BRITISHJOURNAL OFPSYCHOTHERAPY

EDITORIAL

Volume 27, Number 3, August 2011

The way in which a patient makes use of the clinical setting in individualpractice is the concern of the first two papers in this issue of the Journal. Howdoes the patient use the symbolic space and actual physicality of the consultingroom? What kind of object is their therapist, at the outset, and as the workprogresses? First of all, questions of entering into and leaving treatment pre-occupy Liza Catan, in ‘Panic and flight: claustro-agoraphobia in the consultingroom’. Catan makes central use of the work of Henri Rey on a spatial concep-tion of the mind, and specifically his formulation of claustro-agoraphobia-philia:‘very primitive, oscillating states of mind’ in which patients ‘idealize places andsituations where they are not’, with ‘palpable anxiety and continual flightbetween a range of alternatives’. She links this with Meltzer’s claustrum as a‘safe haven’ phantasized as providing protection from ‘the emotional pains ofnormal growth and individuation’. Catan rigorously focuses on the ‘beginningand ending of treatment for, while claustro-agoraphobia can break out at anypoint, its defining emotional reactions and behaviours tend to erupt with par-ticular violence and clarity’ around beginning and leaving treament. In twocomplex, detailed vignettes, she reports on an initial consultation (after whichthe patient made no further contact) and a longer piece of work. Reflecting onthe two cases, she links Rey’s conceptualization with recent post-Kleinian theo-ries of destructive narcissism and in particular the work of Britton on theconceptualization of psychic and material space.

Next, for Lorna Berger, in ‘Some thoughts on working with regression inpsychoanalytic psychotherapy’, there is an unavoidable ‘spectre at the centre ofthe paper’, in that her account is inspired by an ongoing case about which shefeels she can say little due to concerns about confidentiality.That said, the paperranges over a group of themes that apply in a situation of therapeutic regres-sion. Locating her discussion in the existing literature on regression, and herown wide experience, Berger emphasizes the importance of thorough assess-ment in order to establish whether a patient who may need (or wish) to regresswill be able to tolerate the boundary conditions of analytic work; the wayin which the patient uses the consulting room – cathected as ‘projectionsfrom their internal reality’; and the psychotic components in severe regression.Considering technique, and noting that Winnicott, Balint and Ferenczihad not ‘spelled out in any detail’ what should take the place of standardanalytic technique, Berger focuses on the therapist’s tone of voice, the risk of

ISSN 0265-9883

239

countertransference enactment, and the fostering of a ‘triangular space’ wherethe regressive dynamics can be thought about from a more adult perspective.‘There are times when I can make an interpretation in the transference in theusual way, and times when it would be cruel to do so’, Berger observes.Thought-provokingly, she suggests that ‘this sensitivity pertains to all analytical work andis not unique to working with regression’.

Turning to ‘Life Stages’, the papers by Catherine Matheson and by MichelleHamill and Kate Mahony look at the beginning and later stages of life, and atinterventions within public sector settings in which an analytic approach isintegrated with another model. Both papers convincingly argue for the utility ofa combination of approaches at a time of profoundly significant transition in anindividual’s life – and, perhaps, where time and the passage of time have theirown urgency. The papers show the need for a sensitive assessment of not only‘what’ works, but ‘why’ something works, and what part of the patient or hersituation the treatment is speaking to. Catherine Matheson, in ‘What do womenneed? Combining psychodynamic psychotherapy with cognitive techniques inworking with pregnant women and new mothers’, considers the literature onthe psychosocial and unconscious demands of pregnancy, and reports on workwith 76 patients in Maternity and Gynaecology in a London hospital over an18-month period. She describes three cases in clinical detail: two involving anintegration of approaches in one situation of termination and subsequent preg-nancy; a second, with a new mother where child protection procedures wereinvolved; and a third situation with a pregnant woman, using psychodynamicsalone. In each case she evaluates the rationale for the treatment approach,carefully considering the nature of the cognitive and affective forces in play, andlooking at their inter-relation. Branching out, in her discussion, she suggests thatcognitive work could be ‘seen as a bridge between psychic and physical reality’,suggesting that ‘polarization of the debate about the rival merits of CBT andpsychodynamic work is unhelpful’ in guiding practitioners towards achievingbest outcomes for patients.

Michelle Hamill and Kate Mahony, in ‘ “The long goodbye”: cognitive ana-lytic therapy with carers of people with dementia’, locate their equally thoroughdiscussion in the context of prevalence data and prevalence trends for dementiaboth internationally and in Western countries; and in the ongoing debate aboutthe needs of carers. While it is widely acknowleged that carers of people withdementia may be under considerable and cumulative stress, their own well-being has not always been well addressed by mental health professionals, eventhough it is known that the ‘maintenance of a person with dementia in thecommunity has more to do with the well-being and attitudes of family carersthan factors such as the severity of the disease’. Again in London, Hamill andMahony describe the work of a Psychotherapy for Older Adults service, inte-grated within a multi-disciplinary setting. Their specific focus is on the use ofCognitive Analytic Therapy.They provide a case example, of a British woman inher 70s with multiple health problems of her own who was caring for herhusband at home. ‘The pain of him no longer recognizing who she was left herall the more distraught’, as the authors write in their introduction of the case,

240 BRITISH JOURNAL OF PSYCHOTHERAPY (2011) 27(3)

‘but no less determined to continue to care for him at home’. Mrs M completed16 sessions of CAT with follow-up and a further six sessions at a later pointwhen her husband had been placed in residential care. Hamill and Mahonymovingly describe the benefit Mrs M experienced, and the gains sustained,noting that ‘CAT lends itself as a flexible therapeutic model for this work’,having been developed within the NHS as a time-limited model of psycho-therapy with an explicit focus on problems in relationships within the socialcontext.

We return to the physicality of the consulting room, and core debate withinpsychoanalysis, in the fifth paper in this issue. Jeremy Holmes offers us a readingof Relational Psychoanalysis – ‘relatively overlooked in the UK’ – through thework of Donnel Stern, whose writing he praises as ‘accessible yet never over-simplified’. Holmes locates Stern’s influences in the Heideggerian tradition ofGadamer and the later Wittgenstein, emphasizing ‘shared meanings thatemerge in the course of conversation’ over ‘intrinsic truths’. As Holmes puts it,Stern’s four themes of the nature of therapeutic conversation, dissociation,enactment and the search for new meanings ‘represent a critique and restate-ment of the standard psychoanalytic concepts of free association, defence,impasse and interpretation’. Holmes usefully creates a family tree of conceptsfor this discussion, charting similarities with, for example, aspects of a Kleinianmodel of projective identification and of the Fonagy/Target model of unmen-talized experience. In a spirited account, which includes a telling vignette fromanalytic practice, Holmes captures what is distinctive and innovative in a Rela-tional clinical model: ‘A key point is that both analyst and patient, despitedifferent starting points, became “different persons” in the course of thissequence’. He also situates the project ‘as part of a dialectic, an antiphone toestablishment psychoanalysis’, wryly wondering, in his conclusion, ‘if there isstill such a thing in an increasingly pluralized world’.

Ann Scott[annscottbjp@aol.com]

EDITORIAL 241