Learning Along the Way

Further Reflections on Psychoanalysis and Psychotherapy

Patrick Casement

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429793516
• Edition: 1
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

Learning Along the Way sees Patrick Casement trace the development and application of his earlier key contributions to psychoanalytic technique. These include his observations about internal supervision, trial identification with the patient, and monitoring how the analytic space is either preserved or spoiled by the analyst's contributions.

Throughout the book, Casement cautions against preconceptions that steer the analytic process along familiar lines. He advocates a more radical approach that is always open to being led by the process emerging between analyst and patient, frequently leading to unexpected and fresh insights. This work makes a natural pair with Casement's first, most celebrated book, On Learning from the Patient. Here he builds upon all that was outlined before, challenging the reader further and inspiring clinicians to re-think their established ways of working.

Learning Along the Way is an invaluable addition to every clinician's library and an essential aid to practicing psychoanalysts, psychotherapists, counsellors and anyone training in psychoanalysis.

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Chapter 1
On being in touch¹

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What I learned from my training about analytic technique was largely concerned with procedure. But what I learned most from my patients was to do with the analytic process: what helped and what didn’t help. I give here examples that illustrate, in particular, the importance of being in touch with our patients at levels that mean most to them.

Introduction

One view of psychoanalysis puts an emphasis upon correct procedure and yet there is another that is more open to a process that stems from the patient. In my opinion, it is in this latter view that we find the clearest evidence of a patient’s unconscious search for what is needed; and this is sometimes quite other than what the analyst might have expected or may be trying to offer.

Another puzzle, which I also think is worth considering, is the fact that we all believe in following the patient; and yet, in practice, I think we find ourselves taking up quite different positions in relation to the psychoanalytic process.

Of course, focusing upon procedure has its advantages, in that it offers the analyst a greater sense of knowing what to do, and the proper procedures to follow. It also makes it easier to teach psychoanalysis and to distinguish between this and other forms of therapy. And it is generally accepted that all analysts need to be firmly trained in the procedures of classical analysis. But if the procedure side of the dialectic is given too much priority it can overshadow other important aspects of the psychoanalytic process which I now want to illustrate and discuss.

My opinion is that both procedure and process are necessary aspects of any analysis, just as it is essential for a growing child to encounter the functions of fathering, which mothering alone cannot provide. I am also not convinced that these two positions are in any way mutually exclusive.

Childbirth as metaphor

To highlight the differences between procedure and process I would like to consider the different levels of function that we refer to when we speak of the process of birth, for example, and the medical procedures that sometimes go along with this.

The birth process has its own dynamic, its own sequence, direction and purpose. Sometimes, of course, the midwife or doctor in attendance has to intervene to deal with problems as they arise. But the supportive role is normally to assist in a process that has its own life and momentum.

Unfortunately, the medical procedures practised around birth are sometimes formalized, as if these were always needed, which we know can be to the detriment of the initial relationship between mother and baby.

Nevertheless, I think that there may be helpful parallels to be found between that view of procedure, which provides a framework that is available when process falters (as at a birth), and the ways in which we might regard the relationship between procedure and process in psychoanalysis.

In each setting there are times when it is essential that someone is there to act promptly and firmly, in ways that are informed by procedure. Without that a crisis can result which could be fatal. But, in an analysis, if stress is too often put on procedure it can mask the process that emanates from the unconscious of the patient, and the unconscious hope that is a part of that process.

Unconscious hope

I have come to think of the patient’s search for what is needed as a process of unconscious hope (Casement 1990, Chapter 7; 1991, Chapter 17).

What is unconsciously looked for is an opportunity for previously unmet needs to be attended to. These include an unconscious search for understanding and for a more adequate containment of feelings that have been experienced as unmanageable. And the need for this is often indicated by the ways in which patients relate to elements of similarity found in the analytic relationship, which are then treated as if they were the same as elements of past experience. Here, of course, we have a rationale for transference.

I have been particularly impressed by the sense of a patient’s unconscious search for what is needed from psychoanalysis. Even in pathology, when we begin to understand it in relation to a particular patient, we may find indications of what is needed for growth and for healing. And what is needed here is not only to be found in cognitive insight but in forms of relating. To this end, therefore, an analyst who does not resist the interactional pressures from the patient may be drawn into particular ways of relating which can eventually be seen in terms of this unconscious search.

Communication by impact

Because it touches upon the clinical material that I shall be presenting, I wish also to say something about what I have come to call ‘communication by impact’ (Casement 1985: 72–73; 1991: 64–65). I think of this as a generic term that covers all forms of unconscious communication that are contained within a patient’s impact upon the analyst, in particular that of projective identification (Klein 1946) and unconscious role-responsiveness (Sandler 1976).²

If analysts do not inhibit their inner responses in the consulting room, patients can draw the analyst into an affective relationship which can do much to reflect, and to throw light upon, the patient’s internal world and object relationships.³ The analytic relationship may then become an interaction between the patient’s internal world and that of the analyst, as an extension of it.

From another point of view, that of an infant in relation to its mother, Bion pointed out that, when a mother cannot bear to stay with the intensity of her infant’s distress, the infant will be left in a state in which it ‘is reduced to continued projective identification carried out with increasing force and frequency’ (Bion 1967); and, I would add, with the increasing despair of ever finding some one able to bear being fully in touch with that distress.

I am not sure to what extent Bion then related his views to the realm of psycho analytic technique but I have been persuaded by my clinical experience to allow patients to reach me emotionally, and as intensely as may be. I believe that this is essential, so that my understanding of a patient may include the communication of intense feelings, even to the point of my feeling them too.

It is one thing for the patient to have the analyst interpreting intense feelings as if these did not involve the analyst except as a focus for the transference; it is quite another for the patient to sense that his/her own most intense feelings are actually reaching the analyst, are having an effect on the analyst, and are being accepted as a necessary part of what needs to be communicated. And it is likely that some feelings can only be communicated in this direct way.⁴

The analyst can thus get drawn into being emotionally available for precisely those feelings that previously may not have been adequately received by a parent of the patient, or by any significant other.

Childhood trauma does not have to be thought of only as what has happened to a patient, which had been beyond the capacity of the immature ego to manage at the time. Trauma can also occur through what happens within the infant or child, when the feelings experienced are not sufficiently fielded by a parent figure being there to receive them. When there is no-one there to perform this basic parenting function, or when the person who had been there has rejected the impact of distress, that failure in parenting is also experienced as trauma.

So, in my opinion, the psychoanalytic process may need to involve the analyst in being there for what the patient is feeling; not only to interpret it but to experience this directly too. It requires both, the analyst experiencing the patient’s distress, and eventually also being able to understand where this comes from, and why. However, too much interpretation too quickly, in the face of intense feelings, is often experienced by the patient as the analyst being unwilling, perhaps being unable, to bear the intensity of the patient’s feelings. The analyst’s interpreting may then be seen as defensive, and it may be defensive, deflecting (as others probably have) feelings with which the patient may still be having the greatest difficulty.

There can also be a problem with too little interpretation, when the patient’s feelings are being directed at the analyst. Patients are often acutely aware of the fact of having had a significant impact upon the analyst. If the analyst acts as if this had not happened, this can have the serious effect of either invalidating a patient’s perception, which will be confusing, or else the patient is likely to perceive the analyst as being defensive and perhaps needing to be protected in some way by the patient.

I therefore believe that trauma, in the face of overwhelming feelings from within, is the trauma of having to manage what cannot be managed alone. No wonder then that patients have often come to somatise intolerable psychic pain, or in some other way to split it off and/or to repress it. Unconscious hope is then expressed in a patient seeking renewed access to that psychic pain and turning to the analyst for help in processing this, seeking the help which had not been available before. But this will usually include the analyst having to be available for the patient’s rage and/or despair towards the person(s) who had previously failed to be ‘there’ for it.

What I have been describing here goes far beyond a view of psychoanalysis as procedure. I also think that the therapeutic value of a patient finding what is needed in the analytic relationship may have been over-shadowed by a continuing influence of the medical model. That model presupposes that the analyst can be the provider of, or the master-mind within, the psychoanalytic process. And, it may be relevant to remember that doctors are usually trained not to be emotionally affected by their patients.

However, when the role of the analyst can be seen as more interactively responsive than is typical of any medical model, it may be easier to conceive of a patient unconsciously prompting the analyst towards becoming more nearly what the patient needs to find within the analytic relationship. And through this the patient may also begin to find the therapeutic experience most needed. The analyst may thus be drawn into this process in ways that belong to the unconscious search of the patient, and (once again) this is by no means the same thing as the corrective emotional experience (Alexander 1946) which is deliberately provided by the analyst.

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An extended example

I now wish to give some vignettes from my work with a patient who, in my opinion, had been engaged in a psychoanalytic process from his first meeting with me, even though it took him several years before he found his own way to five times per week analysis. Incidentally, though I say that the patient had been engaged in a psychoanalytic process, it would be more accurate to say that he had engaged me in this process.

Background

This patient (I shall call him Mr A) was quite young when he came to me. For much of his first three and a half years he was virtually blind with undiagnosed myopia; he was unable to focus much beyond the distance of about one centimetre. His development was therefore far from normal, but his parents seem to have interpreted his strange behaviour to mean that he was mentally subnormal, or perhaps even brain damaged. Later on, they also criticized him for being a ‘clinging’ child because he would try to hold onto his mother’s clothes. Inevitably, in his own world, he became completely disorientated when he was no longer in physical contact.

After his myopia had been recognized, when he was aged three and a half, Mr A was fitted with very thick glasses; he then began to find his way around the world that he had never seen before. But he had to do this in his own way. He had to touch what he now could see before he could recognize what it was.

Of course, there are interesting parallels between Mr A’s experience of his first years and that of other blind children. But there is one major difference. Blind children are usually known to be blind much earlier than this child was. However, Mr A’s parents appear to have continued to treat him as if he were sighted but in some other way not normal.

A major consequence for Mr A was that he had not only been deprived of any focussed view of the world around him, he was also deprived of anyone understanding his experience of near-blindness or the effects of this not being recognized. This lack of understanding turned out to be at least as great a deprivation for him as his lack of sight had been, and for a long time it left an almost unbridgeable gulf in his relationship to his mother.

When Mr A began school it soon emerged that he was unusually quick at mathematics. He believes that his early years of having to make sense of a world he could not see may have served to prepare him for abstract thinking, because when he came to mathematics it seemed as if it were a language he already knew.

Mr A’s father began to be proud of his son, now that he was doing well at school. He no longer saw him as an idiot. However, in his adolescence, Mr A’s normal rivalry with his father was met by rivalry from his father. It seems that the father had begun to feel threatened by his child’s brilliance in a field of study in which he had always prided himself. The father then began to denigrate his son’s quickness in understanding mathematics, saying that he was ‘being superficial.’ The relationship between father and son then began to deteriorate, leaving Mr A (at that time) with no good relationship with either parent.

The treatment

At his initial consultation Mr A was asking for help with a recurring anxiety about dying. In particular, he experienced this whenever he became seriously short of breath, as in running or other forms of sport.

When he said that he wanted to come for only one session a week, I showed some surprise and suggested that it might be helpful if he were to come more frequently. He then reluctantly agreed to come twice a week.

When Mr A came for his first analytic session I found him in an extremely anxious and distrustful state. He saw me as thinking that I knew best, apparently insisting upon him coming more often t...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Forword
• Acknowledgements
• Introduction
• 1 On being in touch
• 2 A missed opportunity
• 3 Towards autonomy: some thoughts on psychoanalytic supervision (1993)
• 4 Ways of working: a synopsis of contributions to psychoanalytic technique (2018)
• 5 The emperor’s clothes: some serious problems in psychoanalytic training (2005)
• 6 Imprisoned minds (2011)
• 7 The impact of the psychoanalyst upon the analytic process (2003)
• 8 Self-revelation by the analyst
• 9 Keeping in mind (in press, 2019, with Sinason, V. and Sachs, A.)
• 10 Beyond words: the role of psychoanalysis (2009)
• 11 Art therapy (2017)
• 12 The case of ‘Mrs B’ (my burned patient) continues to challenge
• 13 Response to Stuart Pizer’s review (2004)
• 14 Further reflections
• 15 Kate Schechter interview (2007)
• 16 Thérèse Gaynor interview (2010)
• 17 Questionnaire interview (2016)
• 18 My time with cancer: an extraordinary journey (2015)
• Bibliography
• Index