Towards the end of the summer I belatedly caught up on the 2017 ITV series of ‘Unforgotten’, Chris Lang’s crime drama featuring two low key, ordinary looking detectives specialising in re-opening and investigating ‘cold cases’. Avoiding the sensationalism that usually clusters around the unveiling of a violently killed body, it focusses upon the people and the relationships that emerge from the shadows as long-dead lines of enquiry are re-opened. Season 2 is about a murdered man who was sexually abused as a child, and, it emerges, was also a perpetrator. The series asks the viewer to consider what constitutes justice, how to reconcile the victim-perpetrator split we might all rather maintain, and where responsibility lies for containment of the sheer murderous rage that surrounds experiences of abuse, misuse and harm at the hands of others. These are themes familiar to us as clinicians, and they resonated powerfully with me as I read the different contributions in this issue. Several of our authors below are interested in the struggle to contain persecutory feelings of hatred and anger, directed towards the self or others, and how these can be transmuted or understood, or sometimes harnessed to amplify grievance. The papers explore how individual acts of retribution, restitution and forgiveness are the complex end results of choices we make, following experiences we have, that are shaped by the places we find ourselves in – both materially and metaphorically.
Elisabeth Punzi’s article, ‘“Any room won’t do”: Clinical psychologists’ understanding of the consulting room’, looks at the importance of safety in the setting housing the clinical process, specifically, the consulting room. The author describes a small, qualitative research study she conducted in Gothenberg, Sweden, interviewing five experienced clinical psychologists working in public or voluntary sector settings. Her respondents used a range of modalities with clients, but all had engaged in long-term counselling work. Punzi notes that the room used for treatment is both a milieu that communicates something to the client about the clinician, and a place the client imbues with their own meaning. It is a stable but dynamic space in its own right; as one of the author’s interviewees comments, it is ‘the same room’ that is returned to and perceived in different lights over time.
The author initially makes some stimulating links between classic psychoanalytic ideas such as Winnicott’s concept of ‘transitional space’, and more recent ideas drawn from human and cultural geography, and critical psychology. Her theoretical discussion about the way that the imagination is bounded by material things and locations sets the stage for her main point, which is that the room is both a ‘given’ background and part of the imaginary space within which the therapeutic relationship unfolds. Thematic analysis of the interview material is richly illustrated with thought-provoking quotations from her interviewees. The key theme of safety emerges, including confidentiality and comfort, and the author looks at how the clinicians interviewed felt this was achieved in the consulting room. Whilst this might seem a simple sine qua non, the author draws our attention to the amount of thought potentially required to achieve and maintain this steady ‘frame’ for the work. The article sensitively explores key questions of taste and cultural and personal expectations, as well as considering accessibility and the maintenance of the protective boundary between the room and the wider organisational setting within which it is housed.
Two examples relating to aesthetics and architecture stayed with me. One was of the significance of the artwork on the walls – one clinician noted how an apparently innocuous picture of a forest and lake could elicit very different feelings in clients – of peace and freedom (which were the therapist’s own associations) but also, of fear at the remoteness and an association to criminal activity. Another example was of a clinician reporting his ‘ideal’ consulting room – in an old house with an open fire. This led me to wonder what our own phantasies about the ‘ideal’ consulting room tell us about our self-image, our aspirations and our sense of a secure base. How might this differ from some of our clients’ phantasies of the ideal space? It is interesting that the series of ‘Unforgotten’ I referred to above is book-ended during the credits by images of rooms – a teenage girl’s bedroom, a party scene in a nameless suburban front room, a bell tent illuminated by torch light and seen from outside. The rooms, like the consulting room, are not, and should not be, the centre of attention. But Punzi’s paper shows us how, given attention, material settings emerges as saturated with feelings that need to be understood if one is to make sense of one’s clients’ – or in the case of ‘Unforgotten’, the protagonists’ – struggles and choices.
The next main article by Coetzee, Adnams and Swartz, ‘A psychodynamic understanding of parental stress among parents of children with learning and developmental disabilities and challenging behaviour’ starts by reviewing the work of Valerie Sinason. The authors are particularly interested in her point that an individual’s capacities and responsiveness can be defensively blunted in order to avoid an awareness of insufficiency and the anxiety that ensues. They argue for the value of a psychodynamic approach to the dynamics of disability, not least because it acknowledges that defensive primitive emotional responses can be shared and amplified in the parent-child dyad, with tragic consequences. The article builds on Sinason’s work and sets out one way of formulating the parental stress experienced by a sub-set of parents who are caring for adult children with learning and developmental disabilities (LDD) and challenging behaviour (CB).
The heart of the paper lies in a detailed case study of a mother and daughter, ‘Patricia’ and ‘Sue’. The case is drawn from (disguised) clinical data obtained from a research sample of mothers of children with LDD/CB. They were seen for between 8 and 9 sessions within the author’s psychotherapeutic practice. The authors are therefore able to substantiate the themes emerging in the individual case study with reference to other clinical examples. This is a distressing case where the authors are at pains to show the psychosocial complexity behind the clinical presentation. We see how the story is about more than the parental deployment of primitive defences against the child’s very challenging behaviour. It is also about more than the (explicable) deployment of denial, omnipotent control and projective identification on the part of an (adult) child living with longstanding primary disabilities. In ‘Sue’s’ case, Coetzee et al note, these have included altered states of consciousness, difficulties with social comprehension and abstract concept formation and an ensuing frightening struggle to differentiate self from other. The authors describe how ‘Patricia’s’ own adverse reactions to her daughter’s difficulties (self-medicating substance abuse, withdrawal, debilitating guilt and suppressed rage) have become part of a reciprocal and mutually-reinforcing projective system between the two. It is this projective gridlock that the authors go on to unpick conceptually. Alongside this, they argue that therapy, particularly psychodynamic family therapy, can support parents in particular in becoming more insightful about what is going on, so as to be able to counter their more undifferentiated responses, and to unpick the gridlock from their side.
Coetzee et al underline the importance of a non-judgemental stance when examining one’s counter-transference in these settings. Their emphasis on understanding and validating the clients’ very difficult historical and enduring emotional experiences is important. The closing remarks are also informed by the psychosocial and material context in South Africa – wider systems of inequality can make a contribution in depriving and blaming clients. I am reminded again of some of the emotional challenges facing the investigators in the 2017 series of ‘Unforgotten’, when the line between victim and perpetrator is shown to be blurred and questions of responsibility are complex. The emotional reactions of primitive rage, murderousness and terror that emerge when the trauma of abuse is part of the picture are arguably very similar to those emerging in the face of irreversible physical or neurological damage. This paper helps us to see how the profound insult and threat offered by these experiences to the body and mind can spark reactions that become confused with each other at a primitive level. They can ricochet between family members and involved professionals, and get into systems. And as we know, these wider socio-political systems can contribute-in to the creation of judgemental, split and punitive responses, reinforcing a simple victim/perpetrator mentality to oversimplify questions of blame and culpability, making a compassionate, restorative stance difficult to sustain.
The final main article in this issue takes us into a very different conceptual and disciplinary terrain. Margherita and Gargiulo report on a methodologically rigorous psychosocial study of two online communities – bloggers on ‘Pro-Ana’ and non-suicidal self-injury (NSSI) sites. There are interesting links with the previous paper, as the discussion is of e-communities of young women caught up in violent attacks upon the self. The authors begin initially by describing previous research in this area and noting that ‘Pro-ana’ and NSSI websites created by and for these communities can be used in diverse ways, for example, to maintain emotional control, to feel part of a group and lessen feelings of isolation, to disclose states of mind to self and others, and in the case of NSSI, to resist urges to self-injure. However, Margherita and Gargiulo also note that there has been considerable disquiet amongst mental and public health professionals about the ways in which these sites, particularly Pro-Ana sites, may present the cluster of symptoms characteristic of anorexia and NSSI as part of a voluntary, potentially glorified lifestyle choice.
A key theoretical presumption of the article, following the work of authors such as Sherry Turkle and Glen Gabbard, is that cyberspace can be an extension of the intra-psychic and internal universe and therefore a place where unconscious relational patterns and mental processes can be acted out (and potentially worked through). For young people in particular, the authors argue, e-communities offer key spaces for the construction, representation and expression of identity. They may provide a way of seeking help from peers, one that may be preferred to a ‘real’ clinical or therapeutic setting. As clinicians, then, it is helpful to know about how these e-communities may be used by our clients. Margherita and Gargiulo sought to understand both the content and the function of the specific online spaces they researched, performing a cluster analysis on 40 Italian blogs, 20 written by ‘Pro-Ana’ users and 20 written by users of NSSI sites. They conclude that these particular sets of blogs differ both in terms of content and function, with the NSSI blogs containing several thematic clusters relating to control of the body, affect regulation, peer help and the sharing of emotions, and the ‘Pro-Ana’ blogs containing only one very concretely represented thematic cluster tightly linked to anorexic symptomatology and bodily control. It is as if, in the ‘Pro-Ana’ blogs, there is ‘nobody there’ relationally; whereas in the NSSI blogs, although others are a source of pain and ambivalence, they are sought. The article is ambitious in its attempt to make links between a rigorous discursive analysis grounded in qualitative sociological research and more clinically grounded theorising about the characteristic object relational worlds found in patients with anorexia and NSSI. I particularly appreciated the authors’ own imaginative associations to the factorial maps produced later on in their analysis – the ‘Pro-Ana’ map is largely empty, with one small cluster in an otherwise bare ‘relational’ landscape; the ‘NSSI’ map is more populated.
The first of the ’Open Space’ papers in this issue, by Peter Chapman, is entitled, ‘“You can’t say that”: Notes on the nature and culture of contemporary grievance’. Chapman picks up on an important observation Freud made in one of his Introductory Lectures, concerning the ubiquity of free-floating anxiety or fear in psychic life. Chapman describes how social media, with its characteristically truncated, rapid and virtual mode of expression, can provide an outlet for getting rid of this sense of disquiet, arguably something which is part of the human condition. Chapman notes that in many blogs and threads accompanying political news stories and commentaries, the dominant theme is a sense of personal grievance and outrage about the state of (current) affairs – ‘It’s not fair!’ He suggests that something unconscious and primitive becomes attached to discourses of identity politics in particular. Whilst it may continue to be necessary to explore the ways in which the personal can be understood as political (and Chapman gives some contemporary examples), it is not helpful, he points out, to reduce the personal to the political and to make sense of all difficulties and struggles as originating in one’s social identity. Chapman revisits Melanie Klein’s discussion of early aggrieved states of mind in order to highlight how ordinary ‘unfairness’ and painful checks to one’s narcissism can be experienced disproportionally in infancy as the judgement of a vengeful, bad parent – in part, a disguised return of one’s own repressed attempts to injure and slight. Where forums of debate and modes of discourse do not provide opportunities or the requirement for a mature attempt to struggle with one’s own agency and responsibilities, Chapman suggests, we can see debate reduced to the setting up of hierarchies of grievance, and the righteous location of ‘badness’ in others.
The second ‘Open Space’ paper, by Natasha de Meric, is called, ‘Where the Wild Things Are: a lesson on surviving and transforming anger’. The article is a thoughtful meditation on the appeal of this classic children’s picture book, which imaginatively depicts a young child’s experience of consuming rage. ‘Max’ is able to work through his rage, which literally and then imaginatively transports him somewhere wild. De Meric looks at how this conversion is possible, and why his working through takes the form it does. Like many children’s classics, Sendak takes a dark theme and looks at it without sentimentality. What de Meric identifies is the potential exuberance in Max’s wild rage, and what she describes as a ‘Bacchus-like’ intensity to young children’s emotional states. She looks at the early but enduring fear that our most extreme reactive and retaliatory feelings, both voracious love and murderous hate, can be bigger than we are, possessing us so that we, and those we love, are not safe. It is this risky, knife-edge quality to the powerfulness of real feeling that de Meric explores. She argues, using Bion, that it is the containment provided by a caring other, who can tolerate these states without retaliation, enabling a child to come to terms with the feelings and harness them creatively. When Max returns to his safe bedroom after his sojourn with the wild things, there is milk, cake and porridge wordlessly waiting for him, and it has been kept hot for his return. In thinking about Max’s very ordinary but very real struggle I found myself thinking back again to ‘Unforgotten’, and the situation of the child, young person or adult who cannot rely on containment of their rage and do not have a place to go with it, and therefore cannot let it out or let it go safely.
There are two contrasting book review essays in this issue. The first, by Saeed Kalilirad, discusses Jill Bresler’s and Karen Starr’s edited collection on ‘Relational Psychoanalysis and Psychotherapy Integration: An Evolving Synergy’. Kalilirad provides a helpful and detailed overview of each chapter, starting with the introductory chapters, which include a review of historical attempts by analysts such as Ferenczi and Rank to integrate psychoanalysis with other approaches. Kalilirad introduces us to the perspectives of the different practitioners who have written chapters for the main body of the book. They take the opportunity to describe how they have integrated the long term relational psychoanalytic approach with other therapies, most usually, Cognitive Behavioural Therapy. However, as Kalilirad discusses, there are also chapters on integrating humanistic and systems therapy, and the more recent Mindfulness and Dynamic Neurofeedback therapies. Kalilirad’s review presents us with questions he found unanswered by the book, particularly, the contribution that research should make to the evidence base for integrating therapies, and what place briefer psychodynamic work should have in integrative practice.
The second book review essay, by Shushida Dhall, is of Vamik Volkan’s, ‘Immigrants and Refugees: Trauma, Perennial Mourning, Prejudice and Border Psychology’. Dhall locates herself as a practitioner at ‘refugee Resource’, a charity working on the frontline with refugees, asylum seekers and vulnerable migrants, and her experience of the rawness and messiness of frontline work in this area informs her impassioned critique of Volkan’s book. Whilst she acknowledges the strength and subtlety of Volkan’s arguments about the uses we make of the ‘Other’, she finds his analysis of the situation of the refugee to be partial, ill-informed and lacking in discernment. Her review is, in my opinion, appropriately angry; it is an exploration in its own right of the dire psychic positioning of many if not most asylum seekers (including those who have had their appeal rights exhausted) and undocumented and vulnerable trafficked migrants. She speaks movingly about the traumatic limbo these ‘refugees’ are assigned to and raises important questions about whether therapeutic neutrality and empathy is enough, when what may be needed is advocacy and explicit confirmation that for some people, the external social world is indeed actively and currently persecutory beyond endurance.
Towards the end of the issue, the reader will also find five more book reviews. Manuel Batsch considers Gerard Lucas’ ‘The Vicissitudes of Totemism – One Hundred Years after Totem and Taboo’; Linda Cundy discusses ‘Art, Creativity and Psychoanalysis: perspectives from Analyst-Artists’, edited by George Hagman; Lavinia Gomez’ book, ‘Developments in Object Relations: Controversies, Conflict and Common Ground’, is reviewed by Roger Lippin; ’Robert Withers reviews Edward Santana’s book, ‘Jung and Sex’, and Paul Steinberg discusses a range of theoretical clinical approaches to regret, in a collection on the subject edited by Salman Akhtar and Shahrzad Siassi.
This is a rich issue debating some important and complex questions about where traumatic and narcissistic injury shade into one another, what enables toleration of states of outrage and hatred, and how psychodynamic approaches can illuminate these questions.