Inside Margot Wadell – Book Review: Inside Lives

This is a review written back when I was studying psychoanalysis. These articles critiquing psychodynamic texts proved pretty popular (I’m assuming with students, or practicing psychoanalysts) when I initially posted them. Having recently uncovered a couple that had never made their way to the web, I thought why not release them. Hope you find them useful / interesting, despite the rather dense academese.

Stuck Inside, by Norman Rockwell.
Stuck Inside, by Norman Rockwell.

Inside lives (Waddell, 2002) attempts a phenomenological object relations account of psychological development, from infancy to advanced age. Margot Waddell considers the stages of life as states or meta-positions (Waddel, 2002, pp 8), contingent and dependent on earlier developmental negotiation, rather than inevitable developmental milestones. These states represent individuated matrixes of attitude and biological development, in which the positions articulated by Klien and others shift in the context of emotional and intellectual development, external stressors and interpersonal relations. The book examines the impact of biological changes, family of origin, adolescent affiliation, adult individuation and finally the difficulties of coping with degeneration and impending mortality.
Continue reading “Inside Margot Wadell – Book Review: Inside Lives”

Two Saner Views Of Mental Illness

the-hearing-forest-and-the-seeing-field.jpg!HalfHD
The Hearing Forest and the Seeing Field by Hieronymus Bosch

I’ve written here before about how easily the person can become obscured by psychiatry’s fixation on the symptom or a collection of symptoms (syndrome). This is a grave problem with our current conception of mental health, which views psychological symptoms as analogous to symtoms of a physical disorder. While the ‘disease model’ can be a comfort to people who finally have a label for their inexplicable behaviours, hallucinations or delusions, labels tell us little about how to effectively treat such disorders. They too often lead to a life of chronic medication, with the goal of ‘managing’ a ‘disorder’, rather than making sense of the suffering of a person. I’m not suggesting for a moment that psychiatric medication is without its uses, especially in relation to acute states of psychosis or the profound depths of depression. What I will say however, is that (when not a symptom of disease or degenerative processes, or the result of a neurological insult like a stroke or head injury), the symptoms we associate with mental illness – delusions, hallucinations, compulsive behaviours and so on – are meaningful. They relate to processes at work in the individual, and are frequently hysterical in the old Freudian sense.  They serve to express unacceptable emotional suffering, desire, aspects of the hidden and disowned authentic self.

Risk is an amazing podcast, established by The State writer / performer and sex positive campaigner Kevin Allison. I came across the show when Kevin was interviewed by the ever penetrative Marc Maron. Risk is a show where people tell stories. So far, so much like the Moth, or This American Life, or any number of other podcasts leading the storytelling revival. But Risk is different. These stories are confessional, lewd, challenging, often unheard before in public. Allison coaxes his guests to confess secrets, to normalise life events – whether sexual, violent or merely outre, that once brought them shame. In doing so he promotes the self acceptance that Carl Rogers, founder of the Person Centred approach to psychotherapy argued was essential to emotional wellbeing. Risk’s participants are helping to heal the toxic shame that we all carry, to greater or lesser extents, having internalised insult, humiliation and derogation. There are lots of blogs and podcasts that give lip service to self acceptance, complete with motivational poems and posters and wretched screeds against an uncaring world. Risk is different – it’s sexy, funny and performative, it’s joyous. This was brought home to me listening to an episode called ‘Transcendent‘, in which a young woman discusses her experiences with psychotic violence. Without spoiling the story, Becca’s experience of mental illness did not spring forth out of some hidden well of biological disfunction. Our brains can certainly make us more vulnerable to mental illness, genetic studies of the heritability of schizophrenia demonstrate that. But those same stories also demonstrate that mental illness is multifactorial – it is caused by many things, including abuse, poverty, social and familial dislocation. In Becca’s case those things included the loss of her father at an early age, and living up to an enormously demanding false self. A self that demanded success, perfection, to fit in. Her story is one of recovery, and finally coming to accept her experience as heroic, as meaningful.

[audio http://www.podtrac.com/pts/redirect.mp3/traffic.libsyn.com/risk/Transcendent_Thoughts.mp3]

Another inspiring story is that of Eleanor Longden, who as a student was diagnosed with schizophrenia because of her persecutory voices. In recent years online collaboration has encouraged communities to coalesce around people who share the same experience. These experiences can be benign, as in the case of Synesthesia, where reading a number might conjure a sound or colour.  They can even be delightful, as with the strange (and still hardly understood) Autonomous Sensory Meridian Response (ASMR). The can be terrifying and destructive, as is often the case with persecutory aural hallucinations. Eleanor and others with similar symptoms have banded together to form organisations like the Intervoice Network the Hearing Voices Network, that give a voice to those who hear them. Eleanor, now a clinical psychologist, formed a relationship with her voices – which she ultimately came to accept as disowned parts of herself. Examples like hers demonstrate that making meaning from the experience of suffering is one of the most profound ways to transcend it. As psychotherapist and holocaust survivor Victor Frankl wrote, “In some ways suffering ceases to be suffering at the moment it finds a meaning”. Through self acceptance, and with it self revelation and gradual self efficacy, we can find a voice for our suffering, and let it empower us rather than constrain us.

[youtube http://www.youtube.com/watch?v=syjEN3peCJw]

Low cost Psychotherapy in Ireland

the-cure-of-folly
The Cure of Folly, by Hieronymus Bosch

Due to the large number of counselling and psychotherapy courses in Ireland, particularly in Dublin, lots of low cost counselling services are available. Research shows that suicidal teens in particular have a low awareness of available resources, and despite ongoing mental health campaigns, low cost counselling in Ireland has low visibility. As I’m currently training as a psychotherapist, I thought I’d take this opportunity to collate some available resources. These are services which offer free or low cost counselling (usually between 15 and 40 euro), most often from student counsellor / psychotherapists.

Generally speaking (specific conditions and disorders aside) all therapies are roughly equal in efficacy. That is to say it shouldn’t make a huge difference which theoretical orientation your therapist follows (say Freudian, or cognitive behavioural or person centred or whatever).  Don’t worry too much about the terminology – the difference between counsellor, therapist, counselling psychologist, psychoanalyst etc, is likely to be much less in practice than you might imagine from reading the theories behind these approaches.

That said, the ‘real relationship’ between counsellor and client really is important. Which means you really should go shopping. Therapists hate this, but you have my permission to try out as many as you need until you find someone you feel you can trust / relate to. It’s all too easy to get locked into a feeling of obligation to a therapist, rather than admitting they’re not right for you. That said, the opposite is also true. Clients frequently (usually even) feel better after a couple of sessions, and want to quit there and then, because the work is hard. If you can help it, don’t do this. It’s called flight into health, and it’s just a way of avoiding the deeper issues that resulted in the symptoms that made you seek help in the first place. Find someone you can work with, build a trusting relationship, bring real feelings into the room. It will be worth it.

All the following services are staffed by student psychotherapists, usually with a least two years academic work towards a diploma in psychotherapy, as regulated by the Irish Association For Counselling & Psychotherapy. I provide no warranty or recommendation – or guarantee of the services listed. I’m just pulling this together from resources on the web. This, again, is totally incomplete. The magic words to google are “low cost counselling”, and there are lots of alternatives available.

Low Cost Counselling Services

Tivoli Institute
Cost: 15 – 25 euro
Theoretical Orientation: Object Relations, Psychodynamic
Location: Dublin or Galway
Availability: Weekday and weekend (late evenings available)
Number: (01) 2809178 (Dublin) or (086) 405 3413 (Galway), 9.30am and 4.30pm Monday-Friday.

Village Counselling Service
Cost:  5 – 30 euro
Theoretical Orientation: Choice Theory, Person Centred
Location: Killinarden, Tallaght
Number: 01-466-4205 / 087-904-9497, Monday to Friday 8.00am-10.00pm and Saturday 8.00am-6.00pm

PCI College
Cost: 15 – 25 euro
Theoretical Orientation: Person Centred, Family Systems
Location: Clondalkin, Dublin
Number: 076 6024 244. 10 and 3 Monday to Friday

The Counselling Centre Cork
Cost: 30 to 40 euro (reduced, 60 euro full price)
Theoretical Orientation: Humanistic / Person Centred
Location: Cork

Target Counselling
Cost: ?
Availability: Monday – Friday 9:30am – 1:30pm, Monday – Thursday 7:00pm – 9:00pm
Location: Holy Trinity School, Newbrook Road, Donaghmede, Dublin 13.
Contact: 01 867 0279, jean@targeteducation.net.

Portlaoise Family Resource Centre
Cost:  ?
Contact: 057 86 86151, online form
Location: Portlaoise Family Resource Centre , Harpurs Lane, Knockmay, Portlaoise, Co.Laois

Tree of Life Counselling Service
Cost: ?
Location: Malahide, Lusk
Contact: 01 8283992

Liberties Counselling Service
Cost: 10 – 40 euro
Theoretical Orientation: Person Centred
Contact: 01-4736491, info@libertiescounselling.com
Availability:  on Mondays and Wednesdays between 9am and 5pm and Thursday
Location: Liberties Counselling, 11, Meath Street, Dublin 8

Admitting Your Mistakes. Book Review: Psychodynamic Techniques

The Sun Is in Love with the Moon (collaboration with Blaak) by Mr Dejo
The Sun Is in Love with the Moon (collaboration with Blaak) by Mr Dejo

Review: ‘Psychodynamic Techniques’ by Karen Maroda

The Books Objective

‘Psychodynamic Techniques’ (Maroda, 2010) is an attempt to offer a set of ‘culture bound’, historically situated clinical techniques, increasing the ability of psychotherapists to emotionally engage with their clients. Maroda suggests that it is within the affective space of the ‘real relationship’ (Gelso, 2010), that change takes place in psychotherapy, and that by expanding the intercommunicative emotional literacy and affective availability of psychoanalysts, deeper change can be facilitated; especially with extremely damaged and vulnerable clients. The author focuses on practical concerns, from the development of the collaborative working alliance and breaking ‘lulls’ in client engagement, to issues of countertransference revelation and the delicate balance of relating congruently with clients, whilst protecting them from damaging or sadistic expressions of anger or erotic interest. For Maroda, genuine therapeutic practice involves honest engagement with countertransference, both positive and negative. Maroda encourages therapists to expand their range of emotional availability and sincerity within the therapeutic encounter; arguing that it is better to risk mistakes and ‘mended failures’ (Abram, 2007), than to maintain a superhuman veneer of complete acceptance or masochistic impermeablility.

The Book’s Usefulness for Therapists

Maroda’s practical and specific applications of technique provide a clear and consistent perspective, applicable across therapeutic orientations. She argues for a degree of engagement with clients that pre-dates the contemporary mental health fixation with disorder and labelling. Maroda’s specific examples are frequently both novel and theoretically neutral. She provides guidelines for the timing and nature of interventions that are client centred and growth oriented. Maroda provides a blueprint for a ‘here and now’ (Yalom, 2011) emphasis in psychoanalysis that supports rather than detracts from clients lived experience and explorations of past trauma – by attending to how ‘repetitive patterns’ of pathological / self destructive relationship behaviour are revealed in the countertransference. This elucidation of the dynamics of diagnostic countertransference is a helpfully specific and comprehensible explanation of an obtuse and intangible phenomenon.

Maroda, like Patrick Casement, provides a practical guide for the ‘good enough’ therapist, by demonstrating how owning up to her misunderstandings and unhelpful emotional interventions ultimately enabled deeper collaboration in the therapeutic process. This presents both a tremendous challenge and opportunity to therapists, who may fear appearing incompetent or abandoning the veneer of expertise.

Le Pardon de Dieu annoncé à Jérusalem (Isaïe, LIV, 6 10) by Marc Chagall
Le Pardon de Dieu annoncé à Jérusalem (Isaïe, LIV, 6 10) by Marc Chagall

The book recommends a less conflict avoidant approach, erring on the side of honest affective engagement with revelations of negative countertransference (once a trusting relationship has been established), in the understanding that owning and correcting subsequent mistakes in treatment may itself facilitate client growth. This is situated in a broader engagement with the reality of the emotional encounter in general, and the use of ‘breaches and repairs’ as methods for transforming mistakes to opportunities for increased client (and therapist) self awareness.
Much of the detail of Psychodynamic Techniques is concerned with the practicalities of navigating the emotional disclosure Maroda advocates, balancing client needs, containment and congruent emotional engagement, whether in the context of therapist anger, erotic counter-transference or simple boredom. Maroda addresses directly the dangers of client exploitation where lack of engagement with (or over indulgence of) negative counter-transference encourages reaction formation and boundary breaking.

What use would you make of it as a practitioner?

Maroda’s detailed recommendations about the appropriate (client directed) levels of empathic expression, how to employ questions and interventions, the utility of goal setting in therapy etc, are usefully specific, without being overly prescriptive. For me they help to structure a mental map of therapy as a progressive process, rather than a series of single encounters.

Maroda keeps client interests at the centre of the therapeutic process – acknowledging that some clients may not wish to tolerate the iatrogenic suffering involved in depth work. Her descriptions of healthy regression (and it’s differentiation from malignant decompensation) provide a compelling narrative of the process of reintegration of split emotions and repressed traumatic experiences. While her acknowledgement of the role therapists can unconsciously play by failing to provide adequate containment / boundaries (with specific examples from her own cases), is informative: For example, examining how the seductive / abused client can unconsciously recreate in their therapist the feelings of ‘powelessness’ and ‘anger’ they experienced in childhood. Addressing the issues surrounding containment with borderline clients, Maroda outlines a method rooted in understanding of the underlying deficits involved, employing ‘reverie’ and appropriate emotional responses, with a measured understanding of the more extreme emotional sensitivity and acting out typical of BPD.

Depth by M.C. Escher
Depth by M.C. Escher

Maroda acknowledges that therapists will inevitably feed into the countertransference, but that this can direct the therapeutic process rather than derail it. Her suggestion that client resistance or therapist distaste may be the inevitable result of a clash of incompatible ‘patterns of relating’ (Maroda, 2010, pp35) , is a humbling reminder that not all client-therapist pairings are a good fit.

I find Maroda’s psycho-educative approach attractive – especially within the boundaries that she develops in Psychodynamic Techniques; i.e.: teaching social norms and providing constructive feedback in response to expressed client need, or in anticipation of common process. This provides a structure for clients who might be left at a loss by the tabula rasa of less responsive psychoanalysis, without imposing theory or inflexible methodology. Maroda is particularly strong in navigating between reinforcing client dependence, and providing support where needed, and here her case examples are particularly helpful.

I found her elucidation of potential re-traumatisation in the phenomena of ‘kindling’, a novel and important element of understanding regression as a therapeutic process. Maroda’s specific advice about how to hold regressing clients, especially those with attachment disorders, is highly applicable in the clinical setting.

First Steps, Picasso
First Steps, Picasso

Similarly, Maroda’s techniques for tentative client-directed challenges provide a specific guide as to how to tailor interventions. She demonstrates how to assess the efficacy of interventions as they are received, and how to transform missteps into opportunities for deepening the therapeutic relationship. Here she accords with contemporary conceptions of reactance (Dowd & Seibel, 1990) as indicative of therapeutic misdirection, rather than defensive resistance. Admirably she seeks to reduce the role omnipotence of the therapist, by removing the screen and revealing to clients (in so far as is therapeutic) the developing insight of her internal supervisor (Casement, 1995). Maroda closely examines the boundaries surrounding disclosure, and outlines clearly the differences between serving a therapist’s needs and their client’s.

Maroda subscribes to the Winnecottian ideal of the therapist as model of ‘good enough’ functioning / parenting, ‘failing well’ (Abram, 2007), both in order to transcend inevitable misunderstandings in interpretation, and ultimately to provide a model for depressive social functioning. Here Maroda ties her recommendations into published research, rather than case studies alone, something often lacking in psychodynamic texts.

If you were writing this book, what would you add/subtract?

Maroda’s opinion, that therapists should refer clients they dislike or find dull, is appealing, though perhaps not entirely practical – especially in ‘front line’ care provision. Perhaps an acknowledgement of the different treatment scenarios at work in ‘real world’ managed care could have been useful.

Maroda frequently roots her expectations of client’s potential recovery in their past ability to form secure attachments / relationships, and their historic ability to change. While these are likely strong predictors of the success of person centred psychoanalysis, it might have been useful to examine alternative treatments like Adult Attachment Therapy (Lopez & Brennan, 2000) for clients with deep trauma and attachment disorders. Similarly, an examination of the family and individual resilience factors (Hawley & DeHaan, 1996) that differentiate developmental experiences might reveal useful approaches to the amelioration of otherwise untreatable clients.

Memory, by Will Barnet
Memory, by Will Barnet

Maroda assures us that therapists need not be over worried about misdirecting clients, as they are less vulnerable to imposed change than we imagine. I feel she goes too far in this regard, ignoring the liability of client behaviour / discourse revealed by research into the demand characteristics of various psychotherapies (Kanter et al, 2004), and historic abuses like ‘recovered memory syndrome’ (McElroy & Keck, 1995). While clients do possess a tendency toward authentic change, it is demonstrable that this can be misdirected by wilful manipulation or well intentioned conditioning.

Less seriously, Maroda reveals a distaste both of casual drug use (relative to moderate alcohol use) and ambiguous sexual relationships (Maroda, 2012, pp54), that betray a puritanical intolerance.

Maroda’s account of the process of interventions becoming ‘automatic’ lacks an understanding of proceduralisation (Binder, 2004), a basic process in learning that explains how deliberate behaviours gradually become pre-conscious schema. Linking this with a ‘dual process’ account of cognition (Slife et al, 2001) and behavioural economic research into innate cognitive biases (Gigerenzer & Todd, 1999), might provide a more useful understanding of how client’s learned pathological attachment patterns can be neuroplastically ‘re-wired’ through the kind of corrective emotional experiences Maroda advocates.

Any other comments?

In stark opposition to Patrick Casement (Casement, 1995), Maroda falls on the ‘good model’, practical intervention side of the debate in psychotherapy, between passive listening and interpretation on the one hand, and facilitation and ‘helping’ on the other. Her willingness to adopt aspects of other therapeutic approaches, like congruence (from person centred therapies) or behavioural strategies and goal setting (from CBT) is a heartening change from more strictly psychodynamic texts. Her belief that change occurs through “incremental emotional experiences” rather than insight, accords with contemporary neuroscientific research into synaptic plasticity and the practicalities of habit formation (Bennett & Nelson, 2010), and to me represents a more humane and pragmatic psychoanalytic approach. This is reflected in Maroda’s understanding of borderline clients as affectively and cognitively impaired rather than wilfully destructive (Maroda, 2010, pp153) However I do question whether a less directive collaboration in the exploration of values, goals and interpretations might be preferable to the ‘advice’ that Maroda recommends in response to genuine client requests (Maroda, 2010, pp64).

Does the book meet its objective?

Overall Maroda succeeds in delineating a variety of techniques derived from clinical experience and illustrated with vivid case histories, that outline a growth orientated, less asymmetrical psychoanalytic relationship. Tacking therapy as a series of stages or challenges, Maroda remains consistently practical and readable, redefining the ‘good enough’ therapist for our less prescriptive time. Finally, Maroda’s pragmatic, psychoeducative approach tallies with client efficacy research (McLeod, 2011), in creating a collaborative and emotionally honest template for depth work in psychotherapy.

References

Abram, J. (2007). The Language Of Winnicott: A Dictionary of Winnicott’s Use of Words. UK: Karnac Books.

Bennett, S., Nelson, J.K. (2010) Adult Attachment in Clinical Social Work: Practice, Research and Policy. USA: Springer.

Binder, P. (2004). Key Competencies In Brief Dynamic Psychotherapy: Clinical Practice Beyond the Manual. UK: Guilford Press.

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

Dowd, E. T. (1990). A Cognitive Theory Of Resistance and Reactance. Implications for Treatment. Journal of Mental Health Counselling, Vol 12(4), pp 458-469.

Gigerenzer, G., Todd, P.M. (1999). Simple Heuristics That Make Us Smart. UK: Oxford University Press.

Gelso, C. J. (2010). The Real Relationship In Psychotherapy: The Hidden Foundation of Change. USA: APA Books.

Hawley, D.R., DeHaan, L. (1996). Toward a Definition of Family Resilience: Integrating Life-Span and Family Perspectives. Family Process. Vol 25(3), pp 283-298.

Kanter, J.W., Kohlenberg, R.J., Loftus, E.F. (2004). Experimental and Psychotherapeutic Demand Characteristics and the Cognitive Therapy Rationale: An Analogue Study. Cognitive Therapy and Research. Vol 28(2), pp 229-239.

Lopez, F. G., Brennan, K. (2000). Dynamic Processes Underlying Adult Attachment Organisation: Toward an Attachment Theoretical Perspective On The Healthy and Effective Self. Journal Of
Counselling Psychology. Vol 47(3), pp 283-300.

Maroda, K. (2010). Psychodynamic Techniques. USA: Guilford Press.

McElroy, S.L., Keck, P.E. (1995). Recovered Memory Therapy: False Memory Syndrome and Other Complications. Psychiatric Annals. Vol. 25(12), pp731-735.

McLeod, J. (2011). Qualitative Research In Counselling and Psychotherapy. UK: Sage.

Slife, B.D., Williams, R.N., Barlow, S.H. (2001). Critical Issues in Psychotherapy. UK: Sage.

Yalom, I. D. (2011). The Gift Of Therapy. USA: Little Brown Book Group.

At the Edges of Reason. Book Review: Understanding the Borderline Mother

Evacuee Boy by Lucian Freud
Evacuee Boy by Lucian Freud

The Books Objective

Lawson’s book takes a psychodynamic look at Borderline Personality Disorder, particularly in relation to mothering. Lawson outlines the effects on the children of “borderline women”, of the borderline’s intense separation anxiety and hostility in relation to abandonment and criticism. She creates a taxonomy of borderline subtypes, and examines the behaviours typical of each, and how their intense all consuming emotional co-dependence can be transcended by their children. The borderline world as depicted by Lawson is a frightening one – leaving little space for concrete reality or emotional reliability – threatening to annihilate the child, and passed on through the intergenerational transmission of pathology (pp4). The borderline experience is an expressionist one – where internal reality is far less vivid than interior drama, cognitive distortion, overwhelming emotion and paranoia.

The Book’s Usefulness for Therapists

The typology of borderline subtypes described by Lawson provides a way of understanding presenting symptoms, and client childhood experience in therapy. She vividly coveys the volatility and splitting of borderlines and their typical preference for one child over another; since the disturbed relationship they had with their own mothers makes parenting a uniquely difficult relationship for them (pp5). Borderlines ignore the ordinary social norms and boundaries that prevent us from emotionally (and physically) assaulting and manipulating those close to us, feeling threatened to destruction by their children’s growing independence (pp9, 40). Lawson specifies a typology of borderline mothers – based on which internal feeling dominates their experience – the Waif (helplessness), the Hermit (fear), the Queen (emptiness), the Witch (anger) (pp39).

The Waif is a lonely, victimised, addictive, self-denying, anxious, hypersensitive fantasist, her helplessness concealing rage at her neglectful childhood (pp57), alternately indulgent and neglectful of her own children. The waif seeks help, but cannot accept it, since her helplessness is a basic protection (pp58). Her children can become caretakers or exploiters (pp3), and her self-destructive extremes may be aimed at them (pp68).

Hermits by Egon Schiele
Hermits by Egon Schiele

The Hermit is introverted, defended, controlling, driven, hoarding, perceptive, defensively hostile and terrified (pp80). Incapable of close relationships, possessive, projecting guilt and relying on ritual, signs and meanings to ward off fear, the hermit may leave her children denigrated, lacking a certain sense of reality, and incapable of autonomy (pp83). Unsafe alone or with people, the hermit is vulnerable to deep isolation and inner persecutory rumination (pp84, 89). Her paranoia may fixate on disease and illness, or the dangers of the world (pp96, 97).

The Queen seeks attention, is entitled, ambitious, manipulative and volatile, preoccupied with loyalty, status and possessions, and seeks external validation to ward off her all consuming inner emptiness (pp102) and worthlessness stemming from emotional deprivation (pp105). She may use her children as symbols of her attainment, invade their privacy and split from them and others when challenged (pp114).

The Witch creates for others a prison of fear (pp121), out of her punitive cruelty (pp138). She feels persecutory envy, derives self-esteem from other’s fear (pp128), born out of submission to childhood sadism (pp131) and a fundamental belief in her own evil nature and the badness of others (pp137). Her children may be subject to invasion, betrayal, denigration and humiliation (pp131, 141); and may respond with violence, self harm, emotional instability and mental illness (pp132). The witch’s ‘annihilatory rage’ at abandonment may become psychotic, resulting in violent or sexual abuse, or even the murder of her children (pp123, 140). The witch can be a state, rather than an identity, a more extreme aspect that may lie dormant in the other borderline persona (pp130). Lawson’s description of the witch is close to the DSM diagnosis of anti-social personality disorder (related to, if distinct from) psychopathy (DSM, 2000).

Queen of the Butterflies by Salvador Dali
Queen of the Butterflies by Salvador Dali

The inconsistent parenting environment borderline mother’s inner chaos and acting out engenders, leaves their children with a basic existential insecurity (pp8), accompanied by feelings of chronic anxiety, guilt and rage (pp 18). Lawson cites evidence of the long term neurological damage and stress vulnerability accompanying this inner experience (pp14, 49). Children can easily internalise the shaming and guilt projected onto them by their borderline parent (pp16), a concept elaborated by John Bradshaw’s concept of ‘toxic shame’ (Bradshaw, 1988). She compares BPD to Post Traumatic Stress Disorder, as an acquired, neurologically deficit reaction to intolerable external turmoil, neglect and abuse (pp49). This strongly suggests that a combination of medical, psychological and behavioural interventions may be the most effective treatment for BPD. Lawson argues that the psychotherapeutic component of borderline treatment may need to be lifelong management rather than cure (pp50).

Lawson’s depiction of the childhood of children of borderline parents – exposed to the whirlwind of emotional demands, invasion and manipulation, and even psychosis (pp25); should help us be more empathetic to their suffering and uncontainable emotions in adulthood.

Although it’s not the book’s emphasis – the portrayal of the dynamic cycles of destructive behaviours and dissociative responses that develop in families, both exaggerating and normalising the behaviour of a sick parent (and often resulting in the labelling of the child as the ‘identified patient’), is valuable (pp29).

The explanation offered for the father’s passivity in the borderline mother’s exploitation – either schizoid distance or co-dependent narcissism, helps to show how pathological family dynamics can obscure / permit the destructive behaviour of one partner (pp179). However the subtypes Lawson provides of men who marry borderline women are defined more by their relation to the borderline, than their internal characteristics.

What use would you make of it as a practitioner?

Lawson’s citation of Otto Kernberg helped me understand how clients are motivated to avoid the painful cognitive dissonance of their contradictory love and hate feelings about themselves and their borderline parent – and how this can motivate paranoid-schizoid splitting (pp14).
It’s useful to remain aware of the facade that borderlines can create – of efficacy and normalcy, obscuring the pain of their interior worlds and their family life (pp20, 40). I would look for the unstated, implied reality behind criticism of others and emotional turmoil.
Working with young people, I would be more aware of the potential familial strife and dichotomous labelling underlying self harming behaviours, hypervigilance, anxiety and negativity (pp21, 170).

Working with adult clients, I would be more sensitive to cycles of abuse / remorse (pp155), the ‘turn’ (pp133), rapid switches in emotional valence and relating, threats of suicide etc, in response to perceived betrayal; as cues to a potential borderline state. In treating borderlines, and their children – I would seek to ameliorate the effects of their invalidating, denigrating childhood (pp46), by modelling tolerant, reflective containment.

I found the concepts of the ‘all-good’, ‘no-good’ and ‘lost’ child – children treated as projective elements of the borderline’s split internal object relations, (153) useful in understanding roles within the family dynamic. I question Lawson’s conviction that the ‘all-good’ child is necessarily protected from disorder & likely to become a professionally successful, guiltily self abnegating caretaker (pp163, 165). It seems just as likely this child’s lack sense of self and agency could result in passivity and dissociation, or a pathological inability to tolerate the impositions of others. Indeed the ambivalent nature of borderline object relations is likely to lead to children with polarised internal good-bad self representations / object relations – evidenced by the higher prevalence of disorganized attachment in children of borderline mothers (Middelton-Moz, 2006). Similarly, I question the inevitability of borderline development in the ‘no-good’ child. The behaviours Lawson describes seem valuable, but the rigid categories are questionable.

Lawson suggests the validation of dialectical behavioural therapy as an effective treatment for the internalised degradation of borderlines (pp51), I’m interested in learning more about this form of therapy which has shown efficacy in the treatment of this disorder (Palmer, 2002).
Lawson’s recommendations on the treatment of borderlines and their children are pragmatic, and help to explain the fear many clients have of dependency (pp202). She recommends teaching the children of waifs how to support without attempting to save their mother (pp203), by being emotionally direct (pp206, 210), setting boundaries (pp213), and learning to understand their mother’s exaggerations and cognitive distortions, projections, unreliability, negativity and manipulative use of guilt (pp217). Teaching adult children to behaviourally condition their borderline parent into more healthy norms, she suggests, can improve their relationships and independence (pp218). Finally, by reconnecting with their own feelings, they can gain a more certain sense of self (pp224).

In dealing with the hermit mother, her children must manage their reactions to her projected anxiety and fear (pp230), tolerate her distortion, denial and ambivalent treatment (pp233), as well as her paranoia, isolation and rituals (pp 235). Learning cognitive problem solving strategies can help them manage their introjected anxiety (pp238). Some adult children may need to project themselves by cutting off the borderline parent altogether, all will need to create and maintain healthy boundaries (pp241, 244).

Children of the Queen need to resist the urge to curb her excessive behaviour, while developing their separateness and sense of self, and resisting her invasiveness (ppp251, 255, 262). They must set limits on their obedience – while preparing for potentially severe and even psychotic retaliation (pp254). They must resist being pushed into inappropriate financial and emotional indebtedness, or manipulates into family arguments.
Lawson is less encouraging about the children of the Witch, who struggle with feelings of annihilation, and internalised degradation (pp273). Feelings Lawson compares in their severity to that of holocaust survivors (pp275). Their rage may become suicidal or homicidal, and protecting themselves from their mothers provocation may necessitate separation (pp278). These children need to heal the severe defilement they have been subjected to, and avoid giving in to the desire for revenge (pp282). If they cannot, physical illness and potentially severe psychological disorder will result (pp289). They need to learn to manage their interaction with the witch parent, to protect themselves and provide the opportunity for escape (pp285).

The experience of the children of borderlines is one of being disbelieved (pp 298), of being made to feel unworthy. Lawson argues that long term depth psychotherapy can help to rebuild at strong self identity, at a neurocognitive level through synaptic plasticity (pp304), and an interpersonal level, through love.

If you were writing this book, what would you add/subtract?

No space is given in the book to critiquing / reinforcing the construct validity of borderline disorder or personality disorders in general. These disorders are highly co-morbid, and their objective reality has been questioned (Clarkin et al, 1992). Lawson points out that men with ‘borderline’ symptoms are more likely to be violent, and dealt with via the criminal justice system (pp xv), but fails to address the complex social and cultural factors that frame criminality and psychological disorder – demonstrated by the fact that American has the highest incarceration rate in the world (Tsai & Scommegna, 2012), and the overwhelmingly risk and worse outcomes of maternal poverty in mental illness (Saraceno & Barbui, 1997).

Witch going to the Sabbath by Remedios Varo
Witch going to the Sabbath by Remedios Varo

The social components that defuse or exacerbate borderline tendencies, whether it be family culture, or social stratification, are largely unexamined. This is particularly relevant with regard to the powerlessness of women historically, Lawson cites Silvia Plaith, Mary Todd Lincoln and other historically noteworthy women, doomed by their gender to exist in the shadow of their husbands. Lawson takes an easy out, arguing that borderline males are more likely to be ‘treated’ by the criminal justice system, but later describes abusive males as ‘borderline’ (pp155). If this is the case, it seems likely that a borderline parent of either sex, can be as damaging an influence.

Lawson argues for the utility of loving relationships (in meeting emotional developmental needs) as a resilience factor in traumatised childhood (pp43). She frames the typology of borderline as pathological attempts to satisfy unmet childhood needs. It would have been useful to have had a more thorough examination of the many and varied resilience processes that have been found to underlie healthy emotional and cognitive functioning; and how they can be supported in the therapeutic work. Nonetheless, the concept of the ‘invalidating environment’, and the compulsive search for unmet needs are useful (pp26).

As I read Lawson’s book, I’ve been working with a client whose mother fit Lawson’s profile of the Hermit mother almost exactly. This served as empirical confirmation of the books typology, and helped me understand the childhood experience and ‘no-good’ internal world of the client. Although Lawson’s classification of borderline subtypes seems to lack research backing – its vivid depictions and many examples from client journals really do help to understand the almost unimaginable suffering experienced by the children of borderline parents.

Any other comments?

Borderline Personality Disorder has been criticised as a patriarchal concept (Bjorklund, 2006), both because of its relatively high diagnosis in women, and its reinforcement of negative female stereotypes (emotional liability, narcissism, helplessness etc). Although Lawson doesn’t suggest that men do not suffer from the disorder too, by focusing primarily on the borderline mother, she arguably reinforces this perspective.
Similarly, the effect of cultural norms on the development and expression of borderline traits remains unexamined. This is relevant because the model of a separate adult child navigating a relationship with an aging parent, while maintaining their own nuclear family, is unique to Westernised cultures. Lawson’s explanation of the frustrating effects of self help texts, abdicated from behavioural change and individual understanding, is useful (pp263). With its emphasis on positive adaptation to the results of borderline parenting, Understanding the Borderline Mother makes a welcome change from defeatist accounts of personality disorder. Lawson vividly conveys the agonisingly imprisoned inner lives of borderlines and their children.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Bjorklund, P. (2006) No man’s land: Gender Bias and Social Constructivism in the diagnosis of borderline personality disorder. Issues in Mental Health Nursing. Vol. 27(1), pp3-23.

Bradshaw, J. (1988). Healing the Shame that Binds You. USA: Health Communiciations.

Clarkin, J.F., Marziali, E., Munroe-Blum, H. (1992). Borderline Personality Disorders: Clinical & Empirical Perspectives. UK: Guilford Press.

Lawson. C.A. (2004). Understanding the Borderline Mother. Helping Her Children Transcend the Intense, Unpredictable, and Volatile Relationship. USA: Jason Aronson.

Middelton-Moz, J. (2006). How a Mother with Borderline Personality Disorder Affects Her Children. Graduate Student Journal of Psychology. Vol. 8.

Palmer, R.L. (2002). Dialectical behaviour therapy for borderline personality disorder. Advances in Psychiatric Treatment. Vol. 8, pp10-16.

Saraceno, B. Barbui, C. (1997). Poverty and Mental Illness. Canadian Journal of Psychiatry. Vol. 42, pp285–290.

Tsai, T., Scommegna, P (2012). U.S. Has World’s Highest Incarceration Rate. Population Reference Bureau. Retrieved 25th April, 2012
Available: http://www.prb.org/Articles/2012/us-incarceration.aspx

The Object Is Connection. Book Review: ‘John Bowlby & Attachment Theory’

Attachment, by Wu Guanzhong
Attachment, by Wu Guanzhong

John Holmes’ book serves as a guide to John Bowlby’s research in attachment theory, contextualising it in the history of psychodynamic psychotherapy, and tracing its influences on child development and adult outcome research. Bowlby’s influence extends far beyond psychoanalysis and this volume serves as a concise overview of its importance within psychology, social work and social policy. Holmes vividly contextualises psychoanalysis’s rejection of Bowlby, as arising from a conflict between introspection and empiricism, and between warring factions in the post Freudian analytic world. Yet, this is very much a psychoanalytic reassessment of Bowlby’s work on attachment, trauma and loss, and seeks to place him within the context of the psychoanalytic tradition and contemporary practise.

Bowlby’s work emphasised the importance of infant experience and loss (learning), over the developmental patterns hypothesised by Freud and Klien alike (rooted in instinct). In doing so he demonstrated the importance of real trauma in diagnosis and treatment. Bowlby’s willingness to integrate scientific research findings and methodologies into his theories and practice, remind us of the importance of interdisciplinary awareness. Attachment is one of the best evidenced and most productive theories within psychology (Carlson & Sroufe, 1995), in part due to its relative absence of introspective speculation. Integrative psychotherapy could benefit from connecting to findings from other fields, for example the cognitive biases and heuristics discovered by behavioural economists, and the relational insights identified by social psychologists. Holmes commentary on the history of object relations ideas since the time of Klien, is a useful guide to how their predictions have been supported in the scientific literature (pp7); and he works hard to integrate psychodynamic theories with attachment and loss.

In common with Patrick Casement (Casement, 1990), Holmes argues that interpretations are much less important that the real / working relationship in psychotherapy outcomes (pp8). The difficulty of forming this relationship is determined by client attachment style (moderated by real world trauma), and the therapists attunement to the client’s attachment style and level of emotional and cognitive functioning, as well as their ability to contain the transference (pp154). For Bowlby transference is the employment of outmoded models / assumptions of treatment, learned in childhood, in the new attachment relationship of therapy (pp170). Attachment requires no speculative conception of infant experience, in stark contrast to Klienian and Winnicottian conceptions of early object relations (Winnicott, 1971). Bowlby’s model sees love as a distinct adaptive instinct for physical closeness, separate from the satisfaction of other infant physiological needs and psychological drives (pp64).

The maternal deprivation Bowlby identified as so destructive of children’s capacity to form relationships and healthy object relations, helps us understand the roots of severe behavioural disorder (pp39). It should be kept in mind when dealing with family conflict, especially in an institutional context. He leaves us with an understanding of the necessity for children of some parental contact – even in the most disturbed families (pp43), and the grave consequences of total maternal depravation (pp51). However, Holmes sites Michael Rutter – whose research demonstrates that Bowlby exaggerated the intellectual and physiological damage of one-trial separation, and the specific contribution maternal deprivation makes to the multifactorial causes of delinquency (pp50). On the other hand, evolutionary psychology research has evidenced much greater attentiveness of care on the part of direct relations (Webster, 2004), as well as much higher levels of neglect and violence against non-blood related children (Archer, 2013) – demonstrating the very real danger maternal absence creates, adaptively reacted to by the developing child.

Love and Grief (5.4.006), by John Hoyland
Love and Grief (5.4.006), by John Hoyland

The stages of grief, as described by Bowlby – numbing / denial, yearning for the lost object / anger, despair and reorganisation (of relationship with the inner object representations of the lost external object); provide a vivid template for understanding in adaptive object relations terms, how death and relationship failure can be experienced by clients (pp90), and how this is sensitized by their attachment style and history (pp95). The necessity of experiencing and expressing grief and negative emotions in general, ties into the idea that avoided anxiety perpetuates pathology (Marzillier, 2010). Holmes makes the point that frozen grief can be reignited by further bereavement (pp97), especially in avoidant clients (pp183), something we often see arising in client work. I found Parks’ typology of pathological grief (Parks, 1975, cited in Holmes 1993) extremely useful in understanding varieties of presenting grief in clinical work.
As previously noted, Holmes situates Bowlby and attachment theory squarely in the history and theoretical structures of psychoanalysis (pp128). The book provides a fascinating portrait of the early years of post-Freudian psychoanalysis; helping in the process to explain the differences between Klienian, object relations and classical analysis, and between these schools and attachment’s emphasis on the environmental trauma and empirical investigation (pp130). At the same times Holmes (not always convincingly) attempts to reunite attachment and psychoanalysis – with attachment as cause of dysfunction, and analysis as phenomenology. Holmes comparison of Bowlby’s work with that of Winnicott illuminates their shared emphasis on the practical and emotional need meeting aspects of the primary parental bond (pp138); while clarifying their differences – sexual vs attachment drives, explanation vs understanding, and so on (pp140). Attachment theory provides a new way of thinking about defences – as methods of attempting to ensure the persistence of attachment objects or repress the pain of their absence (pp150).

Holmes points out the contribution of risk and resilience factors in moderating the effects of neglect and deprivation (pp53). He also emphasises the importance of current functioning and the protective utility of contemporary relationships, which can be neglected in psychodynamic therapy (pp54). The effect of loss in triggering and creating vulnerability to psychological disorders, is similarly moderated by (perception of, in other words internalised representations of) relationships that serve as resilience factors (pp182).

Insecure attachment, whether ambivalent, avoidant, or disorganised (pp105) seems to underlie many of the relational difficulties which isolate and make vulnerable to psychological illness, clients in therapy (pp68). Understanding how the real or perceived threat of abandonment or betrayal by attachment figures can provoke rejection, hostility and alienation, can help to understand clients in severe distress – and develop interventions which protect them. This is further clarified by the concept of ‘dissuagement’, relating to the use of defences and compulsive behaviours to sooth the anxiety created by the lack of a secure attachment base (pp71); while at the same time evidencing the utility of therapist providing re-parenting graduated failure, as pioneered by Winnicott and Rogers alike (Winnicott, 1971) – especially the necessity of providing containment while the client projects hostile envious transference (pp88). In common with Karen Maroda (Maroda, 2010), Holmes’ suggests a reflexive approach, where Winnicottian graduated failure is facilitated by openly admitting mistakes in the therapy (pp155). Maternal responsiveness (pp85) shares much in common with Winnicott’s idea of the ‘good enough mother’ scaffolding the child’s emotional and intellectual needs (Winnicott, 1971).

Understanding avoidant and ambivalent attachment in terms of distorted adaptations to chronically inadequate / absent parenting, helps to provide a context for insecurely attached client’s distrustful and aggressive projections (pp79). Seeing attachment as underlying relationship difficulties, can help to justify and shape therapeutic strategies focused around the therapeutic alliance (in Bowblian terms, serving the role of the responsive, secure base) (pp153); as well as providing a theoretical basis for more instructive psychoeducative approaches (pp83).

Tehamana has many parents (The Ancestors of Tehamana). by Gauguin
Tehamana has many parents (The Ancestors of Tehamana). by Gauguin

I found Holmes poststructural justification of the healing powers of psychoanalysis’s hermeneutic approach, supportive of my own developing conviction that psychotherapy is a productive meaning making process, rather than an uncovering of a hidden ‘authentic self’. The utility of psychoanalysis is not in the accuracy of its model of mind, so much as the space it offers for the development of the clients psychical reality in the interpersonal containment of the analytic encounter. In other words – ‘aesthetic’ (p144) self discovery is the goal, rather than ‘scientific’ self understanding. There appears sufficient flexibility within object relations to provide a useful model for clients to employ in the understanding of their developmental conflicts and unresolved ambivalences. Viewing therapy in this way respects the client’s own truth, in all its ambiguity and contradictions. It also acknowledges the inarguable evidence for the impact of demand characteristics / suggestion on the client’s discourse and understanding in therapy. Helping the client to construct a meaningful narrative with which to frame their life, and rebuild the ‘narrative incompetence’ wrought by insecure attachment (pp146), by explicitly revising pathological semantic cognitions (pp158), might well be a useful therapeutic technique. I would distinguish this from the avoidant storytelling that client’s can engage in, with a comparison to Bion’s concept of +K learning / experience (Waddel, 2002), lived and felt rather than merely related and symbolically configured. Holmes’ relates that Bowlby’s later theory emphasises the expression of feelings around loss is as important as the loss itself in developing (and healing) trauma (pp162).
Bowbly’s application of ‘feedback loops’ to psychotherapy, fits into behavioural psychotherapeutic approaches which can be preferred by clients who want a more responsive (though not necessarily prescriptive) approach (pp79).

Bowlby’s great contribution is his emphasis on the importance of nature and intimacy of the early connection between the infant and primary care giver (pp21), and the devastating effects of its disruption. I would endeavour to keep this in awareness, as a tool to both predict and understand adult trauma and attachment difficulties.

Bowlby’s ideas about the roots of attachment style, and the intergenerational transmission of attachment were new to me. Holmes describes specific attachment styles, environmentally learned, distinct to either parent (pp106), emerging within the earliest months of life, from the dyadic interaction of child temperament and parent attachment expressed through consistency of responsiveness to infant needs (attunement – which can be understood as an example of projective identification). Holmes cites research indicating the overwhelming contribution of maternal adult attachment style to this dynamic (pp114). This can help to understand not only development – but the necessity of a client centred dynamic in the therapeutic encounter. It also argues for the efficacy of educative approaches which teach parenting and empathic sensitivity (Lukens & McFarlen, 2004) as well as ‘containment’ and reintegration (pp122).
The books interlinking of problematic child behaviours with attachment style (pp122), has important implications for child psychotherapeutic treatment. Although attachment therapies have been distorted to fit directive, abusive psychotherapeutic approaches (Chaffin et al, 2006).

Holmes interlinking of avoidant-attachment and borderline personality helps expand on the conception of borderline as a learned behaviour involving damaged core self-believes / internalised object relations (Lawson, 2004).
Holmes notes “The relentless interpretation of the transference may hypnotically open the patient up to layers of regression and dependency which make such interpretations self fulfilling prophecies” (pp131). A powerful argument for the tentative, client directed interpretation advocated by Patrick Casement (Casement, 1990, 1995).

I found Holmes’ consideration of the differences between Bowlby and Winnicott in relation to reassurance of client re-experiencing trauma in therapy illuminating. I found Patrick Casement’s Winnicottian approach to a client reliving an extreme childhood trauma (Casement, 1995), worrying and unsafe. Casement explains that this approach is an effort to maintain the ‘omnipotence’ illusion of experience as it was, however from an attachment perspective the degree of physical holding requested by the client was reasonable, and not (in this case) a sexual transference.

Holmes makes a useful distinction between psychoanalysis’s concern with sensation and cognitive psychologies preoccupation with perception (pp170).

Holmes addresses the concerns of the modern reader regarding the primacy and ‘monotropism’ of the maternal bond (pp45), and the potential misuse of Bowlby’s institutional critique to justify austerity (pp46), and paternal absence. However Holmes’ revision of Bowlby’s work and influence fails to address the issues raised by gay parenting, single parent and alternative family structures (pp69). Essentially the particularly of the maternal bond is never elaborated on, and Holmes provides little evidence of the effectiveness or ineffectiveness of its replacement in non-nuclear family structures. It would have been interesting to read about the supportive impact (or its lack) in alloparenting cultures (Ahnert, 2005) – or potential connections between ADHD and avoidant attachment (Ladnier & Massanari, 2000).

Alone, by Edmund Dulac
Alone, by Edmund Dulac

I found Holmes contention that narrative coherence is a facet of secure attachment unconvincing (pp110). While the research cited shows clearly that autobiography is more well developed in securely attached children; I’d speculate that novel creativity is frequently higher in insecurely attached individuals, arising from the necessity to create a multiplicity of deep, vivid compensatory narratives to avoid the pain of internal experiences of separation. Little research has been done in this area – but literature has been show to stimulate greater emotional impacts in adults with avoidant attachment (Djikic et al, 2009).

It would have been interesting to read about the ways in which insecurely attached children seek to mollify their attachment difficulties in adolescence through participation in close knit friendship groups / subcultures of like minded teens, and the effect of these strategies (or their absence) in life outcomes. As with Inside Lives (Waddell, 2002), I found Holmes forays into literature, in search of support for attachment / grief (pp98), added little to the book.

While Bowlby’s pioneering family therapy, and the application of attachment to family systems work is fascinating (pp176), I don’t find concepts linking individual / family dysfunction and wider social cultural functioning convincing or predictive. The idea that social problems are the result of subgroups of poorly attached individuals failing to follow the prevailing social agenda (pp202), is both anodyne and paternalistic – ignoring the very real inequalities mentioned by Marris (Marris, 1991, cited in Holmes, 1993) in the ‘competition for security’ underlying class and ethnic conflicts.

Holmes’ book is a marvellously succinct synopsis, not only of Bowlby’s enormous body of research, but also its influence and antecedents. Moreover, the book is coherent, clearly written and above all entertaining (especially when describing Bowlby’s eccentric and rarefied upbringing). Like many great psychotherapists, from Sigmund Freud to Albert Ellis, Bowlby’s theories were influenced as much by his personal experiences as his intellectual influences. Holmes does a good job of showing the roots of insecure attachment and grief in Bowlby’s own life and maternal relations (pp23, 26). He also gives reasonable space to research which has critiqued and refined Bowbly’s ideas, and the impact of those ideas on our management of children. Holmes’ detailed investigation of the implications of attachment theory for psychoanalysis, especially in relation to the real / working relationship, are invaluable. He addresses the most productive interventions and relating style when working with clients across a range of levels of attachment difficulty and environmental insult (pp154). The detail and variety of references and observations in the book make it one to which I will inevitably return.

References

Ahnert, L. (2005). Parenting and Alloparenting The Impact on Attachment in Humans. In C.S. Carter (Ed.), Attachment and Bonding A New
Synthesis (pp 229- 242). USA: MIT Press.

Archer, J. (2013). Can evolutionary principles explain patterns of family violence? Psychological Bulletin, Vol 139(2), pp403-440.

Carlson, E. A., Sroufe, L. A. (1995). Contribution of attachment theory to developmental psychopathology. In D. Cicchetti & D.J. Cohen, (1995). Developmental psychopathology, Vol. 1: Theory and methods (pp. 581-617). England: John Wiley & Sons.

Casement, P. (1990). Further Learning From the Patient. The Analytic Space and Process. London: Routledge.

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

Chaffin, M., Hanson, R., Saunders, B.E., Nichols, T., Barnett, D., Zeanah, C., Berliner, L, Egeland, B., Newman, E., Lyon, T., LeTourneau, E., Miller-Perrin, C. (2006) Report of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems. Child Maltreatment. Vol. 11, pp76-89.

Djikic, M., Oatley, K., Zoeterman, S., Peterson, J.B. (2009). Defenceless against art? Impact of reading fiction on emotion in avoidantly attached individuals, Journal of Research in Personality. Vol. 43(1), pp14-17.

Holmes, J. (1993). John Bowlby & Attachment Theory. UK: Routledge.

Ladnier, R.D., Massanari, A.E. (2000). Treating ADHD as Attachment Deficit Hyperactivity Disorder. In T.M. Levy (Ed.) Handbook of Attachment Interventions. USA: Academic Press.

Lawson. C.A. (2004). Understanding the Borderline Mother. Helping Her Children Transcend the Intense, Unpredictable, and Volatile Relationship. USA: Jason Aronson.

Lukens, E.P., McFarlane, W.R. (2004). Psychoeducation as Evidence-Based Practice: Considerations for Practice, Research, and Policy. Brief Treatment and Crisis Intervention. Vol 4, No 3.

Maroda, K. (2010). Psychodynamic Techniques. USA: Guilford Press.

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

Waddell, M. (2002). Inside Lives. Psychoanalysis and the growth of the personality. London: Karnac Books.

Webster, G.D. (2004). Human Kin Investment as a Function of Genetic Relatedness and Lineage. Evolutionary Psychology. Vol. 2: 129-141

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

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

Mirror Mirror, Jack Vettriano
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).