I am writing this editorial in July 2021 as the government-imposed restrictions against the Covid pandemic are lifting in the UK, bringing much relief to some, but increasing anxiety to others as infection rates of the Delta variant of the virus dramatically increase. Despite the demonstrable efficacy of the vaccines in limiting infections and the severity of illness in those who become infected, anxieties mount again about the increasing pressure on the national health and other public sector in the UK and other countries, with the postponement of non-Covid related interventions and unbearble stresses on staff. Notwithstanding the real challenges in decision-making between balancing the economic recovery against preventing further deaths and debilitating illness, erratic and ambiguous messages and behaviour from governments about how to best handle the pandemic have fostered polarised splits in society: those who become vaccinated versus those who refuse; those who view social distancing as an infringement of liberty and free choice versus those who are terrified of the increased risk of becoming infected; and those whose potential loss of livelihood forces them into contravening social distancing regulations to maintain employment versus those whose wealth protects them from economic adversity.
As in previous issues of this journal published during the pandemic, the papers here are not specifically about Covid but collectively illustrate certain psychoanalytic principles and practice that may be relevant in helping some of those who have suffered from the negative, and at times, devastating, health, social, economic and political consequences of the virus. One of these principles is the ability to tolerate uncertainty, to bear anxiety without precipitously acting on it or discharging it into others. The first paper in this issue ‘Beyond the walls of Camden & Islington Personality Disorder Service: A qualitative study of clinical consultation to external services’ by Andrew White, Abigail Herbert and Pierise Marshall, explores the experiences of clinicians in a London-based personality disorder service who provide clinical consultation to clinicians in external services, helping them to formulate, reflect upon and manage their patients and clients with personality difficulties. Qualitative thematic analysis of interviews with clinicians delivering the supervision consultation service identified themes of ‘Anxiety’, ‘Fragmented Co-working’ and ‘Task Difficulty’ reflecting similar concerns in the clinicians to whom the service is delivered, which reflect in turn the primitive disturbances in the minds and relationships of the patients being managed by the external services. The authors use a Kleinian psychoanalytic framework to show how unprocessed anxieties are projected from patients, to clinicians, to supervisors, and vice versa, causing rifts, distress and tensions between the different parties, loss of confidence in professionals, and difficulties in delivering safe and effective care. One can see that we could very well be talking about the struggles in managing the pandemic in place of those in managing patients with personality disorder. The distancing of professionals from these patients to prevent them from being affected by their disturbance parallels the fear of being infected by a deadly pathogen. The authors stress the importance of reflective spaces and supervision, including for those who are delivering them, where countertransferential affects and reactions can be explored and anxieties processed. Related to this I have referred in a previous editorial to growing demands for Balint groups and other forms of reflective practice to front line workers and other staff closely working with Covid patients.
The second paper, ‘How is the trainee affected by psychoanalytic observation (other than infant observation) during psychotherapy training? A systematic literature review’ by Ally Xiang, also highlights similar themes: the importance of being able to experience and tolerate anxieties without unthinking action in the role of the observer, and the use of the countertransference in being receptive to what is being experienced. This is the first literature review on this topic. Infant observation is an integral component of many psychoanalytic psychotherapy trainings, introducing the trainee to experiencing the countertransference in using their emotional responses as a tool to accessing unconscious material before taking on a patient. But trainees may also benefit from the experience of other psychoanalytic observations. This review focusses on published studies of psychoanalytic observations in other settings, including psychiatric and medical wards, a palliative care unit, social care services, neonatal intensive care units and a day nursery, and shows how health and social care professionals, educators and child carers learnt to reflect on what they have observed and experienced without resorting to action, to use the unconscious as sources of information, to witness projections and to develop a capacity for containment.
The third paper, ‘Compelling images: A contribution to the theory of aesthetic countertransference’ by Liam Bierschenk, also focusses on the place of the countertransference in the treatment with patients with personality disorder, specifically with group art therapy in a National Health Service therapeutic community day service for adults with a diagnosis of borderline personality disorder in the UK. Bierschenk traces the therapy of an individual female patient, and by observing her paintings, published in this paper, explains to the reader how her enigmatic artwork inspired a non-verbal experience of quiet contemplation, awe and reverie within the author that he calls the aesthetic countertransference. Using ideas from Klein, Bion and Grotstein, as well as drawing on art critical theory and mentalization concepts Bierschenk constructs an innovative theory to make sense of his experience and how this enabled him to understand both the pathological and healing processes within the patient.
Finally, ‘The New Depressives and the Challenge of Stigma’ is the final section of Jeremy Clarke’s three-part narrative book review essay of depression memoirs in the public sphere, the first and second being published in previous issues of this journal. The books reviewed here are ‘Manufacturing Depression: the secret history of a modern disease’ by Gary Greenberg, ‘The Other Side of Silence: a Psychiatrist’s Memoir of Depression’, by Linda Gask, ‘Lost Connections: Why You’re Depressed and How to Find Hope’, by Johann Hari and ‘Living Better: How I Learned to Survive Depression’, by Alastair Campbell. These accounts expose how empirical studies of patients with depressive disorders often fail to capture the personal experiences of the condition, sometimes felt to be part of the person’s sense of self. The openness of clinicians to hearing and reflecting on the stories of individual sufferers of depression undoubtedly enhances their ability to provide therapeutic care for this debilitating condition, needed more than ever with the rising rates of depression in both the growing number of people suffering from long Covid as well as those, including children and young people, who may not have had the infection but whose lives have been fundamentally changed by disruptions to education, unemployment, social isolation and the many other negative and far-reaching consequences of this insidious virus.