) provide us with a further helpful insight into the experience of patients at the end of psychotherapy. The two-year follow-up

of these depressed, treatment-resistant patients, who had received psychoanalytic psychotherapy once weekly for eighteen months, showed that their clinical improvement continued throughout the post-therapy period. The researchers conclude that “end-of-treatment evaluations or follow-ups that are too short may miss the emergence of this delayed therapeutic benefit” (p. 312). This also tallies with my personal experience as a researcher on the TADS study. I had the chance to interview both patients and therapists some months after the end of treatment. In almost all cases, I was struck by the rather critical assessments that the therapists made of themselves, focusing on the clinical mistakes they made during the treatment and on their patients’ difficulties that were still not resolved by the end. The patients, on the other hand, were almost universally grateful for the therapy they had received and any positive changes that had occurred. For some of our patients at the Fitzjohn’s Unit, the two years of twice-weekly therapy is the end of treatment. Others will choose to move to group therapy or into other more intensive therapies or analysis. There are yet others, of course, who remain entrenched in a world of grievance and illness. The truth is that for all of these patients, the longer-term outcomes are necessarily uncertain. In an NHS culture so focused on a speedy recovery, it is currently to accept such limitations and to hold realistic contingencies in mind. It is only when we can give up these compelling notions of cure and recovery that we can value the paradoxical benefits of “hopeful hopelessness” and “the progress of sorrow.”

difficult

CHAPTER FIVE

The mine/d field of the internal world: the importance of the setting in work with borderline patients Ellie Roberts

The consideration of the setting is paramount in any context in which psychoanalytic psychotherapy is practised. When working with patients who have suffered trauma and with borderline personalities, however, the setting is often a source of contention. One might consider the setting to be constituted by a variety of conditions—the building in which the treatment takes place, the actual therapeutic room and its furniture, the temporal arrangements, even the demeanour of the analyst—but it also includes the type of work that the therapist does and the around the work that restrict contact with the patient to the analytic time and maintain the confidentiality of the patient’s In this chapter, I wish to focus on these characteristic aspects of the setting in the work of the Fitzjohn’s Unit, where patients are usually offered two years of intensive, twice-weekly followed by the opportunity to join a psychoanalytic group. For all patients, and in particular traumatized patients, the can become a facsimile of their internal world. The therapeutic setting encountered can be filled by such patients with unconscious projections from their wounded past. On perceiving the object— that is, meeting the therapist—within the setting, the latter can

boundaries material.

psychotherapy, setting

ELLIE

ROBETS

quickly be imbued with terrifying imagoes. As James Baldwin (1940) writes in “Many Thousand Gone”: It is not a question of memory. Oedipus did not remember the thongs that bound his feet; nevertheless, the marks they left testified to that doom toward which his feet were leading him. The man does not remember the hand that struck him, the darkness that frightened him, as a child; nevertheless, the hand and the darkness remain with him, indivisible from himself forever, part of the passion that drives him wherever he thinks to take flight. [p. 30]

In his early paintings, the artist Anselm Kiefer explores interiors that also hold the trauma of the past in their very fabric. One of the major post–Second World War artists in Germany, whose main body of work was carried out well after the war (1969–1990), Kiefer’s oeuvre investigates the cultural trauma of the “German Question” following the Holocaust. It is as if he is himself is the impact of the atrocities of the culture that he inherited, in what one might term an après coup manner. In his “Interior” paintings—for example, his 1973 “Germany’s Spiritual Heroes”— he depicts the claustrophobia of cultural memory. Mark Rosenthal (1987) describes it as follows:

suffering The viewer is placed at the entrance of the cavernous room, slightly off centre, engulfed by the wooden beams. . .. The is at once a memorial hall and crematorium. Eternal fires burn along the wall as if in memory of the individuals, but the lower edge of the painting is darkened in a manner that it has been singed. This highly flammable wooden room is in danger of burning, and with it Germany and its heroes will be destroyed. [p. 26] Kiefer’s attitude about a Germany whose spiritual heroes are in fact transitory and whose deeply felt ideals are vulnerable is not only ambivalent but also sharply biting and ironical. [p. 30]

interior suggests

Thomas McEvilley (1996) notes that the natural elements of the room “have been unnaturally recombined and reshaped into a rigid geometrical order that is pitiless. .. . There are no people in these rooms, which are like stage sets awaiting some hideous drama. Who will dare step into them?” (p. 3).

sacrificial

THE MINE/D FIELD

OF THE INTERNAL

WORLD

Kiefer uses the alchemical concept of (Temkin, Rosenberg, & Taylor, 2000) to examine the hidden memories of a post-war Germany trying to move from darkness towards selfnigredo

knowledge and reparation. Based on the idea that nature is always in a continual process of rebirth, nigredo is the stage of and putrefaction out of which new growth can emerge. Paraphrasing his idea in more psychoanalytic terms, one might say that Kiefer believes that the horrors of the world must be faced as inner reality before insight can be gained and transformation can take place. This is what it is like for many traumatized, borderline patients. As in the painting, the patient’s trauma is a raw and concrete the impress of the person’s actual or transgenerational experience. It is this not-fully-symbolized experience that makes its way into the setting and fills the therapist with dread. The therapist’s state of mind is then perceived and acutely measured by the patient and becomes the background colour of the setting in which patient and therapist interact. My work with a patient in the Fitzjohn’s Unit exemplifies and elaborates these phenomena more fully.

decomposition

manifestation,

The patient and the therapist There is a particular psychic intentionality in the way that a prepares to begin work with a patient. Meltzer (1967) describes how

therapist the analyst undertakes to set aside a certain “time of his life”, for an indefinite period, within which he intends to pursue the psychoanalytic method, with no consideration of sacrifice in mental pain to himself, to the limit of his toleration, and within a framework of consideration for the patient’s own physical safety. [p. 80]

The patient, in turn, will arrive with a myriad of problems in his or her social, emotional, and sexual life and usually with some difficulties in establishing a satisfying working life as well. The patient thus encounters the person of the therapist, who, by all

social standards and as the essential part of the setting, is someone who is supposed to be there to help. All too often, however, massive turmoil within the patient leads

to wholesale projective identification, and, as a consequence, and external areas of functioning become poorly delineated. O’Shaughnessy (1992) reminds us of the “inbuilt risk of inherent in the analytic situation (p. 607). She cites Strachey’s (1934) seminal paper where he describes the patient as “all the time on the brink of turning the real, external object into the archaic one; that is to say, he is on the brink of projecting his primitive introjected images onto him” (1934, p. 146). Questions immediately abound in the patient’s mind, followed by assumptions designed to fill the void of not knowing: if the therapist has a mind, then it must be the same mind as that of the patient; if the therapist’s mind asserts itself, then it must be the mind of the patient’s own internal persecutor; if the therapist is recognized as an individual, then he or she must be seen as “wrong” or “not the therapist”. The consultation room itself, in other words, can become transformed into a scene of acute infantile tragedy. movement in of time, and Rapid Rapid movement in phantasy through time, and by means of

internal degeneration”

means

projective identification,

can

to orientate both external

patient

in relation to his

or

leave the

therapist reeling, struggling reality of the in own psychic reality the

reality her

and the internal

countertransference. therapist's The

task is to receive and bear the

projections, elements, and, point, to consider the transference

at

some

metabolizing the experience of being with the patient, to understanding of the dilemma presented. This method itself often severely attacked by such patients, for whom it is the

after

offer is

some

very existence of the other in the setting—as well as the setting itself—that is the embodiment of the problem. Moreover, if the

therapist cannot bear the projections that have been directed at him her, he or she may end up forcing these back into the patient by

or

way of

a

retaliating re-projection.

The familiar definition that locates the borderline patient as

hovering between neurosis and psychosis does not really capture the patient’s much more felt experience of being an outsider. There are various characteristics of this state: weak relationships in flux; a sense of deracination; the compulsion to be in control and to dominate in the face of unbounded space; a propensity to be

constant

a trickster in order to get something—all of which feels unresolved, providing little sense of an integrated self with a capacious internal world. While at its best the psychoanalytic setting may be a form of liminal space where thought and experience can come together to form meaning, one might say that, in these cases, unresolved traumas create a far more problematic, frightening, and dangerous space in which the personality simply cannot gather itself and where the ego is just not strong enough to manage.

considered

These patients may well meet official criteria for the diagnostic

category of borderline personality disorder. However, this nomenclature does not really define or account for the broad spectrum of patients who are treated in the Fitzjohn’s Unit. All of these patients seem to be suffering from a general lack of internal resilience in the face of the traumas they have suffered, and one thing they seem to share is overwhelming anxiety about the of the self and the other. This clearly impacts on their capacity to function in the world. Rey (1977) describes these patients as living in a hinterland between saneness and madness, maleness and femaleness, as neither homosexual nor heterosexual, neither children nor adults. John Steiner (1979), on the other hand, using Klein’s theories of paranoid-schizoid and depressive positions, sees these patients as:

diagnostic

content

. .. capable of a considerable degree of integration, which leads them to make contact with themselves and others and to be on the threshold of experiencing events which produce psychic pain. These experiences, however are felt to have an quality so that contact is fleeting and leads to a cutting off, a retreat, or even a total destruction not only of the object but of the self capable of such feelings, and especially the links between the self and the object. [p. 386]

unbearable

The issue for people who live so much on the threshold is that there is no inner or external sanctuary. There may be temporary escapes through drugs, alcohol, and sexual practices, but there is no felt experience of goodness and safety. Hence, it is often the case that patients offered twice-weekly individual psychotherapy in the Fitzjohn’s Unit find that the very place where the help is meant to occur dissolves in the mind and becomes yet another site of traumatic experience. Through massive defences of projective

essential

identification, the setting itself, in all its forms, is pervaded by the very negative qualities that such patients wish to escape from and find a cure for. And the therapist seems to fit like a jigsaw piece into the patient’s internal world as a replica of the original abusing person or experience. One might say that the therapist has to be able to enter into

these disturbing spaces in order to help these patients who are themselves so torn, split, and unable to do anything other than tread the boards as an outsider. Indeed, the multitasking must simultaneously maintain his or her hovering attention, hear the spoken words, stay attuned to the atmosphere, observe the actions of the patient, and listen out for the vital communications. The therapist is at one and the same time “deeply dreaming” (Donald Meltzer, personal communication) the patient’s unconscious but also staying aware of the emotional impact on him/herself of the patient, using the lightning rod of the countertransference. Working in this setting, the countertransference can be quite unnerving, not least because these patients are capable of tuning in to and examining, with remarkable accuracy, the faults and flaws of the object. Any absence of humility or lack of awareness of his or her own human flaws can serve to unhinge the therapist’s helping, thoughtful self and plunge him or her into defensive behaviour. The experience of being wrong-footed is common, and the can often find him/herself as somehow in the wrong place, both physically and psychically.

therapist

unconscious

therapist

In our weekly Fitzjohn’s staff seminar, a colleague related how,

with a new patient, she had for some reason not firmly indicated the chair that the patient should sit in. As a result, the patient managed to seat herself in the therapist’s chair, behind the couch in the room, while the therapist found herself in the chair usually reserved for the patient! As she faced the patient and contemplated what had happened—how and why the setting had, from the start, been so thoroughly disrupted—her eye caught the notice board above her desk, thus seeing it as a patient might see it. Pinned there, she noticed a postcard from the Freud Museum, featuring Freud’s famous couch. The thought came into her head that this was in fact a very silly image, as the couch had no patient on it: why have a picture of an empty couch? The patient, meanwhile,

was absent-mindedly fiddling with the fabric that covered the couch. What began to dawn on the therapist was that there was neither a patient nor a therapist in the room at that moment. By taking the therapist’s seat, the patient had effectively neutered the therapist, such that the setting now mirrored that of the picture: an empty analytic space, devoid of its personae. If anything, the therapist was now in the patient’s place, and, while this may have made the patient feel temporarily secure, under such conditions no psychic work could take place.

analytic

postcard

Patient G Mr G tells me that he had had to wait too long for help. The promise of it, represented by being on the Fitzjohn’s Unit waiting list, may well have provided a kind of containment-at-a-distance: some anxiety could thus be allayed without him yet having to face the threat posed by actual contact with a therapist. However, while seeming to have temporarily stabilized the patient, the wait for therapy also took on the meaning in the patient’s mind of the therapist’s desire to keep him waiting. For such patients, the setting may already be imbued with both the agoraphobic terror of and the claustrophobic fear of intimacy. So, for Mr G, even the building was quickly seen as a set-up designed to torture and humiliate him. Having first to speak to a receptionist, being asked to wait before being called up to the therapy room where he would then be expected to voice his pain and neediness—all of this led Mr G to feel that he was encountering a therapist who wished only to see him humiliated. Here the external reality of an institution and therapist ready to engage and work with the patient becomes confused with a very different set of paranoid assumptions, where therapist and institution are seen as deceitfully parading the mere pretence of decency.

rejection

This patient had, in effect, co-opted me and the

psychoanalytic

method into his internal world—a world suffused with terror—where he expected to encounter something akin to a Nazi interrogation. The terror was such that our dyad was limited to only two positions, the interrogator and the one interrogated. The experience of my voice and mind was abhorrent to him. From

the earliest moments of the encounter, I was seen in the as the enemy, leading Mr G to make notes of the sessions in order to prove that I was persecuting him. While already in the familiar position of not yet knowing what Mr G needed, I also felt forced—at the same time and from the start—to take upon myself his denigrated version of my best efforts.

transference

Mr G had, for quite some time, been depressed, lonely, and

unable to work. A cycle of self-isolation had continued for years, and even a few days of paid work could make him feel He told me that he had already had some previous some plans to go away, and asked me to change the session time. When I agreed to do so, this seemed only to raise his anxiety further, and he said he could not come at the changed time either. He became insistent that his external activities were far more important than the therapy, that they were the only things keeping him alive. If I insisted on the times I was offering, I would be threatening Mr G’s mental health. If he was expected to this could only mean that the very means of help that he had waited for was now a source of deprivation. Thus, the blame was laid squarely at the therapist’s door: I was accused of cruelty, a failure to understand, and the scene was set for the development of an essentially persecutory transference. Later Mr G would say, “Well I knew from the beginning that you were wrong. You are just like my mother—so how could I ever trust you?”

claustrophobic. commitments,

compromise,

There were many more examples of how the therapist, who at

other times was idealized, became just “wrong”. On one occasion, I said to him that he not only feels that I am the wrong therapist, but feels himself to be all wrong when he is with me: “With your friend you felt you were the right person, that she heard you as you wanted to be heard, while with me you feel unheard and then you feel wrong.” The reply was: “You psychiatrists are all the same—nuts.” Among the variety of psychological defences used by Mr G to

protect himself from the unknown experience of being contained was the use of what Matte-Blanco (1975) calls symmetrical The unconscious uses symmetrical logic, treats the converse of any relation as identical to it, and insists on seeing asymmetrical relationships as symmetrical. This was amply evident in the above material in the way that Mr G cemented the pathological splitting

thinking.

process so as to defend against any depressive feelings of desire and need. He automatically equated his mother with the and declared all psychiatrists, “nuts”. When this classifying method of thinking is used, there is a collapse of space, no real relationship, and therefore no time, process, or difference.

therapist

Any understanding on the part of the therapist caused Mr G

to feel afraid. Understanding became a kind of bullying, which he felt justified in complaining about. Of course, refusing to be must also have been a way of protecting himself against his early experience of not being understood, and he sought instead to identify with an object that could not tolerate the mind of another. Though there was an undeniable tenacity in Mr G that enabled him to stick with me and the treatment for a period of time, there was also a sense that he could do so only in the form of a “sit-in” protest, by becoming a squatter who was intent on torturing his captive object. In such circumstances, the difficult work of the therapist is to weather the absolute rejection and to take note of the dependency that cannot be faced, while all the time measuring the “temperature and distance” (Meltzer, 1976) in the dyad so as not to cause overwhelming feelings of claustrophobia in the patient. The closer the therapist comes, the more intense is the corresponding denigration of him or her by the patient.

understood

The pressure of projections from the patient can force the

analyst to experience the patient’s state of mind and thus behave in

wrong and inappropriate ways (Rosenfeld, 1978). Mr G stirred in me unreasonable guilt, a conviction that I had somehow treated him badly, that I was mad or had acted cruelly. My own desire to retreat from his pain and the terror of the material could only be tolerated with the support of my fellow therapists in the staff seminar. With their help, I tried to keep in mind that the patient felt alone with the consequences of unthinkable historical trauma and that this was the only way he was able to communicate. However, a therapist’s attempts to interpret such material can

be experienced as overwhelming, as the patient cannot bear to reintroject the cruel parts of himself and his objects that he has tried to get rid of. At such moments and to that extent, the patient’s world is the only world that can be allowed to exist—these are times when the therapist’s view must be utterly denied. Rosenfeld (1987) understands that however “tricky” the patients, however

much they distort and undermine, they nevertheless do “seek to communicate their predicament” (p. 32). Unfortunately, though Mr G did continue for quite a while, and in these particular ways, to communicate his predicament to me, in the end I was unable to successfully facilitate any change and the patient left the treatment prematurely. In many ways, he was right: he had waited so long— too long—for someone, for the right kind of help.

Patient H Trust is often raised as an issue early on in treatment. Can the therapist be trusted, and how does the patient know he or she is trustworthy? Trust is dangerous: it requires that the patient be dependent on the therapist for the help that is needed without a guarantee that it will be delivered. The conditions that warrant trust have somehow to be made manifest to the patient, and the therapist has as at his or her disposal only the setting and its boundaries with which to evidence the internal integrity that the patient has yet to experience. Perhaps to ask the question “Can I trust you?” already implies that there is an object in the room that cannot be trusted. Many patients who come to the Fitzjohn’s Unit for treatment have had experiences of their trust being abused. Trust, after all, is not simply a commodity, and it is only through actual experience with another that trust can be encountered and reviewed. Mr H’s experience was that he had lived, internally and

externally, in an atmosphere of suspicion, in a regime that eroded

trust. He was employed by an institution where he only gave the appearance of “working”, while actually behaving dishonestly and parasitically. Control in that environment was in fact achieved through the erosion of trust. He effectively lived in a world that he felt he could control, where trust was obsolete—an environment, as it were, in which children could betray their parents. When the trust that children need to have in their parents is in fact broken, this can be one of the most painful experiences in life. Unsurprisingly, when I saw Mr H for the first time, his need

to control the setting and the therapist was immediately present. Suspicious feelings were aroused when I called him up from the

waiting room two minutes early. Should he be pleased, or was this a malevolent sign? This was quickly followed by: “It is worrying— you are a woman. I do not trust women. I cannot tell you anything. I absolutely do not trust my mother. You look like my mother.” Historically, Mr H had suffered personal and social traumas

that, at the start of his treatment, he could not experience. Instead, he was faced with the choice of being either the victim or the of all manner of hurt, from manipulation to direct torture. So, how could he know that this institution—the Tavistock Clinic, and the Fitzjohn’s Unit in particular—was not either manipulating him or easily manipulated by him? He had to resort to omnipotence to protect himself from the knowledge of his own corruption. And, in this binary, symmetrical system, if the patient is not the corrupt one, then clearly the therapist and her institution must be. Mr H preferred to live in a world without boundaries, and he expected to be able to mould the institution into a place without angles, edges, or ethics and therefore open to corruption. In this way, it could be transformed into a narcissistic object reflecting only the self, a regime allowing the loopholes through which might be co-opted. For this patient, this was the accepted and most sensible way to live; any other view was simplistic and naive.

perpetrator

others

At the same time, Mr H seemed determined that I should not

see the corrupt colouring of his situation. Instead, he lodged a complaint, claiming that it was the organization that he had sought help from that was corrupt. He accused the therapist and her of not being fit for purpose, saying that we were untrustworthy, part of a corrupt regime that “got away with it”. Even when a crime could not actually be specified, the patient was able to suggest that corruption was not something like fraud or murder, but much more ephemeral and not easy to detect.

setup concrete

In the face of such accusations, I at first felt an urgent need to

hold fast to my method, to try to function well enough to bear the complete projection of the internal psychic experience of the patient. As Betty Joseph (1985) states, it was the “total transference situation” that held sway; I was subject not just to the defences of the patient manifesting themselves in the transference, but to the patients’ entire “psychic organization” being brought to bear through the transference. While trying to metabolize the patient’s projections, I also needed to have access to other thinking minds

to help me avoid my own defensive measures and see the pain, disappointment, and trauma in the patient. Corruption, however, has a way of getting into everything, and

Mr H’s transference would centre on the perceived or imagined corruption in me and the way I worked. The times I offered, the holidays I took, the institution and its “cock-ups”—all were seen in terms of a plot against him. If there was something on offer from my mind it was seen as suspect, precisely because it was not the product of the patient’s own manipulation or seduction. In the countertransference, I began to doubt the patient’s every The “dis-ease” of being filled with mistrust was I started to feel that there was a trick at every turn and that I would fall foul of it. However, I came to understand that this was in fact the patient’s state of mind, and that what he needed was that I take him at face value, work with what he brought, while not neglecting to point out glimpses, when I saw them, of the ordinary, decent person that he could be.

statement. overwhelming:

However, Mr H continued to seek reasons to complain about

my corruption, and this took the form of him claiming that I had not let him know when I was taking my holiday break. In the external and internal regime of this patient, there were no legitimate holidays; for him, the only way to take a break from an presence was simply to disappear, which is precisely what he experienced me as doing. Mr H suffered the potentially experience of turning up at the clinic, expecting a session, and finding me not there. The so-called facts regarding who was really responsible for the misunderstanding lay buried in confusion and obscurity. But the event served to confirm and prove to Mr H that the institution and I were both corrupt, that we were covering for each other. Fortunately, the unit administrators did manage to weather the complaint, which allowed me to keep the setting steady and continue with the work. It took a long time and psychic effort for Mr H eventually to be able to say, “Well I have not trusted you. I think I do now, a bit. At least I am still here.”

oppressive devastating

considerable

Under such conditions, the therapist can find him/herself

struggling to establish any firm ground in the setting. The conflict is such that maintaining a position of composure in which thinking is possible starts to feel like an “emperor’s new clothes” scenario, in which the therapist is trying desperately and idealistically to

believe in the illusion that real work is taking place. Meanwhile, the patient seeks safety in “equivalence”, the assumption that he and the therapist are equal or the same, which in fact leaves very little mental space for thinking. While interpretations can be attempted about these dilemmas, the patient might then feel that difference is being forced upon him and that, if there is no parity or equivalence in the relationship, then he is alone and abandoned.

absolute

For example, when Mr H wanted to miss a week of sessions, he

expected me to compensate him by adding them on at the end of his two-year treatment. This seemed logical and reasonable to the patient. He claimed that this time was equivalent to the sessions that I had either cancelled or taken in the form of holidays, thus creating a magical sameness between us. In this way, the feeling that something had been lost could be avoided and the illusion sustained that there is, in fact, no distinction between being a patient and being a therapist. The time of the patient’s life—and, indeed, the time of the therapist’s life—is denied (Meltzer, 1967). There is no future, just static and circular time that can be repeated endlessly as in a Beckett-like incantation. In Hannah Arendt’s Life of the Mind (1971), she says, “To be alive means to live in a world that preceded one’s own arrival and will survive one’s departure”; she makes a distinction between the individual’s finite time span and “time experience” which “provides the secret prototype for all time measurements no matter how far these then may transcend the allotted life span into past and future” (p. 20). It is the sincere endeavour of psychoanalytic work to actually take up the finite time of both the patient’s and the therapist’s life. It is partially true that therapist and patient suffer from the

same disability: each may feel that the ideas of the other are incompatible with their own. Can the therapist really “get it”, understand the patient’s internal rules, the tyranny that the patient is under and that to him or her makes perfect sense? With Mr H, things could begin to change when I started to really appreciate how precarious his world was and the extent to which he saw everyone as untrustworthy and out to exploit him. The fact that he was equally expert in his own form of corruption in this “dog-eatdog world” did not really protect him from the terror of internal and external duplicity.

When I wrote a letter to the patient, expressing my understanding that he was struggling to come to the sessions and offering to be available when he did manage to return, this was felt by the patient as almost completely alien. Still, he found himself able to express, in an ordinary way, his feelings of chilly isolation as well as to experience the hint of an awareness that there may be another way of living. Thus, over time, Mr H began to develop some curiosity about his therapist’s mind. For him, truth had been dismissed as a bourgeois idea that did not exist, had no basis in reality. However, as things shifted a little, his struggle then became whether he could trust the part of himself that was nevertheless discovering some truth, even as the other part of him kept trying to expose all truth claims as corrupt.

previously

Rosenfeld (1978) helpfully asks therapists to examine their own

attitudes to these particular patients and encourages an of their criticisms as communications. Borderline patients seem to have an uncanny capacity to highlight the Achilles’ heel in the therapist, and this can be most uncomfortable: the tables are turned and suddenly the therapist feels as if he or she is the one being analysed. As Rosenfeld suggests, one needs to take note of the criticism, but then to move to a “meta-position” and examine it in the terms of the analytic relationship. A degree of honesty and integrity is required in such work. This may be characterized as feeling that one is walking a kind of tightrope, trying to keep the setting from imploding while at the same time meeting the of humanely alleviating the terrifying states of mind that afflict these particular patients.

understanding

challenge

Meltzer (1978) brings together different ideas regarding the

misapprehension of time afflicting such patients: the fact that they find recollections and expectations indistinguishable from each other means that they are not really able to live in the present. Psychoanalytic work with patients can, however, provide experiences in the present, and, as Meltzer puts it, “having something to think about, whether pleasurable or painful, is the essential precondition for introjection” (p. 466). The introjection of a new experience can then lead to change.

emotional

I began by discussing Anselm Kiefer’s work. His paintings can

certainly be said to capture the chilly horror of encountering the

trauma in the lives of the patients that attend the Fitzjohn’s Unit. Perhaps the role of the therapist in this setting is similar to Kiefer’s as an artist: one needs to take in the concrete manifestation of the trauma from the patient to then assist the patient in applying some plasticity and expression to it, and to create with the patient some space in which to achieve a perspective on these past terrors experienced in the present. Kiefer manages this by using form, visual space, and the humanity of his mind to portray that, out of trauma and horror, something new can grow. At its best, the process of psychoanalytic work can also be a creative process. As my title suggests, out of the patient’s imprisonment within a static but explosive mind—a mind that has been mined by being left unminded, so to speak—there might emerge a more reliable internal space from which to view the world.

CHAPTER SIX

Beginning in the dark Marcella Fok

As a trainee psychotherapist, there are things to be learned from theory and things to be learned from practice—that is, from the actual experience of seeing patients. Within the latter category, there are also very particular things that each patient teaches you, that the patient needs you to find out and know about his or her very own experience and sense of the world, and about which no reading of theory could possibly inform you. Thus, one begins in the dark, but through learning with the patient one succeeds in actually understanding the person who has come to seek help and what it is that he or she is actually looking for. In the process, one also learns how to be a therapist. It is this process that I try to describe here—and it is one that

is easily forgotten. There is a kind of forgetting that is often an outcome of finishing a training and becoming a “professional”; for there is an inherent tension, when one inhabits this professional role, between having accrued the knowledge of the expert and to stay close to the experience of not-knowing.

trying When I arrived at the Fitzjohn’s Unit, I was at a particular

point along this path of development as both a psychiatrist and a psychotherapist, and I was therefore drawn to the remit of the unit—namely, providing psychotherapy to patients with complex

MARCEL A

FOK

psychiatric problems. Looking back, this probably had something to do with my developmental need to become a “useful” and to witness and prove the usefulness of even for the most severe and complex patients.

psychotherapist psychotherapy As a psychiatrist, I was no stranger to the concept of severity in psychiatric medicine, which has a well-established system and lexicon. There are common mental disorders, as distinct from mental illness; there are mild versus moderate versus severe disorders, each with clear descriptive and phenomenological I had received a good psychiatric training and knew the differences: I was trained to assess and ascertain the level of clinical need and severity in each encounter, and to assign care and accordingly. I was already quite clear about what a patient with severe and complex problems looked like, and my hopes of developing and testing my mettle as a psychotherapist were pinned on the prospect of treating such a patient in the Fitzjohn’s Unit.

serious correlates.

treatment

Imagine my disappointment when I encountered my patient, J.

He was a young man, well-educated and of middle-class who worked in a scientific establishment in London and lived in a shared, privately rented flat with a few others around his age. He had no major medical history, had never been admitted to a psychiatric ward, nor attended A&E, nor needed treatment by a crisis team. However, he had fallen prey to “anxiety” and had experienced a kind of breakdown a couple of years before, which led him to seek help from his GP. He did not warrant a referral to a community mental health team but was started on an and, because he requested psychotherapy, was referred to the Tavistock.

upbringing,

antidepressant

He had filled out the assessment questionnaire eloquently and

thoughtfully, giving an account of his breakdown that included plausible explanatory factors, such as having been in a stressful relationship at the time. He talked of the breakdown leaving a mark on him, and the sense of not having fully recovered from it. All this suggested to me a level of insight, self-awareness, and “psychological-mindedness”. It now seemed obvious that he did not really tick the required

box in my mind—that is, he did not seem to belong, by any widely used and recognized criteria, to the category of the severe and com-

BEGINNING

IN THE

DARK

plex patient. In his notes, he had been given the diagnosis, “Recurrent depressive disorder: current episode mild”. At one point the diagnosis, “Personality disorder” was mentioned, but this did not stick. In terms of HoNOS clustering,1 however, he was considered to be in Cluster 7 (“Enduring non-psychotic disorders—high a sub-category under “Very severe and complex problems”).

disability”, nonpsychotic I noted the information from these categories and metrics with

a mixture of recognition and disregard. Though I did refer to them as a way of either confirming or challenging my first impression that the patient was not so severely afflicted, I also sceptically considered the bureaucratic uses to which such clinical metrics are put: How could this patient possibly be considered Cluster 7? Surely, he was at most Cluster 4 or 5 (belonging under “Mild/ moderate/severe non-psychotic problems”)—or so I argued inside my head. But, on the other hand, what did it really matter? Did it matter at all? So, I tried to put the issue of the patient’s severity behind me

and took on the task of engaging the patient in the usual way, by observing the usual framework and protocols of psychotherapy. As I was coming to the Tavistock for the express purpose of seeing this patient, I felt a bit out of my element there and experienced a greater demand to adjust—administratively, physically, and Nevertheless, I managed to find a suitable room and times, duly met with and offered these to the patient, and we started the treatment.

mentally.

The first few sessions went more or less as expected. J attended

regularly, and, though he would say that he was not quite sure where to start, he did bring things to talk about. He talked about his work, the people he met, and the like. He would comment on the task of making it to the clinic from his place of work. He even talked a bit about his previous breakdown. I also dutifully turned up to meet him and tried to understand

what he was bringing and to make some emotional contact with him. It did not happen straight away. Somewhat unexpectedly, I noticed myself feeling uncomfortable in the room and a tension during sessions with him. Initially, I cast this aside and reassured myself that this was not unusual, given my lack of familiarity with the particular setting. I was new to this institution,

experiencing

this building, this room, this specific arrangement and its It made sense that I would feel out of place for a while. I was not familiar with and did not use the same protocol for the patient’s arrival as other clinicians. It caused slight kinks in what might have been a smoother set-up and reception for the patient, but it seemed tolerable. I discussed these differences in my supervision with the senior consultant on the unit. I did not think to discuss very actively in supervision the issue of the severity of the patient’s condition. I had voiced my feeling at the start that the patient did not seem very complex, that he might not really be a Fitzjohn’s patient. Though I felt that my had heard this, he did not see fit to counter my assertion very strongly. He did, however, speak with great interest about his sense of the patient’s internal world; he had met the patient once or twice himself and knew the case a bit.

dynamics. registering

supervisor

My lack of ease in sessions with J did not wear off; if anything,

it got worse. I found it hard to find my place—to find my mind— while in the room with him. On the face of it, he was doing his bit, trying to talk to me about himself. He tended to rationalize, even over-rationalize, and told me that his friends—he is sociable and has plenty of them—say to him, “it’s like you don’t have or want any emotions”. He wanted to think about the future but felt unable to plan or commit to things. He liked variety, to move between things, and could not stay on one thing for long. He was good at what he did—his work required liaising with many collaborators and coordinating large meetings where research plans were and partnerships built. He enjoyed the intellectual of the work—in a cutting-edge field of scientific research—and found it exciting to meet some eminent figures in that field, to hear first-hand about the latest ideas and newest thinking. In his role, he was able to synthesize and link up the ideas from different people in the research consortium, and he did this with apparent fluidity and articulateness. I had no reason to doubt this: his intelligence and eloquence were clear to see.

discussed stimulation

Inclined as I was to disregard my own discomfort, it was

also easy to overlook my patient’s experience of starting therapy with me and, specifically, how internally sensitive he was to the encounters, to my responses to him, and to the breaks between the

sessions. The first break in the therapy—over Christmas—left J in a state that I could not have predicted. In the first session back, he turned up in an extremely flustered state and tried to tell me that he was having a breakdown, that his symptoms had re-emerged. He was tearful and distressed. I could not quite make sense of what he was saying, and he brought a whirlwind of other changes to deal with: over the break he had taken up a new position at work, in a different department, and this meant work now clashed with his usual session times. He was at a loss, caught up in these sudden changes that felt at once both exciting and frighteningly beyond his control. He conveyed that he needed the therapy to continue, but this meant I had to find different days and times for him. In the course of time and in the light of these new experiences in

the therapy, my impression of J had begun to change. All was not as it had seemed with him, or at least not as I had seen it. While outwardly displaying a certain fluency, inwardly he had only a fragile sense of himself as someone with a continuous identity and thus struggled to connect up his thoughts, feelings, and behaviours. In ways that seemed congruent with my early assumption about him not being a particularly unwell patient, nobody in his life really knew how much he struggled with the most ordinary things. On one occasion, for example, he recounted having two parties

to attend, both happening on the same day. After much deliberation, he chose to go to one of them, but while there he found he could not get into it or enjoy the company and, in the end, was left feeling that it had been an utter waste of time. This provided a compelling metaphor for a state of mind that was very familiar to him: he felt tormented by choices he could not make and then always ended up feeling trapped in the wrong one. With other people, especially in groups, he often felt detached and discomfited. He saw his own articulateness as a guise that masked his real experience. In fact, he found other people more real and easier to deal with when, rather than talking eloquently, they stuttered or struggled to find the right words; because, however, he never spontaneously did this himself, people were given no inkling of his disjointed internal world. The work in therapy continued to be testing. When with him,

I felt an intensity that was not closeness so much as a rather

indescribable claustrophobia; I was anxious both of encroaching upon him and of being encroached upon by him. I could not feel at ease and tried my best to hide it. I found the sessions hard to write up afterwards, even though there was never a lack of spoken content. Correspondingly, J seemed acutely and tuned in to my state of mind and what was happening in the sessions. Things I said, interventions I made in sessions that I felt were ordinary and fitting, would startle and have an adverse effect on him.

uncannily I came to see that it was useful that he was having two

sessions

per week because this made it more possible for him to report—and for us to process—his experience of the preceding session. For example, he once arrived for the second session of the week on the dot, but looking tired. He started: “I felt the session ended abruptly yesterday.” Last night he had not felt so well—or maybe he was coming down with something, anyway. He remembered feeling suddenly very tired towards the end of yesterday’s session. In my recollection, the previous session had indeed ended before we could finish discussing something, but I was really struck by the almost visceral force with which this had impacted on him. He also expressed dismay about other aspects of our contact.

At times, when I really tried to understand what he was telling me, or wondered about the different levels of his experience, he would feel disturbed, as if my inquiring stance was itself somehow threatening. He would also wonder whether I was strong enough to take on his problems. On the one hand, this might have been an accurate reading of my discomfort with him, the out-of-place-ness I felt in the setting, or even my relative lack of experience compared to other clinicians he had encountered. On the other hand, he was experiencing something familiar, repeated elsewhere in other intense relationships in his own life, where either or both parties tended to end up in breakdown. I began to realize that my actual experience with him in the room was the most valuable source of information that I needed in order to understand him and his internal world. Instead of seeing it as mostly my problem or trying to hide it, I started to describe and discuss it with him. Not long after the aforementioned Christmas

break and the advent of his new work position which created a clash with one of the weekly sessions, I told him that I would be taking a week’s break at a specified date in the near future. He said that this actually suited him because it meant that he would not need to take a day off work that week. This prompted me to ask some questions about his work week, and he answered my He then very tentatively asked what time the clinic usually opened in the mornings. Only after having then spoken to him straightforwardly about my possible early morning availability did it dawn on me that I had unwittingly responded to what was in fact only a tacit, unstated request—indeed, that I had offered him something that he had not actually asked for!

questions.

When I drew his attention to this, he said that he had thought

to ask but somehow felt it impossible to do so. I then elaborated on this interchange, on how, though he had felt unable to make the request explicitly in his mind, he had nevertheless responded favourably when I offered a solution to the clash between his work and therapy sessions. He acknowledged that this was a very difficulty of his, that he found it incredibly hard to broach or ask for things that, once offered by others, seemed to be perfectly easy and feasible to obtain. By thus describing these interactions, putting them into words, we were able to find some capacity to master the experiences rather than be mastered by them. We spoke about the pressure between us in the room, that whatever one person put out had to be met and matched by the other. It seemed utterly necessary that there be a seamless fit between us. He told me that when I said something in a session, he could sometimes immediately recognize it as an insight—what he called a “no-gap-ness”—but, strangely for him, at other times this did not happen. I, in turn, described how I would often feel a pressure to make some quick statement in response to what he was saying or bringing, rather than being able to pause and consider the issue—on his behalf, so to speak. In other words, there was a mutual feeling that when one of us said something or put an idea forward, it was imperative for it to be met immediately, to be found a kind of fit or match for in the other’s mind. If this did not happen, a palpable, almost visceral discomfort would soon follow.

typical

immediately

Both in life and in the therapy sessions, he was drawn to a way of being with another where there was constant, apparently free-flowing, and seamlessly stimulating exchange, with no gaps or areas of misunderstanding. This no-gap-ness, however, rarely if ever produced a real meeting of minds or creative exchange. The pressure to fit in meant that he was so overtaken by his concern and preoccupation with me and what I might think or say that he would shut down, seize up within, and lose all sense of himself. This corresponded with his experience in the world outside the consulting room. While outwardly able, by way of his fluency and intelligence, to put up a display of spontaneous engagement with those around him, there often came a point, superficially to others, when he would lose all contact with himself and the environment. In group settings, these amounted to episodes of distressing dissociation, depersonalization, and derealization. In one-to-one or more intimate relationships, it could lead him to a state of mental breakdown.

imperceptible

My gradual engagement with the nature of his experience led to

subtle but significant changes in my responses to him and my way of being with him. In one session, nearly a year into the therapy, he said to me: “The way you are talking now tells me that you do understand.” It had taken me all that time to see beneath the surface, to shed my preconceived notions about his mild, “nonsevere” condition, to be able to take up the reality of his distress and make him feel known and understood. He responded, in turn, to my improved receptiveness with a greater capacity to talk about his own experiences. J had arrived at a greater realization of the extent to which he

was emotionally removed from these experiences, to the point where it was almost impossible for him to engage fully and with life and to make something his own: “Most people can say I feel this because of that—I can’t.” His outward fluency and apparent adeptness in the world belied an inward incapacity to put together the pieces of that simplest and most complex of puzzles, ordinary human relatedness. He did not lack the things that many people lament not having, like attractiveness, or worldly resources. He in fact did possess such assets, but what he lacked was the ability to capitalize on them. He had

satisfactorily

intelligence,

felt stuck in his life without fully knowing why, and worse, while feeling that nobody else would know or understand just how stuck he felt. Things gradually did get better. In his words, the difference was

that now he could know when he was anxious, could think about it, and this awareness helped him to feel less stuck. Looking back, I think that my knowing about his experience was an important step in enabling him to know about it and grapple with it himself. And in order for me to know about him, I had to cast aside my preconceptions and be open to what I did not and could not know until I had experienced it with him in therapy. My dilemma thus turned out to be the key to my learning with

this patient, and the making of my learning as a clinician. The psychiatrist in me, an adherent of the established frameworks and tools of clinical assessment, had at first glance found nothing in this patient to cause particular concern. This was not so much an inaccurate clinical assessment, but an incomplete one. Such are, of course, required of clinicians working in a wide range of settings every day, and they are appropriate and justifiable in the context of matching each patient to the available care provision and in deciding what treatment any individual needs. However, the same assessment cannot be a substitute for the sufficient of the patient’s own experience of mental illness, nor can the objective level of clinical severity be taken as the only measure of dysfunction. While these statements might sound obvious, I think their verity is not pointed out frequently enough and can be easily lost in the professional discourse of psychiatry. Working in a somewhat different framework, as a in the Fitzjohn’s Unit, allowed me—indeed, forced me—to recalibrate and to regard my patient J with different eyes. As a I learned to become more available, to tune in to the subtleties of my patient’s internal world which were mostly hidden from plain sight. This quality of indiscernibility or unknowability applied to his perception of himself as well as to the perceptions that others had of him as a person. In the process of therapy, I journeyed from a psychiatrist’s view of him to a psychotherapist’s view. I believe that what is essential here is not a choice of one viewpoint over the other, but of having the flexibility to move

assessments

understanding meaningful

psychotherapist psychotherapist,

between the outlooks and make use of both. The experience of a seemingly not-so-severe patient at the Fitzjohn’s Unit taught me this and turned out to be a highly fruitful lesson for me as a clinician.

seeing Note

1. HoNOS (Health of the Nation Outcome Scale; Wing, Curtis, & Beevor, 1996) is the most widely used routine clinical-outcome scale in English NHS mental health services, for measuring the health and social functioning of people with mental illness. The scale covers sixteen domains, which includes twelve domains of current symptoms and functioning, and four domains of historical problems. Each domain is scored from 0 to 4, with 0 as “no and 4 as “severe to very severe problem” in their respective domains. Ratings on the HoNOS domains form the basis of “clustering” a patient—that is, allocating the patient to a global group of people with broadly similar and care needs as identified from the HoNOS ratings. In the care clustering system, there are a limited number of predefined clusters, each with a designated number and label—for example, “Care Cluster 3: Non-psychotic, moderate severity”. In many services, clustering is meant to be closely linked to decisions about the type, intensity, and length of treatment offered to the patient.

problem”

characteristics

CHAPTER SEVEN

The group as an object Maxine Dennis

In this chapter, I describe an approach to group psychotherapy as practised within the Tavistock Clinic’s complex needs outlining the theory and illustrating it with clinical Insofar as they are under the auspices of the Fitzjohn’s Unit, most of the patients entering the kind of group that I present here have already received two years of individual psychotherapy. These patients then commit to the group therapy for three years. However, a few patients enter the group before having engaged in individual work. What I have come to observe in this work is the way in which the group becomes an object in its own right, with a collective mind to which the members contribute, which they discover and get to know, and to which they relate in different ways. An aspect of this “group object” is that the members bring to it not only their own past lives, but also their present conflicts and struggles, as well as their fleeting hopes for the future. One sees how they bring to life Freud’s ideas about repetition compulsion (1920g) and working through (1912b). With the particular group of patients that I present here, there is a tendency to become stuck and to repeat painful or damaging experiences in just the way that Freud described. They need time and understanding to be able to

service, material.

important

MAXINE

DEN IS

work through these experiences in such a way that development can begin to take place. We observe that when development does happen, it enables hope but, at the same time, stimulates envy and destructive wishes which they direct towards both themselves and others. I hope to show how an object initially experienced as “restrictive” can change and be seen in a better light once the internal environment becomes less cold, bleak, unloved, and unloving. By using the term “restrictive”, I am suggesting a link to the less than abundant or generous nature of these patients’ early experiences. A certain set of expectations therefore dominates their participation in the group, which initially is felt to offer only more-of-the-same kind of limited and limiting experience. Many group members cannot believe that any change is possible. They will have had brushes with life-threatening situations and may be actively suicidal. There is a real struggle against taking in, or introjecting, anything new; instead, denial, turning a blind eye, paranoia, and a tendency to retreat take centre stage.

multiple

Both as the group therapist and as a member of the group, one

is often invited to adopt what can be a perverse and fixed way of relating, obviating any chance of change. That is, as O’Shaughnessy (1980) warned, instead of someone being anxiously aware of inner self-destructiveness and “deflecting it outwards, it is embraced, [and] the ego forms a perverse alliance” (p. 574). As one group patient commented, “my problems become my friends”, making the problems hard to relinquish; they provide cruel but stable This can profoundly limit any possibility of change. Change requires that the patients allow themselves to at least consider ways of understanding, which then may—or may not—be accompanied by different ways of behaving. This more flexible kind of understanding is important in the move towards development—a state of mind in which life instincts prevail—and away from something deadly.

comfort. different The majority of patients have a diagnosis of borderline

personality

disorder, while chronic depression, mania, agoraphobic symptoms, anxiety, eating disorders, and encapsulated psychosis are also common. For reasons of confidentiality, I shall of course not specify the group members’ particular stories, but in general terms they share features such as a history of abuse, dependency

THE GROUP

AS AN OBJECT

issues, and struggles with forming and maintaining relationships and gaining employment. Their difficulties have led them to be extremely harsh and persecutory towards themselves, severely affecting their self-worth. They frequently struggle with the to self-harm and with ongoing periods of suicidal ideation.

temptation A psychoanalytic therapy group usually consists of up to eight

individuals and a group therapist. The therapist fosters an of openness to experience, encouraging members to develop an understanding of each person’s situation—ultimately, each mind—and to appreciate the way in which it manifests itself within the context of the group. Each member’s participation is central to his or her own and to other members’ treatment. As they give expression to their histories and develop a capacity to and reflect, they begin to see ways in which they are both similar to and different from each other. The process of discovering that members have the ability to help each other forms the basis for growth within the group. Exploring how unhelpful patterns from the past are played out in the here-and-now can impact on both the present and the future.

atmosphere person’s remember

This real experience in the here-and-now—of seeing how

members behave, relate to, and get on with each other—provides a

unique opportunity for learning. The struggle to be understood, and an equal struggle with the failure to understand others, helps a member acknowledge that something half thought, or thought in private, can now be talked about and explored. This can bring the relief of acceptance: patients discover that they are not alone in having felt something dreadful or overwhelming. It can also help them begin to see that they are not all bad or hopeless, do have strengths, and are not wholly to blame for what they have suffered. The therapist’s role is to help the group members get to know each other, while also allowing themselves to be known. This constitutes much of the work that takes place within a therapy group. Having to share the group therapist with other members can bring up earlier familial experiences with parental authority and consequent sibling rivalries or alliances, which can then be commented on by both therapist and patients. The therapist may draw attention to the connections between the past and present, thoughts and feelings, fantasy and reality and point out patterns in relationships—all of these represent connections

process

repetitive

between the external and the internal worlds. Perceiving such connections can stimulate patients to begin to observe themselves individually as well as others, to develop a capacity to notice and comment upon their own behaviour and thus form a view of their experience and its meanings. The reference to the “group as an object” draws on the work of

Caroline Garland (2010), who defined certain features of group therapy, where the containment and maintenance of the setting is a joint activity and the group as “object” is felt to belong equally to all the members, existing in the mind of each. In this regard, the group can either be loved (expressed, for example, through regular attendance) or hated (denigrated, rejected, and avoided). It can be a maternal object with a “lap” function, emotional nourishment and understanding; or a paternal object with an “organizer” function, generating insight through verbal comment and interpretation and enabling thinking rather than a rush to action. These maternal and paternal functions, provided by the therapist and in turn by the members, bring together different parts of the psyche in relation to the object that is the group.

psychoanalytic

providing

initially

I would add that maintaining boundaries, on both the vertical

axis (between the therapist and patients) and the horizontal axis (in relations among the group members), ensuring that more or erotic impulses are not acted out, is also an essential part of the group object’s function. This is particularly the case in a group where the bodies and the emotional boundaries of the members have been breached or violated. Moreover, each member’s social identity and culture will also impact upon the internalized view of the self and affect the cohesiveness of the group, so this dimension, too, requires careful attention.

destructive

Clinical material The clinical material below describes the process of a new member joining the group and the group’s engagement with its complicated feelings about welcoming him. There is an awareness of what the

group may wish to turn away from, notably compliance with their destructive aspects. The new arrival occurred within the context of the departure of another member, Veronica, someone who had made good therapeutic progress and therefore left behind a residue of complex feelings in the group. They had found it hard to face the loss of Veronica, a much-loved member who had originally come to the group in a depressed state, literally from her bed. By the time she left, she had made a career change, found new employment, and got married, and those who remained behind were jealous and envious of her achievements. Though her leaving allowed them to feel hopeful about their own possibilities, she also stimulated the contrasting fear that for them nothing more was possible—this was “as good as it gets”. In addition, other struggles became prominent with the of a new member. It revived difficulties of sharing the group therapist (the parental object) with yet another sibling. By allowing in someone new, the group had to deal with the desire of the “mother” for new babies and the conflicts of rivalry. Early feelings about inclusion and exclusion in the family context are laid bare when the arrival of new younger siblings occurs, since they are inevitably perceived as both needy and greedy. There were memories of a previous situation with a particularly explosive member of the group who had only countenanced comments from the therapist and refused to to fellow group members. She had wanted to lay down a rule that the door to the room should be locked at the start, excluding those who came late. This would often have left her as the only group member present, which is precisely what she was unconsciously seeking. The group had not gone along with this proposition, but her angry demands engendered the of strong feelings—rivalries and jealousies—that they all shared, along with the wish to have exclusive attention. They struggled with unresolved anger towards the group therapist for not bringing in the right kind of “baby”—in other words, one that did not take up space or need to be fed in any way. This was expressed by a number of members missing the sessions both before and after a break, an indication of the risks attached to these transitions.

introduction

sibling

listen

recognition

Clinical session The existing members of the group are: Harry (age 49), Persephone (age 58), Jacqueline (age 37), Carol (age 44), Jonathan (age 60), Annabel (age 48), and Zoe (age 39) who missed this session. I go to meet the new member, Simon (who is 59), and take

him to the room, where Harry is already present. They greet each other. Harry looks uncomfortable. I notice how he speaks with his eyes closed—akin to the way in which a newborn may defend against a flood of sensory experience, titrating how much comes in, how much stimulation can be managed. I am both pleased by their initial greeting and at the same time anxious about whether the other members will appear. I am reminded that at the end of the last group Harry announced, “Let’s do something different . .. let’s all make it next week”. He has always tended to take up the role of my co-lead, repeating his family role where he felt that it was his job to keep things going. Nevertheless, he seemed also to be expressing the part of himself that wanted, despite the odds, to make connections with others. I take this as a turn towards life and a move away from a narcissistic preoccupation with himself that stops him from attending regularly, thereby creating discontinuity. This is an issue with which the group as a whole has struggled and which becomes particularly manifest during times of change and upheaval. All members arrive within three minutes of the start. After a

tense silence, Simon says: “I am new here, and I am just waiting to see how things go.” Persephone says: “It must be hard coming into a room with so

many new people.” They smile at each other. Simon continues: “For me, I have had a busy two and half

weeks. I have gone from zero to doing something every day. I am working for a charity organization, trying to sign people up outside the railway station. It was very busy, yes. I did not realize what it would be like.” Persephone and Jacqueline are both interested in what he says.

They enquire further and state that it sounds quite overwhelming. I note how our start is rather like a busy train station, with

members entering in quick succession, one after the other. It is also significant that Simon has come in tentatively, tacitly acknowledg-

ing his position as newcomer, saying that he realizes that he is not one of the big boys. But he also makes himself appealing by showing that he can engage in useful work for others. Perhaps in order not to feel pushed out, Persephone and Jacqueline show their powerful need to mother the new baby, as if saying, “poor baby, it must be overwhelming for you”. Harry asks how Jacqueline is feeling. She says it will be March

before her plaster cast comes off, pointing to her hand. I think to myself that it will likely take until Easter for the group to settle down in relation to the changes. She explains to the new member that she twice broke her wrist through the joint. It did not get after the first time, and this summer she broke it again. It is badly damaged and perhaps will not get better. But she gets good treatment at the hospital—that’s “as good as it gets”. Here I have an association to the film with that title, starring Jack Nicholson, about a man with an obsessional problem who is cured by love. I notice that I am feeling more freedom in my own mind.

better

Persephone asks if Jacqueline might have surgery. Jacqueline

recounts, rather triumphantly, how twice in exactly the same she had been out walking with her mother in broad daylight and tripped on the pavement. This had happened on strange, uneven, cobbled ground. Persephone reminds her: “You said you were glad it was you and not your mother. She is nearly eighty and wouldn’t have been able to get up. I remember when you mentioned it in your first group: they’d said you should sue as a way of getting money. But not in this group. It just shows you how people think.”

circumstances

Persephone is bringing this in as a bit of history, showing the

new member just how much she knows, but in her reference to the mother there is also an association, on quite an unconscious level, to her own murderous wishes. I pick up on the fact that this accident happened during the

break. I suggest that this interruption of the group’s work caused an almost literal break, leaving members feeling alone and as though they themselves could not be fixed. Of course, in a group where there are such profound

difficulties, the holiday break can leave members feeling as if they are

on dangerous ground. One might think about the “accident” as a masochistic attack on the body and the self, a way of diverting and

making safe the murderous wishes towards the mother. Instead, Jacqueline acts out a suicidal impulse to break her own bones. At any point of separation there are painful questions about survival. The members are left with their hostile impulses towards the group therapist, feelings of abandonment, and fears about being able to contain such feelings. Sometimes they will manage to project these feelings into the GP, other professionals, or relatives and friends, leaving them feeling abandoned. Simon explains that he had once slipped at work and was

sacked while off sick. He wished he had sued because he was left without a job and no compensation. Afterwards he had a because he had been working so hard for his degree and could not reap the rewards. The accident had knocked the wind out of him, but then other issues came out, and he has ended up “here with you wonderful people”. This statement seemed to be a heartfelt one.

breakdown

Jacqueline says it sounds like he had a lot of bad luck. Simon

describes having, in the past, jumped out of helicopters, done all sorts of unusual things, yet nothing had happened to him. says, “listening to you makes me think you don’t know why certain things come along and affect you, but they do”.

Persephone

Then Harry says: “We have been struggling with that here, and

what has come up a few times is how to approach those things in a way that contextualizes them, for them to make some sort of sense. In the last few sessions we wondered, how does one approach events in the recent past, or even the distant past, and feel they have been effectively processed and dealt with? Or should we focus on something in the present that is destructive, which never really gets put away? Carol, you were saying you felt particularly uncomfortable with having to look at events in the past and you would rather step away from them to something that is easily identifiable, and can be placed in space and time but still exerts a particular influence.” I wonder whether Harry is highlighting the way the group

reacts when confronted with an interpretation that feels too powerful or close to the bone. There is a sense that something has

been taken in, but the question remains as to whether it has really been used. Harry makes reference to interpretations from previous group sessions, but, given what I know of his struggles with eat-

ing, I wonder how much he has really digested, as opposed to how much he is merely regurgitating. However, his point is still and he is also making reference to a familiar struggle between Carol and rest of the group. Steiner (1992) discusses the difference between patients who want to be understood by the analyst and those wanting to possess the understanding for themselves. Carol seems to be one of the latter, wanting the understanding to be hers without the intervention of the therapist.

poignant,

Harry then says to Simon: “You manage not to get hurt in the

military but then it happens where you are not expecting it, like in the canteen at work—you can get a serious injury there. On a mental level, things can be like that, something that seems normal can recapitulate previous events or experiences not appropriate to that time, and all the feelings of the past can be present. How do we address that so it does not colour everything that happens? I think about myself—am I opening a wound which should have healed a long time ago, or is this a valid form of investigation?” Simon responds: “You summarize what mental health issues

are. You can’t put things in a box and deal with them. I deal with my issues with isolation and cutting myself off from the people I love, my family. When I realized my relationship with my was not good, I absconded and came to London. I lost my house—and most importantly my family—and unintentionally became homeless. That is when all these ugly things, which I had not processed and put in the right place, came to haunt me. I was lost and unable to deal with them. I was abandoned to an aunt when my parents came to the UK. I felt left and unloved. I was on the fringe and unintegrated. And those experiences have been in my mind from an early age, floating around. It was not until the injury to my neck that everything flooded back. I had an overload and was unable to distinguish past, present, and future. I was in a sort of numbness. All I built up in the military and university, this confidence, was dashed. I wished there was an easy solution and I could say, ‘go away, problem’. But the problem becomes your ally, and doesn’t want to let go. I can’t work, and I blame the problems. Society forces you to use the negative problems and it’s me that has to deal with it. I want an answer to put things to rest. Once I talk about them, I can give them a sense of priority. I don’t know if that makes sense.”

family

Harry then speaks again: “When that lack of confidence happens, you feel powerless. I think our main objective is to bring things out into the open, and sometimes we succeed and other times we don’t. We want to see things in a more realistic perspective. Speaking personally, when I feel my worst it’s like a waking dream and things seem more symbolic or dream-like than actual. They lack perspective, and it means that minor events can set me off thinking that I should kill myself, harm myself, or that my entire existence is useless. I think sometimes this is strange to listen to and can seem vague and tenuous. When you talk of isolation [he directs this to Simon], that’s a pattern that has existed for me. I have not seen my family for over thirty years. Sometimes it feels more relevant to me now, my poor relationship with my parents now, than when I was still around them. To have been mistreated, abandoned, disregarded, can become like an imprint, a way of looking at yourself. That was the way they perceived me, so I could feel that must be my role in life. It becomes hard to be around . .. I am rambling a bit here.”

people

Persephone says: “When I felt isolated I would take myself to

church or the park, but I think I felt on the edge of things.” contrasts this with feeling that she is beginning to embrace being on her own. She says, in a rather surprised tone, that she was invited to a charity dinner.

Persephone

Harry thinks that whether Persephone accepts this invitation or

not relates to how much we let anxiety govern our behaviour. He says: “You will probably always have anxiety, which accompanies that sort of thing, but it would be much worse not to let yourself go. In the past, you might have stopped yourself. You are conscious of an option. Two years ago, with the book launch, there was no way I could go. I was afraid that I would be inappropriate and avoided it.” Simon then speaks again and goes on to describe his

struggle with letting people in and relying primarily on doctors and

therapists. Here the group is talking rather poignantly of change and of the value of the group experience for them. I say: “I wonder if this is about opening up one’s home. Thinking about allowing new experiences and people in refers to the new member starting,

discussion

and what that feels like both for the new member and the older members. In the group’s mind, there is also an awareness of other members starting at some stage. I think that we are struggling with how we accommodate the outside and the changes in here. There may be a wish to hop back into bed, retreat, and avoid confronting the anxieties—and that may relate to one’s place in the world, and being able speak here today.” Harry says he feels as though he is performing an autopsy,

looking at organs and detecting a disease contracted over the years. “How can I put any of that into a meaningless . .. I mean meaningful, viable shape?” he asks. “I feel in prison and counting down the days before I am released, but when I am released, then I think about the days until I die. The optimistic thought is, I have lived most of life now and there can’t be more of it left. I feel stupid saying this, to be honest. I really feel stupid. I feel you should not have to listen to this.” I thought his slip significant and related to his tendency at

times to turn an idea into something meaningless, the status quo, to make it “as good as it gets”. Jacqueline says: “What I picked up when you spoke about the

autopsy, what came into my mind, was that the autopsy was a faulty survival strategy, rather than what you think is left of you. Your zombie-like state, what you felt at the time, was needed to protect you from further damage. I saw it as an autopsy on what has not been working for you. When you were saying something was not right or not there in the first place, both can exist. For instance, I have been to two different places for this hand. Both times the doctors said it will get worse—and it was already pretty bad. The first place said, ‘We can’t do anything here—come back when you need a wrist replacement.’ The second place said the same thing, ‘it’s damaged’, but they added there is every point in keeping it as good as possible for as long as possible. That is from saying come back when you need a wrist replacement.”

different This captures some of the group’s predicament about the

recognition of what they can change and what they cannot. To live

with limitation would involve them in mourning what they have lost—a difficult process for them, but necessary in order to face the current reality.

“We are not trying to fix ourselves,” Jacqueline goes on. “We can’t do it on our own. The initial stage is to stop things from worse, slowing it down. It is possible to get to the point of stopping things from getting worse and then something beyond that is the progress you’ll have made.” She points to Persephone— who at this moment seems to carry the hope for the group. Persephone acknowledges that she has made progress, says that she was now engaged in what she felt was “normal” rather than being “paraplegic” all the time. Simon says: “We tend to be self-critical.” Harry then says: “What I am saying is silly . . .” Simon again: “We are too hard on ourselves. In my culture in the village everyone looked after the child. There was a sense of community, a collective. In the UK, it’s not there. We don’t know the name of our neighbour. I hope we can be honest in what we talk about. I am new to the group. The doctor [he points to me] is the only person I met before the group. I hope I can bring things which are challenging. I am taking small steps and if we can all do so we can make improvements. I am touched by what some of you have said but we are good actors. We know how to disguise what is inside. That is why I said earlier that our problems become our friends. I know when I will get a panic attack, a flashback—my body lets me know. Forgive me that I am not going to tell but as my confidence grows in the group I can touch some more. This is the first time I have been in a group setting. We all feel unloved and unimportant. I love my family, but they don’t know that I have a brick wall around me that tells me that I have to deal with everything. Over the years it has become so thick it has become hard to form a relationship with anyone, much less myself.”

getting

everything,

Jacqueline comments: “You feel locked in and locked up at the

same time.” Harry adds: “Yes, and the reference to us being professional actors is right—the effort that it takes does not leave much room for anything else. So much time presenting the false persona to the world—it becomes something you can’t break away from.” Carol then addresses Simon: “Yes, I don’t say much and it’s really hard for me to talk in the room, but what really strikes me about your personality on your first day is that although you are

not feeling it inside, you are talking about yourself in a confident way. I don’t know how long I have been coming here but I have not spoken that much. It strikes me that you want to get help and want to help others, which is such a good attitude.” Persephone agrees: “To come into a group and to express so

eloquently as well is incredible, it is very touching.” This seemed to convey both the felt poignancy but also the need to present the group in a good light to the newcomer, lest he go away. Carol speaks again: “What else do you think?” She looks at the new member. “What you say about being a good actor is very good. The last two days, yesterday in particular, was really bad. I do hide it from my daughter but I could not yesterday. I was in physical pain. My daughter helped me. She gave me tea and a hug. A friend of mine called and I picked up the phone as an impulse and I took a deep breath and was all enthusiastic. I was crying just before. When I put the phone down, my daughter goes, ‘Sst, sst, sst—why did you do that? You pretended you felt fine—well, why didn’t you let your friend know how you really felt because then she could come and talk to you?’ That was a shock to me, because everywhere I go, no one knows of my struggles and that’s how I like it. I hate to think that things which have happened to me will affect me now.” She then describes her day: “Shower, gym, work, study, meeting friends, like normal people: they think I am one of them.” I now speak: “It seems that I, like Carol’s daughter, need to

point out how things can be repeated in the room, how each of you at times, as Carol is saying, can come along and put up a front, so there is no investigation of the pain, and this is detrimental. It serves to support the destruction and neglect which has been, for many of you, your experience.” Harry speaks directly to Carol: “The tears streaming down your

face is an indicator that something was wrong. Maintaining the front maintains the source of the pain. The more you put on the act, the more intense what you are trying to cover up becomes. I used to cut off and engage in a charade for my friends—back when I had friends!—until I needed to start taking it out on my body. When you’re constructing a façade, you are not acknowledging the pain, which can endanger you more than you can acknowledge.”

Carol responds: “I am forty-four, I started work at fifteen, I am doing a degree. This front has taken me here.” Harry persists: “When you say, taken you here—yes, here, to

discuss it. It took me a long time to acknowledge that I was in It took me into not doing anything, self-destructive thoughts and behaviour .. . What the group therapist is saying is that we have an optimistic wish to just feel well and just to encourage, but there is collusion in that and it might encourage things which are not productive as well as going along with things which could be dangerous.”

difficulty.

I notice that he is repeating something I had said in a previous

session, and I am again left wondering about his relationship with what I say: it appears as if he has understood something, but I am left wondering whether it has been fully digested. Is real occurring, or is it an intellectualized statement that serves to protect him against thinking and producing his own meaning?

understanding

Persephone says: “You are making me think of Robin Williams,

the comic genius, and how I got to the point of physically not because of the depression. That’s when I think of being in pure hell and not letting anyone know.”

moving

Carol goes on to describe locking herself in the kitchen and

hitting her legs, calling herself a bitch and a whore in the way her mother used to, beating her with a belt while other family members watched. She says, “we are indoctrinated into just accepting it”. Harry thanks her for sharing this and adds that it does not come

from some weird place but is meant in a genuine way. I say: “There is an anxiety about having a different experience,

where someone halts the violence, where vulnerable feelings can be brought to the group to be explored and understood, as you have been trying to do today. But you are also letting me know how readily you rely on this familiar destructive friend who is so seductive and always available. I think there is beginning to be a real wish to discover a different way of relating to your minds and your bodies.” As the group session ends, the members return to the idea

of violence as a defence against pain and loss. Carol brings this vividly and expresses the wish to punch me for making her, and the group as a whole, face painful issues from which they would rather turn away.

Commentary and conclusions What is evident from this material is the way that the older of the group seem at first to have lost contact with their capacity to change. Perhaps they have projected this capacity into the member who left in a better condition than when she had first arrived; because she is no longer there, they have literally lost sight of their own abilities. When capacities are projected in this way, one is left empty, devoid, depleted, and this exacerbates the envy felt towards those who are perceived as successful or as having desirable qualities, thus spoiling any possibility of a good (Klein, 1952).

members

experience With the new member, by contrast, the group seemed to behave

like the “family holding back”, putting their best foot forward to accommodate the new member. However, perhaps what was here (perhaps represented by Zoe, the member who did not attend) was the hostility, aggression, and other complex feelings that must be present when someone is confronted with change.

missing

This struggle surfaces at various points, rather poignantly, for

example, when Harry questions whether he is “opening up a wound which should have healed a long time ago” or in fact a valid form of investigation. His dilemma speaks to an existential struggle for all patients: is it best to leave well enough alone and avoid the conflict and pain involved in confronting their defence mechanisms? And, in any case, is there even enough time to do such confronting? This concept of time refers specifically to past, present, and future: regretting the time that has elapsed and been lost; dealing with the here-and-now moments; and facing what is, and is not, going to be possible as they go forward.

conducting

In the work with the group, these issues can be related more

specifically to the gap of time between one session and the next, the overall duration of the therapy (how long it will go on for), and the group’s capacity to change internally. Meeting once a week for one-and-half hours does not feel like long enough, even when the members know that they are signing up for a minimum of three years. That they also have to deal with jealousy and competition over “resources”—expressed in terms of limited psychic space, as well as time—frequently leads them to adopt the seductively conviction that nothing can, or should, be expected to change.

negative

This is a position that they will often try to persuade me to share with them. The group, though clearly now regarded with some affection

by its members, still does not quite seem to belong equally to all. At this point of change, the old members fear that the new will occupy the position of “his majesty, the baby”, while they themselves fear being rejected or ejected. I think that the within the session demonstrates that this group is working with the same deep issues that confront us all: how do we manage to welcome the new, while at the same time remembering and mourning what has been lost?

member movement

Throughout this clinical vignette, we witness the oscillation

between life and death. The latter is represented by vicious attacks on the self by particular members, threatening to lead the group as a whole into a masochistic way of relating. One might see this as arising from envy and thus a desire not to get better, not to individuate, not to engage in a process of enquiry leading to fuller participation in the universal existential struggles of humanity. Here again is the internal conflict between maintaining a harmful but familiar status quo and making changes involving a move into an unknown future. Hamlet, we may recall, faced the same dilemma:

To be, or not to be, that is the question: Whether ‘tis nobler in the mind to suffer The slings and arrows of outrageous fortune, Or to take arms against a sea of troubles, And, by opposing, end them. [Act III, Scene 1]

Here Hamlet contemplates a number of possibilities: avenging his father by killing his uncle, Claudius, committing suicide, or simply enduring his situation without complaint. He is in a state of conflict akin to that of the depressed or melancholic patient. He bemoans the unfairness of his predicament but recognizes that taking action will be a violent affair, potentially as harmful as going to war. This is indeed how serious a risk internal change may pose. The impoverished state in which the group members find

themselves may well include the reality of poverty, unemployment, and

a paucity of friendships. From the outside, the therapist may see

a group member’s potential, but often this is not available to his or her own awareness. The members’ examination of their early childhoods and of their difficult past experiences enable them to begin to face their current reality. These are the areas that they may choose to ignore or deny. For instance, Harry’s intellectual capacity is not used in the service of sustaining himself internally (i.e., in emotionally relevant ways) and externally (by way of work), but keeps him balancing precariously on a tightrope where any sudden movement could prove fatal. Facing thoughts about the future is the next hurdle. Group

members cannot predict their futures, but they can arrive at the awareness that being harsh, critical, spoiling, and maintaining an emotionally impoverished state prevents internal growth and development. Given the right circumstances, there is the of kindness, warmth, and generosity towards the others and themselves. This involves examining the meaning of what are often traumatic past experiences, which, as I have shown, may then be played out in the relationship with the group therapist and in the group as a whole. The careful examination of this need to repeat and the containment of these anxieties can provide a group culture, a “group mind”, in which these feelings may be communicated and held until each individual group member is able to address internal and external events. This long and subtle process requires, from each participant in the group, some capacity to mourn, to work through loss, an acknowledgement of the current state of his or her existence, and the wish to survive.

possibility

CHAPTER EIGHT

Supervision and consultation: tuning in to psychotic communications in frontline mental health settings Marcus Evans

secondary benefit of the actual clinical work that place in the Fitzjohn's Unit, with disturbed patients who fluctuate between neurotic and psychotic states of mind, is the provision of a learning environment for other senior clinicians. Our ongoing clinical experience and struggle with such

A

valuable takes

patients

serves as a

constant reminder of the difficulties and

dilemmas Thus, experience insights inherent in all clinical work.

gained

the

from face-to-face work with troublesome

and

patients

can

be

called upon when staff from the unit offer supervision and/or consultation to mental health professionals and teams.

Several members of the Fitzjohn’s Unit have been involved in

consultation and supervision of frontline mental health teams and staff over a long period of time. The psychoanalytic thinking that is the bedrock of the Fitzjohn’s model is valuable for the light it can throw on bizarre symptoms and behaviour, destructive repetitive patterns of thought and action, and the problematic relationships between patients and the teams trying to care for or treat them in psychiatric and other settings. To be sure, patients who suffer from a serious and enduring

mental illness often need psychological, chemical, and sometimes

MARCUS

EVANS

physical containment. The types of setting that provide this containment and the balance of the interventions used will vary according to the patient and his or her level of disturbance at any given time. However, the diagnoses and active employed by psychiatry must be accompanied by a approach to treatment and care. Mental health professionals have to take an interest in the meaning of their patients’ and their verbal and physical communications, which may convey important information about the patient’s internal world and underlying conflicts. This receptive approach requires mental health professionals to have the capacity to make a switch from the active state of mind demanded by many psychiatric interventions to the receptive state of mind required by the need to take in the patient’s emotional state.

interventions receptive symptoms

In the Fitzjohn’s Unit, we regard this as a naturally occurring

process that takes place in the encounter between patient and health professional. However, good mental health care—and treatment—also needs to go beyond this important first step, by trying to understand the relationship between patients’ and their personalities. Indeed, highly disturbed patients need to be cared for by mental health professionals who are in and committed to understanding the meaning behind the presenting problem. Recovery will depend upon the patient’s ability to reclaim his or her capacity for psychological thought and insight. However, the development of insight itself can be a persecutory process, as patients become aware of the fragmentation of their minds and their detachment from shared reality. Post-traumatic depression is a common symptom in patients in the process of recovering from a serious and enduring mental illness, as they often feel they are unable to face the full extent of their difficulties. They may also worry that they are unlovable, unbearable, untreatable, or damaging to others. They may, out of desperation, seek ideal or magical solutions to their problems— solutions that may, in turn, impede the recovery process as patients develop a psychic structure designed to avoid painful realities. John Steiner (1993) makes the point that these defensive need to be respected and understood, as they provide respite

mental

presentations interested

psychological

organizations

SUPERVISION

AND

CONSULTA ION

from demanding anxieties that have to do with fragmentation, on the one hand, and depression, on the other. Consequently, it is the mental health professional who, in the first instance, has to both develop and contain the insights into the nature of a patient’s Understanding the use of defences helps professionals to make sense of the patient’s psychic structure.

difficulties.

In addition to experiencing feelings of anxiety, loss, and despair,

patients who become aware of the extent of their difficulties are also prone to feelings of humiliation. Indeed, the dependence upon professionals and the inevitable imbalance between themselves and the perceived authority can highlight patients’ feelings of inferiority. The fact that mental health professionals are required to assess the patient’s state of mind and functioning can also exacerbate feelings of being looked down on, judged, or shamed. Professionals need to be sensitive to these feelings and, whenever possible, help support patients in managing them. If professionals act in ways that are insensitive to patients’ shame and humiliation, this may exacerbate historical feelings of resentment and in relation to authority figures. If these issues are not they can become the locus of a grievance between patient and professional; this undermines the therapeutic relationship that is central to the process of recovery. However, even if professionals are sensitive to these issues, the sheer imbalance of power in the relationship can still inflame these dynamics. This becomes most evident when professionals are required to execute their roles and responsibilities. In order to avoid the dynamics outlined above, professionals may find themselves adopting approaches that are affected by unconscious forces, as they attempt to avoid any stance that them from the patient. This loss of differentiation and reluctance to take up a position of professional authority can lead to the erosion of professional practice. An example of this can be seen when mental health clinicians reassure patients that their thinking is quite normal or “nothing to worry about”, even when patients say they are becoming unwell. This reassurance leaves responsibility for the problem wholly with the part of the patient that is in touch with the extent of the difficulty. Numerous serious untoward incident investigations have highlighted service failures

unfairness understood, professional differentiates

to listen to patients who had reported that they were feeling unwell and in danger of harming themselves and/or others. Relatives have also often been ignored when they have recognized early signs of breakdown in the patient. Effective mental health work depends on professionals’

willingness to allow themselves to be disturbed by patients while still maintaining a professionally balanced view. However, establishing a therapeutic relationship with patients is complex and may itself be prone to false alliances, deceptions, and denial. These illusions and denials emanate sometimes from the patient, sometimes from the mental health professional, and sometimes from within the mental health system itself.

The therapeutic relationship When things are going well, the professional takes in and with his or her patient’s situation while not becoming either overwhelmed or over-identified, two responses that can lead to clinical difficulties. When the latter situation arises, the anxiety may become abnormally high, leading to antitherapeutic behaviour in the therapeutic relationship. On the one hand, the professional may attempt to cure the patient through “heroic” efforts. This is one of the dynamics driving acts of misconduct, as attempts to rescue the patient can lead to breaches in professional boundaries. On the other hand, the may attempt to distance him/herself from the patient, who is felt to be pervaded by damaged and damaging states of mind. When this happens, the professional may develop a hard, external skin designed to keep the patient and his or her disturbance at a distance and give the impression of cruel indifference.

empathizes professional’s

professional professional In order to develop and maintain a balanced approach,

clinical staff will need settings and structures and, I would argue, a

model that helps them to digest the anxieties and pain involved in therapeutic relationships. Support needs to be provided through supervision, reflective practice, and clinical discussion. These opportunities can help some professionals separate from their

identification with the patient and restore an objective clinical approach, while others are helped to reflect on hardened attitudes in the interests of becoming more emotionally available. Psychoanalytic treatment is not widely available in the NHS,

and although many patients with a severe and enduring mental illness or personality disorder may benefit from such treatment, it would not be the treatment of choice for all patients. I would argue that an interest in the meaning of symptoms and behaviours should be seen as a cornerstone of all mental health treatment and care. Whether or not patients themselves are interested in the meaning of their symptoms, they do benefit from being treated by professionals who understand their point of view. Psychoanalytic thinking and insight provides a model for taking account of the unconscious forces that operate within relationships, and thus for understanding the meaning of symptoms. Clinical discussion about the nature of the relationship between staff and patients, including enactments, can throw light on the clinical problems underlying the patient’s presentation and ways of relating, as the following three vignettes, in which was sought, will make clear.

Nevertheless,

therapeutic consultation Case example 1: the differentiation between health and illness

A mental health volunteer presented the case of Mr N, who had a history of homelessness. He described the man as a lost soul, without personality or identity. I go around to see him every week. Mr N is completely isolated, rarely speaks, and spends his days staring at the wall. I think he is hearing or seeing things, as occasionally he responds to things going on in his mind by muttering or laughing to himself. Mr N does not wash, and the flat is filthy. I have tried to get him assessed by various different services, because I think he is ill, but everyone says there is nothing wrong with him. When they ask him about psychotic symptoms, he denies them, saying only that he has dreams in front of his eyes. On one occasion, out of desperation, I took a mental health professional

around to Mr N’s flat, so that she would see the state of his home, but Mr N would not open the door. The professional said that Mr N did not have to let her in, as this was his choice, and the visit was abandoned. We can see here how Mr N denied the nature of his psychotic by keeping it to himself. He normalized his hallucinations by calling them “dreams in front of my eyes”. The negative effects of the schizophrenia led him to withdraw from contact with the world into a delusional world of his own creation. The patient’s denial and rationalization of his illness, combined with the on the mental health professional to restrict the numbers on a caseload, can lead to a collusion between the mental health services and the patient.

illness external pressure

Patients with serious and enduring mental illness need services

and professionals who are able to listen, take in, and bear the pain of their psychological disturbance. However, the challenge for such professionals is to work out which part of the patient is talking, and with what aim. Is it the healthy part, in touch with psychic reality and the need for help, or the psychotic part, employing denial and rationalization to justify its argument and conceal the real goal of manic self-sufficiency? Or is it the perverse part, which wishes to interfere with the establishment of a truthful picture, or an infantile part that wishes to maintain a position of complete dependence? Healthy aspects of the mind that contain awareness and insight can find themselves wrestling with pathological or defensive elements of the mind, in an ongoing dynamic struggle. The distinction between illness and health is useful when

determining whether the patient’s disturbance has moved from something that convention would describe as “within the normal range”, to something that would be deemed “abnormal”. This helps psychiatrists to make decisions about the necessity for the degree of their responsibility for the patient, and also whether the severity of the condition warrants compulsory in order to care for them. The dividing line between illness and health provides the clarity necessary for making decisions about appropriate action.

treatment, detention

As necessary as it is, however, this sort of medical categorization

does not provide a model for thinking about the dynamic interplay

between different parts of the personality operating within and influencing the patient’s mind. In the example described above, the mental health professional listens to Mr N’s denial and of his illness and decides that he is well enough to make his own decisions. This leaves the patient untreated and the less experienced volunteer with responsibility for a man who is out of touch with the level of his disturbance. Thus, professional and patient alike avoid painful thinking about the patient and the patient’s state of mind.

rationalization

Case example 2: denial and rationalization A community psychiatric nurse (CPN) told a supervision group about a patient in a violent psychotic state, who had recently been admitted to the locked ward for the fourth time in as many years. The patient had been discharged from hospital six months earlier. He felt stigmatized by his psychiatric label and did not like the sideeffects of his medication. Within five weeks he persuaded the CPN to discharge him from follow-up, and he stopped taking his soon after. Several months later, he was detained under mental health legislation and admitted to the locked psychiatric ward yet again, because of his violent behaviour. The nurse explained that she had not liked being left with the feeling that her contact with the patient reminded him of his illness. The patient also felt that contact with psychiatric services undermined his self-esteem and view of himself as better and stronger. Discharging the patient had also opened up a space in the CPN’s overcrowded caseload.

medication

ongoing

The origins of this particular breakdown can be traced back to

the moment when the patient persuaded the CPN that he was well enough to stop having psychiatric follow-up and discontinued his medication. The psychosis had by then already started to its hold within the patient’s personality, as evidenced by his denial of any knowledge of his history, illness, or dependence upon the services, or of the likely outcome of these developments and actions.

reestablish

Professionals obviously have to listen to patients and consider

their views, but the latter can express unrealistic demands, based

on a wish to deny painful realities. Rather than just listening to these wishes and attempting to understand the patient’s conflict and painful psychological state, the mental health system colludes by responding concretely. The capacity to depend upon others, which includes an awareness of limitations, is an important part of any patient’s treatment, care, and potential for recovery. When patients reject the opportunity to form a helpful dependence, they may be forced back into the grip of the more psychotic parts of their personality. This can increase risk and the danger of relapse as their underlying pathology goes Patients’ wish to return to a self-sufficient state of mind that denies underlying difficulties in an attempt to get away from the reality of their dependence may be understandable, as makes them feel small, damaged, or humiliated. However, discharge from services may leave patients deprived of the proper psychiatric help when they find themselves at the mercy of the psychotic aspects of themselves.

sometimes

unrecognized.

dependence

Clinicians need a model for trying to take in and understand

their patients’ communications and suffering. Good practice depends upon practitioners’ ability to use themselves and their own experience as a clinical tool. A psychoanalytic approach a model of the mind that allows for understanding both unconscious and conscious communication. It also provides a way of thinking about the relationship between the patient’s internal and external worlds, as expressed through the transference and countertransference.

provides

From a psychoanalytic perspective, when psychotic anxiety

threatens to overwhelm the individual’s ego, there is a collapse in the ego’s capacity to manage the relationship between internal and external reality. Anxiety about the extent of the damage to their minds, both internally in phantasy and externally in reality, can overwhelm patients with despair. This can drive them to resort to manic defences, based on magical thinking, in order to deny underlying feelings of guilt or impotence. Psychotic elements of the mind can promote unrealistic, omnipotent ideas of cure and selfsufficiency, while the parts of the self that acknowledge the need for healthy dependency are attacked and undermined. Patients in manic states often believe that they can deal with their underlying anxieties about damage by magical means. This includes putting

psychic or physical distance between themselves and the problem, as if difficulties could be located in a particular geographical area and then left behind. In practical terms, this can lead to planning an unrealistic journey, or a change of job or partner. The problem with these mechanisms is that eventually, when the defence can no longer be maintained, they break down.

absconding,

In an attempt to regain control of this chaotic situation, some

individuals may take drastic physical and/or psychological action: patients may, for example, act out violently in order to expel the overwhelming internal state, thereby forcing others to take control of their lives. Others whose minds fragment into psychotic states develop delusional systems in an attempt to gather the mind and provide coherence and continuity. The delusional system binds the fragmented parts of the mind together into a “coherent” belief created by the patient—a belief system that is based, however, on a psychic structure that bears no obvious relation to external reality.

system

Case example 3: the psychotic and non-psychotic parts of the self A CPN from a mental health team presented the case of Ms F who suffered from anorexia and had locked herself in her flat in order to starve herself. She had a habit of hoarding rubbish until it became a health hazard and posed a threat to other residents, whereupon environmental health officers had to be alerted. Ms F telephoned the nurse and said that she felt suicidal and wanted to die. The nurse visited the patient at home, but Ms F refused to open the door, so the nurse had to conduct a constrained and restrained interview with the patient through the letterbox. The nurse said that she was worried about her and was going to talk to her GP to arrange a domiciliary visit. However, Ms F threatened to take legal action against the nurse

if she contacted the GP. A solicitor then telephoned the CPN to complain about her attempt to speak to the patient through the letterbox, saying that she “would take out a charge of harassment” against the nurse who was “interfering with the patient’s human rights”. Several days later the nurse received a letter from Ms F’s

solicitor confirming this threat and warning that she should not be in touch with the GP under any circumstances. The CPN felt utterly helpless and that she was losing her mind as, on the one hand, she had a duty of care and Ms F was clearly ill while, on the other, she was herself in danger of litigation and prosecution if she took what she considered to be appropriate action. Bion (1957) described a division in the patient’s mind between

the psychotic and the non-psychotic (or sane) part. The psychotic part of the mind hates all emotional contact, psychic pain, and meaning. This part of the mind uses violent projection in order to get rid of any awareness of painful conflicts or emotions. The non-psychotic part has the job of thinking about neurotic problems and conflicts in association with emotional pain and meaning. The patient’s mind may alternate between these two states, in what Bion described as “the conflict, never decided . .. between the life and death instincts” (1957, p. 44). When the psychotic part of the mind is in the ascendency, it may fragment and project the non-psychotic part in order to undermine its capacity to think in relation to reality. The vacuum left in the ego is then filled with magical thinking based on omnipotence and omniscience, rather than on reality testing. In the case of Ms F, we can see how the sane part of the mind was being held hostage by the psychotic part. Although the sane part of Ms F made fleeting, limited contact with the nurse in the initial phone call, making her aware of her predicament and expressing her suicidal feelings, the psychotic, murderous part then stepped in and attacked the contact. This was done by the nurse with accusations of professional misconduct if she went against her wishes. The solicitor had also been coerced by propaganda emanating from the psychotic part of the patient, designed to undermine the nurse’s role and authority. Of course, Ms F’s sane awareness still relied upon the nurse’s resilience and capacity to hold on to the bigger clinical picture and, indeed, the nurse’s gut reaction was to realize that the threats were part of the patient’s illness and that the sane part of Ms F’s personality had been taken hostage by the psychotic part. Ms F’s behaviour left the nurse feeling trapped on the horns of a dilemma: if she did nothing, her patient’s condition would

threatening

deteriorate further; if she acted, she would be accused of abusing Ms F’s human rights. This feeling of being trapped gave the nurse an experience of what it must be like to be in Ms F’s shoes when the sane part of her mind was being undermined and weakened by the attacks and accusations of the psychotic part for drawing attention to the extent of her illness. We can see how Ms F’s mental state fluctuated as the

dynamics of her internal world changed. At one stage, the non-psychotic

part of her mind became aware that she was trapped inside a murderous psychotic state that wanted to starve her to death. This sane part of her mind was then able to let the nurse know that she was afraid of being in its grip. However, once Ms F had made the nurse aware of her precarious state, she promptly withdrew into the psychotic internal structure, denying that there was a problem. This psychotic structure then insisted that Ms F attack and the helpful contact with the nurse by threatening her with legal action.

undermine

In discussion, the nurse said that she had felt intimidated by Ms

F’s threat of legal action, on the one hand, but she knew she could not leave the patient on her own, on the other. The nurse said that she found the discussion helpful, as it enabled her to think about the situation. She also realized she needed the psychiatrist’s support in standing up to the intimidation from the psychotic part of the patient. The nurse subsequently reported that she conducted a domiciliary visit with the consultant, who told Ms F that unless she complied with psychiatric care, he would be forced to request a Mental Health Act assessment. The patient agreed to comply, and the need to section the patient was avoided.

clinically consultant

Thus, consultation and supervision provided support for the

nurse in her difficult work with the patient by enabling a space for thinking about the underlying psychotic process. Together we were able to consider the meaning of this anxiety-provoking and situation. Once we could think of the fluctuations between the psychotic and non-psychotic parts of Ms F’s personality, it was possible to understand her perplexing presentation. The group was able to help the nurse separate from the tyrannical influence of Ms F’s psychosis by restoring her relationship with her consultant psychiatrist. The restored relationship between nurse

frustrating supervision

and psychiatrist formed an authoritative clinical structure that could now better withstand the threats and projections emanating from the psychotic part of Ms F’s mind. (We also discussed that the solicitor would need some help to free herself from the influence of Ms F’s psychotic propaganda.) Investigation of the patient’s mind is an important part of good

mental health practice, and mental health professionals need the authority and skill to carry this out in a humane way. The nature of psychosis is such that destructive aspects of the personality, which hate any acknowledgement of need, may attack and either the patient’s sanity or the mental health professionals’ attempts to help.

undermine

From time to time, of course, the non-psychotic part of patients’

minds may be completely overwhelmed by psychosis in a way that forces them to act out their destructiveness physically, resulting in a threat either to themselves or to others. When this happens, the patient may need to be physically contained (under the Mental Health Act 1983) and treated with medication. These interventions are not a substitute for psychological care, but they may be in order to safely care for the patient (Alanen, 1997).

necessary What all three of the above cases suggest is that an important

part of any patient’s recovery is based on the capacity to mourn the loss of the ideal self and to face painful realities. This involves taking back aspects of the self that have been denied, split off, and projected. There are inevitably cycles in this recovery, as it moves between periods of development and mental integration, and periods of disintegration and regression. This is a precarious process that may lead to feelings of guilt and despair, followed by fragmentation and/or a retreat into paranoia, which acts as a defence against depressive feelings about damage that may have been perpetrated. The mental health system has to contain and care for patients

with profound psychological difficulties and fragile egos that are prone to fragmentation in the face of painful psychological and conflicts. Their minds may also be inhabited by destructive aspects of the personality that offer psychotic solutions to problems in order to avoid, rather than experience and bear, painful psychic realities. These various elements wrestle for control over the mind

anxieties

as the patient’s functioning veers between its psychotic and components.

nonpsychotic Patients who suffer from a psychotic illness and/or

personality

disorder, and find it hard to face the extent of their difficulties and suffering, may withdraw from the world of shared emotional meaning into a preoccupation with states of mind based on and omniscience. Ordinary communication may be stripped of its symbolic value and any capacity to convey emotional creating a gulf that leaves mental health professionals and relatives feeling alienated and deprived of meaningful contact.

omnipotence significance,

The danger is that mental health professionals can respond to

such attacks on psychological meaning by becoming mechanistic in their thinking, leaving patients feeling that they are being dealt with by professionals who keep patients and their suffering at too great a distance. Professionals may unconsciously go along with patients’ denial and rationalization by trying to understand them at a neurotic level and joining with them in a manic denial of serious problems. This may alleviate painful realities about the extent of the patient’s damaged thinking, but the patient’s sane part is then left to manage the psychotic part alone, without any psychological support. Alternatively, mental health professionals may try to crush

the psychosis by attacking it with aggressive doses of medication designed to eradicate psychotic signs and symptoms. However, even though psychotic states of mind are serious and may cause considerable suffering and pain to patients and their relatives, the psychosis cannot be eradicated completely, as it represents an aspect of the patient’s mind. This is not to say that psychosis and its side-effects should not be treated medically; the danger is, rather, that we may further persecute patients if we give the impression that aspects of their minds are intolerable. The psychotic part of the personality may be a destructive aspect, but it also needs to be thought about and accounted for. Mental health professionals need to try to “tune in to the psychotic wavelength” (Lucas, 2009) in order to support their patients’ struggle with the psychotic aspects of the self. Even patients diagnosed as suffering from a neurotic

condition or personality disorder who may not be obviously out of

touch with reality can demonstrate evidence of what psychotherapists may describe as psychotic thinking. Though not necessarily psychotic from a psychiatric point of view, these manifestations may nevertheless be based on omniscient and omnipotent ways of thinking that are encapsulated within a neurotic symptom. Acutely disturbed individuals require mental health services to take action and intervene actively in their lives, even sometimes against their will. This is an important function of psychiatry and psychiatric practice, and a reluctance to act may be destructive and unhelpful. However, mental health services also need to take in and think about the meaning of their patients’ symptoms, behaviours, and actions. As I have argued throughout this chapter, it is the absence of an adequate model for thinking about the effects of psychotic communication that can leave professionals in danger of reacting to unconscious forces without understanding them.

Conclusion Over recent years, funding for mental health services in the UK has been consistently cut more drastically than for acute medicine. These financial cuts have driven commissioners to push for in staffing levels and grades of staff, closure of beds, and shorter treatment lengths. The shortage of resources can encourage the employment of manic defences in the mental health system. Treatment length is increasingly based on limited resources rather than on clinical evidence. In spite and in the face of these fiscal and political developments, I would still contend that each patient’s state should, as far as possible, be seen and understood within the context of its overall development and history.

reductions

Mental health professionals need to try to take a long-term view

of their patients, including the fact that they may move in and out of illness over long periods of time. Managers and commissioners need to be helped to understand that mental illness is damaging and serious and at times dangerous and unpredictable, and so usually it cannot be managed on a short-term, one-off basis. In the attempt to reduce costs, the squeeze on the time available for teach-

ing, supervision, and case discussion undermines the reflective capacity of individuals and teams, thus weakening the structures that support the staff’s capacity to digest clinical experience. There is a danger of creating, in the place of these structures, a system that increases the distance between suffering patients and mental health services and professionals. It is in the light of these worrying developments that

clinicians in the Fitzjohn’s Unit do their utmost to maintain the intimate connection and complementarity between the treatment of

patients with severe and enduring personality disorders and the supervision of frontline staff. On the one hand, the experience of once- or twice-weekly work with ill patients in psychoanalytic psychotherapy gives clinicians first-hand experience of the field involved in the treatment of such patients. The ongoing clinical struggle keeps therapists alert to the general difficulties of the work, and this, in turn, helps supervisors stay in touch with the limitations of understanding. On the other hand, examples like those above of psychiatric patients in the acute stages of illness can keep therapists in contact with severe psychopathology on the mental health frontline. Such mutuality is crucial. We believe that the Fitzjohn’s model is particularly helpful when thinking about psychotic or borderline functioning, and it can restore the missing emotional meaning to concrete or acting out. It can improve clinicians’ capacity to remain interested in their patients’ emotional life and enable the clinicians to listen out for rare moments of meaning, even where the or prevailing discourse seems utterly stripped of significance. Patients who act out their disturbance in dramatic ways, who project into their bodies or develop sadomasochistic relationships with others, need mental health staff to be interested in the nature of such communication. This does not mean that the patient either wants or could manage insight at this acute stage of the illness. However, most patients benefit from feeling that they have been understood, even if they become disturbed by the insights.

emotional

communication predominant

understanding necessarily themselves As the Fitzjohn’s therapists know, insight into the nature of patients’ difficulties has first to be understood and worked through by the therapists themselves before it can be interpreted to patients.

This is particularly important when treating patients who are not able to bear the psychological pain involved until there is a that they have secured the understanding and support of their therapists. Ill patients can have a considerable effect on therapists, by provoking them into acting out, and these enactments need to be processed by the therapist before the underlying issues can be worked on in the therapeutic relationship.

feeling

Working with people who have mental illness can be rewarding

and enlightening, but it can also be frightening, boring, frustrating, anxiety-provoking, and stupefying. Patients’ communications and actions can have a disturbing effect on mental health professionals and can provoke them into reactions that try to control the patient’s thinking or behaviour. Although at times actions taken by staff are appropriate and necessary, they may also be driven by a wish to curtail provocative or disturbing elements of the patient’s mind. Ultimately, it is incumbent upon both staff and patients to try

to understand the disruptive and destructive elements in their own thinking. Without this deeper understanding there will be missed opportunities, as the underlying meaning of communication is lost, ignored, or crushed. Psychoanalysis offers a model for thinking about, and providing meaning for, the anxieties that drive us “out of our minds”, and this can reduce the risk of thoughtless action. Finally, in order for this receptive capacity to be sustained in the minds of staff, they need to feel that they are looked after and that senior clinical management take their concerns and feelings seriously. If they do not feel cared for, the morale of mental health professionals can be badly affected, and they then tend to become more anxious and less psychologically receptive to their patients. It is with all of this in mind that the Fitzjohn’s Unit, with its

psychoanalytic model, offers and provides mental health professionals—both its own and those who work in other settings—with a way of thinking about their patients that will help them to make sense of their experience. It also provides them with a language for describing psychological interactions that take place within all therapeutic relationships and for articulating their experiences with patients in a thoughtful and considered way. It helps professionals to see a different dimension of the patient through transference and countertransference in the therapeutic relationship, thus providing

a bridge between the more traditional psychiatric model and the patient’s personality and state of mind. Above all, it encourages professionals to remain curious about their patients—about their functioning over time and in all the different areas of their lives.

CHAPTER NINE

"A quandary of borders": theoretical and clinical thoughts on the borderline predicament Rael Meyerowitz

The quotation in the chapter title comes from a book about the psychic states designated by the term “borderline”. by the psychoanalyst Judy Gammelgaard and originally published in Danish in 2005, it appeared in English in 2010. Gammelgaard approaches her topic in an intellectually wide-ranging way that features theoretical engagements with the psychoanalytic works of Freud, Lacan, Winnicott, Balint, Bion, Segal, Rey, Green, McDougall, and others, but also with philosophical concepts derived from existentialism and phenomenology. It is perhaps in keeping with her approach that she espouses a particular interest in language, suggesting that borderline pathology and its history has provoked a particular need to attend closely to linguistic, terminological, and conceptual dimensions of the issue. This is represented, first and foremost, by the fact that the very title of her book has required her—presumably with the help of her translators—to come up with an apt English neologism to denote an otherwise untranslatable Danish word. The full English title is thus Betweenity: A Discussion of the Concept of Borderline. A Conceptual Framework for the Understanding of Borderline Patients, which immediately suggests that, for Gammelgaard, borderline does not only (or even primarily) denote a diagnostic category,

Written

descriptive,

RAEL MEYROWITZ

helpful or otherwise, but is a term with meaningful connotations and denotations that therefore can and should bear the weight of further exploration, interpretation, and explication. Gammelgaard speaks of how the category of patients referred

to as borderline not only sits troublingly in the diagnostic gap between neurosis and psychosis, but bedevils the institutional borders between the judicial and psychiatric systems, as well as the mental health divide that both links and separates psychiatry and psychoanalysis. It also tends to drive a wedge between the various schools of psychoanalytic theory and practice. As she puts it in her preface to the English edition of the book, “this group of patients on the border continues to highlight the fault lines of psychoanalytic science” (p. xii). A few pages later, she elaborates on these matters as follows: The word betweenity thus understood captures both the scientific endeavour to understand and theorize on borderline pathology and the “transit” situation, in which these patients frequently find themselves. We may need scientific manuals in order to clarify and delineate the pathology in question as we may also need empirical investigation to further our knowledge of borderline disorder, but we cannot do without theoretical speculations as well as phenomenological or even poetic descriptions of what it means to suffer from borderline conditions. [p. xv, my italics]

In a postscript to the English edition, in which Gammelgaard updates her readers on more recent developments in the field, she again speaks of “a widening gap” between two approaches to mental illness. She singles out Peter Fonagy, Anthony Bateman, and their colleagues’ manualized mentalization treatment for borderline patients as the latest incarnation of approaches that are on the side of “empirical and developmental research”. On the other side—that is, of “research that seeks to adapt psychoanalytic metapsychology to experiences arising in our work with ... non-neurotic patients” (p. 217)—she mentions the work of César and Sára Botella. In their book, The Work of Psychic Figurability (2005), they explore borderline phenomena in very different terms, examining the ways in which such patients struggle with a kind of primary negation whereby they can seem incapable of mentally registering—or “figuring”—

"A QUANDARY OF BORDERS"

both internal states of mind and significant objects. The Botellas, says Gammelgaard, are “driven by the desire to understand this non-represented area of the psyche and they have realized that this cannot take place through the processes we know from mental representation and symbolization” (Gammelgaard, 2005, p. 219). Gammelgaard spends the rest of the postscript explicating and advocating such work. She clearly wants to preserve and foster these and other forms of linguistic, phenomenological, and metapsychological research1 and does not want to see it eclipsed by trends that appear to credit only the empirical side of the veritable—and potentially dangerous—split that she has identified.

philosophical,

In our work in the complex needs service of the Tavistock

Clinic, we endeavour precisely not to split these two necessary and complementary approaches to psychopathology but try, rather, to integrate them as far as possible. The ground-breaking Tavistock Adult Depression Study research project (Fonagy et al., 2015), for example, represents an important contribution to empirical research. While several contributors to the present book on the Fitzjohn’s Unit worked on and make reference to the depression study, the book as a whole (and this concluding chapter, in may be seen as representing a more phenomenological perspective and testifies to its abiding importance. To venture a related general statement, the view of represented here is of an intellectual discipline and practice in which the various tensions between body and mind, unconscious and conscious, external and internal, literal and figurative, objective and subjective, scientific and hermeneutic are always being explored or interrogated as openly as possible. At the risk of being placed at a disadvantage in an age that favours monolithic, and sometimes rather concrete, views of science and evidence-based research, psychoanalytic discourse at its best and uses these tensions without trying to resolve them simplistically or reductively.

particular) psychoanalysis therapeutic

preserves

My specific intentions in this final chapter are to present some reflections on certain key psychoanalytic concepts, to exemplify them via my clinical work with a Fitzjohn’s patient, as well as to

forge links with Gammelgaard’s work. In keeping with my own vocational background in the humanities and an abiding interest in the linguistic and literary dimensions of psychoanalysis, I was particularly struck by what Gammelgaard alludes to in her phrase, “the ‘transit’ situation” (2005, p. xv). It chimes with something that I had previously noted and explored—without particular reference to borderline pathology, but within psychoanalytic discourse more generally—about the repetitive “prefix link” among certain psychoanalytic terms, like transference, transition, and transience. My initial interest had been in how Freud and others had coined and developed these concepts, and I began by considering the concepts in the context of the particular sociocultural history and of psychoanalysis; later, I attempted to explore their mutual resonances, as they apply to clinical work and as we theorize about such work. Along with one or two other terms (like transformation, as Christopher Bollas, 1987, uses it, and translation, as Jean Laplanche, 1992, and Hans Loewald, 1978, understand it), I came to see these as constituting a kind of family of closely related concepts—or what might more technically be referred to as “tropes”—within our field.

important development

Writing about such topics enabled me to bring together my

more recent training and experience as a psychoanalyst and with the intellectual and academic interests in that pre-dated and heralded it. On a more personal note, it also helped me to evaluate my own passage—or transfer, or transition—across a series of geographical, vocational, and divides. I first found myself becoming interested in these conceptual and linguistic links towards the end of my academic career in the United States (and while in the midst of my first analysis there), with a particular focus on immigration. Initially, it was the affinity between transference—the term introduced very early on by Freud (1895d, 1912b) and nurtured and cultivated within psychoanalysis ever since—and Winnicott’s (1971) theory of transitional objects and phenomena that drew my attention.2 What I discovered rather more belatedly was that Freud had also written a wonderful little essay on loss and mourning, entitled “On (1916a), and I was struck by the plentiful links between this concept and the other two.

psychotherapist psychoanalysis existential

Transience”

The nuances of my particular concerns with immigration led

me to put conceptual and analogical weight on certain meanings

of the word transference and to appreciate the fact that the psychoanalytic use of the term is itself already derivative or metaphorical. After all, I conjectured, when we consider the dynamics of immigration, we are immediately alerted to the word’s somewhat more literal and concrete meaning because of what it is that immigrants actually do—namely, transfer, or pass over (both physically and psychosocially), to another country and culture. Moreover, in so doing, and for the sake of the processes of integration and they will often find surrogate figures within the adoptive environment to whom they might place themselves in significant relation—to whom, in other words, they might transfer (now in the more psychoanalytic sense) certain complex feelings of allegiance. Considering these matters in the context of the history of itself, it is perhaps apt that we sometimes refer to this intellectual and pragmatic cultural phenomenon as the movement because it is just that: a phenomenon that has not only always been concerned with the dynamic nature of the internal or psychic world, but has itself been dynamic and “on the move”, in an external sense, since its inception. This may be said to have begun with, or taken its original cue or impetus from, the literal migrations of the Freud family (from Moravia to Vienna at the beginning and—albeit after an almost eighty-year sojourn— from there to London at the end) and, indeed, of many of the other early practitioners and patients of psychoanalysis. That Freud’s family, friends, colleagues, and patients were mostly Jewish is a fact intimately related to the long communal, cultural, historical, and even mythological association of the Jews with wandering, migrating, and passing over.

assimilation, psychoanalysis psychoanalytic

No sooner had psychoanalysis begun to establish itself in the

first place—indeed, in its first places or locations, such as Vienna, Berlin, and Budapest—than it was again transformed by transience and by actual geographical transfer or transition across political borders and oceans, from original locations to newer ones. Its itinerant practitioners—made refugees by the upheavals of the Second World War and the Holocaust—had in part to remake and modify it in new contexts and environments, often with success.

spectacular It was in the light of these historical and geographical shifts that

I posited that certain central psychoanalytic concepts—precisely

those having to do with crossing or passing over—have primary, culturally unconscious sources of their own: namely, in the rather more literal language associated with both involuntary exile and perhaps more voluntary acts of migration or immigration (though this distinction is by no means always clear or straightforward). Taking the central concept of transference as prime example, my conjecture is that beyond its actual utility (both clinically and in applied ways), the term’s importance—perhaps its very existence—in the psychoanalytic lexicon owes a great deal to the fact of immigration and its place at the inception and in the subsequent history of psychoanalysis.

formative

Though Freud gave the transference its name (1895d, p. 302)

and was the first to note its effects in therapeutic settings, he only gradually came to accept its operational necessity in indeed, even after he had established it as a welcome and supremely useful analytic tool, he also continued to regard it, somewhat ambivalently, as an obstacle to and defence against the treatment. Given these early foundational doubts, ongoing debates over the precise understanding and the clinical scope and application of the term, as well as considerable differences in the ways psychoanalysis is practised and theorized both here in the UK and around the world, it may even seem surprising that there is as much agreement as there currently is about its conceptual centrality. Transference increasingly became and now remains the veritable sine qua non, or shibboleth, of psychoanalysis and is seen by the majority of analysts as virtually synonymous with the process itself. Though analysts may conceive of or use the transference very differently from one another, their clinical work is nevertheless always tacitly contingent upon—or even at the mercy of—patients’ capacities to cross or pass over, metaphorically speaking, from primary or original objects (parents, siblings, carers) to secondary or “adopted” ones (therapists and analysts). Freud himself divided patients into those who could sustain what he called a transference neurosis and those whose narcissistic difficulties or weakened egos prevented them from doing so; as far as he was concerned, only the former could benefit from psychoanalysis.

psychoanalysis;

treatment

While contemporary psychoanalysis casts its net a little wider

than this (and the very existence of the Fitzjohn’s Unit is a testa-

ment to this), anyone who works with or in the transference will know, perhaps with a moment’s reflection, just what a delicate of the literal with the figurative, the real with the imaginary, this kind of work requires from both analyst and patient. the feelings, anxieties, and desires that the patient transfers to the analyst have both to be sufficiently authentic and heartfelt to make a genuine emotional impact, and yet not so intense as to overwhelm both parties or overrun and destroy the borders of the therapeutic relationship. The same, or at least something quite similar, may be said of the therapist’s own transference or countertransference responses to the patient. These, as we know, are precisely the dynamic difficulties that patients who earn such appellations as borderline (and the therapists who try to work with them) find most challenging.

balance Optimally,

Turning our attention to the term transition (or transitional), we

may immediately note the paradox that it was coined and by a figure who apparently had little if anything to do with immigration or transience. Winnicott was a middle-class a man ostensibly of his own time and place, more or less at home in his native culture, whose life was not much characterized by massive external upheavals, geographic or otherwise. One of Winnicott’s gripes with the psychoanalysis of his day was the demand that its practitioners conform to a formal—and perhaps also foreign-sounding—lexicon that was at odds with his own plain-speaking English style, which he combined with a certain quirky, idiosyncratic lyricism. Always fiercely independent, insisted on speaking and writing in his own language and, in so doing, came not only to say things differently from other psychoanalysts but even to coin several wholly new terms and concepts for the discipline. Perhaps the most famous of these was “transitional object”, a term he introduced to describe the intermediate function of actual, material things—like soft toys or pieces of cloth or blanket—to which young children become attached and on which they rely “to make the transition from the first oral relationship with the mother to the ‘true object-relationship’”, as Laplanche and Pontalis (1973, p. 464) put it. He went on to extend this very concrete and commonplace childhood experience to a wide range of adult phenomena, saying that a capacity for crossing into the realms of

developed Englishman,

Winnicott

transitional or potential space—lying somewhere between and objectivity, reality and fantasy—is the very hallmark of psychic health and well-being, as well as the font of human creativity. For Winnicott, this is of course intimately linked with the importance of a capacity for play—again, not as a childhood luxury, but as the mark of an authentic life, lived in keeping with a true self, expressing itself in its own personal idiom, rather than falsely, defensively, self-protectively, or compliantly.

subjectivity

What is implicit in this set of Winnicottian notions is the idea

of moving back and forth between transitional space and the realms that lie outside or beyond it. In other words, it is a requirement for true transitional phenomena (and, indeed, transferential ones) to be subject to a kind of ebbing and flowing, or coming and going. Winnicott neither expects nor advocates that humans should simply dwell in these interim spaces—that is, convert them from places of temporary respite into fixed abodes where they might reside permanently, at a remove from internal or external reality. It is a developmental achievement to be flexible enough to move freely both into and out of these transitional areas, and, where it is optimal, this facility for gap-crossing, playing with and between different existential modalities, will find both and intrapsychic expression.

necessary

interpersonal In its ordinary, non-pathological form, a transitional space needs to be distinguished from a more pathological phenomenon whereby someone might escape, in a more permanent way, from painful external and internal realities into what John Steiner (1993) has called a “psychic retreat”. Our more difficult chronic patients (those we see in the Fitzjohn’s Unit and those designated as in particular) have a tendency to pervert and misuse such spaces in precisely the way that Steiner highlights, by occupying or colonizing them, converting them from their intended transitional function or status into defensive retreats or hideaways.3

borderline

So, given this historical, cultural, and linguistic backdrop, what

the literal and figurative meanings of these terms imply or invoke is the importance for clinical psychoanalysis of a capacity for or what one might call “trans-ing”.4 Aggregating the meanings of transference, transition, and transience, one might say that together they connote or bespeak flexibility, and movement as such—that is, an ability to pass through or

crossing, psychoanalytic motility,

over, from one position to another, across certain divides, gaps, thresholds, boundaries (and, indeed, borders), not just in a single direction, but back as well as forth. The terms provide a kind of linguistic support structure, the fact that such capacities are not only crucial for mental health but central to psychoanalysis at every level, from individual patients with their particular analysts or therapists, to the highest levels of psychoanalytic theorizing. However, these are often difficult, hard-won capacities: every crossing or passage requires a step away from the safety of home, the past, and the security of what is familiar and familial; a trek through the medium or dangerous divide of the present; and a venture into foreign, future territory where outcomes cannot be known in advance.

corroborating

immediate

Interpolating some of Gammelgaard’s insights as I go along, I now briefly present my work with a Fitzjohn’s patient whom I will refer to as Ms P. She was, in fact, something of a limit case as far as the Fitzjohn’s Unit is concerned, by which I mean that— even for a service whose raison d’être is the specialized treatment of borderline and personality disordered patients—she proved a real challenge and took us right to the edge of our capacities. The therapeutic process with patients like Ms P is often so problematic and tends to run into such extreme difficulties that, amid all the other borders, boundaries, or betweenities that need negotiating, therapist and patient are constantly hovering on the verge of the treatment!

ending Ms P exemplified this only too well. She was in her late forties

when she was referred because a previous treatment had come to an abrupt and unpleasant end, after which Ms P also lodged a against her clinician and the service in which she was being seen. Though it was clear, on assessment, that she could be nowhere else but in the Fitzjohn’s Unit, we also debated long and hard before finally agreeing to offer her treatment. There were strong reservations about her from the start and an that she would not only mount a formidable assault on our therapeutic competence, but would also almost certainly make a complaint if—or, rather, when—things went wrong.

complaint accommodated expectation

Ms P had a long history of difficulties, ranging from debilitating obsessional symptoms, periods of crippling anxiety and very low mood, suicidal ideation, and a variety of acute and dangerous selfharming rituals. She was still living with her aging parents, having been forced to return to the family home in her thirties when her attempt to live independently broke down, mainly because her symptoms had worsened to the point where she could no longer function in her job and could barely get herself out of her house. She also suffered from a number of psycho-physical ailments, including asthma and the beginnings of diabetes, the latter being linked to a tendency to “comfort eat”, as she termed it, though it also constituted a form of self-harm. She was certainly an intelligent woman (she had a university

degree) and did manage, some time after moving back in with her parents, to return to employment and, in spite of the chronic difficulties outlined above, was eventually able to hold down a responsible part-time professional position quite effectively. She had also previously received and benefited from short periods of therapeutic help over the years and at times seemed to have gained some insight into herself and her difficulties. On the other hand, and most of the time, Ms P was terrified, suspicious, and beset by persecutory guilt and shame. She felt under constant attack and at times operated as if she lacked a skin, or any form of reliable self-protection. Ironically, these were also emotions that she managed to hide very effectively for prolonged periods, after which they would emerge with a vengeance. She had never had an adult sexual relationship, but had been “abused” in her early teens by a man who befriended and groomed her. Her memories of him were highly ambivalent: she continued to regard him as both “the man who ruined my life” and as “the only person I have ever loved or been loved by”. It was only after some time in the therapy that she also revealed that she had been treated quite seductively as a very young girl by her father and felt that her mother hated her for it. She spoke of having wanted to die since the age of 4 or 5 years and reiterated many times that she would neither be able, nor would she wish, to survive her father’s death. She even told me, in some detail, about the method, as well as the location, of her proposed suicide.

Ms P not only claimed that her parents did not love her and had never loved her, but felt that they did not even really acknowledge her presence or existence as a child. She consciously thought that when she had returned home as an adult woman, it was with the express intention of both forcing them into a belated recognition of how they had maltreated her and of exacting her revenge on them. She felt that her mother still despised, dismissed, and eschewed her, and she responded to these feelings in kind, not least by deliberately behaving flirtatiously with her father in her mother’s presence, as if laying claim to the status of his real partner. she had a younger brother, by four years, whose existence she seemed never to have acknowledged or recognized: in two years of twice-weekly psychotherapy, this brother was mentioned only two or three times (though I did discover that he had a wife and and led a relatively normal life). Though clearly very isolated, Ms P did appear to retain a small number of close friends, some of whom sounded odd or quirky and were probably also rather disturbed themselves.

Interestingly,

family

Of course, it was through the actual experience of being in Ms

P’s presence and working with her that one really gained access to what she was like. Though she was superficially quite affable (and mildly flirtatious), with a good sense of humour, she also struggled mightily with both intimacy and separateness. In the transference, her chronic ambivalence expressed itself sequentially, as it were. The first weeks and months of our work together were by a very rapid and intense attachment to me. This took the form of trying desperately to show me what a good patient she was, appearing to tolerate and respond to quite challenging finding them uncannily accurate and helpful. One may have been forgiven for thinking, in this early phase, that she was behaving like a more ordinary or neurotic patient. Though I was never fully convinced of this, Ms P was later at pains to persuade me that this initially cooperative impression had been almost entirely a ploy and a façade, a consciously false construction that she had needed in order to mask her fear and desperation. It was only after about a year of psychotherapy that she began to muster the courage (as she might have described it) to tell me that she in fact found many of the things I said hurtful

characterized interpretations,

and being in my presence frightening in the extreme. One of Gammelgaard’s formulations is useful in this regard; she speaks of ... the fear of invasion as a distinctive trait in these patients. However, this is not as unambiguous as it may initially appear. For some, this fear masks its opposite; a wish to passively completely to the Other, as if this capitulation could remove the anxiety. [2005, p. 92]

surrender

As Ms P’s more negative feelings gained impetus and gathered momentum, there came a veritable barrage of accusations: I did not want to listen to her; I deliberately mocked her; I ignored, silenced, and obliterated her; I was a heartless, sadistic therapist who relentlessly invaded her and used my cruel technique as a weapon against her. Gammelgaard comments on how therapists and patients in such situations experience a kind of mutual terror: We fear this withdrawal and the fear of invasion in the transference, where patients often experience our words as threats that strip them of their existence. Words may disempower them to the extent that they no longer feel their own existence. Our well-meaning words can make them feel powerless or rather driven out of their own existence. Not only the words of others; a mere glance can impact their vulnerable existence to the point where they feel unbearably exposed. [p. 91]

Ms P in fact responded in kind: she became insulting and abusive during this time, resorting to expressing out loud rather nasty and prejudicial thoughts and feelings about me and my original family and culture, as she imagined it. This was a bewildering period, but if one thing was clear it was

that this was a far cry from any normal or neurotic unfolding of the transference. For Ms P, it was not merely that I had come to be like or to resemble her parents, but, rather, that I had in her mind become, had concretely turned into, them. As I have put it above, patients like this are able neither to cross successfully into the realm of the transference nor to make a safe exit from that space. Thus, instead of being able to access a place in which a more symbolized version of their struggles might crystallize and become available for acknowledgment and working through, they end up feeling attacked by a concretely terrifying actuality.

literally transitional

Gammelgaard writes of the twisted ways in which borderline patients try “to solve the universal traumas of the soul: the existence of otherness, of gender difference, of generational differences, and of the ultimate loss, of death” (p. 105). She also identifies their minds as suffering from a “lack of inner objects”, leaving a void that is all too often filled with sexual or other kinds of addictions: “The addictive object replaces the object. Addictive objects are transitory rather than (pp. 107–108, my italics). Again, as when she speaks of the transit situation, Gammelgaard is highlighting a crucial between patients who can make transitions and those who end up stuck in an endlessly transitory—and thus static—state. One might describe the latter predicament as like being detained eternally in “no man’s land” (Green, 1977) or in a transit or camp of the mind. In her determination to describe these patients as evocatively as possible, Gammelgaard seems usefully to bring together and forge links between British and French psychoanalytic traditions: Winnicott’s (1971) spaces (transitional and otherwise) and Hannah Segal’s (1954) theory of symbol formation are usefully juxtaposed with André Green’s (1993) “work of the negative” and his ideas about the function of absence in psychoanalysis:

transitional transitional” difference

concentration

A fossilized space arises in lieu of potential space, where fantasy takes the place of imagination and symbolization frequently tends to become concrete due to the flawed binding function of the ego. These people do not feel at home in themselves but are restlessly chasing an external object to serve these functions. Instead of the psychically binding function we see various expressions of the work of the negative, and a form of mental pseudo reality takes the place of normal psychic reality. [Gammelgaard, 2005, p. 198]

The “quandary” that had taken hold of Ms P in relation to myself and her treatment was just the kind of thing that Gammelgaard elaborates in her book. She eloquently captures the of mind of such patients, and, as the following passage attests, one is struck by how easily and accurately her words might also apply to the plight of the actual refugees and exiles whose crises characterize our era:

phenomenology

People with borderline structures are always in a state of flux. They lead a form of transitory existence. They are always on their way to somewhere because they are always leaving. They flee contact as intensively as they seek it, because they are struck by a claustrophobic sense of being deprived of freedom or feel annihilated by an evil inner image. As soon as they try to emancipate themselves, they are caught in an experience of disappearing into the void. [Gammelgaard, 2005, p. 93]

agoraphobic

She goes on to cite two other British analysts who have also written evocatively about such clinical experiences. The first is Henri Rey (1979), again mentioned by several other contributors to this who first spoke of the claustro-agoraphobic symptomatology of these patients—their struggle, that is, to achieve an optimal from their objects. The second is Michael Balint (1968) and his very similar account of “basic fault” psychopathology and his distinction between “ocnophils”—who become too attached to their objects and cannot bear to be parted from them—and “philobats”— who prefer the spaces between objects, attach mainly to their own capacities, and find closeness to others terrifying. Needless to say, many such patients appear to shunt or flip rapidly back and forth between extreme versions of such counter-posed mental states, indicating that these operate not so much as dynamic, dialectical, potentially productive opposites, but as the static obverse of each other, a futile either/or, like two sides of the same coin. Here is yet another image denoting apparent movement that, in the end, goes nowhere.

volume, distance

Returning to Ms P herself, I shall conclude by outlining what actually ensued in her treatment. As the reader is well aware by now, Fitzjohn’s patients are usually offered two years of twice-weekly psychotherapy, followed by the option of entering a longer period of group therapy. As predicted, when Ms P began to voice her grievances to and about me, she also embarked upon a series of semi-formal complaints, consisting of lengthy letters addressed to the chief executive and others in authority at the Tavistock, outlining what she had been put through, in an attempt to prove that she had been let down and betrayed by me. Ironically, however, and in keep-

individual

ing with her chronic and finely balanced ambivalence, she continued to attend her sessions, though much of the time these consisted of little more than concerted efforts to also persuade me that I was cruel and incompetent and to get me to admit full culpability for what she had experienced. In keeping with this irony, though she sometimes demanded to be allowed to begin her therapy afresh with a different therapist, what she really seemed to want was an extension of her treatment with me, claiming that because I had failed her in the first period of the therapy, she was owed this time back and was prepared to persevere with me if the unit agreed to grant it. As we discussed this in our staff seminar and unit meeting, it was clear that, all the grievances notwithstanding, this was Ms P’s transparent and desperate attempt to forestall the ending of the therapy, a prospect that she found utterly unbearable and impossible to contemplate. The case was contemplated at length and by many, from the who had originally assessed her to the department’s head of clinical services. Finally, unusually, and in spite of the opinions of several of the people involved, Ms P was in fact granted a further period of individual psychotherapy, on the basis that this might enable her to make a proper ending with me, and a smoother transition to the group. Needless to say, this is not what ensued. In spite of these efforts to accommodate her complaints, the treatment with me came to an inevitable, abrupt, and unfortunate end, just as her previous had done. There was another brief honeymoon period during which Ms P again felt that she could work with me. Soon enough, however, the more toxic, abusive image of me began to resurface, and all the aggrieved feelings were back in full force. Finally, and much to my surprise, she began her last session before a break by telling me that she was stopping the therapy that very day. A difficult fifty minutes ensued, culminating in a torrent of abusive and vitriolic insults and a dramatic exit—and that was the last time that I saw Ms P. Uncannily but also—in the light of Freud’s (1919h) use and understanding of this term—unsurprisingly, these events occurred on the very day that the two years of therapy would have ended, had Ms P not been granted an extension of her treatment! Inevitably, she later changed her mind and requested to resume

person

therapy

her sessions with me but, after consultation and another discussion in the unit, we thought this neither appropriate nor clinically indicated. It would, of course, be difficult to construe my work with Ms P

as a success, though it would also not be true to say that the two years spent with her were utterly wasted either. By learning from our mistakes or failures (and there is no shortage of the latter in the work of the Fitzjohn’s Unit) and about ordinary mental capacities via their pathologies, we are following a venerable tradition in We note that it is when great existential and psychic divides of one kind or another prove impossible to negotiate for some of our patients, who instead find themselves stuck betwixt and between (or in the transit situation, as Gammelgaard puts it), that we learn to appreciate the significance of these crossings for us all. As all the chapters in this book attest, most of our patients in the Fitzjohn’s Unit have difficulties that may be summed up quite precisely by saying that they are flummoxed by boundaries, find developmental thresholds daunting, and come to particular grief at borders of all kinds. This tends to have been the case throughout their lives and in virtually every area of their functioning. Such patients seem to struggle to accept the psychic facts of transience (and the need to mourn), and they appear unable to “mind the gap” or to make safe crossings of the transference border into and out of the transitional space of the consulting room. That is, instead of being able to experience a more represented or figurative of their battle with internal and external objects—one that might become available for their perusal and contemplation—they are assailed by a mercilessly actual, hyper-real, non-metaphorical, quasi-psychotic version of these phenomena. Returning to my title and theme, this is tantamount to saying—both diagnostically and existentially—that they suffer from what have come to be called borderline conditions, or predicaments, or quandaries. But with them this does does not not mean that that we cannot cannot work work with them or that that But this

psychoanalysis.

version

mean

there is

nothing

we can

we

or

do for them. As I

hope

is

amply

evident

from all the contributions to this book, we believe that the Fitzjohn's Unit has a working model that tries to attend assiduously to the very

particular needs

keep coming

our

of this group of

way and

we

patients.

As

long as they

manage to survive the

pragmatic

and political challenges of our time—financial cost cuts and therapeutic shortcuts—we will continue to offer them our particular package of psychoanalytic help.

Notes 1. The doyen of this conceptual approach is André Green, whose

important paper, “The Borderline Concept” (1977), may be seen as its original and

seminal exemplar. 2. By then I had already written a psychoanalytically inflected book about immigration and literary criticism entitled Transferring to America: Jewish of American Dreams (1995), as well as some related articles about the immigrant or refugee analysts of the 1930s and 1940s who fled persecution in war-torn Europe and whose geographical and professional transition or transfer to the United States (as well as to Great Britain and elsewhere) was instrumental in disseminating the worldwide respectability and popularity of psychoanalysis (Meyerowitz, 1996, 1997). 3. Steiner appears to deal rather perfunctorily, in just a sentence or two, with Winnicott’s profound ideas about transitional phenomena (Steiner, 1993, p. 41). In my view, his otherwise very important book fails to properly develop the similarities and differences between psychic retreats and transitional spaces and ends up dismissing the latter rather reductively. 4. Of course, this term already has another frame of reference and applies to the rather different, currently “trending” phenomenon of gender that has now become a very prominent (and contentious) issue both within the Tavistock Clinic and for the mental health community at large. Perhaps we can do little more here than note the coincidence and leave it to be explored elsewhere.

Interpretations

reassignment

REFERENCES

Alanen, Y. O. (1997). Schizophrenia: Its Origins and Need-Adapted . London: Karnac. Arendt, H. (1971). The Life of the Mind . San Diego, CA: Harcourt. Baldwin, J. (1940). Many thousand gone. In: Notes of a Native Son. MA: Beacon Press, 2012. Balint, M. (1968). The Basic Fault. London: Tavistock. Bell, D. (1997). Primitive mind of state. Psychoanalytic Psychotherapy, 10 (1): 45–57. Bell, D. (2013). Mental illness and its treatment today. Available at: http://chpi.org.uk/wp-content/uploads/2013/12/David-Bellanalysis-Mental-illness-and-its-treatment-today.pdf Bell, D., & Kleeberg, B. (2013). Very troubled patients. In: P. Hobson (Ed.), Consultations in Psychoanalytic Psychotherapy (pp. 164–179). London: Karnac. Bion, W. R. (1957). Differentiation of the psychotic from the personalities. In: Second Thoughts: Selected Papers on PsychoAnalysis (pp. 43–64). London: Karnac, 1984. Bion, W. R. (1962). Learning from Experience. London: Karnac, 1984. Bollas, C. (1987). The transformational object. In: The Shadow of the Object: Psychoanalysis of the Unthought Known . New York: Columbia University Press.

Treatment Boston,

non-psychotic

Botella, C., & Botella, S. (2009). The Work of Psychic Figurability: Mental States without Representation, trans. A. Weller. Hove: Brunner-Routledge. Fonagy, P., Rost, F., Carlyle, J., McPherson, S., Thomas, R., Fearon, P., et al. (2015). Pragmatic randomised controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: The Tavistock Adult Depression Study (TADS). World Psychiatry, 14: 312–321. Freeman, T. (1981). On the psychopathology of persecutory delusions. British Journal of Psychiatry, 139: 529–532. Freud, S. (1895d) (with Breuer, J.). Studies on Hysteria. Standard Edition, 2. Freud, S. (1900a). The Interpretation of Dreams. Standard Edition, 4–5 . Freud, S. (1905d). Three Essays on the Theory of Sexuality. Standard , 7: 125–243. Freud, S. (1911b). Formulations on the two principles of mental . Standard Edition, 12: 213–226. Freud, S. (1912b). The dynamics of the transference. Standard Edition, 12: 97–108. Freud, S. (1912–13). Totem and Taboo. Standard Edition, 13. Freud, S. (1913c). On beginning the treatment (Further on the technique of psycho-analysis I). Standard Edition, 12: 123–144. Freud, S. (1914g). Remembering, repeating and working through recommendations on the technique of psycho-analysis II). Standard Edition, 12 : 145–156. Freud, S. (1916a). On transience. Standard Edition, 14: 303–307. Freud, S. (1917e). Mourning and melancholia. Standard Edition, 14: 239–258. Freud, S. (1919h). The uncanny . Standard Edition, 17: 217–256. Freud, S. (1920g). Beyond the Pleasure Principle. Standard Edition, 18 . Freud, S. (1940e [1938]). Splitting of the ego in the process of defence. Standard Edition, 23: 271–278. Gammelgaard, J. (2005). Betweenity: A Discussion of the Concept of A Conceptual Framework for the Understanding of Borderline Patients, trans. K. Maclean & C. Madden. Hove: Routledge, 2010. Garland, C. (2010). The Groups Book: Psychoanalytic Group Therapy and Practice . London: Karnac.

Edition functioning recommendations

(Further

Borderline.

Principles

Glasser, M. (1992). Problems in the psychoanalysis of certain disorders. International Journal of Psychoanalysis, 73 : 493–503. Green, A. (1977). The borderline concept. In: On Private Madness. London: Karnac, 1996. Green, A. (1993). The Work of the Negative, trans. A. Weller. London: Free Association Books, 1999. Isaacs, S. (1952). The nature and function of phantasy. In: J. Riviere (Ed.), Developments in Psychoanalysis (pp. 67–121). London: Karnac. Johnson, S. (1759). The History of Rasselas, Prince of Abyssinia . London: Dodsley and Johnston. Available at: https://en.wikisource.org/ wiki/The_History_of_Rasselas,_Prince_of_Abyssinia Joseph, B. (1982). Addiction to near death. International Journal of , 63: 449–456. Joseph, B. (1985). Transference: The total situation. International Journal of Psychoanalysis, 66 (4): 447–454. Joseph, B. (1989). Psychic change and the psychoanalytic process. In: Psychic Equilibrium and Psychic Change (pp. 192–202). London: Tavistock/Routledge. Keats, J. (1899). The Complete Poetical Works and Letters of John Keats. Cambridge, MA: Houghton, Mifflin & Company. Kleimberg, L. (2006). Some reflections on the connections between aggression and depression. In: C. Harding (Ed.), Aggression and Destructiveness: Psychoanalytic Perspectives (pp. 181–193). Hove: Routledge. Klein, M. (1930). The importance of symbol-formation in the of the ego. In: Love, Guilt and Reparation and Other Works 1921–1945 (pp. 219–232). London: Hogarth Press, 1975. Klein, M. (1946). Notes on some schizoid mechanisms. International Journal of Psychoanalysis, 27 : 99–110. Klein, M. (1952). The origins of the transference. In: Envy and Gratitude and Other Works 1946–1963 (pp. 306–347). London: Hogarth Press, 1975. Laplanche, J. (1992). Seduction, Translation and the Drives , ed. J. Fletcher & M. Stanton. London: ICA. Laplanche, J., & Pontalis, J.-B. (1973). The Language of Psychoanalysis. London: Hogarth Press. Lee, S. W., Morley, M., Taylor, R. R., Kielhofner, G., Garnham, M., Heasman, D., et al. (2011). The development of care pathways and

narcissistic

Psychoanalysis

development

packages in mental health based on the Model of Human Screening Tool. British Journal of Occupational Therapy, 73 (6): 284–294. Loewald, H. (1978). Psychoanalysis and the History of the Individual. New Haven, CT: Yale University Press. Lucas, R. (2009). The Psychotic Wavelength. Hove: Routledge. Main, T. (1957). The ailment. British Journal of Medical Psychology , 30: 129–145. Reprinted in: The Ailment and Other Psychoanalytic Essays. London: Free Association Books, 1989. Matte-Blanco, I. (1975). The Unconscious as Infinite Sets . London: Karnac. McEvilley, T. (1996). Anselm Kiefer: I Hold All Indias in My Hand [Art catalogue]. London: Anthony d’Offay Gallery. Meltzer, D. (1967). The Psycho-Analytical Process. London: Heinemann. Meltzer, D. (1976). Temperature and distance as technical dimensions of interpretations. In: A. Hahn (Ed.), Sincerity and Other Works (pp. 374–386). London: Karnac, 1994. Meltzer, D. (1978). A note on introjective processes. In: A. Hahn (Ed.), Sincerity and Other Works (pp. 458–468). London: Karnac, 1994. Meyerowitz, R. (1995). Transferring to America: Jewish Interpretations of American Dreams. Albany, NY: SUNY Press. Meyerowitz, R. (1996). Travelling by couch: Jewish immigrant . Culturefront: A Magazine of the Humanities, 5 (3): 28–31. Meyerowitz, R. (1997). Couching the transference, transferring the couch: Immigrant psychoanalysts and Jewish intellectual culture in America. Shofar: An Interdisciplinary Journal of Jewish Studies, 16 (1): 101–113. Moncrieff, J. (2008). The Myth of the Chemical Cure. Basingstoke: Palgrave Macmillan. Moncrieff, J. (2013). The Bitterest Pills: The Troubling Story of Drugs. Basingstoke: Palgrave Macmillan. NIMHE (2003). Personality Disorder: No Longer a Diagnosis of Exclusion. Policy Implementation Guidance for the Development of Services for People with Personality Disorder. Gateway Reference 1055. London: National Institute for Mental Health in England. O’Shaughnessy, E. (1980). Interminably a patient. International Journal of Psychoanalytic Psychotherapy, 8: 573–576. O’Shaughnessy, E. (1992). Enclaves and excursions. International of Psychoanalysis, 73 : 603–611.

Occupation

psychoanalysts

Antipsychotic

Journal

Rey, J. H. (1977). Universals of Psychoanalysis in the Treatment of Psychotic and Borderline States, ed. J. Magagna. London: Free Association Books, 1994. Rey, J. H. (1979). Schizoid phenomena in the borderline. In: E. Bott Spillius (Ed.), Melanie Klein Today: Developments in Theory and Volume 1: Mainly Theory (pp. 203–229). London: Routledge, 1988. Rey, J. H. (1986). The schizoid mode of being and the space-time (Beyond metaphor). Journal of the Melanie Klein Society, 4: 12–52. Rosenfeld, H. (1971). A clinical approach to the psychoanalytic theory of the life and death instincts: An investigation into the aggressive aspects of narcissism. International Journal of Psychoanalysis, 52: 169–178. Rosenfeld, H. (1978). Some therapeutic factors in psychoanalysis. Journal of Psychoanalytic Psychotherapy , 7: 152–164. Rosenfeld, H. (1987). Impasse and Interpretation: Therapeutic and AntiTherapeutic Factors in the Psychoanalytic Treatment of Psychotic, and Neurotic Patients. London: Tavistock. Rosenthal, M. (1987). Anselm Kiefer. Philadelphia, PA: Philadelphia Museum of Art. Segal, H. (1954). Notes on symbol formation. In: E. Bott Spillius (Ed.), Melanie Klein Today: Developments in Theory and Practice. Volume 1: Mainly Theory (pp. 160–177). London: Routledge, 1988. Segal, H. (1993). On the clinical usefulness of the concept of death instinct. International Journal of Psychoanalysis, 74: 55–61. Reprinted in: J. Steiner (Ed.), Psychoanalysis, Literature and War. London: Routledge, 1997. Shuttleworth, J. (1989). Psychoanalytic theory and infant development: Closely observed infants. In: M. Rustin, M. Rustin, L. Miller, & J. Shuttleworth (Eds.), Closely Observed Infants (pp. 22–51). London: Duckworth. Steiner, J. (1979). The border between the paranoid-schizoid and the depressive positions in the borderline patient. British Journal of Medical Psychology, 52: 385–391. Steiner, J. (1992). Patient-centred and analyst-centred interpretations: Some implications of containment and countertransference. Inquiry , 14: 406–422.

Practice.

continuum

International

Borderline,

Psychoanalytic

Steiner, J. (1993). Psychic Retreats: Pathological Organizations in Psychotic, Neurotic and Borderline Patients. London: Routledge. Stewart, H. (1992). An overview of therapeutic regression. In: Experience and Problems of Technique (pp. 101–126). London: Routledge. Strachey, J. (1934). The nature of the therapeutic action of . International Journal of Psychoanalysis , 15: 127–159. Temkin, A., Rosenberg, S., & Taylor, M. (2000). Twentieth-Century and Sculpture in the Philadelphia Museum of Art. Philadelphia, PA: Philadelphia Museum of Art. Westen, D., Gabbard, G. O., & Blagov, P. (2006). Back to the future: Personality structure as a context for psychopathology. In: R. F. Krueger & J. L. Tackett (Eds.), Personality and Psychopathology (pp. 335–384). New York: Guilford Press. Wing, J. K., Curtis, R. H., & Beevor , A. S. (1996). HoNOS: Health of the Nation Outcome Scales. Report on Research and Development July 1993– December 1995. London: Royal College of Psychiatrists. Winnicott, D. W. (1945). Primitive emotional development. In: Through Paediatrics to Psychoanalysis: Collected Papers (pp. 145–156). London: Karnac, 1992. Winnicott, D. W. (1947). Further thoughts on babies as persons. In: The Child and the Outside World: Studies in Developing Relationships (pp. 134–140). London: Tavistock, 1957. Winnicott, D. W. (1951). Transitional objects and transitional . In: Through Paediatrics to Psychoanalysis: Collected Papers (pp. 229–242). London: Karnac, 1992. Winnicott, D. W. (1960a). Ego distortion in terms of true and false self. In: The Maturational Processes and the Facilitating Environment (pp. 140–152). London: Karnac, 1990. Winnicott, D. W. (1960b). The theory of the parent–infant . In: The Maturational Processes and the Facilitating Environment (pp. 37–55). London: Karnac, 1990. Winnicott, D. W. (1971). Playing and Reality . London: Tavistock. Wood, H., & Mills, H. (2015). Audit of Fitzjohn’s Unit Referred Cases for the Referral Period 2011–2013 . Unpublished audit, Fitzjohn’s Unit, London.

Psychic

psycho-analysis Painting

phenomena relationship

INDEX

Aboyade, I., 37–44 abuse, history of, 29, 30, 96 acting out, 38, 41, 127, 128 addictive objects, transitory, 143

Arendt, H., 81 assessment consultation, 26 assessment process, 60 assessor, work of, 26–28

administrator, role of, as conduit, in

Fitzjohn’s Unit, 37–44 affective disorder, 30

agency, role of, 13–14 agoraphobic symptoms, 96 agoraphobic terror of rejection, 75 Alanen, Y. O., 124 ambivalence, chronic, 141 Amino, H., 45–58 analytic situation, inbuilt risk of

degeneration inherent in, 72 anorexia, 121

antidepressants, 14, 86 anti-psychotic medication, 14 anti-therapeutic behaviour, in

therapeutic relationship, 116 anxiety, 96 psychotic, 120

baby observation, 46 Baldwin, J., 70 Balint, M., 131, 144 Barker, H., 59–67 basic fault, 144 Bateman, A., 132 Beevor, A. S., 94 Bell, D., 1–27 betweenity, 132 Bion, W. R., 27, 47, 55, 122, 131 bipolar disorder, 29 affective, 30

bizarre symptoms and behaviour,

113 Blagov, P., 19 Bollas, C., 134 borderline conditions, 132, 146 borderline functioning, 127 borderline pathology, 131–147

borderline patient(s), 40, 41, 65, 132, 143 as between neurosis and

psychosis, 72 importance of setting for, 69–84

traumatized, 71 borderline personality disorder, 61, 69, 73, 96 borderline structures, 144

borderline transference, 27 Botella, C., 132 Botella, S., 132 boundaries:

maintaining, 98 patients’ capacity to disregard, 38

Cassel Hospital, 23, 25 choice agenda, 4 chronic depression, 2, 56, 96 claustro-agoraphobic dilemma, 32 negotiation of, 41

claustro-agoraphobic

symptomatology, 144 claustrophobia, 90

claustrophobic fear of intimacy, 75 clinical work, difficulties of, 113 cognitive behavioural therapy, 35 collusion, 108, 118 community psychiatric nurse

(CPN), 119, 121, 122

Curtis, R. H., 94 day hospitals, 4 death wishes, 10 defence against pain and loss,

violence as, 108 defence mechanism(s): confronting, 109

delusion-based, 56 temporary, vs. distorted

personality, 55

defensiveness, 30

defensive organizations: against depression, 114 against fragmentation, 114 defensive structures, 13 destabilized by therapy, 60 delusional symptoms, 45–58

delusional system(s), 55, 121 denial, 30, 96 Dennis, M., 23, 64, 95–111 dependency issues, 96 depersonalization, 92 depression, 61 chronic, 2, 56, 96

oedipal, 12 treatment-resistant, 15, 31, 35 depressive disorder, 12, 20 major, 36

recurrent, 29, 87

compulsory detention, 118

depressive guilt, 64

concentration camp of mind, 143

depressive personality disorder, 29 depressive position, 73 deracination, 72 derealization, 92 description:

confidentiality, of patients’ material,

69 consultation, for frontline staff, 113–129 countertransference, as lightning

rod, 74 CPN: see community psychiatric

nurse Crisp, A., 15 cultural memory, claustrophobia

of, 70 curiosity: and interest (case example), 50–51

terror of, 51

ideographic levels of, 5

nomothetic levels of, 5–6 despair, sense of, 48

destructive aspects, of group, 99 destructive repetitive patterns of

thought, 113 destructive wishes, 96

detention, compulsory, 118 development, understanding

disorder in terms of, 9

differentiation, therapist–patient, loss of, 115 disorder, understanding, in terms of

development, 9

fossilized space, 143 fragmentation, 66, 115, 124 Freeman, T., 10 Freud, S., 7–11, 55, 74, 131, 134–136,

145

dissociation, 30, 92 distorted personality, vs. temporary

religion, attitude to, 8

dreams, meaning of, 45

“shadow of the object fell upon

eating disorders, 31, 96 ego:

splitting of the ego, 53

defence mechanism, 55

development of, 50, 55

forming perverse alliance, 96 splitting of, 42, 53 weakened, 136 ego function(s), 50 mother’s, baby’s internalization

of, 47 enactments, 117, 128

encapsulated psychosis, 96 envy, 96 Evans, M., 18, 113–129 existentialism, 131

repetition compulsion, 95 the ego”, 10, 56 transference, 134 transience, 134 unconscious, concept of, 45 working through, 95, 142 frontline mental health settings,

psychotic communications in, 113–129

frontline staff, supervision of and

consultation for, 113–129 funding for mental health services

in UK, 126 fusion, idealized primitive, with

father, 57 future, facing thoughts about, 111

father: idealized primitive fusion with, 57 identification with, 50 concrete, 52–54, 57

unconscious, 10, 51

Fitzjohn’s Unit (passim): approaches to mental illness,

integration of, 133 history and approach of, 22–26

length of individual

psychotherapy at, 22, 23, 69, 144 multi-level approach of, 14 patients at, 29–31 referrals to, 26–29 role of administrator in, 37–44 setting in work of, characteristic

aspects of, 69 waiting list, 27, 28, 39, 42, 75

work of, 21–36 Fonagy, P., 31, 35, 66, 132, 133

Gabbard, G. O., 19 Gammelgaard, J., 131–134, 139, 142–144, 146 Garland, C., 98

gender reassignment, 147 “German Question”, cultural

trauma of, 70 Germany, post–Second World War,

70 Glasser, M., 56

grandiosity, 30 Green, A., 131, 143, 147 group: destructive aspects of, 99 masochistic way of relating in,

110 as maternal object, 98

new member joining, 98 as object, 95–111 paternal, 98

sibling rivalry in, 99

group mind, 64, 111

immigration, 134–137, 147

group psychotherapy, 23, 28, 35, 67,

Improving Access to Psychological

95, 98, 144 group therapist, as parental object,

guilt:

sharing, difficulties of, 99

Therapies (IAPT) programme, 26 inner objects:

frightening and persecuting, 33

depressive, 64

persecutory, 63, 64, 140

lack of, 143 inner self-destructiveness, 96

insight, development of, as

hallucinations, 118 Hamlet, 110 harmful behaviour to self, risk of, 30

institutionalization, damage done

Health of the Nation Outcome Scale

intimacy, claustrophobic fear of, 75

(HoNOS), 87, 94 historical continuity, 9 historical trauma, unthinkable,

consequences of, 77 Holocaust, 70, 135 HoNOS: see Health of the Nation

Outcome Scale

persecutory process, 114 by, 5 introjection, 82 invasion, fear of, 142 Isaacs, S., 47 Johnson, S., 59, 61, 63, 66 Joseph, B., 20, 65, 79

Keats, J., 66 Kiefer, A., 70, 71, 82, 83 Kleeberg, B., 21–36 humiliation, patients’ feelings of, Kleimberg, L., 57 115 hysterical symptoms, meaning of, 45 Klein, M., 56, 57, 73, 109

hopelessness, masochistic, 65

human relatedness, 92

IAPT: see Improving Access to Psychological Therapies programme idealization, as magic solution, 8

idealized retreat, 9 ideal self, loss of, capacity to mourn,

124 identification:

with father, 10, 50, 51, 53, 54, 57 unconscious, 10, 51 with patient, therapist’s, 117

psychotic, 10 total (case example), 51–53 ideographic levels of description, 5

illness: denial and rationalization of (clinical example), 119–121 and health, differentiation

between (clinical example), 117–119

Lacan, J., 131 Lane, C., 37–44 Laplanche, J., 134, 137 Lee, S. W., 6 life instincts, 96 and death instincts, conflict between, 122 Loewald, H., 134

long-term psychoanalytic psychotherapy (LTPP), 31,

35, 36 need of, for psychological

disturbance, 4 LTPP: see long-term psychoanalytic psychotherapy Lucas, R., 125

magical solutions, 114 magical thinking, 120, 122 Main, T., 18

major depressive disorder, 36 mania, 96 manic defences, 120 in mental health system, 126 manic denial, 125

manic-depressive disorder, 12 manic flight, 65 manic self-sufficiency, 118 manic states, 120 masochistic hopelessness, 65 masochistic way of relating, in

narcissism, 8, 30 narcissistic difficulties, 136 negation, primary, 132 negative, work of, 143 negative transference, 66 neoliberalism, 18 neurosis(es), 8, 72, 132 as asocial structures, 8

obsessional, 7 transference, 136 neurotic condition/state of mind,

113, 125

group, 110 maternal object, group as, 98

Nicholls, C., 37–44

Matte-Blanco, I., 76 McDougall, J., 131 McEvilley, T., 70 mechanistic thinking, 125 Meltzer, D., 71, 74, 77, 81, 82

Nicholson, J., 101 nigredo, alchemical concept of, 71 NIMHE, 23

mental disorder, and personality

non-existence, sense of, 49

disorder, distinction between, 19 Mental Health Act 1983, 124

Mental Health Act assessment, 123 mental health disorders, 31 mental health system, manic

defences in, 126 mental illness, 1, 3, 4, 6–8, 19, 86, 93,

94, 126, 128, 132 and personality disorder,

distinction between, 11–12

serious and enduring, 113, 114,

118 severe and enduring, 117 Meyerowitz, R., 131–147

migration, 136 Mills, H., 29 mind: dawn and development of, 46–47

fragmentation of, 114 Moncrieff, J., 14 mother:

ego functions of, baby’s internalization of, 47 murderous wishes towards, 102 murderous psychotic state, 123

murderous wishes, 101, 102

nomothetic and ideographic levels

of description, 5–6 normality, vs. abnormality, 7–9 not-knowing, 85 object: addictive, 143

restrictiveness of, 96 obsessional neurosis(es), 7

obsessional rituals, 7 obsessional symptoms, 140 ocnophils, 144 oedipal depression, 12 Oedipus, 70 O’Shaughnessy, E., 22, 25, 64, 72, 96 panic attack, 106 paranoia, 59, 96, 124 paranoid fears, 27 paranoid-schizoid position, 73 paranoid-schizoid thinking, 42 paranoid state of mind, 27 paranoid thoughts, 32 parental object, group therapist as,

99 paternal object, group as, 98

pathological splitting, 76 patients, unrealistic demands of, 119 persecutory guilt, 63, 64, 140

persecutory process, development of insight as, 114 persecutory transference, 76 personality development, illness

as, 11 personality disorder(s), 24, 117, 125 and mental disorder, distinction

between, 11–12, 19 severe and enduring, 127 specific, 30 phenomenology, 20, 131, 143

psychoanalytic psychotherapy, long-term, efficacy of, 31 effect continued in post-therapy period, 67 psychological disturbance,

treatment of, 3 psychosis, 5, 14, 24, 72, 119, 123–125,

132 encapsulated, 96 psychosomatic disorders, 31 psychotic and non-psychotic parts

of the self (clinical example), 121–126

philobats, 144 play, capacity for, 138 Pontalis, J.-B., 137 post-natal depression, 35 post-traumatic depression, 114

psychotic communications, in

post-traumatic stress disorder

psychotic functioning, 127

(PTSD), 30

potential space, 49, 138, 143

primary negation, 132 primitive superego, normal, 7 projective identification, 65, 72, 73 projective processes, 39, 66 psychiatric disorder, 3, 8, 19 role of medication in, 19 psychiatric disturbance, systemic

contribution to, 15 psychiatric liaison, 4, 5 psychiatry and psychoanalysis:

distinction between, 2–5 mental health divide between,

132 psychic equilibrium, restoration of,

13 psychic retreat(s), 138, 147

psychic space, limited, 109 psychoanalysis: function of absence in, 143 and psychiatry, distinction

between, 2–5 and psychiatry, mental health

divide between, 132 psychoanalytic approach, 6–7, 60,

120

psychotic anxiety, 120 frontline mental health

settings, 113–129 psychotic identification, 10 psychotic illness, 9, 125 denial of, 118 psychotic part of personality, 125

psychotic state(s) of mind, 113, 125 murderous, 123

psychotic symptoms, 117

psychotic thinking, 126 psychotic transference, 27 PTSD: see post-traumatic stress

disorder reality testing, 122 recovery centres, 4 recurrent depression, 30 rejection, agoraphobic terror of, 75 relationships, repetitive patterns

in, 97 repetition compulsion, 95

representation, symbolic level of, 56 resistance, 31, 45 restrictiveness of object, 96 retreat, tendency to, 96 Rey, J. H., 32, 40, 57, 73, 131, 144 rigidity and terror (case example),

49–50 Roberts, E., 69–83

Rosenberg, S., 71 Rosenfeld, H., 56, 77, 82 Rosenthal, M., 70

structures and symptoms, distinction between, 12–13

sadomasochistic behaviour, 60 schizoid communication, 40 schizoid mechanisms, 57 schizoid patients, 40

suicidality, 29, 30, 60, 96, 97, 102,

schizophrenia, as withdrawal into

delusional world, 118 Second World War, 70, 135

Segal, H., 20, 131, 143 self, vicious attacks on, 110 self-destructiveness, 30, 60

inner, 96 self-harm, 15, 29, 60, 97, 140 self-hatred, 30 self-objectification, 14 self-sufficiency, manic, 118 sensory experience, flood of,

defence against, 100 separation, 102

setting

student counselling services, 26

subjective frustration, 47–57 121, 122, 140 superego:

persecutory and cruel, 62 primitive, normal, 7 supervision of frontline staff,

113–129

supervisor(s), 32, 64, 88, 127

surgeries, repeated, unnecessary,

profound meaning of (case example), 53–54 symbol formation, 143

symbolic representation, 56 symmetrical logic, 76 symmetrical thinking, 76 symptoms vs. structures, 12–13 TADS: see Tavistock Adult Depression Study

institutional, 15, 17

TAU: see treatment-as-usual group

therapeutic, 13, 17, 114

Tavistock Adult Depression Study

constitution of, 69

containment and maintenance

of, 98 importance of, for borderline

patients, 69–83

liminal space, where thought and experience form

meaning, 73 patient’s need to control, 78 “shadow of the object fell upon the ego” (Freud), 10, 56 Shuttleworth, J., 47

sibling rivalry, in group, 99 specific personality disorder, 30 staff seminar, 22, 25, 27, 34, 74, 77,

145

“third position” of, value of, 63 Steiner, J., 65, 73, 103, 114, 138, 147

Stewart, H., 55 Strachey, J., 72

(TADS), 31, 35, 66, 67, 133 Tavistock and Portman NHS Trust,

24

Tavistock Clinic, 79, 95, 133, 147 Adult Department, 22, 24, 25, 37

Couples Unit, 37 Trauma Unit, 37 see also Fitzjohn’s Unit Taylor, M., 22, 71

Temkin, A., 71 therapeutic relationship, clinical

examples, 116–126 therapist: as intrusive mother, 32 primitive introjected images

projected on, 72 retaliating re-projection by, 72

seen as enemy in transference, 76 structures providing containment

for, importance of, 22

therapy, ending of, 145 total transference situation, 79 toxic transferences, 30 transfer, of immigrants, to another

country and culture, 135 transference, 138

history of, 30 intergenerational transmission

of, 34 unresolved, 73 traumatic past experiences, 30, 33,

69, 111

borderline, 27

traumatized patients, 69

concept of, 136 to institution, 38 meanings of word, 134 persecutory, 76 psychotic, 27 to therapist, 39 toxic, 30

treatment-as-usual (TAU) group,

transference neurosis, 136

transformation, 134 transience, 134, 135, 137, 138, 146 transition, 134, 138 transitional object(s), 43, 137, 143 and phenomena, 134

transitional phenomena, 138, 147

transitional space, 138, 146, 147 transitory state, endless, 143 transit situation, in borderline pathologies, 132, 134, 143,

146 translation, 134 trauma(s):

historical, 77

35, 36 treatment length, based on limited

resources, 126 treatment-resistant depression, 15, 31, 35 unconscious, concept of, 45 violence, as defence against pain and loss, 108 Westen, D., 19 Williams, R., 108 Wing, J. K., 94

Winnicott, D. W., 46, 47, 64, 131, 134,

147 potential space, 138

transitional object, 43, 137, 143 transitional space, 138 Wood, H., 29 working through, 95, 142