Person Centred Psychoanalysis – Book Review: On Learning From The Patient

Mirror, Mirror — Jack Vettriano

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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