Editorial

Cyber suicide and transgender identities are contemporary phenomena that rightly attract much attention and concern, yet which test the limits of our comprehensibility. The individual who explores suicidal fantasies online, and the transgender person who is unhappy with their biological sex, challenge not only commonly held beliefs that in the natural order, living should be prioritised over dying, and genetically determined gender is more ‘real’ than reassignment to the opposite gender, but also more fundamentally challenge our dichotomous conceptualisations of life vs. death and male vs. female. Understanding suicide or transgender issues necessitates a more nuanced attitude, a fluidity in our thinking that allows consideration of a middle area, a transitional space where ideas can be shared, explored and played with, even in matters of life and death, rather than immobilised in psychic spaces that remain cut-off and hidden due to fears of rejection and repudiation.

The first two papers in this issue of Psychoanalytic Psychotherapy address these contentious issues from a psychoanalytic perspective, and in doing so, confront existing psychoanalytic theories and practice which may be perceived as inhibiting the patient’s sense of agency or choice. In ‘What’s in a name? A psychoanalytic exploration’, Rachel Rodgers and John O’Connor describe their study seeking to understand how gender identity and a sense of self develop in six transgender individuals through exploration of their lived experience. This qualitative study applied methodology in which the interview technique employed psychoanalytical ideas by focussing on the interviewer’s counter-transference, and the intersubjective relational dynamic between interviewer and participant, to allow unconscious themes to be included in analysis of the material at different levels. Drawing on Winnicott’s idea of the ‘false self’ and more recent theorising on incongruent mirroring (Fonagy, Gergely, Jursit, & Target, 2002; Lemma, 2012) the authors demonstrate how psychoanalytic thinking evolves to provide a psychoanalytic perspective on states of mind which defy conventional notions of mind and body boundaries.

The rising rate of cyber suicide – completed or attempted suicide influenced by the Internet – similarly attracts public concern and confusion. For therapists, this forces us to explore our patients’ digital lives, in which their minds are sequestered into hidden and barely accessibly spaces – for example, within the ‘Dark net’ – and merge into a collective of individuals pulled towards destruction of the body. This leads us to consider the covert dimensions of their lives, an area between the conscious and unconscious where fantasies and emotions may be frozen to maintain a precarious equilibrium between life and death impulses, or compelled along a deadly trajectory which, if not halted, results in a fatal outcome.

Drawing on the conceptualisations of post-Kleinian psychoanalysts of a mind split between rival parts competing for control of the vulnerable individual and their capacity to tolerate and manage emotional pain and reality, Marc Kingsley, Tom Stockmann and Daniel Wright propose that the psyche of the person who goes online searching for suicide is split between a ‘suicidal part’ and ‘non-suicidal part’ which struggle for domination of the inner life, external relationships and decisions of the suicidal person. This split will inevitably influence the transference and counter-transference within the therapeutic relationship, which if unrecognised, may increase the risk of actual suicide. The psychotherapist’s understanding of risk management in the digital age will inform their interventions aimed at freeing the individual from their entrapment by destructive forces and enabling them to safely explore the function of suicidal ideation within a more creative and hopeful transitional state of mind.

In contrast to the current high profiles of suicide, and the transgender debate, the subject of the next paper addresses an issue that seems to no longer concern policy-makers, commissioners and the media – the continuing deleterious effects of seemingly perpetual organisational changes within the National Health Service (NHS). In the face of this disinterest and neglect, those that continue to work within the system may only survive by employing a range of unhealthy defences, or leave altogether. In their paper ‘The impact of organisational change on professionals working within a Community Mental Health Team (CMHT): A psychodynamic perspective’, Bridget Hanley, Helen Scott and Helena Priest explore the effects of organisational change upon staff working in a CMHT using grounded theory methodology influenced by psychodynamic theory to analyse data from interviews with a range of staff. Key categories that emerged included staff members’ sense of demoralisation of their professional values and integrity; their perception of change within the CMHT, with an increased emphasis on regulation, performance management and proceduralisation; their experience of ‘caring clinicians and uncaring managers’; and their confusion regarding their professional roles and feelings of disconnection and isolation. Unsurprisingly, the consequences of such experiences include a high staff turnover and increased risk to patients. This paper is a welcome addition to a number of papers that we have published in this journal over the last few years regarding the negative effects of financial constraints, cultural changes and reorganisations within the NHS, but it is also a depressing reminder that the recommendations and lessons learned from the Francis Report (2013), which identified a large number of errors, omissions and abuses within the toxic culture of Mid Staffordshire Hospital Trust, may not have been implemented or sustained.

The last two papers in this issue describe innovative psychoanalytically informed work with parents who have separated or divorced, but who remain locked in angry and hostile disputes, which have damaging effects on their children. Up to 25% of divorced parents remain in conflicted co-parenting relationships, which may cause serious emotional and behavioural problems in their children, as well as significant costs to the state as a result of protracted family court proceedings. However, current therapeutic options for such couples are limited, and there is a pressing need to develop interventions that support collaborative post-separation relationships.

Mentalisation-Based Therapy for Parental Conflict – Parenting Together, developed at Tavistock Relations in collaboration with the Anna Freud Centre and University College London, is a therapeutic intervention integrating mentalisation-based principles and techniques within a psychoanalytic couple psychotherapy framework, and which crucially engages both parents together with the aim of reducing conflicts between parents and mitigating the damaging effects of inter-parental conflict on children.

The first of these two papers, ‘Mentalization-based therapy for parental conflict – Parenting Together; An intervention for parents in entrenched separation disputes’ by Leezah Hertzmann, Susanna Abse, Mary Target, Krisztina Glausius, Viveka Nyberg and Dana Lassri, describes the theoretical and practical key elements of the intervention, illustrated with case vignettes, its implementation with this population in the context of a pilot research study and the challenges for therapists working with parents who are struggling with extreme states of mind. The second paper, ‘Parents’ experience of child contact within entrenched conflict families following separation and divorce: A qualitative study’, by Mary Target, Leezah Hertzmann, Nick Midgley, Polly Casey and Dana Lassri, provides a fuller picture of these parents’ experiences of their contact arrangements for their children after separation, by a qualitative study conducting semi-structured interviews, subject to thematic analysis, with 22 parents. The results vividly illustrate the states of extreme anger, depression, anxiety and fears of going mad that these couples are struggling with, and the immense strains on the children who are subjected to their parents’ prolonged disputes. These papers, which vividly expose the serious nature and effects of severe parental conflicts post-separation, provide compelling information to inform best practice for professionals working with this population, as well as future policy directions for services and models of treatment.

Jessica Yakeley
Tavistock and Portman NHS Foundation Trust, London, UK
[email protected]