As more research reveals the enormity of the negative health-related impacts of the Covid-19 pandemic, many of us in the mental health field have become focused on the devastating damage that the virus can wreak on people’s psychological, as well as physical, health. These pathological effects may be due to the direct action of the virus on the brain, such as inflammation, mini-strokes and an increased risk of developing dementia; less clear psychopathological mechanisms resulting in the exhaustion, ‘brain fog’, anxiety, and depression associated with long Covid; the indirect psychological impact of the virus in people who may not have had the virus but who have lost their loved ones, employment, education and many other aspects of their daily lives; and the more global consequences of poor political decision-making, the economic downturn, and neglect of addressing threats to the environment, the discrimination of people of colour, and violence towards women, all of which have been exacerbated by the pandemic, and have provoked both anxiety and anger.
The three papers in this issue are not about Covid and were written before the pandemic; however, they collectively reveal inter-related themes that are pertinent to the virus and its effects. One such theme is the close relationship that exists between body and mind; another is how to process and mourn trauma and loss without resorting to damaging defensive strategies; and a third is the vicious circle of anger and anxiety in interpersonal relationships which may result in symptoms which paralyse a person’s functioning.
The first paper, ‘Unconscious loss processing in diabetes: associations with medication adherence and quality of care’ by Francesco Marchini and his colleagues, is a study from Italy exploring the links between psychopathological dynamic processes and treatment adherence, quality of care, duration of illness and other variables in people suffering from diabetes. The paper draws on a rich psychoanalytic literature linking body and mind, in particular the French psychosomatic school, and more recently that of mentalization.
Using a conceptual framework based on object relations theory and self-psychology, which suggests that disruption in the body-psyche may result in people with chronic physical illnesses from the experience of threats to physical integrity, loss of bodily intactness and narcissistic injuries, the authors assess four ‘damaged-ego related strategies’ in terms of unconscious processes related to these losses and adaptation to living with a chronic diabetic condition. These strategies comprise: empathic identification, which focuses on admiration and positive feelings; mania in which personal loss is denied; frustration, which emphasises personal grief; and destructiveness, which involves the expression of angry and envious feelings. The authors found that those patients whose capacity for empathic identification – their ability to maintain hope and invest in caring relationships towards themselves and others – was greater were less likely to become depressed and more likely to adhere to their medication; whereas those patients who scored high on destructiveness were more likely to experience poor quality of care; and those with manic defences were less likely to adhere to their treatment. Interestingly, age, but not duration of illness, predicted lower empathic identification and higher destructiveness, which the authors interpret, in line with previous research, as being due to older people being more likely to express hostile beliefs such as cynicism and suspiciousness, and therefore less able to process loss. These findings suggest the need for more psychological support for older adults with diabetes.
The second paper, ‘“What are you looking for?”: a psychoanalytically oriented qualitative study of men’s compulsive use of internet pornography’ by Michael McDonald and John O’Connor, explores the intrapsychic dynamics underlying the compulsive use of internet pornography of five men who were interviewed for this study, which took place in Ireland. The narratives of these men, and how damaging they felt that their addiction to pornography was to their lives and relationships, resonate with the experiences of many of the patients I treat at the Portman ClinicFootnote1 who present with problematic sexual behaviours, including excessive use of pornography. The interviews highlight the conflicting feelings experienced by such individuals: on the one hand feelings of anger, aggression, hatred and power, and on the other hand feelings of smallness, shame, anxiety, powerlessness and weakness; and how watching pornography was a way of managing such difficult feelings, which often stemmed from adverse childhood experiences, including premature sexualisation due to direct sexual abuse or exposure to pornography. Retreating into the fantasy world of internet pornography can be seen as bestowing a sense of power and excitement which temporarily compensates for feelings of inadequacy or anger that emerge in their intimate relationships and reverse the power dynamic they experienced in childhood; but such relief is short lived as the sexual gratification obtained from the images is quickly followed by feelings of shame, guilt, depression and inadequacy, which can only be assuaged by turning to pornography again, thus creating a compulsive vicious circle of acting out by discharging psychological distress through the sexual body, underscoring the close links between aggression and sexuality. The authors also found that the men described their use of pornography as a split-off secret activity which they concealed from their partners and family; as well as their sense that in accessing the internet to look at sexual images they were endlessly searching for something that was ill-defined and could not be found, which the authors link to Laplanche’s theory of infantile sexuality where the unconscious seduction of the baby by the mother leaves the child with a sense of unreachable meaning and desire for the lost object, again themes which are common in my patients. This paper also draws attention to the lack of psychological treatments of any modality available for people suffering from compulsive use of pornography, again, a state of affairs that is very familiar to me, as for many such patients that we see at the Portman Clinic, this is the only service they have found which specializes in treating these specific difficulties, and moreover, with psychoanalytic psychotherapy.
The third paper ‘Mentalization-based therapy for a patient suffering from panic disorder: a systematic single case study’ by Stine Høgenhaug and colleagues in Denmark and Austria, describes the treatment of a woman diagnosed with panic disorder with agoraphobia, which is one of the most common psychiatric disorders worldwide, and one which we might expect to have become more common during the Covid pandemic. Panic disorder also illustrates the intimate relationship between mind and body, where panic attacks are seen as catastrophic misinterpretations of bodily and mental events. Panic disorder is most commonly treated with cognitive behavioural therapy (CBT) via exposure and restructuring thoughts to help patients re-evaluate their interpretations of events. However, although CBT may be efficacious, a significant proportion of patients do not benefit, and in the last 20 years psychodynamic therapies have been developed for this condition, most notably panic-focused dynamic therapy, developed and empirically tested by Barbara Milrod, who is a member of this journal’s editorial board. Psychodynamic therapies aim to address the unconscious conflicts and defence mechanisms that give rise to the anxiety symptoms, for example, in some cases panic attacks may be the manifestation of unconscious aggressive fantasies that are unacceptable to the conscious mind.
Mentalization-based treatment (MBT), another psychodynamic therapy, may be particularly useful in this patient population as they have been shown to have a lower symptom-specific reflective function, or mentalizing capacity, rather than lower general reflective function, in that they find it difficult to reflect on their panic attacks and understand their physical symptoms in relation to underlying mental states. The treatment of the patient with MBT described in this paper centred around themes of affect recognition and management, especially suppressed anger and managing conflicts; and boundaries in attachment relationships and developing independence. Again highlighting the confusion between mind and body, as well as between self and other, particular attention was paid to the embodied interaction in the therapeutic alliance in therapy, using daily self-assessments on mentalization-related cognition and body-experience. This paper is a good illustration of demonstrating the value of single case studies, a methodology which is regaining recognition within empirical research in psychological therapies. The study is also a good example of process research in aiming to elucidate some of the mechanisms of treatment which facilitate change – not just exploring the question ‘Does this treatment work?’ but ‘How does this treatment work?’ – by using session to session monitoring, a method often frowned upon by more traditional psychoanalytic therapists, and the microanalysis of therapy sessions to pinpoint how the therapist’s interventions affected the patient’s progress. The positive results of the treatment, in reducing the patient’s anxiety symptoms and enabling the patient to function better in her everyday life, underscore the utility of psychodynamic treatments for mental disorders.
It is also worth noting that none of these studies originate from the UK, which demonstrates the reach that the journal has in attracting submissions internationally, and also reflects the rationale of the recent change of the name of the organisation it represents from the ‘Association of Psychoanalytic Psychotherapy in the NHS’, to the ‘Association of Psychoanalytic Psychotherapy in the Public Sector’ to be more relevant and applicable to psychoanalytic psychotherapists and other interested readers and researchers in other countries outside of the UK.
Notes
1. The Portman Clinic, part of the Tavistock and Portman NHS Foundation Trust, is a National Health Service (NHS) specialist out-patient clinic in London, UK, offering psychoanalytic and psychodynamic psychotherapies for the assessment, treatment and consultation for adults, children and adolescents troubled by problems of criminality, violence, sexual difficulties, or antisocial personality disorder.