British Journal of Psychotherapy最新文献

Originally psychoanalytic understandings concerning the capacity to tolerate otherness were linked to the concept of narcissism. Freud (1914) had originally identified a protective stage of ‘objectless’ primary narcissism in normal development and a secondary narcissism, which involves a withdrawal of attachment to the external object. Recent theoretical understandings have identified very early stages of development, known as primitive mental states, wherein the other is both poorly differentiated and psychically represented, leading to unique anxieties and defences. I wish to demonstrate how in working with such states of mind associated violent exigencies can emerge, which if not identified and carefully managed, can stymie psychic growth. In managing such exigencies, it is proposed that the therapist needs to be available to the patient as what Bick has termed a ‘complex undifferentiated object’. This leads to a way of navigating the point at which the patient can suddenly switch from a desperate need for such an object, to a fear of being annihilated by it. In this process, the value of identifying primitive anxieties through one's somatic countertransference experiences is highlighted, as is the utility of a continuum of developmental anxieties, initially proposed by Ogden (1989), which can be used as a therapeutic compass in such a clinical landscape. Two case vignettes are presented which demonstrate how the presence of the therapist moved from being imperative to the patient's survival to being potentially annihilating, and how this was worked with to facilitate psychic growth.

Initially, Freud proposed two distinctive ways of understanding somatic symptoms: the hysterical conversion and the actual neuroses models. The original conversion model posited that somatic symptoms had meaning and resulted from psychic mechanisms, whereas actual neuroses model proposed somatic symptoms had no meaning and resulted from physiological rather than psychic processes. Psychoanalytic psychosomatics has evolved much since those initial postulates. Insufficiencies in psychic processing of emotional experience has become a key problem for the understanding of somatic symptoms, and consequently supporting psychic processing has become the main technical challenge. Starting from Freud, this paper explores the evolution of explanatory models and technical approaches for the treatment of people affected by so-called ‘psychosomatic’ pathology. Some technical implications of these developments are discussed in relation to a case example.

In this paper the author explores the emerging model of maternal care which Bion uses to understand analytic function and attitude. Inspired by Bion, he suggests that both curiosity and love are important for mothering capacity in nurturing emotional growth, both in childcare and in analytic work. In his view, of central importance in both of these is the strength of the links to the father or paternal figure. He considers that Bion struggled with a problem in his earlier analytic work, illustrated in his paper ‘On Arrogance’, that followed his prioritisation of curiosity, of seeking knowledge, over its emotional impact. The author suggests that Bion's later change towards a focus on the growth of Being (O), and his recommendations regarding the analyst's attitude, namely a disciplined suspension of memory and desire during psychoanalytic sessions, were aimed at addressing this problem, bringing Bion into line with Klein and Freud.

This is an account of my psychoanalytic work with Jozsef, a transgender patient assigned female at birth who ended psychoanalytic treatment abruptly after 1 year. The initial 3 months were three times weekly, then four times weekly for another 9 months. Presenting problems were depression and intense feelings of loneliness. Nothing in the patient's appearance and demeanour, as a 35-year-old man evoked the woman that he had been 10 years earlier. The analysand underwent a double mastectomy but did not dare to undergo genital reconstruction surgery. During his analysis, he described femininity as an illness that he felt the urge to fight off. Following Withers' (2020) framework of multi-level psychological distress evasion, the case illustrates how transgender identification and medical intervention may serve as an attempt to evade profound psychological distress, including attachment trauma and dysregulated affects. Jozsef showed the capacity for mental representation and symbolisation at certain times, but on other occasions, this capacity was lacking. Living with what he had done to his body was less unbearable for him than living with the annihilating suffering resulting from the sense of lacking a primary identity. As his analyst, I believed that the analytic task was to shift the focus from the external concrete reality of the body to bodily fantasies and psychic reality.

Self-harm is common and familiar to many healthcare professionals working in mental health and emergency medicine. Encounters with patients who have self-harmed frequently elicit powerful emotional responses from professionals, which have been explored and characterised in a number of existing qualitative studies. Self-harm serves a number of different functions, ranging from conscious, intrapsychic motivations such as affect regulation, to interpersonal communicative functions which are understood within the psychoanalytic literature to be largely unconscious. This paper aims to explore the unconscious communicative functions of self-harm by characterising the common emotional responses of healthcare professionals encountering patients who have self-harmed, drawing on a narrative review of the existing literature as well as short interviews with clinical staff. Furthermore, this paper aims to understand these responses within the framework of the established unconscious interpersonal functions served by self-harm, thus bridging the divide that can often exist between the front-line exposure to the physicality of self-harm and psychodynamic understanding of the meanings underlying these experiences. The range of responses is organised firstly in terms of the primary emotional reactions, and secondly in terms of the healthcare professional's defences against these emotions, which may themselves be either intrapsychic or enacted. In conclusion, the essential importance of reflective practice in clinical work is emphasised.

The present study aimed to examine adolescents who returned to psychodynamic psychotherapy after terminating a previous psychodynamic treatment and compare them with young people who did not return. We examined the clinical archives of a community-based clinic in Southern Brazil, identifying adolescents who sought psychodynamic psychotherapy after previously terminating a therapy process in the same institution. We carried out statistical analyses investigating the association between variables as well as potential causal relations between them. Age range, symptoms of anxiety/depression, thought problems and the reason for the initial termination were positively associated with returning for a second psychotherapy after the termination of the first one. Rule-breaking symptoms and somatic complaints were negatively associated with returning to therapy. Finally, it was identified that symptoms presented at the beginning of each treatment, such as anxiety/depression, thought problems and aggressive behaviour, were significantly less intense at the beginning of the second treatment. Conversely, somatic symptoms were significantly greater at the second point of referral. Identifying characteristics that may indicate a possible return to treatment can contribute to the optimization of the therapeutic process and facilitate, along with the patient, openness to a new treatment in the future.

This paper explores the historical pathologisation of homosexuality and its lasting impact on gay men's mental health and identity, including some of the author's experiences via an autoethnographic narrative. Through the lens of minority stress theory, it examines how societal stigma, internalised shame and structural discrimination contribute to psychological distress among gay men and the broader LGBTQ+ community. The paper critiques the historical complicity of psychoanalysis in reinforcing homophobic narratives while acknowledging contemporary efforts to redress these biases. The paper argues for a therapeutic approach that situates individual distress within broader sociopolitical contexts, advocating for a culturally competent, psychosocially informed psychoanalysis that is both explorative and affirmative, attending to distal (external) as well as proximal (internal) stressors. Finally, it highlights the ongoing struggles within the LGBTQ+ community, urging a collective effort to dismantle intra-community divisions and resist external oppression.

Analytic and philosophical literature suggests that repetitive failures to make sense of internal and external events can seriously undermine our inner meaning systems, leading to feelings of meaninglessness and despair. Accepting the absurdity of the wish for a completely predictable, understandable and manageable world relieves the despair and liberates us from clinging to generalizations and abstractions. It also encourages us to seek personal meanings of our evolving experiences and embrace the life we come to know. These insights are relevant for the supervisory process that helps the supervisee construct an inner clinical meaning system. Repeated failures to understand clinical situations can undermine the supervisee's clinical meaning system, leading to feelings of meaninglessness and despair in their professional life. Accepting the absurdity of wishing for an entirely predictable and understandable therapeutic world can liberate the supervisee from clinging to clinical generalizations and abstractions. It also encourages the supervisee to search for personal and authentic meanings of therapeutic experiences. The supervisor can promote acceptance of this absurdity by highlighting three components of the supervisory materials: metaphorical language, movement and process and embodied experiences.