The four original papers in this issue, each from a different country, illustrate how psychoanalytic theory and practice continues to be applied internationally in the public sector – the very specific remit of this journal – within the full range of our work as mental health professionals: in the clinical assessment and treatment of patients, in teaching and training, in our own development through personal psychotherapy, in working with the wider institution and society, and of course in research, demonstrated by the different methodologies whereby the topics of each of these papers is investigated and explored.
The first paper, a qualitative study from Dublin, Ireland, ‘Something torn or burst or unbearable: a psychoanalytically-informed exploration of the experience of somatic symptoms’ by Alison Byrne, John O’Connor, Jennifer O’Raghallaigh and Siobhan McHale, makes an important contribution to the growing psychoanalytic literature in the field of psychosomatics, a topic of renewed interest within psychiatry as indicated by the creation of the new diagnostic category of somatic symptom disorder (SSD) in DSM 5. Psychoanalysis, of course, was founded upon Freud’s study and treatment of hysteria, but patients with somatic symptomatology have subsequently often been considered as resistant to exploratory psychotherapy, finding it difficult to relocate their distress from the body to the mind. Byrne and her colleagues expose the lived experience of individuals suffering from somatic symptoms, and the dilemmas of working with them, through the personal accounts of six patients who were seen in a liaison psychiatry service. Themes from these interviews emerged via the application of thematic analysis, with particular attention to conscious and unconscious material and intrapsychic processes including feeling states and other non-verbal aspects of interviews in both interviewer and interviewee, and were interpreted by the authors within a predominantly Kleinian framework centring on Bion’s idea of container-contained. These patients’ suffering, depicted powerfully by their descriptions of feeling controlled by a foreign body, and the authors’ exploration of this, provide us with new understandings of how the links between mind and body can be brutally ruptured.
The next paper, entitled ‘Trainee psychotherapy effectiveness at a psychodynamic training clinic: a practice-based study’ by David Paine, Chance Bell, Steven Sandage, David Rupert, Miriam Bronstein, Christopher O’Rourke, George Stavros, Sarah Moon and Lauren Kehoe, from the US, addresses the question as to whether the outcomes of patients in therapy with trainees are less good than those of patients being treated by qualified and more experienced psychotherapists. The authors used a practice-based evidence approach, as opposed to evidence-based practice – a naturalistic research methodology which lends itself more easily to investigating issues encountered in routine clinical psychotherapy practice, in that the data used is collected routinely (e.g. outcome monitoring), the sample is more representative of the treatment population and there are no controls or randomisation. Although such studies lack the internal validity of randomised controlled trials, they are more representative of practice as usual, and may nevertheless provide sufficient empirical evidence of effectiveness to persuade commissioners to continue to fund a service, or in the case of this study carried out at a community mental health clinic in Boston, Massachusetts, to persuade insurance companies to reimburse the patients being treated by non-licenced trainees in a psychodynamic clinical training programme for psychologists, psychiatrists and social workers. Paine and his colleagues examined the outcomes of 280 patients treated by 52 trainees between 2008 and 2016 and found that the patients showed significant overall clinical improvement in mental health symptoms and psychosocial functioning, with effect sizes comparable to the benchmark effect sizes found in the original validation studies for the measures used in patients with similar levels of distress treated by qualified clinicians. Although the findings of this study would need to be validated by more rigorous controlled trials, they nevertheless replicate the results of previous studies showing that trainees make effective therapists, which is important given that the majority of the clinical work delivered by psychotherapy services in the public sector is often by trainees or newly qualified therapists.
The third paper also explores issues of training, using a qualitative methodology similar to our first paper. In ‘Influence of personal therapy on learning and development of psychotherapeutic skills’ by Katarina Astrand – who tragically died before the paper was accepted for publication – and Rolf Sandell, thematic analysis was conducted on interviews with former students at two psychoanalytic psychotherapy training institutes in Sweden. Personal psychotherapy or psychoanalysis has of course always been one of the essential, and some might argue the most important, requirement of training in psychoanalytic psychotherapy, and is one of the hallmarks of training in this modality compared to training in other psychotherapies where personal therapy is not mandatory. Personal therapy is thought to serve a number of functions and goals for the therapist including increased emotional growth and empathy, improved interpersonal skills and interpersonal sensitivity, increasing self-awareness of one’s own conflicts and values, a greater capacity to mentalise, an opportunity to identify with the role of the patient, and confidence in the value of psychotherapy. However, it is difficult to empirically research the effects of the therapist’s therapy on the therapist’s patients, as well as the role of many other variables such as the frequency of sessions, length of therapy and theoretical orientation of the therapist’s therapist, so that recommendations for therapy differ between different psychotherapy training organisations. Nevertheless, Astrand and Sandell’s study goes some way in trying to identify the different elements of personal therapy that might be important in the personal and professional development of a psychoanalytic psychotherapist. Three key aspects of the influence of personal therapy emerged in the interviews, which the authors categorised as ‘shared experience’, ‘personal influence’ and ‘knowledge integration’. These, in turn, were subsumed under an overall theme of ‘professional subjectivity’, which they describe as a therapeutic competence encompassing an independent and subjective attitude to theory and practice so that psychoanalytic theory comes alive and can be delivered in a personal way. This study also illustrates the value of qualitative research in psychoanalytic psychotherapy in investigating subjective phenomena that may seem elusive and very personal to the therapist. One’s own therapy is, of course, essentially personal, and much of it very private, but this paper shows how the subjects of this study, in their courage in revealing to the external world some of the experiences of how their inner world is shaped by psychotherapy, may benefit all of us in trying to identify which techniques and experiences might be mutative for our patients and ourselves.
Our final paper in this issue also touches on the personal experiences of a psychoanalytic psychotherapist. In ‘Terror in the countertransference: extreme anxiety as a clinician and organisational leader and its effects’ Raman Kapur explores, again within a Kleinian theoretical framework, disturbed and traumatised states of mind via both the methodology of the single case study or clinical narrative of a patient, and through examination of the organisational dynamics of the institution where the author worked in Northern Ireland. In research terms, Kapur uses his countertransference as the instrument of investigation of the patient’s psychopathology – what would be thought of by most as a routine integral part of psychoanalytic technique. But he also shows how his countertransference helped him understand the pathological institutional and political dynamics which paralysed effective functioning within the organisation. Kapur describes how the organisation and its leadership, already traumatised by decades of sectarian violence, unconsciously shifted the fundamental division within the foundational matrix of Northern Irish society from religion to colour, so that the conflict which until now had existed between Protestant and Catholic and was barely contained by more recent political agreements, erupted again when the leadership of the organisation changed from ‘white to brown’, as the author, the son of immigrant Asian parents, took on the role of CEO. Using Hopper’s theoretical elaboration of Bion’s basic assumptions – the fourth basic assumption of aggregation and massification – Kapur shows how the containment of extreme primitive anxieties and the terror of annihilation had failed following the cumulative traumas and failed dependency on parental figures that this society had endured and it was only through the slow and painstaking working through of his own countertransference and understanding what had been projected into him, that he was able to transform the organisation’s culture and functioning from an incohesive, paranoid-schizoid state to a cohesive or depressive position.