Clinical Psychoanalytic Case Studies with Complex Patients (The Psychoanalytic Ideas Series) [1 ed.] 1032065559, 9781032065557

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“Psychoanalytic Clinical Case Studies with Complex Patients: Watching experience at work edited by Anne Zachary includes a wide spectrum of difficult to treat cases. If you buy this book you will learn about the tragic consequences of the tensions between management in NHS trusts and the front-line clinical personnel. Three chapters convey the hard-won understanding that emerges in the treatment of autistic children and adults. The psychosomatic and hysterical reactions to intergenerational trauma feature in another chapter. The reader will be able to follow the analysis of interlocking psychopathologies within a parental couple that enabled the father to move away from longstanding psychotic functioning. The technical difficulties of working with patients who present with gender dysphoria are examined in another chapter. This book will take the reader through the differential diagnosis of the underlying diseases that contribute to dementia, and a treatment that acknowledged the demented patient’s pain and insight. The reader will also learn about psychoanalytic work with patients who exercise ruthless and/ or sadistic violence, and how the clinicians managed their anxieties when working with these patients. I strongly recommend this honest, straightforward book about the disturbing emotional, intellectual and clinical realities encountered when working psychoanalytically with complex patients.” – Donald Campbell is a Distinguished Fellow, Training Analyst and Past President of the British Psychoanalytic Society “Clinical work is at the heart of the many-faceted creature we call psychoanalysis. Psychoanalysis is full of ideas, and ideas about psychoanalytic ideas, its meta-psychology. But again, and again its abstractions need to be earthed in the actual practice of psychoanalytic encounters between analysts and patients. It is this real, human encounter which contains, ultimately, the most moving, interesting and important dimensions of psychoanalysis, nowhere more so than when analysts are challenged by human cases which are enormously difficult to engage with and understand. Often psychoanalysis is the last chance for highly disturbed patients, which ups the ante for patient and analyst alike. Anne Zachary has, therefore, done us all an immense favour in putting together this book of expert clinical work with complex cases, a book that will inform and inspire many different types of readers – patients, analysts, psychologists, psychiatrists, all mental health workers, and those who are simply interested in psychoanalysis and the human spirit. I endorse the book whole-heartedly.” – Francis Grier, Training Analyst & Supervisor, British Psychoanalytic Society, Editor-in-Chief, The International Journal of Psychoanalysis

Clinical Psychoanalytic Case Studies with Complex Patients

Clinical Psychoanalytic Case Studies with Complex Patients is a collection of key case studies that provides a rich resource of information and inspiration for clinicians working psychoanalytically with complex and disturbed patients in a range of contexts. The book is presented in six parts, each introduced with commentary that puts the material into context. It covers a range of topics including autism, violence and perversion, psychosomatics, hysteria, dementia, psychosis and assessment of gender dysphoria. Each chapter presents either a single case study or a selection of case vignettes, examines necessary context and presents additional detail about subsequent treatment. The depth and range of the cases presented provide key insight into and detailed consideration of risk assessment, safe settings and other important preliminary issues. Clinical Psychoanalytic Case Studies with Complex Patients will be of great interest to psychoanalysts in practice and in training, psychoanalytic psychotherapists and other clinicians seeking an introduction to psychoanalytic work. Anne Zachary is a psychoanalyst and retired consultant psychiatrist in psychotherapy based in the UK. She trained in medicine and psychiatry at the Royal Free Hospital and Friern Hospital and specialised in psychotherapy at the Cassel Hospital. She was locum consultant at the Maudsley Hospital before becoming a consultant at the Portman Clinic and consulted to medium secure units and Broadmoor Hospital. She has a specialist interest in acting out behaviours and risk and a sustained interest in female sexuality. She has a private psychoanalytic practice in SW London.

The Psychoanalytic Ideas Series Editor: James Rose

Psychoanalytic Ideas is a series which bring together the best of Public Lectures and other writings given by analysts of the British Psycho-Analytical Society on important psychoanalytical subjects. The focus of this series is to communicate some of the intellectual excitement about the past, present, and future of psychoanalytic ideas. The series aims to help make these ideas accessible to an even larger group of students, scholars, and practitioners worldwide. Clinical Psychoanalytic Case Studies with Complex Patients Watching Experience at Work Edited by Anne Zachary

Clinical Psychoanalytic Case Studies with Complex Patients

Watching Experience at Work

Edited by Anne Zachary

Designed cover image: Getty | Istockexstock First published 2024 by Routledge 4 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 605 Third Avenue, New York, NY 10158 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2024 selection and editorial matter, Anne Zachary; individual chapters, the contributors The right of Anne Zachary to be identified as the author of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library ISBN: 978-1-032-06555-7 (hbk) ISBN: 978-1-032-06556-4 (pbk) ISBN: 978-1-003-20279-0 (ebk) DOI: 10.4324/9781003202790 Typeset in Times New Roman by Apex CoVantage, LLC

Contents

Disclaimer The essence of nurture Foreword List of Contributors

Clinical psychoanalytic case studies with complex patients: watching experience at work

x xi xii xvii

1

ANNE ZACHARY

PART ONE

Support9   1 ‘I’m beyond caring’: a response to the Francis Report: the failure of social systems in healthcare to adequately support nurses and nursing in the clinical care of their patients

11

MARCUS EVANS

PART TWO

Autism27   2a Affect, words and play in autistic children: discussion of Maria Rhode’s clinical case

29

LAURENT DANON-BOILEAU

  2b ‘Finding one’s feet’: body, affect and identifications in a pre-autistic toddler learning to walk MARIA RHODE

36

viii Contents

  3 Analysing Miss Daisy: a psychoanalytically informed treatment of an emerging adult autistic woman

47

ALAN SUGARMAN

PART THREE

Psychosomatics and hysteria67   4 Maternal lineage and transgenerational trauma: time and space in the psychoanalytic encounter

69

LOUISE GYLER

  5a Hysteria and mourning: a psychosomatic case

85

JONATHAN SKLAR

  5b Hysteria and mourning – A psychosomatic case: discussion of Jonathan Sklar’s chapter

98

SUSAN LODEN

PART FOUR

Psychosis103   6 Psychoanalysis, psychosis and the family

105

BRIAN MARTINDALE

PART FIVE

Identity117   7 Finding space to think: technical problems of working with a cohort of trans identified young women

119

MARCUS EVANS

  8a Dementia: prelude to Rachael Davenhill’s clinical material from elderly patients

134

MARTIN ROSSOR

  8b Dynamics of dementia RACHAEL DAVENHILL

137

Contents ix PART SIX

Perversion and violence159   9 A state of inbetweenness: the challenges of working with disavowal

161

STEPHEN BLUMENTHAL

10 Aspects of the process of child analysis

173

ANGELA JOYCE

11 Peter Rabbit was a thief: a case with a background of violence and criminality

189

ANNE ZACHARY

Index

202

Disclaimer

The patients described in this book have been appropriately disguised in various tried and tested ways in order to preserve confidentiality. They (or their parents) and in some cases an institution, may have been asked for permission to publish. Where to ask permission is seen as not helpful to a patient clinically, it is important that all the clinical material published will have been distilled through several formal stages before publication: private supervision, presentation to colleagues (many of them at the scientific meetings at the British Psychoanalytical Society) and the necessary stages of redrafting when writing. By the time of publication the therapeutic intervention is likely to have been some time ago. Anne Zachary, editor

The essence of nurture

During the 1990s the National Health Service (NHS) was massively restructured and split into a marketplace, where provider groups were made to compete for the service users. In mental health, clinicians had to adjust in a steep learning curve to the new presence of both managers and users at their NHS conferences which were usually clinical. The managers appeared young and inexperienced. The users tended to be eccentric and vociferous. This uncomfortable change began to yield creative reward. At one conference, between NHS and other forensic services, a young man who had spent time in prison was invited to be a speaker. He told his story movingly. He told how a probation officer assigned to engage him in prison visited him every morning she was in doing her rounds and said, ‘Good morning’. For two whole years he ignored her, rejected her and gained satisfaction from knowing that he made her feel uncomfortable. After two years he began to respond. Of course, this is a first stage when the clinician reaches out on the front line to the would-be patient in a mothering sort of way. The next stage is for the patient to seek out the therapist who will be available to be used for instance, as the mother to explore and to work through the inevitable deficit within the boundaries of the setting and the analyst’s internal frame. He told us that in short, he went from his contact with the probation officer into therapy, left prison and found work. This vignette has stayed with me over the years – its use of the psychoanalytic frame, its illustration of projective identification, and how it demonstrates the patience and conviction required for the work. Anne Zachary

Foreword

From early on Sigmund Freud recognised patients’ resistance to treatment, not least Dora as early as 1899. From Dora, Freud discovered the negative side of transference. He said that he should have noted that Dora saw something in him which made her suspicious. Transference and then countertransference have constantly caused difficulties in psychoanalytic treatments, but eventually they became important tools in understanding more and more subtle issues that patients bring to us. It is not an easy profession, indeed, as Janet Malcolm (1980) said, it is an impossible one. Well, perhaps not quite impossible, as the cases in this book eloquently tell us, and from which practitioners can take heart from our experiences. It has become a harder form of practice because conditions have changed over time since 140 years ago when Jozef Breuer hypnotised Anna O. Breuer and found her pained experiences in hiding in an unconscious zone in her mind, intentionally hidden behind her symptoms. Today we have conditions whereby well-established non-psychoanalytic therapies have come along over the decades which are quicker, cheaper and less demanding – of patient and of therapist. This has meant that ‘simple’ cases can be cared for more simply. The difficult cases cannot, and they tend more and more to come to the longer and more expensive psychoanalysis – if they can find the time and afford the expense. So, psychoanalysts have inevitably become the specialists in complex and difficult to treat problems. Psychoanalysts set their standards high – like doctors in physical medicine. We are not content to simply deal with symptoms, we want more. And in this, psychoanalysis resembles the medical profession more than the alternative therapies in physical medicine. Whereas homeopathy may treat symptoms, medical professionals seek the causes of symptoms, if they can. And so do psychoanalysts, not the anxiety but the cause of anxiety. But here the similarity with physical medicine stops. Whilst there is an attraction for psychoanalysts to make generalisations and allot patients to categories, or diagnoses as in physical medicine, there is a stumbling block. As every chapter here demonstrates, every person in treatment is a singular individual. And that means each of them (indeed each of us humans) has a unique configuration of our psychodynamics. We have a play of urges and feelings in a pattern unique to each one of us. Fitting us into categories misses something. It misses our individual personhood, our personality.

Foreword xiii

The approach of psychoanalysis must come as near as possible to those individual anxieties, conflicts and the psychological pain. It is an ‘experience-near’ process as we like to say. This is the fascination of caring for the human mind, way beyond that of caring for the body. It is also the source of the great complexity of the work. Well, complexity and fascination go together perhaps, even though that is not easy. This is not to say the generalising approach devoted to precise diagnostic categories has not worked miraculously for general medicine in very many fields. It is just that subjective experiencing (at both conscious and unconscious levels) does not quite fit the mould of physical medicine. A normal mind is a unique idiosyncrasy. However, by identifying ‘complex mental cases’, we are already doing some generalising, and so there may be some degree of categorisation that can be seen as useful. I would like to mention just a few possibly useful generalisations – they come from the psychodynamics, and not from the overt symptoms which can attract superficial psychiatric diagnoses in a pseudo-medical way. In his later years, Freud became somewhat pessimistic about the complex configurations, and in 1937, he referred to some patients as ‘interminable’ cases. He tended to put it down to the dark invisible force of the so-called death instinct. Today, many decades later, it has been possible slowly to open up that darkness a little, with persistent thoughtful practice. That is the point behind this sensitive book. Without pre-empting what the reader will discover, I want now to briefly reflect on those inner dynamics which express themselves as complex and difficult, and that can defeat so many simpler therapies and that then unhappily end up with psychoanalysis. Are there some general factors behind their complexity? As one worker called them many years ago, they are patients who are ‘hard to reach’. What makes them hard to reach? Or, what is the range of individual idiosyncrasies that emerges as that general category? I want here to suggest three factors which might be in play singly or in various combinations with any particular person. The first of these patterns of experience comes from the work I have done with people in the residential setting of therapeutic communities who were unable to maintain work, ordinary relations and a satisfactory life. They joined a selfmanaging community of peers – or partially self-managing. One of the most significant factors in play was the experience of help itself. It became clear it was help and care itself which was the problem giving rise to particularly intractable thwarting responses, unless it was understood. Many such people, perhaps most, have suffered some sort of abuse from people who were in the position of carer. The result was an intense suspicion of care, or maybe it was a confusion over what to expect from those who help – care or abuse. So, when helping care itself is the conflict, then it is difficult to turn easily to carers with trust. This may be easier when in a therapeutic community made up of other help-conflicted people who are themselves a significant element of the community that cares. It is not so difficult to get down to that complicating thread when a major segment of the caring community has that problem in common. Of course, not everyone who has suffered abuse when in the care of an adult or other carer will grow so suspicious of care as an adult, and some will survive with

xiv Foreword

a clearer idea of how to keep in mind the distinction between help and abuse. The implication is that there is more than one factor involved. There may of course be several factors, but an additional one is a more general experience of resenting help even if one has never been seriously abused. It does require some degree of strength of character to cope with the sense of weakness, neediness and helplessness which has to precede the acceptance of help. Such a complicating hatred of the strength that others have significantly complicates the issue of actual abuse suffered in the past, and it can set the stage for a non-progressing programme of care. Added to this is a further factor. That is the impact on those professionals offering help and care when they find themselves confused or identified with an abuser. Such professionals are also thoroughly human, and if confused with an abuser then it puts a significant strain on the capacity of a carer to continue to offer help. It is frequently a reason for professionals to pass on such complicated ‘cases’ to others as the ingratitude and even retaliatory abuse is hard to bear in the light of one’s own benign offering of help. One’s identity as a caring professional can be seriously challenged, and it is not a welcome alternative to gratitude. And sometimes in certain institutions it can call forth a retaliatory response for those who have tried to help. The second area of complexity follows on a little from the last point. There has been growing psychoanalytic awareness and discussion of the subtle ways in which so-called difficult patients present themselves and work with their professionals, including psychoanalysts. Patients end up with therapists, and certainly with analysts because they have reached a despair about themselves and their difficulties in coping with whatever their problems are. They come inevitably with a certain doubt about anyone being able to know how to manage their problems – if they feel their problems are unmanageable, then how can they believe others could help? As a result, they are almost always caught between two strategies: first, to seek help to face problems which they privately believe unmanageable, or on the other hand, to seek assistance in strengthening defensive strategies to continue to try avoiding their anxieties or conflicts. It is now recognised that some people are adept at using their relations with other people for the second of those strategies. And it can be difficult and complex to understand when someone wants psychoanalytic help however to face their own anxieties, and when someone wants help to continue defending against their own pain. It may be quite obvious with some people, but for others the two strategies may be pursued together in conflict or else in rapid alternation and complex and difficult situations unravel. Attention-seeking behaviour is for example very obviously a means of using other people to collude in drawing attention to one thing in order to avoid attention being drawn in some other direction to some other more painful aspect of themselves. Some people are very subtle at exploiting other peoples’ personalities, and that includes the personality of the analyst. Coming to frequent sessions, patients can get to know the psychoanalyst very well, just as the psychoanalyst gets to know their patient. And subtle interactions can slip the psychoanalyst into a role that does not strictly speaking conform to psychoanalytic work. The analyst may be induced to be reassuring, or to become an external super-ego-ish figure much more easily

Foreword xv

dismissed because they are external, and so on. It is often hard for the psychoanalyst to take stock of what pressures they are under all the time. These methods of recruiting the personality of the psychoanalyst are part of the complex difficulties. It requires considerable experience and the assistance of good supervision to bring to the fore these kinds of interactions at the unconscious level. And the third complexity which may be the hardest, and of which I have less experience is the more serious disturbances arising from the inability to grant that there is a sentient mind in other people. Such autistic indifference towards others is not uncommon. It is however usually transient in most of us, or directed to distant and unknown peoples. But some people live in a major and permanent indifference as if unable ever to see the person in other people. Called autism, it is, one can say, never complete, and though I  have only relatively small amounts of experience of an observational kind with children in this autistic state of mind, it did seem as though there are moments of transient connection with others. I cannot say more about this for my own lack of experience. But the inspiring examples in this book make for a fascination for what can be achieved. I have suggested three factors that in various proportions and degrees may come together to produce a complex ‘case’. Perhaps it will be of interest to the reader to consider these pieces of work in the book and to assess how relevant my own observations have been, and indeed what I have not observed. Whatever the value of my reflections here, this book is important just by its very message to recognise the complexity of many of the people we see. But, they are perhaps only a degree more fascinatingly mystifying than the complexity of the average human being that we are. However, to all readers, even those experienced psychoanalysts, please note in these cases the meticulous movement towards listening in to the unspoken experiences of the patients, and the equally meticulous work of understanding meanings in those experiences. Often it may not be the correct meaning at first, but the goingon-finding the right meaning in the smallest detail is the inspiration of the work in this book. For the reader it is more engaging perhaps than for the suffering patient, although of course more relieving for the latter in the long run. Returning to my point about generalisations, maybe it is for the reader to examine this goldmine of examples to consider if there are common threads, general factors in these cases. Are there some generalities of experiencing and relating that bring together the very varied kinds of people in these case examples? It is worth psychoanalysts noting that over the last decades academic psychology has been pioneering single case studies – although they tend to be concerned with behavioural parameters, even if not measurable (Krasney-Pacini and Evans 2018; Morley 2018). Such non-parametric methods could be developed for subjectivity studies, not least single psychoanalytic cases. After all, the Dora case we started with was a single case study that gave Freud sufficient data in the given circumstances to make a major and lasting development to his clinical theories (see also Hinshelwood 2013). Bob Hinshelwood December  2021

xvi Foreword

References Hinshelwood, R.D. (2013) Subjectivity, Single Case Studies and Psychoanalytic Knowledge. London: Routledge. Krasney-Pacini, A. and Evans, J. (2018) Single-case experimental designs to assess intervention effectiveness in rehabilitation: A practical guide. Annals of Physical and Rehabilitation Medicine 61: 164–179. Malcolm, J. (1980) Psychoanalysis: The Impossible Profession. New York: Knopf. Morley, S. (2018) Single Case Methods in Clinical Psychology. London: Routledge.

Contributors

All of the following are published authors, many of them having written and edited books themselves. Many of them have devoted years of service in the National Health Service and still practise psychoanalysis and psychotherapy in the private sector as well as continuing to write. Stephen Blumenthal (UK) is a psychoanalyst (British Psychoanalytical Society) and clinical psychologist, consultant at the Portman Clinic (National Health Service). His interests include Acting Out, sexual and violent and Risk. Laurent Danon-Boileau (France) is an honorary professor in general linguistics and language acquisition at Paris Sorbonne University and a training analyst at Société Psychanalytique de Paris. His specialist interests are in autism and congenital aphasia. Rachael Davenhill (UK) is a retired psychoanalyst (British Psychoanalytical Society) and consultant clinical psychologist. She ran the Old Age Unit in the Adult Department at the Tavistock Clinic (National Health Service). Following this she was a director of Age Matters, an independent clinical, consultation and training service. Marcus Evans (UK) is a psychoanalyst (British Psychoanalytical Society) and retired consultant psychotherapist and mental health nurse. He was head of the nursing discipline at the Tavistock & Portman NHS Trust. Louise Gyler (Australia) is a child and adult training analyst and president of the Australian Psychoanalytical Society, a guest member of the British Psychoanalytical Society and a visiting professor at the Chinese American Continual Training Program at Wuhan Hospital for Psychotherapy. She chairs the programme committee for IPA Asia-Pacific Conference 2023 (India). Bob Hinshelwood (UK) is a psychoanalyst (British Psychoanalytical Society) and a psychiatrist. He worked part-time in the National Health Service as a consultant psychotherapist including in the role of clinical director of the Cassel Hospital. He is a professor emeritus in the Centre for Psychoanalytic Studies at the University of Essex. He has written widely on psychoanalysis, including A

xviii Contributors

Dictionary of Kleinian Thought (1991) and Clinical Klein (1993), as well as the application of psychoanalytic thinking to organisations and institutions. Angela Joyce (UK) is a training and supervising psychoanalyst and child psychoanalyst (British Psychoanalytical Society). She was a founding member of the pioneering Parent-Infant Project at the Anna Freud Centre applying psychoanalysis to working with babies and their families and jointly led the child psychotherapy service. She is currently Chair of the Curriculum Committee at the BPAS and Chair of the Winnicott Trust. Susan Loden (UK) is a training and supervising analyst (British Psychoanalytical Society). She has taught Freud reading seminars and Classical Freudian Psychoanalysis at the Institute of Psychoanalysis in London and was formerly Chair of Curriculum. She is especially interested in theory as it was developed by Freud’s followers after the introduction of the structural model of the mind and the link between theory and clinical practice. Brian Martindale (UK) is a retired National Health Service psychiatrist and psychoanalyst (British Psychoanalytical Society), past chair of the International Society for Psychological and Social Approaches to Psychosis (ISPS) and founding editor of the ISPS book series. He co-founded the European Federation of Psychoanalytic Psychotherapy and has represented the Western European Zone to the World Psychiatric Association. He worked for some years (in London, then in Newcastle-upon-Tyne) in early intervention in psychosis. Maria Rhode (UK) is a child psychotherapist and member of the Association of Child Psychotherapists, a clinical associate of the British Psychoanalytical Society, and an emeritus professor of child psychotherapy at the Tavistock Clinic (National Health Service), where she was formerly a co-convener of the Autism Workshop. She has a particular interest in childhood autism and psychosis, in language development and in infant observation. James Rose (UK) is a psychoanalyst (British Psychoanalytical Society), previously a research fellow, Tavistock Institute of Human Relations, and behavioural scientist and central training manager, responsible for all staff training activities in the former Greater London Council (GLC). Martin Rossor (UK) is a professor emeritus and a principal research associate at University College, London, Queen Square Institute of Neurology. Martin undertook primary research on the neurochemistry of degenerative dementia at the Medical Research Council Neurochemical Pharmacology Unit, Cambridge, before being appointed as Consultant Neurologist at St. Mary’s Hospital London and the National Hospital (National Health Service). He was appointed as national Director of Dementia Research at the National Institute of Health Research to help co-ordinate and deliver the UK Department of Health and Social Care’s research response to commitments under the Dementia Challenge and the G8 Dementia Summit.

Contributors xix

Jonathan Sklar (UK) is an independent training psychoanalyst of the British Psychoanalytical Society and a retired psychiatrist, trained at Friern Hospital and in adult psychotherapy at the Tavistock Clinic, then consultant psychotherapist and head of the psychotherapy department in Addenbrooke’s Hospital, Cambridge (National Health Service). In South Africa he developed a ten-year analytic conference with Mark Solms and taught termly in Chicago for ten years until 2018 as well as regularly in Eastern Europe. From 2007 to 2011, he was Vice President of the Fédération Européene Psychanalysé with special responsibility for seminars for recently qualified analysts as well as new analytic groups in Eastern Europe. He was a board member of the International Psychoanalytic Association in 2015–2019 and is Chair of the Independent Psychoanalytic Trust. Alan Sugarman (US) is a training and supervising psychoanalyst and child and adolescent supervising psychoanalyst at the San Diego Psychoanalytic Center. he is also a clinical professor of psychiatry, University of California, San Diego. He maintains a private practice of child and adult psychoanalysis in Solana Beach, California. His primary interest is in applying psychoanalytic developmental theory to pathogenesis and mutative action. Anne Zachary (UK) is a psychoanalyst (British Psychoanalytical Society) and retired consultant psychiatrist in psychotherapy. Trained in medicine and psychiatry at the Royal Free Hospital and Friern, she specialised in psychotherapy at the Cassel Hospital, also training then as a psychoanalyst. She was a locum consultant at the Maudsley Hospital before becoming a consultant at the Portman Clinic. She consulted also to medium secure units and Broadmoor Hospital (National Health Service). She has a specialist interest in Acting Out behaviours and Risk and a sustained interest in female sexuality. She has a private psychoanalytic practice in SW London.

Clinical psychoanalytic case studies with complex patients Watching experience at work

Introduction This Collection came about after my paper, which is included at the end in Chapter 11, was presented at a scientific meeting of the British Psychoanalytical Society at the Institute of Psychoanalysis in February  2020. (At that point we were not quite ready to accept it, but we would shortly be in complete lockdown along with the rest of the world, something which still threatens. Covid-19 has claimed many lives and changed all our lives in a pandemic, of the kind that happens about every 100 years. The last major one was the Spanish flu, 1919.) A colleague James Rose heard the presentation and as editor of the series called Psychoanalytic ideas, asked me what I thought of putting together a book of complex clinical cases which would effectively act as a teaching aid. These cases would all have been treated by experienced and highly trained psychoanalysts. As lockdown set in, I found that people I asked to contribute, whom I thought would be looking for something to do, were too shocked and preoccupied and not in a frame of mind at that stage to think of finding space for writing. It led on to a search through the annals of the scientific meetings to collect other papers which had been presented there previously and so followed a rough format, also distilled down in regards to confidentiality and possible publication. Maybe there were original papers put away in drawers and not yet offered for publication. (Everyone seemed to feel the need to tidy their houses and belongings during lockdown.) This turned out to be the situation with a number of papers (Davenhill on dementia, Martindale on psychosis); while versions of others had been published in journals (Joyce on violence in child therapy, Rhode on autism with a previously unpublished discussion by Laurent Danon-Boileau); in other edited books (Evans in Armstrong & Rustin, Social defences against anxiety, 2015); or in personal collections (Sklar on psychosomatics with a previously unpublished discussion on tics by Susan Loden). To make the content more international, two writers were invited to contribute, Alan Sugarman from California and Louise Gyler from Melbourne. Louise is a regular visitor to the institute. Marcus Evans’ chapter on gender is newly written as is Stephen Blumenthal’s paper on disavowal. Since Stephen won

DOI: 10.4324/9781003202790-1

2  Anne Zachary

the Estela Welldon Prize in 2021 his work will be published concurrently in the International Journal of Forensic Psychotherapy.1 This book begins with a vignette describing how difficult and lengthy the process can be to engage someone with complex difficulties at a level where they can actually become a patient. A  compassionate and conscientious probation officer had visited a man in prison for two years as she passed by on her regular rounds, until one day he responded to her. He tells his own story in the vignette. Bob Hinshelwood, a familiar figure to present work at the scientific meetings, is known for his research in the field of psychoanalysis and his belief in the value of the clinical case study in this respect. It is very appropriate and a privilege that he agreed to write the Foreword to this book. First, there is a caution about what is often known as ‘burnout’. (Marcus Evans’ paper on the Francis Report has been published before, but an edited version appears here serving to remind health workers that a tragedy like the one that occurred in Stafford Hospital and led to the Francis Report (2013), even so can be repeated. Take the newborn baby tragedy at Telford Hospital (2020) as a sinister example. Psychoanalytic theory and technique applied to teams of health workers offer major advantages for staff well-being and so lower the risk of the cruel, defensive and mindless practices that take hold when burnout threatens. Regular reflective practice, supervision, clinical and theoretical seminars are all widely used now in institutional work. These patients are not to be taken on lightly in intensive therapy, however fascinating they might be. Serious criteria must be considered: timing, not before the court process is complete; not until any targeted victim is no longer at risk and the would-be patient, stable; due attention to the level of risk to themselves the patient, or the practitioner or others; the appropriate setting for maximum safety. Sometimes it is essential to have a receptionist, a director or other colleagues listening out for unrest. Private and isolated consulting rooms are not usually the place, though in Chapter 11 I mention Mr C, with an equivalent history of violence and crime to Mr B, whose case in the National Health Service (NHS) described in detail. Mr C, who had lots of therapy already, years later worked with me in the private sector. In my opinion and using clinical judgement, given my experience with Mr B in the NHS and Mr C’s greater maturity, it was safe enough if not at times, on the edge, to work with him ‘at home’. I realise that these preliminary comments apply most to the forensic patients in my experience and the book might have only contained these. Except that ten years into retirement from the NHS, having worked at an interface with the law, I feel personally out of date and too far distanced from colleagues to stay so specialised. These are patients of mixed diagnosis, all complex in different ways, and in some examples the criteria will apply to them too. Angela Joyce’s violent child patient elicits the most severe negative countertransference among the patient selection. Diagnosis is not the mainstay of psychoanalytic work, but echoing Joyce McDougall, her ‘Plea for a measure of abnormality’ (1988) and turning it in the opposite direction, I decided to structure the book with a plea ‘for a measure of diagnosis’,

Clinical psychoanalytic case studies with complex patients 3

according to fairly loose diagnostic parameters with which not all will agree. It felt important to add some boundaries where there might have been none. The way a patient is made to feel safe within the psychoanalytic setting and frame is most valuable with the complex patient. Each of the 11 chapters detail sensitive and creative clinical work with a single patient, child or adult, institutional or private. They radiate and sing from the page with colour and rich texture and make excellent short stories in the different fields of speciality. I hope the reader will feel they are watching the work, that the clinical material creates mental pictures. What brings all this diversity of topics and dynamics together in the book is a clinical method, psychoanalytic technique, the practitioner having to experience treatment before being seen to be adequately trained to treat patients. Whether it is pure (five times a week) or adapted (once a week in the NHS) or even without any personal therapy at all but attention to the staff needs and tensions in what is currently called ‘reflective practice’, the underlying model is the same. For the patient or the staff, same time, same place, same therapist or group leader, ongoing long term or at least for a decent enough length of time (six months in NHS, it used to be more, at least two years in private practice), the atmosphere with each patient has to be tested. Will the initial idea of six months terrify them, better to go week by week? Is it better to say in practice that a month’s notice will be required (another of the relatively few baseline contractual agreements together with time and place)? If the setting as it is called is in place in this way, then the only demand from the patient is to say whatever comes into their mind during the session. It has to be verbal and not acted out which is particularly important with perversion and violence for instance. Children are different, they roll around on the floor or draw and paint, or splash water, skilfully contained by the focused eye of the therapist. This technique is the exact opposite in aim to other methods of treatment. Cognitive behavioural therapy (CBT) aims to define a symptom and then to work systematically focused on the symptom to reduce and hopefully cure it. (An underlying depression may emerge, and the patient may move on to psychoanalytic treatment.) Drugs also aim to cure or at least block out the symptom. Sometimes a patient in analytic treatment may also require drugs. But in the usual treatment within the psychoanalytic model, the patient says what is in their mind, the more trivial may be the more significant. The symptom will be explored indirectly until it might disappear or at least be adapted, in a shift in the patient’s internal world. In perversion and the forensic world, the dilemma is that ‘Stop it’ really does not work and psychoanalytic treatment takes a long time. The patients in the book are all ‘complex’ and ‘difficult’. This might apply to other agencies having to be involved like the law in the forensic world. Or it might apply to the seriousness of the mental health issue, for example, psychosis, perhaps necessitating being an inpatient in hospital. (Brian Martindale advocates family work at home.) Children have parents who need to be involved, often undergoing actual parent work alongside their child’s therapy. Patients with organic problems

4  Anne Zachary

like dementia depend on the staff for their welfare. Care staff and nurses looking after the elderly are perhaps the most in need of psychological and emotional support, hence the importance of starting the book with a reminder about the Francis Report into what went wrong at Stafford Hospital (2012), only one of the distressingly regular breakdowns in institutional care. Within psychoanalytic theory there are different theories, and the authors write about the ones they prize in their work. Some of the patients will have found their way to therapy by choice. Some might feel dragged ‘kicking and screaming’, terrified. ‘Difficult’ can be thought of in psychiatric terms, the ‘flat’ schizophrenic patient, or the noisy, disruptive personality disordered patient (Hinshelwood 1999), both difficult patients to engage. ‘The patient who is hard to reach’ is the title of a psychoanalytic paper by Betty Joseph (1975). It refers to patients illustrated by Bob Hinshelwood in his Foreword. These patients are often sophisticated professionals, terrified to look at their weaknesses deep down rather than at overtly ill people. They may be working in the field and so confidentiality is a huge issue in publishing clinical material. Diverse in their psychopathology there is no real emotional understanding, and there is splitting in their personality so that one part of the ego is kept from the analyst and the potential analytic work about needs and anxiety. Joseph advises the analyst to concentrate on process rather than content. The analysis becomes a guessing game rather than freely associative and can have a pseudo feel about it. Joseph describes a patient who had night blindness interpreting this as his difficulty in allowing interpretation to lead to insight. He chose twisted carrots for food. Her interpretations were taken in and twisted. Her second patient is a woman who talks about a slippery fish, synonymous with a twisted carrot. She touches on projective identification and perversion, both illustrated in various chapters of this book. Joseph ends with a plea to remain with events immediate to the session and not in the past or outside, to avoid a pseudo transference. As I have already begun to explain, regarding the contents of this book, the cases are listed under diagnostic categories. Bob Hinshelwood says in his Foreword that in psychoanalysis diagnosis is an understated thing, the uniqueness of the individual taking precedence. Neurosis, psychosis and perversion warrant an attempt at distinction, and organic factors are an important added or causative reality, but the sections of the book are somewhat arbitrary and listed so. But I resisted the urge to put them in alphabetical order, one simple move which would have ironically placed ‘organic’ before many of the more psychological diagnoses. Where there are discussions, though these took place after the case presentations at scientific meetings, I  have chosen where necessary (autism, dementia) to put them first if they contain useful, up-to-date information about a subject with which readers of this book may be unfamiliar or unaware. The discussion of tics is left in place since it is the writer’s personal impression of the clinical paper, a prime example of potential disagreement about probable mixed diagnoses. The writer describes his case as psychosomatic with periods of psychosis, while the discussant takes up the observation that the patient has a ‘tic’, an organic problem. This leads to a rare summary of the thinking about ‘tics’.

Clinical psychoanalytic case studies with complex patients 5

This book is offered as a teaching aid but without wanting to discourage the enthusiasm of youth, it comes with a grim word of caution. While working long years myself at the outpatient Portman Clinic which specialises in perversion, violence and delinquency (in the community, prior to, after or instead of more secure, custodial care), it was not an uncommon experience to receive a particular kind of phone call, usually on a Friday evening. The week was over, the cases hopefully contained by the institution, the director informed if necessary; Kew Bridge had been crossed, it was the weekend. The call would usually be from a woman, scared out of her wits, wanting to discuss a patient. It would be the kind of patient I would know about (on the other side of the bridge), a Portman-type patient, risk level high, not in any way processed for safety in outpatient treatment, a private patient, possibly of a trainee. Their wish/expectation would be obvious, that I would see the patient privately and urgently (that night or on Saturday morning?). The discussion would instead be about the GP or the police, perhaps about a consultation for the therapist with me or a colleague the following week, and why was that patient being seen in that unsatisfactory setting by that inexperienced clinician (put in terms of ‘I wouldn’t want them coming to my house’). Perhaps an elective referral into the public services could be arranged. Not that trainees don’t sometimes hold sensitive and complex patients in treatment with good solid supervision all the time, but this might be an unprotected, unsupported, not yet trained, ambitious clinician perhaps desperate to build up a practice, perhaps to help pay for training, perhaps seduced by the excitement of ‘forensics’. How to convey this without seeming unhelpful, superior, withholding, disdainful? The countertransference was after all about the children’s bath time now that the consulting room at home (for more containable patients) was closed for the weekend. My aim would be to convey that just as they felt scared, so would I, to invite such a patient into my house, such that I would not do that and not even now, to help them out of a spot. It was a hard message and in the end it would be my hope that compassion was conveyed in the ill-timed discussion. (Someone now well trained asked me recently if I remembered saying this to her years ago and how much it had helped!) Confidentiality when publishing clinical material is an important issue and often a headache. Remarkably, when arranging the content of this book, it seemed not to be so much of a problem as I expected. In fact, only one potential author raised it at the time of asking. (Another developed misgivings while preparing the chapter, worried about the parents recognising a child, but this was attended to in the disguising.) Perhaps anxiety was not more prominent because most of the cases had been well distilled beforehand, particularly because they had been presented at scientific meetings at the Institute of Psychoanalysis, the main source of the content of this book. Authors may have had the permission of the patient, conflated two or three different patients, disguised the material, or allowed due time to pass, all the usual ways of maintaining confidentiality. It was not something that became an editorial problem. But a major disappointment occurred in the reluctant withdrawal of a paper initially offered by Matthew Patrick. On reflection he felt that his patient material was too sensitive for publication, and his beautiful, stylishly written paper,

6  Anne Zachary

‘And when I love thee not, chaos is come again’,2 was not available. It serves to illustrate that the patient’s interest is the main concern and taken very seriously. My own chapter, ‘A case with a background of violence and criminality: Peter Rabbit was a thief’, has an unusual history regarding confidentiality. Towards the end of his treatment, Mr B was reflecting on the journey he had come through and asked me if I was planning to write it up for publication. I used this opportunity to establish permission. He then turned it into a light-hearted competition about who would make the most money because he intended to ask his clever daughter to help him write it up himself. Also, who would do it first? Would we tell the same story? The race was on. Somehow it takes ten years or so to go back to this kind of work which I am doing now after a little more than ten years’ retirement from NHS work. I am not aware of Mr B’s début, but there are plenty of others, for example, Michael Maisey’s book Young offender: my life from armed robber to local hero (2019). He is now a successful actor. Mr B had also been an armed robber in his youth, but if he did write such a book, in reality it would not be paired with mine publicly unless by him because mine contains disguise and could never include his name. A search from the clinic to find him ten years on to check on his wishes failed, so in faith and with permission from the clinic I have simply carried out my side of the bargain. Lastly, a word about knives. I decided to submit my paper on Mr B to the scientific committee when I did because the London Evening Standard ran an article on the rise in knife crime in London to a new high. (October 2019) This has been a problem for years among young adults, commonly dated from the attack on Stephen Lawrence (1993) and his parents, especially his mother’s untiring efforts to raise the profile of the problem. It is seen recently as a public health problem which spreads like an epidemic. This has had some impact on its prevalence (in Glasgow for instance). The article was reporting a new NHS project in the East End of London where affected families were to be offered therapy for five months to address the issue of knives. I was reminded of Mr B who had carried a knife after he gave up crime long before I met him and continued to carry one in his car until about halfway through his six years of twice-a-week therapy. It had led to his more recent index offence when he got a conviction for grievous bodily harm, having nicked the neck of a youth with his knife and then to his referral to the clinic. I don’t think he ever brought a knife into the clinic, I didn’t know about the one in the car for some time after I began to get to know him. He was definitely a patient who needed to be seen in an institution even though his criminal career had ended about ten years before and the recent offence had been more of an accident while protecting his family from disturbance in the street. Then it was to be another ten years before I  was ready to write him up formally. In May  2022, there was an international forensic psychotherapy conference in London organised by the International Association of Forensic Psychotherapy, lifetime president Estela Welldon and recent chair Carine Minne (IPA representative responsible for work on violence) focussing on violence as a public health emergency.

Clinical psychoanalytic case studies with complex patients 7

This book contains fascinating but heavy responsibilities. It sets out to convey good practice and creative development not only in the forensic sector but across the board of specialities. This is achieved by good training and collegiate practice even among sole practitioners. Anne Zachary June 2023 Notes 1 Psychoanalytic treatment, traditionally five times a week, is only a part of psychoanalysis, an ideology of theories, initiated by Sigmund Freud over a century ago. Psychoanalytic ideas can help to understand the world. Applications include child development, social behaviour, politics, climatology and prevention of nuclear war. Clinical treatment is widely applied in different settings in varying intensity. Numerous eminent psychoanalysts, e.g. Klein, Winnicott, are referenced in this book. All the clinicians in the chapters are psychoanalysts who each describe the setting and intensity of the work presented. Some are using applied psychoanalytic ideas to offer patients once a week treatment, e.g. in the National Health Service (NHS). Here, money is limited and twice a week treatment or psychotherapy is considered intensive. NHS consultants in this field are often trained psychoanalysts. Accredited, specialist psychotherapy training is expected in their teams. Some of the chapters, particularly Chapter 1 (Marcus Evans), focus on staff support, now called ‘reflective practice’. 2 Permission to publish the title was obtained.

References Ockenden D. (chair). (2020). Ockenden Review of Maternity Services at Shrewsbury and Telford Hospital NHS Trust. London, UK: Department Health & Social Care. Francis R. (chair). (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, Executive Summary. Chaired by Robert Francis QC. London, UK: Department of Health & Social Care. Hinshelwood, R. (1999). The difficult patient. British Journal Psychiatry, vol. 174, no. 3, pp. 187–190. Maisey, M. (2019). Young Offender: My Life from Armed Robber to Local Hero. London, UK: Pan. McDougall, J. (1988). Plea for a Measure of Abnormality. London, UK: Routledge.

Part one

Support

Editor’s commentary This book is quite loosely arranged regarding diagnosis. It could have been organised in various other ways, and cross-referencing brings up different links between the chapters. For instance, there are other cases of treating children as well as Maria Rhode’s little girl learning to walk in Chapter  2, eg Louise Gyler’s 12-year-old girl who can’t walk in Chapter 4 and Angela Joyce’s violent prepubertal girl in Chapter 10. Or, with Angela’s case in mind, there could have been a section on countertransference, how that child stimulates the strongest negative countertransference the therapist has ever had to deal with and contain within herself, including her adult patients. Add to this Stephen Blumenthal’s male adult patient (Chapter 9) in disavowal of his real makeup. Then the stirring up universally caused in gender issues (Chapter 7). Or more traditionally, there could have been sections separately entitled Psychosis (Chapter 6), Neurosis and Perversion. Instead, I have chosen to group each case according to the main theme of the clinical work. The book begins with a chapter by Marcus Evans on the necessity to offer psychological support to clinicians.

DOI: 10.4324/9781003202790-2

Chapter 1

‘I’m beyond caring’ 1 A response to the Francis Report: the failure of social systems in healthcare to adequately support nurses and nursing in the clinical care of their patients Marcus Evans

Introduction The Francis Report (2013) outlined the way a group of staff had systemically become detached, cruel and disengaged from their responsibilities. The report highlighted the lack of compassion from nursing staff for their patients. Since then there has been a cacophony of cries for compassionate treatment, courses in compassion and even compassion therapy. I find myself wondering what has gone so wrong that a high court judge has to write a report emphasising the need for compassion in nursing when this should be taken as a given. In my role as a clinician, teacher, manager and supervisor of nurses and other clinical staff at the Tavistock and Portman National Health Service (NHS) Foundation Trust for 20 years, I was able to observe the quality of clinical engagement demonstrated across a wide range of NHS settings. I believe this also put me in a position to assess the relationship between standards of care, the quality of training, staff morale, and the management and support of front-line clinical staff. In this chapter I describe a fragmented management system that fails to authorise and support clinical staff. The target culture and NHS Trusts’ anxieties about survival have created a top-down management system that pushes anxieties about survival down the hierarchy into front-line clinical staff. This persecutory environment can undermine the thoughtful relationship between management and clinical staff necessary for good clinical care to thrive. Although there have been many attempts to bridge the gap between theory and practice, many nurses continue to leave training with deficits in their practical knowledge or experience of what it is to be a nurse. These problems have been compounded by problems in the way nurses are selected and trained. Training still emphasises the importance of the nurse’s theoretical knowledge at the expense of learning through experience. In his letter to the secretary of state, Lord Francis says: Building on the report of the first inquiry, the story it tells is first and foremost of appalling suffering of many patients. This was primarily caused by a serious DOI: 10.4324/9781003202790-3

12  Marcus Evans

failure on the part of a provider Trust Board. It did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the Trust’s attention. (Francis 2013). Proper healthcare has to go beyond the physical care of the patient. Crucially, it has to help the patients and their relatives manage the profound anxieties associated with illness, dependency, death and psychological disturbance. In order to provide appropriate care for their patients, staff need to feel they are supported and valued by a management structure that understands the nature of their work. They also need clinical and managerial structures that help them contain the inevitable anxieties inherent in their work. Unfortunately, this has not been the case in parts of the NHS; consequently, morale is low in many areas. There will have been specific issues and conditions in Mid Staffs NHS Trust, which are important to understand. However, many of us in the nursing profession had been concerned about the direction of travel for some time. If Mid Staffs is treated as an isolated problem, requiring special explanation, rather than an episode that reveals a chronic systemic crisis in the nursing profession, then a vital opportunity for learning will be lost.2 In this chapter, I  outline some theory that I  have found useful when thinking about clinical care and clinical institutions, before examining some of the features that went wrong. I focus on the fragmentation of the authority and support for staff in front-line clinical posts and problems in training that leave nurses without a sufficiently robust professional identity. The therapeutic setting Klein described the healthy infant’s dependence upon the mother for sustenance, care and love in order to support the development of a strong ego and sense of self. When the infant feels safe it feels it is in the presence of a ‘good’ loving mother and has loving feelings towards her. The ‘good’ mother is internalised by the infant in a loving way and forms the basis of the infant’s ego. However, when the infant feels anxious in pain or neglected, it feels it is in the presence of a ‘bad’ threatening mother who fails to provide protection and care. Aggressive feelings towards this uncaring ‘bad’ figure then further threaten the infant’s ego and sense of security. In order to protect the ego and any residual good feeling, the infant projects these aggressive feelings towards the ‘bad’ mother out into the external world. These aggressive feelings are then felt to reside outside the object in the external world and are always threatening to return. Klein described this as the paranoid-schizoid position, and its psychic defences are based on primitive mental mechanisms such as splitting, projection, denial and idealisation (Klein 1935). Over time the infant begins to lessen the split between the ‘good’ mother it loves and the ‘bad’ mother it hates. Indeed, the infant starts to recognise that its aggressive and loving feelings are both directed towards the same mother. This causes feelings of depression and

‘I’m beyond caring’ 13

guilt as the infant is faced with the anxiety of realising that it may have aggressive impulses towards the same mother it depends upon for sustenance and life. Good objects that have been attacked or damaged form part of the internal world. Klein called this state of mind the depressive position, and it may lead some people to pursue an adult career based on reparation, such as nursing or medicine. Klein (1940) also recognised that guilt and depression can lead to a regression into a manic state of mind in which the infant tries to deny its dependence upon the object by denigrating it and employing mechanisms of triumph. Bion (1962) described the infant’s dependence upon the mother for the infant’s emotional, psychological and physical development. He outlined the way the infant’s ego is overwhelmed by raw psychic experiences that are unavailable for thought. Bion outlined the way the infant evacuates and communicates these raw experiences through noises, looks and bodily movements. The mother takes in these raw experiences before using her capacity to empathise and think about the infant’s state of mind. Bion described this as the mother’s capacity for reverie. In order for this process to work, the mother needs to be able to be affected by the communication without being overwhelmed. Thus, the mother’s ability to ‘contain’ the infant’s raw emotions helps turn raw emotional experience into food for thought. In addition to taking in the communication, the infant feels that it is being cared for by a figure that understands its feelings. Implicit in the role of the nurse’s relationship with the patient is the capacity to empathise and contain the patient’s suffering. This involves a process of taking in the patient’s states of mind and projections through observations and contact with the patient’s emotional and physical state (Fabricius 1991). Using the nurse’s own internal experience of suffering and anxieties about illness and damage, the nurse forms an identification with the patient. The nurse conveys understanding of the patient’s anxiety and pain through a compassionate and thoughtful attitude. This is conveyed by the nurse’s manner and in carrying out these clinical tasks. Thus, the nurse contains the patient’s emotional states in the same way as Bion described the mother does for her baby. Segal (1957, 1991) also built on these ideas by describing the difference between a symbolic representation and a symbolic equation. In the case of a symbolic representation, there is an acknowledgement of the difference between the symbol and the object being symbolised. However, in the case of a symbolic equation, there is no differentiation between the object and symbol. In a symbolic equation, there is a complete identity between the object and the symbol. This gives rise to what we mean by concrete thinking – using words as if they were the thing itself. Thus, in a symbolic equation the statement ‘give me a minute’ is literally interpreted as 60 seconds rather than the meaning of the symbolic representation of the idea ‘give me some time’. In order to maintain the difference between a symbolic equation and symbolic representation, the subject needs to be supported in establishing a psychic separation from the concrete object. The capacity to move between empathic identification for the patient’s suffering and objective professionalism is essential in maintaining a mature and healthy

14  Marcus Evans

clinical approach. When things are going well, this identification with the patient is based on the patient being a symbolic representative of the nurse’s own damaged objects but not wholly identified with them in a concrete way. A separation ‘is maintained between the patient’s state of mind and damaged figures from the nurse’s internal world’ (Segal 1957). However, this process requires the nurse to take in and ‘contain’ the patient’s pain, vulnerability and anxiety without being overwhelmed, leading to the danger of an unbalanced symbolic equation in which the nurse can no longer distinguish their own internal damaged objects from the patient the nurse is nursing. In order to develop and maintain a balanced approach, nursing staff need settings and structures that help them digest the anxieties and pain involved in their work. Support needs to be provided through clinical discussion, reflective practice and good management. On the one hand these opportunities can help the nurse separate from the effect of the patient and restore an objective clinical approach, while on the other hand staff who have become hardened are helped to reflect more on the emotional impact of the clinical contact. These organisational reflective structures act like Bion’s maternal reverie and support the nurse through a containment process followed by separation and thought. Thus, reflective practice helps the nurse maintain the difference between the patient as a symbolic representation of the nurse’s own damaged figures and a concrete equation with them. When the nurse loses the capacity to separate their personal anxieties, thus forming a symbolic equation in which the patient becomes concretely identified with the nurse’s own damaged objects, confusion arises. This confusion of the internal world with the external world can either lead to manic and/or heroic attempts on behalf of the nurse to cure the patient or the nurse becomes defeated by the impossibility of their task. The nurse may develop a hard external skin that gives the impression of cruel indifference to keep the patient and the patient’s difficulties at a distance. Time and resources for reflection on the clinical work should not be seen as a luxury but rather an essential part of good clinical (and nursing) practice. Well-led and well-managed teams use these structures as opportunities to examine and think about their clinical practice. Britton (1989) describes the importance of the Oedipal situation in supporting thought and the development of symbolic thinking. He emphasised the importance of the third object (psychically the father) in supporting the mother-infant couple while also providing room for separation and thought. The triangular situation provides a structure for thinking and helps prevent the collapse into concrete thinking or enactments. Teams that treat patients whose clinical condition is accompanied by disturbing psychological states of mind often need the help of an external supervisor. For example, patients in mental health settings with a diagnosis of borderline personality disorder often get under the skin of staff while those with a diagnosis of antisocial personality disorder can induce sadistic responses from staff. These patient groups can have a profound impact upon staff that can undermine the team’s capacity to contain patients. Clinical supervision, run by an external supervisor, who acts as a third object in the way described by Britton, can help to restore the container.

‘I’m beyond caring’ 15

By acting as the third point in the nurse-patient supervisor triangle, the supervisor can provide an appropriate space for thinking about the psychological impact of the work and reduce the pull toward re-enactments (Evans 2011). Leadership and institutional support The nurse-patient relationship takes place within a clinical team structure, which can help to contain the anxieties inherent in clinical work. The team contains individuals’ work with patients by providing a clear structure that supports this task. Good leadership is essential in any well-run team as the leader is responsible for establishing an environment where high-quality clinical care can take place. This leadership provides teams with clear lines of accountability, realistic goals, effective communication, high standards in relation to recruitment of staff, appropriate training, adequate staffing levels and good relationships with ancillary support. The team’s capacity to provide good care is also affected by many factors outside the ward or team, including the quality of managerial support and containment provided by senior clinical managers external to them. Teams need senior clinical managers who are engaged in helping them to resolve the conflicts and dilemmas involved in managing difficult clinical issues. Senior clinical managers also need to help clinical managers to review staff performance and issues concerning recruitment and development. Once again the senior clinical manager can act as a ‘third object’ that helps the ward manager restore their capacity to contain the clinical area. A study from history Menzies Lyth was invited into Kings College Hospital in order to examine a problem in relation to the allocation of trainees within the hospital. She looked upon the problem as a symptom of underlying difficulties within the institution, which she began to explore. At the time of the study (1959), the matron was ultimately responsible for running the hospital as a clinical service. She had extensive authority over all clinical matters, from standards of care to cleaning, catering, laundry supplies etc. This kind of authority was also reflected throughout the hospital, so the charge nurse/ward sister was responsible for all aspects of ward life, including who came into the ward and with what purpose. Matron (and the nursing officers who supported her) would ‘walk the wards’ on a daily basis. This maintained a personal and ongoing link between the wider hospital management system and each individual clinical area. Ward sisters/charge nurses were able to talk to senior nursing management and keep them in touch with the clinical situation on the ward. The managerial relationship was designed to address ongoing problems as well as to help with handling immediate crises. The hospital’s matron was also responsible for the school of nursing and embodied the organic relationship between clinical practice and training. Although this system had many positive attributes, there were also negative aspects, which undermined the benefits of this integrated system. In her paper

16  Marcus Evans

Menzies Lyth outlined the way the system encouraged an over-reliance on nursing officers and matron to make decisions. She described an obsessional institutional defence, which involved pushing responsibility for decisions up the hierarchy in unnecessary and risk-averse ways, undermining ward-level decision-making capacity. Legitimate and necessary anxiety associated with the management of the clinical area and the standard of clinical care was projected away from the clinical setting creating a passive dependent relationship between the sister/charge nurse and nursing officers/matron. It was as if, rather than support the function of the ward sister/charge nurse, the matron ‘third object’ was seen to undermine their confidence and the containing function of the ward. The fragmentation of authority for clinical areas The clear lines of accountability and integration necessary for good morale and good team functioning have been eroded over time in the NHS. As a response to negative attributes of the system, the authority of the matron was removed in the late 1960s. In addition, the clinical managers’ authority for many important care areas such as cleaning, catering and laundry have been outsourced to reduce costs. These changes have had their own negative consequences as they have weakened the clinical nurse managers’ control over key areas of the setting. Also, the responsibility for training has been removed from the clinical area and now resides with the universities. Clinical nurse managers (as they are now called) are left with the responsibility and anxieties about the quality of care available in the clinical setting. However, they are left without much of the authority they need to execute these responsibilities. Consequently, many nurses are reluctant to take positions of authority and prefer to stay on the nursing bank and/or work as agency nurses. In my experience, many nursing staff do not feel they have the necessary authority or the support from those in senior management roles. Assumptions that monitoring, performance management or intervention was the responsibility of someone else. (Francis 2013) Nurses feel that the containing structures are no longer there, and the management is seen as distant and persecutory rather than supportive and helpful. The vacuum in clinical leadership was recognised in the early 1980s with the introduction of Nurse Development Units, but these did not survive the managerial changes of the late 1980s. The new style Modern Matron in 2000 was tasked with arresting the falling standards of clinical care. A failure to tackle challenges to the building-up of a positive culture, in nursing in particular but also within the medical profession. (Francis 2013)

‘I’m beyond caring’ 17

However, the problems are systemic and cannot be solved by re-introducing a post that bears the name but needs more authority and wide-ranging responsibility that characterised the old-style matron. It is like trying to re-invent the wheel but providing no road for it to run on, and serious concerns about standards of cleanliness and the quality of food provided in hospitals remain. Hence, the lack of clear lines of accountability and authority presents an ongoing problem. The effect of survival anxiety on the healthcare system A culture focused on doing the system’s business – not that of the patients. (Francis 2013)

The system that manages the NHS is driven by a belief that competition and targets drive up quality and provide the best guarantee of getting value for money for the taxpayer. It is widely known that only strong NHS Trusts will survive in this new market and that failing Trusts will be taken over. The three main sources of survival anxiety are the internal market, austerity measures and targets. The internal market (early 1990s) fragmented the healthcare system by introducing competition for patient contracts often in care packages. Competition can be healthy, but it can also affect relationships between colleagues and services when destructive rivalry based on triumph and survival starts to infect thinking. The necessary energy entailed was removed from actual healthcare leading to a world of survivors and casualties, winners and losers in a paranoid-schizoid position. Packaged care does not suit all patients, especially those with long-term illnesses who had to fight for their needs. A list of symptoms to be removed did not suit a mental health patient with a particular psychological structure and personality. The effects of cuts The report has identified numerous warning signs which cumulatively, or in some cases singly, could and should have alerted the system to the problems developing at the Trust. (Francis 2013)

As financial constraints have increased, economic pressure has forced a downgrading of clinical staff and of the skill mix required by the team. Nurses frequently have to reapply for their jobs and accept lower salaries, and large numbers of experienced staff have taken either voluntary redundancy or retirement. These changes also mean that healthcare assistants are increasingly left on the front line of clinical care while qualified nurses become more and more responsible for management. Morale amongst nurses is at an all-time low in many areas, and experienced staff are retiring early. Forensic staff working in a high secure setting recently informed me that they were only allowed one qualified staff member for each ward at night.

18  Marcus Evans

A change in shift patterns in many areas means that nurses are working 12-hour shifts with very little handover time. The loss of this overlap time between shifts seriously threatens the crucial teaching sessions, supervisions or reflective practice groups, which are an essential part of ongoing clinical practice and shouldn’t be perceived as a luxury (Evans 2007). These changes can make front-line staff feel as if they are on a treadmill, with very little respite. They may develop an unexpressed resentment of both the organisation and the patients they care for, as they are uncared for themselves. It should be no surprise that ‘burn out’ and clinical ‘mistakes’ are increasing. However, such failures are too often blamed on the individual, with nurses being referred for stress counselling, thereby diverting attention from the systemic causes. In this anxietyfuelled environment, it is commonplace for clinical staff to develop defensive practices designed to avoid criticism rather than to care for or treat the patient. Staff are also frightened to speak out. An institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern. (Francis 2013) Financial pressures and the demands of the target culture mean that senior managers are often unable to really listen to concerns about lack of resources for patient care. Clinical managers who are responsible for meeting their targets and staying within their budget may be tempted to stop co-operating with neighbouring services over resources as they become preoccupied with the financial health of their own area. Once again, this paranoid-schizoid state of mind undermines the need for services and staff in different areas to work together in the interest of their patients. The target culture This failure was in part the consequence of allowing a focus on reaching national access targets, achieving financial balance and seeking foundation trust status to be at the cost of delivering acceptable standards of care. (Francis 2013)

Since the advent of the internal market there has been a substantial shift in the clinician/patient relationship, and the authority of the clinician is no longer accepted as a guarantee of good quality care. Instead, NHS regulatory authorities, commissioners and patients look for ‘objective measurable outcomes’ to provide an assurance of quality and good care. The information gathered can be helpful as it may provide objective information about one aspect of the system’s functioning. The information provided needs to be fed into the managerial system in a way which adds to the overall picture. Then the senior clinical manager in conjunction with the clinical nurse manager can think about the meaning of the information and decide on appropriate action.

‘I’m beyond caring’ 19

However, information often comes back at the clinical area in the form of an anxious directive, ‘your service is failing to hit this target and you need to improve this area of performance’. This sort of directive has the impact of an instruction from an authority external to the ward that overrides any local authority or requirement to think about either the meaning of the figures or the priorities of the local situation. I have also noticed that the communication sometimes contains a moralistic tone: ‘aren’t you interested in improving the service to your patients?’ or ‘don’t you care about the Trust’s Monitor rating?’ In these communications, which are designed to induce guilt, there is no recognition of inadequate staffing levels or front-line clinical realities. This form of communicating can increase the clinical nurse managers’ feeling that people outside the immediate clinical area erode their sense of authority and control. It may also cause a paranoid-schizoid split between front-line clinical staff and managers external to the clinical area. In introducing the first report, I said that it should be patients – not numbers – which counted. That remains my view. (Francis 2013) Although objective measures can be helpful, they provide no more guarantee of good treatment than the clinician’s opinion. Our preoccupation with measuring everything can become a defensive distraction from the task of caring for the patient (Proctor, Wallbank, & Dhaliwall, 2013). The fear of failing to hit the various targets set by the Care Quality Commission, Monitor, NHS Litigation Authority, and Care Commissioning Groups, and failing to maintain a balanced budget, persecute trusts. Responsibility for targets is located with the senior managers running central services such as Human Resources, Clinical Governance, Risk Management, Contracts, and Information Governance. The senior managers running these departments are accountable for overseeing the Trust’s performance against targets, and there are real financial penalties that may threaten a Trust’s future if the required standards are not met. Performance is measured against a series of targets monitoring different aspects of the Trust’s work. The clinical area is required to provide figures and information that contribute toward reports on patient turnover, length of stay, the number of patient complaints, performance against clinical contracts, patient satisfaction, ward cleanliness, standards of information governance, staff sickness, outcome monitoring data, disability data, ethnicity data, case note standards, payment by results figures, outcome measures, mandatory staff training and many others. The risk of failing to reach a target provokes a directive (often by email) demanding an increased effort in the area concerned. Senior managers emphasise the importance of their own targets, and anxiety is often conveyed through the tone of the communication, which takes no account of the clinical team’s capacity. Pressure builds as the demand for immediate action and resolution of a specific problem often ignores the fact that the clinical nurse manager and their staff have to continue running the entire service effectively so that patients receive the attention they require. The clinical team’s resources

20  Marcus Evans

are pulled in different directions as the clinical nurse manager tries to meet the demand to meet targets from different parts of the managerial system. Staff teams are exposed to unrealistic expectations, which have a damaging effect on morale. This sort of environment also increases the likelihood of clinical priorities becoming secondary to the needs of the institution to achieve targets in an attempt to deal with its survival anxieties. Perverse outcomes often arise when this happens, and patients may be discharged when they really need to be in hospital. The danger is that the target culture encourages a ‘blame game’ where no one wants to be left holding responsibility for the failure to hit the target. You can sometimes see how individuals deny responsibility and push the blame elsewhere in the email trail (into which seemingly half the Trust is copied). Targets have undermined clinical judgement. William Halton (2015) notes the presence in the defensive structure outlined by Menzies Lyth of obsessional defences designed to keep the patient and their anxiety at a distance. At the time she wrote, the primary concern was for patient care. By contrast, nowadays the system is confronted by two anxieties coming from different directions. Up from the clinical work come the anxieties related to fears of managing illness, psychological disturbance and dying, while down from the management come institutional anxieties about survival. There is a danger that this system creates a split between management and front-line clinical staff. Far from the system containing front-line staff, there is a tendency for management to push their anxieties into them via shards of survival anxiety. The danger is that this leaves clinical staff feeling blamed, overwhelmed and unsupported. This in turn can lead to loss of morale and poor patient care as clinical staff feel that they are constantly failing on all fronts. Revans showed that there was a direct link between the morale of nursing teams and patient recovery (Revans 1959). The split can also mean that misunderstanding abounds as management filled with their own anxieties about survival turn a deaf ear to the clinical staff’s concerns. The primary purpose of targets has been subverted from the improvement of patient care to the survival of the hospital or clinical unit. The effect of the survival anxiety on the healthcare system resulting from the internal market, financial cuts and targets is that senior management are so anxious and insecure that they are not able to provide the containment and ‘reverie’ that clinical managers need. The resulting lack of empathy from senior managers for clinical staff is one of the factors that leads to the nurses’ lack of empathy for patients. The training of nurses The complaints heard at both the first inquiry and this one testified not only to inadequate staffing levels, but poor leadership, recruitment and training. (Francis 2013)

Nurse training institutions have the task of helping their trainees develop their professional identity in addition to their student’s academic knowledge and technical

‘I’m beyond caring’ 21

ability. This identity is developed through contact with good role models on clinical placements. Over time the student can internalise the qualities of good role models while on placement as they work alongside senior clinical colleagues on clinical placements. As mentioned in the opening paragraphs of this paper, trainees must be receptive to their patient’s psychological state, whilst also being able to separate themselves from their patients and maintain professional objectivity. Menzies Lyth outlined how the patients and relatives transmit their anxieties about illness and mortality to the nursing staff. The staff, in turn, have to manage their own fears around this, as well as any feelings of disgust and vulnerability related to their patients’ physical and psychological condition. The social system surrounding the nurses needs to support the individuals and the clinical area in managing this process. As previously discussed, in her 1959 paper Menzies Lyth described the way the social system within a training hospital created a defensive social system that fragmented the nurse-patient relationship and turned the patient into a diagnosis rather than a fellow human. This was done through a process of fragmenting the nurse-patient contact into task-orientated nursing, for example Nurse A takes the patient’s temperature; Nurse B makes the bed. Nurses would also refer to patients using diagnostic terms – ‘the liver in bed number 25’ – in an attempt to distance themselves from the patient as a person. This fragmentation meant that patients were deprived of a nurse to relate to as a human being with feelings and a capacity for empathy. There was no practice of individual supervision for nurses, and they were not helped to deal with the work’s emotional impact. Nurses were also treated like objects with no individual characteristics or feelings of their own, as Nurse A was sent to surgical and Nurse B to medical with no thought about their individual skills, knowledge or ability to complete the task. This undermined the crucial element of identifying and acknowledging individual interests and abilities. By the 1990s, Project 2000 moved responsibility for nurse training from the schools of nursing, which were attached to the hospital, to the universities. Accompanying this physical move was a shift in the centre of gravity from the ‘hands-on’ learning of the apprenticeship model to academic learning in the classroom. There was also a shift in emphasis in student nurse selection from an aptitude for the vocation of nursing to a preoccupation with academic ability. In the current model, trainees are often supernumerary and spend time observing clinical practice or attending clinical placements for short periods of time. Hardpressed staff are sometimes reluctant to invest time in transient students who are not part of the clinical numbers. Crucially, the quality of engagement between the student nurse and the clinical team supports the student nurse’s identification with clinical colleagues. If the student is committed to the clinical team, they will receive commitment in return. If the involvement with the team is half-hearted or fragmented, the student will not get the support or engagement from the clinical team they need in order to learn (Evans 2009). Nurse tutors used to support placements by visiting the clinical placement regularly, holding teaching sessions on the ward, and observing and assessing clinical practice. The link tutor was also crucial in supporting the student nurse’s ability to manage the emotional demands of direct

22  Marcus Evans

patient contact. In another paper called ‘Psychoanalytic understanding and nursing: a supervisory workshop with nurse tutors’, Fabricius (1995) described her experience of running supervisory groups for student nurses, which aimed to help them digest and then learn from their experiences in clinical placements. This approach helps the student face painful aspects of the work as well as develop the self-critical objectivity necessary for high-quality clinical practice. The ‘evidence base’ and theory behind medicine and nursing provide a vital pillar of clinical training. However, I believe we threw the ‘baby out with the bathwater’ when Project 2000 was introduced, widening the gap between theory and practice. Despite numerous attempts, this gap has yet to be bridged (Hewison & Wildman 1996). In her paper ‘Running on the spot or can nursing really change?’ Fabricius (1991) outlined her belief that the movement from the emotionally charged experience of ‘hands-on’ nursing, which involved being with the patient, to the academic and abstract environment of the classroom represented a wish to retreat from the disturbing aspects of physical and emotional contact with the patient who is ill or dying. Fabricius argued that this represented an attack on the nurse’s maternal function and would ultimately undermine the nurse’s identity as a caring figure from which the nurse derives so much professional authority. Financial pressure on universities has meant that many university link tutors are trying to oversee too many students and cannot give either the necessary tutorial time or make the regular hospital visits to support students or their clinical placements in a meaningful way (DH 2006). A weak or distant relationship between the tutor and the student can mean that the student drifts or fails to make proper use of the experience gained during training. Lack of time to visit the clinical placements means that qualified staff managing these placements do not get to discuss the student with the tutor. Thus, clinical staff, tutors and students struggle to find the time necessary to triangulate their picture of the individual’s development. A recent report suggested there was an ambiguity in the current system regarding who is responsible for failing student nurses who persistently fell short of acceptable standards. This means that some students who have been identified as having persistent problems in attitude and/or ability often continue on into their third year and beyond, despite the fact that there are ongoing questions about their level of functioning. Once again, the defensive nature of the system creates a fragmented social structure that breaks up the relationships necessary to support development. Too great a degree of tolerance of poor standards and of risk to patients. (Francis 2013) As a consequence of the failings in this system, many nurse directors and managers have recognised that recently qualified staff are often unable to complete basic nursing procedures (Department of Health 2006). An additional problem is that many universities have had contracts (with financial targets attached) to fill a certain number of student nurse places. Thus, the quality and aptitude of students recruited may have been less of a priority than the contractual need to fill training places.

‘I’m beyond caring’ 23

We need to ensure that student nurses are interested in caring for people and shift the centre of gravity for training back to the clinical settings. Nursing students must learn best practices from working alongside qualified nurses in live clinical situations. All clinical areas are potentially learning environments, and the teaching function of clinical areas needs to be supported. This system in turn needs to be supported by nurse tutors who have the time to genuinely support the student in learning through their experience. In this way the trainee nurse’s capacity for empathy can be supported, monitored and developed in situ. Conclusion Things have never been perfect in the healthcare system, and ideas of a ‘golden age’ are in themselves defensive and represent a denial of reality. Defences against psychic pain and anxiety are ubiquitous, universal and necessary. However, there are significant differences between primitive defences designed to avoid reality and more mature psychological defences. In the current structure we have supplanted the rather obsessive institutional defence of the 1950s and 1960s for an even more primitive defensive structure. This defensive structure has to deal with the patient’s anxieties about illness, death and fragmentation on the one hand and the Trust’s or clinical service’s concerns about survival on the other. Anxiety and blame are pushed around the system like a pinball bouncing back and forth between the different areas of responsibility. This is reminiscent of defences that emanate from the paranoid-schizoid position as the institution employs defences based on splitting projection, denial, idealisation, denigration and manic triumph. At the same time there has been an erosion of the sorts of structures and relationships that help contain anxiety. The squeeze on the time available for teaching, supervision and or case discussion undermines the time and structures necessary to support the reflective capacity of individuals and teams. Hence, the structures that support the clinician’s capacity to digest experience have been removed in an attempt to reduce costs. Instead, we are creating a system that increasingly distances the patient and their suffering from the nurse. There is also a danger that this system undermines the authority of the clinical nurse manager for the clinical setting as the survival anxiety can create a split between front-line clinical managers who have the responsibility of managing resources in their clinical area and the managers of the central services who carry responsibility for targets. The target and regulatory system also dictates that much authority is located external to the clinical area. Clinical leadership roles are vital containers of anxiety within the healthcare system. However, anxieties about survival and fear of persecution can erode the confidence and authority of the clinical nurse manager. Clinical nurse managers are also often left with anxieties about how they will manage the gap between senior managerial expectations and the capacity of their unit to deliver the clinical standards necessary. The persecutory environment increases the sense of the clinical area being policed by a raft of senior managers rather than supported by senior management colleagues who understand

24  Marcus Evans

what it takes to manage a clinical area. When this happens, it undermines the important function that senior managers can have in acting as the third object that helps clinical nurse managers think through the conflicts, difficulties and anxieties that need to be managed in their clinical area. Over 50 years ago Menzies Lyth was invited in to consult on a failing hospital system. However, we still have not learnt the lessons Menzies Lyth outlined in her paper. Clinical nursing staff need to be supported by an authoritative managerial and clinical structure, which helps the nurse bear the anxieties inherent in the work. In order to achieve this, it is essential that clinical nursing and medical authority is at the heart of the managerial system. Menzies Lyth emphasised her belief that good clinical managers provided the most effective form of staff support. She also outlined the need for clinical areas to be managed by authoritative figures who would take full responsibility for the quality of clinical care provided to their patients (Menzies Lyth 1999). Clinical services need experienced staff who are familiar with the realities of clinical practice and have the necessary authority and experience to know when corners are being cut, standards are being compromised and/or risks are being taken in a damaging way. Whilst financial constraints represent important realities about the limit of resources, their influence has to be balanced against authority derived from clinical realities about care and treatment. Teams also need senior clinical managers who assist them in their difficult job via regular and supportive contact, rather than directives and surveillance. Senior managers also need to have the authority and confidence to communicate difficulties back up the hierarchy as well as communicate important issues down the hierarchy and be prepared to stand up to senior colleagues in order to protect standards of care in front-line services. Central to the Francis Report is the conclusion that the patient and clinical voice are not being heard. The voice that carries knowledge about the effect of cuts and lack of resources and which expresses anxiety about patient care is often treated as if it is the carrier of a disease and needs to be barrier-nursed. In reality, it is often the voice of experience and needs to be listened to. The current top-down management system driven by a target-based and finance-orientated culture has a tendency to push clinical staff’s concerns down the hierarchy and away from the upper tiers of management (Cunnane & Warwick 2013). All healthcare systems have problems, and these are, by their nature, multifaceted. However, when the problems outlined here are combined with the current austerity measures, the scene is set for the eruption of more toxic situations like that exposed at Mid Staffs. It is surprising that similar events are not reported more often. However, listening to nurses present their clinical work has convinced me that, despite the system’s tendency towards fragmentation and the lack of support for front-line clinical staff, there are still large numbers of nurses who remain extremely committed to their patients and endeavour to do the best they can within the existing healthcare system (Evans 2008). My worry is that we have reached a tipping point in this system and can no longer rely on individuals’ valency towards care and responsibility. The persecution inherent in the system creates an environment antithetical

‘I’m beyond caring’ 25

to thoughtful care. The consequence is that only exceptional clinical managers can juggle the demands between the persecution of the ‘target culture’ while keeping the care of the patients at the heart of their thinking. This is not a sustainable position. In theatres that deal with matters of ‘life and death’, you need leaders with experience who can manage the anxieties in the work and can support their front-line staff. These clinical leaders, in turn, need support from senior managers who can help front-line clinical managers contain anxiety and reduce the temptation towards blame fragmentation and splitting. As Lord Francis said in his report, we need to put our patients’ clinical care and nurturing back at the heart of the NHS. In order to do so, we need to start addressing the current moralistic and persecutory culture of the current NHS. Exhorting nursing staff to work harder, be more empathic and feel guilty for shortcomings in clinical services while depriving them of adequate training, managerial support, time or status within the system is a recipe for disaster. The NHS needs to establish a clinical training system that supports trainees through apprenticeship training, repair damage done to the authority of nurses and nursing in the system and develop structures that really support and listen to staff. Notes 1 A shorter version of a previously published chapter in David Armstrong & Michael Rustin, eds. (2015). Social Defences Against Anxiety: Explorations in a Paradigm. Tavistock Series, Karnac, London. 2 In 1999, the Tavistock and Portman ran a conference called ‘Facing the Crisis in Nursing’. Three of the main papers presented outlined problems in the training of nurses and the fragmentation of authority in clinical areas (Menzies Lyth 1999; Fabricius 1999; Evans 2009).

References Bion, W. (1962). A theory of thinking. International Journal of Psychoanalysis, vol. 43, pp. 306–310. Britton, R. (1989). The missing link: Parental sexuality in the Oedipus complex. In The Oedipus Complex Today: Clinical Implications. Karnac Books, London, pp. 83–101. Cunnane, D. & Warwick, R. (2013). Francis Report: What went wrong with NHS leadership? The Guardian Professional, 14 February. Department of Health (2006). From Values to Action: The Chief Nursing Officer’s Review of Mental Health Nursing. DH, London. Evans, M. (2007). Being driven mad: Towards understanding borderline and other disturbed states of mind through the use of the countertransference. Psychoanalytic Psychotherapy, vol. 21, no. 3, pp. 216–232. Evans, M. (2008). Tuning into the psychotic wavelength: Psychoanalytic supervision for mental health professionals. Psychoanalytic Psychotherapy, vol. 22, no. 4, pp. 248–261. Evans, M. (2009). Tackling the theory-practice gap in mental health nurse training. Mental Health Practice, vol. 13, no. 2, pp. 21–24. Evans, M. (2011). Pinned against the ropes; understanding antisocial personality disordered patients through use of the countertransference. Psychoanalytic Psychotherapy, vol. 25, no. 2, pp. 143–156.

26  Marcus Evans Fabricius, J. (1991). Running on the spot, or can nursing really change. Psychoanalytic Psychotherapy, vol. 5, no. 2. Fabricius, J. (1995). Psychoanalytic understanding and nursing a supervisory workshop with nurse tutors. Psychoanalytic Psychotherapy, vol. 9, no. 1. Fabricius, J. (1999). Reflections on the crisis in nursing. Psychoanalytic Psychotherapy, vol. 13, no. 3–5, pp. 203–206. Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry Chaired by Robert Francis QC HC 947. The Stationery Office, London. Halton, W. (2015). Obsessional-punitive defences in care systems: Menzies Lyth revisited. In D. Armstrong and M. Rustin (eds) Social Defences against Anxiety. Tavistock Clinic Series. Karnac Books, London. Hewison, A. & Wildman, S. (1996). The theory-practice gap in nursing: A new dimension. Journal of Advanced Nursing, vol. 244, pp. 754–761. Klein, M. (1935). A contribution to the psychogenesis of manic-depressive states. International Journal of Psychoanalysis, vol. 16, pp. 145–174. Klein, M. (1940). Mourning and its relationship to manic depressive states. In M. Klein (ed) Contributions to Psychoanalysis 1921–1945. Hogarth Press and the Institute of Psychoanalysis, London. Menzies Lyth, I. (1959). The Functioning of Social Systems as a Defence Against Anxiety. Reprinted in Containing Anxiety in Institutions. Free Association Books, London (1988). Menzies Lyth, I. (1999). Facing the crisis. Psychoanalytic Psychotherapy, vol. 13, no. 3, pp. 233–231. Proctor, S., Wallbank, S. & Dhaliwall, J. (2013). ‘What compassionate care means. Health Service Journal, 28 February. Revans, R. (1959). The Hospital as an Organism: A Study in Communication and Morale. Preprint no. 7 of a paper presented at the Sixth International meeting of the Institute of Management Science. Pergamon, Paris, September. Segal, H. (1957). Notes on symbol formation. International Journal of Psychoanalysis, vol. 38, pp. 391–397. Segal, H. (1991). Dream, Phantasy and Art. Tavistock, Routledge, London and New York.

Part two

Autism

Editor’s commentary This section begins with a discourse on children with autism (in Chapter 2a). Originally it was written as a discussion paper following Maria Rhode’s presentation of her patient in Chapter 2b. But many readers, like myself, may not have had much experience of autism, so the order is reversed here. Laurent Danon-Boileau’s thoughtful concepts and ideas in ‘Affect, words and play in autistic children’, will help to introduce the subject. Then in Chapter 2b Maria Rhode in ‘Finding one’s feet’ shares a whole career of experience and describes in exquisite detail a little girl who is late walking. She uses the extreme situation to enlighten what happens more usually but is taken for granted. She refers to the girl as pre-autistic choosing the wise position of not wanting to label a child too soon during development. In Chapter 3 ‘Analysing Miss Daisy’, Alan Sugarman describes his treatment of a young woman who has been diagnosed with autism. He shows how she uses a toy to express her difficulties which helps distance her from too much intensity of feeling when engaged with her therapist. In a different arrangement, Miss Daisy might have been linked to Anne Zachary’s adult patient who identifies with Peter Rabbit in Chapter 11.

DOI: 10.4324/9781003202790-4

Chapter 2a

Affect, words and play in autistic children 1 Discussion of Maria Rhode’s clinical case Laurent Danon-Boileau Among many other topics, Maria Rhode’s wonderful treatment draws our attention to three major issues concerning autistic children, namely emotional life, language and play. The ideas that I have exposed as her discussant all directly stem from a careful reading of her incredibly rich and thought-provoking paper. Emotional life in autism Emotional life in autism is often the target of contradictory judgements: do autistic children have affects or don’t they? Sometimes they are described as overreactive to other people’s emotional states and sometimes as indifferent to what happens around them.2 In Maria’s paper, Lisa is sometimes described as a child who shows no affect (‘she was a fair-haired little girl who would have been pretty if her face had shown any sign of life’), and this feature, says Maria, is widely acknowledged (‘Like Klein’s Dick, most children with autism show little affect or anxiety’). Yet on the other hand Maria also notes that autistic children sometimes show very clear signs of emotional life, when ‘their rituals and stereotypies are interfered with’. And in Lisa’s treatment Maria also notes that the young girl sometimes seems oversensitive to people’s affective state (‘Our tone of voice became slightly less friendly for a minute or so. That was enough for Lisa to collapse onto the floor. It was as though, on a very fundamental level, her bodily strength and co-ordination depended on co-operation between the adults’.) This leads Maria to say that Lisa can also be at times ‘exquisitely tuned to the atmosphere’. Now what can we say about Lisa in the end? How can we articulate the absence of affect that her face reveals with the fact that she can let herself fall down when people around her talk harshly one to the other? If the question is ‘do autistic children have affect?’ the only possible answer seems to be: yes and no. Or: it depends. This of course is not satisfactory and in turn raises new questions. Yet this paradox might result from a confusion: autistic children manifest emotional reactions to what they experience, but affect is perhaps not the best word

DOI: 10.4324/9781003202790-5

30  Laurent Danon-Boileau

to describe it. It would be more convenient to talk about emotions, feelings or ‘bodily terrors’ as Maria puts it. In fact autistic children compel us to make differences between affects and other emotional manifestations: ‘affect and anxiety are foreclosed and bodily terrors are dealt with by bodily means’, says Maria. Autistic children do not seem to show affects in the classical sense of the term, but they certainly have emotional reactions which Maria calls ‘bodily terrors’. And these bodily terrors are expressed through bodily means. Here of course one could object that affect also implies bodily means of expression. A smile or a sad face corresponding to an affect of pleasure or sadness relies on the use of the face, which is a part of the body, except it is not the body as a whole but just of a part of the body. Affects make use of the face but not of the limbs. This leads us to clarify the differences between emotional manifestations. From a general point of view, I  can think of three ways of making these differences: 1 By referring to the excitement involved: both its level and the possibility (or not) to modulate its easing out 2 By referring to the nature of the parts of the body implied, and the complexity of the movements thanks to which the excitement is eased out and/or represented (‘made visible’ to other people) 3 By the presence (or absence) and nature of the fantasies possibly attached to these emotional manifestations Concerning the level and modulation of the excitement involved It seems that the tension corresponding to an affect can be modulated and partly kept within, whereas that of an emotion implies a brutal easing out of tension. Contrary to affect, emotion does not imply any modulation of the easing out of the excitement. As I see it, the difference between affect and emotion in that respect is not (or not only) a question of level of excitement, the excitement of emotion being greater than that of affect. It is also a question of modulation of the discharge, of the easing out. With emotion, the bodily response evacuates at once all the power of the initial excitement. With affect, the excitement remains partly contained. It is because it is partly contained that, as is well known, affect can be transferred or displaced from one representation to another. Autistic children suffer from dismantling, i.e. a lack of motor co-ordination. And a smile or a sad face requires much more modulation of excitement and co-ordination than a brutal outburst of cry or brutal tonic collapse. I see the absence of all modulation of discharge, and the massive or global on/off treatment of excitement as a consequence of a lack of co-ordination. This is how I understand why autistic children have emotions and bodily terrors but no affects.

Affect, words and play in autistic children 31

Concerning the parts of the body and the movements implied in the expression of the emotional manifestation I would say that emotion does not require any co-ordination in the muscular movements that serve to express it. Contrary to affects, emotions are manifested by extreme tonic attitudes of the whole body (hypotonic or hypertonic). But a very refined co-ordination of the movements of the face is required for the standard expression of affect. The movements of the eyes and mouth must be carefully programmed and co-ordinated. This also implies that the subject has an inner representation of the image of the face the subject is showing in relation to each of the subject’s affects. Concerning the association with a mental image or a fantasy A possible link with a representation, a fantasy or a mental image of some kind is necessarily the case when an affect is experienced. Whether a fantasy or representation is present in the case of emotion is more difficult to decide. Lisa’s emotional reactions When Lisa reacts to the adult’s tone of voice by letting herself fall down, it is a clear sign of sensibility to other people’s emotional state. It’s a sort of tonic echo to what she feels in others. But her reaction only implies a global loss of tonicity and no co-ordination. It is just a ‘let go’ movement contrary to the co-ordinated movements of the face implied in the manifestation of any affect. But there is another decisive point that must be taken into account: when Lisa reacts to the adult’s tone of voice, she is not involved in a communication with them, in an exchange and turn-taking circle of questions and answers with the adults around her. When that happens, she does not participate in any exchange. She witnesses an exchange between adults from far away. Therefore, she doesn’t have to frame her tonic answer into the turn-taking scheme of communication. I call these manifestations ‘tangent’ echoes: they only happen when the child witnesses an exchange while not taking part in it. In fact when an autistic child is a partner in a communication, the necessary efforts required to put things together overflow the child’s capacities and the child ceases to show any signs of sensibility – he gives up. But tangent reactions are less constrained than answers in a turn-taking dialogue. They do not have to fill any slot; therefore, they are less demanding in terms of coherence for a dismantled child. In other terms the capacity to show emotional reactions is partly dependent on whether the child is involved in a turn-taking communication or only witnessing it between two persons from far away. This difference is also noticeable when the child is ‘side by side’ with the adult looking at something with them. In that situation, exchanging emotions and ideas is much easier than if the child is in front of the adult, face to face.

32  Laurent Danon-Boileau

Language in autistic children What is language to an autistic child? Autistic children often do not talk or signify to other human beings: they have no proto-declarative pointing (they do not show things to people) and yet, paradoxically enough they talk to themselves, they point for themselves (solitary proto-declarative pointing is often observed). And when they talk to themselves, they name what they see. In her paper, Maria reports that Lisa says ‘light’ ‘pointing to the bulb in the family fridge (in Spanish)’. Besides this solitary and strange use of language, in some circumstances, autistic children do react to what is said to them. They often react to interpretation. In her paper, Maria shows that Lisa stops using her Dad’s hand to grasp an object just after she says, ‘Lisa, you’ve got two hands of your own’: ‘somewhat to my amazement she let go of her father’s hand and used both her own instead’. And we all remember Dick who does not seem to talk much but runs away between the two doors of Klein’s consulting room when she says ‘Dick enters Mummy’. These facts raise the question of the nature and effect of language in autistic children who apparently make no use of it to communicate. Language production Generally speaking, language production has two essential effects depending on whether it is addressed to someone else or to one’s own self. When addressed to someone else language is a means to influence the other’s mind. It’s a sort of action on the other’s mind. When addressed to one’s own self it’s a means to make one’s dreams or memories match what one sees. When Lisa says ‘light’ she speaks to herself. What is exactly the situation? Lisa says ‘light’ in front of the light in the fridge. It lights up when the door opens. Why does Lisa say ‘light’ in front of the thing itself when she uses no word when interacting with others? Why does she speak to herself labelling what she sees when she does not use words to speak with others about what she does not see? As I see it, this paradoxical situation can nevertheless be explained. First, as any autistic child, Lisa is interested in lights and brilliant spots. Yet, to her mind, the lamp in the fridge appears in a very odd context. Normally, a light is not available in such an environment. It can be seen on the ceiling in a dining room or a bedroom. What she sees is similar to other lights that she has seen before, but the context in which it appears is uncanny. Normally lamps do not appear in a closed space, in a box or in a fridge. They appear in open spaces. And in my opinion if she utters the word ‘lamp’ for herself it is because she needs the word to ‘acknowledge’ for herself that notwithstanding the difference in context with the lamp in the sitting room or elsewhere the thing which she sees in the fridge is the same as other lamps seen previously in different contexts. The word signs the recognition of the identity between the light in the fridge and all the lights in the open that she knows.

Affect, words and play in autistic children 33

Why does Lisa talk to herself and not to others? In my opinion it is because talking to others is communication, and communication is too demanding in terms of co-ordination. One has to co-ordinate eye movements, hand movements, wording, intonation; one has to co-ordinate understanding the other and producing adequate answers This is too much for a dismantled autistic child. But it does not prevent her from speaking to her own self when confronted with the surprise of seeing something that she recognises in a context that she does not recognise. Language comprehension and interpretation Why are autistic children, even when they do not speak, so sensitive to the words of their analysts? This is because the use of language in interpretation is outside of communication. In my opinion, interpretation is not communication for one essential reason: the interpreter does not expect a direct answer from the person who receives the interpretation. The interpreter’s words do not take place in a turntaking dialogue. Interpretations build the frame for a tangential exchange, a sideby-side exchange not a face-to-face exchange. Lisa reacts to Maria’s words just as she reacts to the tone of her parents when letting herself suddenly fall down. This is what explains for me the fact that Maria’s words have an effect on Lisa as proves the fact that she lets her father’s hand go. The loosening of her grip is a tonic response to the interpretation. I would say that autistic children can make use of language as long as it is not inserted in a turn-taking dialogue. They understand what is said in front of them when they are not summoned to answer. They can speak when they do not have to adapt what they say to the frame of a turn-taking dialogue. Symbolic play in autistic children Playing becomes symbolic when it reveals an unconscious scenario. This can only be the case if the player is capable of projection. What exactly is the situation with an autistic child? Neurotic children play with babies, Dad and Mum puppets, bottles, animals, miniature toilets. These objects directly call for representations of unconscious scenarios. Autistic children do not seem interested in such toys. They do not seem interested in toys leading to anthropomorphic plays, toys meant for projection. This is indeed what Maria tells us when she says that Lisa ‘had no interest in the dolls’ house’. Autistic children seem to prefer cubes and Lego bricks. At best they play with trains, cars or pop-up toys. In that respect, I have always been amazed that Klein did not give Dick a doll or a bottle or a toilet but a train. This demonstrates her extraordinary intuition for a pathology that she sees for the first time. She ‘knows’ Dick’s interest for apparently ‘non-human’ objects, objects that are not related with the essential functions of the body and/or object relation (contrary to a bottle, a miniature toilet or a pram).

34  Laurent Danon-Boileau

Yet these trains, cars and pop-up toys can embody unconscious fantasies such as a parental coitus. This of course is revealed by Klein’s interpretation ‘the train Dick enters Mummy’. Dick’s reaction to her words proves that he has understood something of it. What shall we then say about projection and symbolic play in autistic children? Are autistic children capable of projection and symbolic plays or are they not? And if ‘Yes’ is the answer, what is the difference – if any – with the plays and projective abilities of a neurotic child? Projection or no projection? The standard answer concerning the difficulties related to play in autism is as we know, that as Maria notes, ‘the ego’s excessive and premature defence against sadism checks the establishing of a relation to reality and the development of phantasylife . . . exploration . . . is brought to a standstill’. In other terms, if autistic children do not play like other children, it is because their defence against sadism hampers all their attempts to project for fear of retaliation from the object. This is why they would be confined to ‘non-symbolic play’ such as manipulations of cubes and other non-human toys like trains and cars. Yet autistic children experience violent frights. Maria tells us that Lisa ‘seemed frightened of the teddy in her box’ and ‘a more troubled boy pointed to different corners of the room and said that his head and penis were scattered there’. The existence of these frights proves that the autistic child does make use of projection. If she did not project, Lisa would not be afraid of anything. Besides, autistic children are also sensitive to interpretations revealing some unconscious aspects of their play (cf. Dick’s reaction when Klein says ‘Dick enters Mummy’), even when these interpretations are made while they play with nonhuman toys such as trains, cars or pop-up toys. It seems therefore that an autistic child is capable of projection. But then why does Dick concentrate on trains and neglect dolls and animals? Does this come from a problem related to his use of projection? Ideational apraxia In my opinion, the lack of investment in a doll or a pram by the autistic child is not the consequence of his incapacity to project. It has to do with an underlying deficit in motor planning, a sort of ideational apraxia. To illustrate my point, I give a personal example. I once gave a hand puppet representing the big bad wolf to an autistic child. He took it and immediately used it as a washcloth pretending to wash his face with it. One could conclude that it was because he was incapable of projecting a story and an unconscious scenario with the wolf. But it isn’t my position. My idea is that he suffered from ideational apraxia, which prevented him from playing any scenario with the wolf. A teapot, a comb, a fork, a knife, a telephone, a screwdriver, a glass, a bottle and a pen, evoke one specific gesture to which the object is more or less tied. A hand puppet of a big bad wolf can do anything and does not evoke any gesture in particular. If the hand puppet

Affect, words and play in autistic children 35

is turned into a washcloth, it is because of its form. But the reason why the child prefers to see it as a washcloth rather than as a wolf is because the washcloth evokes only one gesture to which it is tied. The pretend play becomes possible as the deficit in motor planning and motor evocation is no longer an obstacle. On the contrary, if the hand puppet is used as a wolf, an infinity of gestures become possible, and the child’s deficit in motor planning and ideational apraxia become a problem. This, to my mind, far more than a difficulty to project, can explain the interest of autistic children in trains and cars rather than puppets and animals. With a train or a car, the only possible gestures the child can make are simple. He can roll the train back or forth. He can put it in or out of a circumscribed area. His ideational apraxia is no longer a problem. As time goes by if there are two cars or two trains, simple anthropomorphic gestures can be made (accidents or kissing). A technical question is of course how to help the child change his use of a toy. How do the pop-up pieces of wood turn from food to little persons? How does a train turn into a person, Dad or Dick? The analyst’s aim is not to change the gesture of the child but the meaning of his gesture in his play. The transformation of Lisa’s play with the pop-up toys is in this sense of great interest. At the beginning of the treatment, Lisa does not use the pop-up pieces of wood as persons (puppets) but just as food for the bear. Then gradually their signification changes. It will be obtained through eye contact and shared banging: ‘she made eye contact, then waited for me to bang the people with her, coordinating her suspense with mine and bursting out laughing’. The gesture of the child can remain simple while its meaning becomes more complex. (‘Lisa’s play continued to develop as her parents talked. Often, she swept toys off the table, then flopped down herself as though she were identified with them’.) And the themes can also change: ‘Increasingly, Lisa’s play focused on rivalry and exclusion. The little wooden people jostled each other in competition for a hole in the pop-up toy (in/out)’. Maria Rhode’s treatment clearly shows that autistic children are capable of much more interaction, feelings, thoughts and play than what is sometimes asserted. Due to what could be called sensory-motor difficulties, their mode of communication, relation and reaction to others is different. But when careful psychoanalytical treatment is carried out with their family, a change is possible that makes it possible for these children to express themselves and be understood. Notes 1 This is a version of a discussion paper read at the Scientific Meeting of the British Psychoanalytical Society on 1 May 2019 in response to Maria Rhode’s paper ‘Finding one’s feet: body, affect and identifications in a pre-autistic toddler learning to walk’. 2 In this case, it would be necessary to understand if autistic children do not feel anything or if they just can’t read other peoples’ affects on their faces (and/or do not know how to show their own joy, sadness, fear or anxiety on their own faces).

Chapter 2b

‘Finding one’s feet’ 1 Body, affect and identifications in a pre-autistic toddler learning to walk Maria Rhode

In this chapter I wish to describe how a toddler with serious autistic features learnt to walk, and to consider how this process was influenced both by affect and by various levels of identification with an Oedipal parental couple. This little girl, whom I will call Lisa, was unusual in that she used words and played symbolically well before beginning to walk at the late age of 2 ½ years. Her treatment therefore makes it possible to trace some of the emotional correlates of a physical accomplishment that might otherwise be thought of as a straightforward question of bodily maturation. Walking presupposes at least three capacities: bodily co-ordination, motor planning and the ability to manage the anxieties involved in moving through space. These capacities obviously involve important organic or constitutional components: they equally obviously carry emotional meaning. The neuroscientist Antonio Damasio (1999) has suggested that everyone’s self-concept derives from bodily movement in relation to other people and to objects. More specifically as regards autism, both Greenspan and Wieder (1999) (developmental researchers as well as a psychoanalysts) and the developmentalists Trevarthen and DelafieldButt (2013) have argued for a fundamental underlying deficit in motor planning. I suggest that these viewpoints converge with autistic children’s well-known fear of doing damage. I begin with a brief review of some relevant psychoanalytic findings on body and affect that arise out of work with children on the autism spectrum. As is well known, these children typically suffer from a variety of problems and anxieties concerning the body. Children with Asperger’s syndrome, for instance, are usually ‘clumsy’, while so-called sensory issues (both ‘seeking’ and ‘avoiding’ sensation) are widespread across the spectrum. As Frances Tustin wrote, psychoanalytic work with such children often reveals the fears of falling forever and of spilling out bodily that were outlined by Winnicott (1949) and Bick (1968). It also reveals unusual constellations of the body image. For example, Tustin’s little patient John (Tustin 1972a) had supposed that the ‘red button’ (his word for nipple) was part of his own mouth. When he realised that it was separate from him, he felt that his mouth contained instead a ‘black hole with a nasty prick’. Tustin (1972b)

DOI: 10.4324/9781003202790-6

‘Finding one’s feet’ 37

also describes how children with autism can feel that they have lost other important body parts besides the mouth, or that they are split in two down the midline. A highly verbal latency girl with Asperger’s, who always dragged one leg behind her on the way back to the waiting room after her session, explained to me that it had come off; while a more troubled boy pointed to different corners of the room and said that his head and penis were scattered there. The French psychoanalyst Geneviève Haag (1991) has proposed a developmental model that encompasses such phenomena. Meltzer (1986) had suggested that every moment of contact between mother and baby involved both an emotional link mediated by eye contact and a physical link to do with feeding or holding. Haag then hypothesised that this dual link was successively incarnated in each of the joints of the body of which the child achieved emotional ownership, beginning with the capacity to support their own head and culminating in the ability to use the legs and feet for standing and walking. I give an example of this from Lisa’s treatment. Children with autism do not of course communicate such experiences until they have made substantial progress. Before that, they typically take no notice of adults, whom they are often described as using as pieces of furniture. Melanie Klein, in her 1930 paper on ‘The importance of symbol-formation in the development of the ego’, suggested that her little patient Dick, who would now be seen as autistic, could not tolerate the anxiety caused by the aggressive impulses that are part of ordinary development. As she put it, ‘The ego’s excessive and premature defence against sadism checks the establishing of a relation to reality and the development of phantasy-life . . . exploration . . . is brought to a standstill . . . This withdrawal becomes the basis of the lack of affect and anxiety’. Similarly, Meltzer (1975) stressed the importance of so-called premature depressive concerns in children with autism, as well as describing their unusual sensitivity to other people’s state of mind. Other writers, including Tustin (1994, p. 124), have also observed this sensitivity, and I suggest that it played an important part in Lisa’s difficulties. Like Klein’s Dick, most children with autism show little affect or anxiety unless their rituals and stereotypies are interfered with. As treatment shows and firstperson accounts corroborate, stereotypies serve the vital function of allowing the child to feel in control of the bodily terrors I mentioned earlier. These cannot be mitigated by other people, both because of the child’s apparent absence of affect and anxiety and because of the degree to which the child is cut off from other human beings. Tustin (1980) documented how instead the children attempted to protect themselves by turning to self-generated physical sensations that reassured them about continuing to exist. These sensations might be produced through the manipulation of their own body or by using so-called autistic objects – hard objects that they typically clutched in order to feel strong, and that had no symbolic significance. In other words, affect and anxiety are foreclosed, and bodily terrors are dealt with by bodily means.

38  Maria Rhode

Clinical illustration: Lisa Referral and history Lisa’s parents brought her to the clinic when she was only 17 months old: they came from a South American country with a high level of expertise in autism, and they had been told that she showed worrying signs. According to a screen, Lisa had only a 50% likelihood of a later autism diagnosis; but her clinical presentation was worrying. At 17 months, she was a fair-haired little girl who would have been pretty if her face had shown any sign of life. She made no eye contact, didn’t babble, and was not yet crawling. She was inseparable from her autistic object, a spoon that she clung to. Her parents insisted that she didn’t recognise them. In the therapy room she sat immobile on the floor, clutching her spoon and staring blankly out of the window: her whole body seemed frozen. In those days, there were no diagnostic instruments for 17-month-olds; nowadays, a child who behaved like Lisa would almost certainly receive a diagnosis. Lisa’s parents were still young, but they had been together for many years and in England for ten. Father was an only child brought up by a single mother; he conveyed that he had warm memories of his childhood, when, he said, he had played with the same kind of dolls’ house that I provided for Lisa. His wife came from a large and supportive family, but the sibling born after her had died in childhood. She had been unable to find career openings in England; she had also suffered from a rare, potentially fatal illness soon after arriving. She had recovered well, but the possibility of a recurrence remained a shadow in her mind. Lisa’s older brother was thriving. The atmosphere between the parents was loving and supportive, and they discussed differences of opinion openly. During the year of once-weekly work, there were only perhaps three or four sessions that they did not attend together. As Lisa improved, their vitality and sense of humour became more evident. Everything, they said, had gone well until Lisa was seven months old, when they felt they had suddenly lost her. Mother had had a brief illness at the time (not related to her previous serious one) and had worried that her treatment might have damaged Lisa. They described her as a ‘vegetable’ who did not know who they were, though she could occasionally respond somewhat to professionals. I took up how painful this must be, but Father said they were relieved that she was capable of it: she would have to be a great deal better for them to have the luxury of feeling jealous. They were desperate to try anything possible, though Father wondered whether ‘resuscitating’ Lisa might interfere with her brother’s ‘oxygen supply’. The idea that there is no room for more than one child is, I think, often met with in families with a child on the spectrum, and of course reflects the history of both the parents. An observationally based intervention: rationale and theorisation I need to emphasise that the parents had not given me license to address this history. Mother told me emphatically that she was having cognitive behavioural therapy

‘Finding one’s feet’ 39

(CBT) in order to cope with her sibling’s death, and that this was something she did not wish to discuss. I was not in a position to undertake either ordinary psychotherapy with Lisa or the kind of parent-infant psychotherapy that involves explicit work on the parents’ representations. Instead, I based what I was doing on the therapeutic observation of young children with autistic features that Didier Houzel (1999) introduced as an outreach intervention in France (although, in a clinic setting, I allowed myself to be somewhat more active). Houzel emphasises the importance of receptivity – perceptual receptivity to what is taking place, emotional receptivity to each of the family members, and, most of all, unconscious receptivity of the kind that does not obey an effort of will. (Obviously these factors are central to interpretative work as well.) In observationally based work, description (Alvarez 2010) largely takes the place of interpretation: my aim was to try to make contact with Lisa as well as with her parents, and to see whether I could describe and ‘translate’ what she was doing in such a way as to make it meaningful to them. The rationale for such an approach derives from the degree of invalidation that parents of children with autistic traits are exposed to. Lisa’s parents were convinced she did not recognise them and that they did not exist for her. The clinician or observer may witness something very different, but parents have often had to put up with so much discouragement that they can be very difficult to persuade. Houzel suggests that mothers get swept into a vicious circle of feeling incompetent, and that the observer’s stance can do a great deal to relieve this. I have myself seen interactions that convinced me that a child was trying to make contact with the parents, but where they had suffered so many rebuffs that they could not believe or indeed notice this and all parties spiralled downwards in a vicious circle of discouragement. With time, however, parents can begin to identify with the clinician’s observing function and to feel how valuable is their own gift of attention. In attempting to conceptualise this approach psychoanalytically, I have drawn on Salo Tischler’s paper (1979) ‘Living with a psychotic child’. Tischler described the parents’ experience of invalidation in terms of the internal voice that is present in all of us and that says we are unfit to produce a child who could flourish. That voice is attenuated when development goes well, but greatly strengthened when problems are as major as they are with psychotic or autistic children. Under its influence, parents can find it virtually impossible to notice encouraging signs, which are often quite faint in any case. But if and when things do improve, the parents’ hostile internal presences recede, and a virtuous cycle of interactions can begin. In other words, the parents’ representations are being modified even though they are not being explicitly addressed. Beginnings: dependence on co-operating adults When the family first began to attend, Lisa typically sat immobile on the floor between my chair and her parents on the sofa, and stared blankly into a corner or out of the window. I tried to engage her by means of the toys, particularly a transparent musical humming top with four revolving animals inside it, and a pop-up toy

40  Maria Rhode

with four little wooden people painted in different colours. Unlike many children with autism, Lisa took no interest in a large mirror. She made half-hearted attempts to spin the top, but quickly gave up, though she liked pushing down and releasing the little wooden pop-up people so that they came back into view – a kind of proto-hide-and-seek. She tapped repetitively on hard surfaces, like the table or the humming top. When I imitated what she did, it was possible to make very fugitive eye contact. She had no interest in the dolls’ house, and seemed frightened of the teddy in her box, as though anything evocative of another baby might pose a threat. Gradually it became possible to draw her into the group of adults through imitating the way she used the little wooden people or tapped on the table: this could be amplified into simple rhythmical exchanges. Lisa needed our total involvement. She once cast a delicate, tentative glance over her shoulder in her parents’ direction, became disheartened by their preoccupied expression as they talked, and then remained impossible to engage. Mr and Mrs G responded eagerly when I described the delicacy of her glance: ‘she’s always been like that’. I could see how a vicious circle of mutual discouragement could have arisen, and how easily the outcome of a complex affect-laden sequence could be mistaken for a deficit or a lack of interest. Lisa appeared to take no notice of us; in fact, she was exquisitely tuned to the atmosphere. She began to practise pulling herself up to a standing position while holding on to the round central table with the toys. On one such occasion, I asked for permission to make contact with other professionals seeing her. Father refused: he said he liked to control the flow of information. Mother hastened to add, ‘There’s so little we feel in control of’. Our tone of voice became slightly less friendly for a minute or so. That was enough for Lisa to collapse onto the floor. It was as though, on a very fundamental level, her bodily strength and co-ordination depended on co-operation between the adults. Sydney Klein (1980) has described a four-week-old baby who cried when his parents stopped talking to each other during his feed. As soon as they started again, he settled down. A few weeks later, the pattern had reversed: the baby cried when his parents did talk to each other. Klein proposed a developmental sequence in which a conjoined parental couple, where the father is felt to support the mother, must be experienced before a split can be made and the father becomes an intruder. I thought that Lisa was showing us how she apprehended that first experience of a conjoined parental couple through the parents’ voices in harmony, providing containment in the form of a ‘sound envelope’ (Anzieu 1979). This integrated couple seemed to underpin her own bodily integration. Lisa’s parents were politely sceptical when I pointed out how her collapse had coincided with our changed tone of voice. But they began to tell me new things they had observed her doing at home, though at this stage it still seemed that one of them would take the risk of detecting meaning while the other expressed doubt. Both agreed on Lisa’s pleasure in returning each week to the familiar toys. With my support, they encouraged her not to hold back but to press down with all her strength on the humming top when she tried to make it spin, and they amplified her growing enjoyment in banging the table and growling fiercely: aggression could

‘Finding one’s feet’ 41

begin to be expressed playfully and usefully. They attempted age-appropriate games like passing a toy back and forth to Lisa but could realise that she might need to assert her own claim to it before she could let it go. Lisa’s increasing pleasure in such shared activity was repeatedly interrupted by frightened looks out the window and into the corner that she had previously stared at blankly. From my point of view, her ability to locate something bad in circumscribed places, so that it no longer pervaded the whole room, was an important developmental step (Rodrigué 1955), and mother said it made complete sense to her when I talked about something frightening that was always around the corner: ‘It’s the ghost in our house’. Father disagreed: this made no sense to him at all, and Lisa was just staring at the vertical lines of the window because this was what caught small children’s eye. The way the parents took turns at entertaining the possibility of meaning perhaps explains my countertransference experience: even in these early stages, I never felt overcome by despair as I generally have with children at higher risk. Lisa’s play seemed to me increasingly possible to understand, and the instances of her coming to life that I witnessed or heard about, though scattered at first, were thrilling and encouraging. I also felt that my job was made easier by the parents’ close relationship and the warmth of their occasional references to their families, however much they might say I was mad to suggest the things I did. I am sure that they must have picked up on this feeling, and on the fact that I found their little girl increasingly endearing. The second term: the appearance of symbolic play and speech After a term and a bit, I heard that Lisa, now two years old, had had a bad sore throat with a high temperature during the Christmas holiday (her second break). She had previously begun to babble and to point but had lost her voice. This was encouraging: it is known to be a good sign when children on the spectrum become susceptible to everyday illnesses (Tustin 1990, p. 140). She had also produced her first word: pointing to the bulb in the family fridge, she said ‘Light’ (in Spanish): a telling comment, I thought, on the brighter family atmosphere. Lisa now stopped using her parents’ hand to perform a task. In her first session back, she used both her hands to grasp a toy, then tried to take her father’s hand to do something. I said, ‘Lisa, you’ve got two hands of your own’, and somewhat to my amazement she let go of her father’s hand and used both her own instead. She played a game with me and the pop-up people, in which she made eye contact, then waited for me to bang the people with her, co-ordinating her suspense with mine and bursting out laughing. She had still been using the wooden popup toy to brace herself against with both hands, that is, to provide herself with sensory reassurance in a typically ‘autistic’ fashion. But at the end of this session, while her parents were clearing up, she used the little people in a pretend game to feed the teddy she had previously been frightened of. I described what

42  Maria Rhode

she was doing, and her mother, delighted, leaned over to see. Lisa let go of the wooden block, and with a beautiful, arching movement she reached upwards so that her two hands grasped her mother’s face. Her parents had been hard to convince that they mattered, but the evidence was no longer possible to ignore: instead of using her body to get sensory reassurance from the wood, she used it to reach towards her mother in a gesture full of meaning, and their emotion was moving to witness. Lisa’s play continued to develop as her parents talked. Often she swept toys off the table, then flopped down herself as though she were identified with them. At the end of sessions she played peek-a-boo, making me disappear by looking away, then turning back to face me with a huge smile, waving and saying ‘ByeBye’. In February, she stood the green pop-up person inside a green shape, the yellow one inside a yellow shape, then tried unsuccessfully to stand two men in a blue circle shape. Her parents wondered how they could teach her about colours. I said it looked as though she did know her colours; perhaps she was working out something else. She tried to stand three men in a blue plastic circle: they flopped over. Lisa touched them to her lips, then tried again with the same result. Her father found a blue milk jug in her box and put the three people in it: she was thrilled. I asked, ‘Did Daddy have a really good idea?’ Mother beamed. Lisa played at ‘drinking’ the little people, just as she had used them to feed the teddy. I asked her, ‘Mmmm, does that taste lovely?’ She smiled delightedly at me; I commented to the parents that we were witnessing some pretend play, following on from her feeding the teddy, and they beamed too. She was babbling enthusiastically, ‘Dada, baba, bye-bye, baby’. I  mirrored this, and her parents said she had been doing lots of playing with sounds and singing at home. She threw the little people on the floor: ‘Oh’, I said, ‘Lisa threw them away, really cross, didn’t want them there’. She got down on the floor and retrieved them, again beaming. I said something about being cross and making up, and the parents looked at me as though I were mad, though they agreed that communicating through play made sense. At the end of the session, Lisa began to bawl angrily. I said it was horrid stopping when she’d been doing lots of important things. She glared at me, and I commented, ‘Bad lady’. Her father held her on his shoulder so that she could play peek-a-boo, but she just continued glaring. This was one of very few times when she could be appropriately cross: on the whole, the bad, frightening thing remained in the corner or outside the window, while Lisa continued to depend on people’s obvious friendliness. For instance, she was unable to make sense of what Gergely and Watson (1996) call ‘marking’: the raised eyebrows that even young babies can recognise as meaning a ‘pretend’ sad or angry facial expression. The lack of time to work through anger and its consequences was an important disadvantage of just a year’s work. When Lisa was just over two years old, it struck me that, despite all her progress in relating, pretend play and speech, she was still not walking. Sometimes she

‘Finding one’s feet’ 43

appeared to be identified with the revolving animals inside the humming top and would move in a circle around the table while she watched them spin; but she still needed to hold the table as she did so. However, her parents told me that Lisa was very taken with a new pair of shoes and that she stood for long periods of time in front of a full-length mirror pointing proudly at them. At about this time, she enjoyed an extended sequence of play during which, sitting in her pushchair while her parents talked, she inserted her dummy in her mouth, removed and replaced it, and similarly removed her shoes and replaced them on her feet. It was a sequence I was obviously meant to witness and understand, though I  did not comment: she maintained eye contact and smiled at me throughout. She appeared to be confident that she could make the dummy and shoes come back, and that their departure did not leave her with damage to her mouth or feet. I  would see this as evidence that Meltzer’s ‘dual link’ had been inscribed in her legs and feet in the way that Haag proposed: that enough work had been done on people’s comings and goings for her to trust that her body remained intact, so that she and other people did not have to compete for what Tustin called the ‘extra bit that ensures survival’. The third term: the whole-object Oedipus complex Increasingly, Lisa’s play focused on rivalry and exclusion. The little wooden people jostled each other in competition for a hole in the pop-up toy. Lisa piled little dolls and animals into the dolls’ house and threw it angrily onto the floor. Sometimes she then collapsed onto the floor herself, again as though she were identified with the creatures she had thrown away. Two of the four little wooden pop-up people became Mummy and Daddy (she chose the colours to match the clothes her parents were wearing that day), and they kissed at great length while the other two little people were casually discarded. In reality, Lisa regularly came into her parents’ bed, and, for a number of reasons, they were reluctant to limit this. When Lisa was two years and four months old, her parents decided to return to South America. Previously they had hesitated to uproot the children: now they had greater confidence in Lisa’s continuing progress. The following week, Lisa for the first time proudly took several steps towards me along the corridor. In the room, she made the little wooden ‘parent’ dolls kiss, then repeatedly threw them on the floor, crouched down to retrieve them, and stood up again showing us that she held them in her hand. When her parents began to play at making the little people disappear, Lisa determinedly took them back in an assured assertion of ownership. Her parents’ new-found confidence in facing another migration seemed to come together with Lisa’s own greater confidence that she could throw away the mother and father dolls when she was angry at being excluded from the parental relationship, but then retrieve them and reinstate internal parents within herself. It was these internal parents who could then support her in owning her legs and shoes and in being able to walk on her own two feet.

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Discussion In my view, the sequence of events in Lisa’s treatment illustrates the centrality of affect, and also the absence of any linear progression from bodily experience to representation. As Bion (1991, p. 71) wrote, ‘A child learning to walk is engaged in attempting to make conscious material unconscious; only when this is done can it walk. The same is true of every piece of learning ever done – its success depends on the central operations by which dream-work-alpha is able to transform conscious material into unconscious material suitable for unconscious waking thinking’. I would see Lisa as a child with many strengths, who was unusually sensitive to other people’s state of mind and whose mother happened to have a strikingly expressive face. I suspect that, at seven months, she misconstrued her mother’s distressed expression as indicating damage that Lisa herself had caused (Klein 1930; Meltzer 1975). Her consequent withdrawal led to the vicious circle of discouragement that we could observe when her parents did not immediately respond to her glance. When her parents helped her to own her strength and hostile affect, for instance by growling playfully and pushing hard on the humming top, withdrawal in response to anxiety (as Klein proposed) was no longer necessary. Lisa could then move from staring blankly out of the window to locating a threatening presence there. This suggests to me that the blank look was in fact the negative hallucination of a representation, as Rodrigué (1955) has suggested of a three-year-old with autism; which implies that Lisa had achieved a split between good and bad even at the beginning of treatment. Although she did manage to locate a hostile presence in me at the end of the session I described, she was unable to sustain this. The family’s move meant that we did not have time to work this through in the transference, and that remains a major limitation. While representations were in evidence well before she began to walk, as shown by her fear of the teddy and her capacity for speech and symbolic play, the internal fate of those representations – the secure establishment of a good internal figure – was still incompletely resolved. Lisa had been throwing away and retrieving objects for some months before her first steps, but it is hard to be certain whether she became confident of being able to retrieve her good internal parents and took those first steps as a consequence, or whether the play with the parent dolls was a dramatisation of what her evolving motor capacities meant to her. Emotional and physical developments may well have reinforced each other. Lechevalier (2004) has reported the case of a toddler with serious motor impairment who walked normally after a long treatment, but whose scan still showed major cerebellar abnormalities. The interplay between neurology, emotions and motor capacities is obviously highly complex, with many layers of feedback. Successive stages of Lisa’s motor development were marked by different protoOedipal and Oedipal emotional constellations. First came her dependence on a present, integrated parental couple as expressed by the adults’ voices in harmony. Next, her play with her dummy and shoes, and her smiling expectation of my approval, suggested that owning her feet did not damage a mother figure

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or a parental couple (Tustin 1972b), a theme that appeared previously when she insisted on holding on to toys that her mother was playfully hiding. Finally, being able to stand and walk was linked to retrieving the Oedipal parents as whole objects. Lisa’s increasingly secure internalisation of a parental couple would have allowed a lessening reliance on bodily contact and a greater capacity to move through space. As Schilder (1935, p. 172) wrote many years ago, ‘It seems that the emotional unity of the body is dependent on the development of full object relations in the Oedipus complex’. Acknowledgements Grateful thanks to Robin Anderson, Caroline Polmear, Vic Sedlak and Wilhelm Skogstad for helpful comments on earlier drafts. Note 1 This paper was presented at the English-Speaking Weekend Conference on ‘Body, Affect and Representation’, London, 29 September 2018, and at the Scientific Meeting of the British Psychoanalytical Society on 1 May 2019. Some of Lisa’s material was previously published in Varchevker, A. and McGinley, E. (eds) (2013) Enduring Migration Through the Life Cycle. London: Routledge (Rhode 2013).

References Alvarez, A. (2010) ‘Levels of analytic work and levels of pathology: The work of calibration.’ International Journal of Psychoanalysis 91: 859–878. Anzieu, D. (1979) ‘The sound image of the self.’ International Review of Psychoanalysis 6: 23–36. Bick, E. (1968) ‘The experience of the skin in early object relations.’ International Journal of Psychoanalysis 49: 484–486. Bion, W. R. (1991) Cogitations. London: Karnac Books. Damasio, A. (1999) The Feeling of What Happens: Body, Emotion and the Making of Consciousness. New York: Harcourt Brace & Co. Gergely, G. and Watson, J. S. (1996) ‘The social biofeedback theory of parental affect mirroring: The development of emotional self-awareness and self-control in infancy.’ International Journal of Psychoanalysis 77: 1181–1212. Greenspan, S. I. and Wieder, S. (1999) ‘A functional developmental approach to autism spectrum disorders.’ Research and Practice for Persons with Severe Disabilities 24: 147– 161; https://doi.org/10.2511/rpsd.24.3.147 Haag, G. (1991) ‘Nature de quelques identifications dans l’image du corps (hypothèses).’ Journal de la Psychanalyse de l’Enfant 4: 73–92. Houzel, D. (1999) ‘A therapeutic application of infant observation in child psychiatry.’ International Journal of Infant Observation 2: 42–53. Klein, M. (1930) ‘The importance of symbol-formation in the development of the ego.’ In The Writings of Melanie Klein Vol. I: Love, Guilt and Reparation and Other Works. London: Karnac Books, 1975; pp. 219–232. Klein, S. (1980) ‘Autistic phenomena in neurotic patients.’ International Journal of Psychoanalysis 61: 395–402.

46  Maria Rhode Lechevalier, B. (2004) Traitement Psychanalytique Mère-Enfant: Une Approche au Long Cours des Psychoses de l’Enfant. Paris: Editions In Press. Meltzer, D. (1975) ‘The psychology of autistic states and of post-autistic mentality.’ In Meltzer, D., Bremner, J., Hoxter, S., Weddell, D. and Wittenberg, I. (eds) Explorations in Autism. Strath Tay: Clunie Press; pp. 6–32. Meltzer, D. (1986) ‘Concerning the perception of one’s own attributes and its relation to language development.’ In Studies in Extended Metapsychology. Strath Tay: Clunie Press; pp. 175–186. Rhode, M. (2013) ‘Learning to walk down the corridor: Body image, catastrophic anxieties and supportive internal figures.’ In Varchevker, A. and McGinley, E. (eds) Enduring Migration Through the Life Cycle. London: Routledge. Rodrigué, E. (1955) ‘The analysis of a three-year-old mute schizophrenic.’ In Klein, M., Heimann, P. and Money-Kyrle, R. E. (eds) New Directions in Psycho-Analysis. London: Tavistock; pp. 140–179. Schilder, P. (1935) The Image and Appearance of the Human Body. London: Kegan Paul, Trench, Trubner & Co. Tischler, S. (1979) ‘Being with a psychotic child: A psychoanalytical approach to the problems of parents of psychotic children.’ International Journal of Psychoanalysis 60: 29–38. Trevarthen, C. and Delafield-Butt, J. T. (2013) ‘Autism as a developmental disorder in intentional movement and affective engagement.’ Frontiers in Integrative Neuroscience; https://doi.org/10.3389/fnint.2013.00049 Tustin, F. (1972a) ‘Psychotic depression.’ In Autism and Childhood Psychosis. London: Hogarth Press; pp. 4–31. Tustin, F. (1972b) ‘Autistic processes in action.’ In Autism and Childhood Psychosis. London: Hogarth Press; pp. 32–50. Tustin, F. (1980) ‘Autistic objects.’ In Autistic States in Children. London: Routledge, 1981; Second Revised Edition, 1992; pp. 111–126. Tustin, F. (1990) The Protective Shell in Children and Adults. London: Karnac Books. Tustin, F. (1994) ‘Autistic children who are assessed as not brain-damaged.’ Journal of Child Psychotherapy 20: 103–131. Winnicott, D. W. (1949) ‘Birth memories, birth trauma and anxiety.’ In Through Paediatrics to Psycho-Analysis. London: Tavistock, 1958; pp. 174–193.

Chapter 3

Analysing Miss Daisy A psychoanalytically informed treatment of an emerging adult autistic woman Alan Sugarman

Some years ago, I reported my surprise when a colleague told me that patients with Asperger’s syndrome could not be analysed as though it was a well-accepted fact, rather than just his opinion (Sugarman, 2011). That opinion has been repeated by a variety of well-respected analytic colleagues over the subsequent years. They would be even more adamant that patients with autism cannot engage in a psychoanalytic process. And non-analytic professionals can be even more strident. When trying to help the parents of the patient discussed later receive insurance reimbursement, for example, the peer reviewer cited ‘expert’ opinion that autistic patients could not be helped by psychoanalysis. There are several reasons for this continued belief despite the publication of sophisticated discussions of the value of psychoanalysis for these individuals (Sherkow & Harrison, 2014) and case studies demonstrating the remediation of autistic symptoms with analytic treatment (Sherkow, 2011). One of these reasons involves the continued embarrassment of analysts by Bettelheim (1967) blaming the condition on poor parenting. That etiological explanation, ignoring constitutional contributions, has been a black eye for psychoanalysts for ages. But a more serious reason has to do with the continued impression by many analysts and non-analysts, alike, that conditions involving a significant constitutional component cannot be helped with psychoanalytic treatment. Many analysts, and even more non-analysts, seem not to realise that the current non-linear, dynamic systems model of development (Abrams, 2008, 2011; Galatzer-Levy, 2004; Harrison, 2014; Knight, 2011; Lament, 2011; Mayes, 2001; Olesker, 2011; Olesker & Lament, 2008) allows us to expand our understanding of pathogenesis to include far more than solely drive-defence conflicts, primitive anxieties, immature internal object relations or any other single continuously linear developmental line, even when treating neurotic patients. This model is even more helpful at allowing us to consider and expand the array and interaction of etiological factors to analyse patients that in the past would have been regarded as not analysable because they inhabited the farthest reaches of the widening scope. This is particularly true with those patients whose mental organisation lies on the autistic spectrum. Aside from analysts practicing from a Kleinian/Bionian orientation (e.g. Alvarez, 2004; Meltzer et al., 1975; Polmear, 2004; Pozzi, 2003; Rhode & Klauber, 2004), most DOI: 10.4324/9781003202790-7

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analysts have regarded such patients as lying outside the scope of psychoanalysis proper because of the presumed constitutional/organic/biochemical etiology of their problems. It is as though one single system can automatically make analysis impossible. More recently, child analysts using our more contemporary understanding of the complexity of development are questioning this assumption (e.g. Olesker, 1999; Sherkow, 2011; Sherkow & Harrison, 2014; Sugarman, 2011, 2017). These analysts see all pathogenesis, not just that involving autistic patients, as involving some constitutional element. Development has been reconceptualised to involve a sequence of both continuities and discontinuities ‘occurring within a series of progressive differential hierarchical psychological organizations that arise over time’ (Abrams, 2003, p. 175). There are psychological, biological, and social contributions continuously interwoven through all mental structures and functions (Knight, 2011). Current research demonstrates this truism for autism spectrum disorder (ASD). ‘While there is no one cause of autism and no one autism phenotype, it is quite striking that a number of relatively independent models of ASD seem to be reaching similar conclusions. ASD can be considered to be a potentially reversible neurodevelopmental disorder with experiential/psychological consequences, such as early deprivation of growth-promoting parental input, which contributes significantly to the development and maintenance of autistic impairments and suffering’ (Mahler, 1968; Greenspan, 1992; Dawson, 2008; Herbert & Weintraub, 2012; Helt et  al., 2008; Pelphrey  & Carter, 2008; Szalavitz  & Perry, 2010; Sherkow, 2005, 2011; Singletary, 2006, 2009; Sherkow & Harrison, 2014, p. 146). This interaction between multiple systems of the developing mind results in periodic transformations, and new hierarchically ordered reorganisations, that establish a relative homeostatic equilibrium between all of them, including the biological or constitutional. As Gilmore and Meersand (2014) say, ‘This idea of transcending developmental systems obviates the tendency, among developmental thinkers, to assign decisive importance to a singular system, such as genetic endowment, environment, or their interaction, or developmental moment, such as infancy or early childhood’ (p. 2). A logical extension of such thinking is that even patients whose genetic endowment or dispositional elements includes autism may be analysable, depending on the nature of their mental organisation (Mayes, Cohen, & Klin, 1993; Bromfield, 2000; Pozzi, 2003; Rhode & Klauber, 2004). Rhode and Klauber (2004) note, for example, that ‘emotional experience can facilitate the development of brain structure and function, which can, in turn, make it possible to manage even quite severe deficits’ (p. 267). Complicating the matter is that it is not uncommon to see such patients misdiagnosed as clinicians are slow to realise that the symptoms, character traits, defences and behaviour being addressed in the clinical moment should not be formulated reductionistically or separately to be the result of multiple disorders or related to one childhood experience. One reason for this situation is the continued ambiguity about the parameters or boundaries of the diagnosis of autism. ‘In the field of autism and Asperger’s syndrome, however, we are still far from having identified

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all the elements (with the exception of neurological vulnerability (Gillberg, 1991), and there are even arguments about the widths of the syndrome itself’ (Alvarez, 2004, p.  113). This ambiguity is quite apparent in the recent elimination of the diagnostic category of Asperger’s syndrome, and placement of such patients under the rubric of ASD in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), despite clinical experience and research suggesting they are qualitatively different. The challenge for psychoanalysts is to articulate the most useful ways of working analytically with these patients and to clarify how these approaches can help. Most analysts who work with these patients emphasise the need to avoid classical Freudian technique. Classical genetic or dynamic interpretations are said to feel off the point to these patients and leave them sensing that a foreign way of understanding is being forced on them (Rhode, 2004). Consequently, much of the analytic work with these patients is based on Bionian, British Object Relations or Kleinian theory (Meltzer et  al., 1975; Pozzi, 2003; Alvarez, 2004; Rhode & Klauber, 2004). More than theoretical bias accounts for these preferences. Both classical and modern Freudian technique tend to prioritize verbal interpretation designed to provide insight into unconscious mental content to promote structural change. Too many contemporary Freudian analysts continue to see their task as decoding the unconscious meaning of the patients’ words to help the patient make the unconscious conscious. This approach ignores the finding that autistic patients have significant problems with mentalisation and have never developed a theory of mind (Mayes, Cohen, & Klin, 1993; Mayes & Cohen, 1994, 1996; Shapiro, 2000; Volkmar, 2000; Jacobsen, 2003; Sherkow & Harrison, 2014). Unable to understand their own mind of feelings, fantasies or thoughts, as well as the minds of others, they retreat to perseverative, concrete, odd preoccupations that fend off relating to these others (Sherkow  & Harrison, 2014). All the other important mental functions that cascade from the ability to mentalise their own and others’ minds fail to develop or develop in skewed and deviant ways. Reality testing, separation-individuation, self and object constancy, empathy, affect regulation, narcissistic regulation, etc. are all impaired. Autistic children’s impact on the mother’s capacity for normal mental attunement during development is often recapitulated in their disruption of the analyst’s capacity for empathic attunement during treatment. Autistic patients’ failure to have allowed their mothers to be ‘good enough’ thereby disrupting their mother’s capacity to offer a secure attachment experience is too easily enacted and repeated in treatment. ‘Expressed from a neuroscience perspective, [maternal] preoccupation can be thought of as heightening a mother’s ability to detect and be responsive to infant signals across sensory domains’ (Rutherford & Mayes, 2014, p. 53). But this preoccupation quickly stagnates under the helplessness and hopelessness that autistic infants stimulate through their difficulties in reciprocating or being soothed. It becomes difficult to remain sensitive when the other fails to seem interested or appreciative of one’s efforts. The same thing happens often in analysis. Just as parents adapt in many ways to such infants, so do analysts with

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such patients. Denial and subtle reinforcement of their problems in relating are not uncommon countertransference enactments. Because autistic patients have serious impairments in mentalising, affect regulation, self and object representational capacity, and social language, trying to make them aware of the disguised meaning of their thoughts, feelings or fantasies will only confuse them or cause them to feel rejected, criticised or attacked. Adhering to such an approach can be an expression of the countertransference difficulties mentioned earlier. Instead, we must work with them in a way that helps them to develop a capacity to mentalise. Most autistic patients come to analysis lacking much awareness that they and others have an internal world of thoughts, feelings and fantasies that contribute to behaviour. Likewise, they do not understand that actions and interactions impact this inner world. It is important for analysts not to think of these problems in a linear fashion. As Olesker (2011) notes, too often mentalisation problems and their sequelae are discussed as though they are carried forward in an unaltered fashion through development. It is more useful to remember that they will both affect and be affected by transformations and progressive reorganisations at each developmental epoch. Likewise, they will change during analytic treatment in a progressive but not stepwise linear fashion. In the next section, I describe my ongoing analytic treatment of an autistic young woman. Her history and clinical presentation exemplify some of the diagnostic problems that these patients can pose. And our attempts to engage collaboratively in a psychoanalytic treatment offer one technical approach to promoting mentalisation with such individuals. This approach is not meant to be prescriptive. Rather, it is an example of the flexibility needed with these patients and the utility of a background in treating children while thinking of them developmentally. Lacey Approximately seven years ago I received a call from Lacey’s father asking me to consult about his then 18-year-old daughter. His psychiatrist had told him that I had experience with patients on the autistic spectrum, and that his daughter, Lacey, could benefit from a psychoanalytic approach. Various experts had thought that she might be autistic, but there was no consensus about her diagnosis. Her school system and the parents’ educational consultant were recommending that Lacey be placed in a long-term residential care facility at that time because of her refusal to attend school, rage, emotional lability and seeming disinterest in autonomy. But Mr and Mrs S were desperate to find another treatment approach that could allow their beloved daughter to remain at home. To use American slang, he and his wife wanted to try a last-ditch ‘Hail Mary’ to save Lacey from what they feared would become a lifelong institutionalisation. Despite a lengthy phone conversation, it was not until I met with the parents, in person, that I grasped how completely they had spent their entire parenthood trying to find professionals to ‘cure’ their confusingly impaired child. That parental meeting fleshed out the brief history that Mr S had described in his initial phone call. They

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explained that they had adopted Lacey when she was ten months of age from an orphanage in Africa where she had been abandoned at four days of age. Lacey’s parents described how dismayed they had been to see how neglected and injured Lacey was. At adoption, she was seriously malnourished, emotionally deprived and had a flat space on her skull from having been left lying in her crib in a position that allowed her to suck from a feeding tube. Later brain scans found decreased prefrontal, temporal, occipital and parietal activity in the left hemisphere. Not surprisingly, Lacey’s cognitive, emotional and relational development back in the US was always delayed. In contrast, her physical growth and weight gain were rapid once provided adequate nutrition. Outside of these, every other developmental milestone was significantly delayed; most of her life had involved special schools, psycho-educational interventions and surgical procedures to correct a variety of orthopedic and visual problems. In addition, the parents had consulted with multiple mental health professionals over the years for Lacey’s serious difficulties with self-regulation. Rage outbursts, panic attacks, attentional difficulties and problematic ways of relating with others had led to a virtual smorgasbord of medications and psychiatric diagnoses. None of the many professionals seen offered a compelling diagnosis, explanation of her difficulties or adequate treatment. Perusal of her voluminous medical records revealed the worst applications of a descriptive psychiatric nosological system. Each of Lacey’s symptoms had a specific diagnosis attached to it by one professional or another, while most were also treated with medications specific to that diagnosis. For example, her emotional lability led to a diagnosis of bipolar disorder and treatment with mood stabilising drugs. Problematic concentration prompted an attention-deficit hyperactivity disorder (ADHD) diagnosis and the prescribing of stimulant medication. Perseverative thinking resulted in a diagnosis of obsessivecompulsive disorder and treatment with selective serotonin reuptake inhibitor (SSRI) medication. Poor reality testing was thought to involve psychosis needing anti-psychotic medication, and so on. At the time of the consultation, Lacey would perseverate in her thinking and conversation about various subjects: her country of origin, the nature of her sexuality, her idiosyncratic hobbies, etc. She showed no sensitivity to others’ reactions to being barraged with verbiage about whatever seemed important to her in the moment. Her lack of mentalisation left her unable to grasp that others’ minds could be different than hers and have other interests. Consequently, she gave the appearance of being grossly egocentric and lacking in empathy. Such behaviour led to her being ridiculed and rejected by peers and was used by her treaters and teachers to support the diagnosis of obsessive-compulsive disorder. In addition, she would loudly yell out threats to kill herself or others when overwhelmed by emotions, particularly hurt feelings over feeling ignored. Her parents, fellow students, teachers and treaters were frightened by these rants that they took as literal threats. That is, they were seen as examples of suicidal or homicidal ideation by those around Lacey instead of recognised as just inappropriate expressions of anger or demands for attention. Again, her lack of mentalisation left Lacey not realising the impact of her words on the internal states of those around her.

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Likewise, her emotional lability was interpreted as evidence of bipolar mood swings instead of being recognised as due to her exquisitely vulnerable narcissism and lack of affect regulation secondary to her lacking a theory of mind. Not surprisingly, her interpersonal relations were shallow and confused. Lacey regarded others as existing solely to meet her inordinate wishes for attention, validation and acceptance. Serious sleep problems seemed related to her omnipresent anxiety and sadness as did her attentional difficulties that were misunderstood as ADHD. Compulsive lying, separation problems and excessive guilt were also reported. Finally, her IQ was reported to be 81 despite her seeming notably brighter in conversation with me. Lacey showed me an ability to think abstractly in a way that would be impossible were her tested IQ accurate. A variety of cognitive-behavioural treatments had been attempted by several practitioners, while a cocktail of medications was always being modified due to varying effectiveness and/or problematic side effects. In essence, Lacey’s thick chart revealed that no one understood what exactly her problem was or tried to talk with her about her inner world; rather they focused solely on her behaviour. She was shuffled from one educational setting to another after being either expelled for difficult behaviour or withdrawn by her parents because the school did not understand or help her to deal with her emotional dysregulation. At the time of the consultation, she was refusing to attend her special education program at the neighbourhood high school. In response, the school authorities were urging Lacey’s parents to institutionalise her. Once again, the approach just emphasised behavioural management. After an extensive review of her records, several parental meetings to flesh out the symptom picture and her developmental history, and several sessions with Lacey, I formulated her plethora of symptoms to primarily involve autism and early trauma associated with the emotional deprivation of her first ten months in the orphanage. I thought that her autism, with its constitutionally based problems with mentalising, interacted with a traumatic lack of access to an early figure for attachment, leaving her unable to grasp that the processes and contents of her own and others’ minds caused both her own and others’ behaviour. Consequently, Lacey’s social world felt chaotic and frightening because it seemed so arbitrary and incomprehensible (Sugarman, 2011, 2017). Relating to others became a never-ending series of mishaps leading to omnipresent anxiety, low self-esteem, fears of separating, inappropriate and off-putting behaviour, difficulty distinguishing fantasy from reality and so on. I thought that her intense sadness, anger and general emotional lability were secondary reactions to her problems with understanding her inner and outer worlds. She was also struggling with the sexual and aggressive urges of adolescence and emerging adulthood at the time of the consultation. Based on this formulation, I recommended a trial of four sessions weekly psychoanalysis and weekly parental meetings. It appeared that none of Lacey’s previous treaters or educators had ever attempted to explore her inner world with her or to link it to her problematic behaviours. Inadvertently, their behavioural emphases had only exacerbated her inability to mentalise by focussing solely on manifest behaviour rather than her inner world. I thought that regular parental meetings

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were necessary to teach her parents to think about their daughter’s mind, not just her behaviour. In addition, I find approaching parental work in the way that Novick and Novick (2005) describe useful. Mr and Mrs S readily agreed to this plan with an air of desperation because they felt it was the only chance to avoid institutionalising Lacey. Lacey, herself, agreed to the plan in a more compliant manner. She was not aware of the looming danger of being placed in a residential treatment centre. Rather, she wanted to please her parents and showed some curiosity about my talking with her. Opening phase of the analysis Hence, she took to the analytic frame readily. Our earliest sessions were spent answering her questions about analysis and what made it different than the other therapies she had experienced previously. I thought such questions indicated greater capacity for abstract thinking and mentalisation than her history and testing suggested possible. Her genuine interest in understanding gave me some cautious optimism. I underlined that the major difference involved us talking about her thoughts and feelings with the goal of understanding what went on in her mind. Her most prominent anxiety, at this time, was that analytic frequency meant she was more disturbed than classmates and acquaintances from her previous schools. This early in the treatment, I resorted to reassurance more than interpretations or explorations because her capacity to manage the anxiety associated with verbalising her fantasies seemed tenuous. Thus, we settled on the ‘mantra’ that she suffered from ‘high-functioning autism’ to maintain her narcissistic equilibrium. For the first few years of the analysis, Lacey regularly returned to the idea that she was high functioning to reassure herself that she was not as defective and unlovable as she felt. This narcissistic equilibrium, as well as her tolerance for anxiety and dysphoria, remained precarious in the early stages of the treatment, and so did her comfort with emotionally connecting with me. One early session began with Lacey sitting in the waiting room with her parents while avoiding eye contact with me when I entered and walked with her to my consulting room. She began to cry as soon as she settled into her chair, describing how confusing she had found the words of classmates in her previous school. Lacey exclaimed that she wanted to stab herself because these experiences were so upsetting. I ‘wondered’ whether these ideas of hurting herself might help her to calm herself. My interpretation was primarily intended to encourage her to think about her wishes having meaning. To me, their specific content was less important at that time, although I was thinking about her turning passive into active and self-soothing through self-mutilating fantasies. She agreed and described her interpersonal stresses in more detail, explaining that yelling about stabbing herself seemed the only way to calm herself in the moment. At this early point, I underestimated her ability to work analytically and lapsed into supportive suggestions about alternative self-soothing strategies rather than taking the opportunity to show her how she tried to focus on behaviour rather than her mind to self-regulate. Without warning, Lacey became enraged and stormed out screaming to her parents in the waiting room. I followed and sat quietly while they

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physically restrained her from running out of the office. My quietness was due to my worry that anything I said might only provoke her further. Eventually Mr and Mrs S persuaded her to return to my office without them. Lacey went to the couch upon her return and spoke of wanting to die. I empathised that she probably felt like that was the only way to get rid of her sad feelings and linked this wish to other ways she dealt with sadness – by avoiding situations that might stimulate it or by hiding it beneath her anger. Lacey responded that she was too ‘depressed’ to talk and asked despairingly how I thought I could help her. We talked about her previous treaters as she complained plaintively that people always say they will help her but do not do so. I acknowledged how much she must doubt me and admitted that I could not yet say how I could help her. But she and I together might figure out how she could become happy. Lacey inquired into my ideas about her unhappiness. This curiosity about my mind again seemed positive and unexpected. In an effort to nurture mentalisation, I explained that I suspected that her autism made it difficult to be happy, and that this difficulty had been exacerbated by her ten months of feeling abandoned and neglected in the orphanage. Lacey associated to her shame and despair at having become obsessed with a previous teacher, Miss K so that she felt abandoned by her when she was expelled from the school. I said I suspected that she felt everyone eventually leaves her, to which Lacey replied, ‘They do!’ She then berated herself for being ‘crazy’ and ‘violent’ thereby causing others to leave. I suggested that she might do so to feel in control of the rejection that terrified her. At that point it was time to stop the session. Lacey said that she wanted to have another one with me because our talking had been ‘nice’. These early sessions left me cautiously hopeful about an analytic treatment with Lacey, despite her emotional lability, narcissistic vulnerability and vacillating reality testing. The latter became apparent a month later when Lacey reported wanting to visit a teacher at home after ‘fighting’ with her for three straight weeks at her new school. She worried the teacher might shoot her with a gun if she appeared unannounced. Therefore, she pondered letting the teacher know about her visit in advance. Lacey questioned whether the teacher hated her because she had called Lacey a ‘black bitch’ and a ‘slut’. In addition, the teacher thought that Lacey was gay after observing Lacey ‘humping a friend just to be silly’. During the early years of the analysis, stories like this could not be taken as veridical. It was unclear whether Lacey was consciously making them up, confabulating or episodically delusional. She could eventually admit their fabrication when her parents or I confronted her. But we all remained unsure whether such admission simply involved capitulation to avoid further confrontation or genuine self-realisation. Some useful work was done by my interpreting such ‘stories’ as ways to make sense of a social world that she found confusing. But, other times, she simply dismissed them as being a ‘drama queen’ when I questioned their reality. They slowly abated over the first few years of treatment without direct analysis as our work deepened. Two other themes characterised our early work. One was her unrequited love for a younger boy from school and the other was her sexuality. Noah, the boy at school, suffered from Asperger’s syndrome and had recently ‘come out’ as gay.

Analysing Miss Daisy 55

His newly admitted attraction to boys devastated Lacey as her long-standing crush was disappointed. Sessions were intermixed with plaintive crying or rage over feeling scorned. Often her anger led to peculiar and inappropriate sexual or racist statements. Lacey regularly lashed out with racial or ethnic slurs, infuriating the school staff and parents of the classmates toward whom she vented her spleen, and humiliating and horrifying her liberal, progressive parents. In sessions, she seemed surprised that I remained curious about these ways of expressing her hurt and anger instead of berating her. Seemingly related to her disappointment with Noah was her incessant insistence that she, too, was gay. My attempts to understand how she understood gayness and what she meant by it were usually met with defensive anger that I did not believe her. When pressed for an answer about whether I believed her to be gay, I emphasised its importance to her while explaining that I remained unclear if she understood herself enough to know her sexuality. Interpreting her wish to be like Noah by being gay seemed unwise as it was likely to feel like an accusation or invalidation. Lacey’s sensitivity to whether others liked or were even interested in her was incessantly manifested throughout the early phases of treatment. Thus, my neutrality and evenness of mood were often experienced as disinterest or disapproval of her. I was aware of frequently feeling drained by the need to be exuberant or hyperbolic to prevent her from feeling hurt or rejected. In one early session, she requested that I be ‘more lively’ as she walked in. Exploring the request led her to admit that she assumed anything less than extreme enthusiasm on my part indicated that I did not want to see her. Later in the session she anxiously asked whether it was time to stop when I shifted my position in the chair. I suggested that she leapt to the conclusion that I was ready to leave her because she felt so anxious not understanding why I might have shifted in my chair. At this early point, I had found that trying to explore her sensitivity to separation or rejection more specifically led only to circular statements about not being liked. Hence, I chose instead to focus on her difficulties with mentalising and her attempts to cope with the anxiety that it caused. Middle phase of the analysis The treatment continued to deepen during the first few years. As Lacey found value in talking about her worries, fantasies and preoccupations, she functioned adequately in another new school and developed genuine friendships with two classmates. She spent time with them outside of school and expressed future goals for the first time in her parents’ memories. Thus, she proclaimed interest in eventually moving out of their house and into a group home. She also became interested in ‘going to college’, by which she meant enrolling in programs for individuals like herself that a variety of universities offered on their campuses. Doing so would require her to move to another state because appropriate programs were not available in California. Separation was becoming something that she could think about without panicking until her closest friends graduated from school and moved away.

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It quickly became obvious that the loss of her friends and anticipated loss of her parents and me was more than Lacey could bear. She quickly sabotaged her potential admission to these special college programs while once again refusing to attend school. Lacey also became symptomatically depressed. Various medication changes did not help. Instead, Lacey continued spiralling down while missing sessions because of falling asleep at home and refusing to be awakened by her parents. They, in turn, became frantic at seeing the changes of the last two years slipping away. In this context, I  made two significant changes to the analytic frame. First, I referred them to a new psychiatrist who replaced the strong medications being prescribed with SSRIs and beta-blocker medications. The second frame modification is the point of this chapter. One day during this period, Lacey carried a stuffed monkey into the session. She had often brought in stuffed animals or cartoon figures like SpongeBob in the past; we would talk about them and what she found interesting in the television programs that gave rise to them. This time, I did something different. I began to talk to the monkey in the way I do with the pre-latency children whom I analyse. This was not a planned or well-thought-out intervention. Spontaneously, and for reasons I did not understand, I found myself asking, ‘Hi monkey, what’s your name?’ Equally unexpected, the monkey responded that her name was Daisy. Daisy talked to me in a quite different voice than Lacey’s. She explained that she was a ‘service monkey’ who accompanied Lacey to keep her calm. From that point on, Daisy accompanied Lacey to sessions and everywhere else in her life. When in public situations in which Lacey or her parents might be embarrassed to have a 20-year-old woman carrying a stuffed animal, Daisy rode in Lacey’s backpack. Knowing that Daisy was present allowed Lacey to remain calm. Soon Daisy told me her life story and how she had become a service monkey. I learnt that like Lacey, Daisy was an orphan. Her mother had been a chimpanzee in Africa and her father was the movie star, King Kong. Daisy was six years old when she began attending our sessions. Her father had abandoned his family years ago, so that she had not seen him in years. Daisy’s mother had been killed by hunters, leaving her an orphan in the jungle until some scientists found her and used her in their experiments. Over the years, the story of these experiments evolved to them being the famous Harlow studies with cloth and wire monkeys. Lacey and Daisy had found these studies on YouTube and watched them together. Daisy would cry to me about how cruelly the baby monkeys in the experiments were treated, and how glad she felt to have escaped and found her way to becoming Lacey’s service monkey. Over the past five years we have used this story and others to analyse Lacey’s various conflicts and unconscious fantasies in a way that has deepened the analysis by promoting Lacey’s ability to mentalise. For example, Daisy’s life story allowed us to explore Lacey’s feelings about being adopted, fantasies about her birth mother, and how these feelings and fantasies affect her actual functioning in the external world. We do so through my conversations with Daisy. Daisy reports on what Lacey has been thinking, feeling and doing while I suggest various ways to understand or ask questions to deepen our exploration of Lacey’s internal world.

Analysing Miss Daisy 57

Working as a team with Daisy has been surprisingly fruitful and led to a psychoanalytic process comparable to many I have seen with neurotic patients. For example, Daisy has described to me Lacey’s feelings that her ‘birth mother’ had given her up because she was defective. According to Daisy, Lacey reportedly calls African Americans and autistic individuals, ‘monkeys’, highlighting her pervasive self-devaluation. Not surprisingly, Lacey believed that her autism was the reason that she was abandoned. Both Daisy and Lacey have cried about being abandoned by their mothers with Lacey also lamenting about her autism feeling like a repugnant defect. At other times, Lacey fantasised that she had been abandoned because she was a girl. She knew that her African culture valued male children so that her ‘inferior’ gender could have led to abandonment. During this work, Daisy reported that Lacey had been looking at pictures from African orphanages on YouTube. We discussed how painful these videos were to watch while Daisy elaborated Lacey’s fantasy that she would have died from starvation had she not been adopted. Daisy also told me that Lacey felt ‘different’ because she looked different from the rest of her Caucasian family. Shame about her skin colouring interacted with guilty speculations that her parents must lament having a defective child and wish they could ‘send’ her back to the orphanage. Her intense shame made it difficult for her to believe they genuinely loved her. Her longing for reassurance and tangible evidence of being loved was usually expressed through nonstop barrage of requests for toys, electronics, expensive entertainment like Disneyland or elaborate parties. Lacey’s parents felt beleaguered by what they experienced as simply her demandingness and egocentrism. They were only a middle-class family and felt upset at her seeming obliviousness to their financial limitations. Their resentment was only compounded by the strain of paying for her analysis. In our parent sessions, I tried to help them to empathise with her by explaining the dynamic issues and mentalisation problems contributing to Lacey’s requests. Daisy proved a crucial ally in my efforts to explore this behaviour and its meanings with Lacey. She regularly regaled me with Lacey’s excitement about her latest request and anticipation of the happiness it would bring, or Lacey’s resentful sadness when her parents rejected a request. This first-hand experience of her hunger in the sessions allowed me to point out to Daisy that Lacey never seemed satisfied. As soon as one wish was granted, she was wishing for something else. Had I said this directly to Lacey, she would have felt criticised and hurt. But speaking to Daisy allowed Lacey to consider my point and wonder about it in the play space (Frankel, 2011) we had created. Even then, Daisy and I had to work together to find the correct words to describe Lacey’s inner states. For example, I initially suggested to Daisy that Lacey might be ‘hungry’ for her mother’s love and looked to ‘things’ to ‘fill her up’. That metaphor proved too abstract as Daisy pressed me for how one can be hungry for love or be filled up by ‘things’. Trial and error allowed us to hit on the understanding that Lacey felt that her birth mother must not have loved her, so that ‘things’ helped to make her enormous sadness go away. As Daisy and I  worked through this understanding over the years, Lacey became significantly

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less demanding and stopped her tendency to always plan years in advance for the next holiday and gifts. Daisy also helped me to analyse Lacey’s long-standing tendency to fixate on attractive female teachers, fixations that took on a stalking quality. Approximately a year before Daisy appeared on the scene, a favourite teacher left the school. The parents attempted to mitigate Lacey’s loss, at the time, by arranging for the teacher to be available for weekly phone calls and periodic in-person meetings with her. Soon, however, the teacher’s personal life became too busy to allow such regular contact. By the time that Daisy arrived, Lacey was fuming and feeling betrayed that the teacher claimed to be her friend and care for her, only to abandon her. Soon Lacey began to obsessively follow the teacher on social media, becoming incensed when the teacher found a new boyfriend. Daisy reported that Lacey was particularly preoccupied with the idea of the teacher having sex with the boyfriend. Exploration of this matter with Daisy led her to explain that Lacey was jealous that she did not have a boyfriend with whom to have sex, that she was envious of the teacher’s physical beauty, and that she felt rejected because the teacher obviously preferred being with a ‘boy’ to being with her. Daisy, herself, realised that this last feeling could be traced to Lacey’s fantasy of being abandoned by her birth mother because she was female. By this point in analysis, Daisy was developing a capacity for mentalisation without suggestions by me. Despite extensive and deep work with these feelings, Daisy reported to me one session that Lacey had sent inappropriate emails/texts to the teacher while Daisy was ‘taking a break at the banana shack’. Daisy was quite worried that I would blame her for Lacey’s actions. Further discussion revealed that Lacey’s emails/texts had contained inappropriate and graphic comments about the sexual relationship between the teacher and the boyfriend. But despite Daisy’s anxiety, neither she nor Lacey seemed aware of how frightened or angry these communications might make the teacher or how she might respond. They simply worried that they would get in trouble. Mentalisation had temporarily broken down under the pressure of Lacey’s intense feelings of abandonment and primitive super-ego. Denial, although present, seemed less a factor than Lacey’s lack of empathy that I saw as caused by her fragile and vulnerable mentalising capacities. Based on this sense of her, I shared my anticipation of the teacher’s emotional and behavioural reactions, highlighting how anxious and intruded upon she would likely feel. I explained how these feelings would probably lead her to complain to Lacey’s parents. These explanations were intended to promote Lacey’s capacity to think about others’ internal states and how they could be affected by her behaviour. Being correct on all accounts seemed to give me a credibility in Lacey’s eyes that reinstated Daisy’s curiosity about why Lacey had done what she did. That work allowed me to point out Lacey’s typical expression of hurt and anger through inappropriate sexual comments or behaviour to Daisy. At first, Daisy did not grasp what I meant. Further explanation allowed her to do so and to wonder, herself, why Lacey used sexuality in this way. Exploring this tendency led me to demonstrate that Daisy, too, often made crude sexual comments for reasons that

Analysing Miss Daisy 59

were unclear. Further reflection led Daisy to explain Lacey’s envy of attractive women who were able to attract men who wanted sex with them. During a recent session where we examined this feeling in some depth, Lacey spoke for herself about her envying a pretty friend, and her own mother, who had been a cheerleader in high school. From her perspective her mother ‘was pretty so that all the guys wanted to fuck her!’ In contrast, Lacey sobbed that she felt ‘fat and ugly’ so that no one would ever want to ‘fuck me’. To date, we do not fully understand Lacey’s odd use of sexuality to express aggression. But one element involves it being a defence against her narcissistic vulnerability. In that vein, Daisy was again helpful in promoting Lacey’s exploration of her inner world. Thus, Daisy reported that Lacey wanted to have sex but was afraid of becoming pregnant. Exploring that fear led Daisy to report that Lacey felt that she was incapable of mothering. If she became pregnant, she would be faced with the choice of an abortion or giving the baby up for adoption. Either alternative would be traumatic because it would stir up her feelings about her own birth and adoption. Haltingly, between tears, Daisy described Lacey’s fantasy that her birth mother had considered abortion and probably wished that she had done so. To abort her own child would feel like Lacey was aborting herself. Similarly, to give her baby up for adoption would mean that she was rejecting and abandoning her baby in the way that her birth mother had done. Both Daisy and Lacey sobbed as Daisy described how traumatic that would feel. To solve Lacey’s dilemma of wanting to be a sexual woman and attractive without risking pregnancy, Daisy researched birth control methods. She and Lacey concluded that tubal ligation was the only foolproof method. Together they enlisted Mrs S’s support in convincing Mr S to allow the procedure. After doing so, Lacey set a target date of her 25th birthday. As the date drew near, Daisy talked of Lacey’s wishes and fantasies of being normal so that she could have a baby. She also described Lacey’s wish that she could meet her birth mother and ask why she had been given up. In that context, she admitted Lacey’s preoccupation with and fantasies about sucking other women’s breasts. Doing so would be like ‘the way it was supposed to be’. I added that she meant being normal and being raised by a birth mother who breastfed her. Daisy indignantly told me not to talk so much. I asked whether my words had been correct, and she responded, ‘Yes but talking about these feelings is hard work!’ That work coincided with Daisy bragging about Lacey’s lack of jealousy when her best friend’s boyfriend had asked to join them on a get-together. We both noticed how Lacey seemed more secure in her friendships. Daisy reported Lacey even not being jealous that the best friend was getting a manicure with another friend during Lacey’s session with me. At this point, I will end my discussion of Lacey and Daisy. This chapter is not meant to be an exhaustive discussion of the case. Rather, vignettes from Lacey’s analysis have been offered to illustrate the way in which developing the relationship between Daisy and me facilitated a deep analytic process with a patient who many would regard as beyond the widened scope of psychoanalytic treatment. I turn now to my thoughts about why using Daisy in this way was so helpful.

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How did the use of the stuffed monkey facilitate Lacey’s psychoanalytic process? As mentioned earlier, my way of working via Daisy is a common technique I use in analysing young children. It is based on my experience that children can often mentalise in the displacement offered by play in a way that they cannot if one focuses directly on their internal states (Sugarman, 2003, 2008). Complex mental states can only be examined in the pretend mode without overwhelming anxiety if a child has not yet integrated the psychic equivalence mode with it (Fonagy et al., 2002). Child analysts often try to promote the child patient’s conscious awareness of their own mental processes, while accepting that not all children, especially younger ones, can tolerate direct, self-reflective awareness of their own internal workings. Working analytically with them requires the child analyst to remain cognizant of a young patient’s developmental limitations as well as anxieties about fully knowing their own mind, particularly painful affects (Hoffman, 2006). In many ways the situation is the same with autistic patients. Internal conflict, fear of affects and developmental incapacity affect the degree to which we can promote explicit conscious insightfulness in children, just as they do with patients like Lacey. Such limitations lead child analysts to work in the play via displacement. Doing so helps the child to develop an imaginative narrative, frequently promotes the child’s conscious access to and interest in the internal world of feelings, ideas, wishes, beliefs, fears and so forth (Cohen & Solnit, 1993; Mayes & Cohen, 1992; Scott, 1998; Slade, 1994; Yanof, 1996). Such play can promote conscious insightfulness and mastering of trauma to a significant degree; that is, it fosters the development of more mature forms of conscious self-knowledge. This clearly happened through using Daisy. Staying in the play and discussing with Daisy Lacey’s traumas of being abandoned by her birth mother and having autism, has promoted mentalisation and significant improvement in conscious self-knowledge. Had I tried to do this work by speaking directly with Lacey, she would have been overwhelmed by her affects because she had not yet developed the awareness that internal states like thoughts, emotions and fantasies were not veridical replications of external reality. She, too often, functioned in a mode of psychic equivalence, or symbolic equations (Segal, 1978), lacking an ability to create higher-order mental representations (Tuch, 2007). This use of the displacement into play as a vehicle for promoting mentalisation because it acts as a way station on the route to direct verbal, symbolic awareness and processing can be undervalued or vaguely understood in analytic work (Sugarman, 2003, 2006). Many analysts fail to realise that remaining in the displacement allows the patient with developmentally impaired mentalisation to know their thoughts and emotions without feeling anxious. Because displacement is traditionally categorised as a defence mechanism, it is easy to assume that it should be analysed as such: that is, why does the patient need to displace? Indeed, Ekstein and Wallerstein (1956) stress its defensive function. And, sometimes, its defensive function does eventually need to be analysed. But Neubauer (1994) points out that displacement is an unusual defence because it does not alter that which is being

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defended or even remove it from consciousness. It only changes the venue of the issues being defended. ‘Thus, while most defense mechanisms restrain drive derivatives, displacement places them where ego mastery over them may be obtained’ (p. 108). Consequently, all elements of the issues being dealt with (impulses, memories of trauma, defences, feared consequences, painful affects, prohibitions and ideals) remain consciously visible and available in the displacement. Hence, the analyst of patients such as Lacey can use the displacement into play to promote conscious experiencing and processing of all elements of the inner world. To be sure, most child analysts do use play in this manner. It is the way in which such play can be conceptualised as facilitating the process of insightfulness with older patients who have difficulties with mentalising that is the point of this chapter. Specifically, the play function in the analysis of autistic patients is an important one because it involves the patient’s employment of fantasy to experience and communicate aspects of the internal and external worlds. Daisy’s discussions of Lacey’s mental workings offer an excellent case in point. Mental development is characterised by a gradual progression from concrete, action modes of experiencing and communicating to fantasy modes to ultimately abstract, symbolic ones (Aron, 2000; Santostefano, 1977; Sugarman, 2006; Tuch, 2007). Hence, fantasising is a complex mental process that does not develop until somewhere between the ages of three and five years after several other developmental attainments have occurred. Once it does so, it facilitates a variety of other mental achievements. ‘Particularly for the 3- to 5-year-old child, imagination represents a special mode of mental functioning which allows him to expand his internal object world, motivates him toward increasingly complex relationships with others’ (Mayes & Cohen, 1992, p. 23). Thus, the capacity to use fantasy to process and communicate both inner and outer experience via play is an important mental function to encourage in patients with impaired mentalisation. My willingness to speak with and relate to Daisy, in part, motivated Lacey to self-reflect and think about herself and others in more sophisticated ways. Working and interpreting within the play with Daisy allowed her to put into words, think about and become used to knowing her fears, wishes and prohibitions about her traumas and their related affects without fearing being overwhelmed by the anxiety that might otherwise be stimulated by the pain of knowing trauma-based emotions before she felt ready to do so. ‘The child can in pretend mode use his growing capacity to mentalize without the immediate threat to his internal equilibrium that might arise as a consequence of too direct reference to internal experience’ (Joyce  & Stoker, 2000, p.  1148). The same happened through Lacey and I pretending that Daisy was real and a spokesperson for Lacey. I leave off the description of my work with Lacey with many questions unanswered. What is my analytic goal with her, for example? It seems unrealistic to think that analysis will eradicate her autism. Nonetheless, it has helped her master many of her developmental limitations, already. Sherkow and Harrison (2014) see this significant help with developmental deficits to be a goal of such analyses. Another question involves whether Lacey will ever be able to give up

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Daisy and work analytically in a more direct way. She has made some attempts to do so over the last two years. These efforts have generally been successful; but after a few weeks Daisy comes out of ‘retirement’. I also wonder about termination criteria with a patient such as Lacey. She has already changed far more than her parents ever expected, leaving all of us uncertain about her ultimate capacities. Yet, the fact that I am the same age as her father leaves us all thinking about how to plan for when we will no longer be available. Sometimes, Daisy brings up fantasies about her next therapist when I ‘retire’. Thus, that loss appears to be on Lacey’s mind also and will need to be explored. My hope, however, is that despite these unanswered questions, description of my use of Daisy with Lacey can help us to think heuristically about the analytic treatment of patients with autism. In particular, it offers one way to promote the capacity to mentalise that experts believe is the essential impairment that such patients bring to treatment. References Abrams, S. (2003). Looking forwards and backwards. Psychoanalytic Study of the Child, 58: 172–186. Abrams, S. (2008). Transformation: identifying a specific mode of change: descriptive and conceptual considerations. Psychoanalytic Study of the Child, 63: 312–320. Abrams, S. (2011). Steps and lines: introducing nonlinear thinking into the psychoanalytic conversation. Psychoanalytic Study of the Child, 65: 3–4. Alvarez, A. (2004). Issues in assessment: Asperger’s syndrome and personality. In: The Many Faces of Asperger’s Syndrome, eds. M. Rhode & T. Klauber. London: Karnac Books, pp. 113–128. Aron, L. (2000). Self-reflexivity and the therapeutic action of psychoanalysis. Psychoanalytic Psychology, 17: 667–689. Bettelheim, B. (1967). The Empty Fortress: Infantile Autism and the Birth of the Self. New York: The Free Press. Bromfield, R. (2000). It’s the tortoise’s race: long-term psycho-dynamic psychotherapy with a high-functioning autistic adolescent. Psychoanalytic Inquiry, 20: 732–745. Cohen, P.M. & Solnit, A. (1993). Play and therapeutic action. Psychoanalytic Study of the Child, 48: 49–63. Dawson, G. (2008). Early behavioral intervention, brain plasticity, and the prevention of autism spectrum disorder. Development and Psychopathology, 20: 775–803. Ekstein, R. & Wallerstein, J. (1956). Observations on the psychotherapy of borderline and psychotic children. Psychoanalytic Study of the Child, 11: 303–311. Fonagy, P., Gergely, G., Jurist, E.L. & Target, M. (2002). Affect Regulation, Mentalization, and the Development of the Self. New York: Other Press. Frankel, J. (2011). The analytic state of consciousness as a form of play and a foundational transference. International Journal of Psychoanalysis, 92: 1411–1436. Galatzer-Levy, R.M. (2004). Chaotic possibilities: toward a new model of development. International Journal of Psychoanalysis, 85: 419–441. Gillberg, C. (1991). Clinical and neurophysiological aspects of Asperger’s syndrome in six family studies. In: Autism and Asperger’s Syndrome, ed. U. Frith. Cambridge: Cambridge University Press, pp. 122–146. Gilmore, K.J. & Meersand, P. (2014). Normal Child and Adolescent Development: A Psychodynamic Primer. Washington, DC: American Psychiatric Publishing.

Analysing Miss Daisy 63 Greenspan, S. (1992). Infancy and Early Childhood: The Practice of Clinical Assessment and Intervention with Emotional and Developmental Challenges. Madison, CT: International Universities Press. Harrison, A.M. (2014). The sandwich model: the ‘music and dance’ of therapeutic action. International Journal of Psychoanalysis, 95: 313–340. Helt, M., Kelley, E., Kinsbourne, M., Pandey, J., Boorstein, H., Herbert, M.  & Fein, D. (2008). Can children with autism recover? If so, how? Neuropsychology Review, 18: 339–366. Herbert, M.R. & Weintraub, K. (2012). The Autism Revolution: Whole-Body Strategies for Making Life All It Can Be. New York: Ballantine Books. Hoffman, L. (2006). Do Children Get Better When We Interpret Their Defenses Against Painful Feelings? Paper presented at the 95th Annual Meeting of the American Psychoanalytic Association, Washington, DC, June. Jacobsen, P. (2003). Asperger Syndrome and Psychotherapy. London: Jessica Kingsley. Joyce, A. & Stoker, J. (2000). Insight and the nature of therapeutic action in the psychoanalysis of 4- and 5-year-old children. International Journal of Psychoanalysis, 81: 1139–1154. Knight, R. (2011). Fragmentation, fluidity, and transformation: nonlinear development in middle childhood. Psychoanalytic Study of the Child, 65: 19–47. Lament, C. (2011). Transformation processes and therapeutic action: what David knew. Psychoanalytic Study of the Child, 65: 5–18. Mahler, M.S. (1968). On Human Symbiosis and the Vicissitudes of Individuation. New York: International Universities Press. Mayes, L.C. (2001). The twin poles of order and chaos: development as a dynamic selfordering system. Psychoanalytic Study of the Child, 56: 137–170. Mayes, L.C. & Cohen, D.J. (1992). The development of an imaginative capacity in young children. Psychoanalytic Study of the Child, 47: 23–47. Mayes, L.C. & Cohen, D.J. (1994). Experiencing self and others: contributions from studies of autism to the psychoanalytic theory of social development. Journal of the American Psychoanalytic Association, 42: 191–218. Mayes, L.C. & Cohen, D.J. (1996). Children’s developing theory of mind. Journal of the American Psychoanalytic Association, 44: 117–142. Mayes, L.C., Cohen, D.J. & Klin, A. (1993). Desire and fantasy: a psychoanalytic perspective on theory of mind and autism. In: Life Is with Others: Selected Writings on Child Psychiatry, eds. A. Martin & R. King. New Haven, CT: Yale University Press, pp. 49–64. Meltzer, D., Bremner, J., Hoxter, W. & Wittenberg, I. (1975). Explorations in Autism: A Psychoanalytical Study. Aberdeen: Clunie Press. Neubauer, P. (1994). The role of displacement in psychoanalysis. Psychoanalytic Study of the Child, 49: 107–119. Novick, K.K. & Novick, J. (2005). Working with Parents Makes Therapy Work. Lanham, MD: Jason Aronson. Olesker, W. (1999). Treatment of a boy with atypical ego development. Psychoanalytic Study of the Child, 54: 25–46. Olesker, W. (2011). The story of Sam: continuities and discontinuities in development, transforming in and out of a perversion. Psychoanalytic Study of the Child, 65: 48–78. Olesker, W. & Lament, C. (2008). Conceptualizing transformations in child and adult psychoanalysis. Psychoanalytic Study of the Child, 63: 273–279. Pelphrey, K.A. & Carter, E.J. (2008). Charting the typical and atypical development of the social brain. Development and Psychopathology, 20: 1081–1102.

64  Alan Sugarman Polmear, C. (2004). Finding the bridge: psychoanalytic work with Asperger’s syndrome adults. In: The Many Faces of Asperger’s Syndrome, eds. M. Rhode & T. Klauber. London: Karnac Books, pp. 86–107. Pozzi, M.E. (2003). The use of observation in the psychoanalytic treatment of a 12-year-old boy with Asperger’s syndrome. International Journal of Psychoanalysis, 84: 1333–1349. Rhode, M. (2004). Introduction. In: The Many Faces of Asperger’s Syndrome, eds. M. Rhode & T. Klauber. London: Karnac Books, pp. 1–19. Rhode, M. & Klauber, T. (2004). The Many Faces of Asperger’s Syndrome. London: Karnac Books. Rutherford, H. & Mayes, L.C. (2014). Minds shaped through relationships: the emerging neurobiology of parenting. In: Early Parenting and the Prevention of Disorder, eds. R.N. Emde & M. Leuzinger-Bohleber. London: Karnac Books, pp. 50–69. Santostefano, S. (1977). Action, fantasy, and language: developmental levels of ego organization in communicating drives and affects. In: Communicative Structures and Psychic Structures, eds. N. Freedman & S. Grand. New York: Plenum, pp. 331–354. Scott, M. (1998). Play and therapeutic action: multiple perspectives. Psychoanalytic Study of the Child, 53: 94–101. Segal, H. (1978). On symbolism. International Journal of Psycho-Analysis, 59: 315–319. Shapiro, T. (2000). Autism and the psychoanalyst. Psychoanalytic Inquiry, 20: 648–659. Sherkow, S.P. (2005). Psychoanalytic Approaches to Working with Children with Autism Spectrum Disorder: Case Report by Dr. Susan Sherkow of 2-1/2-Year-Old Boy in Dyadic Psychoanalytic Treatment. Paper presented at American Psychoanalytic Association Midwinter Meeting, New York. Sherkow, S.P. (2011). The dyadic psychoanalytic treatment of a toddler with autism spectrum disorder. Psychoanalytic Inquiry, 31: 252–275. Sherkow, S.P. & Harrison, A.M. (2014). Autism Spectrum Disorder: Perspective from Psychoanalysis and Neuroscience. Lanham, MD: Jason Aronson. Singletary, W.M. (2006, February 21). Forget the Stage Fright, Just Play the Music: The Psychoanalytic Treatment of Children with ASD. Lecture presented at Margaret S. Mahler Child Psychotherapy Lecture at Psychoanalytic Center of Philadelphia, Philadelphia, PA. Singletary, W.M. (2009, January 14). Introduction: Psychoanalytic Approaches to Autistic Spectrum Disorder: Extending the Dialogue Between Psychoanalysis and Neurobiology. Discussion Group, American Psychoanalytic Association Midwinter Meeting, New York. Slade, A. (1994). Making meaning and making believe: their role in the clinical process. In: Children at Play: Clinical and Developmental Approaches to Meaning and Representation, eds. A. Slade & D.P. Wolf. New York: Oxford University Press, pp. 81–107. Sugarman, A. (2003). A new model for conceptualizing insightfulness in the analyses of young children. Psychoanalytic Quarterly, 72: 325–355. Sugarman, A. (2006). Mentalization, insightfulness and therapeutic action: the importance of mental organization. International Journal of Psychoanalysis, 87: 965–987. Sugarman, A. (2008). The use of play to promote insightfulness in the analysis of children suffering from cumulative trauma. Psychoanalytic Quarterly, 77: 799–833. Sugarman, A. (2011). Psychoanalyzing a Vulcan: the importance of mental organization in treating Asperger’s patients. Psychoanalytic Inquiry, 31: 222–239. Sugarman, A. (2017). The importance of mental organization (or character structure) when diagnosing and analysing Asperger’s patients. Psychoanalytic Study of the Child, 70: 239–256. Szalavitz, M. & Perry, B.D. (2010). Born for Love: Why Empathy Is Essential – and Endangered. New York: William Morrow.

Analysing Miss Daisy 65 Tuch, R.H. (2007). Thinking with, and about, patients too scared to think: can noninterpretive maneuvers stimulate reflective thought? International Journal of Psychoanalysis, 88: 91–111. Volkmar, F.R. (2000). Understanding autism: implications for psychoanalysis. Psychoanalytic Inquiry, 20: 660–674. Yanof, J. (1996). Language, communication and transference in child analysis. 1. Selective mutism: the medium is the message. 2. Is child analysis really analysis? Journal of the American Psychoanalytic Association, 44: 79–116.

Part three

Psychosomatics and hysteria

Editor’s commentary In Chapter 4 Louise Gyler introduces a young girl with a background of intergenerational trauma who believes she cannot walk. This connects in many ways with Jonathan Sklar’s man in Chapter 5a who has facial and verbal obsessional tics (illuminated by Susan Loden in her discussion in Chapter 5b). The girl cannot function, and the man has pathological involuntary movements. Aspects of hysteria in both, there is mourning to be done at the centre of both treatments. Each patient can be seen as having psychosomatic problems, the man may even be psychotic. (Note: he has landed in Part three and not in Part four.)

DOI: 10.4324/9781003202790-8

Chapter 4

Maternal lineage and transgenerational trauma Time and space in the psychoanalytic encounter 1 Louise Gyler Many apparently well-balanced people have no strength of character. They make life easy for themselves by avoiding inner and external conflicts. As a consequence they aim at what is successful or expedient and they cannot develop deep-rooted convictions. (Klein, 1960, p. 269)

Unfortunately, the past two years have been a time of catastrophe, causing many people to feel isolated, unsafe and traumatised due to the risks associated with the Covid-19 pandemic. This experience was unimaginable at the beginning of 2020. Most people’s way of living will be changed forever, but we are, yet, to understand fully the consequences for all of us. In this chapter, I aim to explore the impact of traumatic memory traces and phantasies on the development of mind but not an external trauma, like the pandemic, which can re-activate earlier vulnerabilities, leaving us feeling emotionally overwhelmed and powerless. I discuss infantile psychic trauma which becomes inscribed in the mind early in life as an emotionally threatening unrepresented experience. It impacts the development of the mind itself and one’s relationship to one’s mind, interfering with our relationship to the infantile which can motivate our coming into being with aliveness and creativity. Guignard (1995) defines the concept of the infantile as the basic structure of human existence where the organisation of ego drives, phantasies and memory traces are deposited. The infantile both shapes our individual specificity and is universal. Guignard writes that the infantile is: On the frontiers of the unconscious (Unc.) and of the preconscious system (Pcs.), the infantile is the most acute point of our affects, the locus of hope and cruelty, of courage and insouciance. It functions throughout life, according to a double spiral, both processual and signifying. (2020, pp. 188–189) Infantile psychic trauma can be transmitted from one generation to another through the infants’ relationships to their primary maternal objects2 (Faimberg, 2005).

DOI: 10.4324/9781003202790-9

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In this chapter, I explore how infantile trauma can be brought into the therapeutic work, the types of transformations that occur in therapy and, how the intersections of the temporal and spatial elements inherent in psychoanalytic work contribute to the construction of memory and the development of the capacity for thought. Following Klein, I propose that a ‘good enough’ therapeutic experience is not to have all the threads of life and living precisely and cleverly packaged but rather, as the introductory quotation suggests, it is being able to experience deeply one’s emotions, to experience the violent disturbance generated in the conflicts between love and hate, and to be able to express this in a symbolic and creative mode. Klein broadens her understanding of the ‘well-known criteria’ for termination by putting it this way: Two features are usually emphasized in this connection, growth in stability and in the sense of reality, but I hold that expansion in the depth of the ego is essential as well. An intrinsic element of a deep and full personality is wealth of phantasy life and the capacity for experiencing emotions freely. (1950, pp. 45–46) At birth, we are initiated into life, helpless and physically and emotionally dependent on another for our survival. Psychoanalysis offers a rich account of how infantile experience structures and enlivens our coming into being. The archaic processes of taking in (introjection) and giving out (projection) are involved in the dual tasks of identification with another and of a separation and (some) sense of separateness from the primary object for the development of subjectivity and agency. These processes are laden with possibilities as well as vulnerable to disruption and distortion by overwhelming anxieties and phantasies. From Freud onwards, psychoanalytic thinkers have explored and conceptualised these early bodily and mental states and relational experiences involved in the development of the mind. Melanie Klein (1946, 1952) stressed the importance of the primordial mother and crucially the role of the infant’s visceral desires, fears of annihilation, anxieties, phantasies and identifications in relation to her in the development of mind. In formulating her ideas, Klein added the spatial dimension to our meta-psychology. Klein’s work on positions, starting around 1934, marks her point of departure from Freudian theory. In her account of the workings of the infantile mind, Klein describes two positions, the paranoid-schizoid (1946) and the depressive (1935, 1940) which are independent of, and ontologically prior to, the Oedipal period and all linguistically based constructions. They represent both a linear phase of development (diachronic/developmental) and a ‘specific configuration of object relations, anxieties and defences, which persists throughout life’ (Segal, 1973, p. ix), that is, a synchronic structure or psychological organisation. The position that dominates at any moment in time determines the attitudinal response to external reality and the attribution of meaning to experience. Ogden (1992) argues that the positions represent poles of a dialectical process through which the subject is constituted. The dialectical nature of positions involves the interplay of synchronic

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and diachronic features allowing a conceptual space for both the developmental significance of critical periods of maturation and the synchronic primitive dimension of structure. Neither the paranoid-schizoid nor the depressive position and the associated states of mind are ever fully worked through so to a greater or lesser extent both co-exist throughout life. The turmoil generated by our shifting states of mind and the continuing need to re-work them holds the potential, if we can tolerate it, for a rich phantasy and imaginative inner life. In the Kleinian account, the culturally saturated symbol of the ‘breast’ represents the infant’s subjective experience of care, nurture and understanding – or conversely neglect and misunderstanding. The relationship to the ‘breast’ and its functions in the unconscious mind of the infant carry the phantasies – especially the illusion that the ‘breast’ is under the baby’s omnipotent control – about self and other. Contra to Freud, this places the phantasy of the mother at the heart of the construction of subjectivity. At the earliest stages of development associated with the paranoid-schizoid position, the good and bad aspects of the breast and love and hate are largely kept apart by the splitting processes (which include such mechanisms as denial, idealisation, projection and projective identification). In this state of mind, the inevitable breakdown of the split between ‘good’ and ‘bad’ is experienced as overwhelming and threatening to one’s equilibrium and stability. The result of these processes is the subjective experience of confusion, fragmentation and fear. For the infant, then, persecutory anxieties inevitably arise from destructive impulses. But importantly these anxieties can be either reinforced or diminished through the interplay of projective and introjective mechanisms interacting with the external (or environmental) figures. Although, in a developmental sense, the depressive position follows from the paranoid-schizoid position, Klein’s published work on the concept of the depressive position precedes her account of the paranoid-schizoid position. The depressive position concerns the fate of the object inside the mind. In the depressive position, depressive anxieties, guilt and ambivalence are experienced in relation to the mother and her breast (representing her feeding capacity). The depressive position signals an important developmental advance because in the context of good object relations, integration can occur. Klein sees the working through of this position as the central task of childhood (1935, 1940). The onset of the depressive position occurs sometime after three to four months of age when the infant comes to realise that the ‘bad breast’ mother and the ‘good breast’ mother are one and the same, that is the positive and negative aspects of the infant’s relationship to the phantasised mother are no longer located in two distinct images (objects). The ‘good’ and ‘bad’ experiences are now seen as belonging to the one object relationship, that is, the relationship with the maternal object. Thus, destructive impulses directed towards the ‘bad’ mother are felt to endanger the ‘good’ mother. This leads to feelings of loss, guilt and remorse and sets in progress the process of mourning. In a developmental or diachronic sense, Kleinian concepts when attributed to an account of the way infants think and feel are speculative conjectures, as is the case with other psychoanalytic theories describing the psychic states of infants. Spillius

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(2007) distinguishes between the hypothetical account of early infancy and the theory of a mental model which describes the emergence of the mind as in the synchronic conception of Kleinian positions. This double perspective of developmental and synchronic commitments can be observed clinically in the tension between focussing interpretations on the ‘here and now’ analytic relationship and ‘there and then’ reconstructions of the past. According to Spillius, even for analysts with a stronger allegiance to a developmental approach, there is a general contemporary trend to conceptualise and use the paranoid-schizoid and depressive positions as models of mind rather than as developmental phases. Returning to the intrapsychic process of mourning, this process facilitates the working through of the loss of the idealised all good mother and the coming to terms with an actual mother with her inevitable vulnerabilities, imperfections and limitations. The successful working through of these feelings brings about the internalisation of whole objects and the restoration of the mother to a valued and loved state, via the intrapsychic process of reparation. The mother is now recognised as a whole person, having separate thoughts and feelings of her own. This facilitates the development of symbol formation (which is necessary for creativity) and the shift from concrete modes of thinking which are characteristic of the paranoid-schizoid position (Segal, 1957). The working through of ambivalence and depressive anxieties is of central therapeutic concern because it is not only connected with the ability to mourn one’s lost narcissistic omnipotence, but also to separate from the actual external objects. Thus, this process establishes one’s own sense of individuality and capacity to relate to others as whole objects (that is, subjects). The process of mourning can falter or be disrupted because of factors related to the infant (for example due to an excess of sadism and/or envy); the caregiver who may be either too overwhelmed with her own anxieties to manage the baby’s fear and/or need to rid herself of her own anxieties by intrusively projecting them into the baby; and the infant/caregiver relational factors. When the work of mourning is not possible, the loved and good object can be felt to be lost or insecurely internalised. The baby does not possess an internalised good object needed to support an inner sense of worth and value. With no support to manage persecutory anxieties (bad and challenging experiences such as weaning), the baby is usually left with no recourse other than to use omnipotent defences – denial, splitting, projection and projective identification – to deny psychic reality. Klein proposes that early preverbal emotions and phantasies which influence and shape ongoing development can be revived in the therapeutic transferential relationship as ‘memories in feelings’. Memories in feelings often underpin a cover memory (1957, 1961). Winnicott (1965) and Bion (1962a) have extended our understanding of the role of the other in holding and containing the infant’s anxieties and showed how we are dependent upon another for psychic development. Bion’s spatial model of container/contained describes how the infant’s most basic fear, the fear of dying and of non-existence, is projected into the mother’s mind where it needs to ‘sojourn in her psyche’ so through ‘reverie’ it can be processed and de-toxified. If, in time, all goes well in this process, the anxieties can be returned to the infant in

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a manageable form, with the infant introjecting a container able to manage feelings. In this development, Bion re-formulates projective identification as an early mode of communication (Bion, 1959, 1962a, 1962b). Bion differentiates normal and pathological forms of projective identification, and following this development, the analyst’s countertransferential responses come potentially to represent the patient’s unconscious communications. Bion describes a process whereby the infant ‘learns from experience’ to cope with their own inner emotional life through these cycles of projective and introjective identification with a ‘containing’ object (caregiver). Conversely, if the experience goes badly (for Bion, either because of the caregiver’s incapacity for reverie or because of the infant’s excessive envy and sadism), the infant resorts to forcefully excessive use of projective identification which then leads, via re-introjection, to the development of an internal world based upon fragile, distorting and/or malignantly misunderstanding internal object relations (disorders of thought). If containment fails, the process of mourning and the establishment of securely internalised good objects is hampered, resulting in a psychic catastrophe. In delineating this model, Bion (1959, 1962b) begins to differentiate ‘normal’ projective identification from pathological projective identification (Klein’s starting point). The nature and qualities of the external object are a central part of his theory of thinking, as Spillius puts it: ‘Bion’s formulation shows not just that the environment is important but how it is important’ (1983, p. 323, italics in the original). From a different theoretical direction, Laplanche (1997) elaborates how the other is incorporated into the development of mind by focussing attention on the desire of the primary carer. His general theory of seduction reverses the Freudian sources of desire by arguing the child’s unconscious and sexuality are formed by the unconscious desire of the other (primary relationship). While caring and attending to her infant’s needs (feeding, soothing, bathing and so on), the mother/primary carer transmits unconsciously enigmatic messages which engender desire, bodily phantasies and identifications in the infant. In this model, the mother is not merely a mirror, in the sense of a passive reflector of infantile desires and anxieties, or one who can with varying degrees of success or failure de-toxify infantile fears, but she also has her own subjectivity actively in play. This process inevitably generates an excess of meaning – meaning that goes unrepresented and is repressed. We develop subjectivity in the intersubjective encounter of swirling bi-directional desires, anxieties, phantasies and mnemic traces. The primary relationship between self and other is unconsciously represented by symbols, denoting the maternal body and other objects of desire. If the projective and introjective exchanges in the early caregiving relationship are derailed, the nature of symbolic development can be inhibited and disturbed. Symbol formation is necessary for communicating out-of-awareness anxieties and phantasies and for containing them in thought. Psychic development is impeded when there is an inability to take in and represent a ‘good’ maternal object for whatever reason, leaving the infant with little to depend upon for a sense of value and esteem. I now want to illustrate through a clinical example the traumatic potential of this situation when the caregiver herself carries

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unprocessed and unsymbolised traumatic memories and experiences that are communicated in out-of-awareness ways to the infant. Case illustration: Emma When I  first met Emma, she was 12  years of age, and she had believed for six months that she was unable to walk.3 There was no organic pathology to account for her predicament (other attempts at help had all faltered). During the initial interviews, she described sleep problems and an anxious depressed mood, but she was not unduly concerned about her apparent inability to walk, not unlike Freud’s infamous women at the heart of psychoanalytic theory. She described herself as a ‘goodie, goodie’ who wanted to be ‘perfect’ but found it ‘very hard to be that all the time’. Her sessions overflowed with her disappointment in herself but also complaints about the inadequacies of her family, friends and medical staff caring for her. She also believed that she was the long-suffering victim of others’ criticisms. It appeared that the only ‘tolerable’ psychic state that she could occupy was one of narcissistic completion and that all that was negative was projected onto others by whom she felt persecuted. She drew for me a striking picture of her family depicting all family members as the same, that is, the same height, size, shape and dress, and hence, undifferentiated by gender and age. This seemed to convey that her inner life was devoid of any imaginative texture or colour and blandly flattened out into a world of sameness and undifferentiation. Emma told her narrative, thin and disembodied, repetitively for months on end. I saw no underlying pattern that might give some traction on transformation and relief to her suffering. Additionally, I (and all those attempting to help Emma) were also left feeling passive, helpless and anxious in a version of massive projective identification with Emma. Yet, and of course, this powerful psychic evacuation of her mind cost Emma greatly, and in her own words, she felt ‘superficial’ and ‘shallow’. From the outset of the therapeutic experience, a split between an intense overfull emotional experience and an empty emotional state of mind is constructed and externalised. To make sense of this encounter, I  explore Emma’s four-year three-session-per-week psychoanalytic journey from symptom to symbolisation; from her denial of a psychic reality; to the representation of a frightening and persecuting inner maternal figure; and to a representation of inner receptive space which supports her in beginning to mourn and re-work the phantasy of narcissistic completeness – having and being everything. The beginning: emerging from the denial of psychic reality Emma claimed her mother (the most important figure in her internal and external worlds) saw her as having ‘only bad thoughts’. From the outset, she harboured transferential anxieties that her analyst would see her in this way, and she positioned

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herself as the long-suffering victim of the analyst’s complaints about her ‘badness’. In her mind, the other had only two possible positions: one, ‘for her’, that is, accepting her as a helpless invalid or baby who is entitled to abdicate responsibility for herself; and. two, ‘against her’, that is, criticising and complaining about her and pushing her to grow up. From the beginning of her analysis, her mode of relating suggests that, in the transference, she experienced the other as either an extension of herself, not fully recognised as another person, or, on the other hand, as a persecuting other, that is, there was no sense of otherness as difference. There was no third position; no alternate position from which to observe these two restricted possibilities of either a narcissistic merger or persecuting opposition. As Emma’s analysis proceeded (about six months into the analysis), she began to develop an improved capacity to name and articulate her sense of self. She not only, at times, identified feeling helpless and passive but also active and aggressive. But, for Emma, to be assertive was dangerous and precarious, as she feared she could lose control and murder her mother or me. She said in a session ‘what will you think of me being angry . . . you will not like me . . . fearful I might murder . . . lose control’. For Emma, the Oedipal moment of separateness and subjectivity was not only murder but a murder in which the maternal object cannot survive; the maternal object is perceived as too fragile and not able to survive being hated; not a tale of lost and found, as in Freud’s fort/da game, but a tale which is too concretely real with a loss without any hope of mourning and reparation. Also, I think that Emma was able to speak now of murder because she was finding, or beginning to represent in her mind, the possibility of another: that is, there was another to speak with whom she felt could tolerate and contain her murderous rage. Emma’s connection to her inner terrifying world coincides with her beginning to walk with the assistance of aids. As Emma was able to speak more openly about her aggression and destructiveness, she began to be able to recall her anxious understanding of family history and the ‘mothers’ that she would have liked to annihilate from her mind. In her mind, she was a member of a ‘long line of family freaks’, that is, there have been generations of women in her family with serious mental disorder associated with pregnancy, childbirth and loss. In these associations and memories, we glimpse the nature of the traumatic world that Emma had internalised and needed to deny as a desperate attempt for psychic survival. In the face of her internal and external reality, she was left with real questions about her own vulnerabilities, for her reality and phantasy collide. Perhaps, it is of no coincidence that she somatically broke down as she entered puberty. In the pubertal developmental stage, which marks the transition to reproductive womanhood, Emma is caught in both fearing to remember her past and to imagine the future. Time past, present and future is traumatically experienced. Emma talked of her terror in sessions that, if she could not ‘get control over herself’, she believed that she would continue to ‘crack up’ when exposed to any stress, in keeping with her image of her female family members. She described her experience in the following way: ‘like a jigsaw puzzle, full of cracks, ready

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to break apart when any pressure is exerted’. Pressure, for her, meant separations and losses such as those inherent in giving birth and death. It was not safe to be a woman; for her, women were weak, vulnerable and mad. Emma appeared to attempt to cope by evading her inner ‘truth’, by keeping up an illusion that her ‘surface’ was plain and unmarked by her inner world of phantasies, anxieties and defences. This illusion distracted from the cracks beneath the surface. For Emma, her internal sense of containment was not up to the task of holding the complicated and contradictory anxieties and conflicts linked to her transgenerational history. The maternal object could not survive being the target of matricide; the process of separation had not become symbolised but remained too literal and concrete, leaving Emma in a crippling bind. Her fear of a mental breakdown emerged in the here and now transference encounter, transforming the somatic breakdown that brought her to treatment into a mental one. Emma’s unconscious solution to her infantile traumatic mnemic traces and ‘alienated identifications’ (Faimberg, 2005) was to suspend her developmental progress by enacting literal immobility, but her symptom that performed helplessness and dependency also indicated her regressive needs to resolve her early traumatic beginnings. Connecting with a psychic life About two years after the commencement of her analysis and now walking unaided, Emma appeared to be much more able to recognise the reality of her own emotional life, although she remained terrified of others’ judgement, especially of being seen as ‘stupid’, and was easily narcissistically hurt. Her talk was more emotionally alive, and she began to report her dreams around this time. The following two dreams seem to reflect a different version of herself than the one represented pictorially by her at the beginning of her therapy (the unisex drawing). She no longer conceives herself as an impenetrable surface unmarked by traumatic feminine/maternal identifications. First, she dreamed about the subject of ‘emotions’, which were blobs being investigated in a laboratory. The study of the blob required much understanding and patience, but in the dream, just as she began to think that she had discovered it, got hold of it, she found that it had gone inside her. In the second dream, Emma reported that a clear plastic dome-like thing was wrapped around her and then, the wrapping went inside her. These dreams suggest the process of internalisation, of taking in, and the idea that there is an inner space in her mind even though this process leaves her bereft of her plastic narcissistic protection and puts her in contact with sadness. Further, from Emma’s associations, these dreams appear to have reflected her assessment of her development in her analysis. She believed that she started her therapy as an undifferentiated black blob, identified with her primary ‘bad’ maternal object, which she needed to deny by murdering again and again, leaving her ashamed and guilty and unable to internalise a helpful object. In these vignettes, we see the emergence of the idea of an inner psychic space; albeit an inside that appears without differentiation and is unintelligible.

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Later in the third year of her therapy, Emma is more aware of the contradictory parts of her personality – aware that she felt both ‘superior’ in one part and ‘inferior’ in another. She described having an ‘unthinking servant’ and a ‘dictator’ in her. For her, the ‘unthinking servant’ represented one of the ‘line of freaks’, that is, a nervous, crazy woman whose aggression and sexuality must be controlled or quashed by the ‘dictator’. During this time, she also began to experience the analyst’s presence differently and express concern for the other saying, ‘I can’t expect you to be a shadow of me’, that is, a narcissistic extension of her, and began to see her analyst as an ‘ordinary’ person who can manage everyday tasks, for example, talking on the telephone and driving. Could these named activities also be code for her awareness of the mother/analyst as an ordinary ‘good’ woman? Emma’s experience of analytic receptivity began a process of identification that enables the possibility of recovery of the lost ‘good’ object (Brenman, 2006) and the internalisation of ‘the good understanding object’ (Hinshelwood, 2007). In his paper exploring the reclamation of unlived experience, Steven Groarke (2021) identifies three types of mnemic activity involved in a patient’s gathering a sense of past. They are: ‘(1) the retention of bygone objects; (2) the recovery of “forgotten” or repressed objects; and (3) the reclamation of not-yet-conceived objects’ (p. 1113). It is the experience of presence – the containing presence of the analyst – that enabled the absently conceived object to be reclaimed or as Groarke puts it: ‘ “remembered” only in the negative’ (p. 1111). For Emma, the representation of an inner psychic space intersects with past and present temporality to construct a sense of a dimensional self. Mourning and a more complex inner world At the beginning of the fourth year of her analysis, Emma is struggling with depressive feelings which were connected to her recognition of her contradictory states of mind and the loss of her idealised version of self. She said that she both wished and feared going mad: ‘sometimes I wish I would have a nervous breakdown . . . to go into my mind . . . no worries . . . peace . . . walk around in a daze’, that is, to evade the complexity of her psychic reality. Emma recalled an enigmatic fragment of a dream: ‘a painted Asian face’. Her associations were to an Asian woman who had served her recently in a shop. Emma remembered that the woman ‘made a big deal’ of obtaining accurate information from another store about the product that she wanted to purchase. Emma would have preferred to take the product without ‘fuss’, that is, not to recognise that she needed another for her development nor to recognise the other’s value. A second association was to a figurine with a painted black and white face, which was a valued gift from recent work experience. She talked of not liking black, as it reminded her of the ‘black blob’. This dream fragment holds multiple meanings and represents a transformational moment for Emma. It marks a movement towards the use of a capacity for symbol formation, dreaming and associative thought to generate meaning.

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She experiences her conflicts: the conflict between the wish and fear of madness and psychic death; the conflict between the wish for a simple and easy black and white world that does not require dealing with conflicted feelings about solving problems through work; the conflict between tolerating emotions and the evasion of psychic reality by splitting. She is emerging from the ‘black blob’ experience to represent her complex and contradictory states of mind in imagery and thought. Emma’s dream with its condensed symbolic resonances is unpacked in the here and now of transference/countertransference experience. She saw her analyst as offering a foreign encounter (the Asian face – both Emma and her analyst are Caucasian), but it is the foreignness of the analyst’s way of being by looking below the surface that captures Emma’s attention. The work of understanding, however, is difficult and painful. Emma’s experience of care is laced with ambivalence because ‘fuss’ disrupts the ‘daze’ state of mind. The ‘daze’ works as an antidote or defence against mourning and working through the phantasy of omnipotent completeness. In the dream association of the painted black and white face of the figurine, a valued gift, the opposition between the black uncontained blob and the white ‘goodie, goodie’ light-reflecting, pattern-free surface is portrayed. This opposition is now progressively represented in a verbal and symbolic form rather than non-verbally as it was at the beginning of her therapy with her broken physical body and the unisex picture which lacked detail and difference. The ‘Asian face’ standing for an encounter with otherness (foreignness) represents a third position from which to observe and ‘face’ the ‘black/white’, love/hate conflict. Emma describes ‘painted’ both in relation to the dream fragment and the association of the figurine. It is as if ‘painted’ on the one hand captures the analytic representational work of creatively holding the tension between linking thoughts and emotions and the breakdown of thought with its textured forms and meanings. On the other, it suggests her desire to ‘paint’ her world of appearance in black and white terms and not to have to struggle with the enigma of otherness (experienced in the transference as the analyst with her ‘foreign’ ways of thinking but also her own strange and unintelligible out-of-awareness inner world that generates symptoms, dreams and imaginative thoughts). The possibility of conflicts, anxieties, fears and hopes stand side by side rather with the wish to repudiate one or the other side. Ambiguity can be held as a thought rather than a disruptive experience to be enacted. With working through the recognition of her traumatising inner world and recognition of a complex emotionally ladened inner life, Emma was able to take pleasure in her life and terminate her therapy after about four and half years of our working together. Remembering and representing [W]e may say that here the patient remembers nothing of what is forgotten and repressed, but that he expresses it in action. He reproduces it not in his memory but in his behaviour; he repeats it without knowing that he is repeating it. (Freud, 1914, p. 150)

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Emma expressed in action through her somatic symptom her ‘forgotten’ enigmatic messages, early anxieties in relation to her body and her sense of self formed in the context of her early object relations. The symptom enacted her sense of incapacity to develop psychically as a sexual woman. Emma was caught in the chasm between the progressive meanings of her bodily changes and the regressive pull of her traumatic infantile past. Her symptom that ‘burst through’ calls for us to consider both the intersections of temporality and spatiality in psychic life. In his famous Letter 52, Freud outlined that memory traces are re-organised at a later stage in life: I am working on the assumption that our psychical mechanism has come into being by a process of stratification: the material present in the form of memorytraces being subjected from time to time to a re-arrangement in accordance with fresh circumstances – to a re-transcription. (p. 233) Through the course of her therapy, Emma was able through the transferential relationship to recall and put into words her understanding of her transgenerational history, for example ‘the line of freaks’. This, however, was more than simply recalling because the past is constructed through the ‘here and now’ lived experience of the transference relationship. This experience involved retroactive understanding of her ‘alienated identifications’ that left her with the subjective experience of being both empty and overfull, as Faimberg describes (2005). States of emptiness and overfullness were also part of the analyst’s countertransferential experience, especially in the early years of the therapy. While the sessions were filled with ‘noisy’ talk about Emma’s victimhood, I was often left feeling at a loss about the possibility of making any real emotional contact with her, that is, empty of any relational capacity. At the same time, Emma held onto the containing presence of the analyst, rarely missing a session. While Emma’s entrenched and debilitating symptom was very slow to modify, she was not resistant to therapy. This suggests that she was unconsciously aware of her need to re-work her developmental trajectory. The onset of the symptom coincided with Emma entering puberty, and this is undoubtedly significant in the timing of its emergence. It is a time when the meaning of her bodily changes signifies a transition, a move to a futural state, but she was unconsciously seized by her past with its regressive pull. Her ‘feelings in memories’ are given meaning in the transferential experience, and her fragmented memories are re-signified in the context of her current developmental stage. This type of retrospective resignification reflects a version of the concept of Nachtraglichkeit or après coup (Birksted-Breen, 2016; Groarke, 2021). In the clinical example, there is also a broader version of Nachtraglichkeit than the Freudian conception of rearrangement and re-transcription in evidence (Faimberg, 2007). Faimberg argues that Winnicott in his paper ‘Fear of breakdown’ (1974) offers the paradigmatic example of this broader notion. In his paper, Winnicott proposes that patients

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can fear a breakdown in the future that took place in the past when there was no subject to experience it: ‘I contend that clinical fear of breakdown is the fear of a breakdown that has already been experienced’ (p. 104). In this early infantile situation, the infant experiences primitive agonies, for example, unintegrated states, falling into forever, a loss of psychosomatic collusion, a loss of sense of real and loss of the capacity to relate to objects which leave non-accessible traces in the nascent mind. In this sense, there is nothing to remember but, as Faimberg suggests, this fear of breakdown in the future constructs a past. In his exploration of ‘Fear of Breakdown’, Ogden (2014) proposes that Winnicott’s main theme is better stated as: ‘a fear of a breakdown is a fear of breakdown that has already happened but has not – yet – been – experienced’ (p. 211). Later in his paper, Winnicott does write: ‘the patient must go on looking for the past detail which is not yet experienced’ (p. 105). Interestingly while Emma clung to her symptom, she also held onto her therapy suggesting she was looking unconsciously for that which was to be experienced. Towards the end of her therapy, Emma experienced depression, fear of going mad (for example ‘going into a daze’) and the pull to inhabit a black and white world. These were experienced as mental states expressed in words, symbols, dreams and in the transference which contrasts to the somatic symptom that brought her to therapy. Conclusion The development of an inner receptive space is a precondition for thought and memory (Kristeva, 2001; Gyler, 2017); a space where identifications, desires, inscriptions and memories can be symbolised and contained. This representation needs to hold ambiguity, uncertainty, loss and mourning. Backwards and forwards temporality intersects with inner space giving it dimensionality and generating dynamism. When infants experience what I have called a particular type of infantile psychic trauma, representation of the helpful inner object to manage negative experiences is impeded. Psychic reality itself is then experienced as terrifying and is denied by the employment of omnipotent defences. This impairs the development of receptive inner space and full symbolisation. In the case illustration, I suggest the internalisation of the analytic function occurring through the transference and countertransference experience enabled the symbolisation of the receptive interior space. A space which has its origin in the primary caregiving relationship, the originary ‘thinking couple’. To conclude, I want to show an artistic representation of this inner space. Louise Bourgeois’ famous ‘Spider’ is the representation of the relationship between the maternal object and self. Bourgeois says in her 1995 poem Ode à ma mère: My best friend was my mother and she was deliberate, clever, patient, soothing, reasonable, dainty, subtle, indispensable, neat and useful as an araignée . . .

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Je ne me fatiguerai jamais de la representer.

(2007, p. 321)

My best friend was my mother and she was deliberate, clever, patient, soothing, reasonable, dainty, subtle, indispensable, neat and useful as a spider . . . I shall never tire of representing her. With the ‘Spider’, Bourgeois depicts a creative and complex version of the reality of what needs to be held in mind. Her ‘Spider Couple’ extends the idea of the ambiguity of the primary intersubjective relationship – a relationship represented through symbols forged in the dialectics of space and time, past and present time, absence and presence and reverberation and receptivity.

Figure 4.1 Louise Bourgeois’s MAMAN (1999) installed outside the Tate Modern in London in 2007. Photo: Marcus Leith. Source: © The Easton Foundation/Copyright Agency, Sydney.

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The Spider Couple

Figure 4.2 Louise Bourgeois, SPIDER COUPLE, 2003. Bronze, silver nitrate patina; 228.6 × 360.7 × 365.8 cm. Photo: Christopher Burke. Source: © The Easton Foundation/Copyright Agency, Sydney.

Notes 1 An earlier version of this paper was presented at the Chinese–American Continual Training Programme for Senior Psychodynamic Psychotherapists, Wuhan (online). Fall 2020. 2 I am using the term ‘maternal’ to describe the primary caregiver of any gender who provides the baby with a sense of ‘at oneness’ from which the baby over time separates and individuates. 3 A version of this case material was previously published in Gyler (2017).

References Bion, W.R. (1959). Attacks on linking. In W.R. Bion (Ed.), Second thoughts: Selected papers on psychoanalysis. London: Maresfield Library. Bion, W.R. (1962a). Learning from experience. London: William Heinemann Medical Books Ltd.

Maternal lineage and transgenerational trauma 83 Bion, W.R. (1962b). A theory of thinking. In W.R. Bion (Ed.), Second thoughts: Selected papers on psychoanalysis. London: Maresfield Library. Birksted-Breen, D. (2016). The work of psychoanalysis: Sexuality, time and the psychoanalytic mind. London: Routledge. Bourgeois, L. (2007). Destruction of the father reconstruction of the father. M.-L. Bernadac  & H.-U. Obrist (Eds. with texts). London: Violette Editions. Brenman, E. (2006). Recovery of the lost good object. G.F. Spoto (Ed. & Intro.). London: Routledge. Faimberg, H. (2005). The telescoping of generations: Listening to the narcissistic links between generations. London: Routledge. Faimberg, H. (2007). A plea for a broader concept of Nachtraglichkeit. The Psychoanalytic Quarterly, LXXVI, 1221–1240. Freud, S. (1914). Further recommendations in the technique of psychoanalysis: Recollections, repetition and working through. In J. Strachey (Ed.), The standard edition of the complete psychological works of Sigmund Freud. London: Hogarth Press, 12, pp. 145–156. Groarke, S. (2021). The sense of the past: Theoretical and clinical aspects of deferred action. International Journal of Psychoanalysis, 102, 1097–1115. Guignard, F. (1995). The infantile in the analytic relationship. International Journal of Psychoanalysis, 76, 1083–1093. Guignard, F. (2020). Psychoanalytic concepts and technique in development: Psychoanalysis, neuroscience and physics. London: Routledge. Gyler, L. (2017). From symptom to symbolization of receptivity: A girl’s psychoanalytic journey. Angelaki: Journal of the Theoretical Humanities, 22.1, 35–47. Hinshelwood, R.D. (2007). The Kleinian theory of therapeutic action. Psychoanalytic Quarterly, LXXVI, 1479–1498. Klein, M. (1935). A contribution to the psychogenesis of manic-depressive states. In M. Klein (Ed.), Love, guilt and reparation and other works 1921–1945. London: Karnac Books. Klein, M. (1940). Mourning and its relation to manic-depressive states. In M. Klein (Ed.), Love, guilt and reparation and other works 1921–1945. London: Karnac Books. Klein, M. (1946). Notes on some schizoid mechanisms. In M. Klein (Ed.), Envy and gratitude and other works 1946–1963. London: Karnac Books. Klein, M. (1950). On the criteria for the termination of a psycho-analysis. In M. Klein (Ed.), Envy and gratitude and other works 1946–1963. London: Karnac Books. Klein, M. (1952). Some theoretical conclusions regarding the emotional life of an infant. In M. Klein (Ed.), Envy and gratitude and other works 1946–1963. London: Karnac Books. Klein, M. (1957). Envy and gratitude. In M. Klein (Ed.), Envy and gratitude and other works 1946–1963. London: Karnac Books. Klein, M. (1960). On mental health. In M. Klein (Ed.), Envy and gratitude and other works 1946–1963. London: Karnac Books. Klein, M. (1961). Narrative of a child analysis: The conduct of the psycho-analysis of children as seen in the treatment of a ten-year-old boy. London: Karnac Books. Kristeva, J. (2001). Melanie Klein. New York: Columbia University Press. Laplanche, J. (1997). The theory of seduction and the problem of the other. International Journal of Psychoanalysis, 78.4, 653–666. Ogden, T.H. (1992). The dialectically constituted/decentred subject of psychoanalysis. II: The contribution of Klein & Winnicott. International Journal of Psychoanalysis, 73, 613–626.

84  Louise Gyler Ogden, T.H. (2014). Fear of breakdown and the unlived life. International Journal of Psychoanalysis, 95, 205–223. Segal, H. (1957). Notes on symbol formation. International Journal of Psychoanalysis, 38, 391–397. Segal, H. (1973). Introduction to the work of Melanie Klein. London: Hogarth Press. Spillius, E.B. (1983). Some developments from the work of Melanie Klein. International Journal of Psychoanalysis, 64, 321–332. Spillius, E.B. (2007). Encounters with Melanie Klein: Selected papers of Elizabeth Spillius. P. Roth & R. Rusbridger (Eds. & Preface). London: Routledge. Winnicott, D.W. (1965). The maturational processes and the facilitating environment: Studies in the theory of emotional development. London: Hogarth Press. Winnicott, D.W. (1974). Fear of breakdown. International Review of Psycho-Analysis, 1, 103–107.

Chapter 5a

Hysteria and mourning A psychosomatic case 1 Jonathan Sklar

In Studies on Hysteria, Freud and Breuer write about tracing ‘the most various symptoms which are ostensibly spontaneous and as one might say, idiopathic products of hysteria are just as strictly related to the precipitating trauma’ (Breuer & Freud 1893–1895, p. 4). They go on to describe various illnesses, including disorders in the nature of tic. There have, however, been very few case reports in the recent literature on the treatment of such cases. Modern analytic literature often stresses the need to recognise psychobiological bedrock. I argue that an analyst can too quickly accept such a diagnosis as a way of covering over the traumatic gap. Freud, in his paper ‘Neurosis and psychosis’, writes in relation to the genesis of delusions: A fair number of analyses have taught us that the delusion is found applied like a patch over the place where originally a rent had appeared in the ego’s relation to the external world. If this precondition of a conflict with the external world is not much more noticeable to us than it now is, that is because, in the clinical picture of the psychosis, the manifestations of the pathogenic process are often overplayed by manifestations of an attempt at cure or, a reconstruction. (Freud 1924, p. 151) Freud goes on to assert that the aetiology common to the onset of a psychoneurosis and of the psychosis always remain the same: ‘It consists in a frustration, a non fulfilment, of one of those childhood wishes which are forever undefeated and which are so rooted in our phylogenetically determined organisation’ (Freud 1924, p.  151). This is a statement about the importance of unconscious phantasy life rather than aspects of reality. Ferenczi was particularly interested in finding the balance between fantasy and trauma. He writes in a letter to Freud: In all cases in which I have penetrated deeply enough, I found the traumatichysterical basis for the illness . . . The critical view that gradually formed in me in the process was that psychoanalysis engages too much one-sidedly

DOI: 10.4324/9781003202790-10

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in obsessional neurosis and character analysis i.e. ego psychology, neglecting the organic hysterical basis for the analysis; the cause lies in the over estimation of fantasy and the under estimation of traumatic reality in pathogenesis. (Ferenczi & Freud 1920–1933, p. 376) Here is a statement that points in the direction of the need to play with such balances during the course of the analysis. Ferenczi’s view was that the traumatic (body) memory forces itself spontaneously to the fore. He describes the tic as an ego hysteria (Ferenczi 1921, p. 173). Ferenczi’s desire was to analyse as much as possible the reasons that the mind, at times, is not able to know, conceptualise, imagine or feel the affect such that the body is required to take over and carry, as it were, the unconscious emotional load. His idea of penetrating deeply is to tactfully take off the surface cover in order to reveal the ‘rent in the ego’ that for Ferenczi contains descriptions of traumatic landscapes. This chapter describes the impact of re-finding the lost affect in the disappearance of the patient’s mother when the patient was two years old. The feelings generated then and subsequently in unconscious phantasy life became, in Bollas’s term, the idiom of his life (Bollas 1992). It was only after the development of a severe body tic following a family disruption that the possibility of finding lost affect and the capacity for an integration of the psychic and somatic becomes available through the analytic process. Hysterics indicate trouble with the body. As Bollas writes: ‘if a mother has under stimulated the infant, then auto-erotic will stand in for the lack of maternal sensorial care, but if the mother was deeply seductive, then the child will make an unconscious link between self stimulation and maternal love’ (Bollas 2000, p. 31). But what if at the age one would expect the child to be developing psychosomatic theories of sexuality, the more pressing system is absence (through death) of the mother and absence (through breakdown) of the father. Then the natural territory of the play with mother’s body and the development of the Oedipal triangle can become severely disrupted. It is this territory that I am interested in, and in particular the capacity to mourn as the prerequisite for the movement of bodily tic to be able to develop towards emotional accessibility. Proust captures some of these issues in the following: Of course, missing a mistress and the jealousy that lingers on afterwards are physical illnesses just as much as tuberculosis or leukaemia. Yet we need to distinguish among the physical maladies between those that are caused by a purely physical agency and those that act on the body only through the media of the intellect. Above all, if part of our intellect that serves as a medium of transmission is memory – that is if the cause is annulled or removed – however cruel our suffering is, however deep seems the disturbance wrought on our organism,

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it is extremely rare, given the power of thought to renew itself or rather its inability to remain unchanged, unlike bodily tissues, for the prognosis to be unfavourable. Marcel Proust, The Prisoner and the Fugitive (1923–25) The patient A single man in his early thirties was referred with a long-standing obsessivecompulsive disorder. Some months before, the illness had increased to encompass a depressive ruminatory state together with suicidal ideas and a serious motor disturbance. He had been hospitalized for the previous three months, having quite violent and sudden involuntary movements, raising his hands suddenly above his head, moving his head from left to right violently with sudden twisting movements of his whole body. Despite being highly intelligent, he had coalesced his thoughts into a concrete idea that ‘one side of my brain is fighting the other side’. He was very concerned that he might be gay despite his having many indications in the reality of his life to the contrary. He enjoyed dating women and having sex with them and thought the idea of kissing a man abhorrent. Nonetheless, he had a delusional conviction that his destiny was to become homosexual. In addition, he had fleeting thoughts that he might be a woman. He had been investigated by several psychiatrists and neurologists and variously diagnosed with obsessive-compulsive disorder, anxiety and depression, paroxysmal psychogenic movement disorder, and possibly cycloid psychosis. The inpatient treatment had failed to dent his symptoms; in fact, with an inability to look after himself or continue his professional work, life had been emptying out. The psychiatrists wanted him to have further treatment with ‘strong’ anti-depressants, lithium, and electroconvulsive therapy (ECT). Instead, he came into five-times-aweek analysis. Some years before, he had been in analysis, which had been of value in settling his obsessive-compulsive disorder. Despite a plethora of advice to beware of analysis on the grounds that it was likely to make him more ill, and even though also in conflict with a decision he had made never to go into analysis again, he decided to have a second analysis. This was another example of his obsessional state of mind, with a yes-no in reaction to analytic treatment. When Mr  C was two years old, his mother killed herself by hanging, soon after the birth of his younger sister. It seemed reasonable to think that she had been preoccupied for some period of time prior to her death, such that he had had very little freely available time with his mother as a baby. What quality of maternal care he was able to receive from her in such a short time is also unknown. Three years later, his father remarried. He always declined to talk about this early devastation. Instead, there was an emergence into the new family, which seemed strong and loving.

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As a teenager, Mr C was both indecisive and a perfectionist. In his early teens, he was very preoccupied with disease and often checked ‘for something bad in the corner of rooms’. In his early twenties, he had his first depressive breakdown. Two years later, he began analysis for about four years, and in the latter part of this required hospital admission for five weeks due to increasing anxiety, obsessional thinking and depression. In the two years prior to his referral to me, his father suffered a very serious reversal in his successful business and for the first time had great financial difficulties. His stepmother became seriously ill physically, and a few months prior to his recent hospitalisation his parents separated. At the first consultation, he had gross choreiform movements and uttered streams of angry ‘yes-no’. Sitting in a chair in front of a bookcase, he swung his head violently backward, yet each time he missed banging it hard by a hair’s breadth. I took this as a serious sign that his gross movements had an underlying hysteria due to his unconscious capacity to not damage himself whilst indicating doing the opposite. The failure of his brilliant father, for the first time, had devastated him. He also found his parents’ separation terrible. Mr C was a man who managed life by greatly idealising his father in business and his parents in marriage. The devastation in his early life, with the sudden loss of his mother when he was two years old, had been a blanked-out subject, which he was now unconsciously revisiting. He told his story alongside a constant bodily performance of twisting gestures and shouting out ‘yes-no’. He was exhibiting a major mental fragmentation that seemed to be embodied as an attempt to avoid any affect. Rather, it seemed the bodily contortions were meant to take the audience’s mind, as well as his own mind, away from serious traumas, both recent and past, whilst simultaneously performing an enactment of them. Intellectually, he thought that the idea that he was avoiding his feelings by embodying his conflict was probably correct. At the start of analysis, he was on the cusp of leaving hospital, anxious about looking after himself and returning to work. I offered him treatment on the basis that he would need to look after himself enough, be able to bring himself to and from sessions whilst commencing a return to work, initially for two periods a week. As his general functioning improved, his work slowly returned towards normal, and he was able to move from the chair to the couch. His improvement was not from his desire to idealise our work, which was in fact often mocked, but rather his having to face a de-idealisation of his family and professional life in the context of such reappearances in the transference. This was his ambivalence of loving our work and, it became clear, this being his second analysis, that his simply thinking that our work was helpful was a form of resistance to deeper understanding. It did not do justice to his experiences, exemplified by the ambivalence contained in the constant ‘yes-no’ expletives. In time, he began to understand his position better in terms of his ambivalence rather than having to know only that his father was wonderful in everything that he did. Similarly, if it were not the wonderful analysis, he would revert to an opposite position, indicating that I was useless compared to cognitive behavioural therapy.

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A breakthrough came when he spoke about having a rope hanging in his living room and that he played daily with the idea of using it. I offered to look after the rope. Within a few sessions, he brought it to me to keep (temporarily) for him. This was a moment of trust and a linkage between us of concern that included destruction and the actuality that his mother had hanged herself. It was a moment of really taking something seriously and not prevaricating with an obsessional yes-no. It was also a moment when his past was connected to his present but held firmly in a new way, within the analytic relationship. When he spoke of leaving his apartment with its hanging rope, it was a moment of testing me. Certainly, it was a shocking revelation, leaving me to ponder on whether, after any session, he would return home and hang himself. A case could be made for deciding at that moment that the patient was so suicidal that only an inpatient psychiatric setting would be sensible. And yet, he had lived with the rope hanging from the ceiling for a long time and had not harmed himself. The hospital as a place of safety belies the sad notion that it is not uncommon for suicidal patients to kill themselves on hospital wards, where they are usually observed and less often listened to. Mr C was curious, at that moment, about how I would deal with his violent self. In a spontaneous interpretation, I offered care and a home for the rope. I  offered to share the destructive object with him, without demanding something, such as he must give it to me or must go to hospital. It was an offer to deepen our connectedness without my being frightened of his violence. As months went by, he found he had specific thoughts and feelings in relation to his family and work that no longer needed to be balanced instantly by the opposite. As he started to feel particularly angry at various objects and moved away from an emotionally vapid balance, his stereotypy of movement diminished. He began to go to work every day and was able to think deeply within his professional expertise. This was something he thought he had irrevocably lost, and he was very grateful that his fragmented mind was showing signs of being able to have deep and connected thoughts again. Theoretically, I thought that his gross body movements were a hysterical overlay to defend against affect. I decided not to speak about the lessening of the violent movements unless Mr C did so himself. This was because I thought he was vulnerable to immediately doing the opposite; it was his usual way of obsessionally balancing himself as well as being aggressive to the other and avoiding affect. Gradually, he began to realise that he was not some sort of ‘puppet on a string’ (a hanging man), nor was he empty of feelings. Clinical material Mr C began one session by saying that he now found that most of his strange movements mainly occurred when he entered my consulting room. Otherwise, he realised he was much freer in his body movements. After a pause, he added that he knew he could twist the truth. I decided to interpret that the twisting of the truth was also contained in his symptoms of twisted movements of his body. He said

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that there was a strain on his neck and wondered if he was gay or not. ‘Yes-no . . . I am obsessing’. He felt he could turn his brain and twist it the way he wanted it. He could make it straight not gay even though he knew this was not how the brain worked. He thought that his will could move his brain and that the process had become particularly intense two days prior to his recent hospitalisation. He wondered if he was lying to himself. He said that he took some thoughts about his life and then twisted the details to what he would have preferred them to be. He thought that gays were happy when they came out. He thought that his mind created the strange body movements: ‘I manipulate my mind. I don’t question it all the time and although my life is better I will often have a tiny grudge. I want to play a happy world at work but everything is not amazing. I used to be like a rollercoaster, even when well. Moving – changes – sent me into panic. Hang on’. He thought that, recently, every time he had entered a difficult territory, such as a recent party he had given and a trip abroad, this had paid off. He now included his analysis in such a good category. I  said, ‘You think that your mind tells the truth and at times it twists the truth’. He knew that he didn’t lie all the time, but he felt that he could not bear bad feelings, and it was these that he twisted to be away from the truth. He felt that his feelings were just a step away from catastrophe and seemed always to be linked with disaster. ‘I suppose it was because my mother wasn’t there. I was alone in dark rooms, terrified. My father said I would never play with the door closed. I always needed to see my father. I had no feeling of safety’. I  said that, ‘you also noticed how your father looked, especially if you thought father was suffering and in your mind you could twist fantasies in order to make your perceptions look as if your father was ok’. Towards the end of the session, he realised that recently he actually had to say to his father ‘go away’ as he had helped his father enough at that moment. I said that this was new and different from the past; your mother went away and didn’t return and you now dare say ‘go away’. Yes, he replied, it is progress. In this session, as the transference neurosis develops further, Mr  C connects, for the first time, his strange body movements and the clinical setting. His second statement was his idea that he could twist the truth. Mr C is able to describe how, as a consequence of not being able to bear certain feelings because they place him on the brink of catastrophe, he is able to phantasise instead of having to reckon with that which he knows. Truth is disrupted as a protective mechanism from falling into the chasm of affect. Alongside, he also imagines that he is sexually twisted, as his body twists, in being homosexual or even being a woman who wants a man. He continues, in the session, to describe his great fear: ‘I suppose it was because my mother wasn’t there. I was alone in dark rooms terrified’. The reality of his mother’s total absence from his life when he was two years old, and perhaps even before that, includes an idea that nobody else was available to care for him. It is possible to imagine that he was treated with a bodily abruptness by the carer, in all likelihood his father, unused to such matters. His present jerky symptoms could contain a psychosomatic memory of the initial absence of his mother as well as the physical failure of his care that followed. His stepmother only arrived on the scene three years later.

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Mr C’s first breakdown happened when he was two years old, and the environmental loss, replaced by perhaps a much coarser physical caring, could not subsequently have been known about in any conscious way. Both the truth of his loss and how he was possibly unwittingly poorly looked after as a consequence, return as the repressed found representation in hysterical bodily movements and ideas of his of being a woman. He identifies with the lost object although he is profoundly uncertain of any qualities of his mother, being more preoccupied by her death and its abrupt impact on his life, then and now. Utilising such symptoms he also found a way of dealing with the fall of his father and the loss of his stepmother. At the end of the session, Mr C was able to tell his father to go away. Now he was beginning to own his own affect, including his anger towards his father for many things. He could only say this to his father by reaching the point of being able to know that his father, being away, would not also die. Now he could have a more alive relation to him with ambivalence and therefore with less need to contain his anxiety within psychosomatic defences. As this was the penultimate session of the term, I could have subordinated the direction of the free associations in the session to an interpretation pointing out his anxiety about the impending break from analysis. He had an idea of telling his father to go away similar to me telling him to leave my practice for a break. This clearly has a resonance, but its early interpretation only locates me at the centre of his world. Being able to dare push his father away with an unequivocal ‘no’ is profound and is, of course, found, as it were, due to the transference tension close to the end of an analytic term. My point is the importance of locating analytic experience, then and now, at any moment in the analysis. For most of Mr C’s life, the happenings around the time he had with his mother and her sudden suicide when he was two years old, soon after the birth of his younger sister, were wiped out. The new family constellation became the family seemingly with no prior history that could be grasped or imagined. Mr C’s early symptoms included looking with anxiety into the corner of rooms. Something on the edge of what was going on in his life constantly preoccupied him and developed into a system for dealing with the concomitant anxiety as his obsessional defences developed. In a sense, all was sufficiently balanced in his psychic life without history. On the surface, he was living his own life in his own house whilst having a high-powered professional career. Yet he had difficulty in being in a relationship with a woman. If a core part of his unconscious self was the life and early death of his birth mother, then all the solidity of his father’s second marriage, from when he was five years old, including its love, did not address the point of absence. His mother went missing suddenly never to return. Subsequently, during his growing up in the absence of talking about her and her meanings for him, his core emotional life was relegated to the corners of rooms and then covered up in the to and fro of obsessional thinking. Father was only seen as a wonderful kind-hearted character deeply caring for everyone. When father’s world also began to disintegrate, suddenly Mr C’s unconscious recourse was to move towards his own fragmentation. The separation of his parents was then a bombshell. He could no longer mentally hide in a flourishing family life. Suddenly, mother had disappeared again, evoking

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the sudden loss of the original mother. Father no longer on a pedestal and mother absent required greater mental resources if the carapace over his emotional life was not to crack. The obsessional defences were arguably insufficient to deal with the new traumas, and his body ego needed to be put at the disposal of bearing the weight of his mental avoidance. Yet within the symptom is also the link to the solution. Mr C’s body had been in a state of constantly and suddenly twisting itself. This was a motion rather than an emotion. It derived its power from twisting the truth. In addition, he would shout ‘yes-no’ many times as if to show the ambivalent position as balanced when clearly it was not. The importance of the absent mother and collapsed father became significant in relation to Mr C’s loss. Not only did his mother never appear again for him, but the two-year-old also had a psychically broken father in a state of loss. He had no memory of what happened in the three years from mother’s death to his father remarrying. He did know that he called his stepmother ‘mother’ as anything else would have been disloyal to his father. Even more so, it may have pitched father back into being broken by inviting the remembrance of his past. As he noticed the return of his original traumas in the present tense of his family’s difficulties, he began to forge a new relationship with his father. Instead of being instantly available to his father’s summons, he began to realise that much of the relationship was superficial and immature. He began to realise that his father dealt with his own anxiety obsessionally; he needed daily or more reassurance from his son, and it was valued only during the breath it took to utter. Now he could begin a separation from father which, although still involving his love and care for him, also required Mr C’s own selfhood and individuation. Mr C had to painfully realise that his father often did not listen to him, hence the requirement for a repetitious formula described by the family as ‘listening to poor father’. Similarly, he could begin to discern that some of his difficulty with girlfriends in the past was about his unconscious anxiety that they would suddenly leave him as mother had done. To prevent this, he invariably precipitated the leaving. One can consider such behaviour as containing both a killing of a girlfriend as well as protecting her from her own violence, like his mother. It is possible to conjecture that his jerky body movements were an unconscious representation of his sexuality. Concern at being heterosexual was entwined with camp movements (noted also by the neurologist), as this meant for Mr C that he was homosexual. Yet there seemed pretence insofar as his desire to be a woman also contained, alongside identification with women/mother, his loathing of them. It is somewhat well known that some men attempt to partially hang by the neck from a rope in order to increase masturbatory pleasure. At such a moment, sex and death are in close proximity. In Mr C’s case, in addition to the reasons for identifying with her, he would be identifying with his mother’s form of suicide: an act that is rather more a masculine choice of suicide. Perhaps one way of understanding is that if mother kills herself utilising an overtly physical and masculine design, then, in a confusional fragmentation, he can be a camp follower. Mr C’s body bears witness to a psychosomatic

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state that is felt to be emotionally unbearable. As he said in the session, ‘hang on’, and this is what he did with his own rollercoaster body movements. The aftermath of his mother’s hanging necessitated his own hanging on. His thoughts of not just being gay but perhaps really being a woman were an attempt unconsciously to bring his dead mother and absent stepmother alive as himself. He became, in some of his gay camped-up movements, the absent women that he longed for. His other identification with his mother is clear in his erecting a rope in his living room to have available as a concretisation of her death by hanging. Giving up the rope made his affect more available, and he began to feel the present state of the double loss of mother’s and family life. As he became more thoughtful about this and began to mourn, his body was required to twist less and less from truth. The rope is symbolic of a transference position that has several meanings. It represented a deep moment between the two of us, binding him to me, as in an unconscious umbilical connection. It also contained in the transference the beginning of his ability to engage some of his violent hate to the object (myself) without a re-killing. At this point, one might wonder about the risk of his falling into a deep depression as the reality as well as the longevity of his fight against mourning emerged. This did not happen as it was mitigated by his realisation that his mind was returning not just with feelings but with a capacity to think. By not having blank no-go areas in his mind, he could revitalize himself and feel more alive. Similarly, the bodily evocation of the re-evoked missing mother in the 18 months of his present illness, with sudden wild movements towards and away from the person in dialogue, had diminished due to a revitalisation of his imagination. The return to normal body movements came from his ability to imagine beyond the bounds that he had until then placed around family life and idealised. His unconscious demanded that father needed to be preserved on high at all costs. He was the other parent who could still be present. The two-year-old and the child subsequently needed a damper put on the ordinary capacity to unconsciously destroy the parents in the age-specific development of magical-destructive omnipotence. Inevitably, this restriction leads to a diminution in the capacity to metaphorize. For Gubrich-Simitis, describing second-generation Holocaust survivors, the analytic treatment of severely traumatised patients involves trying to reach the trauma that remains unspoken, and thereby releasing the associative and imaginative capacities of the patient. She describes such psychological movement as being from ‘concretism to metaphor’ in the clinical setting (Gubrich-Simitis 1984, pp. 301–319). That seems a valid way of thinking about Mr C, who presents with profound psychosomatic reactions in a mental setting rather devoid of imagination. At the start of analysis, his conflicts had no conscious connection with any history. Perhaps his aggressive movements could be thought of as an intermediate position between concretism and metaphor, as an attempt to move his body to force possible other ways of understanding. The same would be valid for the yes-no repetitions, which clearly show him perseverating between two positions. In this, Mr C had a willing ally, as his father too swept away thoughts and feelings about

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his first wife and family. Mr  C had a highly defended inner life with an unconscious fear and guilt over losing the object, and this was what made his obsessional defences so meaningful in the presence and absence of that which is missing. In one sense, Mr C could be understood as having a hereditary disorder by having, for instance, a genetic disposition to his father’s obsessional state together with his mother’s severe depression. Such a diagnostic direction totally leaves out any experiences, thoughts and feelings throughout his whole life. Rather, it locates his actual life experiences to an annexe, whilst simultaneously taking any treatment hope away. It is important to remember that several psychiatrists had treated him with all manner of anti-depressant and anti-psychotic medication, to no avail. Psychoanalysis was able to restore hope to him. The perfectly lovely relationship with a wonderful father was vacuous and was now replaced by Mr C being able to offer real help to his father. Yet it came at the price of having to see his father’s fall from grace and giving up supporting his father’s constant wish for reassurance about the business. Realising such dialogue was empty enabled Mr A to dare to decline to speak. This led to his having a more mature relationship with his obsessional father. Instead, he could give advice that required a degree of circumspection, with even the possibility of angering his father if he disagreed. Mr A had moved from protecting his father from magical omnipotence to a more real position of being able to know his own hate. Similarly, Mr C moved from playing seriously in an identification with his hanging mother as her hateful gift to the family, to bringing the rope to be cared for transformatively by the analyst. The rope to hang is turned from a concrete fact in his daily life utilised to both torture and deal with unconscious guilt into a metaphor of linkage. It thereby becomes a rope that bound the two together, analyst and analysand, in daring to explore his early and present life beyond the rigid boundaries of his capacity to think. His jerky movements as represented as a puppet on a string may contain an embodied hallucination of what he imagined happened to his mother when she killed herself. His tics point to an enactment of her suicide. Yet in addition to exposing bodily suicide, the act implies that the hanger is still alive. The tic addresses the imagined trauma to his mother, re-creates it in his own body as the only place for him to experience it, and concurrently keeps his mother and himself alive in the struggle. It is remarkable that this behaviour began following the separation of his father and stepmother, a marriage that had lasted for all but five years of Mr C’s life. The unconscious representation of losing his mother again, in the family atmosphere where such matters were not discussed, coalesced with the loss of his stepmother and the downfall of his father. I now look at the slight literature relating to tics in early psychoanalytic studies. In Ferenczi’s paper on tics (Ferenczi 1921), he notes that he had never had a patient who came to analysis for the express purpose of curing tics. He explains the unconscious links between the bodily expressions as hysteria and paranoia, as in drawing unwanted attention to oneself in the grip of strange body movement. Such patients have to cope with their twisted body and expletives being seen by family, friends and at work.

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Ferenczi quotes the research of two physicians, Meige and Feindel, in their book Tic, Its Nature and Treatment. They write that the starting point of a tic may be a hypochondriac self-observation. ‘One day I felt . . . a crack in the neck and at first I thought something had broken’, said a patient, ‘To make sure I repeated the movement without noticing the crack, I  varied it in a thousand ways and more violently. At last, I felt the crack again and this gave me real pleasure . . . however the pleasure was soon disturbed by the fear that I had caused some injury’ (Ferenczi 1921, p. 150). My patient too began his tic with a sensation that something had ‘plopped’ in his head, ‘as if an evil clown had come out’. It coincided with a thought that he would like to kill his sister. A week later, he found himself writing the name of his first analyst, and he spontaneously jumped. This was the start of the body tics. All this time, he was conflicted with thoughts about being ‘sucked back into his family’ or being able to be more separate. In a certain sense, his dilemma was then managed by being hospitalized. Ferenczi (1921) explained the mechanisms of the ‘mysterious leap from the mental to the physical’ in the formation of hysterical symptoms. In conversion hysteria, the object memories repressed by psychic energy are used to reinforce and finally to ‘materialize’ the difficult ego (body) memories associated with them. One can consider that this is one of Ferenczi’s contributions to the development of the theory of hysteria following Freud and Breuer’s early discoveries. For Mr C, enquiry after his mother, let alone mourning as he grew up, was a lost, forbidden subject. It was as if raising the topic would lead to his father’s collapse and even his loss too. This constellation had left Mr C with an area of his mind devoid of being able to imagine. Ferenczi’s paper was discussed at a meeting of the Berlin Psycho-Analytical Society on 9 June 1921, and Abraham contributed a report (Abraham 1921, p. 323). Accordingly, he thought that the tic was a conversion symptom at the anal-sadistic stage. In 1925, Melanie Klein also wrote a paper in relation to Ferenczi’s titled ‘A contribution to the psychogenesis of tics’ (Klein 1925). In it, she describes the analysis of two boys aged 13 and 9 years, and agrees with her former analyst that the tic is a masturbatory equivalent. Her treatment reveals the early object relations of genital, anal and oral sadism on which the tic symptom is based. Whilst accepting that neurotic patients have masturbatory phantasies no different from patients with a tic, she was interested in discovering more specific factors. Klein finally relates the tic symptom with the patient observing and listening very early on in life to parental intercourse, and it is this that is converted into the physical manifestations of the tic as masturbatory phantasy enacted. For my adult patient, the tic symptoms appeared in adulthood with no known early representation. The two-year-old’s observation and/or imagining of his dead mother, together with its sudden and massive impact on his father and family life, becomes the psychosexual source of the phantasy material that eventually develops into tic symptoms. In this case, it is not only infantile sexuality but its relationship with absence, death and the inability to mourn that my patient crafts into adult symptoms due to contemporary disturbances in the family, his parents’ separation and his father’s financial collapse. Yet there is a clear link, prior to his recent

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illness, between early life and relationships with girls, sexual difficulties and homosexual anxiety. Abraham and Torok write convincingly about a type of arrested memory that they describe as endocryptic phenomena (Abraham & Torok 1973). The hidden side of the vast majority of the so-called psychosomatic illnesses is actually the return, by way of pain, sickness and physiological calamity, of the dead who are in mourning. This is so because the melancholic phantasy – the phantasy of empathy with the lost object who is bereft of me – is taboo (Abraham & Torok 1973, p. 162). They ask what happens when endocryptic subjects are visualized in melancholic phantasy. The only resolution available to them is to use their own body in a quasi-hysterical fashion. As Abraham and Torok state, ‘the deceased person is incorporated by the subject in this way, “I carry in me someone who is dead and who cannot digest the fact of having lost me” ’ (1973, p. 163). From this perspective, the dead object unrealised or imagined has a task, which is to know that they have lost the subject. It is a neat reversal of the mourning process in which it is the one left alive who perforce has to miss the dead. The arrested development is stuck in the very requirement that the dead object needs to continuously know what it has lost in the alive person. This unconscious phantasy of the dead looking down in such an alive, so to speak, way is one of the possibilities linking unresolved mourning and hysteria. Published in the same year as Ferenczi’s tic paper, there is a poignant example of this structure in Proust’s Sodom and Gomorrah. The author, in bending down to undo his boot, suddenly remembers that he has forgotten to remember his dead grandmother, ‘Then I thought I remembered that shortly after she died, my grandmother had said to me, sobbing, with a humble expression, like an old servant who has been dismissed, like a stranger: “You’ll allow me to see you sometimes all the same, don’t let me go too many years without visiting me” ’ (Proust 1921, p. 163). In a more recent session, Mr C said, ‘I was always attracted to unstable women. I suppose I have been hanging on to my mother’. I interpreted that he was describing in his language hanging on to a hanging mother, as a form of avoiding mourning. He replied that he was feeling trauerlicht and quickly realised that on speaking about his sad feelings, he had reverted to his mother tongue. He then remembered that his stepmother knew he needed psychological help when he was eight or nine years old. He had gone to a party in a school classroom. Everyone had gone by the time he arrived, and he sobbed. Mr C was able to move in his free associations to hanging on to his dead mother, to speaking of sadness in his mother tongue, to remembering a childhood memory of crying when everyone was missing. Clearly, these are free-associative references back in time, unconsciously linking to when he was two years old and his mother disappeared. Such sequences enabled him to begin to invest in a new process of mourning. Not all causes of conversion hysteria contain such elements. However, a particular form of mourning is the undead subject, something that André Green has written about very evocatively. The work continues, and the groundwork has been laid for the next stage of analysis. He has stayed away, more or less, from the frightening arena of a sexual

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relationship with a woman. His unconscious anxiety that soon after penetration one or other of the couple will have to be violent, or a ‘lust murder will need to happen’, is beginning to be understood. Staying in analysis is a representation, in itself, of a developing capacity to stay and face reality. Nonetheless, the unconscious representations of the hanging mother are profound and will need to be worked through not just about the postcoital state but also when his partner becomes a mother herself. This will be a future test for the efficacy of the analytic process. Despite a great deal of inpatient care, medication and time away from work responsibilities, with the onset of intensive analytical treatment, his general hysteria and passivity in relation to the demands of ordinary life were able to change considerably over some seven months during that particular phase of the work. I expect this is due to his mind and capacity for free association, as well as his violent phantasies, being taken seriously. Mr C was able to move from hysterical body movements to mourning for a dead mother and an idealised family. Note 1 A version of this chapter was presented at the scientific meeting of the British Psychoanalytical Society on 5 December 2007. It was previously published in Landscapes of the Dark by Jonathan Sklar, Routledge, 2011.

References Abraham, K. 1921. Contribution to a Discussion on Tic. In Selected Papers on Psychoanalysis. London: Karnac Books, 1997, pp. 323–325. Abraham, N. and Torok, M. 1973. Self-Self Affliction: Notes on a Conversation on “Psychosomatics”. In The Shell and the Kernel: Renewals of Psychoanalysis, vol. 1. Chicago: Chicago University Press, 1994, pp. 162–163. Bollas, C. 1992. Being a Character. New York: Hill and Wang. Bollas, C. 2000. Hysteria. London: Routledge, p. 31. Breuer, J. and Freud, S. 1893–1895. Studies in Hysteria. In The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 2. London: Hogarth Press, p. 4. Ferenczi, S. 1921. Psychoanalytical Observations on Tics in Further Contributions to the Theory and Practice of Psychoanalysis. London: Hogarth Press, 1950, pp. 142–173. Ferenczi, S. and Freud, S. 1920–1933. The Correspondence of Sigmund Freud and Sandor Ferenczi, vol. 3. Cambridge, MA: Harvard University Press, 2000. Freud, S. 1924. Neurosis and Psychosis. In The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 19. London: Hogarth Press, pp. 147–154. Gubrich-Simitis, I. 1984. From Concretism to Metaphor: Thoughts on Some Theoretical and Technical Aspects of Psychoanalytic Work with Children of Holocaust Survivors. Psychoanalytic Study of the Child, 39, pp. 301–319. Klein, M. 1925. A Contribution to the Psychogenesis of Tics. In Contributions to Psychoanalysis, 1921–1945. London: Hogarth Press, 1948. Proust, M. 1921–1925. Sodom and Gomorrah, the Prisoner and the Fugitive. In Search of Lost Time (Trans. J. Sturrock). London: Allen Lane, 2002.

Chapter 5b

Hysteria and mourning – A psychosomatic case 1 Discussion of Jonathan Sklar’s chapter Susan Loden I am grateful to Jonathan Sklar and to the Scientific Committee for giving me the opportunity to respond to this fascinating case history. It is neither wise nor fitting to argue with a clinical success, and I don’t propose to do so. Rather, I would like to try to draw our attention to some of the complex theoretical issues touched on in Chapter 5a, particularly in regard to the relation of the symptom to hysteria. Clinically, Jonathan made two bold moves, based on his past experience and his clinical intuition, that allowed the analysis to take root and to become meaningful to the patient. First, despite the patient’s presentation with an alarming array of regressive symptoms and varying psychiatric diagnoses along with medical advice to avoid psychoanalysis, Jonathan made his own assessment that the patient could be reached despite ‘major mental fragmentation’. He noticed that the patient had self-preservative tendencies, and he assumed that his gross bodily movements were an attempt to communicate by re-enactment a past traumatic history. I imagine there were also remnants of good intellectual functioning. It was a brave act to agree to try to help this patient whom many analysts would have regarded as too ill for their private practices, and it is clear the patient regarded this as a lifeline and took it. Second, he describes a breakthrough when the patient spoke about a rope in his living room and his thoughts about using it. Jonathan offered to look after it for him. In this moving encounter the patient experienced Jonathan as an analyst who took his concerns seriously, but did not panic, and offered the firm holding, concern and involvement that he had sorely missed. Theoretically, Jonathan links the patient’s symptom to Freud and Breuer’s early conception of hysteria and traumatic memory in Studies on Hysteria. There they state that the patient’s symptom is ‘strictly related to the precipitating trauma’, memorializing the trauma in a bodily conversion. He then cites Ferenczi’s 1921 paper on tic along with a later letter from Ferenczi to Freud in which Ferenczi argued that psychoanalysis had taken a wrong path in underestimating traumatic reality in pathogenesis. The tic, he believed, directly represents a memory of trauma forcing itself through to expression, an ‘ego hysteria’. Freud’s patient Emmy von N, described in Studies on Hysteria, was an intelligent woman with a variety of symptoms including spasms of the neck and convulsions of the facial muscles along with clicking sounds that interrupted her speech. She DOI: 10.4324/9781003202790-11

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shouted out ‘protective formulas’ such as ‘don’t talk’ or ‘keep still’. Freud classed some of her symptoms as hysterical, some as organic. Freud became acquainted with Gilles de la Tourette and his ideas during his year in Paris with Charcot. He used Tourette’s descriptive terminology in his own descriptions of Emmy and mentioned that he had thought in the beginning that Frau Emmy suffered from tic convulsif but had evidently decided in favour of hysteria because her symptoms appeared to have symbolic meaning (Pappenheim 1980). They were ‘mnemonic symbols of pain’, or long-forgotten traumata (Freud 1895). The case of Emmy von N (Fanny Moser) was to prove the case with the least satisfactory outcome of all Freud’s paradigmatic hysterics, the first to be treated with the hypnotic method, and the most refractory to the supposed abreaction. Later he seemed to have become convinced that ‘there was an organic factor in the question’ after all, as Ferenczi mentions in his paper on tic (Ferenczi 1921), and Freud left Ferenczi to his speculations. Freud seems to have felt ‘taken in’ by Emmy von N. His involvement with hysterical symptomatology and the search for symbolising compromise formations had blinded him to other aspects of Emmy’s character, including a long-standing involvement with a number of physicians, some of whom became her lovers, and to whom she told a number of lies. In the end Freud felt he had been manipulated. In a letter dated 13 July 1935 to Fanny Moser’s daughter, he apologized for ‘my bad diagnostic error’ (Togel 1999). Whether Freud had later decided that Fanny suffered from an organic disease or some other psychopathology is not clear. Ferenczi followed his own line of thinking on tic, linking traumatic neurosis and tic in having a common origin (defence against dammed up libido which cannot be abreacted following a strong affect of fright, when the mental apparatus was overwhelmed with stimuli which could not be repressed). But he goes on to say that tic patients ‘are of a mentally infantile character, narcissistically fixated’. The tic patient simply discharges his pent-up impulses, with a physiological reflex that is a defence against affect still more primitive than repression. Hysteria, he says, is a transference neurosis in which the libidinous relation to the object is repressed and appears as a conversion symptom (a symbolisation). ‘With tic, on the contrary, it would seem that no relation to the object is hidden behind the symptom’. Later, he adds that the obvious identification of the tiqueur with an object that he imitates hides a lack of real interest in the object. Tic-like imitations are caricatures of the object and often operate in an ironical sense. He sums up the difference between hysterical conversion and tics and catatonias (which he groups together) as being in the one case the expression of genital object love regressively expressed as auto-erotism and in the other pure auto-erotism which has to some extent adopted genital qualities. Descriptively, the patient has not progressed to the genital phase, but conceptually Ferenczi retains the notion of hysteria in the concept of an ‘ego hysteria’, ‘a conflict between an ego nucleus and narcissism’, to my mind a confusing concept. The central defining features of hysteria seem to have gotten lost. The issue of the International Journal of Psychoanalysis in which Ferenczi’s tic paper was published carried a discussion of his ideas by other contemporary analysts including Abraham, who disputed Ferenczi’s opinion that no relationship to

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an object was concealed in the tic. Abraham linked tic and obsessional neurosis: in both the double relationship to the object expressed is an anal and sadistic one. ‘Tic was a regression one step lower than the hysterical conversion symptom and approached nearer to catatonia than to hysteria’ (Abraham 1921). He placed the tic somewhere between psychosis (paranoia) and hysteria. After this early psychoanalytic interest in tic, the discussion seemingly went rather quiet, with the exception of Melanie Klein’s clinical paper referred to by Jonathan. Fenichel summed up psychoanalytic contributions to date in 1946 in his discussion of pregenital conversion, following Abraham’s designation. The tic, he said, owes its origins to the mechanism of conversion but is essentially different from hysteria. The patient with a tic ‘shows all the archaic features of a regressed personality’, both compulsive and narcissistic. Movements that were once the concomitant of an affect (rage, anxiety, grief, excitement) have become the equivalent of the affect, appearing in its place. Freud had singled out control of motility as one of the functions of the mature ego; loss of control of this major function implies a serious lack of ego integration. The muscles behave like independent personalities and may be feared and hated by the patient as if they were threatening objects. Fenichel puts it that the relation between the ego and the rebellious muscles supplants, in narcissistic personalities, object relations that have been lost. In the 1940s Margaret Mahler and her colleagues studied children with tic syndromes and published a series of papers on them from a developmental point of view (Mahler 1944, 1949). She concurs with the view that many ticqueurs are highly narcissistic and agrees that in tics appearing in adulthood the psychodynamics are closely akin to those in traumatic neurosis (reaction to an injury). In both childhood and adulthood, the tic can discharge aggressive impulses and can at the same time provide libidinal gratification. From Freud onwards (in The Interpretation of Dreams) a theoretical link was made between tic and masturbation. (Ferenczi especially emphasised that tic could be a stereotyped equivalent of onanism.) It is at the same time a holding on and a letting go, a discharge of impulses or affects, and a diffuse defensive reaction against showing any of these. Graeme Taylor, whose work on psychosomatics has been particularly influential in the US, in the paper on a case of spasmodic torticollis cited by Jonathan applies an entirely different model to the symptom, the so-called dysregulation model. This approach is aimed at overcoming early structural deficits involving affect regulation and the maintenance of a stable sense of self. It disregards unconscious driverelated conflicts and explicitly refutes the idea that something like torticollis is in any way a form of conversion hysteria. Taylor believes that perverse and violent fantasies and enactments reflect early psychic traumas that generally underlie alexithymic mental functioning. Primitive emotions have not been encoded into any symbolic form and remain as unregulated somatic states. Arrested early development is a consequence of faulty early object relationships, a lack of attunement and a lack of reciprocity with a sensitive caregiver. The symptoms are simply rudimentary emotions, not defences against conflict. The patient he describes had suffered recent narcissistic injuries including the loss of a friend who was an ‘external

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regulator’, someone who helped maintain narcissistic equilibrium. We can see the parallel to Jonathan’s patient who had recently suffered the loss of his idealised family, in particular his stepmother. Interestingly, although the affect regulation model and the traditional psychoanalytic model make different assumptions about the underlying dynamics, the clinical treatment described by Taylor and that by Jonathan seem quite similar. Taylor emphasises awareness of the patient’s psychic pain, an acknowledgement of the deficiencies in the family relationships, a serious but calmly containing view of the symptoms, ‘constructive interventions which restored a stabilising positive transference’ in an attempt to activate memories of warmth and affection. He is also aware of the need to keep firm boundaries, not to collude with the patient’s sense of victimisation, and to teach the patient to name his affects and to use them as signals for action or reflection. Where does this excursion through the theoretical literature leave us with regard to Jonathan’s patient? Jonathan thought his patient had the capacity to be helped and treated his symptom as a communication. The patient responded and began to bring the symptom into the treatment as a manifestation of transference, a very positive sign. My own working assumption would be that Mr A was unlikely, at the age of two years, to have seen his mother’s body hanging, nor would he have had much idea what that meant even if told. He would most likely have been exposed to half-understood whispers and rumours, a partially concealed secret in the family that was never openly discussed nor affectively worked through. The father’s habitual denial and need for reassurance would support this idea. The hanging fantasies were more probably a later elaboration, and I believe it was these fantasies, charged with ambivalence, that were re-enacted in the symptom. They were not a ‘burnt-in’ representation as occurs in a traumatic memory; however, I am sure they expressed a lived, cumulative traumatic history. The tic symptom is intimately associated with what is secret and what is revealed, and I wonder if the patient was letting people know that he knew the secret, possibly with the aggressive irony of the ticqueur described by Ferenczi. In one of Mahler’s studies (1944) on motility and the vicissitudes of affective expression, she points out that early in life the motor equipment chiefly serves to reunite child and mother. This child lost his mother at the age of two years. He was a child who had nowhere to run, no one to help moderate his feeling states nor to soothe and/or give words to his emotions. The conditions were right for the development of psychosomatic states. A child deprived of a mother or mother substitute between the ages of two and five years would find it difficult to pass normally through the Oedipal phase towards genitality and object love. Jonathan mentions the connection between hanging and erection, and it is possible that the symptom was overdetermined by a connection to sexuality (the identification with mother implying castration, and the terror of a regression to anal-sadistic forms of sexuality). Conversion can occur along the whole spectrum of psychopathology, at any stage of development, and as in this patient the somatic pathway is open, I would be interested to know if the symptom abates and disappears, or whether it will reappear and take on new meanings as the analysis progresses.

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Note 1 This is a version of a discussion paper read at the Scientific Meeting of the British Psychoanalytical Society on 1 May 2019 in response to Jonathan Sklar’s paper of the same name.

References Abraham, K. 1921. Discussion of Tic. International Journal of Psychoanalysis, 2, pp. 477–482. Fenichel, O. 1946. Pregenital Conversions. In Psychoanalytic Theory of the Neuroses. London: Routledge and Kegan Paul. Ferenczi, S. 1921. Psycho-Analytical Observations on Tic. International Journal of Psychoanalysis, 2, pp. 1–30. Freud, S. 1895. Studies on Hysteria. Standard Edition, vol. 2. London: Hogarth Press. Mahler, M.S. 1944. Tics and Impulsions in Children: A Study of Motility. Psychoanalytic Quarterly, 13, pp. 430–444. Mahler, M.S. 1949. A Psychoanalytic Evaluation of Tic in the Psychopathology of Children – Symptomatic and Tic Syndrome. Psychoanalytic Study of the Child, 4, pp. 279–350. Pappenheim, E. 1980. Freud and Gilles de la Tourette: Diagnostic Speculations on “Frau Emmy Von. N”. International Review of Psycho-Analysis, 7, pp. 265–277. Taylor, G.J. 1993. Clinical Application of a Dysregulation Model of Illness and Disease: A Case of Spasmodic Torticollis. International Journal of Psychoanalysis, 74, pp. 581–594. Togel, C. 1999. “My Bad Diagnostic Error”: Once More About Freud and Emmy von N. (Fanny Moser). International Journal of Psychoanalysis, 80, pp. 1165–1173.

Part four

Psychosis

Editor’s commentary Brian Martindale has devoted his long career largely to the study and treatment of psychosis, drawing on innovative Scandinavian techniques which offer a richness of psychoanalytic techniques and understanding. His chapter stands alone in its work in the family, in the community and with the individual patient who may also be the family/community carrier of a wider problem. His approach reminds me of the efforts of Joel Kanter in America (Kanter, J. [1990] Community based management of psychotic patients: The contributions of D.W. and Clare Winnicott. Clin SWJ. 8[1]: 23–40).

DOI: 10.4324/9781003202790-12

Chapter 6

Psychoanalysis, psychosis and the family 1 Brian Martindale

Introduction This chapter illustrates psychoanalytically based work with a family where a member had a major psychosis and which, by necessity, took place in the family home. Peaking in the 1950s and 1960s, many psychiatrists who were also psychoanalysts, such as Sullivan (1953), Lidz (Lidz and Fleck, 1985) and Laing (Laing and Esterson, 1971), studied the family where there was psychosis and described patterns and constellations they considered as contributing to vulnerability to psychosis. I have previously written of the tendency to attribute those describing these kinds of empirical findings as blamers. Others used psychoanalytic findings as opportunities to blame either therapists or families. Freida Fromm Reichman used the unfortunate words ‘schizophrenogenic mother’. This infamous example contributed to the denigration of psychoanalysts who became tarred as blamers. Ted Lidz, psychoanalyst, and Professor of Psychiatry at Harvard in the 1950s and 1960s, who conducted perhaps the most extensive psychoanalytic research on families and psychosis, wrote towards the end of his life: I .  .  . find it very distressing that, because the parents’ attitudes and interactions are important determinants of schizophrenic disorders, some therapists and family caseworkers treat parents as villains who have ruined the lives of their patients.2 I have suggested previously that psychoanalytic therapists became so anxious about being accused of blaming that there has been a retreat by such professionals from pursuing interest in the family and psychosis. Blame in psychosis is of considerable psychoanalytic theoretical and clinical importance operating at individual, family, professional and wider societal levels, but blame is not my further focus in this chapter (see Martindale, 2017). Despite these anxieties about blame, I  became involved in psychosis services and found that outcomes were dramatically improved when I engaged the family from the very beginning. But because the issue of blame is so toxic, I did not call meetings ‘family therapy’; I had to manage my anxiety that my work would lead DOI: 10.4324/9781003202790-13

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to accusations (from both fellow professionals and from family members) that my approach was a blaming one and my fears that my own, sometimes critical, feelings towards families would inadvertently be expressed. I was considerably supported in conducting family work from a psychodynamic perspective by my contact with the Finnish psychoanalyst Yrjö Alanen and knowing of the improvement in outcomes following the introduction by his team of routine family engagement in his need-adapted approach to schizophrenia (Alanen, 1997. This forms the basis of Open Dialogue and Open Dialogue for Psychosis, an evidence-based approach that is now gaining a foothold in an increasing number of services (Putman and Martindale, 2021). Family work in the home The main reason for family work taking place in the home is simply that it is often the only place where family work is possible because many families will not get to a clinic for multiple reasons. Ms X is now 31. When 21, and still living with her family at home, a psychiatrist wrote a letter after Ms X failed to attend her clinic assessment, (the GP had diagnosed a paranoid psychosis). The psychiatrist wrote that, if Ms X was to become motivated to attend, a further appointment could be made. Ten years of Ms X’s life then passed by without any mental health intervention and she led a very limited reclusive life. In the past, any of us might have taken a similar approach without stopping to think about our own lack of motivation and our rationalisations against reaching out to someone too disturbed to engage with our favoured setting. There are advantages in doing therapeutic work in the home besides that of engaging the person with psychosis: 1 One can more readily engage with siblings, friends, parents and grandparents who all influence one another in healthy and unhealthy ways. 2 Related to (1): Psychosis is an alienating condition; relationship breakdown is often a consequence if not a cause; actively involving key others makes it increasingly possible to reverse or minimise the alienating process and to support capacities and address problematics between people. 3 Key persons may have become exhausted or otherwise disturbed. Taking seriously the state of other family members, sometimes even getting them a good night’s sleep or enabling parents with a psychotic youngster to have time together for the first time in years may help turn the tide. 4 In psychosis the mind may ‘splinter’, and Freud’s crystal metaphor is useful: If we throw a crystal to the floor, it breaks; but not into haphazard pieces. It comes apart along its lines of cleavage into fragments whose boundaries, though

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they were invisible, were predetermined by the crystal’s structure.  Mental patients are split and broken structures of this same kind. (Freud, 1933, SE 1964, p. 59)   By a predetermined structure, Freud is almost certainly referring to developmental capacities and vulnerabilities in managing life’s vicissitudes and opportunities. In a clinic these may not be visible in the person whose mind has now fragmented. In the home, there may be much more tangible evidence of prior capacities and vulnerabilities in the person and in the family’s capacities and limitations. One may also see photographs, hobbies, musical instruments, football team photos, certificates, let alone pets. 5 In writing this chapter, I  found I  could think of working in the home as akin to having a ready-made domestic therapeutic community, and I  was reminded of my several years working on the Cassel Hospital family unit (Kennedy et al., 1987). Our psychosis early intervention team routinely saw the patients in their homes together with family members. However, as I was the team psychiatrist with a caseload of often nearly 100 compared with the key workers, whose caseload was no more than 15, it was only possible for me to organise my week so that I had just one family and one individual in psychoanalytic therapy. So, the family I now present is not an ‘extraordinary’ case, but one where I took the lead in regular family work over 15 months, working with particularly co-operative care co-ordinators, about whom I mention more at the end of this chapter. Ben, Brenda and their children I thank Ben and Brenda, not their real names, for giving me permission to write about them. I first encountered Ben, Brenda and their children as the team psychiatrist, but it was much more than a year later that I offered to work with the care co-ordinator in fortnightly and then weekly psychoanalytic family work in their home until the family had to leave our three-year-long service. Ben and Brenda were both in their late 20s. They had a girl aged eight years, and a troubled son of about five years with a diagnosis of attention-deficit hyperactivity disorder (ADHD) and autism. I focus initially now on Ben’s history though I would normally take the background and perspectives of all members, observing closely their interactions. Ben is from a working-class background and the oldest of four siblings. From early childhood he suffered with frequent grand mal epilepsy and during adolescence had neurosurgery without benefit. His mother rather ‘mollycoddled’ him. Initially, he spoke of an idealised childhood but later revealed that his father was a heavy drinker and often aggressive, sometimes physically, to family members including Ben’s mother. Ben often intervened between them. We now know the father often threatened to kill Ben as well as to eject Ben’s several years younger

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brother who became increasingly delinquent and involved with drugs and alcohol. Ben was and is terrified of identifications with the brother and any threat of eviction. Although Ben was mother’s ‘angel’, a story that also impressed me was of an occasion when Ben’s mother tried to set Ben a boundary but he literally ‘went missing’, leading to great anxiety for the mother, perhaps exacerbated by fears of an epileptic fit. After hours of neighbours and police searching, Ben came down from a tree from where he had been observing the frantic chaotic activity! Ben left school at age 16 years and met Brenda in an art college foundation year and soon moved in with her family. He has never sustained work or completed a course of study, breaking off usually it seems from fear of being bullied by peers. He has indeed been attacked several times, seemingly stigmatised for his epilepsy. Four years before contact with us, a colleague diagnosed a depressive disorder following assaults and deterioration in his epilepsy and other physical health issues. Ben told us that, even before that time four years ago, he had been experiencing voices/auditory hallucinations but had been terrified of revealing them, fearing being locked away just as he feared his father would eject him from the family home. At referral to our service, he had admissions to hospital with further depression and voices about which he remained rather secretive. He then had recurrent day hospital admissions following a series of overdoses. When I saw him for the first time, it was at his home, and Brenda was heavily pregnant with their third child. Ben was spending extensive time alternating between lying on the living room sofa or sitting at his computer where he searched for spyware that he believed was operated by doctors regulating a pain meter in his left ear. He believed that these devices allowed other people to constantly monitor his thoughts and keep watch over him. On one occasion he tried to cut the pain meter out of his ear with a knife. Ben often heard several different voices; some were violent commands instructing him to harm himself and accusing him of being involved in a murder in the local area with the voices telling him he had blood on his hands. The voices often had a ringleader called Paul. A while before admission to our service, Ben was in a pub and was mistaken by the barman for his brother. The barman subjected Ben to humiliating comments whereupon Ben impulsively attacked the barman sufficiently severely that Ben was given a probation order. (Ben is not a regular or heavy drinker and him being violent is rare in his history.) Ben’s voices also would instruct him to kill their neighbours. This related to an additional likely precipitant of his deterioration to that of the pub incident. Their restless son with ADHD and autism had jumped from their first-floor window when Ben was supposed to have been taking care of him. Social services then paid for safer double-glazed windows, further riling the neighbours with whom there was mutual antagonism partly around the son’s anti-social behaviour in their backyards. Ben had developed complex delusions that the neighbours and police had also inserted listening devices and bugs into the dividing walls. He began tearing wallpaper off the walls and cutting through wires. This, and Ben’s lack of useful activity and the repetitive overdosing was obviously an enormous strain on Brenda. Despite active support from a competent care

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co-ordinator and anti-psychotic medication from a colleague, the situation did not improve over the subsequent year. I became involved again and revisited the history enquiring much more of Brenda’s history. This resulted in my making a family psychodynamic formulation which I felt had considerable explanatory power for the lack of progress and also resulted in my offering to join with the care co-ordinator in meeting with the family regularly. Psychodynamic formulation The key element that I extracted from Brenda’s history was that she had no good internal male object supportive of a woman’s needs as wife or mother. She therefore had no expectations of Ben to surmount any of his difficulties and be at all available as a husband and father. (Her mother gave up hope and left Brenda’s father when Brenda was the age Brenda and Ben’s own daughter was at this point.) Without Brenda’s history and awareness of the repetition, the care co-ordinator had been suggesting to Brenda that she might leave Ben if he did not stop his destructive and regressive behaviour. With Brenda now having three children, one severely disturbed and her husband being like a disturbed needy fourth child, she was close to the breaking point of her own self-sufficient character tendencies and her projection into Ben of her needy self, for which she has considerable contempt. Ben clearly had a massive psychotic split in his psyche, with cruelty and violence located exclusively outside of his subjective self, taking the form of his voice people and in the people of his delusions and in the external world that he avoided. His depleted non-psychotic self has minimal resources to contain difficult feelings, especially those involving humiliation and shame. He was vulnerable to responding to the voices with both violence and belittlement towards himself (suicidality) and sometimes towards others. Ben’s avoidance of attempting father and husband activities defended against the risk of his experiencing humiliation and violence both towards him and from within him. In a double bind, his regression leads to what he most fears (being rejected by the care co-ordinator and Brenda into the dangerous hostile outside world if his regressive dependency needs are too much for either of them). His suicidal gestures, although straining Brenda enormously, also lead to alternative but precariously dependable situations (by which I mean the hospital and day hospital) where Brenda gets respite from him and Ben respite from Brenda and family demands. In terms of the work we subsequently undertook, I  cannot stress enough the interlocking psychopathologies of Ben and Brenda. Therapeutic alliance This formulation was the basis of the psychotherapeutic work. I remember spelling out to Ben and Brenda my awareness of the historical absence for Brenda of any male figure who contributed positively to a household and that she seemed to have

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no hope or expectations of Ben. I also verbalised clearly my sense that Ben only anticipated humiliation and shame if he were to try to contribute to the household. We asked them quite concretely whether they were both interested in working with us to see if we could challenge these two perspectives that I sensed were causing them both such huge problems and such an impasse. Neither theme had ever been verbalised before; our preparedness to offer this focus seemed to motivate them to engage with us. We met on Monday mornings, soon after the oldest two children had gone to school although the three children were very present in the holiday periods. The third child, now several months old and crawling, was always present. A psychiatrist colleague who had known Ben for some years agreed to manage medication issues. Ben and Brenda came to understand that change would involve Brenda not always stepping in to relieve Ben, and our sessions often involved us encouraging the two of them to discuss at a conscious level what Ben might try in the coming week and what Brenda could do to support Ben and what this would mean managing in herself. An important aspect of our work was helping them increasingly to clarify for either of them as to what factors, feelings or actions had got in the way or might get in the way for them both in achieving tasks in what was like a domestic therapeutic community. Of course, this approach elicited transference issues to one another and to us, as well as us needing to observe our countertransferences of which I share a couple of examples. Countertransference Here is a countertransference feeling that both the care co-ordinator and I had in the first therapy sessions. We both felt quite bothered by an uncomfortable feeling of uncertainty as to how much of our exchanges with Ben and Brenda had been taken in. In some way the exchanges felt ‘crazily’ sane to us both. We soon realised that these feelings resulted from their being many more people in the room than we could see or hear, and some of these others had different attitudes to the co-operative ones being expressed! Indeed, the main thrust of our work was to allow these other voices into the room; though at the same time us understanding together why they might not want to be seen and heard. Ben told us that his voices were relatively silent when we were visiting but were often active afterwards. As we showed interest in the content of his voices, Ben became open that his voices tried to get the upper hand and would try to give Brenda ‘grief’ (recall the child Ben hiding up the tree during the chaos he had created). The voice persons were not convinced that Brenda meant it when she stood up to this activity. This was demonstrated very soon after we declared our preparedness to work with Brenda and Ben, as Ben soon took a further overdose. On this occasion, Brenda showed she meant business by not allowing Ben back in the home immediately from hospital as she had tended to in the past. When Ben returned,

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he seemed more determined to take some responsibility, and the voices were silent for a while. I have found particularly helpful the framework of Mike Sinason (Sinason, 1993) and Joscelyn Richards (Richards, 1993) and their further conceptualisation and therapeutic approach arising from Bion’s delineation of the psychotic and non-psychotic personalities (Bion, 1957). We began to openly verbalise the very distinct personalities with different aims in the single body of Ben. For example there was a Ben who genuinely wants to be more capable of playing a fuller part in bringing up his children – but there is also a (child) Ben that wants to be ‘wrapped in cotton wool’ (his words) especially when the (not-me psychotic) voice people were out to humiliate him or Brenda and when the voices made serious accusations and threats against him if he were to try to achieve something difficult for him. This led to fear and sometimes confusion between the Ben who was prepared to feel inadequate with something new and the cruel person secretly mocking his struggles (secret otherwise they, the cruel voices, would be attacked). Likewise, with Brenda, we verbalised her struggle between taking the easy route (in her own way being like Ben); the easy route for her was doing everything herself, and the hard route was leaving space for Ben; but then having to contain her contemptuous and belittling tendency as well as facing the reality of Ben’s anxieties, fear of failure and humiliation; as well as Brenda knowing of Ben’s sadistic side which might work on both of them. I hope this gives just a flavour of the complexity. In keeping with Bion (1957), Sinason (1993) and Richards (1993), it is important to hold onto the psychic reality that, for Ben, his voices were subjectively of quite distinct and separate persons from Ben himself. It became clear that those voice persons (inaudible and invisible to us) felt seriously threatened especially by my presence as the doctor. They believed that my intention was to be rid of them, to kill them quite concretely as persons. This helped understand (1) the voices’ own commands to Ben to ‘kill first’ in order for the voice persons to survive and (2) the tendency of the persons with the voices to be quiet during meetings but to be prominent sometime after we had gone and to oppose any aspect of the work of the session in which they had felt threatened. (Of course, in much of psychiatry the aim of doctors is to ‘kill off’ voices.) Though this certainly did not happen ‘overnight’, it meant we had to allow these beliefs to emerge into the open. The care co-ordinator and myself and Ben and Brenda had to discuss quite concrete ways in which it was possible for the voice persons to continue to co-exist both in the room with us and then have some place in the planning of their daily lives. Once the voice persons began to cautiously trust that their existence was ‘accepted’ (a crucial aspect of Sinason and Richards’ work) and we were not going for their extermination, then their motivations and other characteristics were allowed into the room, and there was a place for them in the discussions between us. Our aim was to try and support the non-psychotic potentially pain-bearing Ben and Brenda to gradually have a greater say and capacity in the relationships, but this did not mean threatening the very existence of those other personalities.

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I now give a concrete example from early in the work of how difficult and complicated this could be. Ben was doing more in the house, doing some renovations, and spending more time with the children. The focus shifted to the end of each day and the evening settling of the children for bed. It emerged in one meeting that Ben would not do anything around bathing the children because he experienced voices accusing him of paedophilic activity. We were still feeling our way and did not know what to make of this: which character was speaking and with what motives. Knowing of Ben’s capacities to act out in various ways – such as overdoses and the violent pub outburst, our own anxieties about his potential behaviour around bath time led us to feel obliged to raise questions – including where either of them in their named persons Ben and Brenda had thoughts or images of any sexual preoccupations with the bodies of their offspring. Of course, the response was a definite no. Following this meeting, Ben phoned the care co-ordinator saying the voice persons were making threatening remarks wanting to kill him (Ben), and he was finding it very hard to stand up to these. At an additional meeting with the care co-ordinator without me, Ben said he felt that I had been on the side of the voice persons accusing him of being a paedophile. Brenda also spoke to the care co-ordinator of her discomfort at my questions, and they were considering discontinuing the meetings and wanted to meet with the medication consultant to resume Ben’s anti-depressants. The care co-ordinator contained their concerns sufficiently and expressed support for Ben and Brenda to bring the various voices expressing dissatisfactions to our next meeting; being able to do this was a most important step for them and for their dissatisfaction to be taken seriously. I am not suggesting for one moment that it was possible in this meeting to differentiate the motives for all the voices, but at least it was possible to open up a dialogue about possible motives including their ideas about our own motives. Ben soon reported that he was bathing the children and in time could do this without significant anxiety from the cruel undermining voices that persisted. There was less acting out outside of the therapy space, and the struggle between the different personalities for dominance was much more open. A major exception regarding acting out was of the suicide-like action by Ben on the local bridge when the care co-ordinator announced her forthcoming departure. Ben created something akin to the chaos of his childhood, running away and hiding up a tree, yet put himself at risk of slipping on the bridge. I later give a second example of acting out at the time of the end of our work with them. Remorse In the last months of our work, their nine-year-old daughter had a sore throat and refused to eat over some days. She spoke of a friend’s father dying recently from vomit inhalation following an alcoholic binge. In speaking of her fear of dying if

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she were to vomit from her sore throat, she also spoke for the first time of how fearful she had often been that her father might die when he had vomited from overdosing. Hearing this, Ben was considerably upset. He had not previously considered the effect of his overdoses on his children. He vowed never to overdose again, and he never has. A telling countertransference enactment Now I want to convey a very telling countertransference enactment of ours. The new care co-ordinator and I would meet with Ben and Brenda in the presence of their third child. Brenda would feed and play with him, and the infant would often crawl across to Ben and try to climb up Ben’s leg. Week after week, Ben would gently, but disconcertingly to us, push the child away back to his mother and not engage him in any playful activity. There were plenty of toys around, and we were hearing that Ben was now spending substantive time occupying and playing with all the children, so we were bemused. Attempts to understand this were met with the psychic equivalent of his dismissiveness towards his son’s attempts to engage him. One day, quite spontaneously, the care co-ordinator and I got down on the floor and took the aeroplane, the fire engine and ambulance and made the appropriate noises playing between Ben and Brenda much to the ‘amusement’ especially of Brenda but with no impact on Ben. On our way back from the meeting to our clinic, I found myself verbalising to the care co-ordinator that there was no way we could tell our colleagues we had been on the floor playing with a toy fire engine and ambulance. I was thinking of the ridiculing comments I would receive such as ‘what the hell do you think you are doing Martindale, an expensive consultant spending your time in such a frivolous way, you should be ashamed’. The penny dropped; I  realised, from my identification with him, how terrified Ben was of ridicule, and I remembered his violent outburst when the pub landlord taunted him. This event allowed us to help Ben to further verbalise years of ridicule and actual physical violence, once even with an iron bar from a gang of peers tormenting him for his odd appearance and his epilepsy, let alone the threats from his father. We understood too how this linked with his wishes to be mollycoddled and his fears of humiliation from ourselves in front of the more competent Brenda and his fear of his own vengeful violence erupting. We could also understand more his pride when he sometimes showed off to us some renovation he had made in the house. Violence in the face of humiliation His violence at humiliation did erupt one Christmas, not long before our work had to stop. He and Brenda had invited over his mother and his sisters and his brother and his girlfriend for a day during the Christmas period. The brother and girlfriend got drunk and became abusive in front of the children and Brenda, who subsequently showed them the door. In doing so, the dog was inadvertently let out

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onto the communal green in front of the terraced dwellings where the brother still was shouting abuse at Brenda, who was beside herself with rage. She called Ben to do something about this and to get the dog. Ben was overwhelmed by the demand, especially the humiliating public scene, and slapped Brenda to calm her down. Despite this event, our work was quite successful at improving Ben’s capacities as a father and husband and equally important in shifting Brenda to have increasing expectations of him, modest to begin with, in the same way that our expectations had to be modest. Her expectations were too much at that Christmas-time moment. In the 15 months available, we seemed unable to modify the very reasons we had to change the traditional psychoanalytic therapy frame of clinic-based work. The family work was done in the home mainly because it would have been impossible for them to have sustained clinic visits at that stage of our work. The scene on the communal green illustrated fully Ben’s fear of him not being able to cope with public humiliation and demonstrated his consequent violent response when his ‘humiliation pain meter’ limit was exceeded. Ten-year follow-up This work took place ten years ago, and I emailed the consultant psychiatrist to ask if he could provide a ten-year follow-up: Yes, X is doing really well. You did a durable job with him and his family. He is still with his wife and the marriage is strong. His daughter is doing brilliantly but his son who has autism is very behaviourally disturbed and the stress of looking after him does trigger X’s voices from time to time. I’m not sure about the youngest child but X never mentions any problems . . . His anxieties in the community have been improved in a sustained fashion and there is no evidence of paranoia. Psychoanalytic family work and impact on mental health professionals I would like to end by stressing that working psychoanalytically with families in this way is an excellent educational setting for mental health colleagues to get firsthand experience of psychoanalytic thinking in practice. Although I am not claiming that their work with this family with me was the primary motivating factor, both care co-ordinators who worked with me with this family are now qualified as British Psychoanalytic Council psychodynamic and psychoanalytic psychotherapy practitioners, respectively. Acknowledgements: I would like to show my appreciation of the skills of Nicky Garner and Judith Smith, the two care co-ordinators who worked with me and with Bill, Brenda and their family, who so generously allowed me to work alongside them.

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Notes 1 Dr Martindale has presented different aspects of his work on psychosis in the National Health Service at the scientific meeting of the British Psychoanalytical Society on more than one occasion. 2 https://en.wikipedia.org/wiki/Theodore_Lidz.

References Alanen, Y.O. (1997). Schizophrenia: Its Origins and Need-Adapted Treatment. London: Routledge. Bion, W.R. (1957). Differentiation of the Psychotic from the Non-Psychotic Personalities. In: Second Thoughts. London: Heinemann, Karnac Books, 1967. Freud, S. (1933). New Introductory Lectures on Psycho-Analysis and Other Works. Translated and edited by Strachey, J. (1964). The Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 22, pp. 1–182. London: Hogarth Press, p. 59. Kennedy, R., Hymans, A. and Tischler, L. (1987). The Family as In-Patient: Families and Adolescents at the Cassel Hospital. London: Free Association Books. Laing, R. and Esterson, A. (1971). Sanity, Madness and the Family. New York: Basic Books. Lidz, T. and Fleck, S. (1985). Schizophrenia and the Family. New York: International Universities Press. Martindale, B. (2017). A Psychoanalytic Contribution to Understanding the Lack of Professional Involvement in Psychotherapeutic Work with Families Where There Is Psychosis. British Journal of Psychotherapy, 33:2, 224–238. Putman, N. and Martindale, B. (2021). Open Dialogue for Psychosis: Organising Mental Health Services to Prioritise Dialogue, Relationship and Meaning. Milton Park, Abingdon, Oxon and New York: Routledge. Richards, J. (1993). Cohabitation and the Negative Therapeutic Reaction. Psychoanalytic Psychotherapy, 7:3, 223–239, doi: 10.1080/02668739300700191 Sinason, M. (1993). Who Is the Mad Voice Inside? Psychoanalytic Psychotherapy, 7:3, 207–221. Sullivan, H.S. (1953). The Interpersonal Theory of Psychiatry. New York: WW Norton & Co.

Part five

Identity

Editor’s commentary This section of the book looks at problems at either end of the lifespan. Gender issues in young people are so painful and conflicted today, and dementia in the elderly is equally topical for different reasons. The young are trying to find their identity; the elderly are losing theirs. Dementia is organic, caused by actual damage or deficit in the brain. Gender problems are ‘biological’, dissatisfaction with the gender denoted by our being male or female, belief that one can choose which one to adopt. Sexuality and gender used to be thought of as two different categories, the one biological, the other stemming from personality. Freud’s universal psychic bisexuality bridges the gap to begin discussing how people feel. These are furiously political issues and not the main theme of this book. Some people have a syndrome such as androgen insufficiency syndrome, where a child who looks like a girl is actually an XY chromosome boy whose body, due to a genetic alteration does not respond to testosterone. Where this is partial, they may not look like either and adults, the parents and the doctors, might have to choose for the child at birth. That might seem a rather old-fashioned focus now, given recent advances in the culture and politics of the field. In Chapter 7, Marcus Evans, who has a profound talent for being able to speak and be listened to, to act and be effective when a child’s development, future fertility and general well-being are at risk, writes very clearly about the confusion for the young person in this predicament. In my view, time itself and therapy, rather than medication to delay the onset of hormone production, is enough. It is not unusual to have to try to save an adolescent from themselves for a temporary period in their young life.1 Dementia is a relatively modern disease form, and in Chapter 8a Martin Rossor opens this section of the book with an up-to-date classification of what is known about the different kinds. It may not appeal to everyone reading a clinical book like this, but it is essential for doctors who will appreciate its systematic underpinning of our more fluid ways of working psychologically. Dementia is highly political and emphasised by the recent pandemic when older people were particularly vulnerable. Those institutionalised became a danger to the

DOI: 10.4324/9781003202790-14

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health of each other and their carers and vice versa until adequate safety structures could be adopted and the new vaccine distributed widely enough. In Chapter 8b Rachel Davenhill calls this ‘a cull of the elderly’ which would not be everyone’s view. What must not be lost in the polemic is the beauty of her clinical material where she monitors the steady loss of identity that is caused by dementia and the pain and the insight, often intermittent but no less distressing, that such a patient has. Also, the creative way in which art can help to express what is happening, in the example of how different people understand the picture of the boy with the violin, most of them thinking, in line with the destructiveness of the disease process, that there is damage in the picture. In this section of the book, we have come full circle in terms of the difficult work for the families and the carers, often the same people, the need for family and staff support, in another category of the work force who could benefit from reflective practice. Note 1 In 2022, the National Health Service Gender Identity Unit at the Tavistock clinic was closed while further evidence for hormone blocking drugs is collected. The disagreement with psychoanalysts on the staff of the main clinic involved a feeling that individual patients were not given enough space and exploration before treatment began, hurried along by the child’s approaching puberty. How the change of policy and closure came about is well documented in the general press and includes some landmark court rulings (NHS to close Tavistock gender identity clinic for children. The Guardian, 28 July 2022).

Chapter 7

Finding space to think Technical problems of working with a cohort of trans identified young women Marcus Evans

Using a composite example, this chapter describes some of the technical difficulties therapists face in private practice when working with a cohort of young women who plan to embark on a medical transition. Although each patient is unique, I start by outlining a similar clinical profile which presents the therapist with similar clinical difficulties. The young women I describe give the impression of having failed to internalise a good object that could support their transition from childhood to adulthood. They have a history of anxious attachments to their primary object, whom they feel has failed to provide them with ideal care. A history of early attachment difficulties related to parental mental health, separation loss or preoccupation with another sibling is common. Indeed, considerable clinical evidence suggests that subsequent psychological separation, associated with weaning, the birth of a second child or a partner’s introduction, is difficult to bear. There is a fear of fragmentation of the ego on the one hand and the effect of aggression towards the primary object on the other. This group often harbours deep-seated grievances towards the failed ideal object, which interferes with the process of identification. There is a hatred of the mother’s sexuality which is often experienced as evidence of the primary object’s betrayal. The development of secondary sex characteristics at puberty can then be experienced as a trauma, like the introduction of an alien experience that is responsible for destroying the possibility of a return to the yearned-for ideal relationship with the mother. This group of patients develops an ‘if only I were a boy’ belief that it is believed would cure them of their dysphoria and experience of alienation. Many believe that they have been born in the wrong body and that the only way they can live a productive life is if they are supported in their desire to transition (Malone, Wright, & Robertson, 2019). The patient may agree to see a therapist to reassure their parents that their psychological state has been thoroughly investigated before medical transition. Although many are minors, some are 18 years old and older. When they attend sessions, it sometimes appears as though they go through the process to reassure their parents that they have been through a thorough psychological evaluation process. The individuals’ doubt, conflicts and confusions are often projected onto the parents. When parents express their concerns about the possible harm or long-term considerations, losses and risks, they are accused of being interfering and controlling. DOI: 10.4324/9781003202790-15

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The therapist must find a setting in their mind in which, although they are able to empathise with all parties, they continue thinking for themselves. In the referral email, parents often state that they were unaware of their children’s wish to transition before puberty. This profile fits the description of rapidonset gender dysphoria (Littman, 2018). The parents may describe a child with various pre-existing mental health difficulties, including social anxiety, eating disorders, autism and attention-deficit disorder. Parents often contest their child’s claim to have had long-standing ideas that they were born in the wrong body. The parents say that this idea emerged at puberty. It must be noted that the children referred are a self-selected group. The parents referring their daughter have invariably read some of the things my wife, Susan Evans, and I have said publicly about the need for a careful psychological evaluation before commencing any medical procedure for the treatment of gender dysphoria. This group of individuals gives the impression of being lost, living in a twilight world outside of life and spending large amounts of time online in their bedrooms. They often find a home in groups that encourage transition. The influence of social media and the group sense of belonging is significant when trying to understand this patient population. However, this chapter concentrates on the technical difficulties of working with them in psychotherapy. Treatment is difficult, as this group of patients often say that they cannot reflect on their mind’s functioning and feel detached from their bodies, which is experienced as disgusting. In the first instance, the curiosity and interest that one might expect in the patient’s mind and body resides in the therapist. The patient’s lack of curiosity may prompt the therapist to ask questions to avoid persecutory anxieties about the process. This can push the therapist into being overactive in their approach rather than following the patient’s material. One gets the impression that this group of patients are watching life from behind a screen, as if they are terrified of life. This group of patients often come across as children and young adults filled with anxieties associated with their sexual lives and the transition from childhood to adulthood (Laufer & Laufer, 1984). As we mentioned earlier, they often are not concerned about whom they spend their time with, the sort of clothes they wear, or what they do with their time and body. Instead, they are focused on their wish to eliminate the natal sex and replace it with the opposite sex (Perelberg, 2019). Any attempt to explore the wish to transition by the therapist can be experienced as a cruel form of control, as if the therapist was deliberately undermining their freedom to choose their gender while forcing them to think about doubts, conflicts and confusion. The services often reflect this intolerance of doubts, conflicts and confusions, claiming that certainty, i.e. the absence of doubt, is a sign of health rather than a cause for concern. Who would not have doubts about decisions with such far-reaching and yet unimaginable consequences? When spending time with this group of patients, it is difficult to imagine that they fully understand the implications involved in medical transition, including loss of sexual functioning or capacity to experience an orgasm. Although some of the group are over age

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18 years, they have limited experience of sex and seem to be disgusted by the idea of adult sexual relations. The battles that often occur in the home between the parents and the child are repeated in therapy. ‘It’s my body, and I  will have a mastectomy if I  want one’ becomes a battle about whether the therapist is working to the patient’s agenda of supporting the wish to transition in an unquestioning way or whether there is room to think with the therapist about what is going on. Bell (2020) describes a state of mind where the wish to think over time and understand why a particular child has developed gender dysphoria comes to be seen as an expression of ‘transphobia’, creating a paranoid universe, a world in which ‘you are either for me or against me’, that is, there is no room for a mind that just wants to think about things. The concrete nature of the patients’ communications can squeeze the therapist’s capacity to think symbolically, particularly when the concrete actions may have serious long-term implications for the patient’s body and sexual functioning. The patient’s capacity for symbolic thought breaks down under emotional pressure. Words are often experienced as concrete actions rather than vehicles of symbolic communication. This leads to an inhibition in the capacity to free associate, and thoughts are often treated as if they could cause damage and lead to harm or violent conflict. The importance of the setting The difficulty finding space to think about meaning outside the dyad of ‘for or against’ transition comes into the therapy at the start of therapy in the transferencecountertransference relationship. There is an immediate question over the goal of therapy. Whom is the therapist working for? The parent who wants the patient to give up thoughts of transition or the patient who believes that transition is the solution to their difficulties? The therapist has the task of trying to establish a position in which they can empathise with the patient’s position and the parents’ concerns while also establishing a setting in which they can explore the meaning and unconscious motives behind symptoms and planned actions. At a conscious level, the patient often presents themselves as certain, while doubts and confusions are often projected onto parents, where they can be dismissed and attacked as bigotry. However, therapists may then be experienced as trying to force these unwanted and threatening experiences back in the patient, which risks making them ill. The patient may convey to the therapist their wish to think about their difficulties as a cruel process that undermines their perceived solution to their difficulties. Given the fragile nature of the therapeutic relationship, the therapist may feel tempted to leave conflicts over medical transition outside the consulting room to foster the therapeutic alliance and avoid a repetition of a sado-masochistic relationship between the mother and the child in the transference. However, avoiding the issue can leave unconscious fantasies unexplored and in danger of erupting into the therapy at any time. Aggressive action towards the self and directed at the objects enter the therapy in dramatic ways; for example, the patient may suddenly inform the therapist that they are about to commence cross-sex hormones, without any

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discussion or time for reflection and thought. Similarly, they may explore the possibility of mastectomy. Sadly, it is such a relatively easy operation to perform and adult female patients referred to the Portman Clinic in the past had usually already had bilateral mastectomy before psychodynamic consultation (personal communication Anne Zachary). The therapist has the task of trying to establish and maintain a setting in which they can empathise, understand and be sympathetic towards the patient’s point of view while maintaining their capacity to think about the meaning of these states of mind. The starting point for the therapy would be the nature of the contract. Who wants the therapy and what for? The therapist must try and establish a position in which they can explore the patients’ difficulties without colluding with thoughtless action on the one hand or advocating for conformity on the other. The first test of how these different positions will be managed often takes place over the patient’s name. Patients generally insist that they are called by the name they have chosen rather than their given name, even if they are still in the early stages of social transition and are still known in some parts of their life by their given name. I agree to use the chosen name while keeping in mind the given name and what it represents; what do they imagine the chosen name will provide for them, and what does the given name represent? Why do they hate their given name so much as they invariably do? All these questions may take time to emerge during therapy. The therapist is constantly treading a line between following the patient’s material and knowledge that the patient often controls the therapeutic encounter to the extent that exploration of the patient’s internal world is seen as a threat. I now describe some technical difficulties working with a 21-year-old natal woman Jane who wished to transition. At the time of seeing her, she had not taken puberty blockers or commenced taking cross-sex hormones. She agreed to attend therapy at her parents’ request. She was worried that she had comorbid problems and was rushing into a medical procedure with long-term consequences without understanding the underlying issues. Jane suffered from anxiety and depression and was treated by the general practitioner with anti-depressants. Jane’s parents divorced when she was young, and although she still had contact with her father, her mother raised her. Jane has a younger sister and attends college while living at home with her mother. However, Jane was still known by her chosen name (Sam) in some areas and her given name (Jane) in others. I respected her wishes to be known by her chosen name while keeping her given name in mind in the therapy. In this chapter, I use her given name to describe her. This was a session that took place some four months into her once-weekly therapy. Jane is a tall and thin, androgenous-looking woman dressed all in black. Session 1 Jane came into the session saying that she felt tired and hopeless, and it was complicated for her to think of new things to say as her mind went blank. I thought she felt under pressure to speak but was also unsure whether therapy would make any

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difference. I thought it was possible that Jane still felt hopeless about herself and our work together. After a short silence, Jane said that she had a lot going on in her mind, but she wanted to distract herself from these thoughts because they were connected to her dysphoria, and she did not think they were helpful. I said that I thought she and I were working at cross purposes as I asked her to think about what was going on in her mind while she thought I didn’t understand, while she believed her capacity to distract herself was protecting her from thinking. She nodded in agreement with this after I paused. I said she was worried that talking about herself would expose the degree of her self-hatred, which left her feeling humiliated and even more hateful of herself as she was aware that there was something seriously troubling her. After quite a long pause, she said that some men were painting the outside of the house next door. I replied that I thought she desperately wanted to get away from her difficulties and paint over the problem. However, I also thought she was worried that the problem of her dislocation from her body and self-hatred would not go away. Jane looked angry when she said she was fed up having to persuade people that she was a man. I replied that we did not yet understand the split between her mind and body or why she hated her female sexuality so much. I said that she would decide what she wanted to do in the long term. However, the therapy was an opportunity to explore some of the issues that troubled her before she decided about medical interventions that had serious long-term consequences. Jane then told me about an upsetting dream in which her given female name was written on a name tag rather than her chosen name. She later looked in the mirror to see a shapely female figure, with breasts and hips. Jane mentioned that she was very disappointed to have had such a dream. I pointed out that she was upset at not getting rid of the female self and sexuality because her body had a life of its own, and could, however, not control the way others saw her. Jane replied by saying that she felt more herself when she was Sam. I replied by saying that I thought she did not feel that she had a home anywhere and felt her body was alien to her. Her mind played a critical role, and she was unsure if the therapy was a safe place where she could discuss things with me. Jane said she realised that the idea of transition would not cure the dysphoria and that she did not ever really remember feeling comfortable anywhere. This made her feel like she had no place where she felt comfortable, not with the women in a woman’s body or the men. Jane said she felt most comfortable when she went for a weekend with her father, and they would go exploring the coastline. Discussion of the session Joseph (1975) describes a group of patients who are difficult to reach because they withdraw from being involved in life to the point that they mock the desire to engage in it. Jane gives the impression of watching life from her bedroom while playing with all sorts of ideas of what type of existence would be manageable.

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She retreats into a superior place in her mind in many ways, looking down on the body’s desires, passions and conflicts she despises. Any attempt to understand, which inevitably leads to some experience of pain, is treated with great suspicion. In many ways, Jane seems to believe that the only way she can come alive is to get rid of her female sexuality, which she hates passionately. The dream seems to indicate that a part of her is aware that she cannot just eradicate her female sexuality. This irritates Jane, as there is evidence that she cannot control her unconscious awareness of her natal sex. There seems to be a part of Jane that wants to escape from the role she has adopted in conscious life. I was struck by her description of her dream, which she could not discuss in the earlier sessions due to the shame of talking about herself. I am also conscious that I sounded like her mother, who often points out the reality of her natal sex and her concerns about the self-harming nature of the transition. Jane tries to push away conscious awareness of her natal sex, and I feel pleased when the dream brings it back into consciousness. Jane goes on to say she feels most comfortable walking on the coastline with her father. This could represent the triumph over mother as she joins the men as a way of distancing herself from the women. It could also represent the emergence in the transference of a paternal figure whom she feels can contain her anxieties and explore her mind. The following session took place several months later. Jane started by saying that she still feels down and has not been feeling well. Jane talked about her concern she was wasting her parents’ money but worried that nothing would change. I said that I thought she compared herself with what she imagined would be my ideal patient, someone who could think imaginatively about themselves and could engage and make use of the therapy. I said that I thought she believed that her sister would better use the time and that I wondered if she thought I would prefer to see her. She went on to say that she had never liked herself and that she was worried that nothing would change and that she thought she would kill herself. After a long pause, Jane informed me that she had a gender clinic appointment and that her parents had been upset and concerned to hear this. I thought she felt guilty about changing from being her parents’ daughter, but she feels this is the only way to make room for herself. Jane said that she did not like being the centre of attention and hurting her parents because they did not deserve it. She wished she could accept herself as a woman and that life would have been a lot easier if she could. I thought Jane regarded her female sexuality as belonging to her mother and sister, but not to her. (It was as if she felt she could not find a place for her female sexual identity inside her.) Jane said she did not ever think of herself as being female and went on to say that she liked spending time with her father, who was more measured and less emotional than her mother. She said that her obsessivecompulsive disorder had been getting worse, and this was leading to her becoming more isolated. I said that I thought at times Jane worried when I brought up her hatred of her female sexuality, I  was trying to encourage her to look at the link between her hatred and her wish to transition.

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Jane said she didn’t know why people questioned her wish to transition. I said I was thinking of the walks with her father on the coastline, which she enjoyed. I also thought she felt more able to talk when we explored her mind together rather than when she felt I was taking the lead and pushing a particular agenda. Jane said that she was worried she had become increasingly isolated. I said it was as if she felt she was trapped inside some state of mind that left her feeling isolated. Like the exploratory walks with her father, she knew there was some help here with me, but she didn’t know how to make use of it. Discussion of the session I take the start of the session as a complaint against the therapy for failing to remove or cure her suicidal self-hatred, which leaves her with no alternative but to transition. I interpret to Jane that this view of me as a failure is a projection of an internal sense of persecution as she believes she fails to live up to the ideal patient. At this point, I think Jane sees me as a narcissistic therapist who isn’t interested in her experience but only wants to be admired. I thought the anxieties about wasting her parent’s money were related to an awareness that she was unwilling or unable to bear the full emotional cost of the treatment herself. Her worry and doubts about the cost of transition were lodged in her parents’ mind rather than hers. Her mother was tormented by the idea that her daughter might be about to undertake a medical treatment that would do permanent damage. Awareness of the pain caused to her parents may well be associated with unbearable guilt and suicidal ideation. Bion (1959) described the way failures of containment could lead to problems internalising the primary object as a good internal figure that can think about the infant’s experience. Instead, the infant internalises an unavailable object that hates all emotional ties and attachments. He describes the development of an egodestructive super-ego that hates and mocks all dependence and attachments. The ego-destructive super-ego then attacks the failed ideal object, blamed for breaks in ideal containment. It is possible that Jane was insecurely attached to her mother and failed to internalise a sufficiently robust internal good object. She then yearns for a return to the idea of an ideal mother-daughter relationship while blaming her mother’s sexuality for destroying this blissful situation. The emergence of Jane’s sexuality, which is associated with her mother, is also hated. The internal conflict between the ego-destructive super-ego and the ego identified with the failed ideal object is first lodged in the conflict between Jane’s mind and her unwanted sexuality and then enacted in a tormenting way between her mother and herself. In many ways, Jane blamed her mother’s sexuality, which led to the birth of her sister and broke the ideal mother-daughter relationship. The belief that she can transition is partly an attempt to protect her mother from resentment that she believes would kill her mother, and partly acts as revenge directed towards her mother. In a way, it was as if she was saying ‘if this is what mothers do, I  do not want anything to do with it’. In phantasy, the object is filled with hatred and

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faeces due to unconscious attacks, meaning that any wish to attach herself to the good object needs to be defended against. I think the obsessional defences are then employed to protect her from the contamination as she retreats into a superior self-sufficient world. This manifests itself in the transference as if any feeling of attachment or claim by the therapist to offer good things needs to be defended against. The obsessional defences act as a way of protecting her from bad feelings that have been projected into the object. However, I also think the emergence of the father in the material represents the idea of a good therapist that could help her explore things, including her perceptions of him in a safe way that doesn’t threaten to overwhelm or control her. Pressure in the countertransference The danger of the patient embarking on premature medical procedures increases pressure on the therapist to protect the patient from thoughtless action. Pressure in the countertransference is increased by the patient’s tendency to project doubt or capacity for thought about losses into the therapist. The patient then watches to see if there is any evidence that the therapist wants to control or coerce the patient into their agenda. The issue of coercion needs to be addressed in the early stages of the therapy as the patient will have questions about whether the therapy is genuinely for them or if the therapist is working on behalf of the mother and her agenda. While the therapist may quite understandably have their reservations about the harmful effects of premature transition, they need to establish a position in which they are interested in understanding the patient’s point of view even if this felt harmful. For example, female patients might believe that they cannot live life until they have removed any evidence of feminine sexuality. How does the therapist find room to explore this issue without falling into the trap of collusion on the one hand or coercion on the other? This patient group often believes they cannot separate from a primary object without concrete changes to their body. Limentani (1979) points out that some female patients feel that transition is adopted to avoid fears of being engulfed by the primary object. There is no possibility of establishing a mind or body of their own. They often believe that transition will destroy their relationship with the family once and for all. There are many cases on social media of broken familial relationships because of conflicts. There is often a particularly heated conflict between the mother and the daughter over the wish to transition. The mother feels that the daughter is damaging herself by wanting to remove her female characteristics. In contrast, the daughter sees this as part of her liberation from the influence of her mother. As if the transition is part of a process of claiming her body for herself. Deep-seated resentment and grievance are directed towards the female sexual body, which is seen as betraying them. Their developing adult sexuality is unconsciously associated with an internalised version of the failed ideal object that needs to be removed. The refusal to identify with the maternal object led to a hypersensitive and conflictual relationship. It is common for the father (or partner) to either be

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absent or in some way outside the mother-daughter dyad. The father might be caring and concerned but somehow unable to effectively offer a different perspective. Next session After a brief silence, Jane talked about the clay sculpture she was making for her mother’s Christmas present. She added that both her parents loved her sculptures. I said that I thought she liked doing something that bought both her parents together. Jane agreed and went on to say that her uncle used to be a sculptor, and he used to teach Jane, but then stopped when he emigrated. There was then silence, and she said she could not think of anything else to say. I commented that she struggled to put things into words, which she assumed was what I wanted. She did not feel she communicated well in words but was more comfortable communicating through actions or her sculptures. Jane said she liked making things, and it gave her parents much pleasure. I pointed out that she had not told me what the sculpture was about. Jane said she had made a gargoyle. I said I thought she felt relieved to bring her parents something that gave them pleasure because a lot of the time, she thought she was like this gargoyle. Jane said that it was the only time she felt like she had something positive to offer those around her. She went on to say that she thought the sculpting made her feel like she was attached to the world. I said she might hope that the therapy could help her develop sculptures that conveyed what she was like or how she felt, even if she feared these pictures might appear to be unpleasant or unacceptable. After a long pause, Jane said that she looked at others and wanted what they had. She wanted to let go and get more involved in life, but she found it impossible to relinquish control. I took up the belief, ‘If only you get rid of my female sexuality, I could come to life’. I reminded her that her body and natal sex seemed to have a life of their own in the dream. She agreed but mentioned that it was only a dream, and she could not stand her body when she woke up. I responded by saying that it was as if her body was like the gargoyle, something otherworldly, something that people did not understand. She seemed to have a belief that the only way she could have a life of her own was if she distanced herself from this body and the sexuality her parents had given her. Jane said that she did not like herself and had been selfconscious of her body for as long as she could remember. Discussion of the session In this session, I thought the gargoyle symbolised the monstrous part of Jane that has terrified her parents and particularly her mother. It is possible that by bringing this material to the therapy Jane is hoping to find an analytic home that could provide some understanding of this aspect of herself. Jane hopes she has found a thoughtful environment where she might be assisted in expressing the parts of herself which she fears may be unlovable or unacceptable in a compassionate way. When working with this group of patients, one is struck by their detachment from

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their body and bodily concerns. The statement about the feeling of attachment to the sculpting material seemed to represent some movement in the direction of being attached to an external medium which Jane believed seemed to ground her. I also thought the communication via her art provided a bit of space between us, as if the sculpture gave us both a bit of room in which we could reflect on what the communication meant. Discussion of this patient group I have been focussing on a group of female patients looking to transition from female to male who hates their female sexuality, which they blame for displacing them from the ideal position in relation to the maternal object. This displacement may be due to a sibling that takes the parents’ attention due to serious psychological or physical illness, the birth of a younger sib or a partner who is felt to prematurely intrude into the relationship between the mother and infant. This patient group feels they must protect the primary object, which they frequently see as fragile and needing protection from their hatred and resentment. They oscillate between wanting to attack the primary object, through ideas of transition and a wish to protect it. The development of an ‘If only I  were a boy’ daydream-like solution (Evans, 2022) is often developed to establish an imagined separation between this perception of this fragile but needy primary object and themselves. The hatred of the failed ideal object is often internalised and becomes the basis of hatred towards their female sexuality (Evans  & Evans, 2021). There is a deep-seated grievance towards the mother and redirected towards oneself, which they believe can only be cured by changing the body to no longer identify as a sexual female. In many ways, the illusory solution of changing their gender to the opposite gender acts out their resentment towards the primary object they feel has betrayed them while protecting the primary object from aggressive attacks that they do not believe they can repair. However, this ambivalence position changes when the idea shifts to an action plan to transition as if the grievance now needs to be concretely enacted. The idea of transition represents a psychic retreat from developmental demands, particularly anxieties aroused by sexual development. The girls and young women in this cohort are disidentifying with female sexuality as part of a rejection of the failed ideal object. In a way, it is an act of revenge: ‘I blame your sexuality creativity for displacing me as the loved object, and if that is what female sexuality is all about, I want no part of it’. Many girls and young women in this group say that they do not want to have children or a family, and the parents are being punished for their perceived failings. Hatred is particularly directed towards the genitals that they see as potentially creating a baby or the breasts associated with feeding a baby. Discussion of the technical difficulties Technical problems of treating this group of patients are represented by the concrete nature of the patient’s mind as thoughts and words are often confused with actions.

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Consequently, there is a wish to control the therapeutic encounter by restricting access to thoughts which are potentially experienced as dangerous. They may project aspects of their inner world either into their bodies or into the external world in the form of parents or authorities in the external world. Indeed, gender clinics often get stuck in identifying with the child’s point of view, arguing that the child was certain that they wanted to transition, as if certainty in these matters was a sign of health rather than evidence of a defensive state of mind that leaves no room for questioning, examination or doubt (Evans, 2020). Questioning what this belief system is based on is often experienced as hostile. The individual believes they have found the solution to their problems, and the therapist is trying to push doubt and anxieties back into them by questioning the nature of their belief. Of course, as therapists and as adults, we know through experience that short-term solutions often have long-term costs, which need to be examined and thought about. In many ways, the more the idea of transition is regarded as providing a concrete solution to psychological problems, the more likely any subsequent transition would disappoint, as physical changes to the body’s secondary sex characteristics do not change the natal sex or remove psychological difficulties related to sensitivity or vulnerability. This patient group can experience any attempt to question the nature of their beliefs as hostile. The therapist is trying to push doubts or unwanted aspects of the self back into the individual. The restriction in the capacity to think and verbalise can leave the therapist feeling deprived of the material they need to understand the patient. This frustration can drive the therapist into overactivity in asking questions or jumping to conclusions about the material. This can make the patient feel difficult compared to the imagined ideal patient who can freely express their thoughts and feelings. In this way, the sense of being a difficult child can be repeated in the therapy. Unlike the ideal daughter in their parents’ minds, they feel they are seen as difficult, even unacceptable. Aggression towards the therapist for their failure in understanding may also repeat transferential experiences of having been a difficult or unappreciative child. They are moving towards a conviction that the full force of their contempt and hatred will destroy the therapeutic situations. Two stages of treatment Steiner (1993) draws attention to the technical problem of working with patients who communicate threatening aspects of their inner world to the therapist. These patients may feel intruded upon when the analyst tries to give insight to the patient about the nature of the projections. These interactions can lead to the patient withdrawing back into a defensive position. They fear that the therapist wants to force some unwanted aspect of reality into them or get them to submit to a harsh version of reality that fails to understand their position. In the first instance, Steiner highlights the need for the therapist to tolerate the patient’s view of the therapist and the therapeutic encounter. They can perceive the therapist as being unhelpful, defensive, misunderstanding, arrogant, cruel, moralistic or obsessed with pushing their

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theories into the patient irrespective of the pain it might cause. Steiner argues that insight might only be given back to the patient after their view of the therapist has been tolerated and taken in by the therapist. Patients who project in a very concrete way require the therapist to take in their perception of the object as the first stage of a two-stage therapeutic process. The patient also needs to hear the therapists thinking about their difficulties. In the second phase of therapeutic work, the therapist must separate from this identification and think about the patient. Problems can arise in both phases: In the first phase, the therapist can get stuck identifying the patient’s point of view, which does not leave room for objective assessment, while the second stage can introduce ways of thinking that interfere with the patient’s view of themselves. In the case of Jane, I tried to keep in mind that I needed to understand the way she was seeing me. In the first instance, she would see someone who agrees with her parents’ view of her wishes to transition as destructive. I also tried to keep in mind her feeling of humiliation of having to put her difficulties into words, as she would often be attacked and mocked by her ego-destructive super-ego that perceived any weakness or difficulty. Third, the therapy process would inevitably lead to disappointment, as talking about her difficulties would increase awareness but not lead to a magical solution. The therapy was always measured against the promised power implicit in the concrete physical solution; psychotherapy involves pointing out the difference between omnipotent thinking, which promises dramatic magical solutions, and reality-based thinking, which limits omnipotence. This sort of insight involves quite a loss, and the individual must acknowledge that their dependence upon omnipotent forms of thought that attempt to change and deny reality come at quite a cost (Steiner, 2015). Psychological change is dependent on the individual’s ability to acknowledge their attachment to omnipotent forms of thinking and the excitement that accompanies the capacity to deny reality. However, the therapist also needs to respect the patients’ needs for their defences. These rigid belief systems defend against fears of depressive guilt for remorselessly attacking the good object on the one hand and fragmentation on the other. The parents of this group of patients are often tyrannised by their children’s gender dysphoria and fear that questioning their wish to transition leads to suicide. On the other hand, plans to medically transition can increase the individual’s sense of omnipotence and give rise to excitement they believe will triumph over both their parents and reality. The use of omnipotent defences bolstered by the promise of what medical interventions can deliver is a potent and seductive psychological cocktail that makes the work of psychological exploration difficult and sometimes impossible. In a paper titled ‘Transitory identities: some reflections on gender identities’, Lemma (2018, pp. 1089–1106) states: I aim to explore what can appear to be, in some cases where medical intervention is sought, a premature embracement of the empowering potential of transgender identification. This state of mind can undermine the painful psychic work required to establish what transgender means to the person – an understanding

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critical to post-operative adaptation if they intend on body modifications to reduce incongruence with the given body. Quinodoz (2002) highlights the importance of ‘psychotic and neurotic mechanisms in treating a transsexual patient’. The therapist must bear in mind the different levels of functioning within the patient. Many trans identified individuals hold onto a fixed, yet unexamined belief that the transition will cure their difficulties. In these cases, the trans identity functions like an overvalued belief system used to deny and triumph over painful realities. However, de-transitioners have written that their belief in transition as a solution to their difficulties broke down when realities about the limits of medical transition became evident, i.e. that they would never be able to change sex. Many de-transitioners say that they wished that a professional might have explored their conflicts and doubts before taking a path of irreversible medical transition. While many trans patients have considerable doubts and give up their wish to transition, others are very fixed in their thinking and vulnerable to breakdown and suicidal ideation when transition fails to provide the promised solution. The therapist has an essential role in helping the patient differentiate between the idea of transition as a compromise that includes a realistic assessment of what is and is not possible and transition as an overvalued belief that attempts to deny rather than accept reality. The ability to consider Jane’s point of view in the first instance helped develop the therapy as a container that could think about her and her experience. I then drew attention to how her mind worked – the dominance of the ego-destructive superego, which was so full of hatred of herself. I tried to draw attention to the mind’s restrictive quality while understanding that analysis of the self-hatred can raise anxieties about the damage done. Drawing attention to the extent of self-hatred can produce feelings of shame and humiliation, leading to a negative therapeutic relationship. Many of these children and young people turn to concrete medical intervention when any psychic equilibrium is challenged. In many ways, the therapy treads a tightrope between the wish to develop a therapeutic relationship, allowing the therapist and patient to explore different aspects of the personality and ways of relating, and bringing in some of the aggression directed towards the therapy through plans to transition. This can be difficult to manage, as some of the planned actions can leave the therapist feeling provoked by the irreversible nature of medical interventions. Wishes to protect the individual from long-term harm or a desire to help the patient think can be experienced as intrusive or controlling. Of course, the therapist is bound to worry about short-term medical solutions with long-term harmful effects. However, the therapist must resist the temptation to play God as if they know how patients should live their lives. In the end, all of us must make decisions about the best way of leading our lives, and many of these decisions involve compromises and losses. While it has long been recognised that a certain proportion of trans identified individuals make a successful transition, another group (and their numbers are increasing since the changing demography of the group) regret their transition.

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The contaminated object Another difficulty relates to the belief that unconscious attacks lead to contamination and justified suspicions of the object and its motive. The therapist must also be aware that impulses to rescue the patient from their mental state, although wellintentioned, lead to a cohesive approach in the therapy. Supervision is essential in working with these cases, as the supervisor outside the dyad of therapist and patient can pick up on any cohesive tendencies in the therapeutic approach. It must be acknowledged that the child’s wish to transition can in part be driven by a healthy wish to separate from the primary object and form their own identity. What can be analysed is the idea that separation can only occur if there is some concrete and physical separation from the primary object. The self-sufficient system against all attachments, including attachment to the body and the desires and impulses located in the body, can also be analysed to comment on the fear of life and the desires for life. As said earlier, these children are often conscious of how their stance leaves them feeling isolated and detached from any desire for life. Money-Kyrle (1971) outlined the difficulty we all have in coming to terms with certain facts of life, including the passage of time and our mortality, the differences between the sexes, which were necessary for procreation, and our dependence upon a good maternal object in infancy. Illusions are created to avoid what is feared, which would amount to a catastrophic collision between a child’s omnipotence and reality. Relinquishing the omnipotence threatens the child with depressive collapse and attacks on the failed ideal object, which it is believed would cause irreparable damage. In this chapter, the group I am describing develops alternative versions of reality, which they then try to inhabit to avoid the realities described. In a way, it is like trying to rewrite the facts of life with the parental intercourse being replaced by the relationship between the individual and medical science as the creative couple. However, forcing the patient to face reality before the reason for the defence has been understood is likely to lead to an impasse or breakdown in the therapy. Conclusion In the case outlined earlier, we can see how Jane is looking for a relationship with an object who can help her explore her mind without being provoked into a coercive or controlling stance. The therapist is trying to provide a psychological home in which different elements of the personality can be thought about. Any therapists working in this area need to establish a setting in which they are supported in withstanding the counter-transferential forces towards unquestioning acceptance of the patients’ beliefs and desires on the one hand or over controlling authoritarianism on the other. The force for concrete responses to the concrete nature of the patient’s communication can also interfere with the therapist’s capacity for creative thought. Where the therapist finds that they are supported in their work, either with supervision or through support from colleagues, they can recover their capacity for symbolic thinking. This can deepen emotional contact with the access to unconscious

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material being increased over time. These developments enabled the therapist and patient to function more effectively as a therapeutic couple as a result. The interpretation of the aggression towards the self can open the possibility of exploring their fears of aggression and the inhibition in their relationships and life. References Bell, D. (2020). First Do No Harm. International Journal of Psychoanalysis, 101(5): 1031–1038. Bion, W. R. (1959). Attacks on Linking. International Journal of Psychoanalysis, 40: 308–315. Evans, M. (2020). Freedom to Think: The Need for Thorough Assessment and Treatment of Gender Dysphoric Children. BJPsych Bulletin, First View, pp. 1–6. Available at https:// doi.org/10.1192/bjb.2020.72. Evans, M. (2022). ‘If Only I Were a Boy . . .’: Psychotherapeutic Explorations of Transgender in Children and Adolescents. British Journal of Psychotherapy, 38(2): 269–285. Evans, S. & Evans, M. (2021). Gender Dysphoria: A Therapeutic Model for Working with Children, Adolescents and Young Adults. Bicester: Phoenix. Joseph, B. (1975). The Patient Who Is Difficult to Reach. In P. Giovacchini (Ed.) Tactics and Techniques in Psychoanalytic Therapy, vol. 2. New York: Jason Aronson, pp. 205–216. Laufer, M. & Laufer, M. E. (1984). Adolescence and Developmental Breakdown: A Psychoanalytic View. New Haven, CT: Yale University Press. Lemma, A. (2018). In a Paper Entitled Transitory Identities: Some Reflections on Gender Identities. International Journal of Psychoanalysis, 99(5): 1089–1106. Limentani, A. (1979). The Significance of Transexualism in Relation to Some Basic Psychoanalytic Concepts. International Review of Psychoanalysis, 6: 139–153. Littman, L. (2018). Rapid-Onset Gender Dysphoria in Adolescents and Young 13 Adults. Available at https://journals.plos.org>plosone>articles (last accessed December 11, 2020). Malone, W., Wright, C. & Robertson, J. (2019). No One Is Born in the Wrong 22 Body. Quillette. Available at https://quillette.com/author/william-j-malone-colin-m-23wrightand-julia-d-robert/ (last accessed December 11, 2020). Money-Kyrle, R. (1971). The Aim of Psychoanalysis. International Journal Psychoanalysis, 52: 103–106. Perelberg, R. (2019). Sexuality: Configurations of Excess. London: Routledge. Quinodoz, D. (2002). Termination of a Fe/Male Transsexual Patient’s Analysis: An Example of General Validity. International Journal of Psychoanalysis, 83: 783–798. Steiner, J. (1993). Problems of Psychoanalytic Technique: Patient-Centred and AnalystCentred Interpretations. In Psychic Retreats: Pathological Organisations of the Personality in Psychotic, Neurotic, and Borderline Patients. London: Routledge, pp. 116–130. Steiner, J. (2015). The Use and Abuse of Omnipotence in the Journey of the Hero. Psychoanalytic Quarterly, 84: 695–718.

Chapter 8a

Dementia Prelude to Rachael Davenhill’s clinical material from elderly patients Martin Rossor

The word dementia is beset with problems. It has major emotional connotations, conjuring up visions of an elderly person with severe loss of memory, wandering at night as a shadow of their former self. It has political connotations with warnings of the tsunami of affected patients overwhelming health services and the economy. Its use within medicine is also beset with problems as it is used to describe a syndrome, a cluster of symptoms and signs, and a group of diseases. Strictly speaking, the term dementia describes the situation where an individual presents with a number of cognitive difficulties that might include for example memory, language, perception, judgement etc. To justify the use of the term dementia, the cognitive impairments together need to be sufficiently severe to interfere with social and work activities. Historically this had been useful when imaging of the brain was rudimentary, and a term to describe widespread cognitive impairment, that was likely to be due to a neurodegenerative process, was useful to distinguish from those with a focal deficit that might be due to a tumour. However, this has led to the view that the neurodegenerative diseases that commonly lead to a dementia syndrome present as a global impairment with no characteristic features that might differentiate the underlying disease, let alone differences at an individual personal level. This is now seen to be far from the truth. Dementia, as a syndrome, can be associated with a multitude of underlying diseases particularly later as the disease progresses. Some underlying causes are reversible, such as metabolic disorders, and many are rare. The common neurodegenerative diseases, Alzheimer’s disease (AD), dementia with Lewy bodies (DLB) and frontotemporal degeneration (FTD) account for the majority, particularly in the elderly. They also often co-exist with vascular disease due to multiple small strokes and small vessel disease. ‘Vascular dementia’ can occur in isolation but is becoming less prevalent as mid-life vascular risk factors such as hypertension, diabetes and smoking are better controlled. The main degenerative dementias are discussed briefly later. Although dementia is commonly seen in late life, it can present in early life when the causes are often genetic. AD is the commonest cause of dementia in later life, either alone or in combination with vascular disease. It is the archetypal dementia and typically associated with a loss of episodic memory. Our episodic memory allows us to recall events DOI: 10.4324/9781003202790-16

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or episodes in our life; what we have just done, whom we visited yesterday, where we parked our car. The loss of episodic memory reflects the selective vulnerability of the hippocampi and connections which subserve memory functions. Impairment in establishing memory and rapid forgetting underlie these deficits. As the disease progresses other cognitive domains such as language, planning and judgement and visual and spatial perceptual functions are affected. Rarely, in some individuals with AD, episodic memory is spared at least early in the disease. In a variant, referred to as posterior cortical atrophy, the disease predominantly affects the occipitoparietal cortex. The variant results in a variety of symptoms relating to an inability to process visual information. The commonest is locating static objects in space, ‘looking without seeing’, whereas moving objects whose perception depends on a different unaffected neural network can be seen. Other symptoms involve colour misperception with colour seeping out of the spatial boundaries of an object, and a sense of suddenly being upside down. Unsurprisingly, unless aware of the panoply of symptoms, these patients are often dismissed. DLB, another common disease in the elderly, is usually associated with Parkinson’s disease as it shares the same underlying molecular pathology. DLB shares with AD an impairment of episodic memory with additional visuoperceptual difficulties which can fluctuate throughout the day. Sleep is disturbed with prominent acting out of dreams with shouting and sleepwalking (REM sleep disorder). A characteristic feature is the development of visual hallucinations. The hallucinations are silent and usually non-threatening. They are of animals and people, sometimes deceased relatives. On occasion the hallucinations may appear very small or Lilliputian. The third major group of degenerative dementias are the FTDs, which comprise a greater proportion of diagnoses in the younger patient and are often familial. FTDs can be divided into two broad groups, a behavioural variant and a primary progressive aphasia group in which there is disintegration of speech and languages; behavioural variant FTD can be particularly challenging for the family and for health professionals in terms of management. Behaviours change in many ways and can present with apathy, impaired decision-making, disinhibition with socially inappropriate comments and sexual innuendo, and loss of empathy. Loss of empathy can be particularly distressing. Spouses often speak of the change in personality making a stranger of their loved one. These deficits reflect damage to the frontal lobes. Patients are commonly unaware of the change in their behaviour and impaired function, a condition referred to as anosognosia. Anosognosia is an unawareness of a deficit that is also seen in AD where the patient may not be aware of their memory impairment. Often this may be a psychological reaction to minimise the problem, but in others it is an integral part of the neuronal network failure. In this regard it is similar to the unawareness that can occur in left hemiplegia following a right-sided stroke. In right-handed persons, the individual may be unaware of the paralysis and even claim that the limb is not theirs. Another example is Anton’s syndrome or denial in cortical blindness. Strokes that damage both occipital lobes lead to blindness although some residual

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vision may remain at a subconscious level. Patients with Anton’s syndrome vehemently deny their loss of vision. In these situations, the lack of awareness relates to loss of function in the neural networks that subserve monitoring or awareness of normal function. This second group of FTDs, the primary progressive aphasias, are usually divided into two groups. The progressive non-fluent aphasias that are predominantly speech failures, and semantic dementia; only the latter will be considered further here. An important distinction is made between episodic and semantic memory. Episodic memory, our ability to remember day-to-day events or episodes in our lives, is severely impaired in AD. By contrast, semantic memory refers to our memory for knowledge that encompasses memory for concepts and facts. It is this memory system that is damaged in semantic dementias. Visual semantic memory, our memory for what visual objects represent, can be affected, but it is more common to see an impairment of verbal semantic memory. In this situation the meaning of words is gradually lost in a hierarchical order such that fine-grained exemplars are lost first. Thus, for example, somebody may begin to lose the meaning of the words ‘sparrow’, ‘robin’ and ‘warbler’, but retain the meaning of the word ‘bird’ before this is also lost. The verbal semantic loss affects comprehension and output, with speech becoming more circumlocutory and sparser whilst retaining prosody and overall fluency using only a small residue of words before these are also lost. Throughout the course of the disease, episodic memory may be well preserved with the ability to recall where items have been placed and routes to follow. These examples can only serve as brief introductions to the dementia spectrum and to illustrate the fact that cognitive impairments in dementia are by no means global. Moreover, it would seem that these different diseases provide important insights for psychoanalysis. The different patterns of impairment reflect differential vulnerabilities of neural networks to the disease process. The therapeutic approach offered by psychoanalysis and psychotherapy must be mediated by neural networks, some of which will be damaged themselves. This is perhaps best illustrated by the examples of anosognosia. The interaction is different for the carer, where understanding of the specific challenges of the different diseases is important.

Chapter 8b

Dynamics of dementia 1 Rachael Davenhill

Purblind and Font in the odds ‘n’ ends drawer one might find what one is looking for among the biros and string purblind spectacles you might find anything half-remembered by the mind’s claw lemon rind what the hell was that for? there must have been a reason (a thought sublime) for a tin with tiny teeth in paper clip and rubber band entwine a fragment in familiar hand quink black and curséd font mine-dark the drawer her confidante so she wrote (one must be kind) as poison seeks an antidote where is my mind? almost anything will do to bring it back to you (Gareth Writer-Davies 2021)

DOI: 10.4324/9781003202790-17

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Introduction A key issue relating to the care of people with dementia is the containment of despair. This chapter is based on work undertaken whilst running the Old Age Unit in the Adult Department at the Tavistock Clinic as well as from my own family experience of dementia. In the Old Age Unit we assessed and treated people with depression and dementia, along with family members who were caring for them. A number of these patients were referred from the Dementia Unit at the National Hospital for Neurology and Neurosurgery in London. One of the richest experiences of my career took place when I met Professor Martin Rossor, who made it possible for me to undertake a 12-month psychodynamic observation of the Dementia Research Unit he managed. This enabled me to understand in depth both the patient and the staff experience through the process of assessment, consultation, investigation and eventual diagnosis of dementia, as well as learn much about rare and familial dementias. Following this I saw a number of research patients from the unit for consultations and psychotherapeutic treatment. In 2006, Martin and I  gave a talk at the Institute of Psychoanalysis on the ‘Dynamics of Dementia’. In Martin’s Introduction and in my chapter there is the essence of that occasion, along with an ‘Afterword’ written during the ongoing global pandemic which has acted as a neon light, shining brightly on every single flaw in our treatment of people who are older. In the original talk, Martin presented vignettes of his own clinical cases and vividly communicated the challenges for services working with patients as well as family members and staff who often have very little space to process the impact of diagnosis. He conveyed how important the hospital visit or the memory clinic is both for the person who hears they may be developing dementia and for their family. I then described a case of early onset dementia and a psychodynamic observational study of a person with dementia in a continuing care setting. The psychoanalyst, Henri Rey, referred to the actual building in which a diagnosis takes place as an important factor in containing vast amounts of distress which he called ‘the brick mother’. In the first part of his talk, Martin described the split between research and clinical functioning and the inevitable guilt embedded in any research in this area. One of the areas we thought about, for example, surrounded the role of the MRI scanner. This big scanner is an enormous symbol of potency, yet it contains no therapeutic function in the area of dementia. It is predominantly a research tool to track deterioration in the brain, something my patient poignantly refers to when she speaks of her experience in the next section. In preparing the joint talk, Martin and I unpacked the question as to how our different worlds of research and psychotherapeutic practice might link up. We agreed one point of linkage would be in the area of what I have called the ‘internal scanner’. By this I mean making use of our own mind to explore and understand the state of mind of the other. Both the person who has been given the

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diagnosis of dementia, but, just as importantly, the state of mind and needs of the main caregiver(s). The survival of the person with dementia is intimately bound up with those who care for them. This is often carried out unseen and unacknowledged by family members, with an estimated six million people caring for a spouse or parent, a sixth of those providing more than 50 hours a week care with little respite. In dementia, where verbal and symbolic communication may be difficult, the pre-verbal mechanism of projective identification operates more forcefully, and caregivers, whether immediate family or staff in residential or nursing homes, have a crucial function in containing those split off and deteriorated aspects of the person they are with, often at great cost to themselves. Why at such cost? Because there is the need to mourn the loss of, in many cases, a lifelong partner. But the process is complicated because it is not a loss in the more usual way, through physical death, but a long and sometimes painfully drawn out witnessing of the death of the self – of someone once known and understood in relationship to themselves, with the daily struggle to translate and make sense of the person’s distressed and at times bizarre communications, often conveyed non-verbally through projective identification, which may now replace ordinary language. Kitwood (1990, pp. 117–140) suggested that the problem [I]s not simply that of damaged brain cells, but also of damage to the psychological self and the good feeling that would sustain it. It is, I believe, quite correct to regard unattended dementia as a semi-psychotic state . . . Dementia is envisaged as a break in cohesive awareness, a failure of the process of consistent symbolisation, so that the person has lost his or her bearings in the world, and is invaded by feelings from within. He observed that when organic deterioration occurs, there may also be a breaking down of the individual’s lifelong defences which leaves the person exposed and vulnerable to perhaps quite catastrophic anxiety and rage. Riviere (1952) referred to the fear of losing one’s own identity, through the disintegration and splitting of the ego, as one of the most acute and painful anxieties accompanying schizophrenic disorders, and I think this is equally true for the person with dementia. However, compared to 30 years ago when I first worked in this area, a ‘quiet revolution’ has taken place in terms of living with dementia. Research now provides strong evidence that early interventions individualised for the person with dementia and their families are effective in the short and long terms (Clare, 2021, 2022, written communication), and there is a growing body of work on early onset dementia indicating that for some people psychotherapy can be helpful (Cheston  & Ivanecka, 2017; Davenhill, 2007). Sinason (1992) described working with a man in late middle age with an early dementia. She thought that the facticity of the organic deterioration had to be acknowledged and that, whilst this

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was not transformable, the emotionally caused impairment remained open for change. When the organic deterioration is severe with a loss of capacity in the individual to mentalise internal objects, then there is a clear limit to the role formal psychotherapy can play. Psychoanalytic ideas can then continue to inform a detailed understanding in thinking about the challenges of developing structures for intervention which will contain both the patient and those who care for them in situations where the carer eventually takes on the role of ‘auxiliary ego’ for the person with dementia. Having emotional contact with fragmented experience, as we know from the ordinary work from the consulting room, is very difficult, and it is understandable that carers with little support may be less able to tolerate emotional contact with the person with dementia. However, the importance of trying to provide adequate support for family members caring for someone with dementia cannot be ignored. Andrew Balfour has pointed to clear research evidence indicating that whether people with dementia go into institutional care or not and even how long they live are linked quite specifically to the quality of relationship with carers, which is itself affected by factors such as carer strain. There is some evidence that increased need for care and increased dependence on the part of the person with dementia are linked to declining well-being for the carer over time (Clare, 2022, written communication; Kurten, Dietzel, Kolominsky-Rabas,  & Graessel, 2021). The maintenance of the person with dementia in their own home has more to do with the well-being of people with dementia who are shown to be the most at-risk group (Cantor, 1983; Morris, Morris, & Britton, 1988) and consists of those who have had the poorest relationships pre-morbidly. The quality of the caregiving relationship is underscored by the finding that low levels of interaction between partners in the marriages of people with dementia predict the move to hospital care and even the mortality of the individual with dementia two years later (Wright, 1991, 1994). This has powerful implications and highlights the clinical significance of work that aims to support and provide containment for carers. Research into self-awareness and dementia Andrew Balfour (1995) undertook a piece of psychodynamic research assessing evidence of self-awareness in the later stages of dementia. He asked people with dementia to look at pictures from a projective test called the Thematic Apperception Test (Murray, 1943) and then to describe what they saw. He found that the use of pictures elicited responses even in those people who were in the advanced stages of dementia, providing that attention was paid to ‘snatches’ of lucidity in otherwise disconnected narratives. (The pictures provide a way in to talk about and understand more of the patient’s experience in the way Klein’s (1940) toys allowed access to the unconscious of her child patients.) When people in the advanced stages of dementia were shown a picture of a boy contemplating a violin on a table in front of him, their responses featured a

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Figure 8b.1 A   dark brown, glossy painting of a sad boy with a violin, it may be broken.

preoccupation with damage and disability. Many of the comments were contained within mostly incoherent material. (A matched control group who had no cognitive impairment did not make reference to the theme of damage): There are tears in the violin. He is not very keen on the violin. He has probably been practising it and it hasn’t gone quite right. He’s in despair over his violin. He looks blind. There is something wrong with him. I don’t know whether he thinks at all, he is thinking about the violin and wishing for better health. The violin is upside down, I think there is something wrong with it. This last was said by a woman who, according to the results of cognitive testing, was the most impaired of the group. Interestingly, it was interjected into almost wholly disconnected speech – most of what she had said had seemed entirely unrelated to the picture.

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Another woman also at a later stage of dementia commented: He’s in despair over his violin, he can’t get it to do the thing he wants. He’s despondent about what he’s been able to take in. A further theme that emerged related to anger and withdrawal as in the following: I think I would give up on the violin. I love music but I can’t stand the squealy motions . . . I should say he’s fed up. He’s had the violin and he finds it’s not coming out with the tunes . . . They’re not how he wants them to be anymore . . . He’s given up, or he wants to give up after finding he’s not playing as he thinks he should. Art and Alzheimer’s disease In a remarkable sequence of paintings, the artist William Utermohlen produced a large number of self-portraits following the diagnosis of Alzheimer’s disease. His continued capacity to both convey affective states of mind and evoke a response to his paintings in the viewer is very important in terms of ongoing communication. Despite his illness, Utermohlen remained within the careful framework of his craft with a continued capacity through his work to convey affective states of rage, despair, anxiety, etc. non-verbally at a point where words could no longer be spoken (Crutch, Isaacs, & Rossor, 2001). Pat Utermohlen, William Utermohlen’s wife, attended the Applied section meeting at the Institute of Psychoanalysis when this chapter was first read (2006) and showed a number of William Utermohlen’s paintings, illustrating the artist’s figurative work pre-diagnosis. These were usually of two or more people, often his wife and friends, sometimes including himself. Following diagnosis as the dementia progressed, he painted himself alone, in a series of self-portraits between 1995 and 2000. (See ‘Looking into Later Life: psychodynamic approaches to depression and dementia in old age’ [Davenhill, 2007] for many reproductions of Utermohlen’s work in the final chapter by Patrice Polini.) These paintings were repeatedly of his head, showing a preoccupation with the brain, particularly after he had received a request from the dementia unit for permission to undertake a post-mortem on his brain for research purposes after his death. Eventually eyes disappeared from his pictures, and towards the end his work portrayed a series of masks. The distress and depression associated with the ongoing awareness of the loss of self- awareness which William Utermohlen conveys so effectively in his paintings is something that can be thought and talked about with patients who want to explore what is happening to them early on in their diagnosis. The following section uses words rather than pictures to illustrate this. Whilst dementia is a terminal illness, the process of being able to think about and plan how to live life with a life-limiting condition is actually life giving for the person and their

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Figure 8b.2 A pen and ink drawing of the bent figure of the artist, William Utermohlen, one of series of self portraits of the artist William Utermohlen, as his dementia developed.

family. Time matters, and what we do with time is precious. In the last 20 years, major advances have been made through innovative and hopeful research initiatives enabling people with dementia and those who care for them to hold fast to the things we know matter in terms of a decent quality of life: music, movement, touch, the mitigation of loneliness and therapeutic support for depression and anxiety (Orgeta et al., 2014). Psychodynamic consultation in early onset dementia: Mrs J I first met Mrs J, a 57-year-old woman, on a Dementia Unit where she had been diagnosed with early onset dementia two years previously. It took six months for National Health Service funding to be arranged so that she could be seen within my Old Age Unit, and I was unsure whether she would remember me when she eventually arrived for the first assessment meeting with me. When she came into the room, she immediately remembered that she had seen me in the Dementia Unit previously, observing one of the nurse-led clinics she had been attending. She said that she thought my sitting with the nurse was part

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of my training and that she hadn’t realised I was properly qualified, so was she part of my research? I said as part of my contact with the Dementia Unit, we had wondered if people coming to see the doctors and nurses there might like further time to think and talk more about what was happening to them through the process of diagnosis. I said that I would be interested to understand more about her experience and what was on her mind if she wanted to talk with me, and that we could then decide together whether that was something she wanted to continue in the future or not. Mrs J said there was a lot she wanted to talk about, that she felt she hadn’t talked to anyone other than to give replies when she went to do the tests at the dementia unit. She hated the tests, especially the maths one. She wanted to get through to the people testing her that she had never been good at maths, it wasn’t a good indicator of her ability as she could never score very well. She became fraught every time she got a letter to go to the unit as she knew she was going to be tested. I enquired what she made of the testing. She said she hated it because it was to measure deterioration. Having said that, she’d gone there a few weeks ago and things seemed to be stable at the moment. She hoped to be put into another trial for a drug that was about to be released. She hated the title of the Dementia Unit and thought if I was going to help patients I should ask them to change the name. It was a terrible name, she felt awful every time she saw the name. Every time she got a letter from the Dementia Unit with their name at the top, her heart sank, because the word was hopeless. I took up Mrs J’s possible anxiety about the assessment consultation with me as though she might feel her contact with me now as yet another test. She said, ‘why couldn’t the unit come up with a name like SCOPE – what was it that had replaced, some awful word? SP . . . SP . . . SP’. I said, ‘Spastic Society’. She said, ‘Yes, terrible title, and isn’t SCOPE much better as it means there seemed to be more scope for things to develop, whereas dementia says, “That’s the end”, which is a killer’. She went on to say that was the problem with the tests – they would just show her reducing. I commented that I wondered whether she was both relieved at the development with the referral here where she could talk about what was on her mind, but that talking also brought in her anxieties about handicap. She said she had barely told anyone other than her husband about her diagnosis of early onset dementia as immediately once they knew people started to talk to you as though you were a simpleton. At the hospital she didn’t like the testing, but she also didn’t like people’s manner as they all spoke in this kind tone. And when they did, she wanted to say she still had a brain. I said I thought she was angry with me when I’d suggested it might be a relief to be able to talk about things on her mind which included what was happening to her brain. She said that she knew she had a brain and so did they because they wanted it for their research. She’d just agreed to be involved in another research trial. When she had gone along just over a year ago, she had been put in a drug trial and didn’t know whether the drug she was taking now was a placebo or a new

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anti-dementia drug. She still doesn’t know. But it was interesting because she’d seen a programme on the television the other night and there had been a discussion about placebos and faith, and how the mind can really affect the outcome even if it’s a placebo. She had a lot of time for that – she thought she must have the mind of a Christian. She had been told a year ago that she would lose her sight by now. That had been the worst point. Yet she hadn’t, so she doesn’t know if it’s a placebo or not, but she was taking part in more research as then she could keep seeing someone at the Dementia Unit. I said I thought she was telling me that she had faith in the unit, and she must also be wondering about what faith she could have in coming along here to see me today. She said that I’d said I was interested in what went on in her mind and so was she. So that was a start. The problem was she didn’t know how long she would have a mind for. I invited her to tell me about herself in whatever way she wished. Mrs J started to describe her family and said her father had an ‘electronic brain’ and had been involved in developing computer technology – when he’d started his work computers were nothing like now, they had filled up the whole room (I wondered about the transference to the doctors and research equipment at the dementia unit). She was still managing to work but wasn’t sure how much longer that would last. She then remembered an episode of Star Trek she had been watching on the television where everyone slowed down. It was all in slow motion, and one of the characters had said that if you lose your REM you lose everything. She then asked me whether I knew what REM was. I acknowledged this and asked her about her dreams. She replied that she never used to dream, though her husband did, but she did now. Why, was I interested? I commented that she knew I was interested in what went on inside her and that she felt her dreams were something she was saying she’d not paid much attention to before the diagnosis, but there was time now if it was something she wanted to talk about with me. She then told me her dream which was finding herself in a car, sitting and driving. Her associations were that of course she couldn’t drive anymore, although she still did sometimes though she wasn’t supposed to. She went on to say that her husband remembered his dreams. (I was aware that she’d barely mentioned her husband and children.) I said that I thought it was very important for her to know that I would remember her dreams, and the dreams she was also having to give up, like being able to drive the car anymore and that it also linked to her relationship to her husband and children and the dreams they may have had together about the future which the diagnosis impacted upon. Mrs J started to cry and said it was harrowing. She thought it was different to cancer which was a death sentence, because when she’d been told she had dementia she thought she had been condemned to know that she was going to have a living death. Her father had died of cancer and so had her brother. He had only been

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two years old, and she was six years old when he died. She told me how much she had loved her little brother, and it had been terrible as they couldn’t touch him or cuddle him as he bruised so easily. She was weeping and said she hadn’t expected any of this to come up, or that she would cry. She hadn’t cried with anyone since she had been told the diagnosis. I thought the car in her dream as well as representing the internet world, which she clearly had the psychic capacity to inhabit at this point, was also a possible communication about the containment of the therapy which she simultaneously knew if she got into that she would also have to get out when organic deterioration became too great. In telling me about her little brother she was also telling me about her terrible dilemma that she now needed someone else to hold her as she had wanted to hold her little brother. Yet her warning to me is that if I touch her, even lightly, it may be too painful and inflammatory. It was near the end of the time, and she asked if I thought there was any point. She realised she had a lot to talk about. What she wanted me to understand was she knew that what made her human was her brain, but it wasn’t just her brain she was frightened of losing, it was what was in her brain. She paused, crying, struggling to find the right words: [S]he thought the brain was a beautiful thing, but it wasn’t just a bit of her body. No, it was more than that – it contained her . . . character . . . and that is what she was so afraid of losing. The question mark, in terms of outcome, was whether she could let me reach her mind and talk about her fears and needs post diagnosis and, if this was really addressed and articulated, whether it might buffer and delay the complete loss of mind. In terms of the connection between neuroscience and psychoanalysis, a key area is how we think about the impact containment of powerful emotional states on cognitive functioning can have. Kitwood has called this the process of ‘rementing’, rather than dementing, where a buffering of deterioration at times seems to take place when a firm, consistent structure of meaningful care is in place. Waddell (1998) wrote of an older woman with dementia who seemed to regain, at times, a capacity for meaningful responses when the daughter was able to articulate her fears: Each time this occurred it was as if mental pathways which had seemed to be totally overgrown or mysteriously to diverge where once there had been a single track, had for a moment, cleared, or miraculously rejoined. Dementia is a double disorder, in which there is both an organic dementia alongside a functional disorder (anxiety/depression) and, if seen in this way, then it becomes possible to intervene psychoanalytically early on in the dementing process.

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At the core of any thinking in this area, I would suggest that we have to fundamentally locate our focus on the area of loss and the unconscious fear of death (Segal, 1958). In a 1952 paper, ‘The unconscious fantasy of an inner world reflected in literature’, Joan Rivière (1952a) emphasised how this fear can impact on our psychic structures. It is a striking paper in its humanity. The current crisis in the area of long-term care for people with dementia in this country arose in a climate within which Margaret Thatcher could say, as a matter of course, that [T]here is no such thing as society, only individuals. Contrast this with Rivière, writing of the processes of projection and introjection in 1952 (p. 173): [T]here is no such thing as a single human being, pure and simple, unmixed with other human beings; each personality is a world in himself, the company of many . . . We are members one of another. Prior to that, in what could be a searingly accurate account of the meaning of the dementing process to the individual and to those who care for them (although she was not addressing this specifically in her paper), she wrote (Rivière, 1952b, p. 174): It is true that people as well as animals are known to pine away and die when their loved ones vanish. We are not concerned here with material realities only; death is not only a matter of whether the breath leaves the body and the heart ceases to beat. That is one item of the experience of death it is true; but is that all that death means to us? It is probably the most important factor in death because it is irrevocable; namely, the cessation, the disappearance, comparatively sudden, of a living existence, an entity, a person, a personality, a most complex and composite structure of attributes, tendencies, experiences, idiosyncrasies, good and bad, as well as the body they belong to it is all this which disappears; from one moment to the next it is here and it is gone. So when one fears one’s own death, it is all this which one will lose, one’s ‘life’ in both senses – one’s present breath of life, and one’s past life out of which one’s identity is constituted. And it was this latter point, at the end of my meeting with Mrs J, I felt she was aware of and needed me to take in. Psychodynamic observation of old age I now want to shift the lens from the family as carer to the institutional setting and illustrate this with material from the supervision of a detailed psychodynamic

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observation carried out by a course member on the old age course I ran at the Tavistock Clinic. Psychodynamic observation is a very powerful learning tool whereby the person visits a particular setting for an hour once a week and writes about their experience afterwards in as much detail as possible. This is then taken to a supervision group, and like an onion, in terms of unlayering the group transference and associations to the material presented, a true and rich picture of what is happening at an unconscious as well as surface level emerges. The following observation illustrates the way in which, unless there is a mind to take in the needs of the worker/carer as well as the person with dementia, crucial understanding can be lost. The observation took place in a specialist unit for people with severe dementia. Nearly all the residents had lost their capacity to speak and were physically unable to do things for themselves. Claire, the observer, arrived at the unit and sat at a table where there was a clear view of the main lounge. Mrs G was lying on a big sofa in a foetal-like position with her back facing away from the room, wearing an old cardigan, brown tights and slippers. She was asleep and breathing heavily. Her hair was messy. A table with a newspaper on it was next to the sofa where she was lying. The nurse told Claire that Mrs G had only moderate dementia and was able to walk independently and talk but had been moved into this unit as she had been very disturbing to the other residents in the next-door unit where there were no, or very mild, dementia patients. Mrs G woke up briefly and turned round to face the room. She shut her eyes again. Meanwhile, another resident came in and asked if there was a spare newspaper. The nurse said yes and gave her the newspaper on Mrs G’s table. Mrs G immediately opened her eyes, looked at the table and shouted: ‘I haven’t got a paper now!’ Then she shouted, ‘What a noise!’ Her face was screwed up and she looked very unhappy. A nurse went and sat next to her and asked if she was OK Mrs G screwed up her face and tutted. The nurse went to get up, but Mrs G grabbed her and said: ‘Don’t leave me, it’s lonely’. The nurse said she would sit a while if that is what Mrs G wanted. She sat with her for about 30 minutes, and Mrs G slowly relaxed, closed her eyes and went back to sleep. When the older woman was asleep, the nurse got up to start getting dinner ready. After about ten minutes, she said to the care assistant: ‘You had better wake Mrs G up so that she can get ready for lunch’. The care assistant woke up Mrs G and told her it was dinner time. Mrs G said: ‘Dinner time, is it? What are we having?’ She was trying to sit herself into an upright position. The care assistant replied: ‘Beef stew’. Mrs G replied, ‘Disgusting’. She went back to lying down again and looked unhappy. Suddenly she became very anxious and said: ‘Where’s the toilet? I’m going to do it. . . . I can’t stand up, my legs have gone’.

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The nurse went over and said it was because her legs were tired because they’d been up all morning, and they would be OK once Mrs G started walking. Mrs G said, ‘Will you go with me?’ She seemed terribly anxious. The nurse said, ‘Yes, of course’. She helped Mrs G to stand, and they walked slowly to the toilet together, the nurse walking quietly with her as they went. Mrs G seemed to become more stable on her feet and calmer in herself. After going to the toilet, the nurse brought Mrs G back to her chair and then went to get her dinner from the kitchen. On her return, she put it in front of Mrs G who looked at it and said, ‘That looks like a pile of shit. I’m not eating that shit!’ She pushed the plate away and it nearly fell on the floor. Mrs G kept repeating: ‘It’s bloody rubbish, shit it is, shit!’ She lay back down again. Another nurse came over, asked her to sit up and said that she would get her something else. ‘How about a sandwich?’ Mrs G did not answer. The nurse took away the plate of stew and brought a sandwich over. Mrs G looked at it and said, ‘What’s this, more of your shit?’ The nurse said it was an egg sandwich, at which point Mrs G threw it on the floor. The nurse asked her if she wanted any rice pudding. Mrs G said, ‘What, does it have jam?’ ‘It can do’, the nurse replied. ‘OK’, said Mrs G. When she was given the rice pudding, she moved her spoon up and down in it, then crashed it down and said, ‘It’s shit’. She looked very unhappy and went to put her head back on the pillow on the sofa. The nurse asked her if she would like a cup of tea, and Mrs G looked at her for a while. The nurse paused and then asked for a care assistant to carry on distributing tea to the other residents. She then sat down, next to the old lady, and gently took her hand. Mrs G started to cry. She closed her eyes and kept crying. As a reader of this observation, you will have had your own associations to what has been described. In the supervision group where the observational material was presented, there was a richness in the group’s free associations to the material. At one level the observation showed the very real difficulties of mixing together different levels of disturbance. Mrs G’s real distress seemed to start when the newspaper was removed – the newspaper connecting her to the world of no, or only mild, deterioration. She is then left, perhaps, full of an indigestible awareness of being surrounded by what she may become – silent and immobile, like so many of the other residents in this unit for severe dementia. It is possible to see the nurse’s concern and kindness in her contact with Mrs G, but this, in itself, is not enough. The nurse also needs knowledge. This cannot come from within as she, like any nurse or care assistant working in this setting, is bombarded with shit and despair, and she moves towards the concrete solution of feeding and toileting. The shouting starts again when Mrs G is woken up and offered dinner. Mrs G asks to go to the

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toilet but everything is still shit. She seems to feel persecuted by something awful being aroused in her yet again and makes it clear she wants to get rid of something by asking to go to the toilet. What she actually needed was for something to be returned which is her newspaper. The newspaper which was taken away served to represent the less deteriorated world she is still capable of inhabiting which was stolen away from her when she was moved prematurely to the unit with more deteriorated residents. When the newspaper was taken away, she rightly complained that this was shit. The truth of the matter is that she was, in fact, in a very shitty situation and had to close her eyes in despair as the only way of protecting herself from having to perceive again the situation she now finds herself in which she has no control over. Through close observation, it could be seen that Mrs G’s escalation of distress followed the removal of the newspaper which connected her to the world of more normal functioning. Just as something has settled, she is then offered food again. But it is not this sort of food that sustains her at this point. What she needs is a mind that is capable of taking her in and thinking about her state of mind as well as body. Indeed, this is what we saw when the nurse stopped offering food and offered her understanding of Mrs G’s loneliness when she sat and held the older woman’s hand until her distress receded and she was able to sleep. The observer was able to think this through with the support of the supervision group after the observation itself had taken place. However, and not at all unusually on the unit being observed or many other nursing and residential homes, there was absolutely no forum in which the nurse could talk about and process her experiences, and the opportunity for a real understanding of what had occurred with Mrs G was lost. In her paper ‘Mourning and manic-depressive states’ (1940, p. 142), Klein commented that: Through tears, which in the unconscious mind are equated to excrement, the mourner not only expresses his feelings and thus eases tension, but also expels his ‘bad’ feelings and his ‘bad’ objects, and this adds to the relief obtained through crying. In the observation of Mrs G, what is striking immediately seems to be her verbal defaecation – everything, she says, is shit. However, this isn’t a meaningless evacuation but is accurate in terms of the situation she finds herself in. She needs a receptive container to take in and understand her struggle with dignity and humiliation, issues which are embedded in the profound anxieties expressed by many people when faced with decisions about admission to residential or nursing homes. What is noticeable to anyone working with some patients suffering from severe dementia or psychotic depression is the presence of faecal smearing and incontinence at times. In a staff supervision group in a nursing home for people with severe dementia, a mental health worker described the dread of all the staff who had to look after Mr  X, an 82-year-old man who had come in as an emergency admission. Every night he would defecate and smear himself, the bed and the walls

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of his room. The staff were beside themselves with rage and had taken to sedating him heavily and avoiding entering the room at night. When I went further into this with the group, it transpired that none of the staff knew anything about the old man. As is very common with sudden admissions, no history had been taken, and there was nothing at all in the case notes beyond the date of admission. Slowly they learnt more about Mr X and his life prior to admission, and then, over a number of highly charged discussions, the staff group were able to think about the possible meaning of the smearing and incontinence as a concretisation of failed mourning. They agreed to take turns sitting with Mr X after supper, trying to articulate some of his inarticulate distress about the shitty situation he found himself in, overwhelmed by the sudden move from his home, but also overwhelmed by the rapid movement in the onset of his loss of mind where he found himself unable to communicate verbally. He remained a challenging resident to care for, but with a consistent approach by the staff group, particularly through the night, which emphasised regular and reliable contact with Mr X; whilst he remained occasionally incontinent, the faecal smearing eventually stopped. It seemed to me that the level of intolerable persecutory anxiety experienced by Mr X diminished to some degree, which in turn lessened the degree of violent projections into staff and rendered their feelings of sadism in the countertransference to a more manageable proportion. Afterword in the light of Covid-19 The last thing Freud ever read before his death in September 1939, at the age of 83 years, was a short story by Balzac called ‘The shrinking skin’ which he wryly commented to his personal physician, Schur, was pretty apt given his physical deterioration. Freud’s mind of course remained intact right up until the end of his life. Dementia, however, does involve mourning the shrinking and eventual loss of mind. It hooks into one of the key primitive anxieties of babyhood – the fear of falling into the abyss of ‘nameless dread’ and never ultimately returning from it. At the very beginning and the very end of life, in terms of the dementing process, there is an immense dependence on the object, and this is more acute in the advanced stages of dementia. At the beginning of life there is, however small, an ego that can be worked with. At the end in severe dementia, there is not even that advantage. Constitutional advantages have disappeared in terms of psychic resilience, and survival does then depend on the capacity of the object to support humanely what often feels to the caretaker like a living death. This of course is what people early on in the dementing process, where there can be ongoing levels of self-awareness and a capacity to reflect on past, present and future, often speak of – the torment of having to live with an awareness of knowing one’s own selfawareness will diminish over time. The difficulty in the later stages of dementia is that, in terms of internal containment, no robust mental structure, as we would understand it dynamically, in terms of the capacity for self- awareness, for thought, in a sustained way is left. The immediate care of the person with dementia is with the family or carers. In

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the National Health Service (NHS) these are teams of nurses, doctors and nursing assistants, psychologist, occupational therapists, social workers, etc. But the bulk of care predominantly takes place in people’s own homes with either unpaid or underpaid family carers or poorly paid carers with very limited time from social care settings, along with residential and nursing homes. Fifteen years after delivering this paper, the split between NHS and social care remains as riven as ever. Patients with dementia, albeit a terminal illness, are regarded as needing social care, not NHS care. They remain deprived of easy access to the sort of support both financial and emotional that a patient with cancer, for example, might receive. There is still no Royal College of Social Care with a clear career pathway for staff to move through with ongoing supervision and pay scales in line with NHS scales for the complex and demanding work undertaken. It is a damning indictment of a first-world country in which successive governments have continued to turn a fatal blind eye to the reality of what is needed and plan accordingly. The care of people who are older in this country is undertaken by family members and often very poorly paid and unqualified staff, who are the only ones left holding those elements of the person they care for in memory – the person they once were and yet are now in daily contact with the person they are now, which is ‘not their old self – not themselves at all’. Given that the basic mental apparatus no longer holds firm, the ego is emptied out – there is a weakening, a draining out of the ability to process, to articulate, to think, to understand. A  reversion eventually takes place to a reliance on basic instinctual rhythms – to do with voice, taste, touch, movement, smell and so on. That is why the maintenance of a live consistent rhythm of routine with well-supported carers is so important. What the person with dementia requires is someone prepared to stay with them and, in terms of containment, struggle to try and find meaning in communications which may otherwise appear to be meaningless. In order to do this, the caretakers themselves have to feel supported. Containment for the carer carrying the daily pressure of looking after an older person who is severely mentally as well as physically deteriorated is crucial and, as with mothers and tiny babies, such support is erratic in its provision and dependent on a large number of factors. If it is not provided, we know from research that there can be terrible miscarriages when abuse, both physical and mental, of people who are older takes place, as we know it does with babies whose parents do not feel sufficiently internally or externally supported. Toward the end of 2019, and the early part of 2020, scientists warned of a virus, Covid-19, which quickly turned into a lethal and worldwide pandemic. In terms of the truth, the whole truth, and nothing but the truth, what then happened was an almost immediate process of unthinking state-induced geronticide. Older people, untested for Covid-19, were decanted out of hospitals into residential and nursing homes where residents and staff were unvaccinated and where the appropriate personal protective equipment (PPE) was not fully provided for many staff

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for weeks, sometimes months to come, leaving them exposed and vulnerable to Covid-19 infections brought in from hospital settings. This led to the inevitable cull of many people who were older in their care, and included the death of staff themselves, a disproportionate number of whom were from black and minority ethnic groups. On 17 March 2020, four days after the World Health Organisation (WHO, 2022) declared Covid-19 a global pandemic, 25,000 patients were moved following instructions from the government from hospital into care homes, including those infected with Covid-19. Finally, on 23 March 2020, the UK was locked down for the first time. Guidance for hospitals on 2 April 2020 clearly stated: ‘Negative tests are not required prior to transfers/admission into care homes’. The introduction of regular testing into homes was not announced until 6 July 2020. Donnelly (2020) highlighted the very different stances of ‘cocooning or culling’ in relation to people who are older as follows: During April 2020, as thousands of residents in England died of Covid-19 in care homes, the journalist James Warner wrote: Not to put to fine a point on it, from an entirely disinterested economic perspective, the Covid-19 might even prove mildly beneficial in the long term by disproportionately culling elderly dependents. (Warner, J. 3.4.2020, Telegraph) In contrast, Leo Varadkar, on 17 March 2020, had advised people who were older to stay at home ‘for several weeks’ with systems evolving to ensure food support was delivered. Unlike culling, he thought doing this would save lives: [P]articularly the most vulnerable, the most precious in our society. We call it cocooning. Words can act as missiles or shields. They are not neutral and impact on attitudes and what actually happens next. People with dementia and other residents in care homes quite literally had their backs against the wall unable to get out, relatives unable to get in, locked into their room for months on end. Varadkar’s communication, in the words he carefully chose, aimed to provide hope that people who were older would receive safe, continuing care. Whilst heroic efforts were made in many continuing care settings to provide this, the evidence supports the fact that in a period of months during the spring and summer of 2020 and beyond, there was a cull of older people. Those who did not die lost most of their human rights in the ensuing 18 months (De Chang et al., 2020). Those who did not die of Covid-19 then still continue to die of undiagnosed conditions such as cancer and heart disease now. Many GPs refused to visit older people living in their own homes, and, other than Covid-related cases, most specialist clinics in hospitals relating to other conditions were cancelled for months on end.

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In a coruscating report on the failure of government to ensure a ‘safe cocoon’ for highly vulnerable people in care homes, many with dementia, Kate Allen, Director of Amnesty International UK (2020), is clear: The Government made a series of shockingly irresponsible decisions which abandoned care home residents to die. . . . The appalling death toll was entirely avoidable – it is a scandal of monumental proportions. Major violations of the human rights of older people in care homes, many with dementia, took place during the pandemic, and indeed, as I write, continue to take place. Of note were their right to life, their right to health and their right to non-discrimination. Managers of large care home groups confirmed that, ‘It varied across the country, but GPs and district nurses have not come into the majority of our homes since the beginning of the pandemic. Not even to carry out essential work’. In terms of enhanced prompts toward the cull of people in their care, Amnesty International’s research indicated that Care Home Managers were told by GP surgeries and Clinical Commissioning groups (CCGs) to insert ‘Do Not Attempt Resuscitation’ (DNAR) forms into the files of residents ‘as a blanket approach’: ‘A group of six Sussex CCG’s issued DNAR guidance on 23 March 2020, to 35 GP surgeries and 98 care homes. The document instructed all practices to: ‘Search your clinical system for any care home patients who do not have a resuscitation order recorded (either “not for” or “for” resuscitation) and put appropriate orders in place’. Whilst lack of PPE was scandalous in the NHS initially, it remained scandalous in care homes for many months into the pandemic, with care home staff and home carers left without PPE until July 2020 and beyond. Families were unable to visit their relatives. Whilst an obvious solution was to integrate family members into the care home teams as ‘Essential Care-Givers’ from day one of the lockdown, this did not take place until January 2021. Amnesty International highlighted the cruel consequence of a thoughtless sadism in relation to care home residents and their families with the following example: I have not been allowed to visit my poor mum for 6 months. She is bed-bound and is on the first floor so window visits have not been possible. Her room is right next to a fire exit so I could go to her room without having to pass through the home but ‘bedroom visits’ are not allowed. I have been informed (by the manager) by email that I will ‘only be able to visit when she is dying’. Perhaps the greatest gift we can give to ourselves and others as mental health professionals is the ability to contain anxiety, especially in times of heightened expression and uncontained emotion arising from community trauma. The Covid-19 pandemic let the genie of fear, uncertainty and knee-jerk responses that were not able to be

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processed thoughtfully out of the bottle. This resulted in the most vulnerable of our society, namely those in care homes, people who are older, people with long-term chronic conditions and infants and children, experiencing the greatest disruption to their lives and broader well-being, with sometimes catastrophic effects on mental and physical health. We wanted to keep them safe, to keep them alive, but as months passed, many of those who lived were cocooned in a shroud of loneliness and isolation. In all but name they were labelled ‘Other’ and were treated accordingly. They became the excluded, outcasts in their own land, and were sent back ‘to the one great blooming and buzzing confusion’ (James, 1890) that they had emerged from a lifetime ago. We cannot turn the clock back. As psychoanalysts and psychologists one of our tasks together is to continue to seek ways to contain anxiety and metabolise the effects of community trauma in order to digest the overwhelming. The psychoanalyst, Hanna Segal, wrote that ‘Silence is the real crime’(1997). Let us never forget, never remain silent in bearing witness to the fact that many people, and particularly those people who were older in care homes or needing ongoing care in their own homes paid, perhaps needlessly, with their very lives. Acknowledgements From my psychoanalytic community I want to express my gratitude for the continued influence of Dr H. Segal and Dr R. Anderson. And to thank my colleagues Dr Andrew Balfour and Professor Martin Rossor for the work we did together in the past. I am grateful to Gareth Writer-Davies for allowing me to include his poem ‘Purblind and Font’ at the beginning of the chapter. Finally, I am grateful to Professor Linda Clare, Revd Dr Sue Foster and Dr Adrian Datta for their support and detailed input to the final version of this chapter. The writing is dedicated to my parents and Cathune Cape, all of whom died in the last two years. Note 1 This chapter records a joint meeting of the Applied Section of the Institute of Psychoanalysis London (2006) (Rachael Davenhill speaking) and specialist neurologist in dementia Martin Rossor (Chapter 8a).

References and further reading Amnesty International. (2020). As if Expendable: The UK Government’s Failure to Protect Older People in Care Homes During the Covid-19 Pandemic. Report. London: Amnesty International. Balfour, A. (1995). Account of a study aiming to explore the experience of dementia. Psychologists’ Special Interest Group in the Elderly Newsletter, 53: 15–19. Cantor, M.H. (1983). Strain among caregivers: A study of experience in the United States. The Gerontologist, 23: 597–604.

156  Rachael Davenhill Cheston, R.; Ivanecka, A. (2017). Individual and group psychotherapy with people diagnosed with dementia: A systematic review of the literature. International Journal of Geriatric Psychiatry, 32(1): 3–31. ISSN 0885-6230. http://eprints.uwe.ac.uk/28981. Clare, L. (2010). Awareness in people with severe dementia: Review and integration. Ageing & Mental Health, 14(1): 20–32. Clare, L.; Nelis, S.; Whitaker, C.; Martyr, A.; Markova, I.; Roth, I.; Woods, R.; Morris, R. (2012). Marital relationship quality in early-stage dementia: Perspectives from people with dementia and their spouses. Alzheimer Disease and Associated Disorders, 26(2): 148–158, April–June. Crutch, S.J.; Isaacs, R.; Rossor, M.N. (2001). Some workmen can blame their tools: Artistic change in an individual with Alzheimer’s disease. Lancet, 357(9274): 2129–2133, June 30. Davenhill, R. (2007). Looking into Later Life: Psychodynamic Approaches to Depression and Dementia in Old Age. London: Routledge. De Chang, et al. (2020). Epidemiologic and clinical characteristics of novel coronavirus infections involving 13 patients outside Wuhan, China. Journal of the American Medical Association, 323(11): 1092–1093. Donnelly, S. (2020). The elderly & Covid-19: Cocooning or culling: The choice is ours. QJM; Monthly Journal of the Association of Physicians, 113(7). Guss, R.; La Fontaine, J.; Buckell, A.; Knibbs, T.; Palfrey M. (2014). Clinical Psychology in the Early Stage Dementia Care Pathway. Leicester: British Psychological Society. Guss, R.; Middleton, J.; Beanland, T.; Slade, L.; Moniz-Cook, E.; Watts, S.; Bone, A. (2014). A Guide to Psychosocial Interventions in Early Stages of Dementia. Leicester: British Psychological Society. James, W. (1890). The Principles of Psychology. Vol. 1. Henry Holt and Co. Kitwood, T. (1988). The contribution of psychology to the understanding of dementia. In: Gearing, B.; Johnson, M.; Heller, T. (eds.), Mental Health Problems in Old Age. London: Wiley. Kitwood, T. (1989). Brain, mind and dementia, with particular reference to Alzheimer’s disease. Ageing and Society, 10. Kitwood, T. (1990). Explaining senile dementia: The limits of neuropsychological research. Free Associations, 10: 117–140. Klein, M. (1940). Mourning and its relation to manic depressive states. International Journal of Psychoanalysis, 21: 125–153. Kurten, L.; Dietzel, N.; Kolominsky-Rabas, P.; Graessel, E. (2021). Predictors of one-yearchange in depressiveness in informal caregivers of community-dwelling people with dementia. BMC Psychiatry, 21: 177. Morris, L.W.; Morris, R.G.; Britton, P.G. (1988). The relationship between marital intimacy, perceived strain and depression in spouse caregivers of dementia sufferers. The British Journal of Medical Psychology, 61: 231–236. Orgeta, V.; Qazi, A.; Spector, A.E.; Orrell, M. (2014). Psychological treatments for depression and anxiety in dementia and mild cognitive impairment (review). Cochrane Database of Systematic Reviews: 1–45. O’Shaughnessy, N.J.; Chan, J.E.; Bhome, R.; Gallagher, P.; Zhang, H.; Clare, L.; Sampson, E.L.; Stone, P.; Huntley, J. (2021). Awareness in severe Alzheimer’s disease: A systematic review. Ageing and Mental Health, 25(4): 602–612.

Dynamics of dementia 157 Rivière, J. (1952a). The unconscious fantasy of an inner world reflected in literature. In: Hughes, A. (ed.), The Inner World of Joan Rivière: Collected Papers 1920–1958. London: Karnac Books, 1991. Rivière, J. (1952b). The inner world in Ibsen's ‘Master Builder’. International Journal of PsychoAnalysis, 33: 173–180. Segal, H. (1958). Fear of death—Notes on the analysis of an old man. International Journal of Psychoanalysis, 39: 178–181. Segal, H. (1997). Silence is the real crime. In: Psychoanalysis, Literature and War: Papers 1972–1995. London: Routledge. Sinason, V. (1992). The man who was losing his brain. In: Mental Handicap and the Human Condition: New Approaches from the Tavistock. London: Free Association Books. Waddell, M. (1998). Inside Lives: Psychoanalysis and the Growth of the Personality. London: Duckworth. World Health Organisation. (2022). Global Status Report on the Public Health Response to Dementia. Geneva: World Health Organisation. Wright, L. (1991). The impact of Alzheimer’s disease on the marital relationship. The Gerontologist, 31: 224–326. Wright, L. (1994). Alzheimer’s disease afflicted spouses who remain at home: Can human dialectics explain the findings? Social Science and Medicine, 3(8): 1037–1046.

Part six

Perversion and violence

Editor’s commentary Perversion in the theoretical, psychoanalytic sense is included here as it has the same roots as violence, stemming from aggression but development having taken a different, more sophisticated course – to involve sexuality. Hans Sachs illustrates this in his theory that at puberty the Oedipus complex does not continue to resolve but divides like light through a prism. The components are lost in a confusion of fragments which can then be glimpsed in the history and slowly and painstakingly put back together in therapy as illustrated best in my view, by Joyce MacDougall. In Chapter 9 is Stephen Blumenthal’s work with a patient who disavows his emotional self in relationships. He has whiled away many years as a sex worker. Theoretically, he can be thought to have a perversion, illuminated by one psychoanalytic definition, his presenting problem being one that ‘crosses a body boundary’ (Glover, 1932), and in another, that he ‘sexualises his aggression’ (Glasser, 1979). His behaviour in relationships does not amount to violence but it will be sadomasochistic. Violence can be categorised as either primitively self-preservative or sado-masochistic (Glasser). Or in place of self-preservative, ruthless (Don Campbell). In practice it can be difficult to place clinical examples in one or the other category, human relationships being so complex and theory just an attempt to explain. But sometimes, when studied, it can be shown that one type can turn into the other under pressure, that sado-masochism can fail and regress to primitive reflex action, for instance when a woman says she is leaving a man and he erupts. Stephen’s writing is beautiful and warrants the Estela Welldon Prize which risked our losing his chapter because of copyright. But a lengthy email stream with the publishers (acquiring a rather perverse dynamic of its own), resulted in success, the dual publication in the International Journal of Forensic Psychotherapy and this book for which after all, the chapter was written. Addressing violence directly, the case of Angela Joyce’s child patient in Chapter 10 who is physically violent in the consulting room contrasts with the case of an adult male in Chapter 11 who must not be violent in the consulting room for obvious practical reasons. Angela describes how violent she herself could feel in the countertransference working with a prepubertal girl. It is so important and

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preventative to be able to admit such feelings to oneself, the therapist and then hopefully, the patient, or the mother of a small child, or the carer of an elderly person can do the same. Lastly, in Chapter 11 I  present my patient, a formerly violent, ex armed robber and thief, a man who could easily be seen as the one in the essence of nurture vignette at the front of the book. Violence is an important category to include in this book, along with gender issues and dementia, because it is another worrying epidemic. For too many years now, London has been the scene of an increasing number of knife crimes amongst young people. This patient in his day was one of them. The reasons behind it are not simple, not all bad and not easily categorised. It involves the ‘haves’ and the ‘have nots’, and envy is at the heart of the case. The sadness, deficits and mistakes in his life story are profoundly moving, alongside a stance of never forgetting in the consulting room that there has been the violence. Words are essential, and my patient had to learn how to find them. In Glasgow a few years ago violence was declared a public health issue, contagious and requiring stringent inputs, not least resources and understanding. It led to a decrease in the figures for violence (Evening Standard, 2019). This book was being prepared just as the International Association of Forensic Psychotherapy held its annual (30th) conference in May 2022 in London, entitled ‘Violence as a global Public Health emergency: preventing, treating and humanising the dangerous mind’. Its outgoing president Carine Minne and its lifelong president Estela Welldon should feel proud. If anything can offer a solution to this sort of problem, it is psychoanalytic understanding. References Editorial (29/10/19) Treating violence like a disease: could the Glasgow model work here? London Evening Standard. Glasser M. (1979). Some aspects of the role of aggression in the perversions. In: Sexual deviation. Ed: Rosen I. Oxford: Oxford University Press, pp. 278–305. Glover, E. (1932). Roots of crime. Madison, CT: International Universities Press.

Chapter 9

A state of inbetweenness The challenges of working with disavowal 1 Stephen Blumenthal

Introduction When S leaves the room following a session, the tissue on which he rests his head on my couch looks unused; his head has left no impression. Yet something about him left an impression, and I offered him twice weekly therapy, a scarce resource in the publically funded National Health Service (NHS). S who is 51 years old is an able man, but he whiled away his time and his talents working in the adult sex industry. He took pleasure in the benefits illusion provided and suppressed reality, along with his creativity. He suffered increasing bouts of depression prior to his referral as mid-life lifted the veil on his sense of failure to achieve what he knew he could. S treads lightly on the world, but as his therapy over eight years progressed, he found himself tied to it, which he experienced both as an anchor and an encumbrance.2 A dissociative split in consciousness is often described in working with challenging patients. No less common is a presentation such as S, of emotional detachment. The person is felt to be out of reach, in a psychic retreat (Steiner, 1993) of sorts. This creates a numbing atmosphere, which can provoke the clinician to withdraw. The thwarting of our efforts to make emotional contact has the potential to induce an anti-therapeutic response, which risks derailing the therapeutic journey. Disavowal as described by Freud (1925, 1927, 1938a, 1938b) is a helpful conceptual tool to orient ourselves. This involves a distortion of emotional significance, rather than a distortion of perception, as in the case of a dissociative split in consciousness (Basch, 1983). I describe the way in which two realities can be maintained simultaneously through the distortion of emotional significance. This particular defensive constellation acts as custodian, offering protection from contact with the other, which is experienced as potentially overwhelming. Contact risks creating awareness of an inner sense of devastation and feared breakdown. Safety is achieved, but at the cost of denuding mental life of meaning.

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Clinical material S is an embodiment of contradiction. He is present, yet remote, his affective states a mystery to him and me as we struggle to grasp what makes him tick. The clock indicates the passing of time, but an atmosphere of timelessness pervades his therapy. Softly spoken, mild mannered and intellectual, S wears the tweed jacket of an academic. Parsimony describes his manner and his slim physique. Left to his own devices, he would consume books not food, and he has a deep-rooted conviction that he can satisfy himself. He has a vast knowledge of literature, and he is an accomplished artist and musician. He has a passion for Old Master drawings, and has spent time copying certain works with absolute precision, describing the need to enter into the artist’s very being to produce the exact angle and pressure of the pencil in order to produce the perfect facsimile, which he emphasises, is not a copy. S quotes and lives by Flaubert’s (n.d.) maxim: ‘anticipation is the purest form of pleasure’. Like the lightness of his touch, he claims little, and so conceals his rapacious self, which is left outside the therapy in his interaction with prostitutes where his insatiable appetite is apparent. I could count the number of times S has made a demand on me on one hand. One of these took place the first time I met him, when he cried in despair when reliving the catastrophe of his adolescent breakdown, culminating in two failed suicide attempts. Another occurred when he became fleetingly aware of his desire to connect with his partner and child and cried out in anguish: ‘but what do I do?’, provoking a rare emotion in me, a state which gradually became more familiar. I have an oddly contradictory experience with S of being on the outside looking in; yet I am involved. Making a demand causes him to feel that he gives something of himself away. He experiences intense and unbearable loss; and the dangerous feelings of dependence. I feel viscerally his efforts to keep me at bay. His wishes become intertwined with mine, and the more fulfilling life he desires is transformed into my aspiration. This is a repetition of the over-libidinized relationship he had with his mother who was voracious in her unremitting determination for his success. Her unfulfilled ambition to use her mind was transferred to her precociously bright son. The way in which I am held in the therapeutic relationship shows clearly the transference anxiety: like his mother, I will set up my garrison within him, so S ensures his safety by carefully constructing a fortification of his own. S’s work as an essential cog in the machine of the sex industry was for a good period of his life, the perfect metonymy for the cocktail of desire and negative feelings towards his mother and the triumphant reversal of being colonized by her. He played a pivotal role in arranging sex parties and marketing brothels. He functioned as an indispensable middle man, where he could indulge his appetite for sex and domination with the illusion of being on the inside, with privileged, special access to a harem of attractive young women. They treated him as a dignitary, wanting to make an impression on him as the gatekeeper to his prestigious establishments. At an intellectual level, S acknowledges sadism, although the emotional aspect is unavailable to him. He enjoys sex with a stranger, but cannot bear to know

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the person he touches. In a disclosing moment, he told me that he gets pleasure from knowing that they are beautiful now, but they will be ruined, and he was there before their demise. I feel chilled by his declaration and check my impulse to retaliate with criticism. This unusually candid statement evokes a strong emotional reaction in me and a vista of potential work opens up to explore together. I glimpse the possibilities for analytic work if I am able to translate my countertransference into a shared understanding which could be helpful to him. If I could just harness this moment of S’s emergence from the privacy of his solitude. This gradually dissipates, as a numbing inaccessibility draws a veil over a potentially explosive eruption. Shortly after starting therapy, S met a woman 15 years younger who paid for her studies by working as a prostitute, in search of a rescuer and a father to herself and the children she craved. At first, I considered the relationship an enactment to avoid too overwhelming a contact with me. Yet they developed a surprising closeness, and I had to re-evaluate my formulation. He was initially opposed to her coming into his home; he never permitted anyone into his intimate space. But after an agonizing back and forth, she moved in. They had a baby boy, who is now four years old and the apple of his eye. At the start of the relationship, they had blood tests for sexually transmitted diseases, and S discovered that he had hepatitis C with significant liver damage, a disavowed fact of which he was vaguely aware due to feelings of discomfort in his abdomen. This is a concrete metaphor for his psychological state: he never allowed himself to know about his damaged self; he has known but not known, turned a blind eye, allowing the pathology to establish a foothold. He allowed himself to hope that a new wonder drug would cure him, not least because he saw a future with and for his son. This was successful, but the damage may have gone too far. S expresses gratitude for the positive impact the treatment has upon his life. I confess some gratification in the apparent dramatic reduction in his work – he now only has one client, the owner of a brothel. Yet a disquiet remains that his ‘one client’ is a half-measure and signifies an eternal attachment to his pathology. Like the hepatitis, the treatment can reduce the virus to ‘barely detectable’, but this may be the harbinger of a ferocious return. S’s background is one of strict and pious Christianity, where excess was shunned and frugality celebrated. He is a committed atheist but carries this prudent attitude in his body and in his being. His mother is described as a dominating figure, preoccupied with her son’s precocious talents, a narcissistic extension of herself. He feels she took an interest in what he did, but not in him. She controlled him with emotion and if he did not do as she wished, she punished him with emotional withdrawal. He withdrew into books and drawing in the secret world of his attic room. He developed a studied obduracy in response to her over-cathexis of his intellect and the rejection of his emotional needs. Father had a difficult early life; abandonment by his birth parents, an orphanage and adoption. He was apparently present but emotionally distant.

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S was always top of his class. But in adolescence, he became increasingly oppositional, defiantly sitting in class, reading complicated theoretical texts and refusing to comply with the syllabus. He devised a plan at age 15 years to deliberately fail his O’ levels and commit suicide in a secret, dark Gothic pact with himself. He set about failing his exams but passed one subject, because he could not resist answering a question offering a critique of the education system. S took two potentially fatal overdoses a week apart and waited to die, reporting this to nobody. He dropped out of school where he had been popular and good at sport. He withdrew to the public library for two years where he read complex, intellectual tomes with a feverish intensity, and he lost all his friends. S then set off with a guitar and a backpack and spent years travelling the world on a shoestring and taking a keen interest in the historical sites he visited. After his eventual return, he obtained a series of good jobs where his promise was noted and there was some success, but he always left before this was realised. He then studied art and was tipped for success, but once again withdrew. S finally found his home when he began attending swingers’ parties. He soon discovered that he could put his artistic and marketing talents to use, and he was quickly adopted by people who saw his potential. Disavowal and retreat S’s disavowal of reality and his retreat are epitomized by the following dreams: in one he was leaving Russia by plane. It was dark and raining, and there was a strange stormy light. In the other, he was leaving his home shire on a bus; again it was dark and raining. He saw a teddy bear belonging to his son. He felt anxious, there wasn’t enough time, and he felt he should not have put off his departure for so long. S’s thoughts went to the romantic pull of Russia, the literature, the deep and mysterious countryside and the immense open landscape. He once flew across this vast country. He had a window seat and the sun did not set; it was an eternal day. He became lost in the landscape; rivers like intertwining snakes, forests for thousands of miles. The rain in the dreams reminded him of magnificent thunderstorms he saw, it was dark and light at the same time, a darkness not of night but of thunderstorms in the day. There is a sense with S that awareness begins to open up for him, as is his life particularly with his son. Yet there is a terrible sadness about the time lost and a question as to how long he has to live. Like the recounting of the dreams and his associations, a pattern emerges in sessions when he expresses a sense of alarm and makes emotional contact with me, but this is transitory, and I experience a sense of disconnection from the intensity of apprehension I had thought was evident. As he elaborates his dream thoughts, he gets further away from his anguish about his losses and the darkness within himself. There is an urgency about the passing of time, but his associations lead to a limitless eternal day. I feel drawn in to the

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strength of his feelings, and then imperceptibly I am disorientated. I find myself the detached observer once again, wondering what occurred between us. Such drift is evident in a session following a holiday, when he talks about how worried he feels. He then drifts off into a memory from the holiday. He is on a jetty with his son, and he notices his son is frightened of the sea. I say: I notice in coming back an atmosphere of being like the sea. There’s nothing solid, there is a feeling of drift, of meandering. It is hard to focus upon the thing that concerned you, on a darkness in you. The sea was frightening, but not any longer. This strikes a chord, and he lets me know that he lives in a dream world and does not really notice my absence. He says: I just drift away, into another world. It’s something that I’ve always done. I was always a daydreamer, somewhere else, on a planet of my own. . . . I spent endless time in timeless places. I’ve created these timeless places around me; like the brothels. You enter a different world where there’s no time. . . . I’m not even aware I am doing it. Sometimes I suddenly realize how destructive my work is. Should S leave this retreat or stay in it? In the dreams, what at first appeared a place to leave, a place of darkness, becomes a remote refuge in the aeroplane, reminiscent of his attic room, where he is omnipotent and self-sufficient. He disavows conflict and anxiety and is insensitive to the suffering of the young women whose youth is squandered. He feels no craving as he looks through a pane of glass, cut off from the storm. Time stands still. I too feel distanced, looking through a transparent barrier at the transference-countertransference storm. Then to my surprise and his he says in a sudden eruption of despair: Why do I put things off? When I do, they just get worse and worse and cause me more suffering. I am desperate . . . Life is finite. How much of (my son’s) life will I  see? With a child, it’s different. Everything you do doesn’t end in death. . . . I need to be there for him. . . . I need to leave something good for him. There is a momentary window in which he expresses an appetite and makes a demand upon me, and there feels to be the potential for a stormy engagement. After these rare statements, I call time, and S rises to leave. I look down to see the tissues on the pillow in a dishevelled state. Discussion The temporary suspension of reality and of the constraints it imposes provides the basis for imaginative fantasy. The child at play believes wholeheartedly that they

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are a superhero, for example, whilst perception remains intact. Fantasy is a building block of thinking, and disavowal of reality plays its part. But the flight into fantasy signifies a distinct mental manoeuvre which can derail psychic development. The child left ‘alone’ may take refuge in a world of illusion to manage the unbearable void, and this can become organised as a pathological structure (Colombi, 2010). In this psychic vacuum, falsehood masquerades as truth, omnipotence triumphs over dependence, and love is diminished. S seemed able to represent his internal world. He has a prolific dream life, an abundant imagination and a good knowledge of literature which he seems able to use as metaphor. S is undoubtedly creative, but he channelled much of his imaginative capability into establishing a solipsistic parallel world. He inhabited a remote place on the cusp of creativity and of retreat in which time did not pass. There he straddled two realities and kept secret his pleasure in the demise of youth and vitality; a self-imprisonment which was both gratifying and tragic. Blass (2015) enumerates the different meanings of splitting within psychoanalysis and distinguishes dissociative and disavowal types. The dissociative kind involves splitting off whole personalities, whereas disavowal splits off awareness of disturbing realities or their meanings. This non-psychotic form of denial involves a ‘displacement of value’ rather than hallucination. ‘Two psychical attitudes’, writes Freud (1938b) of disavowal, ‘have been formed instead of a single one – one, the normal one, which takes account of reality, and another which under the influence of the instincts detaches the ego from reality. The two exist alongside each other’ (p. 202). Disavowal, according to Basch (1983), ‘is not a distortion of perception per se, but only a defence against that percept’s personal significance’ (p. 145). Disavowal eliminates the significance of things rather than their perception. S’s splitting off and projection of aggression maintained his psychic equilibrium. The disavowal of enmity protected him from acknowledging an inner sense of devastation and consequently of a feared breakdown. Disavowal functions to keep disparate and contradictory parts of the self separate from one another in order to preserve a psychic reality in which antipathy is both hidden and idealised (Steiner, 1993). This comes at a price. It restricts emotional life by preventing the working through of the traumatic significance of negative experiences (Basch, 1983). S’s evasiveness with me corresponded with his account of a mother whom he experienced as over-cathecting his intellect. He felt she demanded an independence he could not sustain. He learnt that feelings of dependence and vulnerability were dangerous and shameful and so gave up his reliance on anyone other than himself. The retreat he established took a physical form in the way of his attic room as a child, the brothel-world of adulthood, and ultimately, a place within himself where time stood still. S’s perception remained intact, and he recognised the veracity of different realties, but the emotional meaning was altered. When disavowal is prominent, says Britton (1998), knowing and not knowing exist side by side, and a state of inconsequentiality prevails. S maintained two psychical attitudes simultaneously; one

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in which he experienced no conflict about the ‘useful’ service he provided, and another that he was wasting his time and contributing to net harm in the world. In a disclosing moment, he told me that his work was ‘destructive’, yet he continued this with indifference. S turned a blind eye to the calamity of his adolescent breakdown. He concealed it from the eyes of the adults around him, ensuring their impotence, and of course from himself, at an emotional level. He thereby maintained the hidden breakdown into adulthood and remained temporally frozen. Steiner’s (1993) concept of the psychic retreat is an umbrella term for a variety of pathological organisations. Whilst splitting and disavowal are a fundamental aspect of any retreat, there appear to be some retreats governed by more dissociative elements and others in which the use of fantasy is rooted in disavowal, as S illustrates. S did not repress his impulses, rather he inhabited two realities. In one he experienced his sexual and aggressive appetite unabated, and in another he embodied his mother’s religious abstemiousness and her prohibitions. As the work progressed, S emerged from his retreat and became more available. Yet disavowal was so strong and worked so well that he repeatedly returned to his aeroplane world and maintained a foothold in the brothel. It seemed engagement threatened him with a feared catastrophe. This pattern of emergence and retreat was evident in those poignant moments when he made contact with his emotions, which then rapidly dissipated, such as the return from holiday. A moment of potential emotional intensity, such as his son’s fear of the sea, washed away like the tide. I experienced a sense of dislocation; questioning myself as to the veracity of his involvement. His associations to the dream did not elaborate the latent content; rather they took him away from his feelings of time being short and of loss. He hung on to a trace dose of the world of prostitution with his one client, just as there was always the trace of the ‘barely detectable’ virus. Fetishism, says Freud (1938b), is a particularly favourable subject for studying the question of disavowal. There is a distinctive quality to the way in which the concrete fetish object contains a density of meaning, a true metonym. In ‘Splitting of the ego’ (1938a), he describes the case of a boy who developed a fetish. This followed his seduction by an older girl and following this, masturbating and being discovered by his nurse who threatened him with castration. Through the mechanism of disavowal, he continued masturbating with apparent boldness, yet simultaneously and in contradiction, he developed an intense fear of being punished by his father. In a similar way, S was indifferent to his work in the adult sex business and the moral conflicts, guilt and shame associated with it. At the same time, he experienced persecuting anxieties relating to his unfulfilled potential. There was a marked sense of inconsequentiality and unreality, as Britton (1998) describes it. He was indifferent, yet S experienced a sense of dread that caused him persistent and at times overwhelming suicidal depression. S’s disavowal was his means of managing a powerful and dangerous maternal object unfettered by the intervention of a robust paternal object. He was driven to defeat me by remaining remote. At times I was forced to participate as an observer, who knew his patient was elsewhere.

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Further clinical material A dream towards the end of S’s therapy illustrates some further aspects of disavowal relevant to our discussion. After seven years of therapeutic work, S’s situation improved. He described a more satisfying and loving relationship with his partner, there was a warmth and kindness in his description of her, an engaging relationship with his son, who was apparently thriving, and improved work prospects in the form of an online art business. He was distinctly less remote and more emotionally engaged with me. He expressed real worries about his health, and he managed to sustain engaging with these anxieties rather than characteristically disavowing them. S began to realise his dream of moving to the countryside, to the area he came from. He wanted to establish a life there with his family. He was now a man situated in time, with a past and a future. We discussed an end-date a year hence. He then had the following dream: I was fishing off the beach and I hooked a salmon. This was strange because salmon are not caught off the beach, but I thought: perhaps it was an estuary; that place between the sea and the river. I reeled the salmon in and just as it was getting up onto the beach, a man fishing next to me picked it up and threw it over to me and I caught it and struggled with it. I took an implement which is used to kill fish, called a priest. I used to fish with my uncle in Yorkshire and we used the priest to kill the fish we caught. It is weighted with lead, like a club, and I hit the fish on the back of the head. But in the dream the fish didn’t die, it was now in a half-alive state. It continued to struggle and somehow it got into the water. I looked for it, but the water was rough and murky. I managed to grab hold of it and bring it back to the beach, but it was half dead and had lost its lustre. Salmon are such beautiful, regal fish, but this was now half dead. I wasn’t sure whether I threw it back in or if it got back to the water itself, but it just drifted, half alive and then it disappeared. S’s associations were to beaches on the north-east coast of England. Although it is technically Yorkshire, the people there talk with a north-eastern accent: ‘So it’s kind of not really Yorkshire any more’. He thought about rivers in Scotland where the salmon go to lay their eggs. He said that there are dwindling stocks of salmon. His thoughts kept returning to the cruelty of the act of killing the fish; he had done it hundreds of times. But this was a long time ago; he is a vegetarian and he could not bring himself to kill a fish now. In the months that followed the dream, S and I talked about the many themes condensed into it and the connection with ending his therapy. The beautiful, regal salmon which had lost its lustre was reminiscent of what he said many years before about how the girls were beautiful now, but he was seeing them before their demise. The salmon conveyed his thinking about himself: he was acutely aware of his physical health problems and his mental state of half-aliveness. But he could now allow his therapy to come alive, and he had regrets about his use of it previously. At that

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moment, I think the ending of the therapy felt to him like a death, and I was the presiding priest. S always occupied a place between things, neither one thing nor another, he was always between places, Yorkshire or the north-east, in the surf but not in the sea; in the estuary. He lived in the fresh water and in the salt water, in the world and in a brothel. With the ending of therapy, he worried about his being a fish out of water. The dream showed an emergence from his retreat and signified the way in which the aeroplane world protected him from psychic conflict, from the shame of vulnerability and from depressive anxiety. In the dream his aggression is present, but it becomes split off as he associates: he used to kill fish, but not any longer. I was concerned with a detail he left out of his associations; namely that salmon return to where they are from not only to reproduce but also to die. I think S was able to convey through the dream the sense that he felt hooked by a cruel, vengeful object who wielded a priest behind him. Perhaps equally so, the salmon could swim away, albeit in a half-alive state. Regardless, I was left anxious about S’s departure. After all, he made two serious attempts on his life, and he had never properly left home, so to speak. In the course of these discussions, S experienced a profound melancholia as he thought about the imprint he had left upon the world in the form of his work, and the lack of influence he had in relation to his potential for creativity. He thought about his son, and his sincere wish to leave something positive and edifying behind as his legacy. He experienced intensely the sense that not ending suited him. He said: It’s like I want to keep something open. Like anticipation, something that never ends. It’s kind of endless. . . . But then I actually do want a resolution, I can’t bear this state of inbetweenness. Discussion This state of inbetweenness protected S from knowing about his aggressive impulses, which are disowned, placed in a self, belonging to a long time ago. It forestalls the experience of the dangerous, shameful feelings of dependence. He conveys a wish to prolong the therapy indefinitely and to avoid experiencing loss. In the course of this work, S became acutely aware of his reliance on his mother. He had never properly left home. He may have done so practically many years previously, but his parents acted as the fulcrum of his activities since then. He created a life which was like a negative photographic image of his parents’, doing exactly the reverse of what they aspired for him. The qualities of S’s attachment became more evident in this last phase of therapy. It was clear that he remained tied to his mother; he was reliant upon her. His retreat was an attempt to establish a prelapsarian paradise, in which time did not exist. This anaclitic attachment, based upon dependence, signified the transference

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relationship. Disavowal denuded S’s relationships of meaning. This is perhaps a defence against an overwhelming invading/abandoning maternal object (Glasser, 1979, 1992). S existed side by side with the object, but he protected himself from engaging emotionally. Basch (1983) captures the way in which this distortion of significance manifests in the transference-countertransference: [T]he person who consciously disowns or disavows his presence is not really saying ‘I am not here’, but, rather ‘Just because I am here does not mean I have to talk to you, so, for practical purposes, and as far as you are concerned, it is the same as if I were really absent’. (p. 134) The use of disavowal, which distorts significance and meaning, has an impact on symbolic functioning. Whilst S’s dreams were powerful in signifying his conflicts, there was a manner in which these representatives remained in the dream. Whilst they could be apprehended, they could not be owned by consciousness and thereby integrated into his self. This is reminiscent of Bion’s (1957) description of the psychotic person who ‘moves, not in a world of dreams, but in a world of objects which are ordinarily the furniture of dreams’ (p. 269). However, there is a crucial difference in quality to psychotic thinking. In the case of disavowal, the capacity to use symbols does not break down completely. It is based upon distorting significance rather than perception. The dream symbol becomes an object, it becomes furniture because it is robbed of emotional significance. The ‘priest’ in the dream has a concrete, furniturelike quality, and S struggled in a wakeful, conscious state to sustain an emotional engagement with what his dreaming mind produced. The parallel world S created for safety impeded artistic creativity because the creation of the artist is not the object represented, it is its own, distinct ‘creation’, a symbol, not the thing symbolised. In this sense, S’s creations were concrete objects, a kind of symbolic equation, though different from that described by Segal (1957), which she based on the splitting characteristic of a psychotic process. In this case, the symbolic equation is based on disavowal. The dream of the half-alive salmon is indicative. It is a partial symbol, but it is halfway to a representation of himself and of his disavowed aggression. Like the half-measure of disavowal Freud described, so too the symbol is a semi-symbol. S forcefully projected his anxiety about leaving, which led me to doubt the possibility of ending therapy. In so doing, time itself was stretched out. He thereby realised the timeless places he inhabited. S’s psychic retreat enabled the denial of the passing of time, one of the facts of life, as described by Money-Kyrle (1971). It took considerable work to confront his mortality and the ending of his therapy. Concluding remarks Disavowal and splitting of the ego are ubiquitous and varied in their manifestation. This can be relatively benign and is the basis for creative imagination and play. It

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is a necessary means of protecting the psyche from the exigencies of the demands of external reality. But this form of splitting can take on a more troubled character in which reality is profoundly distorted by altering significance and meaning. This is the crucial difference between fantasy and imagination in how we elaborate what we perceive. The retreat based upon disavowal is powerfully protective in maintaining psychic safety. The purpose is to deny need and the passing of time. Yet such an organisation is also limiting of engagement with self and others, and with creative potential. In making a momentary demand upon me, S fleetingly became aware of feeling unbearable and intense loss as he experienced the dangerous feelings of dependence. Whilst a degree of integrity remained in relation to his retreat, there was a reversibility of projective identification, which arose from the working through of mourning, and the regaining of parts of the self which had been scotomized and lost. In cases such as the one described, the evident suffering arising as a consequence of analytic work can be experienced as the catastrophic loss of an ideal state (Steiner, 2013). Undoubtedly there is excitement in concealment, but it is ultimately based upon hiding shame. Thus, not only does one need to relive in the transference-countertransference the experience of the loss the infant experiences of the ideal state, but also the shame of revelation, the removal of concealment, and being observed as small and needy, as omnipotence is exposed as illusion (Steiner, 2006, 2011, 2013). Two parallel worlds existed: one a facsimile, the other reality based; one timeless, the other bound by time; one in which he was omnipotent, and the other in which he needed and depended on others. These worlds began to collide, and S was able to communicate to me that, like his mother, I should not mistake his apparent self-containment for self-sufficiency. Acknowledgements My thanks to Heather Wood, Stan Ruszczynski and John Steiner for their comments on earlier versions of this paper. Notes 1 This chapter was awarded the Estela Welldon Prize in 2021 and is to be published in the British Journal of Psychotherapy. 2 S provided his full consent to the use of this clinical material. All identifying information has been altered in order to protect confidentiality.

References Basch, M. (1983) The perception of reality and the disavowal of meaning. Annual of Psychoanalysis XI: 125–153. Bion, W. (1957) Differentiation of the psychotic from the non-psychotic personalities. International Journal of Psychoanalysis 38: 266–275.

172  Stephen Blumenthal Blass, R. (2015) Conceptualizing splitting: On the different meanings of splitting and their implications for understanding the person and the analytic process. International Journal of Psychoanalysis 96: 123–139. Britton, R. (1998) The suspension of belief and the ‘as-if’ syndrome. In: Belief and Imagination: Explorations in Psychoanalysis. London: Routledge. Colombi, L. (2010) The dual aspect of fantasy: Flight from reality or imaginative realm? Considerations and hypotheses from clinical psychoanalysis. International Journal of Psychoanalysis 91: 1073–1091. Flaubert, G. (n.d.) http://notesoffthecuff.blogspot.co.uk/2012/12/anticipation.html#. WkjrGMJFA0Q Freud, S. (1925) Some psychical consequences of the anatomical distinction between the sexes. In: Standard Edition, vol. XIX. London: Hogarth Press, pp. 241–258. Freud, S. (1927) Fetishism. In: Standard Edition, vol. 21. London: Hogarth Press, pp. 149–157. Freud, S. (1938a) Splitting of the ego in the process of defence. In: Standard Edition, vol. XXIII. London: Hogarth Press, pp. 271–278. Freud, S. (1938b) An outline of psychoanalysis. In: Standard Edition, vol. XXIII. London: Hogarth Press, pp. 241–258. Glasser, M. (1979) Some aspects of the role of aggression in the perversions. In: I. Rosen, ed. Sexual Deviation, 2nd ed. Oxford: Oxford University Press. Glasser, M. (1992) Problems in the psychoanalysis of certain narcissistic disorders. International Journal of Psychoanalysis 73: 493–503. Money-Kyrle, R. (1971) The aim of psychoanalysis. International Journal of Psychoanalysis 52: 103–106. Segal, H. (1957) Notes of symbol formation. International Journal of Psychoanalysis 38: 391–398. Steiner, J. (1993) Psychic Retreats. London: Brunner-Routledge. Steiner, J. (2006) Seeing and being seen: Narcissistic pride and narcissistic humiliation. International Journal of Psychoanalysis 87: 939–951. Steiner, J. (2011) Seeing and Being Seen: Emerging from a Psychic Retreat. London: Routledge. Steiner, J. (2013) The ideal and the real in Klein and Milton: Some observations on reading paradise lost. Psychoanalytic Quarterly 82(4): 897–923.

Chapter 10

Aspects of the process of child analysis 1 Angela Joyce

Michelle’s single mother approached me when Michelle was seven years old asking if I had a vacancy to see her child. At the time I did not but nearly two years later she once again got in contact, still worried that her adopted daughter had ‘attachment problems’. In the second session with Michelle now aged nearly nine years, she suggested that we play a game with the baby doll, that she was in my tummy and I was to give birth to her; Michelle was the baby’s big sister. I am going to use some material from this three times per week, four-year-long analysis to consider some aspects of the specificity of the process of child analysis and its links with adult analysis. Michelle’s preoccupation with her origins and her wish for a family with siblings so transparent in the opening sessions, was not so easily approached. I was to learn that it was a continuous source of internal irritation, rather like a scab that is scratched and never heals. Addressing it directly would inevitably provoke rage, physical attack, shouting and agitated action including running out of the room. I was challenged throughout her treatment to discover ways of being with her such that the continuing rawness of her experience could safely be in the room with us, known and possibly understood. She was the only child, adopted by her single mother at five months old. Michelle was intensely anxious around separations and was both hostile and clinging to her mother physically and emotionally. Michelle was not doing well at school and found it very difficult to make and keep friends as she was demanding and very jealous. A bright part of this otherwise despairing picture was that this mother-child pair was in the midst of a large extended family with aunts, uncles, cousins and a grandmother who had only recently died and whom Michelle told me about in our first session. They were very important to Michelle as well as the object of much painful envy and jealousy. We can see at the outset that the child analyst is presented with a complex mix of internal and external factors. Who is suffering and who brings the child patient? Indeed, who is the patient? Who wants the treatment and who consents to it? This puts the potential analytic process concerned with the internal world of the child squarely in the context of the external world, of the family and/or the child’s school, and emphasises the dynamic tension between the inner and outer world of the child both in the analytic process and in the child’s ongoing development. It DOI: 10.4324/9781003202790-20

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raises the question of the ways we may understand the child’s difficulties as located primarily within their own psychic economy, the outcome of the interplay of their innate potential with the experiences with which they have met (a very familiar analytic question since Freud), and the ongoing contribution the child’s external family and social relationships make to their functioning, health and disturbance. Perhaps the child’s disturbance has a function for the family, and the motivation for and resistance to change then is located in a complex web of relationships within and at the same time external to the child. We can see how dependent the child is upon the way the parent/s perceives and understands their problems. It faces us with the question as to how or whether this parental/family/school context might be included in our psychoanalytic work in order to promote and protect the treatment of the child. In an institutional clinic context, this is potentially taken care of by a multidisciplinary team, but in private practice these considerations have to be catered for either through collaboration with colleagues or by including work with the parents and outside agencies in our practice. As much as children are dependent upon the adults to find them analytic treatment, so they are dependent upon the adults in their world for their commitment to sustaining the treatment until it reaches its appropriate conclusion. It is not untypical for a child’s difficulties to become concentrated in the analytic setting whilst in the external world the child’s functioning seems much better. The parents then may feel that the analysis has done its work, the child’s difficulties are resolved and decide to withdraw from treatment. All this has to be managed and constitutes a significant tension in the creation and protection of the psychoanalytic space in work with children. These are questions that are rarely so directly present in the treatment of an adult but are major considerations affecting the process of psychoanalytic treatment of children. However, these so-called external world intrusions also bring into focus the very complexity of the analytic work, and of the division between ‘internal’ and ‘external’. From a different perspective, we can think about these issues in relation to Winnicott’s thesis of transitional space (Winnicott 1971), in which the ‘me’ of the patient and the ‘not me’ of the outside world as represented by the analyst contain the paradox of our human existence, expressive of our very intricate living both inside ourselves and with other people: ‘internal’ and ‘external’. In the analytic work this paradox has to be held and the child’s experience of herself-inthe-world (the world of the analytic setting, as well as her family, school and other things) given space. Often this can be very difficult, expressed in ways such as the child never talking about their outside world, but conveying in their way of being their sense that the outside intrudes, is felt to be dangerous, cannot be countenanced or is there to be complied with, etc. The arrangements I made with Michelle and her mother were that I would see Michelle three times per week and her mother once a term. I endeavoured to set up regular parent work sessions with a colleague for the mother, but this foundered for a number of different reasons. This is not uncommon but as Jack and Kelly Novick pointed out in their book (Novick & Novick 2005), the absence of work

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specifically focused on the parenting is a risk factor in analytic work with children. The analysis is much more likely to succeed when parents are engaged in analytic work on their parenting. The process of child analysis Vignette 1 Michelle used the toys provided from the outset to make up stories, sometimes but not always involving me in the play by asking me to ‘be’ certain characters. She had been playing with the wild animals for several sessions, making up stories whose narrative reflected much confusion about who belongs to whom in convoluted family relationships, stealing relations, loyalty conflicts and especially a theme of children not knowing who their father was. In one session Michelle set out the wild animal figures with two adult tiger and lion fathers playing with their cubs. She incorporated a model of a sphinx that was on my bookcase, making her into a ‘goddess’, and ‘flew’ her down to where the animals were playing together. She made the goddess be friendly to the cubs and their fathers and so they all seemed to be having an enjoyable time. All of a sudden she made the goddess snatch the young cubs and ‘flew’ them far away from their fathers into the mountains. I talked about how frightened the cubs must be, stolen from their fathers like that. She told me to take the part of the fathers and instructed me to make them search for their stolen cubs. I played these parts with the toy lion and tiger as they went on a long and hazardous journey across rivers, up valleys until they found the goddess’s cave. I talked about their fear for the safety of their children, their anger with the goddess for tricking them. I also talked about their determination to find the cubs. When they reached the cave they found their cubs, but Michelle said they did not recognise their fathers because the goddess had put a spell on them so they would forget their previous life and believe that the goddess was their mother. I then sympathised with the predicament they were all in because of the spell; the conflict the cubs might feel, wanting to believe that the goddess was their mummy, but somehow feeling that it wasn’t true. Michelle was quiet and watchful as she authored this story, interested it seemed in my response and what I would make of it. This narrative can be thought of as a representation of Michelle’s view of her adoption, an indication of the sense she had made of the story she had been told about it and her inner experience of her history. From this perspective, it reflected her belief that she had been stolen against the wishes of her father and that she only believed this person (the goddess/adopted mother) was her mother because of a

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trick. Indeed, it possibly also reflected her feeling or fear of being cut off from her history, particularly from her paternal origins and being lost forever in a maternal realm through this spell. The latency issues of her gender identifications also are suggested in this material, and there are the transference aspects, her fear that in coming to see me I would, like the goddess, somehow trick her and steal her away; her wish that I might be the father who would rescue her from the territory of the maternal. I had already had the experience with Michelle from so early in the treatment that she found it very difficult to make use of any direct links from her play into her own personal concerns. She was often restless and provocative, leaving the room several times when the comments I made were too near what felt like the rawness of her states. She did not readily feel relieved or understood though any interpretative process offered by me. I could have interpreted any one of these themes and in the session, I decided not to ‘spell’ out these links directly. It seemed that we could with some safety know and understand more about her understanding of the story of her life, her adoption and her sense of her current predicament without it being disrupted by turbulent action, the manifestation of her extreme anxiety, by working with this play in displacement. This is a particularly Anna Freudian style of child analysis, recognising the communicative nature of play but also the value of the defence of displacement and its use technically (Sandler, Kennedy & Tyson 1980). For children whose ego capacities are limited in ways such as the poor toleration of strong affects which may feel to be potentially overwhelming, the analyst’s location of comments largely in the play can mean that the feelings, phantasies, wishes, defences, etc. are elaborated in the ‘displacement’ of the play, probably with greater acceptance and response by the child. Michelle could be helped in this way, in an analytic exploration that at some future point might be more directly integrated into her account of herself. In addition, the work in displacement can be seen as having reverberations throughout the child’s experience of herself; unconsciously it functions to make links, contributing to the child’s internal elaboration of meaning of her experiences, in the here and now. The child may not be able or inclined to demonstrate this in an obviously insightful way, but as with the associative process of an adult, the way the material moves on can be indicative of these more unconscious or pre-conscious processes. So too in adult analysis, work that does not necessarily directly address the transference in the session but follows the analysand’s associative flow, in this model also is seen as reverberating through the psyche. As this analysis proceeded, I had to restrain Michelle several times from attacking me when I linked her play too directly to her feelings and thoughts about herself and her life, either in the transference or referring to other aspects of her life, which she found intolerable. I came to understand it in several ways but largely to do with the overwhelming sense of shame and humiliation she felt about her adoption and her lack of a father. She let me know many times that she found my comments intrusive and nosey, but that her own curiosity about me and my life which could not be satisfied, felt too concretely as her banishment from her birth family, where

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in fantasy she had a father and a mother, and sisters and brothers. These happy (and unhappy) family scenarios were played out again and again, in the narrative scenes similar to that described earlier where I could talk to her there about the jealous rivalries, fears, wishes, disasters, etc. in displacement. From time to time I  also talked to her about what I saw as her defensive use of displacement, her fears about talking directly to me and her greater ease in showing me in her play what she was concerned about. Invariably this got a hostile response and many times led to the play being interrupted. This invokes such concepts as the treatment alliance, and analytic tact which refer to the necessity of the analyst even in the face of acute negative transference, being able to establish and retain with the patient the basis of agreement about why they are meeting in the way they are. It also, in a more complicated way for work with children, points up the issue of consent to treatment, who gives it and how it is sustained at the most difficult times. In my experience it is not so uncommon for children of this age to be so reluctant to talk directly about themselves to an analyst or child psychotherapist. However, when it is so resolute and uncompromising it seems to be related to situations where the child is not just suffering from intra-psychic conflicts that are painful and are defended against, but in some way they are linked to problems at a more process level of mental functioning. It seemed to me that Michelle, over most of her time in analysis, found thinking about her feelings directly, overwhelming. In another language, her capacity for affect regulation was very flimsy and easily rendered useless when subjected to floods of unmodulated stimulation. If I interpreted her play directly, my words would seem to push Michelle back into the action mode of functioning. I had to find ways of being with her that were not avoiding the painful affects but allowed their recognition to be bearable. I want to say something here about the nature of interpretations in child analysis. We have already seen something of the problem of ‘translating’ from one form of expression into another: narrative play into commentary about the child’s inner world of fantasy, self-object relations, affects, etc. One of the arguments given for this kind of intervention is that it helps the child move from the mode of action to verbalisation and secondary process functioning. However, as we see in a later vignette, that is not by any means always the outcome, especially with a child whose psychopathology is non-neurotic and more severe. Perhaps there is also a more general principle here, that of the necessity of the child analyst to stay as close as possible to the child’s way of expressing themselves. This is a complicated issue especially if we think about the function of play for a child. For this I turn to Winnicott. His views about forms of communication do not differentiate much between ‘the vitally important subtle communicating of the mother-infant kind’ (Winnicott 1958), the child playing and beginning to speak, and the adult talking. He saw them as aspects of the human repertoire of representation and communication. Thus, verbalised, one might say conventional interpretation by the analyst is not privileged but instead one of several modes that can reach the child in an emotionally real way, responding to their primary capacity for communication. Indeed, Winnicott’s views about the analyst’s response to the child’s

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play are rather special; he was very clear that the analyst’s job was not to disrupt the play by interpreting its meaning. Playing in itself is constitutive of the unfolding of the child’s personal pattern, of the child’s preoccupations, those things the child is ready for and is interested in. It is essentially a transitional activity, full of potential and inconclusive. This quality of openness is also linked to the function of playing as equivalent to free association in the analytic setting. To pin it down through interpretation with particular (closed) meaning rather than to open it up through playful extension, would only risk inviting compliance or resistance: play stops when one of the participants becomes dogmatic (Phillips 1988). Michael Parson’s 2007 paper considers these ideas from the point of view of adult psychoanalytic work in the Independent tradition (Parsons 2007). In a rather different tradition linked more to Wilfred Bion, Antonino Ferro has stressed the limiting influence of what he calls ‘saturated interpretations’, instead favouring a stance from the analyst which promotes the opening up of the ‘bi-personal field’ (Ferro 1999). Although the function of play has been the subject of extensive debate between child analysts, it is largely seen as a fundamental mode of expression of preadolescent children and therefore potentially equivalent to words that form the free association in adult work: it is a central part of the material of the analysis as Melanie Klein discovered. Anna Freud is well known for her view that a child is not capable of free association and that play is not equivalent to free association in adult analysis. My impression is that most people trained in the Anna Freud tradition no longer hold to that, and this is a reflection of the way different traditions have infiltrated into each other. Free association, that distinct mode of analytic discourse, is linked to the analyst in a state of free-floating attention, being able to listen to the threads that weave in and out of content and process of the analysand’s material. But the possibility of ‘free-floating attention’ seems to me to be an elusive quality in child analysis as the action in the consulting room often speeds along and the child analyst does her best to follow and keep an open mind as to what is going on. As in adult work everything that happens is heard by the analyst as a communication, the meanings of which may or may not emerge in the process. It is the analyst’s response to the child’s play that enables it to become woven as threads of the unfolding psychoanalytic process. This response is largely derived from the analyst’s imaginative elaboration of the patient’s communications, at conscious, pre-conscious and unconscious levels. The analyst, by treating the action and play as communication by the child, of ways of being, of preoccupations, defences, anxieties, etc. creates the baseline of an analytic process which is paradoxically interpersonal as well as intrapsychic. Often with young children the analyst will be invited by the child to engage in play, perhaps to take roles in the elaboration of a narrative, the different meanings of which may emerge over time but equally may remain hidden or obscure. ‘Interpretation’ may take place in this elaboration in quite different ways, following the play in action, focussing on the characters in the narrative story the child is creating, the affects between them, the wishes and impulses evident within a character, or from one to another or simply follow the child’s lead in extending the dramatic

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narrative. This can be seen as supporting the paradoxical development of mental structure, e.g. by allowing for repression, promoting super-ego development, etc. and at the same time providing the ‘opportunity for the child to have a location in play where feelings, phantasies and wishes may be apprehended, reflective capacity developed and insight derived’ (Mayes & Cohen 1996, p. 1148). In addition, the analyst’s actions qua actions may convey an interpretation but without words directly. For example, taking part in a game of ‘catch’ conveys to the child the analyst’s recognition of the child’s wish to connect with the analyst; it may be elaborated in all sorts of ways such as following the child’s counting before the ball is dropped; observing who drops the ball and how it is retrieved, the force with which it is thrown, etc. all redolent with meaning which may or may not be put into words. A verbalised interpretation, ‘translating’ the play, saturated in primary process, into secondary process form may not yet be meaningful to the child, and, as in Winnicott’s view, may also unhelpfully disrupt the child’s creative play activity. Vignette 2 Approaching the first holiday break, Michelle brought a 3000-piece jigsaw puzzle to the session announcing it urgently through the intercom system when she arrived. She was very keen that we should do it together but immediately had to leave the room to go to the toilet. This puzzle was actually far too hard for her but for some time she talked of completing it and that it would take us three to four weeks. I commented that that would take us to the summer holidays. She gradually began to pile the pieces into my lap so that it soon was overflowing, and I said that she wanted me to sort out all these bits and how complicated that was. Soon afterwards as this continued, I said that she wanted me to put all the bits of herself together so she could have a picture of herself and that she knew it would take quite a long time for us to do that together. She quietly listened sorting out the bits to match them. At the end of this session, she wanted to leave the puzzle with me to which I agreed. The following day she returned and repeated the early part of the previous day’s session: she wanted to do the puzzle but soon went to the toilet. She became despondent when she could not easily match the pieces of the puzzle together, and I talked about her sense that this was going to be too much, that the puzzle was enormous and that it would take a very long time not just the weeks she had described yesterday. She added ‘if we ever get started’, and then abandoned the task, instead pouring the pieces over herself and the chair. The pieces were scattered all over me and the room. We then had to collect the pieces together in the box, and this was repeated several times. This play had an edgy, determined quality to it. I eventually said, ‘Imagine all these pieces of the jigsaw puzzle were like little pieces of you Michelle, and they all belonged together like in the box, inside you; but

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sometimes you feel that all the bits of you just pour out and like the jigsaw some might get lost; so that the big picture can’t be completed’. She wanted me to help her keep all these bits together when this threatened. The affect in the room became calmer for a little while, but after going to the toilet again Michelle initiated a game of ‘catch’ with the soft ball and then a guessing game where there were no clues. She became volatile as she insisted that I guess what I could take away on a fantasised holiday in California. Everything that I suggested was rejected as incorrect by her, and I said that it seemed that she did not want me to go on this holiday. Michelle protested that she did, but then approached me provocatively, sitting next to me on the arm of the chair, and then on top of me and going for my glasses and t-shirt in an insistent and forceful way, seemingly to see my breasts. When my verbalising of limits failed, I had to restrain her by holding her wrists, saying at the same time that she was showing me how close she wanted to get to me – even be my baby and me her mummy/analyst – but that these feelings were very hard and so she also had ‘fighty’ feelings to push me away. This only inflamed her and she leapt up saying she was leaving. I said that it wasn’t yet time but that I realised that she was feeling very uncomfortable with what I had said and it had made her want to go. Michelle remained agitated and ran out of the room and up the stairs and then down and back into the consulting room. She pushed me and tried to kick me. I said to her that I wouldn’t let her do that, I needed to keep us both safe, restraining her, but that we could try to understand what she was trying to tell me. I continued, as Michelle stayed close but agitated, that I thought she was feeling full of fighty feelings that she has when she wants to be close but feels frightened. Michelle grabbed some pencils and threw them at the light and ceiling and suddenly stopped as one hit the light. She was immediately worried about what she had done, and I linked this with her worry about hurting me when she was in this sort of state. Michelle became somewhat calmer but was still quite agitated as the session came to an end. These agitated states were a feature for some time in the early part of this analysis and returned at times of great pressure throughout. As can be seen in this material, they were related in the transference to Michelle’s ambivalent dependency upon her maternal object, clinging and at the same time fighting to get away. The extent of the threat of fragmentation she felt under, expressed by the 3000 pieces of jigsaw scattered so eloquently over me and my room, was directly addressed as a symbolic communication to the analyst after some time and repetition in the session, and it led to a calmer period for a while. The game of catch, however, highlighting again the tenuous link she had with me that was to be broken, led to a more direct game about the holiday. Verbalisation of her wish that I stay did not calm the situation but instead inflamed it and led to her intruding on my physical body space, prompting

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another direct interpretation about her regressive wishes to be my baby and me be her mummy analyst. Perhaps I got it wrong or maybe I went too far here, not allowing sufficiently for Michelle’s need to keep her defences more intact. Perhaps she wanted me to say that I would take her away with me. What came to me was her wish for me to stay with her. We all have to make these judgements of whether, when and in what way the patient can face their own psychic reality; respecting the patient’s defences that have developed for good reason to protect them from what feels to be intolerable anxiety, has to be balanced with the need to disrupt and challenge them in such a way that enables psychic change to occur. Michelle regressed indeed, to action that was fuelled by her anxiety and agitation that only somewhat abated with her fear that she had damaged my room and me. Being a child analyst can be dangerous at times; the risk of the child decompensating and regressing to a body/musculature-based action mode of functioning can lead to injury and require management as well as understanding and interpretation. The task for the analyst is varied: to be for the child an auxiliary ego who can process the powerful feelings that are aroused and bear the threat of being overwhelmed; to take in projections of intolerable states and work with them internally, resisting the provocation to retaliate and confirm the child’s worst fears that they are hateful; to keep some thoughtful, imaginative capacity available, capable of seeing beyond the immediate fight to its underlying significance, even if that couldn’t be spoken at the time but held in mind for a later opportunity. Sometimes it can feel as if there is a siege taking place. Many times in the early months and perhaps the first couple of years of work with Michelle, my affective response was one of intense hostility, even hatred when attacked by Michelle. I could feel it in my own body when forced to restrain her; the tension in my muscles as I struggled to prevent physical injury and to hold on to some space for thought. I have rarely had to bear such intensity of negative feeling in my work with adults. It seems more likely to manifest in raw form when treating a child who is in a disturbed state and/or is physically threatening. I imagine that analysts who work with violent adults may experience a similar intensity of feelings in their countertransference. For Michelle in this session the meaning of my going away aroused unbearable feelings. This first holiday break provoked the separation anxiety that had been described at referral. One of the problems of the intensity of the response provoked in me as this session proceeded was that it put under severe pressure the need for me to survive her intrusive aggressive attacks. I think that this was her attempt to see just that: would I be provoked into retaliation or could I survive? Her separation anxiety reflected the fundamental issue as to whether indeed she could survive outside the intense ambivalence of her relationship with her maternal object and perhaps reflected that archaic imprint of her original separation from her birth mother; physical separateness invoked the fear of psychic disintegration. The fragments of jigsaw and her subsequent behaviour conveyed a sense of her feeling in danger and the necessity for safety. My sense of being literally intruded upon and

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then in danger reflected the way she was pushing into me her experiences of the unbearable. From a Winnicottian perspective (Winnicott 1971), her attacks upon me can be understood as her attempts to create separateness that could be survived. They contained a search for a response from me that might help her discover where she ended and I began, so to speak. I was sorely tried as my own defensive aggression was stirred up in the countertransference and threatened to confirm her belief that to separate (and indeed to be together) was a disaster. What she sought was my non-retaliation which would enable her to put me, and find me outside her omnipotent control, thus demarcating the boundary between self and other, a necessary requisite for independent psychic life and psychic survival. With a child the nature of the ‘destructive’ attack understood in this way is more likely to be at this level of the body; the regression implied, or indeed the enactment of a state which developmentally has never been adequately established would be connected to the more infantile use of the body as a conduit for affects that are not adequately mentalised. These issues raise the question also of the meaning of the rule of abstinence, avoiding gratification to the analysand with the purpose of heightening the underlying conflicts giving rise to pathology so that they can be addressed in the ‘here and now’ of the analytic situation in an alive and immediate way. Most child analysts at least to some degree enter into the play with the child. Inevitably this involves quite a different scene in the room, with the interplay between adult analyst and child patient often engaged in action, movement, physical contact, which can be infused with effects of a variety of qualities and intensity. This is very different from the scene of adult psychoanalysis with the couch, chair, no physical activity just words and silence, albeit laden with phantasy and affect of varying intensity. With more disturbed children or at times as I have described when feelings are overwhelming, the analyst may be subjected to barrages of assault, physical and verbal, sometimes mediated in the play and at other times aimed directly at their person. The child may find it intolerable to stay in the room, may run out or insist that they need the toilet or wish to return to the waiting room and the parent. The role of the analyst’s verbalisations in this scenario can seem quite different from an adult setting, as the child may ask, demand or otherwise engage the analyst in attempts to gratify impulses that are peremptory and immediate. The task of holding and containing becomes a complex matter, sometimes not just articulating the impulse or conflict or anxiety that is driving the behaviour, but also actively setting limits to prevent the child hurting or damaging themselves, the analyst and the physical setting of the treatment. In more extreme circumstances this can also include bringing the session to an end in order to ensure safety. Indeed, with some children it can seem at these times, that putting mental states into words only exacerbates the situation. The analyst has to wait until the child has been helped to calm in other ways before an interpretive mode can be used and words used effectively to understand what has been going on (Winnicott 1947).

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Analyst as new developmental object Following this idea that Michelle was also seeking a response from her analyst that would promote her psychic development is reflective of a particular view of our work which recognises this as part and parcel of our human condition: the underlying seeking after psychic growth and the developmental process. This perhaps is a feature of the Independent tradition but also of the Anna Freudian tradition as well. An aspect of work with children (perhaps we could say with adults too?) is the role of the maturational, developmental process that constitutes a ‘pull’ that can be harnessed in the service of the psychoanalytic process. Indeed, the aim of restoring the child to the path of normal development was central to Anna Freud’s conceptualisation of the analytic process and reflected her profoundly developmental approach to the whole enterprise. It underlines a particular view that ‘normality’ is inextricably linked to the ongoing epigenetic unfolding of the developmental process that in pathology is ruptured or otherwise deviated from. Thus, analytic success is seen as the healing of this rupture or the restoring of the child’s development from a deviant path. Within this tradition the notion of the analyst as a new developmental object as well as a transference figure has been conceptualised. This has been an aspect of the Anna Freudian tradition of child psychoanalysis but has been extended to be included in the understanding of adult psychoanalysis also (Hurry 1998). As well as recognising and working with the transference repetition in the treatment, the analyst also disrupts the transference expectations, thus challenging the patient to experience and consider something unexpected and new through the analytic relationship. In this conceptualisation the analyst does not set out to be different from the transference object, but it is in the nature of the work that the analytic function provides a new object experience and the patient’s psychic development is promoted and enhanced. From the Independent tradition of child psychotherapy, the so-called present relationship is described by Monica Lanyado (Lanyado 2004) as operating alongside transference aspects and contributes powerfully to the ongoing therapeutic process. This is not a style of work that seeks to give the analysand a ‘corrective emotional experience’. More, that it recognises that if psychoanalysis is a treatment based on the relationship between analyst and patient, then an endless repetition in the transference has to be disrupted in order for change to occur. Thus, with Michelle we could say that my awareness of and internal work with the hatred prompted in me by her behaviour, my struggles not to give way to an enactive retaliation involving fighting (a transference-countertransference enactment) also helped disrupt the transference expectation, challenging Michelle’s internal self-object relational representations, a stepping stone towards change. However, within this model of child analysis, the analyst as a new developmental object may well do things that actively promote the child’s psychic development. For instance, the verbalisation of affects, their naming, description of their quality, intensity, object, etc. may be an entirely new experience for a child (and indeed it may also be for an adult). Inevitably this is an imprecise process where often the analyst has to intuit the subtlety of the child’s emotional states which are defended

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against, distorted, etc. and presumably will quite often get it wrong. However, the child will have an experience of an other who seeks to recognise their inner states and give words to them. Paradoxically, if we take Winnicott’s differentiation of psyche and mind, the first being the imaginative elaboration of the somatic and the mind arising in the inevitable and necessary gaps in the mother’s adaptive holding, we can perhaps see how the child’s experience of being held by the analyst’s understanding, expressed in words, can give rise to a more stable mental structure within which representations of a variety of affects leads to increases in their tolerance and use in the mind and psyche (thought and imagination). For some children their difficulties will be understood not in terms of the expression of psychic conflict but psychic deficit. In these cases, the ruptures to development have radically interfered with the construction of the mental apparatus such that the possibility of intrapsychic conflict has not yet been achieved. A psychoanalytic aim then would be focused on the development of these capacities. Vignette 3 In a Thursday session towards the end of the first year of treatment, Michelle was continuing a game using the families of the wild animals. In this story the family was breaking up because the father had decided to divorce his wife. He was a violent father. The baby in the family was to be taken away from the family because now the mother was a single mother and a judge decreed that she could not look after her. She created an elaborate narrative of the mother frantically trying to keep this baby by secreting her away so nobody could find her. The mother was the object of attack from several quarters including the father and other wild animals. I talked about how everyone seemed to be very angry with the mother especially the father and wanted to hurt her whilst the mother was desperate to keep her baby. She made the elephants smash the mother against the wall but then the game started to unravel as Michelle then became quite provocative directly towards me, threatening to throw an ornament at me from the bookcase. Because the work had now moved away from the displacement probably as a result of Michelle’s agitation disrupting her capacity to play, I decided to interpret directly what was happening and said that it seemed I was like the mummy, and she wanted to attack me for not providing her with a Daddy who would stay. She immediately said that she did have a Daddy, that he was a secret Daddy, only she and her Mum knew about him, and he lived somewhere else. After some more potentially violent behaviour she transformed what was happening into a ‘show’, singing a song she had sung before, repeating the words ‘when it seems all your hopes and dreams are a million miles away, I will be there for you’. I silently listened to her and after she had ended said that she wanted me to be here for her no matter what she did. She allowed this without further comment, and the affect in the room was calm.

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This plea for unconditional love from a joint paternal/maternal figure was very raw, and close to Michelle’s feeling that her adoption had not provided her with this. It seemed she was seeking an experience in the analysis that she felt was lost when her fantasied family of origin had broken up. Perhaps she was also showing in the play that the analytic baby so under threat was protected in the analysis. I wonder now if the secret daddy was me in the transference whom she could appeal to in her song to be there for her. The transformation of the volatile enactment in the session into the singing play which gave expression to her longings followed the verbalised interpretation of the transference and reflects the greater use Michelle was able to make of my interventions by this point in the work. It also reflects her creativity and unselfconsciousness in drawing upon her different capacities to let me know about herself. This I think is what can be so special about work with children: what adult could burst into song in this way to express something that probably couldn’t so easily be said directly. At this point I would like to make reference to the issue of the role of insight in the analytic process, whether and to what extent it is seen as a goal of treatment with children and indeed the extent to which this is a central feature of all analytic work. The Process of Change Study Group (Journal of Infant Mental Health 1998) examined the ‘something more than insight’ that figures in the analytic process and which they saw as constitutive of the elements that give rise to psychic change. They highlighted the elements of the unfolding relationship between analyst and patient, observing the way in which any session would have its ‘going along’ movement which would be punctuated by ‘moments of meeting’, when something would happen between the participants, analyst and analysand, which would move the process on in a different way, now containing a new way in which these two people could be together. These aspects of the process reflect the dynamic tension between different psychic agencies and also the interpersonal nature of the analytic enterprise. The ‘going along’, the minutiae of interaction between the analyst and patient constitutes the unfolding and elaboration of the child’s inner world, catalysed by the kind of analytic listening and responses that the analyst provides. In this session Michelle’s song could be said to constitute ‘a moment of meeting’ that transforms the connection between patient and analyst in their ‘going along’ in the treatment. Vignette 4 Towards the end of the second year of treatment, the content of her play began to change reflecting Michelle’s move towards puberty and adolescence. She had a relatively early puberty, her periods starting around her 11th birthday. She was unpredictable in her responses to the comments I made, though she was very interested in the way I participated in her creation of narratives. Her stories which had always involved families now were more focused on the adolescent children and what they got up to. Invariably they

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were stories now of romantic or sexual interest, how girls and boys ‘got off’ with each other. They revealed thoughts about rivalry and jealousy between partners and expectations of unfaithfulness and lack of loyalty. There was also cruelty and sadism in the way these characters treated each other with little evidence of hope and love. Towards the end of one session, Michelle used the doll and animal figures to play out a scenario where boys and girls linked up together with a quality of secrecy and unpredictability, spreading rumours about characters being dumped without warning and teaming up with others. A rumour spread around that two characters of a cat and a turtle had slept together and the girl cat was pregnant, only 15 years old. The turtle was the boy and in the play they were together as a family for a year, apparently happily. Then suddenly after a year a man came and took the child away as there was a rule that nobody under the age of 20 years could be parents. The child was a boy named John, and he was sent to live with another family. His parents tried to find him and managed to do so as he was having his fifth birthday. At first, he did not recognise them but then he did but said to his ‘step parents’ that he loved them because he had been with them longer. Then the birth parents were very sad. and John wanted to go with them. It was the end of the session, and I said to Michelle that she was telling me her thoughts about growing up and being a young woman who might have a baby, but also about who she imagined had been her birth parents and why she had been separated from them. She looked at me directly but said nothing. The following day she returned but was in retreat from this poignant material. She brought with her a set of Pokemon cards, and we spent a long boring time playing them, ordering, categorising and sorting them. I said to her that in the session the day before things were not so safely ordered, which prompted her to leave the room to go to the toilet. Later as the card play was repeated, I said indeed yesterday was much more messy than today, with the 15-year-old girl having a baby but later losing him. I further said that I had got the message that she wanted me to know that she was struggling with these ideas about where she had come from and how she came to be with her Mum. She had been talking loudly over me but at this point she stopped and looked straight at me and said, ‘I know drrrr!!’

The point I want to highlight from this material is the way the play moves on under the pressure of the developmental process. I think this is a particularly Anna Freudian perspective, which gives great significance to the power of the drives and their impact upon the mind. In this story Michelle incorporates her budding adolescent interest in sex into her fantasies about her origins, and I propose her implicit question as to whether this will also be her fate. Will she be a girl (like her

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birth mother) who loses her baby because of some arbitrary rule? She makes the baby a boy, which I see as a thinly veiled attempt at disguise. It is interesting also to think about how this might point to gender identity conflicts that are now being challenged by her move into puberty and the arrival of her adult sexual body. Her latency obsessional defences are brought to bear on these fantasies as she retreats in the following session into playing cards ordering and sorting. I feel the affect in the room as a strait jacket of boredom to constrain the potentially explosive nature of these fantasies. Conclusions There is much more that could be said about this particular child analytic treatment. My purpose has been to use this material to highlight specific aspects of analytic work with children especially from an Anna Freudian and Independent perspective. I have focused on the complexity of the relationship between internal and external reality as the child patient is brought by her mother who sees her in need of help. Harnessing the child’s wish for help and the implicit question of consent to treatment was a problem most of the time with Michelle. She was able to use her imagination to communicate in play the issues she was struggling with to herself and her analyst, but it remained difficult to some degree for her to tolerate more direct discussion and verbalisation. I understand this as being related to the fragility of her ego development, where her capacity for affect regulation through the mediation of thought was precarious. This is at the level of mental process, but at the level of content I also see it as connected to a profound and continuing loyalty conflict: if she was to give herself over to her analysis too wholeheartedly, she risked betraying the mother who had adopted her, which perhaps in the transference reflected her loyalty conflict between her birth mother and adopted mother. This dynamic tension between process and content is part and parcel of all analytic work but perhaps has a particular valency in child analysis as the development of mind and psyche is still ongoing and analytic work potentially has such an impact. I have focused on the place of play and especially the technique of the use of displacement, enabling analytic work to proceed although the child’s own direct experience may only be implied rather than spelled out. Without this technique I think I would not have been able to hold Michelle in the treatment nor would it have addressed such a wide range of her concerns. Through the process, which continued across her entry into adolescence, Michelle was able to have somewhat of a new object experience with her analyst as well as transference work which was not always working ‘in’ but with the transference in mind. Note 1 A version of this chapter was published in the Psychoanalytic Study of the Child, PSC 2011 65: 132–168.

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References Ferro, A. (1999) The Bi-Personal Field. London: New Library of Psychoanalysis, BrunnerRoutledge. Hurry, A. (Ed.). (1998) Psychoanalysis and Developmental Therapy. London: Karnac Books. Special Edition Journal of Infant Mental Health (1998). Lanyado, M. (2004) The Presence of the Therapist: Treating Childhood Trauma. Hove and New York: Brunner-Routledge. Mayes, L., & Cohen, D. (1996) Children’s developing theory of mind. Journal of the American Psychoanalytic Association 44: 117–142. Novick, J., & Novick, K. (2005) Working with Parents Makes Therapy Work. Lanham, MD: Jason Aronson. Parsons, M. (2007) Raiding the inarticulate: The internal analytic setting and listening beyond countertransference. International Journal of Psychoanalysis 88(6): 1441. Phillips, A. (1988) Winnicott. London: Faber Modern Masters. Sandler, J., Kennedy, H., & Tyson, R. (1980) The Technique of Child Analysis: Discussions with Anna Freud. London: Institute of Psychoanalysis and Karnac Books. Winnicott, D.W. (1947) Hate in the Countertransference in Through Paediatrics to Psychoanalysis (1982). London: Hogarth Press. Winnicott, D.W. (1958) Psychoanalysis in the Latency Period. London: Hogarth Press. Winnicott, D.W. (1971) Playing and Reality. Harmondsworth: Pelican Penguin Books.

Chapter 11

Peter Rabbit was a thief A case with a background of violence and criminality 1 Anne Zachary

Therapy tends to take place much later in life than when the trauma at root is operative. In the acute phase the patient would not be reachable behind the mixture of violence, addictions, symptomatology and generally unstable lifestyle that might prevail. My patient Mr B who had lived a stormy teenage life of crime into his twenties, had been a reformed character for more than ten years until a year before we met. He had become a family man and a worker and was maturing as he approached age 40 years. But a crisis occurred and because he still carried a knife, when he felt his family was threatened by an unruly gang outside his house, he happened to nick the neck of one of them and received a conviction for Grievous Bodily Harm. The roots of the trauma are usually in childhood and to immediately shift the focus to a more childlike level, many people, possibly worldwide, will remember the story of Peter Rabbit from their childhood. Beatrix Potter used stories to help children to play and to develop their imagination. Beginning a chapter about crime with a children’s story might seem a little ‘soft’, but Peter will feature again later in my patient’s own story. Mr B serves to represent the modern-day perpetrators though his treatment was years ago. Like him they are often themselves victims, creating other victims in an unconscious repetition of their own trauma. The Tale of Peter Rabbit is a cautionary one (Potter 2002). Peter lives with his mother and his three sisters, Flopsy, Mopsy and Cottontail, at the edge of Mr McGregor’s garden. Like his father, Peter is a thief, prone to stealing cabbages. A gruesome moment in the story is when the reader is reminded that having been shot by Mr McGregor, Peter’s father was put into a pie by Mrs McGregor. When thought is going into providing more services in a worrying epidemic of knife crime, my case stands as a reference that the psychoanalytic model reaches these problems in society. In a previous paper (1994), I  have written about a young male arsonist. The same theoretical roots are as relevant to Mr B as they were to him. Aichhorn, the author of Wayward youth (1925) underpins the current understanding that every anti-social act is rooted in the unconscious. He sets out to prove that delinquency consists fundamentally of a state of arrested or regressed personality development. This state might remain latent or under the impact of further experiences lead to manifest delinquency. He pointed out that the symptoms and DOI: 10.4324/9781003202790-21

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the underlying fundamental problem are constantly confused, stressing that the worker should make it their sole aim to understand the psychic state of which the delinquent action is merely a symptom. Limentani (1966) said that when the environment does not understand the behaviour then the behaviour becomes worse. Winnicott (1956, 1975) believed that any anti-social behaviour could be seen as a sign of hope. He is describing the anti-social tendency in the normal child which then leads to understanding the offender. The anti-social behaviour stems from deprivation, and Winnicott says that lack of hope is the basic feature of the deprived child. It may be awkward if it is your bicycle which is stolen; but others not personally involved can see hope underlying the theft, the hope of replacing the deficit left by the original deprivation. Mervin Glasser urged all new staff at the Portman Clinic to see a variety of patients with different perversions, or expressions of violence, and at least one adolescent, but he highlighted ‘a good burglar’. If they could be engaged, they would do well. Since Mr B’s treatment took place in the National Health Service at the clinic, specific attention should be paid to the theoretical context in which we worked there. In an earlier era, Mr B could easily have been my ‘Violence Workshop’ patient though he came to the clinic some years after and hopefully benefitted from my experience in that weekly workshop. Convened by Mervin Glasser and referred to in ‘On violence: a preliminary contribution’ (Glasser 1998), each participant brought a patient with a history of violence in rotation for clinical discussion. The sessions were always typed up and the Violent Act studied in the material with the object of trying to distinguish self-preservative (primitive) violence from sado-masochistic (sophisticated) violence. This was a most complicated and difficult task and often both types of violence might be demonstrated by the same patient at different times. Don Campbell prefers to name the primitive form of violence as ‘ruthless’ (personal communication). He was central to the in-house teaching and support of the learning of new and younger staff members. He gave a most important lecture years later which consolidated his ideas about the countertransference difficulties when the response is in part physical (Introductory lecture series, Institute of Psychoanalysis, 21 March 2018). The workshop developed and used two elaborate instruments, the Portrait, (modelled on the Profile at the Anna Freud Centre) and the PIM, (the Psychodynamic Interactional Matrix). The PIM began to take on a fascinating 3D effect on the wall diagrams we constructed. All this before the days of the internet. How much further might things have been taken with that addition to our tools? [Mervin died in November 2000.] More recently there have been numerous other ‘workshops’ at the Portman in which to study patients theoretically. Just as I was leaving (2010), a series of subjects was studied within a framework known as ‘Portman Lore’. This included sexual abuse. An interesting point was made that the term ‘sexual abuse’ risks losing the important distinction between paedophilia and incest. For instance, in incest

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there is love as well as hate whilst in paedophilia, ironically given its name, there is only hate. Thank goodness for these workshops given the nature and disturbance of the patients we were treating. Working closely together provided professional support and safety as well as theoretical development. Working with these patients involves venturing into deep waters. This requires diagnosis to avoid being pushed into the split of two dimensions: punishment, or disavowal of psychosis in an infectious delusion of sanity. Incest can be seen as a last-ditch attempt to avoid psychosis (personal communication, Brian O’Neill). Mr B illustrates this very directly in some disturbing material more than halfway through his six years of twice a week treatment. (By then he could be reason‑ ably articulate and coherent having begun therapy fidgeting and not really knowing what to say.) The extract is relevant because of the close connection that can exist between violence and sexuality. Another ‘Portman’ theory, the sexualisation of aggression, is documented by Glasser in ‘Some aspects of the role of aggression in the perversions’ (Rosen 1979), a description of how sado-masochism protects the object from primitive violence. It is also important to mention in this chapter, ‘the core complex’, first described by Glasser (my capital letters): ‘. . . a deep-seated and pervasive LONGING for an intense and most intimate closeness to another person . . . a ‘merging’, a ‘state of oneness’, a ‘blissful union’. In others a normal state of loving, in the (pervert) this carries with it, ‘a permanent loss of self, a disappearance of his existence as a separate, independent individual into the object, like being drawn into a “black hole” of space’. This leads to an experience of ‘ENGULFMENT’, sets up an ‘annihilation anxiety’, leading to the reaction of ‘flight from the object, retreating to a ‘safe distance’ in a (. . . ‘narcissistic withdrawal’). The pain of ABANDONMENT ensues, and the cycle repeats itself in a never-ending dynamic economy’. This is demonstrated by the patients seen at the Portman who will characteristically miss sessions around a break or want to end treatment. I present some material before the history which follows. There is a worrying Friday session: Mr B recounted some distressing experiences in childhood. After the parents’ divorce, his mother was always in the pub, there was no food, instead maggots in the cupboards and he had to sleep with his sister who wet the bed so he would be drenched and have to go to school smelling foul. His mother would bring home a man to sleep with and others would come too. She would tell them to lie across the ends of the kids’ beds. One would climb in with him but he would fight him off. He dreaded what must have happened to his sisters. Suddenly the mood in the session changed.

My son will never have to have such awful experiences. We have given him everything he needs. My wife goes to work at night. About once a week, he climbs into bed with me. In the morning when we wake up we just have fun, play games.

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[This sent a chill right through me] Th: You will find this very hard to hear but don’t you think your son should stay in his own room? Haven’t you all moved house because he desperately needs to get out of his parents’ bedroom? [I thought he would shout or walk out] Pt: He protested at first making a distinction between the drunken men’s sexual fondling and his own loving cuddles but then the penny seemed to drop and he said, ‘I don’t want him to turn out gay. Is that what you mean?’ Th: All sorts of possibilities . . . Pt: I’m going to give it some serious thought because I am a very boundaried person. Then on Wednesday he says he will talk about his lust on Friday. (A pattern has developed out of his earlier difficulties in talking to me, where Mr B often tells me at the Wednesday session what he will talk to me about on Friday.) Friday session: He was wearing his cycling gear, a new venture [another addiction]. A big man, he lay down heavily on the couch [a small single divan conjuring up an image of a seedy boarding house, it shook precariously and I wondered often whether it might collapse]. He punched the pillow behind his head to prevent it from falling into my lap. [I can still remember the awful scar on the back of his bald head where he was mugged a year into treatment] Pt: He said, ‘I’m going to talk about my lust’. He went on to complain that as a relatively new thing he lusts after women on the street, women with big boobs . . . ‘I didn’t do it before, I shouldn’t be doing it’. Th: I try to encourage understanding why and when as opposed to shouldn’t. [In the Wednesday session he had told me he had had his first ‘bike rage’. He used to have ‘road rage’ when he carried a knife in his car. But this seemed different to me, he would be more vulnerable on a bike, perhaps the inevitable brush with a lorry. In my mind he had been ogling a woman and had not seen the lorry] Pt: It didn’t happen when I was playing poker (two years of that). Th: You call it lust but it sounds like yearning. Pt: If one of them propositioned me I’d be helpless. I’d destroy everything. [he means his marriage] People do. It happened to me and X (he names his wife). I was sexually abused, and she was violently abused. Th: I tried the idea of yearning again linking it to his childhood, lack of love, food.

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Pt: What have breasts got to do with food? (Unconscious, one of many such faux pas he comes out with.) I’m talking about sexual attraction, the poker, the lust, they are stimulants for life. Th: I say I think it links to what he didn’t get from his mother, what he doesn’t get from me, and I’ve cancelled next Wednesday’s session. (He knows this from a previous announcement.)   He changed the subject. ‘My daughter’s come home’. (She wants to join the Army and is studying at her maternal grandmother’s.) ‘She’s very loud’. If she wants to use the toilet and her sister is in the bath she goes, ‘bang, bang, bang’, on the door. I’ll be glad when she’s gone back. Isn’t that a terrible thing to say? Th: To lust after women in the street is safer than lusting after me or the women in your house. Pt: But I would never lust after my daughters. [I think of the recent and similar conversation we have had about his son. The boy, now eight, seeks out his parents’ bed and they have created a little bed of his own at the bottom of theirs.] Th: Like you would never abuse your own son. But you know those things happen, happened in both yours and your wife’s families. No thought, just action. I repeated, ‘The women in the street are a safer option’. Pt: ‘I’ll have to mull that over’. [Courageous and unusually generous of him, I thought] This material when discussed at the Friday meeting perhaps contributed to the later ‘Portman Lore’ focus on ‘Sexual Abuse’. At the time it was also felt that the two sessions were being sexualised into two big boobs. Mr B erotizes the trauma earlier in his life to produce this technicolour material. But here is the history and background to give the material some more context. Mr B After a hesitant start during assessment and some once a week work, Mr B settled into intensive (NHS) treatment, twice a week. He was a family man in his thirties. He had married his childhood sweetheart and they had several children. He had his own business as a painter and decorator and preferred to work alone. His wife worked as a nursing assistant, and he had had some experience of this work himself. He was referred by his probation officer having received a conviction and community sentence for Grievous Bodily Harm. His youngest child, a son, had been newborn when a gang of young people was harassing the neighbourhood, smoking and taking drugs, having sex in cars, making a lot of noise. The family had to run the gauntlet of this gang on their stairwell every time they tried to go in and out of their upstairs flat. Eventually Mr B could contain himself no longer and

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threatened one of the gang with a knife that he always carried. It nicked the boy’s neck. At the time of his new offence, he had been studying to become a mental health worker. The conviction brought to light his previous criminal history from many years before which he had not declared to his college. As a teenager he had become involved with his father’s ‘gang’ of professional criminals. They regularly burgled houses, often armed and on one occasion he himself was armed, caught and sent to prison where he spent four years. He was 17 years old and so he was in a young offenders’ institution. He spent his 18th birthday in a van being transferred to an adult prison. It had been a most traumatic and unspeakably painful time of his life. Because he had not declared all this when beginning his studies, this prevented him from continuing. He had had to go back to decorating, and he felt that his new and more positive prospects in life had collapsed. His early life and criminal career made up much of the content of his therapy as he worked through the trauma of his childhood. But to set the scene, he told me that on leaving prison at age 21 years, he had returned to his career as a professional criminal until he was 26 years old. He had married his wife who had waited for him while he was in prison and by then they had a family. He wanted to give them a better start. He discovered religion, studying on the Alpha course,2 and he was befriended by the local church women. He made a commitment to ‘going straight’ and became a reformed character. By the time he came into treatment he had become disillusioned with the church and felt intruded upon by the women. He thought I was going to be another one of ‘them’. But having a childhood sweetheart, that relationship having developed into marriage, he could make a relationship with me. We began once a week. Mr B had an awkward manner, felt embarrassed alone in a room with a woman, found it very difficult to sit still for 50 minutes and quickly ran out of things to say. He would bring water and drink it at intervals. When it was gone, he would prepare to leave as if he had nothing else to do. But gradually he settled down and told me that he remembered enjoying visits to an older woman for tea when he was young. It had been formal and pleasant, proper tea cups and saucers and cake. They would have discussions, and he learnt some manners. This memory seemed to enable him to converse more easily with me, and he showed himself to be quite articulate. That was all we had, there would be no tea and cake. He was desperate to belong to that woman’s/my world. He wanted to leave his own deprived childhood behind, give his children something better in life. He spent the first year at pains to impress upon me how well he had done and how ideal their family life was. Picnics in the park, games, helping with their schoolwork, those children were to have everything they could wish for. The fact that they were still living in the cramped and unsuitable flat, that he had ruined his professional chances, that he was not a happy man were all things he preferred me not to touch upon. I felt the pressure of his resistance. He had an addictive personality and struggled relentlessly to overcome his weaknesses for, at different times: alcohol, cannabis, prescription analgesia and anti-depressants; collecting ‘antiques’; and later on in treatment and a very

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difficult problem, gambling in the form of television poker. There was always something. If it wasn’t overeating, then it was over-exercise. At the end of the first year, having not drunk alcohol for ages he went to a party, got drunk and was mugged by a gang on his way home. He arrived for his session prior to the first summer break with a huge scar, recently stitched, across the back of his bald head. It looked sinister, reflected his vulnerability. I came to understand it as a violent act towards me, for offering this space which was often so painful, a mad thing to do? On return in the autumn, he moved to the couch. This resulted in an immediate lowering of mood, and I felt some concern. We began to meet twice a week, and he seemed more contained. During the second year a new preoccupation arose which moved us on a little from the over-positive view he liked to hold about his family life. The next generation, his own children and his nephews and nieces, were becoming teenagers. The cousins and their friends were acting out and getting into trouble, and Mr B felt that he could intervene and protect them. In his overzealous and heavy-handed manner, he succeeded in ‘wasting police time’ and was almost charged again. But this was the nearest he came to getting into further trouble during treatment. In keeping with his ideal he took his family on their first holiday abroad during the second summer break. He didn’t enjoy it at all, it was too hot, bottles of cola ‘cost the Earth’. He was pleased to be back. Jumping on to the little couch which shook precariously as usual, he would get up and try to rearrange the curtains, paranoid about the people across the street seeing in. It was so lively and ‘bedroomy’ I  managed to get the curtains exchanged for a blind, but he forever berated the shoddy workmanship that left the old curtain brackets in place. I had to consider what I was being ‘blind’ to, perhaps an increasing level of paranoid ideation and risk of psychosis? Meanwhile I  was busy trying to contain his ‘larger than life’ character. He dressed skimpily in sports attire, tattoos easily visible, swearing and gesticulating as he tried to put his pain into words. Gradually he opened up about his family of origin. The youngest of several children himself, until he was eight years old it had been a reasonably stable family. But his parents separated then and the first he knew of it was when he was summoned to the headmaster’s office and given sweets because his mother had arrived at the school to change their life with news of a divorce. She took him away in a taxi to a new home where they lived with his siblings. Everything changed. He went to a new school, fended for himself on the street and at home, lived in filth and deprivation whilst his mother spent all her time at the pub and brought home drunks, some of whom abused him. He would occasionally go to his father’s house where the conditions were better, but his father was a professional criminal and from an early age he was involved in violent and sinister operations. An acquaintance of his father then seriously sexually abused him when he was 11 years old. He tried to avoid visits but as he grew would be co-opted into criminal pursuits as part of the ‘gang’. After being caught and imprisoned at age 17 years, he broke contact with his father but had just been reconciled with him before the start of treatment.

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His father was dying. His death must have contributed to his commitment to the therapy. Left with only his mother’s unsatisfactory place, as a very young adolescent he would scavenge in the bins outside the food shops after closing time to get enough to eat and began thieving and ‘Taking and Driving Away’ with his friends. My heartstrings would be stretched when he described a particular shop, one I could picture from my own memories. About the most painful story he told me was of stealing a car, crashing it into a wall when pursued by police, jumping over a wall to get away but then having to manage without hospital attention until his wounds healed. It must have been too easy to hide these from his neglectful and drunken mother. Another more indirect story but equally sad was about the only time he took on a colleague to help with a painting and decorating job. It was a young apprentice, as deprived and underprivileged as he had been, who was addicted to drugs and one day, died overnight from an overdose so did not turn up for work next day. It was as if he could only bear to employ someone worse off than himself. There were also more positive memories. He would sometimes meet his male teacher in the street and be taken to a café for a big breakfast. It is hard to imagine that being possible these days, the safeguarding boundaries around potential paedophilia being so stringent. It probably helped to save Mr B’s life. Meanwhile, his family was growing up, becoming teenagers and Mr B was very involved in their world. One day, a boy bit one of their friends outside school. Mr B was incensed, jumped into the car with his daughter, collected her friend, drove around to the boy’s house and banged on the door. The girls would probably not have known about the hammer he put in his car before the event. Or about the knife he had always carried in the car until he told me about it nine months earlier but then he put back on this occasion. The boy came to the door but before Mr B could reprimand him, he noticed the boy’s mother behind him, drunk like his own mother and cowering. He was disgusted. He gave the boy verbal abuse only and left. After that he gave up carrying the knife at all. I think of the knife as a transitional object (Winnicott, 1953).3 The middle years of treatment were stormy and bleak. He became very disturbed and depressed. His capacity to speak normally was seriously affected and for whole sessions he would just swear at me. He couldn’t bear his envy of what he saw as my world, of my education and profession. He would criticise me mockingly for not being able to do more when I was paid so much, knew so much. He eventually had to give up his own work, too envious of the good job his clients were getting from him in their big houses while he struggled on in his overcrowded flat. Halfway through treatment, this represented a painful yet therapeutic breakdown. The swearing centred around the c*** word, unmistakably feminine, most certainly a diatribe unconsciously intentioned for his own mother. He had taken on some contract work at night, trying to save enough money to move house. Even this involved temptation. He found himself becoming attracted to a cleaner and to preserve his marriage he left the job. There were various older women who came into his life during treatment. He had feelings for a woman at the

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gym, so he gave up his exercise regime. He would occasionally go to the pub, but if a woman caught his eye he would leave and become teetotal again for months. If I tried to interpret these women as representations of myself, he would become either slightly mocking or overly polite as his way of rejecting my attempts to make sense of things. When I tried the other tack and likened myself to his neglectful and ‘drunken’ mother, he would veto this too saying that no one could be as bad as that as if I just didn’t understand. In fact, my impression throughout the whole of our time together was that he never once accepted outright anything I said, but as time went on this seemed after all not to be true in that things shifted and he came out of his breakdown having to a certain extent, addressed and worked through the trauma. I think the material described earlier illustrates this process. The transference could be quite positive but when he resisted interpretation, intensely negative. Again, I felt the strength of his marital relationship held him in therapy with me. A central focus of this trauma was on his time in prison. He was bullied and fought back, becoming totally unmanageable. He was caged in solitary confinement for weeks on end. He received no mail only to find out later that a prison officer had cruelly hoarded it. How the ‘system’ repeats the trauma, a sado-masochistic solution. A time that I am left knowing virtually nothing about is of his return to professional criminality for five years after his release from prison. He did trust me enough to talk about witnessing a death in a street fight once when he was abroad somewhere, but he said he had not himself killed anyone. This was a useful and constructive moment in terms of my statutory responsibilities. Things began to recover when at Christmas in the fourth year he managed with the help of his GP and case manager at the Portman to get his family rehoused to a larger flat. He decorated it and took up painting as art. He had to recycle much of his collection of ‘antiques’ in the process of moving, and as it was Christmas he brought me a present. It was a large ceramic figure of Peter Rabbit, one that might be on display in a bookshop advertising the Beatrix Potter books. It stood about 18 inches tall, was fragile and ugly, apart from what it represented. At this stage in the treatment, it was a failed metaphor. Whereas Peter Rabbit could be mischievous, Mr B had needed food to survive. The concrete replica underlined our understanding of the story. What was I to do with this gift? I couldn’t reject it, felt profoundly moved by its significance, remembering the children’s story at the beginning of the chapter. I spoke to the senior child psychotherapist. She said, ‘But it’s hideous!’ I agreed, feeling that it summed up the feeling of the whole sad and painful treatment. The solution was to put it on a high shelf in the children’s therapy room. After all, in my room I had to consider my other patients. The treatment continued and a crisis occurred when Mr B had a confrontation with a new neighbour, a woman, over her dogs. He resisted attacking her, another illustration of his being held in therapy. Things would have settled down if the new neighbour had not by coincidence been related to the boy who had bitten the schoolfriend. Also, the neighbour, aware of this, retaliated against Mr B and set fire to his new house. He became naturally very worried and insisted on yet another

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move as an emergency. The council responded though a shared garden plot at the next address left Mr B feeling paranoid and uneasy. There was a change in the leadership of the Children’s’ Team at the clinic. The hideous statue was felt to be a risk, might topple if a disturbed child ran amok, was really my responsibility. Peter Rabbit was evicted, and I could only move him to my own room. I put him on top of the filing cabinet. Mr B noticed him and said jauntily, ‘Oh, I see he’s back’. This led to an examination of the relevance of Peter Rabbit, himself fatherless yet like his own father, a criminal in his own right; who himself also stole food from Mr McGregor; who was aware of his father’s violent end, caught and shot by Mr McGregor and put in a pie by Mrs McGregor. For the first time Mr B seemed to see some sense in what I said. He offered to ‘take him home soon’. This led to the final phase of treatment in which Mr B began to ‘steal’ regularly from the clinic in the form of regular series of missed sessions. (He had always missed the odd session[s] around breaks in core complex fashion.) Perhaps it was time to end, but when I  raised this it made him very anxious. Peter Rabbit was central to the planning. First of all, during what would be the last summer break the room had been redecorated and when I  returned, to my dismay I  found that the rabbit’s ears had been broken off. Had he been knocked off the filing cabinet accidently? Had he been attacked? I quickly repaired the ears with superglue. Very aware of the underhandedness of this action, as I thought about it, it occurred to me also that perhaps the ears had been weakened by having been broken and repaired before, that I might have received damaged goods in the first place. It occurs to me now in my somewhat guarded writing that as a therapist of a criminal one listens with adapted ears, not those of the police or the law. But when Mr B said that he might take Peter Rabbit home soon, I felt that I had to tell him about the repair. He took it in his stride, still believing that no one could match his own parenting skills and instead he talked about ‘disposal’. He offered to relieve me of the task, and we had to do a certain amount of work on his darker side when he suggested ideas such as leaving him on the wall of the clinic for passing children to play with. I had the thought of the poor rabbit being kicked into a thousand pieces by youths or dropped by an unsuspecting child causing disappointment. But then he became more emotional and said that the best place for the rabbit was in the overgrown garden at the back of the clinic, after all it was where he belonged, in a garden. By now planning my own leaving, a few months after his, I must have had an investment in this idea, a memento to us both. But on discussion with colleagues, it was clear the rabbit had to leave. Somehow, in the unconscious way that institutions work, Mr B reacted to the discussion and took the rabbit away after the very next session. Pt: I think I’ll take him home today. But there are no charity shops open on the way, perhaps not today. Th: You need to take him home, away from the clinic, in order to be able to leave fully yourself. You can’t leave part of yourself here, the criminal part. You feel abandoned like Peter Rabbit.

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  He laughed. ‘Why are we spending so much time talking about such a silly thing? A statue of Peter Rabbit!’

He switched into what I saw as his religious defence though he wouldn’t hear of it. This is a return to the beginning of treatment when he had thought religion was the answer. Pt: ‘How lucky I am to have found God. How wrong it was to think of leaving Peter Rabbit in the clinic garden as a reminder to the clinic of me, a sin of idolatry. As if I am God’. I try to shift the focus back to his need to feel remembered as a human being but he continues the religious theme. With gratitude he considers my contribution: Pt: You have given up your life to people like me. A: You feel like God and you make me sound like Jesus. [How to acknowledge his gratitude? I know it has saved his life again having this treatment but he is so fragile, he might just laugh.] At the end of the session, he went over to the filing cabinet, picked up the rabbit, tested his ears and asked if he could take one of my empty boxes. (They were there ready for my own packing, something we had already discussed.) He left with the statue under his arm. Later, the receptionist said that he had stopped to write something on the box. At the next session he told me that he had written, ‘Please take me home’ and left the box at the bus stop outside the clinic. Of course, Mr B was about to lose the home he had found in the clinic (Kennedy 2014). This involvement of a third party, a replica of Peter Rabbit the thief, in the content of the sessions struck me as being rather like child therapy using toys. It had been introduced by the patient, at first not made use of, but then unwittingly this was stimulated by the Child Team and their boundaries. The experiences of the rabbit whilst in the clinic, being thrown out of the children’s room, being unprotected by me so that his ears got broken, until he was left at the mercy of some passing schoolmaster to take pity on him at the bus stop, mirrored his own experiences in life but in a lighter form. He had had half his childhood stolen from him in the parents’ separation, been neglected by his mother and then broken up in prison. At least the bus stop was off the clinic premises and some sort of boundary towards a more appropriate, that awful word again, ‘Disposal’. It made space for some kind of final journey. Why would a burglar make a good patient? I think because if you can engage them, as Glasser said, they do well. Mr  B needed careful and delicate work to achieve this. In Winnicott’s way of thinking (1956, 1975), there is great hope. The straightforward formulation is that they break in and steal because they have been broken into and been stolen from themselves in life. The unconscious wish is to

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violate the mother’s body in the house that is burgled, the person who is robbed. This is clear in Mr B’s story. The meaning of a weapon is important. Possession might boost confidence and self- esteem, allay anxiety, instill a feeling of power. Careful assessment of an individual’s relationship to a particular weapon will help determine the nature of any actual violence. Mr B was protecting his family when he injured the youth by nicking his neck with the knife he carried. Was it a sado-masochistic act? Was it a punitive act to teach him a lesson? It is possible that it was purely a ruthless, self-preservative act. The violence workshop would have assessed the Portrait and applied the PIM to try to clarify the nature of the violence further. At the end of treatment Mr B no longer resented the privileged classes so much, he was doing quite well himself. He had managed to get involved in voluntary mental health work with men’s groups, wanting to help them avoid some of the pitfalls of his own life. The work with him though painful and difficult much of the time was also very rewarding and enjoyable. His playfulness within the boundaries of the setting which he and I could trust was something I grew to value. By the time he left he had turned 40 and seemed, certainly wanted to be, a solid and balanced, articulate family man, some of the traumata of his past hopefully laid to rest. Mr B who was in treatment represents all the other patients who came for assessment, court reports or treatment over the years. Without exception there is always a connection to be made between the index offence they have committed or broken boundary they have created and the life story they tell. Inevitably the story is sad, often tragic, and one wonders why no one saw the index offence coming, offered help which might have prevented it. On the other hand, whether my patient would have accepted help then or responded to it is another question, in fact there is evidence that he pushed it away. What is important is that in a hopeful way, criminal charges, conviction, can become an opportunity for change. The prominence of Peter Rabbit in Mr B’s story illustrates that in therapy it is the damaged child in the violent, offending adult that is the issue and that working through the trauma of that damage happens very much on a childlike level. Freedom is also important so that it is best if any Treatment Order is held outside the clinic.4 Mr  B progressed during treatment from an inarticulate, rough-edged man to being more thoughtful and more mature with positive direction in life. Thanks to him, years later I took a patient with a similar history into private psychoanalytic treatment, pleased to be able to use again, hard earned skills. Mr C had not had the setback of a new offence after ‘going straight’ for many years and had progressed quite far in his endeavour to work in the field.5 He was in some ways much more sophisticated than Mr B. He told me that when committing offences he dressed in crocodile shoes and clothes made of cashmere, while Mr B would have worn his familiar sports attire and trainers. But inevitably there were many likenesses not only in the history, with a violent and deprived childhood and a lost adolescence with addictions, crimes and imprisonment, but in the treatment (five times a week) as well, with the swearing, a visceral sense of the physical in the countertransference and the same need to assess risk regularly. Mr B and Mr C could be more

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honest with themselves than many other patients in my experience as illustrated by Mr B’s material. They had come from one extreme to the other. Acknowledgements My thanks to Brian O’Neill, then chair of the Institute scientific committee, to James Rose, current series editor of Psychoanalytic Ideas who suggested this book and to Don Campbell for his ongoing encouragement and support. Notes 1 A version of this chapter was read at the Scientific meeting of the British Psychoanalytical Society on 19 February 2020. 2 The Alpha course is offered by the Church of England to discuss life’s big questions and encounter Jesus. 3 Winnicott’s theory of the baby’s teddy bear acting as a stepping stone to separation from the mother. It allows a space to develop psychically. 4 The court may impose a Treatment Order which if it breaks down means the patient will be called back to court. Since psychoanalytically based treatment requires the patient’s own freedom of choice about attendance, the classical arrangement is for the Treatment Order to be held outside the clinic by the probation officer. 5 I am not recommending this, but it can be inevitable.

References Aichhorn A. (1925) Wayward youth. New York: Viking, 1935. Glasser M. (1979) Some aspects of the role of aggression in the perversions. In: Sexual deviation. Ed: Rosen I. Oxford: Oxford University Press, pp. 278–305. Glasser M. (1998) On violence: A  preliminary communication. International Journal of Psychoanalysis 79, 887–902. Kennedy R. (2014) The psychic home: Psychoanalysis, consciousness and the human soul. London: Karnac Books. Limentani A. (1966) On acting out and working through. International Journal of Psychoanalysis 47, 274–282. Potter B. (2002) The tale of Peter Rabbit. London: Penguin Books, Warne & Co, 1902. Winnicott D. (1953) Transitional objects and transitional phenomena: A study of the first not-me possession. International Journal of Psychoanalysis 34, 89–97. Winnicott D. (1956) The anti-social tendency. In: Through paediatrics to psychoanalysis. London: Hogarth Press, 1975. Zachary A. (1994) The meaning of the delinquent act: A link between asthma and arson. Psychoanalytic Psychotherapy 8, 77–86.

Index

Note: Please note that page numbers in italics indicate illustrations. Abraham, K. 95, 100 Abraham, N. 96 affect: affect regulation in child analysis 177; and Alzheimer’s disease 142; in autistic adults 50, Aichhorn, A. 189 Alanen, Yrjö 105 Allen, Kate 154 Alzheimer’s disease (AD) 134 – 135; and art 142 – 143, 143; see also dementia Amnesty International 154 Anna Freudian perspectives 176, 178, 183, 187 anosognosia 135 antisocial personality disorder 14 Anton’s syndrome 135 – 136 aphasia 135, 136 arrested development 96, 100 – 101, 189 Asperger’s syndrome 36, 37, 47, 48 – 49; see also autism attachment: anxious 119, 125 – 126; in autistic patients 49; lack of 52, 132; and transference relationships 169 – 170 autism: analysis of Rhode’s clinical case 29 – 35; autism spectrum disorder (ASD) 48, 49; emotional life 29 – 31; ideational apraxia 34 – 35; language/speech 32 – 33, 41 – 43; pre-autistic toddler learning to walk 36 – 45; projection, capacity for 34; psychoanalytic treatment of adults 47 – 62; symbolic play 33 – 35, 41 – 43; theory of mind 49 – 50

Balfour, Andrew 140 Balzac, Honoré de 151 Basch, M. 166, 170 Bell, D. 121 Bettelheim, B. 47 Bick, E. 36 Bion, Wilfred R. 13, 14, 44, 72 – 73, 111, 125, 170, 178 Bionian theory 49 bipolar mood swings 51, 52 “blamers” label 105 Blass, R. 166 Blumenthal, Stephen 1 – 2, 159, 161 – 171 body movements, normal 93 Bollas, C. 86 borderline personality disorder 14 Bourgeois, Louise 80 – 81, 81, 82 breasts, symbolism of 59, 71, 193 Breuer, Anna O. xi Breuer, J. xi, 85, 98 British Object Relations theory 49 Britton, R. 14, 166 – 167 burnout 2 Campbell, Don 190 Charcot, Jean-Martin 99 children: parent-infant psychotherapy 39; and psychoanalytic process 173 – 187 clinical engagement in NHS (National Health Service) settings 11 – 15; see also Francis Report (2013) cognitive behavioural therapy (CBT) 3, 38 – 39

Index 203 concrete thinking 13 – 14, 72, 128 – 129, 130; progression to fantasy modes 61 confidentiality 5 – 6 container/contained spatial model 14, 72, 131, 150 contamination, fear of 126, 132 countertransference 50, 110 – 112, 113, 163; see also transferencecountertransference relationships Covid-19 pandemic 1, 69, 151 – 155 Damasio, Antonio 36 Danon-Boileau, Laurent 29 – 35 Davenhill, Rachael 118, 137 – 155 Delafield-Butt, J. T. 36 dementia: and caregiver relationships 139 – 140, 152; during Covid-19 pandemic 151 – 155; definitions and causes 134 – 136; organic deterioration 3 – 4, 117, 139 – 140, 146; overview 117 – 118, 137 – 139; psychodynamic consultation with patient 143 – 147; psychodynamic observation in institutional setting 147 – 151; and self-awareness 140 – 142 denial 23, 50, 72, 74 – 76, 101, 135, 166 depressive position/states 13, 70 – 71, 77 – 78 detachment, emotional 127 – 128, 161 disavowal of reality 161 – 171 displacement 60 – 61, 128, 176 – 177 dissociative split in consciousness 161, 166, 167 Donnelly, S. 153 Ekstein, R. 60 endocryptic phenomena 96 episodic memory 134 – 135, 136 Evans, Marcus 1, 2, 11 – 25, 117, 119 – 133 Evans, Susan 120 Fabricius, J. 22 Faimberg, H. 79, 80 family work: case study 107 – 114; centered in family home 106 – 107; family dynamics and psychosis 105 – 114 fantasy, as mental process 61 Feindel, E. 95 Fenichel, O. 100 Ferenczi, S. 85 – 86, 94, 95, 99 – 101 Ferro, Antonino 178

fetishism 167 Francis Report (2013) 2; Marcus Evans’ response to 11 – 25 Freud, Anna 176, 178, 183; see also Anna Freudian perspectives Freud, Sigmund 151; on complex cases xiii; crystal metaphor 106 – 107; Dora’s case xi; on disavowal 161, 166, 167; Letter (52) 79; Studies on Hysteria 85, 98 – 99 Freudian technique 49 frontotemporal degeneration (FTD) 134 – 135; see also dementia gender dysphoria 119 – 121 gender identity 117; transgender persons 119 – 133 Gergely, G. 42 Gilmore, K. J. 48 Glasser, Mervin 190, 191, 199 Green, André 96 Greenspan, S. I. 36 Groarke, Steven 77 Gubrich-Simitis, I. 93 Guignard, F. 69 Gyler, Louise 1, 69 – 81 Haag, Geneviève 37 Halton, William 20 Harrison, A. M. 61 Hinshelwood, Bob xii-xv, 2, 4 homosexuality 87, 90, 92, 93, 96 Houzel, Didier 39 hysteria 85 – 97, 98 – 101 ideational apraxia 34 – 35 identity, loss of, with dementia 139 – 140 incest 190 – 191 Independent perspectives 178, 183, 187 infantile psychic trauma 69 – 81 infant-maternal relationships see maternal relationships insight, role of in analytic process 60, 130, 185 internal market (National Health Service) 17 – 20 Joseph, Betty 4, 123 Joyce, Angela 2, 159 – 160, 173 – 187 Kitwood, T. 139, 146 Klauber, T. 48

204 Index Klein, Melanie 12 – 13, 37, 70, 95, 100, 150, 178 Klein, Sydney 40 Kleinian theory 49 lability, emotional 50, 51 – 52, 54 Laing, R. 105 language/speech in autistic children 32 – 33, 41 – 43 Lanyado, Monica 183 Laplanche, J. 73 Lawrence, Stephen 6 Lechevalier, B. 44 Lemma, A. 130 – 131 Lewy Body dementia (DLB) 134 – 135; see also dementia Lidz, Ted 105 Limentani, A. 126, 190 Loden, Susan 98 – 101 Lyth, Menzies 15 – 16, 20, 21, 24 MacDougall, Joyce 159 Mahler, Margaret 100, 101 Maisey, Michael 6 Malcolm, Janet xii Martindale, Brian 3, 105 – 114 maternal relationships 12 – 13, 71 – 81; hysteria and mourning 86, 90 – 94 McDougall, Joyce 2 – 3 Meersand, P. 48 Meigne, Henry 95 Meltzer, D. 37 memory 78 – 80; arrested 96; episodic 134 – 135, 136; loss of 134 – 135; re-organisation of 79; semantic 136; traumatic 69 – 70, 86, 98 mentalisation: in autistic patients 49, 50, 51; displacement into play to promote 60 – 61 Minne, Carine 6, 160 mnemic activity 73, 76, 77 Money-Kyrle, R. 132, 170 Moser, Fanny 99 motor development 30, 34 – 35, 36 – 45, 87 mourning 77 – 78; and hysteria 85 – 97, 98 – 101 Nachtraglichkeit 79 names, given vs. chosen 122, 123 narcissistic equilibrium/regulation 53, 101 National Health Service (NHS): and care of dementia patients 152; internal

market, restructuring, and cuts xi, 17 – 20 Neubauer, P. 60 neurology 44; see also motor development Novick, Jack 53, 174 – 175 Novick, Kelly 53, 174 – 175 nurse-patient relationships: clinical engagement in therapeutic settings 11 – 15, 23 – 25; fragmentation of authority 16 – 17; institutional support 15; Lyth’s analysis at Kings College Hospital 15 – 16; nurse manager roles 23 – 24; and resources within NHS framework 17 – 20; training of nurses 20 – 23 nurse training 20 – 23; Project 2000 21, 22; theory contrasted with practice 22 objects: analyst as new developmental object 183 – 187; and attachment, transgender patients 125 – 126, 128; contaminated objects 132; dependence on in dementia 151 – 152; internalisation of 77; object relations 71 – 73, 95 – 96, 99 – 100; primary, and countertransference 126, 170; primary, healthy separation from 132; and anxious attachment 119; and symbolic play, autistic children 33, 37, 38; symbolisation of 13 – 14; “third object” 14 – 15, 24; wholeobject Oedipus complex 43 – 45 obsessive-compulsive disorder 51, 87 Ode à ma mère (Bourgeois) 80 – 81 Oedipal situations 14, 36, 43 – 45, 70, 75, 86, 101, 159 Ogden, T. H. 70, 80 Olesker, W. 50 organic factors of causation 4, 36, 48, 74, 86, 99 paedophilia 190 – 191 paranoid-schizoid position 12, 23, 70 – 71, 72 parent-infant psychotherapy 39 Parkinson’s disease 135 Parsons, Michael 178 Patrick, Matthew 5 perseverative thinking 49, 51 perversion 3, 4, 159, 190 – 191 Peter Rabbit, symbolism of figure 189, 197 – 199

Index 205 play: in child analysis, interpretation of 177 – 178; engagement in with child 178 – 180; symbolic play in autistic children 33 – 35, 41 – 43; as vehicle for mentalisation 60 – 61 Portman Lore 190 – 191, 193 posterior cortical atrophy 135 Potter, Beatrix 189, 197 prism metaphor for Oedipus complex (Hans Sachs) 159 Process of Change Study Group 185 Proust, Marcel 86 – 87, 96 psychic retreat 128, 161, 164, 166 – 167, 170 – 171 psychoanalytic model/technique: with children 173 – 187; contrasted with other techniques 3; overview 1 – 2, 7n1; theoretical frameworks 4, 49; use with autistic adults 47 – 62 Psychodynamic Interactional Matrix (PIM) 190 psychodynamic observation 147 – 151 psychosis, 4, 85, 105 – 114, 191 psychosomatosis 85 – 97, 98 – 101 “Purblind and Font” (Writer-Davies) 137 – 138

semantic memory 136 sexual abuse 190 – 193 sexuality 117; sexualisation of aggression 191; theories of 86 Sherkow, S. P. 61 Sinason, Mike 111, 139 – 140 Sklar, Jonathan 85 – 97; analysis of case history Sklar compiled 98 – 101 Sodom and Gomorrah (Proust) 96 speech failure in dementia 136 Spider (Bourgeois) 80 – 82, 81, 82 Spillius, E. B. 71 – 72, 73 splitting: dissociative vs. disavowal 166, 167, 170; Freud on 167; processes of 71, 72 Stafford Hospital incident 4; see also Francis Report Steiner, J. 129 – 130, 167 Studies on Hysteria (Freud & Breuer) 85, 98 – 99 Sugarman, Alan 1, 47 – 62 Sullivan, H. S. 105 symbolic play in autistic children 33 – 35, 41 – 43 symbolic representations contrasted with symbolic equations 13 – 14

Quinodoz, D. 131

Tale of Peter Rabbit (Potter) 189, 197 Tavistock Clinic, Old Age Unit 138 – 155 Taylor, Graeme 100 – 101 Telford Hospital incident 2 Thatcher, Margaret 147 Thematic Apperception Test 140, 141 theory of mind 49 – 50 therapeutic alliance 109 – 110, 121 tics 4, 94 – 95, 99 – 101; and masturbation 100; tic convulsif 99 Tics and Their Treatment (Meigne & Feindel) 95 Tischler, Salo 39 tonic attitudes of body 30 – 31 Torok, M. 96 Tourette, Gilles de la 99 transference-countertransference relationships 75, 76, 90, 170, 183; with transgender patients 121 – 122, 126 – 127; see also countertransference transferential relationships 79 transgender persons 119 – 133 transgenerational trauma 69 – 81 transitional space, theory of 174

rearrangement/re-transcription 79 – 80 reflective practice 3, 14, 118 Reichman, Freida Fromm 105 Revans, R. 20 reverie 13, 14, 20, 72, 73 Rey, Henri 138 Rhode, Maria 48; analysis of Rhode’s clinical case 29 – 35; on pre-autistic toddler learning to walk 36 – 45 Richards, Joscelyn 111 Rivière, Joan 139, 147 Rodrigué, E. 44 Rose, James 1 Rossor, Martin 117, 134 – 136, 138 Sachs, Hans 159 sado-masochism 121, 159, 190, 191, 197 Schilder, P. 45 “schizophrenogenic mother” 105 Schur, Max 151 seduction, theory of 73 Segal, Hanna 13, 155, 170 self-awareness and dementia 140 – 142

206 Index Trevarthen, C. 36 Tustin, Frances 36 – 37 Utermohlen, Pat 142 Utermohlen, William 142, 143 Varadkar, Leo 153 violence: and criminality 189 – 191, 200; knife violence 6; and perversion 159 – 160; and splitting 109, 113 Waddell, M. 146 Wallerstein, J. 60 Warner, James 153

Watson, J. S. 42 Wayward Youth (Aichhorn) 189 weapons, symbolism of 200 Welldon, Estela 6, 160 Wieder, S. 36 Winnicott, D. W. 36, 72, 79 – 80, 174, 177 – 178, 182, 190, 199 Writer-Davies, Gareth 137 – 138 Young offender: my life from armed robber to local hero (Maisey) 6 Zachary, Anne 1 – 7, 122, 189 – 201