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CONTAINMENT: THE TECHNICAL AND THE TACIT IN SUCCESSFUL PSYCHOTHERAPY

by Robert M. Young

I don’t know how psychotherapy works. However, I don’t find that very odd. I have some ideas, but to tell the truth I think of them as away of comforting myself while I get on with doing psychotherapy, something I do over thirty hours a week and think about for quite a lot more hours as I teach, write, edit and talk to colleagues.

What I propose to do tonight is share those ideas and to look behind them to other ideas which I believe to be more helpful in explaining what I do.

First, of course, psychotherapists, at least ones of my persuasion, make interpretations. I was taught only to make transference interpretations, but after I stopped having supervisions i.e., after a decade of training and postgraduate training, I slowly moved on to making any interpretation I thought might help my patients. Then one day a patient asked me what was the relationship between my interpretations and therapeutic benefit. There was a time I’d interpret the question, but I thought it a reasonable one, and this patient was not prone to use theory as a place to hide. The answer I had been taught was that a truthful or accurate interpretation of a patient’s unconscious motivations, the more primitive the better, and after being worked through, reduces primitive anxieties. This, in turn, makes the patient less trapped in his or he neurotic patterns. The emphasis was on the accuracy of the interpretation.

However, an image came into my mind, and after pondering it, I decided it was what I believed, so I spoke it. I said. ‘Do you know what a pedalo is?’ ‘Yes’, she said, ‘a sort of bicycle boat’. ‘Imagine us on a pedalo in the ocean. We have to go on pedalling, sometimes fast and furiously, sometimes in a more leisurely way. At the bottom of the ocean there are large plates like the ones that we are told move with infinite slowness to reshape the earth’s crust. The pedalling is what we say to each other, especially my interpretations. The movement of the plates is the therapeutic benefits from our work. If we don’t pedal, the plates don’t move. If we do, they do move or are very likely to. What goes on in the huge depth of water between the pedalo and the plates no one knows.’ I grant that this is an inelegant picture. Its main attractions are to draw attention to the very large gap in understanding, symbolised by the depth of the water, between the therapeutic discourse and the psychic change in the inner world of the patient. This is in sharp contrast to the cinema rendition of psychotherapy where the therapist figures out the moment of trauma and, hey presto!, the patient is cured. I am thinking, for example of how Ingrid Bergman cured Gregory Peck in ‘Spellbound’ or how Sean Connery cured his wife in ‘Mandy’. This is the cathartic model: remove the block and life flows again.

Actually, we do know a thing or two about what happens between the pedalo and the plates, but I’m not confident about it, and the longer I practice, the more I think what I say is diminishing in relative importance compared to how I say it and how I am. However, I am confident about two things that are essential for psychotherapy to work. They are the role of the analytic frame and the fact that what we interpret is not the patient’s material but our own countertransference to that material. I’ll discuss each of these topics.

First, the analytic frame, of which abstinence is a central aspect. Marion Milner, who coined the phrase ‘analytic frame’, wrote about an analogy between providing boundaries for the analytic situation and a picture frame:

The frame marks off the different kind of reality that is within it from that which is outside it; but a temporal spatial frame also marks off the special kind of reality of a psychoanalytic session. And in psychoanalysis it is the existence of this frame that makes possible the full development of that creative illusion that analysts call the transference. Also the central idea underlying psychoanalytic technique is that it is by means of this illusion that a better adaptation to the world outside is ultimately developed (Milner, 1952, p. 183).

Some years later Josť Bleger wrote,

Winnicott (1956) defines “setting” as ”the summation of all the details of management.” I suggest... that we should apply the term “psychoanalytic situation” to the totality of the phenomena included in the therapeutic relationship between the analyst and the patient. This situation comprises phenomena which constitute a process that is studied, analysed, and interpreted; but it also includes a frame, that is to say, a “non-process”, in the sense that it is made up of constants within whose bounds the process takes place (Bleger, 1967, p. 511).

There are many elements of the analytic frame. It is a room - a physical setting. It is a set of conventions about how one behaves. It is a state of mind - a mental space. It is all of these at once and something more, something ineffable. It has been described as a facilitating environment and as a container. It needs to be a safe enough place for psychotherapeutic work to occur, a place where the patient can allow herself or himself to speak about things which are too painful or taboo or embarrassing to speak about elsewhere. The essence of the safety of the space is that the patient can project things into the therapist which are contained by the therapist, detoxified and given back in due course in a form which can be used as food for thought.

If I listed all the factors making up the analytic frame, I would still miss out some things and not capture its essence. The things I will spell out are, therefore, examples, designed to set you thinking. The point is that the frame should make the analytic space which it bounds a suitable place for analytic work. It should be quiet. No interruptions, phone calls, answering the doorbell. It should not have very personal pictures in sight or other mementoes which reveal personal matters or relationships. It should be pleasant and comfortable. It should, as far as possible, remain the same.

In part, the analytic frame takes the form of a contract about what the patient can expect and what the therapist will and will not do, will or will not allow, what can and cannot be expected. In this sense it includes the ground rules, implicit and explicit, of the analytic relationship’ (Langs and Searles, p. 43), a basic framework, customs and practices which have developed over the history of psychoanalysis and psychotherapy. Their overall purpose is to minimise uncertainty and ambiguity and to make a big contribution to containment.

There are a number of desiderata about the therapist’s behaviour and demeanour. She or he should answer the door promptly and begin and end the session on time. Most agree that she should not give out personal details, although some believe that there are occasional circumstances when this may be appropriate, though only when it contributes to the patient’s understanding, i.e., never gratuitously or self-indulgently. The bill should be presented at the same session every month (i.e., regularly). Sessions should not be changed unless necessary and, when they are changed, maximum notice should be given. Information about breaks or fee changes should be given well in advance. Occasions for differing over sessions, breaks, fees or any matter concerning the frame should be minimised. Bleger stresses that the frame ’should be neither ambiguous nor changeable nor altered’ (p. 518). Robert Langs argues that when the frame is broken a misalliance pathological symbiosis exists between therapist and patient until it is mended and until the break is understood and interpreted (Langs & Searles, pp. 44, 127).

The frame holds something in. It defines a border or limit. Confidentiality is guaranteed, but it is judiciously breached in training cases, when case material is taken to supervision, which is why it is unethical not to mention that one is a trainee. The law also specifies some exceptions to absolute confidentiality - certain criminal acts. Boundary maintenance is another way of conveying what containment means. The patient is being helped to hold himself together, to feel held, neither too tightly nor too loosely, as one holds a baby in distress, imparting a sense of care, taking in and not reprojecting anxiety.

It has been argued by Bleger that the analytic frame is the place where the madness is held so that the therapist and patient can have a space to think and feel about maters felt with a degree of intensity which is painful but still bearable. It keeps overwhelming distress at bay, while allowing something short of that to be thought about. ‘The frame as an institution is the receiver of the psychotic part of the personality, i.e., of the undifferentiated and non-solved parts of the primitive symbiotic links’ (Bleger, 1967, p.518). It contains ‘the most regressive, psychotic part of the patient’ (p. 516). The implication is that when the frame is breached, these forces are likely to be let loose.

Having conveyed some basics, I must now say that there are exceptions to practically everything I have said. For example, the analytic frame is not confined to the room where the therapy is done. It is ideally tacitly in the minds of both therapist and patient all the time. It is there when you open the door or speak on the phone. It is carried with the patient (or not) between sessions: it is internalised. It is conveyed by the therapist’s demeanour, tone of voice, pauses, silences, grunts, the wording of any note or letter that it is appropriate to send to the patient. It is evident in pauses. It is all aspects of analytic space. To maintain the frame is to maintain the analytic relationship. As I said, its essence is containment.

Acting out is breaking the analytic frame. (There is also a concept of ‘acting in’, whereby the transgression occurs inside the therapy room, but I do not find this idea useful and will not employ it.) Acting out is not defined by what the patient does. Rather, it is characterised by the motive - to break the frame. For example, if the therapist and patient meet by chance outside the consulting room, e.g., at a party or at the cinema, the frame has been broken, and it is important to interpret the encounter, but it is possible that no one has acted out. It could be argued that every act which is characterised as acting out could occur for other reasons. If the patient is late, the reason may be a stoppage on public transport or a traffic jam. If the patient is persistently late, she is acting out. There is, however, another level of meaning here. The patient may have a perfectly good story about being late, even including events out of her control, but she may also unconsciously relate to that explanation in a way that involves acting out.

There are many fairly routine examples of acting out: not coming to sessions, unnecessarily phoning the therapist, bringing gifts, not paying the bill or doing so in a way which invalidates the payment (cheque unsigned, wrongly dated, numbers and words not the same, even the payee’s name incorrect), refusing to speak, flooding with speech, coming early, reluctant or even refusing to leave at the end of the session, shouting, screaming, preventing the therapist from speaking, dressing provocatively, acting seductively, lying, bringing inappropriate things to the session (e.g., mobile phone, tape recorder), taking a holiday before or after an analytic break (thus extending the break). I had a patient who was usually on the couch but came into a session and turned the upright chair away and sat down with her back to me. I only wish I had made the interpretation that there was something she could not face. Another stood on the threshold of the therapy room and would not come in. After a long time it occurred to me to say that he wanted me to feel the panic of being on the edge that he felt. He then came in and sat down and began work.

Acting out is a substitute for verbal expression. It is expressive, symbolic communication, but it is not reflective. The patient is acting rather than reflecting. Where acting out is, thought cannot be.

One feature of acting out is that the therapist is usually put under pressure to do something he would not otherwise do - to go after the patient in some way, e.g., to write to the patient or phone, to reveal something, to move, to change a session, to press the patient, to relent about a decision or take a firm line, even to lose his temper.

Many believe that a good therapist is less likely to have patients act out, but I am not so sure. If you want to take account of the purist position in these matters, read the writings of Robert Langs or perhaps Carol Holmes (1998), a follower of his ‘communicative’ approach. It is also true that acting out always has a meaning, just as a dream or a parapraxis does. It conveys a message, and the therapist’s job is to interpret it - to get the message and convey that one has got it. Some say that the patient acts out because he cannot find any other way of conveying that message. As the example of my patient who stood on the threshold of the therapy room shows, the way to deal with acting out is to make the appropriate interpretation, one which hits the spot, reduces the primitive anxiety and allows the patient to re-enter the analytic space on the agreed terms, i.e., that he remain on the couch (or in the chair) and take part in a talking therapy. I did not make the appropriate interpretation to the woman who turned the chair around and sat in it with her back to me, and she left therapy abruptly.

Persistent acting out indicates a deeper, untouched or unresolved conflict. I have a patient who always comes late and another who used to come very late. The first is indicating an ambivalence about coming at all, so he comes but always late. The other offered two explanations. First, she could not bear the thought of being kept waiting but felt that if she came late, I would always be there and come quickly to the door. The baby would not be left crying, unattended to. She also had low self-esteem and felt she wasn’t a full person and did not have enough to say to fill a whole session, so she came twenty minutes late, believing that she could just about fill three fifths of a session. She offered a different rationalisation every day about what had delayed her, but the coming late stayed the same. Then we changed her session time to one she had before, and thereafter she came on time. It emerged that she had felt displaced and when she got back the original slot, she felt she had been given back her ’own rightful time’.

I had another patient who acts out frequently over money matters. She was highly reactive and stormed out and held out until I made contact and drew her back into coming to her sessions. She came from a family in which money matters were fraught to the point of involving the law, and she was particularly jumpy about them, often accusing me of holding views about her which were demeaning and of acting in an unfair way. At one time she was so defensive about paying me that she would give me the monthly payment before I gave her the bill. Matters of fees and payment were frequently the occasion for an outburst and sometimes a threat or short-term decision to leave therapy.

Another way of referring to these matters is the concept of abstinence. The therapist is supposed to abstain from doing various things which would perhaps be natural in a social situation. He should not speak to the patient while walking from the door to the therapy room or after the session ends. He should never be gratuitously self-revealing about personal matters and not otherwise unless it is directly contributory to the work and even then very sparingly. He should not lightly offer opinions or advice or make moral judgements about the patient’s material (although tacitly conveying such opinions and judgements seems to me inevitable). Some say he should never ask questions. That is not my position. He should concentrate on interpreting the unconscious. I think this degree of abstinence is practically impossible to maintain, but it is the goal. This is not the same as saying that the therapist should be cold and too formal, just that she should not chat or exchange opinions. If, as I believe, what we do is to interpret our countertransference (a topic I’ll return to in a moment), it is essential that this be done in a temperate, civil and level way. To do otherwise is to reproject the patient’s transference projections and to act out in the countertransference. There are those who believe in a judicious ’expressive use of the countertransference’, in which the patient is carefully told what response she elicits in the therapist. I think this is a dangerous practice, but it has its advocates.

Psychoanalytic psychotherapists are almost all agreed that one should not have social relations with patients. Most agree that the transference never ends and that the patient may need to return, so social relations with ex-patients are also contraindicated. The same taboos apply to physical contact between therapist and patient and ex-patients. I learned about this the hard way. My analyst, an elderly and rather formal man, shook hands with me at the end of each term. I took up this end-of-term gesture when I began my own practice but soon abandoned it. One female patient with a strong sexual transference, who also had severe fertility problems, missed her next three periods. Another, a woman in her late fifties with a particularly intense romantic transference, went straight to a shop from having her hand shaken at the end of her first term of therapy with me, bought a red dress and told the people in the shop that she was having a baby. A supervisee who had been in the habit of hugging a patient gave up this practice under my guidance, and the patient came to feel that this abstinence from physical comforting allowed a greater degree of intimacy in the verbal realm. This supervisee, who was initially unconfident about what she had to offer, also sometimes let sessions run over time, until the patient told her that this made her anxious that the therapist could not handle (contain) her distress. These examples show that abstinence and boundaries are important for the patient and help her to feel safe and contained. This approach is characteristic of orthodox psychoanalytic psychotherapy. Some therapies which have derived their identity by breaking away from some of these forms of abstinence involved various forms of ’the laying on of hands’. I am convinced that not touching leads to greater intimacy.

The most important and charged area of abstinence and of potential acting out is that of sexual relations between therapist and patient. There are various estimates of how often this happens. Somewhere between two and ten per cent of male therapists have sexual relations with their patients, and about two or three per cent of female therapists do. The analytic space is an Oedipal space, and the analytic frame keeps incest at bay. The analytic relationship involves continually offering incest and continually declining it in the name of analytic abstinence and the hope of a relationship that transcends or goes beyond incestuous desires. Breaking the analytic frame in this way invariably involves the risk of child abuse and sleeping with patients or ex-patients is precisely that.

Martin Bergmann puts some of these points very nicely in his essay on transference love (Bergmann, 1987, ch. 18). He says,

In the analytic situation, the early images are made conscious and thereby deprived of their energising potential. In analysis, the uncovering of the incestuous fixation behind transference love loosens the incestuous ties and prepares the way for a future love free from the need to repeat oedipal triangulation. Under conditions of health the infantile prototypes merely energize the new falling in love while in neurosis they also evoke the incest taboo and needs for new triangulation that repeat the triangle of the oedipal state (p. 220).

With respect to patients who get involved with therapists or ex-therapists, he says that they claim that “‘unlike the rest of humanity I am entitled to disobey the incest taboo, circumventing the work of mourning, and possess my parent sexually. I am entitled to do so because I suffered so much or simply because I am an exception’” (p. 222). Such sexual relations may seem a triumph to the patient, but, as Freud eloquently observed,

If the patient’s advances were returned it would be a great triumph for her, but a complete defeat for the treatment. She would have succeeded in what all patients strive for in analysis - she would have succeeded in acting out, in repeating in real life, what she ought only to have remembered, to have reproduced as psychical material and to have kept within the sphere of psychical events. In the further course of the love-relationship she would bring out all the inhibitions and pathological reactions of her erotic life, without there being any possibility of correcting them; and the distressing episode would end in remorse and a great strengthening of her propensity to repression. The love-relationship in fact destroys the patient’s susceptibility to influence from analytic treatment. A combination of the two would be an impossibility.

It is, therefore, just as disastrous for the analysis if the patient’s craving for love is gratified as if it is suppressed. The course the analyst must pursue is neither of these; it is one for which there is no model in real life. He must take care not to steer away from the transference-love, or to repulse it or to make it distasteful to the patient; but he must just as resolutely withhold any response to it. He must keep firm hold of the transference-love, but treat it as something unreal, as a situation which has to be gone through in the treatment and traced back to its unconscious origins and must assist in bringing all that is most deeply hidden in the patient’s erotic life into her consciousness and therefore under her control. The more plainly the analyst lets it be seen that he is proof against every temptation, the more readily will he be able to extract from the situation its analytic content. The patient, whose sexual repression is of course not yet removed but merely pushed into the background, will then feel safe enough to allow all her preconditions for loving, all the fantasies springing from her sexual desires, all the detailed characteristics of her state of being in love, to come to light; and from these she will open the way to the infantile roots of her love (Freud, 1915, p. 166).

From the therapist’s point of view, ‘When the transference relationship becomes a sexual one, it represents symbolically and unconsciously the fulfilment of the wish that the infantile love object will not be given up and that incestuous love can be refound in reality’ (Bergmann, 1987, p. 223). This is a variant on the Pygmalion theme. The analytic relationship works only to the extent that the therapist shows, in Freud’s words quoted above, ‘that he is proof against every temptation’ (Freud, 1915, p. 166). Langs puts this very well when he says that ‘the therapist’s appropriate love is expressed by maintaining the boundaries’ (Langs & Searles, p. 130).

Nevertheless, as I have indicated, alarmingly many therapists do sleep with their patients. If the motives for abstinence are not sufficiently strong, the situation is perfect. There is opportunity in the therapy hour and on the analytic couch. There is no fear of interruption. The patient has placed herself in the therapist’s hands, under his care, trusted to look after her. In their omnipotent and incestuous way of seeing things, what could be a more tender and intimate way of doing so? When the transgression is discovered (usually when the therapist belatedly finds himself), the matter is frequently brought before a professional ethical committee, and the therapist is struck off, suspended and/or required to undergo further therapy. I know of a case where this was done twice with a training therapist and supervisor who took up the practice again and finally had to be permanently removed from the professional organization.

Turning now to my second large topic, the countertransference, I begin by saying that what happens inside the analytic frame is that the patient talks - or not - and does some other things. We make responses; most significantly, we make interpretations. I have heard it said that we really make only one basic interpretation. ‘You are speaking as if I was your mother/father’ or whatever internal object the patient is projecting into you, the therapist. That is, patients’ problems stem from inappropriately transferring the untoward feelings that they have about significant persons onto us, and we point out that they are mistaken and that life would be better if they’d stop making these false accusations and take life more as it comes and give it an even chance rather than prejudging things, distorting them and repeating self-limiting patterns learned in infancy and childhood.

I know I am making it sound awfully simplistic, so let me try to enrich the model. Patients behave toward us in neurotic ways, i.e., they react to us as if we were the problematic people in their inner worlds. We’d like to shift their internal objects so that they are less caught up in repetition compulsions, delusions and other reactions that are making them unhappy, unfulfilled, sexually hung up or whatever. In classical psychoanalysis the therapist was thought of as observing the patient, spotting their distortions and pointing out the mistaken attributions, the transferential material. The therapist was considered to be objective. Insofar as the therapist was not objective he or she was considered to be incompletely analysed. You could tell this if they reacted inappropriately toward the patient as a result of an unconscious reaction to the patient’s material. This was called counter-transference, i.e., a reprojection. A conscientious therapist would spot this reaction, keep it to themselves and reflect upon it or get some further analysis. However, in the period just after the Second World War, a number of people here and in the US had second thoughts about the countertransference and thought it would be a good idea to pay some attention to it. Donald Winnicott and Margaret Little among the Independents, thought this, and Roger Money Kyle, a Kleinian did, too. What Money Kyrle said was that when your unanalysed countertransference leads you to make a wonky interpretation, the patient senses that you are in trouble and relates to you as a damaged object. Getting back into a good therapeutic alliance takes some work. Paula Heimann, who shifted allegiance from the Kleinians to the Independents, wrote two influential papers on learning from the countertransference, but her recommendation was that you should listen to it in order to reduce the likelihood of its occurrence. Harold Searles, a greatly gifted American analyst of no particular school, went further and advocated being in constant touch with your countertransference and making your efforts to decipher such reactions the basis of your interpretations. British Kleinians took the same line, tough independently, and ended up arguing that what we do is not make objective observations of our patients’ material. On the contrary, we take in their projections, attend to them, detoxify them in our own inner worlds and make interpretations based on our ruminations which, hopefully, will be of use. Two features of this changed perspective are important. First, we attend to the total situation of the patient and what his or her material evokes in us. We are not, as it were, looking objectively at the patient through an optical instrument. Instead, we are resonating in our deepest subjectivity to what they put into us and what it evokes in our unconscious. This means that we should keep our own counsel until we have made sense of our countertransference. I remember one of my supervisors offering the following good advice: ‘Sometimes all you can do is hold onto the arms of your chair’.

I’ll give you an example from my recent work. I have a patient who always comes in looking angry. She rarely begins talking without prompting, and her first utterance is often that she wonders if she should stop coming or whether the therapy is doing her any good. In the course of the session we almost invariably climb out of this slough of despond and get somewhere. She leaves in a better frame f mind, often with a thank you, only to return with the same negative anticipations. I found myself over time not looking forward to the beginnings of our sessions and bracing myself for her expressions of disappointment. One day, however, I found myself saying, after she had told me a particularly poignant story about her father’s distressingly superficial reaction to something important and painful she had said to him, that with a father like that and a mother who was preoccupied with her own self-pity, it’s not surprising that she comes to me anticipating not being heard, taken in or supported and angry about it before she got to the door. I linked this to other situations in her work and home life where she had a hair trigger and lost her temper very early in situations where is was not at all obvious to me that they would end as badly as her outbursts led them to do. I was led to this interpretation by how she made me feel. She did not expect the objects of her feelings to hold, contain and draw the hurt from her painful experiences in life. Her premature outbursts ensured that she would be disappointed. She creates what she expects, what she fears, and, of course, she gets back from life he echoes of her own anxieties.

A paper by Irma Brenman Pick takes the normality of countertransference to its logical extreme, without a trace of seeing it as something to be got rid of. She carefully considers it as the basis of understanding throughout the session: 'Constant projecting by the patient into the analyst is the essence of analysis; every interpretation aims at a move from the paranoid/schizoid to the depressive position' (Brenman-Pick, 1985, p. 158). By this she means that we are constantly trying to shift the patient’s thinking from an approach dominated by extreme splits, concrete thinking and punitive guilt to a frame of mind in which life is a continuum, where there is a whole range of options other than the two extremes -- where there is a middle ground. We strive to encourage thought that is not persecutory but, rather, shows concern for the object, and guilt is not punitive but leads us to repair the object rather than thinking in terms of attack and counter-attack.

Brenman Pick makes great play of the tone, the mood and the resonances of the process: 'I think that the extent to which we succeed or fail in this task will be reflected not only in the words we choose, but in our voice and other demeanour in the act of giving an interpretation...' (p. 161). Most importantly, she emphasises the power of the projections and what they evoke countertransferentially: 'I have been trying to show that the issue is not a simple one; the patient does not just project into an analyst, but instead patients are quite skilled at projecting into particular aspects of the analyst. Thus, I have tried to show, for example, that the patient projects into the analyst's wish to be a mother, the wish to be all-knowing or to deny unpleasant knowledge, into the analyst's instinctual sadism, or into his defences against it. And above all, he projects into the analyst's guilt, or into the analyst's internal objects.

'Thus, patients touch off in the analyst deep issues and anxieties related to the need to be loved and the fear of catastrophic consequences in the face of defects, i.e., primitive persecutory or superego anxiety' (p. 161). As I see it, the approach adopted by Brenman Pick takes it as read and as normal that these powerful feelings are moving from patient to analyst and back again, through the processes of projection, evocation, reflection, interpretation and assimilation. Moving on from the more limited formulations of an earlier period in the writings of Winnicott, Heimann and even Money-Kyrle, these feelings are all normal, as it were, in the processes of analysis. More than that, as she puts it, they are the essence.

As I said earlier, Kleinians have not always taken this view of countertransference. Klein had begged Heimann not to deliver her first paper on countertransference and told Tom Hayley in the late 1950s that she thought countertransference interferes with analysis and should be the subject of lightning self-analysis (Grosskurth, 1985, p. 378). According to Elizabeth Spillius, ‘Klein thought that such extension would open the door to claims by analysts that their own deficiencies were caused by their patients’ (Spillius, 1992, p. 61). Having said this, it is important not to be too literal about the use of the term ‘countertransference’. Klein’s subtle interpretations of her patients’ inner worlds - especially their preverbal feelings and ideas - only make sense in the light of her ability to be resonant with their most primitive feelings, and Wilfred Bion’s injunction to ‘abandon memory and desire’ is made in the name of countertransference, whatever term we attach to the process. Indeed, it can be said that his writings are about little else.

Implicit in the way I have been speaking about the phenomena of countertransference is a model for knowledge - that the way we really learn is from the Other's response to what we convey. We learn by evoking and provoking. We do not learn by imparting but by re-experiencing what we have projected and has then been passed through another human being (though that person may be held in imagination). We learn by putting something out and finding out what comes back. Our relationship with the world is a phenomenological 'I-thou', not a scientistic 'I-it'. It is evocative knowledge.

In the analytic relationship, it turns out that the real justification for the free-floating attention that is characteristic of psychoanalysis is that it makes our minds available for the patient's projections and facilitates their search for the resonances in us for what they feel. Freud said, 'He should simply listen, and not bother about whether he is keeping anything in mind' (Freud, 1912a, p. 112). Bion put it poetically in his injunction that the analyst should 'impose upon himself the positive discipline of eschewing memory and desire. I do not mean that "forgetting" is enough: what is required is a positive act of refraining from memory and desire' (Bion, 1970, p. 31).

If this sounds a bit mystical, so be it. The Argentinian analyst Heinrich Racker shares an appropriately Oriental parable: One day an old Chinese sage lost his pearls. 'He therefore sent his eyes to search for his pearls, but his eyes did not find them. Next he sent his ears to search for the pearls, but his ears did not find them either. Then he sent his hands to search for the pearls, but neither did his hands find them. And so he sent all of his senses to search for his pearls but none found them. Finally he sent his not-search to look for his pearls. And his not-search found them ‘(Racker, 1968, p. 17).

Once one is in this state, one is open to the patient's unconscious and to the injunction that 'Constant projecting by the patient into the analyst is the essence of analysis' (Brenman Pick, 1985, p. 158). And at the other end of the analysis lies the ability of the patient to take back his or her projections. This is an important criterion of improvement. Bearing projections is the whole basis of containment: the therapist can bear to take in and contain the projections, to hold them and give them back, in due course, in the form of accessible interpretations.

I am suggesting that countertransference - as an aspect of projective identification - is not only the basis for analytic work but central to the basic process in all human communication and knowing. We only know what is happening because we are moved from within by what we have taken in and responded to from our own deep feelings. The space between people is filled - when it is and to the extent it is - by what we evoke in one another.

I have two concluding thoughts. First, in my announcement for this talk, written months ago before I had thought much about it, I said I would review various theories of how psychotherapy works. There are 45 papers in the main psychoanalytic journals on the nature of the therapeutic action of psychoanalysis. I have read many and perused more, beginning with James Strachey in the 1930s, moving on to Hans Loewald in 1960, as well as innumerable workshops and critiques, including a very interesting one by Herbert Rosenfeld. These are available on the CD-ROM of Psychoanalytic Electronic Publishing of those journals. Having reviewed this literature, I do not have anything to draw from it that, in my opinion, is as helpful as what I have been telling you.

In closing, I want to draw your attention to the writings of R. D. Hinshelwood, whose Dictionary of Kleinian Thought is a very valuable resource for understanding the therapeutic process. In particular, he writes very helpfully about containment and the work of Bion. He argues that the concepts of container and contained offer the key terms of reference for how we relate to our own minds, to the minds of others and to groups and institutions. Containment is the essence of what we do with our patients’ projections, which we metabolise, detoxify and give back in the form of an interpretation which - if we do our job -- is potentially helpful in allowing them to take back their projections and bear the vicissitudes and pain that are inescapable features of the lives of mature people and which we have vainly tried to evade with our neurotic symptoms.

Talk given in the CONFER series, ‘How Psychotherapy Works’, at the Tavistock Centre, London, 20 May 2003.

Copyright: The Author

Address for correspondence:

26 Freegrove Road, London N7 9RQ
robert@rmy1.demon.co.uk
Web site and writings: http://www.human-nature.com


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© Ian Pitchford and Robert M. Young - Last updated: 28 May, 2005 02:29 PM

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