Talking About The Talking

CHAPTER TITLE I
FROM ID TO INTERSUBJECTIVITY
FROM ID TO
INTERSUBJECTIVITY
Talking About the Talking Cure
with Master Clinicians
Dianna T. Kenny
First published in 2014 by
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CONTENTS
ABOUT THE AUTHOR AND THE PSYCHOTHERAPISTS vii
FOREWORD xi
CHAPTER ONE
Where the talking began: the birth of psychoanalysis 1
CHAPTER TWO
Beyond Freuds psychoanalysis 45
CHAPTER THREE
Dr Ron Spielman: object relations psychoanalysis 99
CHAPTER FOUR
Professor Jeremy Holmes: attachment-informed 143
psychotherapy
CHAPTER FIVE
Dr Robert D. Stolorow: intersubjective, existential, 179
phenomenological psychoanalysis
v
vi CONTENTS
CHAPTER SIX
Professor Allan Abbass: intensive short-term dynamic 213
psychotherapy
CHAPTER SEVEN
Historical continuity and discontinuity in the meaning 251
of key psychoanalytic concepts as revealed in the
transcripts of interview
CHAPTER EIGHT
Commentaries on the transcript of an analytic session 265
CHAPTER NINE
Textual and conceptual analysis of psychotherapists 297
commentaries on the transcript of the analytic session
CONCLUSION: One tree, many branches? 323
NOTES 327
REFERENCES 331
INDEX 361
ABOUT THE AUTHOR AND THE PSYCHOTHERAPISTS
Dianna T. Kenny, PhD, MA (Sch Couns) BA (Hons) ATCL DipEd

MAPsS MAPA, is Professor of Psychology at the University of
Sydney, Australia. She has also been, at various times, a teacher,
school psychologist, child and adolescent psychologist, psycho-
therapist, and marriage and family therapist. She is the author of over
200 publications, including six books, the most recent of which are
Young Offenders on Community Orders: Health, Welfare and Criminogenic
Needs (Sydney University Press, 2008) (with Paul Nelson), The
Psychology of Music Performance Anxiety (Oxford University Press,
2011) and Bringing up Baby: The Psychoanalytic Infant Comes of Age
(Karnac, 2013).
The psychotherapists
Allan Abbass MD, FRCPC, is Professor, Director of Psychiatric

Education and Founding Director of the Centre for Emotions and
Health at Dalhousie University in Halifax, Canada. He is an award-
winning educator, having been recognised on a regional and national
level for developing excellent education programmes. With over
vii
viii ABOUT THE AUTHOR AND THE PSYCHOTHERAPISTS
125 publications, he is also a leading researcher in the area of short-

term psychodynamic psychotherapy, having led a Cochrane review
and several other reviews of the literature. He has also completed and
published clinical trials in psychotherapy including randomised
controlled trials. He currently provides several training programmes
around the world and has facilitated new psychotherapy clinical and
research programmes in several countries.
Jeremy Holmes, MD, FRCPsych, BPC, worked as Consultant Psychia-

trist and Psychotherapist in the NHS for 35 years. He was Chair of the
Psychotherapy Faculty of the Royal College of Psychiatrists 1998
2002. Now partially retired, he has a part-time private practice;
teaches on a Masters and Doctoral psychoanalytic psychotherapy
training and research programme at Exeter University, where he is
visiting Professor; and lectures nationally and internationally. His
many books include The Oxford Textbook of Psychotherapy (2005, co-
editors Glen Gabbard and Judy Beck), Storrs The Art of Psychotherapy
(Taylor & Francis 2012) and Exploring In Security: Towards an
Attachment-informed Psychoanalytic Psychotherapy (Routledge) which
won the 2010 Canadian Psychological Association Goethe Award. An
extended introduction followed by a 6-volume compendium of the
most important papers in Attachment (2013, Benchmarks in Psychology:
Attachment Theory, SAGE) is co-edited with Arietta Slade. Jeremy was
recipient of the 2009 New York Attachment Consortium Bowlby
Ainsworth Founders Award. Literature and the Therapeutic Imagination,
and John Bowlby and Attachment Theory, 2nd edition (both Routledge),
are due 2013.
Ron Spielman, MBBS, FRANZCP, is a psychiatrist, psychoanalyst

and training analyst of the Australian Psychoanalytic Society. After
qualifying as a psychiatrist in 1972, he became Director of a
Therapeutic Community with the then North Ryde Psychiatric Centre
in Sydney and later Co-ordinator of Alcohol and Drug Services in the
Northern Sydney Health Region. Both these experiences led to a need
to better understand the aetiology and treatment of severe personal-
ity disorder. It was this that led to training to become a psychoanalyst.
He has since taught and supervised fellow health professionals in
psychodynamic and psychoanalytic theory and practice in seminars
and courses of the Sydney Branch of the Australian Psychoanalytical
ABOUT THE AUTHOR AND THE PSYCHOTHERAPISTS ix
Society, the NSW Institute of Psychoanalytic Psychotherapy, and the

Royal Australian and New Zealand College of Psychiatrists.
Robert D. Stolorow, PhD, is a Founding Faculty Member at the

Institute of Contemporary Psychoanalysis, Los Angeles, and at the
Institute for the Psychoanalytic Study of Subjectivity, New York City.
He is the author of World, Affectivity, Trauma: Heidegger and Post-
Cartesian Psychoanalysis (Routledge, 2011) and Trauma and Human
Existence: Autobiographical, Psychoanalytic, and Philosophical Reflections
(Routledge, 2007) and co-author of eight other books. He received the
Distinguished Scientific Award from the Division of Psychoanalysis of
the American Psychological Association in 1995, the Haskell Norman
Prize for Excellence in Psychoanalysis from the San Francisco Center
for Psychoanalysis in 2011, and the Hans W. Loewald Memorial
Award from the International Forum for Psychoanalytic Education in
2012.
To Mary Kenny
who conquered adversity with her indomitable spirit, her Irish humour,
and her generous heart.
With my love and admiration

FOREWORD
In this book Dianna Kenny sets out to discover what remains of Freud
in contemporary psychoanalytic practice. To do this, she engages us
in an intensive dialogue with four eminent practitioners. While no
four people can be said to be representative of an entire community
of practitioners they are each distinctive and different with respect
to their theoretical framework and the cultural milieu within which
they operate. After the interviews, she lets them loose on a therapy
transcript, which acts as a kind of Rorschach inkblot onto which they
project their fantasies about the patient and the therapist.
Before we meet the four clinicians, Professor Kenny sets the scene
with an unusually lucid exposition of the core ideas of Freud and
post-Freudian psychoanalysis. This is an heroic task to accomplish in
two chapters but she achieves it with remarkable fluency. Inevitably
some detail is missing but the core ideas are so clearly enunciated that
these chapters alone will prove to be invaluable to any person seeking
to navigate this complex and jargon-infested territory.
The four interviews that follow are themselves outstanding exem-
plars of psychoanalytic enquiry. I cannot put it more clearly than
Robert Stolorow, who said at the end of the interview Your questions
were very thoughtful and incisive. It is clear that Professor Kenny
xi
xii FOREWORD
had a plan that she brought to each interview. Her plan was informed
by a close reading of the published work of each clinician and curios-
ity about how their ideas and approaches related to other strands of
psychoanalytic thinking. However, she never allowed the plan to get
in the way of the conversation and many of the questions were stim-
ulated by the thoughts of the person she was interviewing. Indeed,
there were times when the questions were as interesting and infor-
mative as the responses.
This is a scholarly work, with all the key ideas assiduously foot-
noted or referenced. The reader will have no difficulty further explor-
ing any of the many thought-provoking fragments that the conver-
sations weave together. However, it is much more than scholarly.
There is an intimacy to the interviews, which enables each clinician to
tell a very personal story. We are constantly reminded that an intel-
lectual journey is shaped by life experience and not just by reading
and ideas. For clinicians this is in part vicarious life experience
through constant engagement with patients. However, through these
interviews we also learn about formative personal life experiences
such as the death of a spouse, working in an overburdened health
system, or the search for a father.
When it comes to the transcripts, each of the therapists adopts the
position of the master clinician or therapy supervisor. Here we
encounter something of the superego of each clinician. They are not
always in agreement as to what the therapist might do better but they
share what might best be described as a clear vision for how the work
should proceed. Stolorow put it most graphically when he said in
response to one of the therapists interventions, The therapist is still
pursuing a cognitive behavioural approach, which is not, at this point,
helpful to the patient. Each of the clinicians felt strongly about both
therapist and patient and were emphatic in their advice-giving to the
therapist which was motivated by an unwillingness to provide tacit
endorsement of interventions that they considered less than ideal
from their perspective.
However, after the thoughtful and sometimes humble communi-
cation in the four interviews, the assumption of the role of expert
came as something of a shock. There is a lot we can learn about ther-
apeutic technique from the responses to the transcript. It also reminds
us how strongly identified clinicians are with the patient and how
FOREWORD xiii
little patience they can have with therapists, who struggle with their
patients down difficult byways.
Those with a more academic orientation will especially appreciate
Professor Kennys textual analysis of the responses of the four clini-
cians to the clinical transcript. She uses a formal text analysis program
as well as a conceptual thematic extraction process to identify both the
distinctive voices of each clinician and some of the communalities that
lie behind these voices. This is an invitation to further research, which
I suspect will be both stimulating and challenging for many readers.
It is also the means by which Professor Kenny draws together some
of the disparate strands that have emerged in the clinical discussions,
and in the analyses of the clinical transcripts, to bring her work to a
conclusion.
I hope you enjoy this book as much as I have. It did not set out to
provide you with a complete or fully integrated picture of contempo-
rary psychoanalytic thinking; it does, however, provide you with an
excellent overview. Furthermore, it will give you more than a glimpse
into the world of the practicing clinician. It may also help you under-
stand something Allan Abbass did not when he said I dont know
what might be happening in psychoanalytic treatments that take so
long . . . I cant see the added valuethe health dollar is so stretched.
Psychoanalysis may not be the most cost effective treatment but the
conversations with Spielman, Holmes, and Stolorow do take us to
where we might find some of the added value.
Robert King, PhD, FAPS

Professor and Coordinator of Clinical Psychology Training
School of Psychology and Counselling
Queensland University of Technology
It hardly seems necessary any longer to argue in favour of the exis-
tence of current ideas that are unconscious or subconscious. They are
among the commonest facts of everyday life. (Freud (with Breuer),
1895d, p. 222)
When are we to begin making our communications to the patient?

When is the moment for disclosing to him the hidden meaning of the
ideas that occur to him, and for initiating him into the postulates and
technical procedures of analysis? The answer to this can only be: Not
until an effective transference has been established in the patient, a
proper rapport with him. It remains the first aim of the treatment to
attach him to it and to the person of the doctor. (Freud, 1913c, p. 139)
. . . the unconscious . . . carves out its own signature on the transfer-

ence and starts to bring things out unconsciously which are unique to
this patient. (Dr Ron Spielman, this volume, p. 120)
You cannot explore, you cannot think, you cannot play unless you feel
safe. (Professor Jeremy Holmes, this volume, p. 154)
. . . we try to be assiduously phenomenological, focused exclusively on

emotional experience and how it is organised . . . emotional experience
always takes form within constitutive relational contexts . . . formed
by the mutual interplay between two or more worlds of experience
. . . (Dr Robert Stolorow, this volume, p. 181)
It is the therapeutic attachment that mobilises all the other attachment

feelings and all the feelings about being hurt in attachments in the past
and this is basically what the therapy is about. (Professor Allan
Abbass, this volume, p. 216)
CHAPTER TITLE 1
CHAPTER ONE
Where the talking began:

the birth of psychoanalysis
onsider this section of the eulogising poem in memory of

C Sigmund Freud, written by W. H. Auden in 1939.
. . . he merely told
the unhappy Present to recite the Past
like a poetry lesson till sooner
or later it faltered at the line where
long ago the accusations had begun,
and suddenly knew by whom it had been judged,
how rich life had been and how silly,
and was life-forgiven and more humble,
able to approach the Future as a friend
(Auden, 1939)
It refers to psychoanalysis as a process of recit[ing] the Past like a

poem (i.e., working through) until understanding dawns (i.e., insight
is achieved: . . . it faltered at the line where / long ago the accusa-
tions had begun / and suddenly knew by whom it had been judged),
allowing one to recover a sense of the value of life and to view the
future with optimism and confidence (. . . to approach the Future as
1
2 FROM ID TO INTERSUBJECTIVITY
a friend). Thus, Audens poem captures some of the essential quali-

ties of psychoanalysis as therapy. But psychoanalysis is more than
this:
. . . [psychoanalysis] essays to change the structure of the patients

mind, to change his view of things, to change his motivations, to
strengthen his sincerity; it strives, not just to diminish his sufferings,
but to enable him to learn from them. (Menninger & Holzman, p. xii)
Psychoanalysis is not only a form of treatment; it is also a theory or a

set of theories and a research method; it is . . . a science of man
. . . a branch of knowledge, and . . . an investigative tool (Lothane,
2006, p. 711). Psychoanalysis has had a long gestation and has experi-
enced multiple rebirths over the course of its history, leading some
current authors to complain that there has been such a proliferation of
theories of psychoanalysis over the past 115 years that the field has
become theoretically fragmented and is in disarray (Fonagy & Target,
2003; Rangell, 2006). The aim of this book is to assess the degree of
actual, as opposed to imagined fragmentation of psychoanalytic
theory and practice, using four branches of psychoanalytic psycho-
therapyobject relations, attachment-informed, existentialphenome-
nological and intensive short term dynamic psychotherapyas my
case study. A brief chronology follows, the aim of which is to identify
those factors from the multiplicity of theories that currently abound
that cohere under the generic rubric psychoanalysis.
Freuds psychoanalysis: an evolution

The name Sigmund Freud is synonymous with psychoanalysis, so we
must start by observing that there are two distinct Freuds. Freud, the
intellectual and man of history, letters, and the world, offers insights
into the human condition which have been accepted into popular
culture and expressed in books, songs (Rosenbaum, 1963; Spitz, 1987)
films, and poems (Akhtar, 2000; Beres, 1952, 1957; Holmes, 2004a,b).
Freud wrote texts on literature and art, and analysed works of litera-
ture. His first such work, Delusions and dreams in Jensens Gradiva
was published in 1907. Freud offered theoretical insights into the
normal human condition, in particular the historically new view that
man is primarily an animal driven by instincts (Freud, 1915c, 1920g)
WHERE THE TALKING BEGAN: THE BIRTH OF PSYCHOANALYSIS 3
who undergoes growth via universal developmental (psychosexual)

stages (Fliegel, 1973) which are influenced by family and social life, in
opposition to the prevailing view of his time that man was Gods
highest creation. Freud (1908c) challenged the cherished belief that
man is a rational being primarily governed by reason, replacing it
with the disturbing notion that man is, in fact, driven by unacceptable
and, hence, repressed aggressive and sexual impulses that are
constantly at war with his civilised self. The other Freud developed
psychoanalysis as a theory and a method of treatment and was some-
what of a celebrity healer of psychological ills in nineteenth- and
twentieth-century Vienna. Notwithstanding, the two Freuds converge
in the creative literary imagination that constructed many of the
analogies and metaphors that constitute the psychoanalytic project,
nowhere more vividly drawn than in the imagining of the Oedipus
complex.
Freud himself and Freud scholars (Jones, 1953; Strachey, 1955) con-
sider that the Studies on Hysteria (Freud (with Breuer), 1895d) mark the
beginning of psychoanalysis, although the ideas on which psychoana-
lysis is based were prevalent before and during this time. See, for
example, Leckys (1891) observation that The conceptions of child-
hood will long remain latent in the mind, to reappear in every hour of
weakness, when the tension of reason is relaxed, and the power of old
associations is supreme (p. 96).
However, an essay, On the psychical mechanism of hysterical
phenomena: preliminary communication, published separately in
1893 and reproduced in the Studies on Hysteria (pp. 118), was a theo-
retical precursor to many of the foundational principles that subse-
quently defined psychoanalysis. This essay is remarkable for its
insights, but only two short passages are possible here:
A chance observation has led us . . . to investigate . . . the symptoms of

hysteria,1 with a view to discovering their precipitating cause, the
event which provoked the first occurrence, often many years earlier .
. . In the great majority of cases it is not possible to establish the point
of origin by a simple interrogation of the patient . . . This is in part
because what is in question is often some experience which the patient
dislikes discussing; but principally because he is genuinely unable to
recollect it and often has no suspicion of the causal connection
between the precipitating event and the pathological phenomenon.
As a rule it is necessary to hypnotize the patient and to arouse his
memories under hypnosis of the time at which the symptom made its
first appearance; when this has been done, it becomes possible to
demonstrate the connection in the clearest and most convincing fash-
ion. (Freud (with Breuer), 1895d, p. 3)
This passage places the causes of the symptoms of hysteria firmly in

the psychological, not the neurological domain, thus moving thinking
about the cause of hysterical symptoms from the brain to the mind,
thereby presaging the notion of repression.2 In these views, Freud
(1893f) was greatly influenced by Jean-Martin Charcot (Didi-
Huberman, 2003; Miller, 1969). Later in the essay, Breuer and Freud
discuss the symbolic nature of the symptoms, foreshadowing the idea
of hidden meaning, the need to express the affect associated with
the traumatic memory, a process later termed catharsis, and the need
to bring the repressed trauma into conscious memory, a process called
abreaction.
In other cases the connection . . . consists only in . . . a symbolic rela-

tion between the precipitating cause and the pathological phenome-
non . . . For instance, a neuralgia may follow upon mental pain or
vomiting upon a feeling of moral disgust . . . [Such] observations . . .
establish an analogy between the pathogenesis of common hysteria
and that of traumatic neuroses and . . . traumatic hysteria. . . . Any
experience which calls up distressing affects such as those of fright,
anxiety, shame or physical pain may operate as a trauma of this kind
. . . We . . . presume . . . that the memory of the trauma acts like a
foreign body which long after its entry must continue to be regarded
as an agent that is still at work . . . We found . . . that each individual
hysterical symptom immediately and permanently disappeared when
we had succeeded in bringing clearly to light the memory of the event
by which it was provoked and in arousing its accompanying affect,
and when the patient had described that event in the greatest possible
detail and had put the affect into words. (Freud (with Breuer), 1895d,
pp. 56)
Taken together, these two extracts capture the essence of classical

psychoanalytic theory, which can be summarised as follows: the
central tenet of Freuds psychoanalytic theory is the concept of the
unconscious, from which he derived two corollary concepts: hidden
meaning and repression. The unconscious refers to the existence of
thoughts and feelings of which we are not aware that motivate our
strivings and behaviour. The contents of the unconscious are usually

experienced as painful and/or forbidden and, therefore, have been
repressed, that is, excluded from consciousness, in order to reduce the
associated anxiety, guilt, or conflict. However, the excluded material
continues to influence behaviour because it is so emotionally charged
that it demands expression. Individuals express their repressed
thoughts or feelings in subtle or symbolic ways, including through the
development of symptoms. In the case history of Frulein Elisabeth
von R, Freud described the process thus:
The actual traumatic moment . . . is the one at which the incompati-

bility forces itself upon the ego and at which the latter decides on the
repudiation of the incompatible idea. That idea is not annihilated by a
repudiation of this kind, but merely repressed into the unconscious.
When this process occurs for the first time there comes into being a
nucleus and centre of crystallization for the formation of a psychical
group divorced from the ego a group around which everything
which would imply an acceptance of the incompatible idea subse-
quently collects. The splitting of consciousness . . . is accordingly a
deliberate and intentional one. At least it is often introduced by an act
of volition; for the actual outcome is something different from what
the subject intended. What he wanted was to do away with an idea,
as though it had never appeared, but all he succeeds in doing is to
isolate it psychically. (Freud (with Breuer), 1895d)
Such behaviour has a hidden meaning that must be uncovered and

consciously re-experienced, together with its associated affect.3 This
was the first of Freuds models of the functioning of the mind that
became known as the affect-trauma model.
The unconscious and the concept of repression

The idea of the unconscious (and unconscious meaning) in Freudian
theorising is so fundamental to an understanding of psychoanalysis
that it warrants special attention. Freud understood the uncon-
scious to contain ideas that are, paradoxically, not only not able to be
thought about but which remain completely unavailable to thought.
Despite this, these hidden ideas exert a profound effect on daily life.
The unconscious is the locus of dynamic psychic activity, the place
where wishes, impulses, and drives reside, a place not beholden to

the realities of logic or time or the constraints of socially acceptable
behaviour. It is a dynamic reservoir of archaic phantasies that
proliferate in the dark (Freud, 1915d, p. 149), an infantile and
anti-social Utopia (Frosh, 2003, p. 14) that exerts upward pressure for
expression.
The concept of repression is essential, not only to an understanding
of the unconscious but to psychoanalysis itself; Freud described it as
the cornerstone of psychoanalysis (Freud, 1914g, p. 16) and viewed
repression as the prototype of the Unconscious (Freud, 1923b),
describing . . . the very great extent to which repression and what is
Unconscious are correlated (Freud, 1915d, p. 148). In fact, Freud
viewed repression as the mental process that creates the unconscious.
One of the vicissitudes an instinctual impulse may undergo is to meet

with resistances which seek to make it inoperative. Under certain con-
ditions . . . the impulse then passes into the state of repression . . . If
what was in question was the operation of an external stimulus, the
appropriate method to adopt would obviously be flight; with an
instinct, flight is of no avail, for the ego cannot escape from itself. At
some later period, rejection based on judgement (condemnation) will be
found to be a good method to adopt against an instinctual impulse.
Repression is a preliminary stage of condemnation, something between
flight and condemnation; it is a concept which could not have been
formulated before the time of psycho-analytic studies. (Freud, 1915d,
p. 146)
Repression is, therefore, a defence mechanism that keeps unconscious

material out of conscious awareness. Freud identified two types of
repression. The first he called primal repression, which acts on the
basic, biological drives or the . . . psychical (ideational) representative
of the instinct being denied entrance into the conscious, resulting in
fixation. The representative in question persists unaltered from then
onwards and the instinct remains attached to it (Freud, 1915d, p. 148).
In the second form of repression, repression proper, anxiety-
producing material that is available to consciousness is repressed
because it threatens to overwhelm the ego with anxiety.
Repression proper affects mental derivatives of the repressed repre-

sentative, or such trains of thought as, originating elsewhere, have
come into associative connection with it. On account of this associa-

tion, these ideas experience the same fate as [that which] was primally
repressed. (Freud, 1915d, p. 148)
None the less, these ideas press for expression and sometimes break
through to the surface, often in disguised form, such as in dreams,
slips of the tongue, jokes, and symptomsmanifestations that Freud
called the return of the repressed (p. 148), a process that today is
called an enactment (Cambray, 2001; Chused, 2003; Eagle, 1993;
Friedman & Natterson, 1999; Ivey, 2008).
The patient remembers nothing of what is forgotten and repressed,

but . . . expresses it in action. He reproduces it not in his memory but
in his behaviour; he repeats it, without, of course, knowing that he is
repeating it. (Freud, 1914g, p. 148)
Freud later defined the ego in two ways: first, as the structure need-
ing protection from the unconscious; second, as the repressing force
that keeps disturbing material at bay. Since the process of repression
is itself unconscious, there must be an unconscious part of the ego.
With this understanding came a change in the understanding of the
role of anxiety. Freud believed at first that repression caused anxiety;
he subsequently came to the view that it was anxiety that motivated
repression (Freud, 1926d).
Freud at first understood repression to be an attempt to ward off
memories of traumatic experiences:
All the experiences and excitations which . . . prepare the way for, or
precipitate, the outbreak of hysteria, demonstrably have their effect
only because they arouse the memory-trace of these [previous] trau-
mas in childhood . . . (Freud, 1896b, p. 166).
Freud specified that the trauma was sexual in nature:
Hysteria . . . [cannot] be fully explained from the effect of the trauma: it

had to be acknowledged that the susceptibility to a hysterical reaction
had already existed before the trauma. The place of this indefinite
hysterical disposition can now be taken, wholly or in part, by the
posthumous operation of a sexual trauma in childhood. Repression of
the memory of a distressing sexual experience which occurs in maturer
years is only possible for those in whom that experience can activate
the memory-trace of a trauma in childhood. (Freud, 1896b, p. 166)
He later revised this view, believing that it was not traumatic experi-
ences or memories, but conflicted impulses, wishes, and desires, with
their attendant anxiety, that motivated repression, in particular,
. . . the compelling force of the pleasure principle. The psychical appa-

ratus is intolerant of unpleasure; it has to fend it off at all costs, and if
the perception of reality entails unpleasure . . . the truth must be sacri-
ficed. Where external dangers are concerned, the individual can help
himself . . . by flight and by avoiding the situation of danger . . . But
one cannot flee from oneself; flight is no help against internal dangers.
And for that reason the defensive mechanisms of the ego are con-
demned to falsify ones internal perception and to give one only an
imperfect and distorted picture of ones id. In its relations to the id,
therefore, the ego is paralysed by its restrictions or blinded by its
errors . . . (Freud, 1937, p. 392)
Hence, Freud shifted his focus on external trauma to a focus on inner

conflict as the core of psychoanalytic theory and psychoanalysis
(Eagle, 2011). Contemporary psychoanalytic theory reverses this
shift, as we will see in the conversations in the coming chapters, re-
focusing on external (mostly interpersonal) trauma as the locus of
psychopathology.
The talking cure

The process that resulted in the . . . the invention of the first instru-
ment for the scientific examination of the human mind (Strachey,
1955, p. xvi) began with Josef Breuers patient, Anna O (Bertha
Pappenheim), whom he treated between 1880 and 1882. This is a
remarkable case because the treatment of Anna O included all of the
critical elements of the emerging theory of psychoanalysisthe
unconscious, repression, hidden meaning, sexuality, and transference.
Anna was a talented patient. Talent was suggested by subsequent
analysts to be a prerequisite for a successful psychoanalysis; see, for
example, Ferenczi (1955), who stated that An inspired patient and
her understanding physician shared in the discovery of the cathartic
forerunner of psychoanalysis (p. 109). Breuer described his twenty-

one-year-old patient thus:
. . . markedly intelligent, with an astonishingly quick grasp of things

and penetrating intuition. She possessed a powerful intellect . . . and
great poetic and imaginative gifts, which were under the control of a
sharp and critical common sense . . . she was completely unsug-
gestible; she was only influenced by arguments, never by mere asser-
tions. Her willpower was energetic, tenacious and persistent;
sometimes it reached the pitch of an obstinacy which only gave way
out of kindness and regard for other people. (Freud (with Breuer),
1895d, p. 21)
Freud believed that the ability to develop a transference relationship

was essential to analysability (see next section). There have since been
thousands of papers written about analysability and how to assess it
(see, for example, Erle & Goldberg, 1984; Frosch, 2006; Karon, 2002;
Paolino, 1981; Peebles-Kleiger, Horwitz, Kleiger, & Waugaman, 2006;
Rothstein, 2006; Rubovits-Seitz, 1988).
Bertha Pappenheim coined the term talking cure because her
treatment entailed endless detailed recounting of her experiences,
memories, and hallucinations in, at times, twice daily hypnosis ses-
sions with Breuer. She had a truly daunting array of symptoms. Using
the above method, Breuer claimed to cure her of
. . . paralytic contractures and anaesthesias, disorders of vision and

hearing of every sort, neuralgias, coughing, tremors, etc., and finally
her disturbances of speech were talked away. Amongst the disorders
of vision, the following, for instance, were disposed of separately: the
convergent squint with diplopia . . . restriction of the visual field;
central amblyopia; macropsia; seeing a deaths head instead of her
father; inability to read . . . (Freud (with Breuer), 1895d, p. 35)
Breuer described his therapeutic procedure with Anna/Bertha thus:
. . . in the case of this patient the hysterical phenomena disappeared

as soon as the event which had given rise to them was reproduced in
her hypnosis which made it possible to arrive at a therapeutic tech-
nical procedure which left nothing to be desired in its logical consis-
tency and systematic application. Each individual symptom in this
complicated case was taken separately in hand; all the occasions on
which it had appeared were described in reverse order, starting before

the time when the patient became bed-ridden and going back to the
event which had led to its first appearance. When this had been
described the symptom was permanently removed. (p. 35)
Her final symptom, her enactment of the labour pains of an hysterical

(phantom) pregnancy (also called pseudocyesis) resulted in Breuers
precipitous termination of her therapy. Breuer did not record this
aspect of his treatment of Anna/Bertha in his case report in Studies on
Hysteria (pp. 2147). There are two sources describing the occurrence
of this event in her therapy. First, Freuds biographer, Ernest Jones,
recounts that this event occurred co-extensively with the birth of
Breuers daughter, Dora;4 second, it was discussed in letters between
Freud and his wife, Martha (Appignanesi & Forrester, 1993). Freud
subsequently had similar experiences of a less dramatic nature with
his own patients (e.g., one patient threw her arms around Freuds
neck) and he decided, as a result of these experiences, that it was
necessary to abandon hypnosis (Freud, 1936).
Because Anna O was widely considered to be the germ cell of the
whole of psychoanalysis (Cranfield, 1958, p. 320), her case has been
the subject of intensive scrutiny. Breuer, writing from incomplete
notes 1314 years after he treated Anna, produced the first account in
Studies on Hysteria. Freud himself gave different accounts of the case
to Carl Jung, Stefan Zweig, and his biographer, Ernest Jones (Clark,
1980). Much later, Dr Henri Ellenberger (1972), drawing on newly
discovered documents, concluded that
. . . the patient had not been cured. Indeed, the famed prototype of a
cathartic cure was neither a cure nor a catharsis . . . Anna Os illness
was the desperate struggle of an unsatisfied young woman who found
no outlets for her physical and mental energies, nor for her idealistic
strivings. (p. 279)
After the phantom pregnancy and Breuers precipitous abandonment

of his patient, Anna spent many months in a sanatorium, where she
became dependent on morphine (Clark, 1980). Referring to her many
years later in his Introductory Lectures on Psycho-analysis (Freud,
19161917), Freud described her in lecture XVIII as follows: . . . in a
certain respect she has remained cut off from life: she remained healthy
and efficient, but avoided the normal course of a womans life (p. 274).
The hysterical disorders (now called conversion reactions) of

Freuds nineteenth-century Viennese, mostly upper-class, young and
middle-aged females rarely present for treatment today, at least not
in the way in which these women presented. An examination of
many of the case studies recorded from that time will prompt
the observation that conversion reactions appeared to be the secret
language of capable but repressed and disempowered women, many
of whom, like Bertha Pappenheim, were intelligent and well educated,
but stifled and unfulfilled. Both Breuer and Freud were well aware
of this dimension to their patients. Breuer described Bertha as a girl
who was
. . . bubbling over with intellectual vitality, [but who] led an extremely

monotonous existence in her puritanically-minded family. She embell-
ished her life in a manner that probably influenced her decisively in
the direction of her illness, by indulging in systematic day-dreaming,
which she described as her private theatre. (Freud (with Breuer),
1895d, p. 22)
In later life, Bertha Pappenheim recovered from her disabling symp-

tom complex sufficiently to become an activist, a feminist, and a
philanthropist, finally finding an outlet for her energy and intelligence
in social work among the Jewish population.
The case of Anna O pointed Freud in the direction of his new
method of therapy, while Breuer decided that the intensity and
duration of the treatment required to effect a cure and the danger
of untoward reactions was too onerous a burden for him and he
subsequently referred such cases to Freud.
Transference
This transference, alike in its positive and negative form, is used as a
weapon by the resistance; but in the hands of the physician it becomes
the most powerful therapeutic instrument and it plays a part scarcely
to be over-estimated in the dynamics of the process of cure. (Freud,
1923a, p. 247)
In an early paper, Fragment of an Analysis of a Case of Hysteria (Dora),

Freud (1905e) discussed the nature of transference in some detail.
What are transferences? They are new editions or facsimiles of the

impulses and phantasies which are aroused and made conscious
during the progress of the analysis . . . they replace some earlier person
by the person of the physician . . . psychological experiences are
revived, not as belonging to the past, but as applying to the person of
the physician at the present moment. Some of these transferences have
a content which differs from that of their model in no respect whatever
except for the substitution. These then . . . are merely new impressions
or reprints. Others are more ingeniously constructed; their content has
been subjected to a moderating influence to sublimation . . . and they
may even become conscious, by cleverly taking advantage of some real
peculiarity in the physicians person or circumstances and attaching
themselves to that . . . Transference is an inevitable necessity . . . There
is no means of avoiding it . . . it must be combatted . . . This happens,
however, to be by far the hardest part of the whole task. . . . Trans-
ference is the one thing the presence of which has to be detected almost
without assistance and with only the slightest clues to go upon . . .
transference cannot be evaded, since use is made of it in setting up all
the obstacles that make the material inaccessible to treatment, and
since it is only after the transference has been resolved that a patient
arrives at a sense of conviction of the validity of the connections that
have been constructed during the analysis. (p. 116)
Freud returned repeatedly to the concept of transference, rethinking

and refining its nature and characteristics. In the Five lectures on
psycho-analysis (Freud, 1910a), he again clarified and modified his
ideas about the transference and the central roles of fixation and repe-
tition, as follows:
The patient . . . directs towards the physician a degree of affectionate

feeling (mingled . . . with hostility) which is based on no real relation
between them and which . . . can be traced back to old, wishful
fantasies of the patients which become unconscious. Thus the part of
the patients emotional life which he can no longer recall to memory is re-
experienced by him in his relation to the physician . . . (p. 51, my italics)
This passage is prescient of what future psychoanalytic theorists

called preverbal trauma. This type of trauma, while not available to
episodic memory, is stored affectively and is available to analytic
scrutiny via the transference (Knoblauch, 1997; Slochower, 1996a).
In The dynamics of transference, Freud (1912b) makes his now
famous comment that it is impossible to destroy anyone in absentia
or in effigie5 (p. 108). In Remembering, repeating and working-

through (1914g), Freud described transference as
. . . an intermediary realm between illness and real life, through which

the journey from the one to the other must be made. The term trans-
ference was first used to describe displacement phenomena . . . Trans-
ference is the process whereby the analyst becomes, at different times,
people from the patients past (e.g., mother, father, sibling). (p. 154)
The transference is also the process whereby the analystpatient

relationship comes to resemble the motherchild relationship, in
which the patient develops an attitude of expectant, dependent recep-
tiveness toward the analyst (Freud, 1912b). Thus, the transference,
once identified, came to be understood as pivotal to the therapeutic
process, not only as the locus of therapeutic action in psychoanalysis,
but in everyday life. Transference supposes that we repeat, in our
current relationships, patterns of interactions that contain our uncon-
scious expectations and phantasies from our earliest relationships.
Therefore, we misrepresent, distort, and misrecognise patterns of
relationship in our current lives that create interpersonal difficulties
that bring people into therapy. These same patterns are played out in
the relationship with the analyst. Transference phenomena are uncon-
scious and, from the outset, serve both the functions of resistance and
revelation. Transference is encouraged in the analytic situation
through the withdrawal of the analyst from full presence, preventing
the reality-testing of real life, and allowing the adoption of an accept-
ing and non-judgemental stance that encourages increasing depen-
dence in the patient. In this highly emotionally charged relationship,
the analyst offers interpretations about the patients distortions from
the past. How to decide on the correctness of an interpretation and to
distinguish transference from non-transference phenomena will be
taken up later.
Development of theory: from the affect-trauma model to

topographical and structural models of the mind
The affect-trauma model
We have just discussed the elements of the first of Freuds theoretical
models, the affect-trauma model. However, a brief recapitulation is
in order here because of its importance in contemporary psycho-

analysis. Essentially, this model proposed that the symptoms of
hysterical patients had hidden psychological meaning related to
major emotional traumata that the patient had repressed (Freud,
1895d, pp. 48105, 135181, 253305). The struggle for expression of
this trauma resulted in the presenting symptoms, which constituted a
symbolic expression of the strangulated affect related to the trauma.
Freud believed that the processes of abreaction and catharsis (initially
achieved under hypnosis) related to this trauma would resolve
patients symptoms and cure them of their hysteria.
The affect-trauma model was co-extensive with Freuds seduction
theory because Freud initially believed that a significant proportion of
the traumas reported by his patients related to child sexual abuse
(childhood seduction).
I . . . put forward the thesis that at the bottom of every case of hyste-
ria there are one or more occurrences of premature sexual experience, occur-
rences which belong to the earliest years of childhood but which can
be reproduced through the work of psycho-analysis in spite of the
intervening decades. I believe that this is an important finding, the
discovery of a caput Nili in neuropathology. (Freud, 1896a, p. 203)
With further clinical experience, Freud understood that some of these

reports were of sexual fantasies related to unconscious wishes that
arose from biological drives and that the presenting psychopathology
was a failed attempt to master these sexual drives, about which
patients felt ashamed and guilty.
Freud believed that traumatic neuroses were, in fact, a repetition
or variant of the original trauma experienced by all infantsa feeling
of helplessness. Unlike subsequent theorists, such as Winnicott, who
argued that infantile trauma could be avoided or mitigated by good
enough mothering, Freud believed that the original infant trauma
could not be avoided because the felt helplessness of the infant is help-
lessness in relation to its own instincts. Thus, Freud proposed that
infantile traumas are universal and differ only in their intensity
between individuals and that such traumas have an impact on all sub-
sequent development. Accordingly, the child attaches to its mother
out of fear of this feeling of helplessness and the attendant fear that it
will not survive without assistance from caring adults. So, the desire
for contact and attachment is born of fear and is, thus, a secondary
instinct. This position has been subsequently challenged (Bowlby,
1958).
Although Freud perceived sexuality as the dominant determinant
of psychological functioning in his early writings, his realisation of a
more fundamental instinct, self-preservation, created a problem for
the role of sexuality in his theorising. He concluded subsequently that
resolving issues in infantile sexuality, such as the Oedipus complex,
represented a simultaneous working through of the primitive anxi-
eties that are linked to the traumatic loss of the object (Van Haute &
Geyskens, 2007, p. xx). In this regard, Freuds theorising was greatly
affected by his observations of the post traumatic stress disorders in
soldiers returning from the First World War. Prior to 1920, Freud
believed that most neurotic symptoms were related to the repressed
experiences of infantile sexuality. After this time, Freud gave primacy
to the experience of trauma, a position that became a central tenet of
subsequent psychoanalytical theorising and speculation (Miliora,
1998; Mills, 2004; Muller, 2009; Naso, 2008; Oliner, 2000). The traumas
of war and the constant imminent threat to survival must surely come
closest to repeating the feeling of helplessness of the infant and the
associated anxiety. The proximal trauma triggers the distal archaic
infant anxieties, resulting in a traumatic neurosis. Freud understood
the symptoms, including repeated nightmares and reliving of the war
trauma, as an attempt to master the trauma psychologically. Freud
had identified the phenomenon of the compulsion to repeat (Freud
(with Breuer), 1895d, p. 105) both in actual life and in the transference
relationship with the analyst in his earliest cases and understood this
as a form of remembering. In Remembering, repeating and working-
through, Freud (1914g) came to the conclusion that psychopathology
(neuroses) is a magnification of universal human phenomena (Van
Haute & Geyskens, 2007, p. 33). The helplessness and dependency
that we all experience as infants are reactivated in subsequent experi-
ences of threat, anxiety, and loss.
The topographical model

Freud outlined his topographical theory in Studies on Hysteria and
revisited and reworked his ideas some years later in The uncon-
scious (1915e). Below is his original exposition:
.. . . a psychical act goes through two phases as regards its state,

between which is interposed a kind of testing (censorship). In the first
phase the psychical act is unconscious and belongs to the system Ucs.;
if, on testing, it is rejected by the censorship, it is not allowed to pass
into the second phase; it is then said to be repressed and must remain
unconscious. If, however, it passes this testing, it enters the second
phase and thenceforth belongs to the second system, which we will
call the system Cs. But the fact that it belongs to that system does not
yet unequivocally determine its relation to consciousness. It is not yet
conscious, but it is certainly capable of becoming conscious . . . that is, it
can now . . . become an object of consciousness without any special
resistance. In consideration of this capacity for becoming conscious we
also call the system Cs. the preconscious.6 (Freud, 1915e, p. 173)
Freud proposed two or three psychical systems in the mind; he

referred to these as psychical topography. In addition to understand-
ing the dynamic processes occurring, Freud now argued that we also
needed to identify in which system or systems these psychical acts
were operating. He coined the term depth psychology to indicate
that he had advanced the field beyond the psychology of conscious-
ness (p. 173). Freud cautioned that Our psychical topography has for
the present nothing to do with anatomy; it has reference not to anatom-
ical localities, but to regions in the mental apparatus, wherever they
may be situated in the body (p. 175). This new proposal created a
number of further questions, not the least of which is whether the
same idea can exist simultaneously in two or more of these systems.
With the . . . topographical hypothesis is bound up that of a topo-

graphical separation of the systems Unconscious and Conscious and
also the possibility that an idea may exist simultaneously in two places
in the mental apparatus . . . if it is not inhibited by the censorship, it
regularly advances from one position to the other, possibly without
losing its first location or registration . . . conscious and unconscious
ideas are distinct registrations, topographically separated, of the same
content. (p. 175)
Freud subsequently renamed his depth psychology, metapsychology,

in which all psychological phenomena were examined from three
different perspectives: topographical, economic, and dynamic. The
topographical analysis identified the system in which the psychic
action was occurring, the economic analysis assessed the quantity of
psychic energy being expended, and the dynamic analysis explored

the conflict between the pressures from instinctual drives (wishes,
strivings) and the ego defences that are deployed to prevent the
release of the forbidden material from repression (Quinodoz, 2005).
Freud argued that the action of analytic therapy was centrally con-
cerned with the management of repression:
All repressions take place in early childhood . . . In later years no fresh

repressions are carried out; but the old ones persist, and their services
continue to be made use of by the ego for mastering the instincts . . .
We may apply to these infantile repressions our general statement that
repressions depend absolutely and entirely on the relative strength of
the forces involved and that they cannot hold out against an increase
in the strength of the instincts. Analysis, however, enables the ego,
which has attained greater maturity and strength, to undertake a revi-
sion of these old repressions; a few are demolished, while others are
recognized but constructed afresh out of more solid material. These
new dams are of quite a different degree of firmness from the earlier
ones; we may be confident that they will not give way so easily before
a rising flood of instinctual strength. Thus the real achievement of
analytic therapy would be the subsequent correction of the original
process of repression, a correction which puts an end to the domi-
nance of the quantitative factor. (Freud, 1937c, p. 227)
The structural model

According to Freuds structural model, which he introduced in 1923,
our personality is an organised energy system of forces and counter
forces whose task is to regulate and discharge aggressive and sexual
energy in socially acceptable ways (Gramzow et al., 2004). This model
refocused attention on the importance of the social environment and
the role of relationships with primary care-givers, elements that were
less evident in the first two models, which were primarily concerned
with intrapsychic processes and drives (Mayer, 2001).
Freud proposed three structures, which he termed id, ego, and
superego. At birth, we are all ida series of sexual and destruc-
tively aggressive impulses that seek gratification. Freud conceptu-
alised the id in the following way:
The id . . . has no means of showing the ego either love or hate. It can-
not say what it wants; it has achieved no unified will. Eros and the death
instinct7 struggle within it; we have seen with what weapons the one
group of instincts defends itself against the other. (Freud, 1923b, p. 59)
The id, the home of unconscious drives and impulses, operates

according to a primary process that is very different from conscious
thought, or secondary process thinking. It has no allegiance to ration-
ality, chronology or order, and is fantasy-driven via visual imagery.
As the child develops, so does the ego, the reality tester, the ratio-
nal part of the personality. Freud actually used the German word Ich
to denote this structure in his structural model. Ego was the
English translation of this word, but its meaning denotes Ithat
part of the self that a person recognises as me. It is the role of the
ego to regulate the primitive impulses of the id, the relentless and
punishing superego, and the demands of external reality. The ego
protects itself from the unconscious by developing repressing forces
(defence mechanisms) that keep repressed material from breaking
through to consciousness. Gradually, the child learns to delay imme-
diate gratification, to compromise, accept limits, and cope with
inevitable disappointments.
Between the ages of four and six years, the superego develops. The
superego is formed out of the internalised or introjected values of
parents (or other significant care-givers) (Freud, 1923b) and society
and becomes the persons conscience, from which an ego ideal, the
standard by which one measures oneself, is formed (Kilborne, 2004).
In order to achieve this regulation, we employ a series of defence
mechanisms (in the topographical model, this process was termed
censorship) of which repression is the most fundamental.
The adults ego, with its increased strength, continues to defend itself
against dangers which no longer exist in reality; indeed, it finds itself
compelled to seek out those situations in reality which can serve as an
approximate substitute for the original danger, so as to be able to
justify, in relation to them, its maintaining its habitual modes of reac-
tion. Thus we can easily understand how the defensive mechanisms,
by bringing about an ever more extensive alienation from the external
world and a permanent weakening of the ego, pave the way for, and
encourage, the outbreak of neurosis. (Freud, 1937c, p. 238)
Therefore, to live comfortably with our repressed wishes and fanta-

sies, second line defences (sublimation, rationalisation, projection, and
displacement) may be called into play (LeCroy, 2000). Sublimation

refers to a socially adaptive way of dealing with aggressive and sexual
energy. Sport and competition are two examples. If sublimation fails,
we might resort to denial and refuse to recognise the real nature of our
behaviour. For example, an excessively flirtatious female might deny
her sexual intent or an alcoholic might deny he has a drinking prob-
lem. Rationalisation is the process of giving an intellectually plausible
explanation for ones behaviour that denies its true motive. Projection
is a defence mechanism whereby an individual attributes those char-
acteristics, motives or behaviours that he cannot accept in himself to
other people. McWilliams (1999) defined projection as the process
whereby what is inside is misunderstood as coming from outside (p.
108). For example, an ambitious, competitive individual might criti-
cise his colleagues for being overly ambitious and competitive. In
displacement, we deflect our feelings onto the wrong target. A man
angry with his boss will come home and shout at his wife and chil-
dren. A child who is angry with his teacher might become aggressive
and defiant towards his mother. Sometimes, people are so afraid of
the intensity of their feelings that they will behave in the opposite
way, as a means of keeping powerful impulses under control. This is
called reaction formation. For example, someone who is afraid of
being dependent might behave in a defiant, individualistic, and inde-
pendent fashion to compensate for unmet dependency needs. A very
aggressive or critical individual might behave passively or compli-
antly. These behaviours are usually rigidly adhered to because the
person fears that a slight loosening of control will result in the break-
through of the repressed impulses (Beattie, 2005).
The development of the structural model resulted in some signifi-
cant changes to psychoanalytical theory. These changes contained
within them the embryos of object relations theory. For example,
Freud (1923b) came to realise that the gratification of drives was not
the infants only needs; rather, an internalised image of the mother
with whom the child could identify was now regarded as necessary
for normal development. Freud also argued that the resolution of the
Oedipus complex came about through the childs relinquishment of
the sexual rivalry for the parent of the opposite sex and identification
with the parent of the same sex. Both of these processes involve iden-
tification with internal objects, which is the basis of object relations
theory.
Further, Freud significantly modified his understanding of the

nature and cause of anxiety. In his early theorising, anxiety was under-
stood to be related to the fear of discharge of unacceptable sexual or
aggressive drives. Subsequently, Freud (1926d) understood anxiety to
be, simultaneously, an affective signal for danger and the motivation
for psychologically defending against the (perceived) danger. Freud
proposed four basic danger situations: the loss of a significant other;
the loss of love; the loss of body integrity; the loss of affirmation by
ones own conscience (moral anxiety). When an individual senses one
of these danger situations, motivation for defending against the anxi-
ety is triggered. Freud also distinguished between traumatic (primary)
anxiety, which he defined as a state of psychological helplessness in
the face of overwhelmingly painful affect, such as fear of abandonment
or attack, and signal (secondary) anxiety, which is a form of anticipa-
tory anxiety that alerts us to the danger of re-experiencing the original
traumatic state by repeating it in a weakened form so that measures to
protect against retraumatisation can be taken.
A topographical structural model

A number of psychoanalytic writers have attempted to integrate the
topographical and structural models because the ego, id and super-
ego do not suffice to outline the whole area of psychoanalytic topog-
raphy . . . [nor] what the pathways of communication are among the
three provinces (Eissler, 1962, p. 13). Freud, in his original topo-
graphical model, proposed that censorship occurred between the
unconscious (Ucs.) and the preconscious (Pcs.). He later modified his
thoughts on the location of censorship, expanding his view to include
another location of censorship, between the Pcs. and conscious (Cs.)
(Freud, 1923b). In his structural model, Freud later attributed the func-
tion of censorship to the unconscious part of the ego, thus linking
censorship with the ego defences, and with the moral censorship of
the superego. In The Ego and the Id (1923b), Freud discusses the respec-
tive roles of the ego and superego in managing the Oedipus complex:
The super-ego retains the character of the father, while the more
powerful the Oedipus complex was and the more rapidly it suc-
cumbed to repression (under the influence of authority, religious
teaching, schooling and reading), the stricter will be the domination of
the super-ego over the ego later on in the form of conscience or

perhaps of an unconscious sense of guilt. (p. 34)
Sandler and Sandler (1983) proposed a three box model, in which

the id and the Ucs. were considered to be equivalent. This first box or
system contained not only instinctual wishes, but infantile reactions,
infantile wishes or wishful fantasies that have developed early in life
and are the outcome of all the transformations that defensive activi-
ties and other modifying processes have brought about during that
period (Sandler & Sandler, 1983, p. 417). These pressing impulses
and urges that push for expression are the subject of massive repres-
sion that results in infantile amnesia, which constitutes the re-
pression barrier, that is, the first censorship. The contents of this
system (the child within the adult) are modified through processes
of ego development, experience, and the development of language,
which allows them to be expressed either in socially acceptable ways
or through symptoms.
The second box, or system, is equivalent to the uncensored Pcs.
and comprises the unconscious ego and the unconscious superego.
The contents of this system include the derivatives (modifications)
of repressed childhood wishes, impulses and fantasies (Sandler &
Sandler, 1983, p. 419) from the first system that have progressed
beyond the repression barrier. Once in the second system, these deriv-
atives cause perturbations in psychic equilibrium, arousing conflict
and painful feelings that must be managed via secondary processes
and the defence mechanisms. Sandler and Sandler (1983) describe this
system as a highly organized psychological system, attuned to real-
ity but working outside consciousness (p. 419). This system generates
unconscious fantasies and thoughts, which may be experienced but
not expressed in significant relationships, in particular, the transfer-
ence relationship in psychoanalysis. The censorship that occurs in this
system has, as its primary function, the avoidance of shame, embar-
rassment, and humiliation. As children are exposed to additional
socialising experiences, which are the agents of the second censorship,
they become increasingly able to predict the disapproval of others,
thereby becoming their own disapproving audience.
The third system, the system Cs., is the locus of rational conscious
thoughts and feelings as well as derivatives of the contents of the
second systems thoughts, impulses, wishes, and fantasies, which
have their expression via acting out, through the manipulation of

others, including the analyst, or retreat into illness or other forms of
regression, obsessive rumination, or phobic avoidance. These deriva-
tives embody the childs psychic history, and have been modified
during development by defensive processes and represent the infan-
tile aspects of the self in relation . . . to its objects (p. 422). Sandler and
Sandler note that patients invest their analysts with social authority
that has been internalised during the second censorship, which the
analyst uses to assess the developmental functioning of his patient
and to apprehend his infantile aspects, so that these forbidden, unac-
ceptable wishes, impulses, and fantasies can be uncovered, integrated,
and reworked. Sandler and Sandler (1983) conclude:
Once the patient has been able to accept the reality of the here-and-
now thoughts and feelings that occupy the second system, particularly
the thoughts and fantasies that arise in the transference, and his
second censorship resistance has fallen away in that . . . context, it is
appropriate to reconstruct what has happened in the past . . . in the
knowledge that such reconstructions have as their main function the
provision of a temporal dimension to the patients image of himself in
relation to his world, and help him to become more tolerant of the
previously unacceptable aspects of the child within himself. (p. 422)
The schematic representation below (Figure 1) captures the integ-

rated topographical and structural aspects of this psychoanalytic
meta-theory.8
Development of technique: from hypnosis, suggestion,

and catharsis/abreaction to free association,
interpretation, and analysis of resistance
Many of the ideas that were later to form the bedrock of psycho-
analytic theory were present in the early writings, as the case study
below will show. Many are clearly evident in The psychotherapy of
hysteria (Freud, 1895d, pp. 253305) in which the concepts of the
unconscious, resistance, defence mechanisms, transference, and the
notion of the analytic attitude are introduced. Freuds technique was
not derived from theory. His technique was intuitive and evolution-
ary; theory followed to explain the observed clinical phenomena.
Figure 1. Freuds model of personality structure.
In 1885, Freud, having just completed his medical studies, trav-

elled to Paris to study hypnosis under the neurologist, Jean-Martin
Charcot. Upon his return to Vienna, he established a private practice
in neurology. He quickly realised that most of his patients did not
have organic disorders and that traditional medicine at that time had
little to offer them. The prevailing treatmentselectrotherapy, hydro-
therapy, massages, and rest cureswere ineffective, and what little
effect was produced came about as the result of positive suggestion
that these therapies would be helpful. Today, we call this the
placebo effect (Antonaci, Chimento, Diener, Sances, & Bono, 2007;
Bensing & Verheul, 2010; Capps, 2010). Freud turned to hypnotherapy
and hypnotic suggestion in an effort to assist his patients, but not for
long, as we shall see in the following discussion.
A detailed case study (Freud, 1896b) of a young mother success-
fully treated by hypnotism bears all the hallmarks of the mature
psychoanalytic theory that was to evolve over the next thirty years.
Briefly, the case involved a mother who, having just given birth to her
second child, was unable to breastfeed her newborn. As she had expe-
rienced the same difficulty with her first child, she was determined to
succeed with her second child. Freud noted with interest that not only
could the mother not breastfeed, but that in order to prevent herself
from vomiting when the baby was brought to her, she had ceased
eating herself, was unable to sleep, and had become depressed.
Freuds first hypnosis focused on suggestions about the success she
would have in feeding the baby, and how she would experience none
of the worrying symptoms associated with her inability to sleep and
to eat without vomiting. This intervention led to a day of successful
breastfeeding, following which the young mother relapsed. Freud was
called back the next night. On the second occasion of hypnosis, Freud
was bolder in his hypnotic suggestions, which focused on the
mothers need to be fed before she could successfully feed her baby.
Freud suggested to her that when she awoke, she would demand her
dinner from her mother before having her infant brought to her for
feeding. This treatment resulted in a permanent cure and the mother
was able to breastfeed her baby for eight months. From this case,
Freud posited the notion of the antithetic idea, which, through a
process of dissociation, becomes unavailable to conscious awareness
but acts against ones conscious intentions as a counter-will against
which the patient feels powerless. What appears to have occurred in
this intervention is that Freud mobilised the anger in the mother about
an (unconscious) experience she herself had had as an infant of not
being sufficiently fed and encouraged her to express that anger to her
own mother over not being given her dinner before commencing to
breastfeed.
Although Freud had not yet formulated his theories of uncon-
scious action or catharsis/abreaction that he documented in Studies on
Hysteria, it is likely that the clinical success of this case was due to just
such a cathartic process. Thus, the concept of the unconscious appears
early in his work and is later to become one of the foundational
concepts of psychoanalysis. In A note on the unconscious in psycho-
analysis (1912g), Freud offered this definition of the unconscious:
Now let us call conscious the conception which is present to our

consciousness and of which we are aware . . . Thus an unconscious
conception is one of which we are not aware, but the existence of

which we are nevertheless ready to admit on account of other proofs
or signs . . . The well-known experiment . . . of the post-hypnotic
suggestion teaches us to insist upon the importance of the distinction
between conscious and unconscious and seems to increase its value. . . .
The mind of the hysterical patient is full of active yet unconscious
ideas; all her symptoms proceed from such ideas. It is in fact the most
striking character of the hysterical mind to be ruled by them . . . The
term unconscious . . . designates not only latent ideas in general, but
especially ideas with a certain dynamic character, ideas keeping apart
from consciousness in spite of their intensity and activity. (pp. 260,
262)
Although Anna O and his own patient were excellent hypnotic

subjects, subsequent patients were not so amenable to suggestion or
hypnosis, whereupon Freud adapted the technique into an analytic
attitude that required him to listen to all that the patient had to say
without any attempt at interference or at making short cuts (p. xvi).
The inability of many patients to be hypnotised was the first in a series
of obstacles that had to be overcome and for which new techniques
had to be found. The second was resistance to treatment, which Freud
defined as patients unwillingness to co-operate in their own cure.
From resistance came the concepts of defence and repression and the
techniques of free association, dream analysis, and exploration of
what Freud called primary process and its influence on conscious
thoughts.
Freud believed that Neurotics turn away from reality because
they find it unbearable . . . In seeking to understand the psycholog-
ical significance of the real external world . . . not just for neurotics but
for mankind in general (Freud, 1911b), Freud took as his starting
point that
. . . unconscious mental processes . . . the older, primary processes

. . . [were] governed by . . . the pleasure principle. These processes
strive towards gaining pleasure; psychical activity draws back from
any event which might arouse unpleasure (here we have repression)
. . . The state of psychical rest was originally disturbed by the peremp-
tory demands of internal needs. When this happened, whatever was
thought of (wished for) was simply presented in a hallucinatory
manner . . . the non-occurrence of the expected satisfaction, the disap-
pointment experienced . . . led to the abandonment of this attempt at
satisfaction by means of hallucination. Instead of it, the psychical

apparatus had to decide to form a conception of the real circumstances
in the external world and to endeavour to make a real alteration in
them. A new principle of mental functioning was thus introduced;
what was presented in the mind was no longer what was agreeable
but what was real, even if it happened to be disagreeable. This setting-
up of the reality principle proved to be a momentous step. (p. 219)
In 1914, Freud reviewed the changes in theorising and technique that

psychoanalysis had undergone in the few brief years since its incep-
tion. These theoretical changes were accompanied by changes in
psychoanalytic technique. Freud traces those changes in his paper
Remembering, repeating and working-through (Freud, 1914g).
Beginning with Breuers cathartic method, using hypnosis, the tech-
nique involved the
. . . bringing directly into focus the moment at which the symptom

was formed, and in persistently endeavouring to reproduce the
mental processes involved in that situation, in order to direct their
discharge along the path of conscious activity. (Freud, 1914g, p. 147)
Remembering and abreacting were the key elements in this technique.

In normal people, Freud observed the discharge of a large amount of
affect associated with painful experiences; in his hysterical patients, he
observed not only amnesia for memories of the painful events, but
also for the affects that attached to those memories, leading him to
believe that not only had the memories to be recalled, but that the
accompanying affect must be discharged in a process Freud later
called catharsis, or abreaction. The achievement of abreaction was
postulated to signal the cessation of symptoms (Thornton, 1949).
Throughout his career, Freud struggled to understand the locus of
therapeutic action. In his last paper, he achieved a rapprochement
between id-analysis and ego-analysis.
The essential point is that the patient repeats these . . . [defensive

mechanisms] during the work of analysis . . . he produces them before
our eyes . . . In fact, it is only in this way that we get to know them.
This does not mean that they make analysis impossible. On the
contrary, they constitute half of our analytic task. The other half, the
one which was first tackled by analysis in its early days, is the uncov-
ering of what is hidden in the id. During the treatment our therapeutic
work is constantly swinging backwards and forwards like a pendulum

between id-analysis and . . . ego-analysis. In the one case, we want to
make something from the id conscious, in the other we want to correct
something in the ego. The crux of the matter is that the defensive
mechanisms directed against former danger recur in the treatment as
resistances against recovery. It follows from this that the ego treats
recovery itself as a new danger. (Freud, 1937c, p. 238, my italics)
Free association
Free association was not Freuds invention. It has a long history in the
arts, beginning with its first recorded appearance in a comic play (The
Clouds) by the ancient Greek playwright, Aristophanes, in which the
subject was instructed (by the character playing Socrates) to lie on the
couch and say whatever came into his mind (Rogers, 1953). Other
appearances of the technique are noted in Hobbes Leviathan (1651) in
which he describes trayns of thoughts . . . unguided, without design
. . . as in a dream . . . [a] wild ranging of the mind . . . (McAlpine &
Hunter, 1956). Freud (1920b) frequently mentions the work of
Friedrich Schiller, a German poet, philosopher, and historian, who
proposed a theory of animal (forerunner to Freuds sexual instinct),
spiritual (forerunner to Freuds ego instinct), and play drives (fore-
runner of free association), which Schiller believed stimulated crea-
tivity. Freud was also aware of the work of Ludwig Boerne (1823),
including The Art of Becoming an Original Writer in Three Days, which
extols the virtues of free association in enhancing creativity. Frances
Galton (1879) (in Zilboorg, 1952) also explored free association, which
he called associated ideas.
Free association became the first fundamental rule of psycho-
analysis (Freud, 1914g, 1923b).9 In the second stage of technique
development, Freud abandoned both hypnosis and abreaction, replac-
ing them with a new focus on free association and the analysis of the
resistance. The German freie Einflle has the meaning spontaneous
thoughts, by which Freud meant utterances that were not goal-
directed or self-critical (Lothane, 2006). The analysand is instructed to
allow a free flow of associations, emotions, and images to emerge.
When a defensive blocking of those associations occurs within the
analysand, this blocking is called repression. When it is motivated by
the analystanalysand dyad via the transference, it is called resistance.
Freud hoped that the technique of free association would simultane-

ously expose and undo both repression and resistance (Boag, 2010).
The task became one of discovering from the patients free associa-
tions what he failed to remember. The resistance was . . . circumvented
by the work of interpretation and by making its results known to the
patient. The situations which had given rise to the formation of the
symptom and the other situations which lay behind the moment at
which the illness broke out retained their place as the focus of inter-
est; but the element of abreaction receded into the background and
seemed to be replaced by the expenditure of work which the patient
had to make in being obliged to overcome his criticism of his free asso-
ciations, in accordance with the fundamental rule of psycho-analysis.
(Freud, 1914g, p. 147)
Free association required the patient to say whatever came into his
mind, with no attempt to censure or organise his thoughts, thereby
becoming a passive observer of his own stream of consciousness.
Freud instructed his patients to Act as though . . . you were a trav-
eller sitting next to the window of a railway carriage and describing
to someone inside the carriage the changing views which you see
outside (Freud, 1913c, p. 135).
The treatment is begun by the patient being required to put himself in

the position of an attentive and dispassionate self-observer, merely to
read off all the time the surface of his consciousness, and on the one
hand to make a duty of the most complete honesty while on the other
not to hold back any idea from communication, even if (1) he feels that
it is too disagreeable or if (2) he judges that it is nonsensical or (3) too
unimportant or (4) irrelevant to what is being looked for. It is
uniformly found that precisely those ideas which provoke these last-
mentioned reactions are of particular value in discovering the forgot-
ten material. (Freud, 1923a, p. 238)
Freud (1923a) was so impressed with free association that he thought

the material arising from its outcomes warranted a new name,
psychoanalysis, which he described as an art of interpretation
(p. 239). Freud found that the material produced from free association
hinted at hidden meaning and that it was the analysts task to
discover these meanings. To do so, the analyst was required to
surrender himself to his own unconscious mental activity, in a state
of evenly suspended attention . . . and by these means to catch the

drift of the patients unconscious with his own unconscious (p. 239).
Freud believed that the pleasure principlethat is, the striving
after pleasure and the avoidance of unpleasuregoverns all psychic
activity, all of which must be considered meaningful, including dis-
continuities of consciousness such as dreams, jokes, slips of the
tongue, and selective forgetting. Hence, all psychic activity is contin-
uously striving to achieve pleasure, and to discharge sexual and
aggressive energy. The unconscious is, thus, understood as psychic
continuity masked by a discontinuous consciousness (van Haute &
Geyskens, 2007). The aim of analytic treatment is to access the psychic
continuity masked by conscious discontinuities. This can purportedly
be achieved by free association, which lifts amnesia and allows direct
access to the unconscious.
Fenichel (1938) was less optimistic about the capacity of free asso-
ciation to deal with the patients self-censorship.
As long as only the id is being investigated, the defences of the ego

appeared merely as interferences which had to be disposed of as
quickly as possible . . . Free association . . . does not really dispose of
the dynamically decisive defences and a complete docility in the
patient with regard to the fundamental rule is therefore in practice
impossible. The picture actually given by free association is an alter-
nation between derivatives of the id and the defensive actions of the
ego . . . the impulses of the id strive towards consciousness and are
allies of the analyst, the unconscious elements in the ego have no incli-
nation to become conscious and derive no advantage from so doing.
(pp. 118119)
It was Anna Freud who identified the need to expose and interpret the
defences of the ego in order to reduce the psychic discontinuities.
Interpretation
Guntrip (1993), who commented that Psychoanalytic interpretation
is not therapeutic per se, but only as it expresses a personal relation-
ship of genuine understanding (p. 140), highlights the importance of
a genuine personal relationship between analyst and analysand as the
bedrock of the psychoanalytic process, without which psychoanalytic
technique cannot be effective. Interpretation constitutes the verbal
participation of the analyst in this process. The technique of interpre-

tation was developed to explain the influence of primary process,10
which is accessed via free association. It has many functions, includ-
ing making connections between seemingly disparate utterances of
the patient, confirming, clarifying, confronting patients with their
contradictions, correcting misrepresentations, pointing out omissions
or distortions, giving insight, synthesising, asking occasional, judi-
cious questions, and interpreting dreams. The type and complexity of
the interpretation, ranging from holding (Slochower, 1996a,b) to
symbolic decoding, depends on the level of pathology (Aguillaume,
2007, p. 239), the perceived readiness of the patient to hear the inter-
pretation, and the strength of his ego to manage it. Silence is also part
of the process of interpretation. It is applied to increase the frustration
of the patient to an optimal level. Too little frustration is too gratify-
ing and is likely to prevent the patient from reaching repressed,
unconscious material; if it is too much, the analyst is perceived as
persecutory (Arlow, 1961).
Freud believed that two conditions must be met before an inter-
pretation is given: the first is that the patients repressed material must
be judged to be close to consciousness and he must be firmly attached
to the analyst via the transference to prevent flight, either from the
repressed material or from the analysis itself (Friedman, 1991). The
aim of all psychoanalytic interpretation is to strengthen the ego via
self-knowledge through the demonstration of the activity of the
defences that prevent the gaining of insight. Sandler, Dare, and
Holder (1973) offer this generic definition of interpretation: . . . all
comments and other verbal interventions which have the aim of
immediately making the patient aware of some aspect of his psy-
chological functioning of which he was not previously conscious
(p. 110).
Three types of interpretation have been described: resistance inter-
pretation (Castelnuovo-Tedesco, 1986), content interpretation (Blom-
field, 1982), and transference interpretation (Schafer, 1982; Stewart,
1987). In all forms of interpretation, the task of the analyst is to help
the patient become aware of the repressed aspects of his mind (Freud,
19161917, p. 435). However, this may involve change and Change is
seen quite routinely as involving loss of control and a danger of losing
ones identity, separateness, and wholeness (Castelnuovo-Tedesco,
1986, p. 262). Thus, the patient resists this process; he tries to avoid
becoming conscious of his own wishes and impulses. Analysis of the

resistance involves understanding and pointing out how patients
keep important ideas or feelings out of awareness, or how they stop
themselves from speaking. In The dynamics of transference (1912b),
Freud stated,
. . . if a patients free associations fail, the stoppage can invariably be

removed by an assurance that he is being dominated at the moment
by an association which is concerned with the doctor himself or with
something connected with him. As soon as this explanation is given,
the stoppage is removed, or the situation is changed from one in
which the associations fail into one in which they are being kept back
. . . Thus the solution of the puzzle is that transference to the doctor is
suitable for resistance to the treatment only in so far as it is a negative
transference or a positive transference of repressed erotic impulses.
(pp. 101, 105)
Dealing with resistance is a relentless and often thankless task for the
analyst, who must repeatedly point out/interpret these resistances
throughout the entire course of the analysis before they actually take
hold. Both resistance and content appear in the transference relation-
ship and this will need to be interpreted when it arises. Daily events
that occur in the lives of patients during their analysis call forth old
responses and defensive patterns.
Transference interpretations are directed to the unconscious, with
the aim of making unconscious sources of pain conscious and, thus,
available for scrutiny. Freud believed that the emotional aspects of
insight and working through could only be developed and interpreted
in the transference, in the immediacy of the here-and-now, which,
during the course of the analysis, becomes a condensed, co-ordi-
nated, and timeless version of past and present (Schafer, 1982, p. 77).
The concept of counter-transference, defined as the effect of the
patient on the analysts unconscious feelings (Armony, 1975), consid-
ered such a centrally important part of the analytic relationship today
(Bernstein, 1993; Opdal, 2007), was infrequently mentioned in the
writings of Freud. However, Freud was aware of its existence; his
recommendation that all analysts undergo both analysis and self-
analysis implies that the analysts self can intrude on the therapy in
unhelpful ways. He was reminded of its significance in his therapeutic
encounters, particularly in his analysis of Dora. In his subsequent
struggle to understand her premature termination, he warned the

analyst that countertransference must be recognised and overcome
(Freud, 1910k). Freud later wrote that the analyst must turn his own
unconscious like a receptive organ towards the transmitting uncon-
scious of the patient (Freud, 1912e, p. 115), implying the need for
introspection, receptivity, openness, and empathy in the analytic
stance.
Resistance
Freud was intrigued by the phenomenon of resistanceit appeared
early and frequently in his writing. For example, in 1900, in Dream
of Irma, Freud observes:
The adoption of the required attitude of mind towards ideas that seem
to emerge of their own free will and the abandonment of the critical
function that is normally in operation against them seem to be hard to
achieve for some people. The involuntary thoughts are liable to
release a most violent resistance, which seeks to prevent their emer-
gence. (1900a, p. 102)
In Fragment of an Analysis of a Case of Hysteria, Freud (1905e) noted,
. . . and so it happens that anyone who tries to make [the patient] well
is to his astonishment brought up against a powerful resistance, which
teaches him that the patients intention of getting rid of his complaint
is not so entirely and completely serious as it seemed. (p. 43)
Freud emphasised that although psychoanalytic technique had under-

gone major revisions, the . . . aim of these different techniques has, of
course, remained the same. Descriptively speaking, it is to fill in gaps
in memory; dynamically speaking, it is to overcome resistances due to
repression (Freud, 1914g, p. 148).
In the third major change in psychoanalytic technique, the thera-
pist was advised to abandon attempts to focus on the problem and to
. . . content himself with studying whatever is present for the time

being on the surface of the patients mind . . . he employs the art of
interpretation mainly for the purpose of recognizing the resistances
which appear there, and making them conscious to the patient. From
this there results a new sort of division of labour: the doctor uncovers
the resistances which are unknown to the patient; when these have
been got the better of, the patient often relates the forgotten situations
and connections without any difficulty. (Freud, 1914g, p. 147)
Freud recognised early that the treating physician was not immune
from the vicissitudes of resistance:
. . . if the doctor is to be in a position to use his unconscious . . . as an

instrument in the analysis, he must himself fulfil one psychological
condition to a high degree. He may not tolerate any resistances in
himself which hold back from his consciousness what has been
perceived by his unconscious; otherwise he would introduce into the
analysis a new species of selection and distortion which would be far
more detrimental than that resulting from concentration of conscious
attention. (Freud, 1912e, p. 116)
He identified resistance as the enemy of the psychoanalytic process:
The length of the road over which an analysis must travel with the
patient, and the quantity of material which must be mastered on the
way, are of no importance in comparison with the resistance which is
met with in the course of the work . . . The situation is the same as
when to-day an enemy army needs weeks and months to make its way
across a stretch of country which in times of peace was traversed by
an express train in a few hours and which only a short time before had
been passed over by the defending army in a few days. (Freud, 1918b,
p. 11)
Patients enter psychoanalysis with both hope and dread (Mitchell,

1993). The psychoanalytic situation is somewhat seductive in its invi-
tation to say whatever is on ones mind to a receptive and non-judge-
mental other. Most analysands welcome the opportunity to unburden
themselves, as a confessant with his/her priest, and experience the
relief of confession (i.e., catharsis/abreaction). As the analysis pro-
ceeds, the patients communications begin to include material that he
might not understand or initially did not feel the need to discuss.
Guilty secrets and aggressive and sexual fantasies emerge that arouse
fears of retaliation and punishment, or loss of self-esteem and the
esteem of others. Thus, the patient experiences ambivalence, the pull
to continue with self-exploration and the push to retreat into previous
modes of adjustment for which he had developed coping strategies.

The patient is now in a dilemma: he must choose between the known
psychological discomforts of his current life or anxiously plunge into
exploration of dangerous possibilities for change. The hesitation,
doubts and fears that this situation creates is known as resistance. The
analysis becomes a duel between the competing forces impelling
recollection, repetition and expression and the forces and devices of
resistance (Menninger & Holzman, 1973, p. 104). Freud believed that
resistance was present throughout the analysis, and that the patient
used his defensive repertoire in the service of resistance, which
opposes change (Freud, 1926d). Paradoxically, both the motivation for
resistance and the resistance itself may be unconscious (Freud, 1920g).
Resistance manifests in many forms, including concealment of known
facts, forgetting, tardiness, absences, prolonged silences, intellectuali-
sation, somatisation, acting out, and erotisation.11
In From the History of an Infantile Neurosis (1918b), Freud used a
fixed termination date to bring the analysis of the Wolf Man to an end
in order to manage the resistance.
I determined but not until trustworthy signs had led me to judge that
the right moment had come that the treatment must be brought to an
end at a particular fixed date, no matter how far it had advanced. I
was resolved to keep to the date; and eventually the patient came to
see that I was in earnest. Under the inexorable pressure of this fixed
limit his resistance and his fixation to the illness gave way, and now
in a disproportionately short time the analysis produced all the mate-
rial which made it possible to clear up his inhibitions and remove his
symptoms. (p. 11)
In Inhibitions, Symptoms and Anxiety (1926d), Freud described five

types of resistance:
1. Repression resistance: involves the defensive action of the ego to

buttress repression, to prevent making the unconscious conscious
related to the unconscious fear associated with this process.
2. Transference resistance: during the patients re-experiencing of
previous relationships with the analyst, the analysts abstinence
frustrates the gratification of the regressive wishes of the patient,
leading to anger and disappointment in the analyst, and resis-
tance to tell him anything.
3. Epinosic gain resistance: reluctance of the ego to give up the advan-

tages that have accrued as a result of the illness (i.e., inertial pull
to remain ill). Today, we call this phenomenon secondary gain
(Katz, 1963).
4. Repetition-compulsion resistance: emanating from the id, there
remains a pull by the unconscious on repressed instinctual
processes that work against the ego as it struggles to relinquish
the ego resistances (i.e., self-directed aggression).
5. Superego resistance: this is represented by a need for punishment
in order to assuage feelings of guilt.
In general, any attempt to influence the therapist or to exert some

effect on hereither to please or to displeaseis considered a form
of resistance. Freud concluded that overcoming the resistances was
. . . an essential part of the process of cure . . . and that unless this was
achieved no permanent mental change could be brought about . . .
(Freud, 1923a, p. 249).
Regression (transference neurosis)

A further process is needed to fully explain the emerging psycho-
analytic technique: regression, or the development of the transference
neurosis (Blum, 1971; Calef, 1971; Chessick, 2002). Regression is a
highly contested concept within psychoanalysis, as Bions quip illus-
trates: Winnicott says patients need to regress; Melanie Klein says
they must not regress; I say they are regressed (Bion, in Britton, 1998,
p. 71).
Psychoanalytic treatment involves the induction, via free associa-
tion and the uncritical and unobtrusive presence of the analyst, in a
setting of introspection and understanding, of a regression (also called
the transference neurosis), in which the analysand becomes child-
like (i.e., returns to more primitive ways of feeling, experiencing, and
behaving, including a preoccupation with the self) and emotionally
dependent on the analyst, so that she can grow up again with a more
benign parent/analyst, having recollected, understood, and mastered
repressed experiences. Winnicott (1955) reconceptualised the analytic
setting as a reparative motherinfant relationship, in which the thera-
pist provides some of the maternal functions missing in the original
motherinfant dyad. However, he took a rather extreme and literal
view of regression:
. . . regression to dependence is part . . . of the analysis of early infancy

phenomena, and if the couch gets wetted, or if the patient soils, or
dribbles, we know that this is inherent, not a complication.
Interpretation is not what is needed, and indeed speech or even move-
ment can ruin the process and can be excessively painful to the
patient. (p. 23)
While not all analysts take such an extreme view, most agree that
regression involves a period of induced ego disorganisation and
reorganisation, during which the analyst becomes a new object or
(secure base, in attachment theory terms) that emboldens the patient
to dare to take the plunge into the regressive crisis of the transference
neurosis which brings him face to face again with his childhood
anxieties and conflicts (Loewald, 1960, in Menninger & Holzman,
1973, pp. 5152). Loewald (1960) used the following analogy:
Transference is pathological insofar as the unconscious is a crowd of

ghosts, and this is the beginning of the transference neurosis in analy-
sis: ghosts of the unconscious imprisoned by defenses but haunting
the patient in the dark of his defenses and symptoms . . . In the
daylight of analysis the ghosts of the unconscious are . . . led to rest as
ancestors whose power is taken over and transformed into the newer
intensity of the present life, of the secondary process12 and contempo-
rary objects. (p. 29)
What is important in the analytic setting and the transference in con-

temporary psychoanalysis, especially to the very vulnerable patient
(i.e., those with disturbances of the self), is the experience of a mater-
nal presence that is unobtrusive, reliable, and highly attuned to the
patients inner experience so that the patient may find a transforma-
tional quasi-maternal object relation in the analytic experience
(White, 2006, p. 139), a reworking of the original object relation that is
. . . known not so much [as] an object representation, but as a recur-
rent experience of beinga more existential as opposed to represen-
tational knowing (Bollas, 1979, p. 14).
Because the analyst cannot fulfil the patients anachronistic wishes,
the patient becomes increasingly frustrated and angry with the
analyst. The anger might be expressed directly or in the form of
resentment, depression, or discouragement. Although Freud believed
that frustration, of itself, was not an effective form of treatment, he
viewed frustration as the main source of action in effective psycho-

analysis. We discussed earlier that the first fundamental rule of
psychoanalysis was free association; the second was that the analytic
treatment should be conducted in a state of abstinence.
As far as his relations with the physician are concerned, the patient
must have unfulfilled wishes in abundance. It is expedient to deny
him precisely those satisfactions which he desires most intensely and
expresses most importunately. (Freud, 1919a, p. 164)
Freud believed that failure to adhere to this rule in therapy would

hinder the patient becoming more capable of managing the actual
tasks of his life. The analyst must abstain from responding to the
patients pleas, charges, manoeuvres, requests, and demands . . . This
controlled frustration permits the patient to directly confront his
interpersonal style, that is, his conditions for loving and hating
(Menninger & Holzman, 1973, p. 56). The search for love becomes a
compelling focus in the regressed state. It is reminiscent of the yearn-
ings of a nursing baby at the breast . . . (Menninger & Holzman, 1973,
p. 64). These infantile experiences are relinquished or transmuted by
the mature adult, but not by those who have not received sufficient
love in early life. Such patients will eventually seek tangible proof of
love from their analyst. Initial politeness and obedience to the rules of
the therapy will give way under the pressures of mounting frustration
due to the therapists non-response to expressions of anger that can no
longer be restrained by good manners or fear. All of the patients
symptoms may be viewed as attempts to simultaneously suppress,
repress or express her pervasive anger and helplessness (rage). All of
the patients unconscious strivings, impulses, and neurotic patterns
are expressed in the transference relationship and, thus, become
evident to both analyst and patient and available for examination and,
one hopes, verbal communication. The constancy of the therapist
through all the oscillations in the mood and behaviour of the patient
is reassuring, stabilises the patient, and gradually frees her from trans-
ference distortions, which in turn reduces the extreme fluctuations in
the patients mood. All the while the unregressed, healthy part of the
patients ego (the observing self) forms an alliance with the therapist
to assist her to overcome her resistance to treatment, to become aware
of the transference distortions, and to remain motivated in the task of
self-exploration (introspection) (Sterba, 1951).
Regression arises out the analysts capacity to create and maintain

ambiguity that is reflected in the transference. Ambiguity is created by
the analysts abstention from providing opinions, advice, affirma-
tions, or validation to the patient. According to Spivak (2011),
. . . the patient is asked to suspend disbelief and to deal with a para-

doxical reality in which his experience of the transference is both
real and unreal, both past and present. The patient must be able to
tolerate . . . not knowing the reality of his experience . . . the person
is frozen in time as primary process merges past, present and future
into the timelessness of the unconscious . . . The interplay of regression
and ambiguity activates . . . unconscious fantasies, drives, and inter-
nal objects [which] are externalized into the transference. (pp. 125
126)
Spivak warns that regression may be hazardous because an already

overwhelmed ego may be re-traumatized on the path to repair. That
the analysand hovers between trauma and repair while on the couch
is an unavoidable risk within the process (p. 126).
It is self-evident that at some point in the analysis, the transference
neurosis must be reversed and resolved. How does this occur? A
number of candidate processes have been proposed. These include the
uncovering of repressed trauma, remembering forgotten or half-
remembered experiences that have haunted the patient (i.e., making
the unconscious conscious), the abandonment of fixation points in a
thwarted development, discharge of unhealthy emotion via the pro-
cess of abreaction, insight through interpretation, or the softening and
modification of a punitive superego. All these processes are thought
to extend the boundaries of the observing ego and, thus, increase self-
reflection. Later theorists, revisiting Ferenczi, pointed to the role of a
corrective emotional experience (McCarthy, 2010) or decondition-
ing or extinction of noxious emotional experiences through emotional
exposure (Wilamowska et al., 2010). To sum up:
Having gone back to the beginnings of all his misunderstanding and

misinterpretations and mismanagements, having conceded his errors
and forgiven those of others, having recognized the unrealistic nature
of some of his cherished expectations and love objects and methods of
procedure, the patient gradually begins to put away childish things.
(Menninger & Holzman, 1973, p. 74)
Once this point in the analysis has been reached, the working through
phase of treatment begins. Infantile feelings and goals become less
compulsive and the patient starts to feel freer to develop more adult,
adaptive means of relating to self and others.
It is interesting to observe that psychoanalysis as a therapeutic
technique emerged in the process of trying to understand current,
mostly hysterical or psychogenic, symptoms in light of current events
in a persons life. However, the importance of infant and childhood
experiences in the aetiology of the disorders that Freud treated in late
nineteenth- and early twentieth-century Vienna quickly became
apparent both theoretically and therapeutically. Even in the earliest
works, there are frequent references to the origin of hysterical symp-
toms in traumas that occurred earlier in life, often in childhood.
However, most of these experiences occurred in the post-verbal
period, were accessible to memory (often under hypnosis), and could
be verbalised. What is remarkable about the case study of the new
mother described earlier is Freuds intuition regarding the aetiology
of her presenting difficulties in some unresolved experience during
her own infancy, although clear articulation of such links was several
years away. When they did appear, however, their character had
changed to a focus on infant sexuality, as opposed to the implied
experience of either maternal neglect or misattunement, as in this
young mothers infancy. In the preface to the second edition of Studies
on Hysteria, published in 1908 thirteen years after the first, Freud adds
infantilism to his original theory of catharsis.
. . . The developments and changes in my views during the course of

thirteen years of work have been too far-reaching for it to be possible to
attach them to my earlier exposition without entirely destroying its
essential character. Nor have I any reason for wishing to eliminate this
evidence of my initial views. Even to-day I regard them not as errors
but as valuable first approximations to knowledge which could only be
fully acquired after long and continuous efforts. The attentive reader
will be able to detect in the present book the germs of all that has since
been added to the theory of catharsis: for instance, the part played by
psychosexual factors and infantilism, the importance of dreams and of
unconscious symbolism. And I can give no better advice to anyone
interested in the development of catharsis into psycho-analysis than to
begin with Studies on Hysteria and thus follow the path which I myself
have trodden. (Freud (with Breuer), 1895d, p. xxxi)
Regression, like many concepts in psychoanalysis, has become a

somewhat ambiguous phenomenon. Ambiguity arises in the literary
and metaphorical turn of many analytic writers and in the subsequent
translation of these metaphors into clinical technique (Spurling, 2008).
Some of the varied uses of the term regression include
an evocation of the primitive . . . to convey the arrival of something

primitive in the treatment, whether it be the level of development, of
experience or part of the mind in the patient or a primitive form of
relationship between patient and therapist. (Spurling, 2008, p. 526)
Freud (e.g., in Mourning and melancholia) used the concept of

regression to denote both topographical and temporal factors: topo-
graphically, to depict a movement back from verbal to perceptual
processes, and temporally, to depict a return to earlier stages of devel-
opment, for example, from secondary to primary process thinking.
Note his statement, for example, Melancholia, therefore, borrows
some of its features from mourning, and the others from the process
of regression from narcissistic object-choice to narcissism (Freud,
1917e, p. 250). These uses overlap, of course, since primary process
thinking is essentially a perceptual process. Both Winnicott and Balint
used the term topographically, in the sense of connecting with a
deeply buried part of the mind: for example, Winnicotts true self,
or Balints basic fault, and temporallyWinnicott believed that
patients needed to re-experience their past traumas and that this was
accomplished via a return to the infantile state of dependence on not
only the analyst but also the analytic setting.
With the recognition that the analytic relationship reflects, to some
extent, the motherbaby relationship (Winnicott, 1960), the therapeu-
tic setting has become an integral part of the analytic attitude.
Winnicott (1955) paid particular attention to making the setting
predictable, reliable, and constant: . . . the setting represents the
mother . . . and the patient is an infant (p. 20). He believed that the
setting should be a quiet, non-distracting, expectable environment
that supports the development of the transference relationship
(Guntrip, 1975; Modell, 1989). The setting may be understood as an
extension of the analysts mind and as a container of early emotions
(Carpelan, 1981; Gilmore, 2005).
Winnicott (1955) distinguished regression and reassurance, which
he considered should rarely form part of psychoanalytic technique.
The patient comes into the analytic setting and goes out of it, and
within that setting there is no more than interpretation, correct and
penetrating and well-timed . . . [However,] [w]hat could be more reas-
suring than to find oneself being well analysed, to be in a reliable
setting with a mature person in charge, capable of making penetrating
and accurate interpretation, and to find ones personal process
respected? It is foolish to deny that reassurance is present in the clas-
sical analytic situation . . . The whole set-up of psycho-analysis is one
big reassurance, especially the reliable objectivity and behaviour of the
analyst, and the transference interpretations constructively used
instead of wastefully exploiting the moments passion. (p. 25)
Winnicott argued that in the transference, the past comes into the
present of the analytic relationship; in regression, the present becomes
the past. For other writers, regression signals the need for a change in
psychoanalytic technique, such as a withdrawal from active interven-
tion and interpretation in order to give the patients self-experience
sufficient time and space to unfold (Spurling, 2008, p. 527). Similar
descriptions of this process appear in, for example, Ferenczis princi-
ple of relaxation, Winnicotts regression to dependence, Balints
notion of life becoming simpler and truer (Balint, 1968, p. 135),
Slochowers (1996b) holding in which the otherness of the analyst
is minimised in order to prevent impingement on the patients unfold-
ing process, or Bollass (1987) use of the analyst as a transformational
object (p. 247) rather than a transference object that facilitates the
patients struggle to know his true self. The purpose of this process of
regression is to provide the basis for the emergence of hope and a new
beginning (Winnicott, 1955).
Spurling (2008) challenged the apparent excesses of previous ther-
apists who stepped outside the analytic frame for patients in a
regressed state, including the hand and finger holding of Winnicott,
who allowed regular out of session contact or actually assisting some
patients with life tasks. Masud Khan went even further and engaged
in sexual relationships with some of his patients, behaviour that today
would be considered a serious boundary violation. Spurling argues
that the concept of a therapeutic regression is vague and carries multi-
ple meanings. It privileges a particular state in analysis (that in some
cases might even be iatrogenically induced), which he contends prop-
erly belongs to the analysis as a whole.
Termination
We will complete this overview of classical Freudian theory and tech-
nique with a few words about termination of the analysis. This is a
very vexed issue, even today (Hill, 2011), and although many areas of
psychoanalytic theory, technique, and practice are heavily contested,
issues related to termination remain among the most problematic.
Woody Allen makes a humorous and ironic allusion to the problem of
termination in this interaction between Annie and Alvy in Annie Hall:
Annie: Oh, you see an analyst?

Alvy: Y-y-yeah, just for fifteen years.
Annie: Fifteen years?
Alvy: Yeah, uh, Im gonna give him one more year and then Im
goin to Lourdes.
In Analysis terminable and interminable, Freud (1937c) stated,
A constitutional strength of an instinct and an unfavourable alteration

of the ego acquired in its defensive struggle in the sense of its being
dislocated and restricted these are the factors that are prejudicial to
the effectiveness of analysis and which may make its duration inter-
minable. (p. 220)
Strachey (1937) notes Freuds growing scepticism about the efficacy of

psychoanalysis as a therapeutic or prophylactic agent. His doubts
extend to the prospects of preventing not merely the occurrence of a
fresh and different neurosis but even a return of a neurosis that has
already been treated (p. 213), as exemplified in this comment from
Freud:
It looks almost as if analysis were the third of those impossible

professions in which one can be sure beforehand of achieving unsat-
isfying results. The other two, which have been known much longer,
are education and government. (Freud, 1937c, p. 248)
Freud was critical of attempts to reduce the length of therapy. Rank

(1924), for example, believed that the source of neurosis was the act of
birth, and if this neurosis could be resolved, the whole neurosis would
dissipate, thus greatly shortening the length of the analysis to a few
months. Freud was unimpressed with this idea:
We have not heard much about what the implementation of Ranks

plan has done for cases of sickness. Probably not more than if the fire-
brigade, called to deal with a house that had been set on fire by an
overturned oil-lamp, contented themselves with removing the lamp
from the room. (Freud, 1937c, p. 216)
For lengthy analyses, Freud set fixed termination dates, in an attempt

to motivate the patient to move on with the work. However, he
remained cautious of this strategy because of its potential harm. He
wondered whether . . . there [is] such a thing as a natural end to an
analysis is there any possibility at all of bringing an analysis to such
an end? (p. 219). Freud argued that the analysis ended when
. . . two conditions have been approximately fulfilled: first, that the

patient shall no longer be suffering from his symptoms and shall have
overcome his anxieties and his inhibitions; and secondly, that the
analyst shall judge that so much repressed material has been made
conscious, so much that was unintelligible has been explained, and so
much internal resistance conquered, that there is no need to fear a
repetition of the pathological processes concerned. (p. 219)
Some analysts viewed the end of therapy as a form of mourning.

For example, Ferenczi (1927) believed that the transference neurosis
could be completely resolved and that analysis could end once the
mourning process had been completed. Similarly, Ekstein (1965)
stated that
. . . this mourning at the end of analysis must be understood not

simply as the loss of the analyst as a person, but rather as the patients
farewell to his infantile self as well as to the transference projections
of the past. (p. 57)
Klein (1950) believed that the analysis was not complete until the
persecutory and depressive anxieties had been reduced, and the nega-
tive and positive transference analysed. Others were less optimistic
about the final outcome of psychoanalysis. For example, Ekstein
(1965) felt that
. . . the possibility of perfect therapeutic results have made us give up

the myth of the perfect Freudian man,13 the post-ambivalent genital
character, and we have become more and more sceptical about termi-
nation in terms of an ideal ending point. (pp. 5859)
Menninger and Holzman (1973) offered a number of criteria that

could assist both analyst and patient in the decision about the timing
of termination. These included the achievement of a more integrated
ego, in which the split between the observing ego and the regressive
part of the ego has been mended, the punitive qualities of the super-
ego have been replaced by a more realistic ego ideal, interpersonal
relationships are characterised by a more mature capacity for intimacy
and interdependence, that aspects of work, play, and ideas are
balanced and satisfying, and that the patient has a greater capacity for
frustration tolerance and accepts the impossibility of obtaining infan-
tile gratification from the analyst. The patient relinquishes his view of
the analyst as magically omnipotent and accepts the analyst as a
person. This will follow once the transference neurosis has been
resolved. However, Freud should have the last word on termination:
Our aim will not be to rub off every peculiarity of human character for
the sake of a schematic normality, nor yet to demand that the person
who has been thoroughly analysed shall feel no passions and
develop no internal conflicts. The business of the analysis is to secure
the best possible psychological conditions for the functions of the ego.
(Freud, 1937c, p. 250)
Freud (1933a) had a certain wry sympathy with Woody Allens char-
acter, Alvy, in Annie Hall,
I do not think our cures can compete with those of Lourdes. There are
so many more people who believe in the miracles of the Blessed Virgin
than in the existence of the Unconscious. (p. 152)
CHAPTER TWO
Beyond Freuds psychoanalysis
enniger and Holzman, (1973) boldly declared, There is . . .
M an implicit philosophy and ethic in the psychoanalytic expe-

rience . . . love is the greatest thing in the world . . . the intan-
gible gains of psychoanalytic treatment extend out into the universe.
They are immeasurable . . . (p. 182). Notwithstanding, schisms arose
early in the theory and practice of psychoanalysis and there was little
love lost between Freud and his fallen acolytes. There were four main
reasons for the schisms:
1. There was disagreement about the primacy that Freud afforded
to sexuality and a shift in emphasis from sexual to social causes
of psychopathology.
2. There were disagreements about technique and the locus of
therapeutic action.
3. Interpersonal processes came to the fore in contrast to the
purportedly intrapsychic focus of the original theory.
4. There was a change in focus from pathological development to
normal developmental processes.
These themes are addressed in various ways in the conversations with
the master clinicians in the coming chapters.
45
While Freud was primarily concerned with psychopathology and

its origins, Hartmann and Anna Freud were interested in the
processes underlying normal development, including the role of the
environment in shaping personality (Hartmann, 1939). Hartmann
argued that humans, like all living organisms, were designed to
survive in their environmentsnot just physically, but psychologi-
cally. Consistent with his views about the human capacity for adap-
tation, Hartmann believed that the infant was born ready, with
conflict-free ego capacities, to interact with an average expectable
environment. Psychological defences that arose in response to conflict
could become adaptive in the service of socialisation, through a
process of neutralisation of their sexual and aggressive origins.
Sullivan (1953, 1964), who worked with people with schizophre-
nia, also formulated the view that personality unfolds in an interper-
sonal context, in the recurrent interactions between self and others.
(You will observe a strong focus on the interpersonal in all of the
conversations recorded in the coming chapters.) Sullivan stressed that
human behaviour could only be understood within an organism
environment complex and that the innate physiological and emo-
tional needs of the infant could only be satisfied in an interpersonal
context, in the first instance, by the mother. Thus, in therapy, Sullivan
sought explanations for psychopathology in a detailed analysis of the
interactions between the patient and his significant others.
One of Sullivans most significant contributions was his under-
standing of the devastating effect that an attack via ridicule, mockery,
misattunement, or other invalidating response on the tender emo-
tions, that is, feelings of love and gratitude or the expression of
highly valued thoughts or memories, has on development. Repeated
failure of validating experiences of these tender emotions from care-
givers results in a chronic sense of personal devaluation, dysphoria,
emptiness, and worthlessness. Future exposure or expression of these
feelings risks the experience of shame, which is felt with devastation
(Sullivan, 1953).
Hartmanns work was foundational for a generation of develop-
mental ego psychologists such as Spitz (1945), whose study of chil-
dren who failed to thrive in foundling homes during and after the
Second World War left no one in doubt about the crucial role that the
care-giving environment plays in both physical and emotional devel-
opment. Spitz was responsible for critical new conceptualisations of
BEYOND FREUDS PSYCHOANALYSIS 47
the role of the mother in development, the reciprocal influence of the

motherinfant dyad, and stranger anxiety, all concepts derived from
observations, interviews, and longitudinal follow up of motherinfant
dyads (Spitz, 1945, 1950a,b, 1951). Other influential developmental
ego psychologists were Mahler and Jacobson. Jacobson (1964), in her
book, The Self and the Object World, reworked Freuds concepts of
inwardly directed sexual and aggressive drives to include the signifi-
cance of environmental influences, in particular early relationships,
and the importance of interactions between biology and experience in
shaping development.
One of the most influential thinkers to emerge from ego psychol-
ogy was Heinz Kohut (19131981). His work departs in significant
ways from his predecessors in that he conceptualised human experi-
ence, not in terms of forbidden wishes, conflict, and guilt, but in terms
of self-experience, of isolation and alienation from oneself and others,
that gave rise to a sense of meaninglessness and an absence of inner
vitality or sense of joie de vivre. Kohut defined psychoanalysis as a
. . . psychology of complex mental states which, with the aid of the
persevering, empathic-introspective immersion of the observer into
the inner life of man, gathers its data in order to explain them (1977,
p. 302). Kohut gave primacy to the empathic mode of observation, in
which the analyst is an active participant who enters into the subjec-
tive world of the patients experience. Kohuts self psychology
model is founded on three basic needs, or selfobject experiences,14 for
the development of a healthy sense of self. These are the need to
be viewed with joy and approval, to have another who supports

the childs sense of vigour, greatness, and perfection;
have a powerful other from whom the child may derive a sense
of calm and infallibility;
have selfobjects who are like the child, with whom the child can
identify and find a place in which he or she feels at home, like the
others there.
Each of these developmental selfobject needs are reproduced in

psychoanalysis in three transference relationships, termed the mirror-
ing transference, the idealising transference, and the alter ego, or twin-
ship, transference, respectively. There is empirical support for the
existence and independence of the three types of selfobject needs
proposed by Kohut, as well as their association with attachment

quality and affect regulation (Banai, Mikulincer, & Shaver, 2005).
Perhaps the greatest shift from classical psychoanalysis in self
psychology and attachment-related psychotherapies is the centrality
assigned to the curative power of attunement/empathy, rather than
insight or interpretation. Kohut (1984) believed that optimal empathic
failuresthose failures of empathy in the analyst that can be success-
fully managed by the patientcontribute to the development and
consolidation of self-capacity, which entails the ability to tolerate the
reintegration of previously rejected or split-off parts of the self. This
process constitutes structural change in psychoanalysis, which is
argued to have strong parallels in the development of psychic struc-
ture in the infant (Beebe, 2005; Beebe & Lachmann, 1988).
The increasing importance assigned to the mutual influence of
the analystanalysand dyad as the locus of therapeutic action became
known as the intersubjective field (Atwood & Stolorow, 1984). The
importance of interactive mutual influence patterns in psychological
development has been recognised by a number of key researchers, and
it appears in many forms; for example, in Vygotskys concept of the
intermental (Vygotsky, Hanfmann, & Vakar, 1962), in Fairbairns
innate interpersonal relatedness (Fairbairn, 1946), Sullivans (1953)
interpersonal field, and in the accounts of both self psychologists
(Kohut, 1971, 1977, 1984) and relational (Mitchell, 1993), and intersub-
jective/existential psychoanalysts (Stolorow, 2005a). All question
some of Freuds basic assumptions (e.g., the primacy of the aggressive
and sexual impulses). Both the new wave of psychoanalysts and exis-
tential phenomenologists (e.g., Heidegger, Sartre, and Merleau-Ponty)
argue that we are embedded (and only exist) within our social/
relational context. There is no being, only a being-in-the-world
(Heidegger, 1962); there is no baby, only a motherbaby couple
(Winnicott, 1965b). I have argued elsewhere (see Kenny, 2013) that this
is a somewhat extreme view that is not supported by research in infant
development or research on the motherinfant dyad that shows the
interactive mutual influence between mothers and their infants that
is present almost from birth (Beebe, 2006; Beebe & Jaffe, 2008).
The term relational was first used by Greenberg and Mitchell
(1983) to separate the new psychoanalytic thinking from classical
drive theory and to integrate two major theoretical traditionsthe
British object relations theories and American interpersonal psycho-
analysis. The latter focused on current interactions between analyst

and analysand, rather than intrapsychic structure, and the analysts
empathicintrospective stance, while object relations theory empha-
sised the internal world of objects which resulted in the neglect of
actual relationships beyond the earliest primary relationships
between mother/care-giver and infant.
There has been much heated, but often little enlightened, debate
between relationalconstructivist and classicalstructural analytic
schools (for critiques, see Hoffman, 2007; Mitchell, 1995). Rangell
(2006) deplored the proliferation of theories and the consequent frag-
mentation of theorising in the field. He argued that many post
Freudian theories suffered from either one of two fallacies, the first of
which was pars pro toto (substituting a part of the theory and treating
it as a whole). He includes in this group Jung (focus on mysticism and
spirituality), Adler (focus on aggression and power), and Rank (focus
on infancy and the birth process). Freud described his erstwhile
protgs (Jung and Adler) contributions to psychoanalysis as twis-
ted re-interpretations of his own theories (Freud, 1918b). On Jungs
position with regard to archetypes, Freud had this to say:
I fully agree with Jung in recognizing the existence of this phyloge-

netic heritage; but I regard it as a methodological error to seize on a
phylogenetic explanation before the ontogenetic possibilities have
been exhausted. I cannot see any reason for obstinately disputing the
importance of infantile prehistory while at the same time freely
acknowledging the importance of ancestral prehistory. (Freud, 1918b,
p. 7).
The second fallacy involves setting up false dichotomies and polaris-

ing camps along those lines. Rangell cites the very public dispute
between Fenichel and Alexander with respect to the proper analytic
attitude. Fenichel advocated adherence to the neutral analytic stance,
requiring the analyst to give insights via interpretations, while Alex-
ander asserted that the curative factor in therapy was the corrective
emotional experience, in which the analyst provided what had been
missing in the analysands early life. A careful reading of Freuds case
studies show that such a division is a false dichotomythe analytic
attitude was intended from the outset to be both insight producing
and emotionally corrective.
The field abounds with straw man fallacies. Stolorow (2006)

argued that attempts to dichotomise human experience as subjective
(internal) or objective (external), or intrapsychic or interpersonal, are
misguided and constrain genuine understanding of experience. For
example, the initial danger situation that signals anxietyhelpless-
ness in the face of overwhelming affectis an internal experience.
When the infant learns that an external object, such as a parent or
other care-giver can alleviate his distress, the danger situation
becomes one of fear of the loss of the love object, or fear of the loss of
love from the love object, which are interpersonal experiences. When
the love object is internalised, that is, a mental representation of the
care-giver is constructed in mind as primarily nurturing or punish-
ing, available or unavailable, predictable or unpredictable, the experi-
ence once again becomes internal. Mitchell (1993), a relational psycho-
analyst, likewise agrees that all personal motives have a long
relational history.
The very capacity to have experiences necessarily develops in and

requires an interpersonal matrix . . . there is no experience that is not
interpersonally mediated. The meanings generated by the self are all
interactive products . . . If the self is always embedded in relational
contexts, either actual or internal, then all important motives have
appeared and taken on life and form in the presence and through the
reactions of significant others. (pp. 125, 134)
Integration: fantasy or reality?

In this section, we will briefly consider whether it is possible to
achieve integration of the many current versions of psychoanalytic
theory and whether integration of theory and practice can also be
achieved. A related question is whether theory actually informs the
practice of psychoanalysis. Despite differences in emphases, most of
the early psychoanalysts subscribed to the basic tenets of early
psychoanalytic theory: the unconscious, repression, other defences,
resistance, transference, and the role of childhood trauma in the aeti-
ology of psychopathology. These concepts remain focal points in
current psychoanalytic practice, as you will see from the conversa-
tions with the contemporary practitioners in this volume. However,
the field gradually diverged; concepts were introduced that did not
form part of the original theory. Failure to achieve consensus with
respect to basic concepts compromises the scientific status of a disci-
pline. Rangell (2006) summed up the concerns of many in the field of
psychoanalysis today: Do we have many theories, hundreds of
psychoanalyses or even in the opinion of some, guided by the demo-
cratic ideal, a theory for every analyst or even for every patient?
(p. 218).
There have been many attempts to integrate and clarify psycho-
analytic concepts into a coherent theory. Kernberg (1969, 1974, 1976,
1995, 2001; Kernberg, Yeomans, Clarkin, & Levy, 2008) proposed a
synthesis of instinct theory and the structural model with object rela-
tions theory and ego psychology. Sandler (Sandler & Freud, 1980)
clarified the use of the terms id and impulse and how they might
be reinterpreted:
. . . what we should consider to be the instinctual or id unit that is

worked on and transformed by the ego . . . [I]t is not clear . . . whether
the term impulse refers to drive energy, to some unknowable urge, or
whether it refers to an unconscious wish [that] contains mental
content. [Is it] sufficient for us to speak of the instinctual wish, and to
treat this as a psychologically irreducible unit? If we do this, then we
would think of the wish, after a certain point in development has been
passed, as involving self and object representations, and we could also
see the aim of the instinctual wish as being represented to the ego. So
while on the one hand we might speak of the id as the source of
instinctual drives, on the other we might perhaps better refer to the
instinctual wish as the psychologically meaningful id-element. (p. 200)
Westen (2002) also attempted a synthesis of basic psychoanalytic

concepts and the language used to described them. He wanted to clar-
ify . . . the implicit rules that guide psychoanalytic thought and
discourse . . . avoiding [issues] that lead to theoretical imprecision and
confusion of theory and metaphor (p. 857). Frosh (2002) has likewise
offered a set of generic definitions of the key concepts in psycho-
analysis in an attempt to bring clarity to an increasingly diverse and
complex theory. One of the most helpful attempts at synthesis has
been offered by Pine (1988), who argued that psychoanalysis has
produced four psychologiesthe psychology of drive, ego, object
relations, and the self.
1. The psychology of drive is concerned with instinctual urges,

wishes, fantasies, defence, and conflict.
2. The psychology of ego is concerned with adaptation, reality test-
ing, and ego defects (Hartmann, 1939), defined as develop-
mental failures in adaptation that have resulted in diminished
capacities for affect regulation, impulse control, or the attainment
of object constancy.
3. The psychology of object relations (Fairbairn, 1944, 1946) is
concerned with the internal images and dramas of the early
object relations that are embodied in conscious and unconscious
memories, which are repeated or acted out in current relation-
ships and within the transference. Fairbairn proposed that chil-
dren who had not experienced good enough mothering in early
life increasingly retreated into an inner world of fantasy objects,
which were used as substitutes for absent real objects, in order to
satisfy the need for nurturing relationships (Segal, 1980).
4. The psychology of the self is focused on the ongoing subjective
experience of the self (Kohut, 1977) and issues related to bound-
aries, feelings of fragmentation, continuity and self-esteem, and
capacity to manage frightening self-states.
We will revisit this issue of integration in the final chapter of this

volume, after we have examined the integrative elements in the four
psychoanalytic theories discussed in the intervening chapters.
Integration of analytic theories

There are two principal components of psychoanalytic treatment: the
interpersonal, represented by the analystpatient dyad through the
lens of which all other dyadic relationships are examined, and the
intrapersonal (intraspsychic) dimension that explores the patients
psychic subjectivity in both the present of immediate experience and
through the reflective construction and co-construction of meaning.
Fiscalini (1994) describes the fundamentals of analytic enquiry as
comprising a human relationship between two people; an effort to
form . . . a personally meaningful narrative or interpretation of ones
living, past and present; and a lived experience of that process and
relationship (pp. 115116).
In the psychology of drive, the verbal interventions consist of

interpretations of unconscious conflict in an atmosphere of calm
acceptance of all the patients fantasies and aggressive and destructive
urges; in ego psychology, interpretations focus on old, maladaptive
defences. In the psychology of object relations, the interpretation aims
to free the analysand from responding to new situations as if they
were the internalised object relationships from the past. The analyst,
who remains attentive, concerned, and non-judgemental, gradually
provides a new, corrective object relationship for the patient. In self
psychology (and ego psychology) when working with ego defects, the
focus is not so much on interpretation, but on holding, which allows
the emergence of intolerable self-states into awareness, from where
they can be articulated and understood. All four psychologies aim for
immediacy in the interpretation, delivered within the context of an
intense patientanalyst relationship that really matters to both analyst
and analysand (Pine, 1988).
To recapitulate, all four psychologies of psychoanalysis bring
about change through interpretation that resonates with the patient as
real or true, occurs within the immediacy of a mutually mean-
ingful analytic relationship, and which manages areas of ego defect
or deficiency by holding, reconstruction, and explanation that allows
the patient to understand, verbalise, and gain some mastery over the
areas of deficit. Is there an integrative glue that binds these four
psychologies? One could argue, with Emde (1990), that the common
denominator is the empathic availability of the therapist:
Early appearing motivational structures are strongly biologically

prepared in our species, develop in the specific context of the
infantcaregiver relationship, and persist throughout life. These moti-
vational structures can also be regarded as the fundamental modes of
development. As such they are life-span processes that can be mobi-
lized through empathy in the course of therapeutic action with adults.
(p. 882)
Even in drive theory, the therapist is non-judgementally and calmly

available to hear the shameful confessions of their patients with
respect to their taboo sexual and aggressive impulses. Reliable avail-
ability is a prerequisite for the experience of empathy. Empathy
is creative, generative, affirmative, and transactional. It is properly
exercised from a prepared mind, involves vicarious introspection,

and depends on cognition, perspective-taking and a knowledge
about the [patient] and the situation (Emde, 1990, p. 887). Empathy
shares the analytic space with interpretations, whose function is to
guide the patient to his next step; good interpretations arise out of
therapeutic availability and are expressed creatively through meta-
phor, paradox, and even irony (Rothenberg, 1987).
Since Alexander and French (1946)corrective emotional experi-
enceand Kohut (1971, 1977)corrective empathic experience
made therapist empathy the linchpin of successful therapy, and infant
research has confirmed the importance of maternal attunement for
healthy development (Beebe & Lachmann, 2002), empathic attune-
ment has become a key concept in many psychoanalytically orientated
therapies. Analytic empathy and emotional availability are now
understood to have a developmentally enabling role in adult psycho-
analysis (Emde, 1990, 1992). The corrective analytic experience
described by Abrams (1976) entails the development, in the pre-
oedipal patient, of a narcissistic transference in order to . . . reactivate
the chaotic, confused, undifferentiated feelings and impulses of early
life. A corrective analytic experience can thus set the patient on the
road to maturation (p. 220). More recently, analysts talk of the
corrective relational experience in interpersonal psychoanalysis
(Fiscalini, 1994; Piers, 1998; Rotenberg, 2006), in which the
. . . actuality or reality of the analysts personality plays a crucial role

in the patients clinical expression of his or her transference, and the
patterning of its subsequent analytic life, thus forming an integral part
of analytic data and process. (Fiscalini, 1994, p. 125)
Integration of theory and practice

Psychoanalysis faced a truly daunting challengeto develop a scien-
tific approach to understanding and theorising human subjectivity.
Janet (1925) was highly critical of what he perceived to be Freuds
theoretical empire building: he claimed that Freud
. . . changed first of all the terms I was using; what I had called
psychological analysis, he called psychoanalysis; what I had called
psychological system, in order to designate that totality of facts of
consciousness and movement, whether of members or of viscera,

whose association constitutes the traumatic memory, he called
complex; he considered a repression what I considered a restriction of
consciousness; what I referred to as a psychological dissociation, or as
a moral fumigation, he baptized with the name of catharsis. But above
all he transformed a clinical observation and a therapeutic treatment with a
definite and limited field of use into an enormous system of medical philoso-
phy. (p. 41, my italics)
Freuds (1923a) claims were, ostensibly, somewhat more modest:
Psycho-analysis is not, like philosophies, a system starting out from a

few sharply defined basic concepts, seeking to grasp the whole
universe with the help of these and, once it is completed, having no
room for fresh discoveries or better understanding. On the contrary, it
keeps close to the facts in its field of study, seeks to solve the imme-
diate problems of observation, gropes its way forward by the help of
experience, is always incomplete and always ready to correct or
modify its theories. There is no incongruity (any more than in the case
of physics or chemistry) if its most general concepts lack clarity and if
its postulates are provisional; it leaves more precise definition to the
results of future work. (p. 253)
Freud insisted on the indivisibility of theory and practice in psycho-

analysis (although he later expressed his preference for theory):
In psycho-analysis there has existed from the very first an inseparable

bond between cure and research. Knowledge brought therapeutic
success. It was impossible to treat a patient without learning some-
thing new; it was impossible to gain fresh insight without perceiving
its beneficent results. Our analytic procedure is the only one in which
this precious conjunction is assured. It is only by carrying on our
analytic pastoral work that we can deepen our dawning comprehen-
sion of the human mind. This prospect of scientific gain has been the
proudest and happiest feature of analytic work. (Freud, 1926d, p. 256)
In accord with Freuds prescient words, recent scholarship has

argued that psychoanalysis need not be defined by a particular
metapsychology, personality theory, developmental model, or clinical
theory. None the less, the marriage between theory and practice has
never been harmonious and the dilemma regarding the relationship
between theory and practice in psychoanalysis has persisted. In order

to close the gap, we must identify the central aim of psychoanalysis,
its method of investigation, and its domain of enquiry (Stolorow,
1992). Stolorow, Brandchaft, and Atwood (1987) defined the aim of
psychoanalysis as the unfolding, illumination, and transformation of
the patients subjective world (p. 10). This aim is a little more grandi-
ose than Freuds original aims of making the unconscious conscious,
replacing id with egoWhere id was, there ego shall be (Freud,
1937c, p. 214)or transforming . . . hysterical misery into common
unhappiness (Freud, 1895d, p. 305). To achieve their aim, Stolorow
and colleagues (1987) recommended an attitude of sustained em-
pathic inquiryone that consistently seeks understanding from with-
in the perspective of the patients own subjective frame of reference
(p. 10). They have been good students of Freud (1912e, p. 111), who
exhorted the analyst to do just thatto
. . . surrender himself to his own unconscious mental activity, in a state

of evenly suspended attention, to avoid so far as possible reflection
and the construction of conscious expectations, not to try to fix
anything that he heard particularly in his memory, and by these
means to catch the drift of the patients unconscious with his own
unconscious. (p. 239)
For both Freud and Stolorow, therapeutic action occurs in the in-
vestigation of the patients experience of the transference relationship.
This process requires the analyst to continually reflect on his or her
own personal subjectivity (countertransference). The individual
subjective worlds of the participants in the analytic dialogue and the
intersubjective world co-created by both parties are, thus, the subjects
of investigation.
Every transference interpretation that successfully illuminates for the

patient his unconscious past simultaneously crystallizes an illusive
presentthe novelty of the therapist as an understanding presence.
Perceptions of self and other are . . . transformed and reshaped to
allow for the new experience. (Stolorow, Brandchaft, & Atwood, 1987,
p. 60)
Stolorow (1992) requires the concepts of psychoanalytic theory to

meet two criteria in order to be relevant to therapeutic work: first,
they must be experience-near . . . that is, [they] pertain to the organi-

zation of personal experience (p. 160); second, they must [occur]
within a relationship, that is, they must be relational (Mitchell, 1988).
Although the language of experience-nearness is relatively recent,
the concept and its therapeutic focus have certainly been present in
psychoanalytic thinking from its early days. See, for example, Freuds
references to the importance of direct affective knowing:
Informing the patient of what he does not know because he has

repressed it is only one of the necessary preliminaries to the treatment.
If knowledge about the unconscious were as important for the patient
as people inexperienced in psycho-analysis imagine, listening to
lectures or reading books would be enough to cure him. Such
measures, however, have as much influence on the symptoms of
nervous illness as a distribution of menu-cards in a time of famine has
upon hunger. (Freud, 1910k, p. 225)
To have heard something and to have experienced something are in

their psychological nature two quite different things, even though the
content of both is the same (Freud, 1915e, p. 176).
Dewey (1929) also understood this difference between experience
far and experience near knowing: From knowing as an outside
beholding to knowing as an active participant in the drama of an on-
going world is the historical transition whose record we have been
following (p. 291).
The theme is taken up repeatedly in subsequent psychoanalytic
literature. See, for example:
Knowing from a book on botany that a green persimmon is astringent

is quite different from knowing it by biting into one. Indeed, the
essence of the psychoanalytic process is that reading about it and
experiencing it are two quite different ways of knowing. (Mennin-
ger & Holzman, 1973, p. xi)
Instead of searching for seemingly illusory connections between the

theories and practices of psychoanalysis, Fonagy (2003) advocates a
radical decoupling of analytic theory from analytic technique in order
to allow clinical practice to develop empirically and theory to evolve
out of newer patterns of clinical practice. The evidence that exists is
for a theory of mind that contains unconscious dynamic elements.
Evidence is, however, lacking for the translation rules for moving
from psychological theory to clinical practice (p. 24). Freud would
have had no argument with this position:
. . . the most successful cases are those in which one proceeds . . . without any
purpose in view, allows oneself to be taken by surprise . . . and always meets
them with an open mind, free from presuppositions. The correct behaviour
for an analyst lies . . . in avoiding speculation or brooding over cases
while they are in analysis, and in submitting the material obtained to
a synthetic process of thought only after the analysis is concluded,
(Freud, 1912e, p. 114, my italics)
Fonagy and other mainstream psychoanalytic thinkers, writers,

and practitioners might not as yet have become aware of develop-
ments in theory and practice contained in a form of short-term dyna-
mic psychotherapyintensive short-term dynamic psychotherapy
(ISTDP)whose transparent methods of data collection in the form of
video-recorded interviews between therapists and patients have
resulted in both an empirically supported theory of psychopathology
and personality based on attachment theory and a highly effect-
ive psychotherapy for a wide range of clinical disorders (Abbass, 2005,
2006; Abbass, Hancock, Henderson, & Kisely, 2006; Abbass, Lovas, &
Purdy, 2008; Abbass, Town, & Driessen, 2012) (see Chapter Five).
Concerns about privileging theory over practice have echoed
through the decades from Freud to Fonagy: for example, from
Guntrip (1975), Theory . . . is a useful servant but a bad master . . .
Therapeutic practice is the real heart of the matter (p. 145), and
Wallerstein (2006), who sees the task as
. . . reconcil[ing] the search for meanings and reasons through the indi-
vidual exploration of a unique human life with the effort also to fit the
findings derived from that search into the explanatory constructs of a
general theory of the mind . . . (p. 307)
Recently, Appelbaum (2011) offered the following radical reformula-

tion of psychoanalysis as a clinically based interpretive discipline
(p. 1) in which the core of psychoanalytic practice is unashamedly
humanistic and where practice is guided by the individuality of the
dyadic encounter (p. 1).
Psychoanalytic clinical practice was founded on trial and error;
basic techniques like free association were derived empirically rather
than deduced from pre-existing theory. Consequently, Kleinian ana-

lysts have learnt to be more circumspect in interpreting envy and
destructiveness, Winnicottian analysts are more cautious about
encouraging regression, and modern analysts are more focused on
understanding mental states than forbidden drives and impulses.
Current technique appears to remain more recognisably Freudian
than diverse current theories (Fonagy, 2003), as will become apparent
in the conversations with contemporary psychotherapists in the
coming chapters.
The nature of reality in psychoanalysis
Freud (1915a) puzzled over the nature of reality in his discussion of

transference love, a frequently occurring product of the analytic situ-
ation:
We have no right to dispute that the state of being in love which

makes its appearance in the course of analytic treatment has the char-
acter of a genuine love . . . . [T]ransference-love is characterized by
certain features which ensure it a special position. In the first place, it
is provoked by the analytic situation; secondly, it is greatly intensified
by the resistance, which dominates the situation; and thirdly, it is lack-
ing to a high degree in a regard for reality, is less sensible, less
concerned about consequences and more blind in its valuation of the
loved person than we are prepared to admit in the case of normal love.
We should not forget, however, that these departures from the norm
constitute precisely what is essential about being in love. (p. 168)
Earlier in the essay, he stated,
For the doctor the phenomenon signifies a valuable piece of enlight-

enment and a useful warning against any tendency to a counter-trans-
ference which may be present in his own mind. He must recognize
that the patients falling in love is induced by the analytic situation
and is not to be attributed to the charms of his own person. (p. 160)
Others have subsequently tackled the question regarding what con-

stitutes reality in the psychoanalytic encounter. Rosegrant (2010)
codified three clinical realities in psychoanalysis:
1. Factual reality, which comprises an account of what really hap-

pened, as far as this can be determined.
2. Psychic reality, which expresses emotional, personal meaning
that may also contain elements of fact, but which are not germane
when talking to the client about their psychic reality.
3. Co-constructed reality: a reality that is negotiated and construc-
ted between people in the intersubjective field. The intersubjec-
tive world of the relational psychoanalyst is a postmodern project
of multiple realities.
In the following extract, Mitchell (2004) addresses the psychic and co-
constructed realities described by Rosegrant (2010).
For previous generations of clinicians, technique referred primarily to

behavior. What should the analyst do? What should the analyst refrain
from doing? . . . We have come to realize that the meaning of whatever
the analyst does or does not do is contextual and co-constructed. The
analyst cannot decide on the meaning of the frame unilaterally. For
some patients, silence is a form of holding; for others, it is a form of
torture. For some patients, interpretation conveys deep recognition
and self-expansion; for others, it is a form of violent exposure. For
some patients, the analysts self-disclosure might offer a unique . . .
form of authenticity and honesty; for others, it is a form of charismatic
seduction and narcissistic exploitation. For some patients, questions
represent a . . . willingness to join and know them; for others, ques-
tions are a surreptitious invasion. It is no longer compelling to decide
that these events are what we want them to be and that when patients
experience them otherwise they are distorting. Interpersonal situa-
tions are ambiguous and can be interpreted in many different ways,
depending on our past and our dynamics. (pp. 540541)
The past and dynamics to which Mitchell refers include our infancies.
How do we know and understand infant experience? What aspects of
that experience inform our adult relationships, including the transfer-
ence? Stern (1985) identified two types of infantthe observed infant
and the clinical infant. The observed infant has been constructed from
precise observations and recordings of those observations in
controlled conditions in scientific settings; the clinical infant has been
constructed, or rather co-constructed, retrospectively in clinical
(mostly psychoanalytic) settings with mostly adult patients. Until the
advent of ingenious infant research methods, adult inferences about

the subjective experience of infants that were fashioned into narratives
or life stories and even psychoanalytic theories provided most of the
evidence related to the internal world of infants. Stern argued that
this latter method resulted in distortions of the reality of the lived
experience of infants and gave rise to two serious conceptual fallacies
regarding infant development.
1. The first is the tendency to adultomorphise infants and to ascribe

to them capacities that developmental neuroscience has subse-
quently demonstrated do not exist at the time asserted by many
psychoanalytic theories.
2. The second is the tendency to re-create infancy from the histories
of adult psychoanalytic patients and to pathologise early states of
normal development based on adult psychoanalytic material.
Some writers (e.g., Wolff, 1996) have argued that infant research is not
relevant to psychoanalysis because the data of psychoanalysis is
language, a capacity that has not yet been acquired by the infant. This
is a specious argument, because infants develop knowledge about
themselves, their world, and their relationships non-verbally, non-
symbolically and implicitly and this knowledge forms the basis of
their object relationships (Kenny, 2013), which later become accessible
through language in the transference (Lecours, 2007b; Talberg, Cuoto,
De Lourdes, & ODonnell, 1988; Talvitie & Ihanus, 2002). This brief
discussion on psychoanalytic reality highlights another major ques-
tion in psychoanalysis, that is, the role of language, given the empha-
sis in current psychoanalytic therapies on infant states of mind
(Madigan, Moran, & Pederson, 2006; Muscetta, Dazzi, De Coro, Ortu,
& Speranza, 1999; Wrye, 1996). It is to this topic that we will now turn
our attention.
Language in psychoanalytic theory and practice

Many writers have noted the linguistic commonalities between
philosophy (see, for example, the conversation with Robert Stolorow,
Chapter Six), psychoanalysis, and poetry, and the superiority of the
poetic form in the elucidation of human subjectivity (ODwyer, 2008).
I mention this here briefly because Freud revered the poets, both for
their insights into human nature and their ability to express the inef-
fable. Freud brought his literary sensibilities to bear on his struggle to
develop a language that could adequately characterise his emergent
theorising. Freud (1923c) described psychoanalysis as the art of inter-
pretation and noted strong affinities between poetry and his own
endeavours: (Everywhere I go I find that a poet has been there before
me;15 Poets are masters of us ordinary men, in knowledge of the
mind, because they drink at streams which we have not yet made
accessible to science16). Eliot (1975) also exalted the poet who, like the
psychoanalyst, . . . is occupied with frontiers of consciousness
beyond which words fail though meanings still exist (p. 111). Akhtar
(2008) argued that poetry arises from the preverbal era of infantile
experience and can therefore assist us to mentalise the unspoken
substrate of subjectivity.
Holmes (2010a) (see Chapter Four) has also drawn compelling
similarities between psychoanalysis and poetry.
. . . [there are] formal similarities between poetry and psychoanalysis

. . . both regularly arouse suspicion and incomprehension, yet people
often turn to them in states of heightened emotion . . . since the appro-
priate image or metaphor can mirror or evoke feelings in the listener
in a way that facilitates empathic attunement . . . metaphors are an
indispensable means by which we reach into anothers inner world.
(p. 87)
Poetry and psychoanalysis use metaphor17 to evoke, discover and

create meaning . . . to help bridge the (ultimately unbridgeable) gap
between what experience is like and what we can say it is like
(Seiden, 2004, p. 638). Metaphors can simultaneously expand con-
sciousness and organise it; they can elucidate, obscure or disguise
meaning; they can assist the release of painful ideas in a manageable
way. Metaphors can turn the tragic into the absurd, offer a form of
play in the therapeutic space, and assist in the articulation of mean-
ings hitherto concealed. Metaphors, because of their fuzzy edges,
multiple meanings, and ambiguity, highlight . . . uncertainty as an
essential condition of consciousness (Seiden, 2004, pp. 643644).
Aristotle exhorted the metaphor: The best thing by far is to be a
master of metaphor, which he viewed as a sign of genius . . . [the
capacity for] intuitive perception of similarities and dissimilarities
(Aristotle, 1947, p. 58). It was of great interest to me to discover that

the German word Freud used, bertragung (literally, transfer or
transference), to describe the most important relational construct in
psychoanalysis is derived from the Greek word for metaphor, meta-
pherein ( ), which means to transfer or carry over. The Latin
derivation of the word transference maps on to the Greek verb
meta = trans and pherein = ference. This linguistic device
exists in all languages and was first defined in Aristotles The Poetics
(ca 335 BC), referring to the shift or transfer of a word from its normal
use to a new one (Richards, 1965),18 a process that can be understood
as metaphoric transformation. Thus, there is a close relationship
between the concepts of transference and metaphor, since both refer
to the act of carrying across. Metaphors carry meanings across fact
and phantasy, conscious and unconscious, while transference carries
experiences across time and person to the here and now of the analytic
situation with the analyst (Holmes, 2004c).
Freuds early psychoanalytic project was the clarification of puzz-
ling materialsymptoms, dreams, jokes, slips of the tonguewhich
were often expressed in metaphoric or other symbolic, ambiguous
form. Transference itself is an exercise in ambiguity . . . the transfer-
ence bridges . . . internal infantile object representations and the
analyst being that as-if object: This is metaphors definition; this is the
structure and function of ambiguity (Szajnberg, 2011, pp. 67). Freud
was a master of metaphor. He explained the different levels of
consciousness as a tree with its trunk in daylight and its roots in
darkness (Breuer, 1893, p. 228). He used archaeological and military
metaphors (Mitchell & Black, 1995) to paint a portrait of man at war
with himself, beset by conflicts between the id, ego, and superego, of
man living with tension between the need for culture and society but
at odds with the instinctual inhibition required to live in social groups
(Freud, 1930a), as man coping with the battle between unconscious
wishes and impulses and the defences that struggle to keep them out
of awareness (Boag, 2010; Sandler, 1994). In Beyond the Pleasure Prin-
ciple (1920g), Freud commented that when one is trying to describe
new and elusive concepts, one might need to borrow them from other
disciplines because the new discipline lacks a vocabulary of its own.
Hence, in addition to metaphors, Freud resorted to analogies (e.g.,
likening repression to a book that contains offensive material (Freud,
1937c, p. 236)), myths (e.g., Oedipus complex), and words from other
languages (e.g., id, ego, superego;19 sadism20) to explain his insights.

As tantalising as it is to communicate in this way, Freud (1937c) was
not seduced by the poetic appeal of such descriptions and concluded
that analogies never carry us very far (p. 236), cautioning that they
may obfuscate rather than clarify conceptual meaning.
None the less, the use of metaphors and other language devices in
the psychoanalytic encounter proliferated (Knoblauch, 1997, 2007) in
an attempt to access the unconscious, semantically unformulated, non-
verbally encoded communications of patients. Knoblauch (1997)
encourages analysts to engage on a non-verbal level of exchange,
thereby providing . . . the medium for catalysing the transition from
pre-symbolic interactions to symbolic language (p. 491). Seiden (2004)
cautioned that while metaphor has a useful function, in . . . transliter-
ating or transposing analytic processes by way of literary or filmic or
poetic simile . . . (p. 598) it might, if applied excessively, confuse and
complicate, rather than clarify meaning.
The concerns of poets and psychoanalysts are, thus, not too dis-
parate, since they both grapple with the very edges of experience and
struggle to express that which seems elusive, at times wordless, and,
indeed, unknowable: [t]he unconscious is by definition unknowable
. . . The psychoanalyst is therefore in the unfortunate position of being
a student to that which cannot be known (Ogden, 1989, p. 2). Eliot
(1975) assigned to poetry the task of . . . transmut[ing] . . . personal
and private agonies into something rich and strange, something
universal and impersonal (p. 17). Eliot asserts that if poetry does not
elicit an emotional reaction in the reader, then the poem lacks mean-
ing, and, indeed, might no longer be considered a poem. When the
word psychotherapy is substituted in this sentence, it remains
equally true. If psychotherapy does not elicit an emotional reaction in
the analysand, then therapy lacks meaning, and, indeed, might no
longer be considered therapy. Neither the force nor logic of an argu-
ment can effect change. One must feel an insight in ones bones to
effect change (Yalom, 1989, p. 35). The challenge for psychoanalysis is
to move the patient from an intellectual to an emotional, experiential
understanding of self.
Lest we get too carried away with the notion of psychoanalysis
as metaphor, I will conclude this section with some cautionary
comments. In critiquing Kleinian metaphors, Margulies (2002) prob-
lematised the practice, observing that
. . . the metaphor takes flight and then while in flight it loses its status
as a metaphoric extension, and becomes . . . a new reality, a co-
constructed reality, spiralling outward as if it were now solid and
confirmed. We go from airy metaphor, to data that seem poetically
consistent, to a sense of a grounded reality. Often I was not
convincedthis is someone elses religious conviction . . . (p. 1046)
I will defer to Winnicott (1955) for the last word on this subject:
The idea of psycho-analysis as an art must gradually give way to a

study of environmental adaptation relative to patients regressions.
But while the scientific study of environmental adaptation is undevel-
oped, then I suppose analysts must continue to be artists in their work.
An analyst may be a good artist, but (as I have frequently asked): what
patient wants to be someone elses poem or picture? (p. 24)
The language of the talking cure
Almost from the outset, there were disagreements between Freud and
Breuer about how to articulate and interpret their clinical observa-
tions, as this comment on their competing interpretations of the clin-
ical facts in the early case studies attests:
The case histories are followed by a number of theoretical reflections,

and in a final chapter on therapeutics the technique of the cathartic
method is propounded, just as it has grown up under the hands of the
neurologist. If at some points divergent and indeed contradictory
opinions are expressed, this is not to be regarded as evidence of any
fluctuation in our views. It arises from the natural and justifiable differ-
ences between the opinions of two observers who are agreed upon the facts
and their basic reading of them, but who are not invariably at one in their
interpretations and conjectures. (Freud (with Breuer), 1895d, pp. xxix
xxx, my italics)
Notwithstanding, psychoanalysis is the talking cure (Anna O, in

Freud (with Breuer), 1895d) whose primary focus is to make mean-
ingful the presenting symptoms by understanding and bringing into
awareness unconscious processes, early experiences, dreams and the
transference (a process Anna called chimney sweeping p. 29).
The psychical process which originally took place must be repeated as

vividly as possible; it must be brought back to its status nascendi and
then given verbal utterance . . . language serves as a substitute for action; by
its help, an affect can be abreacted . . . speaking is itself the adequate
reflex . . . when it is a lamentation or giving utterance to a tormenting
secret, e.g. a confession. If there is no such reaction, whether in deeds
or words . . . or tears, any recollection of the event retains its affective
tone to begin with. (Breuer, in Freud, 1895d, pp. 9, 11, my italics)
Breuer, in his case history of Anna O, stated that when Anna experi-
enced . . . a string of frightful and terrifying hallucinations . . . her
mind was completely relieved, when, shaking with fear and horror,
she had reproduced these frightful images and [gave] verbal utterance to
them. (Breuer, in Freud, 1895d, p. 29, my italics)
Later, Breuer commented that her
. . . ideational complexes were disposed of by being given verbal expres-

sion during hypnosis . . . on the day after giving verbal utterance to her
phantasies she was amiable and cheerful . . . the products of her imag-
ination persisted as a psychical stimulus until it had been narrated in her
hypnosis, after which it completely ceased to operate. (p. 30, my italics)
Finally, all her symptoms were talked away (p. 34, my italics). Freud,
similarly, had great respect for the power of language to communicate
literally and symbolically. He observed how symptoms in his hyster-
ical patients were a symbolic expression of the actual trauma, that the
hysterical symptoms restored the original meaning of the words
because . . . the description was once meant literally (Freud, 1895d,
p. 181).
As Freuds psychoanalytic techniques and methods unfolded, the
verbal communication between analyst and patient was privileged
over other forms of communication, leading him to conclude that a
correct verbal interpretation was both curative and transformational
because it had the capacity to make the unconscious conscious. In his
Preliminary communication (Freud (with Breuer), 1895d), Freud
discussed the proposed mechanism of cure in hysteria in these terms:
It brings to an end the operative force of the idea which was not abre-
acted [discharged as emotion] in the first instance, by allowing its stran-
gulated affect to find a way out through speech; and it subjects it to
associative correction by introducing it into normal consciousness . . .

(p. 17, my italics)
These early case studies were written in a clear and compelling way,
firmly grounded in clinical observation and introspection. They repre-
sent intriguing phenomenological narratives that invite the readers
participation, empathy, and understanding because the humanity of
both the patient and the analyst is compelling in the written record.
Freud (1895d) himself noticed the poetic and narrative quality to his
early writing:
. . . even I myself am struck by the fact that the case histories which I
am writing read like novels . . . a detailed discussion of the psychic
processes, as one is wont to hear it from the poet . . . allows one to gain
an insight into the course of events of hysteria. (p. 50)
Eliots (1933) view about the function of poetry resonates with Freuds
intuitions about his poetic prose.
[Poetry] may make us a little more aware from time to time about the
deeper, unnamed feelings that form the substratum of our being, to
which we rarely penetrate; for our lives are mostly a constant evasion
of ourselves . . . (p. 55)
Perhaps we are all poets in our unconscious!
. . . there emerges from time to time in the creations and fabrics of the
genius of dreams a depth and intimacy of emotion, a tenderness of
feeling, a clarity of vision, a subtlety of observation, and a brilliance of
wit such as we should never claim to have at our permanent command
in our waking lives. There lies in dreams a marvellous poetry, an apt
allegory, an incomparable humour, a rare irony. A dream looks upon
the world in a light of strange idealism and often enhances the effects
of what it sees by its deep understanding of their essential nature
(Freud, 1900a, p. 62).
Difficulties arose for Freud in the process of transforming his astute

clinical observations into the conceptual and theoretical frameworks
that gave rise to theoretical edifices such as instinct theory, seduction
theory, the topographical model of the conscious, the preconscious,
the unconscious (Paniagua, 2001; Wylie, 2002) and the structural
model of the id, ego, and superego (Brenner, 2003; Sandler, 1974).
Theorising subsequently became more dense and jargonistic, prompt-
ing Stein (2001) to comment:
Consistent with psychoanalysiss diverse tribal sociology, analytic

writers often use what amount to intra theoretic dialects founded in the-
oretic assumptions and concepts understandable and meaningful only
to those who practice from a similar orientational perspective. (p. 598)
Psychoanalysts have searched for creative solutions to this problem of

language, recognising that the proper subject matter of psycho-
analysis is the study of meaning, which can be expressed through
semiotic systems other than language (Yalom, 1989). Therapeutic
metaphor bridges the divide between language and semiotics. Its
imaginative function enables perceptual discovery and expanded self-
knowledge and understanding (Ricoeur, 1978). Live metaphors
(Friedman, 1983, p. 143) help us to understand one thing in terms of
another and to direct the mind to new levels of abstraction, support-
ing exploration without specifying its outcome a priori before the logic
of either system is fully grasped. All degrees of abstract thinking are
built up of layers of metaphor . . . metaphor is the currency of the
unconscious mind (White, 2011, p. 147).
Lest poetry be unduly privileged in the psychoanalytic encounter,
Gadamers (1975) notion of the conversation as art form shares many
features of the analytic conversation. Both are open-ended explo-
rations of new realms of experience or evidence, particularly in areas
that may be difficult to specify, quantify, or make tangible. Conver-
sation requires participant immersion, a suspension of directional
intent or anticipation of a predicted outcome, thus creating the possi-
bility of the emergence of new insights and understandings that could
not be foreseen. A genuine conversation may, therefore, be transfor-
mational in much the same way as a psychotherapeutic dialogue
(Caruth, 1987). Freud, in his descriptions of his early case studies,
used the word conversation to describe his verbal interchanges with
his patients, characterising the analytic process in a remarkably simi-
lar way to the description of a conversation given by Gadamer.
The analyst is certainly able to do a great deal, but he cannot deter-

mine beforehand exactly what results he will effect. He sets in opera-
tion a certain process . . . [that] once begun, goes its own way and does
not admit of a prescribed direction, either in the course it pursues or

in the order in which the various stages to be gone through are taken.
(Freud, 1913c, p. 130).
This non-directional immersion in the subject matter of the conversa-

tion finds its analogue in Meissners (2000) concept of bidirectional
listening, in which the analyst shifts his attention between listening to
the patient and to his own internal state in order to deepen the
communicative space between analyst and analysand. Mitchell (2004)
extends this notion to the individuals entire interpersonal field:
Our minds are not static structures that we carry around for display
in different contexts. What we carry are potentials for generating
recurrent experiences that are actualized only in specific contexts, in
interpersonal exchanges with others . . . [O]ur very thought processes are
composed of language and interiorized conversations with others. Therefore,
we are embedded, to a great extent unconsciously, in interpersonal
fields, and, conversely, interpersonal configurations are embedded, to
a great extent unconsciously, in our individual psyches. (p. 539, my
italics)
Non-verbal communication in the talking cure

The problem of language in psychoanalysis goes far beyond concerns
regarding the inappropriate use of metaphor or the appeal to other
semiotic functions. The role given to language is central to the ques-
tion regarding the proper subject matter of psychoanalysis. This ques-
tion has become more pressing in view of the increasing emphasis on
the importance of preverbal stages of development in contemporary
psychoanalysis (Fonagy & Target, 2003; Gergely, 1992; Green, Cren-
shaw, & Kolos, 2010; Wilson, Fel, & Greenstein, 1992) and the recog-
nition of both symbolic and non-symbolic codes of mental functioning
(Lecours, 2007). Non-symbolic codes might persist into adulthood for
those who have suffered severe psychological trauma in childhood,
particularly in the earliest stages of pre-linguistic development
(Beebe, Rustin, Sorter, & Knoblauch, 2003; Bonovitz, 2003, 2004).
The inability to symbolise is accompanied by the use of primitive
defencescompulsion to repeat, splitting, projection, projective iden-
tification, dissociation, and fragmentationand affects that are
unmentalised and unregulated (White, 2011). Freud (1915e) recog-

nised these two codes of mental functioning by describing how
conscious ideas could be split into word presentations and thing
presentations, which he understood to be the sensory experience of
a phenomenon after the linguistic component had been repressed.
Non-symbolic codes can be expressed in motoric, visceral, or sensory
systems. In some philosophical, phenomenological, and psychothera-
peutic literature, primacy has been assigned to non-verbal experience
as the foundation on to which conscious, linguistic experience is
superimposed (Zeddies, 2002).
Put simply, the first forms of human communication are non-
verbalthe urgent cry of the distressed infant who is hungry, cold,
wet, in pain, or in need of contact comfort. Gradually, over the first
three years of life, the early primitive forms of communication give
way to verbal and other forms of symbolic communication, but the
need for parental action or gratification persists. The process of regres-
sion in psychoanalysis facilitates the patients experiencing of the
analysts words on both a symbolic and more primitive level. Slo-
chower (1996a) expresses the view in her discussion on the concept of
holdinga view to which many object relations therapists sub-
scribe (Fairbairn, 1946, 1958; Girard, 2010; Winnicott, 1945, 1958,
1963)that both words and memory can be bypassed in the uncover-
ing and re-experiencing of the original affective experience of (prever-
bal) trauma.
. . . [the concept of holding is] . . . linked . . . to the idealized maternal

metaphor, in which the analyst/mother is viewed as all-knowing and
all-giving . . . [the appeal of this] metaphor was associated with . . . the
maternal analysts reparative powers. If the analyst can symbolically
become the mother, the possibility of reworking early trauma is enor-
mously increased; what cannot be remembered can be re-experienced and
then repaired; the patient can, in fact, be a baby again, with a better,
more responsive mother. (Slowchower, 1996a, p. 13, my italics)
Such passages highlight the dialectic regarding the proper role of

language in psychoanalysis. Holding involves the suspension of the
search for meaning; it gives primacy, not to the verbal interchange,
but to the analysts affective presence and capacity to provide an emo-
tionally protective space . . . in order to facilitate the evolution of the
patients self-experience (Slochower, 1996a, p. 3). Holding explicitly
precludes interpretation and requires the analyst to . . . receive

material without changing its meaning . . . (p. 6). Such a holding
frame is required for patients who are . . . struggling with the depen-
dency needs characteristic of infancy (p. 8). Holding, as described by
Slochower, is akin to Winnicotts primary maternal preoccupation
(Leckman, Feldman, Swain, & Mayes, 2007; Winnicott, 1963, 1986) in
which the mother experiences her infants needs as if they were her
own, reflecting the emotionally responsive, highly attuned stance of
the analyst. During holding, the analysts symbolic, as opposed to
interpretative, function is primary.
While depicting the task of psychoanalysis as . . . clarifying mean-
ing: the meaning of unconscious process, of early experience, of trans-
ference material . . . (p. 1), Slochower also asserts that the temporary
suspension of the active investigation of meaning must occur at vari-
ous stages of the analytic process because
. . . clinical movement is effected not as a result of an active analysis

(or interpretation) of dynamic process or of mutual enactments, but
because of the analysts capacity to create an emotional space that . . .
protects the patient from the impact of the analysts otherness. (p. 2)
This process does not constitute the entire therapy and the goal
remains the establishment of a collaborative relationship between
analyst and patient.
We have learnt a great deal from infant observation research about
the nature of experience as it unfolds from birth. This literature is
reviewed in detail elsewhere (Kenny, 2013), but, for now, the conclu-
sions drawn by Stern (2010) seem apposite. Although psychoanalysis
is a talking therapy and necessarily privileges linguistic processes
such as narrative and interpretation, the deepest level of meaning
derives from
. . . lived engagements with others around central developmental

needs, as these engagements are represented in implicit, procedural forms
of memory . . . [T]his level of enactive representation encodes the most
profound aspects of human experience . . . (pp. 660661, my italics).
Tuber (2008), commenting on Winnicotts paper, Communicating

and not communicating, captures Sterns concept of enactive repre-
sentation.
What is essential for Winnicott is that the baby invents its own mother,
indeed makes her come alive . . . the baby turns the mother into a
series of verbal nouns: milk-giver; warm body-holder; smiling face-
maker; the mother becomes an action the baby needs and over time
these action states coalesce into a being the baby creates as mother.
(p. 36)
None the less, psychoanalysts necessarily rely heavily on language

mundane, everyday language and figurative, comparative, and meta-
phorical languageas a means of communicating and co-creating
meaning with their patients. Gadamer (1975) argues that language is
central to human experience; even those forms of communication that
are not linguistic, such as emotion and music, pre-suppose language
and come to be understood linguistically. What the analyst says and
how he or she says it are critical to the analytic experience. Stolorow
(2008a,b) believes that the loss of ones sense of being occurs for those
whose painful emotional experiences of chronic misattunement
become unremittingly traumatic in the absence of a reparative rela-
tional context in which these experiences can be acknowledged, toler-
ated, and integrated. While recognising that emotional experience is
primarily bodily in early life, Stolorow (2008c) views language as crit-
ical in the emotionally reparative process.
It is in the process through which emotional experience comes into language

that the sense of being is born, and that the aborting of this process brings
a loss of the sense of being. The loss and regaining of ones sense of
being are profoundly context dependent, hinging on whether the
intersubjective contexts of ones living prohibit or welcome the coming
into language of ones emotional experiences. (p. 116, my italics)
Stern (1983, 1997) also conceptualised the central therapeutic action in

psychoanalysis to lie in the dialogic creation of meaning of previously
dissociated and mostly unformulated aspects of self-experience. The
analyst first receptively witnesses the traumatised, dissociated self-
experiences and then assists in giving voice and assigning words to
them, that is, constructing a narrative of these previously unbearable
experiences through the dyadic collaboration with his patient.
Dissociated parts of the self can be tolerated and assimilated when
analyst and patient reflect upon them in their therapeutic con-
versation. The receptive, witnessing analyst is eventually internalised
and becomes available in subsequent meaning making and narrative

construction.
Child analysts also recognise the importance of translational pro-
cesses from the non-verbal to the verbal in therapy. Anna Freud
viewed language as an indispensable prerequisite for secondary
process thinking (A. Freud, 1965, p. 32). Melanie Klein, in The
importance of words in early analysis (1927) (Klein, 1975) argued
that even in the analysis of young children who primarily
act [out] and dramatize their thoughts and phantasies . . . [words are]
the bridge to reality which the child avoids as long as he brings forth
his phantasies only by playing . . . [It] always means progress when
the child has to acknowledge the reality of the objects through his own
words. (p. 314)
Daniel Stern (1985) points to the importance of language development

even in very young children because it . . . permits the child to begin
to construct a narrative of his own life (p. 162). However,
. . . language is a double-edged sword [because] it . . . makes some

parts of our experience less shareable with ourselves and with others.
It drives a wedge between two simultaneous forms of interpersonal
experience: as it is lived and as it is verbally represented. (p. 162)
Common principles of psychoanalytic theory and practice

Despite the proliferation of theories and perspectives, all psycho-
dynamic theorising, regardless of the school to which one subscribes,
is underpinned by a number of common principles, tenets, and prac-
tices, which are supported by a strong body of research obtained by
the scientific method. Two over-arching principles and five tenets
underpin contemporary psychoanalytic theory. The two principles are
psychic determinism, defined as the lawful regularity in mental life,
states that all behaviour has one or more causes, and multiple deter-
mination, which states that the same (unconscious) motive can result
in diverse behaviours and a given behaviour may be a function of
multiple motives (Malan, 1979; Malan & Osimo, 1992). The tenets are:
1. A proportion of ones mental lifeincluding thoughts, feelings,

and motivesis unconscious, (occurs outside of conscious
awareness). These unconscious wishes, motives and feelings

exert a significant impact on behaviour, can lead to problematic
symptoms such as anxiety, and cause concern and distress to
individuals who may not understand the source of their symp-
toms or the reasons for their behaviour. To understand conscious
experience, we need to bring to awareness aspects of oneself that
are out of awareness.
2. Inner conflict is inevitable and ubiquitous because people must
find a way to meet their needs within the constraints imposed by
communal living. People can also experience conflicting emo-
tions towards the same person or situation, resulting in the need
to find compromise solutions. Conflict also arises because of the
struggle between competing (unconscious) wishes, affects, ideas,
and drives.
3. Childhood experiences lead to the development of stable person-
ality patterns and these in turn affect the way people relate to
themselves and others.
4. These childhood experiences are mentally represented within,
are enacted in new relationships, and underpin the development
of symptoms, including anxiety. These mental representations
also shape interpersonal expectations and self-representation.
5. Personality development involves the development of the ability
to self-regulate both impulses and emotions, and the achieve-
ment of a mature, autonomous self (Westen, 1998).
Blagys and Hilsenroth (2002) identified seven features of psy-

choanalytic/psychodynamic therapeutic practices that reliably
distinguish them from other therapies, in particular, the cognitive
behavioural therapies (CBT). These are summarised below.
1. Focus of therapy sessions is on affect and expression of emotion in

contrast to CBTs focus on cognitive factors such as thoughts and
beliefs. This is based on the view that it is emotional and not intel-
lectual insight that mediates change in therapy.21
2. Exploration of attempts to avoid distressing thoughts and feelings (often
referred to as resistance and defences in more classical termin-
ology), the aim of which is to discover the underlying emotions
that are thought to be too painful to confront. In contrast, CBT
focuses on faulty cognitions, called cognitive distortions, but does
not explore the emotional substrate of these distortions.
3. Identification of recurring themes and patterns (called schemata or

narratives, by which people make sense of their experience). CBT
has a greater emphasis on specific antecedent and consequent
events that together make up the reinforcement history of the
individual.22
4. Exploration of early life experiences, particularly as they relate to
current difficulties for which the patient has sought therapy.
Significant attachment figures often take centre stage in this
exploration, as these developmental relationships are repeated,
frequently unknowingly, in current relationships. William Faulk-
ner captured the essence of this process in his quip, The past is
not dead . . . it is not even past. By contrast, CBT has a focus on
current difficulties and symptoms and eschews the relevance of
past history in managing current problematic behaviours.
5. Focus on interpersonal relations, both adaptive and maladaptive;
these are sometimes called object relations to denote the mental
representations that people build up of themselves (self-concept)
and others in the process of their interpersonal relating with
significant others. In CBT, the focus is on the persons relation-
ship with their current environment and symptoms, rather than
on their relationships, either past or present.
6. Focus on the therapy relationship. The interpersonal relationship
between the therapist and patient provides a fertile and potent
learning opportunity, since earlier and current problematic rela-
tionships are enacted in the relationship with the therapist. This
brings the problem into the room and into the present, allowing
it to be observed and worked with as it unfolds. The feelings that
arise between patient and therapist are referred to as transference
(the feelings that the patients project on to the therapist) and
countertransference (the feelings stirred up in the therapist by the
patient). In CBT, the therapist, while needing to be respectful of,
and empathic towards, the patient, is not the central focus of the
therapeutic contact, which remains firmly on the relationship
between the patient and his symptoms.
7. Exploration of wishes and fantasies. Psychodynamic therapies
encourage open attention to all the passing thoughts and feelings
that arise in the therapy hour, and encourage the patient to
express them freely in a process known as free association. Such
a process encourages wide ranging self-reflection, allowing the
emergence of a deep knowledge of self and others previously

prevented by rigid defences and attempts to protect against
uncomfortable emotion. In many other therapies, including CBT,
the therapist often formulates a treatment plan, one hopes in
consultation with the patient, and then directs the content of the
sessions according to this plan.
We will return to these practices in the final chapter, when we review

how each of the therapists from the four orientations explored in the
coming chapters have approached these elements.
Contemporary issues in psychoanalytic theory and practice

In a highly critical paper on the current state of psychoanalysis in the
UK and USA (and indeed Australia), Kirsner (2004) references Kern-
bergs (1986) various characterisations of psychoanalytic institutes as
monasteries, trade schools, art academies, and universities. Kirsner
identifies a religious, cult-like fervour in psychoanalytic circles and
describes what he calls . . . an odd religious element that suffuses
psychoanalysis, even at scientific meetings, which so often has a sense
of a religious observance as ritualistic . . . There is often an element of
prayer, even incantation, at presentations . . . (p. 341).
In continuing the religious metaphor to analyse what he perceives
as the current malaise of psychoanalysis, Kirsner argued that the
seminarian approach in many psychoanalytic institutions serves the
dual purpose of bridging the gap between real and claimed know-
ledge, the latter of which imbues the psychoanalyst with analytic
authority. In the absence of real knowledge or evidence, the insti-
tution authorises the laying on of hands by those with the author-
ity to train. Claimed or pretend knowledge is transmitted by
anointment of analytic descendants via the training system, especially
through the training analysis (p. 341).
Indeed, Freuds religious fervour for psychoanalysis was noted by
Alexander (1934) in his review of Freuds New Introductory Lectures on
Psycho-analysis:
Freud cannot escape the fate of most of the great scientists, that of
becoming also a philosopher . . . This philosophizing of Freud which
he calls a scientific Weltanchauung is nevertheless a philosophy . . .

After all, scientific thinking is also subject to the limitations of the
human mind as well as to its wish-fulfilment tendencies . . . The confi-
dence in absolute natural laws, seen from the psychological point of
view, is only a modem substitute for God-Almighty. There is no ques-
tion that in science the human mind is able to approximate the goal of
objective knowledge. The portrait of this new God bears a greater
resemblance to nature than the old one, but it still remains a picture
painted with human hands. (p. 346)
Others attempt to mount the argument that psychoanalysis is both

science and religion, since both, at some level, are concerned with the
big questions of finding fulfilment, purpose, and meaning in life and
confronting good and evil as inner states. For example, Zeddies
(2002) pondered the nature of analytic authority and understanding in
psychoanalysis, arguing that, in some respects, psychoanalysis is a
cultural product that incorporates prevailing societal moral values
that underpin its ethical convictions.
Symington (2004) argues that Freuds unconscious is not amoral,
and that neither religion nor psychoanalysis can be useful if based on
appeals to authority instead of serving as exhortations to personal,
existential reflection. However, both psychoanalysis and religion have
constructed edifices that he finds pathological and alienating from
the main aim of bothto find ways of loving others. Margulies (2002)
notes the fervour with which adherents of different schools of psycho-
analysis revere their respective dogmas that seem so strange to non-
believers. Speaking in Kleinian, Jungian, or Lacanian languages can be
likened to speaking in tongues; they are a form of myth-making to
which adherents must be inducted.
Is psychoanalysis an art? This question was addressed in the
section on the role of language in the talking cure, where parallels
were drawn between the use of metaphor, poetry, and conversation
in artistic and psychoanalytic endeavours. Holmes (2010a) devoted a
chapter in his book Exploring in Security to assess the contribution that
poetry can make to psychotherapy. Both, he argues, are concerned
with emotional expression and the processing of difficult and, at
times, elusive feelings. Like Akhtar (2000, 2008), Holmes recognises
the role of poetry in assisting us to mentalise, but concurs that the
primary experience in both poetry and psychoanalysis is somato-
sensory. It is the task of the therapist . . . to read the text that the
patient brings and to back-translate words into affective-bodily

experience (Holmes, 2010a, p. 92). The words in poetry and psycho-
analysis trigger preverbal experiences that must be brought into
the verbal domain and further explored in relation to the patients
inner unformulated experience (p. 92). Stolorow (2005) also
contends that in order to contextualise emotional experience, integra-
tion of its somatic and symbolic components is required, since early
emotional states are exclusively bodily. The concerns of poets and
psychoanalysts are, thus, not too disparate, since they both grapple
with the very edges of experience and engage in a struggle to express
that which seems elusive, ineffable, and, at times, wordless, in search
of meaning.
Home (1966) argued that a discipline whose primary focus is on
meaning-making renders it a humanity:
In discovering that the symptom had meaning and basing his treatment
on this hypothesis, Freud took the psycho-analytic study of neurosis out
of the world of science into the world of the humanities, because a
meaning is not the product of causes but the creation of a subject. This
is a major difference; for the logic and method of the humanities is
radically different from that of science, though no less respectable and
rational, and of course, much longer established. (p. 43)
There is much current support for the view that psychoanalysis
. . . rests on a philosophical foundation that enables practitioners to

grasp or at any rate to glimpse, what it means to be fully human, and
to relate the concrete specificity of the patients complaints to a more
comprehensive and encompassing view of human existence. (Burston
& Frie, 2006, p. 284)
These are fascinating issues and the interested reader is referred to

King (1992), Kurzweil (2008), Schlessinger (2008), and Wallerstein
(1986, 2006) for a more detailed discussion.
The unconscious, the nature of reality,

and the source of psychopathology
The metaphor of the unconscious remains a central defining feature of
both the theory and practice of psychoanalysis, and as the locus of
psychopathology, among other functions. However, there has been a

shift in the conceptualisation of the contents of the unconscious from
Freuds repressed instinctual representatives (forbidden impulses,
drives, and phantasies) to intolerable, dissociated, unformulated self-
states or affects that could not be integrated because of the absence of
a responsive enough environment (Stolorow, 1992). They derived
from and represent internalised object relationships (or representa-
tions of interactions with significant others) operating at various
levels of psychological organisation, ranging from archaic to highly
structured (Bohleber, 2011) and that are enacted in interpersonal rela-
tionships.
Such unintegrated affect states become the source of lifelong inner

conflict, because they are experienced as threats both to the persons
established psychological organization and to the maintenance of
vitally needed ties. Thus affect-dissociating defensive operations are
called into play, which reappear in the analytic situation in the form
of resistance. A defensive self-ideal is often established, which repre-
sents the self, purified of the offending affect states that were
perceived as intolerable . . . and the inability to fully embody this
affectively purified ideal then becomes a continual source of shame
and self-loathing. It is in the defensive walling off of central affect states,
rooted in early derailments of affect integration, that the origins of what has
traditionally been called the dynamic unconscious can be found.
(Stolorow, Brandchaft, & Atwood, 1987, pp. 9192, my italics)
Thus, the dynamic unconscious contains intolerable affects that have

been defensively dissociated to protect against re-traumatisation. The
intersubjective unconscious is fluid in the sense that these defensive
processes are responsive to the nature of the care-giving environ-
mentgreater attunement results in less affective dissociation in
fewer affective domains.
There have been many reworkings of Freuds vision of the uncon-
scious. Space does not permit a full exposition of the shift from
Freuds dynamic unconscious to the intersubjectivists relational un-
conscious, to Bions and Grotsteins (2009) symbolic, meaning-making
unconscious that supplies the external world with metaphors and
poetic images (Bohleber, 2011, p. 288), to Newirths and Presss
(2003) generative unconscious, which is conceived as the source of
subjectivity. Newirths conceptualisation invokes Winnicotts true
self and Bollass unthought known. In the final analysis, all of

these conceptualisations are metaphors containing implicit theories
and world views that guide clinical practice (Appelbaum, 2011).
The nature of reality in psychoanalytic theorising became prob-
lematic with the acceptance of the unconscious as the engine of mental
life. Although the early debates about the cause of psychological
disorderin actual experience (external reality) or childhood phan-
tasy (psychic reality)have largely been resolved through advances
in psychoanalytic theorising and empirical research using longitudi-
nal study designs (Card & Little, 2007; Hoff, 2006), it is instructive to
review how Freud tackled these issues:
Neurotics turn away from reality because they find it unbearable . . .

[W]e are now confronted with the task of investigating the develop-
ment of the relation of neurotics and of mankind in general to reality,
and in this way of bringing the psychological significance of the real
external world into the structure of our theories. (Freud, 1911b, p. 218)
In Formulations on the two principles of mental functioning, Freud

describes a phenomenon that was later called psychic equivalence,
a process whereby the individual equates the internal and external
worlds, believing that what exists in the mind must exist in external
reality, and that which exists in the outside world must also exist in
the mind. Hence, the projection of fantasy to the outside world results
in the experience of the fantasy as reality. A related concept
pretend modeis a mental state that has no referent in physical
reality. These two modes are mirror images: psychic equivalence is
too real and pretend mode is too unreal. Both are divorced from the
real world and the function of the ego. These modes are develop-
mental processes that precede the capacity for self-reflection and
mentalization, that is, the understanding that thoughts and feelings
are mental states that might or might not impact on the real world
(Bateman & Fonagy, 2004).
The strangest characteristic of unconscious (repressed) processes . . . is

due to their entire disregard of reality-testing; they equate reality of
thought with external actuality, and wishes with their fulfilment
with the event just as happens automatically under the dominance
of the ancient pleasure principle. Hence also the difficulty of distin-
guishing unconscious phantasies from memories which have become
unconscious. But one must never allow oneself to be misled into

applying the standards of reality to repressed psychical structures,
and on that account, perhaps, into undervaluing the importance of
phantasies in the formation of symptoms on the ground that they are
not actualities, or into tracing a neurotic sense of guilt back to some
other source because there is no evidence that any actual crime has
been committed. (Freud, 1911b, p. 225)
Freuds original trauma-affect model (i.e., that trauma is caused by

external events, such as child sexual abuse, whose associated affects
have not been expressed and worked through) is really not far
removed from current models arising from infant research that have
refocused attention on the effect of the environment, in particular the
psychological environmentthe intersubjective or relational matrix
(Mitchell, 1993)into which infants are born that can have both
enhancing and devastating effects on development (Beebe, 2000;
Beebe, 2006; Beebe & Jaffe, 2008; Winnicott, 1986).
Psychological trauma
The more subtle shift within this refocus on the external relational
environment has been the changing view of what experiences consti-
tute trauma. As with many complex psychological issues, Freud
(1926d) presaged this difference, although his original conceptualisa-
tion of trauma was event based (e.g., death of a parent; sexual abuse).
However, he later revised his theory of anxiety, distinguishing
between traumatic (primary) anxietywhich he defined as a state of
psychological helplessness in the face of overwhelmingly painful
affect, such as fear of abandonment or attackand signal (secondary)
anxiety, which is a form of anticipatory anxiety that alerts us to the
danger of re-experiencing the original traumatic state by repeating it
in a weakened form so that measures to protect against retraumatisa-
tion can be taken. You will notice that in these definitions of anxiety,
Freud is not talking about single, discrete events that cause the
trauma, but about a generalised fear of an anticipated experience, a
position much closer to post-classical Freudians, attachment theorists,
and relational and intersubjectivist theorists (Diamond, 2004).
In The First Year of Life, Spitz (1965) said, I cannot emphasize suffici-
ently how small a role traumatic events play in [infant] development
(p. 139). Most traumatic experiences of childhood are now under-

stood to be caused by the chronic misattunements of parents and their
failure to meet the basic psychological needs of their infants (Bate-
man & Fonagy, 2004). This view closely aligns with Spitzs view that
adverse affective climates created by problematic motherinfant inter-
changes were traumatogenic. Wallin (2007) distinguishes between
large-T trauma, which involves the experience of natural disasters
such as floods, fires, tsunamis, war, social dislocation, suffering repea-
ted physical or sexual abuse, actual abandonment, or parental men-
tal illness or severe substance abuse, and small-t trauma, which takes
an abundance of forms and has varying descriptors, for example,
shock trauma, retrospective trauma (a trauma that acts retro-
actively in memory) (A. Freud, 1972), strain trauma (which overtaxes
the resources of the psychic apparatus) (Kris, 1950), cover trauma
(analogous to cover memories) (Kris, 1950), silent trauma (which has
no obvious outward manifestation) (Hoffer, 1952), cumulative
trauma (Khan, 1963), secondary trauma (Sandler, 1967), relational
trauma (Bond, 2010; Brandchaft, 2002; Schore, 2009), and pathologi-
cal accommodation (Brandchaft, 2007; Taerk, 2002), in which repea-
ted, severe, and unrepaired disruptions to the relationship between
parent and child occur, but which are likely to remain undetected and
invisible to the outside world, since such families often appear to func-
tion very well. Winnicott (1974) describes a
. . . pattern . . . in which the continuity of being was interrupted by the

patients infantile reactions to impingement, these being environmen-
tal factors that were allowed to impinge by failures of the facilitating
environment . . . To understand this it is necessary to think not of
trauma but of nothing happening when something might profitably
have happened. It is easier for a patient to remember trauma than to
remember nothing happening . . . (p. 45)
Mitchell and Black (1995), in their description of traumatising

empathic failures . . . as attention becom[ing] prematurely diverted
to survival, to the parents needs, to the self-distorting adaptation to
the external world (p. 210), capture Winnicotts concept of impinge-
ment and Brandchafts idea of pathological accommodation.
In Freuds structural model, unconscious wishes compete with
each other and with conscious wishes for expression and gratification.
Repressive forces that prevent the satisfaction of instinctual needs
press for consciousness, thereby creating conflict and anxiety. Today,

the source of psychopathology is no longer considered to be due to
horizontal splits between the ids sexual and aggressive drives, the
containing forces of the superegos guilt and the egos anxiety about
the conflict, as classical psychoanalysis postulates, but to aborted
developmental processes that create vertical splits between different
self-states that have not been integrated because they contain unbear-
able psychic pain that has been defensively dissociated (Kohut, 1971;
Kohut & Wolf, 1978). This view is not too different from Breuers orig-
inal thoughts about the altered states of consciousness that he
observed in his hysterical patients (Freud (with Breuer), 1895d) or
Winnicotts notion of true- and false-self organisations that have been
very widely applied in the literature (Cassimatis, 1984; Daehnert,
1998; Dorpat, 1999; Giovacchini, 1993; Newman, 1996; Stern, 1992;
Tagliacozzo, 1989; Winnicott, 1965a).
In directing the central focus of self psychology to the actual
trauma perpetrated by parents on their children, Kohut was described
as the most powerful dissident . . . on the contemporary psycho-
analytic scene (Gedo, 1986, p. 99). In addition, the therapeutic tech-
niques of self psychology were understood to have developed in
reaction to the
. . . iatrogenic effects of classic psychoanalytic technique . . . neutral-

ity, anonymity, abstinence, long silences, exclusive reliance on inter-
pretation with virtual elimination of the impurities of the emotional
relationship. Being impossible in theory as well as in practice, it became
tout court a negative emotional relationship, i.e., a chronic narcissistic
injury. It is not a coincidence that many Kohutian analyses were second
analyses after orthodox analytic failures. (Migone, 1994, p. 90)
The nature and role of trauma in psychopathology was, therefore, one

of the key differences that opened up between Freuds classical
psychoanalysis and most of its subsequent offshoots: beginning with
object relations theory (libido is not primarily pleasure-seeking, but
object-seeking (Fairbairn, 1952, p. 137)), ego psychology, self
psychology, attachment-based psychotherapies, and the intersubjec-
tive approaches, which all replaced the focus on conflictual internal
drives with the identification and working through of faulty early
relationships through a reparative therapeutic relationship that is
regarded as critical to therapeutic action.
Countertransference and one- and two-person psychologies
Countertransference is a recognition that the analyst is human, has an

unconscious, and is capable of strong, and sometimes irrational, feel-
ings towards his/her patients. Freud understood the countertransfer-
ence to arise in the physician as a result of the patients influence on
the analysts unconscious feelings and, thus, every analysts achieve-
ments are limited by what his own complexes and resistances permit
(Freud, 1910k). Freud (1915a) cautioned analysts about the danger of
experiencing tender feelings towards the patient and advised the
maintenance of a neutral stance that would contain the countertrans-
ference. Examples of countertransference responses include feeling
bored, drowsy, depressed, angry, or uneasy during or after a session,
erotic feelings, security-seeking or narcissistic attempts to impress the
patient, cultivating continued dependence due to fears of losing the
patient, forgetting or being late for appointments, arguing, or provid-
ing excessive reassurances. Such countertransference reactions may
alert the analyst to unverbalised themes or feelings in the patient. Pro-
jective identification, a concept introduced by Klein (1975), is closely
related to the concept of the countertransference. Projective identifi-
cation, a process involving the patients evacuation of unbearable feel-
ing states into the therapist, informs the countertransference. It is both
a defence mechanism and a form of communication (Bion, 1963). The
analyst must have the capacity to be a container of the patients projec-
tions and to give them back to the patient, transformed in a way that
makes them tolerable for reintrojection (Carpelan, 1985, 1989).
With changes in the conceptualisation of the countertransference,
the concept of transference inevitably changed. The classical view of
transferencethat the analyst functions as a reflective mirror on to
which is projected the patients phantasies and impulsesgave way
to the Kleinian and Bionian conceptions that the analyst is a container
into which the early introjects and the analysands responses to, and
phantasies about, them are projected. Unlike in classical analysis, in
which the analyst was the arbiter of what was real or unreal
(fantasy), Klein argued that the processes of projection and introjec-
tion, and, hence, transference itself, were part of normal as well as
pathological functioning, originate in infant psychological processing,
and are, therefore, ubiquitous phenomena. For Klein, transference
develops in the same way that object relations emerge during infancy.
This means that it can be very difficult to differentiate reality from

fantasy and transference from non-transference transactions in analy-
sis, and in real life, for that matter. Since envy and destructive feel-
ings are central to infant psychological development, the negative
transference, which is an expression of these feelings in the analysis,
must be fully worked through before splits can be resolved and an
integration of the personality becomes possible.
Bion (1959, 1962), akin to Klein, identified the containing and
metabolising functions of the countertransference, the role of which
was to receive and digest the patients projective identifications.
According to Bion, this process is akin to the capacity of the infant to
engender in its mother feelings that he himself does not want and
which he wants his mother to have. Bions use of the word engen-
der suggests a willingness on the part of the mother to be impregna-
ted with the infants emotionsof fear, delight, anger, or excitement.
His mother cultivates in herself the capacity to take in her infant in
this way. Thereby, this process becomes a powerful form of commu-
nication between mother and infant and represents the form of com-
munication that becomes possible in the analytic dyad.
Space does not permit a full historical overview of the evolution of
the concept of transference, and since the psychoanalytic view of
transference has been covered in some detail in Chapter One, we will
fast-forward to a brief summary of the radical view of Lacan, who
challenged the notion of the analyst as the arbiter of truth and know-
ledgethe subject supposed to know (Lacan, 2001). Lacan observed
that most people present to analysis with the fantasy that the analyst
apprehends the secret meaning of the patients utterances and
gestures and holds the answers to the patients questions. The subject
supposed to know is invested with this omniscience by the primitive
phantasising of the infant self of the analysand. Lacan argued that part
of the process of analysis is the relinquishment of this imaginary state
of mind that invests hope in the analyst as the source of the solution
to all that ails one. Lacan (1992) rejected both Freudian and Kleinian
good and bad object views of the transference. Rather, the transfer-
ence dissolves and the analysis terminates when the patient has come
to the understanding that no one, not even the analyst, possesses the
answer to the meaning of life. Enlightenment and selfhood are
achieved when we realise that only we can know our questions and
that no-one can be master of the unconscious (Frosh, 2003, p. 98).
Despite the prevailing presentation in many secondary and ter-

tiary texts on Freud that early psychoanalysis was founded on a one-
person psychology (Aron, 1990), Mitchell (2000) argued that psycho-
analysis has always been centrally concerned with human related-
ness (p. ix). The seduction, instinct, and drive theories addressed the
impact of others on psychopathologythe seducer in seduction
theory and fantasised others in instinct and drive theory. The recog-
nition of countertransference itself speaks to the understanding that
there are two people in the analytic space, communicating and mutu-
ally influencing each other. While Freud advocated adherence to the
principles of neutrality, abstinence, frustration, and anonymity, he
also realised that the analysts warmth and sympathy were crucial ele-
ments in a successful analysis (Menninger & Holzman, 1973). Thus,
the perceived shift in emphasis from a one-person (focus on the intra-
psychic world of the analysand) to a two-person perspective (focus on
the interpersonal relationship between the analyst and analysand)
should not be overstated.
Many of Freuds successors (e.g., Sullivan, Lagache, Fromm-
Reichmann, and Loewald) explicitly viewed the analytic relationship
as a two-person transaction. Fromm (1964) alerted practitioners to the
importance of the analysts reactions to their patients, viewing these
as containing critical analytic data, but warning constraint in self-
disclosure. Fromm believed that people came into therapy in search of
an authentic relationship. He was, therefore, somewhat critical of the
holding and mirroring positions adopted by object relations and
self psychologists because he considered that they detracted from the
authenticity of the therapistpatient relationship and infantilised the
patient. These concerns have also attracted considerable interest and
debate in the more recent literature (Bollas, 1983; Bonaminio, 2008;
Davis, 1978; Ehrlich, 2001; Slochower, 1996a; Wachtel, 2009). The orig-
inal stance, in which the analyst and patient were in no way consid-
ered equal, has given way in some models, such as relational psycho-
analysis, to a more personal form of relating in which the mutual
influence, expressed in transferencecountertransference interactions,
of the analytic dyad is considered central to psychoanalytic work
(Mitchell, 2002).
Countertransference [is] no longer an obstacle but a tool, and neutral-

ity [is] understood as an influence-masking illusion . . . interpretation
of transferencecountertransference dynamics [i]s the fundamental

analytic tool. It is very important not to assume that the patients expe-
rience of the analyst is a distortion, a temporal displacement from
early childhood . . . The patient reacts to the analystthrough past
experience and unconscious dynamics, to be sureas a real, non-
transparent person in the here and now. The analyst has to keep a
focus on the patients experience of the analysts participation . . . If the
analysts impact on the process is not made explicit, the process
becomes . . . persuasion rather than cure . . . [or] a manipulative trans-
ference cure. . . . [T]he analysts interactive involvement in the process
is an inevitable contaminant, but the patients autonomy can be
preserved by a vigilant analysis of that contaminant. (Mitchell, 2004,
p. 540)
The intrapsychic and interpersonal worlds are interdependent and

both must necessarily occupy a place in the analytic relationship.
However, the analyst is no longer the blank screen on to which the
patient projects all his strivings and longings, but a skilled participant
who responds to the patient authentically, with deep emotional
engagement, in the here and now of the psychoanalytic encounter
(Mitchell, 1993). Building on the early work of Sullivan (Bromberg,
1980; Cortina, 2001; Sullivan, 1953), many current practitioners
consider this level of responding to the patient to be a prerequisite of
effective treatment (Dorpat, 1999; Fogel, 1989; Gerson, 2002; Havens,
1986; Maroda, 2002; Van Der Heide, 2007). Accordingly, the counter-
transference, once considered a nuisance or interference in the
psychoanalytic process, has now come to be understood as a signifi-
cant contributor.
The worlds finest tennis players train five hours a day to eliminate
weaknesses in their game. Zen masters endlessly aspire to quiescence
of the mind, the ballerina to consummate balance; and the priest
forever examines his conscience. Every profession has within it a
realm of possibility wherein the practitioner may seek perfection. For
the psychotherapist that realm, that inexhaustible curriculum of self-
improvement from which one never graduates, is referred to in the
trade as countertransference. (Yalom, 1989, p. 87)
The countertransference in the therapeutic relationship is the means

by which the analyst can access his own thoughts and feelings about
the patient in a way that allows him to . . . be empathic and identify
with the patients affective state, while remaining sufficiently psychi-

cally available to help transform the patients communications into a
symbolic form useable by the patients ego (Williams, 2005,
p. 195).
The proper use of countertransference and the issue of analyst self-
disclosure continue to stimulate considerable discussion. On the one
hand, Kernberg (1994) argued strongly against disclosure, stating that
the analyst needs complete freedom to explore all aspects of the coun-
tertransference and that disclosure would interfere with that process.
On the other hand, Mitchell and Black (1995) argue for selective coun-
tertransference disclosures because . . . experience is pervaded by
repetitive selfother configurations established in early significant
relationships that are likely to appear in the analysis through trans-
ferencecountertransference interactions (p. 249). They further
argued that judicious self-disclosure enhances the authenticity of the
analytic relationship and, hence, the analytic collaboration.
Authenticity in the analytic relationship is a theme that has persisted
in psychoanalytic scholarshipsee, for example, Szasz (1966):
Freuds discovery of the transference and his assumption that this was
the sole relationship to the analyst served to deny unbearable reality.
Actually, the analyst must function as both real and transferred object for
the patient and these distinctions must be kept clear by both of them;
otherwise analysis is impossible. (pp. 308309, my italics)
This theme is taken up again by Mitchell (1993), in Hope and Dread in

Psychoanalysis:
. . . the analytic relationship could be defined as unreal, in contrast to

real relationships in the rest of the analysts life. Yet the unreal dimen-
sions of the analytic situation often serve to make possible a much
deeper, personally riskier, more profound experience than is possible
in real life. In this sense, the analytic relationship is more real, for
both participants, than non-analytic relationships. (p. 148)
Peter Lomas (2000) argued the same point in these terms:
I think there is a danger of therapy being used as a defence by suppos-

ing that it is not connected with ordinary life. People sometimes say
to me, Look, this isnt real and I say, Well, its as real as anything
else thats happened today in our lives. (p. 59)
The goals of psychoanalysis
Psychoanalysis, according to Freud, was a science whose subject

matter was the exploration of the human mind by an objective inves-
tigator (the analyst) who used a particular method (free association).
He envisaged its proper home within the natural sciences and its
proper outcome the discovery of historical truth about the symptoms.
Although the early goals of psychoanalysis aimed at affecting a
cure, usually defined as the resolution or relief of (hysterical) symp-
toms, Freud progressively reconfigured these goals, later advising
that the analyst analyses without analytic zeal or the imposition of a
priori goals of the analysis.
The question regarding the goal of psychoanalysis is deceptively
simple, but in reality is complex and multi-layered. First, there is an
underlying paradox between the stance of goallessness or desire-
lessness as the correct analytic attitude and the far-reaching goal of
achieving a fundamental reorganisation of the personality (Waller-
stein, 1986). Second, there are outcome goals, structural goals, and
process goals. Outcome goals include, among others, symptom reduc-
tion, emotional maturation, the capacity to form intimate relation-
ships, enhanced autonomy, reduced dependence on medical services,
or a strengthened sense of inner freedom and identity (Holmes,
1998a). Structural goals encompass progressive changes in the inner
world of the patient as therapy proceeds, such as a reduction in the
strength of a punitive superego or greater integration of dissociated
self-states, depending on the theoretical orientation of the analyst.
Process goals are the means by which structural and outcome goals
may be achieved; they include the establishment of a reliable setting
and clear boundaries, the development of the unconscious therapeu-
tic alliance, resolution of the positive and negative transferences, and
management of termination. Different process goals may be required
for different outcomes: for example, empathic attunement may sup-
port the development of the capacity for intimate relationships, while
resolving the negative transference may address the patients hate and
envy, although most of these goals and processes necessarily overlap.
Of course, goals are also expressed in theory-concordant language: for
example, ego psychologists increase the capacity of the observing ego,
self-psychologists foster self-cohesion. Others focus on process rather
than outcome. For example, according to Varga (2005), one of the key
aims of psychoanalysis is to identify and reduce the repetitive trans-

ferencecountertransference interaction structures (p. 667) that
occur between analyst and patient. There is empirical support that
reduction in these repetitive interactional patterns is associated with a
concomitant reduction in patients psychopathology (Jones, 2000).
The seemingly simpler, more mechanistic models of human func-
tioning, such as operant conditioning (Skinner, 1953), the behavioural
and cognitive therapies (Beck & Clark, 1997; Hollon & Beck, 2013;
Prins & Ollendick, 2003), biological psychiatry, psychopharmacology
(Blanco, Antia, & Liebowitz, 2002; Trimble, 1996), and evidence-based
practice (Chambless & Ollendick, 2001) have all competed with (con-
temporary) psychoanalysis as a way of understanding the life of the
mind. These have more in common with the initial positivist focus on
cause and cure that defined early psychoanalytic theorising than the
current experiential/relational/existential focus of current psycho-
analytic practice (Atwood & Stolorow, 1984; Stolorow, 2006; Stolorow,
Atwood, & Brandchaft, 1988; Stolorow, Brandchaft, & Atwood, 1987).
These approaches have often been criticised for settl[ing] for only
symptomatic changes or changes in overt behavioral patterns in
terms of observable, external (i.e., superficial) criteria (Wallerstein,
1986, p. 750) in contrast to psychoanalysis that attempts a recon-
struction of the personality rather than the limited goal of symptom
relief (Oberndorf, 1950, p. 395).
Contemporary psychoanalysis has not donned the restrictive
mantle of the scientific method; rather, it has favoured a hermeneutic
framework to validate psychoanalytic propositions (Strenger, 1991).
In hermeneutics, the burden of proof or evidence lies not in the scien-
tific method, but in the confirmatory constellation of coherence,
inner consistency, and narrative intelligibility (Ricoeur, 1977, p. 866).
The challenge is to find the best narrative fit rather than objective
historical truth. From a hermeneutic perspective, psychoanalysis is
understood as a process in which stories are told and retold until the
best possible story is foundone that makes sense of the self-experi-
ence of the analysand and allows for the inclusion of previously
repressed or dissociated aspects of the self (Steele, 1979).
According to critics, hermeneutics changes the nature of the
psychoanalytic process, and, consequentially, its goals. For example,
for Spence (1993), psychoanalysis becomes a process of construction
rather than reconstruction, whose goal is to find narrative fit rather
than historical truth, and whose function is not that of historical

scientist, but of poet and aesthete, who co-creates a dialogue of
present and future choices with the analysand, rather than engaging
in a forensic uncovering of the past, by the provision of creative, as
opposed to veridical, interpretations. Wallerstein (2006) argued that
hermeneutics is not an alternative to empirical scientific methods in
the advancement of psychoanalysis and that, indeed, psychoanalytic
research must proceed incrementally through the rigorous application
of the scientific method to subjective clinical data. Wallerstein viewed
the hermeneutic criterion of internal consistency as a truth claim to be
akin to predictive validity in the natural sciences. He cites Poppers
argument that objective knowledge is conjectural in all sciences
because all observations are directed by theory or hypothesis. Kuhn
(1977) similarly noted the false dichotomy often proposed between the
seemingly neutral language of observation and the theoretically
loaded (biased) language of explanation. From the outset, data are
viewed through the lens of the observers paradigm (Heisenberg,
1958) and Freud was no exception. Fonagy (2000) suggests that, with
the adoption of the hermeneutic method to validate psychoanalytic
practice, with its emphasis on explanation, an unfortunate conse-
quence has been the overproduction of theory.
However, in many psychoanalytic circles, the secrecy, lack of
transparency, and failure to apply the safeguards of the scientific
method constitute a major problem for the field. In particular, the
secrecy in which the analytic encounter, the raw data of the science of
psychoanalysis, is shrouded is a significant issue that has not been
satisfactorily addressed.
Much of the data on which theories are based derive from individual
relationships between patient and analyst. Confidentiality and privacy
are certainly important issues, but what happens to a science when few
data are directly shared with others? A scientific community becomes
more illusion than reality unless a considerable amount of significant
data is shared, not just the conclusions. (Kirsner, 2004, p. 341)
Fonagy (2000) also expresses concern about the unavailability of raw

clinical data, arguing that the provision of clinical narrative reports,
which are the data shared between psychoanalysts, are . . . neces-
sarily selective in ways that undermine their scientific usefulness . . .
(p. 226). By its very nature, the recall of a dyadic interaction will be
subject to bias, error, omission, and distortion; recall cannot capture

those processes in the interaction that are unconscious because they
are not available to introspection.
Practitioners of a newer form of psychoanalysisintensive short-
term dynamic psychotherapy (ISTDP)constitute a notable exception
to the code of secrecy that shrouds the more classically orientated
psychoanalyses. ISTDP is a short-term psychotherapy that shares with
other short-term psychotherapies a number of common features,
which include maintaining a therapeutic focus (as opposed to the free
association of psychoanalysis), active therapist involvement (as
opposed to the non-intrusiveness and passivity of psychoanalysts),
the use of the transference and the therapeutic alliance. ISTDP practi-
tioners videotape every session for later analysis, supervision, and
consultation. Through the examination of the minute particulars of
thousands of therapy sessions, its founder, Habib Davanloo (2005)
and his followers (of which Professor Allan Abbass, in this volume, is
one) have developed and refined the practice of psychoanalytic
psychotherapy and developed a theory arising directly from clinical
observation. In addition, they have developed a classification of
patient responses along dimensions of resistance and fragility, so that
treatment can be specifically tailored. The goal of this therapy is
simple: to assist the patients actual experience of their true feelings
about the present and the past (Davanloo, 1995a, p. 2). This form of
therapy will be discussed with Professor Allan Abbass in Chapter Six.
Holmes (1998a) described two major shifts in the theoretical focus
and goals of psychoanalysis. Although all forms of psychotherapy
aim to integrate a divided self, the ways in which these splits have
been understood have changed. For Freud, the splits were horizontal,
occurring between the conscious and unconscious; the aim of analysis
was to make the unconscious conscious (Freud, 1905d, 1933a). With
the advent of Kleinian theory and object relations, the splits were
conceived as vertical, in which parts of the self were dissociated,
projected, and disowned (Hinshelwood, 1997). The aim of analysis is
to reclaim the disowned parts of the self, rather than removing repres-
sion, so that forgotten memories can be recovered. The second shift
comprises a focus on deepening the patients awareness of the
present, in particular the here and now of the therapeutic
encounter, rather than engaging in a reconstruction of the past. You
will notice this emphasis in most of the conversations in the coming
chapters: all focus on the importance of the transferencecounter-

transference in the here and now as a mutative means of highlight-
ing habitual characterological or syntonic defences and other
maladaptive responses as they are enacted in the therapeutic setting.
Holmes (1998a) resolves the paradox between the needed aim-
lessness of the therapy process and the need for aims and outcomes
of therapy by drawing a parallel between the therapists provision of
himself as a secure base who is responsive and attuned to his
patient but who does not prescribe the direction in which the session
travels, providing the opportunity for the patient to face his pain,
bring it into language, and experiment with new ways of being in the
world with increased capacities for autonomy and intimacy.
Table 1 presents an overview of some of the aims of psycho-
analysis from a range of perspectives. It is by no means an exhaustive
list, but will give a flavour of both the convergences and pluralism of
psychoanalytic discourse.
Aims of this book

My primary goal in writing this book was to ascertain how con-
temporary psychoanalytic psychotherapy is theorised and practised
by contemporary clinicians and to identify the commonalities and
differences between four different schools of psychoanalysis
object relations, attachment-informed psychotherapy, existential/
phenomenological/intersubjective psychoanalysis and intensive
short-term dynamic psychotherapyand the degree of their diver-
gence from what is now known as classical Freudian psychoanalysis.
I wanted to ascertain the degree to which the bedrock concepts of
psychoanalysis, such as the unconscious, transference, and the
defences and resistance are understood currently and how they are
worked with in contemporary psychoanalytic/dynamic psychothera-
peutic practice. I was also interested in the role of affect in contempo-
rary dynamic psychotherapy, and how well it has survived amid
therapies based on cognitive and neurocognitive principles.
Conversation is an intimate engagement that enhances under-
standing beyond that which is found in the scholarly literature.
Although participants in these conversations were extensively pub-
lished, engaging with them in conversation about their therapeutic
Table 1. Summary of the goals of psychoanalysis from different theoretical

orientations.
Orientation Locus of therapeutic action

What is the goal of therapy? How effective do we consider
psychoanalysis to be therapeutically? Is what the
psychoanalytic patient gains health or is it wisdom? Is it a
freedom from pain or an increase in self-knowledge? Is it a
treatment or an educational process? (Menninger, 1958, p. 6)
Freud . . . much will be gained if we succeed in transforming your

hysterical misery into common unhappiness (Freud, 1895d,
p. 305)
Interpretation of the transference (Freud, 1910a)
The work of analysis aims at inducing the patient to give up
the repressions belonging to his early development and to
replace them by reactions of a sort that would correspond to
a psychically mature condition (Freud, 1937d, p. 257)
Overcoming resistance to the discovery of resistances
(Freud, 1937, p. 394)
Where id was, there ego shall be (Freud, 1933a, p. 80)
Classical Corrective analytic experience (i.e. interpretation of
(Freudian) transference distortions) (Baker, 1993)
Introjection of the analysts observing ego (Sterba, 1934)
Introjection of analysts superego that replaces the primitive
destructive mother imago; interpretation of the patients
primitive projections (Strachey, 1934)
Resolution of the transference and the regressive infantile
neurosis by interpretation (Gill, 1954)
Insights derived from interpretations of unconscious
processes (Greenson, 1965)
Neo-Freudian Analysis of the defences and the transference (A. Freud,
1936)
Corrective emotional experience (Alexander & French, 1946)
Ego psychology Increased tolerance of drives and a taming of the instincts
and conflict/ (Freud, 1927c, p. 37)
defence theory Defence analysis (Fenichel, 1939, 1941)
True structural change in the ego whereby dependent
behavior is given up . . . because [the analysand] has come
to feel and understand his dependency in such a way that
he no longer needs it or wants it (Gill, 1954, p. 773)
(continued)
Table 1. (continued).
Kleinians/ Reducing splitting and projective identification (Klein,
object relations 1975)
Interpretation of anxiety and the negative transference
(Reich, 1926)
Patients experience of the analyst as a good object and
letting go of the internalised bad object (Fairbairn, 1952;
Ogden, 1983)
Facing emotional truth (Bion, 1970)
At the end of the analysis, the analyst becomes devalued
and useless, i.e., de-idealised, and the analysand accepts his
own incomplete state (Bion, 1965)
Moving from K to
K (Symington & Symington, 1996)
Self Therapeutic action occurs not primarily through self-under-
psychology standing but feeling understoodthrough the feeling of
solidarity (Rorty, 1989) and the empathic bond (Kohut,
1984)
The ability to tolerate the reintegration of previously
rejected or split-off parts of the self (Kohut, 1984)
Attachment- Being recognised and understood by another (Winnicott,
based 1941)
. . . psychoanalysis is no way of life. We all hope our
patients will finish with us and forget us, and that they will
find living itself to be the therapy that makes sense
(Winnicott, 1969, p. 712)
Attachment to the analyst is a pre-condition before
interpretation can be effective; importance of care and
concern (Gitelson, 1962, p. 14)
Learning about ones mind; reflection as a conscious,
cognitive process (Fonagy, 1999)
Containment, insight and new experience (Holmes, 1998a,
p. 230)
Healingmaking wholethe divided self (Holmes, 1998a,
p. 230)
Relational/ . . . the unfolding, illumination, and transformation of the
intersubjective patients subjective world (Stolorow, Brandchaft, &
Atwood, 1987, p. 10)
Corrective relational experience (Mitchell, 1995); patients
introject the structure of the analytic relationship (Loewald,
1960)
(continued)
Table 1. (continued).
Relational/ If the analyst cannot be experienced as a new object, the
intersubjective analysis never gets underway; if he cannot be experienced
(cont.) as an old one, it never ends (Greenberg, 1986, p. 98)
. . . the patient [must] experience the analysts mind as a
place within which the patient exists as an internal object . . .
toward whom the analyst relates with agency and freedom
(Spezzano, 2007, p. 1564)
Co-construction of a coherent narrative truth (Emde, Wolf,
& Oppenheim, 2003)
. . . the coming into language of ones emotional
experiences (Stolorow, 2008b, p. 281)
The analyst, through sustained empathic inquiry,
constructs an interpretation that enables the patient to feel
deeply understood. . . . psychoanalytic interpretations . . .
derive their mutative power from the intersubjective matrix
in which they crystallize (Stolorow, 1994, p. 43)
Therapeutic action is the creation of meaning (Stolorow, (2002)
Patient and analyst collectively scan and revise old views of
reality for the purpose of co-constructing new narratives
that change the patients expectations, assumptions, and
decision-making (Renik, 1993)
Lacanian Therapeutic action consists in gently pushing the patient
away from his comforting assumption that he can depend
on the analysts authoritative endorsement, gradually
forcing him to become his own self-sufficient authority
(Lacan, 1976)
At the end of the analysis, the analyst no longer occupies
the place of the subject supposed to know (sujet suppose
savoir) and appears instead as a limited and incomplete
subject (Lacan, 1976)
Integrationist Therapeutic action requires the development of a new
relationship with ones internal (creativity and play) and
external (love and work) worlds (Diamond & Christian,
2011)
Therapeutic action uses a reliable wish that patients have to
understand themselvesa wish they present either at the
outset (Renik) or that is developed in treatment (Lander).
They both suppose that therapeutic action at least partly
piggybacks on that wish (Freidman, 2007)
The subject accepts (without conflict or guilt feelings) the
indelible marks of childhood that have resulted in the
formation of his character (Lander, 2007, p. 1151)
philosophy and practice was a profound and enlightening experience,

which brought to life the theoretical perspectives from which each of
these psychotherapists practised in an immediate and personal way. It
is my hope that the reader might similarly engage with the transcripts
of interview, and with the therapists commentaries on the analytic
session, and, in so doing, enhance their understanding about the
common deep roots and conceptual and theoretical structures under-
pinning contemporary psychoanalytic/psychotherapeutic practice.
Below is a preliminary conversation I had with Professor Jeremy
Holmes, one of the interview participants, about my aims and moti-
vations for writing this book in the chosen format. (JH = Jeremy
Holmes; DK = Dianna Kenny.)
JH: Where you are coming from with this? What gave you the
idea? What is your objective in doing this book in the format of inter-
views?
DK: It actually grew out of a book that Ive just finished called
Bringing up Baby: The Psychoanalytic Infant Comes of Age [Kenny, 2013].
In that book, I explored 120 years of theorising about infancy. Because
a lot of theories about infancy actually originated with psycho-
analysis, I became interested in how psychoanalytic theory itself has
evolved over those 120 years. In addition, some of the more recent
theorising about mutative change in psychoanalysis uses the
motherinfant relationship as an analogy for the analystpatient rela-
tionship, and views psychoanalysis as a reparative developmental
experience. I wanted to understand how this experience is conceptu-
alised and enacted therapeutically in the newer branches of psycho-
analytic psychotherapy.
JH: Why did you select an interview format for the book as
opposed to simply looking at what people had written and published?
DK: I am interested in understanding both the personal and profes-
sional motivations of clinicians who adopt particular therapeutic prac-
tices and how their conceptualisations affect their way-of-being with
their patients, to borrow from intersubjective/phenomenological
approaches. I studied the body of work of each of my chosen thera-
pists, and was deeply impressed, but wanted them to come to life for
me in a personal way. Peter Fonagy said that clinical practice should
be allowed to unfold without the encumbrances of untested theory.
Perhaps this is happening more now than previously, but clinicians

often still feel bound to hold membership to a particular orientation
object relations, attachment-based, intersubjective, Lacanian. I wanted
to understand the personal motivations, anchors and constraints
of identifying oneself with a particular brand of psychotherapeutic
practice.
JH: OK . . . Its what I call the fly on the wall problem. In other
words, you are a fly on the wall in a consulting room, how do you
know when its a Lacanian analysis or relational analysis, or classical
Freudian analysis. Would the fly notice any differences?
DK: Thats one of the interesting questions that I will address in this
book, not from the perspective of the consulting room, but theoreti-
cally, in conversations with you, the clinicians. This book is concerned
with the internalised (theoretical) models by which currently practis-
ing psychotherapists are guided. I read, after I conceived this project,
that Peter Kramer was interested in doing a similar thing, which he
described as a thought experiment . . . [to find out] what remains of
Freud [Rudnytsky, 2000, p. 81]. I dont believe that he carried this
idea through, but he has succinctly stated my purpose. Im trying to
identify whether there are a core set of therapeutic understandings
that are common across the four theoretical approaches I am investi-
gating in this book. To this end, I am asking all my participating
psychotherapists to comment on a transcript of an analytic session. I
will then analyse these data to determine whether the commonalities
and synergies across the different theoretical orientations are greater
than the divergences.
Before we begin . . . a note about terminology. Two of the four thera-
pists, Dr Ron Spielman and Dr Robert Stolorow, identified themselves
as psychoanalysts. The other two, Professor Jeremy Holmes and
Professor Allan Abbass, identified themselves as psychoanalytic
psychotherapists. In order to use an inclusive term throughout the
book, I have used the words psychotherapist, therapist, and
clinician when referring to the four as a group.
CHAPTER THREE
Dr Ron Spielman: object relations

psychoanalysis
DK: Thank you for talking with me today about the talking cure.
Could we start by your telling me what professional and personal
experiences directed you into the profession of psychoanalysis?
RS: I was a young psychiatrist interested in the treatment of person-

ality disorder, and while Id heard about psychoanalysis and psycho-
analytic concepts in my training, I really had, with hindsight, no idea.
I ended up directing a therapeutic community without really knowing
much about what I was doing. I was running groups and had had
99
clinical experience in a hospital. Then an analyst fortuitously came

from America, and offered supervision at the hospital. Id had previ-
ous supervision for psychotherapy when I was doing my psychiatry
training, which was a very negative experience. It wasnt good for me
and it wasnt good for my patient. The American analyst came and
offered to run a clinical supervision group at the hospital, which I
joined with perhaps four or five other colleagues. Over the space of a
couple of years it slowly dawned on me that this fellow knew and
understood things in a way that Id never heard. He had depth of
understanding of the mind and how people worked. I had a psycho-
therapy patient at the time that I took to the clinical group, but along-
side that, my day-to-day work was running this therapeutic
community on social awareness of peoples interactions and I had very
little idea of the internal workings of the mind. One day, I was sitting
there thinking, here I am running this therapeutic community, of about
twenty patients and ten colleagues, and I dont know whats going on
[laughs].
DK: Were you using a model?
RS: Group field theory and probably basic developmental concepts
and certainly I had an idea about the unconscious and symptoms as
proposed by Freud [Spielman, 2006a], anxiety and other similar
concepts, but it certainly wasnt sophisticated. I didnt know about
transference and countertransference to the extent that I do now. So it
dawned on me that this man was helping me on a one-to-one basis
with this one patient, and I needed that understanding. So I continued
running the therapeutic community for a number of years, and then
added an interest in drug and alcohol, and I became interested in and
was asked to run the community drug and alcohol programme as
well. I did it alongside, which was a mistake, because I was trying to
do two things at once, both of which required much more depth of
commitment. Then one day there was a political crisis in the adminis-
tration when I really felt that the administration wasnt supporting the
clinical work and I thought I had to leave. So I went into private prac-
tice, although I had originally wanted to work psychoanalytically in
the hospital setting, but it wasnt possible. So I went into private prac-
tice just about the same time as I actually applied for and started my
analytic training. When I applied for training as a psychoanalyst I
thought I could do it from the public sector. I was committed to that,
DR RON SPIELMAN: OBJECT RELATIONS PSYCHOANALYSIS 101
but it wasnt on, so here I am in private practice. That all happened in

the late 1970s.
DK: Youve been practising psychoanalytically ever since?
RS: Ever since, yes.
DK: How would you define psychoanalysis?
RS: [Laughs] Freud originally described it as three thingspsycho-
analytic treatment, psychoanalytic concepts, and psychoanalysis as a
tool to investigate the mind. All three concurrently work with each
other. Psychoanalysis as a tool to investigate the mind guides what we
do in the consulting room. Its not therapy-orientated, per se, but
psychoanalytic therapy is therapy-orientated. However, it overlaps
to undertake psychoanalysis as a therapy means understanding the
mind. The concepts are separate from the therapy and the techniques;
the scientific technique is separate from therapy, but you cant do one
without the other.
DK: A lay understanding of psychoanalysis would be that it is a
form of treatment. The consuming public wouldnt necessarily under-
stand the other definitions of psychoanalysis.
RS: Perhaps, but as a form of treatment, it is guided by the concepts.
DK: Sure. But how would you explain what you were doing? If you
offered somebody a psychoanalytic treatment, how would you
explain to that person during their first session what you were going
to do together?
RS: Well, by the time somebody gets referred to me, theyve been
introduced to the idea of psychoanalysis because I dont get people off
the street.
DK: No [laughs].
RS: Theyre being referred to me as a psychoanalyst, so youd
expect a little bit of understanding . . . What Id say wasId ask
you to use the couch and talk about whatever comes to mind. I will
listen and when Ive got something useful to say, Ill say it. Thats as
much as I would like to say. To say anything more is to interfere with
what might come up. After you invited me to do this interview, it
raised a question. Im very much in favour of demystifying, but
theres something about the mystery which is valuable, because it

doesnt impose anything. When its mysterious, youre not defining
and determining what should happen. I would give a minimal
amount of information and then hope for it to become persuasive in
itself. Psychoanalysis is interested in unconscious motivation; its
interested in how the past informs the present, how the present is a
repetition of the past, and this all becomes evident as the work goes
on. One does not actually tell people this at the beginning, but even
now, talking about it indirectly with people who read this wishing to
undergo psychoanalysis, I do have some reservations to say that I
might be spoiling the mystery and spoiling the value of discovery by
saying this is what youre going to find.
DK: At the same time, you said they come with some knowledge,
some preconceptions . . .
RS: Yes. OK. They do, they do. But those you can deal with because
theyll introduce them, but if they come from me, it has a different
flavour, like an expectation, a feeling that I have got to live up to
something.
DK: So you want their introduction to the process to be uncontam-
inated by preconceptions or expectations. You stated that there were
three elements that you would introduce to people on their first
visitthey would use the couch, say whatever came into their minds,
and that you would comment when you felt you had something help-
ful to say. How would you proceed if they felt reluctant to use the
couch?
RS: Well, Id regard that as a resistance from the outset. I wouldnt
insist by any means, but from then onwards I would be inclined to
interpret anything that I came to understand as informing that resis-
tance, why theyre reluctant to use the couch. Now, there are lots of
colleagues who think theres no need to use the couch. Im persuaded
that its a really important part of what psychoanalysis is, in as much
as it takes the face-to-face-ness out of it, and relieves the patient of a
need to focus on the real person of the analyst. The stories are that
Freud originally used the couch because he couldnt bear to be looked
at; if thats the case, he serendipitously got on to something really
important, and Ive become convinced over the years, from what
patients say, that they come to really appreciate not having to worry
about looking at me and that they feel freed by being able to look at
the ceiling or anywhere else rather than me, and that they can say
things that they probably wouldnt say if they were saying it face-to-
face. So it is a freeing experience and it enhances free association,
which is an important part of the method. Its something that Freud
got on to as well, the idea of saying whatever comes to mind, without
censoring, because the theory suggests that one thing leads to another
and you can trace along a chain of associations that become meaning-
ful. You cant always know, by any means, but very often its an
important part of what goes on, that the meaning of D comes from A,
B, C. On its own it wouldnt mean anything and its something about
the unconscious that, in fact, given a fair chance, it will exploit this
phenomenon; the unconscious will make itself heard. Things remind
people of things in the unconscious sense of remind. Since becoming
a psychoanalyst, Ive taken an extra interest in words. Ive always
been interested in words, but I just used the word remind meaning
re-mind. There is folk wisdom in language; words, in fact, contain
very sophisticated psychological concepts. The idea of re-mind is
bringing back to mind again and its in the word itself, in the English
language. There are countless examples of this that come up over and
over again. Our minds, our social minds, our language contain
psychological reality, or psychic reality.
DK: Undoubtedly, words are important in psychoanalysis, but

there are now a number of schools of psychoanalysis that privilege
non-verbal aspects of communication as much as the verbal aspects of
the psychoanalytic encounter. How do you balance the verbal with
the non-verbal?
RS: Well, I try to have a balance. Its not one or the other. Its both.
The non-verbal is at a minimum when youre sitting behind the couch,
but its not absent. By non-verbal, Im not talking about body lan-
guage; Im talking about affect. Affect is a very important part of
analytic work, what is felt, not necessarily heard. I pay really close
attention to words, perhaps more so than other people think is neces-
sary, because I can work out some things by the words that are used.
Ill actually even hear a different word in my mind than a word a
patient might say.
DK: Can you think of an example?

RS: A patient was talking about a dream today and he said, I got
a speeding ticket by accident. I listened to the whole dream and
eventually said, How does one get a speeding ticket by accident?
and then he described the dream in ways that he hadnt described the
first time, putting in some more detail. He and his father were both
riding motorcycles. His father had been speeding but the policeman
fined him rather than his father. His father avoided something that
eventually ended up on him. So it was unjust, not accident, but acci-
dent just seemed like the wrong wordit didnt make sense to me.
By questioning it, there was a truth that he was defending against, not
necessarily to deceive me, but unconsciously he used a different form
of words to avoid the emotional impact of having been unjustly
treated by his father. Patients will often use a word that that will
minimise an affect.
A patient yesterday stated, I was shocked when something or
other happened. I thought, Why are you shocked? This is a good
thing. Why were you not pleasantly surprised? because it was a
better-than-usual outcome of a series of events. What was shocked
was an unconscious part of her that prefers destructiveness rather
than constructiveness. Any other person listening wouldve thought,
Why werent you pleasantly surprised? This is nice. But it was
shocking to the part of her that doesnt want niceness.
DK: Would you interpret that immediately?
RS: Id draw attention to it and then we would try to explore along
the lines that we have just discussedI eventually said what Ive just
said. A part of you was shocked because its not the way it wants
things to be. It wants things to be repetitiously self-destructive. On
one hand, thats an intellectual interpretation and its not in the trans-
ference, but I would hope, in due course, to find a manifestation of
that phenomenon in the transferencecountertransference. On their
own, these intellectual insights dont bring about mutative or trans-
formative change, but I would hope to hold that sort of thing in mind
and then try to link it to something thats actually going on in the
room, as I say, between the two of us.
DK: I imagine that it would potentiate it, though. When it does
come up in the transference, its not a completely new or alien
concept.
RS: Its not new and it may be a manifestation of something that

weve hopefully understood, but when its in the room, it then has
more oomph and can bring about change. Intellectual insight on its
own doesnt bring about enough change. It can bring about some, but
certainly not enough. Something has to happen to allow the patient to
re-experience this event anew and understand it anew in the light of
the analytic relationship.
DK: Weve just been talking about a very important concept in
psychoanalysis, and thats the transference. Can you say something
about that?
RS: Thats what psychoanalysis is mostly all about. Freud discov-
ered lots of amazing things, given that he was a lone ranger for a while.
He didnt have a supervisor or a therapist; he was on his own. He actu-
ally got on to the importance of transference very early onthe idea
that something was being relived in the relationship which had little to
do with the real presence of the doctor and had a lot to do with the past.
So, apart from its beginning in cases of hysteria, which is where the first
transference was experienced, the couch and the transference became
the key elements to psychoanalytic exploration of the mind and of treat-
ment. The body of concepts flowed thick and fast thereafter.
The next big development in psychoanalysis was the counter-
transference. Freud used the word to describe a phenomenon that
arose in psychoanalysis that was to be avoided. The countertransfer-
ence consists of feelings of the therapist for the patient about the
patient which have nothing to do with the patient; it has to do with
the therapists own past life and past experiences, and thats one of the
reasons why we have a training analysis, to try to do some work on
ones own issues, hopefully to keep them out of the field as much as
is humanly possible. The new concept of the countertransference is
that the therapist is a feeling organ who can feel and experience things
that are being projected by the patient and have relevant feelings that
are determined more by the patient than by the therapist himself. By
being an instrument of sensitive attunement to the patient and by
paying attention to the countertransference, one learns a great deal
more about the patient than if it were only the transference. They go
together. One of the main theories that guides the form of psycho-
analysis I do, and most of us here in Sydney, is object relations, and
that is the relationship between a subject and an object. If it were just
transference, it would focus on whats going on in one half of the rela-

tionship, whereas the relationship between A and B is also a relation-
ship between B and A. Things can go in either direction or sometimes
both; the therapist needs to tune into both, not just whats being
projected on to them, but what they feel in relation to that as well.
They can sometimes have projected into them feelings that the patient
is totally unaware of and denies, and to try to then get an integrated
concept of the projection; the introjection is much more important
than simply one-way traffic in the transference.
DK: This term projection has entered the lay lexicon.
RS: Yes, lots of Freudian terms have found their way into popular
language.
DK: Can you say something more about the concept from a psycho-
analytic perspective?
RS: Freud thought that disavowed aspects of the patients own
thoughts and feelings are projected on to the other. They were inter-
nal aspects of the patient that are attributed to the other person, in the
case of therapy, the therapist. They might be appropriate, but it
doesnt mean that they dont belong inside the patient as well. In real
life, you can project on to anybody, and marriage is full of projections
and introjections. Every relationship contains projections and intro-
jections. Thats how we human beings relate with one another and
people get attracted to each other on the basis of projections and intro-
jections. So it has to be a fit for a relationship to work, ideally to work
well, but it often works badly because the more the relationship relies
on projections, the worse it is, because more is being put out on to the
other person than is being owned. So one of the goals of psycho-
analysis, one of the objectives, is to locate the projections and have
them taken back. If a person can take back into themselves what they
project, not only are they more self-aware, but it strengthens their ego
because they take back something that theyve expelled and theyre
stronger for it. Even if its a bad or an unpleasant thing, its better to
have it inside than sent away and then become disconnected from it.
DK: I presume the processes of projection and introjection are
unconscious. Theyre out of awareness, and thats how the uncon-
scious comes inwith that way of relating?
RS: Yes, thats right.

DK: You just mentioned that you work in a model called object rela-
tions. Can you say something about that model?
RS: Its based on the Kleinian model. What Freud talked about was
more focused on structures such as id, ego, and superego, conflicting
within the mind and resulting in anxiety and phobias, and other
symptoms that arise from affect being channelled and defended
against, whereas Klein focused on internal objects. Her approach is
about how objects relate to each other, and sometimes the subject is
the subject of her internal objects, while at other times she is the object
of somebody else who is the subject. Its basically about who does
what to whom in the internal world and how the internal world
works. What goes on in the inner world is a representation of past
experience, real past experience, very much coloured by internal
phantasy.23 The objects that live inside the mind are a combination of
reality and fantasy. What was done to one and what it meant and how
it felt and what it now means. What lives in the mind of any given
adult are a whole family of objects. If theyre whole objects, then they
closely represent whole real people, like mother and father and
brother and teacher and boss andbecause they exist in the mind
even when those people arent presenttheyre always there. The
problem arises when the internal objects dont really conform to the
whole real person and theyre much more dominated by phantasy.
For example, nobody can have had only a bad mother. Mothers can
certainly be bad, but they did feed you once at least [laughs] and
looked after you and cared for you. Every object is a mixture of good
and bad in reality, but it depends on how they live in the mind and
whether the mind of the adult or child is dominated by a distorted
object, by which I mean an object that is less whole, and has lots of
parts and functions that dont represent the actual person.
I remember one of my teachers once saying something Ive never
forgotten: analysis gives you your parents back. It gives you back
something closer to the real parent than the one that you come into
analysis with. You come into analysis with distorted versions of the
real object. Even if the parent were really bad, to have him or her back
better understood and with the experience of analytic treatment, its
probably a version of the parent you can more easily live with, closer
to the real parent, and whom you may be able to forgive, if that person
had reasons that you come to understand as to why they were the way
they were, rather than they just got out of bed every morning and
wanted to treat you badly. You know, you come to understand that
they were traumatised too, and troubled, so the objective is to restore
a closer-to-reality version that can be accepted.
DK: That is a very helpful clarification of the work that object rela-
tions psychoanalysts do with the patients internal objects, particu-
larly the parents of ones childhood. Were there any particular
theorists that influenced your thinking and practice?
RS: Freud, of course. Ive been mainly influenced by the Kleinian,
post-Kleinian [Spielman, 2006b] and neo-Kleinian [Lombardi, 2006]
models. The British object relations school includes the Independents,
who are analysts who did not identify with the Kleinians. I certainly
am not a Kleiniandont aspire to be one. The British object relations
group have been most persuasive for me. In America, we have post-
Kleinian theorists like Ogden and Bion [1963] who have also made
contributions. I dont use Bion concepts a lot other than as part of
object relations theory. Latin-American psychoanalysts think similarly
to the British object relations school, but they have come at it their
own way through their own traditions. Not reading Spanish, I havent
been influenced by them as theoreticians, but you come across them
at conferences and we hear their papers being simultaneously trans-
lated and theyre talking the same language as us. People to whom I
can relate are talking British object relations no matter what continent
theyre from. Ive even been to a conference in India where Indian
analysts have presented clinical material and their patients sound like
my patients. Those analysts themselves have been taught by British
object relations analysts, so thats not surprising, but the patients
sound like theyve got the same inner worlds, living in that culture, as
patients here. Theyre very familiar clinical cases and the clinical
discussion is very familiar.
DK: It is interesting that the inner worlds of people are essentially
the same across cultures. This is particularly intriguing given how
apparently different formative experiences are for people from differ-
ent cultural, ethnic, and religious backgrounds. This observation lends
support to an ethological/attachment theory understanding of human
development and human relationships. Do you see any relationship
between your concept of object relations and attachment theorys idea

of internal working models?
RS: Thats a very interesting question and something Ive given a
lot of thought to. The notion of internal working models is another
way of talking about internal objects. No doubt about that. Even
Daniel Sterns concept of RIGs [1985] . . .
DK: Representations of interactions that have generalised . . .
RS: . . . are each ways of describing things that exist in the mind for
which we have evidence that theyre there, because they behave in
consistent ways. But there are radically different notions of how they
got there with attachment theory and object relations. As I understand
it, internal objects get there in the way I was alluding to earlier, by
reiterations of projections and introjections. If we analyse different
behaviours in the strange situation [Ainsworth, Blehar, Waters, &
Wall, 1978] from a psychoanalytic point of view, we find that infants
with less-than-benign internal objects will not smoothly accept the
mothers return and will perhaps split off their own abandoned self
and treat the mother herself as the abandoned object by projecting
their own abandoned self into her and take on the position of the
rejecting object. It is this and similar processes that form adult inter-
nal objects.
My understanding of attachment theory is that it gets there in a
different way, more biologically and less psychically; theres some
biological imperative that controls how the mother and the baby inter-
act with each other, how the baby responds to the mothers comings
and goings, but it doesnt include any concept of phantasy. Attach-
ment theory does not allow for the babys contribution as much as
psychoanalytic models do. Persecutory objects that come to occupy an
infants internal world appear to be a combination of actual experience
and unconscious phantasy, and these exert a significant influence in the
internal world of an individuals particular object relationships. While
there must, no doubt, be some biological basis for the attachment
behaviour between mother and infant, it seems evident that internal
phantasies can override the logical need for a reattachment following
a separation.
DK: Attachment theory does understand that the baby is a major
contributor to the relationship, both externally with the real mother
and internally with the internal object mother. There are correspon-
dences between psychoanalytic notions of projection and introjection
and attachment theorys idea of the infant exploring the mental state
of his mother which, if the mother is sufficiently sensitive and
attuned, allows him to find himself reflected as an agentic being in her
mind. Bowlbys attachment theory [Bowlby, 1973] argued that it was
the actual relationships of early childhood and not so much the inter-
nal phantasies about them that shape us. One of the differences
between object relations theory and attachment theory is that attach-
ment theory is not so interested in phantasy per se, as originally under-
stood in early psychoanalytic theorising and as you have just outlined.
RS: Not at all and not in the transference and countertransference
by definition. So I dont really understand what attachment-informed
psychotherapy does. Ive never heard anybody present a case. Addi-
tionally, if you listen to people presenting cases from different
schools, a good clinician is a good clinician no matter what they think
guides them. But when we talk with each other about some of our
theories, some of them are just radically incompatible with each other.
This is the case with psychoanalysis and attachment theory. Peter
Fonagys written a book about it.
DK: Peter Fonagy [Fonagy & Target, 2003] tries to integrate psycho-
analytic thinking and attachment theory. There are significant syner-
gies between the two. However, there are also some fundamental
tensions that appear difficult to reconcile. Take affects and affect regu-
lation, for example. Both theories acknowledge the importance,
indeed primacy, of affect in both the development of the sense of self
and in mutative change in therapy. However, psychoanalytic theory
views affects as bodily experiences that are connected with drives and
instincts, arising within the conflicted mind, whereas attachment
theory argues that infants affective experience and capacity for affect
regulation arises in the interaction with early primary care-givers.
You asked the question, What do people in attachment-based
psychotherapy do? This therapy is informed by the four major types
of attachment and the adult behaviour that arises as a result of a
patients state of mind with respect to attachment that they brought
with them into adulthood. The four attachment types in childhood are
secure, avoidant (insecureavoidant), ambivalent, (insecureresis-
tant), and disorganised. Children internalise their dyadic relationships
with their primary care-givers that guide all subsequent ways of relat-
ing to others. That is, they carry a state of mind with respect to attach-
ment that is a template from which they understand and conduct their
relationships. These states of mind are secure (autonomous), preoccu-
pied, dismissing, and unresolved/disorganised. In attachment-based
psychotherapy, the assessment process includes an evaluation of the
persons state of mind with respect to attachmentit rarely falls
exclusively into one of the four main types. There can be significant
overlaps, but they guide the therapists understanding of the patients
expectations of relationships. Attachment types in infancy predict
adult states of mind with respect to attachment. Secure parents have
secure infants; preoccupied parents tend to have ambivalent infants;
dismissing parents, avoidant infants, and disorganised parents, disor-
ganised infants.
RS: So what do you do then?
DK: The attachment style informs the nature of the transference. For
attachment-based psychotherapists, transference is regarded as inte-
gral as it is in psychoanalysis and is considered the locus of mutative
change. That is because patients will repeat their early attachment
style within the therapeutic relationship and in that way it is brought
into the room and worked with directly. Jeremy Holmes, who is also
part of this conversation, put it well when he said, What good ther-
apists do with their patients is analogous to what successful parents
do with their children. The therapist becomes the secure base that
was missing in early development, from which the patient can access
and explore painful affects and split off parts of the self, own them
and integrate them.
RS: Well, its just another way of describing what happens, I
suppose.
DK: It is really, because lets take someone with a dismissing state
of mind with respect to attachment. In the psychoanalytic literature,
this pattern has been described as narcissistic self-sufficiency. Both of
these conceptualisations describe people who have been profoundly
disappointed by their attachment figures and become defensively self-
reliant and distancing in their relationships because their attachment
figures were too unreliable or misattuned to allow them to feel safe
and understood in those early relationships. Both narcissistically self-
sufficient and dismissive patients have unresolved rage and grief

about early attachment failures, and long for the lost ideal parent. The
same dynamic is operative, because I am arguing they are the same
type of patient. Im interested in seeing these synergies, because, as
you say, even though the theories might be very different, what
people actually do clinically might turn out to be quite similar. Would
you agree?
RS: Well, I agree with your description, but I dont agree that deal-
ing with it has much in common from a psychoanalytic point of view.
I recognise dismissive behaviour as part of the narcissistic constella-
tion, but the rejection by the patient would be much more actively
attributed to the patient than a failed parent in a psychoanalytic
approach. Yes, there might have been a failed parent once upon a
time, but now, in the room, the manifestation of dismissive behaviour
is because of the refusal of the patient to allow the therapist to be
important. Yes, maybe based on past disappointments, but in the
room at the moment, the patient is saying to the analyst, I dont need
you and you dont exist and youve got nothing to offer, so their
resistance is a resistance against acknowledging their yearnings and
longings. Youd then try to get to the fact that theyre actually defend-
ing against a great neediness by appearing to be so self-reliant and
dismissive. So yes, probably talking about something that had its
origins in the same infantile experience, but its being understood in
the room in different ways.
DK: It occurred to me as you were speaking that this awareness
develops in a staged way. First, the person needs to understand the
nature of their internal objects and where they originated before they
can accept that what they are dealing with in the room with the analyst
are their own affects, resistances, and so on . . . You described affect as
being highly important in psychoanalysis. People with a dismissing
state of mind with respect to attachment have been described as affect-
phobic. Theyre afraid of their own affects and feelings.
RS: Yes, but their rage and their longing and their yearning and
their love and their hatred and envy are all there and need to be
worked with. I dont think theres much room in attachment the-
ory for envy. It plays a very big part in object relations understand-
ings.
DK: There is room for the full range of emotions in attachment-

based psychotherapy but I am interested to hear you say more about
why you think envy is not considered in attachment theory?
RS: In most patients you eventually have to address serious envy
either envy or being envied, and inevitably both. A lot of patients
downplay their own abilities in the world. Ive got one patient who
famously at the beginning of therapy talked about not rising above
her station. This is a quote from her mother, Dont rise about your
station. This is a very capable woman who had a lot of abilities, but
was really very fearful of and reluctant to make an impression on the
world. She was ambitious, but she feared being envied, feared being
accused of rising above her station in the here and now, wherever she
went. So she did not progress in her profession as well as she might
have for fear of provoking envy. She was equally very envious of
people who had things that she was envious of. Envy and being
envied are the two sides of the transferencecountertransference.
Sometimes the patient fears being envied and sometimes they are
envious. Theyre either the envied object or the envying object. Nearly
everything is two-way. Envy is probably more a psychoanalytic
concern than in most other therapies.
Destructiveness is much more a feature of psychoanalytic work
than any other psychotherapythe attempt to deal with negativity
and destructiveness when its present, as it is most of the time. I cant
think of any patient ever where their own self-destructiveness hasnt
been an important part of the workself-defeating, self-destructive,
otherwise theyd be out there getting on with it. Every patient comes
because theyre doing themselves in in some important way. It wont
be obvious to start with, but itll become obvious.
DK: Do you see this fear of being envied that you have just
discussed as related at all to the more populist notion of a fear of
success?
RS: Yes, sure. Anybody whos afraid of success is afraid of the tall
poppy syndrome being exercised on them, and thats a very common
thing. People are fearful of standing out, putting their head above the
parapet. Weve got lots of popular phrases that reflect this very thing.
Its much more common than people are aware of.
DK: Very much so. It reminds me of a Jungian analysis of perfor-
mance anxiety in which the performer is perceived to become
detached from the herd and any criticism of his performance by the
audience renders him an outcast for his audacity. I wonder if we could
talk about the all-important frame in psychoanalysis. There are a
number of elements involved but I dont want to pre-empt your
response. So lets start with my asking you what elements you would
consider essential in setting up a psychoanalytic frame?
RS: The all-important frame . . . When I teach, I try to liken our
consulting room to a surgical operating theatre, not to make it sterile,
but to say how important it is to keep it clean of contaminants. The
idea is to set up the frame, the milieu, the environment, whatever we
want to call it, within which this work is going to be done. There are
so many variables in any human relationship but we attempt to
minimise them, to rule some variables out.
DK: Can you give an example?
RS: Well, all the variables that theoretically emanate from therapists,
to try and make it as much about the patient as possible. Youve got the
room to be as quiet and bland as possibleyes, this rooms bland.
Theres very little that intrudes on the patient but everything in this
room has meaning to me. Theres a little story attached to everything
except the wastepaper basket and the heater. The only three paintings
on the wall mean a lot to me. These little things on the desk have sto-
ries important to me. The couch belonged to that person whom I told
you influenced me originally. When he went back to America, I inher-
ited his couch because wed become friends, but its basically a bland,
unintrusive room. Theres nothing that really impacts on you although
it is not just bare walls but its kept to a minimum.
DK: Yet you have some very personally important items in here.
RS: Yes, I do, but whatever the patient makes of the objects in the
room is the important thing, even though there are bits and pieces of
me. When a patient comes to the door, Ill open the door; I cant help
smiling but I dont say anything. I dont say, Hello, how are you?
because the focus is on them from the minute that they cross the
threshold to the door. As soon as I hear them enter the building, Im
focused on how quickly they come up the stairs, whether they delay
and what they sound like. Ive got one patient who drags himself up
the stairs; it feels like hes coming to an execution every day. Others
come more enthusiastically. You can get a sense and a feel of whats
going on in them before they even come into the room. They go and
lie down and Im sitting behind the couch, and the whole focus is on
them. The main idea is to provide an environment within which
everything that happens theoretically originates from them although
I am, of course, part of it. If I say something early on, Ive become
involved; if I dont say something, that also has an effect on what
evolves. Theres no way that youre not part of what goes on in some
way, and I will discuss with myself in my own mind whether I say
something earlier or later or wait orto try to get more information
from them before I try to make up my mind what is worth saying, but
the focus is really on the patient.
To make this a knowable, predictable and safe space, you have to
have boundaries and thats why we call it a frame. They come in,
theyve got control over when they come in, they can be late if they
want to, they can knock on the door early, but generally speaking, the
expectation is that they dont. If somebody comes markedly early, I
say, Well, its not your time yet. Youll have to go back to the wait-
ing room. Nobody uses the waiting room. They all come in at the
right time, but Ive got control over the end of the session. I own the
end of the session; they own the beginning, even though theyre
invited to come at a particular time. So that plus my dates: I tell them
about my planned breaks within the first few weeks of the beginning
of every year, my plans for the whole year in terms of when Ill be
here and when I wont be here.
DK: So you are in charge of the setting and the timing. What about
payment and payment for missed sessions?
RS: I charge for missed appointments because my commitment is
to be here; their commitment is to come and pay for their session. This
is part of the frame. The holiday dates, number of sessions per week,
the more the better. Its hard these days to get people to come five
days a week, but five is better than four, and four is better than three,
and three is better than two. One is barely worthwhile these days in
terms of psychoanalysis. A lot of people do once-a-week psycho-
therapy. But to call it psychoanalysis, coming five days a week and
having a two-day weekend is the ideal, using the couch. Anything
short of that is resistance. Weve settled on four or five days a week
and these days, we accept four days a week, because in this busy time
and age and it is very costly. Four days in a row and a three-day
weekend is nearly as good as five days and a two-day weekend. As

soon as you get to three days a week, and a four-day weekend, the
balance shifts. As soon as theres more break than there is involve-
ment, it changes. Its no longer as intense and as valuable on that level.
It doesnt mean you cant do good psychoanalytic psychotherapy
twice a week or even once a week if you know the patient well, but
you cant know them as well as if they come five days a week for a
number of years, by definition. The involvements just not as intense.
It doesnt bring the same benefits in terms of depth and intensity that
five days does. I often say that as soon as the balance is more not being
here than being here, then its not as intense. The analytic process
doesnt develop as effectively.
DK: When you say people have to pay for missed sessions, how do
you define missed? For example, if theres a medical emergency or
theyre in hospital, or giving birth, or they have to attend their fathers
funeral?
RS: They are missed sessions. If they dont come, its a missed
session.
DK: For whatever reason?
RS: For whatever reason.
DK: I imagine that would make a lot of people quite angry.
RS: It does make a lot of people quite angry [laughs]. My revered
teacher that I refer to, the one that got me into this in the first place,
he used to say you charge for missed sessions except for births and
funerals. Ive come to think, well, why make the exception? Because
the reasonthe principle on which you charge for missed sessions
is no different whether its for births or funerals.
DK: Even if its an emergency?
RS: Its not a matter of compassion; its a matter of a mutual
commitment. My commitment is to be here; theirs is to pay, to come
and pay for my time. I sell my time and my minds attention. I know
it sounds harsh; whenever Ive tried to teach about the frame, you
always get the same arguments. I sound worse about this than I am,
but any not charging for missed sessions is falling short of clinical
competence. Of course, if a patient cant pay, as has happened, I cant
charge them. But Ive got Medicare here, which I actually find an
intrusion and interference becauseand I envy my non-medical
colleagues in this regardbecause they have a direct financial rela-
tionship with their patient. They charge them and the patient pays.
Medicare supports and subsidises and makes psychoanalysis accessi-
ble to a lot of people who probably couldnt get here otherwise. But it
interferes with this direct relationship of paying for what youre
getting. This is not just a question of economic pragmaticsthat Im
selling my time and Im entitled to be paid. I genuinely think that a
huge amount of work gets done over this issue because it, at base, is
about object relations. Its about regard for the objectthe otherand
concern. Maturity is about being able to have regard for the other and
being able to treat them well and not abuse them, and all these issues
come into payment or not for a missed session.
Patients who pay for missed sessions without question are equally
as problematic as those who dont want to pay, because theyre gloss-
ing over what you quite rightly say are feelings of anger, but this can
be worked through. If you were a landlord and you charge rent and
say, You can come and live here as long as you pay rent or until I sell
the premises, which is the equivalent of my retiring [laughs], if the
patient goes off on a holiday, they dont say, Im not going to pay
you rent for three weeks. Thats the way it is. This is the issuethe
persons asset is their property and they rent it. Compassion doesnt
come into it. You might be happy to say, If you cant pay me this
week, Ill wait til next week. But they wont go as far as saying,
Well, you dont have to pay me at all. A compassionate landlord
might say, All right, I understand youve got some financial troubles
this month and Ill wait til next month, but they cant endlessly say,
Well, you can have the use of my assets and I dont get any return
on it. Thats making it sound callous but what we eventually get to
is how the person regards me and treats me and theyve come to
acknowledge that Im offering this and they have responsibility to pay
for it as much as I have of being here in as good a shape as I can be
and never cancelling, but I regard it as very important that I be here
in as good a condition as I can, and they come to appreciate that. They
marvel that you dont take days off, other than the ones that you
say youre going to. Sometimes you have to give notice and say, I
cant be here on such-and-such a day, unexpectedly, but its been
very rare.
DK: It ties you down as much as the patient?

RS: Working this way does tie you down, but it also frees you
because I can take holidays when I want. Im my own boss. But I do
it in a knowable and predictable pattern through the year, because my
comings and goings, like the mothers comings and goings, are an
important part of psychic life. Im free to take the number of weeks
holiday I want, but the other side of the coin is a commitment to be
here for as long as I work this way. I cant say, Oh, its a lovely day
today. Ill go and play golf or go sailing. I cant do that. For young
women, for example, if they want to get into this profession of psycho-
analytic psychotherapy, or psychoanalysis, you know, having a baby
is a really big event, a crisis, in their professional life because its going
to disturb people and theyre going to get angry with you for aban-
doning them or preferring your own baby to them. So you actually
become the object of a lot of feelings which you could live without,
but you actually buy into making yourself available to have people
very angry, abusive, dismissive, contemptuous, envious in ways that
other ways of working dont invite. But you invite it because thats
what youre here to try to uncover. Thats another reason why the
frame is so important, to have it as knowable as possible, so any devi-
ation from it that evokes all these feelings can be addressed in safety.
The safety is for the therapist as well as for the patient, to give some
reference point for things. If I turned up late every now and then, I
could never deal with lateness in a patient.
DK: It is clear that doing this type of work involves a significant
personal as well as professional commitment. The work is also very
demanding. Even with the years of training undertaken to become a
psychoanalyst, it cannot be easy to be the recipient of so much patient
negativity. How do you protect yourself from burnout or from taking
too much on?
RS: You have a peer group; thats the key point. We allwe
Sydney analystsI dont know about around the world, but here in
Australia, theres an expectation that you belong to a peer group.
Psychotherapists do the same. You go along and discuss your cases
and talk about the issues as they arise. You have a community of
colleagues that respect what you do, and you respect what they do,
and we mutually feel were doing the right thing. So thats reassuring.
I dont think you could work like this as a lone ranger. Youve got to
be part of a community and certainly a close supportive peer group

where you can go and talk about problems. Taking enough weeks
holiday in any given year is also a self-care thing. I dont think you
can work intensely this way more than X hours a day and Y hours a
week in a row. For me, X hours a day was never more than eight, and
preferably seven, and as Im approaching retirement, its fewer than
that still. But ten weeks in a row is four times ten, forty weeks a year
is the standard pattern that Ive had over all the years. Not all my
colleagues do that, but probably most would have at least three breaks
a year. I have four. It used to be more or less the school terms, because
patients had schoolchildren, but that doesnt apply any more to them
or to me. That pattern has persisted. But Id have fewer qualms now
about taking a break at an unusual time of year and copping the flack,
because you could work with it, but I wouldnt go out of my way to
provoke anybody, as long as Im giving enough notice, like months,
Id be happy to take an unusually timed break. The standard pattern
is enough weeks break for my own sanity, so to speak. So that plus
talking to people-colleaguesis what you do to avoid burnout.
DK: Is there anything else about the frame, for example, the dura-
tion of each session?
RS: Well, fifty minutes. Thats an inheritance from Freud. Before I
knew anything about analysis, I used to do group therapy, and stan-
dard practice in the hospital was an hour. The group ran for an hour.
I used to think an hours not long enough. So I instituted two-hour
groups and then I had a go at four-hour groups. But things didnt start
to happen until the last ten minutes, no matter how long the group
was. That sounds a bit glib, but the point Im trying to make is the
right amount of time is close to an hour, and anything longer than that
is too long from a concentration point of view. If anythings going to
happen, it needs to happen earlier rather than later so that you can
work on it. So if you have a longer time, it just provides a longer time
for resistance; hence, the fifty-minute hour. If youre going to have
appointments every hour, you need ten minutes in between for a bit
of mental hygiene and also for people to arrive and leave. So whether
it was forty-seven minutes or fifty-three minutes, fifty minutes is
probably good. Its the right proportion of a sixty-minute hour, so its
a combination of convenience and appropriateness. Im quite con-
vinced that fifty minutes is long enough for both of you for something
meaningful to happen. As long as there are five fifty-minute sessions

in a row in a given week, thats a nice rhythm. We talk about rhythm,
the rhythm of the week, Monday after the weekend, Friday going into
the weekend, and Wednesday is the day you do the work. Thats a bit
glib too, but its genuinely a rhythm where the patient has to find their
way back to the mother whos abandoned them last Friday, contact
her again, feed from her again, and then be aware that shes about to
go off and do her own thing either with the other siblings or the
husbandthis is what it all means. When you leave at the end of the
week, have a weekend of your own, have your own life, it evokes all
these early infantile feelings that every human being has to encounter.
It brings them into the room without being provocative. The rhythm
of the week somehow evokes (which is a better term than provokes)
all these important underlying issues. Thats why the consistency, the
reliability, and knowability are important, and the durationthe next
question you will ask me is how long therapy goes on?
DK: [Laughs] Youve read my mind!
RS: As long as it needs. Thats variable. It generally takes about four
years for things to get going and it takes the best part of four years to
establish and maintain the frame to get the patient, not necessarily
cognitively, but to feelingfully find their way into the process. The
processthe unconscious [Spielman, Busch, Vazquez, & Feldman,
2010] processstarts to get going and at the beginning of any therapy,
its generally the same in regard to all sorts of issues. You get a feeling
of the patient reacting to the stringency of the frame and getting irri-
tated by having to come and say things at particular times, to tell their
story and start to report their daily lives, start to get a feel of you in a
way that means something to them rather than who you really are, and
then by around about three and a half, four years, the unconscious
then carves out its own signature on the transference and starts to
bring things out unconsciously which are unique to this patient.
In the early years, I could be talking to any patient. But the trans-
ference is carved into the analysis by the unconscious in a way that
represents this patients unique experiences and things start to get
enacted, acted out, that are unique to this person. From there, the
process takes another indefinite number of years. Im aware that I
tend to see people quite a lot longer than some of my colleagues. I
havent asked anyone to leave except for one person to whom I said,
Its time for you to think about going. Generally, I wait until they
give me enough indication that their unconscious is ready to go and
then we work on termination. Seven, eight years would be a mini-
mum to do enough work on a not grossly disturbed patient, but really
sick patients need a lot longer.
DK: That is a very long commitment to one patient. How do you
maintain interest over such a long period?
RS: Its endlessly fascinating and boring at the same time [Spielman,
1997a] [laughs]. Once I make a commitment, I hang in there.
If it does get boring or uninteresting or feels unproductive, thats
different from someone whos ready to go. When somebody has done
the work and is ready to go, you then do the work on leaving, which is
interesting in its own right. However, if it grindsnot to a haltbut if
its grinding, its because theres resistance and then you have to try to
figure out whats going on in the transference and the countertransfer-
ence, and work on that. Its endlessly interesting in terms of theres
always something to think about, wonder about, work on, deal with,
and as long as the patients committed to coming and paying and
taking some interest, then its a working partnership. By definition,
part of the patient is resistant from the word go, and you have to accept
that youre working against the resistance all the time. Otherwise they
wouldnt be a patient. Everybody is resisting, to a considerable degree,
knowing themselves in ways that might be better if they did know
themselves. Theres too many ways of avoiding knowing but not
everybody has to know him- or herself if they dont want to. But as
soon as they come across my door, the threshold, thats part of the
deal. We have to know, we have to face whats to be known as best we
can.
DK: Yes, the contract must be fulfilled. What happens at the end
lets say an eight-year, five-times-a-week contact with a personis it
just the end or are there different ways of terminating?
RS: Well, it starts to become the end when theyve got better things
to do with their time than to come here. Thats not meant in a nasty
way. There have been reasons for coming and then they find that out
that there are more things to do and they are now in a position to do
them. So the idea of finishing has got to be because I dont need to
come any more and I can better enjoy my life than I did before. Then
the process of letting go becomes an important one. All the issues tend
to get revived and sometimes theres a resistance to go and the patient
will start to become symptomatic again in order to say, You cant
kick me out. Its endlessly variable, but there are lots of commonali-
ties too. Everyones unique with respect to this question of letting go.
So it depends what the model is. The model could be the death of a
parent or the model could be growing up and leaving home, in two
different styles of leaving and reasons for leaving. One patient I
remember vividly, when it came to leaving, said, I want to leave like
a boat leaves, not leaving like an aeroplane leaves, because leaving by
aeroplane, you go through the doors and thats it. With a boat, youre
holding on to the streamer until they go out of sight. So ones a more
a weaning type of leaving and the other one was an abrupt shut-the-
door-and-never-look-back type of leaving. These were the two things
that she had in mind. Weve worked on what both of them meant.
With some of my patients, wed drop sessions before leaving and for
others, wed set a date and wed go five days until the last day. By
choosing when it comes time to leave, it gets talked about how you go
about it. They all imagine that theres the textbook way of leaving,
which there isnt. Youve got to try to tailor it to each individual. Some
wean themselves off me and others say, Well, thats the date and I
will work analytically up until the last day. Ive had both experi-
ences, and theyre both valuable as long as you get the right one for
the right patient. Youre not going to know that until its too late
[laughs]. Some people set a date and revise it.
DK: What about coming back after termination?
RS: That can happen and does happen. Ive had some people come
back and Ill just see them once a week for a while to deal with a
particular issue. Some will come back because it was an unsatisfactory
ending. Well have another go. They leave again andso the idea is
to maintain the frame forever. Once they do leave, Im here in the way
that I always was. Theres no social or getting in touch withon a
casual basis, I try to preserve myself as available if they ever need me
again . . .
DK: As a therapist?
RS: . . . in the cleanest possible way. So theres no never darken
my doorstep again, but many have a fantasy that thats what it is;
that once they leave, Ill never want to know about them or have any
contact from them. Whatever the fantasy is, hopefully it gets worked
on before they actually leave. So if somebody wanted to write a letter
and tell me how theyre getting on, that would be most welcome, but
the idea is that they should be able to go and get on with it without
being attached in a way thats shackling to them.
DK: Sure. Would you respond to the letter?
RS: Id say, Thank you for your letter. Thats all.
DK: But you wouldnt respond in a more personal way?
RS: I wouldnt write back and say, How are you and whats going on?
DK: OK, so this minimal responsiveness occurs in the interest of
maintaining the frame, even after patients have left. . . . Can you say
a little bit about dreams and dream analysis?
RS: Freud made a big thing out of it, and rightly so, but dreams are
part of the material nowadays. Its the royal road to the unconscious
in the sense that it tells you things that a conscious account of oneself
wouldnt tell you, but they are not elevated to any special rolethey
are just part of the material and the free association [Spielman, 2001].
Having said that, a dream thats told at the beginning of a session is
different from one thats told in the middle from one thats told at the
end. Patients might say at the beginning of the session, I had a dream
last night, . . ., then its part of the agenda. If youre in the session and
you make an interpretation and they say, Oh, that reminds me of a
dream, thats much more spontaneous and revealing and important,
and if they tell you a dream at the end of the session, then they dont
want you to know about it and interpret it [laughs]. So it depends on
whereabouts in the session it comes, the content, and whats it in
response to. It is a special revealing set of material, but not in any
different way to acting out or acting in or anything else thats driven
by less-than-conscious deliberation.
DK: So psychoanalysis as it is practised today treats dream material
in the same way as any other material that is brought into the session,
like the unusual choice of words that we talked about earlier?
RS: Anything thats determined by something theyre not con-
sciously out to tell you. That can be lots of things. Its one way that the
unconscious can have a say and I dont think you can interpret every
dream or every bit of every dream. But I take them seriously and do
my best to hold them in mind through the whole session. I dont do
dream analysis in the sense of question and answer, but it doesnt
mean I dont ask questions. I dont systematically work my way
through a dream in a way that Freud may have done at the beginning.
Its not an expectation, but if a patient doesnt bring dreams, youd
wonder whats going on. So not to dream or not to report dreams is
a resistance because we know everybody dreams, so why arent
they bringing them along and telling them. On the other end of the
spectrum, the record was a patient telling me seven dreams in a row,
which I couldnt possibly work with. I was being overwhelmed with
something for some other reason that day. So everything has to be
taken on its merits on the day. Theres no dream analysis, in
inverted commas, thats elevated above anything else that might
happen in the session, to my way of thinking.
DK: Can you comment on whether oedipal issues are still consid-
ered part of the analytic process?
RS: They are always there. Freud came through the oedipal door-
way and Melanie Klein came through the infantile dependency, need-
iness, envy, destructive baby doorway. Klein was more identified with
the pre-oedipal; Freud with the oedipal, but Freud couldnt do every-
thing. What he did was impressive but a combination of oedipal and
pre-oedipal is necessary. If oedipal issues are dominant at the begin-
ning, theres something wrong, because it indicates that pre-oedipal
issues are likely being defended against. When one comes into analy-
sis, ones coming in as a newborn baby into this relationship, and there
are dependency issues that should take pride of place. If a patient is
excessively oedipal at the beginning, then it means that the oedipal
issues have become intense because the other issues are unbearable.
On the other hand, people can get stuck in their dependency issues
and never get, or dont want to get, to oedipal issues. Thats resistance
as well. If a woman patient is excessively histrionic at the beginning,
Id have no doubt that the relationship with her father has interfered
with her relationship with her mother, and that Im seeing
daughterfather issues as a cover-up for motherbaby issues. So Id be
trying to get hints and clues of the pre-oedipal issues. Likewise, if a
man is excessively rivalrous with me at the beginning, the same
applies. Its a cover-up for his dependency and neediness and longing
and yearning for me to be a good mother, even though Im a male.
Regardless of the sex of the therapist, the unconscious drives the
issues. I actually think its easier for a male to be felt as a maternal
object than it is for a female therapist to be seen as a paternal object.
It doesnt mean that a woman doesnt have paternal or phallic aspects
that can be either projected on to them or enacted in their own right.
The gender of the therapist shouldnt matter, but in some sense, it
probably does. It might make it harder for things to come to the fore,
but they inevitably will.
This raises another interesting question about how the Oedipus
complex, which is a three-person phenomenon, gets manifested in a
two-person environment. When I was younger I once had the fantasy
that real analysis would have male and female analysts sitting behind
a one-patient couch and although itd be doubly expensive, youd be
able to project on to the female what belongs to the female, on to the
male that which belongs to the male. Now, of course thats impracti-
cal, but it just highlights for me the question of what the patient does
about the third party in an oedipal conflict. Ogdens been foremost in
writing about what he calls the analytic third [Ogden, 2004].
Sometimes psychoanalytic theory is seen as representing the father.
The Lacanians call it the Law of the Father. I imagine its hovering
in the room in some way. The third persons there in fantasy because
every patient has a fantasy that youre married, whether youre
married or not, and that there are siblings, whether there are siblings
or not, that is, other patients. So theres always the fantasy of the
others. Oedipal issues are terribly important because they are part of
development.
Analysis without addressing oedipal issues is unimaginable. If
oedipal behaviour is used defensively against pre-oedipal issues, then
youd have to try to get to the pre-oedipal first, and then the oedipal
later, but you dont determine the timetable. The unconscious does
that. Whether I think its coming at an appropriate time and in an
appropriate way is something for me to consider, but once its there
in its own legitimate right, its terribly important.
Freud said some amazing things about the importance of the
oedipal complexthat the mind could not develop effectively with-
out resolving this complex; that you couldnt have a mind that could
really know what it needs to know until the two-person world
becomes a three-person world and that becomes resolved. So, its a

big topic, really, in terms of epistemophilia. Freud talked about an
epistemophilic instinct, which is an amazing concept really; that was
a precursor to placing huge importance on knowing and not knowing
and defending against knowing and attacks on knowing. There are
lots of models of what goes on in psychoanalysis and no one of them
is the only one. But the idea of allowing yourself to know what needs
to be known is terribly important, as is looking at what prevents you
from knowing.
DK: What came into my mind as you were speaking is that increas-
ingly were seeing children growing up with same-sex couples. What
thoughts do you have about the oedipal issues in that situation?
RS: Politically incorrect ones. In theory, a child should have a
healthy mummy and daddy; that is the best way for a child to develop
an optimal mind that will serve it well in its adult life. Thats the ideal
model. Goodness knows that there are pathological heterosexual
couples, so having a loving, caring, stable, same-sexed two-person
couple, which is better than one person, looking after you is probably
better than having warring, hostile, destructive, hateful, murderous
people of whatever stripe. I do think that the optimal is what a child
is entitled to, but the unconscious makes the best of whats offered. In
my experience, even stable homosexual couples somehow or other
either deliberately or unconsciously allocate roles to themselves; ones
more maternal, the others more paternal. Its driven by their
psychologies and inevitably that will be experienced by the child.
Even though there are two mummies, one of them is more like a
daddy than the other, and if there are two daddies, one is more like a
mummy than the other. Thats fine. But as you are probably alluding
to, theres lots of debate in the popular press, and in parliament
currently and everywhere about the pros and cons. The word marri-
age implies a combination of two things that are different. A and B
marry; A and A dont marry. In ordinary language, you dont marry
like things. PsychicallyIm not talking morallythe developing
baby has to differentiate itself from its mother and it has to be able to
differentiate differences, including the differences between men and
women. If you introduce sameness in a way that doesnt allow differ-
ence, you are precluding something that the developing child needs
to grapple with in their own way rather than have it imposed on them.
Marriage has to do with the notion of difference, so the same-sex

marriage is different from same-sex union. Same-sex union is much
truer psychically. Its a union rather than a marriage, psychically. I
dont think this would be a readily accepted argument.
DK: No, probably not.
RS: None the less, difference is important, developmentally, and
sameness is a defence against difference. So part of the aetiology of a
homosexual mind is something about not having grappled with
difference.
DK: It appears to me that one of your concerns with same sex
unions becoming parents is the absence of difference and differentia-
tion in the parental couple. Is there a similar absence in a single parent
raising children?
RS: Again, its less than optimal. Obviously, in a practical sense,
one has to accept that it happens, and children grow up for better or
for worse. A lot of children suffer from being in a single-parent family,
but it will depend hugely on the reasons why theres only one parent.
A bereaved mother is different from an abandoned mother, and a
woman who sets out to have a baby without a father is an entirely
different psychic scenario again. So generalising is difficult because
every situation is different. If a woman sets out to have a baby on her
own and keep the father out for her own psychological reasons, then
that baby is born into an environment, a psychic environment, where
there are unconsciously expressed attitudes about fathers, about
males, regardless of whether the babys a male or a female. The father
whos been lost in the war is different from one whos died of a heart
attack. A father whos abandoned the woman for another woman is
different from one who has abandoned her for another man, which
happens these days.
DK: All these different scenarios create different psychic realities for
the remaining parent and his/her children.
RS: Every case is unique. Psychoanalysis really tries to focus on the
uniqueness of the individual and not to import any generalisations,
like those Im making now. I cant not have my experience. But I like
to think that every new patient is a new patient. I often say when Im
teaching that every patient is a challenge to my theories. If ultimately
I cant understand them, my theories are wrong. But on the other

hand, if I intrude my theories before Ive had a chance to get to know
the patient, thats not appropriate either. So I try to be a theory-free
zone for as long as is humanly possible.
DK: This might be a good place to ask whom you think is suitable
for psychoanalysis.
RS: Well, thats a good question too [laughs]. In practice, every-
body; no, in theory, everybody. In theory, everybody, and in prac-
ticeif you start to go through what the literature says about what the
indications are and whos appropriate, you come up with a pretty
healthy person.
DK: Yes, exactly [laughs]. It always seemed to me to be a conun-
drum, since the healthy, or should I say high functioning, people are
perhaps less in need of intensive psychotherapy.
RS: Its always bothered me, too. Youve got to have some real
strength to do the hard work of psychoanalysis. But, by definition, the
people who come are very damaged. So my criterion has been, and I
dont know that Id apply it if I was starting out knowing what I know
now, but it has been that anybody who wants to come and who will
come more or less at the appointed time, will leave at the appointed
time, will see that I get paid, and will try to work, Ill try to work with.
But that does preclude a lot of people who will never get through the
front door, and it precludes a lot of mad people who probably could-
nt tolerate it. Mad psychotic, Im talking about. But a seriously
personality-disordered patient who is motivated can be worked with.
I do a lot of supervision. I hear myself saying to people over and over
again, if theyll come and if you can bear to be in the room with them,
and if they feel like theyre trying, give it a go. Because we cant know
in under three or four years, but you can know at around about three
or four years that its really not a goer. But by then youre stuck.
DK: Why stuck? Is it because you cannot take the initiative to
terminate?
RS: Well, you dont throw people out. They can leave themselves if
it feels hopeless enough, but in my experience, people who get going
keep going until they get as much out of it as they can. Those who are
not suitable self-select very early.
DK: . . . and leave early?

RS: Yeah, they leave in under a year. Anybody who sticks it out
beyond a year, generally speaking, wants to give it a go. That doesnt
mean to say that they wont have serious unconscious reasons for
resisting. Theres this notion of malignant regression and negative
therapeutic reaction. These are things that come up in the course of
analysis which are very dangerous and destructive. You do your best
to try to keep on interpreting. Malignant regression is a well-known
phenomenon whereby patients regress and it becomes very difficult
for them to live their lives and for them to be in the room. Its a seri-
ous condition thats very disruptive to both a therapists and a
patients life.
DK: How does it manifest?
RS: Patients become regressed and find it hard to cope; they go
madder in an obvious way than they were to start with, and cant
meet their responsibilities out there in the world and act out in the
therapy in demanding ways that are inappropriate. They ring up on
weekends and stay in the room and wont leave when theyre
supposed to leave and demand to be looked after and hospitalised if
necessary. That can happen, but if it becomes an entrenched thing, it
destroys the process.
DK: How do you manage someone who wont leave?
RS: With difficulty. Its difficult. Its terrible. Its only happened to
me a few times. Its happened to colleagues. Eventually they do leave,
but the fantasy of having to call the police arises andbecause, gener-
ally speakingyouve got someone else due in ten minutes. These are
the practical problems that one invites by working this way, and if
you knew it at the beginning, youd think twice about doing it. But
you cant predict it with any given patient.
DK: You said with difficulty and you had the fantasy of ringing
the police. What do you actually do and say?
RS: You say things that you dont like to have to say, like, Youve
just got to go now. This is not tolerable. Ive got somebody else
coming in a few minutes. We cant work if you insist on doing this.
These are not interpretations.
DK: [Laughs] Right.

RS: Youd hope to try to do interpretations during the session, and
at the next session, you might try to work on what happened the
previous time, but its no light thing. When malignant regression
takes hold, its a serious thing. Negative therapeutic reaction is a
different phenomenon where someones threatening to get better and
in a serious way they get sick again because the idea of getting better,
which means leaving therapy and getting on with it, is more than they
can tolerate. It is a reaction against the possibility of therapeutic
progress. That can get you into a vicious circle, endless and not offer-
ing any hope of having a good outcome, which is not good for either
of you. It becomes a relentless negative transference.
DK: Just to clarify, a negative transference is different from a nega-
tive therapeutic reaction. In the negative transference, hostile feelings
towards the analyst become part of the material to be worked with. In
negative therapeutic reaction, progress in the analysis is compromised
and perhaps undermined because the patient comes to resist a posi-
tive outcome because s/he cannot tolerate the prospect of termination.
How do you deal with that situation?
RS: Interpretatively, hopefully . . . Sometimes the unconscious is
stronger than the interpretation and wont give up. Then youve got
to try to find some other way of saying it or work out if youre miss-
ing something or the person is sicker than you thought. The other
difficulty that can be uncovered is a different form of malignant
regression. Its a regression to something malignant that was there
earlier but has been covered over in life, but uncovered as the result
of the work. To uncover something as nasty as that, somewhere in
between malignant regression and negative therapeutic reaction,
something really overpoweringly nasty comes into the room of a
psychotic nature. It doesnt yield to being talked about in a sensible
way. These patients are generally deluded. They develop a psychotic
transference. These can come up without being predicted. Thats the
problem. Theoretically, everything should yield to a good enough
interpretation made often enough. Theyre never one-offs; interpreta-
tions dont work one-off. Thats why working through is another
concept that Freud developed very early on: issues need to be worked
through. Theres no such thing as a clever one-off interpretation.
There are glib and wild analytic interpretations, but working through
is a long-term, slow, painstaking process, and by definition has to

encounter these nasties along the way. If you dont really encounter
these difficulties and engage with them, then probably you havent
gone deep enough.
DK: Could you say something about malignant narcissism?
RS: That is there to start with. Thats not something that arises in
the course of the analysis. Thats what a person isa malignant
narcissist.
DK: Do you recognise these problems early in the analysis?
RS: No, I dont think you do. I dont think you can.
DK: Would you recognise a malignant narcissist early?
RS: If someone is so arrogant and hostile and dismissive and abu-

sive at the beginning, theyre not going to last very long. Im not going
to put up with it if its relentless and the person is not prepared to
think about it. Someone has just come to mind who was like that.
After about six sessions, I said, Look, you dont have any interest in
listening to what Ive got to say; youre just here to be destructive and
abusive, and I dont think theres any future in continuing. Stop
coming. Thats the only person I can think of in all my years of prac-
tice that I asked to stop coming.
DK: How did he respond to that?
RS: He went. He went, and I must say I was relieved. You always
worry that theyll do something nasty on the way out, but no, he knew
he was a nasty piece of work. Hed talked about it. Once you open
your door to somebody, you take what comes and then you have to
deal with it as best you can. Im not going to put up with being abused
relentlessly if theres no give. If theres not an interest to do something
about it, you understand if a persons doing it defensively. Nobody
does it for fun, although thats probably not true [laughs]. But theyre
not going to come to a therapist for fun and use their time and spend
money. So you can think, all right, the poor fellow is defending
against something even more unbearable. But theres no future in my
subjecting myself to this for years if he genuinely doesnt have some
small desire to be otherwise.
DK: These are the really difficult issues that can arise in the analytic
process and they cannot necessarily be forewarned. It takes a great
deal of stamina in the analyst to manage such situations. I guess we
need to move on to other difficult areas [laughs]. For example, weve
touched on the role of sexuality in talking about oedipal issues, but
are there other issues related to sexuality that you think must be
addressed in psychoanalysis?
RS: Yes. Analysis is a sexual encounter in terms of two people
having intercourse. It is, from day oneits intercourse in the Kleinian
sense of a mother and a baby, a breast and a baby, a nipple and a
babys mouth. Thats sexual and its erotic and the interaction is a
manifestation of those unconscious issues, and you look for echoes in
the way ones talked to, whats talked about, the way ones treated,
that have to do with those early things. Likewise, with actual inter-
course, or perverse intercourse, homosexual intercourse; you know,
its not penisvagina, but its intercourse. Its a model that actually can
inform the language of an interpretation, such as our intercourse,
when we have intercourse, with what youre looking for in inter-
course with me, how you treat me during our intercourse. So, its
not an everyday word that youd use, but its certainly a common
enough one. It would guide an understanding of whats going on
between us. Ideally, the relationship would show evidence of how the
person behaves in intercourse or looks to be treated in intercourse;
to be abused, or to be abusive, or to titillate or to tantalise or to be
phobic of being penetrated by a good interpretation. The language
lends itself to trying to see what goes on in the relationship with a
view to it transferring to real life. The intercourse between the thera-
pist and the patient needs to be of a wholesome, mutual, respectful
nature with appropriate gratification, without acting out; its got to be
gratifying to understand oneself, its got to be gratifying to have some-
one trying to understand you. You cant take that out of it. You cant
say its a sterile relationship of just words that are being tossed into
the air. Theres a relationship that theoretically should translate into
the real world. Perverse sexuality finds its way into perversions of
transference and hopefully is experienced, identified, described,
worked through andIm just thinking of a gimmicky thing that
I came up with a few years agowhere I talked about a series of
X-es, you know . . . that the relationship is X-perienced and
X-plored and X-plained.
DK: . . . and excised and expunged, if necessary [laughs].

RS: [laughs] . . . expunged. That sounds good, yeah. Yeah.
DK: How do you think psychoanalytic theory informs child rearing?
Are our child-rearing practices acceptable? How would you change
them?
RS: Id change them in impossible ways. Ideally, youd have a good
enough mother and a good enough father who dont project their own
unresolved issues into an infant, and dont have ghosts in the nursery
la Selma Fraiberg [1975]; that you would actually have the parents do
their own work before they have a baby but thats not going to happen.
They could go to mothers groups with a psychoanalytically informed
facilitator who would help them to discuss issues that arise and mutu-
ally engage with other mothers as wellbecause every mother by
definition is going to have mixed feelings about her baby, no matter
how healthy she is. Every father is going to be resentful of the mother
who has the baby sucking on her breast and hes not. Hes kept out of
the bed and . . . so by definition, being human involves trauma and
conflict and crises and if one can deal with them internally rather than
by acting out and projecting, the better for all concerned. I often have
fantasies of making psychoanalytically informed guidance available
for young parents. But its not on. There are too many people who are
in too much trouble already who suck up what limited resources there
are. There are not enough of us to go around for the well ones. But
often I would like to write articles for newspapers that might be in-
formative, or in magazinesthere must be dozens and dozens of
parenting magazines. Again, as I said at the very beginning, to talk
about these things doesnt really help in an attempt to de-mystify
something that is valuable in the experiencing. The only way to really
know what weve been talking about for a couple of hours is to experi-
ence it and the general public arent interested in that, and rightly so.
Theyve got better things to do. Those who need it ought to do it, but
these ideas and concepts are very different from living them.
DK: However, psychoanalytic concepts and advice arising from

the study of the human infant that was built on psychoanalytic theory
have contributed to major shifts in child-rearing practices; for exam-
ple, from scheduled feeding to demand feeding, from bottle-feeding
back to breast feeding, from premature weaning and toilet training,
from corporal punishment. Reading about concepts of childhood from

earlier centuries really does highlight the major rethinking that we
have undertaken over time in the way we understand and treat our
children.
RS: Yeah. Sure.
DK: So some of these principles have actually found their way into
best practice recommendations.
RS: They have indeed. But even recommendations are difficult to
put into practice, because an obsessional mother by definition is going
to be rigid. Ive worked with attachment theory psychologists, Ive
seen their videos, and theyre sometimes quite terrifying. What you
see in a strange situation interview, a so-called healthy mother whos
just come along to help the psychologists do their research, are some
very dramatic, larger-than-life, technicolour enactments of the
mothers psychopathology. Shes not a patient; shes just come along
because shes been invited to participate in some research. You see the
projection into the baby of quite terrifying affect and you see the baby
startle and pull back and defend. You probably know about watch,
wait, and wonder [Cohen et al. 1999; Dawson, 2008; Muir, 1992],
which is a way of doing therapy with mothers and babies, in which
you try to use psychoanalytic notions to help the mother understand
whats actually going on right now and why. Watch, wait, and
wonder, experience, explore, explain, and hopefully expunge
[laughs]. It takes time and it cant be institutionalised, it cant be pack-
aged. But youre right; these things, like Freudian slips, have found
their way into the culture, and maybe were progressing. Yet, every
day brings something horrific in the newspaperlots of people suffer.
DK: Yes, so much suffering inflicted on people by their own govern-
ments. Its always distressed me to see malignant narcissists become
heads of government.
RS: [Laughs] Indeed.
DK: Can you comment on how that might happen, how people like
Adolf Hitler, Joseph Stalin, Mao Tse Tung, Pol Pot, Papa Doc, Idi
Amin, Muammar Gaddafi, Saddam Husseinthe list appears dis-
tressingly endlessrise to power and destroy their own people? How
does that happen, and why does it happen repeatedly?
RS: It has happened and will continue to happen. Its a frightening

combination of an individuals powerful need to dominate and serve
their own interests, and the populations need to be led by no matter
how bad a father. A strong father is something unconsciously desired.
I dont think its genetic. Its something about our psyches that make
us yearn for thisbut at the same time, that so-called strong father is
enacting some of the worst of our aggressions and destructiveness
and hatreds and murderousness for us. Group psychology and group
dynamics are issues that Freud touched on only very briefly because
its such a huge topic in its own right. The army and the church were
his two examples, so from time immemorial, weve lived in societies
where weve had these twin institutions that somehow or other meet
some of our needs. To become an individual, a healthy individual in
society, is a very difficult task. It takes a lot of work and a lot of help
from ones care-givers, hopefully a mummy and a daddy, a reason-
ably well mummy and daddy, who can help us develop our own
mind. Anything short of that makes us vulnerable to group process,
peer group pressure, party politics, cults, the works.
DK: So youre saying that the need for a strong father overrides the
misgivings about the other qualities of these leaders?
RS: Unconsciously, yes, it does, even in our society. We were
polarised between Julia Gillard [now former Prime Minister of
Australia] and Tony Abbott [at the time of interview, federal leader of
the opposition, currently Prime Minister of Australia]. She was on the
one hand trying to represent herself as an inclusive, open consensus-
leader and at the same time trying to be tough.
DK: Its an impossible situation, isnt it?
RS: Its an impossible situation, yeah.
DK: Finally, how, if at all, do you think psychoanalysis deals with
the ultimate questionthe existential questionof the awareness of
our own mortality and, prior to that, our smallness in the universe?
RS: Thats part of psychoanalytic work, and theres nothing myst-
erious about that. Being big and being little is part of psychoanalytic
work. Youve got adults who feel very little because it derives from
their having been little. They hate me being big or having a big income
or driving a flashy car that they might imagine or owning this house.
Big and little is as much a part of psychoanalytic work as is the

Oedipus complex. Its part of pre-oedipal issues.
DK: But its a bigger question than big and little because big and
little both fade away into nothing. There is a difference between big
and little but a vast difference between little and nothing.
RS: Well, they fade away and become something else. Theres big
and little and theres mummy and daddy and theres differences and
theres being able to leave home, being able to face ones death and
the death of others. Actually, the end of the analysis is a death. So
issues of mortality and loss come up. The idea of being able to health-
ily face ones own mortality is part of analytic work, because anything
other than being able to face ones mortality is a residue of grandios-
ity. Thats a word we havent used yet, but grandiosity, omnipotence,
these are all integral to the work along the way in whatever guise they
come up. Psychoanalysis does address every human issue in one way
or another, but it tries to do it in a down-to-earth way in the context
of the reality of this two-person relationship. Its not played out on the
world stage. I might have fantasies of running Australia better than
the incumbents do, but thats got nothing to do with my psycho-
analytic self; thats unresolved issues in me [laughs] that I shouldve
got over. I cant open a newspaper without thinking, my God, I could
do better than that.
DK: Why havent you got over it?
RS: Well, thats interesting.
DK: [Laughs].
RS: I dont want to be an isolationist; Im still part of society. I prob-
ably should be able to be a bit more accepting of the way things are.
Whether its Pol Pot or Bob Brown or John Howard or Hitler, theyre
realities of human existence and were probably marginally better off
than we were once upon a time. Its slowly, very painstakingly slowly,
getting somewhere, but well destroy the planet before we do.
DK: Thats a pessimistic note on which to end our discussion
[laughs].
RS: [Laughs] Is it really? Right. Youll have to come back again and
see if I feel better in a few years.
DK: [Laughs].
RS: No, no, there is inevitability. If I ever meet God, I will complain
to him about a design fault in our minds that destructiveness is part
of us, beyond whatever abuses weve suffered. Its not just because
many people get abused that they become abusers, but theres some-
thing about our psychic structure that includes negativity and
destructiveness, which ideally needs to become integrated. We hate
[Spielman, 1997b] before we love and love is a triumphgenuine love
as opposed to pseudo-loveis a triumph over negativity. Is that a
more optimistic way to end our discussion?
DK: It occurred to me as you were speaking that I doubt God would
recognise easily the psychic fault that you describe because we are
created in His image and He would have to recognise the fault in
Himself.
RS: Im sure he does [laughs]. But its intrinsic in a lot of religious
philosophy that we are divided selves. The good and the evilit
wasnt there before we got here, so its just a metaphor for what were
talking about now; an acknowledgement that theres a battle between
good and bad forces. I dont like the concept evil, but certainly good
and bad, constructivedestructive, which were all charged with
trying to harness, integrate, live with, including that were going to
die one day.
DK: Do you find it odd that people talk about a benevolent, munif-
icent God, and yet they fear that theyll be struck down by this same
God for wrongdoing?
RS: Its just a manifestation of projectionprojection of these things
that weve been talking about on to God, on to the external world.
DK: Is God a projection?
RS: Yes, unequivocally. To my credit, when I was young, I had a
book, Man Created God [Sell, 2011], on my shelf that I bought when I
was a teenager. Im proud of myself that I could recognise that as a
reality. Someone wrote it obviously, but when I saw it in the book-
store, I said, Ive got to have that book.
DK: Similarly, I have a book on the sadomasochism of Christianity
[see also Carrette, 2005].
RS: [Laughs] yeah, well . . .
DK: I had to have that book [laughs].
RS: Well, its absolutely right. We are a species characterised by a

divided mind. Along whatever dimension you want to discusssado-
masochism or big/small or alive/dead, male/femaleits all about
conflict.
DK: . . . the dialectic.

RS: . . . the dialectic, yes. Of late, Ive become interested in the
notion of paradox. Theres conflict, paradox, and irony. These three
are very interesting states of mind. Tolerance of paradox is a very
important achievement, if one can tolerate two opposite truths, which
is different from a conflict. Conflict can be either/or and you can settle
for one or the other. Irony is, Isnt it amazing that in the light of this,
you think that? Thats ironic. But it is a very mature achievement to
be able to tolerate a paradox.
DK: . . . to engage in dialectical reasoning.
RS: Can you say more about that?

DK: Dialectics is associated with the German philosopher, Georg
Hegel [2010], who proposed a form of argumentation in which the
truth is arrived at through a process of stating a thesis, developing an
antithesis (or opposite argument), and then resolving them into a
synthesis, in which elements of both thesis and antithesis can co-exist.
In this way, we can potentially resolve apparent contradictions. One
of the interesting aspects of dialectics is that the tension between
conflicting or contradictory forces is also the factor that maintains
these opposites in some form of interaction. Our disciplines (of
psychology, psychiatry, and psychoanalysis) are replete with such
dilemmasfor example, the nature/nurture debate in developmental
psychology has yielded to the view that individual and context are
indivisibly interconnected; there is a dialectic in psychosomatic illness
in pain medicine. I have just read an interesting book [Glocer Fiorini
& Canestri, 2009] on the dialectic between timelessness and time and
how this dialectic can yield to the atemporality of the transference
countertransference relationship. Freud had a complex view of
temporality within psychic experience. He argued that the processes
within the unconscious are timeless, yet capable of development and

influence. He appeared to anticipate Einsteins concept of time as
subjective and non-linear, in opposition to the scientific notion of time
as linear, precise, and objectively measurable. There is a similar dialec-
tic in the development of the self between the notion of the emergence
of the self from mutual intersubjectivity and the realisation of me-
ness as discussed by William James [1892] or as mineness as
discussed by Robert Stolorow, who is part of this series of conversa-
tions, and as it appears in Eriksons idea of identity formation that
occurs in adolescence [Erikson, 1980]. I think that analysts need to be
profound dialectic thinkers.
RS: I see what you mean by dialectic. Im saying something slightly
different; its to accept that two incompatible things are true, which is
different from the truth of one being found in the other. The best
example clinically of a paradox is a patient who talks about not being
able to get his mind around the idea that I care for him and that he
has to pay me.
DK: I also see that as one of the fundamental paradoxes of the
psychoanalytic relationship [laughs].
RS: I could say I dont care for him, but of course I do. The mani-
festation of how he gets me to care is that he has to pay me. So, theres
an inherent paradox in the idea that I dont care and I do care. Im a
commercial entity thats just selling my time and who throws a few
words at him every now and then, and the idea that I actually care for
him, but I dont profess to care for him, because if I do profess to care
for him, then I interfere with his own maturing ability to care for
himself and to create his own caring object inside himself without me
having to say, But arent I a good therapist because I care for you?
As a human being, I cant say to you, I would do this work if I didnt
care to make a difference, but theres a paradox, because I need to be
not invested in him in order for him to get the most out of what I offer.
Thats a paradox in a sense.
DK: Yes, exactly. It is a profound paradoxone that causes im-
mense frustration.
RS: When he can get his mind around that, hell be further down the
road than he is now. Its something he addresses more so than a lot of
other people that Ive worked with. Thats how I got on to thinking
about this. I am a bit more optimistic than I was a few minutes ago.
DK: Yes, yes. But you only have to scratch the surface to get to
pessimism [laughs].
RS: Or realism. If thats the way it is, thats the way it is. We cant
be Pollyanna-ish about it. Theres a difference between being realistic
and pessimistic.
DK: Thats true, but reality can often be quite depressing, cant it?
RS: Well, thats the wrong word to use. Depressing is a pathological
word from my point of view; saddening, maybe.
DK: Saddening, distressing.
RS: Not even distressing. Look, we have to come to terms with our
mortality, we also have to think that the planets going to come to an
end. It is. Its not infinite. It cant go on forever. It wont end in our
lifetime, but theres a reality that there are finite resourcesthis much
oil in the ground or this much carbon in the air or oxygen or un-
polluted water or food. Finity and infinity is another problem we have
to grapple with. Things are finite. Time is finite. Sessions are finite. My
life is finite. My working life is finite. My patients currently have to
come to terms with the fact that Im not going to work forever. I let all
of them know that in the next little while, little being a few years, Im
retiring.
DK: Whats a few?
RS: Dont know, around three to five, something like that.
DK: OK. Well, they cant say they havent had ample notice.
RS: They havent had a figure, but the idea that Im not immortal is
something they have to work with too. This cannot go on forever.
Theyre my last batch of patients. When they go, Ill have retired. Im
not going to shoo anyone away unless someone refuses to go in a
reasonable amount of time, which will be three to five years. They will
have had a significant amount of time already, so its not as if some-
ones being booted out. Its another human issue thats part of the
work, isnt it? Finiteness.
DK: Absolutely. Melanie Klein was devastated when her analyst,
Karl Abraham, died a few months into her analysis.
RS: Yeah. Well, fair enough. Thats not part of the deal, to die on
somebody too early. But on the other hand, its a human thing to do
[laughs].
DK: Indeed. I guess this conversation is also finite and although I am
sure there is much more we could have discussed, this is perhaps a
good place to finish, contemplating our finiteness and mortality
[laughs]. I really appreciate your speaking with me about the talking
cure today. Thank you.
CHAPTER FOUR
Professor Jeremy Holmes:

attachment-informed psychotherapy
DK: Thank you so much for participating in this project of conver-

sations with practising psychotherapists. I am thrilled to have you as
part of the team. Can we start by your telling me about the personal
and/or professional experiences that directed you into the profession
of psychoanalysis, and in particular, attachment-informed psycho-
analysis?
JH: Freuds Introductory Lectures was sitting on my parents book-

shelf. My mother was Jewish and my parents were middle class.
143
When I was growing up, it was normal for middle-class intellectuals

to be aware of Freud. From the age of fourteen, I realised that I was
better at humanities and arts, but at the same time I was fascinated
with physics, cosmology, and biology. My career ambition was to
become a research scientist, but once I got to Cambridge, I realised
that others were far better than me at these subjects, so I had a last
minute change of direction to train as a doctor. This was the heyday
of R. D. Laing and David Cooper, who came to Cambridge and gave
a lecture; we all crammed in to hear him. I cant remember a word he
said. Until that moment, as an infantile leftist, I wanted to change
the world. Coopers message was: If you want to change the world
you must change yourself too. That was the moment I decided to do
medicine and then psychiatry. My clinical years were at University
College London. We had some wonderful lecturersMichael Balint,
Heinz Wolf, who were very charismatic, especially for medical
students. Antony Bateman was one of their heirs. I learnt from them
that psychiatry can be humane and psychodynamic. For a while I was,
however, diverted out of psychiatry and became a physician, with a
particular interest in psychosomatic illness. After that I started psychi-
atry training and gravitated naturally to the psychodynamic end of
psychiatry (the sciencearts divide is ubiquitous, like left and right in
politics). I also then went into analysis myself. I needed help. Charles
Rycroft was my analyst. Despite reservations about Charles clinically,
I see myself as within his tradition. I am highly sceptical of psycho-
analytic fundamentalism. John Bowlby was my intellectual father; I
revere Bowlbyhe is a giant. He attempted a humane yet scientific
approach to the mind as opposed to dogma and doctrine. In terms
of my own development, I identify to some extent with Bowlby,
although he came from a much posher background than mebut
we both had war-torn childhoods. Bowlby was a bit avoidant, as was
I. Both our fathers were absent during crucial years. Charles Rycroft
too: his father died when Rycroft was eleven. Attachment theory
felt like a natural home to meits a marriage of psychoanalysis
and evolutionary biology and ethology. Bowlby [1988, p. 62] expres-
sed it perfectly: All of us, from the cradle to the grave, are happiest
when life is organised as a series of excursions, long or short, from
the secure base provided by our attachment figures. Jung said
that psychological theories are disguised forms of autobiography.
Unconscious forces influence our conscious thoughtswe need to
PROFESSOR JEREMY HOLMES: ATTACHMENT-INFORMED PSYCHOTHERAPY 145
understand imaginative leaps in great scientists in the light of their

developmental history, as Bowlby did in his last great work, the
Darwin biography.
DK: Yes, and perhaps these interviews will also be, to some extent,
an oral autobiography! The idea that our developmental history is
fundamental to understanding ourselves is accepted within psycho-
analytic circles but not elsewhere, where the ideas somehow become
disconnected from the thinker of those ideas and his or her motiva-
tions. This is evident in symptom-based treatment approaches like
cognitive behaviour therapy. How do you identify yourself?
JH: I am a psychoanalytic psychotherapist. I am not a member of
the International Psychoanalytic Association (IPA) because I have not
trained as a psychoanalyst. I side-stepped this form of control and this
hierarchybut of course also missed out on the cross-fertilisation and
camaraderie but evaded the necessary submission to the yoke of
authority. I was, of course, influenced by Charles Rycroft, who even-
tually left the IPA, and John Bowlby, who remained a member of the
IPA but was persona non grata for many years within the British soci-
ety. I am also a maverick. Do you know who Maverick was?24 He was
a cattle rancher. In those days, cattle ranchers all branded their cattle
to prove ownership but Maverick refused to brand his cattle. I am a
natural integrative psychotherapist. I have been influenced by a range
of therapies; I have also trained as a family therapist. I am totally anti-
branding.
DK: Your motto is Dont fence me in! [laughs] . . . In your revision
of Storrs Art of Psychotherapy [Holmes, 2012a], you define psycho-
therapy as the art of alleviating personal difficulties through conver-
sation in the context of a personal, professional relationship. Could
you say something more about how you define psychoanalysis and
the nature of the relationship between analyst and patient?
JH: My basic model of the analytic relationship is the parentchild
relationshipsecurely attached children have a different develop-
mental history compared with insecurely attached children. Maternal
sensitivity correlates with security. But there is a transmission
gapthe term sensitivity is vaguewhat is it that makes mothers
sensitive? There is a similar issue with defining the therapistpatient
relationship. We know that therapy works, but still dont know
what it is that produces changeis it therapist sensitivity? If so, what

are its components? This is still an empirical question.
DK: Ainsworth and colleagues [Ainsworth & Wittig, 1969; Ains-
worth, Bell, & Stayton, 1974; Ainsworth, Blehar, Waters, & Wall, 1978]
developed rating scales to assess maternal sensitivity, which they
tried to quantify along dimensions such as acceptancerejection, co-
operationinterference, and accessibilityignoring. Of course, with all
rating and observational scales, validity depends on the expertise of
the raters. Beatrice Beebe and her colleagues [Beebe, 2005, 2006; Beebe
& Lachmann, 2003; Beebe & Sloate, 1982] have made considerable
progress in identifying the nature and quality of motherinfant
interactions and in identifying maternal interactional characteristics
that are more likely to result in securely attached infants. What are
your thoughts about this body of work?
JH: Beebe is interested in facial gestures between mothers and
infants. One of her studies also looked at vocal communication. She
got mums to sing along with their babies and recorded the melodic
relationship between mothers and infants vocalisations. When they
reached one year of age, she classified their attachment using the
Strange Situation and then looked at the vocal interaction that
occurred between mother and her infant at four months of age.
Mothers fell into three categories; one group was tone deaf; the
second group sang in unison with their infants; the third group sang in
a more harmonic and jazzy way. The infants of these mothers were
more likely to be secure than the infants of either of the other two
groups of mothers. This was a lovely empirical demonstration of what
I call partially contingent mirroring. Photographic mirroring is not
sufficient; partially contingent mirroring seems to be one of the things
that therapists do with their patients. They mirror and then take them
a step further. This is a fascinating research area . . . it is cutting edge
studying the minutiae of relationshipsto understand the develop-
mental processes that occur in normal infancy. The idea of relational
sensitivity as the basis for therapeutic success is a long way from
psychoanalytic metapsychology. Thomas Kuhn talked about ground-
breaking paradigms. Bowlby created a new paradigm that is still very
current and this was taken up by Mary Ainsworth in the USA.
DK: Is there a meaningful distinction between psychoanalysis and
psychodynamic psychotherapy? You have distinguished between the
psychotherapies based on frequency of sessions: four or five sessions

a week is psychoanalysis; three sessions a week is psychoanalytic
psychotherapy and one or two sessions per week is psychodynamic
psychotherapy. Is frequency the key discriminator between these
forms of psychotherapy or are there othersfor example, the conduct
of the therapist and the content of the therapeutic conversation?
JH: There is no absolute distinction between these terms; they are
terms of convenience, of politics. Timingfrequency has little to do
with the definition of how analytic a therapy is. The discrepancy
between what people say they do and what they actually do is one of
my hobby-horses. Nothing extraordinary will happen just because
someone is having a five-days-a-week therapy. All frequencies of
therapy will involve transference and countertransference and
defences if the therapist is working from a psychoanalytic perspective.
That might be once weekly, while, by contrast, a five times weekly
therapy might well be mainly supportive and non-mutative.
DK: You talk at length [Holmes, 1999] about the elements under-
pinning a psychodynamic relationship in practice (e.g., transference
[Holmes, 2004a] and countertransference, both from an attachment
perspective [Holmes, 1997a] and what you call the ethical counter-
transference [Holmes, 1997b], patterns of defence and preconception,
projective identification [Holmes, 2011a], patterns of attachment, and
the therapeutic relationship [Holmes, 2009], among others . . .). Per-
haps some or many of those phenomena exist in other forms of ther-
apy but psychoanalytic therapy is the only form that acknowledges
the importance of these elements and actively works with them in the
therapeutic encounter.
JH: The main power of therapy cant be fully defined in terms of
specific elements. Change comes as much from the non-specific
aspects, especially from the therapeutic relationship. There is an estab-
lished relationship between good outcomes and length of treatment
but the theoretical position is not so important. The skill of the thera-
pist is a better contributor to outcome than type of therapy practised.
We also know that the longer a therapy goes on, the less theoretically
driven it becomes. The quality and character of that relationship is a
feature of those two individuals, so each long-term psychoanalytic
dyad has its own character. I like Tom Ogdens notion of the analytic
third; as a therapy goes on so the third takes over, and is a mani-

festation of the joint projects and personalities of analyst and patient.
DK: In your 2000 paper, you state that attachment theory is an
offspring of psychoanalysis. What aspects of classical Freudian analy-
sis remain in attachment-informed psychotherapy?
JH: In that paper, I explore how insecure attachment relates to the
classical psychoanalytic defence mechanisms. In the classical para-
digm, defences are forms of affect regulation. In the attachment para-
digm, the purpose of defences is also affective regulation, but, in
addition, they are ways of maintaining contact with an object in
suboptimal environments. It is the type and quality of interpersonal
contact that creates the defence.
[At this point in the interview, the technology failed and the audio,
but not visual, connection was lost for eight minutes. JH observed
DKs frustration and anxiety as she tried to rectify the problem.]
JH: Now, look, this is a good example, because we are talking
about affect regulation. You have been really upset and frustrated by
the technology not working. In the classical psychoanalytic model,
that would be interpreted as deriving from the way you handled your
id impulses as a child. I would say its an interpersonal issue and
between us we have to handle this unpleasant affect associated with
the frustration that goes with technology that we dont feel completely
at home with, so that brings your reaction into the relational sphere.
Thats the difference between the classical psychoanalytic model
where defence mechanisms are all located within the individual and
the attachment relational model where they are essentially interper-
sonal. I see myself as a relational/attachment psychoanalyst. I am
interested in the way in which the care-giver helps the infant cope
with his overwhelming affect of fear or hunger, or feeling of aban-
donment, and indeed excitement; the way that is handled in this inter-
personal field is translated into the psychoanalytic consulting room.
The essence of what goes on in the consulting room is a reworking of
the handling of affect. That can be done in a defensive way where
affect is suppressed as in the deactivating strategy, or in a secure-
making fashion where the affect can be dealt with in small amounts
through the presence of a sensitive care-giver. There is a radical differ-
ence there. The role of the analyst isnt just to interpret the defence
mechanisms; it is to rework the defence mechanisms while becoming

aware of and commenting on them at the same time. And that is the
essence and the skill and the difficulty and the excitement and the
frustration of psychoanalytic work. One is simultaneously engaging
with patients and helping them to find a vantage point from which
they can observe this relationship.
My latest idea is that there is this five-stage model that applies to
all intimate relationships.
1. Stage one is what I call the primary attachment relationship. A lot of

the attachment literature focuses on the care-seeker, on the child
and the infant, and how stress and threat and illness activate the
attachment dynamic and then a secure base is sought. But there is
a parallel process in the care-giver. When we are presented with
distress, we are biologically programmed to respond to that
distress, whether it is a small animal, or a stranger who is injured,
or one of our loved ones, children, spouses, partners, pets, or even
our plants that need attention. I live in a rural area; there are sheep
and lambs there. When the ewes see me coming, they immedi-
ately call their infants, their baby lambs, to come to them because
they see a potential threat. There is this reciprocal biological rela-
tionship between care-giver and care-seeker. So stage one is the
response we as therapists make to distress. And what do you do
when you respond to distress? You set your own preoccupations
to one side. You immerse yourself in the vulnerability of the care-
seeker. Bowlbys idea was that infants were not going to survive
in the primitive savannah unless adults were highly protective of
them. So stage one is this primary attachment relationship. Its a
little bit like Winnicotts notion of primary maternal preoccupa-
tion, which is unconscious, not in the classical psychoanalytic
sense, but in the sense that it is biologically programmed.
2. Stage two is what I call reverie; in this stage you allow yourself to
enter empathically into the inner world of the patient so you can,
to use Thomas Ogdens phrase, dream your patient. You experi-
ence your patient inside yourself. Now we are beginning to
understand the neurobiological aspects, including mirror
neurons. Something is triggered off in us by our patients distress
that enables us to imaginatively put ourselves in the patients
shoes.
3. Stage three I call logos, and this is related to interpretation. The

empathic resonance of stages one and two is only part of the story
because it has to be turned into verbal recognition that becomes
a shared meaning between patient and therapist, which they can
then use. You are giving this logos, this interpretation, this com-
ment, to the patient but you must be in empathic resonance with
her also in order to help with that patients affect regulation. For
instance, in my response to your distress about the technology, I
hope that my voice was reassuring, I hope I kept saying, Dont
worry; its fine. We can always do this another day, those kinds
of things, thats the way in which the therapist assists with their
patients affect regulation. I hope you dont mind my using it as
an example.
DK: Actually, its a very good example, but I am just hoping that
when you could hear me and I couldnt hear you that I wasnt using
too many expletives, thinking that you could not hear me at your end
either [laughs].
JH: But it doesnt matter how many expletives you used because
thats the whole point. In the consulting room those expletives would
be your way of trying to contain and hold your distress. And the great
thing about the consulting room is it doesnt matter what you say. You
can eff and blind25 to your hearts content if thats what you want
to do because its a hypothetical situation; you can do things there that
you wouldnt perhaps be able to do in real life.
4. Stage four is what I call action or decision or consequence and they

flow from this relationship in terms of change in the persons life.
Then comes
5. Stage fivereflectionlooping back and looking at the whole
process, looking at what happened, what went right, what didnt
go right and so on.
Anyway, thats all been stimulated by your asking about defence

mechanisms and my trying to link the psychoanalytic notion of
defence mechanisms with this more interpersonal model that flows
from the attachment perspective.
DK: Defence mechanisms are, of course, related to adaptation and
coping but to relate them to the interpersonal is interesting because,
as you were saying earlier, the defence mechanisms were considered

intrapersonal phenomena in classical psychoanalysis.
JH: They are at the start anyway. This a very simple attachment
model, but lets say you are a six-month-old or a nine-month-old child
and you have a stressed mother. She may be stressed socio-economi-
cally, she may be wondering where she is going to get her next meal
or how she can pay the mortgage, she may be having marital conflict,
she may not have a partner. But you are an infant, you need your
mothers protection because, as Winnicott says, there is no such thing
as a baby. An infant without her parent or protector will die. You
become distressed for whatever reason; if you express too much affect
your mother, rather than being able to help you with that, soothe you,
may push you away. It may be too much for her. So you learn a
defence mechanism and the defence mechanism here is whats now
technically known in the attachment literature as deactivation.
Basically, you close down your feelings. That way your mother will
protect you but you pay a price and the price is you are not so much
in touch with your feelings; your affective universe is diminished,
your pleasure in life may be diminished, your flexibility may be
diminished. There are always trade-offs, in all aspects of psychologi-
cal life. Here the trade-off is: security takes precedence over affective
expression. Thats looking at a defence mechanism from an interper-
sonal perspective. Attachment research shows that there are continu-
ities between defensive and interpersonal patterns in early childhood
and adult life, which is quite remarkable; Freud predicted it. The child
I have just described will grow into an adult who is dismissive, as
assessed by the Adult Attachment Inventory, somebody who needs
relationship, but when they are in relationship they are unable to
express themselves fully; they are unable to respond to their partners
emotional needs or expect their partner to be responsive to their
emotional needs. They will be relationally compromised, handi-
capped even. If that person then comes into therapy, that relationship
will be reproduced in the therapy situation. The patient will present a
rather affectless account of his or her life. If therapy is successful, the
therapist provides a setting in which it gradually becomes more and
more safe to express the affect which they suppress and that enables
a reworking of the defensive structures and perhaps possibly a move,
using Vaillants model, to a more mature defensiveness. They may be
able to make a joke about their feelings, which is better than not
expressing feelings at all. That would be a move from repression to
suppressionto using a mature defence like humour. That is an
attachment perspective on the psychotherapeutic task.
DK: What particular defences in the classic psychoanalytic sense would
parallel with this dismissive, deactivating type of attachment style?
JH: Obsessional defences would be seen that way. One of the crucial
growth points currently in this way of looking at things is the concept
of disorganised attachment and the relationship between disorganised
attachment and psychopathology. Disorganised attachment is rela-
tively uncommon in non-clinical populations but very common in
psychopathology. Where you have highly stressed care-givers, where
you have children who present to clinics with a variety of symptoms,
where there is a history of physical or sexual abuse in the family, then
disorganised attachment seems to be very prevalent. Disorganised
attachment is a very interesting area that needs to be explored more.
Splitting, dissociation, and role reversal are the common defences,
whereby you project your own vulnerability into another person and
look after it over there rather than in yourself. Those are typical pat-
terns you see in disorganised attachment and they are highly relevant
to one of the big issues for psychoanalytical psychotherapy, which is
borderline personality disorder. A cutting-edge area is the attachment
concept of disorganised attachment and how that relates to personality
disorder in adults and how that in turn relates to the kinds of thera-
peutic strategies that are going to be helpful with such people.
DK: In a recent paper [Holmes 2010b] you state that all good thera-
pies share three common features: the work is accomplished via a
secure attachment relationship with the analyst/therapist, meaning-
making, and change-promotion. You state that patients can only
meaning make and risk change when they feel securely attached to
their therapist.
JH: Yes, I also propose that an attachment meta-perspective may
reconcile apparent differences between the different psychoanalytic
schools. In order to promote change we must place our patients in a
benign bind: this involves close engagement, discrepancy between
client transferential expectations and therapist response, and explo-
ration and articulation of the feelings arising from these discrepancies.
DK: Your mention of the need to articulate feelings dovetails with

your emphasis on the importance of mentalization as a helpful
therapeutic strategy. Peter Fonagy also supports mentalization as a
central goal of therapy, particularly for people with borderline
pathology. I think the concept was introduced by Mary Main. If I
remember correctly, she talked about cognitive monitoring as a form
of mentalization.
JH: Mains term was metacognitive monitoring, yes. The actual
word mentalising comes from the Francophone literature. Le mental-
isation was quite a common phrase used in French psychoanalytic
writing; then it was introduced into English texts by Peter Fonagy in
the late 1980s. You are quite right; that flowed directly from Mary
Mains notion of metacognitive monitoring. What goes on in the
consulting room is a way of fostering the clients capacity to mentalise.
I like to use the metaphor of a vantage point. Therapy, the consulting
room, provides a vantage point from which a person can begin to look
at him- or herself but also to look at themselves in relationship. Affect
regulation in this relationship has a particular quality; it is a relation-
ship that can also look at itself. So therapist and patient together look
at themselves in action and this process fosters the capacity for
mentalising. Borderline personality disorder is a disorder of affect
regulation in the sense that the borderline person very quickly
becomes affectively aroused: I have had enough of this, Im off, and
they storm out of the session. I heard a lovely example in a supervi-
sion session recently where the patient looked at the therapists book-
shelf and said, I am going to pick all those books up and throw them
across the room, and the therapist, who, in a previous life, had been
a school teacher, said, You most certainly will not. [Both laugh].
Now, that would actually be a very good example of the kind of thing
that people like Fonagy and Bateman are writing about when they
write about fostering mentalising because one of the features of
mentalising is that you cant think unless you feel safe. Arousal drives
out mentalising. I usually say if you are just about to be eaten by a lion
you dont sit there and say, Now, what is going on in the mind of
that lion? Whats going on in my own mind? You just have to get
the hell out. The problem that a lot of borderline patients have is that
they so easily become aroused, rendering them unable to think about
thinking; thats the essence of mentalising, being able to think about
your feelingsthe knowledge of the heart, as George Eliot calls it.
When that therapist said, You most certainly will not, although that
sounds about as unpsychoanalytic as you can get, she was actually
saying, We are not going to be able to work together unless this is a
safe space and I am going to make this space safe. Without that secu-
rity there can be no mentalising. We are still within the attachment
paradigm and the basis of the attachment paradigm is contained in
the title of my book, Exploring in Security [2010a]. You cannot explore,
you cannot think, you cannot play unless you feel safe. In therapy
there is always an oscillation between dealing with arousal and stress
and fear and helping those feelings to be assuaged so that one can
then begin to start thinking about what is going on. There is the
constant dialectic between the affect and thinking about the affect, and
gradually the capacity to mentalise, to monitor oneself, to think about
oneself becomes internalised. Thats possibly one reason why effective
therapy takes time because that is a complex skill to learn. Its like
learning to play the piano; you cannot learn to play the piano, as you
well know, unless you put in your 10,000 hours. Malcolm Gladwell
[2008] has made the point that no leading musician and no leading
sportsman and no leading thinker has ever got there without putting
in 10,000 hours of practice. Learning the skill of mentalising may not
need 10,000 hours of analysis, but it needs quite a few hundred hours!
Thats possibly what Freud was intuitively getting at when he coined
the phrase working through.
DK: Gladwell was quoting Ostwald [1994] when he reported the

10,000 hours requirement for expertise to develop. This brings to mind
Barbra Streisand, who forgot the words to one of her songs in a con-
cert in Central Park in 1967, and who subsequently gave up public
performances for twenty-seven years. In her come-back concert in
1994 in Madison Square Gardens, she came out on stage and said,
The only reason I am standing here before you is my $350,000
psychoanalysis [laughs].
JH: Thats really interesting . . . obviously very relevant to perfor-

mance anxiety which I know you are an expert on [Kenny, 2011]. I
have a counter-example to that storyLaurence Olivier. My father
was an actor, so I heard this in-joke. Olivier was playing Hamlet and
he was in the middle of one of the most famous speeches ever, O,
what a rogue and peasant slave am I! He couldnt remember a single
word after that, so he simply started reciting the London Underground
Tube names but in Shakespearean rhythm until it came back to him.

So, he would go, Charing Cross, Waterloo, Paddington, but saying it
in a very theatrical voice and of course the audience didnt even notice,
and especially with Shakespeare where you only understand about a
half of it if you are lucky anyway, and then he was back on track. This
is an example of someone who had a tremendous amount of self-
confidence that would carry him through. Its put me in mind of a
really important issue that I have been fascinated with, which is
rupture and repair. One of the features of secure relationships is that
they have very well-established rupture and repair mechanisms. If we
go back to this idea that there is an analogy between what goes on in
the consulting room and what goes on between sensitive and secure
motherchild dyads or parentchild dyads, one of the features of
secure relationships is a good rupturerepair mechanism, because the
fact is that parents are out of tune with their infants a lot of the time. Its
just an observational fact. The same is true of couples, the same is true
of romantic relationships, husbands and wives are out of sync with
each other quite a lot of the time. But in secure relationships that get
out of sync, you cycle into repair mode. The child whose mother is
thinking about something else or is worried about paying the bills or
has gone off to the loo, the child then expresses distress and the mother
immediately responds and re-establishes some contact with the child.
So there is Laurence Olivier, who has a major rupture but also confi-
dence; he has the trust, he knows that his memory will be there for him
when he needs it, just like he knew possibly that his care-giver would
be there for him when he needed her. Maybe Barbra Streisand took
$350,000 worth of psychoanalysis to acquire that sense that there
would be somebody there for her when she was in distress. (Or maybe
Barbra Streisand and Lawrence Olivier represent Rosenfelds thin-
skinned and thick-skinned narcissism, respectively.) Psycho-
analysis may have an idealised theory of what help is so that, when
you have had your psychoanalysis, you can sail through life with no
problems at all, which is nonsense; we all face problems and some of
them are of our making. One hopes that there will be fewer of our own
making after we have had psychoanalysis but nevertheless some will
be of our own making and some will be things over which we have no
control whatsoever. We are all going to die; our loved ones are all
hostages to fortune, as Francis Bacon put it. Psychoanalysis equips
us with the capacity to cope with loss and stress and difficulty rather
than moving us into some idealised world in which none of that ever
happens. It has to do with the scaffolding, the architecture of the ther-
apeutic relationship and the parallel between that and the parentchild
relationship. Eventually that scaffolding is removed and we are, with
luck, equipped to face the world without it.
DK: You wrote a paper recently on the superego [Holmes, 2011b],
in which you said that the superego is concerned as much with safety
as with sex and that it is heir to the attachment relationship. I
wonder if you could comment.
JH: Well, this is the heretical thing where I dont see eye to eye with
my psychoanalytic colleagues. I dont believe in infantile sexuality; its
a myth. Thats not to say, of course, that infantile sensuality is not
hugely important. Of course, the body of an infant and the body of a
mother and a father are drawn to each other like magnets and the child
seeks warmth and physical protection from her care-givers. When the
child is at the breast, the child is not just having some feeding experi-
ence because we know that infants go on sucking at the breast long
after their need for milk has been satisfied. The whole mouth is drawn
to the breast and presumably achieves or receives sensual satisfaction.
Now, if you want to call that sexuality, fine, but I dont want to call it
sexuality, which I say only kicks in with puberty, and is a separate
behavioural system. Of course there are sexual issues between
parents and children, there is no question about that. Little boys have
erections. Little girls may have sexual feelings that we can detect and
record, and similarly, of course, some women, when breastfeeding,
may experience sexual feelings. Fathers get erections from time to time
when their children are on their knee and I dont think thats necessar-
ily an abusive situation. I am not denying that sex is around, as it were,
in the parenting relationship but I dont see it as central or as primary;
Freud was just plain wrong about this. He was wrong because he
wanted a coherent theory. Since his theory is based around libido or
what drives us, and the glue of relationships, and he sees libido as
essentially sexual, then, without a security motivator, which is what
attachment is, he has to have infantile sexuality. That leads on to the
Oedipus complex. I want to rewrite the Oedipus complex in attach-
ment terms, to look at it from an evolutionary perspective, that is, a
childs need for the parent is not the same as the parents need for the
child. Do you know Hrdys work [Hrdy, 1999]?
DK: Yes.
JH: Hrdy is interested in infanticide and the fact that parents do

sometimes kill their children. This is certainly a phenomenon in the
biological world. The child has a paramount need for its parent but
the parents need for the child is mitigated because they may also have
other children; they have a partner by whom they can generate more
children. This is a purely evolutionary perspective. Attachment theory
is essentially an evolutionary theory, and although Freud was
Darwinian, it was not in the same way that Bowlby was. I see the
Oedipus complex in terms of the conflict between the childs absolute
need for the mother and the mothers need to balance her love for the
child, her protection of that child, with a love for her other children
and her love for her partner . . . Freud argued that the little boy had
sexual feelings for his mother and saw the father as a sexual rival. I
see it much more in terms of an evolutionary or genetic rivalry, which
is easily overcome in that the father can also be a superb attachment
figure. So, I dont believe in infantile sexuality. Having said that, lets
get back to the superego. A superego, in classical psychoanalytic
terms, is an internal representation of oedipal prohibition. It consti-
tutes the father saying to the child, No, that woman, your mother,
my wife, belongs to me. So the child suppresses his sexual needs and
his sexual feelings under the influence of the superego. Well, I am
trying to rewrite the superego in attachment terms and in my view
this prohibition is essentially a way of protecting the child, so that a
mother who says to the toddler, No, when the child goes towards
an electric light socket is installing in the child a superego, a prohibi-
tive superego yes, but one that keeps her child safe. Thats the basic
idea. In that paper, what I am examining is the difference between a
benign superego and a harsh punitive superego, because we all have
to learn to take risks. Our primitive superego says, No, dont do this,
dont do that, but in order to develop and progress we need to feel
enough security in ourselves to say, Well, I know this is a risk. I
know if I kiss this girl I am going to feel, Help, I may be rejected. Or
I know if I do a bungee jump off this bridge I may die, but in order to
enlarge my sense of self, in order to explore the world fully, I am
going to have to do things that feel a bit risky. I have got to feel suffi-
ciently secure inside myself to be able to undertake this task. So the
paper is really about (a) rewriting the superego in terms of security
rather than sex; and (b) about how, on the basis of secure attachment,
we can begin to take risks, whether these are sexual risks or risks in a
wider sense. I dont think it is a particularly successful paper; it fell on
deaf earssadly, because my theory of therapeutic action is also
within that paper. A person comes into therapy with a whole set of
defences. If the therapist provides sufficient safety, he can challenge
the person to divest themselves of those defences and move to a less
defended position. I sometimes see this as a very crudeI almost
hesitate to say this especially to an Australian colleaguebut one of
my little metaphors for this is the joey and the marsupial, because, as
I understand the biology, you have got this little tiny creature that
emerges from the womb and then has to climb up the side of the
mothers belly to get into the pouch for further development to take
place. Now, thats a very scary thing to think about because that joey
is incredibly vulnerable at that moment of climbing. In therapy the
patient has to become incredibly vulnerable before the developmental
process can resume. I am also trying to indicate that what one is doing
in therapy is simultaneously giving a message to the patient that it is
safe, that the therapist is going to look after them, he is not going to
push them further than they can tolerate but at the same time will not
collude with them and reinforce the superego, but challenge and
create a different relational environment to what they expect and have
had instilled in them through their developmental experience. So,
therapy is all the time playing with challenge and security.
DK: You have just highlighted an interesting juxtapositionthat to
live fully, we need both challenge and security; the therapeutic situa-
tion is a microcosm and training ground for working with this juxta-
position, which is also somewhat paradoxical. Therapy is, at the same
time, a place where the therapist creates both maximum security and
maximum uncertainty.
JH: Yes, I really believe that. It is a very simple point, but when
you go to see a therapist you absolutely need to know that that person
is reliable; they are as good as their word. If they say they will see
you next week at 10 oclock, they will see you at 10 oclock. You also
need to know that this person isnt going to exploit you sexually,
financially or in terms of gossip, so in terms of confidentiality. That
space, that hour that you are offered is inviolable; people arent going
to intrude on it because it is going to be quiet and comfortable. This
creates conditions of security. Then the patient comes in and essen-

tially the therapist doesnt say very much. Now, in other forms of
therapy, such as CBT, the therapist directs the patient, the therapist
takes control of the session, the therapist continues to be reassuring,
whereas in psychoanalytic work one is really rather unreassured, one
might just not even say anything when the patient comes inI some-
times just make a gesture to indicate the floor is yours or say no
more than where do you want to start or tell me the story. Thats
pretty scary; another example of that is perhaps the use of silence. I
believe that silence can be very persecutory if it goes on too long; but
there must be a reticence, the therapist holds back, and creates a space
into which, with luck, the patient will be able to express herself, feel
safe, take a risk. Its quite risky talking about yourself and the more
you trust your therapist the more likely you are to be able to take that
risk. Its really a simple point, this idea of maximum security and
maximum uncertainty.
DK: Simple, yet also paradoxical and profound.
JH: Yes . . . the patient says, Well, what am I supposed to talk
about? or, Ask me some questions, and I would probably say,
Well, what kinds of questions would you like me to ask you? or
something like that, pushing it back.
DK: If the patient then tells you what questions to ask, what
happens then?
JH: Well, lets imagine a patient comes in and I say, The floor is
yours, the patient says, I dont know what to talk about, please
give me some guidance here. So I might say, Well, what kind of
guidance are you looking for? And the patient might say, Well, I
dont know where to start. Should I talk about my childhood? Should
I talk about whats going on now? I really believe in a light touch in
therapy, not exactly making jokes all the time, not a Woody Allen
situationbut just playing. Winnicott said psychoanalysis is learning
to play, so you are playing. If its the first session I might say, OK,
lets hear a story which has led up to your coming to see me and
sitting in this room on this particular day and maybe that will give us
a clue as to where we want to go next. When you are up against so
much anxiety, the first thing to accomplish is to lower that anxiety so
you can begin to do some work. If I felt the patient was so panicky
that their mind had gone blank, I would definitely make some semi-
helpful remark. So, again, its all the time playing with security and
exploration. If there is a paramount need for security, if the attach-
ment system is activated, no exploration is possible. If I feel a person
is just so anxious that they are in a state of attachment panic then
that has to be dealt with. I might say, It sounds like you are feeling
really panicky, perhaps you are wishing you had never come here in
the first place, so we might focus on that. I tune into the affectthats
what I call the reverie: I feel the patients anxiety and then I give a
logos, I try to give a name to it, and then assess whether the patient
picks up on that logos. I feel that psychoanalytic theory is so far
removed from this kind of issue but this is really where I feel we need
to focus our attention and where we need theoretical models. We need
experimental explorations and thats where the attachment paradigm
provides such a good context for that because its (a) really interested
in the minutiae of relationships, and (b) it has this experimental
empirical culture.
DK: You said in your book, Exploring in Security, that co-constructed
meanings are the only therapeutic truths. This statement is an apho-
ristic way of summarising what you have just been saying.
JH: Yes. It takes us back to Tom Ogden and the psychoanalytic
third and the fact that in the end you are working together with
somebody to try to create something that makes sense to both of you;
its a joint project. Another metaphor that I rather like comes from
Donnel Stern [2006, 2012], who is a relational theorist. He has been
influenced by Daniel Stern [1985, 2004] (they are not related). Daniel
is a giant of child development research, a psychoanalyst and a leader
in the Boston Change Process Study Group [Bruschweiler-Stern et al.,
2010]. Donnel Stern is interested in Hans-Georg Gadamer, who is a
Heideggerian philosopher. Gadamer proposed the concept, fusion of
horizons. He says that all truths are conversational truths. Whether
you are reading Hamlet or talking to someone, you are still having a
conversation. He is saying something and you are seeing whether you
agree with him or whether you understand what he is saying or trying
to visualise what he is saying. Donnel Stern uses this phrase fusion
of horizons, from Gadamer. I like that; the patient comes in with his
world view, the therapist comes in with her world view and then they
have a conversation and attempt to achieve a fusion of horizons in the
sense that they are then both looking at the same thing in a way that
satisfies both of them.
DK: I would like to move on to a discussion of some of the key
elements in the psychoanalytic approach and get a response from you
on some of the issues, for example, the use of the couch. I was inter-
ested to read your perspective in Seeing, sitting and lying down
[Holmes, 2012b] that the face is insufficiently theorised in psycho-
analysis. We have spent some time discussing that earlier on in our
conversation. But it is certainly also related to this question about
patients using or not using the couch. Could you say something about
that?
JH: To some extent the couch is a bit like the QWERTY keyboard.
We are stuck with the QWERTY keyboard because the early type-
writers used to jam up if they put the letters in more logical order.
From a logical point of view there is no particular reason why we
should use the QWERTY keyboard because we all use word proces-
sors and computers, but we are just stuck with it. Using the couch is
just what Freud did; it goes back to hypnosis, in fact, and Freuds pre-
psychoanalytic hypnotic arrangements. We are all heirs of Freud, so
we use the couch. There is nothing wrong with the QWERTY
keyboard; we are all used to it and we all use it. I personally dont feel
that one necessarily needs to confine the use of the couch to the more
frequentthree to five times a weekanalyses. Some of my once-
weekly patients use the couch. We need to consider the benefits or
otherwise of the couch, which I try to spell out in that paper. There
are huge advantages. There is a sense in which you are held, you are
lying down, you can dream more easily, daydream, you can pursue
your unconscious more easily. Tom Ogden says there is something
about sitting behind patients and not having to interact with them in
a facial way that enables the analyst to dream their patient and to
pursue their own countertransference. Empathic responses perhaps
follow more easily. From those points of view there is a sense in which
using the couch can foster the psychoanalytic process. There are
disadvantages too. A patient who has been dropped affectively or
emotionally as a child, or who has never been held, may need the reas-
surance of actually seeing a responsive analyst/therapist in front of
them; to feel that they have got someone who is really attuned and
responding in a minute-to-minute way with facial contact. Another
downside to the use of the couch is that it may foster dependency and
regression that doesnt actually lead anywhere, so one needs to be
aware of that. I refuse to be pinned down by the concrete, thats why
I dont think psychoanalysis can be equated to the use of the couch, to
five times a week sessions at all. The essence of the psychoanalytic
approach is that it is exploratory as opposed to supportive. There are
various aspects of the couch that foster that exploratory culture but
they may also be inimical to it as well at times. I do use in my prac-
tice a mixture of lying down and sitting up, as indeed I experienced
myself as a patient. So thats my position.
DK: People do fluctuate in the same analysis between using the
couch and sitting up. Most would agree that it needs to be a flexible
arrangement and whichever method allows that freedom of explo-
ration is what would direct the use or the non-use of the couch.
JH: The important thing is the meaning of it. I had a patient whom I
thought would be suitable for the couch, and invited her to use it, and
she said, No way, I can barely get into the room let alone lie down.
Thats the state we are still at but its possible that in a few months or
even years she will feel safe enough to get on to the couch. There are
other patients whom I feel possibly get on to the couch a bit too read-
ily, because they are slotting into a preconceived psychoanalytic model
without actually looking at what the meaning of it might be. If a
patient has been on the couch and then suddenly decides to say, I
dont want to be on the couch any more, I want to sit up, that is not
good or bad; its something to be explored. Maybe they dont really
trust the analyst, or they are terrified of what they might find if they
really regress. Or they feel they have had enough, they need to move
on, they want to have a fair fight with the analyst and get into some
aggressive competitiveness that is really not so easy when you are
lying down and the other person is sitting up. There are 101 different
issues to think about in relation to the couch. Its what we do, what we
feel comfortable with, thats how we have been analysed, and thats
the culture. This is one of the paradoxes that I still struggle with, which
is this idea that I am an integrated, maverick therapist but I also have a
mother tongue. Esperanto and a general language do not really work.
Everyone speaks his own language whether its English or Chinese or
Italian or Dutch. In order to express yourself fully, you have to be
absolutely conversant with the particular, to use Hobsons phrase
(which he got from Coleridge), the minute particulars; you have to

be absolutely conversant with your own particular language. For most
psychoanalysts the couch is part of their language and if you dont use
the couch, well, in a way you are restricting your linguistic universe,
even though calling a table la table or la tavola is still the same object,
but nevertheless we all have a slightly different perspective on it.
DK: Thats a very nice analogy. You have just touched on something
that I really wanted to talk about because its still a very controversial
subject and thats the idea of regression. Bion [Britton, 1998] was
reported to have said, Winnicott says patients need to regress;
Melanie Klein says they must not regress; I say they are regressed.
What are your thoughts on therapeutic regression?
JH: Regression. Yes, I noticed I was using that word and I dont
think I have got anything terribly useful to say about it. Winnicott
talked about regression in the service of progression and I sometimes
use a French proverbreculer pour mieux sauter. In other words, you
run back in order to jump better. So in order to progress, and I do
believe you need toas I was saying with my joey and kangaroo
modelyou need to be able to divest yourself of your habitual
defences in order to move to a more mature and sophisticated use of
defences. In that sense, effective therapy is inherently somewhat
regressive. The controversy arises when a patient curls up on the
couch like a little foetus and says, I want to be fed by my mummy.
There was a culture in the 1950s, 1960s, 1970s of going along with
thata romanticising of the analytic process. You will find it in the
literature; you will find it particularly in people like Winnicott. I, on
the whole, am rather against that sort of thing. I feel maybe its
because I am a psychiatrist who sees a lot of borderline patients. We
do know that inappropriate psychoanalytic treatment can actually
make borderline patients worse. And we are talking here about very
difficult patients. My general rule is if you are working with a very
difficult patient you need two professionals. You need a psycho-
analyst and you also need a case manager. Its the job of this case
manager to deal with suicidal crises, to admit the patient to hospital
when they need it, to prescribe medication when its appropriate, to
help with the practical problems of housing and so on . . . It may be,
and in fact it sometimes is the case, that a psychoanalytic treatment
may precipitate some kind of breakdown. I dont necessarily think its
a good thing to try to contain that within the therapy and I dont think
its really the psychoanalysts job to manage that breakdown. I feel the
case manager has to deal with that. Its the psychoanalysts job to help
the patient look at and understand whatever is going on for them,
including a breakdown that might require them to go to hospital. The
analyst cannot move out of his analytic role into a case-management
role. For psychotherapy to work the patient needs to have a suffi-
ciently functioning ego to get him or herself to therapy, to be able to
talk to the therapist, and in private practice to pay for the therapy. The
regressive aspect needs to be handled by a case manager rather than
the therapist. I am a bit suspicious of regression. Of course, regression
does happen but its in the context of the therapy. The patient needs
to be able to get up off the couch and walk out and continue with their
basic coping, their basic living. Heinz Wolf used to say, Well, its
nearly time to stop now and I am going to have to hand you back to
yourself.
DK: [Laughs] I like that.
JH: Thats like saying OK, regression happens in the session, but
its got to be reversible. If its irreversible, it may sound heroic and
wonderful but I am a little bit sceptical and suspicious.
DK: Yes, thats a nice way of putting itthat it needs to be assessed
on an individual basis. For some patients, there can be a certain
bounded regression but one must be sure that the patient can come
out of it effectively at the end of each session.
JH: Yes, thats right. I dont really believe in heroic psychoanalysis.
One hears about it and people like to write about it but I am sceptical.
DK: Would you call encouraging regression heroic?
JH: We all tell stories; everything everyone writes about his
psychoanalytic work, including myself, is a story. That comes back to
what I was saying earlier about the fly on the wallthe fly on the wall
isnt telling stories, it is actually observing what really goes on. I am
not saying that those of us who write about what goes on in the
consulting room are making it all upand we have a problem with
confidentiality so it all has to be disguised in some waybut we
inevitably choose particular cases that are telling a story that we want
to tell.
DK: So you would be quite disapproving of Winnicotts treatment

of Margaret Little, for example?
JH: That was in my mind. No, I wouldnt be disapproving but I

would be disapproving of drawing any general conclusions.
DK: [Laughs] That was a very political answer.
JH: Because I am a Winnicottian; I love Winnicott; he was charis-

matic and I also see him as a maverick, a one-off kind of person. So I
would take what he said with a little bit of salt.
DK: I have been reading the interviews that Peter Rudnytsky [2000]
conducted with some really interesting people like Enid Balint and
Mary Ainsworth and your analyst, Charles Rycroft. It was fascinating
to me how so many of them were critical of Winnicott. They say there
is a mythology around Winnicottthat he wasnt this huge teddy
bear who was so wonderful and warm. They identify another side of
him that hasnt survived into the history or the mythology of the man.
For example, Enid Balint said that people make him cuddlier than he
was . . . [that] he was actually tough and very hard but absolutely
trustworthy (p. 22). Charles Rycroft was much less flattering. He des-
cribed Winnicott as a prima donna, totally self-absorbed and very
strange (pp. 7274).
JH: A colleague of mine, Joel Kanter in Washington, has written a

book about his wife, Clare Winnicott, a collection of her papers
[Kanter, 2004]. I wrote an introduction to that book and she was
obviously a sane, feet-on-the-ground kind of person. An example is
that Winnicott had a really rather sick relationship with Masud Khan.
There was a big scandal about Masud Khan and his behaviour and
particularly about the way he seduced his patients. He was a rampant
narcissist although also an incredibly brilliant and original mind. The
psychoanalytic society was seduced by him; he was their first oriental
candidate . . . Anyway, he and Winnicott used to meet once a week to
discuss cases and Winnicott was really rather collusive with Masud
Khans behaviour with some of his patients. Winnicott kept saying to
Claire, Come on, lets have Masud to dinner, and Claire Winnicott
said, I am not going to have that man in this house [laughs]. So
she kept Winnicott in touch with reality. There was no doubt that
Winnicott was one of the giants in the psychoanalytic world. Everyone
has clay feet and he certainly had a few. My main objection to him is
that he was rather unscholarly; he didnt acknowledge anyoneits as
though all his ideas originated with him, whereas in fact, he was the
product of a whole tradition.
DK: You open your paper on the issue of money in psychotherapy
[1998b] with a quote from Freud (1913c): Money matters are treated
by civilised people in the same ways as sexual matters, with the same
inconsistency, prudishness and hypocrisy (p. 131). It is really such a
central issue in psychoanalysis, I think it deserves some air time.
JH: Money is a form of exchange and all human relatedness is
based on exchange. For example, mother and infant exchange smiles,
parents exchange the labour of rearing children for the chance of
genetic survival, a form of immortality. But money also breeds greed
and envy and can be divisive and a source of conflict. Just as patients
need the regulation of time and place to establish their secure thera-
peutic base, in a similar way, financial exchange is an explicit part of
the therapeutic contract. Fenichel (1946) made the brilliant insight that
in the pre-oedipal stage, infants demand unlimited love and avail-
ability from their care-givers, which corresponds to what he called a
pre-pecuniary stage of development. During the oedipal phase,
children learn that they must share mother with father (and other
siblings) and that love and money have demands, for example, for
reciprocation and limits. This is a similar lesson that patients must
learn in therapythat it is a form of exchange between analyst and
patient, and that neither love nor money is unlimited.
DK: I know we have touched on the oedipal issues but I would be
interested in hearing your perspective on whether the integration of
attachment and sexual feelings towards ones partner is an indication
of the resolution of oedipal conflicts and attachment insecurities. You
were saying earlier that psychoanalysis is not very good at defining
its aims, or what would constitute a positive outcome, or what mental
health is. I was interested to read Peter Lomass view on the aims of
psychoanalysis. He says that the concept of health or being restored
to health does not cover its aims. Rather, he invokes a moral dimen-
sion and says that psychoanalysts are trying to help patients to
become better people, to live a good life in the Aristotelian sense, so
I am wondering about your perspective on these issues and how
attachment and sexuality figure.
JH: My immediate response to the first part of your question is to

recall a colleague of mine, Morris Eagle, who wrote a really interest-
ing chapter in a book edited by Diana Diamond and Sidney Blatt
called Attachment and Sexuality [Diamond, Blatt, & Lichtenberg, 2007].
His view is thatand I dont actually fully agree with himbut his
view is that we have these two separate dynamics, the sexual behav-
ioural system and the attachment behavioural system and that a long-
term partnership, such as a marital relationship, is always a bit of a
compromise between those two. A marriagethis could be a homo-
sexual marriage, so I am not just talking about it heterosexuallybut
a marriage obviously contains both attachment and sex. Now, you can
get extreme examples of those, where there is one without the other.
At one end is the unconsummated marriage which has attachment
with no sex. At the other end, there is rape. In rape, there is no attach-
ment at all; there is just some kind of sex going on, at least from the
male point of view. Where I subscribe to the oedipal idea is that
everyone has to cope with rivalry, envy, and jealousy. We under-
estimate the role of the sexual dynamic at our peril and I am not in
any way underplaying the sexual dynamic. I just happen to believe
that the sexual dynamic really only kicks in during adolescence, thats
when teenagers begin to undo their attachment relationships with
their primary care-givers, with their parents, to some extent. They
then move their attachment relationship into their peer group and as
development progresses, they pair off and sexual partnership emerges
out of that. Adolescence has these three stages; first, the undoing of
the intense attachment relationship with parents; then the forging of
the beginnings of attachment relationships with peers and mentors so
that their secure base becomes their peer group. You see this in
extreme forms with gang formation, which often happens when
theres no father. These boys move from an attachment relationship to
their mother to a gang, which then becomes their secure base. In stage
three, there is the differentiation out of a sexual relationship, where
sexuality and attachment are a counterpoint one to the other.
On the second element in your question, I do agree about the
Aristotelian idea of what it is to lead a good life, and that to be a good
person means being a coherent and integrated person rather than
being riven by splits and repressions. Aristotelian virtue ethics is
different from utilitarianism, and, as a huge generalisation, I would
say psychoanalysis is more virtue-ethics orientated compared with,
for example, cognitivebehaviour therapy, which is essentially utili-

tarian. That said, I dont believe in psychoanalysis for its own sake as
a kind of secular religion. From my medical point of view the point
and purpose of therapy is to alleviate suffering and help overcome
psychological difficulties, including illness. Most people manage to
live good(ish) lives without recourse to therapy. So that is a utilitarian
aim one might say, but it uses Aristotelian virtue-ethics means to
achieve that utilitarian end. So that brings us back to the questions
about how we define psychological maturity.
DK: Yes, the question is now looking quite complex and multi-
faceted.
JH: Indeed. Is it resolution of the Oedipus complex, but what does
one mean by resolution of oedipal complex? Resolution is the devel-
opment of the capacity to tolerate a three-person relationship. Clearly,
one of the purposes or functions of marriage is reproduction. If
prospective parents are going to be effective parents they are going to
have to tolerate the presence of a third person in their relationship.
The sexual relationship becomes relatively sidelined in the early
days following the birth of a child. The father needs to develop the
capacity to allow his partner to have this intimate, physical, sensual
relationship with her baby. His capacity to do that must relate to some
extent to his own developmental experience of having been able to
tolerate his parents having a life apart from him while at the same
time knowing that if he was in distress they would respond to him.
One way of looking at it takes us back to exploring insecurity. In other
words, resolution of the Oedipus complex in attachment terms would
be to say sex is all about exploration. You can only feel really safe to
explore your sexuality or your bodily feelings, and your partners, if
you both feel safe. People really only have sex in safe places, thats
why it takes place in bedrooms, in dark places, in secluded places
where you know that you are safe, where you are not going to be
attacked by a predator. Only when you are safe can you reach heights
of excitement; another paradox perhaps, or more of a dialectic. From
the attachment point of view there needs to be a degree of security,
you need to be able to trust in order to have a sexual relationship.
Equally there needs to be, I suppose, a sense that if there is a security
need it will be met. In that classic situation where the parents are
having sex or want to have sex and the baby cries in the night, how
does that couple and that family cope with that? This may be a rather
sexist way of looking at itbut is the father able to switch off and say,
OK, babys distress takes precedence over my sexual needs. My
partner has got to be available for our babys security and that is more
important than my sexual need. Now, if children have had develop-
mental experiences in which they are simultaneously allowed to let go
of their parents, they cannot feel so driven by envy and rivalry and
exclusion and fear that they have to intrude on their parents sexual
relationship. This will happen if they know that if there were a crisis
the parents would respond to them.
DK: Its actually stimulated another question. I have a colleague

who says that attachment theory doesnt theorise or deal with nega-
tive emotions very well, yet you have been using terms like envy and
rivalry. What are your thoughts?
JH: Maybe there is some truth in that, but I dont really agree
because the main negative emotion that attachment theory writes
about and Bowlby was interested in was anger. Whether or not that is
a negative emotion might be open to debate, but obviously envy and
rivalry can manifest themselves as anger. If you discover your partner
is having an affair, you respond to that with anger, but underneath the
anger may lie Oedipal insecurity, envy, and rivalry. I would say that
attachment theory does have something to say about negative emotion
but it sees them in terms of attachmentthe primary function of anger
is to activate attachment behaviour. It works both waysif the child
feels angry, he will activate the care-giver to attend to him. The first
thing that happens if you feel threatened and the parent isnt there, is
that you get angry. I sometimes give an example from adult life: if you
arrange to meet your partner at a certain place and time for coffee and
they dont turn up, or they turn up half an hour late, and you say,
Where the hell were you? you are expressing anger but that anger is
actually fuelled by an attachment dynamictheir non-appearance
activates your attachment needs and in order to re-establish contact
with your secure base you express anger. Its about rupture and repair.
Ill give another example from the developmental origins of attach-
ment. I remember as a child when I was probably aged about eight. I
grew up in London and there was a big main road near where we lived
and my mother was very keen on walks so we used to go to the park a
lot. On the way back, we had to cross this main road. I was with my
mother and she would have been pushing a pram with my younger
sister. Anyway, I ran ahead across the main road and when she caught
up with me she hit me and said, Dont you ever do that again. Maybe
this is why I became a psychotherapist! I thought, I dont get this, why
is she hitting me? She should be pleased that I am here and I am still
alive and we are reunited. But of course, by hitting me she was ensur-
ing that it didnt happen again; I would think twice about running
across the road if I thought I was going to get a slap for doing so. So
going back to the question, does attachment theory theorise negative
emotion: I would say yes. Now, how does this relate to envy and jeal-
ousy or the oedipal situation? Well, lets go back to a pathological
scenarioa couple with a new baby and the baby cries while the
parents are having sex. One or other of the parents might get very
angry with that child and that can be understood in terms of attach-
ment rivalry. The father is saying to or about his wife, You belong to
me. What the hell are you doing disrupting our sex life by going off to
look after your crying baby? If the parents dont come, the baby says,
Look, I am going to die in here if you dont come soon. In both cases,
the negative emotion is attachment-related. I am very interested in the
neo-Kleinian model of the Oedipus complex, which is quite relevant to
mentalising. Ron Britton is probably the best exponent of the neo-
Kleinian model. He recasts Oedipus in mentalising terms. He argues
that the oedipal child, the three-year-old child, whose parents are off
behind the bedroom door having sex, will feel excluded and has to
experience loss and loneliness. But in that process, that child also
acquires a mind of his own. He thinks, Well, I am free, I can think my
own thoughts. I am no longer so dependent on my mother; I am an
independent being. These are the beginnings of mentalising. The
beginnings of thinking your own thoughts can be seen in terms of the
oedipal dynamic. Here we are moving away from a concrete infantile
sexuality model to a much more metaphorical one that includes this
attachment aspect and mentalising.
DK: Your reference to the metaphorical just now leads us nicely into
the next discussionon language. You have written a lot about the
use of language in psychotherapy and psychoanalysis. You have a
strong interest in literature and poetry and you understand the thera-
peutic relationship in terms of metaphor and analogy. So I was
wondering if you could bring all of those interests together in a
comment about language in psychoanalysis.
JH: Where to start? At the end of my book, Exploring in Security, I

make a semi-joking point that I sometimes ask colleagues, You have
had ten years of analysis, what do you remember? What stays with
you? And usually its relatively few things but its often a metaphor;
its often a really powerful image. Ill give an exampleand its just
one word and the word was dumped. This was somebody who had
some problem in childhood that meant that they were dumped by
their parents with their grandparents, who were actually hopeless
with children. This was somebody who subsequently dumped other
peoplewives and girlfriends and his own children. The analyst
picked this up and used this word dumped and somehow that word
became a talisman for everything that was very significant in the
persons psychopathology. So I do think language is very important.
Now, we are talking and I am trying to be quite thoughtful and to
answer your points and get a framework. Whereas when I am with a
client, I just try to experience myself almost like a vessel or vehicle out
of which emerges language. Thats what I am calling logos in the model
that I outlined earlier. As a psychiatrist and therapist I have seen a lot
of psychiatric interviews or seen video tapes and I believe that the
effective therapist intuitively, without even realising that they are
doing it, adjusts their language and their linguistic universe to that of
the client and to the clients vocabulary, the clients IQ, the clients
linguistic universe. I like Jonathan Lears word, idiolect. I usually
give the example of couples and families who have certain key phrases
that mean something to them but do not mean anything to anyone else;
it may be a family joke or something like that. Thats what I call idio-
language, in other words, its a unique, specific linguistic world that
intimate partners share. The same is true in psychotherapy and psy-
choanalysis: one developsone begins to developan idio-language
with ones patient so you dont have to explain everything because you
know what they mean and they know what you mean. I dont want to
labour the point because it can be a bit clunky, but nevertheless the
capacity to pick up on the patients metaphors and play with them is a
really important part of therapeutic work. I am very intrigued by what
metaphor is and I still dont really know the purpose of it, but its
something to do with how the metaphor gets you inside somebody
elses head. You want to create the third, the route to the third is
through metaphor, and that applies to poetry because you then share
the experience, the affective experience, of the poet; it somehow
resonates with your own. For example, a patient might say something
like, I have had a really rough day today. Now, that actually is a
dead metaphor. So the therapist might say, Well, rough in what way?
Was it like walking through a ploughed field or walking on glass? I
am just making this up now . . . Then the patient might say, Oh, yes,
it was really like wading through a ploughed field, my legs felt heavy,
and then the therapist might say, Well, how are we going to get the
mud off those boots today? I feel that that kind of communication is
an integral part of good therapy. Dream analysis is really metaphor
work because a dream is a kind of metaphor. Mmm . . . Do I give this
example? I am slightly hesitant but I will. I had a dream the night
before last in which I was being captured by the Nazis. I woke up and
thought, now why did I dream that? Then I remembered that I had an
invitation to speak in Germany at a conference, so that was an obvious
link. Then I started to think, well, I am actually quite frightened of
exposing myself in that environment. So the dream was like a
metaphor that led me both to my preoccupation, the days residue, but
it also led me to the affective world of anxiety and fear and competi-
tiveness. Every dream analysis to me is metaphor work. I suppose the
final point about language is a research study I recently read that
suggested that there was a correlation between good outcome in ther-
apy and the therapists use of metaphor. We are usually taught to play
with the patients metaphors, but sometimes therapists come up with
something that really strikes home to the patient and makes the patient
feel that they are understood. The difference between saying to a
patient, Well, it seems as though you suffer from anxiety, thats the
kind of thing a psychiatrist might say, vs. saying, Well, sometimes it
feels as though you are a frightened child and havent got anyone there
to protect you. That metaphor of a frightened child is a clich but its
still a metaphor. Then the patient may be able to build on that and they
might say . . . let me give you an actual example of my father-in-law,
now dead, but when the First World War was over he was five years
old and he was at school and the entire school left to go and celebrate
the end of the war and he was forgotten; he was stuck in the school and
he was obviously completely terrified. The patient might then come up
with a memory like that. I feel this metaphorical way of working is
absolutely integral with what we are trying to do as therapists and its
something to do with empathy. That empathic resonance is communi-
cated via metaphor. This also happens in literature and poetry.
DK: That was a very clear exposition on the importance of

metaphor in therapy. The link between metaphor and dream analysis
was refreshing. You appear to subscribe to the view of dreams as a
process of working through, of integrating material, of problem solv-
ing as opposed to the original view that dreams are hallucinatory
wish-fulfilments. None the less, both views regard the deciphering of
symbolic material as essential to the process of understanding and
interpreting dreams. On this point, I was interested that in your own
dream you talked about the fear of being captured by Nazis and the
immediate association was the fact that you are about to go to
Germany to present at a conference there. However, your earlier
comments about the International Psychoanalytic Association might
be relevant to understand your dreamyour perception of the IPA
as metaphorical Nazis who insist on psychoanalysis being under-
stood and trained and practised in a particular way. Perhaps you
are feeling quite rebellious about thatyou are a self-proclaimed
maverickand will not goosestep for them, but you also fear their
wrath [laughs].
JH: Well, thats a great interpretation. Yeah, its a great interpreta-
tion. You are absolutely right but it makes me think of a personal
history aspect to this. I am a rebellious adolescent who, because of the
war and because of my fathers injury (I had a slightly handicapped
father), I never really had my oedipal battle. I got away without the
oedipal battle. One of the things about attachment theory is that
Bowlby became my father. I shied away from psychoanalysis because
it was a bit of a matriarchy. I am not saying this is in any way
consciously matriarchal, but the predominant culture in British
psychoanalysis is Kleinian. So its a kind of matriarchy even though
many of the Kleinians are male and Ron Britton is a good example.
Nevertheless, I needed to find a good father whom I could feel was
stronger than me and cleverer than me and more powerful than me
and into whose shoes I could step. So this is a good example, isnt it,
because you took what I said in terms of my perception of the IPA
as a totalitarian organisation [laughs]; I partially responded to that
but then moved it in a different direction. Thats exactly what I
mean about the power of metaphor. I took your metaphor, the idea of
the Nazis and goosestepping, but moved it to the word totalitarian,
so in a slightly different direction in terms of a gender issue. Maybe
totalitarianism is non-oedipal in the sense that a totalitarian regime is

a homogenous regime, its not a marriage. A marriage is always a
mixture and the question is to what extent the British Psychoanalytic
Society is a marriage. I would say it isnt. Its an uneasy compromise,
the so-called gentlemens agreement. But it wasnt a proper marriage;
it was a semi peaceful co-existence. It remained a series of indepen-
dent, sequestered, isolated groups that havent fully cross-fertilised
with the predominant totalitarian regime, which is the Kleinian
model. That may be changing now; I am out of it. This is probably
relevant to Rycroft as well, because Rycroft was really driven away by
the Kleinians. Rycroft, as I said, had an absent father; his father died
when he was eleven. I have identified with him also but I needed to
get beyond himwhich is why Bowlby was so importantto resolve
my Oedipus complex. And of course, ironically, attachment theory is
mainly about mothers!
DK: What a charming set of examples of how metaphorical

meandering leads us to personal meaning. Before we conclude
today, I wanted to ask you how psychoanalysis, and attachment-
informed psychoanalysis in particular, helps us to manage our exis-
tential anxieties.
JH: Thats a nice little question [laughs]. I suppose the funda-

mental existential anxiety is the fear of death. Its highly relevant to
someone of my age. How do you come to terms with death? To the
extent that I am able to come to terms with death, I look to neither
psychoanalysis nor attachment theory but probably to a Buddhist
approach. Change and transience and life and death are all part of a
continuous process. The way in which people relate to the idea of
death is influenced by their attachment perspective; I was having a
conversation with my wife about this the other day. It is how one
visualises the moment of ones death. I, as an avoidant, deactivating
character, see it as a completely isolated moment. In my fantasy of
death I am not surrounded by loved ones who are holding me and
moving me into this world of non-being, I am alone. The event that
stimulated this conversation was a recent visit with one of our sons
and grandsonin a foreign country. I was saying goodbye to them at
the airport and then I went through into the waiting lounge. I thought
that there was now no way I could communicate with my son and that
this is what death is like. You can no longer look after your loved
ones. You are alone; you are cut off from your attachments. It would
be an interesting study to relate a persons attachment style to their
fantasy of the nature of death. My wife visualises herself surrounded
by her loved ones.
I dont believe in infantile sexuality and I dont believe in the death
instinct. From the psychoanalytic point of view, existential anxiety
relates to the death instinct and it would be something to do with how
one comes to terms with ones rage, ones destructiveness, ones
murderousness. I see rage and destructiveness and murderousness as
all perversions of attachment. Rage and destructiveness are ways of
trying to establish a connection with the object, with the inaccessible
object. Rage, rage against the dying of the light is Dylan Thomass
model. Thats an attachment rage that is saying, Where are you? I
need you. I need you to be with me. From an attachment point of
view, if you have come to terms with existential anxiety, you know
that there is a good object inside you so the security is there; you dont
need to rage against the dying of the light. From a psychoanalytic point
of view you are raging against the dying of the light because you are
owning your death instinct manifestation. In a way, Dylan Thomas is
praising this protest against the dying of the light, thats healthy anger,
healthy aggression: why have I got to die? I suppose the only other
point that I would make about dying and death is the question, If I
could lead my life again, would I make the same mistakes? From a
Buddhist perspective I suddenly realisenot that I believe in any
literal way in reincarnationbut the knowledge that you have
acquired through learning from your mistakes isnt completely lost;
its passed on to the next generation (admittedly with a lot of the
mistakes too!). One way of dealing with ones existential angst is the
idea of the next generation and your legacy to your children, your
grandchildren, your friends, all our relationships, brothers, sisters,
spouses, which is a completely relational picture. One might say the
psychoanalytic model is a much more individualistic oneeach of us
must come to terms with our death instinct. Anyway, I dont know, its
a really interesting issue that I had never thought about before in this
context.
Another existential issue that is very relevant to psychotherapy
is the extent to which one is master of ones destiny, or driven by
unconscious psychobiological forces. At an experiential level, psycho-
analysis does empower people, so that they feel less at the mercy of
their unconscious; at another level, possibly an existential one, it can
help its subjects to accept and come to terms with the fact that they
are probably far less in control of things than they like to think. That
paradox could be called existential. Im not sure that attachment
theory has any more to say about that than mainstream psycho-
analysisbut the idea of mentalising, which has come out of an
attachment approach, is relevant here. Finding a safe place from
which to view ones feelings and actions leads on perhaps to the capa-
city to see ones life in a less attached (in the Buddhist sense) way
and to accept life in all its varietyabsurd, vain, beautiful, transient,
ultimately perhaps from a human perspective, meaningless, but
locally hugely meaningful and significant.
DK: I resonate with your thoughts on both of these existential anxi-

eties, as well as with the existential anxieties themselves, so I would
like to revisit your story about saying goodbye to your son and walk-
ing into the waiting lounge at the airport. Earlier in our discussion,
you said that your fantasy was that you would be alone at the moment
of your death but when you were talking about your son you said
death was the feeling of not being able to look after your loved ones.
It seemed to be a reversal of your original fantasy.
JH: Mmm.
DK: Do you feel that your attachment figures will not look after
you, will not be with you in the moment of your death or that you
cannot be with them in the moment of their death?
JH: I am a deactivating, avoidant person so I dont think in terms

of being looked after. I operate from a self-sufficiency model. I am a
possible example of disorganised attachment whereby you transfer
your own non-looked-after-ness on to your object and thus become a
compulsive carer for others. Having said that, I am also a bit of a
dumper, so at that moment of going into the airport lounge, I was
letting go and then had this feeling that I cant do my habitual job,
which is looking after other people. Therefore, the idea of being help-
less and dying makes me feel empty; it makes me feel that the only
thing that gives meaning to my life is looking after other people. But,
OK, this is turning into a therapy session.
DK: [Laughs] Heaven forbid! Perhaps this is a good place for us to

finish. Thank you so much for joining me in this conversation.
JH: Its been good for me as well as for youwell, I hope its been
good for youanyway, its been very interesting.
DK: Endlessly so, and yes, it has been a wonderful experience for
me. Thank you.
CHAPTER FIVE
Dr Robert D. Stolorow:
intersubjective, existential,
phenomenological psychoanalysis
DK: Thank you so much for joining me in this conversation. Can we

start by your giving me an outline of the experiences that directed you
into the profession of psychoanalysis, and intersubjective psycho-
analysis in particular?
RDS: I became interested in psychoanalysis after I did a psychoana-

lytically orientated pre-doctoral internship when I was a graduate
179
student in the 1960s. I really enjoyed doing psychoanalytic work, so at

that point I decided to go for psychoanalytic training rather than go
get another degree in philosophy, because I had become so disillu-
sioned with psychological research. I went for psychoanalytic training
in New York in 1970. The thing that got me going in terms of my
particular approach was meeting George Atwood at Rutgers, where I
took a job as an assistant professor in 1972. We embarked upon a
series of studies of the subjective origins of theoretical systems. We
studied Freud, Jung, Wilhem Reich, and Otto Rank psychobiographi-
cally [Atwood & Stolorow, 1993; Atwood, Stolorow, & Orange, 2011].
In each instance we found that the most abstract, universalised and
absolutised concepts were directly derived from their particular
psychological organisation and an attempt at solutions for their own
psychological dilemmas. We decided that since these metapsycholog-
ical systems could be shown to derive from the subjective concerns of
their creators, what we needed was a framework for us to study
subjectivity itself that was broad enough and encompassing enough
to understand the various phenomena that the other theorists
addressed and to comprehend the theories themselves as psychologi-
cal products. We called our framework psychoanalytic phenomenol-
ogy. This framework took the experiential world of the individual as
its central focus. The phenomenological focus led us inexorably into a
contextualist point of view [Stolorow, 2011a] because we realised that
these experiential worlds, these emotional worlds, always take form
within relational or intersubjective contexts whether in early dev-
elopment or in the therapeutic situation. Heidegger [1962, p. 152]
expressed this beautifully: A bare subject without a world never is.
DK: Thats very much a fundamental underlying theme in your
work. Youve written about the close link between lived experience,
in particular, traumatic experience, and the philosophical theories
expounded by some of the great philosophersNietzsche, Kierke-
gaard, Wittgenstein, and Heidegger, for example. I wonder whether
you have pondered the world experience of behaviourists like J. B.
Watson [Watson & Rayner, 1920] and B. F. Skinner [1953, 1969] that led
them into their particular way of understanding human behaviour.
RDS: I dont really know their personal histories. They wrote
about life from the point of view of methodological objectivism, which
is a flight from subjectivity itself. In our viewmyself and George
DR ROBERT D. STOLOROW: INTERSUBJECTIVE . . . PSYCHOANALYSIS 181
Atwoodsuch pretensions of objectivity represent a grandiose

evasion of the finitude of human understanding.
DK: Did you become disillusioned with radical behaviourism and
the direction that the discipline of psychology was taking?
RDS: Yes. I remember when I was a graduate student, one of my
fellow students entered my office very excited and said, Bob, guess
what? I found some way to prove that people think. I felt that that
kind of thinking was on the wrong track. I think that psychology actu-
ally took a misstep when it tried to separate itself from philosophy to
become an empirical, objective science. In so doing, it distanced itself
from that which was humanly meaningful. I had this fantasy of
getting a doctorate of philosophy after I finished my doctorate in clin-
ical psychology, but I had to wait thirty-seven years to do that.
DK: Was it worth the wait? [laughs]
RDS: Oh yes, it was worth the wait, even though I became a student
again in my twilight years.
DK: Its great that you went back to the roots of psychology, as well
as the roots of your own thinking. Can you comment on how you
distinguish intersubjective psychoanalysis from other forms of
psychoanalysis by highlighting some of its unique signifiers?
RDS: I think there are two central distinguishing features. One is that
we try to be assiduously phenomenological, focused exclusively on
emotional experience and how it is organised. We eschew specula-
tions about metapsychological and metaphysical entities like id, ego,
superego [Stolorow, Orange, & Atwood, 2001a,b] and so on, which I
view as crypto-metaphysics. The first thing we try to be is assiduously
phenomenological. When I lecture about this I say experience, experi-
ence, experience. The second thing is our presupposition that emo-
tional experience always takes form within constitutive relational
contexts, contexts formed by the mutual interplay between two or
more worlds of experience, so the second basic proposition is context,
context, context.
DK: So experience and context are the two critical elements.
RDS: Right, this is why I call the framework phenomenological
contextualism.
DK: How is that different, for example, from attachment-informed

psychoanalysis, which is also concerned with contextualism although
the term is not used?
RDS: An attachment-informed psychoanalysis relies on research-
driven categories. Its not strictly phenomenological because it takes
the categories that were used to conduct attachment research and then
focuses on those as the universally relevant ones. I dont really like
attachment theory because I feel that the categories that are used are
research driven rather than coming out of clinical phenomenological
enquiry. Ive got to tell you that the category of secure attachment is
a complete oxymoron. There is no such thing.
DK: Theres no such thing as secure attachment?
RDS: Of course not, because we are all finite.
DK: Because we are all finite, we all have existential anxiety and
cannot therefore be secure in the sense of evading angst. Is that what
you mean?
RDS: Right. We can have the illusion of secure attachment, but no
attachment is secure because traumatic loss can occur at any moment
[Atwood, Orange, & Stolorow, 2002].
DK: That would presuppose an ever-present consciousness of that
possibility, wouldnt it?
RDS: Yes
DK: But individuals day-to-day are not anticipating or expecting a
traumatic loss, and indeed, most do not experience it, at least not in
the Western world, although traumatic loss is a daily given in places
like Africa and the Middle East.
RDS: Right, because human beings are very good at evading their
finitude.
DK: Its an interesting dilemma youve raised, because if you were
totally focused on context and experience, and people are good at
evading their finitude, then they have the illusion of secure attach-
ment, which represents a subjective experience that arises in the
context of those conditions that promote what attachment theorists
call felt security, which is a phenomenological concept.
RDS: The focus on experience doesnt mean that you restrict it to

conscious experience or the description of conscious experience,
because phenomenology as a philosophical discipline has always been
concerned with investigating and illuminating structures of con-
sciousness that are pre-reflective. We call them the pre-reflective
unconscious [Stolorow, 2005b]. Philosophical phenomenology, start-
ing with Kant and Husserl, sought to identify the universal structures
of experience, whereas psychoanalytic phenomenology wants to iden-
tify those structures that take form within the individuals unique
intersubjective history, much of which is unconscious. The evasion of
finitude, which would be a defensive structure, isnt conscious, but its
shaping experience none the less.
DK: Can you give an example of how that might be observed in a
person?
RDS: I think that the best context in which to see it is when that
evasion has been blown apart, and thats exactly what emotional
trauma does [Stolorow, 2008b]. A good example on a collective level
would be the fall of the World Trade Centre on September 11, 2001. I
dont know if you saw it live. We saw it live here in California. Theres
no way that anybody watching that World Trade Centre fall and the
instant deaths of 3,000 people; theres no way that on watching that
devastation that one could not recognise the precariousness and tran-
sience of our existence, and of the existence of everyone we love. It
was right in our face. So the evasion is best revealed when the
evasions are blown apart, shattered. Thats what trauma does,
whether for an individual or a collective.
DK: One of the fundamental themes that you come back to repeat-
edly is this idea of emotional trauma fracturing ones continuity of
being. I hope you dont mind my using the example of your wife,
Dede, because youve written about her in a number of papers. You
said that Heideggers concepts of angst and world-collapse and being-
toward-death were concepts that helped you deal with the grief of
that loss. Im wondering if you could illuminate, at an emotional level,
how those concepts helped you with your grief.
RDS: They helped me put my emotions in a broader context of exis-
tential significance. I actually wrote about the phenomenology of
trauma several years before studying Heidegger. I lost my late wife on
February 23rd, 1991. I describe an experience twenty months later

when I was at a conference where my new book, Contexts of Being, was
delivered to a display table hot off the press. This was in 1992. I
whirled around to show the book to my late wife, Dede, because she
would have been so happy to see it; of course, she had died twenty
months earlier. I woke up one morning and found her lying dead on
our bed four weeks after her cancer had been diagnosed. This whirl-
ing around to show her my book and finding her gone is what I call
a portkey, to borrow a term from Harry Potter,26 that instantly trans-
ported me back to that morning when I woke up and found her dead.
My state of mind at that conference in 1992 was a state that had two
principal features. One was that my professional world became mean-
ingless and insignificant; the significance of my world just collapsed,
and my everyday world collapsed when I was transported back to
that trauma. The second feature was that I felt completely alienated
and estranged from everybody else. I felt like an alien being. I wrote
that up in a paper that was published in 1999. It was called Pheno-
menology of trauma and the absolutisms of everyday life [Stolorow,
1999a]. As Heidegger said, If I take death into my life, acknowledge
it, and face it squarely, I will free myself from the anxiety of death and
the pettiness of life and only then will I be free to become myself
[Heidegger, 1998].
DK: So trauma shatters these absolutisms and brings about a col-
lapse of those presuppositions that give us the illusion of safety and
security.
RDS: Yes. I wrote a paper after the conference describing my state
and focusing on those two featuresthe world losing its significance
and feeling like an alien, being estranged from everybody else. Two
years after writing that paper, I formed a leaderless philosophy study
group in which we spent a year doing a close reading of Heideggers
Being in Time [1962]. When I came to his description of the phenome-
nology of angst or existential anxiety, I practically fell off my chair,
because the two central features of angst, as Heidegger described it,
were exactly the two central features that I experienced and described
in my traumatised state: loss of significance of the everyday world,
and what Heidegger calls the feeling of uncanniness, of not being at
home in the everyday world, a feeling of estrangement, and alien-
ation. His account of angst was that it was a mood or an affect state
that discloses authentic being-toward-death as he put it, that one

experiences angst when one really owns up to the finitude of ones
existence. I would say, expanding on Heidegger, the finitude of the
existence of everyone we care about and love. So I was off and
running then with Heidegger because I felt that his existential philos-
ophy gave us a framework for grasping the existential significance of
emotional trauma.
DK: You identified at an emotional level with Heideggers writing at

a time during which you were experiencing a traumatic grief state. Its
interesting because I have the same feeling about your writing; when I
read your papers, I am at home there. I know exactly what you mean.
RDS: Thats great. I am glad to hear that; glad you feel that way.
DK: Yeah . . . I would like to ask you about Winnicotts notion that
when we experience as an adult what feels like an overwhelming
crisis or trauma, it is a repetition of a past, developmental loss that has
not been fully processed or integrated. Im wondering if that has
perhaps been your experience.
RDS: Well, I think it can bean adult onset trauma can be a retrau-
matisation. But that was not the case for me. I had never experienced
a traumatic loss before of the magnitude that I experienced when my
late wife died. However, if you look at it more existentially, rather
than adult trauma being a repetition of a particular childhood trauma,
I would say human existence, stripped of its sheltering illusions, is
inherently traumatising. In Heideggerian jargon, we might say were
always already traumatised. Because of our finitude and the finitude
of those we love, trauma is built into the structure of our existence.
Even if we havent been previously traumatised, any trauma brings us
face to face with the traumatising dimension of finite human existence
itself.
DK: It is a fundamental ground of human existence from which we

can hide but from which we cannot, ultimately, escape. When, as a
young person, did you grasp that notion of finitude and, hence, mean-
inglessness?
RDS: I dont think I really grasped it until my late wife died. I had
the intellectual understanding but I did not have the experience of it.
I wouldnt say that I grasped it until I actually had the experience of

being traumatised.
DK: Freud made this point many timesthat intellectualising about
and emotionally experiencing something are very different and it is
only the direct emotional experience and working through of the
affective state that is mutative in psychoanalysis. In the situation that
you describe, it was a double trauma in the sense that you hadnt
previously had cause to think about your life in that way before. So,
you were confronted with a very present trauma as well as the under-
lying realisation of your finitude.
RDS: Well, I think I had thought about it before. I had a friend when
I was fourteen years old who is still a friend of mine after all these
years. At the age of fourteen, he and I were constantly talking about
death and the implications of death for our existence and the mean-
ing of life, but it was intellectual, it wasnt felt. It wasnt an emotional
owning up to finitude as happened in 1991 . . . My late wife and I used
to say, Ill love you forever. And wed say that frequently. So there
it is, right therethe illusion of infinitude, blown apart; that illusion
was shattered. I had never had that experience before.
DK: Is it still a present experience?
RDS: Oh yeah. Thats why I said in my last book that another
oxymoron is trauma recovery. Finitude is not an illness from which
we can ever recover. It is always already traumatising. We can cover
it up, which a lot of people do. But I made a commitment not to do
that. I wanted to stay with it and think about it and grasp it and try
to help other traumatised souls around the world. Thats where I
found meaning after the trauma that shattered my world.
DK: If we dont recover from trauma, how do you see the goals of
your therapeutic work? If youre working with a traumatised person,
how do you understand what youre doing with that person?
RDS: The goal is to integrate the trauma psychologically so that it
doesnt have to be evaded by dissociative and other pathological
defences. The idea is to integrate it so that it becomes a seamless
aspect of who one is in ones world. Traumatised people often have
flashbacks, or what I call portkeys; thats because theyre keeping
the trauma in some kind of state of dissociation so that it pops out
unexpectedly. I think whats helpful is the capacity to move in and out

of ones current world and ones shattered world of trauma without
having to defensively keep them apart. Thats what I mean by inte-
gration; it becomes part of who one is and what ones world is, rather
than having to be kept defensively sequestered. The goal is not recov-
ery; the goal is integration.
DK: Bowlby [1980] also viewed integration as the primary task of
grief work. How do you know when integration has occurred?
RDS: You can tell because the persons emotional world has become
expanded to include the impact of the trauma. The trauma has been
kept separate from ones ongoing emotional world. Ones emotional
world can now include that and its impact. Another consequence is
that it may bring about a shift in what really matters to a person. For
example, you can sometimes see a shift, as trauma becomes inte-
grated; we can see a shift in the person from being dominated by
shame to experiencing other wonderful feeling states, like sadness,
grief, angst, feelings that are built into our existence [Stolorow, 2011b].
Theres a shift in ones emotional life. The person who undergoes that
shift comes to the realisation that the eyes of others, how the eyes of
others see me is not really what matters. You are really grasping the
finitude of human existence. Other peoples eyes dont really matter.
What matters is that youre living your life according to what you
really care about.
DK: These comments remind me of your 2011[c] paper in which
you argue that the core of the experience of individualised selfhood is
the sense of mineness [Stolorow, 2009] of ones experiential life.
Right now, though, you are saying that a traumatised person may
have to navigate trauma as a shaming experience before reaching this
sense of mineness. Do you see trauma as a shaming experience?
RDS: It can be, because people are ashamed of actually being in a
state of trauma. Well, let me be more careful here. I think there are
traumas that are primarily shaming, for example, kids who grow up
being mercilessly criticised and devalued. The nature of the trauma
includes severe shaming. There are also many instances in which
being traumatised in any way is experienced as shameful because you
feel so vulnerable. I dont know if youve noticed this, but people tend
to shun the experience of trauma in other people. You dont go there
with other people, partly because it brings them into contact with their
own finitude and their own vulnerability to trauma. Thats another
reason why traumatised people often feel alienated and alone,
because no one wants to get near their experience of traumatisation.
DK: So what happens for some traumatised people is that they do
not experience attuned relationality, which you define as the others
attunement to and understanding of ones distinctive affectivity, and
that such contexts are necessary to sustain ones sense of mineness.
In its absence, the experience becomes doubly traumatising because
the experience of trauma itself can be alienating and place one outside
of this illusion of security and certainty of the absolutisms of every-
dayness, and secondarily traumatising because no one wants to move
with them into that space.
RDS: Thats exactly right. And a lot of therapists dont want to go
there either.
DK: Indeed.
RDS: But they must try.
DK: Yes, yes, we all try. You talked earlier in our discussion about
the pre-reflective unconscious. In your writing you discuss other
forms of unconscious, such as the unvalidated unconscious and the
ontological unconscious, as well as the better understood dynamic
unconscious. Can you talk more about these different ways of under-
standing the unconscious and how they are related within intersub-
jective psychoanalysis?
RDS: They have one thing in commonthey are all constituted inter-
subjectively [Stolorow & Atwood, 1999]. The pre-reflective uncon-
scious is a system of organising principles, formed in a lifetime of rela-
tional experiences, that pattern and thematise our lived experience.
These principles are not repressed as such, but they operate outside of
reflective self-awareness. We have reconceptualised the dynamic
unconscious as those affect states that are barred from coming into
language, coming into discourse, because theyre perceived to be too
dangerous and unwanted. The contents of the dynamic unconscious
have been met with massive malattunement [Stolorow, 2008a] and
thus came to be perceived as threatening to needed ties to care-givers.
In this context, we understand repression as a negative organising
principle that determines which emotional experiences cannot come

into full being. The unvalidated unconscious refers to emotional
experience that never comes into language or discourse, not because
theyre barred, but because they were never even responded to
linguistically in the first place. So the dynamic unconscious has to do
with contexts of danger, while the unvalidated unconscious has to
do with contexts of emotional impoverishment.
DK: You make an interesting distinction between the dynamic and
unvalidated unconsciousboth have dangerous contents, so to speak,
but the contents of the dynamic unconscious have been conceptu-
alised but not articulated, while the contents of the unvalidated
unconscious have not even come into language. The process of
coming into language is important in intersubjective psychoanalysis
because it is through this process that the sense of being is born.
Failure of these emotional experiences at either level result in what
you call ontological unconsciousness, which you define as the loss of
ones sense of being.
RDS: That is a very good summary. I gave an analogy with a build-
ing to try to explain all of these forms of unconsciousness. If you
consider a building, various floors of the building represent levels of
conscious awareness, levels of linguistic articulation. The basement
would be the dynamic unconscious. Here, emotional experiences are
kept from seeing the light of day, the light of discourse, because
theyre perceived to be too threatening or forbidden. The unvalidated
unconscious corresponds to unused raw materialsbricks, lumber,
cinder blocks and so on, lying around on the ground outside of the
building. They never make it into the structure of the building. The
pre-reflective unconscious isnt in the building at all. Its in the archi-
tects drawer. It contains the organising principles. The ontological
unconscious is a metaphor that I created to describe the loss of the
sense of being in the context of experiencing trauma for which there
is no context of human understanding. I suppose it could have
elements that are similar to both the dynamic and the unvalidated
unconscious; that is, experiences of traumatisation could be kept out
of language and discourse because they are perceived to be unwanted
by those around us, or there could be an aspect where it doesnt get
articulated at all because theres no response to the traumatised state
in language and discourse. So it could have elements of both the
dynamic and the unvalidated. I want to underline that these various

forms of unconsciousness that we talked about are prime examples of
the paradigm shift that were advocating, because for Freud, the divi-
sion between conscious and unconscious was a fixed intrapsychic
structure within an isolated Cartesian mind [Stolorow, Orange, &
Atwood, 2001a,b], whereas were saying that the boundaries between
conscious and unconscious are properties of the intersubjective
systems in which a person lives. Those boundaries change depending
on whether the context of ones living is receptive or unreceptive to
ones emotional experiences.
DK: Is the ontological unconscious the home for unintegrated
trauma? Im wondering how the ontological unconscious comes into
language.
RDS: I think it comes into language when youre with someone, a
therapist or an analyst or a spouse or a friend, who wants to talk about
it, who wants to talk about the trauma with you, rather than stay away
from it and shun it. In my own experience that I described, I lost my
sense of being when I didnt have a place to bring my traumatic grief.
Instead of feeling grief, I would feel lethargic, empty, almost like I
wasnt there. My grief showed up psychosomatically. When I found a
receptive context of human understanding, I started to grieve and I
came alive in that grief. A sense of being was revivified in that grief.
DK: Not all grief is the same; not all people respond to loss, even of
significant others, with the same degree of intensity and with the kinds
of experiences that you have been talking about. What do you think
underlies the differences in the expression of emotion related to loss?
RDS: There are all kinds of reasons for the differences. One has to do
with the nature of the loss, which in turn has to do with the nature of
the bond with the lost person. The loss of a person with whom one has
constituted a whole emotional world is going to be much more shat-
tering than the loss of someone who has been on the periphery
of ones emotional world, even if its somebody that you love. For
example, the loss of elderly parents is really not that shattering. Its
painful. But by the time an elderly parent dies, that parent is not
ordinarily central to ones emotional world. He or she can be, but ordi-
narily not. The other factor has to do with whether ones surround is
receptive or unreceptive to ones grief. Going back to the pre-reflective
unconscious, these organising principles give meaning to ones

emotional experience, including the experience of grief. If one has
formed a shame principle in the course of development, then even
natural feelings of grief and loss can be experienced as shameful.
Theres a whole range of different factors that can contribute to differ-
ences in the experience of grief.
DK: The early part of your response implied an attachment theory
focusfor example, you talked of the nature of the bond with the
lost person. I was interested in this comment in view of the difficul-
ties you outlined with attachment theory, that people are classified
according to empirically derived categories. The nature of the bond
between people can also be understood to belong to particular
categories; for example, disorganising, disorientating, and unresolved
states of mind about the loss experience.
RDS: The categories are empirically derived but theyre also prod-
ucts of the researchers presuppositionswhat they want to study
and what they can study. Can I tell you a little vignette that illustrates
what Im talking about here? I was at the American Psychological
Association Convention a couple of weeks ago and I was attending a
meeting of an APA committee whose mandate was to formulate treat-
ment guidelines. They reported some research about therapeutic
effectiveness of different approaches. It was very interesting because
maybe fifteen or twenty per cent of the variance was accounted for by
differences in approach or differences in technique. Maybe twenty or
thirty per cent was accounted for by random factors in the patients
lives. And fifty or sixty per cent of the variance was due to what they
called non-specific elements in the therapeutic relationship. I asked
them why they were calling them non-specific. I said, They are only
non-specific because you havent specified them; you havent studied
them because they dont fall within your presuppositions about what
it is important to study. I can give you a really specific factor that is
enormously important to the treatment of trauma states. That is the
ability to tolerate horror and not move away from it. It is very specific.
I am positive about that. I am making the point that these categories
are partly determined by the presuppositions of the researcher. There
has been no research to my knowledge that examines the relationship
between the therapists ability to tolerate horror and the effectiveness
of their work with traumatised patients.
DK: How do you define horror?

RDS: I dont know if I can define it. Finding somebody dead is pretty
horrifying. It is one of the affect states that accompanies trauma.
DK: I think you are right with respect to the circumscription that
psychology has undergone because of its obsession with empirical
investigation and the application of the scientific method. It is quite a
dilemma in the field. The whole discipline has become atomised in
order to get papers into the respectable journals.
RDS: That is absolutely true. But APA seems to be turning around a
little.
DK: It does. There has been a small shift away from nomothetic
studies and a greater encouragement of the idiographic approach,
which is quite encouraging. There was a paper in Psychological Science
in 2010, which amazed me, because it discussed the need to return to
a blend of the two methods in order to better understand human
subjectivity in all its complexity.
RDS: There is a special section coming out in December in the APA
journal Psychotherapy, entitled The renewal of humanism in psycho-
therapy, to which I am a contributor. They have asked people from
every perspectivebehavioural, psychoanalytic, psychotherapy
research, other forms of therapyto present our points of view on the
renewal of humanistic attitudes and ideals within the respective
branches of psychotherapy. We will each contribute a commentary on
the other participants point of view.
DK: That sounds excitingI will look out for that paper. If we
examine the process of psychoanalysis from an intersubjective pers-
pective, to what extent is it still functioning according to some of the
basic clinical strategies of classical psychoanalysis, using its metapsy-
chology and techniques such as free association, transference, inter-
pretation, and understanding resistance, for example?
RDS: As to classical metapsychology, it has no place at all in our

theoretical perspective. In my clinical approach, I put a heavy empha-
sis on enquiry and interpretation and the particular issues that I am
most interested in enquiring about are those organising principles that
shape the patients emotional experience and how those show up in
the interaction with me in the form of the transference. That is still a

strong focus of mineenquiry and interpretation that is experience
near, not the kind of interpretation that knows beforehand what is
going to be interpreted. A lot of doctrinal psychoanalysts, whether
Freudian or Kleinian, already know in advance what theyre going to
interpret before they have actually engaged in a mutual exploration
with their patient. I use interpretation governed by these two basic
principlesexperience, experience, experience, and context, context,
context. I think free association is an oxymoron. If you remember the
origin of it, Freud called it the fundamental rulethe fundamental
rule of free association!!
DK: [laughs] Yes, indeed. I dont think Ive ever seen that discussed
in the literature, nor have I previously considered the internal contra-
diction of a rule about freely associating.
RDS: It doesnt take into account the intersubjective context, the
patientanalyst relationship that is shaping the patients associations.
You know that old research, I think it was in the 1960s and the 1970s
that showed that patients in Freudian analysis would start having
Freudian dreams; patients in Jungian analysis would start having
Jungian dreams and so on. So much for free association, more like
prime examples of co-created association.
DK: Yes, indeed.
RDS: You can invite a patient to say whatever comes to mind, but
that doesnt mean that its going to be free, free of context, especially.
There are certain other classical presuppositions which I think are
ludicrousthe concept of neutrality, that the analyst will be neutral
with the patient, is ridiculous. The idea that the analyst can be objec-
tive about the patient is also ridiculous. The analyst is a participant,
always a participant in the intersubjective field, and is always co-
constituting the patients experience within that field. Some years ago,
I was invited to present at the annual meeting of the American
Psychoanalytic Association, the ultra-conservative organisation in the
US. I gave a paper entitled Deconstructing the myth of the neutral
analyst [Stolorow & Atwood, 1997]it was pretty subversive. Its
probably no accident that I wasnt invited back to speak until another
dozen years had passed. Neutrality is a myth; objectivity is a myth. I
actually heard it claimed that if a patient doesnt lie on the couch, its
not true psychoanalysis, which is ludicrous, ridiculous. The reason the

couch was instituted was that Freud couldnt stand patients looking
at him, so he put them on the couch.
DK: It would be hard to imagine conducting an intersubjective
psychoanalysis without eye contact.
RDS: I am pretty flexible about these details. I like to make decisions
about them based on meaning rather than rules. I remember having a
patient many years ago who, when she felt safe with me, and when
she was having a kind of a positive developmental experience with
me, she would lie on the couch. She felt safe, like she was being held
in her mothers lap. When she felt unsafe with me, she sat up. She was
not going to be that unguarded with me when she felt that I was
dangerous. So in that case, whether the patient used the couch or the
chair was a manifestation of what she was experiencing in the rela-
tionship. It was very valuable.
DK: Yes, thats interesting. So would you interpret the movement
from the couch to the chair in her case in terms of the accuracy of your
own empathic engagement?
RDS: I conceptualise two basic dimensionslet me back up here . . .
What is important in the therapeutic relationship is the experience of
the relationship that is shaped by the patients intersubjectively
derived organising principles. The same is true of the analyst. The
patient and analyst are continually organising each other according to
their personal meanings. Transference is the experience of the rela-
tionship as shaped by the therapists and patients intersubjectively
derived organising principles. The patient and analyst are continually
organising each other according to meanings that pervade their expe-
riential worlds. I found it very useful to conceptualise two broad
dimensions of transference, two broad classes of organising princi-
ples. One is the developmental transference. This occurs when the
patient is looking to the analyst for the missed, lost, aborted, or
needed developmental experiences. This patient had to experience
being on mothers lap, being held by mother. The other form of trans-
ference I called the repetitive transference, in which the patient antic-
ipates, fears, or actually experiences a repetition of the original
traumatisation. The repetitive dimension is a source of conflict and
resistance. Does that answer your question?
DK: Yes, to some extent. Thank you. Can we return to the question
regarding the movement from the couch to the chair with the patient
whom you described? Was that movement related to the loss of the
accurate empathic immersion of the therapist in that patients subjec-
tivity?
RDS: There are many things that can produce a shift like that, one of
which is bad, unattuned, unempathic interpretations. Other things
that could produce a shift like that are silences, the meaning given to
silences by the patient, anticipating the endings of sessions. Ending of
sessions for some patients can be retraumatising. In between sessions
can be retraumatising. A patient can leave a session in a wonderful,
expansive, developmental transference, but when the patient comes
back the next time after the separation having been experienced as
traumatising, they come back into therapy behind a brick wall. All
kinds of things, including unempathic interpretations can cause a shift
towards the repetitive, retraumatising dimension of the transference.
DK: You have just been describing the developmental transference
and the experience patients have of being held, or sitting in mothers
lap. As an intersubjective psychoanalyst, would you work with what
is commonly called infant states of mind?
RDS: I call them archaic states of mind and the answer is yes, I
work with archaic states of mind.
DK: OK. Is there a difference between archaic and infant states of
mind?
RDS: I dont think so.
DK: How do you work with archaic states of mind?
RDS: As with any emotional experience, I would try to dwell in them
with the patient and try to grasp them in their formative contexts, past
and present.
DK: What about the notion of resistance in psychoanalysis from an
intersubjective perspective? Im wondering whether you view the
concepts of impasse and resistance as similar.
RDS: No, resistance comes from the danger dimension, from the
repetitive part of the transference. Freud published a marvellous
paper in 1926[d], Inhibitions, Symptoms and Anxiety. In that paper, he
changed his mind about repression. Formerly, he had conceptualised

anxiety as being a product of repression. Your libido gets repressed
but it has to come out somewhere, so it comes out as anxiety, which
acts as a safety valve phenomenon. He changed his mind in his 1926
paper; he said that anxiety is a signal of an impending danger that
actually brought about repression. The implication of that shift in
Freuds thinking is that from that moment on, traditional analysts
should have been thinking about resistance analysis as danger analy-
sis, as an analysis of impending danger. Thats what resistance is
about. If you take an intersubjective view of danger, which Freud did
not, you understand that the experience of danger is co-constituted
within the intersubjective field, that theres something coming from
the side of the analyst thats lending itself to the patients experience
of endangerment. So working with resistance, in my view, is working
with the emotional experience of endangerment as its showing up in
the intersubjective field of the therapeutic relationship. Its like the
repression barrier between the conscious and the unconscious. The
concept of resistance is contextualised; it is not a property of the
patients isolated mind. Its a property of the intersubjective system,
which has become dangerous. In my experience, this usually comes
about as a result of unrecognised things going on in the therapy.
DK: These kinds of experiences, if not attended to, can create im-
passes that impede therapeutic progress. Is this a concept that you use?
RDS: Impasses [Atwood, Stolorow, & Trop, 1989] in my experience
come about as a result of unrecognised processes going on in the inter-
subjective field of the therapeutic relationship. We conceptualised two
intersubjective situations back in the 1970s: the first is intersubjective
conjunction, a situation where there is an overlap between the emo-
tional world of a patient and the emotional world of the analyst. The
other we call intersubjective disjunction, in which case theres a wide
disparity between the worlds of meaning of the patient and the ther-
apist. Either of these two situations can create an impasse if they are
taking place outside of the therapists awareness. A conjunction that
is not recognised can lead to a folie deux between the therapeutic
dyad. The patients experiences are organised so closely to those of the
analyst such that the analyst might think that the patient has good
reality testing about the human condition because it conforms to the
analysts world view. Because the patients experiential world is
organised so closely to that of the therapist, the therapist may miss the
psychologically important material to be investigated there. This leads
to a stalemate. The analysis goes on but not much is happening.
An unrecognised disjunction can have very dramatic effects. This
may be what you had in mind when you asked me your question. In
this situation, the analysts interpretations are being directed to a
subjective situation that from the patients standpoint doesnt exist, so
the patient is being relentlessly misunderstood. Those experiences can
be extremely retraumatising for the patient. There are certain inter-
pretive approaches that regularly do thatthose that come out of the
classically Freudian and Kleinian traditions.
DK: Im interested in whether intersubjective psychoanalysts do
any diagnostic work. Theres been a lot of recent literature on work-
ing with, for example, people diagnosed with borderline personality
disorder, or, to use the more correct terminology, borderline states. Do
you undertake any diagnostic formulation with people when they
first come to see you?
RDS: Neverbecause I am among a growing group of people in
the United States who are very critical of the whole DSM [Diagnostic
and Statistical Manual (American Psychiatric Association, 2013)]
enterprise. Heres the way I characterise it in a blog that I wrote. The
DSM is the pseudo-scientific manual for diagnosing sick, isolated,
Cartesian minds [Atwood & Stolorow, 1997] that fails to take into
account the context embeddedness of emotional experience and all
forms of emotional disturbance. This is covered in the early work we
did on so-called borderline statesone can describe a borderline state
but not a borderline patient. My friend and collaborator, Bernie
Brandchaft, and I wrote a paper that had a rather subversive subtitle
Pathological character or iatrogenic myth? (Brandchaft & Stolorow,
1984]. It was on borderline states, in which we argued that the so-
called borderline character is an iatrogenic myth. Bernie had also
written about impasses, along the lines that we have just been talking
about. What we found when we were first starting to write this paper,
is that if you took a very vulnerable, archaically organised patient
and worked with that patient according to the theoretical ideas and
therapeutic recommendations of Otto Kernberg, pretty soon that
patient will start showing all the features of a so-called borderline
personality [Brandchaft & Stolorow, 1987]. The pages of Kernbergs
books will come alive right before your eyes. On the other hand, if
you take that same vulnerable, archaically organised patient and treat
him or her according to the theoretical ideas and technical recom-
mendations of Heinz Kohut, that patient pretty soon is going to look
like a severe narcissistic personality. The pages of Kohuts books will
come alive right before your eyes. Until theres a severe disruption
in the therapeutic relationship, the patient will start to look like
Kernbergs patient again. I think borderline states are not only prod-
ucts of the psychological structures within the patient, they are co-
constituted in an intersubjective field by the patients psychological
structures and the way these are understood and responded to by
the analyst. We extended that idea to all forms of manifest psycho-
pathology, from the psychoneurotic to the overtly psychotic. They all
have to be understood as being constituted, or rather, co-constituted
within an intersubjective context. This holds for every form of manifest
psychopathology.
DK: You are proposing that the so-called borderline pathologies can
be reproduced in therapeutic relationships that are not properly
attuned to the emotional states of the patient. You use the terms co-
constituted or co-created to describe this intersubjective process. It
is a cornerstone of your theory. Im wondering how you situate the
concept of countertransference within that conceptualisation.
RDS: Its not a concept that I use any more [Stolorow & Atwood,
1994]. Originally, the term countertransference was used because
Freud wanted to distinguish between the patients transference and
the analysiss transference. He viewed the analysts transference as a
reaction to the patients transference. This is silly. There is no differ-
ence between the analysts transference and the patients transference.
They are the samethey are both transference. I think we can expunge
the concept of countertransference and talk about the patients and
analysts organising principles and how they interacthow the
analysts unconscious organising principles interact with the patients
unconscious organising activity. This constitutes the intersubjective
system. Hopefully, the analyst, having been analysed, has more reflec-
tive awareness or can readily reach reflective awareness about his or
her organising activity; if not, the analysis would be a disaster.
DK: So the idea of countertransference is not required in intersub-
jective psychoanalysis. You do not see the need to make a distinction
between transference and countertransference, because what were

dealing with are interacting unconscious organising principles in both
the analyst and patient.
RDS: Yes, that is how I see it.
DK: I dont know if the phrase, increments of separation, is your
term, but Im wondering whether theres any relationship between
that concept and Winnicotts idea of holding or Bions concept of
the containercontained.
RDS: It is not a concept that I use. It came up in a joint paper years
and years ago that I did with Frank Lachmann and Beatrice Beebe. It
had to do with a patient who was traumatised by the separations from
the analyst; how that trauma over a long period of time gradually
became integrated so that the patient could tolerate longer and longer
periods of separation. I think its related to Winnicott in the sense that
when a patient is in any kind of traumatised state, whether its sepa-
ration trauma or any kind of trauma, the patient needs a kind of
emotional holding, and thats Winnicots idea, which is very valuable
in emphasising that. I dont like Bions idea of the containercontained
because theres too much Cartesian stuff there. The Cartesian mind
was a container. Kleinian analysis, which influenced Bion, retained a
caricatured version of Cartesianism. In analysis the therapeutic
version of the container concept is expressed in the idea of projective
identification. Melanie Kleins concept of projective identification
one isolated mind putting its contents into another isolated mind
sounds like demonic possession to me.
DK: Right [laughs]. Thats quite a graphic way of describing it.
RDS: I hate the concept of projective identificationthe idea of one
isolated mind shoving its unwanted contents into another isolated
mind. In these situations, we have to pay a lot of attention to
language, which I do, because Cartesianism is encoded in the
language that we use. There was a time in which I was doing a lot of
consultation, people who had experienced therapeutic failure,
analytic failure, and very often had been traumatised by their analy-
ses. Some of the cases were heartbreaking. The misuse of the concept
of projective identification is very frequent. The patient is given no
opportunity to understand their emotional experience because the
analyst might be having some unwanted experience, and they would
say, Thats not my experience, thats your experience. You are

putting that into me. That process is really damaging to the patient.
DK: How would you manage a therapist in supervision who was
reporting such a process to you?
RDS: I would say, Look, the emotional experience that you are
having is yours; it does not belong to the patient, it belongs to you. If
you think that your emotional experience is similar to the patients
or is in some way being evoked by the patients emotional experience,
that is different. It is something that you can investigate. You cannot
think of yourself as an empty container into which the patient is shov-
ing his or her unwanted contents. If I had a supervisee who insisted
on seeing things that way, she or he wouldnt last very long.
DK: Yes, this can rapidly turn into blaming and shaming of the
patient, I imagine.
RDS: Absolutely. I had somebody in my study group once. I ran
these study groups about thirty years ago. She was giving me an
example that would prove projective identification. She was sitting
with an archaic patient, and shethe therapistbegan to experience
an altered state of consciousness. She actually looked me straight in
the face and said, Now that has to be projective identification; that
altered state of consciousness cannot be mine. It has to be coming
from the patient. So do you know what my intervention was?
DK: No.
RDS: I burst into hilarious laughter, uncontrollable laughter. It was
so transparent. She just didnt want to own that as an aspect of her
own experience. She had to ascribe it to the patient.
DK: How did she respond to your laughter?
RDS: I dont remember; it was a long time ago.
DK: You talk about the locus of therapeutic action as the empathic
immersion with and understanding of the patient. How does that
become enduring for the patient? The patient might experience that in
the intersubjective field with you as the therapist, but how does that
specific intersubjective experience become an enduring feature of the
patients subsequent emotional experience?
RDS: I am not sure that I can answer that, but I would not use the
phrase empathic immersion because that still has a Cartesian qual-
ity that one mind can become immersed in another mind. I prefer the
phrase empathic introspective enquirya tracking of my experi-
ence along with the experience of the patient and how the two are
influencing each other. Anyway, what this work aims at, I would call
intelligibility, sense making. When someone can understand the
others emotional experience, in particular, the principles or themes
that are helping to shape the patients emotional experience, the
patients experience gradually becomes more intelligible to the
patient. Its that intelligibility or that understandability, I think, that
the patient gradually takes possession of as part of the patients own
expanded psychological organisation. My friend, Donna Orange, uses
a phrase that I think is a good way of describing the therapeutic
process. She refers to it as making sense together.
DK: OK. So you are not sympathetic to concepts like internalisa-
tion or identification as a way of conceptualising the therapeutic
process.
RDS: No, I am not sympathetic to these concepts. The question
becomes, What is internalised and what does it go into? Into what
is something internalised?
DK: I suppose ones mind [laughs] . . . I realise this is a Cartesian
concept [laughs]in fact, one of the central constructs of Descartess
dualism is the mind.
RDS: Yes, Descartess mind is a structure. His mind is an entity, a
container of contents. Descartes called it a thinking thing which is
ontologically separate from the rest of reality. You have this isolated
mind which is res cogitansthe container of contents. There is no
extension, so how does it make contact with the rest of reality? Youve
got this mind with its inner contents. But the question is, how does
this thinking thing thats a container of contents make contact with
the rest of reality? Locke and others have argued that it makes contact
by forming ideas that are contained within the thinking thing that
more or less correspond to external reality. Then you get the whole
question of epistemology. How do you determine whether the ideas
contained within the isolated mind are accurately representing enti-
ties in external reality?
The whole Cartesianism of representation is what we want to get

rid of. Its also become part of our common sense, so that organising
activity, for example, emotional organising activity, is not taking place
inside the patient. Its an organising activity of emotional experience
in general; these are ways of being in the world out therethey are
context-embedded, through and through. Theyre not just in the
patient. These are ways of being-in-the world. Whatever Im feeling
with you right now is a way of being with you, not something thats
just taking place inside of my cranium. Part of the field that were part
of is my emotional experience of you, just as your emotional experi-
ence with me is also part of that field.
DK: OK. So you dont use the concept of mind.
RDS: Thats right.
DK: So what replaces that? I mean, its a kind of Cartesian question,

but what is inside the patient that you work with if not a mind?
RDS: Organising activity. Theres a certain way in which beings are

organised.
DK: This construct reminds me of Sterns [1985] concept of a repre-

sentations of interactions that have generalised or RIGs. Is that not a
structure?
RDS: It is a structure, yeah.
DK: And yet it is not a mind?
RDS: It is not a mind because mind is an entity. Descartess philoso-

phy has become common sense. We think of the mind as a container of
content, a thinking thing, which is ontologically separate from the rest
of realitya thinking substance that has no extension in space.
Internalisation is a fantasy or a metaphor of something from the
outside coming inside. The object relations school uses the term inter-
nalised object relationsthe idea of external relationships being taken
inside where they become part of the patients endopsychic world
again, a Cartesian notion of something external being transposed
into an inner sphere [Stolorow, 2001; Stolorow, Orange, & Atwood,
2001a,b]. To what extent is my experience of you right now external?
The whole dichotomy of internalexternal is Cartesian metaphysics.
DK: So the process of intelligibility has to do with what exactly, if

its not taking in something that wasnt previously available?
RDS: The trouble is that youre using a Cartesian metaphor to
express something that needs to be otherwise expressed. Most of the
time when people use the terms internal, inside, inner, what
they are referring to phenomenologically is mineness. When you
say, taking insomething from the outside going inside to an inner
sphereI would say that it is not going inside of me; it is becoming
mine. It is an experience of ownership.
DK: Are you saying that the experience is always there in a differ-
ent form perhaps, in a form that is not yet able to be articulated or
owned or made intelligible?
RDS: Right. Initially, the patient might experience sense-making as
belonging to the analyst. But gradually, over a long period of time, the
patient comes to be able to own the sense-making. He begins to expe-
rience it as his or hers or mine. Eventually, every time that you are
tempted to fall into the Cartesian language of inner, internal, inter-
nalisation, and all that, you will understand that what youre talking
about is the phenomenology of mineness, of ownership. The whole
dichotomy between internal and external is just Cartesian meta-
physics.
DK: So ownership refers to a process or organising activity becom-
ing conscious, able to be articulated, intelligible?
RDS: Yeah! I think so, or it can just become more second nature and
less conscious.
DK: OKit can become more second nature and less conscious, but
is there a process in which it first has to become intelligible and
brought into language before it can become so well integrated to the
point that it can become unconscious or second nature?
RDS: I think so. I put a lot of emphasis on language and the process
of bringing emotional experience into language. Currently, in other
forms of psychotherapy, the focus seems to be shifted to prelinguistic
experience. I think it is a very important part of psychoanalytic ther-
apy, this process of bringing the emotional experience and the intelli-
gibility of emotional experience into language. Its very important.
This is central to the way I work. I am not saying that prelinguistic
issues arent importantthey are, and they are going on all the time.
But all of it needs to be brought into language and made intelligible.
DK: When youre working intersubjectively to bring the patients
emotional experience into language, Im wondering what language
patients will end up speaking, and whether they will speak an inter-
subjective language with you?
RDS: I hope not. What I try to do is speak the patients language.
DK: Yes. But what Im asking is not so much about the words that
they choose, but whether it takes on an intersubjective flavour in the
way that those analysed by Klein take on a Kleinian perspective and
understand their emotional processes using Kleinian concepts and
language?
RDS: Yes and no. One of the big differences between intersubjective-
systems theory and every other psychoanalytic framework is that we
dont prescribe any universal contents of experience. It is not a content
theory. Freuds was a content theory. The Oedipus complex was at the
centre of everything: all roads led there. Melanie Kleins was a content
theorythe paranoid position, the depressive position; she left out the
missionary position. Kohuts was a content theory, with his trinity of
selfobject needsidealising, mirroring, and twinship. Ours is not a
content theory. It is a process theory. Our two basic tenets are first,
experiencethat is, investigating the unique themes and principles or
meaning structures that take shape in a persons unique developmen-
tal history. There is no prescribed content; and second, contextall
these principles and structures always take form within an intersub-
jective or relational context. So my patients take on those broad
process principles, but they are not content principles.
DK: I understand. In terms of therapeutic action, it could be des-
cribed as experience that becomes conscious, able to be articulated,
brought into language, intelligible, and then becomes second
nature.
RDS: I would say that something is becoming mine. It is not going
inside of me. It is just becoming mine.
DK: OK. This notion of becoming mine implies to me a form
of integration so complete that it becomes a seamless, that is,
an unconscious, process that influences ones way-of-being in a

Heideggarian sense. Have I understood your usage correctly?
RDS: Yes, I think so. In a mutative therapeutic process, emotional

experiences become seamlessly integrated into my emotional world
and my sense of selfhood, where the my indicates a pre-reflective
sense of ownership.
DK: Is the process of becoming mine in any way synchronous

with Winnicotts true self [Winnicott, 1960], which he defines as the
unfolding of ones inherited potential in the context of good enough
mothering, which I understand to be the provision of a consistent and
responsive environment and what you would describe as empathic
introspective enquiry?
RDS: Yes, emotional experiences become mine (integrated) when

they find a hospitable relational home of human understanding in
which they can be held.
DK: Reflecting on the dream process is interesting in the context of

our discussion of the notion of mine. A dream is mine in the sense
that I am the dreamer, but dreams presumably also arise initially
within an intersubjective field. How do you understand dreams, and
how do you deal with dreams that patients bring?
RDS: Freud had some good ideas about working with dreamsto
ask for associations to elements of the dream, to look at what he called
the day residue, what happened during the day, which I call the inter-
subjective context of the dream. He also asked about the affect in the
dream, because he felt that this was the least distorted part of the
dream. There are two things that I would add to the Freudian way of
working with dreams. One is that Freud denigrated the manifest
content of the dream, the dream story, because he felt that it was the
last phase of dream distortion. The last phase of dream distortion was
that the mish-mash created by the primary process has to pass an
aesthetic requirement, had to make sense, to be a coherent story. But
for Freud, the coherence in manifest dreams was the most distorted
part of the dream, so he would not do much with the manifest content.
He would take the fragments or elements in the story and get associ-
ations to those details or fragments. However, I think the manifest
story is very helpful because it contains direct encoding of the
patients central organising principles, not in the details of the dream,

but in the thematic structure of the dream, which, abstracted from the
concrete detail, is often a window or direct pathway into the thematic
structure of the patients emotional world. I try to extract the broad
themes of the dream to help me understand the patients organising
principles and to bring those into conversation. So dreams can be very
useful.
Second, because the thematic structure of a dream reflects the
thematic structure of a patients emotional world, dreams can also give
direct access to the transference. Its a microcosm of a patients
emotional world. I use dreams that way to provide clues about whats
going on in the patients transference. I always regard every dream as
being in some way a transference communication. Once communicat-
ing ones dreams becomes part of the therapeutic process for someone,
the dreams become a way of communicating with the person to whom
you are bringing the dreams about your relationship with that person.
DK: I have understood during the course of this conversation how
imbued I am with Cartesian metaphysics, in such a way that this type
of thinking is second nature to me (laughs). Why do you think
Cartesian metaphysics is so embedded in the way that we think about
ourselves?
RDS: Well, thats a good question. For one thing, language structures
all of our experience. Cartesian metaphysics is encoded in the
language that we use. Second, Cartesian thinking is a rich source of
empirical objectivism. It lends itself to the scientific method. The meta-
physical concept of the Cartesian mind is reassuring [Stolorow,
1999b]. I have got this thinking thing that is not context sensitive; a
thing like a cup is going to be a cup whether I am holding it or you
are holding it; its going to be the same cup. Things are ontologically
protected against context embeddedness. We are reassured against
finitude. A thing has substance, solidity. All Cartesian thinking
creates metaphysical illusions because having a mind, having a think-
ing thing as opposed to an experience that will be constantly shaped
by ones context, reassures us, creates the illusion of permanence and
substantiality. Were reassured against the finitude of our emotional
life because we have this thing; its all taking place within this thing.
We have this metaphysical illusion, in other words, a reassuring illu-
sion, like all metaphysical illusions.
DK: Would you say, then, that fundamentalism of all kindsreli-

gious, political, ideological, and therapeuticare almost a caricature
of this Cartesianism, and also, using the language that you abhor, an
extreme form of projective identification?
RDS: They all share in common some form of metaphysical illusion,
an absolute or universal reality, an eternal truth of some kind. We dont
have to worry about global warming, for example, and climate change
because God wouldnt let that happen to humanity. Not to worry.
We can continue to destroy the earth, the ozone layer, not to worry.
DK: I imagine that you would also quarrel with the discipline of
psychologys organising principles, which, when one reflects on it,
contain endless Cartesian splits. We have discussed at length the split
between internalexternal. Now, I am thinking, for example, of the
split between cognition and emotion in psychological theorising.
RDS: Yes, this is a serious a Cartesian split in psychologythis sepa-
ration of cognition from emotion that has pervaded Western society,
and not just the discipline of psychology, but psychology departments
themselves. Have you ever noticed that psychology departments are
split along the same lines as Descartes metaphysics? You have got a
faculty that deals with the cognitive development and one that deals
with affective development and never the twain shall meet. I think
cognition and affect are a unity, always. Cognition, perception, emo-
tions, theyre always in unity, but we artificially separate them. The
first form of cognition is affect. The pre-linguistic baby knows itself
and the world through bodily affects. Early on in life, theres no sepa-
ration between cognition and affect whatsoever.
DK: This split is also evident in the different psychological therapies
that have developedthose that are more focused on emotion and
those that privilege cognition, like the cognitivebehavioural thera-
pies. You were talking earlier about the therapeutic process as a
process of meaning-making. What is the role of cognition in that
process?
RDS: In my view, meaning-making is a process in which emotion and
cognition are inseparable. Meanings are cognitiveaffective unities.
DK: Do you think the concept of meaning-making is similar to
Fonagys idea of mentalization?
RDS: I havent studied it carefully; I have an allergic reaction to

Cartesian-sounding words like Fonagys mentalization [Fonagy,
Luyten, & Strathearn, 2011]. My hunch is that what Fonagy is talking
about when he uses this unfortunate word is what I would call the
bringing of pre-linguistic and pre-reflective experience into language
or discourse, the bringing of affective experience into language.
DK: It is a complex enterprise to train oneself to let go of isolated
mind thinking because every time we open our mouths we are being
implicitly Cartesian.
RDS: Well, if we are thinking that way, yeah. If you pay a lot of atten-
tion to language, which I do, Cartesian ideas are encoded in the
language that we use.
DK: That is a problem in itself, because language defines our world
view; that is, our world view is circumscribed by the language we
have to describe our experience. Gadamer, in Truth and Method [1975],
argues this exact pointthat we are embedded in a historically condi-
tioned set of prejudices enshrined in culture and language, which
constitute preformed understandings that organise our subjective
experience. This issue is also related to your earlier comments about
the so-called non-specific elements in the therapeutic relationship.
RDS: Theres a quotation from Heidegger that I love that captures
this. It is one of my favourite Heidegger quotations. Language is the
house of being. In its home, man dwells. Language structures all of
our experience of being-in-the-world.
DK: If it is the case that we are born into a contextually embedded
Cartesian world view, if thats not too much of a paradox, how does
one then understand ones experience differently?
RDS: The post-Cartesian philosophies that have emerged, such as
those of Heidegger and Gadamer, Merleau-Ponty and Derrida, for
example, are based on a deconstruction of Cartesian concepts. The
non-Cartesian alternatives that Continental philosophers came up
with are very helpful as antidotes to the Cartesianism into which we
are born. Another thing that is helpful is to reflect on what might
be the purpose of these metaphysical illusions. A good example of
this is projective identification. This concept is used in a very self-
serving way by therapists and analysts. I mean, they can put all their
unwanted emotional experiences with the patient outside of their

own psychological world. I think it is very useful when one is falling
into metaphysical illusions of one sort or another, whether its
Cartesianism or any other, to reflect on what purpose is being served
by that.
DK: It is a form of comfort, presumably; it somehow exonerates the
therapist.
RDS: Right. I think it is most of the time. Making a sharp distinction
between inside and outside is very reassuring against what I have
called the unbearable embeddedness of being. Holding on to that
sharp distinction disavows our radical embeddedness.
DK: Is it only unbearable if the context is unbearable?
RDS: It becomes unbearable in the context of trauma.
DK: Yes, thats what I mean. But in other ways, the embeddedness of
being need not be unbearable.
RDS: It need not, except if you have a belief, like I do, that as finite
beings, we are always already traumatised; trauma is built into the
structure of our existence. Thats when it becomes unbearable.
DK: When one really embraces the finitude of our being.
RDS: Or when one is shoved into it kicking and screaming.
DK: This leads me to a discussion regarding how suicide is under-
stood from an intersubjective perspective. Winnicott said that suicide
is really putting an end to the physical body in the same way that ones
affective self had already been destroyed; that physical death by
suicide is the final stage in the process of self-annihilation.
RDS: Suicide is very context embedded. Winnicotts is one explana-
tion; one has already experienced psychological annihilation [Atwood,
Orange, & Stolorow, 2002] and continuing to live feels unbearable in
the context of that. Another reason that people can commit suicide is
intense shame and self-hatred. Others cant tolerate the uncertainty.
We know that were going to die, but we dont know when. Some
people cant tolerate that uncertainty so they have to make it into a
certainty, like doing the job themselves. Suicide is certainly a way of
ending uncertainty. There are all kinds of different reasons that we
cant keep living, including Winnicotts notion of the unbearability of
living in a state of psychological annihilation. However, I think a lot of

suicides are about shame and humiliation.
DK: I once worked with a family whose eighteen-year-old son
ended his life by suicide. They lived on a farming property in a
rural region. On the day he died, he drove to the furthest corner of the
property and shot himself. He left a note in the car that said nothing
other than Bury me under this tree. The trauma of this boys suicide
was overwhelming in itself, made more so because the way in which
he did it meant that his parents could never integrate the trauma.
RDS: That is an experience of horroryou were asking about horror
earlier. Here is an example of absolute horror.
DK: It certainly horrified me. Could you speculate as to the mean-
ing of that behaviour?
RDS: It would be very difficult to do so.
DK: It is interesting that many families say that they did not foresee
the imminent suicide of their child.
RDS: The boy was perhaps in a traumatised state that his family
members were not paying attention to. It may have been too painful
for them; people resist the pull to experience anothers traumatised
state. They want to shun the experience of trauma.
DK: This boy was embedded in a desperate economic situation, like
many farmers in Australia, who are constantly faced with imminent
ruin because they have no control over the elements and are subject
to floods, droughts, pestilence, and market forces. Farmers almost
always have an uncertain future.
RDS: That kind of uncertainty can be a type of trauma that becomes
unbearable.
DK: Yes, indeed . . . Have we covered the major issues to your satis-
faction?
RDS: Yes, I think we have.
DK: Thank you so much for engaging in this conversation with me
and for your insights. I have found it most illuminating.
RDS: Thank you. I think your project is really interesting and I am
impressed by the extreme thoughtfulness with which you have
approached this interview. Your questions were very thoughtful and

incisive.
DK: Thank you so much. When I read your work, I experience a
deep resonance with your writing, and at times, I have felt comforted
by it. Immersing myself in your writing has certainly been much more
than an intellectual exercise for me.
RDS: I have had that response from other people, especially from
people who have experienced trauma.
DK: Yes, I guess that is the portal, or the portkey, to really under-
standing your work and your readers reactions to it.
RDS: Thank you. I have enjoyed this conversation immensely.
CHAPTER SIX
Professor Allan Abbass: intensive

short-term dynamic psychotherapy
DK: Can we start by your telling me what personal or professional

experiences directed you into the profession of psychiatry and then
into the practice of ISTDP?
213
AA: I started out in family medicine and emergency medicine. I had

patients in my practice who had symptoms that I couldnt help with
[Abbass, 2005]. People would come for medical complaints, but I
couldnt actually figure out what was causing these problems using my
standard medical training. So I ended up starting to talk to people more
and I taught myself some elements of interpersonal therapy out of a
book. I found it fruitful to talk more with these patients who would
come with these complaints and with various anxieties and depression.
It was around this time that I was talking to one of my senior colleagues
who had had some exposure to ISTDP. I had no clue what it was, but
he said that based on my interests, I would really be interested in it. I
had always been a very self-reflective person, always interested in how
the mind works, how my own mind worked, how past and present
experiences have shaped me. I was doing a lot of self-reflection so when
my colleague mentioned this form of therapy, I looked into it and I
found out that I could train in this while I completed the second year
of my family medical residency. My course advisers agreed that I could
split the year and do this for half the year and do family practice to
complete my residency for the other half of the year. That was how I
got my initial exposure to ISTDPin Montreal at McGill University.
DK: Were you actually taught by Habib Davanloo?
AA: Yes, for eight months of the year that I was there, Dr Davanloo
was also there. He was doing live interviews all day on Monday and
would come out and teach during treatment session breaks. Trial ther-
apies were being conducted all day long; I watched videos, and there
were a couple of days in the week where we would have a supervi-
sion group or live interviews, or watch someones tape. I got to do
some intake assessments, and I got to see cases and was provided
supervision based on case videotape. Most of this training was
provided by one of Dr Davanloos senior trainees. That was my first
exposure to psychotherapy training, in fact. I had not had any expo-
sure to the more traditional psychoanalytic training so I didnt have
anything to unlearn.
Thereafter, I attended core training with Dr Davanloo from most
of 1991 to 2001. Core training was comprised of weeklong videotape-
based immersion courses and three or four blocks per year of four
days of group videotape supervision. Since then Ive continued to
attend the immersion courses nearly every year in Montreal.
PROFESSOR ALLAN ABBASS: INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY 215
DK: Was it somewhat of an advantage not having had previous,

more traditional psychodynamic training?
AA: Its possible that made it easier for me to actually learn this
methodthe fact that I didnt have other theories in the way. ISTDP
theory made a lot of sense to me, but the process of watching it on the
videos was, at first, shocking to me because of the level of activity. I
had trouble distinguishing between the therapist being active and
focusing on emotions and actually criticising and attacking the
patient. I couldnt separate those out at first. I wondered what he was
doing to the patient because the therapists activity was so pointed at
what the person was doing. What I didnt understand then was the
timing of the therapists interventions and all the clarifying that goes
on before you can actually challenge a persons behaviours. That part
of the process was happening so efficiently in Dr Davanloos work
that it was hard to see until I got more exposure to it myself. At the
end of each interview, the patient would be so appreciative, open, and
released that I recognised that something important was going on.
Thats why I stuck through it and I kept going with the training. I was
sitting there watching live interviews where he would be in another
room doing these trial therapies for hours in the day. He would come
out intermittently and talk about the process with us. This was a really
intensive exposure for me, having had no other exposure to hang my
hat on.
DK: It is really interesting for me to hear about your initial reaction
to this form of therapy because quite a few therapists to whom I have
spoken have had that same reactionincluding myselfof being
initially horrified about how the patient was being treated. Some of
them got over it but others felt that they were not able to practise this
type of therapy because it ran counter to their self-perception as a
therapist.
AA: Yes, I know what you mean. When I was watching those video-
tapes, it was anxiety provoking, but I didnt even recognise that I was
anxious because I thought he was attacking the patient. Sometimes I
was laughing out loud in class and saying, What are you doing in
there? When I started to recognise what was going on in the process,
thats when I started to notice I was anxious and having feelings
mobilised that were triggered by sitting there watching those inter-
views. I became aware that what was being activated by this exposure
to these intensive attachment exercises were my own attachment feel-

ings. It is the therapeutic attachment that mobilises all the other
attachment feelings and all the feelings about being hurt in attach-
ments in the past and this is basically what the therapy is about. I got
the benefit of that just with the training, with my own supervision,
seeing my own patients, watching my own videos, challenging
myself, consciously, actively not defending. It was quite an emotional
time, a challenging time, a learning time. I think that that was neces-
sary for me to learn, and also to stay with it. Now, if I had been fright-
ened and afraid of the process, I definitely would have stopped. If I
decided I didnt want to feel anxiety, I didnt want to feel emotions,
then I would have dropped out of training. Just by letting myself
become aware and start to feel emotions, I became aware quite early
on that there was such a gap in medical education, the gap being that
we werent taught about emotion physiology, what emotions are, how
they affect the body, what the impact is when they are blocked and
obstructed. All we were taught is how to treat irritable bowel
syndrome and panic with pills and some conversational approaches,
but all these other medical symptoms, such as chest pain and muscu-
loskeletal pain were taught mainly from the medical perspective,
which, to me is non-effective.
Based on having a dramatic experience with my first case that had
marked improvement over twenty sessions, I couldnt deny that this
was a very important process for this person, and for me. On that
basis, I decided to go back and do a psychiatry residency so that I
could teach and research this therapy, and make sure that it got into
the medical curriculum. Its really whats driven me over these past
twenty-two years.
DK: Have you undertaken any personal therapy or analysis?
AA: I havent had any therapy at all. I had previously had a couple
of counselling sessions when I was in medical school in second or
third year, where I met with a senior counsellor concerning the break-
up of a relationship. I think I went two or three times, just to deal with
the grief. I have never had exposure to psychotherapy otherwise as a
patient, except through the process of the training itself. Every time I
watched the video, I put myself mentally on both sides and watched
every hour of every video. I spent at least three to four years doing
this work with each video. Every hour Id watch and go through it
and see what emotions were going on in me. Quite quickly, early on,
what started to happen was when the patient would have break-
through of feeling, I would also have a parallel experience. Id be
having a breakthrough of feeling and the patient would be having a
breakthrough of feeling. So I got the therapeutic benefit out of all that,
just by tuning into the patient and sticking to the process of engaging
with him, not defending, being present and encouraging that person
to be present with me and to feel emotions that were being activated
by sitting with me, and then tying it altogether, and remembering
that. So therapy with my patients was having a therapeutic effect on
me; a lot of my colleagues reported the same experiences as me.
DK: You dont feel concerned about these breakthrough feelings or
the effect they might have on your patients?
AA: When a therapist is really stuck and blocked in one place with
the same thing happening patient to patient and its not getting
dislodged or cleared out by a supervision process, then he or she
might have a trial therapy of a few sessions or more. I guess it goes
against the theory that absolutely everyone has to have therapy, or has
to have years of therapy, or has to go to treatment in order to be able
to provide treatment. Im one example, and I know others too, for
whom it just wasnt required, and we can still provide high quality
therapy.
DK: So you virtually learnt on the job from patients and through the
supervisory process. I think more conservative psychoanalytic thera-
pists would be concerned that this represents a significant departure
from basic minimum requirements in more mainstream psycho-
analytic training.
AA: Im sure it is. I have had the same events happen that patients
have described during my training and supervision. It was the same
process. The stimulus was deciding to be present with the patient and
to let things happen, not to avoid things.
DK: So you were feeling parallel experiences with the patient. For
example, if the patient were having a breakthrough of grief, would
you experience grief as well?
AA: Sometimes. I was more thinking of the complex emotions of
rage and guilt, because grief would pass on its own without it being
in the room, although, sometimes, it would be. I would have some

parallel emotiona parallel experience for the patients grief, and for
the patients terrible story. Some of these stories are horrendous
what people have gone through in their lives; I dont know how they
make it through. This is part of grief, and sharing the patients stories.
I was thinking of what we call repeated unlocking, where a patient
comes in, defended, and feeling anxious, detached, and avoidant. So
we encourage them; together we focus to bring the feelings to
consciousness. They experience the complex feelings, they experience
the positive feeling, and they experience the physical pathways of
their rage. Theyre looking at an image of what that rage would like
to do. Theyre looking at the image on the floor. At first, it starts off
as if its me on the floor, but as they continue to look it becomes some-
one else from the past. For example, one patient had a feeling of rage
in her body. When I asked her what she wanted to do, she said that
she wanted to take me and flip me over and throw me against the
wall. So I am flipped against a wall and I asked her, What do you
see? I see a small Chinese man, and I dont know why. Shes look-
ing and she doesnt even know who he was. The next week, she came
back and said, I found out who that man was. That was my father
when I was really small. Thats the way he used to dress. She had
seen him in this very tight suit, and he was very thin at the time. As
he aged he got bigger and he didnt wear this type of suit any more
so he didnt look the same as he did now. However, the image she saw
in the session was an image of her father from when she was an infant
and was given away to care. This was a huge trauma experience.
These images and experiences are what we call a major unlocking of
the unconscious [Davanloo, 1995b].
When patients have those experiences, I have had some parallel
experience of my ownpast emotions showing up in parallel. I use
those feelings as a marker that the patient is experiencing emotions
too. When I am experiencing my own feelings, they are really strong
predictors that the patient was actually connected with their feelings.
So its really helpful. Now, today, Im sitting with a patient and I will
feel a parallel activation within me of rage, guilt, sadnessall these
feelings arise in parallel with the patients experience. But it doesnt
connect to anything within me per se. These feelings are just tied to the
patients experience. Im just picking up her emotions like a mirroring
process. Im just tuning in and I feel it with them. Its really helpful
because, first, they dont feel alone with their emotions. Second, it
gives me confidence that theyre actually feeling rather than just intel-
lectualising about it, and talking about it, which we want to help them
not do most of the time. They can intellectualise and talk about things,
but the work is actually feeling the feelings, experiencing them, not
just chatting about them. Were not just intellectualising and tying
things together, but going through the next step of experiencing
emotionsdealing with unresolved pain, rage, guilt about the rage,
and then being kind to themselves and stopping the anxiety and
defences from wrecking their lives any more. We want this to occur
as efficiently as possible.
DK: Do you consider those parallel feelings that you have while
working with a patient to be countertransference?
AA: Initially, I would call those feelings complex countertrans-
ference feelings. I was having a breakthrough of complex counter-
transference feelings, meaning that they were related to my own
attachments, pain, rage, guilt about the rage, grief, loving feeling.27
All these feelings were being mobilised by the process of engaging
and working with the patients. However, in recent years when Im
talking with my patients, Im usually having a parallel experience
that has to do with empathic attunement, allowing me to resonate
with their emotions. I dont consider this to be countertransference in
the classical sense because these feelings are not linked to anything in
my unconscious from the past. They are just an empathic experience
with my patient, a mirroring event. For us, countertransference is
used very rigidly to define transference of unconscious, unresolved
emotions from the past to the present. Some therapists and models
define countertransference as any feeling that comes up in the thera-
pist. But we try to separate the two; one is related to unconscious
feelings and secondary unconscious anxiety being triggered by the
patient, and the other is not primarily linked to unconscious anxiety
and feelings. Those feelings are related to tuning in to the patient.
To engage a patient with intense therapeutic pressure and challenge
will activate unresolved emotions in the therapist and can then
produce anxiety and defence against these feelings, sabotaging treat-
ment.
Were a herd species. When someone is alarmed, we all have our
receptors on and we can all become alarmed at the same time. Thus,
mirroring and empathic attunement are normal responses. We need

to clear up emotional obstructions in ourselves so that we can access
this system therapeutically in order to be able to be present and iden-
tify and feel things with the patient. I cant tell you how many times
I have been sitting with a patient and I feel some somatic anger
coming into my bodya heated movement upwardand the patient
is sitting there saying theyre not feeling any anger. So Id say, If you
felt anger, would you say so? and they say, No. I dont tell anyone.
I would ask if there are any feelings of anger right now, and the
patient says, Yes, there is. I have to go and ask because Im feeling
it. You have to actually ask some people directly if they have a feeling
because they wont offer it. I use my feelings as an indicator of what
the patient is feeling. One of my patients said to me, One thing about
working with you that I have noticed, and its important to me, is that
I can never lie to you. I could never fool you because you always knew
if there was a feeling happening or not!
DK: Are you saying that you sometimes anticipate the feelings of
patients and you use that to encourage them to express whatever it is
they are experiencing?
AA: No, I would not call that anticipation because Im not
consciously doing that. Its just happening, Im just feeling it. One
patient, for example, was talking about her father calling her names.
For a split second, I felt a shoot-up of anger in my body. But my
patient was getting choked up and anxious. She missed the anger. I
just said, What did you feel the second you were talking about your
father before you got all choked and anxious? Then she backed up
and felt the anger, and then her desire to choke her father. In that way,
all the feelings became connected. In that example, I didnt anticipate
the anger, but when I felt it, I realised that she must have felt it too,
but it was so quickly covered up by the anxiety and by choking
herself. It happened so fast that she didnt even see it. It was like a
flash, like a flashbulb. It is in those flash moments that you can pick
up the subtle passage of feeling that gets covered over really
quicklyinstantly repressed or projected outward. To do that, weve
got to be comfortable and relaxed. Weve got to be real and notice our
own emotions and not be afraid of them.
Davanloo talks about having a clear corner of the unconscious
mind so that you can see the patient for who they are without the
clutter of our past getting in the way and distorting the read. We can
then engage with our patient distinct from our own past complex feel-
ings and anxieties. Otherwise we are stuck, detached, anxious, or
defending. The therapist can end up sabotaging the treatment process,
being critical of the patient and not explaining what theyre doing,
getting misaligned.
DK: I can imagine that some therapists might have more difficulty
than you have had in finding that clear space in the unconscious.
AA: Perhaps. If we look at the average of five trainee residents in
psychiatry Ive had over the past seventeen years, on average, there is
one resident in each year who seems to be able to grasp the process
efficiently with good anxiety tolerance, typically a warm, likable,
sociable person. There are three who struggle with learning the
methodtheyre blocked up to some extent. They cant see things too
well, and they have some process to go through. The fifth is usually a
fragile person, meaning their anxiety interrupts their cognitive
perceptual function. They cant see or hear or think when they start to
engage a patient. They cant sit in the interview very well at all. So a
longer process is required for them to get used to working in this way,
to desensitise to their own anxiety, and start to be aware and start to
feel emotion. There is an extra added training phasea desensitisa-
tion phasewhere the anxiety tolerance increases.
DK: Are these fragile trainees eventually able to become ISTDP
therapists?
AA: They are if they persist in the training. But if a person has
significant fragility, theyre not going to be learning in the first months
because they wont be able to remember any of it. It all disappears
every week because the anxiety blocks it out. But if they persist, then
by six months to a year of training, they start to be able to focus in the
first fifteen to twenty minutes of the interview. Other than that,
they dont get anything much done in the interview. Its very flat and
intellectual. All theyre really doing is trying to keep their own anxi-
ety down, just trying to hold themselves together. They have got to
get used to that; its more about capacity building. For the three
trainees in the middle, its more about building awareness of emotion,
understanding tactical defences [Davanloo, 1996a,b]. Theyre not as
burdened by anxiety or defence. It is more about interrupting their
own defences, tuning into emotions, staying focused, using the inter-
ventions. The fifth person can actually sit in on the interview and
apply elements of ISTDP almost immediately. So, on average, there
are one-fifth of trainees with good capacity. This is from a pool of
people the university has recruited far and wide, who are thought to
have good interpersonal skillsthat is, above average to start with.
DK: OK, so it is really quite difficult to identify people who are suit-
able for this kind of work. What ongoing training have you had
beyond your training during your residency?
AA: I am continually training and learning case by case. Last year,
I went to an immersion course. I go almost every year. In addition, I
had supervision with Davanloo in blocks for several years to 2001. In
the block training from 1991 upward, there were different foci for each
training block. It all occurred on video [Abbass, 2004]the teaching
and the supervision. This allows us to look back and see whats going
on, how we felt, to review it, to allow transmission of the information
to other colleagues and learners. The video is the partner in the devel-
opment and dissemination of Davanloos method.
DK: The transparency with which ISTDP is practised and taught is
in sharp contrast to the secrecy in which psychoanalysis is conducted.
I wonder if I could turn your attention to the core skill set that you
teach your residents undergoing ISTDP training?
AA: Sure. The first is ability to provide the central technical inter-
vention, which is called pressure [Davanloo, 1999a], although the term
is a misnomer. What we mean by this is encouraging our patients to
be present with us, to identify emotions, and not to defend; to do
something good for themselves. Pressure interventions include ques-
tions such as: Can you tell me about your problems? Can you give a
specific example? Can you tell me how you feel? How do you experi-
ence those feelings? These questions support the therapeutic attach-
ment and begin the process of building an unconscious therapeutic
alliance in order to start to reach the persons defences. To do that, one
has to be comfortable to be with another person, to be engaged and
present with them, and to have emotions ourselves. Otherwise we
wont do the pressure, we wont want the person to be open with us;
we would want to keep them far away. For about one third of
patients, all you require are pressure interventions.
DK: So this group of patients only require pressure to have an

unlocking of the unconscious. Is that what you meant?
AA: Yes, these are low to moderately resistant patients, who have a
relatively small amount of attachment trauma and subsequent emo-
tions. But patients who are more traumatised, earlier in life, are highly
resistant. These patients respond to the pressure efforts to help them
open up by becoming tense, defensive, closed up, guarded, and
blocked. Thus, instead of opening up they pull away. They dont
know theyre doing it. Its involuntary. So our task is to clarify what
theyre doing, which is hurting their own effort, and interfering with
what we are trying to do together. We start to clarify that, so that they
see the problem, and then challenge them not to defend.
Thus, we enter the phase of challenge, which is the second techni-
cal skill an ISTDP therapist needs to understand and be able to
provide. In this phase, we challenge, collaboratively and collectively,
the defences that are understood to be the problem. I might say, Do
you notice that you have detached, are avoiding me . . . now your eyes
go away, youre closing up and slowing down? Do you notice that?
And then I say, But if you do that, its going to cut off what were
trying to do together. Do you know what I mean? Then I say, So if
you dont go detached, if you dont hurt yourself that way . . .
Interestingly, challenge is very supportive for the person because its
done to help the person out. Youre helping a person to do the best for
themselves. So challenge is required for highly resistant patients, and
in one of my studies, 55% were highly resistant. The remainder are
either low to moderate resistant or fragile. Low resistant patients have
only grief and they arent locked. They just have grief and they just
use minor defences to cover the grief. So, here is an example.
Patient: My father died when I was fourteen and Im having trouble deal-
ing with it.
AA: So the problem has to do with your father, pertaining to your
fathers death?
Patient: Well, it might be a little bit about that [using her defences]. Im
not sure.
AA: But when you came in you said you thought that it was about
your fathers death.
Patient: Well, I think it must be.
AA: OK. Tell me about your relationship with your father.

Patient: Well, I dont really remember my father.
AA: Do you mean you dont remember him? [minor defence]
Patient: [Gives an account of the day her father died]
AA: Theres a lot of painful feeling in you right there, when you talk
about this. [And then the grief just comes out].
Thats the whole treatment, concluded in one session in this low

resistant patient. There was no rage in the unconscious at all. There
was no self-harming, self-destructive system, no personality prob-
lems, only some minor symptoms of adjustment disorder. Her
defences were correspondingly minor diversionary tactics. These
defences really serve to tell us that we are in the right place and to stay
there: since they are directional arrows, they are almost part of the
alliance!
Now, the moderately resistant patient has some rage and some
guilt about the rage, and grief. For those patients, pressure is enough
to break through the defences, bring up the complex feelings and
open up the unconscious. These complex feelings are experienced and
open the memory banks, which bring this clear imagery and recollec-
tion of the events that lead to the defences. It becomes an unlocking,
without much else except pressure.
Highly resistant patients defend and put walls up in the room and
thats when we need to bring challenge to interrupt, otherwise they
just get more detached and the process goes dead. It becomes a stale-
mate. These are patients who could not be treated with more classical
psychoanalysis or other forms of treatment because they are just too
defended. This model of therapy was developed for precisely these
highly resistant people.
Another category is high resistance with repression. In this group,
when the emotions are activated they are instantly repressed, perhaps
into the stomach, into depression, or into muscle weakness. Instead of
the feelings coming up, they just go weak and sick in the body and
become depressed and tired as a result of that instant repression. That
group needs capacity building first. By this, we mean bringing struc-
tural changes at the level of unconscious anxiety and defence in order
to change the anxiety discharge pathways and defensive pathways
around: with this work, unconscious anxiety starts to operate in the
voluntary muscles versus the smooth muscle of the body. Defences

shift from instant repression to ability to self-observe, intellectualise
and isolate affect. Once this is achieved, they can start to feel safely.
Davanloo called this the graded format, in which we alternate pres-
sure with stopping and intellectually examining phenomena: this
helps the person observe the process and learn to self-reflect. This shift
brings a shift in the unconscious anxiety discharge pathway toward
voluntary muscle tension. Other psychotherapy models also use simi-
lar elements with these populations, but we optimise them purpose-
fully by watching the body anxiety patterns. We work right up to the
emotional level beyond which they cannot manage the activation and
are about to repress, then we intellectualise at that level. This process
gradually increases the level of activation before repression takes
over. This method is about as efficient as you can get to build capa-
city. This set of methods was discovered and developed from exten-
sive videotape review, including retrospective review of successfully
treated cases.
DK: Is this process of capacity building similar to Fonagys concept
of mentalization?
AA: Peter Fonagy and I discussed this at length once. We identified
some parallels between mentalization and our capacity building
approach. A conference comparing and contrasting the approaches
would be welcome. For us, the ability to isolate affect and to observe
it causes unconscious anxiety to go into the voluntary muscles, for
example, causing hand clenching and sighing respirations. That gets
the anxiety out of the bowel, out of the blood vessels, out of the rest
of the body. It just makes the patient tense; then they can start to feel
from that level. Theyre now ready to be able to tolerate the emotions
at the unconscious level. That is the objective for us but not the end of
the process: it is a first step to being capable of tolerating painful, anxi-
ety-provoking, unresolved emotions.
The other group of patients are those who have fragile character
structure and borderline organisation. They require intensive capacity
buildingwhich begins with helping them to develop psychic inte-
gration. We have to help them identify and understand their projec-
tions and projective identifications, and splitting defences. But the
process is the same, moving anxiety, for the first time, into the volun-
tary muscles, and increasing self-reflection. I say for the first time
because its usually a developmental problem where the patient never

developed the ability to be anxious. Its always been split and
projected out. When you block their projections, anxiety tends to come
in the form of cognitive disruptionthey start to have blurry vision,
fuzzy-headedness, and drowsiness. When we work with these
patients, theres no challenge. Its all pressure and then stopping and
talking about it; observing it and intellectually examining it, tying it
together, recapping and linking. So capacity building is another key
technical skill the ISTDP therapist must know.
For the highly resistant patient, we have challenge and an inter-
vention called head-on collision [Davanloo, 1999b], which is a com-
plex form of challenge and high pressure. It is essentially a statement
of the reality of the limits of what the therapist can do, the potential
of the patient, the problem of the resistance, and a lot of encourage-
ment for them to do something about it. Inevitably, if its well timed,
this will lead to a breakthrough to the unconscious.
DK: What are the essential differences between pressure and chal-
lenge?
AA: Pressure encourages the patient to do something good for
himself, as opposed to saying, dont do that. Pressure brings acti-
vation; the pressure is uplifting as it encourages a healthy action.
Challenge is interrupting harmful behaviour. Here, the therapist says
dont. When we say dont, we are activating different centres in
the persons mind than when you say do. Pressure results in acti-
vation and challenge results in inhibition. The key is the timing of the
challenge. Based on tens of thousands of hours of videotape
researchIve got over 2,000 caseswhen the defences start to move
into the room, when patients start to defend and detach and avoid and
go away from us, that represents mobilisation and crystallisation of
the anxiety and defences, which becomes an obstacle between us. This
is the time to start to clarify and challenge the resistance. If we do it
before then, its theoretical or hypothetical and the patient feels perse-
cuted because they dont understand it. This can result in a misal-
liance and prevents the rise in all the dynamic forces, including the
unconscious therapeutic alliance. So timing is critical. If resistance
isnt there, you dont want to talk about it. We wait until it shows up,
and then clarify it and challenge it with the patient. Misunderstand-
ings about timing occur typically at times when therapists become
confused about ISTDP and perceive it to be harmful. Misapplication

results in drop-out or adverse events.
DK: When there is a misalliance and the patient retreats or goes
back into resistance, do you acknowledge that it was a therapeutic
error creating that misalliance or do you just go back a few steps and
start again?
AA: It depends on what the source of misalliance is.
DK: Lets take, for example, mistiming the challenge as the source
of misalliance.
AA: If we challenge prematurely, the patient will go flat, but it
doesnt necessarily result in a misalliance. We might get an argument
because we dont clarify what it is we were challenging, and the
patient doesnt understand it, so we end up with a debate. In this situ-
ation, we just back up and clarify what it is we are talking about. We
have to express to the patient, in actions, that we have the highest
respect for the person, but the lowest regard for their self-harming
resistances. If you can couple together a strong positive regard for the
patient with a distinct lack of respect for behaviours that are harming
a patient, then you can do this approach here, without getting too
anxious about it. The therapist must be able to tolerate complex feel-
ingsthat is, be able to love and hate at the same moment and
not act out. The therapist can feel those emotions and not defend and
not get anxious and not get detached and not harm the other person.
Thus, the therapist can hold these complex feelings together. That
helps the patient to do the same, and that opens up the unconscious,
bringing these complex feelings all up together. This was Davanloos
major discovery: namely, identifying the need for the actual experi-
ence of complex feelings in order to unlock the unconscious. What we
dont want to do is splitcriticise or idealise the patient. There is a
therapeutic middle ground in which the therapist is working with the
patient against his defences. Have I answered your question?
DK: You have partly answered it. I also wanted to know whether
you would acknowledge a therapeutic error if you believed one had
occurred.
AA: When an intervention is confusing or a patient took offence at
somethingdepending on how theyre expressing thatIll just say
that really wasnt what I was intending to do. So, yes, Ill acknowledge
that I wasnt intending to do it and that will bring back the anxiety
and defences. They might come back to the next session and say, You
know, Im really [sighs] . . . [theyre all anxious], something
happened last session. Im not sure I liked it [sighs] . . . Ill say, Can
we look at how you felt with me? Youre tense when you are talking
about it. There is something happening. Can we look into it? Thus,
in this case, rather than apologise, the best move is to see what
complex feelings are being mobilised as the patient is talking about it.
If they didnt have a positive feeling about what I did and truly felt
it was something negative I did to them, then they wouldnt be
anxious any more. They would not be tense. They would not be
defending. They would be telling me that they didnt like it without
any unconscious signals. When thats happening, I know that theres
something that I messed up, missed, misunderstood, or just transmit-
ted wrongly.
We have so many cultures and languages here in Canada, things
can easily become misunderstood. You can be having a bad day, your
intervention was mistimed or any combination of factors can produce
a misalliance. The therapeutic decision the therapist makes is always
based on unconscious signals. Unconscious anxiety in the voluntary
muscles is a solid positive marker to keep going and focus on whats
going on emotionally under the tension. Its important not to get hung
up on words too much at that point, but just to go with the feelings.
Many patients defences centre around creating misalliances, debates,
and arguments with others to keep a distance, so a patient simply
saying the words you did something wrong does not necessarily
mean much!
DK: What are the major diagnostic indicators you use to place
people on the spectrum of resistance and fragility?
AA: This is a central skill set in ISTDP, namely, doing a psycho-
diagnostic evaluation of the anxiety and defensive patterns and levels
in patients. I have already mentioned voluntary muscle tension. Then
there is anxiety discharged in the smooth muscles like the bowel,
airways, and blood vessels. This anxiety pathway goes with depres-
sion, irritable bowel, and migraine; the person flattens out. The third
dimension is cognitive perceptual disruption where the person loses
vision or it gets blurry, or they lose hearing, or feel numbness; they
can even black out or faint. With motor conversion, there is no tension
in the voluntary muscles at all and muscles in one part of the body are
weak.
Davanloo identified three types of major resistance. The first is
isolation of affect, where the person intellectualises but does not feel
anything. The second is repression, which goes with smooth muscle,
conversion, and major depression. The emotions get repressed and
they go into those body systems. The third is projection and projective
identification. When projection is occurring, there is no unconscious
anxiety, but when you interrupt it, these patients tend to go to cogni-
tive disruption first. A person with striated (voluntary) muscle anxi-
ety will often report fibromyalgia and pain in the body, as well as
intellectualisation and emotional detachment. These tend to cluster.
All of these factors are assessed in the first minutes of the first inter-
view. We assess the level of resistance, the degree to which emotions
are mobilised, and the degree to which the patient sees their defences.
If you add these parameters together, it tells you which way to go.
You can really make a decision based on a few algorithms.
DK: Do you see patients with simultaneous striated and smooth
muscle tension?
AA: Not in the same second; theres a transitional period where
they might have some smooth muscle firing but the striated muscle is
relaxed. Research shows that people with irritable bowel and high
blood pressure look more relaxed than normal controls, because they
dont have voluntary muscle tension. Most patients have a threshold
above which they have smooth muscle anxiety, although when it is at
a lower level, they get voluntary muscle tension anxiety. So they can
have fibromyalgia, a whole lot of pain in their body, but when they
are coming to your office, they get diarrhoea just by getting out of the
house. Once in the office, they have a migraine and look flat. They
dont have any tone. Their stomachs cramping. When theyre at
home, theyre relaxed but tense, that is, relatively calmer.
If a person with cognitive disruption comes into your office and
they cant see well and theyre confused and cloudy, when theyre at
home at night, theyre scared someones going to come in and attack
them. Theyre really projecting a lot. They cant take a shower because
they cant hear the sounds and theyre scared. A different level of rise
occurs when theyre at home compared with when theyre out. It
changes its manifestation also. Some people start with a low level
where they can have striated muscle tension, then they have a higher
rise and the anxiety goes into the smooth muscle. At an even higher
level, they get cognitive disruption. So, on a bad day, theyre really
flustered and cloudy-headed; on a medium day, their stomach cramps
and they feel a little sick. On a really good day, theyre just tense.
Tension is best because at least theyre not in the bathroom feeling
weak and vomiting.
The transcript you presented for comment reminds me of a patient
of mine who had suffered depression for five years and was off work.
He said, My problem has to do with my childhood. He was tense
with sighing respirations and was ruminating in an intellectual way.
I said, I see you are anxious. Can we look into what feelings you have
coming in here? He said, Yeah. My childhood was difficult . . . I
said, But right now, in here with me, do you notice that youre really
tense? What is coming up here with me? I didnt go into the child-
hood rumination. The guy had had therapy for years and he still
wanted to talk about his childhood in a detached way. I opted to
mobilise the unconscious to look at what was driving all this uncon-
scious anxiety. So thats what we did for the first fifteen minutes.
There was a nice breakthrough, with complex feelings with me. In the
midst of the passage of feelings, including rage and guilt, he was
seeing a visual image of the face of his father. He had five sessions and
returned to work after being off work for so long. So, you can have a
lot of conversations, but if theyre all tensed up and defending against
the emotions, there is little value in that because people are already
able to intellectualise.
Were interested, as a dynamic psychotherapy, in helping our
patients to feel their actual emotions, not just to know them, but to expe-
rience them. Feeling the emotions is the key. They must first have the
capacity to tolerate emotions and then to feel emotions that cause
anxiety and defence. That process helps the vast majority of patients
with a broad range of problems86% of referred psychiatric patients
can benefit from this approach, that is, five of the six people coming into
a psychiatrists office in Canada were candidates for this approach.
DK: I was astounded when you told me that you have seen 2,000
patients in your career so far because a psychoanalyst would only see
between seventy to 100 patients in a whole career.
AA: Thats right. I remember calculating that. For example, Winni-

cott saw fewer than 100 patients in his whole career. By the time I
finished my psychiatry residency, I had already treated as many
patients as Winnicott, including some treatments that involved deal-
ing with early life phase trauma. I dont understand what might be
happening in psychoanalytic treatments that take so long unless the
goals are other than to work through unresolved unconscious emo-
tions. Like most of us, I have never viewed psychoanalytic treatment
being conducted. I have only heard conversations or read about
psychoanalysis. I dont know what it really looks like, unlike our treat-
ments, which are all videotaped and visible to practitioners. I cant see
the added value in all that many sessions, especially in Canada and
other countries were the health dollar is so stretched.
DK: I guess it is free association and greater therapist passivity that
together prolong psychoanalytic treatment?
AA: Dr Davanloo was very frustrated by the inactive stance in
psychoanalysis and what he found to be the questionable effective-
ness of it. He was trained as an analyst, so he had an insider perspec-
tive. He argued that therapists had to be more active to handle
resistances and to turn patients against their defences. Also, he was
concerned about the long waiting lists in Montreal in the public clin-
ics for long psychoanalytic treatments. So, shorter therapies were born
of necessity. He, and a few others including Peter Sifneos [1990],
James Mann [1996], and David Malan [1976, 1979], worked in the
1960s and 1970s to develop their own methods. David Malan aban-
doned his own approach due to lack of includable patients and collab-
orated with Dr Davanloo for many years. Having said this, ISTDP for
fragile and high resistant cases with repression is usually over 40
sessions so this is not truly short-term, but still much shorter than
for the same patients undergoing psychoanalysis.
DK: I noticed that Davanloo uses Malans triangle of person and
triangle of time as a conceptual basis for therapeutic intervention.
AA: Those triangles actually pre-date Malan [Ezriel, 1952; Mennin-
ger, 1958], but Malan emphasised them, brought them to prominence.
DK: OK. Are the triangles a major focus for you when you are work-
ing with your patients? Do you make those links?
AA: About one-sixth of my therapeutic activity is linking. In the first

session, it is a little higher at 19% [Abbass, Joffres, & Ogrodniczuk,
2008]. I use the triangles to tie together the feelings, anxiety, and
defences, from the past and current relationships and the therapeutic
relationship. We help patients see the tie-in between past and present
and we recap a session using the two triangles. This forms a psycho-
logical structure. It probably wires up some neurons to link past
present and opens up some gateways between pastpresent emotions
that are triggered with the therapist. Many patients come in and dont
even know they have linkages. Unconsciously, it doesnt exist or its
not activating. They actually require help to make those linkages. These
are central elements. This is one of the common factors across psycho-
analysis and psychotherapy; making the unconscious conscious is
another common theme. Were just as interested, obviously, in uncon-
scious processes as are other psychoanalytic therapists. The differences
are found in the level of activity. In the study of the first session, we
found that there were almost a hundred interventions an hour. That is
ten times the number of interventions some other models employ.
DK: There are clearly some commonalities between ISTDP and

psychoanalysis. I wonder if you could discuss these a little more and
also highlight the differences between the two approaches.
AA: The majority of all interventions are reaching for the person
stuck underneath the anxiety and defences. We consider this effort, as
expressed by pressure interventions, to be a central key. They have to
know we really want them to be present with their horrendous stories
and emotions. The only way we can communicate that is by reaching
to them with pressure, with interventions. Its not enough to say, I
really want to know you and I want to know your terrible stories.
Weve got to show it by our actions. Our actions are really actively
trying to encourage the person to be present with us. So the level of
activity and the central focus on emotional experiencing is what
distinguishes ISTDP from some other models. Psychoanalytical thera-
pies have these same foci when the process is going efficiently. But we
actively make those things happen; we dont wait for the patient to get
there before we intervene.
DK: I notice also that there is much less focus on history taking in
ISTDP. I recall Winnicott saying that psychoanalysis can be viewed as
one very lengthy history taking. You often dont have too much detail
at the point where you get the breakthrough of feeling about the key
people in the patients life. Even then, there is no pursuit of an almost
forensic history taking that occurs in other therapies.
AA: ISTDP with resistant patients is all about process, which means
opening the unconscious and helping the patient feel the emotions
and work through them. Up to that point in time, we dont care about
content. Content-based review can itself become a resistance and
delay access to the unconscious in resistant cases. In more fragile cases
and those with repression, there is more history taking and develop-
ing of the whole narrative as part of building psychic integration and
structure to be able to access the unconscious safely.
DK: You have this aspect in common with intersubjective/experi-

ential/phenomenological psychoanalysis. Their two key concepts are
experience and context. I think you are actually saying the same thing.
AA: Yes, it is all about process and what is happening in the room
right now. We work purposely to establish the unconscious thera-
peutic alliance; this is the alliance thats buried in the unconscious that
allows the patient to bring the images and the linkages and all the core
content clearly into the present. We aim to help get this unconscious
alliance dominating over resistance; getting the memory banks to fire,
to move beyond the frontal inhibitory systems in the brain. We want
to activate the emotional centres and emotional memory systems to
fire up louder, or at higher volume, whatever it needs to do, to go
beyond the inhibitory system. Until that happens, thats all were
focused on. We dont care what words are said, largely. This may
sound like a terrible thing to say. Sometimes we get patients who want
to beat around the bush for ten sessions or 100 sessionsthe patients
life is passing and we will interrupt this rumination for his or her own
sake. Likely the patient has already previously done that for hundreds
of hours and it didnt go anywhere, so we are not going to allow that
situation to repeat itself. If a patient comes in and tells me his father is
really nasty and starts to go into detail with ranting about his father, I
will cut across that and say, Right now, you are anxious; can we look
at that? Then we start to get a breakthrough of the complex feelings.
The rage is coming and then he is looking at the image on the floor
the damaged body there. I say, Looking down there, what do you
see? You would think he would see his father, but no, he sees his
mother. On the surface, he thought it was all about his father, but
actually in the unconscious at that point it was about his mother.
Often, feelings towards one parent are defended against by ruminat-
ing defensively about the other parent. For example, the patient was
angry with his father because his mother died and his father became a
drinker and virtually abandoned him, but the feelings related to his
mother dying were avoided. So when we achieved the breakthrough,
it was all about his mother, and he couldnt believe he had those feel-
ings about her. That changed everything for him. His annoyance with
his father was conscious and was defensive, too. This is why were
more interested in establishing the unconscious therapeutic alliance
and not getting hung up on the ruminations of the resistance in
anxious resistant patients. Thereafter, the content becomes central; the
patient starts speaking eloquently, even poetically about his life, with
imagery and emotion. Thats because the resistance has really been, to
some degree, either reduced or removed by the process.
DK: So you are saying that once you reduce the resistance, relevant
parts of the personal history follows, such as, for example, in the case
you just described, you learnt that the patients mother died and his
father fell apart emotionally, leaving the patient as a boy abandoned
by both parents.
AA: Thats right. I dont need to know the persons childhood.
When the alliance is established, they will tell me whats going on,
and I follow them. All I need to know is how to help them to be with
me. When that happens, the emotions emerge and everything else I
just follow and underscore and recapitulate. If defences return, Im
back on process again. Im back to helping them be back with me, to
beat down their defences. Then I am following again, following the
alliance, underscoring and so on.
DK: I imagine that this process would be especially important in
resistant patients because they will not respond until work has been
done on reducing their resistance.
AA: Yes, thats right. Here is a big difference between ISTDP and
psychoanalysis. Interpretation in resistant patients is actually
contraindicated. We use pressure, and challenge and head-on colli-
sion. An interpretation is only given after breakthrough. In the case
of graded work, we make interpretive linkings. Some people would

call that interpretation. In the highly resistant patient, that is a waste
of time from the perspective of this model. Thats why at least some
varieties of classical psychoanalysis wont work with these patients.
DK: What do you think makes interpretation ineffective?
AA: In resistant patients, it doesnt add anything. Moreover, it
supports intellectualisation and increases defensiveness. Thus, it can
even compound and prolong treatment.
DK: Presumably because they are not experiencing the emotion in
the present with you?
AA: No, and the other thing that happens is you risk the develop-
ment of a transference neurosis.
DK: Davanloo, unlike many current forms of psychoanalytic prac-
tice, discourages any form of regressive behaviour in ISTDP, includ-
ing intense dependent and erotic transferences, explosive affective
discharge, or the use of regressive defences. What is anti-therapeutic
about these phenomena, given that ISTDP theory states that there is a
direct relationship between the intensity of murderous rage and guilt
and the degree of resistance that must be overcome?
AA: Why add a neurosis to a person who already has neurosis? We
define transference neurosis as a build-up of feelings with the thera-
pist, thereby making the feelings towards the therapist part of the
problem, part of the neurosis. We want to avoid that altogether, and
we do, by bringing the feelings out that are mobilised towards us. We
help patients to feel the feelings as soon as they are evident so that
theres no build-up of feelings towards usno ambivalence, no
destructive or sexual feelingsbecause we actively keep all that out of
the way. Thats a big part of some psychoanalytic processesdevelop
the neurosis and then analyse it, but Davanloo and I see transference
neurosis as a really destructive force. You must remember I have not
had an analysis or psychoanalytic training and have been trained and
work through the lens of Davanloo, so this is my bias.
DK: Nevertheless, ISTDP is still a psychoanalytic therapy because
it is centrally concerned with experiencing emotion in a relation-
ship in the here and now, and there is a fundamental focus on the
unconscious and resistance. The cognitivebehaviour therapies are

not focused on any of those three elementsthe unconscious, the
therapeutic relationship, and resistance. A focus on non-verbal (body)
behaviour is central to ISTDP and is used to identify the type of soma-
tisation that is occurring during the session (striated or smooth muscle
tension, cognitiveperceptual disruption, and conversion reactions)
and the degree of fragility in the personality.
AA: Yes. We are interested in the signalling system of the uncon-
scious, which indicates whether or not unconscious anxiety is being
experienced in striated muscle tension. We look for that because, if it
is there, we can go directly to the feelings. The neurobiological path-
way of striated muscle unconscious anxiety goes up the sensorimotor
strip of the cortex, starting with thumb tension and hand clenching
and then up towards the neck and face. It also goes down to the
muscles between the ribs, the diaphragm, abdomen, legs and feet. In
a seated person, the main indicators are hand clenching and sighing.
The person doesnt notice their hand clenching or their sighing; they
dont notice theyre hyperventilating. They can have some discomfort
from the muscles getting tight, but dont notice it because it is uncon-
scious anxiety. When we see that, its a green light to go right to the
feelings that are there in the room and that are being mobilised.
DK: How are you with people who are crying?
AA: If it is due to grief, I will try to facilitate that very painful feel-
ing, or Id say nothing because its already being felt. I dont need to
say anything. For example, if a person just had a feeling of rage pass
and they can see the loving eyes of the father that they just murdered,
and all this painful guilt is emerging, we would facilitate that or say
nothing and let it be felt.
But if its self-directed anger, that is, being angry at oneselfwe
call this a regressive defence that manifests in choking themselves,
being harshly self-critical and crying due to neck tension. Then we
actually will focus on the feelings that are being mobilised because it
means there are some feelings that were triggered with us that turned
inward. So we try to uncover the feelings that were triggered with us
first before the patient turned the anger in on him- or herself. In this
situation, we apply pressure. So, how we respond to crying depends
on the meaning of the crying.
Guilt has its own somatic pathway and so does grief. These are
different emotional somatic pathways. We have been teaching
emotion physiology in our new medical curriculum for a number of
years to all the medical students, and the medical and surgery resi-
dents at our university too. We want a literate medical system, doctors
who can understand the emotional effects on the body and how to
pick these things up. We want our doctors to be more self-aware.
DK: Can you say a bit more about these different pathways for the
different emotions?
AA: Yeah. The somatic pathway of rage starts in the bottom of the
body, feet and lower body, with heat, energy, or a fireball moving
upward. It moves upward and as it does, it displaces any tension and
anxiety all the way up as it passes up. So the tension stops when the
heat and anger come up. It goes up to the neck, down the arms to the
hands with an urge to clench and express aggression, and in some
people it then goes to the jaw, with an urge to bite. So rage moves
from the lower spinal levels upward.
Unconscious anxiety moves from the top spinal levels downward.
It starts in the middle of the neck and goes south. The emotions are
going north, upward, and pushing outward the unconscious anxiety
all the way up. Thats the somatic pathway of rage. There is an urge
and some thoughts about aggression. It has a wave that comes and
goes like a sine wave.
The somatic pathway of guilt involves upper body constriction
and pain when the person experiences remorse looking at the dead
person. Its guilt about rage and often is accompanied by the pain of
grief as well. It has a wave that comes and goesa solid wave. During
the middle of it, the person cant talk. There is too much pain and
theyre immersed in it.
Grief is not so much a solid wave. Its not as painful in the same
physical sense as guilt is. It comes and goes, and the core content is
loss; there are also loving feelings and feelings to attach. There is also
a moving warmth in the body, mid-body, chest and an urge to em-
brace or reach toward a person.
These things are physiologic events but we dont talk about or
think of them that way. I think psychology has missed this in almost
all textbooks. The literature there is confused because they usually
confuse rage with anxiety, the behaviour, the defence, and the body
experience. When you look at books on emotion, its confusing.
When you understand emotion the way Davanloo does and work
with the emotions in this way, you get directly to childhood issues
and all the painful feelings and trauma. Before then, the anxiety and
defence cover all the feelings up, and thats why people appear in
your office.
DK: Do you draw on Steven Porges polyvagal theory to under-
stand these physiological pathways of the emotions that you have just
described? The polyvagal theory [Porges, 2001, 2007] explains how an
increasingly complex neural system developed in order to regulate
the different neurobehavioural states needed to deal with environ-
mental challenges. Porges argued that the physiological states under-
lying all survival-related behaviours are associated with one of three
neural regulation pathways or circuits. The three circuits and their
associated behavioural strategies are the freeze response or playing
dead, which is the most primitive circuit, the fight/flight response,
and the communication/social engagement circuit. The theory states
that under increasing levels of threat, people move to circuits that
have an older evolutionary history. I have read some papers on ISTDP
that refer to Porges theory with respect to these neuro-emotional
pathways that you have just described. This leads me into my next
question.
I work with musicians with severe music performance anxiety.
These musicians often report bizarre experiences; for example, when
they start to play their instruments under conditions of social threat,
they report that their limbs feel as if they do not belong to them, or
theyll look at the music but feel unable to read it. Others report
explosions going off in their brains and so on. How would you
understand such symptomatology?
AA: You are describing a person with fragile character structure that
is associated with depersonalisation, derealisation, and dissociation
under the burden of the anxiety. For musicians, it is likely connected to
the assessment people are going to make of their performance. It has to
do with being scrutinised, which is related to the trigger of a trauma
response that mobilises a lot of painful feelingrage, and guilt about
the rage. Usually its very heavy rage, and that leads to cognitive
perceptual disruption. They dont notice these feelings. If you have a
session or two or three or four with these people, it makes a huge

difference. They become able to look at a crowd and smile. Before that,
theyre scared, robotic or frozen. They would have prepared for the
performance mechanically and then go do it and dont think about it.
But that strategy doesnt make the best performers, obviously. Theyre
not in it, even though they can play it. Performers need and want to be
in it, connected to themselves, able to bring a feeling of joy to the
performance instead of feeling terrified about it.
DK: Yes, the emotions are extremely intense. Many musicians have
told me that going out on stage to perform is akin to torture. They
actually use the word torture.
AA: For fragile patients, their unconscious rage actually has a
torturing quality; its intense to the point that they not only want to
punish somebody, they want to make the person suffer a torturing
experience, for which they feel very guilty. So when they try to reach
to that feeling, they get all cloudy and cant see straight, and get dizzy
and drowsy until you help them acquire the capacity to face it. Its a
hell of an experience for them because its strong rage, so theres a lot
of guilt in it. Thats why theyre disorganised. You can build up the
anxiety tolerance though. Fragile character structure is a result of
trauma in infancy, inside the first two years of life, plus a lack of
compensatory relationships to develop more adaptive defences.
DK: Do you space the sessions differently for people with fragility
compared with other, less damaged patients? For example, would you
see them more often than once a week?
AA: Its generally once a week, and its usually for an hour. If its
every two weeks, Ill make it an hour and a half. If, for some reason,
a person can only come monthly, I might make it three hours. Theres
another thing called block therapy, where a person will come for, say,
sixteen hours of treatment over a few days. Thats usually for people
flying in from a distance. We give them sixteen sessions in a few days
and they are able to have sometimes ten or more unlockings, which
has a huge effect on them.
DK: And that doesnt vary with the level of pathology?
AA: No, not usually. When I first started to do this work, my
sessions were longer. I just had them longer on purpose. I wanted to
make sure I had time with the patient and had time to do what we
could do. I was having about two hour sessions. But everythings
gone shorter over time. As far as a trial therapy, I average about ninety
minutes. When I first started out, I would leave a whole afternoon and
take several hours to do a trial therapy. Now, its more efficient.
However, sometimes, people need a series of sessions before you can
tell if they are likely to benefit or not, because patients often have a
broad range of problems to deal with. Some have bona fide medical
conditions; others live in really bad social situations. Serious medical
or social problems can interrupt therapeutic efforts.
DK: In very fragile patients whom youre only seeing once a week,
would there be a risk of major attachment crises occurring between
sessions?
AA: Even with fragile patients, it is very rare for them to go into
crisis between sessions. We just dont see it. Once we get the ball
rolling with a good trial therapy, the patient feels contained between
sessions. I dont get the phone calls, desperation emails; that is very
rare. The therapy has a containing effect on patients from the outset.
The person is doing hard work in the session, and theyre the first to
tell you, this is hard. If the person has been projecting his or her whole
life and blaming everybody else, and youre sitting there helping them
stop doing that, thats hard. So they know its hard work, but it gives
them something to chew on in between sessions, and they feel like its
going in the right direction. So their hope goes up and theyre acting
out goes down. I have heard of only a very few suicides that have
happened in relation to this form of therapy, and typically those
people were not attending therapy at the time of the suicide and had
major psychological problems, including histories of psychosis and
repeated suicide attempts.
DK: What might undermine the success of a therapy in the absence

of these complications?
AA: Misalliance or technical problems. Theres a rate of non-

response though. If were going to have a non-outcome, were going
to find out quickly because we start off with a trial therapy. If a
persons not going to respond or theres some issue thats going to
prevent treatment from being effective, were going to discover that at
the outset. So rather than embark on a long treatment and hope its
going to eventually get somewhere, we do a trial therapy, which is a

very strong predictor of outcome. I do not accept a person and say Im
going to treat them for years. Trial therapy will indicate the odds of a
successful therapy. It also gives the patient an opportunity to assess
whether they are interested. Simply put, it is not for everyone and
everyone is not suitable for it.
DK: How do you manage those people whom you find unsuitable
for this approach?
AA: If after five or ten sessions we see a non-response, we would

either do a consultation or consider termination. If we dont see any
signals of unconscious issues emerging, we cant discern any activa-
tion of the unconscious, if there is a complicated social setting, sub-
stance dependence, or a psychotic process operating, we refer them
for other appropriate treatment.
DK: How do people respond when you tell them that you think the
best course of action is to refer them somewhere else?
AA: Its virtually always a mutual decision. We discuss it with the

patient before acting.
DK: So there is a group of patients for whom this therapy is contra-

indicated?
AA: Yes. We have had an occasional patient, for example, with

delusional disorder, who becomes fixated on having this treatment
because they saw it in the newspaper. So we try. But really the person
is psychotic and we really cant do a lot there. Were not seeing any
unconscious signal. Theres no internal process. Either the person is
externalising or their problems are actually all external and we cant
treat external problems with this approach. Theres no psychodyna-
mic treatment for external problems: external problems require an
entirely different responsea socially based strategic response, like
getting them into secure accommodation or out of a situation in which
they are being abused or harassed. These external problems need to
be addressed first before unconscious issues would be accessible.
DK: What is your approach to treating patients who present with a

long medication history of psychotropic drugs?
AA: About 95% of people come to therapy in our service on psycho-

tropic medications. We stop the medication most of the time. Over my
career as a psychiatrist, for every pill Ive prescribed, Ive stopped
twenty.
DK: I imagine that you are not popular with big Pharma [laughs].
AA: There are some well-meaning drug companies and reps who
want to help patients and will fund education in the psychotherapies.
They want to help their company also, but they know medication is
not enough. They know that other treatments are needed. We are
completing a study [Abbass, Kisely, & Rasic, n.d.] showing a $10,000
cost reduction per patient after an average of seven sessions of ISTDP
treatment by reducing hospitalisations and physician costs. In the
three year follow-up, costs reduced by $10,000 per patient compared
with the previous three years.
DK: Thats quite astounding. The fact that you are able to treat so
many more people than the more traditional psychotherapies makes
it much more cost and time effective. What are your thoughts about
the age of the patient? Is there an upper and/or lower limit?
AA: I have worked with patients as young as twelve years old; I
have a colleague who has worked with even younger children. ISTDP
can be effective with young people if they can work like an adult and
have some striated muscle unconscious anxiety. We should also con-
sider family therapy when younger people present for therapy. I like
Minuchins work [Minuchin, 1974]this form of family therapy has
some elements in common with ISTDP.
As for the upper age limit, Ive worked with people in their seven-
ties and eighties. We typically do a short course of therapy, usually
less than ten sessions, for an adjustment issue, even though they may
have long-standing issues and possibly character issues.
DK: Do you see decreased responsiveness in this older age group
the cant teach an old dog new tricks issue?
AA: No, on the contrary. Therapy seems to help them out quite a
bit. In fact, one of our studies showed that this older age group had
greater medical service cost reduction compared with younger popu-
lations [Abbass, Kisely, & Rasic, n.d.].
DK: Many studies internationally show that the bulk of the medical
costs for any one person occur in the proximal years before death, so
there is greater potential to reduce these costs because of the initially
higher medical costs in this age group.
AA: Thats right, but we are seeing this cost reduction, sustained in
long-term follow-up, as the patients become even older.
DK: ISTDP grew out of classical Freudian psychoanalysis. There are
both commonalities, for example, mobilising the positive transference
(Davanloos unconscious therapeutic alliance) and removing the
major resistances, and differences between Freudian psychoanalysis
and ISTDP. For example, ISTDP does not use the couch, free associa-
tion or a passive therapist. Can we look at each of these? I gather
that everyone sits up for ISTDP.
AA: Yes, thats right. We want to use chairs with arms, so that we
can follow the rise of striated muscle anxiety and to be face-to-face,
squared up to maximise eye contact. Eye contact is important in terms
of early attachment because the early bond is through the eyes, so we
are really interested in having eye contact.
DK: We have touched on free association, which is the cornerstone
of classical psychoanalysis, but do you have any other comments on
it here?
AA: We dont use free association and I believe that in many or most
cases, it sets the stage for a victory of the resistance, through delaying
therapeutic ingredients. Our goal is to mobilise the unconscious thera-
peutic alliance and access the pathogenic emotions as rapidly as the
patient can bear. To do this we actively work on the resistance in order
to reach to the patient stuck underneath the resistance.
DK: Because the ISTDP therapist is so active, silence occurs less
frequently in ISTDP compared with other therapies that use silence as
a therapeutic tool. How does ISTDP view the function of silence? Is
there a place for silence in ISTDP?
AA: Yes. There is a place for silence. When a person sits there
passively, I might go silent as a way to use pressure to encourage the
patient to become more active. So Ill sit and wait, thereby exerting
pressure. This is one situation, by the way, where an analytic stance
may be quite effective.
DK: Do you acknowledge or deal with oedipal issues?
AA: Sexualised attachment with the opposite sexed parent doesnt

form any pathology on its own, but rage with a sexual component
carries with it huge guilt. Its part of the rage and guilt system, but
thats not the Oedipus complex. Thats sexualised rageraping or
sexual violence is part of rage. Sexualised rage is not the same as an
affectionate sexual feeling. Theres case-based evidence for the oedi-
pal theory in specific cases as a major pathogenic force. I have not
observed it in any of my cases, nor has Davanloo. Ive heard of
patients actually correcting the therapist when he tried to suggest an
oedipal triangle at one point.
DK: As did little Hans, Freuds famous case that purportedly

proved the Oedipus complex, when his father suggested an oedipal
dynamic [laughs].
AA: The reality is that the patient is likely to want to murder the
same sex parent because that parent interrupted the relationship with
their opposite sex parent. For example, if a father keeps thwarting the
efforts of his son to attach with his mother, the boy is going to start to
feel jealousy and rage toward his father, and then guilt about the rage
towards his father.
DK: And a similar process would occur with a daughter?
AA: Yes.
DK: Do you have a position on therapist self-disclosure?
AA: Self-disclosure doesnt really come up much. It might happen

if a person just tosses out a question. For example, if Im focusing on
the feelings of children, the patient might say, Do you have kids?
and Ill just say yes. Then they go on. We dont make a big to do about
it. I dont want to interrupt things by getting hung up on a simple
question.
DK: What about touching patients?
AA: I dont do any touching; its not in the realm. I might shake
hands after a session if the patient offers a hand but I dont offer a
hand. I dont put a hand on their shoulder or offer a hand as a gesture
of comfort, although I know that some colleagues do.
DK: What is your attitude towards gift giving?

AA: As far as gift giving, tokens that reflect the collaboration that
we had are really nice. Because our treatments are typically short, we
dont have to deal with some of the issues that arise in the more
prolonged therapies in which strong attachment bonds form with the
therapist.
DK: How are dreams worked with in ISTDP, if at all?
AA: In 1992, I remember saying to Dr Davanloo that most of my
patients dont bring dreams to their sessions. I asked him why. He
said, Thats because they dont need to bring dreams because youre
unlocking the unconscious [Davanloo, 1996c] each time they come
and the content is coming through in the day time in the session.
Theyre dreaming while theyre awake. So we refer to the uncon-
scious alliance that patients form with the therapist as dreaming while
awake. They are seeing dream-like images coming up in the session.
Even between sessions, some patients report looking in the mirror at
their teeth and seeing fangs. When they look at their hands, they see
hair like a wolf. Then they look out to their swimming pool and
theres the mutilated body of their mother floating around in the pool.
This is the unconscious alliance. This is dreaming while awake. So we
dont get into dreams per se; we dont need to. One exception is during
the capacity building phase in patients with low anxiety tolerance or
fragile character structure. In this setting, dreams are used as vehicles
to build capacity to tolerate complex emotions and anxiety.
DK OK. What factors constitute the essential mechanisms of
change in ISTDP. This question is related to termination, so we will
tackle them together. Davanloo [2005] states that termination can be
considered when the patient is symptom free, shows multi-dimen-
sional structural character change and that the pathogenic organiza-
tion of the unconscious has been totally removed (p. 46). How do you
achieve these outcomes?
AA: The first mechanism of change is building capacity to tolerate
anxiety. That has a good effect on its own; it helps to build the capa-
city to achieve breakthrough to the unconscious. If the patient can
tolerate a high rise in emotion without defending and without getting
sick, this will bring about change and symptom reduction. However,
breaking through to the unconscious rage and guilt and experiencing
the guilt and the rage will bring character change. It brings a soften-
ing of the interpersonal space. Theyre not afraid of killing anybody.
Theyre not on a guilt trip interrupting all their relationships. Thats
an important change agent in this approach. Thats when you see
interpersonal problems changing and this improvement in interper-
sonal relationships strongly correlates with cost and service use
reduction. To be clear about total removal, in the real world, we do
many partial courses in which the depths of pain, rage, and guilt are
not fully worked through in highly resistant and fragile cases. In
moderate and low resistant cases, the bulk of the unconscious is exam-
ined and worked through.
DK: Davanloo states that many patients have experienced major
trauma early in life, which is associated with primitive, unconscious,
murderous rage, guilt, and grief in relation to early attachment figures
and that these factors give rise to major resistance and major charac-
ter disturbances. What advice does ISTDP offer with respect to child
rearing practices to help prevent such disturbances?
AA: If parents project on to the child, that will agitate the child, so
when we treat a parent, were treating their child too. How many
times do you see children improve when you treat their mother and
father? For example, a mother comes in complaining, My childs in a
terrible shape. Hes got ADHD, conduct disorder and obsessive com-
pulsive disorder. Hes on all these pills. Then you treat the mother,
and they say, Oh, whats happened? My sons got better, doing so
much better in school, is so much easier to manage. We havent
treated the child but we have reduced the parents projection on to the
child and when we can do that, it takes the burden off the child and
the parent can then be more attuned to the child.
DK: What about our world which is continually in crisis and
conflict?
AA: Id say the commonest threats are projective processes and
herd mentality that comes out in people who feel attacked, and who
react as a herd and declare the other side an enemy. It becomes herd
versus herd, and the projection sticks there; it becomes a way of
reducing anxiety for people who have neurosis. In some conflict situ-
ations, people experience less anxiety and depression because they
have an external threat to deal with.
It is a similar dynamic in abusive relationships. A person in an

abusive relationship is under constant threat. They dont have many
symptoms; theyre just externally burdened. They maybe tired and
afraid, but when the victim gets out of that relationship, they collapse
with severe depression and self-destructiveness, and suicide becomes
a risk. We think things should improve after getting out of an abusive
relationship but they dont because the person is imploding. They
have always had the rage and guilt within themselves, and it is trig-
gered by their abusive husbands. When a person no longer has an
external abuser, the internal abuser kicks in. The aim of therapy is to
help them deal with the underlying feelings. This is a very common
scenario, this repetition compulsion in people like this. We under-
stand it as a self-punishing superego system, which is also built to
protect others. The superego has a positive function, but it is also self-
constricting, so theres a negative function there as well.
DK: How do you interact with a person who comes in complaining
of existential angst, of meaningless, of the futility of a life that is finite?
AA: If I see someone coming in with that presentation, they are
usually tense and ruminating. I make a decision about how to proceed
on the basis of unconscious signals, of unconscious anxiety and
defence. If I see that, and if someone comes in vague and ruminating
about the world, I might say, Whats happening when you come in
here to meet with me because youre talking about these things, but
Im not really getting a sense of who you are. Im hearing your theo-
ries and these thoughts going round, but who are you in there? Then
I will start pressing for them to be present with me. Then the tension
will come and then the defences will come, and then well be in the
process of opening up the unconscious. Usually there are some unre-
solved issues that are getting triggered by the phase of life. Different
life stages bring different challenges. This implies an emotional
process with losses, so these types of patients will come for a meeting
or two, or a handful of meetings, to sort out whatever is being trig-
gered by that phase of their life.
For a person who becomes obsessed and ruminates about the
meaning of existence, I think it is a process of uncovering the uncon-
scious meaning of whats going on. I am just going to focus on the
feelings that are there under the anxiety and see if they can really be
present with me in order to sort out what it is thats making them
worried and tense and anxious. Soon, the symptoms and worries and
phobias will start melting down. In patients who are highly resistant,
we are uninterested in content until the unconscious therapeutic
alliance is activated. In low resistant patients, the content is already
there; they are already open, but those people are really rare in the
clinical world. Ive only seen six or seven out of approximately 2,500
patients. I havent even seen ten low resistant patients with no rage in
the unconscious. Thats probably because Im a psychiatrist and its
harder to get to me. But there are people out there who have no buried
rage. They just have grief related to specific losses and my role is to
help them feel the grief. It doesnt take much since they only have
minor defences. However, for the highly resistant patient, where there
is rage and guilt, it takes much more work.
DK: How does ISTDP understand fundamentalism? For example,
there was an incident in Denmark in which Muslims rioted because a
cartoon depicted the prophet Mohammed in a disrespectful light. We
had a similar incident in Australia in which a riot broke out as a result
of a video clip that was posted on the Internet being interpreted as an
insult to the prophet. In that demonstration there were children as
young as three years old who had been given placards to hold in
the street that said, Behead all infidels who insult the prophet,
Mohammed.
AA: I think many religious structures can become an element of
resistance. Also, within these structures can also be elements of
alliance. The worlds major religions support positive regard for
others. If you think about it, what is it that prevents people from doing
that with each other and having a high regard for each other, and
furthering the development of one another? The answer is resistance.
Its like jealousy. If a person is developing and someone doesnt want
them to develop, they feel jealous about it and want to thwart the
efforts of the person who wants to develop. Parents can do it with their
children, but so can neighbouring communities or countries. If one
country has more money or resources, this can produce envy in their
neighbours and lead to attempts to undermine them in some way. The
same thing can happen within different religions. Simplistically, this
type of behaviour can be understood as a defensive structure, which
also contains elements of alliance (the herd mentality). Societies and
cultures shape both health and pathology of all its members.
Underlying all the structures of culture, though, are just hurt

people, with their emotional pain, rage, and guilt that stimulate
unconscious anxiety and defences. That part can be cleaned up. Its
harder to address the social problems, financial imbalances, the prob-
lems of politics, governments, religious differences; these are tough
problems to tackle.
DK: Yet, some people override the herd mentality or collectivism
which are so important to the survival of social groupsthe idea that
what is good for one is good for alland become what is described in
mainstream psychiatry as antisocial personalities or sociopaths, those
who disregard and violate the rights of others.
AA: If a person enters the world with positive self-regard, he is able
to access his own emotions and understanding of other people. These
capacities provide the potential for that person to make a useful
contribution in the world. They have no need to blame or attack
others. Davanloo defines mental health as good anxiety tolerance
the ability to tolerate ambivalence, to tolerate mixed feelings, to see
multiple perspectives without splitting, without turning anger inward
and getting sick, or outward and blaming and attacking. Its a simple
definition, and we have efficient, specific ways to turn a long course
of treatment into a short course of treatment with the first goal being
to build this capacity.
I would like to meet some of those people you are referring to and
talk. I have worked with offenders or former offenders. I had one guy
who was carrying a gun for the whole treatment. He told me at the
end of therapy and Im glad I didnt know. This guy said to me, I
have an antisocial personality disorder; I dont think youre going to
be able to help me. Then he started heaving a lot of sighs and started
to work. This guy had completely adapted to his environment and it
became understandable as to why he had become a gangster. If you
knew this guys story, you would understand that it was the only way
he could have survived. So we got a process going; he had uncon-
scious anxiety. He was not a sociopath; he was not a guy without a
conscience. In fact, he had too much conscience. So he could be
helped. He will do less harm when he feels better about himself. This
other man sexually assaulted a child. We focused on how he felt with
this child during the assault. He reported a massive, murderous rage
mobilising towards this child. Instead of murdering the child, he
abused him. But when he had murdered the child in his head and he
felt the rage, he was looking at the image and saw the eyes of his
father. The guilt started pouring out. Every one of the children whom
he assaulted was his father. Instead of murdering his father, he abused
children, in an attempt to prevent himself from committing murder,
but he was burying his feelings. He was also self-destructing to avoid
perpetrating more harm. He was transferring his feelings from his
father on to the children whom he abused.
DK: If we distil your key message, I think it would be that herd
behaviours and the response to the environment you have described
all have similar roots within the unconscious experience of individ-
ual members of a social group, and until these are understood and
addressed, we cannot expect to see positive changes in our world of
conflict and strife. Would this be an accurate summary of your posi-
tion?
AA: I think that among several psychosocial factors, unconscious
rage and guilt drive much of the self-destructive and other-destructive
conduct we see in the world today. Ive seen many people go from
harming to helping others when they have better anxiety tolerance
and a better regard for themselves through working through under-
lying rage and guilt. It is obvious to me that this is a key factor. The
good news is it can happen through psychodynamic psychotherapy
and need not take years or tens of thousands of dollars in the vast
majority of cases.
CHAPTER SEVEN
Historical continuity and

discontinuity in the meaning of key
psychoanalytic concepts as revealed
in the transcripts of interview
n this chapter, we will compare Freuds theorising regarding some
I of his key psychoanalytic concepts and how he applied them in

psychoanalysis with those of our four psychotherapists. The
discussion will be limited to comparative comments of four critical
conceptsthe unconscious, the role of affect, resistance and the
defences, and the transference, and its modern day conceptual com-
panion, experience-nearness. A much more thorough working
through of the same issues will be undertaken with respect to the clin-
icians commentaries on the transcript of an analytic session (see
Chapters Eight and Nine).
The unconscious
The unconscious had many functions in the early theorising of Freud

(and Breuer). Below are some examples. These are followed by state-
ments from the interviews of the four psychotherapists on their
understanding of the unconscious and how they apply that under-
standing in therapeutic practice.
251
Freud: . . . the importance of dreams and of unconscious symbolism

. . . (Freud & Breuer, 1895d, p. xxxi)
. . . unconscious suggestion . . . (Breuer & Freud, 1893, p. 7)
The actual traumatic moment . . . is the one at which the incompati-
bility forces itself upon the ego and at which the latter decides on the
repudiation of the incompatible idea. That idea is not annihilated by a
repudiation of this kind, but merely repressed into the unconscious.
(Freud (with Breuer), 1895d)
. . . unconscious ideas exist and are operative . . . large complexes of
ideas and involved psychical processes with important consequences
remain completely unconscious . . . and co-exist with conscious mental
life . . . (Freud, 1915d, p. 178)
The unconscious prefers to weave its connections round preconscious
impressions and ideas which are either indifferent and have thus had
no attention paid to them, or have been rejected and have thus had
attention promptly withdrawn from them. (Freud, 1900, p. 563)
. . . the domination of the super-ego over the ego . . . in the form of
conscience or perhaps of an unconscious sense of guilt [my italics].
(Freud, 1923a, p. 34)
. . . the thought and ideation of the conscious waking ego stands
alongside of the ideas which normally reside in the darkness of the
unconscious but which have now gained control over the muscular
apparatus and over speech, and indeed even over a large part of
ideational activity itself: the splitting of the mind is manifest. (Breuer,
1893, p. 229)
RS: Persecutory objects that come to occupy an infants internal

world appear to be a combination of actual experience and unconscious
phantasy, and these exert a significant influence in the internal world
of an individuals particular object relationships.
. . . the unconscious . . . carves out its own signature on the trans-
ference and starts to bring things out unconsciously which are unique
to this patient . . . the transference is carved into the analysis by the
unconscious in a way that represents this patients unique experiences
and things start to get enacted, acted out, that are unique to this
person.
. . . dreams are part of the material nowadays. Its the royal road to
the unconscious in the sense that it tells you things that a conscious
HISTORICAL CONTINUITY AND DISCONTINUITY 253
account of oneself wouldnt tell you, but they are not elevated to
any special rolethey are just part of the material and the free asso-
ciation . . .
JH: . . . Unconscious forces influence our conscious thoughts . . .
Bowlbys idea was that infants were not going to survive in the
primitive savannah unless adults were highly protective of them. So
stage one is this primary attachment relationship. Its a little bit like
Winnicotts notion of primary maternal preoccupation, which is
unconscious, not in the classical psychoanalytic sense, but in the sense
that it is biologically programmed.
There is a sense in which you are held, you are lying down, you
can dream more easily, daydream, you can pursue your unconscious
more easily. (Comment related to using the couch).
[An] existential issue that is very relevant to psychotherapy is the
extent to which one is master of ones destiny, or driven by uncon-
scious psychobiological forces. At an experiential level psychoanalysis
does empower people, so that they feel less at the mercy of their
unconscious . . .
RDS: . . . phenomenology as a philosophical discipline has always
been concerned with investigating and illuminating structures of
consciousness that are pre-reflective. We call them the pre-reflective
unconscious. Philosophical phenomenology, starting with Kant and
Husserl, sought to identify the universal structures of experience,
whereas psychoanalytic phenomenology wants to identify those
structures that take form within the individuals unique intersubjec-
tive history, much of which is unconscious.
[There are many forms of the unconscious]the pre-reflective
unconscious, the unvalidated unconscious, the ontological unconscious
and . . . the dynamic unconscious. They have one thing in common
they are all constituted intersubjectively. The pre-reflective uncon-
scious is a system of organising principles, formed in a lifetime of
relational experiences, that pattern and thematise our lived experi-
ence. These principles are not repressed . . . but they operate outside
of reflective self-awareness. . . . the dynamic unconscious is those
affect states that are barred from coming into language, coming into
discourse, because theyre perceived to be too dangerous and unwan-
ted. The contents of the dynamic unconscious have been met with
massive misattunement and thus came to be perceived as threatening
to needed ties to care-givers. In this context, we understand repression

as a negative organising principle that determines which emotional
experiences cannot come into full being. The unvalidated unconscious
refers to emotional experience that never comes into language or
discourse, not because [its contents are] barred, but because they were
never even responded to linguistically in the first place. So the dyna-
mic unconscious has to do with contexts of danger while the unvali-
dated unconscious has to do with contexts of emotional impoverish-
ment. Finally, there is the ontological unconscious, defined as the loss of
ones sense of being.
AA: . . . moderately resistant patient[s] ha[ve] some rage and some
guilt about the rage, and grief. For those patients, pressure is enough
to break through the defences, bring up the complex feelings and
open up the unconscious. These complex feelings are experienced
which open the memory banks, which bring this clear imagery and
recollection of the events that lead to the defences. It becomes an
unlocking, without much else except pressure.
For the highly resistant patient, we have challenge and . . . head-on
collision which is a complex form of challenge and high pressure. It is
essentially a statement of the reality of the limits of what the therapist
can do, the potential of the patient, the problem of the resistance, and a
lot of encouragement for them to do something about it. Inevitably, if
its well timed, this will lead to a breakthrough to the unconscious.
The therapist must be able to tolerate complex feelingsthat is, be
able to love and hate at the same moment and not act out. The
therapist can feel those emotions and not defend and not get anxious
and not get detached and not harm the other person. Thus the thera-
pist can hold these complex feelings together. That helps the patient
to do the same, and that opens up the unconscious, bringing these
complex feelings all up together. This was Davanloos major discov-
ery; namely, identifying the need for the actual experience of complex
feelings in order to unlock the unconscious.
* * *
All four clinicians understood the unconscious in much the same way
as Freud, that is, as a reservoir of unconscious ideas and feelings that
influence behaviour, ideas that align with Freuds notion of the
dynamic unconscious (which Freud also described as the repressed
unconscious), and which Dr Stolorow defines as . . . those affect
states that are barred from coming into language . . . because theyre
perceived to be too dangerous and unwanted, a definition most
would agree constitutes repression. Dr Stolorows pre-reflective
unconscious (a system of organising principles formed in a lifetime of
relational experiences, that pattern and thematise our lived experience.
These principles are not repressed . . . but they operate outside of
reflective self-awareness) is akin to Freuds Preconscious, but with a
stronger relational component that maps onto Sterns (1985) concept of
RIGs (representations of interactions that have generalised), a concept
from attachment theory to which Professor Holmes alluded. Freud,
however, conceived an additional dimension to the pre-conscious that
has perhaps been lost in current conceptualisations. Freud explored
the relationship between jokes, dreams, and the unconscious (Freud,
1905b). He argued that the comic process forms part of the pre-
conscious, and that . . . such processes . . . run their course in the
pre-conscious, but lack the cathexis of attention with which consciousness is
linked (p. 220, my italics); that is, they operate outside reflective self-
awareness. Note, however, the understanding of dreams in Dr
Spielmans and Professor Holmess commentsboth explicitly agree
with Freud that dreams may provide an entre into the Unconscious.
Dr Stolorows phenomenological perspective on the nature of the
unconscious has broadened and more clearly explicated several facets
of the unconscious, in particular with the distinction between danger
(dynamic unconscious) and emotional impoverishment (unvalidated
unconscious), for which I could find no parallel concept in Freud.
Further, the concept of the ontological unconscious, although presaged
by Winnicott, Kohut, and others, is one of the clearest expositions of
the existential dimension of the Unconscious to date.
Affect
Freuds affect-trauma model was his first coherent theory of the origin
of psychopathology. It was primarily focused on the role of affect, and
its abreaction and catharsis as the means of cure. Below are some of
Freuds (and Breuers) comments about the role of affect in aetiology
and treatment. These are followed by statements from the interviews
of the four psychotherapists on the meaning of affect in their psycho-
analytic thinking and how they apply that thinking in clinical practice.
Freud: Any experience that calls up distressing affectssuch as

those of fright, anxiety, shame or physical painmay operate
as a trauma . . . each individual hysterical symptom immedi-
ately and permanently disappeared when we had succeeded
in bringing clearly to light the memory of the event by which
it was provoked and in arousing its accompanying affect, and
when the patient had described that event in the greatest
possible detail and had put the affect into words. (Breuer &
Freud, 1893, pp. 56)
The psychical process which originally took place must be repeated as
vividly as possible; it must be brought back to its status nascendi and
then given verbal utterance (p. 9) . . . language serves as a substitute for
action; by its help, an affect can be abreacted . . . If there is no such reac-
tion, whether in deeds or words . . . or tears, any recollection of the
event retains its affective tone to begin with. (Breuer & Freud, 1893,
p. 11, my italics)
[The cure in hysteria] . . . brings to an end the operative force of the
idea which was not abreacted [discharged as emotion] in the first
instance, by allowing its strangulated affect to find a way out through
speech. (Breuer & Freud, 1893, p. 17, my italics)
Any event that provokes unconscious memories liberates the whole
affective force of these ideas that have not undergone a wearing-away,
and the affect that is called up is then quite out of proportion to any
that would have arisen in the conscious mind alone. (Breuer, 1893,
p. 238)
RS : By non-verbal, Im not talking about body language; Im talk-

ing about affect. Affect is a very important part of analytic work . . .
what is felt, not necessarily heard . . . Patients will often use a word
that will minimise an affect.
JH: The essence of what goes on in the consulting room is a
reworking of the handling of affect. That can be done in a defensive
way where affect is suppressed as in the deactivating strategy; or in a
secure-making fashion where the affect can be dealt with in small
amounts through the presence of a sensitive caregiver.
RDS: . . . the bringing of pre-linguistic and pre-reflective experience
into language or discourse, the bringing of affective experience into
language.
AA: Defences shift from instant repression to ability to self-observe,

intellectualise and isolate affect. Once this is achieved, they can start
to feel safely.
* * *
The synergies between Freud (and Breuer) and our four therapists,
and among the four therapists themselves, are so compelling that they
hardly need further discussion. All agree that affect is centre stage in
the therapeutic process, and that therapy is a process whereby stran-
gulated affect . . . find[s] a way out through speech, or to paraphrase,
to bring pre-linguistic and pre-reflective experience into language.
If one were to identify the historically continuous glue that binds all
the iterations of psychoanalytic theory over the past 120 years, I
would argue for the central role of affect. Isolation of affect and its
consequent failure to be integrated, via repression and splitting, is,
broadly speaking, the dynamic process underlying most forms of
psychopathology.
Defences (resistance)
In Freudian theory, the idea of the unconscious, affect, defence, and
resistance are closely intertwined. The patient is invariably defending
against painful affect, and will resist that affect coming into awareness
through the employment of a range of defence mechanisms that
generally operate unconsciously. There are many examples in Freuds
writing of this close inter-connectedness as the following examples
show. I will discuss transference and defence together in the follow-
ing section on synthesis to avoid repetition.
Freud: . . . defence . . . is repressing ideas from consciousness.

(Freud, 1926, p. 173)
. . . defence [is] the deliberate suppression of distressing ideas which
seem to the subject to threaten his happiness or his self-esteem . . .
(Breuer, 1893, p. 214)
. . . defence is . . . the deliberate deflection of consciousness from
distressing ideas . . . (Breuer, 1893, p. 235)
I had to overcome a resistance, . . . by means of my psychical work I
had to overcome a psychical force in the patients which was opposed
to the pathogenic ideas becoming conscious (being remembered) . . . it

occurred to me that this must no doubt be the same psychical force
that had played a part in . . . generating . . . the hysterical symptom
and had at that time prevented the pathogenic idea from becoming
conscious. What kind of force could one suppose was operative here,
and what motive could have put it into operation? . . . I recognized a
universal characteristic of such ideas: they were all of a distressing
nature, calculated to arouse the affects of shame, of self-reproach and
of psychical pain, and the feeling of being harmed; they were all of a
kind that one would prefer not to have experienced, that one would
rather forget. From all this there arose, as it were automatically, the
thought of defence. (Freud (with Breuer), 1895d)
Compare Freuds (and Breuers) view on the role of resistance and the
use of defences with the four clinicians accounts.
RS: . . . if [the therapy] grindsnot to a halt, but if its grinding, its

because theres resistance and then you have to try to figure out
whats going on in the transference and the counter-transference, and
work on that.
. . . in the room at the moment, the patient is saying to the analyst,
I dont need you and you dont exist and youve got nothing to
offer, so their resistance is a resistance against acknowledging their
yearnings and longings.
. . . part of the patient is resistant from the word go, and you have
to accept that youre working against the resistance all the time.
Otherwise they wouldnt be a patient. Everybody is resisting, to a
considerable degree, knowing themselves in ways that might be better
if they did know themselves.
JH: The role of the analyst isnt just to interpret the defence mech-
anisms; it is simultaneously to rework the defence mechanisms while
becoming aware of and commenting on them at the same time . . . I
sometimes use a French proverbreculer pour mieux sauter (you run
back in order to jump better). So in order to progress . . . you need to
be able to divest yourself of your habitual defences in order to move
to a more mature and sophisticated use of defences. In that sense,
effective therapy is inherently somewhat regressive.
RDS: The evasion of finitude, which would be a defensive structure,

isnt conscious, but its shaping experience none the less.
The goal is to integrate . . . trauma psychologically so that it

doesnt have to be evaded by dissociative and other pathological
defences . . . it becomes a seamless aspect of who one is in ones world.
Traumatised people often have flashbacks or what I call portkeys;
thats because theyre keeping the trauma in some kind of state of
dissociation so that it pops out unexpectedly. I think whats helpful
is the capacity to move in and out of ones current world and ones
shattered world of trauma without having to defensively keep them
apart. Thats what I mean by integration; it becomes part of who one
is and what ones world is, rather than having to be kept defensively
sequestered. The goal is not recovery; the goal is integration.
AA: . . . when the defences start to move into the room, when
patients start to defend and detach and avoid and go away from us,
that represents mobilisation and crystallisation of the anxiety and
defences, which becomes an obstacle between us . . . Our goal is to
mobilise the unconscious therapeutic alliance and access the patho-
genic emotions as rapidly as the patient can bear. To do this we
actively work on the resistance in order to reach to the patient stuck
underneath the resistance.
Transference (and experience nearness)

Experience-nearness, although a contemporary, experiential, phenom-
enological concept, is discernible in Freuds view of the psycho-
analytic encounter and is present in each of the therapists interviews
and commentaries. It denotes the idea of immediacy and a present, in-
the-room focus, which Freud first captured in his discovery and clin-
ical use of the transference. Compare these comments from Freud
about the transference (and indeed the concept of experience near-
ness) and from our four clinicians taken from their interviews:
Freud: . . . transference of an already formed emotional relation on to

a new object. (Freud, 1900, p. 197)
. . . transferences . . . are new editions or facsimiles of the impulses and
phantasies which are aroused and made conscious during the
progress of the analysis; but they have this peculiarity, . . . they replace
some earlier person by the person of the physician . . . a whole series
of psychological experiences are revived, not as belonging to the past,
but as applying to the person of the physician at the present moment.

(Freud, 1905a, p. 116)
Psycho-analytic treatment does not create transferences, it merely
brings them to light, like so many other hidden psychical factors. . . .
In psycho-analysis, . . . all the patients tendencies, including hostile
ones, are aroused; they are then turned to account for the purposes of
the analysis by being made conscious, and in this way the transference
is constantly being destroyed. Transference, which seems ordained to
be the greatest obstacle to psycho-analysis, becomes its most powerful
ally, if its presence can be detected each time and explained to the
patient. (Freud, 1905a, p. 117)
. . . the part of the patients emotional life which he can no longer recall
to memory is re-experienced by him in his relation to the physician
. . . (Freud, 1910a, p. 51)
We will now review the four psychotherapists understanding of the

transference with respect to its quality of experience-nearness and
observe the concordances with Freud.
RS: One of the main theories that guides the psychoanalysis that I
do . . . is object relations, . . . that is the relationship between a subject
and an object. If it were just transference, it would be just a focus on
whats going on in one half of the relationship, whereas the relation-
ship between A and B is also a relationship between B and A. So
things can go in either direction or sometimes both, the therapist
needs to tune into both, not just whats being projected on to them,
but what they feel in relation to that as well. They can sometimes have
projected into them feelings which the patient is totally unaware of
and denies, and to try to then get an integrated concept of the projec-
tion; the introjection is much more important than simply whats one-
way traffic in the transference.
. . . there might have been a failed parent once upon a time, but
now, in the room, the manifestation of dismissive behaviour is
because of the refusal of the patient to allow the therapist to be impor-
tant. Yes, maybe based on past disappointments, but in the room at
the moment, the patient is saying to the analyst, I dont need you and
you dont exist and youve got nothing to offer . . .
Psychoanalysis does address every human issue in one way or
another, but it tries to do it in a down-to-earth way in the context of
the reality of this two-person relationship.
JH: [In the] primary attachment relationship . . . you immerse yourself

in the vulnerability of the care-seeker.
A patient who has been dropped affectively or emotionally as a
child or who has never been held may need the reassurance of actu-
ally seeing a responsive analyst/therapist in front of them; to feel that
they have got someone who is really attuned and responding in a
minute-to-minute way with facial contact. [my italics]
RDS: . . . I am most interested in enquiring about . . . those organis-

ing principles that shape the patients emotional experience and how
those show up in the interaction with me in the form of the transfer-
ence. That is still a strong focus of mineenquiry and interpretation
that is experience near, not the kind of interpretation that knows
beforehand what is going to be interpreted.
AA: We define transference neurosis as a build-up of feelings with

the therapist, thereby making the feelings towards the therapist part
of the problem, part of the neurosis. We want to avoid that altogether,
and we do, by bringing the feelings out that are mobilised towards us.
We help patients to feel the feelings as soon as they are evident so that
theres no build-up of feelings towards usno ambivalence, destruc-
tive or sexual feelingsbecause we actively keep all that out of the
way.
Synthesis and conclusions

There are two opposing trends in contemporary psychoanalysis. The
first is the endless reworking of psychoanalytic theory into variants,
schools, and positions, each with its own vocabulary, nuance, and
emphasis (Rangell, 2006). The other trend attempts to synthesise the
psychoanalytic process, to discover core concepts and constructs that
travel well across partisan theoretical boundaries. Bacon (2002)see
for example:
What I mean by psycho-analysis . . . is not a fixed identity, method

or body of thought, but rather a shorthand for an ex-centric, unsettling
way of looking at people which is always at variance to established
commonsenses and which is far more interested in the not said or
unsayable than in the already speakable or spoken (p. 251)
and others, for example, Green (1997), have cut a swathe through the
metapsychology and minutiae of psychoanalytic theory in order to
identify the heart of a psychoanalytic process, . . . as a form of organ-
ization . . . of the internal development of the patients psychic
processes, or as exchanges between patient and analyst (p. 9).
While there have been shifts, rifts and developments in psycho-
analytic theory and practice over the past 120 years, the nature of this
shift is more evolution than revolution. Freud offered a Kuhnian para-
digm shift (Kuhn, 1962) regarding the way in which we construct
human subjectivity and intersubjectivity by his discovery of the
unconscious and all the concepts that flowed from that discovery. This
summary and its conclusions in no way seek to minimise the signifi-
cant contributions of subsequent theoreticians, but to place psycho-
analytic theory and practice into a continuous historical framework
that includes commonsense folk psychology whereby we try to
understand each other by ascribing to ourselves and others intentions,
reasons, desires, and wishes . . . and Aristotles syllogism (Eagle,
2011, p. 43), in which the unconscious remains the sun around which
the planets of the transferencecountertransference and its dynamic
forces of resistance in the form of defences revolve. Indeed, Eagle
(2011) argued that much of the history of psychoanalytic interven-
tions and techniques can be seen as constituting various means to
uncover and identify unconscious motives (p. 42).
Freud began with the affect-trauma model, to which contemporary
psychoanalysis now essentially subscribesin which external trauma
and not internal (instinctual) conflict, lies at the heart of psychopathol-
ogy. Object relations theory identifies both actual experience and
phantasy (fantasy) as causes of trauma:
What goes on in the inner world is a representation of past experience,

real past experience, very much coloured by internal phantasy. The
objects that live inside the mind are a combination of reality and
phantasy. What was done to one and what it meant and how it felt
and what it now means. (Spielman, this volume, p. 107)
In the other approaches, including attachment-informed and inter-

subjective approaches, there is a stronger real, external experience
focus in understanding trauma that gives rise to intolerable self-states
or emotions (affect) that cannot be processed or integrated. However,
it would be inadvisable to create a false dichotomy along these lines
as it is not possible to develop object relations (internalised mental

representations) without external experience, or to understand exter-
nal experience without individual meaning-making.
Notwithstanding this difference in emphasis regarding the locus of
trauma, each of the five (including Freud) clinicians demonstrate a
similar conceptualisation of the transference as a process whereby
repressed infantile trauma is brought into the room and enacted with
the therapist. Thus, the meaning of the transference as a re-enactment
or activation (in Freuds terms, the pressing of repressed wishes for
discharge, entry into consciousness, and expression in action) of early
trauma and early traumatic relationships in the analytic dyad remains
unchanged (White, 2006).
Most current therapists focus on immediate affect and the impor-
tance of bringing traumatic experiences into language. Freud was
similarly aware of the importance of re-experiencing strangulated
affect to achieve mutative change. We have already discussed the
reciprocal nature of the modern (two-person) psychoanalytic relation-
ship that stresses intersubjectivity as a central principle, in which both
analyst and analysand are intensely engaged in a psychoanalytic pro-
cess and in which both are changed by the experience (Ogden, 1999).
Freud was not far from apprehending the importance of the interper-
sonal relationship between patient and psychoanalyst with his trans-
ference-countertransference concept. Both are now understood to be
sources of important unconscious communication and information,
not as obstacles or contaminants of the psychoanalytic process.
Repression is the master defence that prevents awareness and
discharge of painful affect through the splitting of consciousness.
Breuer and Freud (1895d) described the task of repression as the
prevention of painful mental contents entering the great complex of
associations (p. 9), as the failure of a pathological idea to enter
extensive associative connection (p. 11), whereby it could experi-
ence correction and affective discharge, notions that surely presaged
the current concept of integration of split off self-states and un-
bearable psychic pain. The horizontal splitting of consciousness in
early psychoanalytic therapy has morphed into the vertical splitting
of self-states in modern forms. Each of our four clinicians had their
unique way of expressing these ideas. Here are a couple of examples.
Dr Spielman described a patient for whom a particular experience
shocked . . . an unconscious part of her that prefer[red] destructive-
ness rather than constructiveness (this volume, p. 104). Dr Stolorow

captured the idea in these terms:
I think whats helpful is the capacity to move in and out of ones

current world and ones shattered world of trauma without having to
defensively keep them apart. Thats what I mean by integration; it
becomes part of who one is and what ones world is, rather than
having to be kept defensively sequestered. The goal is not recovery;
the goal is integration. (This volume, pp. 187, 258259)
The question arises, How are various concepts and vocabularies

of psychoanalytic theorising enacted in the immediacy and moment-
to-moment two-person communication in the therapeutic context?
After all, an attuned transference interpretation can be difficult to
distinguish from an intersubjective moment (White, 2006, p. 142)
a moment of mutual recognition (White, 2006, p. 183)and both
may result in mutative change. Whether focused on early life trauma
or the universe of internal objects and part-objects, one must learn to
negotiate external reality, as a necessary condition of psychological
growth. Whatever ones orientation, it appears that the modern psy-
choanalytic project invites participants to take a leap of faith, to relin-
quish the relative safety of a foreclosed, defended universe in which
the subject has constructed passably cohesive and meaningful, if
uncomfortable, life narratives in favour of a stance of maximal open-
ness to new experience, including new forms of relating, however
initially disorganising, disorientating and incoherent this experience
may feel, thereby potentiating . . . aesthetic or ecstatic cathexes of
objects . . . as actualizations . . . which may have lain previously
dormant (White, 2006, p. 183). The aim of psychoanalysis, therefore,
is not simply the resolution of intrapsychic conflict, but to become
fully alive as a human being (Ogden, 1999). In Bions (1984) terms, it
is a process of getting to know. By entering a state of reverie or
negative capability, both analyst and analysand become more intu-
itive, thereby initiating a series of transformations of experience,
thoughts and emotions.
In the coming chapters, we will further explore contemporary
psychoanalytic thinking in a more experience-near manner than the
typical psychoanalytic case study.
CHAPTER EIGHT
Commentaries on the transcript of

an analytic session
s part of the process of ascertaining how much of Freud
A remains in the contemporary psychotherapies, and to deter-

mine the synergies and divergences in their respective
approaches, I asked each therapist to read and comment on a tran-
script of a portion of an analytic session of a patient who had been in
five-days-a-week psychoanalysis for three years. In addition to the
transcript of the session, each therapist was given only the informa-
tion presented below.
This is an excerpt from a session three years into a five-times-a-week

psychoanalysis. The patient, Dr X (aged fifty-three) is a scientist whose
contract is ending and who is seeking alternative employment. The
patient was terminating employment involuntarily because of prolonged
and unaddressed issues related to bullying and mismanagement in the
workplace. Dr X presented with decompensation symptomsdepression,
anxiety (panic) about the future, tearfulness, and exacerbation of long-
standing psychosomatic symptoms (e.g., headaches, dizziness, episodes of
binge eating). There was a marital separation at the end of the first year
of analysis. The patient has three adult children, two of whom were work-
ing overseas. Dr X was the third of eight children from a migrant family.
The early life account indicates a high level of emotional deprivation and
265
physical punishment as well as intense sibling rivalry and physical

violence between the siblings. The analysand describes an angry, explo-
sive father and a misattuned, overburdened mother. There were just too
many children and not enough of anythingmaterial or emotionalto go
around.
Dr Ron Spielman: object relations psychoanalyst
My comments will be informed by my object relations approach to

analytic work. This implies that analysands have in their inner world
a range of part objects and whole objects which/who relate to one
another in a manner that reflects the past and current experience of
how people treat each other [an Inner-Weltanschauung]. In any given
relationship between objects, the analysand may be on either side of
the relationship, the active or the passive side, the doer or the done to.
I am guided by the question Who is doing what to whom? Is the
analysand acting upon the analystor is the analysand feeling acted
upon by the analyst?
Patient: I found out on Friday evening that I did not get the job.
Therapist: How did you feel about that?
RS: I consider that there needs to be a compelling reason to make

any kind of intervention so early in a session. My assumption from the
reference to Friday evening is that this is a Monday sessionthere-
fore, after a weekend. A patient with some three years of experience
of being in analysis should not need to be asked How do you feel
about that?
At the beginning of any session, my main aim is to try to get a feel
of the analysands state of mindand the nature and quality of the
transference today. I would also be interested in any feelings I may
have in response to their early behaviour in this session (i.e., potential
countertransference feelings).
Thus, I would be waiting to hear what further the analysand
saidor didnt sayin regard to their opening gambit. If there were
a silence, I would be (even) more strongly convinced that the experi-
ence of the weekend was important.
COMMENTARIES ON THE TRANSCRIPT OF AN ANALYTIC SESSION 267
Above all, I seek to get a feel of what the analysand is bringing to

each new session in terms of my guiding question: how is the
analysand acting on me or feeling acted upon by me? In this specific
instance, how is the patient responding to the experience of having
had a weekend break? Is he defending against the experience in some
discernible way? Is he angry with me about having been left?
In other words, I need time to listen to what the analysand brings
before making any intervention that will inevitably influence the
sequence of events once I speak. Likewise, waiting too long also
affects things. Getting this balance right is important.
Patient: I had mixed feelings, some of it was disappointment, some of

it was relief, because, as we discussed, the job was not suitable
to me . . . some of it was feeling nothing. However, on my way
home, I stopped at the supermarket and bought an enormous
amount of junk food and just sat at home on Friday night and
went on a massive binge and consumed it all.
Therapist: Tell me about the binge eating.
RS: I am now quite sure that this opening material does have to do
with the weekend. This is not merely an automatic analyst response,
but early infantile issues notably express themselves around week-
ends and this binge eating does seem to have to do with filling the
emptiness of the weekend. From the little history available, this
patient does have relevant emotional deprivation in early life, and
feels mother was misattuned.
So . . . I would be prepared to say something like You feel you
lose your position with me here on the weekend and needed to fill
yourself with junk food to deal with the emptiness. [I have changed
job to position for the purposes of this interpretation.]
Patient: I used to binge a lot when I was younger. It started after I got
married. I remember once my mother had upset me terribly. It
was around Christmas time and I had just prepared the
Christmas cakesthey were ready to go into the oven. I just sat
down with a teaspoon and ate the raw cake mixture out of one
of the cake tins.
Therapist: I think you are terribly upset about not getting this job [Yes,
THIS job], but you dont allow yourself to really feel the upset.
You do that a lot, not allowing yourself to feel your feelings. So
you go on a binge to comfort yourself. We really need to attend

to this part of you. There is a part of you that has to have things
just solike this job, you had to have this job; there was no
other suitable job, even though you gave me several really
good reasons as to why this job would probably not suit you.
What would you say to your son if he came home and said that
he could only work for one companyit had to be that
company and no other?
RS: This interpretation goes on a bit too muchand focuses on the

external reality. We really do need to attend to this binging-to-comfort
behaviour.
Patient: I would advise him to keep his options open and to cast a wide
net.
Therapist: But you do not do that for yourself. You are not really aware of
this part of you that must have things just so. It constrains you
in your thinking, prevents you from thinking more creatively
about issues.
Patient: I was wondering how I would be coping with this work crisis
had I not been coming here, because it seems to me that I am
not coping very well with it, even though I have had three
years to prepare for it and have been coming here the whole
time.
RS: I interrupt here to emphasise that the three years of coming

here has not (yet) prepared the analysand to deal with weekend inter-
ruptions to the five-day-a-week rhythm of the analysis. Weekend
breaks are manifestations of maternal misattunement by the very
nature of the break: the analysand feels the absence of the analyst and
working through what this form of experience is and what it repre-
sents is essential analytic work.
The purposein my mindof trying to take advantage of poten-
tial weekend material is to try to access these early infantile feelings.
This (potentially) has much more to offer than dealing with external
realities.
Patient: I have had a horrible couple of weeks raging and stressing

about this. I got the impression that you were very frustrated
with me as well. It felt like I was sinking into a quagmire . . .

[pause]
. . . Last night I was talking to a friend who is an analyst and I
commented that people often cannot make clear or detailed
statements about what they came away with from eight or ten
years of analysis. She said that is perhaps how it ought to be
because the changes that occur are so organic and incremental
that they become integral to the person such that analysands
can no longer point to change in themselves. I found that
very interesting . . .
Therapist: Are you wondering what you are getting out of your analysis
or worrying that you might not remember everything that
happens here?
RS: Yes! I consider the analysand is making a critical comment

about the analyst and the analysis. This is partly a transference
phenomenon, having to do with implicit criticism of not having had
enough from mother, and the quagmire experience of not having
been able to be understood as an infant, as well as a feeling that the
analyst is frustrated with the analysandand partly to do with the
current experience of having the infantile feelings not acknowledged
by the analyst.
Patient: I am concerned about these things; that is partly the reason that
I keep a diary . . . I do like to remember what happens and what
we discuss here. At the same time, it worries me that when a
crisis turns up, I am as dysfunctional as ever in trying to deal
with it. I have always put the blinkers on and not wanted to
know about difficult issues or difficult decisions to be made. I
tend to pretend that it isnt happening, but it seeps in some-
where. I will get a migraine, or become flat and listless and feel
like all the life has drained out of me. I feel like a draft horse
with blinkers on such that it can only see in one direction and
does not have to think about the twists and turns in the road.
RS: The diary-keeping behaviour is a form of obsessive defensive

behaviour to hold the analysand together between sessions and over
weekends. There is also a description of somatising behaviours as a
defence against the experience of psychic pain . . . and so not having
to think about twists and turns in the road [in life].
Therapist: Is that how you see yourself? As a draft horse who has to
produce 1,000 words a day to justify its existence?
Patient: I have always had this feeling that I have to justify my exis-
tence; that I must always have something to show for every
day. My motto is carpe diem. Goethe said that there is nothing
more precious than this day. Thinking about losing my job
through no fault of my own makes me feel very panicky, unfo-
cused, unmotivated, without direction . . .
Therapist: What is the panic about?
RS: I would rather try to talk about losing me; again, not for knee-
jerk weekend reasons . . . but to access feelings of loss which are
inevitably relevant in one form or another.
Carpe diemseize the daycould be an encouragement by the
analysand of the analyst to seize the opportunity to address these
painful issues of deprivation (too many children and not enough
of anything) and being overlooked by the analyst-mother who is
confronted by the needs of so many other children: the analysts other
patients and the analysts own real life.
Patient: About my world coming to an end . . . the loss of my job . . . the

loss of myselfthe same old, same old . . . it is like the dreaded
carbon tax that everyone has been gloom and dooming about.
The reality is that nothing changed on Monday when it was
introduced . . . I am, like the Australian media, an inveterate
catastrophiser.
RS: My world comes to an end when I am left alone at the

weekend . . . and I lose my self.
Therapist: All this when you said that nothing need change once your
employer stops paying you. You have said that you will not be
financially stressed when they stop paying you. You also said
that you still had a great deal of work to complete . . . Is this so?
Patient: I know I am very inconsistent. I tell myself it is not a catastro-

phe for the reasons that you have just outlined.
Therapist: I asked you whether your work will change after your contract
ends and whether you will have any financial stress and you
avoid the question and tell me about your inconsistencies.
Patient: The answers to your questions are no and no, the work will
not changeI still have at least a years work to do, and no,
I will not be financially stressed if I dont get another job
immediately.
Therapist: So what is this panic about having to find another job right
now?
Patient: When the end date arrives, I will be a pretender in a sense,

hanging on to the institution even though I am not really a part
of it any more.
[pause . . . silence]
RS: These last few interchanges between analysand and analyst

seem to me to be about reality and the weekend issue is (temporar-
ily, as it turns out!) lost. I consider the silence an expression of
(temporary) despair, before again resuming the real (intrapsychic)
theme.
Patient: I was speaking to my mother on the weekend and she told me

that my brother had come to visit. He was sitting at the table
reading the newspaper when my mother said that he should
think about getting a job, given that he has been seven years
out of work and he has exhausted most of his wifes financial
resources. He became extremely angry and threw the newspa-
per at her and then got up from the chair and threw the chair
at her. He then stormed out and has not been in touch since.
RS: The weekend issue returns!!

There is a child angryvery angry!with mother. The mother is
overly concerned about the getting of the joband, apparently, less
attuned to the childs wish to just be with mother.
The silence was a mini-storm-out and the analysand has
returned (in contrast to the brother in the story).
Therapist: What did you think of your mothers comment that he should
get a job?
Patient: I thought it was fair enough. He has no shame; he has been

depending on his wife all these years and contributing nothing.
I have never heard him express gratitude to her.
Therapist: Are you worried that your mother would think less of you if
dont have a job?
Patient: No, not in the same sense as my brother, because I have never
been dependent on anyone. I have always worked and carried
my weight my whole life. What worries me is who or what I
will be when I leave work. I will feel like nothing, that I dont
have a place on this earth. I may as well be dead.
Therapist: If you are only Dr X and have no other identity, then when you
leave your job, you will feel that you do not exist, that you are
nothing.
Patient: When I was young, I felt such a burden to my mother. The only
thing I could do to ease her load was to do things for her, to
pull my weight, to do chores. It didnt make a difference, of
course, nothing could make her happy, but that is where my
work ethic comes from. Also from my father . . . he worked
sixteen hours a day just trying to keep body and soul
togetherto feed the family and put clothes on our backs.
Therapist: This view of yourself as a draft horse with blinkers on, work-
ing, producing things, justifying your existence.
Patient: I have never not worked. I cannot imagine not working; the
word retirement freaks me out. I cannot imagine doing noth-
ing. I would sink into a deep depression and not be able to
move.
RS: Again, the analyst appears not to take up the transference

communications which I have tried to show are at least likely to be the
core of the unconscious communication in this excerpt of the session.
The analysand now talks about not being able to imagine not work-
ing. I consider this need to work to be an expression of a manic-type
of behavioural characteristic of this analysand as a defence against the
psychic pain of unmet dependency needs.
Yes indeed . . . otherwise I would sink into a deep depression and
not be able to move!!!
Therapist: What is wrong with doing nothing?

Patient: Everything is wrong with doing nothing. Doing nothing is like
death.
RS: Yes, doing nothing is like death.

I feel these last few sentences of the analysands material in the

excerpt confirm that the session has been about unmet dependency
needs and loss . . . and the analysands characteristic manic style of
defence against this by working.
To be out of a job is to expose the analysand to the threat of feel-
ing dead.
The analyst needs to address this by at least talking about how this
feels. It may even require going through a period of real unemploy-
ment to highlight these important feelings and, as analyst, I would not
be counselling reality approaches to getting a new job (if one is
needed) but rather try to enter the feelings of having to provide for
oneself when one despairs of the parental care one yearns for ever
being forthcoming.
This is one of the paradoxes of analytic work: by talking accurately
and empathically about such despairing feelings, the analysand feels
understood and cared for psychically, without needing to be cared for
in any kind of reality sense. Genuine psychic growth results from this
kind of work.
Dr Jeremy Holmes: attachment-informed psychotherapy

JH: From an attachment perspective, I feel its best to avoid direct

questions, especially at this stage in analysis and, indeed, in the
session, where one wants to let things develop of their own accord
(one cant avoid it to some extent in the initial sessions). Beebe and
colleagues show how mothers of infants classified as disorganised in
their attachment loom in on their children, rather than playing
interactively. Too many direct questions might be analogous to
looming, which the patient may find intrusive and anxiety pro-
moting. Id have rather just said Hmmm . . ., or You didnt get
the job . . ., or, perhaps better still That was Friday, just before a
weekend . . . (implicitly linking the stressful event with the wait for
the secure base opportunity of the Monday session).

it was relief . . . some of it was feeling nothing. However, on my
way home, I stopped at the supermarket and bought an enor-

mous amount of junk food and just sat at home on Friday night
and went on a massive binge and consumed it all.
JH: I would rather try something like Thats interesting . . . or

There sounds like a sequence there. The horrid pain of the job rejec-
tion, the need for comfort and soothing, and then the blow-out . . .
(the latter a more vernacular phrase than bingeing). I would see
binge eating as a self-soothing strategy that relates to disorganised
attachment in which the child has to find means, however self-defeat-
ing, to soothe herself, in the absence of an effective care-giver. So,
given that it was a Friday, is the patient saying, in effect, You werent
there, so I had to resort to my own method of affect regulation?
of the cake tins.
JH: This important story has the hallmark of a hyperactivating

attachment messageit started after I was married (did marriage
arouse attachment needs but fail to assuage them? Does sex, or the
lack of it come into it somewhere?); the behaviour is also connected
with attachment issues to do with mother.
Therapist: I think you are terribly upset about not getting this job, but you
dont allow yourself to really feel the upset. You do that a lot.
So you go on a binge to comfort yourself. We really need to
attend to this part of you.
JH: I would favour a more tentative style: I wonder if there is a

connection between the mental pain of not getting the job and the
bingeing . . . [making a bodymind link which is inherently mental-
ising]. An attachment perspective is always dialogic, relational, open
to correction, with therapist and patient looking together at an aspect
of the patients life, rather than the analyst speaking from a privileged
or expert position. Ultimately, the patient is the final arbiter on
his/her life.
Therapist (cont): There is a part of you that has to have things just so
like this job, you had to have this job; there is no other
suitable job, even though you gave me several really
good reasons as to why this job would probably not suit
you. What would you say to your son if he came home
and said that he could only work for one companyit
had to be that company and no other?
JH: This is OK as far as it goes, although one might comment that

this is very CBT in that the therapist is offering a cognitive challenge
to the patients obsessionality, rather than getting in touch with the
underlying anxietythe fear of an abyss and clinging to a tawdry
secure base in the shape of the job in the absence of anything more
genuinely comforting.
net.
JH: Well, the cognitive challenge seems to have workedat a

cognitive level!
about issues.
JH: This might be heard as critical, enhancing feelings of shame

and inadequacytherapy as a vocabulary of denigration, as Laing
once put it.
time. I have had a horrible couple of weeks raging and stress-
ing about this. I got the impression that you were very frus-
trated with me as well. It felt like I was sinking into a quagmire
. . . [pause . . . silence]
JH: If, as Bion suggests, the patient is sometimes the analysts

supervisor, here is the patient making the same point. He hears the
implicit criticism and exasperation contained in the previous inter-

pretation. I would pick up on thisI wonder if you are saying that
not only do you have a horrible time at work, but you come here and
get criticised for being rigid and failing to cope with adversity, and
whats more, having to wait for a whole weekend before insult is
added to injury . . .
There might, alternatively, be a case for responding directly to the
question Are you frustrated with me? I might have said, Actually,
I think my last remark was rather critical and unsympathetic. I am
really sorry. Perhaps it is a reminder to both of us how easy it is to be
buffeted off-course by rejection and loss and to end up attacking
oneself, or in my case my patient, rather than getting to the root of the
problem.
Patient (cont.) . . . Last night I was talking to a friend who is an analyst

and I commented that people often cannot make clear or
detailed statements about what they came away with
from eight to ten years of analysis. She said that is
perhaps how it ought to be because the changes that
occur are so organic and incremental that they become
integral to the person such that they can no longer
point to change in themselves. I found that very inter-
esting . . .
Therapist: Are you wondering what you are getting out of your
analysis or worrying that you might not remember every
thing that happens here?
JH: Id rather say something like I wonder what you think about
that in relation to what goes on in here . . .? That puts the patient at
the zone of proximal development rather than the analyst (a) asking
direct questions, (b) telling him that he is worrying. Or, take another
tack: one might say Hmmm . . . perhaps you are wondering whether
you might give me the sack, and give the job of analysing you to
someone more organic and incremental . . . Then you might really
get through to me just how awful it feels to be summarily dismissed,
and see ones lifes strategy go up in smoke.

JH: I would probably say something like Thats a great metaphor

[although some might feel that as patronisingafter all he is a
scientist and doesnt need me to butter up his intellect!]. Lets think
about that for a moment. Where did those blinkers come from? Who
put them on? Why were they necessary? Do you always have to be a
beast of burden . . .? What would it be like to kick over the traces? I
believe it is always reinforcing going with the patients metaphors.
Like dreams, they come from the unconscious or the creative imagi-
nation and express the patients true emotions. A good patient
metaphor is worth a thousand clever interpretations. Also it has the
squiggle game quality of playful interaction typical of secure attach-
ments.
JH: Here the analyst does something similar, butperhaps I am

being over-criticalI feel there is an implicit whats wrong with you;
why do you have to be so obsessional and goal-driven? Perhaps
there is a parallel process here; I am being critical of the analyst in
a similar way to how the analyst seems to be handling the patient (i.e.,
critically).
tence; that I always must have something to show for every
JH: Here, assuming we are nearing the latter third of the session
(which in my experience is the best place for such things), I would
venture a complete interpretation, one that, la Strachey, tries to

bring together present, transference, and past: No job; no analyst at
the weekend; this makes me think about a big absenceperhaps in
your childhoodan abyss, a hole, a vacuum which food-bingeing
helps temporarily to alleviate, but which ends up leaving you with a
bigger hole than before. Its very scary . . .
JH: Direct questionas above
Patient: About my world coming to an end . . . the loss of my job . . .

myselfthe same old, same old . . . it is like the dreaded carbon
tax that everyone has been gloom and dooming about. The
reality is that nothing changed on Monday when it was intro-
duced . . . I am, like the Australian media, an inveterate cata-
strophiser.
JH: The message here is: try as one might, nothing really helps,
including analysis. Id have said, It sounds as though you are verg-
ing on despair, including feeling a bit hopeless about what we might
achieve here . . .
that you still had a great deal of work to complete . . .
JH: CBT challenge again. Nothing wrong with that.
Patient: I know I am very inconsistent, because I tell myself it is not a

catastrophe for the reasons that you have just outlined.
JH: i.e., I am doing my best to be a good patient.
JH: I really dont understand this one. Is it a probe, a clarification,

a challenge, a reprimand?
Patient: The answers to your questions are no and no, the work will not
changeI still have at least a years work to do, and no, I will
not be financially stressed if I dont get another job immedi-
ately. And yes, I have work to finish.
now?
JH: CBT track again

of it any more.
JH: So what were really looking at here iswho are you? Do you
have an inner core identity apart from your work? Thats an issue for
anyone who retires or is made redundant, but maybe has an extra
poignancy for you because . . . (Here I would need some biographi-
cal/developmental data to provide chapter and verse.) The basic
message is that the current trauma is a repetition of previous loss/
stress/developmental difficulty. As Winnicott, quoting Nietzsche,
said, the dreadful has already happened.

get a job?
JH: Thats certainly one strategy, and not far from the one I have
been advocating in that the therapist wants to help the patient think
about his own thinking (i.e., to mentalise better). But it is a bit too
focused. I would have rather said something like, How did you react
to that . . .? In fact I think its an opportunity to go further: Well,
youve been coming here for three years, and it hasnt been cheap; I
wonder if you arent feeling pretty frustrated with me and our work
together and would like to throw my Freudian book at me and storm
out . . .? Maybe thats what you really wanted to do to those bastards
who didnt give you the job. Tell them to stuff their bloody jobthat
way maybe the bingeing might not have been necessary. Or am I
diverting aggression away from me (the putative analyst) by bring-
ing in the job at the end like that?

dont have a job?
JH: I really dont think patient and analyst are on the same
wavelength. It feels like parallel lines, each pursuing their separate
agenda. Id be wondering if something is being enacted herea de-
activated attachment where real engagement (which might entail
anger and despairbut also hope and love) is sacrificed for the sake
of a modicum of secondary security.
Patient: No, not in the same sense as my brother because I have never
nothing.
JH: Thats OK as far as it goes as a Rogerian reflection. But I would

go for marked mirroring (Fonagy and colleagues) and pick up on
the word dead, partly as an actual suicidal feeling, partly as a
description of the session itself, which feels pretty dead, partly going
to the word deadly as an expression of venom and anger that
cannot be expressed and so is turned against the self. I might say,
That phrase may as well be dead is zooming round my brain with
alarm signals . . . or something like that, and wait for the response.
work ethic comes from. Also from my father. He worked
JH: Good, back to the patients metaphor, but it needs to go a step

further. Therapist comments need to be only partially contingent
(Beebe; Gergely & Watson). We need to take the patient a little beyond
where they currently are. What about, I wonder if something similar
is going on here between us. You follow my suggestions, de-cata-
strophise, etc., but you feel you are a burden, that I am frustrated with
you, and somehow, like your mother, I keep missing the real point:
your misery, your anger, your fear of the abyss . . .
move.
JH: I am sure this was said with the best of intentionstrying to

help the patient to take a different angle on his plight. But my imagi-
native identification with the patient makes me hear this as shame-
inducing and critical: Youre doing something wrong, thinking
wrongly. Whats wrong with you? You are faulty in some way, at
fault. And dont blame me for being a bad therapist. You are not like
your brother, you dont throw things. You just submit like a dumb
beast of burden.
All this is ultimately crushing the patients spiritinducing a
deathfulness rather than shoots of liveliness and hope. At worst, ther-
apy is the disease of which it purports to be the cure.

death.
JH: Are therapist and patient doing nothing? Can they conjure a
something out of that nothing? Can liveliness and meaning erupt
into the vacuum: anger, rage, fear, vulnerability, longing, love . . .?
Can the analyst provide primary security, rather than reinforcing and
repeating secondary security strategies such as hyperactivation and
disorganisation and self-soothing, including the self-soothing of
nihilism?
After the commentary was concluded, JH sent the following post-
script:
Your bio of the patient did not reveal his/her sex. That I unquestion-
ingly assumed the patient was male stands out for me. I thought it was
an interesting example of what is too easily glibly passed off as coun-
tertransference, without really dissecting what that consists of. From
a relational, and I would say attachment perspective what matters is
the therapistpatient fitjust as the motherchild fit is what matters
in attachment. Secure mothers can cope with a range of infant tempera-
ments and still provide secure attachments. For insecure mothers, the
fit is what determines the outcome. Here, my slightly skewed assump-
tions about maleness (scientists tend to be male; men binge and cook as
well as women) meshed with the patients masculine identification and
obsession with work to the exclusion of all else. I think we need to get
those thoughts or something like them into the commentary.
Dr Robert D. Stolorow: intersubjective/

existentialist/phenomenological psychoanalysis
RDS: In general, the therapists style seems to me to tilt toward

a cognitivebehavioural, didactic approach that challenges and
seeks to correct the patients emotional experience rather than dwell
in and deepen the exploration of such experience. From a phenome-
nologicalcontextualist perspective, I see two potential problems: (1)
the patient might feel that her emotional pain and traumatic states are
being pushed away by the therapist, and (2) the therapist does not
appear to investigate the impact of his style on the patients transfer-
ence experience.

RDS: I might have said, Tell me what you were feeling just before
you started to eat.
of the cake tins.
Therapist: I think you are terribly upset about not getting this job, but you
dont allow yourself to really feel the upset. You do that a lot,
not allowing yourself to feel. So you go on a binge to comfort
yourself. We really need to attend to this part of you. There is
a part of you that has to have things just solike this job, you
had to have this job; there was no other suitable job, even
though you gave me several really good reasons as to why this
job would probably not suit you. What would you say to your
son if he came home and said that he could only work for one
companyit had to be that company and no other?
RDS: After commenting that the patient doesnt allow himself to feel
upset, the therapist does not wonder out loud, as I would do, about
why this is so. Instead, the therapist challenges and tries to correct the
patients need to have things just so, rather than enquiring into what
makes that necessary.
net.
RDS: The patient is being compliant with the therapist.

about issues.
RDS: The therapist is directly critical of how the patient is emotion-

ally organised.
had I not been coming here, because it seems to me that I am not
coping very well with it, even though I have had three years to
prepare for it and have been coming here the whole time.
RDS: There is therapeutic gold here that the therapist doesnt mine.
I would have asked, How am I making you feel worse?
Patient: I have had a horrible couple of weeks raging and stressing

about this. I got the impression that you were very frustrated
with me as well. It felt like I was sinking into a quagmire . . .
[pause] . . . Last night I was talking to a friend who is an analyst
and I commented that people often cannot make clear or
detailed statements about what they came away with from
eight to ten years of analysis. She said that is perhaps how it
ought to be because the changes that occur are so organic and
incremental that they become integral to the person such that
analysands can no longer point to change in themselves. I
found that very interesting . . .
happens here?
Patient: I am concerned about these things; that is partly the reason I
keep a diary . . . I do like to remember what happens and what
RDS: The therapist is not helping the patient dwell in and integrate
painful affectnot very surprising given the therapists unwelcoming
way of responding to it. So the patient has to continue to dissociate

and somatise the emotional pain that the therapist is not helping him
to bear.
day.
RDS: This is what I call substitute value or performative value,

as opposed to having a core sense of inherent value.
Patient: My motto is carpe diem. Goethe said that there is nothing more
precious than this day. Thinking about losing my job through
no fault of my own makes me feel very panicky, unfocused,
unmotivated, without direction . . .
RDS: Great! An enquiry about painful affect! And the patient res-
ponds to the enquiry by disclosing below that he is experiencing a
state of world-collapse and self-lossi.e., a state of psychological
annihilation! This is extremely important!

catastrophiser.
RDS: This cognitivebehavioural intervention by the therapist ap-

pears to have undermined the important deepening that just occurred.

RDS: More compliance by the patient.

RDS: The therapist is still pursuing a cognitive behavioural

approach, which is not, at this point, helpful to the patient.
not be financially stressed if I dont get another job immediately.
RDS: More patient compliance.
now?
RDS: The patient might interpret this comment about his panic as
shaming.
of it any more.
RDS: This association indicates clearly that the patient is experien-

cing the therapist as a shaming mother in the transference. I would
ask, Did I just shame you?
get a job?
dont have a job?
RDS: Again, the patient is in terror of falling into a state of psycho-

logical annihilationof world-collapse and self-loss.
nothing.
RDS: Yes, an attuned comment by the therapist!

RDS: The patient is explaining how he has relied on performative

value for a sense of identity and even of existing.
move.
RDS: For the patient, not working = doing nothing = falling into a
state of non-being.
RDS: OMG, therapist, your patient has just told you!

death.
RDS: Doing nothing is like deaththat says it all. The therapist

really needs to understand this catastrophic feeling in the patient and
dwell in that together rather than try to change the patients faulty
cognitions at this point in the therapy.
Professor Allan Abbass: intensive short-term

psychodynamic psychotherapy (ISTDP)
AA: The first thought in trying to review this transcript from the
perspective of Davanloos model is that it is impossible to make a
treatment decision based on text, or words alone. In ISTDP, decisions
are informed on the gestalt of verbal, but more so non-verbal, con-
comitants of unconscious anxiety and defence. Thus, the model
requires seeing a patient and activating the attachment system to
determine a road map for the process of moving to the unconscious.
It is for this reason that all training and supervision in ISTDP are
conducted via videotape review.
For me to comment on this case, I will make an assumption that
indeed there are actually unconscious emotions that are not resolved
as part of this patients problems. If there are unresolved unconscious
emotions covered with defence, then these will be visible as much
through indicators such as rate and pace of speech, non-verbal
gestures, posture, and quality of eye contact, as they will by words.
AA: The first set of interventions in an ISTDP session is based on the

following elements: format of unconscious anxiety, degree of
syntonicity of defence, degree of rise in complex feelings, degree of
resistance present in the transference relationship, and willingness of
the patient to focus on internal emotions.

AA: The primary focus in ISTDP would not be the description of the
binge; rather the feelings the person has mobilised by the current
event, or better, the emotions mobilised in the transference while
reviewing the story. The main point here is that content exploration is
contraindicated as it is seen as prolonging treatment and augmenting
defences in all cases except those with poor anxiety tolerance, disso-
ciation, or major depression. If we assume this is a highly resistant
(character neurotic) patient, then content exploration is equal to
dialoguing with the resistance and protracts the treatment, making
transference neurosis possible to probable.
of the cake tins.
Therapist I think you are terribly upset about not getting this job, but you
dont allow yourself to really feel the upset. You do that a lot,
not allowing yourself to feel. So you go on a binge to comfort
yourself. We really need to attend to this part of you. There is
a part of you that has to have things just solike this job, you
had to have this job; there was no other suitable job, even
though you gave me several really good reasons as to why this
job would probably not suit you. What would you say to your
son if he came home and said that he could only work for one
companyit had to be that company and no other?
AA: This type of intervention is an interpretation coming from the

expert. It would be contraindicated to interpret in the setting of a
highly resistant person as it sets up an activated transference where
the therapist ends up in the shoes of a critical mother, for example.
This blocks the rise in the key therapeutic ingredients in ISTDP: the
complex feelings and unconscious therapeutic alliance. So we would
avoid this.
The simple primary intervention in what looks like a low rise in
the complex feelings here is pressure, encouraging the patient to be
present and identify any underlying avoided feelings in the room
while talking about the current event.
net.
about issues.
AA: Again this is a dictum coming from an expert. As accurate as it

may be, it would be likely to flatten out the rise in the complex feel-
ings and unconscious alliance. It would protract therapy and can
promote regressive responses.
time. I have had a horrible couple of weeks raging and stress-
ing about this. I got the impression that you were very frus-
trated with me as well. It felt like I was sinking into a quagmire
. . . [pause]
AA: Why is the patient thinking you would be critical? Is it because

the interventions preceding it (and possibly in earlier sessions) already
contained criticism encased in a well-intended interpretation?
Patient . . . Last night I was talking to a friend who is an analyst and I

commented that people often cannot make clear or detailed
statements about what they came away with from eight to ten
years of analysis. She said that is perhaps how it ought to be
because the changes that occur are so organic and incremental
that they become integral to the person such that analysands
can no longer point to change in themselves. I found that
very interesting . . .
happens here?
AA: These phenomena suggest that the patient is mired in repres-

sion as a major resistance against underlying intense emotions includ-
ing rage and guilt about the rage that keeps being mobilised but not
breaking through. It suggests the patient has not had much, if any,
experience of her own unconscious emotions because he is still domi-
nated by the major resistance of repression.
The other element here is the introduction of feelings toward the
therapist. In the ISTDP frame we would encourage the patient to expe-
rience these feelings viscerally and thereafter express them as a route
to the unconscious therapeutic alliance and the dynamic unconscious.
If we take the statement on its face, the patient is expressing his view
that the treatment is slow and of questionable value. In that case, the
ISTDP therapist would also examine whether treatment is proceeding
efficiently or at all. In this session, the patient is somewhere between
about 500 and 750 sessions of treatment. ISTDP ranges from 140
sessions in low to highly resistant cases and up to 150 sessions only
in severely fragile cases. We expect clear evidence of response within
the trial therapy session or, at longest, within the first ten sessions
in this model or else there is a major reconsideration of the process,
consultation with a peer, and examination of possible obstacles.
catastrophiser.
AA: Again it is hard to know from text alone, but this patient may
have fragile character structure where the underlying intense
emotions interrupt cognitive functioning. These same patients can
have somatisation and depression. If this be the case, then the process
indicated is to build structural capacity to tolerate unconscious anxi-
ety through a specific process Davanloo called the graded format.
Cycles of pressure to feelings followed by intellectual recapitulation
build capacity to self-reflect. This process can be optimised by keep-
ing as high a rise in unconscious anxiety as the patient can tolerate.
Therapists typically underestimate these patients capacity and end
up with prolonged, intellectualised treatments that become difficult or
impossible to terminate.
AA: Again this is a form of challenge where the risk is of the patient
feeling criticised and put down. Challenge in ISTDP is reserved for
when resistances are crystallised in the room creating an obstacle to
mobilising the unconscious. If done too early, it risks misalliance,
dependency, transference neurosis, and delayed rise in the uncon-
scious alliance.

AA: This is another example of challenge that can be received as a

criticism. This can be an explanation of why treatment is taking
several hundred sessions, since mobilisation of the underlying feel-
ings can be interrupted by this type of intervention from the ISTDP
framework. It would produce irritation devoid of positive feelings

and prevent a rise in the unconscious therapeutic alliance.
not be financially stressed if I dont get another job immediately.
AA: The patient sounds irritated here, but note no breakthrough to

the unconscious is happening, just the start of an argument, an extra-
psychic conflict.
now?
AA: This sounds like an argumentative reply to an irritated patient.

of it any more.
I was speaking to my mother on the weekend and she told me
AA: Here it makes me think that the patient feels criticised in the
way his mother criticises the brother.
get a job?
AA: Here I think his comment about his brother is equal to self-
criticising, having internalised the punitive mother. And this punitive
self-commentary may be becoming activated due to the blockage of

feelings with the therapist, compounded by premature challenge.
dont have a job?
nothing.
AA: This suggests that the patient transfers all the complex
emotions from parents on to others, including the therapist. In the
ISTDP frame, we would facilitate the experience of these emotions
directly in the room: this would serve as a gateway to these emotions
and also as a vehicle to cutting down the anxiety, building anxiety
tolerance, and building the power of the unconscious therapeutic
alliance.
move.
death.
AA: My overall view of the above segment is that the process is

intellectualised and somewhat lacking in psychodynamic structure
toward specific psychodynamic goals. I think this is both a product
and cause of the therapist taking subtle shots at the patient and risk-
ing transference neurosis. We dont know about the patients anxiety
discharge pathways and anxiety tolerance so we dont know how
rapidly the patient can access and experience his unconscious, so this
puts us in the dark about what pace may be optimal from the ISTDP
frame.
The other risk that should not be understated is the risk of having
treatment go for hundreds of sessions more than it needs to: someone
has to pay for this and someones life (plus the therapists career) is
passing by as time goes on. If the goal is to build capacity, the treat-
ment should aim for this as rapidly as possible. If the patient has capa-
city, then, in the ISTDP frame, strong encouragement to be present in
the room, identify and experience the emotions that still go to repres-
sion, self-criticism, detachment, and intellectualisation are called for in
order to accelerate the psychodynamic process.
CHAPTER NINE
Textual and conceptual analysis of

psychotherapists commentaries on
the transcript of the analytic session
n order to assess the degree of similarity and difference in the
I conceptualisation of the therapeutic process by these four psycho-

analytic psychotherapists from four schools of psychoanalytic
psychotherapyobject relations, attachment-informed, existential/
phenomenological, and intensive short-term dynamic psychotherapy
each psychotherapists commentary on the transcript of the analytic
session was subjected to textual and conceptual analysis using
Leximancer (Version 4.0). Leximancer is an automated content analy-
sis software tool used to find meaning in text-based documents.
Concepts are defined as sets of interrelated words that capture a
central theme. Leximancer attempts to remove possible researcher
bias by automatically detecting the concepts and main themes in
textual data, which is examined to select a ranked list of the most
significant lexical terms in the text on the basis of word frequency and
co-occurrence with other concepts or categories, such as, in this study,
psychotherapists from different theoretical orientations (Smith &
Humphries, 2006). These terms are used to generate a thesaurus of
related words that become weighted concepts.
In addition to the automatically detected concepts, Leximancer
provides a number of editorial options that allows researchers to
297
remove concepts of little interest or value (e.g., things come) and

to merge similar or identical concepts that are clustered together prior
to analysis if they occur as synonyms in the text (Leximancer Manual,
2012). For example, in this study, the concept patient encompassed
words like patients, analysand, and analysands; the concept
analysis included the concepts of therapy and treatment and all
their lexical variants. Similarly, the words analyst, analysts, and
therapists were represented by the word therapist and the words
child, infant, infantile, and infancy were combined into one
concept child when all occurrences of these words indicated that the
therapist was referring to early experience. The word critical sub-
sumed the words criticism, criticised; criticises, and the words
absence, abyss, and vacuum were represented by the concept
vacuum. Finally, the concept activate included the words acti-
vated, activating, mobilise, mobilising, and mobilisation.
The researcher can insert and add defined concepts that are
considered central to the analysis to the list of automatically detected
concepts (Smith, 2003). Preliminary analyses identify concepts that are
linked to most other concepts and which, therefore, do not add clar-
ity to the concept map or its interpretation. Commonly occurring con-
cepts like the are called stop-words; they are automatically detected
and removed by the programme. Study-specific words that are
distributed throughout the concept map are user-identified from
preliminary analyses and may be iteratively removed because they
result in loss of differentiation and stability of the concept map. In this
analysis, the indiscriminate concepts were feel and its variants
(felt ,feeling, feelings), job, patients, and analyst. These
were removed and the analysis re-run.
Based on both the automatically detected and user-defined con-
cepts, Leximancer generates a thesaurus of terms associated with each
identified concept. These relationships are presented visually using a
concept map that spatially represents the degree of distance between
the concepts and, in this study, the four categories (i.e., psycho-
therapists). The map is a visuo-spatial summary of the content of their
commentary on the analytic therapy session, highlighting the main
concepts and how they interrelate among and between each other and
the four speakers. Coloured spheres or coloured text identify local
clusters of concepts, which represent themes; they form around highly
connected concepts, which are represented by grey dots. The concept
TEXTUAL AND CONCEPTUAL ANALYSIS OF . . . COMMENTARIES 299
map presents concepts according to sizethe bigger the sphere, the

more important the themeand colour code: the hot colours (red,
orange) are the most important and most frequently (co-)occurring
concepts. The cooler colours (green, blue) are less central and less
frequently occurring themes and concepts. Colour significance
follows the order of colours in a rainbowred, orange, yellow, green,
blue, indigo, and violet. Location on the map indicates the degree of
association between concepts and speakers. Concepts and categories
located in close proximity are closely connected and tend to co-occur.
The pathways (grey dots, representing concepts and connective lines)
navigate the most likely path in conceptual space between concepts,
and assist in the interpretation of the map. In summary, the concept
map shows the main concepts discussed in the transcript: how they
relate to each other, the relative frequency of occurrence of each
concept, how often concepts co-occur within the text, and the central-
ity of each concept, defined as a theme in which the concept occurs. If
categories have been specified, all of these functions can be ascer-
tained with respect to each of the categories individually, as in this
analysis of the preferred concepts of our four psychotherapists.
The connections between concepts and their proportionality rela-
tive to each other can be calculated by assigning 100% relevance to the
most frequently appearing concept. The relevance indicators for the
remaining concepts are calculated by dividing their number of
appearances by the number of appearances of the most frequently
appearing concept, which is deemed most relevant.
Results
The concept map
Figure 2 displays the concept map for the most prominent themes and
concepts arising in the four commentaries on the transcripts and the
locations of the four psychotherapists (RS, JH, RDS, AA) in conceptual
space, in relation to those themes and concepts and to each other.
The thematic summary includes a connectivity score that indi-
cates the relative importance of the themes.
In this map, the largest and most densely populated theme (red
text) can be described as the elements that are required to establish a
Figure 2. The concept map.
therapeutic process. This theme had 100% connectivity. It contains

concepts related to therapy such as talking, exploring emotions and
attempts to avoid them through dissociation, activating (the attach-
ment system) and experiencing the transference, processes central to
psychodynamic psychotherapy. Its near and overlapping neighbour
(orange text) represents the more complex processes that unfold as
therapy progressescentred thematically around the unconscious
(with 72% connectivity), and unconscious processes, the experience of
complex emotions, (complex) transference feelings, resistance, and
defences such as repression, and making therapeutic interventions
such as identifying these complex processes, and helping the patient
to express and tolerate them.
Dr Spielman and Professor Abbass were most proximal to these
two prominent themes; Professor Abbass had the largest number of
context blocks (i.e., he provided the longest commentary) and used

more classically psychoanalytic language to describe the therapeutic
process in ISTDP. Dr Stolorow and Professor Holmes are more distal,
by virtue of the fact that they used a different therapeutic language
and vocabulary. However, we need to consider the degree to which
their modes of communication about the therapy session represent an
alternative form of expressing its dynamics or whether they perceived
the actual dynamics and processes to be different from their col-
leagues. We will take this important issue up later. For now, we will
examine the conceptual and thematic foci of each of the psycho-
therapists with respect to the two key themestherapeutic process
and the unconscious.
Dr Spielman used terms related to the concept analysis fifteen
times. Examples include:
. . . my object relations approach to analytic work . . . implies
that the analysand has in their inner world a range of part
objects and whole objects which/who relate to one another in
a manner that reflects the past and current experience . . .
. . . the three years of coming here has not (yet) prepared the
analysand to deal with weekend interruptions to the five-day-a-
week rhythm of the analysis.
. . . the analysand feels the absence of the analyst . . . working
through what this form of experience is and what it represents is
essential analytic work.
This is one of the paradoxes of analytic work: by talking accu-
rately and empathically about . . . despairing feelings, the
analysand feels understood and cared for psychically, without
needing to be cared for in any kind of reality sense.
Professor Abbass did not use the actual word analysis at all
in his commentary. However, he talks frequently about its related
concepts, for example, ISTDP, a treatment founded on psychoanalytic
principles (thirteen mentions), the psychodynamic process (three
mentions), psychodynamic structure, psychodynamic goals,
psychodynamic process, and treatment (ten mentions): . . . it
is truly impossible to make a treatment decision based on text, or
words alone; content exploration is contraindicated as it is seen as
prolonging treatment . . .; dialoguing with the resistance . . .
protracts the treatment . . ..
Professor Holmes used the concept analysis four times.
I feel its best to avoid direct questions, especially at this stage

in analysis.
. . . perhaps you are wondering whether you might give me the
sack, and give the job of analysing you to someone more organic
and incremental . .
Try as one might, nothing really helps, including analysis.
Therapy as a vocabulary of denigration, as Laing once put it . . .
Dr Stolorow did not use any of the words in the concept analy-
sis.
With respect to the second principal theme, Professor Abbass used
the concept unconscious eighteen times in his commentary com-
pared with very low usage by the other three therapistsDr Spielman
(1), Professor Holmes (1), and Dr Stolorow (0). Examples of Professor
Abbasss five uses of the concept unconscious include:
[therapeutic] decisions are informed . . . on the gestalt of verbal

[and] non-verbal concomitants of unconscious anxiety and
defence;
Thus, the model requires . . . activating the attachment system to
determine a road map for the process of moving to the uncon-
scious;
. . . there are unresolved unconscious emotions covered with
defence;
The first set of interventions in an ISTDP session is based on the
following elements: format of unconscious anxiety . . .;
It suggests the patient has not had much, if any, experience of
his own unconscious emotions because he is still dominated by
the major resistance of repression.
Although we might expect Professor Abbass and Professor

Holmes to share many overlapping concepts, given that both base
their therapeutic practice on attachment theory, in fact, Professor
Holmes is more strongly connected with Dr Stolorow. These two ther-
apists have a primary focus on the phenomenology and experience-
nearness of the analytic encounter. Professor Holmes was centrally
concerned with issues related to attachment experience and quality,
the degree to which the therapist could provide a secure base, instil
hope, and assist the patient to internalise a good enough mother/

therapist who could eventually support a self-soothing capacity in the
patient. A key nodal pathway for Professor Holmes was vacuum
fearsecurityhope. Dr Stolorows aims are congruent with this focus.
He was primarily focused on the immediate experience of affect and
saw his task as helping the patient to dwell in that affect, in this case
the catastrophe of world-collapse experienced by the patient,
precipitated by the job loss and the consequent feeling of psychologi-
cal annihilation.
The focus of Professor Abbasss therapeutic approach, by contrast,
was on the development of the capacity to tolerate anxiety about the
expression of anger with respect to attachment ruptures that occurred
in early life, and to overcome resistances (especially repression) to the
experience of these feelings in the transference relationship. A key
nodal pathway is tolerateanxietyunconsciouscomplexidentify
emotionsresistancerepression.
Each of the therapists has a unique conceptual lexicon specific to
his orientation. Dr Spielman, the object relations analyst, was
concerned with the patients unmet dependency needs originating in
infancy, and has a nodal pathway to that effect: talkingintegrating
analysisemotionsresistancedefencedependence. A closely related
theme is the meaning of silences in the session and the impact of the
analysts weekend absence, during which the patient lost the
analyst, on the patients state of mind during the session. He was the
only one of the four psychotherapists to be concerned with the mean-
ing of silence (as a foreground concept) in the session and hence the
concept silence is linked only to him.
Dr Stolorow used language specific to existentialist/phenomeno-
logical enquiry; his therapeutic activity remained uniquely focused on
the two concepts that he stressed in his interviewexperience (of
affect) and context (dwell). An indicative nodal pathway is binge
affectsomatisedwell.
Professor Holmess approach was grounded in the attachment-
based concepts of security, self-soothing, and hope. He privi-
leged the use of metaphor, both the patients and the therapists, as an
entre into the unconscious process; each of these concepts are nodally
connected only to him. Attachment was a central concept, the early
aim of therapy being to establish himself as a secure base from which
the patient could explore his insecurities and painful emotions of
rejection and fear, and eventually to internalise a good mother/thera-

pist that builds the capacity to self-soothe; for Professor Abbass, acti-
vating the attachment system is a therapeutic strategy that gains
access to the patients unconscious. Activation in ISTDP is a more
challenging process that does not aim to achieve the internalisation of
a good object, but to provide direct access to unconscious processes.
The third major theme was work (55% connectivity). This concept
proved difficult to interpret because it was used in three different
ways, the first as it pertained to therapeutic concepts such as work-
ing through, analytic work, our work together, and the like. The
second usage denoted ones job/employment as in, The analysand
now talks about not being able to imagine not working. I consider this
need to work to be an expression of a manic-type of behavioural char-
acteristic of this analysand as a defence against the psychic pain of
unmet dependency needs (Dr Spielman). Dr Stolorow uses the
concept to denote job/employment, as follows: For the patient, not
working = doing nothing = falling into a state of non-being. Professor
Holmes also uses the concept in this way: . . . what were really look-
ing at here iswho are you? Do you have an inner core identity apart
from your work? There was also a third usage of the theme that
denoted success (e.g., Well, the cognitive challenge seems to have
workedat a cognitive level!, Professor Holmes). Professor Abbass
does not use the concept work in any of its meanings.
The quadrant report

The results of the thematic and conceptual analyses can also be repre-
sented using a quadrant map (Figure 3). This representation plots the
ten most frequently occurring concepts for each of the four psycho-
therapists along two axesrelative frequency and strength. The four
colours denote the four psychotherapists. Relative frequency is a
measure of the conditional probability of the concept within the cate-
gory of interest, in our case, each psychotherapist. Strength is a
measure of the conditional probability of the category given a partic-
ular concept; in other words, strength is a measure of how often the
particular category (psychotherapist) uses the concept of interest.
Concepts in the top right hand quadrant are the most frequently
appearing and strongest concepts.
Figure 3. Quadrant report showing strength and relative frequency scores for
the main concepts used for each psychotherapist.
Examination of the top right-hand quadrant reveals that Professor

Abbasss central theoretical conceptsthe unconscious and complex
emotionsare located there; the concepts tolerate, anxiety, emo-
tions, and transference are also important emphases. Dr Spiel-
mans two key concepts are silence and weekend. By comparison,
Dr Spielman used the word weekend fifteen times, compared with
Professor Holmes (3), Professor Abbass (0), although there was one
implied usage, in this comment: . . . given that it was a Friday, is the
patient saying in effect you werent there, so I had to resort to my
own method of affect regulation?, and Dr Stolorow (0). Examples of
Dr Spielmans usage of the concept weekend are as follows:
If there were a silence, I would be more strongly convinced that

the experience of the weekend was important;
. . . [regarding] a weekend break. Is the patient defending
against the experience . . .? Is he angry with me about having
been left?
. . . early infantile issues notably express themselves around
weekends; [I would say] You feel you lose your position with me
here on the weekend;
. . . deal with weekend interruptions to the five-day-a-week
rhythm of the analysis; Weekend breaks are manifestations of
maternal misattunement . . ..
Professor Holmes understood the concept weekend in the same

way as Dr Spielman. Here are some examples of his use of this concept:
That was Friday, just before a weekend . . . (implicitly linking

the stressful event with the wait for the secure base opportu-
nity of the Monday session);
. . . having to wait for a whole weekend;
No job; no analyst at the weekend; this makes me think about a
big absenceperhaps in your childhoodan abyss, a hole, a
vacuum . . .
The concept silence also has much greater prominence in Dr

Spielmans profile, even though he uses the word only three times,
because none of the other three therapists used the concept at all:
If there were a silence, I would be (even) more strongly

convinced that the experience of the weekend was important;
I consider the silence an expression of (temporary) despair . . .;
. . . the silence was a mini-storm-out. . .
Dr Stolorows two central concepts, dwell (3) (e.g., the thera-

pists style seems to me to tilt toward a cognitivebehavioural, didactic
approach that challenges and seeks to correct the patients emotional
experience rather than dwell in and deepen the exploration of such
experience) and affect (2) (e.g., The therapist is not helping the
patient dwell in and integrate painful affect), are not used by the
other therapists, although it should be noted that the concept emo-
tion, a synonym for affect, was important for all four therapists.
Ranked concepts for categories (therapists)

Figure 4 displays a quantitative summary using a ranked bar chart of
the most prominent concepts found within each psychotherapists
commentary on the transcript. The percentages match the quadrant
co-ordinates in the Quadrant report and reflect the same strength and
frequencies contained there. This additional analysis also involves
Figure 4. Ranked concepts for each psychotherapist, with relative frequency and
strength expressed in percentages and prominence ratings expressed as bar charts.
selecting each therapist as a category in order to determine the most

prominent concepts, represented mathematically by the prominence
score within in each category (therapist). Prominence scores are
defined by a combination of their strength and frequency characteris-
tics. The frequency score represents a conditional probability that a
text extract belongs to a particular category (therapist). This measure
is affected by the distribution of comments across therapists. The
strength score is a reciprocal conditional probabilityit determines
the probability that a concept comes from a particular therapist.
Strong concepts distinguish among the therapists, whether or not the
concept is used frequently. Good examples include Dr Spielmans use
of the concepts silence and weekend and Dr Stolorows use of the
concepts affect and dwell.
These concepts are ranked using an algorithm that considers both
their strength and frequency characteristics. The prominence value is
determined by calculating the number of times a concept (a) appears
in a particular therapists transcript (C) relative to the total number of
context blocks (usually defined as every two sentences) in the total
text and the occurrences of (a) and (C) in the total context blocks.
Frequent, strong, and prominent themes

As can be seen from the table of ranked concepts for each therapist,
these four master clinicians comments on the transcripts of interview
were true to their respective theoretical positions. At first glance,
there appears to be little overlap between each of their ten most fre-
quently appearing concepts. However, closer examination reveals a
great deal of consensus regarding their respective understanding of
this patient and their interpretation of the psychic meaning of his
behaviour. We will first examine the two strongest concepts for each
therapist in turn. This will be followed by a discussion of how the trans-
ference was understood and worked with by each of the four therapists.
Professor Abbass: the unconscious and complex emotions
The two prominent concepts for Professor Abbass were uncon-

scious and complex, whose use was related to the experience of
complex emotions and its subset, complex transference feelings.
Professor Abbasss transcript shows that he used the concept uncon-

scious nineteen times. Examples include:
Challenge in ISTDP is reserved for when resistances are
crystallised in the room creating an obstacle to mobilising the
unconscious;
This . . . [explains] why treatment is taking several hundred
sessions since mobilisation of the underlying feelings can be
interrupted [and] produce irritation devoid of positive feelings
and prevent a rise in the unconscious therapeutic alliance;
. . . unconscious anxiety and defence . . .;
. . . unresolved unconscious emotions covered with defence . . .;
a dictum coming from an expert, as accurate as it may be . . .
would . . . flatten out the rise in the complex feelings and un-
conscious alliance. It would protract therapy and . . . promote
regressive responses;
In the ISTDP frame we would encourage the patient to experi-
ence these feelings viscerally and thereafter express them as a
route to the unconscious therapeutic alliance and the dynamic
unconscious.
Professor Abbass was allocated 90% likelihood for this concept
because two of the other three therapists also used this concept, albeit
not as frequently. Dr Spielman used the concept once when he
discusses unconscious communication; Professor Holmes used the
concept once: . . . metaphors . . . [l]ike dreams . . . come from the
unconscious or the creative imagination and express the patients true
emotions . . . Dr Stolorow does not use the concept directly. Thus,
two of the twenty-one usages of the concept unconscious across all
four commentaries constitute 10% of total usages. Thus, 90% of usages
are ascribed to Professor Abbass, and 5% each to Dr Spielman and
Professor Holmes.
Computerised content analysis does not factor in implied concepts
and usage, and, as we shall see, attention to unconscious processes is
prominent in all four therapists and is unambiguously implied in the
commentaries of the other three therapists, who were all mindful of
the quality of the interpersonal relationship, the nature of the patients
communication in the therapeutic dyad, and the experience-near
aspects of the patients behaviour and disclosures, which all imply
unconscious processes. Consider these examples:
Dr Spielman: I consider the silence an expression of (temporary)

despair, before again resuming the real (intrapsychic) theme.
Professor Holmes: This important story (about binge-eating) has
the hallmark of a hyper activating attachment message . . .
Dr Stolorow: . . . the patient has to continue to dissociate and
somatise the emotional pain that the therapist is not helping him
to bear.
Professor Holmes: attachment and emotional vacuums

Professor Holmes was centrally concerned with the quality of attach-
ment (relative strength 88%) in the therapeutic relationship, that is,
whether the therapist could provide a secure base from which the
patient could explore in security. Most of his subsequent prominent
concepts related to the quality of the attachment experience; for exam-
ple, the emotional vacuum, his second most frequently occurring
concept, signified disorganised attachment, which was experienced
by the patient following the job loss; he filled the vacuum with binge
eating, for example, I would see binge eating as a self-soothing strat-
egy that relates to disorganised attachment in which the child has to
find means, however self-defeating, to self-soothe in the absence of an
effective care-giver. Professor Abbass also used the concept of attach-
ment: . . . the model requires . . . activating the attachment system to
determine a road map for the process of moving to the unconscious.
Although the concept of attachment was not prominent in the other
two commentaries, it is certainly implied. The concept of transfer-
ence, which constituted a key substrate of all four commentaries,
implies attachment. Indeed, psychoanalytic definitions of transference
are sometimes given in terms of attachment. See, for example, Van
Barks (1955) definition: . . . irrational emotional reactions [are]
ascribed to the transference or attachment by the patient to the doctor
of unconscious infantile feelings previously attached to an early
parental figure . . . (p. 5) and Thomas Szasz (1966), Breuer retreated
from psychoanalysis through failure to recognize the transference in
Anna Os erotic attachment (p. 308).
Dr Stolorow: affect and dwell

As we have already observed, Dr Stolorow was predominantly
focused on the concepts affect (experience) and dwell (context),
and, to a lesser extent, on how the patient dissociates and somatises

distress in order to remain experience far from distressing affects,
for example, the patient has to continue to dissociate and somatise
the emotional pain that the therapist is not helping him to bear.
These two concepts appear only distally related to the concepts of the
unconscious and attachment, but closer examination reveals strong
synergies between these concepts and the existential concepts of
affect and dwell. Patients must feel safe enough and sufficiently
held before they can allow themselves to dwell in their painful affect.
Dr Stolorow talks of the therapist helping the patient to bear this
painful affect, which is a position akin to the provision of a secure base
from which the patient can safely explore his inner world. The
concepts of dissociation and somatisation imply that unconscious
processes are at work because the patient is working hard to avoid
bringing these painful affects into awareness and confronting them
directly. Professor Holmes observes the patients defensive behav-
iours and the appropriate therapist response in these terms: Can
the analyst provide primary security, rather than reinforcing and
repeating secondary security strategies such as hyper activation
and disorganisation and self-soothing, including the self-soothing
of nihilism? comments that are concordant with Dr Stolorows exis-
tential focus.
Dr Spielman: silence and the weekend

For Dr Spielman, the concept of silence and its meaning in each of its
occurrences during the session occupied one of his central foci, as did
the meaning of the weekend loss of the therapist. These two
concepts are related to absence, concepts that were also prominent, but
expressed differently, in both Professor Holmes and Dr Stolorows
commentaries. Silence is the loss (absence) of communication in the
session (although silence is a form of communication), for example,
I consider the silence an expression of (temporary) despair, before
again resuming the real (intrapsychic) theme; The silence was a
mini-storm-out. The weekend denotes the loss (absence) of therapist
availability, for example, My world comes to an end when I am
left alone at the weekend . . . and I lose my self. It is noteworthy that
Dr Spielmans interpretation, My world comes to an end, is phenom-
enologically close to Dr Stolorows concept of world-collapse;
Dr Spielmans interpretation that the patient loses his self on the

weekend maps closely on to Dr Stolorows concept of self-loss, and
all of these interpretations sit comfortably with Professor Holmess
fear of the abyss. From his opening comments, both Professor
Abbass and Professor Holmes, like Dr Spielman, were also cognisant
of absences, that the bad news was delivered on Friday, just before
the weekend . . . and that the binge-eating was a dysfunctional form
of self-soothing (JH) or affect regulation (AA) in the absence of a
containing therapist. Professor Holmes used several synonyms to
express the concept of absence: No job; no analyst at the weekend;
this makes me think about a big absenceperhaps in your child-
hoodan abyss, a hole, a vacuum which food-bingeing helps
temporarily to alleviate, but which ends up leaving you with a bigger
hole than before.
The use of the concept transference

The pattern of usage of the concept transference, the other bedrock
concept, together with the concept unconscious, of psychoanalytic
theory and practice, is interesting, first because it figured low in the
top ten concepts for each of the four therapists. It was ranked sixth
for Professor Abbass, eighth for both Dr Spielman and Dr Stolorow,
and lower than tenth for Professor Holmes. As I noted earlier, as help-
ful as automated qualitative analysis can be, it cannot detect implied
concepts and meta conceptual connections in complex text. It also
cannot make a determination about whether the frequency of occur-
rence of a particular concept is the sole signifier of its importance in the
conceptual space. The concept of transference is a case in point.
Dr Spielman used the concept three times:
At the beginning of any session, my main aim is to try to get a

feel of the analysands state of mindand the nature and qual-
ity of the transference today.
I would also be interested in any feelings I may have in response
to their early behaviour in this session (potential countertransfer-
ence feelings).
I consider the analysand is making a critical comment about
the analyst and the analysis. This is partly a transference
phenomenon, having to do with implicit criticism of not having

had enough from mother, and the quagmire experience of not
having been able to be understood as an infant . . .
accounting for 23% of the total usage. Professor Holmes used it once
explicitly (I would venture a complete interpretationone that, la
Strachey, tries to bring together present, transference, and past),
although it is implied in his comments regarding the therapist becom-
ing a secure base for his patient, suggesting that the development of
a positive transference is seen as necessary for a good therapeutic
outcome in attachment-based psychotherapy. Dr Stolorow used it
twice (the therapist does not appear to investigate the impact of his
style on the patients transference experience; the patient is experi-
encing the therapist as a shaming mother in the transference).
Professor Abbass used the concept seven times, accounting for 57% of
all usages. Below are four examples:
. . . degree of resistance present in the transference relationship;

The primary focus in ISTDP would not be the description of the
binge; rather feelings the person has mobilised by the current
event, or better, the emotions mobilised in the transference while
reviewing the story;
. . . content exploration is equal to dialoguing with the resistance
and protracts the treatment, making transference neurosis possi-
ble to probable;
. . . an interpretation coming from the expert . . . would be
contraindicated to interpret in the setting of a highly resistant
person as it sets up an activated transference where the thera-
pist ends up in the shoes of a critical mother.
The patients transference experience

Close investigation of each of the commentaries on the transcript
reveals that all four therapists identified a similar transference experi-
ence for this patientthey all concluded that the patient perceived
the therapist as a critical, shaming, non-attuned mother. Below are
examples from each therapist.
Dr Ron Spielman
. . . implicit criticism of not having had enough from mother,
and the quagmire experience of not having been able to be
understood as an infant . . .
. . . the analyst appears not to take up the transference commu-
nications which . . . are . . . likely to be the core of the unconscious
communication.
Professor Jeremy Holmes

I wonder if something similar is going on here between us. You
follow my suggestions, de-catastrophise, but you feel you are a
burden, that I am frustrated with you, and somehow, like your
mother, I keep missing the real point: your misery, your anger,
your fear of the abyss . . .
Dr Robert Stolorow
This association indicates clearly that the patient is experiencing
the therapist as a shaming mother in the transference. I would
ask, Did I just shame you?
I am being critical of the analyst in a similar way to how the
analyst seems to be handling the patient (i.e., critically).
Professor Allan Abbass

. . . the patient feels criticised in the way mother criticises the brother.
Repairing the transference experience

Each of the therapists offered similar advice to the treating therapist
with respect to improving the patients transference experience. Note
the strong convergences between all four psychotherapists. For
example, Can the therapist seize the day? (RS); Can therapist
and patient conjure a something out of that nothing? Can liveliness
and meaning erupt into the vacuum . . .? (JH); Can they mine the
therapeutic gold in the patients disclosures? (RDS); Can the ther-
apy pick up its pace from being slow and of questionable value?
(AA). Some further examples are given below:
Dr Ron Spielman
Carpe diemseize the daycould be an encouragement by the
analysand of the analyst to seize the opportunity to address these
painful issues of deprivation (too many children and not enough of
anything) and being overlooked by the analyst-mother when he/she
is confronted by the needs of so many other children: the analysts
other patients and the analysts own real life.
Professor Jeremy Holmes

I really dont think patient and analyst are on the same wavelength.
It feels like parallel lines, each pursuing their separate agenda. Id be
wondering if something is being enacted herea deactivated attach-
ment where real engagement (which might entail anger and despair
but also hope and love) is sacrificed for the sake of a modicum of
secondary security.
Can the analyst provide primary security rather than reinforcing
and repeating secondary security strategies such as hyper activation
and disorganisation and self-soothing, including the self-soothing of
nihilism?
Dr Robert Stolorow
There is therapeutic gold here that the therapist doesnt mine . . . The
therapist is not helping the patient dwell in and integrate painful
affect . . . [From his interview: I am most interested in enquiring
about those organising principles that shape the patients emotional
experience and how those show up in the interaction with me in the
form of the transference.]
Professor Allan Abbass

Why is the patient thinking you would be critical? Is it because the
interventions preceding it (and possibly in earlier sessions) already
contained criticism encased in a well-intended interpretation?
[The patient] is expressing the view [that] the treatment is slow
and of questionable value.
. . . The process indicated is to build structural capacity to toler-
ate unconscious anxiety through a specific process Davanloo called
the graded format. Cycles of pressure to feelings followed by intel-

lectual recapitulation build capacity to self-reflect. This process can be
optimised by keeping as high a rise in unconscious anxiety as the
patient can tolerate.
Commonalities in the case formulation
We have just discussed the similarities in each of the four therapists

perceptions of the nature of the transference relationship. In this
section, we will further explore these synergies with respect to their
understanding of some of the key themes in the therapy transcript for
this patient that have not, as yet, been explored in depth.
The meaning of work

For the patient, the ostensible focus of the session were feelings
and attitudes towards work in general and the job loss in particular.
Each of the therapists explored and hypothesised the psychic func-
tion that work fulfilled for this patient, and what was perceived to
be lost as a result of the job lossfor example, loss of psychic
function, loss of self, loss of performative value. For instance, Dr
Spielman believed that the patients focus on work represented a
manic defence:
. . . this need to work [is] an expression of a manic-type of behav-
ioural characteristic of this analysand as a defence against the psychic
pain of unmet dependency needs.
For Professor Holmes, the meaning of the job was to stave off
. . . the fear of an abyss. [The patient] cling[s] to a tawdry secure
base in the shape of the job in the absence of anything more genuinely
comforting . . .
Similar to the interpretation expressed by Professor Holmes, for Dr
Stolorow, the patients reaction to the job loss signifies . . . terror of
falling into a state of psychological annihilationof world-collapse
and self-loss; For the patient, not working = doing nothing = falling
into a state of non-being; This is what I call substitute value or
performative value, as opposed to having a core sense of inherent
value.
Professor Abbass stated that direct attention to content is generally

contra-indicated and that most patient utterances should be directed
toward the goal of
. . . facilitat[ing] the experience of these emotions directly in the
room: this would serve as a gateway to these emotions and also as a
vehicle to cutting down the anxiety, building anxiety tolerance and
building the power of the unconscious therapeutic alliance.
In summary, work was perceived variously as a manic defence, as
clinging to a tawdry (secondary) secure base, as a way of prevent-
ing falling into a state of non-being, and as avoidance of difficult
emotions. Conceptually, a tawdry (secondary) secure base is very
close to the existential concept of substitute or performative value.
Thus, each of the therapists has conceived the meaning of work as a
defensive manoeuvre that protects the patient from confronting the
painful affects of emptiness, world-collapse, and self-loss.
The meaning of binge eating

Another significant theme in the transcript was the psychic meaning
of the patients binge eating. Each of the therapists addressed this
component of the patients presentation and offered interpretations
of its meaning in the context of his overall psychic organisa-
tion. Presented below are the formulations offered by the four thera-
pists.
Dr Spielman:
. . . early infantile issues notably express themselves around
weekends and this binge eating does seem to have to do with filling
the emptiness of the weekend; I would be prepared to say some-
thing like you feel you lose your position with me here on the week-
end and needed to fill yourself with junk food to deal with the
emptiness. [I have changed job to position for the purposes of
this interpretation.] We really do need to attend to this bingeing to
comfort behaviour.
Professor Holmes:
The horrid pain of the job rejection, the need for comfort and
soothing, and then the blow-out . . . (the latter a more vernacular
phrase than bingeing). I would see binge eating as a self-soothing
strategy that relates to disorganised attachment in which the child has

to find means, however self-defeating, to self-soothe in the absence of
an effective care-giver.
Dr Stolorow:
. . . the patient has to continue to dissociate and somatise the
emotional pain that the therapist is not helping him to bear.
Professor Abbass:
The primary focus in ISTDP would not be the description of the
binge, rather feelings the person has mobilised by the current event or
better, the emotions mobilised in the transference while reviewing the
story.
Dr Stolorow expressed a very similar response to the patients account

of bingeing.
I might have said, Tell me what you were feeling just before you
started to eat.
As for the interpretations of the meaning of work, the primary
interest in each of the therapists was to identify the underlying
(psychodynamic, intrapsychic) meaning of the patients binge eating.
All concurred that it was a way of filling an inner emptiness, a form
of self-soothing and affect regulation, and a defensive manoeuvre
to avoid directly experiencing the underlying psychic pain.
The meaning of feeling dead

Here are the responses of each therapist to the patients statement:
What worries me is who or what I will be when I leave work. I will
feel like nothing, that I dont have a place on this earth. I may as well
be dead.
Dr Spielman:
Yes, doing nothing is like death . . . this session has been about
unmet dependency needs and loss . . . and the analysands character-
istic manic style of defence against this by working. To be out of a job
is to expose the analysand to the threat of feeling dead.
Professor Holmes:
I would . . . pick up on the word dead, partly as an actual suici-
dal feeling, partly as a description of the session itself which feels
pretty dead, partly going to the word deadly as an expression of

venom and anger that cannot be expressed and so is turned against
the self . . .
Dr Stolorow:
. . . the patient is in terror of falling into a state of psychological
annihilationof world-collapse and self-loss.
Professor Abbass:
This suggests that the patient transfers all the complex emotions
from parents on to others, including the therapist. In the ISTDP frame,
we would facilitate the experience of these emotions directly in the
room: this would serve as a gateway to these emotions and also as a
vehicle to cutting down the anxiety, building anxiety tolerance, and
building the power of the unconscious therapeutic alliance.
There are several interpretations to the theme of feeling dead in the
transcript, and each therapist highlights a different constellation of
meanings. The key themes are:
1. Unmet dependency needs and loss . . . (RS);

2. A suicidal feeling in both its physical (JH) and phenomenological
aspects (RDS);
3. Unexpressed anger turned against the self (JH and AA);
4. Projection of complex emotions from parents on to others (AA).
These themes all have in common an awareness of a defensive

process that is operating to keep the patient from acknowledging
unexpressed emotionson the one hand, unmet dependency needs
and feelings of loss, and on the other, anger about those unmet needs.
The defences of introjection and projection have also been implied
themes 2 and 3 are introjective and theme 4 is projective.
What were the perceived therapeutic goals?

Each of the four therapists identified specific therapeutic goals and the
tasks that needed to be accomplished in order to achieve those goals.
Dr Spielman:
Weekend breaks are manifestations of maternal misattunement
by the very nature of the break: the analysand feels the absence of the
analyst and working through what this form of experience is and

what it represents is essential analytic work.
The purpose . . . of trying to take advantage of . . . weekend mate-
rial is to . . . access . . . early infantile feelings. This (potentially) has
much more to offer than dealing with external realities.
Professor Holmes:
So what were really looking at here iswho are you? Do you
have an inner core identity apart from your work? Thats an issue for
anyone who retires or is made redundant, but maybe has an extra
poignancy for you because . . . (Here I would need some biographi-
cal/developmental data to provide chapter and verse.) The basic
message is that the current trauma is a repetition of previous
loss/stress/developmental difficulty. As Winnicott, quoting
Nietzsche, said, the dreadful has already happened.
Dr Stolorow:
Doing nothing is like deaththat says it all. The therapist really
needs to understand this catastrophic feeling in the patient and dwell
in that together rather than try to change the patients faulty cogni-
tions at this point in the therapy.
Professor Abbass
If [the patient] has capacity . . . in the ISTDP frame, strong encour-
agement to be present in the room, identify and experience the
emotions that still go to repression, self-criticism, detachment, and
intellectualisation are called for in order to accelerate the psychody-
namic process.
Three of the four therapists stated their therapeutic interest in
uncovering some aspect of early developmental trauma that they
believed underlay the patients current catastrophic reaction to the job
loss. This was expressed as accessing . . . early infantile feelings
(RS), the current trauma is a repetition of a previous loss/stress/
developmental difficulty (JH), and identify[ing] and experienc[ing]
the emotions that still go to repression (AA). Although Dr Stolorow
did not explicitly state that this was his therapeutic task and evinced
a much more present-focus, it would be inevitable that the process of
dwelling in painful affect would eventually connect the patient with
early trauma and the unconscious. In his interview, he stated that:
The focus on experience doesnt mean that you restrict it to conscious

experience or the description of conscious experience, because
phenomenology as a philosophical discipline has always been con-
cerned with investigating and illuminating structures of conscious-
ness that are pre-reflective. We call them the pre-reflective
unconscious. (Chapter Five, this volume, p. 183)
The therapeutic goals of all four therapists were affect-orientated, that

is, the goal was to identify unconscious, affective pain related to
unmet dependency needs, experiences of loss, abandonment, and
anger about early developmental failures, to work through them in
the therapeutic (transference) relationship, and finally to integrate
them. This appears to be the treatment sequence for most current
dynamically orientated psychotherapies (see Chapter Two, this
volume, pp. 4598).
Conclusion: one tree,
many branches?
n this book, I sought to answer two questions: (i) What remains of
I Freud in current psychoanalytic theorising and practice? and (ii)

To what extent are the different branches of contemporary psycho-
analysis linked conceptually and in practice?
I have concluded from my analysis of the four psychotherapies
studied here that they are, indeed, direct descendants of Freuds
psychoanalytic practice (if not metapsychology) and that underneath
somewhat different vocabularies and therapist behaviour in the room,
they share a common genotype. Dr Spielman, in his interview, said
. . . a good clinician is a good clinician no matter what they think

guides them. But when we talk with each other about . . . our theories,
some of them are just radically incompatible with each other. (Chapter
Three, this volume, p. 110)
What, at first glance, might appear radically incompatible, on closer

examination of these four therapists responses to the transcript of
the analytic session we can discern that each therapist is directed by
a similar set of underlying theoretical (Freudian) precepts. These
include the nature of the therapistpatient relationship (i.e., the
two-person psychology), the importance of the transference (and
323
countertransference), the therapeutic stance of listening with a third

ear for the symbolic/metaphoric communications of meaning in the
patients utterances (i.e., unconscious communications), and the
efforts they each make to encourage the patient to be fully present in
the room (i.e., experience-near, in phenomenological terms).
I would encourage interested readers to return to the second chap-
ter of this book and compare the interviews and commentaries with
the theoretical precepts argued to underlie current psychoanalytic
practice and decide for themselves whether the foundations of these
four psychoanalytic offspring are, indeed, the heirs of Freudian
psychoanalytic practice. I am not arguing in this book that examina-
tion of all current incarnations of dynamic psychotherapy would have
led to the same conclusions. Jungian and Lacanian analysis, for exam-
ple, would, no doubt, complicate the picture I have painted here and
point to greater divergences from Freudian psychoanalytic thinking
than has been evident in the four chosen psychotherapies. However,
using the evidence from this examination of these four forms of
contemporary psychoanalytic psychotherapy, I argue that the deep
structure of the process is convergent, even though the theorising and
vocabulary might initially indicate otherwise.
However, each of the therapists phenotypical presentations, that
is, how they actually behave in the therapy room with their patient,
would, no doubt, reveal some distinct differences, both as a result of
the different personalities of each of the therapists and with respect to
their different analytic approaches. For example, Dr Spielman, the
object relations psychoanalyst, expects the patient to use the couch
and regards refusal as a resistance. The other three therapists do not
require its use in such a prescriptive way. ISTDP therapists never use
the couch; on the contrary, they insist on the use of a chair with arms
so that physical discharge patterns can be readily observed. They also
seat the patient square on to the therapist because they regard eye
contact with the therapist as a critically important element in the
process. I imagine that Dr Spielmans personal presentation would be
more abstinent and neutral than the other therapists, with more insis-
tent adherence to a strict psychoanalytic frame.
The most obvious difference between these four psychotherapies
is the stance of ISTDP therapists, who would be clearly distinguish-
able from therapists from the other three forms of psychotherapy
examined here by their directive activity, minimisation of the transfer-
CONCLUSION: ONE TREE, MANY BRANCHES? 325
ence neurosis, time-limited format, therapeutic structure (i.e., use of

the central dynamic sequence), a focus on both verbal and physical
manifestations of anxiety, and encouragement of emotional discharge
through both channels. In order to make ISTDP widely available,
ISTDP therapists offer therapy in block mode for patients who need to
travel a great distance to access an ISTDP therapist. Block mode
involves the provision of an intensive therapy experience in a range
of formats, including two- and three-hour sessions daily over the
course of a week. This would be followed by a one or two month break,
after which the patient returns for another intensive block of therapy.
The effectiveness of this form of therapy challenges the view that
the fifty-minute hour is the optimal duration of an analytic session.
Because ISTDP therapists make their video-recorded therapy
sessions available to colleagues and students, one has direct access
to the actual therapeutic experience of both patients and therapists
in this form of therapy. One of the problems with almost all other
forms of dynamic psychotherapy is that video recordings of patient
sessions are rarely made available for study or scrutiny and we are left
with second-hand case reports, which are inevitably laden with their
therapists perceptions and interpretations of what transpired in the
session, as our only source of evidence.
Notwithstanding, I hope that you, the reader, have deepened your
experience and understanding of these four branches of contemporary
psychoanalytic psychotherapy through your experience-nearness to
the minds (notwithstanding Dr Stolorows objection to this
Cartesian notion!) of these four master clinicians.
NOTES
1. Hysteria was the term given to the presentation, mostly by women, of a

constellation of unexplained physical symptoms that included paralysis,
muscle contractures, pseudo seizures, pain, fatigue, tics, aphonia and
food aversions, inter alia. Charcot believed that the symptoms arose as a
result of an emotional response to a traumatic incident in their past. He
called hysteria with an emotionally traumatic origin traumatic hysteria.
2. Repression is a defence mechanism identified by Freud. It is a process
whereby mental content is removed from awareness (Madison, 1961).
3. The use of the term affect requires clarification. In his early writing,
Freud defined affect as the quantity or force or energy of an instinctual
drive. In the Studies on Hysteria, Freud refers to strangulated affect that
has not found release or discharge. The term affect later assumed a
much broader definition and incorporated a range of emotions that
included anxiety, mourning, guilt, love, and hate (Freud, 1926d).
4. This account is incorrect. Breuers last child, Dora, was born on 11 March
1882, three months before Annas phantom pregnancy (Clark, 1980).
5. Alternative translation: The dragon cannot be slain in effigy.
6. The idea of a preconscious has received empirical support in the concept
of perceptual defence, a process whereby people keep out of awareness
threatening stimuli, such as the word cancer (Poloni, Riquier, Zimmer-
man, & Borgeat, 2003).
327
328 NOTES
7. Freud rarely referred to the death instinct after its appearance in Beyond
the Pleasure Principle (1920g). He conceived of it in the context of his
observation of the compulsion to repeat in the war neuroses following
the First World War, a phenomenon that could not be explained by the
pleasure principle. The concept is both theoretically and clinically redun-
dant in Freudian psychoanalysis (van Haute & Geyskens, 2007) and will
not be discussed further here.
8. http://www.kheper.net/topics/psychology/Freud.html. Accessed 24
March 2011.
9. Robert Stolorow makes an interesting comment on free association in his
interview (see p. 193), describing it as an oxymoron.
10. Primary process is defined as the logic and rules of the unconscious
(Brakel, Shevrin, & Villa, 2002).
11. The patient experiences the analysis as if it were an erotic experience
deriving from infantile wishes relating to his/her parents. The analytic
relationship may be sexualised (eroticised) in any of the ways that the
developing child experienced physical pleasureoral, anal, phallic, geni-
tal (Opdal, 2007).
12. Secondary process is defined as rational thought, the egos reality-testing
capacity (Rycroft, 1956).
13. The perfect Freudian man has the following characteristics: heterosexual
potency, and capacity for love, object relationships, and work (Menninger
& Holzman, 1973).
14. Selfobjects are defined as the experience of essential psychological func-
tions that sustain the self, and which are experienced as part of the self,
although the functions are provided by another (Kohut, 1971, 1984); that
is, selfobject needs are satisfied (or not) by external figures in ones life.
15. This is a caption on a wall of the Freud Museum in Vienna and is attrib-
uted to Freud.
16. www.age-of-the-sage.org/famous_familiar_quotes.html
17. A metaphor is a poetic substitution of an uncommon word for a more
ordinary one and, thus, has the capacity to connect elements on the basis
of their relatedness (metonymy) or equivalence (metaphor).
18. The first recorded use of a metaphor is found in the poem, Epic of
Gilgamesh, in the Sumerian language (Damrosch, 2007).
19. It is not correct to assign the origin of these terms to Freud, who used the
everyday German words, das Ich I (I), uber-Ich (over-I) and das Es (It) to
describe these concepts in his structural metapsychology. It was, in fact,
A. A. Brill, one of Freuds English translators, who introduced the words
id, ego, and superego.
NOTES 329
20. Sadism means love of cruelty, derived from the French word sadisme,
which originated from Count Donatien A. F. de Sade (17401815), who
earned notoriety for the cruel sexual practices he described in his novels.
21. More recent CBT models are increasingly including an emotional
processing component.
22. There are now schema-focused CBT approaches, which address internal
representations of ones reinforcement history.
23. For a definition and discussion, see Klein (1923), and Laplanche and
Pontalis (1973).
24. Samuel Maverick (18031870) was a Texan lawyer, politician, rancher,
and signatory to the Texas Declaration of Independence. The word maver-
ick came to denote independence of mind.
25. This is a euphemistic expression for fuck and blimey (may God blind
me).
26. The concept of the portkey is found in Freuds (1900a) Interpretation of
Dreams:
If a few bars of music are played and someone comments that it is

from Mozarts . . . Don Giovanni, a number of recollections are roused
in me all at once, none of which can enter my consciousness singly at
the first moment. The key-phrase serves as a port of entry through
which the whole network is simultaneously put in a state of excitation.
It may well be the same in the case of unconscious thinking. The rous-
ing stimulus excites the psychical port of entry which allows access
to the whole . . . phantasy. (p. 497)
27. ISTDP is based on elements of classical Freudian psychoanalysis (focus

on the unconscious, the transference, and the major resistances) and
attachment theory. From the attachment perspective, Davanloo proposed
a universal attachment rupture process that comprises bonding, attach-
ment, trauma, psychic pain, rage, guilt about the rage, avoidance of feel-
ing, development of self-destructive symptoms and defences.
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INDEX
Abbass, A. A., xiiixiv, 58, 92, 98, 214, arousal, 153

222, 232, 242, 300305, 308310, associated, 5, 81
312315, 317320, 331 bodily, 207
Abrams, E. K., 54, 332 cognitive-, 207
abuse, 117, 131132, 137, 241, 250 development, 207
see also: relationships discharge, 235, 263
child, 250 dissociation, 79
external, 247 distressing, 4, 256, 310
internal, 247 experience, 70, 110, 171, 208, 256,
sexual, 14, 8182, 152 303
substance, 82 expression, 151
adjustment, 34, 242 force, 256
disorder, 224 immediate, 263
Adult Attachment Inventory, 151 intolerable, 79
affect(ive), 4, 12, 26, 66, 69, 74, 7879, knowing, 57
93, 103104, 107, 110, 112, 148, -orientated, 321
151, 154, 160161, 172, 188, 205, overwhelming, 50, 148
207, 225, 251, 255258, 261262, painful, 20, 81, 111, 257, 263,
306, 308, 310311, 327 see also: 284285, 306, 315, 317,
integrate/integration, 320321
isolate/isolation, self -phobic, 112, 311
accompanying, 4, 26, 256 presence, 70
361
362 INDEX
regulation, 48, 52, 110, 148, 150, anxiety, 47, 15, 20, 43, 50, 74, 81, 83,
153, 274, 305, 312, 318 95, 100, 107, 148, 159160, 172,
signal, 20 196, 214216, 218221, 224230,
states, 79, 88, 184, 186, 188, 192, 232234, 237238, 245248, 254,
253 256, 259, 265, 273, 294, 303, 305,
strangulated, 14, 66, 256257, 263, 317, 319, 325, 327 see also: death,
327 existential, primitive,
terrifying, 134 unconscious(ness)
tone, 66, 256 anticipatory, 20, 81
-trauma model, 5, 1314, 81, 255, 262 associated, 15
universe, 151 attendant, 8
unpleasant, 148 childhood, 36
aggression, 19, 35, 49, 135, 237, 280 depressive, 43
competitiveness, 162 discharge, 295
drive, 20, 47, 83 ego, 83
energy, 17, 19, 29 infant, 15
healthy, 175 moral, 20
impulse, 17, 48, 53 muscle, 229, 243
individual, 19 pathway, 228
origins, 46 patterns, 225
repressed, 3 performance, 113, 154, 238
urges, 53 providing, 225
Aguillaume, R., 30, 332 signal, 20, 81
Ainsworth, M. D., 109, 146, 165, 332 stranger, 47
Akhtar, S., 2, 62, 77, 332 tension, 229
Alexander, F., 49, 54, 76, 94, 332 theory of, 81
Allen, W., 42, 44, 159 tolerance, 221, 239, 245, 249250,
American Psychiatric Association, 289, 294295, 303, 317, 319
197, 332 traumatic, 20, 81
American Psychological Association, underlying, 275
191 Appelbaum, J., 58, 80, 332
anger, 24, 34, 3637, 85, 117, 169, 220, Appignanesi, L., 10, 332
236237, 249, 280282, 303, Aristotle, 6263, 262, 332
314315, 319, 321 Arlow, J. A., 30, 332
healthy, 175 Armony, N., 31, 332
pervasive, 37 Aron, L., 86, 332
self-directed, 236 attachment (passim)
somatic, 220 approach, 176
unexpressed, 319 aspect, 170
angst, 175, 182185, 187, 247 behaviour, 109, 167, 169
Antia, S. X., 90, 335 bonds, 245
Antonaci, F., 23, 332 crises, 240
INDEX 363
deactivated, 280, 315 authentic/authenticity, 60, 8688, 185

disorganised, 152, 176, 274, 310, relationship, 86
318 avoidant, 110, 144, 174, 218
dynamic, 149, 169 infant, 111
erotic, 310 insecure-, 110
exercises, 216 person, 176
experience, 302, 310
failures, 112 Bacon, F., 155
feelings, xiv, 216 Bacon, R. J., 155, 261, 333
figures, 75, 111, 144, 157, 176, 246 Baker, R., 94, 333
insecure, 148, 166 Balint, E., 165
issues, 274 Balint, M., 4041, 144, 333
message, 274 Banai, E., 48, 333
model, 150 Barlow, D. H., 38, 359
needs, 169, 274 Barwick, M., 134, 337
origins of, 169 basic fault, 40
panic, 160 Bateman, A., 80, 82, 144, 153, 333
paradigm, 148, 154, 160 Beattie, H. J., 19, 333
perspective, 147, 150, 152, 174, Beck, A. T., 90, 333, 345
273274, 282, 329 Beebe, B., 48, 54, 69, 81, 146, 199, 273,
point of view, 175 281, 333334
quality, 48 behaviour, 5, 7, 19, 35, 37, 41, 60,
rage, 175 7374, 109, 132, 165, 180, 192,
relationship, 156, 167 215, 227, 236, 238, 248, 254, 266,
primary, 149, 253, 261 268269, 274, 308309, 311312,
research, 182 317, 323324 see also: attachment,
rivalry, 170 cognitive, sexual
secure, 110, 145146, 152, 158, 182, adult, 110
277, 282 characteristic, 272, 304, 316
sexualised, 245 correct, 58
style, 175 dependent, 94
system, 160, 288, 300, 302, 304, dismissive, 112, 260
310 harmful, 226
theory, 36, 58, 81, 108110, 113, 134, herd, 250
144, 148, 157, 169170, 173174, human, 46, 180
176, 182, 191, 255, 302, 329 neuro-, 238
therapeutic, xiv, 216, 222 obsessive defensive, 269
trauma, 223 oedipal, 125
Atwood, G. E., 48, 56, 79, 90, 95, patterns, 90
180182, 188, 190, 193, 196198, problematic, 75
202, 209, 333, 357 radical, 181
Auden, W. H., 12, 333 regressive, 235
364 INDEX
socially acceptable, 6 Calef, V., 35, 336

somatising, 269 Cambray, J., 7, 336
strategies, 238 Canestri, J., 138, 344
therapies, 90 Capps, D., 23, 336
Bell, S. M., 146, 332 Card, N. A., 80, 336
Bensing, J. M., 23, 334 Carpelan, H., 40, 84, 336337
Beres, D., 2, 334 Carrette, J. R., 137, 337
Bernstein, J., 31, 334 Cartesian, 190, 197, 199, 201203,
Bion, W. R., 35, 79, 8485, 95, 108, 206209, 325
163, 199, 264, 275, 334 Caruth, E. G., 68, 337
Black, M. J., 63, 350 Cassimatis, E. G., 83, 337
Blagys, M. D., 74, 334 Castelnuovo-Tedesco, P., 30, 337
Blanco, C., 90, 335 Chambless, D. L., 90, 337
Blatt, S. J., 167, 338 Charcot, J.-M., 4, 23, 327
Blehar, M. C., 109, 146, 332 Chessick, R. D., 35, 337
Blomfield, O. H., 30, 335 Chimento, P., 23, 332
Blum, H. P., 35, 335 Christian, C., 96, 338
Boag, S., 28, 63, 335 Chused, J. F., 7, 337
Boerne, L., 27, 335 Clark, D. A., 90, 333
Bohleber, W., 79, 335 Clark, R. W., 10, 327, 337
Bollas, C., 36, 41, 80, 86, 335 Clarkin, J. F., 51, 347
Bonaminio, V., 86, 335 cognitive behavioural, 282, 306
Bond, A. H., 82, 335 approach, xii, 286
Bono, G., 23, 332 intervention, 285
Bonovitz, C., 69, 335 therapies, 74, 207
Borgeat, F., 327, 351 Cohen, N. J., 134, 337
Bowlby, J., 15, 110, 144146, 149, 157, conflict, 5, 17, 21, 36, 4647, 52, 63, 74,
169, 173174, 187, 253, 335 83, 94, 96, 133, 138, 157, 166, 194,
Brakel, L. A., 328, 335 246, 250
Brandchaft, B., 56, 79, 82, 90, 95, 197, extra-psychic, 293
336, 357 -free ego capacities, 46
Brenner, C., 68, 336 inner, 8, 74, 79
Breuer, J., 811, 26, 63, 6566, 83, instinctual, 262
251252, 255257, 263, 310, 327, internal, 44, 83, 262
336 intrapsychic, 264
British Psychoanalytic Society, 174 marital, 151
Britton, R., 35, 163, 170, 173, 336 oedipal, 125, 166
Bromberg, P. M., 87, 336 unconscious, 53
Brown, M., 134, 337 conflicted
Bruschweiler-Stern, N. C., 160, 336 impulses, 8
Burston, D., 78, 336 mind, 107, 110
Busch, F., 120, 354 conflicting emotions, 74
INDEX 365
conscious(ness) (passim) see also: Cortina, M., 87, 337

unconscious(ness) countertransference, 3132, 56, 59, 75,
activity, 26 8488, 100, 105, 110, 121, 147, 161,
attention, 33 198199, 219, 258, 282, 312, 323
awareness, 6, 24, 7374, 189 see also: reaction, transference
deliberation, 123 disclosures, 88
discontinuities of, 29 ethical, 147
ego, 252 feelings, 219, 266
expectations, 56 response, 84
experience, 70, 74, 183, 320321 Cranfield, P. F., 10, 337
intentions, 24 Crenshaw, D. A., 69, 344
matriarchal, 173 Cuoto, J. A., 61, 358
memory, 4, 52
mind, 256 Daehnert, C., 83, 337
normal, 67 Damrosch, D., 328, 337
object, 16 Dare, C., 30, 353
pre-, 16, 20, 67, 252, 255, 327 Davanloo, H., 92, 214215, 218,
process, 95 220222, 225227, 229, 231, 235,
psychology of, 16 238, 243246, 249, 254, 288, 292,
restriction of, 55 315, 329, 337338
state of, 200 Davis, H. L., 86, 338
thought, 18, 21, 25, 144, 253 Dawson, H., 134, 338
wishes, 82 Dazzi, N., 61, 350
context/contextual, 22, 53, 60, 69, 78, deactivate/deactivation, 148,
138, 160, 164, 175, 180, 183, 151152, 174, 176, 256 see also:
188190, 193, 195196, 204206, attachment
209, 233, 254, 264, 282, 301, 303, death, xii, 9, 81, 122, 136, 174176,
308, 310, 317, 328 see also: 183186, 223, 243, 272, 281,
interpersonal, intersubjective 287288, 294, 318, 320
embedded, 197, 202, 206, 208209 anxiety of, 184
of the reality, 136, 260 fantasy of, 174
relational, xiv, 48, 50, 72, 145, fear of, 174
180181, 204 implications of, 186
continuity/discontinuity, 29, 52, 82, instinct, 17, 175, 328
183 physical, 209
Cooper, D., 144 De Coro, A., 61, 350
corrective De Lourdes, M., 61, 358
analytic experience, 54, 94 depression, 24, 36, 84, 140, 214, 224,
emotional experience, 38, 49, 54, 94 228, 230, 246, 265, 292 see also:
empathic experience, 54 anxiety
object relationship, 53 deep, 272, 281, 287, 294
relational experience, 54, 95 major, 229, 289
366 INDEX
position, 204 disorder, 39 see also: adjustment

severe, 246 clinical, 58
development(al), 14, 22, 40, 4748, 51, delusional, 241
5355, 74, 81, 96, 125, 127, 139, hysterical, 11
158, 167, 169, 191, 303, 313 of affect regulation, 153
see also: affect(ive), of vision, 9
transference organic, 23
cognitive, 207 personality, 99, 128, 152153
difficulty, 279, 320 borderline, 197
early, 94, 111, 180 post traumatic stress, 15
ego, 21 psychological, 80
emotional, 46 dissociation, 24, 69, 72, 79, 8990,
experience, 97, 158, 168169, 194 92, 152, 186, 238, 259, 285, 289,
failures, 321 300, 310311, 318 see also:
functioning, 22 affect(ive)
healthy, 54 defensive, 79, 83
history, 204 psychological, 55
human, 108 Dorpat, T., 83, 87, 339
infant, 48, 61, 81, 160 Driessen, E., 58, 331
internal, 262 dyad(ic), 27, 48, 52, 58, 147
loss, 185 analytic, 8586, 263
needs, 71 collaboration, 72
normal, 19, 4546, 61 interaction, 91
of language, 21, 69, 73 motherinfant, 35, 4748, 155
pathological, 45 relationship, 110
personality, 74 therapeutic, 196, 309
problem, 226
process, 45, 80, 83, 146, 158 Eagle, M., 78, 167, 262, 339
psychological, 48, 85 ego, 58, 1718, 2021, 27, 2930,
relationships, 75 3435, 37, 42, 44, 51, 56, 6364,
technique, 27 68, 80, 88, 94, 106107, 181, 252,
theory, 13, 58 328 see also: anxiety,
thwarted, 38 integrate/integration,
trauma, 320 unconscious(ness)
universal, 3 adult, 18
Dewey, J., 57, 338 alter, 47
diagnosis/diagnosing, 184, 197, -analysis, 2627
228 capacities, 46
Diamond, D., 81, 96, 167, 338 defects, 51, 53
Didi-Huberman, G., 4, 338 defences, 17, 20, 29
Diener, H.-C., 23, 332 development, 21
discontinuity see: continuity disorganisation, 36
INDEX 367
function, 44, 164 existential, 2, 36, 48, 77, 90, 93, 135,
ideal, 18, 44 175176, 183, 185, 247, 253, 255,
instinct, 27 282, 297, 303, 311, 317
observing, 38, 44, 89, 94 anxiety, 174176, 182, 184
overwhelmed, 38 Ezriel, H., 231, 339
psychology, 47, 5153, 83, 89
regressive, 44 Fairbairn, W. R. D., 48, 52, 70, 83, 95,
resistance, 35 339340
super, xii, 1718, 2021, 35, 38, 44, Fairholme, C. P., 38, 359
6364, 68, 83, 89, 94, 107, fantasy, 50, 80, 8485, 107, 122123,
156158, 181, 247, 252, 125, 129, 176, 181, 202, 262
328 see also: sexual
waking, 252 -driven, 18
Ehrlich, F. M., 86, 339 objects, 52
Eissler, K. R., 20, 339 of death, 174175
Ekstein, R., 43, 339 original, 176
Eliot, T. S., 62, 64, 67, 339 Farchione, T. J., 38, 359
Ellard, K. K., 38, 359 Faulkner, W., 75, 340
Ellenberger, H. F., 10, 339 Fel, D., 69, 359
Feldman, M., 120, 354
Emde, R. N., 5354, 96, 339
Feldman, R., 71, 348
empathic, 32, 48, 5354, 67, 75, 87,
Fenichel, O., 29, 49, 94, 166, 340
161, 273, 301
Ferenczi, S., 8, 38, 41, 43, 340
analytic, 54
Fiscalini, J., 52, 54, 340
attunement, 54, 62, 89, 219220
fixate/fixation, 6, 12, 34, 38, 241
availability, 53
Fliegel, Z. O., 3, 340
bond, 95
Fogel, G. I., 87, 340
engagement, 194
Fonagy, P., 2, 5759, 69, 80, 82, 91, 95,
experience, 54, 219
97, 110, 153, 207208, 225, 280,
failures, 48, 82
333, 340
immersion, 195, 200201 forbidden, 5, 17, 22, 47, 59, 79, 189
inquiry, 56, 96 Forrester, J., 10, 332
-introspective, 47, 49, 201 Fraiberg, S., 133, 341
mode of observation, 47 free association, 22, 25, 2731, 35, 37,
resonance, 150, 172 58, 75, 89, 92, 103, 123, 192193,
envy, 59, 85, 89, 112113, 117, 124, 231, 243, 253, 328
166167, 169170, 248 French, T. M., 54, 94, 332
Erikson, E. H., 139, 339 Freud, A., 29, 46, 73, 82, 94, 341
Erle, J. B., 9, 339 Freud, S. (passim) see also:
existence, xiv, 4, 11, 25, 31, 44, 47, 49, psychoanalysis/psychoanalytic
174, 183, 185187, 209, 247, 270, A note on the prehistory of the
272, 277, 281, 285, 287, 291, 294 technique of analysis, 27, 335,
human, 78, 136, 185, 187 342
368 INDEX
A note on the unconscious in New Introductory Lectures on

psycho-analysis, 24, 341 Psychoanalysis, 44, 92, 94, 342
An Autobiographical Study, 10, 342 Observations on transference-love,
Analysis terminable and 59, 84, 342
interminable, 8, 1718, 27, On beginning the treatment, xiv,
4244, 56, 6364, 94, 342 28, 69, 166, 342
Anna O (Bertha Pappenheim), On the sexual theories of children,
811, 25, 6566, 310 3, 341
Beyond the Pleasure Principle, 63, Pcs., 2021
328, 342 Recommendations to physicians
Charcot, 4, 341 practising psychoanalysis,
Civilization and its discontents, 63, 3233, 56, 58, 341
342 Remarks on the theory and
Constructions in analysis, 94, practice of dream-
342 interpretation, 62, 342
Cs., 16, 2021 Remembering, repeating and
Delusions and dreams in Jensens working-through, 67, 13, 15,
Gradiva, 2, 341 2628, 3233, 342
Dora, 1011, 31, 327 Repression, 67, 252, 342
Five lectures on psycho-analysis, Studies on Hysteria, xiv, 35, 911,
12, 94, 260, 341 1415, 22, 24, 39, 56, 6567, 83,
Formulations on the two principles 94, 252, 258, 263, 327, 341
of mental functioning, 25, The aetiology of hysteria, 14, 341
8081, 341 The dynamics of transference,
Fragment of an Analysis of a Case of 1213, 31, 341
Hysteria, 11, 32, 341 The Ego and the Id, 6, 1820, 27, 342
From the History of an Infantile The future of an illusion, 94, 342
Neurosis, 3334, 49, 342 The Interpretation of Dreams, 32, 67,
Further remarks on the neuro- 329, 341
psychoses of defence, 78, 23, The unconscious, 1516, 57, 70, 342
341 Three Essays on the Theory of
Inhibitions, Symptoms and Anxiety, Sexuality, 92, 341
7, 20, 34, 55, 81, 195, 327, 342 Two encyclopaedia articles, 11, 28,
Instincts and their vicissitudes, 3, 35, 55, 252, 342
342 Ucs., 16, 2021
Introductory Lectures on Psycho- Wild psycho-analysis, 32, 57, 84,
Analysis, 10, 30, 76, 342 341
Jokes and their relation to the Wolf Man, 34
unconscious, 255, 341 Frie, R., 78, 336
Lines of advance in psycho- Friedman, L., 30, 68, 96, 343
analytic therapy, 37, 342 Friedman, R., 7, 343
Mourning and melancholia, 40, 342 Fromm, E., 86, 343
INDEX 369
Frosch, A., 9, 343 Hill, C. A. S., 42, 344

Frosh, S., 6, 51, 85, 343 Hilsenroth, M. J., 74, 334
Hinshelwood, R. D., 92, 344
Gadamer, H.-G., 68, 72, 160, 208, 343 Hoff, E., 80, 345
Gedo, J. E., 83, 343 Hoffer, W., 82, 345
Gergely, G., 69, 343 Hoffman, I. Z., 49, 345
Gerson, S., 87, 343 Holder, A., 30, 353
Geyskens, T., 15, 29, 328, 358 Hollon, S. D., 90, 345
Gill, M. M., 94, 343 Holmes, J., xiv, 2, 6263, 7778, 89,
Gilmore, K., 40, 343 9293, 95, 9798, 111, 145, 147,
Giovacchini, P., 83, 343 152, 156, 161, 255, 273, 301306,
Girard, M., 70, 343 309318, 320, 345346
Gitelson, M., 95, 343 Holzman, P. S., 2, 34, 3638, 44, 57,
Gladwell, M., 154, 343 86, 328, 349
Glocer Fiorini, L., 138, 344 Home, H. J., 78, 346
Goldberg, D. A., 9, 339 Horwitz, L., 9, 351
Gramzow, R. H., 17, 344 Hrdy, S. B., 156157, 346
Green, E. J., 69, 344 Humphries, M. S., 297, 354
Greenberg, J. R., 48, 96, 344 Hunter, R. A., 27, 349
Greenson, R. R., 94, 344 hysteria, 34, 7, 14, 6667, 105, 256,
Greenstein, M., 69, 359 327
grief, 112, 183, 185, 187, 190191, common, 4
216219, 223224, 236237, 246, traumatic, 4, 327
248, 254
Grotstein, J., 79, 344 id, 8, 1718, 2021, 26, 29, 35, 51, 56,
guilt, 5, 14, 21, 33, 35, 47, 83, 96, 6364, 68, 94, 107, 148, 181, 328
217219, 224, 230, 235239, -analysis, 2627
244250, 254, 291, 327, 329 Ihanus, J., 61, 358
sense of, 81, 237, 252 immortality see: mortality
Guntrip, H., 29, 40, 58, 344 impasse, 195197
impulse, 6, 12, 18, 2122, 29, 31, 37,
Hancock, J. T., 58, 331 51, 54, 59, 63, 74, 84, 148, 259
Hanfmann, E., 48, 358 see also: aggression, conflicted,
Harris, J., 17, 344 primitive
Hartmann, H., 46, 52, 344 control, 52
Havens, L., 87, 344 erotic, 31
Hegel, G. W. F., 138, 344 forbidden, 79
Heidegger, M., 48, 160, 180, 183185, instinctual, 6
208, 344 powerful, 19
Heisenberg, W., 91, 344 pressing, 21
helplessness, 1415, 20, 37, 50, 81, 176 repressed, 19
Henderson, J., 58, 331 sexual, 3
370 INDEX
Insko, C. A., 17, 344 field, 48, 69, 148

instinct(ual), 2, 6, 14, 1718, 42, 51, 86, matrix, 50
94, 110 see also: death, ego, model, 150
impulse, sexual processes, 45
conflict, 262 psychoanalysis, 4849, 54
drives, 17, 51, 327 relations/relationships, 44, 48, 75,
epistemophilic, 126 79, 86, 246, 263, 309
fundamental, 15 situations, 60
inhibition, 63 style, 37
needs, 82 trauma, 8
processes, 35 worlds, 87
repressed, 79 intersubjective, 56, 60, 81, 83, 9598,
secondary, 15 139, 183, 188, 192, 194196, 198,
strength, 17 200, 204, 209, 253, 262264
theory, 51, 67, 86 see also: subjective/subjectivity
urges, 52 context, 72, 180, 193, 198, 204205
wish(es), 21, 51 field, 48, 60, 193, 196, 198, 200, 205
integrate/integration, xiii, 20, 22, 48, matrix, 81, 96
5052, 72, 7879, 83, 85, 89, 92, psychoanalysis, 48, 93, 179, 181,
96, 106, 111, 137, 145, 162, 188189, 194195, 197198,
166167, 173, 185187, 190, 199, 233, 282
203205, 210, 225, 233, 257, systems, 190, 196, 198, 204
259260, 262264, 284, 303, 306, world, 56, 60
315, 321 see also: reintegration intervention, xii, 24, 200, 215, 222,
affect, 79 226228, 231232, 262, 266267,
ego, 44 288290, 292, 300, 302, 315
of theory, 52, 54, 110 active, 41
intensive short-term dynamic behavioural, 285
psychoanalysis (ISTDP), 58, pressure, 222
9293, 213215, 221223, primary, 289
226228, 231236, 238, 242243, technical, 222
245246, 248, 288289, 291295, verbal, 30, 53
297, 301302, 304, 309, 313, introjection, 84, 94, 106, 109110, 260,
318320, 324325, 329 319
International Psychoanalytic isolate/isolation, 5, 47, 136, 174
Association (IPA), 145, 173 affect, 225, 229, 257
interpersonal, 46, 50, 52, 69, 148, mind, 190, 196197, 199, 201, 208
150151, 214, 222, 246 moment, 174
context, 46 Ivey, G., 7, 346
difficulties, 13
expectations, 74 Jacobson, E., 47, 346
experiences, 50, 73 Jaffe, J., 48, 81, 334
INDEX 371
James, W., 139, 346 Leckman, J. F., 71, 348

Janet, P., 54, 346 Lecky, W. E. H., 3, 348
family, 171 Lecours, S., 61, 69, 348
in-, 154 LeCroy, D., 19, 348
Joffres, M. R., 232, 331 Levy, K. N., 51, 347
joke(s), 7, 29, 63, 152, 159, 255 Leximancer Manual (Version 4),
Jones, E., 3, 10, 90, 346 297298, 348
Jung, C. G., 10, 49, 77, 113, 144, 180, Lichtenberg, J. D., 167, 338
193, 324 Liebowitz, M. R., 90, 335
Little, T. D., 80, 336
Kanter, J., 165, 346 Loewald, H. W., 36, 86, 95, 348
Karon, B. P., 9, 346 Lojkasek, M., 134, 337
Katz, J., 35, 346 Lomas, P., 88, 166, 348
Kenny, D. T., 48, 61, 71, 97, 154, 346 Lombardi, K. L., 108, 348
Kernberg, O. F., 51, 76, 88, 197198, Lothane, Z., 2, 27, 348
346347 Lovas, D., 58, 331
Khan, M. R., 41, 82, 165, 347 Luyten, P., 208, 340
Kilborne, B., 18, 347 Lyons-Ruth, K. C., 160, 336
King, R., 78, 347
Kirsner, D., 76, 91, 347 Madigan, S., 61, 348
Kisely, S., 58, 242, 331 Madison, P., 327, 349
Kleiger, J. H., 9, 351 Main, M., 153
Klein, M., 35, 43, 59, 64, 73, 77, 8485, Malan, D. H., 73, 231, 348349
92, 95, 107108, 124, 132, 140, Mann, J., 231, 349
163, 170, 173174, 193, 197, 199, Margulies, A., 64, 77, 349
204, 329, 347 Maroda, K., 87, 349
Knoblauch, S. H., 12, 64, 69, 334, Mayer, J. D., 17, 349
347 Mayes, L. C., 71, 348
Kohut, H., 4748, 52, 54, 83, 95, 198, McAlpine, I., 27, 349
204, 255, 328, 347 McWilliams, N., 19, 349
Kolos, A. C., 69, 344 meaning/meaningful, 2829, 41, 50,
Kramer, P., 98 5253, 58, 60, 6266, 68, 7073,
Kris, E., 82, 348 7778, 85, 96, 103, 114, 120, 146,
Kuhn, T. S., 91, 146, 262, 348 150, 152, 160, 162, 174, 176, 181,
Kurzweil, E., 78, 348 186, 191, 194196, 204, 207, 210,
219, 221, 236, 247, 255, 263264,
Lacan, J., 77, 85, 96, 98, 125, 324, 282, 297, 303304, 308, 311, 314,
348 316318, 324 see also:
Lachmann, F. M., 48, 54, 146, 334 unconscious(ness)
Laing, R. D., 144, 275, 302 hidden, xiv, 45, 8, 14, 28, 62
Lander, R., 96, 348 making, 7879, 152, 207, 263
Laplanche, J., 329, 348 of binge eating, 317
372 INDEX
of feeling dead, 318319 Morgan, A. C., 160, 336

psychological, 14, 51 mortality, 135136, 140141, 166
meaningless, 47, 176, 184185, 247 Muir, E., 134, 337, 350
Meissner, W. W., 69, 349 Muller, R. T., 15, 350
memory, 4, 78, 12, 32, 39, 56, 7071, Muscetta, S., 61, 350
82, 155, 172, 224, 233, 254, 256,
260 see also: conscious(ness) Nahum, J. P., 160, 336
emotional, 233 narcissism, 40, 84, 111, 155, 165, 198
episodic, 12 constellation, 112
traumatic, 4, 55 exploitation, 60
Menninger, K. A., 2, 34, 3638, 44, 57, injury, 83
86, 94, 231, 328, 349 malignant, 131
mentalise, 62, 70, 77, 80, 153154, 170, object-choice, 40
176, 207208, 225, 248, 274, 279 transference, 54
metaphor(s)/metaphorical, 3, 40, 51, Naso, R. C., 15, 350
54, 6265, 6870, 72, 7680, 137, Natterson, J., 7, 343
153, 158, 160, 170174, 189, neurosis, 15, 42, 78, 235, 261, 328
202203, 277, 281, 303, 309, 324, infantile, 94
328 transference, 3536, 38, 4344, 235,
Migone, P., 83, 349 261, 289, 292, 295, 313, 325
Mikulincer, M., 48, 333 traumatic, 4, 1415
Miliora, M. T., 15, 349 Newirth, J., 79, 350
Miller, I., 4, 350 Newman, K. M., 83, 351
Mills, J., 15, 350
Minuchin, S., 242, 350 Oberndorf, C. P., 90, 351
mirror(ing), 62, 86, 146, 204 object, 22, 36, 48, 63, 73, 96, 105, 107,
attunement, 220 148, 163, 175176, 202, 260, 262,
contingent, 146 264 see also: conscious(ness),
event, 219 narcissism, transference
images, 80 abandoned, 109
marked, 280 bad, 85, 95
neurons, 149 caring, 139
photographic, 146 constancy, 52
process, 218 distorted, 107
reflective, 84 envied, 113
transference, 47 external, 50
misattunement, 39, 46, 72, 82, 111, fantasy, 52
253, 265, 267268, 306, 319 good, 85, 95, 175, 304
Mitchell, S. A., 33, 4850, 57, 60, 63, inaccessible, 175
69, 81, 8688, 95, 344, 350 internal, 19, 38, 79, 96, 107110,
Modell, A. H., 40, 350 112, 264
Moran, G., 61, 348 loss, 15
INDEX 373
love, 38, 50 Ogden, T. H., 64, 95, 108, 125, 147,

maternal, 125 149, 160161, 263264, 351
part-, 264, 266, 301 Ogrodniczuk, J. S., 232, 331
paternal, 125 Oliner, M. M., 15, 351
persecutory, 109, 252 Olivier, L., 154155
real, 52, 107 Ollendick, T. H., 90, 337, 352
rejecting, 109 Opdal, L. C., 31, 328, 351
relations, 2, 36, 5153, 61, 70, 75, 79, Oppenheim, D., 96, 339
84, 86, 9293, 95, 98, 105, Orange, D. M., 180182, 190, 202, 209,
107109, 112, 117118, 252, 333, 357
260, 263, 266, 297, 301, 303, Ortu, F., 61, 350
324, 328 Osimo, F., 73, 349
theory, 19, 4849, 51, 83, 108, Ostwald, P. F., 154, 351
110, 262
representation, 36, 51, 63 Paniagua, C., 67, 351
-seeking, 83 Panter, A. T., 17, 344
self-, 47, 204, 328 Paolino, T. J., 9, 351
transformational, 41 Parker, C. J., 134, 337
whole, 107, 266, 301 pathological, 36, 43, 77, 84, 126, 140,
ODonnell, S., 61, 358 170, 186, 197, 259, 263 see also:
ODwyer, K., 61, 351 development(al)
oedipal, 124125 see also: accommodation, 82
cognitive behavioural, conflict phenomenon, 34
battle, 173 Pederson, D. R., 61, 348
child, 170 Peebles-Kleiger, M. J., 9, 351
behaviour, 125 phantasy, 1213, 63, 66, 73, 79, 81, 84,
doorway, 124 107, 109110, 259, 262, 329
dynamic, 170, 244 see also: primitive,
excessively, 124 unconscious(ness)
idea, 167 archaic, 6
insecurity, 169 childhood, 80
issues, 124126, 132, 166, 244 internal, 107, 109110, 262
non-, 174 phenomenology/phenomenological,
phase, 166 xiv, 2, 48, 67, 70, 93, 97, 180184,
pre-, 54, 124125, 136, 166 203, 233, 253, 255, 259, 282, 297,
prohibition, 157 302303, 311, 319, 321, 324
situation, 170 philosopher(s), 27, 76, 138, 160, 180,
theory, 244 208
triangle, 244 philosophy/philosophical, 45, 55, 61,
Oedipus complex, 3, 15, 1920, 63, 70, 7678, 97, 137, 180181,
125, 136, 156157, 168, 170, 174, 183185, 202, 208, 253, 321
204, 244 physiological, 46, 216, 237238
374 INDEX
Piers, C., 54, 351 psychotherapy, 2, 9293, 97, 116,

Pine, F., 51, 53, 351 118, 145147, 152, 297, 324325
poet/poetry, 12, 9, 27, 6162, 6465, relational, 86, 90
6768, 7779, 91, 170172, 234, technique, 26, 29, 32, 35, 4042, 66,
328 83
Poloni, C., 327, 351 theory, 24, 8, 12, 15, 19, 22, 24, 26,
polyvagal theory, 238 42, 45, 50, 52, 5557, 61, 73, 76,
Pontalis, J.-B., 329, 348 80, 90, 92, 97, 110, 125, 133,
Porges, S. W., 238, 351 160, 257, 261262, 264, 312, 323
primitive, thinking, xiixiii, 48, 51, 5758, 110,
anxiety, 15 264, 324
defences, 69 training, 180, 214, 217, 235
forms of communication, 70 treatment, xiii, 23, 35, 45, 52, 101,
impulse, 18 105, 163, 231
phantasising, 85 work, 86, 113, 135136, 149, 159,
projection, 94 164, 180
Prins, P. J. M., 90, 352 psychodynamic, 73, 144, 147, 215,
projection, 1819, 69, 84, 106, 241, 318
109110, 133134, 137, 160, 225, goals, 295, 301
229, 240, 246, 319 see also: process, 295, 301, 320
primitive, transference psychotherapy, 7475, 146147,
of fantasy, 80 250, 300
processes of, 106, 246 structure, 295, 301
projective identification, 69, 8485, 95, Purdy, A., 58, 331
147, 199200, 207208, 225, 229
psychoanalysis/psychoanalytic Quinodoz, J.-M., 17, 352
(passim) see also: interpersonal,
intersubjective, world rage, 37, 112, 175, 217219, 224, 230,
classical, 4, 48, 83, 93, 148149, 233, 235239, 244, 246250, 254,
151152, 157, 192, 224, 235, 282, 291, 329 see also: attachment,
243, 253, 301, 329 sexual, unconscious(ness)
contemporary, xi, xiii, 8, 14, 36, 51, Rangell, L., 2, 49, 51, 261, 352
69, 73, 76, 83, 90, 93, 97, Rank, O., 42, 49, 180, 352
261262, 323325 Rasic, C., 242, 331
Freudian, xi, 2, 4, 93, 243, 324, Rayner, R., 180, 359
328329 reaction, 18, 28, 50, 66, 83, 86, 94, 130,
interpretation, 2930, 96 148, 198, 211, 215, 256, 316
practice, xi, 2, 42, 45, 50, 5558, 61, ab-, 4, 14, 22, 24, 2628, 33, 38,
7374, 76, 9092, 235, 262, 312, 255
323324 allergic, 208
process, 1, 29, 33, 57, 87, 90, 161, catastrophic, 320
192, 235, 261263 conversion, 11, 236
INDEX 375
emotional, 64, 310 secure, 155

formation, 19 therapeutic, 83, 87, 111, 147, 156,
hysterical, 7 170, 191, 194, 196, 198, 208,
infantile, 21, 82 232, 236, 310, 323
initial, 215 traumatic, 263
therapeutic, 129130 Renik, O., 96, 352
transference, 84 repression, 38, 11, 14, 1618, 20, 25,
untoward, 11 2728, 30, 32, 34, 37, 50, 55, 57,
Reich, W., 95, 180, 352 63, 70, 79, 92, 94, 152, 167, 188,
reintegration, 48, 95 see also: 196, 220, 224225, 229, 231, 233,
integrate/integration 252255, 257, 263, 291, 295, 300,
relational, 4850, 54, 57, 60, 63, 81, 302303, 320, 327 see also:
9596, 98, 146, 151, 158, 160, 175, resistance, unconscious(ness)
188, 205, 253, 255, 274, 282 aspects, 30, 90
see also: context, object, barrier, 21, 196
psychoanalysis, trauma, experience, 15, 35
unconscious(ness) force, 7, 18, 82
matrix, 81 impulse, 19, 31
relationships, 13, 17, 21, 34, 49, 52, 55, infantile, 17, 263
57, 6061, 63, 7475, 83, 88, 91, instant, 224225, 227
96, 105106, 108109, 111, 114, massive, 21
117, 124, 132, 136, 145147, material, 30, 43
149153, 155156, 160, 165, primal, 67
167169, 175, 191, 194, 199, 202, process of, 17, 35, 80
206, 216, 224, 235, 239, 244, proper, 6
246247, 255, 260, 263, 266, 298 psychical structures, 80
see also: attachment, authentic, state of, 6
development(al), dyad(ic), trauma, 4, 38, 263
interpersonal, object, sexual, wishes, 18, 21, 263
transference resistance, 6, 11, 13, 16, 22, 25, 2728,
abusive, 247 3135, 37, 50, 59, 74, 79, 84,
analystpatient, 13, 53, 71, 86, 97, 9294, 102, 112, 115, 119,
145, 193, 263, 323 121122, 124, 192, 194196, 224,
analytic, 31, 4041, 53, 8688, 95, 226229, 231, 233236, 243, 246,
105, 139, 145, 263, 328 248, 251, 254, 257259, 262,
current, 52, 75, 232 288289, 291292, 300301, 303,
early, 47, 53, 83, 88, 110111, 263 309, 313, 324, 329
intimate, 89, 149 analysis of, 22
motherchild/infant, 13, 35, 40, 97, censorship, 22
146 epinosic gain, 35
parentchild, 29, 145 internal, 43
personal, 29, 145 interpretation, 30
376 INDEX
powerful, 32 secondary, 280, 282, 311, 315

repetition-compulsion, 35 seeking, 84
repression, 34, 291, 302 Sedikides, C., 17, 344
superego, 35 Segal, H., 52, 353
transference, 34 Seiden, H. M., 62, 64, 353
violent, 32 self, 18, 22, 31, 3536, 39, 4648,
retraumatisation, 20, 38, 79, 81, 185, 5052, 56, 64, 72, 75, 79, 90, 92,
195, 197 95, 110111, 136, 139, 157, 270,
Richards, I. A., 63, 352 280, 311312, 316, 319, 328
Ricoeur, P., 68, 90, 352 see also: object
Riquier, F., 327, 351 abandoned, 109
Rogers, B., 27, 352 -absorbed, 165
Rorty, R., 95, 352 affective, 209
Rosegrant, J., 5960, 352 -analysis, 31
Rosenbaum, J. B., 2, 352 -annihilation, 209
Rotenberg, C. T., 54, 352 autonomous, 74
Rothstein, A., 9, 352 -aware, 106, 188, 237, 253, 255
Rubovits-Seitz, P., 9, 352 -capacity, 48
Rudnytsky, P. L., 98, 165, 353 -care, 119
ruminate/rumination, 22, 230, -censorship, 29
233234, 247 civilised, 3
Rustin, J., 69, 334 -cohesion, 89
Rycroft, C., 144145, 165, 174, 328, -commentary, 293
353 -concept, 75
-confidence, 155
Sances, G., 23, 332 -constricting, 247
Sander, L. W., 160, 336 -critical, 27, 236, 293, 295, 320
Sandler, A., 2122, 353 -defeating, 113, 274, 310, 317
Sandler, J., 2122, 30, 51, 63, 68, 82, -destructive, 104, 113, 224, 247, 250,
353 329
Sathy, V., 17, 344 -directed, 35, 236
Schafer, R., 3031, 353 -disclosure, 60, 86, 88, 244
Schlessinger, N., 78, 353 -distorting, 82
Schore, A. N., 82, 353 divided, 92, 95
secure/security, 44, 111, 145146, -esteem, 33, 52, 257
151, 154160, 168169, 175, 182, -evident, 38
184, 188, 241, 282, 303, 310 -expansion, 60
base, 36, 93, 111, 144, 149, 166167, -experience, 41, 47, 70, 90
169, 273, 275, 302303, -exploration, 33, 37
310311, 313, 316317 false, 83
making, 148, 256 -harm, 224, 227
primary, 282, 311, 315 -hatred, 209
INDEX 377
-hood, 85, 187, 205 origins, 46

-ideal, 79 partnership, 167
-improvement, 87 practices, 329
infantile, 43, 85 psycho-, 3, 39
-knowledge, 30, 68, 94 rage, 244
-loathing, 79 relationships, 41, 167169
-loss, 285, 287, 312, 316317, 319 risks, 158
observing, 28, 37, 225, 257 rivalry, 19, 157
-perception, 215 trauma, 7
-preservation, 15 violence, 244
-proclaimed, 173 sexuality, 8, 15, 45, 132, 156, 167168
psychology, 4748, 53, 83, 89, 95 figure, 166
-punishing, 247 hetero-, 126, 167, 328
-reflection, 38, 75, 80, 214, 225, 292, homo-, 126127, 132, 167
316 infantile, 15, 39, 156157, 175
-regard, 249 model, 170
-regulate, 74 perverse, 132
-reliant, 111112 Shaver, P. R., 48, 333
-representation, 74 Shevrin, H., 328, 335
-reproach, 258 Sifneos, P., 231, 353
-select, 128 Skinner, B. F., 90, 180, 353
-serving, 208 Sloate, P., 146, 334
-soothing, 274, 282, 303304, Slochower, J., 12, 30, 41, 7071, 86,
310312, 315, 317318 353354
-state, 5253, 79, 83, 89, 262263 Smith, A. E., 297298, 354
-sufficient, 96, 111112, 176 Sorter, D., 69, 334
true, 4041, 7980, 205 Spence, D. P., 90, 354
-understanding, 95 Speranza, A. M., 61, 350
Sell, H. A., 137, 353 Spezzano, C., 96, 354
sexual, 7, 45, 132, 156 see also: abuse, Spielman, R., xiv, 98, 100, 108,
impulse, instinct(ual) 120121, 123, 137, 255, 262263,
behaviour, 167 266, 300306, 308312, 314319,
drives, 14, 19, 47, 83 323324, 354
dynamic, 167 Spitz, E. H., 2, 354
encounter, 132 Spitz, R. A., 4647, 8182, 354355
energy, 17, 19, 29 Spivak, A. P., 38, 355
experience, 7, 14 splitting, 5, 44, 48, 6970, 85, 92, 95,
fantasies, 14, 33 109, 111, 152, 167, 207, 214, 220,
feelings, 156157, 166, 235, 244, 261 225227, 249, 252, 257, 263
intent, 19 Cartesian, 207
matters, 166 horizontal, 83, 92, 263
needs, 157, 168169 vertical, 83, 92, 263
378 INDEX
Spurling, L. S., 4041, 355 Taerk, G., 82, 358

Stayton, D. J., 146, 332 Tagliacozzo, R., 83, 358
Steele, R. S., 90, 355 Talberg, G., 61, 358
Stein, A., 68, 355 Talvitie, V., 61, 358
Sterba, R., 37, 94, 355 Target, M., 2, 69, 110, 340
Stern, D. B., 72, 160, 355 termination, 10, 32, 34, 4244, 85, 89,
Stern, D. N., 6061, 71, 73, 109, 160, 121122, 128, 130, 241, 245, 265,
202, 255, 336, 355 292
Stern, S., 83, 355 Thomas, D., 175
Stewart, H., 30, 355 Thompson-Hollands, J., 38, 359
Stolorow, R. D., xii, xiv, 48, 50, 56, 61, Thornton, N., 26, 358
72, 7879, 90, 9596, 98, 139, Town, J., 58, 331
180184, 187188, 190, 193, transcript(s), xixiii, 9798, 230, 251,
196198, 202, 206, 209, 254255, 265, 288, 297, 307309, 313,
264, 301306, 308316, 318320, 316317, 319, 323
325, 328, 333, 336, 356357 transference (passim) see also:
Strachey, J., 3, 8, 42, 94, 278, 313, countertransference, mirror(ing),
357 narcissism, neurosis
Strathearn, L., 208, 340 activated, 289, 313
Streisand, B., 154155 communication, 206, 272, 314
Strenger, C., 90, 357 development(al), 194195
subject(s), 5, 10, 12, 21, 25, 27, 6566, distortions, 37, 94
78, 105, 107, 176, 257, 260, 264 effective, xiv
subjective/subjectivity, 50, 52, 62, 93, erotic, 235
95, 139, 180, 192, 195, 197 see also: experience, 282, 313
intersubjective/intersubjectivity feelings, 300, 308
analysis, 96 idealising, 47
approaches, 83 interpretation, 3031, 41, 56,
concerns, 180 264
experience, 52, 61, 182, 208 love, 59
frame, 56 nature of, 11
human, 54, 61, 262 negative, 31, 85, 89, 95, 130
matrix, 96 non-, 13, 85
origins, 180 object, 41
personal, 56 phenomena, 13, 269
world, 47, 56, 95 positive, 31, 43, 243, 313
Sullivan, H. S., 46, 48, 8687, 357 projection, 43
Swain, J. E., 71, 348 psychotic, 130
Symington, J., 95, 357 relationship, 9, 15, 21, 31, 37, 40, 47,
Symington, N., 77, 95, 357 56, 288, 303, 313, 316, 321
Szajnberg, N., 63, 358 repetitive, 194
Szasz, T., 88, 310, 358 resistance, 34
INDEX 379
trauma/traumatic (passim) see also: dynamic, 57, 79, 87, 188189,

affect(ive), anxiety, attachment, 253255, 291
development(al), disorder, ego, 2021
hysteria, memory, neurosis, elements, 29
repression, retraumatisation, emotions, 231, 288, 291, 302, 305,
sexual, war 308309
childhood, 78, 50, 69, 82, 185, 231, expectations, 13
246, 263264 experience, 24, 250
cover, 82 fantasy, 21, 38
cumulative, 82 fear, 34
emotional, 14, 183, 185, 327 feelings, 31, 84, 310
experience, 78, 15, 70, 72, 8182, forces, 144, 175
180, 188189, 211, 218, generative, 79
263 ideas, 25, 252, 254
external, 8, 262 impulse, 18
infant, 14, 239, 263 issues, 132, 241
large-T, 82
level, 225
loss, 182, 185
life, 252
relational, 82
material, 30
retrospective, 82
meaning, 5, 247
secondary, 82, 188
memories, 52
shock, 82
mind, 68, 220
silent, 82
motivation, 102
small-t, 82
motive, 73, 262
strain, 82
ontological, 188190, 253255
Trimble, M. R., 90, 358
phantasy, 80, 109, 252
Trop, J. L., 196, 333
Tuber, S., 71, 358 process, 65, 71, 80, 94, 120, 232, 300,
302, 304, 309, 311
unconscious(ness) (passim) see also: mental, 25, 56
conflict, conscious(ness), rage, 239, 245, 250
intersubjective/ reasons, 129
intersubjectivity reflective, 188
action, 24 pre-, 183, 188189, 191, 253, 255,
anxiety, 219, 224225, 228230, 320
236237, 242, 247, 249, 288, relational, 79
292, 302, 309, 315316 repressed, 254
communication, 263, 272, 309, 314, signals, 228, 241, 247
324 strivings, 37
concept of, 4, 22 suggestion, 252
desire, 135 superego, 21
drive, 18 symbolism, 39, 252
380 INDEX
therapeutic alliance, 89, 222, 226, Wilson, A., 69, 359

233234, 243, 247, 259, 289, Winnicott, D. W., 14, 35, 4041, 48,
291, 293294, 309, 317, 319 59, 65, 7071, 79, 8183, 95, 149,
thought, 21, 329 151, 159, 163, 165, 185, 199, 205,
transmitting, 32 209, 231232, 253, 255, 279, 320,
unvalidated, 189, 253255 359360
wishes, 14, 51, 63, 74 Wittig, B. A., 146, 332
Wolf, D. P., 96, 339
Vakar, G., 48, 358 Wolf, E. S., 83, 347
Van Bark, B. S., 310, 358 Wolf, H., 144, 164
Van Der Heide, N., 87, 358 Wolff, P. H., 61, 360
Van Haute, P., 15, 29, 328, 358 world (passim) see also: interpersonal,
Varga, M. P., 89, 358 intersubjective, subjective, war
Vazquez, S. G., 120, 354 collapse, 183184, 285, 287, 303,
Verheul, W., 23, 334 311, 316317, 319
Villa, K. K., 328, 335 emotional, 180, 187, 190, 196,
Vygotsky, L., 48, 358 205206
experiential, 180, 194, 196
Wachtel, P. L., 86, 358 external, 18, 2526, 7980, 82, 96,
Wall, S., 109, 146, 332 137
Wallerstein, R. S., 58, 78, 8991, inner/internal, 49, 52, 6162, 80,
358 89, 96, 107109, 149, 252, 262,
Wallin, D. J., 82, 358 266, 301, 311
war, 3, 15, 63, 82, 127, 144, 172173 psychoanalytic, 165, 209
First World, 15, 172, 328 real, 80, 132, 246
neuroses, 328 view, 80, 160, 196, 208
Second World, 46 Wrye, H. K., 61, 360
trauma, 15 Wylie, H. W., Jr., 67, 360
Waters, E., 109, 146, 332
Watson, J. B., 180, 359 Yalom, I. D., 64, 68, 87, 360
Waugaman, R. M., 9, 351 Yeomans, F. E., 51, 347
Westen, D., 51, 74, 359
White, J., 36, 263264, 359 Zeddies, T. J., 70, 77, 360
White, R. S., 68, 70, 359 Zilboorg, G., 27, 360
Wilamowska, Z. A., 38, 359 Zimmermann, G., 327, 351
Williams, P., 88, 359 Zweig, S., 10

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CHAPTER TITLE I

Copyright 2014 to Dianna T. Kenny.

All rights reserved. No part of this publication may be reproduced, stored in

British Library Cataloguing in Publication Data

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ABOUT THE AUTHOR AND THE PSYCHOTHERAPISTS vii

CONCLUSION: One tree, many branches? 323

Dianna T. Kenny, PhD, MA (Sch Couns) BA (Hons) ATCL DipEd

Allan Abbass MD, FRCPC, is Professor, Director of Psychiatric

125 publications, he is also a leading researcher in the area of short-

Jeremy Holmes, MD, FRCPsych, BPC, worked as Consultant Psychia-

Ron Spielman, MBBS, FRANZCP, is a psychiatrist, psychoanalyst

Society, the NSW Institute of Psychoanalytic Psychotherapy, and the

Robert D. Stolorow, PhD, is a Founding Faculty Member at the

With my love and admiration

Robert King, PhD, FAPS

When are we to begin making our communications to the patient?

. . . the unconscious . . . carves out its own signature on the transfer-

. . . we try to be assiduously phenomenological, focused exclusively on

It is the therapeutic attachment that mobilises all the other attachment

Where the talking began:

onsider this section of the eulogising poem in memory of

It refers to psychoanalysis as a process of recit[ing] the Past like a

a friend). Thus, Audens poem captures some of the essential quali-

. . . [psychoanalysis] essays to change the structure of the patients

Psychoanalysis is not only a form of treatment; it is also a theory or a

Freuds psychoanalysis: an evolution

who undergoes growth via universal developmental (psychosexual)

A chance observation has led us . . . to investigate . . . the symptoms of

This passage places the causes of the symptoms of hysteria firmly in

In other cases the connection . . . consists only in . . . a symbolic rela-

Taken together, these two extracts capture the essence of classical

strivings and behaviour. The contents of the unconscious are usually

The actual traumatic moment . . . is the one at which the incompati-

Such behaviour has a hidden meaning that must be uncovered and

The unconscious and the concept of repression

where wishes, impulses, and drives reside, a place not beholden to

One of the vicissitudes an instinctual impulse may undergo is to meet

Repression is, therefore, a defence mechanism that keeps unconscious

Repression proper affects mental derivatives of the repressed repre-

come into associative connection with it. On account of this associa-

The patient remembers nothing of what is forgotten and repressed,

Freud specified that the trauma was sexual in nature:

Hysteria . . . [cannot] be fully explained from the effect of the trauma: it

. . . the compelling force of the pleasure principle. The psychical appa-

Hence, Freud shifted his focus on external trauma to a focus on inner

The talking cure

forerunner of psychoanalysis (p. 109). Breuer described his twenty-

. . . markedly intelligent, with an astonishingly quick grasp of things

Freud believed that the ability to develop a transference relationship

. . . paralytic contractures and anaesthesias, disorders of vision and

Breuer described his therapeutic procedure with Anna/Bertha thus:

. . . in the case of this patient the hysterical phenomena disappeared

which it had appeared were described in reverse order, starting before

Her final symptom, her enactment of the labour pains of an hysterical

After the phantom pregnancy and Breuers precipitous abandonment

The hysterical disorders (now called conversion reactions) of

. . . bubbling over with intellectual vitality, [but who] led an extremely

In later life, Bertha Pappenheim recovered from her disabling symp-

In an early paper, Fragment of an Analysis of a Case of Hysteria (Dora),