Downloaded by [New York University] at 12:48 14 August 2016 the THERAPEUTIC IMAGINATION

Downloaded by [New York University] at 12:48 14 August 2016 THE THERAPEUTIC IMAGINATION

Imaginative play is a key aspect of successful psychotherapeutic treatments. Psychotherapy helps clients get in touch with, awaken and learn to trust their creative inner life, while therapists use their imagination to mentalise the suffering other and to trace the unconscious stirrings evoked by the intimacy of the consulting room. Working from this premise, in The Therapeutic Imagination Jeremy Holmes argues unashamedly that literate therapists make better therapists. Drawing on psychoanalytic and literary traditions both classical and contemporary, Part I shows how poetry and novels help foster therapists’ understanding of their own imagination-in-action, anatomised into ﬁve phases: attachment, reverie, logos, action and reﬂection. Part II uses the contrast between secure and insecure narrative styles in attachment theory and relates these to literary storytelling and the transformational aspects of therapy. Part III uses literary accounts to illuminate the psychiatric conditions of narcissism, anxiety, splitting and bereavement. Based on Forster’s motto, ‘Only connect’, Part IV argues, with the help of poetic examples, that a psychiatry shorn of psychodynamic creativity is impoverished and fails to serve its patients. Clearly and elegantly written, and drawing on the author’s deep knowledge of psychoanalysis and attachment theory and a lifetime of clinical experience, Holmes convincingly links the literary and psychoanalytic canon. The Thera- peutic Imagination is a compelling and insightful work that will strike chords for therapists, counsellors, psychoanalysts, psychiatrists and psychologists.

Downloaded by [New York University] at 12:48 14 August 2016 Jeremy Holmes worked for 35 years as a Consultant Psychiatrist and Medical Psychotherapist in the NHS. He is currently Visiting Professor at the University of Exeter, UK, and lectures nationally and internationally. Recent publications include The Oxford Textbook of Psychotherapy, Storr’s The Art of Psychotherapy and Exploring in Security: Towards an Attachment-Informed Psychoanalytic Psychotherapy. This page intentionally left blank Downloaded by [New York University] at 12:48 14 August 2016 THE THERAPEUTIC IMAGINATION

Using literature to deepen psychodynamic understanding and enhance empathy

Jeremy Holmes Downloaded by [New York University] at 12:48 14 August 2016 First published 2014 by Routledge 27 Church Road, Hove, East Sussex BN3 2FA and by Routledge 711 Third Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2014 Jeremy Holmes The right of Jeremy Holmes to be identiﬁed as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identiﬁcation and explanation without intent to infringe. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Holmes, Jeremy, 1943– The therapeutic imagination : using literature to deepen psychodynamic understanding and enhance empathy / Jeremy Holmes. pages cm 1. Imagery (Psychology)–Therapeutic use. 2. Imagination–Therapeutic use. 3. Psychoanalysis. 4. Psychotherapy. I. Title. RC489.F35H65 2014 616.89′14–dc23 2014002652 ISBN: 978-0-415-81957-2 (hbk) ISBN: 978-1-138-78949-4 (pbk) ISBN: 978-1-315-87982-6 (ebk) Typeset in Times New Roman by Wearset Ltd, Boldon, Tyne and Wear Downloaded by [New York University] at 12:48 14 August 2016 To my patients – who have taught me so much Downloaded by [New York University] at 12:48 14 August 2016 This page intentionally left blank Downloaded by [New York University] at 12:48 14 August 2016 CONTENTS

Preface ix Acknowledgements xiv

PART I The poetics of psychotherapy 1

1 The therapeutic imagination: George Eliot and Daniel Deronda 3

2 Discovery: Seamus Heaney and Marcel Proust 16

3 Non- discursiveness: Robert Lowell 28

4 Repair: Hugo Williams 43

5 Loss: Wordsworth’s Ode 52

PART II Psychotherapy and narrative 63

6 Attachment and narrative: Conrad’s Heart of Darkness 65

Downloaded by [New York University] at 12:48 14 August 2016 7 Change: Llosa’s Aunt Julia 86

8 Society: Evelyn Waugh and Jane Austen 89

PART III Psychotherapeutic approaches to psychiatric diagnoses 109

9 Anxiety: Wagner’s Siegfried 111

vii CONTENTS

10 Splitting: Stevenson’s Dr Jekyll and Mr Hyde 115

11 Grief and loss: Milton, Tennyson and Donne 128

12 Narcissism: Ovid and Wilde 134

PART IV ‘Only connect’: psychotherapy and psychiatry 159

13 Meaning v. mechanism: Forster’s Howard’s End 161

14 Toughness v. ‘wetness’: Armitage 171

15 Facts v. feelings: Abse, Olds, Holub and Larkin 174

Postscript 181

References 183 Index 193 Downloaded by [New York University] at 12:48 14 August 2016

viii PREFACE

The rationale for this compilation is the link between literary and psychodynamic aesthetics.1 Books and consulting rooms may seem very different domains – although few of the latter are book- free – but novelists and poets can be helpful to psychotherapists in a number of ways. First the voices of literary giants, if suitably harnessed, lend authority and a species of validation to psychotherapeutic ideas. Second, literary examples provide case-illustrations without the attendant difﬁculties of conﬁdentiality and non- generalisability. Third – and here is the main focus of this work – there are parallels between the literary and the psychotherapeutic imagination, so that understanding literary creativity can enhance psychotherapeutic skilfulness. Literate therapists, I suggest, make better therapists. This theme is explored in the introductory chapter, which is an extended ‘conversation’ between Freud, Coleridge and George Eliot. I argue that psychoanalysts particularly interested in creativity and spontaneity, of whom Bion is an outstanding example, were drawing on a pre- psychoanalytic tradition with roots in German Romanticism, translated into the Anglo-Saxon world by Coleridge, Keats and Wordsworth. The use of literature in psychoanalysis is far from new. Freud was deeply versed in the Western cultural tradition, drawing freely on art and literature – but, oddly, not music – to illustrate and buttress his arguments. At the kernel of his theories lies the Oedipal myth; without Sophocles there could have been no Freud, and no psychoanalysis; Ernest Jones (1948) famously ‘analysed’ Hamlet in Oedipal terms. The psychoanalytic literature is replete with psycho-

Downloaded by [New York University] at 12:48 14 August 2016 literary magpies drawn to glittering examples from the canon. Among contemporary analysts Ogden (1999), Wright (1991, 2010) and Britton (1998, 2003) have been particularly skilful in their use of literary examples. Williams and Waddell (1991), and Canham and Satyamurti (2003) have speciﬁcally linked psychoanalytic and literary thinking. This book is in that tradition, but with two distinct features. First, its orientation is unashamedly practical. The author has a workaday background in psychiatry and psychodynamic psychiatry, and brings psychoanalytic ideas to bear on the quotidian world of the clinic and public health settings. Each chapter

ix PREFACE

addresses a particular clinical problem, using literature to extend its range of reference and reverberation. A second distinctive aspect derives from attachment theory (Holmes 1993/2013, 2010) as a significant psychodynamic voice. I am reaching here for three-way links between evidence-based understanding of parent–infant interactions, the processes of literary creativity and therapeutic efficacy. What ‘good’ parenting, good literature and mutative therapy have in common is the paradoxical combination of security of form with creative uncertainty and exploration, dubbed by Feeney and van Vleet (2010) as the ‘exploration paradox’ in which adventurousness and secure attachment go hand in hand. A hallmark of sensitive parenting is ‘partially contingent mirroring’ (cf. Beebe et al. 2012) – the capacity of parents to respond to and imitate their children’s ‘gestures’, physical and later verbal, but to take them one step further, leading the child in turn to expand on her parent’s elaborations, and creating a vibrant interpersonal field, ‘third’ (cf. Ogden 1994), or transitional space, distinct from the contributions of either party. Vitality and innovation – Winnicott’s (1971, p. 39) ‘creative living’ – flow from this balance between non-controlling structure and boundaried playfulness; rhyme without replication. Acquiring the capacity to inhabit this world, and to turn it to therapeutic advantage, is the essence of psychotherapeutic training, a life-long process in which assimilation of theory and active practice inform and nurture one another. Mentalising or ‘mind-mindedness’ is a mark of security-creating relationships (Meins et al. 2001; Allen et al. 2010). We can never see directly into the mind of another person. Good parental care entails imaginative identification with her children on the part of the parent, drawing on the capacity to be aware of her own affective states and partially match them with those of her children, while allowing for error and correction (cf. Holmes 2010). These in turn derive from that parent’s experiences with her parents and caregivers as a child. The experience of having been ‘mentalised’ (i.e. experienced as a distinct and sentient being with one’s own projects, desires and emotions), it is hypothesised, is the basis of intergenerational transmission of secure attachment, the foundation for the ability later in life to mentalise others, including one’s own children. Literature can, from this perspective, be seen as a mentalising via regia. In the novel, with the help of the omniscient author, the inner world of the Other

Downloaded by [New York University] at 12:48 14 August 2016 (in this case the novels’ ‘characters’) is freely accessible to the reader in ways that are impossible in real life. Similarly, poetry provides a window into the lineaments of normally opaque affective and corporeal experience. Dennett (2006) compares religious experience, in which the deity is imagined as having access to our inner thoughts, with learning to play card-games, initially ‘hands up’. Once the rules are learned, players surmise or calculate as best they can what is in their opponents’ and/or partner’s hand. Here ‘playing the game’ stands as a metaphor for everyday mentalised interaction. This is what makes ‘play’ utterly serious, tapping into the bedrock paradox of social life: the

x PREFACE

need to see into the inner world of the Other, yet the impossibility of ever fully being able to do so. Following Dennett’s logic, in the early stage of skill- acquisition the tyro’s ‘hand’ (a proxy for the ‘inner world’) is openly visible. Literature analogously provides free access to the inner world of the Other – albeit only in the world of literary imagination – thereby enhancing readers’ capacity to understand the ways of the mind, including their own. Psychoanalytic therapy can similarly be thought of as a ‘hands up’ game in which patient and therapist look together at the entire gamut of the patient’s thoughts and feelings as they arise in the therapeutic situation. The essence of ‘free association’ and ‘transference’ consist of this ‘duet for one’ played out in the space between therapist and patient. The therapist works on the principle that any and all of her countertransference feelings, insofar as they have been evoked by the patient, need to be given a voice, providing as they do indispensible clues to the patient’s inner world. These are typically split-off and otherwise inaccessible feelings transmitted unconsciously to the therapist. These need to be brought into play with interpretations. The latter can be re- formulated as open-handed revelations which the patient assimilates in order to better understand herself and her impact on others. Interpretations are ‘true’ in the poetic sense to the extent that they emanate from the authentic inner world and voice of the therapist, but not because they represent some objective or quasi-scienti ﬁc truths about the individual to whom they are directed. My project is based on the idea of ‘meaning holism’ (Cavell 2002). Meanings, especially those with which psychoanalysis is concerned – emotional, existential, arising out of a person’s developmental history – are not conﬁned to narrow chan- nels, but spread, free-associatively, across a broad linguistic and cultural terrain. The analyst’s capacity to resonate in this wide-ranging way to her patients’ presence, gestures and utterances is the basis for the combination of accurate mirroring, and playful translocation and re-working of feelings that is intrinsic to therapeutic change. Ogden and Ogden (2012), in a neat inversion of Freud’s ‘where id is there ego shall be’, aphoristically characterise this process as the ‘unconsciousnessing’ of conscious experience. Implicit in this is the idea that experience, if lived to the full, is an amalgam of conscious perception, bathed in the affective and associative overtones brought by the unconscious, and that both psychoanalytic therapy and literature explore and foster this seam of being.

Downloaded by [New York University] at 12:48 14 August 2016 Interpretations, like poems and scientiﬁc equations, are thus compressed and condensed knots of emotional truths which ramify in multiple directions. From an attachment perspective, the ‘purpose’ of both poetry and interpretation is the co- regulation of emotion (cf. Schore and Schore 2008). The ‘stories’ which patients and therapists co- construct or reconstruct in sessions, which can only be versions of objective truth, have a soothing and affect-regulating function. Similarly, the completeness and coherence of a novelistic narrative, even in its post- modern versions, where disorganisation and chaos are both captured and partially redeemed, aims at a sense of satisfaction. In each case – interpretations, literature,

xi PREFACE

stories – language is the vital bridge from the inner world of feelings to the shared world of the Other: the flesh made word. Memorable words and phrases are the counters – from small change to ingots – that make up psychoanalytic theoretical space: the ‘un- thought known’, ‘Oedipal situation’, ‘depressive position’, ‘unformulated experience’, ‘autobiographical competence’, ‘secure base’, etc. Each has its own ambiance, and like language itself, each represents a common tradition which needs to be brought to life in any specific clinical situation. Some caveats about the parameters and limitations of these essays – in the sense of attempts, from the French essayer – are needed. Most of the examples are drawn from the mainstream English literary canon, the novels and poems to which people would have been exposed in the course of their schooling and beyond. I claim no literary sophistication or expertise; cultural and literary experts would doubtless find my choices sophomoric, not to mention embarrass- ingly restricted by the author’s class, generation and ethnicity. I confine myself to the written word, the area to which my sensibilities are most drawn. A comparable set of essays could, and indeed have, been written about theatre (e.g. Rustin and Rustin 2002), music (e.g. Rusbridger 2008) art (e.g. Fuller 1980) and film (Gabbard 2001). This project differs however in that, rather than using psychoanalytic ideas to illuminate the arts, it aims in the opposite direction, bringing artistic insights to bear on clinical work. Another disclaimer concerns my position vis- à-vis the boundary between accounts of therapy and fiction. However much one may argue that therapeutic stories are ‘fictions’ in that they represent one among many possible inner truths as much as objective realities, there is still a clear distinction to be made between therapists and patients together reconstructing what a person might be, or have been, feeling in real-life, and the imagined, ‘made up’, stories that are the stuff of novels. Comparably, a poem, however authentic and true to experience and to the power and beauty of language, is still crafted, an artefact, a ‘phantasmago- ria’, to use Yeats’ word (Hollis 2011), not a real live person speaking directly and spontaneously to another. There is a no- man’s-land between fiction and therapy explored by literarily gifted therapists (e.g. Yallom 1989; Grosz 2013). But this hybrid genre remains questionable since it is unclear whether it is possible to serve simultaneously the need for truthfulness to a messy and loose- ended reality and the aesthetics of artistic coherence. Whether this work falls into that particular trap is for the reader to decide. With

Downloaded by [New York University] at 12:48 14 August 2016 the help of literary examples, each focuses on a particular clinical theme. They fall into four groups. Part I recruits literature to help think about the workings of the psychotherapeutic imagination; yoking literary and psychotherapeutic narratives, Part II is based around prose works that illuminate how change comes about in psychotherapy and its social role; Part III argues that literature and psychoanalytic understanding can, if suitably harnessed, throw light on the phenomenology of spe- ciﬁc psychiatric diagnoses; ﬁnally, Part IV uses literature to probe the troubled relationship between psychiatry and psychotherapy – a topic which, with a foot in each camp, has been one of the author’s on-going professional preoccupations.

xii PREFACE

The opening chapter is a manifesto for the rest of the book, based on a detailed analysis of a specific incident from George Eliot’s late novel, Daniel Deronda. Arising out of this, I propose a five- stage model of ‘the therapeutic imagination’ underpinning clinical encounters, which I dub primary attachment, reverie, logos, action and reflection. The following chapter builds on writers’ self- reflections on the creative process, linking this with the struggles of trainee psychotherapists as they try to master the paradox of the ‘technique of spontaneity’ that is integral to the psychodynamic approach. Chapter 3 looks at metaphor as a fundamental aesthetic principle revealed in poetry, linking this with ‘transference’ as a species of metaphor. The next chapter, based around a poem by the contemporary poet, Hugo Williams, looks at the psychotherapy session as an aesthetic ‘object’, and how underlying formal principles of creativity apply equally to the therapist’s and poet’s art. Finally in this section, Chapter 5 looks at art more generally and how both therapy and poetry- making entail recovery from loss. Story and narrative are clearly common to both literature and therapy. Part II is based around Mary Main’s Adult Attachment Interview (Main 1995). Her innovative and psychodynamically relevant research strategy revealed how people’s narrative style reveals their fundamental attachment disposition. Helping patients to articulate their story in truthful and emotionally satisfying ways is fundamental to the psychotherapeutic process. This theme is explored with the help of Joseph Conrad, Jane Austen and the Peruvian Nobel Laureate Mario Vargas Llosa. The categorising zeal of psychiatric diagnosis and the whole-person approach embodied in psychotherapy are sometimes seen as mutually exclusive. Part III challenges this by showing how great artists such as Wilde and Wagner can help understand and respond, in ways that make psychotherapeutic sense, to specific patterns of mental distress. Dissociative identity disorder, anxiety, grief and narcissism are considered from this literary/psychodynamic perspective. Part IV takes its motif from Forster’s famous invocation: ‘only connect’. Building on the ‘two cultures’ theme already discussed in Part II, it aims to foster a conversation between the science of psychiatry and the art of psychotherapy, arguing for approaches to mental health that encompass both brain and mind. I suggest that the glimmerings of a rapprochement are to be found in recent discoveries showing how experience inscribes itself on the brain, and, via

Downloaded by [New York University] at 12:48 14 August 2016 epigenetics, may be transmitted to subsequent generations. Psychotherapy’s task is to re-work the mental representations of adversity, and, thanks to neuroplastic- ity, to instil more positive developmental pathways. I draw on literary examples to help foster Forster’s vision.

Note 1 ‘Critical reﬂection on art, culture and nature’ (Kelly 1998, p. 521).

xiii ACKNOWLEDGEMENTS

Pathology by Miroslav Holub appears here by permission of Penguin. Lines from E. M. Forster’s Howards End appear here by permission of The Provost and Scholars of King’s College, Cambridge and The Society of Authors as the E. M. Forster Estate. ‘The catch’ by Simon Armitage, ‘Dinner with my mother’ by Hugo Williams and ‘The dinner’ by Seamus Heaney appear here by permission of Faber & Faber, as do lines from ‘The building’ by Philip Larkin, ‘East coker’ by T. S. Eliot and Selected Prose by Seamus Heaney. Downloaded by [New York University] at 12:48 14 August 2016

xiv Part I

THE POETICS OF PSYCHOTHERAPY Downloaded by [New York University] at 12:48 14 August 2016 This page intentionally left blank Downloaded by [New York University] at 12:48 14 August 2016 1 THE THERAPEUTIC IMAGINATION George Eliot and Daniel Deronda

Imagination is deﬁned in the Oxford English Dictionary (1973) as ‘that faculty of the mind by which we conceive of the absent as if it were present’, illustrating this with Shakespeare’s oft-quoted (Williams and Waddell 1991) credo (put into the mouth of Theseus in A Midsummer Night’s Dream):

And as imagination bodies forth The forms of things unknown; The poet’s pen Turns them to shapes, and gives to airy nothings A local habitation and a name. (Shakespeare 1911/1962)

If, as Barratt (1984) suggests, psychoanalysis is in essence a ‘negative dialectic’, i.e. a discipline whose starting point is absence (cf. Green 1997; Gurevich 2008), concerned with that which is unconscious, repressed, dissociated, split off – as Conan Doyle might have put it, a discourse of the dog that didn’t bark – then imagination is a key psychoanalytic capacity. The collaborative job of patient and analyst is to conjure up, capture and transform what is missing, or conspicuous by its absence, from the patient’s mental life. The starting point of this chapter is the idea that the means by which this is achieved is through harnessing the imagination in speciﬁc and systematic ways. Shakespeare’s Theseus points to some important aspects of the workings of the imagination. First, like the unconscious, it is impersonal – an ‘it’ rather than

Downloaded by [New York University] at 12:48 14 August 2016 an ‘I’ – bodying things forth rather than purposively thinking them up. Second it is corporeal, being both in and of the body, especially, but not exclusively the visual system; imaginative activity starts with a quasi- bodily feeling or half- glimpsed ‘form’, or image, in the mind’s eye. Third, there is an intimate relationship between this embodying process and language: the ‘pen’ of the poet transforms ‘forms’ unknown into deﬁnite ‘shapes’, places and names. Theorising imagination can be traced to a coherent intellectual framework, but one that tends to be downplayed in today’s clinical and political climate. Its origins lie in the German romantic tradition which predates, but undoubtedly

3 THE POETICS OF PSYCHOTHERAPY

influenced Freud, which also has its own independent lineage in Anglo- Saxon culture. This in turn has fed back into the British contribution to psychoanalytic thought and practice. The roots of imagination as a construct lie with Kant, Schelling and German Romanticism (Watson 2010). Coleridge introduced these ideas into the Anglo- phone world (Holmes, R. 1999), transforming them in his own idiosyncratic way. They were developed psychoanalytically by Sharpe (1940), Bion (1962), Winnicott (1971) and Rycroft (1985); and more recently by Britton (1998), Ogden (1997), Turner (2004), Ferro (2012) and Waddell (1998). These authors clearly draw on pre-1914 Freud (Barratt 1984, 2012) where the romantic impulse of The Interpretation of Dreams and the development of free association technique were still to the fore. In addition, I suggest that there is a Coleridgean tradition which contributes to their thinking in a separate line of intellectual influence. Rycroft (1979, p. 167), for example, saw it as his aim to ‘marry the thinking of Freud and Coleridge’. What then is the ‘therapeutic imagination’? The related phrase ‘clinical imagination’ is not new (e.g. Havens 1982; Dimen 2001; Rustin 2001). The purpose of adding a definite article, capitalising the concept and broadening from ‘clinical’ to ‘therapeutic’ is to suggest – in a spirit which might perhaps be seen as anti- imaginative – that imagination can be systematised and anatomised, and that it provides a useful framework for thinking about the components of psychoanalytic activity in the consulting room. Jung saw an aim of psychoanalysis as fostering its patients’ ‘active imagination’ – whether through daydreaming, painting, writing or other artistic activities (cf. Holmes 2012b). Within the Anglo- Saxon tradition the phrase is the medical/ psychotherapeutic analogue of ‘the poetic imagination’ (Weir 1996). Psychoana- lytic writers compare the poetic transformation of experience into words with a similar process in psychoanalytic sessions. A key lineage runs backwards from Bion’s injunction to the analyst to be ‘beyond memory and desire’, through Keats’ ‘negative capability’ – the ability to be remain in doubts, mysteries and uncertainties – to Coleridge’s ‘willing suspension of disbelief ’. Full play of the imagination entails temporarily bracketing off veracity-testing; in the world of the imagination anything goes – and needs to be allowed to – if the necessary ‘dream work’, in its wider sense, is to be given free reign. Bion picks up on the Coleridgean notion of poetic ‘reverie’ and uses this to

Downloaded by [New York University] at 12:48 14 August 2016 describe the analyst’s state of unprejudiced receptiveness, reborn in Ogden’s idea of ‘dreaming the session’. The animating notion is that of the capacity of the analyst, like the poet, to allow thoughts and feelings spontaneously to arise within her; to transform these imaginative stirrings into gesture and words which can be put to therapeutic use; and thereby to help the patient better understand his unconscious thoughts and feelings. Poetry and therapy both, represent a ‘raid on the inarticulate’ (Eliot 1954, p. 31). But psychotherapy is not poetry; as Britton rightly says, the analyst who explores ‘his own psychic reality while attributing it to the patient . . . has

4 THE THERAPEUTIC IMAGINATION

forfeited his role of analyst’ (Britton 2003, p. 103). Therapeutic imagination, while sharing some features of poetic imagination, has a distinct identity and structure of its own. It can be thought of as a general process informing clinical encounters, whether medical, psychiatric or psychotherapeutic. In addition to reverie, it comprises a number of other components which feed into, and flow from, the act of reverie. These can be divided into a five-part sequential structure. The first step, following Bowlby, might be called primary attachment. Reverie, the poetic analogue is next. Then, Coleridgean again, comes logos. These are then followed by action and reflection. This cycle repeats itself in a ‘fractal’ way in both micro- moments of the session, as an overall trajectory for whole sessions, and for on- going periods or ‘passages’ of a therapy.

Daniel Deronda Before developing these ideas in more detail, let us look at a specific example, taken not from the consulting room, but the literary canon. In George Eliot’s last great novel, Daniel Deronda (1876/1986), the eponymous hero rescues a young woman from suicide – which might be seen as one of the ultimate justifications for psychotherapeutic work. Eliot was fluent in German and would have been fully conversant with German Idealist and Romantic ideas. This, I suggest, forms the philosophical background to her account of a proto- psychodynamic encounter and suicide rescue (cf. Rotenberg 1999; Waddell 1989). This Romantic connection is tangentially referred to when Eliot states that Deronda, a beautiful young man, ‘bore only disguised traces of the seraphic boy “trailing clouds of glory” ’ (Eliot 1876/1986, p. 225) – an explicitly Wordswor- thian/Coleridgean reference to the former’s Intimations of Immortality (cf. Chapter 5). Deronda chafes against his formal and narrow education:

He longed now to have the sort of apprenticeship to life which would not shape him too deﬁnitely, and rob him of the choice that might come from a free growth . . . Deronda’s demerits were likely to be on the side of reﬂective hesitation . . . (ibid. p. 220)

Free growth and reﬂective hesitation might be seen as desirable antecedents of a career as a psychotherapist. Downloaded by [New York University] at 12:48 14 August 2016 The story begins in London. One evening while rowing on the Thames, Deronda notices a slim dark girl at the river’s bank, whose

‘eyes were ﬁxed on the river with a look of immovable statuesque despair’.

Momentarily, their eyes meet:

‘he felt an outleap of interest and compassion towards her’.

5 THE POETICS OF PSYCHOTHERAPY

Then he reﬂects ruefully on his reaction: perhaps it is just because she was beautiful that she excited his interest. But no:

‘I should not have forgotten the look of misery if she had been ugly and vulgar’

he says to himself. He rests on his oars in a state of ‘solemn passivity’. Reaching the bank, he

‘enters a state of ‘half- speculative, half-involuntary identiﬁcation of himself with the objects he was looking at’, wanting to ‘shift his centre till his whole personality would be no less outside than the landscape’. (ibid. p. 228)

Suddenly he sees the girl preparing to plunge herself into the river. Quickly he sculls across, and ‘speaking but very gently’:

‘Don’t be afraid . . .You are unhappy . . . Pray, trust me . . . Tell me what I can do to help you’.

She responds and reminds him that she had heard him singing earlier. He replies:

‘But I fear you will injure yourself staying here. Pray let me carry you in my boat to some place of safety.’

Daniel realises that the girl has stirred a chord in him, evoking thoughts of his own mother, about whom he knew nothing:

‘The agitating impression this forsaken girl was making on him stirred a ﬁbre that lay close to his deepest interest in the fates of women – “perhaps my mother was like this one” ’.

She enters the boat (his surrogate consulting room), and he rows: ‘they went along swiftly for many minutes without speaking’. For Daniel: ‘his ﬁrst impression about her, that her mind might be disordered, had not been quite dissipated: the project of suicide was unmistakable . . .’. He longs to begin a conversation,

Downloaded by [New York University] at 12:48 14 August 2016 but abstains, ‘wishing to encourage the conﬁdence that might induce her to speak ﬁrst. At last she did speak’:

‘I like to listen to the oar’ ‘So do I’ ‘If you had not come I should have been dead by now’ . . . Deronda was mute: to question her seemed an unwarrantable freedom . . . ‘I want to know nothing except what you would like to tell me’.

6 THE THERAPEUTIC IMAGINATION

‘This morning when the light came I felt as if one word kept sound- ing within me “Never, never!” But now – I begin – to think’ her words were broken by rising sobs – ‘I am commanded to live . . .’.

Deronda takes her to the house of a family friend whose mother and sisters he knows will look after her. In the cab the story of the Maenads comes to mind. How:

. . . outworn with their torch- lit wanderings they lay down in the market- place, and the matrons came and stood silently around them to keep guard over their slumbers . . . He could trust the women he was going to for having hearts as good.

Finally Deronda thinks about his experience, while the author reﬂects on that reﬂection:

. . . how to make sure that snatching from death was rescue? The moment of ﬁnding a fellow- creature is often as full of mingled doubt and exultation as the moment of ﬁnding an idea.

This episode may seem somewhat remote from the analytic consulting room. But the image of the river provides a perfect metaphor for the flux of experience – the stream of consciousness – that is the medium of psychotherapy. Deronda aligns himself with the force of the river to direct his boat, to drift, or rest, as the situation demands – a metaphor comparable to Freud’s rider- horse image for the relationship between the conscious and unconscious self (Freud 1900). The fluidity of character Deronda both seeks and is afflicted by is thereby instantiated. Like Shakespeare, his ‘. . . nature is subdued/to what it works in, like the dyer’s hand’ (1911/1962, Sonnet 111). The first vector of therapeutic imagination – here Deronda’s – is the clinician’s alignment or attachment to the person in need of help or cure. The elements of this include: eye contact; an excitation of focus and attention; an ‘active passivity’; identification and a partial dissolving of the self into the object. Next comes reverie: the therapist allowing the process of connection with the other to flow through him, as through an aeolian harp, and to activate its chosen heart-strings.

Downloaded by [New York University] at 12:48 14 August 2016 These ‘melodies’ inevitably also reflect the therapist’s own deepest themes – for Deronda the search for the missing mother, which, it later turns out is the girl’s mission too; her suicidal despair reflects a feeling that this is unattainable. Next comes logos, the ‘poet’s pen’: putting experience into words. Here, like the good therapist, Deronda holds back, creating a potential space into which the girl can speak. Only when she makes a seemingly irrelevant comment ‘I like to listen to the sound of the oar’ does he respond, with an identificatory remark ‘So do I’. This then opens the floodgates (staying with aquatic metaphors) for her to talk about suicide.

7 THE POETICS OF PSYCHOTHERAPY

The ‘sound of the oar’ here is a ‘third’ – a shared experience, like a dream or reverie which can be picked up by either participant. Later Deronda’s own internal reverie – the Maenad story – passes through his mind as a spontaneously arising conﬁrmation of the rightness of his rescue plan. Finally, come action and reﬂec- tion. After considering the alternatives, Deronda decides the best thing would be to take the girl to his friend’s family – a community treatment plan perhaps. Finally he looks back on the whole episode with the help of the author/supervisor – has he done the right thing? Is rescue really preferable to death if one is in extremis? What has he let himself and the girl in for? Deronda has dared disturb the universe; but will it be a better or worse place as a result?

The ﬁve components Having attempted to illustrate these sub-categories of therapeutic imagination, let’s examine each in more detail.

Primary attachment Mothers are biologically primed to fall in love with their babies. Adults and older children similarly respond with involuntary nurturing responses to infants, small animals and distress calls. The attachment relationship, although usually described from the point of view of the care- seeker, while asymmetrical, or ‘lop- sided’ (Barratt 2012), is reciprocal. A distressed infant activates nurturing behaviours in the care-giver until the separation-triggered distress is alleviated. Parents of chronically ill children are in a constant state of attachment arousal and will go to almost any lengths to help their child’s recovery. The Heidegerian philosopher Levinas elevates this biological response to an ethical plane (Orange 2011). He argues that ‘proximity’ to the Other, the neighbour, elicits the response ‘me voici’ – ‘I am here’, and that the presence of the Other places an inescapable obligation to be our brother and sister’s keeper. Freud questioned whether it was the role of the psychoanalyst directly to alleviate suffering, or merely to help the patient to understand its infantile origins – a process he saw as intrinsically curative. But the starting point of any clinical encounter is ‘the kindness of strangers’ (Williams 1993), sought or offered: the mutual alignment of a distress-alleviating search on the part of the patient, with

Downloaded by [New York University] at 12:48 14 August 2016 the therapist’s capacity to allow that pain and unhappiness into her heart, so that healing can begin. This model of primary attachment encompasses such concepts as ‘the therapeutic alliance’, the ‘real relationship’ and the ‘working alliance’. But these do not perhaps do full justice to the power and significance of the primary connection between the clinician and suffering stranger. The notions of empathy and identification carry us some way, but a key aspect is the therapist’s capacity to enter into the inner world of the Other. Here, Eliot suggests, the helper’s personality is as much outside him/ herself (‘in’ the patient) as within the confines of his or her individual self.

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Reverie In the ﬁnal lines of To a Nightingale (1973), as the poem and the bird’s parting notes fade, Keats, a devoted Coleridgean, asks himself whether the beauty and ecstasy experienced when listening to the invisible bird’s song was a

‘. . . waking dream? Fled is that music. Do I wake or sleep?’.

Like a writer, the imaginative clinician has to capture the art of the waking dream, of being simultaneously awake and ‘asleep’. As Plato puts it in The Sophist: ‘We make a house by the art of building. By the art of painting we make another sort of house, a man-made dream produced for those who are awake’. The same can be equally said of poetry. The clinician must be awake and alive both to the reality of the patient and his story, to the boundaries and parameters of the clinical situation, and, like Keats’ fading nightingale song, to the inevitable ending and loss that will follow intense connectedness. At the same time she must be able to ‘dream’ lucidly, in the sense of letting her own thoughts and feelings flow impersonally through her, observing them, holding them in readiness for consideration, first with herself and then with the patient. There is a kind of secular ‘reverence’ in this ‘reverie’. The patient is the focal point around which the therapist’s reverie revolves, and however ill, destructive, rageful, or even obnoxious he or she appears, the patient’s inner world is the one and only object of interest. This idea of the free play of the waking-dreaming mind is crucial to Col- eridge’s theorising of the imagination. He first developed it in his early poem Frost at Midnight, linking the ‘thin blue flame’ of the fire in the grate, his infant son’s quiet breathing and the breath of life, and the animating Spirit which he believed permeated the universe. A crucial Coleridgean distinction is between this quasi-divine imagination and what he calls ‘fancy’ (Coleridge 1817/1983, p. 161). While both ‘imagination’ and ‘fancy’ have different connotations to our twenty-fi rst-century ears to those evoked in Coleridge and his contemporaries, the distinction is a crucial one, and remains as relevant today as it was then. For Coleridge, ‘imagination’ is the vital force that ‘dissolves, diffuses, dissi- pates, in order to re-create’ (ibid.). It takes reality and reshapes it into a new and living form. It is unifying and truth-seeking. ‘Fancy’ by contrast is an inert, Downloaded by [New York University] at 12:48 14 August 2016 passive, superficial, dull medium which ‘receives all its materials ready- made’. It proceeds by association and impression rather than transformation and recre- ation. The difference could be compared to the contrast between a painting and an uncomposed photographic snapshot. Transposing this dichotomy into the clinical situation, the therapist’s aim is to help the patient transform inchoate experience into a vivid image – a thought, dream or fantasy – which typifies the essence of his or her inner world in that specific life-moment. This ‘relational reverie’ is inescapably interpersonal. The

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therapist’s contribution, her imaginative crystallisation of experience, happens intuitively and semi- consciously as she allows her reverie to play on and with the living reality of the patient. Contrast that with a formulaic, box- ticking, symptom-focused, response in which the totality of the patient’s being is unac- knowledged, where the unity of the individual is fragmented into discrete non- interacting systems, and where an ‘answer’ emerges from a sterile alogarithm. The one is a living active encounter with a fellow human; the other an inert juxtaposition of symptoms/‘complaints’ and procedures; as Heath (2012) puts it, the contrast between a concern with ‘real people with real problems’, as opposed to ‘units of medical need’. Deronda needed no checklist to tell him that the girl was suicidal. He focused on her, imaginatively identified with her, entered into a state of ‘speculative half- involuntary identification’ with her; he just knew that she was in danger and needed help – his reverie told him so. Going with the flow of the river, and of his clinical imagination, confident that his intentions were benign, her beauty not- withstanding, he approached. The moment had arrived when reverie has to reveal itself, where a feeling in the flesh has to become word – or logos.

Logos For Coleridge, a Kantian-Romantic-Christian, the word is God. The poet, through his imagination has partial access to universal truth, manifest in his poetic utterance. Therapists may similarly overvalue the importance of interpretations, their ‘correctness’ or otherwise, as opposed to the non- verbal ‘gesture’ of their attention and availability. But, sooner or later, the dream/reverie has to be ‘told’. A hypothesis, generated by the therapist’s reverie, must be tested against the reality of the patient’s response (cf. Havens 1982). How does the therapist ﬁnd the words to communicate the feelings that the patient has aroused in her? A number of preliminary points need to be made about this. First, the most potent intervention may be a pregnant silence, a holding back of words, as for Deronda, despite his longing to initiate a conversation. His reticence is what makes it possible for the girl to confess her suicidal impulses. Paradoxically, as Winnicott (1971) and Ogden (1997) emphasise, respect for patients’ inviolate private self makes it easier for them to reveal their inner world to themselves and their therapists. Security is a necessary precondi-

Downloaded by [New York University] at 12:48 14 August 2016 tion for exploration (Holmes 2010). Second, language is a two-way enterprise. Words link. The patterns of words and their reverberations ‘belong’ to neither party, they are a joint creation, and ultimately derive from the impersonal linguistic world which both have inherited. Together therapist and patient create a unique ‘ideolect’ (Lear 2009). Third, the non- verbal or musical aspect of speech is as important as their content: tone, timbre, tempo, rhythm and volume (cf. Canham and Sath- yamurthi 2003). Deronda’s capacity to speak ‘but very gently’ is what per- suades the girl to enter the boat. Fourth, while therapists need to be clear,

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coherent and consistent in their approach and formulations (which is not to say that they do not also need to be able to embrace their confusions and muddles), no single theoretical model holds hegemony. Like language itself, and unlike ‘reality’, imagination is relatively unconstrained: it can take a potentially inﬁnite number of forms and manifestations. Nevertheless, poetic language is enshrined in established ‘forms’: sonnet, ballad, vers libre, vil- lanelle, etc. It is perhaps not entirely fanciful to compare different psychoanalytic theoretical stances to these, in that a particular viewpoint – Kleinian, Relational, Lacanian, etc. – provides familiar vehicles through which the analyst’s ‘pen’ (her utterances) can, for the patient’s sake, comprehensibly body forth the shape of things unknown. Relational reverie entails empathic resonance with the patient’s affective state. Countertransference feelings – often mere scraps of images, vague wisps of ideas – are scrutinised by the analyst’s conscious self, using the capacity to classify, categorise and verbalise. Those quasi-formulated thoughts are then used for further engagement with the patient. This might take the form of a transference interpretation with no explicit reference to the therapist (contemporary psychoanalytic standard practice), a holding back altogether on the grounds that the time is not ripe (Deronda, anticipating Winnicottian tact) or a more-or-less explicit account of the therapist’s feelings (relational psychoanalysis).

Action We might speculate that evolution has endowed humans with imagination for two main reasons. First, imagination is needed in order to facilitate social living. We need, through imaginative identiﬁcation, to be able to anticipate the needs, desires and projects of the Other. Autism can be seen from this perspective as a radical dysfunction of the imaginative system (Baron- Cohen 2003). But these supposed feelings of the imagined Other are, seen from a mentalising perspective, no more or less than hypotheses: the mind is inherently subject to error and mis- construal, and therefore of necessity open to correction. Second, we imagine in order to generate an array of possibilities, thereby helping us choose the best course of action in any particular situation. Hence the military doctrine – time spent in reconnaissance is never time wasted. The ulti-

Downloaded by [New York University] at 12:48 14 August 2016 mate purpose of therapy is to enhance the patient’s agency and action-potential (Knox 2011). At the end of his ‘assessment- interview’, we see Deronda align his imaginative identiﬁcation with the girl, and his formulation (‘suicidal, alone, in need of Maenad-type feminine succour’), with the referral possibilities:

Shall I take her back to my house? – no she would be overwhelmed by the opulence and machismo of my guardian, and put off by his snobbish wife. What about my friend’s mother and sisters? Yes, that would be ideal; they are kind and unpretentious and nurturing.

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Clearly in on-going therapy, as opposed to assessment, no such ‘management decisions’ are taken. Yet there is always an action moment as the boundaries of the session are observed and the therapist announces, as in Eliot’s namesake’s Wasteland (Eliot, T.S. 1969): ‘time gentleman please’. Action, unlike imagination, is always precluding: ‘if this, then not that’. The therapist aims to foster the maximum possible imaginative freedom within the brief conﬁnes of the 50-minute hour, but equally ﬁrmly observes the rigorous – some might say unimaginative – boundaries of therapy.

Reﬂection According to Ricoeur (1970), psychoanalysis is a ‘school of suspicion’. What is consciously experienced in human experience and interaction is always less than there might be; we have an inﬁnite capacity for self-deception; we travel towards, but never arrive at psychic truth. Ultimately we can only be experts on ourselves; equally, there are always aspects of the self that cannot be seen without the help of another; growth occurs by enquiring into what has been left out, and then facilitating movement towards a wider, more inclusive, sense of self. This means that self-monitoring, meta-cognition, self- scrutiny or mentalising – the terms are nearly equivalent – are integral and indeed central to therapeutic imagination. Deronda thinks that he is not drawn to the girl because she is beautiful, but by her by distress. But he could be wrong; he is after all a single, vigorous, albeit virtuous, young male. He thinks that he is doing the right thing to rescue her – but perhaps death might sometimes be preferable to extreme suffering. We think that we have discovered a new and exciting idea – but we could be, and often are, mistaken.1 It is incumbent upon clinically imaginative clinicians to subject themselves to self-scrutiny of this sort – and to acknowledge that there will inevitably be things that they cannot see, do not want to think about. They will need the vision and decentred perspective of a supervisor to discover their true feelings and motiva- tions. By the logic of the negative dialectic, the ‘beam of intense darkness’ (Grotstein 2009), the lacuna points to what is present yet missing.

Impediments to therapeutic imagination Downloaded by [New York University] at 12:48 14 August 2016 The sequence described above, and illustrated in Daniel Deronda’s engagement with Mirah, is of course idealised – a council of perfection. The challenge of real-life clinical work lies in remaining true to therapeutic imagination while acknowledging and helping overcome the obstacles inherent in problematic relational patterns. The suffering patient brings anti-imaginative expectations into the consulting room – ‘minus K’, one might say (Bion 1962). The clinician’s skill lies in creating therapeutic leverage from the discrepancy between these ingrained transferential patterns, and her still- active therapeutic imagination

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(cf. Lear 2009). Especially with highly disturbed patients, each of the five stages presents its own difficulties. Primary attachment is characteristically problematic when working with people suffering from Borderline Personality Disorder (Bateman and Fonagy 2004). Such people either shun engagement or cling to it; appropriate proximity arouses overwhelming anxiety, often originating in childhood experiences of traumatic or neglectful care-giving. When it is offered therapeutically it may appear unbearably threatening. Therapists must expect turbulence around the boundaries of therapy, and, like Deronda’s tactful handling of Mirah, communicate a stance of non-controlling, boundaried, availability. Standing apart from one’s reverie, and observing its perturbations, while engaging with the inner world of the patient, is a cardinal analytic skill. The therapist may feel her reverie to be colonised by the patient’s projected unwanted thoughts; there may be a deadness and an absence of imagination reflecting the patient’s affective shut- down; there may be an efflorescence of images and thoughts as though the inner world is all that matters, in stark contrast to the emptiness of the patient’s everyday life. Birkstead-Breen (2012) suggests that inhibition of reverie is characteristic of analytic impasse, and that such blocks can be relieved if the analyst is able to make use of visual imagery or bring her fantasy- thoughts into play during the session. Moving from reverie to logos – finding, as Coleridge put it, the ‘best words in the best order’ (1827) – requires tact, timing and tone. In the cut- and-thrust of the consulting room things do not always proceed straightforwardly, or sequen- tially. Logos may inappropriately precede reverie. Here is an example.

A woman in her early forties, married with a daughter aged ten, sought therapy for depression and secret drinking. In the assessment interview she described how her younger sister had died in tragic circumstances soon after the patient’s now-rocky marriage, but this topic had not come up in sessions since. In session five the patient was discussing how difficult it was to be firm with her daughter about eating potato crisps without permission. After she had described one such incident, the therapist commented: ‘you sound more like two sisters squabbling than mother and daughter’. He then heard himself saying ‘you have got a sister haven’t you?’. Then, with a sickening

Downloaded by [New York University] at 12:48 14 August 2016 realisation, he struck his forehead, saying ‘oh my goodness, I’m so sorry, of course your sister died’. This rupture led onto a much deeper discussion about the patient’s relationship with her sister, and exploring how she hadn’t really wanted children, and might well not have allowed herself to become pregnant, had her sister lived. Subsequent sessions suggested that disentangling her feelings about her sister from those towards her daughter had enabled her to be both ﬁrmer, and warmer in a more motherly way while handling her daughter.

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One might view this sequence as based on out-of-consciousness reverie on the part of the therapist, in which part of his mind mirrored the present yet absent role of the sister’s death in the patient’s life. This reverie erupted unexpectedly in his tactless logos – the dead sister was an ‘absent presence’ in his mind just as it was in the patient’s. Here the sequence went from logos to reverie rather than vice versa. The patient’s generous acceptance of the therapist’s apology, based perhaps on a still intact primary attachment, meant that little harm was done, and, as it turned out, the conversation was productive. In different circumstances the rupture might have been irreparable. The decision vector in therapeutic imagination can equally go awry through enactments; here the therapist’s actions may embody unprocessed and unex- pressed reveries, even if done for the best possible motives. Deronda might have taken Mirah to his adoptive father’s grand establishment (a) as a way of trying to impress her with his potency (countertransference enactment arising out of his own unprocessed feelings), or (b) as a manifestation of Mirah’s ambivalent feelings to her powerful yet abusive father (Deronda’s resonance to her inner world). Finally, reﬂection and reality-testing, away from the session, with a supervisor and/or one’s ‘internal supervisor’ is an indispensible part of therapeutic imagination. Very junior and very senior analysts are perhaps most at risk here. As Storr (Holmes 2012b), neatly put it, ‘even the Pope has a confessor’.

Therapeutic imagination in non-psychotherapeutic settings While the therapeutic imagination model ﬁts perhaps best with the dynamic of psychoanalysis and psychoanalytic psychotherapy, it represents more general features of therapeusis, and can also be applied to non- psychotherapeutic settings. Here is a medically oriented example:

A middle-aged woman, the wife of a physician, suffered from a variety of incapacitating symptoms: insomnia, back pain and nausea. Pulling various medial strings her well- meaning but misguided husband arranged for her to see a consultant endocrinologist; he in turn referred her to a nephrologist; who then sent her onto a gastroenterologist. All could ﬁnd ‘nothing’ wrong, yet her symptoms persisted. Eventually her

Downloaded by [New York University] at 12:48 14 August 2016 family doctor took control. He called a halt to hospital referrals, said that he was convinced she was suffering from depression, stopped all irrelevant medication (painkillers whose side- effects mimicked the symptoms of serious disease) and prescribed anti- depressants, while offering her a series of extended consultations. Her symptoms abated.

The patient had been subject to a series of deeply unimaginative clinical experiences. Each of her ‘systems’ had been subject to scrutiny, but the unifying effect of reverie was missing, the physicians driven not by their clinical imaginations

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but in Coleridge’s terms, by ‘fancy’ – i.e. superﬁcial, un-contextualised, proto- colised procedures. None had the capacity to encompass her whole being, to apprehend the totality of her life-world. It took the family doctor’s engagement, clinical intuition/reverie, diagnostic organising logos (‘depression’) and clear action-plan for improvement to begin. No doubt he was also monitoring himself in case he was missing a serious illness, while taking into account the possibility that he might be driven by competitiveness and envy of his hospital colleagues, rather than the patient’s best interests.

Conclusions Imaginative therapeusis is a particularly Anglo-Saxon contribution to psychoanalytic clinical theory – perhaps more accurately Saxon- Anglo, in that its origins are Germanic. Pioneered by Coleridge, German romanticism took root in British intellectual and cultural life in the ﬁrst part of the nineteenth century, and has remained since, in part a backlash against the formalism and chill clarity of the Left brain-dominated Enlightenment (cf. McGilchrist 2011). Among others, Bion and Winnicott cross- bred a Coleridgean notion of the imagination against the structural psychoanalytic model. This project has been more recently further developed by Ogden, Britton and Ferro. It is beyond the scope of this chapter to track this intellectual history in any detail. Its aim rather has been to suggest a step-wise structure against which the clinician can evaluate her intuitive clinical pathways. It is also a mini-manifesto, championing the concept of the imagination as a valid and relevant force, in contrast to what, in Coleridgean terms, is the superﬁcial and sterile ‘fancy’ that represents much of what passes for psychological therapy in the contemporary world.

Note 1 Who has not in their dreams stumbled upon a world- shattering truth, only on waking to realise the banality of that seemingly precious vision? Downloaded by [New York University] at 12:48 14 August 2016

15 2 DISCOVERY Seamus Heaney and Marcel Proust

The aim of this book is to recruit literature and its authors to help capture and convey the essence of psychotherapy. The living shared experience which consti- tutes the psychotherapeutic encounter is necessarily elusive. The focus of this chapter is a core component of psychotherapeutic work: the process of discovery. The therapist’s role is to create conditions in which such discovery can take place; without security there can be no exploration, but equally where security is just too comfortable the stimulus to explore is inhibited. Getting that balance right is a core therapeutic skill. I approach my topic tangentially, via three non-psychotherapeutic examples – one scientific, two literary. A concluding section explores how these literary analogies may inform the teaching and supervision of psychotherapy. The point of these comparisons is not to elevate the status of psychotherapy from a quotidian craft to a creative art, much less a science, but to acknowledge that writers (and scientists) face problems similar to those confronted by psychotherapists. This applies both to the primary activity of writing (Wordsworth’s ‘emotion recollected in tranquillity’) but more especially to secondary attempts to give an account of the creative process itself. Since writers by definition are likely to have special literary skills, any description they give of themselves at work should be of interest to self-re flective psychotherapists (which should be a tauto- logy – and, as we shall later see, a ‘taught’-ology!). This comparison may also help to illuminate the latent activity that underlies the therapist’s apparent passivity. I start with an incident which occurred in supervision:

A postgraduate student came with the report that she had suddenly

Downloaded by [New York University] at 12:48 14 August 2016 noticed a great change in her patient. Both patient and therapist were attractive young women in their late twenties. The patient had had a disturbed and difﬁcult background: she was an illegitimate child whose mother had only married when she was ten. She had never really accepted her stepfather and half-siblings, and left home after a row with her mother – who was a doctor – over a boyfriend. Two marriages had followed and her depression, which was the presenting problem, coincided with the birth of her ﬁrst child. The therapy proceeded with a transference of compliance and covert rivalry, eagerly noted and

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interpreted by the therapist – who was stimulated by the patient and enthusiastic about the treatment – but with no real feeling of change. Then, suddenly, in the session before the supervision, came a break in the deadlock. The patient arrived wearing a dress for the ﬁrst time. She began to speak of her envy of her colleagues at work – she was an actress – and of how she longed to look and carry herself like them. The therapist had mentioned at the start of the session that she would be away soon and the patient then went on to speak of her envy of the therapist, of her feeling of anger and abandonment about the break, and to remember similar experiences as a child when her doctor-mother left her to go to work, and later to go on holiday with her new husband. In discussing what might have happened, the therapist suggested that she might have been preoccupied with preparation for her forthcoming psychiatric examinations (hence the break) and so perhaps had been less anxious to help her patient. She had – to use a phrase deployed by E. P. Thompson (1982) in a different context – ‘leant off ’ her patient, and in doing so had created the conditions in which something new could happen.

I begin with this rather commonplace anecdote because it contains within it the key ingredients of the psychotherapeutic method: an attempt to create conditions within which a therapeutic experience can occur, which can then be identiﬁed and understood. As outlined in the previous chapter, there are a number of sequential elements in this process.

1 Structure Dynamic psychotherapy may appear to the uninitiated as a vague, formless activity. In fact a prerequisite of successful psychotherapy is a definite structure. This consists first of the setting itself – the regularity of time and place; second, the consistency of the therapist’s personality and posture – non- revealing, non- directive, empathic, warm but non-possessive; and third, of the theoretical orientation that informs his or her questions, interventions and interpretations. This containing structure, firm but not rigid, allows feelings to concentrate, especially those between therapist and patient, just as the strong walls of a crucible are an essential for a chemical reaction to proceed. One patient described this structure as a ‘tennis

Downloaded by [New York University] at 12:48 14 August 2016 wall’ against which he could bounce his feelings, knowing that they would be returned in a predictable way, but often at a new angle. The same patient commented that after three years of therapy, ‘I have changed so much but you [the therapist] seem to have remained exactly the same as when I ﬁrst walked in.’

2 Space A structure, or boundary, automatically deﬁnes a space within which therapy can take place. The concept of space in therapy has been discussed by several

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authors (e.g. Kohon 1999; Pedder 2010). The calm receptiveness of the consulting room mirrors the therapist’s vacant (but, one hopes, not vacuous) ‘inner space’ available for the patient to begin to explore her feelings. In the example I have given, it was the movement from concentration to relaxation or ‘leaning off ’ that created the space that allowed change to take place when the therapist became preoccupied with her exam. She stopped trying too hard. Perhaps the most potent form of psychotherapeutic space is silence. The therapeutic dialogue differs radically from ‘normal’ conversation in that it contains, and indeed even revels in, pauses, silences and lulls. In these, therapists adopt a posture of active listening in which they are attending both to the patient and to their own inner world whose ‘contents’ (the therapist’s countertransferential fantasies) are often a guide to the state of the patient. This may lead to a comment or interpretation, followed by another silence in which the patient may identify his or her own inner space and its contents. Thus there is a sequence of silence (space) – comment (structure) – new space, allowing for the emergence of the third step in the psychotherapeutic method: discovery.

3 Discovery Given structure and space (a crucible and its chamber) and the reactants of therapist and patient, the conditions are set for change: something new can now happen in the safety of the therapeutic laboratory. Initially this will be the reve- lation of unexpected or unwanted feelings, private thoughts and fantasies, forgotten emotions, hidden patterns. As therapy proceeds, these feelings come to focus more and more on the therapeutic process itself, the transference. A central aim of therapy is to allow this process of discovery to happen. For Bion (1962) this creative faculty of the mind, inhibited in neurosis but released in therapy, is alpha-function; Winnicott speaks of ‘learning to play’ (Winnicott 1971); Malan (1979/2013) of the ‘leapfrogging’ which follows a correct interpretation, the sequence of interactions in which both patient and therapist alternately build on what the other has said. Discovery may be a term preferable to the more usual ‘insight’ for a number of reasons. First, true insight has to be differentiated both from insight in the psychiatric sense of not being psychotic, and mere intellectual insight. Second, the notion of insight often arrogates the therapist: insight is what therapists

Downloaded by [New York University] at 12:48 14 August 2016 ‘have’ and what they ‘give’ to their patients. Third, discovery is a dynamic term and therefore emphasises the importance, not of insight as such, but the acquisition of insight. The patient is helped as much by the emotional experience that accompanies discovery as by the insight itself. Discovering is as important as what is discovered. This, in my view, follows from the general aim of psychotherapy which is to enhance the autonomy or self-agency (Knox 2011) of the patient (Holmes and Lindley 1997). The imaginative leap required for discovery contributes to the development of autobiographical competence which is a precondition of autonomous action.

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This is not to claim that any act of discovery is necessarily therapeutic. The central vehicle of change in analytic therapy is transference. It is the uncovering of feelings about the treatment and the therapist – transferential experience – that makes insight come alive. Only through transference is the patient likely to experience how his ‘internal parents’ can continue to inﬂuence feelings and actions long after childhood has been left behind. This leads to greater autonomy both because of the inherent spontaneity of the autonomous imagination, and because the internal world, once discovered, no longer becomes a limiting inﬂu- ence on action. There is perhaps a paradox inherent in this account: therapy, a maieutic (i.e. mid-wife) method, facilitates the predictable emergence of the unexpected. The psychotherapeutic method is a known structure that, through the interplay of space and structure, fosters the discovery of unknown feelings.

4 Description The fourth element is the language and theory in which this process is described (cf. ‘logos’, Chapter 1). This includes both the private shared language, or ‘ideolect’ (Lear 2009) with which patient and therapist communicate, and the theoretical language with which therapists ‘think’ and which links them with their colleagues and psychotherapeutic tradition (cf. Birkstead-Breen 2012). My argument here is that these linked elements, like the repeated steps of a dance, form the essential pattern of the psychotherapeutic method. They are to be found both at the level of the individual session and also in the overall trajectory of the treatment. This approach places imaginative discovery at the heart of psychotherapy. In view of the continuing debate about psychotherapy’s uncertain status as an art or science, it may be of interest to compare the psychotherapeutic method with descriptions of scientiﬁc and artistic discovery.

Scientific discovery: Medawar Consider first one of psychoanalysis’s severest critics: P. B. Medawar. Despite his hostility to psychoanalysis he has much to say that is of interest to the psychotherapist who wishes to understand and teach his craft (Medawar 1975). The scientific method, as the Popperian Medawar sees it, is based on the

Downloaded by [New York University] at 12:48 14 August 2016 ‘hypothetico-deductive’ system. In this, hypotheses are subjected to critical experiments in which they may be falsiﬁed. Where then do hypotheses come from? Here is Medawar’s answer to that:

Every discovery, every enlargement of the understanding, begins as an imaginative preconception of what the truth might be. The imaginative preconception – a ‘hypothesis’ – arises by a process as easy or as difﬁcult to understand as any other creative act of mind; it is a brainwave, an inspired guess, a product of a blaze of insight. It comes

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anyway from within and cannot be achieved by the exercise of any known calculus of discovery. (Medawar 1975, p. 94)

The giveaway in this passage is the dismissive ‘anyway’. Medawar, in common with many creative thinkers, both artistic and scientific, probably does not wish to examine his imaginative capacity too closely for fear of inhibiting it. In my view psychotherapy is a method – a ‘calculus’ – which creates conditions under which personal discovery may occur. The nature of these conditions may well be structurally similar to those governing artistic and scientific discovery. For Medawar the essence of the scientific method is the interplay between hypothesis and experiment:

The dialogue I envisage is between the possible and the actual, between what might be true and what is in fact the case – a dialogue between two voices, the one imaginative and the other critical. (Medawar 1975, p. 95)

In the scientific method, hypothesis is tested via experiment, reality is ultimate arbiter of the truth. In psychotherapy, reality is reviewed from the perspective of discovery. The painful reality of the patient’s distress or difficulty is seen in a different light as hidden feelings are discovered. The past cannot be altered, but it can be re-interpreted and so re- experienced. In science the hypothesis proposes, the experiment disposes. In psychotherapy reality proposes, discovery disposes, in the sense that the patient’s mental pain is a given, but it can be re- interpreted and re- experienced in the light of the unconscious ingredients which make it up. One aim of therapy is to release creativity – the same creativity which, for Medawar, is integral to scientific innovation. This is not necessarily creativity associated with any tangible artefact or scientific advance, but merely a sense of inner freedom and so an enlarged possibility for autonomous choice, action and enjoyment. The structural elements I am putting forward are precisely that ‘calculus of discovery’ which Medawar adumbrates. The sequences that I have described, structure, space, discovery – or, as in Chapter 1, attachment, reverie, logos, action, reflection – are not arbitrary, but

Downloaded by [New York University] at 12:48 14 August 2016 are fundamental patterns that underlie creative, imaginative and therapeutic activities. In support of this, let us turn now to two writers who have been especially interested in the workings of their own imagination.

Artistic discovery: Seamus Heaney The ﬁrst example comes from the poet and Nobel Laureate Seamus Heaney. He contrasts two important elements in poem- making (Heaney 1980). These are what he calls craft, i.e. mechanical skill in metre, rhyme, etc., akin to Coleridge’s

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‘fancy’ (see Chapter 1), and ‘technique’ which is more akin to our term ‘discovery’ – Coleridge’s ‘imagination’ – since it is about un- or dis-covered feelings into words and down onto paper, or screen. A similar distinction applies in psychotherapy: it is possible to be theoretically proﬁcient in the rules of psychotherapy – creating the proper setting, making the ‘right’ interpretations – and yet, for nothing signiﬁcant really to happen with the patient. This is pure craft, empty without discovery. However, therapists who are all discovery and no craft may engender powerful feelings in themselves and their patients that they cannot really turn to therapeutic advantage. The transference may become too intense, and the patient may break off, or the therapist may become forgetful and inconsistent, missing sessions or not telling patients about breaks – all resistances engendered by discovery without craft. This is Heaney:

I think technique is different from craft . . . Learning the craft is learning to turn the windlass at the well of poetry. Usually you begin by drop- ping the bucket halfway down the shaft and winding up a taking of air. You are miming the real thing until one day the chain draws unexpectedly tight and you have dipped into waters that will continue to entice you back. You’ll have broken the skin on the pool yourself. At that point it becomes appropriate to speak of technique rather than craft . . . It involves the discovery of ways to go out of the normal cognitive bounds and raid the inarticulate: a dynamic alertness that mediates between the origins of feeling in memory and experience and the formal ploys that express them . . . Technique entails the watermarking of your essential patterns of perception, voice and thought into touch and texture . . . That whole creative effort of the mind’s and body’s resources to bring the meaning of experience within the jurisdic- tion of form. Technique is what turns, in Yeats’ phrase, ‘the bundle of accident and incoherence that sits down to breakfast into an idea, something intended.’ (Heaney 1980, p. 54. Italics added)

Several phrases in this passage can be applied to psychotherapy.

Downloaded by [New York University] at 12:48 14 August 2016 ‘Miming the real thing’ Students often start out by a kind of miming of therapy often based on an imitation of their own teacher, supervisor or therapist. It is important in supervision to accept this phase, but also to help the student to mark the moment when the ‘real thing’ occurs. It is often important too to learn to fail. The student in supervision mentioned earlier had had a previous patient who had suddenly broken off treatment, probably because of the intensity of the therapeutic atmosphere. This failure had taught her not to try so hard next time.

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‘Raid the inarticulate’ Psychotherapy is always working on the edge of confusion and chaos, on or near the borders of an abyss. The teacher has to help the student not to run away from confusion but to live with it, to accept and understand it. Simple techniques for escape from confusion are sometimes invaluable. Often students say in supervision what they ‘really’ felt about a session but were somehow unable to communicate directly to the patient. The supervisor’s job will be to help students express those thoughts during the session itself, and to gain the courage to do so in future sessions.

‘Dynamic alertness’ This is yet another attempt to describe that the state of negative capability, free ﬂoating attention, unfocused awareness or reverie is essential to creative work and yet so difﬁcult to achieve. It is this that creates the space that is needed for the patient’s self-discovery to happen.

‘Watermarking’ This image has potent implications for therapy. Patients are struggling to identify their feelings, to find their own voice. For Heaney this struggle takes the form of an internal dialogue. In therapy the dialogue is ‘external’, with the therapist, but the aim of therapy should be to initiate a dialogue which, after treatment ends, patients can continue to have with themselves. Indeed therapy can be seen as temporarily externalising a dialogue with an inner Other, that, once therapy is over, becomes a life-long companionship with oneself (cf. Meares 1993). According to Bloom (1973), every writer is engaged in an ‘Oedipal’ struggle with his poetic ‘parents’, the literary tradition he inherits. When he finds his own way to voice his feelings he has broken free, incorporated his past, but extended it. Gabbard and Ogden (2009) describe a comparable struggle for psychoanalysts as they too find their own voice and in doing so, have to find a way to simultaneously honour and ‘kill’ their psychoanalytic forebears. Heaney (1980) goes on to quote his own poem:

The Diviner Downloaded by [New York University] at 12:48 14 August 2016 Cut from the green hedge a forked hazel stick That he held tight by the arms of the V: Circling the terrain, hunting the pluck Of water, nervous, but professionally Unfussed. The pluck came sharp as a sting. The rod jerked with precise convulsions Spring water suddenly broadcasting Through a green hazel its secret station.

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The bystander would ask to have a try He handed them the rod without a word It lay dead in their grasp until nonchalantly He gripped expectant wrists. The hazel stirred. (p. 48)

The diviner’s forked stick stands metaphorically for poetry – the vehicle through which feelings can be located, mediated, controlled. The technique of psychotherapy does the same job, seeking the salt water of tears in the session. In the poem there is an important formal relationship between the sought water and the sap of the stick: a ‘green hazel’ ﬁnds ‘spring water’ – poetry conjures up the feelings that it describes. A similar arrangement applies to the ‘green stick’ of transference which permeates the whole of the psychotherapeutic relationship: therapy is designed to bring back, or ‘broadcast’ buried feeling through the creation of transferential experience – but in a controlled and so modiﬁable form. Another theme that comes out in this poem is the debilitating power of the expert. The supervisor has to be careful not to induce feelings of helplessness in the student by implicitly boasting his or her own prowess. Heaney goes on:

Technique is what allows the first stirring of the mind round a word or an image or a memory to grow towards articulation . . . The crucial action is preverbal, to be able to allow the first alertness or come- hither, sensed in a blurred or incomplete way, to dilate and approach as a thought or a theme or a phrase. Robert Frost put it this way: ‘a poem begins as a lump in the throat, a homesickness, a lovesickness. It finds the thought and thought finds the words’ . . . technique is more vitally and sensitively connected with that first activity where the ‘lump in the throat’ finds ‘the thought’ than with ‘the thought’ finding ‘the words’. (Heaney 1980, p. 56. Italics added)

‘To be able to allow’

Downloaded by [New York University] at 12:48 14 August 2016 This is another version of the ‘space’ step in the sequence I have described. A mental ‘leaning off ’ is needed for the origins of a poem to be captured; a similar process is needed for patients to ﬁnd their feelings and therapists their interpretations in psychotherapy.

The ‘lump in the throat’ ﬁnds ‘the thought’ This emphasis on technique rather than craft is reminiscent of Winnicott’s (1971) dictum – we help our patients more by giving back to them what they

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have told us than we do by clever interpretations. This is the basis of Rogerian therapy and the converse of the furor therapeuticus that can afﬂict some highly theoretically sophisticated therapists.

Artistic discovery: Proust I move on now from the muscular cadences and rhythms of Heaney to the deliciously smooth prose of Marcel Proust. I make no apology for quoting from what must be one of the most famous passages of self-observation in modern literature. Proust (or his protagonist) is handed a cup of tea. In it he dips a petite Madeleine. This teacake immediately arouses in him a memory. But of what?

I put down my cup and examine my own mind. It is for it to discover the truth. But how? What an abyss of uncertainty whenever the mind feels that some part of it has strayed beyond its own borders: when it, the seeker, is at once the dark region through which it must go seeking, where all its equipment will avail it nothing. Seek? More than that, create. It is face to face with something which does not exist so far, to which it alone can give reality and substance, which it alone can bring into the light of day. (Proust 1941, p. 17. Italics added)

This would do – were it not for Proust’s slightly overblown style – for a description of the anxiety that the psychotherapy student (and the patient) may feel when ﬁrst confronted with the area of uncertainty which they have to enter: the panic which both may feel when ‘the history-taking has to stop’. Something new has to happen. But how to make it? In the following passage, Proust describes the phase of structure or concentration that delineates space into which a memory or feeling can come. The function of the therapist at this stage, by creating the setting, by facilitating remarks, is to help build that structure or container that the patient needs.

I decide to attempt to make it [the memory] reappear. I retrace my thoughts to the moment at which I drank the ﬁrst spoonful of tea. I ﬁnd

Downloaded by [New York University] at 12:48 14 August 2016 again the same state illumined by no fresh light. I compel my mind to make one further effort; . . . I clear an empty space in front of it. I place in position before my mind’s eye the still recent taste of that ﬁrst mouthful, and I ﬁnd something start within me, something that leaves its resting-place and attempts to rise, something that has been embed- ded like an anchor at a great depth; I do not know yet what it is, but I can feel it mounting slowly; I can measure the resistance, I can hear the echo of great spaces traversed. (Proust 1941, p. 18. Italics added)

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The next passage describes the moment of discovery of the memory (it reminds him of the teacake his aunt gave him as a child in the village of Combray). The hook to the past is the taste of the teacake. This, like transference, is the connection that allows the memory to surface. The transferential moment is a living experience in the session (the patient’s angry response to the therapist’s announcement of her holiday) that can provide a bridge to the signiﬁcant past (the absence of the patient’s mother). The key phrase in the passage that follows is the ‘magnetism of an identical moment’. There is a movement from concentration to relaxation and then, under the pull of this magnetism, to discovery:

Will it ultimately reach the clear surface of my consciousness, this memory, this old, dead moment which the magnetism of an identical moment has travelled so far to importune? I cannot tell now that I feel nothing, it has stopped, has perhaps gone down again into its darkness, from which who can say whether it will ever rise? Ten times over I must assay the task, must lean down over the abyss. And at such time the natural laziness which deters us from every difﬁcult enterprise, every work of importance has urged me to leave the thing alone, to drink my tea and to think merely of the worries of today and of my hopes for tomorrow, which let themselves be pondered over without effort or distress of mind. And suddenly the memory returns. (Proust 1941, p. 18. Italics added)

My final quotation is perhaps the most famous of all, and justly so. This is partly because of its sheer beauty, but also because it describes so clearly the movement from depression and ruination, through memory, to recollection and reparation that is the essence of therapy. Another aspect of this passage is its implicit sexual imagery. Proust describes a ‘vast structure’, filled with a tiny drop of ‘essence’. This may be seen as a concrete and bodily expression of the regenera- tive power of sex. Ultimately ‘the ego is first and foremost a bodily ego’ (Freud 1923, p. 17) and sexual metaphors will probably apply at some stage to the process of therapy:

When from a long-distant past nothing subsists, after the people are dead, after the things are broken and scattered, still, alone more fragile,

Downloaded by [New York University] at 12:48 14 August 2016 but with more vitality, more unsubstantial, more persistent, more faith- ful, the smell and taste of things remain poised for a long time, like souls, ready to remind us, waiting and hoping for their moment amid the ruins of all the rest; and bear unfaltering, in the tiny and almost impalpable drop of their essence, the vast structure of recollection. (Proust 1941, p. 48. Italics added)

Consider an example in which the patient taught the student – Proust- like – to think metaphorically. The patient complained that her chair was always stuck

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right in the corner of the room. One day she arrived to ﬁnd it, by accident, moved nearer to the therapist. She became very excited and began to tell him how she had always felt trapped and stuck away as a child and how angry she was that, as she saw it, her parents had not bothered to help her out of the ‘corner’ of her misery. Transference is a special form of metaphor involving the carrying over of feelings and emotions from one situation to another via ‘the magnetism of an identical moment’; these moments are often turning- points in therapy. They reveal in an inescapable way, the nature of the patient’s internal world and the distortion it imposes on their view of contemporary reality. At the same time these transferential moments bring with them the affect which, like Proust’s lost memory, may otherwise continue to haunt but elude the patient.

Conclusions I have tried to demonstrate an underlying sequence which is fundamental to successful psychotherapy and to relate it to other creative activities. A theory of the psychotherapeutic encounter itself is just as necessary as ‘formal’ psychodynamic theory. The literary parallels I have tried to draw provide some validation of a staged model and in particular of the part played by creativity in the psychotherapeutic process. I will now draw some conclusions about how this approach may inform the teaching and supervision of psychotherapy. The teacher has one overall and a number of specific tasks. The overall task of the trainer is to act first as ‘midwife’, then ‘health visitor’ and later as ‘tutor’ to the treatment: to help trainee and patient to create and sustain a living therapy with a boundary and character of its own. The trainer must be familiar with the lifecycle of a therapy on a broad scale – the phases of starting, symptom loss, transference neurosis (positive and negative), resistance, depression, reparation, illusionment–disillusionment, grief, loss and acceptance. He or she must also be aware at a micro-level of session-to-session issues of lateness, absence, silence, over- talkativeness and other details of therapeutic rhythm. Some of the more specific tasks of the trainer may be derived from the account I have given of the psychotherapeutic method. These include:

Downloaded by [New York University] at 12:48 14 August 2016 1 Helping the therapist to ﬁnd the right level at which to do therapy. Students, and patients, can tolerate very different distances from ‘the abyss’. There always has to be some confusion and anxiety, but not more than each can cope with. 2 Identifying what therapist and patient have left out. Therapy always involves a ‘raid on the inarticulate’ and the supervisor needs to point to areas which remain unspoken or are conspicuous by their absence. 3 Knowing the importance of failure. Most students (and all teachers started off as students) have had important failures when they were, to use Heaney’s

26 DISCOVERY

words, in the ‘miming’ phase of learning to do therapy. The inevitable mistakes that students make often provide rich opportunity for understanding more about themselves and their patients. 4 Knowing how to create conditions in which something can happen; knowing when to concentrate with firm limit- setting and probing questions, and when to back off and so create an ‘empty space’. The rhythm and tact of this balance constitute the true art of therapy. The supervisor has to be able to help the over-controlling student who is all concentration and no space at one extreme, and at the other, the trainee who is all space and letting things happen and so is overrun by the patient. The supervision session often creates a ‘second-order transference’ or parallel process between trainer and trainee, which reflects this clinical relationship between student and patient. 5 Helping the student to recognise and voice transferential experience when it occurs. This is perhaps the most important and the most difficult skill to impart. Students have to learn to recognise the metaphorical nature of the material their patients bring, alongside its actuality, and to see understanding metaphor as one of the prime purposes of their craft. 6 To find a shared language with which to reflect on and describe what is happening.

It is hardly necessary to add that these six ways where the teacher can help the trainee parallel those in which, with luck, dynamic therapy may help the patient. Downloaded by [New York University] at 12:48 14 August 2016

27 3 NON- DISCURSIVENESS Robert Lowell

Let’s start with an everyday clinical example.

The patient is a farmer. He’s late for his session. He apologises, saying that someone had forgotten to shut the gate into a ﬁeld, his horse had escaped into the lane, and couldn’t be left alone until the adventurous equine had been corralled back into its rightful place. All very straightforward and clear – and a seemingly good reason for tardiness. And yet . . . there was something else. In the previous session the patient had, very uncharacteristically, abandoned his habitual stiff upper lip and cried copiously when describing a painful bereavement. Was the horse- story, realistic as it was, perhaps also the patient’s way of communicat- ing to the therapist (and himself ) something about the dangers of opening the ﬂood- gates, and his wish once more to bottle up feelings, to be ‘left alone’ with them in the missing ten minutes of the session.

So there are two stories here: one, in Langer’s (1951) terms, ‘discursive’, factual sequential, everyday; the other ‘non- discursive’: affect- related, tangential, symbolic, ramifying, ‘left-fi eld’ (and also given to puns – here we have a story about a horse that had left its field). The therapist’s efforts to address the second layer to his story led to the charge that the therapist was ‘mad’ – adding yet another narrative twist concerning this man’s fear of his own ‘madness’; but that is yet another story. According to Rycroft (1985, p. 103), whose influence is to be felt in more

Downloaded by [New York University] at 12:48 14 August 2016 ways than one throughout this book, Freud set himself the impossible task of conﬂating discursive and non- discursive discourse, with resulting muddle that continues to this day:

. . . much of Freud’s work was really semantic . . . he made a revolutionary discovery in semantics, viz. that neurotic symptoms are meaningful disguised communications, but . . . owing to his scientiﬁc training and allegiances, he formulated his ﬁndings in the conceptual framework of the physical sciences.

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The aim of this chapter is to correlate poetry and psychoanalysis as non- discursive disciplines. Its context is the above view – one that Freud started with and to which he eventually returned (Barratt 2012; Bettleheim 1982) – that psychoanalysis, whatever its scientiﬁc aspirations, is fundamentally a linguistic or interpretive discipline, concerned with meaning rather than mechanism (cf. Hoffman 2009). I shall concentrate on three aspects of presentational symbolism: metaphor, ambiguity and wholeness. My starting point is a poem by the American poet Robert Lowell (1959) describing his stay as a patient in a mental hospital near Boston University (B.U.). One verse has been omitted.

Waking in the Blue The night attendant, a B.U. sophomore, rouses from the mare’s nest of his drowsy head propped on The Meaning of Meaning. He catwalks down our corridor. Azure day makes my agonized blue window bleaker. Crows maunder on the petrified fairway. Absence! My heart grows tense as though a harpoon were sparring for the kill. (This is the house for the ‘mentally ill’.) What use is my sense of humour? I grin at ‘Stanley’, now sunk in his sixties, once a Harvard all-American fullback, (if such were possible!) still hoarding the build of a boy in his twenties, as he soaks, a ramrod with the muscle of a seal in his long tub, vaguely urinous from the Victorian plumbing. A kingly granite profile in a crimson golf-cap, worn all day, all night, he thinks only of his figure, of slimming on sherbet and ginger ale –

Downloaded by [New York University] at 12:48 14 August 2016 more cut off from words than a seal . . . These victorious ﬁgures of bravado ossiﬁed young After a hearty New England breakfast, I weigh two hundred pounds this morning. Cock of the walk, I strut in my turtle-necked French sailor’s jersey before the metal shaving mirrors, and see the shaky future grow familiar in the pinched, indigenous faces

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of these thoroughbred mental cases twice my age and half my weight. We are all old-timers, each of us holds a locked razor.

Responding to the poem Unconventional in form, conversational in tone, confessional in content, we are almost in the realms of free association in a psychotherapeutic session. We have to remind ourselves that what it depicts are also fictions, imaginary constructions. What distinguishes it from a factual description of life in a hospital ward? If we approach the poem as a discursive statement it tells us little that we did not know already, certainly less than we would learn, say, from the descriptions of life in the now obsolete mental hospitals that used to be the mainstay of psychiatric treatment in the US and UK. Similarly, if we approach psychotherapeutic sessions as discursive statements they might seem to be no more than interminable accounts of well- known neurotic symptoms. The task, rather, in approaching the poem is to find and respond to its meaning in non- discursive mode. The reader must enter a state similar to that required in ‘listening with the third ear’ (Reik 1948) to a psychotherapeutic session: free-fl oating attention, a state of active receptiveness or negative capability, in which a meaning can emerge – evoked by, but distinct from the surface, or factual meaning. In the poem, an artefact, each image is chosen to evoke these deeper meanings and is the end- result of a deliberate selection by the poet from his own consciousness. In the psychotherapeutic session the therapist and patient together have to learn to select out the significant thoughts, images and feelings, and separate them from the less meaningful. Let’s now pick out five images from the poem for discussion. The first, coming in the second line, is the B.U. sophomore’s ‘mare’s nest of his drowsy head’. This sounds at first like a simple descriptive metaphor based on the hair/ mare chime in which the student’s head is compared with a horse’s, conjuring up a young man’s long mane. Then we realise that there is no horse, that a mare’s nest means something purely imaginary, a nest for a mythical beast like a unicorn. So we are led from the thought ‘boy’s head’– ‘horse’s head’ into his head where we find his dreams (night-mares) which are, like a mare’s nest,

Downloaded by [New York University] at 12:48 14 August 2016 impossible and wonderful. This then becomes a metaphor for the setting of the poem – a madhouse – perhaps also for the poem itself, for the Meaning of its Meaning (one of whose authors, I. A. Richards, was a literary critic who had once planned to be a psychoanalyst, Richards and Ogden 1923/1989). The image ‘mare’s nest of his drowsy head’ becomes a hook which, by imposing the ﬁeld- force of metaphor, can draw out a string of associations, just as a strong magnet will hold up a chain of iron ﬁlings. This process is clearly similar to Freud’s suggested method for the analysis of unconscious material in psychotherapeutic sessions in which one ‘association’ leads onto another.

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Next we come to the image of Stanley as a seal. We have already been prepared to think about cetaceans when Lowell turns his heart near the start into a harpoon, and the idea recurs in the unquoted stanza in which an inmate is described as being ‘redolent and roly- poly as a sperm whale’. There is another faint reference to amphibiousness when, towards the end, the poet talks of his ‘turtle-necked French sailor’s jersey’. The jump from silent-man-in- the-tub to seal, or perhaps seal-in-zoo, is not far. From there we are taken to thoughts of the hospital as an aquarium (‘in the blue’) in which rare beasts are kept, to the idea of the inmates as prey that can be harpooned, and again to the poem itself, which becomes a spear with which painful, ‘agonized’, feelings can be lanced. Lowell’s seal man – like Ted Hughes’ animal folk and even Freud’s ‘Rat- Man’ – is a modern example of the search for animal parallels with man, for correspondence between the natural and the human order. Aesop’s animals – or the astrological bestiary – are men-in-beasts, emblems on to which speciﬁc human moral qualities have been projected: the cunning fox, the proud ambitious frog, the delicate stork. These contemporary poets explore the contrary theme of beast-in-man. Pre-modern man, searching for control of the natural world, endows it with human qualities. Modern man, knowing more of seals than souls, searches for truth in the natural order that might illuminate his own uncertainties. Psychoanalysis is not just about meanings, but about biological and bodily informed meanings (cf. Barratt 2012). This takes us on to the next metaphor, contained in the line ‘makes my agonized blue window bleaker’. Here the poet links the azure (heavenly blue) of the sky with that of his own eyes (agon- eyes), contrasting its brilliance with his dejection. This use of the body and its sensations as a reference point is, like animal parallels, a recurrent poetic theme. George Herbert (1991), 400 years before Lowell, similarly linked the heavenly bodies and his own:

Man is all symmetry Full of proportions, one limb to another, And all to all the world besides: Each part may call the furthest, brother: For head with foot hath private amity, And both with moons and tides.

Downloaded by [New York University] at 12:48 14 August 2016 (p. 91)

Ella Sharpe (1940) describes how the apparently abstract remarks made by patients in therapeutic sessions can often be linked to specific bodily experience which may have occurred in childhood. The patient who says he has ‘wandered off the point’ may be referring to feeding difficulties as an infant; the person who is always ‘messing things up’ may be talking about problems of sphincter control. Similarly, the man who is on the ‘fringe of things’ may have difficulties with penetration, and the woman who is preoccupied with her ‘depression’ may

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be speaking of the female genitals. This unconscious metaphor-making is not so far removed from the medieval poet who speaks of his ‘gentle cock’, ‘which every night it percheth him/In my lady’s chamber’ (Gardner 1957, p. 183). A fourth group of images in the poem cluster around the words ‘petrified’, ‘granite’, ‘ossified’. Petrify and ossify are obvious plays on words. An ‘azure day’ is brilliant and jewel-like, but hard as lapis lazuli. These images evoke thoughts of the inmates as fossils: solidified, turned to stone, set. This convergence of images on a central point or meaning is analogous to Freud’s concept of over-determination. Cavell’s ‘meaning wholism’ (2002; see Preface) suggests a model in which a central thought or fantasy – in the poem the idea of fossilisa- tion of specimens within a museum – organises around itself a cluster of words and images at varying distances from the core. From fossils and hardening we are led inevitably to thoughts of death. This is evoked dimly by ‘azure’ which takes us heavenward, and by the dark crows on the fairway, which might symbolise death. Stanley’s obsession with his figure reflects a whole cultural attitude towards ageing and a desperate attempt to deny it through slimming; the men are mummified in their passive resistance to growing old. This leads on to the final metaphor ‘each of us holds a locked razor’. This image of frozen violence reverberates back through the poem, from the blunt edges of the metal shaving mirror to the blue windows of the start. What began as a personal image, ‘my heart is sparring for the kill’, has become a general metaphor for the human predicament; and the idea of the hospital as a more general metaphor for a sick society. Lowell’s private pain, generalised in this way, can be shared and so lessened.

Metaphor and transference Transference is central to psychoanalysis, and distinguishes it from other ‘talking cures’ such as counselling or cognitive behavioural therapy. The idea of transference is based on the idea that the patient re-experiences in vitro with the therapist the unconscious assumptions, emotions and desires that underlie his general behaviour and which ultimately derive from his childhood. Once made conscious, these can be understood, modiﬁed, transcended. The basis of transference is ﬁnding similarities, analogies and parallels between the therapist–patient relationship and these earlier situations. The impersonal context of analysis aims to

Downloaded by [New York University] at 12:48 14 August 2016 maximise the visibility of such patterns and structures. The task of the therapist is pattern-recognition. In this, his own reactions are vital: he has to enter a transferential mode in which he reads the patient’s unconscious responses to treatment as a metaphor for earlier and outer reactions. The process is very similar to the movement that occurs in reading a poem, in moving by metaphor from its outer surface to the deeper meaning. Transference and metaphor share etymological roots (Pedder 2010). Meta- phor comes from Greek and transference from Latin but the sense is identical: meta/trans/across – phor/fereo/to carry: both signify to ‘carry across’. Metaphor

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carries across or links apparent dissimilarities: fact and fantasy, inner and outer, personal and public. It contains what Paul Ricoeur (1970) calls a ‘split reference’ to truth and fiction, like the Majorcan storytellers who preface their tales by saying ‘it was and it was not’. Transference may be thought of as a special type of metaphor in which early childhood feelings are carried across into the relationship with the therapist. Like the poetic metaphor, the transference relationship is both a fact and a fiction, both is what it seems and is not. The therapist is mother, lover, persecutor – and a professional trying to understand and help. Crows on the petrified fairway are symbols of fear and death – and dark birds on a frozen golf course. From this perspective we can see why it is that the underlying parental relationships revealed through transference are not literally true. One patient, for instance, stated that he had at times feared it would be impossible to end therapy without the death of the therapist or himself. This related to an intense ambivalent relationship with his father. While it was probably true that he had hated his father and wished him dead many times as a child, it was also untrue in that he had never lifted a finger to hurt him, and in fact loved him deeply. To say that he wished to kill his father was as true and untrue as to say that each of us carries a locked razor. This point is well made by Laplanche and Pontalis (1980, p. 173):

When Freud speaks of the transference repetition of past experiences, of attitudes towards parents etc., this repetition should not be understood in the literal sense that restricts such actualisation to really lived relationships. For one thing, what is transferred, essentially, is psychic(al) reality – that is to say, at the deepest level, unconscious wishes and the phantasies associated with them. And further, manifestations of transference are not verbatim repetitions but rather symbolic equivalents of what is being transferred.

The ‘psychic reality’ revealed in transference takes the form of an image that arises in the mind of therapist or patient. This has to be agreed on by both – it has to feel ‘right’ or ‘true’. It is a shared reality that is neither entirely private to the patient, nor is it a general feeling that would be applicable to any other person or moment. What is experienced in the transference is not an ‘Oedipus complex’, say, but a speciﬁc feeling: for instance, a fear or wish that either the

Downloaded by [New York University] at 12:48 14 August 2016 therapist or the patient might die. Although the image may feel as though it was ‘out there’ waiting to be found, rather as some poets have described ‘discovering’ their poems, their job being simply to write them down, in fact it is called into being by the relationship between patient and therapist – a ‘third’ (Ogden 1997). This is also perhaps what Bion (1962, p. 5) was referring to when he said that ‘psychoanalysis is that primitive type of communication that requires the presence of the object’. A similar process is at work in creating ‘poetic reality’. We may summarise Lowell’s poem by saying that each of us has the potential for murder or suicide,

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but it is in the image of the locked razor that this thought comes alive and becomes the basis of a shared meaning. Every reader will make something slightly different of this, each contributing to a common pool of personal meanings. The metaphor, standing transitionally (Winnicott 1971) between the entirely unspoken private thought and the generalisation, is poetic and analytic truth. Eliot (1975, p. 9), mixing his metaphors, compared the result of this metaphorical process to an alloy produced by the poetic enzyme, a sea- change that ‘transmutes personal and private agonies into something rich and strange, something universal and impersonal’. A consequence of this viewpoint is that analytic theory becomes not so much a body of objective knowledge as a set of rules and guidelines – heuristics – for interpreting transferential metaphors. Theory and therapy are intimately linked – theory is a language for describing the experience of therapy. Musical theory or poetic criticism have a similar relationship to their arts. Innovations in analytic theory – in understanding narcissistic disorders, for example (Kohut 1984) – are similar to innovations in musical or poetic form: a new language is created which enables new territory to be explored. Rycroft (1968) sees symbol formation as a general psychological function. The capacity to respond to poetry – and comprehend transference – depends on the development of ‘imaginative competence’ (Holmes 1997). This faculty evolves in the course of childhood, starting with the linguistic and imaginative freedom of the toddler and young child in which fantasy and reality are still intermingled, and continuing into adolescence with the development of the autonomous imagination, and an increasing sense of the challenges and limitations of ‘reality’. In describing this process Trilling (1950, p. 98) quotes the eighteenth-century philosopher Vico:

Poetry is the primary activity of the human mind. Man, before he arrived at the stage of forming universals, forms imaginary ideas . . . before he can articulate, he sings: before speaking in prose, he speaks in verse; before using technical terms he uses metaphors, and the metaphorical use of words is as natural to him as that which we call ‘natural’.

Downloaded by [New York University] at 12:48 14 August 2016 Trilling goes on to suggest that ‘psychoanalysis is a science of metaphor . . . it makes poetry indigenous to the very constitution of the mind. Indeed, as Freud sees it, the mind is in the greater part of its tendency exactly a poetry- making organ.’ These themes can now be illustrated by some clinical examples.

As a workday instance we may take a patient – a young woman who had been in therapy for some time following repeated self-mutilating episodes – who began a session by commenting in a rather attacking

34 NON-DISCURSIVENESS

way that there were never any personal papers on the therapist’s desk and wondering if any other doctors used the room. This remark could have had a number of meanings: a complaint that the therapist himself was too impersonal, or a disparaging wish to switch therapists. However, it soon became clear that the true signiﬁcance of this was the feeling that material discussed in the sessions was ‘cleared away’ each week, and that the patient was complaining that her sessions were not frequent enough. This emerged when she said how she often felt depressed in the middle of the week but the therapist was not there, and the feeling had passed by the time the session came round. This then linked with her present sadness at being separated from her father who lived abroad, and with the feelings of anger that he never really listened to what she said when they did meet. This then connected with memories of blankness she had experienced during long separations from her parents as a child when they went away on business trips.

The initial transferential percept was the empty desk. This then became a linking metaphor which gathered in feelings at a number of different levels: anger and sadness towards her father; childhood memories of separation and depression; her feeling of getting short shrift from her therapist. In the Lowell poem the slow pace and sparse diction evoke the poet’s desola- tion and separation from life. In the same way the tone and manner in which the patient brings material provides a metaphorical key with which patient and therapist may unlock the past.

An example comes from a patient, one of whose presenting symptoms included a conﬂict over homosexuality. After he had been in treatment for some time it became apparent that, although bringing plenty of ‘interesting’ information, particularly dreams, he was in some way controlling the sessions, simultaneously holding back and offering his ‘material’ as though to excite and stimulate the therapist. Knowing that the patient had at times as a lonely adolescent had sexual encounters with older men in which he felt special and powerful, the interpretation was offered that therapy had become a kind of psychic fellatio to which he had been driven by fear and loneliness just as he had been in his

Downloaded by [New York University] at 12:48 14 August 2016 teens. In the next session he said how shocked he had been by this comment which he had visualised literally. He then linked this to feelings of exclusion he had experienced when he saw his parents kissing and holding hands as a child, and his envy of his mother for her passive power over his father whom he wanted all to himself. The discovery in his teens of the power of his penis to attract men had then given him a feeling of triumphant retaliation for this exclusion which he had reproduced with his therapist, and in which he was unconsciously identiﬁed

35 THE POETICS OF PSYCHOTHERAPY

with his mother. In this sequence he had moved from personal distress and intense shame and controlling dependence on the therapist, to a universal biological experience – of being a helpless child, feeling excluded and envious, of wanting to be loved. His distress, in Eliot’s word, had become impersonal. After this there came an interesting shift in his attitude towards his mother. Near the beginning of treatment he had described a dream which, he said, summed up their relationship. He was standing by the door of his house trying to leave, but he could not because she was holding his testicles. She had him by the balls. After this sequence he went back to the dream, but now its metaphorical signiﬁcance had changed: he felt that she was cradling him in a gentle, protective way. He was then able to admit a similar change had occurred in his attitude towards therapy.

A change of perspective like this is an essential part of the psychotherapeutic process. As treatment progresses a patient’s metaphors change level or deepen, giving a richer and more varied set of possible responses, resonances and relationships. The first patient had a dream that expressed this neatly. She dreamed that she was flying in an aeroplane that was likely to crash. Suddenly she found she was in another plane flying higher up and so more safely. She had moved on to a ‘higher plane’. The process could be seen as an increase in an individual’s inner valency, offering a greater range of options for connection and combination. Bion’s (1962) concept of ‘attack on linking’ reflects the reverse of this, whereby an individual diminishes his valency, as a defensive and retaliatory manoeuvre. Powered by metaphor, psychotherapy oscillates between here- and-now experience with the therapist to childhood and back. First, the transference metaphorically ‘stands for’ a childhood feeling or relational constellation. In the case above, the patient simultaneously excited and frustrated the therapist – this is what he did to his homosexual partners in his teens and what he imagined his mother doing to his father as a child. Behind this are his feelings of exclusion and loneliness, and the rage and wish for revenge that they evoke in him. But once they are ‘metaphorised’ – ‘represented’, mentalised, turned into language – they are now accessible for re- working. As a child he had felt trapped by his mother just as he later did by therapy; now he feels protected. A defective

Downloaded by [New York University] at 12:48 14 August 2016 reality has imprinted itself on the developing child. This creates an inner template of fantasy by which reality is experienced and controlled, both a means of survival and a distorting inﬂuence. In adulthood this template then actively reproduces the kind of relationships and situations from which it had been pas- sively moulded in childhood. Once the patient can turn this passivity into agency, he is in a position to change – to re- think and live with rather than be lived by the past. Therapy involves re-awakening and personalising an individual’s dead metaphors, the unconscious assumptions by which he lives. These reveal themselves all

36 NON-DISCURSIVENESS

of the time, but especially in symptoms, actings out, innuendo, puns, plays on words, dreams and transference. Psychoanalysis provides a set of rules for decod- ing these metaphors. Sometimes psychoanalytic imagery, if used insensitively, remains lifeless, a set of fossilised clichés – ‘the bad breast’, ‘the Oedipal situation’ – an overworked shorthand that has become a dead end. This may also happen in poetry when conventional poetic images – sun, moon, rain, flowers, etc. – fail to come alive. In art, aesthetics attempts to evaluate and define artistic truth, to separate the good from the bad and the lifeless. A similar aesthetic is needed in psychotherapy. Therapist and patient may have a strong sense that a particular interpretation is right; this is usually defined intuitively. When an interpretation ‘clicks’ or ‘works’ the feeling is often described as a physical sensation of ‘rightness’ or of illumination, rather as A. E. Housman’s test of good poetry was whether it gave him a tingling sensation at the back of his neck (Dirda 2011, p. 20).

Ambiguity The ambiguity inherent in some psychoanalytic concepts has been seized on by many of its critics (Medawar 1975). An example is the notion of reaction formation, which holds that any strongly felt psychological attitude may conceal its repressed opposite. The Casanova as a repressed homosexual, the paciﬁst as a potential murderer and so on. The over-enthusiastic use of this sort of reasoning may occasionally lead to absurdity, or to the closed thinking of which Popper and his followers have been so critical. But psychoanalysis is touching here to a fundamental aspect of human thought (cf. Holmes and Lindley 1997). Ambiguity and paradox also seem to be near the heart of poetic languages. Poetic epigrams, such as ‘the Child is Father of the Man’ (Wordsworth 1994), ‘Damn braces. Bless relaxes’ (Blake 1977, p. 45), or ‘I was angry with my friend/I told my wrath, my wrath did end./I was angry with my foe;/I told it not, my wrath did grow’ (ibid. p. 67), make the leap from literature to psychology without difﬁculty. An early champion of the virtues and varieties of ambiguity in literature has come from William Empson (1930/2008, p. 3) who claims that ‘the machina- tions of ambiguity are among the very roots of poetry’. A central notion is that of the coexistence of opposites. This may apply at the level of a single word: for example the Latin word altus which can mean both high and deep. Freud used

Downloaded by [New York University] at 12:48 14 August 2016 this point to illustrate his contention that in the unconscious there are no negat- ives, and that at the level of the unconscious opposites are not incompatible, any more than they were for Catullus when he wrote ‘Odi et amo’. Empson extends this by showing that poetic language itself has ambiguity built into it. This is true even at the level of adjectives and adverbs, since each qualiﬁcation of a noun or verb can imply the opposite of that qualiﬁcation. Thus we commonly suspect that the patient who is very sorry that he is late may in reality be far from sorry. Empson (1930/2008) ingeniously shows how a negative may imply the very thing that it denies. In Pope’s couplet:

37 THE POETICS OF PSYCHOTHERAPY

Expatiate free o’er all this scene of man; A mighty maze! but not without a plan. (1976, p. 39)

We are compelled by the grammar to consider the possibility that there just might not be a plan – why else mention that there is one, and then use the convo- luted double negative? It comes as little surprise to learn that an earlier version had read

A mighty maze, and all without a plan.

Similarly Keats’

No, no: go not to Lethe . . .

takes us – like the much-clichéd ‘elephant in the room’ – straight there (1973, p. 348). The concept of an ‘earlier version’ could be seen as a linguistic expression for the activity of the unconscious. The ambiguousness of language alerts us to the unconscious meanings that slip through the bars of logical thought. In trying to reconstruct what may lie behind a dream or phantasy, or slip of the tongue we are always searching for the ‘earlier version’, the poetry that escapes with the prose. One aspect of this is the ambiguity created by the fact that words have music as well as meaning, sonority as well as sense. Psychoanalysis, like poetry, is a spoken language. Assonance or dissonance, the play between sound and meaning, are crucial elements in poetry. In Waking in the Blue, Lowell uses ‘ow’ and long ‘o’ sounds throughout – drowsy, sophomore, bravado, pound, old, razor – creating an atmosphere of timelessness evocative of mental-hospital wards. In psychotherapy and psychoanalysis the patient’s tone of voice – angry, self- pitying, childish – often provides vital information. Bateson’s famous ‘double bind’ hypothesis (Bateson 1972) was based on the discrepancies that can exist between the content of a message and the tone in which it is delivered. Ambiguity in language is normally avoided by context, which is indicated by grammar and sense. Psychoanalysis sees a symptom as inherently ambiguous, a

Downloaded by [New York University] at 12:48 14 August 2016 necessary compromise between inner need and outer constraint. The aim of therapy is to ﬁnd a context – usually a childhood context – in which the symptom makes sense, and so loses its ambiguity. The use of paradox in family therapy is another example in which there is a search for a different context for the unwanted problem. Once found, this becomes the symptom’s ‘positive connotation’ (Palaz- zoli 1978): for example, an adolescent’s delinquent behaviour may be seen as an attempt to bring warring parents together through worry. Similar shifts of context – sea-changes – occur in psychoanalysis so that ‘weakness’ may come to be seen as healthy vulnerability, ‘failure’ as a necessary rebellion and so on.

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An important aspect of ambiguity in psychotherapy is the idea of reconciliation of opposites, or integration, to use a Jungian term. Implicit in Freud’s writing are the notions of reconciliation, compromise and sublimation. They are there in his image of the horse and rider as a model for the healthy relationship between unconscious and conscious, and his ironic prescription of the replace- ment of neurotic misery with ‘ordinary human suffering’ as the aim of treatment. The impulse to reconciliation is also implicit in Lowell’s poem title which balances an ambiguity in the meanings of the word blue: blue in the sense of depressed, and blue in the sense of constant (true blue), the blue of the sky and the ‘azure day’.

Wholeness The idea of the harmonious resolution of ambiguity leads on to a third important characteristic of aesthetic languages, one that is intrinsic to Freud’s description of the primary processes. This is the quality of wholeness or Gestalt. A poem or a piece of music or even a picture may have a narrative drive that is more or less important, but we also require that it should exhibit coherence, be a whole, in the sense that every part fits with every other part. There are several characteristics of this quality of coherence. First, each part of the whole points to and in some way ‘contains’ every other part. We can usually identify the whole of a symphony or poem from a single phrase, just as we ‘know’, from the first word uttered by a familiar voice on the telephone, who is speaking and what their emotional state is likely to be. This quality is related to ‘style’ or ‘tone’ and is distinct from content. This can be compared with the holograph, a laser- generated image in which each part contains in reduced detail the information present in the picture as a whole. A second quality associated with wholeness is timelessness. A picture has no particular ‘direction’ and is thus extra-temporal in that it does not insist on being ‘read’ in any order. The same is partially true of a poem in that the ending is informed by the beginning, but the opening of the poem is also reflexively influenced by what is to come. A third and perhaps paradoxical feature of wholeness derives from Matte- Blanco’s (1975) description of the unconscious as its being a series of ‘infinite sets’: that is, there is no end to the elements that the wholeness encircles. In the interpretation of a poem – or a person in therapy – there are a

Downloaded by [New York University] at 12:48 14 August 2016 number of meanings and interpretations that apply, each of which may have its own level, and none of which need be incompatible. Between the surface of a work and its deep meaning there is an inﬁnite series of layers. These three features – interconnectedness, timelessness and limitlessness – are all also ingredients in psychotherapy. A patient mentioned once remarked that ‘psychotherapy is based on sound ecological principles – everything is recycled, nothing wasted’. He was referring here to the principle that the therapist is primarily interested in pattern and process, rather than goals. He is, or should be, concerned with every aspect of the process that is created between

39 THE POETICS OF PSYCHOTHERAPY

himself and the patient, whether the patient is a little late or a little early, whether he initiates the end of the session or leaves it to the therapist, the manner and tone in which the story is told. The patient may naïvely expect the truth to be found in the distant past, in the content of his story; but the context and manner of its telling are equally revealing. They tell what the patient has made of what he is made of. It is sometimes said that the whole of treatment is ‘contained’ in the first session, and the theme of a particular session is often to be found in the patient’s opening remarks or initial expression (cf. Holmes 2012b). Much of the art of therapy consists in finding the connections between apparently unconnected elements within a session, of finding a single thread or nuclear theme, a fantasy or affect that summarises the hologram. An example of this would be the notion of the primal scene which reflects an individual’s fundamental view of the male– female relationship expressed in bodily sexual terms. From this basic equation a whole series of subsidiary relations can be deduced: the person’s attitude towards his own body, that of the opposite sex and so on. This can be compared with Chomsky’s concept of a ‘deep structure’ to language from which, by transformational grammar, a potentially infinite series of sentences can be generated (2008, p. 39). Patients frequently express surprise at a therapist’s capacity to remember details of past material, but this too is a consequence of the holographic organising principle by which apparently disconnected elements are understood and so remembered. The idea of timelessness is well- established in psychotherapy, most notably in dream- interpretation, in which the elements of the dream may be read in any order, whatever the narrative flow of the dream itself. A consequence of this feature of aesthetic language is that it adopts a different approach to causality than that demanded by logical sequencing. It is not that childhood traumata cause adult neuroses, but rather that both are connected in a psychological circuit or mental structure. In psychoanalytic shorthand this circuit would be described in terms of a particular fantasy. This links also with the concept of over-determination. One senses that Freud was never entirely happy with his observations that many factors and fantasies underlie a particular symptom or element in a dream. His rational scientific training taught him that one event should have one unambiguous cause. The concept of over-determination is a rather uneasy attempt to retain the idea of unitary cau-

Downloaded by [New York University] at 12:48 14 August 2016 sation by postulating a single higher cause – overdetermination – that embraces the observation of multiple causation. The idea of wholeness on the other hand suggests that multiple and non- incompatible relationships are an inherent prop- erty of the poetic and psychotherapeutic modes. If poetic and psychotherapeutic truth is inherently inﬁnite this is not, however, a justiﬁcation for the seeming endlessness of some analyses. There is no clear relationship between the number, frequency and duration of psychotherapeutic treatments and the eventual result. Perhaps we should echo Baudelaire and admit that analyses, like poems, are never completed, only abandoned.

40 NON-DISCURSIVENESS

A ﬁnal aspect of the wholeness of aesthetic language comes from the etymological link between wholeness and healing. The explicit goal of psychotherapy is to heal troubled minds. A healing function is also implicit in poetic activity. This is how W. H. Auden (1963, p. 61) formulated one of what he called the ‘dogmas of his art’:

Every beautiful poem represents an analogy to the forgiveness of sins; an analogy not an imitation, because it is not evil intentions which are repented of and pardoned but contradictory feelings which the poet sur- renders to the poem in which they are reconciled.

The wholeness of the poem heals. Psychotherapeutic treatment also involves the surrender of the patient to the treatment in the hope that contradictory feelings – love and hate, aggression and guilt, the desire for independence and the need for relationship – will be reconciled. As Marcus (1974) puts it, the patient tells, at the outset, an incomplete story, which, by the end of treatment, has changed:

because the narrative account has been rendered in language, in conscious speech, and no longer exists in the deformed language of symptoms, the untranslated speech of the body. At the end, at the successful end, one has come into possession of one’s own story. It is a ﬁnal act of self- appropriation, the appropriation by oneself of one’s own history. (p. 73)

Conclusion The aim of this chapter has been to look for points of similarity between poetic and psychotherapeutic activity. The fact that it is possible to make such a comparison at all has been used by some to argue that psychoanalysis is an ‘art’ rather than a science and so, in our science- based culture, to question its status and validity. This led to a defensive and rather sterile approach to psychotherapeutic research, a preoccupation with ‘outcome’ and a neglect of process. A broader view of the mind and imagination points to fundamental psychological mechanisms: an approach that embraces both poetry and psychoanalysis may reveal fundamental ways of thinking that any general psychology would also need to take into account. Downloaded by [New York University] at 12:48 14 August 2016 An evolutionary account suggests that humans – along with their higher primate cousins – need to be highly skilful in social interaction for individual and group survival. The evolution of imagination has enabled members of the group to understand one another’s feelings, and so to fulﬁl the essential cooperative functions of nurturing, reproduction and security. Hazlitt anticipated this when he emphasised the importance of the ‘sympathetic imagination’ – or, as we might now dub it, ‘mentalising’ (Holmes 2010) – quoting Cleopatra: ‘He’s speaking now, or murmuring “where’s my serpent of old Nile?” ’ as an example

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of imagination’s myriad mirrorings as Shakespeare imagines Cleopatra imagining Anthony imagining her. A poem is a specialised device for the communication of imaginative feeling. As Auden (1963) said, poetry provides no programme for action; it offers a deliberate escape from the adult necessities of action and decision. Bronowski (1978, p. 25) echoed this when he said that a poem is so arranged that ‘it posi- tively discourages you from deciding which of its imaginary actions (which of its possible meanings) you like best and should follow’. In this sense poetry enriches, but does not guide. Psychoanalysis – in contrast to other therapies – works in a similar way. No action is suggested or encouraged. The therapist remains involved, but eschews advice or practical intervention. In this will-less atmosphere of neutrality and deliberate unreality the imagination can ﬂourish. The patient can experience his own and others’ feelings – especially those that are central to his ‘biological destiny’ (Rycroft 1985). This in turn may lead him to act in more coherent and integrated ways, enhancing adaptation and group survival. Downloaded by [New York University] at 12:48 14 August 2016

42 4 REPAIR Hugo Williams

In an attempt to establish strengths as well as pathology, my routine history- taking includes asking patients what they are interested in, and what their idea of an enjoyable activity might be (note that the use of the conditional is already a step into the ‘active imagination’ brought alive by both therapy and poetry). Rarely, if ever, does poetry come as the answer. Poetry is deﬁnitely a minority interest. Nevertheless, at times of emotional intensity, whether painful or joyful, people turn to poetry, trite or great, as a means of containing and expressing their feelings. Since those moments are central to what we do as psychotherapists, if we wish to enhance the depth and quality of our work, it is perhaps worth listening to what poets have to tell us. In this chapter, once again through the vehicle of a particular poem, I explore the common ground between poetry and psychotherapy. Based on this, I also look at the Kleinian concept of reparation (Segal 1991) from an attachment perspective. Poetry and psychotherapy are strange, yet compatible, bedfellows. Both regularly arouse suspicion and incomprehension, yet people often turn to them when in states of heightened emotion – love, elation, despair, confusion, loss and bereavement. As I have suggested, both could be seen as means with which to enhance the capacity for mentalising: the capacity to ‘think about feelings’ or to be ‘mind- minded’ (Meins et al. 2001). Finding the right words in the right order (Coleridge’s famous deﬁnition of poetry) is a crucial skill for therapists (and their patients) as well as poets, since the appropriate image or metaphor can mirror or evoke feelings in the listener in a way that facilitates empathic attunement. If sorrow can be given

Downloaded by [New York University] at 12:48 14 August 2016 words, feelings shared and objectiﬁed, their power to distress or overwhelm is mitigated. Poetry and psychotherapy are both concerned with repair of the endlessly rent human experiential and communicative fabric. We can never have direct access to another’s feelings. Metaphors can be seen as probes by which we reach into another’s inner world. We ask: ‘what did it feel like when your mother died; your partner abandoned you; you wanted to kill yourself . . .?’. Matte-Blanco (1975), working with an analogous dichotomy to Langer (see Chapter 3), translates Freud’s (1911) ‘two principles of mental functioning’ – the one logical, classifying, verbal, the other emotive, image-based, in which

43 THE POETICS OF PSYCHOTHERAPY

contradictions can be tolerated – into what he calls asymmetrical and symmetrical thinking. The mind, exploring, understanding, classifying and manipulating its environment, is constantly comparing one thing with another, symmetrising (‘my wife is just like my mother’) and asymmetrising (‘my wife is the very opposite of my mother’). Metaphor is a symmetrising device: it shows how everything is like something else. When a patient uses metaphor or simile to describe his depression – ‘it’s like being in a dark room and not being able to find the way out’ – a window is opened (to use a reverse metaphor) into his inner world. We begin to put ourselves in his place, to see what it might be like to be him. Poetic metaphors are of course just one among many. There are psychotherapeutic lessons to be learned from a life drawing class, in which a combination of empathic identification with the body to be depicted and objective appraisal of its lineaments is required. If your passion is golf, teeing up, getting lost in the rough, holing in one etc., or, for farmers, losing and finding an errant horse, will serve to outline the ups and downs of a typical psychotherapeutic day. But since metaphor is central both to poetry and psychotherapy – finding the right words in the right order to communicate an affective experience – poetry may have a special contribution to make to psychotherapeutic work (cf. Ogden 1999).

Poetic and psychotherapeutic parallels Let us go straight to a specific poem and see how unravelling its meaning and mechanics may help illuminate what psychotherapists get up to. I have chosen Dinner with my Mother by the contemporary British writer, Hugo Williams (1994). Biographical information on the author would no doubt help illuminate aspects of the poem, but the reader is invited to consider the poem as a self- sufficient ‘subjective- object’, just as it is sometimes desirable to respond to an account of a psychotherapy session as an ‘unseen translation’ in its own right without the obscuring impact of excessive life- history data (Padel, personal communication 1975). Like a case history, my hope is that the poem provides qualitative evidence of the power and relevance of poetry. I have chosen it (or did it choose me?), from a possible infinite number of examples, because it is accessible, short, ‘good’ (i.e. in my judgement, emotionally authentic and well crafted) and describes a

Downloaded by [New York University] at 12:48 14 August 2016 seemingly everyday event but with the strong emotional overtones which might crop up in a routine psychotherapy session. The title and content are self- explanatory.

Dinner with my Mother My mother is saying ‘Now’. ‘Now’, she says, taking down a saucepan putting it on the stove. She doesn’t say anything else for a while

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so that time passes slowly, on the simmer, until it is ‘Now’ again as she hammers out the steaks For Steak Diane I have to be at hand at times like this for table-laying drink replenishment and general conversation. But I am getting hungry and there is nowhere to sit down. ‘Now’ I say, making a point of opening a bottle of wine. My mother isn’t listening. She’s miles away testing the sauce with a spoon narrowing her eyes through the steam.

‘Now’ she ways very slowly, meaning which is it to be, the rosemary or tarragon vinegar for the salad dressing?

I hold my breath, lest anything should go wrong at the last moment. But now it is ready. ‘Now’ Our time to sit and eat.

Let us suppose that part of the impulse to write a poem, or to consult a psychotherapist, comes from the need to make sense of, or do psychic work on, something that seems painful, confusing or troubling in the subject’s mind. Can we learn something about the minutiae of the reparative process by looking at the poem from a psychotherapeutic angle? What was Williams’ protagonist wrestling with in this poem, and what conclusions can we draw from his or her feelings about his or her mother and their relationship? I select six aspects where parallels might be Downloaded by [New York University] at 12:48 14 August 2016 drawn between the reparative aspects of poetising and psychotherapising.

Finding a space for mentalising The writer Doris Lessing (2007), in her Nobel acceptance speech asks:

have you found that space, that empty space which should surround you when you write? Into that space, which is like a form of listening, of attention, will come the words and the inspiration.

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The therapist’s ‘frame’ (consistency of place, room, time, technique) and poetic form (the bounded ‘empty space’ of the blank page, the ‘form’ of stanza, rhyme and rhythm) are the therapeutic analogues. Williams uses the space provided by his poetic form to explore the difﬁcult emotions aroused in him by both wanting to please and get close to, but also being irritated and controlled by, his possibly forgetful or even incipiently Alzheimer-suffering, mother. For mentalising to operate there has to be a safe space, both literally in the therapist’s room and also an ‘internal’ space in his or her mind.

The search for emergent meaning In both a psychotherapeutic session and a poem there is a dialectic between expectable form and the infinite possibilities of new or ‘emergent meanings’ (cf. Hunt et al. 2012). The structure of a session is formalised and familiar, yet neither patient nor therapist know in advance what is going to happen during the 50 minutes of their session, other than that there will be moments of both meeting and missing, of rupture and repair. Similarly Williams’ poem, with its careful arrangements of groups of four lines and steady metrical beat, has a formal structure which allows for the containment of uncertainty and tension – we can’t be sure if that meal is ever going to get onto the table! The ‘subject’ and form of both poetry and psychotherapy is the processing of difficult feelings. Heightened negative emotions – in this case fear (Mother: ‘Am I really up to making a meal? Am I losing it?’) and irritation (Poet: ‘My mother really is annoying’) are inimical to exploration and mentalising. The holding and security provided by the therapeutic situation, and by poetic form facilitates co-regulation of these difficult feelings and thus the emergence of playfulness and exploration.

Recursiveness A therapy session, like a poem, and unlike ‘real life’, being bounded, has a clear beginning, middle and an end – but not necessarily in that order. As in Eliot’s (1876/1986) oft- quoted second quartet, East Coker, ‘in my beginning is my end’. There is a recursive aspect to a poem and a psychotherapy session. Therapists need to attend closely to the opening and closing features of a session, since, under the pressure of anxiety, they contain in compressed form much of what is

Downloaded by [New York University] at 12:48 14 August 2016 to come and what has been. Williams’ deceptively simple poem loops back on itself as its sense emerges slowly on careful second and third readings. The repeated, and at ﬁrst sight rather unimportant, ‘Now’, might be a pre- Alzheimer verbal mannerism, or an invocation of the importance of communication, of two people being in the same place at the same time. As with our feelings- frightened farmer the meaning of a psychotherapy session is often illuminated by looking back at the opening moments in the light of subsequent developments. A casual remark about the weather as the patient enters the therapy room may, as it turns out, reﬂect her

46 REPAIR

underlying emotional tone. A patient who comments that he is late because he has ‘had difficulty parking’, may be wondering if the therapist really has sufficient space to accommodate his neediness, and so on. Freud’s notion of ‘nachtraglichkeit, aprez-coup, or afterwards-ness’, much enamoured of contemporary psychoanalysts, especially those in or influenced by the Francophone tradition (Quinodoz 2006; Harris and Bass 2011), refers to the way in which, psychologically, the past is not a fixed lost entity but constantly revised in the light of subsequent experience. The recursiveness of poetry and psychotherapy sessions could be seen as mini-examples of nachtraglichkeit in action. Loss is mitigated by mentalising, capturing, Proust- like, what has seemed irretrievable into a dynamic loop constantly oscillating between past and present.

‘Action replay’ Wordsworth (1802/1954) famously deﬁned poetry as ‘emotion recollected in tranquillity’. Both lyric poetry and psychoanalytic work have the capacity to focus on tiny fragments of experience, replay them, tracing their emotional links backwards in time and ‘sideways’ with other sets of experiences and emotions. Subjecting one’s experience to this type of slowed- down close reading is synonymous with mentalising. Williams attempts to take his mother’s monosyllabic ‘Now’ and, frame by frame, put it under the poetic microscope. Similarly, attending to the minute particulars (Hobson 1985) of sessions – small fragments of interaction – are an essential part of therapeutic and supervisory work. Noticing a non-verbal response of averted eyes and slight blanching to an interpretation, the therapist might ask: ‘what happened just now when I made that comparison with your relationship with your father?’. The patient might say ‘I was shocked; I felt you had no right to say that’, and so on. Supervision often similarly homes in on a small segment of therapeutic interaction, and, holo- graphically, reconstructs from it an entire relational constellation.

Somato- sensory experience Action replay focuses on the component parts which make up, and contain within themselves, an elusive whole (see Chapter 3). In responding to a poem, and a patient, we need to oscillate between the ‘minute particulars’ and the

Downloaded by [New York University] at 12:48 14 August 2016 overall feel of the patient/session/poem. The latter might be called ‘dreaming the patient’ (cf. Ogden 1997) – allowing the therapist’s unconscious to resonate in an unfettered way to that of the client – as Freud recommended, with ‘evenly suspended attention’. The devil is in the detail, the minute particulars, but also in the overall contour of one’s response. We need to be able to ﬁnd eternity in a grain of sand, but to dream the whole dune too. A dream is in a sense outside time, and so impervious to loss. Both poems and sessions evoke somato-sensory experiences grasped through ‘reverie’, i.e. the reader or therapist’s ‘daydreams, fantasies, ruminations, bodily sensations,

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derivatives of unconscious inter-subjective constructions’ (Ogden 1997, p. 76). As described in the opening chapter, the capacity to weave loss- defying thoughts out of these dream-like elements is the crucial contribution of psychoanalysis to the achievement of psychic health. Although the medium of communication is primarily verbal, the therapist’s starting point is often corporeal. A supervisee reported that in the course of a session her patient had described a friend as having ‘passed away’. The use of this conventional term jarred (note physicality of the metaphor, albeit one that is near defunct!) on her consciousness, although she could not initially say why this was so. Further exploration revealed that in fact the friend had committed suicide, and thinking about that had been unbearably painful for this patient whose mother had similarly killed herself when she was a child, so much so that she had to wrap the event up in a euphemism. There is a dialectic in which the use of a word or phrase triggers off non-verbal, or perhaps more accurately ‘preverbal’ – ‘language of thought’ – reactions in the listener, leading to a return to the linguistic realm, and further exploration of what it denotes in terms of the utterer’s inner unformulated experience (Stern 2009). Comparably, the music of Williams’ poem – its steady, almost stately metre, the repetitions and dreamy rhythms interrupted by the abruptness of phrases and words like ‘hammer out’ and staccato ‘steak’ – enables it to penetrate, to be physically absorbed into our body/mind, and, once inside, for us to be able to think (or in Ogden’s sense ‘dream’) about it and its multiple meanings. In both poetry and psychotherapy there is a constant interplay between feelings and language. As suggested, identifying and then finding what initially may be no more than a vague ‘shape’ for these feelings leads on to the attempt to find words to describe them, and via the process of mentalisation, to begin to delineate meaning. The therapist’s task is to ‘read’ the ‘text’ which the patient brings, ‘back- translating’ words into affective/bodily experience. She does this by the reverse process within herself, ‘reading’ her physical and emotional responses (‘countertransferences’), and then finding words to capture them. These interpersonal physiological sensations invariably have a temporal aspect – they are ‘feelings in time’, and this often is a pointer to their meaning. This is manifest in both poem and session by the balance between tension and its resolution. Psychoanalytically the poem could be compared to the struggle of an infant at the breast gripped by hunger, longing to ‘latch on’ to a slightly dis-

Downloaded by [New York University] at 12:48 14 August 2016 tracted and self-preoccupied mother. One reading of Dinner with My Mother might imagine a final moment of bliss when breast and nipple come together via the ‘let-down reflex’ and the milk begins to flow: ‘our time to sit and eat’. An alternative take on the poem’s ‘high level ambiguity’ (Zeki 2008; see Chapter 3) might view the bleakness of the non- meeting of preoccupied mother and son continuing right through to a miserable end: the protagonist in the poem needs to open a bottle of wine if he is to tolerate his mother’s mild narcissistic self- preoccupation. Common to both accounts, the story is one of rupture and attempt at repair, successful or unsuccessful.

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Self- referentiality According to Eagleton (2007, p. 21), again trying to pin down non-discursive language, poetry:

is always at some level language which is about itself. There is something circular or self-referential about even the most publicly engaged of poems. The meaning of a poem is far less abstractable from its total process of signiﬁcation than is the meaning of a road sign. This is not to say that you cannot give a summary of a poem’s content . . . [but] the resume is likely to be less informational. Poetry is something which is done to us, not just said to us. The meaning of its words is closely bound up with the experience of them.

As McLuan (1964) famously put it, ‘the medium is the message’ – a statement equally applicable to psychotherapy. Poetry and psychotherapy are ‘onomato- poeic’ in the sense that their form and content are indissolubly linked. A psychotherapy session has an intrinsically self- referential quality that sets it apart from ‘ordinary’ discursive discourse – whatever the client brings provokes the therapist to ask herself ‘now what, apart from its self-evident connotations, might all this have to say about “us”?’. When, say, a patient talks about the need to find a driving instructor, the therapist immediately wonders if she is looking for more guidance than she feels she is getting in the therapy, and how this links to her absent father in childhood. The psychotherapeutic analogue of a ‘poetic moment’ is a ‘moment of meeting’ (Lyons- Ruth et al. 2001) – or indeed of non- meeting – between therapist and patient, and attempting to follow the chain of associations this conjures up. Something ‘happens’ in the session: therapist and client then look together at what it is that has happened and try to understand it. The transference/countertransference matrix is the force-fi eld that evokes such emotion- laden unconscious memories. Every story, reaction, feeling and experience brought to the session is examined in the light of the therapist/patient relationship, including the very act of understanding, itself not exempt from scrutiny. Eagleton suggests that poems contain explicit or covert reference to the act of poetry- making itself. Williams, like his mother, is ‘hammering out’ something in his poem – using words and the patterns they create to make sense of an experi- Downloaded by [New York University] at 12:48 14 August 2016 ence. The poet has to choose his words as carefully as finding the right dressing for a salad. The poem, like the meal, is ‘simmering’ in his mind; nothing is said, until the ‘Now’ moment, when it can be written down, arises. The capacity to ‘think about thinking’ implicit in this self- referentiality is a key feature of mentalising. The mentalising mother is able to feel her feelings towards her infant – overwhelming love, protectiveness, anxiety, frustration, fury, etc. – and at the same time be aware that she is feeling these feelings, and to use them to repair interruptions in the continuity of their relationship. Standing outside the

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remorseless ﬂux of existence, poetry and psychotherapy both have the capacity to create an alternative universe, in which through self- reﬂexion, a degree of repair, mitigation or acceptance is possible.

Objectification As an artefact, the poem itself is present to the reader over and above the events and objects to which it refers. That is what gives it its objectivity and general relevance. Williams’ poem is not just an account of a mother and son preparing supper – it is about mother-love, filial love, unmediated Oedipal love, the gulf between the generations. The poem ‘reads’ us – in that it evokes particular feelings and memories in its readers – just as much as we read it. Poetry presents our feelings to us in an objectified way – it mentalises them for us. It presents a constant interplay between our verbal representation of reality, and the experience that representation seeks to instate. The poet is always in a dyadic relationship to his ‘material’. Out of the ‘nothing’ of the blank piece of paper he creates an other, with whom he begins to have a conversation – the nothingness of which could be construed as an ultimate rent in the continuity of existence. What finally emerges as the poem is the poet’s attempt to make sense of that ‘conversation with himself ’. As already suggested, the therapist’s role can likewise be thought of as helping the patient to have a conversation with him or herself – a ‘duet for one’.

Attachment and repair As in the poem, there is in therapy a continuous dialectic of intimacy and discon- nection. As a session ﬁnishes and the next is anticipated, the ever- ending movement between absence and presence, loss and recovery, is the grist of psychotherapy. A poem is a device for turning subjectivity of feelings into share- able objectivity. A psychoanalytic session, via its focus on the relationship between therapist and patient, is a device for exploring and containing the ‘fort and da’ of relationships. The objectiﬁcation of the inevitable misunderstandings, exploitations, absences and failures of communication is an essential step in the process of repair. Both poetry and psychotherapy can be seen as reparative in this sense. Bion (1997) saw thinking as arising out of absence – as his analysand Samuel

Downloaded by [New York University] at 12:48 14 August 2016 Beckett might have put it ‘no breast, imagine a breast’. In a more restricted sense mentalising can be viewed as enabling us to cope with the inevitable breaches, lapses, lacunae, failures, narcissistic self- preoccupations, disruptions and potential traumata of everyday life. To mentalise is to construct a reparative bridge over the chasm of loss. Separation and attachment are the dialectical twins from which a new synthesis can emerge. The Kleinian perspective sees reparation as making good the psychic devas- tation wrought by aggression unleashed in the face of deprivation and absence. The murderous and murdered ‘bad breast’, full of projected hatred, is brought

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back to life through the creative process (Segal 1991). Aggression and reparation are indissolubly linked. By contrast, attachment sees mentalising as a built-in repair-mechanism helping us to survive the inevitable and ‘objective’ – as opposed to the ‘subjectivity’ of hatred and aggression – separations and losses that are the reverse side of the attachment coin. Gross disruptions of care in childhood compromise mentalising in ways that link to the symptomatology of Borderline Personality Disorder (Holmes 2010). Tragically, the bigger the rent, the more mentalising skills needed to withstand it. Children who can articulate their perception of their caregivers as stressed, intoxicated, depressed, etc. are protected against disorganisation of their attachment representation compared with those who cannot make that judgement (Slade 2005; Slade et al. 2005). Similarly the ability to recognise one’s own feelings of rage or aggression or despair for what they are – ultimately ‘just thoughts’ – is a bulwark against self-destructive acting out. Most therapies for Borderline patients, whether behavioural, dialectically Buddhist, transference- focused, or Kleinian, aim to foster this capacity, or skill. Where does poetry ﬁt in with this viewpoint? There is a powerful link between poetry and loss – people turn to poetry at moments of great joy or great sadness, either because there is an intrinsic awareness either that happiness cannot last for ever, or in an attempt to re-establish the fabric of existence rup- tured through death or separation. The business of poetry is to generate truthful and beautiful images, i.e. feeling-toned mental representations of experience, through which the ‘lost object’ can be ‘reinstated’ (Segal 1991) in the mind. The external object is lost, but mental continuity still maintained. Poetry has the power to conjure up images in the internal world in a way that keeps the on- goingness of reality intact in the face of loss. By creating language that ‘onomat- opoeically’ represents and recreates experience, the poet reaches out across the chasm of loss to a listening other. Words, when used poetically, through rhyme, rhythm, metre, tempo, tone and assonance, re- establish connection and continuity. This connectivity of poetry – the way that rhyme, pulse, images get ‘into’ us – is comparable to the ‘scaffold’ of the psychotherapeutic session. The poem becomes a living thing that ‘holds’ us for the duration of our attention to it. Similarly, a held child/patient can use mentalising to overcome despair and denial (the end- stages of unmourned loss), and thus himself hold hope in mind. We habitually try to avoid, blot out or kill

Downloaded by [New York University] at 12:48 14 August 2016 the pain which life, especially when traumatic, inﬂicts on us. As Ogden (1997, p. 992) puts it:

we turn to poetry and to psychoanalysis . . . with the hope that we might reclaim (or perhaps experience for the ﬁrst time) forms of human alive- ness that we have foreclosed to ourselves.

Poetry and psychotherapy have a part to play in that ever-renewing process of, metaphorically, ‘staying alive’; sometimes literally so.

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A common occurrence in any long-term therapy is the proferring by the patient of something they have ‘made’ – a Christmas card, a cake, a poem or picture. The conventional psychoanalytic approach here is to see the object of item in much the same way as Freud viewed dreams: a covert expression of hidden impulses, the task of the therapist being to ‘read’ the unconscious meaning which the artefact both reveals and conceals. A model here might be Freud’s (1928) discussion of a story by Stephan Zweig in which a middle-aged widow, whose sons no longer needed her, is attracted to a young man whom she sees at a casino. Her first glimpse of him is his hands as they place his bets. She decides to ‘rescue’ him from his addiction to gambling and, in the process, ends up in bed with him. He promises to renounce gambling, she gives him money for his journey home and they part. But later the next day she discovers, to her despair, his hands once more playing the tables at Monte Carlo. For Freud the emotional power of the story lies in its covert account of the struggles which beset young men concerning masturbation. Gambling equals masturbation: compulsive, guilt- laden, promising immediate gratification but ultimately dissatisfying. The affair with the older woman reflects the deepest repressed longings of a young man, to regress to an infantile state of physical union with his mother, while her part in it can be seen in terms of a failure to mourn the loss of her sons, and a wish to recreate an idealised caring relationship. Gender themes are also played out in this story – the masculine wish to merge once more with the mother, and terror at doing so, the female longing for closeness with a man as compensation for her loss of her mother- role, and with it her inner mother.

Downloaded by [New York University] at 12:48 14 August 2016 We see here both the limitations and potential of the psychoanalytic approach. To our contemporary ears, the equation of masturbation with gambling appears simplistic, not least because, unlike Freud, we are no longer living in an era in which ‘masturbatory insanity’ is taken seriously by the medical profession. Nevertheless, the suggestion that compulsive gambling, like drug addiction, pro- miscuity or repetitive self-harming, might represent or symbolise compensatory self- soothing activity has a contemporary resonance. For Freud, a symbol, like an image in a dream, is a disguised representation of an unconscious thought that has been banished from consciousness. Furthermore,

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he claimed that symbols are intimately bound up with the body, or the self and its immediate relationships. He distinguished between symbolisation and sublimation, the latter being the ‘healthy’ expression of unconscious meaning in which the force of unconscious drives had been sufficiently attenuated. The early analysts were keen to make links between sophisticated sublima- tory activities and early bodily functions. Thus Freud suggested that the craft of weaving arose out of female shame about penislessness and the concealment of the fact by pubic hair, while Fenichel (1946) argued that the origins of musical ability are to be found in the infant’s pleasure in belching and breaking wind. Today, this looks like reductionism at its most absurd, yet there is no doubt that the body and its functions provide a basic reference point for metaphor. To take the most obvious example, roundness tends to be a fundamental female symbol, straightness a male one. Like all communication, even when what is entailed is the turbulence of sound-waves produced by one person’s vocal cords impacting on another’s oral tympanum, artistic production is necessarily physical: the hand that draws the line or string, the body that mimes. Freud’s contention that the unconscious is preoccupied with the fundamental corporeal facts of existence – birth, feeding, sex, parenthood, illness, death – which tend to be symbolised in dreams, daydreams, fantasies and art, remains as true today as when it was first proposed. Furthermore, contemporary evolutionary theorists now argue that artistic creation relates to sexual selection – ultimately a way of showing off to secure a desirable (i.e. biologically fit) mate. In Freud’s (1923) ‘tripartite model’, the ego has a synthetic function, bringing the individual in relationship to the reality principle while at the same time attempting to satisfy the pleasurable desires of the id and the prohibitions of the superego. From the perspective of the arts, the structural model suggests that the ego’s function is to create forms of expression in which perceptions and feelings arising in the id can be symbolised, while at the same time arranging a mora- torium on the strictures of the superego. From an attachment perspective, the ‘superego’ is the critical parent of the avoidant child. In secure attachment, the art or music room or stage are places – Winicottian spaces – where normal social rules are relaxed, where ‘anything goes’, where ‘messes’ can be made, loud noises are permitted, unrestrained gestures, leaps and bounds are encouraged or, in the case of drama, where fixed roles can be relinquished as the individual tries out the feelings associated with different characters.

Downloaded by [New York University] at 12:48 14 August 2016 Daniel Stern (1985) argues that the sense of self emerges out of activities which can be seen as fundamental to artistic activity. He sees maternal ‘attunement’ as a key theme in which the parent taps into the infant’s rhythms of activity, vocalisation or physical expression. Thus, for example, a mother may be playing with her child on the ﬂoor. The child might be ‘singing’ in a rhythmic fashion and the mother will pat him or bang the nearby rug in time – this is what Stern calls ‘cross-modal attunement’, the vocalising senses being linked with the kinaesthetic. This, Stern argues, will strengthen the child’s sense of himself as an abstract centre of being, not tied to any one sensory modality, mirrored by the

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mother’s responsiveness. The mother acts here as an ‘auxiliary ego’, helping to create a temporary artistic ‘form’ as she joins in with the infant’s vocalisations, and reflecting back to him a pattern that is not identical to his own creation, but is sufficiently related (‘in tune’) for the child to begin to sense who ‘he’ is (cf. Beebe et al. 2010). If Stern’s model is correct, it can be traced back to the primary I–Thou relationship of infancy. We discover who we are through our actions and artefacts. Initially, a parental presence is needed to shape the ability of the child to use his body as an instrument and then to offer the tools of self-expression – the spoon to bang, the pencil to scribble, the music and the ‘bouncer’ with which to dance. Later an internal dialectic is created in which part of the self interacts with the medium of artistic expression, which, in turn, is scrutinised and shaped by a more reflective part of the self, which will, for example, question whether something feels artistically ‘right’ or not. Art in therapy can help the discovery and strengthening of the sense of self. Art is always communicative, even for the lonely artist in his garret. It is always an attempt to get in touch with the self, through an external medium, which in its origins requires the presence of another. The artist is ‘attached’ to his artefact as though it were a person, but can play and experiment with a relationship that both has a life of its own and is completely under his control. We have moved from consideration of psychoanalytic meanings in art – the hidden Oedipal longings revealed in the Zweig short story, for example – to the fundamentals of artistic production itself. Both have central therapeutic value. Through looking at himself, with the help of a therapist, in his pictures or poems a patient may understand preoccupations previously hidden from his conscious understanding. He may find that he has depths of which he was unaware, and feel a strengthened sense of worth and self- esteem as his creativity becomes more accessible. At the same time, the very act of artistic production creates the container for feelings that may have been lacking in childhood and puts the patient into a state of relatedness to himself and the world that may have been stunted in the traumatic environment in which he grew up. Art enables the object to be created in imagination, to be grieved, attacked, separated from or transformed in a way that was impossible in the course of abusive or constrained development. I now turn to a specific example of the interplay of childhood experience and

Downloaded by [New York University] at 12:48 14 August 2016 creativity and draw out some conclusions relevant to psychotherapy.

Wordsworth’s ‘Ode on intimations of immortality from recollections of early childhood’ Let us start with some brief biographical facts. Wordsworth was 32 years old when he wrote the Ode (1994), about to marry Mary Hutchinson and planning a secret visit to France to say goodbye to Annette Vallon, who he had met ten years earlier at the time of the revolution and by whom he had had a daughter,

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Caroline, whom he had never met. His mother had died when he was eight, after which, with the help of his sister Dorothy, he had become a passionate nature- lover. The famous starting epigram calmly sets out the underpinning theory and the state of mind which, after much struggle and difﬁculty, the poem ﬁnally achieves:

The child is father to the man And I could wish my days to be Bound each to each by natural piety.

The unspoken theme of the poem concerns how it is possible to maintain continuity in the face of loss and trauma – not just immortality in the religious sense, but also in the sense of ‘going on being’, symbolised by the notion of the eternal spirit. Wordsworth’s initial image for loss centres on vision, in both its literal and ecstatic – as in ‘visionary’ – sense. He mourns the loss of the ‘celestial light’ which ‘I can see no more’. Then comes the ambiguous line, the sort that lin- guists delight in:

To me alone there came a thought of grief

Was it Wordsworth only who was troubled by grief, or was it because he was ‘alone’ and orphaned that grief hits him? In either case, the answer comes immediately – perhaps too immediately, like a consolatory thought – almost a cognitive behavioural intervention – that pushes away the unhappy feeling rather than fully experiencing and thinking about and metabolising it:

A timely utterance gave that thought relief And I again am strong The cataracts blow their trumpets from the steep No more shall grief of mine the season wrong.

True, he ‘gives sorrow words’, turns the feeling into an ‘utterance’, but somehow it all seems too easy at this stage. Off he goes in an almost manic peon: ‘all the

Downloaded by [New York University] at 12:48 14 August 2016 earth is gay’, everyone is happy and joyful, man and beast: ‘The fulness of your bliss I feel’. Then suddenly, once more the shadow returns:

Oh evil day! If I were sullen While Earth itself is adorning This sweet May morning . . .

This is a super- egoish thought – ‘how could you dare to spoil other’s joy with your misery?’, which, turned around, could read as the rage of the bereaved,

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railing against the mother who left him, and fate for ‘forcing’ him to abandon his primary love-object. Then, for the ﬁrst time in the poem, he moves into what Britton (1998) calls his ‘thoughtful’ as opposed to manic mode:

. . . there’s a Tree, of many, one, A single ﬁeld which I have looked upon Both of them speak of something that is gone The pansy at my feet doth the same tale repeat Whither is ﬂed the visionary gleam? Where is it now, the glory and the dream?

There is still a problem to be solved, simple ecstasy won’t do. Nor, in the long run, will clinging to a secure base, although that will be a necessary ﬁrst step. There is something that needs to be thought through. He turns to what at ﬁrst is a purely intellectual solution, which is not to say that it is not deeply helpful. It is the simple but profound idea that heaven is not where we are going to, and therefore about which we can know little, but where we have come from, and therefore about which we know everything, if only we could remember it. To help with that remembering is part of poetry’s task. ‘Our birth is but a . . . forgetting’, sure, but

Not in entire forgetfulness And not in utter nakedness . . . Do we come/from God who is our home (my emphases)

If we can build on the remnants of past love we will be able to ﬁnd a home, a secure base, which can help us to withstand mortality and loss and change and breaks in continuity. But why do we spend so much time trying to forget our celestial past? Why, returning to the visual imagery, does growing up involve a fading of the vision into the light of common day? Wordsworth’s answer is once more to be understood in terms of the contrast between a manic and ‘thoughtful’ solution. Earth is a stepmother, anxious to distract her foster children from their loss, offering

Downloaded by [New York University] at 12:48 14 August 2016 them the ‘pleasures of her own’, much, perhaps, as Dorothy might have done to try to console her grief- stricken younger brother, and vicariously, herself, at the time of their mother’s death. Now we come to stanza eight, the apex of the poem, where the contradictory feelings with which the poet has been struggling are juxtaposed most starkly. It starts with an echo of Wordsworth’s great epigrammatical paradox: the child as parent, sage, best philosopher, mighty prophet, ‘eye amongst the blind’, tall in his might and freedom, in contrast to his actual physical size. Here, perhaps still a little manic. But then comes the rub: why, oh why,

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. . . with such earnest pains dost thou provoke The years to bring the inevitable yoke Thus blindly with thy blessedness at strife?

This is a cri de coeur with which psychotherapists are all too familiar: the patient who has ‘everything going for him’, but who is unable to value what is good within him, and who self-defeatingly manages to make himself and everyone around him miserable. The remainder of the poem is a resolution of this paradox; a resolution which is itself a paradox, since it takes a paradox to undo a paradox. There is joy:

The thought of our past years in me doth breed Perpetual benediction . . .

But it is not a simple harking back to good times that helps – to the ‘delight and liberty’ and ‘new-ﬂ edged hope still ﬂuttering in his breast’ (Wordsworth reminding himself here of his revolutionary, and perhaps sexual, fervour at the time of the French revolution), to the ‘mad endeavour’ – but rather, and here’s the paradox,

. . . for those obstinate questionings Of sense and outward things Fallings from us, vanishings; Blank misgivings of a creature Moving about in worlds not realized, High instincts before which our mortal nature Did tremble like a guilty thing surprised.

It is only because we know that joy is transient, because, unlike the lambs and other animals, we suffer and tremble and experience loss, that we are able to value the dim recollections of ‘the eternal silence’. If we take suffering seriously, rather than running away from it, pain points us to its resolution. Without pain there could be no healing, just as, in the Buddhist schema, the ﬁrst step towards overcoming suffering is to accept that suffering is inevitable, and indeed in the Christian story, Christ’s sacriﬁce is the cornerstone of redemption. The bereaved

Downloaded by [New York University] at 12:48 14 August 2016 boy can look back beyond his misery to ‘those first affections’, ‘that immortal sea/Which brought us hither’, and know that he was loved, and that the memory of that love cannot be taken away from him. And now, in the final two stanzas, at last the tone of the poem becomes relaxed and elegiac. With his new-found security, the poet does not have to rush manically to imitate the lambs, but can join them ‘in thought’. He can accept that although nothing will bring back the ‘hour/of splendour in the grass, of glory in the flower’, there is no need any longer to grieve. Suffering transformed in this way becomes soothing. The ‘philosophic mind’ is able to see ‘through death’.

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This new perspective, encompassing and accepting loss, goes beyond it to something deeper. The object can be reassured in its turn that all will be well: ‘forebode not any severing of our loves’. The ‘habitual sway’ of everyday nature can be enjoyed unambiguously, no longer passionately adored perhaps, but also not hated for reminding the poet of how things were and can no longer be. The poet has ‘come through’ (as D. H. Lawrence 1989 put it), he has won his palms in a race in which the only way to win is to lose, and to know that one has lost. The blown ﬂower reminds us that change is unchanging. Humility, fear, empathy for nature, acceptance of transience, takes us to a place ‘too deep for tears’. Whatever chaos and loss rage around us, there is a ‘heaven-haven’ (as Hopkins 1967 put it) with the power to calm and comfort, and move us towards a state of acceptance and non-attachment that is beyond suffering. Ultimately, by embracing change we can help overcome our vulnerability to it.

Poetry and psychotherapy I want now to reiterate some by now familiar links between poetry and psychotherapy from these reﬂections on the Ode. First, it is important to approach poetry, as much as patients, ‘beyond memory and desire’. Our initial task is to open ourselves to the poem as it stands, to attune and align ourselves to it, and try to enter the mind of the poet, without imposing our own models or preconceptions, seeing avoidant attachment here, manic defence there, and so on. Such theorising is permissible, but only after we have fully grasped the poem (or the patient) in its own terms. Second, poetry is based on words, but words used in a very special way. For Lacan (1977), the word is the paternal Oedipal sword, categorising and separating, and disrupting the primary narcissistic fusion of subject and object, of mother and child. So here’s another paradox: poetry uses words to re- establish that lost pre-verbal unity. Words reach out across the divide between inner worlds, re-establishing connectedness – or attachment. This happens at the level of meaning, but also physiologically: rhyme and rhythm link bodies across the spaces that separate them. The non- verbal and para- verbal aspect of verse evoke the soothing sounds of parents with their infants, and the ‘mmm . . .’s and ‘Let’s see . . .’s of psychotherapists with their patients. Third, in both poetry and psychotherapy, there is always an inherent

Downloaded by [New York University] at 12:48 14 August 2016 struggle in the search for meaning. ‘Difficulty’ seems to be inherent in this process. Unlike prose, where meaning is usually manifest and transparent, we have to wrestle to understand a poem with its concentrated latent implications and reverberations. I must have read the Ode many times, but there are still parts that are obscure and resist explication. Deciphering a dream can be similarly difficult; and how often do we finish a session with a patient and say to ourselves ‘I really didn’t understand what was going on there’? This aspect of responding to both poetry and what goes on in psychotherapy can be seen from an attachment perspective as the shifting balance between disorganisation

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and coherence. We have to be able to tolerate the poem’s obscurity, and the consequent feeling in the reader of splitting and falling apart of meanings, secure in our ‘negative capability’, and in the knowledge that a resolution will emerge, given time, attentiveness and faith. Similarly with patients we have to attune ourselves both to their and our own feelings, without knowing in advance what they ‘mean’, or how they ﬁt into a pre-determined schema. Fourth, writing poetry can, like undergoing psychotherapy, be seen as ‘narcissistic’, self- indulgent even, but both use narcissism to overcome narcissism. With the help of the therapist, the psychotherapy patient begins to learn how to talk to and listen to himself. Where previously there was just a ‘blob’ – as many patients describe themselves and their misery – a subject and object emerge. But where is this object to be found? It is certainly not ‘on the page’, any more than the music which we hear exists on the score. The poem exists in inner space, projected, as it were, onto an internal screen within the mind. Poetry is seen and heard in the inner eye and ear; to understand a poem, we have to be able to ‘see’ its meaning, hear its music, bring its visual and auditory imagery to life within ourselves. Similarly in psychotherapy, the patient is brought into touch with his inner world where his true feelings, and ideas about himself and those to whom he is close, are projected. Finally, what kind of a thing or ‘object’ is a poem? It is neither entirely ‘out there’ on the page, nor wholly ‘in here’ in the mind of the poet/reader (a poem, ultimately, has at some level to be comprehensible, i.e. available for external scrutiny and evaluation). It can be described as an ‘external–internal object’, a ‘self-object’ (Kohut 1971), a ‘transitional object’ (Winnicott 1971), a ‘poetic third’ (Ogden 1987) arising out of the inter-subjectivity of poet and reader. Its rhythms and music give it the characteristics of a secure base in that it has the power to soothe, but also to contain and hold ﬁrm in the face of powerful and often unbearable feelings. This ‘poetic third’ is an extension of Ogden’s notion of the ‘analytic third’, the transferential relationship that is both real and an illusion created by the patient’s mind. In both therapy and poetry, there is an idea of ‘movement’ as the poet struggles with the emergent meaning of his poem, and in the course of psychotherapy, both in the individual session and over time. In Kleinian thought, this movement is always along the continuum paranoid-schizoid position to depressive position.

Downloaded by [New York University] at 12:48 14 August 2016 Britton (1998) sees Wordsworth moving from a manic identiﬁcation with nature as an escape from mental pain, to a depressive position characterised by thoughtful and more distanced acceptance of pain and joy. It seems to me, however, that Kleinian thought makes coming to terms with loss as the key to psychological maturation a much more straightforward process than in fact it is. There is a paradox, or at least a difﬁculty, at the heart of depressive position that can easily be glossed over. How do we come to see that the object we hate and the object we love are one and the same, that sadness and joy are often intermingled, that without pain there can be no happiness? This is not

59 THE POETICS OF PSYCHOTHERAPY

merely an intellectual move, any more than Wordsworth has got himself out of his dilemma by his idea that we come from, rather than, are going to, heaven. But he still has to feel his way free, as do our patients. There is an inherent mystery in the reconciliation of opposites. To move from Wordsworth to T. S. Eliot (1986), on the one hand:

Time past and time future What might have been and what has been Point to one end, which is always present

– whatever our hopes and imaginings, our actions and achievements, in the end all we have is the present moment. On the other:

If all time is eternally present All time is unredeemable

– without a notion of history, of how things might have been and might be, different redemption (or psychotherapeutic cure) is impossible. Finally,

Human kind Cannot bear very much reality.

From an attachment perspective, as for Wordsworth, loss is always equipoised with connectedness. Without the containing presence and later the internalised representation of the therapist, or the poem, or the idea that we still trail some residual clouds of glory, the movement from paranoid-schizoid position to depressive position is impossible. Without the analytic or poetic third, the sufferer is stuck with his nihilism and his narcissism. With the help of a poetic secure base we can relax enough to listen to footfalls in the memory, follow them down the passage into the rose garden. Psychotherapy is not just about a grim coming to terms with loss. Like poetry, it also, and necessarily, puts us in touch – physiologically, emotionally, cognitively – with our ‘ﬁrst world’, so that, with luck, we can live more fully in our ‘second’.

The uses of art in therapy Downloaded by [New York University] at 12:48 14 August 2016 How does all of this relate to actual practice of therapy? The analytic therapist might argue that she does not need art materials, journals, stories or poems, because everything that the patient says or does is an unconscious kind of poetry, the unravelling of whose meaning is her primary job. Focusing on pictures or music might prove a distraction from this task, an enactment by the therapist that could be counter- therapeutic if it enables the patient to hide behind her pictures, rather than face up to real interpersonal anxieties. Even dream-interpretation, so close to the heart of psychoanalysis, has to be undertaken cautiously, since

60 LOSS

endless discussion of dreams can be an avoidance of painful aspects of the therapeutic relationship – anger, envy, disappointment or undeclared love. Of course, many patients in long-term analytic therapy do bring poems, pictures or other artefacts into their sessions. It would be churlish as well as foolish for the therapist to ignore these, or to see them as ‘merely’ enactments. Being in therapy puts patients in touch with previously unmetabolised feelings. The experience of being contained within therapy provides a model which the patient often spontaneously tries out for himself, away from therapy. And art or writing is in itself a containing space for holding and thinking about feelings. The analytic therapist, therefore, might argue that while access to creativity is often a mark of progress in therapy, it is peripheral to the analytic process itself. The analytic interchange is in itself a creative activity – a ‘verbal squiggle game’ which calls on the spontaneity of both therapist and patient. There are, of course, occasions when the arts of artefacts enter into this process. Two examples follow by way of illustration.

Russian dolls Alison had been in analytic therapy for eight years. Outwardly successful, she suffered from depression and found it difﬁcult either to live contentedly alone or to sustain close relationships. She had vivid memories of the scorn her father had poured on a picture she had made at school of which she had been rather proud. She habitually tried to please her therapist, while at the same time secretly trying to manoeuvre him towards giving her the love and praise which she so desperately wanted. She gradually progressed and began to think about ending therapy. At the Christmas break preceding the appointed ending at Easter, she presented him with a wrapped gift. He thanked her, said that he would open it later and, using standard analytic techniques, invited her to talk about the meaning of the present. Alison was insistent – he must open the present now. He did. It comprised a nest of Russian dolls. ‘Open them up’ she insisted. She then described how she had found the dolls in a junk shop and found that the ‘baby’ doll was broken. Using modelling clay, she had then painstakingly repaired it, so that it was almost indistinguishable

Downloaded by [New York University] at 12:48 14 August 2016 from new. This was a decisive moment in therapy. Alison had at last been able to show some assertiveness; the doll clearly symbolised and summarised the work that had been done over the years. The outer dolls stood for her many false selves, effective, but ultimately unable to hold her close to others or maintain self- esteem. The work of therapy had centred round the need to repair her ‘inner child’, facing the impossibility of altering the damage that had been done, but which, though still wounded, now felt much more whole.

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Here the use of an artefact had spontaneously broken into the analytic frame with beneﬁcial results. The therapist had protected his technique but was ﬂexible (and human) enough to adapt to the needs of the moment. In this example, it was the patient who brought art into the treatment. In the next example, it was the therapist who did so.

The ancient mariner Oliver went away on holiday for a week with his wife. On his return he reported that the first few days had been pretty bad and that he had felt very cut off from his wife. They had then had a row, in the course of which he had suddenly seen how awful it must be for her to have to live with him. He was filled with compassion for her and, in his words, ‘the barriers suddenly came down’ and they were able to remain close for the rest of the holiday. As he was listening to this story, I had a vivid image of the famous passage in Coleridge’s Ancient Mariner in which the parched, sleepless and guilt- ridden mariner, whose companions are all dead, watches the water-snakes in the sea and, in a moment of compassion for his fellow creatures, ‘blesses’ them. At that moment, the albatross falls from his neck, he is able to sleep at last, wind returns, rain falls and his companions wake from the dead. The snakes, symbols of evil, are suddenly seen as innocent living creatures, symbolizing perhaps the mariner’s own projected evil with which he has suddenly come to terms. As he forgives himself, so his depression lifts. All this seemed to fit Oliver’s plight so well that the therapist risked telling the patient of this parallel. Fortunately, Oliver was able to respond, and compared his early presentation to the ancient mariner who clutched at anyone who would listen to his story. As the therapy continued, the phrase ‘an ancient mariner situation’ became a shorthand for various emotional states of guilt and desperation, but also a byword for compassion and the possibility of escape from depression.

The purpose of these examples is to show how, like it or not, aspects of art will inﬁltrate themselves into psychoanalytic work. Patients will often use art as a container for feelings, especially in once- weekly therapy where sessions may not

Downloaded by [New York University] at 12:48 14 August 2016 be available when needed. A continuing theme has been the difference between the actual presence of a secure base with the need for physical proximity at times of distress, and the idea of an ‘internal’ or representational secure base which can itself reassure, or lead to emotional proximity to loved ones, including therapists. Art lies in an intermediate zone between the two: an artefact is a physical and inherently inert object, but with the power to soothe and ﬁnd meaning in inchoate experience.

62 Part II

PSYCHOTHERAPY AND NARRATIVE Downloaded by [New York University] at 12:48 14 August 2016 This page intentionally left blank Downloaded by [New York University] at 12:48 14 August 2016 6 ATTACHMENT AND NARRATIVE Conrad’s Heart of Darkness

Introduction To watch a virtuoso pianist like Vladimir Askenazi play a Beethoven sonata is to witness the multiple levels of aesthetic communication which art entails. The music tells a structured story – with its contrasting principal themes, development section, resolution, coda, conclusion, etc. – all of which emerge vividly in the hands of the maestro. But our enjoyment is sensory as well as narrative – the sound, rhythm, ‘touch’ of the music are woven into the story, without which the performance is as lifeless as a prose description of a poem. Watching, we see the artist’s whole body, not just his mind, engaged in the playing – hands, arms, back, neck, face, and, fascinatingly, lip movements reminiscent of a baby at the breast. Poetry and prose coalesce, fused into a magnificent whole. In the next three chapters we move from poetry to prose. In some ways this is analogous to the developmental progression from ‘pre-Oedipal’, two person relationship of infancy, to the Oedipal, three-person world of the toddler and beyond. Poetry captures the raw material of self–other experience, finding the right words to capture our primal contact and communication with the object. Prose moves us into the complexities of rivalry, exclusion, loss, possession, power and the vagaries of time, or moments seized or eluded. Joseph Conrad’s Heart of Darkness (1899/2003) begins and ends on a packet ship moored on the River Thames, with the narrator Marlow sucking at his gut- tering pipe. Within this narrative space, the reader has been taken on a compelling and horrific journey into the interior – both geographic and psychological. The book is a story within a story, framed by the river itself, whose reaches, Downloaded by [New York University] at 12:48 14 August 2016 unlike stories, are unpunctuated: stretching in a spacial continuum from London across the oceans to the heart of the Congo, and in time from the present back to the Roman invasion of Britain. This contrast between the structure and boundedness of the story, and the fluidity and formlessness of reality, forms the background to this chapter. There is also an opposition between artifice and nature, which can be expressed psychoanalytically as a contrast between the apparent actuality of the dream narrative and the patchwork of fragmented associations and ‘day’s residues’ that a dream

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evokes. Bollas (2007) takes this as a general paradigm for the activity of the unconscious, which he sees as continuously fashioning lived life into stories, and then dismantling and dispersing those stories in the light of further experience. I shall follow this theme throughout this chapter which is both an exposition and a critique of the ‘narrative turn’ (Howard 1991) in psychotherapy. I consider ﬁrst some general aspects of narrative, and then its application to psychotherapy practice. My aim is to weave together contemporary psychoanalysis (Bateman and Holmes 1995), attachment research and narrative theory into a common story. My main argument is that narrative forms one half of a duality that lies at the heart of psychotherapy. This dichotomy can be expressed in a number of different ways: narrative and its deconstruction; prose and poetry; primary and secondary processes; story and image; ‘when . . . then’ and ‘present moment’; then and there and here and now. Things go wrong, I shall argue, when the balance of this duality is disrupted – too much prose and not enough poetry, or vice versa. Psychopathology, which I approach largely through attachment theory’s distinction between the various types of insecure attachment, can be seen in terms of an excess of one or other element. Let us begin with two contrasting clinical stories.

Example one: the constrictions of ‘story’ Tom, an unemployed youth of 20 living with his parents and 15-year- old sister, was referred by his family doctor for help with his ‘compulsive gambling’ which was causing enormous concern within the family. When Tom was interviewed alone the story that emerged was as follows. He had been unemployed since leaving college two years previously. Both his parents were working. During the day, while they were out and his sister at school, he would take items from the house such as video machines or his father’s tools, sell them to his friends and then proceed to spend the money on fruit machines. Things had come to a head when he had smashed the family car, which he had taken without asking and was driving without insurance, while on his way to a local gambling arcade. Tom, a shy and young-looking 20-year old, described how difﬁcult things had been since leaving college: how he had been unable to settle

Downloaded by [New York University] at 12:48 14 August 2016 in a job, and how his father had had a period of unemployment which meant they had lost their home and had to move into a smaller house. He had missed his Dad dreadfully when lack of local jobs meant that he had had to work away from home. When asked about his ‘winning fantasies’ in gambling, he spoke of how he dreamed of restoring both the family fortunes and his own reputation within the family. When Tom was interviewed with his parents a rather different picture emerged. Tom’s father, clearly a good man at the end of his tether, was constantly criticising his son; Tom’s mother was obviously

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depressed, sitting mostly silent with tears running down her face. They explained how they were convinced that Tom was ‘on drugs’: he was pale and tired all of the time, irritable and monosyllabic, just like the descriptions in the leaflet a friend had given them. They were then asked to confront Tom with this possibility in the session. Tom denied using drugs (as he had in the individual session, apart from occasional cannabis), while the parents looked nonplussed. The therapist suggested that his exhaustion and irritability might reflect depression rather than drug dependence. As Tom’s father continued to express his exaspera- tion – saying how they had several times been on the point of throwing Tom out but could not bring themselves to do so – the boy became visibly upset. The therapist reminded him of what he had said about his feelings while his father had been away. ‘Missed you dad . . .’ he said tentatively. Father was stopped in his tracks and looked tearful. With prompting he began to say ‘You’re not a bad lad, son, it’s just that you do bad things’. Tom went on to say how he felt an outsider in the family, while his parents and sister formed a cosy little threesome. Again mother and father looked upset, and mother began to say how she felt caught between her husband and son, and how, against her better judgement, she gave in to Tom’s demands for money. The session ended with the parents determined to be firmer with Tom, if necessary locking valuables away during the day, and with Tom and his father giving each other what seemed to be a genuine hug of reconciliation.

At the start of the session this family seemed trapped within a very restricted ‘story’ of their situation. Seeing Tom as a ‘compulsive gambler’ or a ‘drug addict’ made some sense of their distress, if only to medicalise it and so shape it in such a way that they could elicit help. The purpose of the psychotherapy was to introduce some perturbation into this rather rigid narrative, to disperse it for long enough for a new story to coalesce, one with more complexity, allowing for a greater range of emotional expression. The new story was one of a lost youth trying to rescue his family fortunes, of parents torn between lenience and violence, of the looming impact of unemployment. The crucial moment in the session came when Tom told his father he missed him, and his father responded

Downloaded by [New York University] at 12:48 14 August 2016 by becoming tearful. At that moment he seemed to listen to his son again, and see him as a person, not as a clichéd ‘story’. Momentarily, both escaped from their stereotyped version of events into a new envelope of shared feeling. In this example there is a movement from a secure but narrow ‘illness narrative’, through the dangers but creative possibility of uncertainty and unstoried immediacy, to the possibility of a new and less constricted narrative. Here, then, there was an excess of ‘story’. In the second example by contrast, we see un storied disturbance and emotional danger, in search of a therapeutic narrative that might provide a satisfactory ﬁt with experience.

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Example two: searching for a story that fits James, a successful teacher plagued by depression, arrived at his fifth session seven minutes late. Despite an apparently positive therapeutic alliance, the therapy had not been going well – therapist and patient struggled to find a real focus with which to work, James tended to expatiate about his situation and his life, but no real pattern emerged, certainly nothing that could be useful to him. In this session, both James and his therapist knew that James was angry with the therapist – James had asked the therapist to run a seminar for a group of teachers at his school, but the therapist had declined, on the grounds that it would interfere with the therapeutic process. James started the session by explaining that he was late because he had been helping a friend pull his car out of a ditch. The therapist mused to himself on the different possible stories of which this incident could form a part. He offered a fairly conventional transference comment: ‘Perhaps you are hoping I will pull you out of the ditch of your depression – you are showing me the way’. No, this did not seem to fit. James spoke of his need always to be looking after others – family, fellow-teachers, pupils, and now the friend who was stuck in the ditch. This linked with James’ childhood story: a feeling that his mother never really liked him, and was always fussing over his sister and brother. This led on to James’ feeling of rejection over the therapist’s refusal to speak at the seminar. Together, the therapist and James pieced together that by being late he was saying ‘I am angry with you. You don’t care about me. You are more interested in everyone else. Right, I’ll show you how people should be helped. I’ll get them out of their ditches even if you leave me in mine.’ Immediately, James began telling the therapist how helpful something he had said in a previous session had been. The therapist commented: ‘Do you notice how much your own aggression seems to threaten you? No sooner do you criticise me, than you have to tell me how wonderful I am, perhaps for fear I will retaliate or abandon you’. James laughs – a confirmatory response that the new story was on target.

In order to progress, both Tom and James had to face their fears. Tom and his Downloaded by [New York University] at 12:48 14 August 2016 family had to let go of their limited ‘teleological’ (see Fonagy 1995) account (‘he’s on drugs that’s why he’s “bad” ’) and allow the possibility of a family- wide set of painful emotions. James had to stand back sufficiently from his confusion (and his conviction of the ‘equivalence’ between his perceptions and what was unalterably the case) to allow a story to coalesce, however painful that might be. In James’ case the affective response confirmed that a story has been found that fits. This time, a narrative focus was helpful in filling in missing parts of a

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story – what was missing for James was his feeling of marginalisation, his rage about that, and yet the fear that were he to express anger it would further ratchet up his rejection. The previous example seemed to illustrate the opposite: tears marked liberation from the constrictions of the old story. The work of psychotherapy is to ﬁnd stories that ﬁt with experience. This may mean disrupting clichéd stories, or reaching for a narrative that can better comprehend the confusions of everyday feelings. Affective responsiveness seems to be one way of gauging how successful this process has been. But how does one establish the truth or otherwise of a narrative? Can a story be emotionally true, while being factually incorrect, and vice versa?

Can there be a science of narrative? Jerome Bruner (1986, p. 11), who was also worried at the discursive/non- discursive dichotomy, argues that there are two kinds of approaches to truth:

A good story and a well- formed argument are different natural kinds. Both can be used as a means for convincing another. Yet what they convince of is fundamentally different: arguments convince of their truth, stories of their lifelikeness. The one veriﬁes by eventual appeal to procedures for establishing formal and empirical truth. The other estab- lishes its truth by verisimilitude.

As an advocate of narrative, Bruner’s use of the word ‘verisimilitude’ is risky, given its deﬁnition in the Oxford English Dictionary (1973) of ‘having the appearance of being real or true’. Critics of psychotherapy might argue that this is a con- cession that the stories elaborated in psychotherapy can lay no more claim to the truth than can myths or fairy stories. How can this charge be answered? Bruner’s response, I believe, would be that there is truth in myths and fairy stories – emotional truth rather than factual truth – which can be judged, not by scientiﬁc standards, but by such tests as whether the story rings true, feels ‘right’, is satisfying, coherent or touches the listener emotionally. Ironically, a play has verisimilitude if it compels the audience to remain in a state of ‘suspension of disbelief ’ for the duration of the performance. Similarly, psychotherapeutic case histories could be Brunerian ‘good stories’ which have a paradigmatic value in

Downloaded by [New York University] at 12:48 14 August 2016 their own right, even though, by the standards of a ‘well formed argument’, by themselves they prove nothing. The criteria of a ‘good story’ certainly apply to psychotherapy. Psychothera- pists are constantly using their intuition to evaluate the patient’s narrative, asking themselves if it makes sense or hangs together, questioning aspects and anoma- lies that don’t quite ﬁt, probing clichés or phrases and well-worn narratives for what might lie beneath. As with Tom, the quest is always for a more elaborated, all- embracing, spontaneous, individualised, ﬂexible story that encompasses a greater range of experience.

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This evaluative activity, akin to aesthetics, is part of the ‘art’ of psychotherapy. But can there also be a science of narrative, including one that would encompass the narrative aspects of psychotherapy? One response is to concede that the quest is fruitless and that there can be no science of psychotherapy. The hermeneutic school of psychoanalysis, of whom Spence (1982) and Schafer (1992) were leading exponents, argue that what matters in psychotherapy is not objective or ‘historical’ truth, which is, in their view, in any case inherently unknowable, but ‘narrative truth’, i.e. something akin to Bruner’s verisimilitude. The main drawback of this position is the implication that a psychotherapeutic narrative is no more or less likely to be true than any other account of the patient’s distress, whether religious, narrowly ‘organic’ in the psychiatric sense, or delusional. My objection to this position is not based on a fear of losing the respectability that the mantle of science confers. Nor would I want to deny that psychotherapy is, among other things, a moral rather than a narrowly scientiﬁc discourse, in which questions about what it is to lead a good life and to ﬂourish as a human being are central (Holmes and Lindley 1997). My main worry about the hermeneutic turn in psychotherapy is that it threatens to cut psychotherapy off from aspects of science – especially from evolutionary biology, developmental psychology and contemporary neuroscience (Holmes 2012b) – where dialogue is both necessary and possible.

The contribution of attachment research While the immediate goal of psychotherapy may be to remove symptoms; behind that lies a set of more general and more ambitious objectives, to help the sufferer to ﬂourish, to foster well-being and so on (cf. Shedler and Westen 2007). These can be seen in terms of the development of a strengthened and more ver- satile set of selves: a more secure self, a more creative self, a more coping self, a more resilient self, a more autonomous self, a self with a greater capacity for intimacy. In contrast with the Cartesian cogito, narrative theory sees the ‘I’ not as a ﬁxed and pre- existing entity, but as an autobiographical self, formed out of the interplay between agency and contingency, needing to be ‘told’ to another, i.e. storied, before it can come into being (Brockmeier 1997). The telling of a self implies a built-in dialogical structure. There is always an ‘other’ to whom the ‘self ’ is telling his or her story, even if in adults this takes the form of an

Downloaded by [New York University] at 12:48 14 August 2016 internal dialogue. What are the origins of this ‘self- story’? How do we begin to learn about ourselves and our feelings? For psychoanalysts, Winnicott’s notion of maternal mirroring provides a model both of normal development, and of the possible role of therapy. When the mother looks at the baby, according to Winnicott (1967, p. 34), ‘what she looks like is related to what she sees there’. This clinical insight is supported by Gergely and Watson’s observations (1996) that an attuned mother helps her infant identify feelings by mirroring behaviour that has two characteristics. First, the mother’s facial expressions of emotion are marked by

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exaggeration, so that the child can see that they are reflections (of the baby), not expressions (of the mother’s affective state) and not real. Second, they are contingent on the child’s feelings, so that they arise only in response to the child, which in itself has a soothing function. Here we see the beginnings of a possible representation of, or story about, the self and its feelings. ‘Marking’ is related to the highlighting, figure/groundedness of narrative; contingency is linked with the way in which, unlike real life, stories hang together in a coherent way. Gergely and Watson’s (1996) speculations are based on the three decades of research on infant–mother interaction arising from Bowlby’s attachment theory (Holmes 1993/2013). Attachment research links this understanding of early life with clinical narrative in adults. The way we tell stories reflects our fundamental stance towards the world. The development of the adult attachment interview (AAI) by Mary Main and her colleagues (Main 1995) provided a scientific tool sophisticated enough to pick up some of the subtleties of the narratives that are the stuff of clinical reality. The AAI was developed as an attempt to find an adult analogue of Mary Ains- worth’s (1982) ‘strange situation’. The ‘when . . . then’ of the ‘strange situation’ studies the response of one- year-old children to brief separation from their caregiver. Securely attached children protest on separation; on reunion, their protests are accepted, ‘metabolized’ and soothed by their caregiver (which includes facial mirroring discussed above); they then return to exploratory play. Three well-known patterns of insecure attachment are recognised. Insecure-avoidant children protest little on separation, and on reunion with the caregiver hover nervously nearby; insecure-ambivalent children protest, but cannot be pacified when their caregiver returns, burying themselves in her lap or clinging furiously to her. The insecure- disorganised pattern was established after re- examination of videotapes of children who could not easily be classified as avoidant or ambivalent. These children show no coherent pattern of response, ‘freezing’ or collapsing to the ground, or leaning vacantly against a wall on reunion. In average populations about one-fi fth of children are avoidant, one- sixth ambivalent and one in twenty disorganised, although the proportion of the latter goes up dramatically in vulnerable groups, such as the socio- economically disadvantaged and where the mothers have been abused as children (Crittenden 1988). AAI is an audio-taped, semi-structured psychodynamic assessment session, whose aim is to ‘surprise the unconscious’ into revealing itself by asking detailed

Downloaded by [New York University] at 12:48 14 August 2016 questions about relationships with parents and signiﬁcant others, and about losses and separations and how the subject coped with them. Its system of cat- egorisation deliberately parallels those developed for the ‘strange situation’. As a psychometric instrument, the AAI is original in that its scoring system is based not so much on content as on the form and structure of the subject’s narrative style. Narratives are classiﬁed into one of four categories: ‘secure–autonomous’, ‘insecure–dismissive’, ‘insecure–preoccupied’ and ‘unresolved’. The key quality of secure–autonomous narratives is coherence: the subject is able to speak logically and concisely about their past and its vicissitudes, however

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problematic these may have been. Insecure–dismissive narratives (equivalent to avoidant attachment styles) are unelaborated and unrevealing: the subject may state that they have no memories of childhood before the age of 11, or that their parents were ‘brilliant’, without being able to amplify or produce relevant examples (cf. Tom). By contrast, in insecure–preoccupied narratives (equivalent to ambivalent attachment styles) the subject appears bogged down in their history, telling rambling and inconclusive stories as though past pain was still alive today (cf. James). The unresolved category is rated separately, co- existing with the others and referring to points in a narrative where the logical flow is interrupted, broken or disjointed. Main suggests that these narrative fractures may represent the emergence of previously repressed traumatic memories, and may be related clinically to dissociative states. The AA1 was developed within a theoretical framework that predicted that there would be connections between attachment experiences in childhood and narrative style in later life. Main and others have shown that, along with other measures looking at ‘autobiographical competence’ (Holmes 1992), such as picture completion and ‘tell-a-story’ tasks, attachment patterns in infancy are remarkably predictive of adolescents’ AAI status when measured some 15 years later (Benoit and Parker 1994; Slade and Holmes 2013). Fonagy et al. (1991) showed that the outcome of the AAI administered to prospective parents was a good predictor of attachment status of their subsequent one-year-old children, 20 months later. Mothers with secure-autonomous narratives tended to have children who were secure in the ‘strange situation’, while dismissive parents tended to have insecure–avoidant infants. Even more significantly, Fonagy et al. (1995) found that the capacity to think about oneself in relation to others – reflexive self-function (RSF ), mentalising or mind- mindedness (Meins et al. 2001) – is a key determinant of whether mothers whose own childhoods were traumatic will have infants who turn out to be insecure in the ‘strange situation’. The capacity for mentalising is a vital protection against psychological vulnerability in the face of environmental difficulty: an important finding for psychotherapists, since a large part of their work could be seen as enhancing mentalising in their patients. Clearly, too, mentalising is related to narrative competence: in order to tell a story about oneself in relation to others, one has to be able to find a vantage point from which to reflect on oneself – to see oneself, partially at least, from the outside – and this in turn

Downloaded by [New York University] at 12:48 14 August 2016 depends on the experience of maternal mirroring. Given their stability and predictive power it is reasonable to assume that attachment status and AAI classification are tapping into some meaningful psychological configuration. Attachment status seems to relate to patterns of parental handling in the first year of life, and is thus clearly an interpersonal phenomenon. Parental responsiveness to infant effect – of which the mirroring function is a central component – is a key determinant of secure attachment. In summary, environments may be consistently responsive, consistently unresponsive or inconsistently responsive. Mothers of secure infants pick their babies up

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more quickly when they show signs of distress, play with them more and generally seem more aware of them and their needs than the parents of insecure children. Parents of children who show the avoidant pattern are more brusque and functional in their handling, while parents of those who show the ambivalent reaction tend to be less attuned to their children’s needs, often ignoring them when they are obviously distressed and intruding upon them when they are playing happily. The ‘strange situation’ measures the enactment of the child’s relationship to her parents. The AAI by contrast defines individuals’ narrative account of their experience – a movement from mechanism to meaning, from attachment behaviour to representation of attachments. While attachment emerges from parental handling, narrative style has to do with individuals’ relationship with themselves. Between the ‘strange situation’ and the AAI a process of internalisation has taken place, which comprises an individual’s self- concept, representations of their significant others and the relationships between them, and their awareness of, and ability to report on, these phenomena. What then can we say about the origins of these kinds of awareness, and their relationship to security and insecurity? Here, Meares (1993) has developed a hypothesis based on what he calls ‘self-narrative’. He starts from Winnicott’s (1971) notion of the child’s need to be able to play ‘alone in the presence of the mother’ if a stable ‘true’ (in attachment terms, secure) sense of self is to emerge. By providing a quiet background presence, the mother, in a typical Winnicottian paradox, enables the child to forget her, and to concentrate on the self- exploration that is the essence of solitary play. If, on the other hand, the mother is unavailable, or inconsistent, or un-attuned, the child will be forced to think about his or her parent, and so be liable to develop a distorted representation of him or herself. Meares (1993) studied tape recordings of the type of speech used by 3- to 4-year-olds during this solitary play. Following Vygotsky (1962), he calls this ‘inner speech’, although at this particular stage in linguistic development it is audible and therefore available for scientific study. Inner speech has specific features that differentiate it from social speech. Rather like Freud’s (1911) contrast between primary and secondary processes, inner speech, unlike social speech, is non-discursive: disconnected and incomplete, words flowing into one another by association rather than following a logical progression. Audible ‘inner speech’

Downloaded by [New York University] at 12:48 14 August 2016 stops rather abruptly around 5- to 6-years-old. It is reasonable to speculate that self-awareness, which is so bound up with a sense of self, privacy, awareness of emotional truth and falsehood, and the ability to plan and to reﬂect on emotions, is a continuation of this play-talk described by Meares. What started as an interaction, shaped by the attachment dynamic, becomes internalised, so that the child now has within himself: (a) the vigilant yet non- intrusive maternal function; (b) the generative playful function; and (c) the capacity to put feelings into words. Acquiring inner speech means becoming intimate (‘intimate’ provides an etymological link between emotional proximity and

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communication) with oneself: knowledge of oneself goes hand in hand with knowledge of others. If required, the playing child can report on the goings on of the inner world: ‘I was pretending the mummy had gone away and the baby was sad.’ As an adult, perhaps during an AAI, they might be able to say: ‘When my parents separated I used to pretend that my doll’s mother had gone away and then returned.’ Psychoanalytic psychotherapy recreates the childhood situation of being ‘alone in the presence of another’; ‘free association’ perhaps none other than inner speech externalised once more. The acquisition of inner speech is a developmental function. We can imagine how it could be disrupted in ways that might correspond with insecure patterns on the AAI. If the parent is unavailable, the child may be so concerned with maintaining proximity that he will be unable to play and so find his inner voice, leading to dismissive narratives and difficulty with intimacy. Preoccupied narratives may reflect unmetabolised pain that has not been transmuted into the metaphor of play: the sufferer is searching for a safe container and using whoever happens to be at hand for that purpose. If the parent has been intrusive, the child’s self- narrative may be contaminated with a ‘false- self ’ parental narrative, always thinking and feeling what is expected rather than what might have emerged had more disinterested parenting been available. Finally, if the environment is traumatising the whole ‘containment/self-narrative’ envelope may be obliterated, leaving lacunae and discontinuities in the texture of inner reality and its representation in inner speech. These ideas can be linked with the notion of a child’s ‘theory of mind’, as developed in the psychoanalytical literature by Fonagy et al. (1995), Leiman (1995) and Hobson (1993). Fonagy argues that traumatised children lack a ‘theory of mind’ in the sense that they have difficulty in seeing others as having feelings, intentions and desires, any concomitantly cannot accurately define their own inner world. Faced with aggressive or sexually intrusive parents, the process of inter- subjectivity in which children share their experiences of the world with their caregivers via visual cueing, imitation and so on, is inhibited. Leiman (1995) sees this in terms of inhibition of the normal mediating function of the parent, who, under favourable conditions, helps to create shared meanings in the transitional or interactive space between the child and his or her objects. To perpetrate cruelty, the abuser has to remove from their consciousness the knowledge

Downloaded by [New York University] at 12:48 14 August 2016 that the child can experience fear, pain, disgust and so on (the ultimate example of this is the abuser who then murders the victim in an attempt to obliterate mirroring altogether; unthinkable though they are, such things happen, as front-line psychiatrists like myself will miserably attest). The child grows up in a world in which feelings, and meanings, are discounted or obliterated. At the same time the child is dependent on the abuser, and may indeed be strongly attached to them. There is often a vicious circle, based on the attachment dynamic, in which the more the child is traumatised, the more they cling to their attachment ﬁgure, who is thereby encouraged to perpetrate further abuse, and so on. The abused

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child is also likely to deny the existence of their abuser’s mind, since not to do so would be to face the unacceptable fact that those one loves and on whom one depends have malevolent intentions towards one. In summary, the findings of attachment research suggest that there may be objective criteria – coherence, succinctness, relevance, etc. – by which to evaluate the ‘verisimilitude’ of a clinical narrative. It also points to powerful links between the ‘narrative truth’ of the clinical situation and the ‘historical truth’ of the patient’s actual biography. The autobiographical self can be seen in terms of an inner object with which an individual has a relationship, comparable to ‘external’ relationships, which can be understood in terms of different attachment styles. At a clinical level, the psychological fluidity of the secure–autonomous individual can be contrasted with the relatively static (in psychoanalytical terms ‘defended’) positions of avoidant or ambivalent attachment. Gergely and Watson’s (1996) ideas suggest that there is a close relationship between the development of the self and secure attachment. ‘Marking’ enables one to distinguish one’s own feelings from those of others, and is thus a bulwark against the excessive use of projective identification. Where ‘marking’ breaks down, which may be particularly the case in ambivalent attachment, the child may be unable to distinguish her feelings from those of the mother: ‘Is it my feelings I am seeing myself in the mirror, or hers?’ Contingency is related to the ‘truth’ of one’s feelings, helping one to ensure that there is a correspondence between an emotion and its representation. Here, avoidantly attached children may be especially vulnerable, since they have not had the wrappedness of attention that is needed for them to ‘find’ their feelings in the mother-mirror. Those who are securely attached therefore can: (a) distinguish between their own experience and that of others; (b) represent and so tell the story of their feelings and (c) have the capacity to break up their stories and reform them so that they are more in keeping with the flux of experience. Ambivalent individuals are so close to their feelings that they cannot achieve the objectification akin to Gergely and Watson’s (1996) ‘marking’ – needed for a working story. Avoidant people, by contrast, cling to a stereotyped version of themselves and their past, and feel threatened by the idea of the constantly updated narrative, one that is regularly checked for contingency, that is characteristic of creative living.

Downloaded by [New York University] at 12:48 14 August 2016 The linguistic triad and the triangles of psychotherapy Patients seek help in a state of uncertainty and confusion. Something is ‘wrong’, but they do not know what this is, or what to do about it. Footsteps may have to be retraced: a story is needed which will both explain how they arrived where they are and point the way forward. Psychotherapy, like art, ‘holds a mirror up to nature’. The patient learns to put his or her feelings into words; these are then ‘reflected back’ by the therapist (‘marking’); the patient then re-checks this reflection for its congruence – whether it ‘feels right’; finally a representation, or story is formed. In

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the remainder of this chapter I shall explore the formula: raw experience plus meaning equals narrative. Patients learn to build up a ‘story-telling function’ which takes experience from ‘below’, and in the light of overall meanings ‘from above’ (which can be seen themselves as stored or condensed stories) supplied by the therapist, fashion a new narrative about themselves and their world. This schema can be compared with the linguistic triad of signiﬁed (the object), sign (its verbal representation) and the lexicon from which the sign is drawn (Brockmeier 1997). The sign is linked to the referent via the world of language. Similarly, a story is linked to what I am calling ‘raw experience’ – what is pointed to – via a world of meanings. It seems likely that the capacity to make this link is a developmental function, mediated by early attachment experience. The attuned mother responds to her infant’s affective state, via identiﬁcation, based on her own ‘lexicon’ of feelings (Fonagy’s RSF ). A ‘story’ is offered to the infant (‘Oh you’re feeling cold, bored, cross, wet, tired, hungry . . .’ etc.) which in turn forms the germ of that child’s RSF. If the caregiver is avoidant, the range and complexity of the stories will be limited; if intrusive, will fail to match the child’s experience, imposing her own experience on his or hers. Care- givers do not just sooth their infants, they also symbolise the soothing process. In later life the child in whom this has failed may lack both the capacity for self- soothing (so characteristic of borderline patients) and the ability to talk about, or symbolise their distress. Here we have a model for transgenerational transmission of psychopathology, and a picture of how psychotherapy might help break that cycle. How then does the psychotherapist function as an ‘assistant autobiographer’? In this concluding section I shall consider some ways in which the narrative principles impinge on the psychotherapeutic process.

Narrative as a therapeutic technique The ﬁrst task of the therapist is to assist the patient to tell their story. The starting point will be some form of distress: something is not right, things have gone wrong, the sufferer is not as they would like themselves to be. Desires have been thwarted, hopes dashed. The attachment research outlined above suggests that secure attachment is marked by coherent stories that convince and hang together, where detail and overall plot are congruent, and where the teller is not so

Downloaded by [New York University] at 12:48 14 August 2016 detached that affect is absent, is not dissociated from the content of the story, nor is so overwhelmed that feelings ﬂow formlessly into every crevice of the dialogue. Insecure attachment, by contrast, is characterised either by stories that are over elaborated and enmeshed (un-‘marked’), or by dismissive, poorly ﬂeshed- out accounts, that lack contingency. In one it is barely possible to discern a coherent story at all; in the other the story is so schematic or vague that it lacks the detail upon which verisimilitude depends. Starting with the assessment interview, the therapist will use their narrative competence to help the patient shape the story into a more coherent pattern. With

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an enmeshed patient the therapist will introduce frequent ‘shaping’ remarks or punctuations such as: ‘We’ll come back to what happened to you as a child in a minute; first let’s hear more about what is troubling you right now . . .’. Note the ‘We’ll . . .’, ‘Let’s . . .’ construction in which therapist and patient are brought together as joint authors of the story. This is the beginnings of objectification, but also a model for an internal observing ego (or self- reflexive self ) that can listen to and modulate feelings. Shaping a story is the narrative version of the modulation and responsiveness of the security-transmitting caregiver. With a dismissive patient the therapist will elicit narrative in a different way, always searching for detailed images, memories and examples that bring per- functory stories to life. ‘What was your mother like . . .?’; ‘Can you remember an incident that illustrates that . . .?’; ‘When did you first start to feel so miserable . . .?’; ‘When you say you feel depressed, what does that feel like . . .?’; ‘Whereabouts in your body do you experience your unhappiness . . .?’. In both cases, the therapist offers intermittent summarising or ‘marking’ remarks, which serve to demarcate ‘the story so far’, and to confront the patient with a narrative construction against which to measure the raw material of their experience. Some of these comments may be purely, yet pointedly, descriptive: ‘When you were talking about your relationship with your husband you appeared to be apathetic and defeated, yet when you started to tell me about your children you become quite animated!’ Others will be more general and overarching: ‘You seem to be confident about your relationships with women, including your mother and girlfriends, but feel much more uncertain when you come to speak about men . . .’. These kinds of interventions would perhaps be classified as ‘pre- interpretations’, yet by translating a shared experience into verbal form they are interpretative in the sense of carrying over experience in one medium (‘raw experience’, affect) into another (words, narrative conventions). Here again we find a variant of the semiotic triad of signified, sign and language. As therapy proceeds the shaping process becomes less obvious, and is probably most evident in the therapist’s rhythms of activity and silence, the balance between verbal interventions and ‘mmm . . .’s, grunts and indrawn breaths. Like an attuned parent, the effective therapist will intuitively sense when patients need stimulus and direction to keep the thread of narrative alive, and when they need to be left alone to explore their feelings without intrusion or control. Some- times, especially when the therapy feels stuck, the therapist may simply describe,

Downloaded by [New York University] at 12:48 14 August 2016 or tell the story of what has happened, either in a particular session or a sequence of sessions: ‘You started off today seeming rather sad, and finding it hard to focus, then you began to talk about how difficult you always find Christmas, then you mentioned your friend’s aunt who died suddenly’. This story may well provoke a realisation, or moment of insight such as: ‘Oh . . . it was Christmas when my grandmother died, I always feel a bit down at this time of year . . . maybe that is why. . . .’ This will mark the end of this narrative sequence; the narrative is dispersed, mingled with new experience, until a new narrative sequence emerges.

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In psychoanalytical psychotherapy the transference becomes a ‘meta- story’ which shapes the overall therapeutic interaction. Each session consists of a number of narrative episodes: what happened on the way to the session, an argument at work, something that happened with a partner, a memory from childhood and so on. Luborsky (1984) has shown that most therapy sessions contain roughly three such episodes. Let us say the patient starts the session before a holiday break by talking about an incident at work in which his boss asked him to do a job, but without showing him clearly how it was to be carried out. The therapist might comment: ‘There seems to be a story here about being left to fend for yourself without proper support. . . .’ This might then prompt the patient to talk about how his parents left him in charge of his younger brother without explanation, and how frightened and angry he felt about this. This in turn may lead to a sudden realisation about how upset he is about the coming break. A core story is emerging about abandonment and the response it evokes. Implicit in my argument so far is the view that psychological health (closely linked to secure attachment) depends on a dialectic between story- making and story- breaking, between the capacity to form narrative, and to disperse it in the light of new experience. In Main’s (1995) evocative phrase, the securely attached child shows a ‘fluidity of attentional gaze’, and in adult life narrative capacity similarly moves between fluidity and form, between structure and ‘de- structuring’, construction and deconstruction. This capacity ultimately depends on being able to trust both intimacy and aggression (Holmes, J. 1996), which form the basis of much psychotherapeutic work. Intimacy provides the closeness needed if meaning and experience are to be woven into narrative; trusting one’s aggression enables these stories to be broken up and allowed to reform into new patterns. The attachment perspective I have adopted suggests three prototypical pathologies of narrative capacity: clinging to rigid stories; being overwhelmed by unstoried experience; being unable to find a narrative strong enough to contain traumatic pain.

Nodal memories: deconstruction dismissive narratives Just as language is inﬁnite but based on a ﬁnite number of simple grammatical rules, so, despite the potentially limitless capacity of memory, most people have a small number of prototypical memories that epitomise their fundamental rela-

Downloaded by [New York University] at 12:48 14 August 2016 tionship to others and to the world. These often concern important transition points – the birth of a sibling, a ﬁrst day at school and so on. They might be called ‘nodal memories’ in the sense that they represent a concentration of the assumptions, fantasies or working models about the self in relation to others. They may be actual or imagined. The subject usually ‘reads’ a particular meaning into them which acts as an organising principle around which they structure their present-day experience. One patient learned that she had been left in her cot for ﬁve hours after her birth: in her mind this represented (and explained) all her subsequent feelings of

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cut- offness and rage about being abandoned by lovers, friends, etc. Another, mentioned already dreamed that he was standing at the door of the flat in which he had grown up, with his mother holding his testicles: ‘There you are’, he would say ‘they’ve got you by the balls’ (cf. Chapter 3). A third focused all of his feelings of being intruded upon by his mother, and lack of recognition for his achievements by his father, on his circumcision as a baby. Countless examples could be enumerated: the woman who had a terrible row with her mother the night before she died of a heart attack, and continued to blame and punish herself with depression thereafter; the young man thrown out of the house by his father, whom he claimed was ruining family life with his bad temperedness. In the process of psychotherapy these nodal memories become re-worked. First, they have to be unpacked – ‘cracked up’ in Bollas’ (2007) terms – and then reassembled, taking on a new perspective. The woman in the cot came to see that her mother was simply following the child-rearing fashions of the day, and that her furious attempts to be self-suf ficient – to mother herself – had indeed cut her off from the good things her mother did have to offer. The testicle dream became transformed into an image of a mother trying to protect her son and his generativity from the harshness of the outside world. The same man had another dream which was simply an image of the post office tower: ‘I suppose that’s a phallic symbol’, he said glibly. But what really seemed to fit was the tower as a symbol of communication, a way of linking with others which this lonely man so desperately craved. The man who so resented his circumcision, now a successful test- pilot, came to see how his phallic prowess and fear of having his wings clipped flowed from his longing for a father to whom he could get access (the father had abandoned the family when the patient was 15) and who would see him as an equal. The depressed woman whose mother had died came to see her self-blame as a desperate wish that she could have at least some control over her fate, however painful. Finally, the man who argued with his father saw how he might have provoked the argument in order to stimulate his normally conciliatory father to be more authoritative. In each case the patient comes to see that there are many versions of the same story. Therapy provides an opportunity for the subject to begin to see himself from the outside; to forgive parents as well as to blame them; to see and own his contribution to circumstances, rather than viewing himself as a helpless victim;

Downloaded by [New York University] at 12:48 14 August 2016 and to recognise that there are occasions in which fate deals us cards over which we have no control.

Example three: changing the narrative context of memory Dave was in his mid- fifties when he suffered from a prolonged depression triggered by being made redundant from the firm in which he had worked his way up from the shop floor to be factory manager. His father had died in the war when he was two, and his widowed

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mother struggled to make ends meet for herself and her two children. He had always tried to be a ‘good’ boy, to help his mother, had worked hard and was an indefatigable servant of his employers as well as father-fi gure to those who worked under him. In his depression he alternated between attacking himself for his failure to prevent the firm from going into receivership, and violently attacking his bosses for their financial mismanagement. In one typical state- dependent moment of recall he vividly and guiltily remembered an incident from childhood in which he had been at the cinema with some other boys. One of them proudly produced a half- crown which he stated that his dad, whom he claimed was ‘very rich’, had given him – and then accidentally dropped it. Dave immediately offered to help him retrieve it, which he did, whereupon he walked out of the cinema with the money in his pocket. Fifty years later this scrupu- lously honest man was still berating himself for this callous act of theft. When the therapist gently suggested that perhaps he had felt that he, as a fatherless child, was entitled to purloin the money that this boastful son’s father had given him, there was a sudden shift in the session as tears came to Dave’s eyes. A new context for his depressive, guilt-laden story had been created, one which encom- passed his pain as well as his crime.

‘Negative capability’ and ambivalent narratives This chapter began by contrasting the security of narrative prose with the poetic impulse to make contact with the ‘thing itself ’, suggesting that psychological health might depend on a balance between these opposing psychic tendencies. The prosaic structure of narrative contains, reassures, soothes – but may also constrain, control and distort. Lyric poetry can be a liberation from story, enabling us to see the world with fresh eyes, but its capacity to fragment meaning takes us dangerously close to the limits of understanding. In the previous section we saw how, starting from nodal memories, psychotherapy can help break up stories and so broaden the range of admissible experience. Equally, there is often a need to ﬁnd ways of capturing the confusion and vagaries of overwhelming feelings.

Downloaded by [New York University] at 12:48 14 August 2016 Here Keats’ ‘negative capability’ – the ‘ability to remain in doubts, uncertainties and mysteries’ – is vital. The therapist has both to be able to tolerate confusion, while trusting that a meaningful pattern will eventually emerge.

Example four: ﬁnding a narrative thread Naomi’s sessions were confused and rambling, moving rapidly from topic to topic and from past to present and back again. She was tearful for much of the time, and seemed to ‘ﬂop’ into her chair, gazing

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imploringly at her therapist, without ever clearly stating what was wrong or what she wanted. She ‘didn’t know why she had come . . . she had had a bad week . . . lots of worries about her 15-year- old son who was getting nowhere at his school . . . it all started when she discovered that a friend had also been raped by the same man who had raped her when she was 17 . . . her mother was dying then so she couldn’t tell her or her father, they had too much to worry about . . . with two small kids and a new husband it’s difficult to find time to talk . . . she met her first husband almost immediately after her mother’s death . . . it was a relief to get away, the atmosphere was so sad . . . it was odd when her father remarried after her mother died, she couldn’t get used to him holding hands with a new woman . . .’ Gradually piecing together the story of the rape and her mother’s illness seemed to help. She had left home at 16 after many rows with her mother and was working as a nanny. When her mother became ill she was expected to return home tο look after the house. The rape happened on the way back from a party with a man she hardly knew. She described it in graphic detail. She arrived home in the middle of the night. Her father called down: ‘Alright?’, as he always did. She could not bring herself to tell him, he was so worried about her mother. All this had happened 20 years previously, but it seemed like yesterday, she was not much older than her son is now. He is so difficult to talk to. Now things began to fall into place. The therapist commented: ‘You did not talk to your mother, just rowed, and then she died; you could not burden your father; now you worry about your son, but can’t talk to him; in coming for help you are looking for someone who will listen to the story you kept to yourself all those years ago.’ ‘I did tell my doctor – but he told me to forget about it, he wasn’t much good, he committed suicide in the end.’ Now at last a pattern was emerging – of painful feelings of loss and worry, of wanting help but never quite trusting it, of clinging on with words – listening to the long rambling stories at least means someone is there, even if they can’t really ‘hear’ the meaning behind the words. The therapist mused; ‘Perhaps you are wondering if I will be able to take it, or whether I will get angry, and let you down like the others, whether I am really prepared to listen to how dis-

Downloaded by [New York University] at 12:48 14 August 2016 tressed you are.’

Here there was a movement, from fragmentary and often poetic feelings, images and themes, through a period of confusion, to a resolution in which a more solid interpretative story or pattern emerged. This is a familiar pattern with preoccupied/enmeshed narratives. The session starts with laying out the jigsaw pieces; an edge or container is formed; then images begin to come together – here a cloud formation, there a face; ﬁnally, there is a rapid period in which the pieces fall into place and the beginnings of a full picture appears at last.

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Stories in search of a voice: working with trauma In the case above, Naomi had been traumatised by the rape, but she was able to talk about it to some extent, and with a little prompting could give a detailed and convincing account of what happened. For others, memories of traumatic events are associated with such unpleasant emotions that they are avoided in a phobic way. At the extreme of this is traumatic amnesia or repression. There is evidence that in these situations memory for trauma is organised differently from ‘normal’ memory. The subject will recall images, or physical sensations but not a coherent sequence of events. If they are asked to recall the trauma during neuroimaging there is activity in parietal regions of the non-dominant hemisphere (Van de Kolk and Fisler 1996), while normal memories evoke dominant hemisphere activity. This suggests that traumatic memories have not been processed into a verbal, narrative, form, but remain in a ‘raw’ primary process state. Trauma breaks through (or ‘pierces’, the etymological origin of the word) the self–other dialogue that underpins thought and language. The narrative self, is obliterated, and all that remains are dissociated images and sensations. When it is a caregiver who is responsible for the trauma, then this likelihood is increased since, as argued earlier, the perpetrator is the very individual whose responsibility is to help with the process of symbolisation and soothing. Feelings of shame, typical of trauma survival, are an elaborated version of this: the sufferer is an outcast, unworthy of attachment, rejected of men. Basic trust has broken down. Therapy can help, but often with extreme difficulty. The sufferer has to feel sufficiently held to risk the extreme emotional pain that may be associated with recall of the trauma (cf. Chapter 5). Some means of symbolising or mirroring raw experience is required – often poetry, draw- ings or guided fantasy are first steps towards the elaboration of a coherent narrative of the trauma. The therapist becomes witness, but how can he or she, possibly grasp the unthinkable? The therapist stands for the part of the victims’ self that could not bear to look at what was being done to them. By revealing the story to themselves the victims fear they will become enmeshed in the story, unable to escape. Previous narrative defences, such as psychic numbing, dissociation of feelings from story, selective forgetting or even fragmentation of personality will be challenged as a more coherent and often unbearably painful account emerges, but one that seems to correspond more closely with Downloaded by [New York University] at 12:48 14 August 2016 experience. Thus, trauma victims are often initially avoidant, and later become potentially trapped by their story. Turning trauma into narrative in therapy requires a sequential process, starting with the overcoming of avoidance by imagery, and later moving to a more objective, distanced position where the victim can identify with the therapist’s benign concern. The fact that minor aspects of trauma can be played out symbolically in the transference helps with this process, since it becomes shared, and therefore potentially narratable.

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The role of the therapist Working with traumatised patients tests not just the skills of therapists but also their personal strengths. Their moral maturity will be exposed, especially their ability both to use their own feelings in the service of the therapy, without allowing them to direct, dominate or intrude upon the patient. Williams and Waddell (1991, p. 19) traces the evolution of George Eliot’s sensibility from the early novels, which, they argue ‘suffer from an intrusive imposition of self, a persistence of personal elements that block her creative vitality’, to her mature novels, which

seem to produce a force and refinement of writing which is wholly distinct from that which seeks to express aspects of character which are superficially much nearer to her own experience in the sense of personal longings and aspirations. The danger then . . . is the imposition of feeling from the outside, resulting in sentimentality and pseudo- emotion. The emotional space necessary to, and produced by, that distinctness invites an identification on the part of the reader with . . . the inner qualities and characteristics of the object rather than the external and more available ones.

A similar maturity would be a goal for therapists who will inevitably draw on their own experience and preoccupations in their identification with patients, but at the same time have to find a distance – Waddell’s ‘distinctness’ – that enables them to allow the patient’s imagination to flourish, unimpeded by control or manipulation. Thus the therapist’s attachment style, and pari passu their narrative style, will be an all-important element in determining the outcome of therapy. Enmeshed therapists tend to impose their own narrative on patients, or get bogged down in interminable stories that have no end, while those with avoidant styles may fail to pick up on vital emotional cues and jump to unwar- ranted conclusions. The therapist’s task is to be attuned while retaining balance, a position I have called ‘non- attachment’ (Holmes, J. 1996), but which could also be seen as finding a ‘vantage point’, as the following concluding anecdote tries to illustrate.

Example ﬁve: non- attachment as trauma narrative

Downloaded by [New York University] at 12:48 14 August 2016 emerges After more than a year in weekly psychotherapy, Dave, already mentioned in example three, revealed with intense shame that he had been at approved school in his late teens. He then said that he had been admitted to psychiatric hospital around that time, a fact he had only vaguely alluded to before. Then he spoke of the circumstances leading up to the admission. It seemed that he had doused some rags in petrol, wound them round his legs and set ﬁre to them. As he spoke of this the

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therapist sat silently, rapt with attention, picturing vividly this now pon- derous silver haired, late middle- aged man as a 17-year old. There was still a mystery to unfold. How did it all hang together? What ‘made’ him do it? Dave spoke of his naval school, to which, as a bright naval rating’s orphan he had a scholarship, and the contrast between his schoolmates’ parents who appeared on speech day in their ofﬁcers’ regalia, while his mother and stepfather never came (they could not afford the train fares), and if they had would have shamed him with their shabbiness; of his envy and contempt for these well- heeled lads who had no inkling what it was to suffer. All this seemed relevant to his feelings about his ‘posh- accented’ therapist, to whom he was strongly attached, and yet could not fully trust. This too was sensed ‘impersonally’ by the therapist [the author] – he could feel the hostility, the longing, the envy, the dependency, but in an objective way, that seemed to have little to do with him as a person. At this intense moment he did not exist; he was a projection of his patient’s inner world, and yet at that moment felt intensely alive and very much himself. Then Dave made the missing connection: one of the staff at the approved school was sexually abusing the boys in return for cigarettes, and had made advances to Dave. He was deeply ashamed about this coercive propositioning which touched his longing for closeness (still speaking of his never-known dead father as if he were a close companion), his anger at the abuse of that craving, his embarrassment and confusion. This was what had led up to the episode of self- harm. As he listened, the therapist felt the story almost as if it were happening to him, yet impersonally – both fully involved and at the same time watching, observing, still able to protect the boundary of the session, both for himself and the patient.

This is an inadequate attempt to capture an intense quasi- mystical moment in therapy – moments that occur regularly but infrequently. Perhaps, in the end, this is what therapy is about: the emergence of a story that is both intensely felt (captures ‘raw experience’) and has an objective validity (congruence, contingency, verisimilitude). The therapist’s speciﬁc contribution to this process is as witness, holder of the narrative boundary, ‘subjective-object’ (in Winnicott’s

Downloaded by [New York University] at 12:48 14 August 2016 terms), facilitator and one who is able both to lose himself and remain true to himself in the process. Winnicott writes of the importance of ‘bringing the trauma into the area of omnipotence’ (Winnicott 1971). In the transference the therapist becomes both the longed for and the abusive object – but because trans- ferentially rather than actually so, one that is potentially transformational. Dave’s therapist was responsible for creating a dependency, and with that the hope that, at last, Dave would have the enduring inner object, the missing father, he so longed for. At the same time that hope was constantly (‘sadistically’) dashed by the realisation that his father could never come back to life again.

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Conclusion Such moments of insight, however signiﬁcant, can never be ﬁnal points of arrival. Each story is there to be revised in the light of new experience, new facets of memory, new meanings. I have tried to bring to life the cycle of narrative construction and deconstruction that I believe is central to the therapeutic process. I have argued that narrative has its psychobiological origins in the ‘marking’ and contingency of maternal mirroring. I have traced the links between infant attachment patterns and adult narrative styles. I have tried to show how, in psychotherapy, the therapist shapes the patient’s story-telling and mirrors their affective experience in a way that leads to a more secure sense of self. My concluding hope is that some fragments of this story will coalesce in the mind of the reader to form the building blocks for more tales, as yet untold. Downloaded by [New York University] at 12:48 14 August 2016

85 7 CHANGE Llosa’s Aunt Julia

According to Goethe, (Polti 1916) ‘there can be but 36 tragic situations’, although later Foster- Harris (1959) narrowed this down to three basic literary plots. Whatever the arithmetic, arguably there is in any novel a basic underlying emotional structure in which personal or interpersonal tension, conflict, quest, developmental challenge or problem is stated at the outset and then, through the action, modified in some way to an ending, whether happy, tragic or inconclusive. Similarly in therapy there is, at least in the minds of patient and therapist a sense of movement from presentation of a symptom, its explication and understanding, to attempts at resolution, accommodation or modification. One of the central characters in the Peruvian Nobel laureate Garcia Llosa’s ‘magical realist’ masterpiece, Aunt Julia and the Scriptwriter (Llosa 1975) is a psychiatrist. In true tongue- in-cheek post- modern style the novel contains a number of ‘stories within a story’, one of which depicts a fictional psychoanalytic therapy. In it is to be found the three essential ingredients of good therapy: attachment and affect regulation; meaning making; and change promotion. This chapter focuses on the latter. Change comes about through getting in touch with desire and emotional truth. We can make good choices only if we can come to see what it is that we really want in life. Truth is an indispensible guide to action: the more we uncover the veil of ignorance which surrounds our deepest wishes, the more likely are we to see a way forward out of our difficulties. In the novel Lucho, a travelling drug salesman whose wife of three months is pregnant, is involved in a horrendous road accident. A child suddenly runs in

Downloaded by [New York University] at 12:48 14 August 2016 front of his car; he stops; while examining the moribund child on the highway, he is himself run over by a juggernaught truck whose brakes have failed. The child is killed and he is badly injured. He makes a full physical recovery but develops appalling Post Traumatic Stress Disorder (PTSD). He is unable to sleep, concentrate, relax or contemplate travelling in a car. His wife has a miscarriage, the marriage breaks down and she returns to her parents. Eventually his company send him to a renowned psychotherapist, Dr Acemila, a middle-aged, cultured woman with a formidable reputation.

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Her ﬁrst move puzzles Lucho: she asks him not about his problem, but his constipated bowels, and immediately prescribes regular use of prunes with his breakfast. Only then does she say (p. 180)

You may [now] tell me what is troubling you. But I warn you I shall not castrate you of your problem. I shall teach you to love it, to feel as proud of it as Cervantes of his useless arm, or Beethoven his deafness.

Here we see her skilful management of Lucho’s attachment anxiety. Like a parent in the ‘strange situation’, by distraction and physical soothing she reduces his panic to manageable proportions. She offers a positive connotation and sooths his fragile ego by linking it with famous men (neurologists comfort people suffering from epilepsy by reminding them that Julius Caesar and Dos- toyevsky were similarly afﬂicted). Lucho is now ready to explore his feelings. Once the story is told she immediately moves to meaning-making, offering a seemingly shocking interpretation (p. 181). She explains that: ‘so called acci- dents [do not] exist; they [are] merely subterfuges invented by men to hide from themselves how evil they were’:

You wanted to kill that little girl . . . and then you were ashamed of what you had done, and afraid of the police or Hell, so wanted to be hit by the truck, as punishment for what you had done or as alibi for murder.

Her formulation is inherently mentalising, in that even a horrendous road accident can only be understood if the part played by the mind in its construction and narrative re- construction is taken into account. She communicates to Lucho that unremarkably (‘your story is so banal and stupid it bores me’), there is a part of his mind inhabited by murderousness, stimulated, we speculate by the imped- ing arrival of a baby, threatening to wrest his wife from his sole possession. Unacquainted with this aspect of himself he is horriﬁed, so relentlessly punishes himself with mental pain. Attachment and meaning-making now accomplished, Dr Acemila now moves onto her change-promoting prescription. The working- through she suggests entails a change of attitude, and a homework task. She gives him a written prescription: ‘exercises for living sincerely’. If he is to live authentically he has to

Downloaded by [New York University] at 12:48 14 August 2016 accept his hostility towards children, see how demanding, difﬁcult, and time and money-consuming they can be. He must get in touch with his aggression and feel able to dislike child- beggars, the whining, puking children of his friends and the ways in which they destroy women’s beauty and detach them from their men-folk. In addition he is asked to re- enact the scene of the accident by building a model of it with children’s toys – to bring the trauma, in Winnicott’s terms, into the realm of omnipotence (Casement 1985). Lucho is now in a bind which can only lead to cure. If he disobeys Dr Acemila and becomes loving towards children, his good feelings have returned;

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if he submits to her prescription, his crippling guilt is undermined, sense of helplessness lessened. One day he frightens himself by thinking he might actually physically attack a child. In a blind panic he orders a taxi and rushes to Dr Acemila’s surgery. Suddenly he realises that he has travelled to her without a second thought in a once-dreaded automobile. He is on the first steps to ‘cure’. He reconciles with his wife, and she becomes pregnant again. But Lucho is worried that his hatred of children may return in relation to his own child, fearing that he may become an ‘infantical recidivist’. Dr Acemila’s replies (p. 190): ‘have no fear: you’ll recover before the fetus grows eyes’ (and be able to see its father’s murderousness). As befits a post- modern tale however, the concept of ‘cure’ remains in doubt; we are left wondering whether Dr Acemila’s certitude is to be trusted, or whether she is madder than her patients, or her ‘friends’ as she prefers to call them. Due allowances must be made for poetic licence. Dr Acemila’s ‘integrative’ combination of nutritional therapy, Kleinian interpretation and cognitive behavioural therapy cannot be routinely recommended (I once saw an advertisement in a Los Angeles newspaper for ‘psychoanalysis and colonic irrigation: first session free’). Nevertheless, the moral of this tale is germane. Her triad of attachment, meaning-making and change-promotion gets results. And the literary genre of magical realism itself is paradoxical. The novel rests on the questionable premise (based on Llosa’s own life) that an 18-year old can transcend the Oedipal incest taboo and happily marry his 32-year old aunt by marriage. The reader is poised between vicariously enjoying the transgressive aspect of sexual love, and knowing that in reality it is doomed to failure. Paradoxically, by imaginatively exploring in this way the extent to which fantasy can invade ‘real life’, the contact barrier (Bion 1962) between the conscious and unconscious minds is strengthened, a precondition for psychic health. The act of closing a book, the falling of the curtain at the end of a play, the silence when a musical performance comes to an end, the sequestered special places inhabited by art – the galleries, theatres, concert halls, libraries – all reinforce this boundary, so that the non- discursive realm can strengthen its identity, and so maintain its equal status with the world of Caesar’s Mammon. Downloaded by [New York University] at 12:48 14 August 2016

88 8 SOCIETY Evelyn Waugh and Jane Austen

This chapter recruits two novelists, Waugh and Austen, and two critics, Leavis and Snow, to help tackle two related questions. What are the ingredients leading to ‘mutative moments’ in literature and therapy? How might the social role of psychotherapy be widened? In the opening scenes of Evelyn Waugh’s novel Scoop (1938/2003), William Boot, nature correspondent of the Daily Beast, famous for such lines as ‘feather- footed through the plashy fen passes the questing vole . . .’, is summoned from his remote country seat to the metropolis. The newspaper’s proprietor, Lord Copper, has been tricked by the brilliantly scheming Mrs Algernon Stitch into appointing Boot war correspondent to the Civil War in the remote country of Ishmaelia. Copper brooks no refusal; every time Boot protests that his speciality is nature, not war, he doubles his salary. Boot goes, and eventually returns a hero, having, through sheer naïveté and luck, got the story which eluded the sophisticated Fleet Street journalists. But he was the wrong Boot all along. Mrs Stitch’s protégé was Courtney Boot, the fashionable novelist. Memories of this plot came to mind when I opened, with excitement and some anxiety, an invitation to give the British Journal of Psychotherapy annual lecture. Had they got the wrong person? What could a rural refugee, only partially assimilated into the mainstream of psychotherapy, have to say that would be relevant or interesting? But then, like Waugh’s readers, I abandoned myself to the Oedipal reverie of the changeling, the naïve younger brother, who, with the help of the good fairy, outﬂanks the corrupt patriarchal order. Tempering this fantasy with reality, I began to think that perhaps there was something to be said

Downloaded by [New York University] at 12:48 14 August 2016 for a view from the periphery, a rural worm’s-eye view of urban psychotherapy. I reminded myself that Waugh had also made a move from London to the West Country, that Scoop marks the transition from the witty chronicler of the gay young things of the 1930s to the more serious concerns of his later novels; that psychotherapy might need, if not a barefoot view, at least a gum-boot as well as a Gucci. To continue in this homespun vein, I sometimes view a psychotherapy session as a tangled skein of wool in need of unravelling. The ﬁrst task is to ﬁnd a loose end and to work back from that to the main theme of the session.

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My themes here are assimilation, envy and inequality. As in a session, I shall be approaching them from a number of different angles – first literary, then sociopolitical, finally clinical. Talcot Parsons, a psychoanalytically trained sociologist, saw the social function of psychotherapy in terms of the assimilation of alienated individuals into the mainstream of society (Parsons 1951); this view of the role of psychotherapy has to be reconciled with the Kleinian understanding of the part played by envy in preventing the assimilation of good experiences. The issue I am preoccupied with in this chapter is the problem of how envy may be overcome and assimilation achieved, when the inevitable helplessness of infancy is reinforced by real material deprivation; and whether psychotherapy has sufficient outsight to face this issue. I shall approach this theme via the ‘two cultures’ debate which broke out in the 1960s between the novelist- scientist C. P. Snow (Snow 1959) and the literary critic F. R. Leavis (Leavis 1962), and led me to re-read their work, hoping to throw some light on the continuing debate between biological psychiatry and psychotherapy. I start with Leavis, a seemingly natural ally in the literary–psychotherapy parallels this book aims to explore. The ‘Leavisite’ approach had an impact on literary and cultural thought which lasted half a century, stretching from his first championing of T. S. Eliot’s The Waste Land in the 1920s, until the seismic shifts in political and cultural life in the early 1970s led to the gradual eclipse of Leavisism as a dominant paradigm in literary criticism. For Leavis, the critic approaches the text in a spirit analogous to the way the analyst responds to the patient’s material; on the basis of this he makes a judgement, analogous to an interpretation:

A judgement is personal and spontaneous or it is nothing . . . The form of a judgement is ‘This is so, isn’t it?’, the question asking for confir- mation that the thing is so, but prepared for an answer in the form, ‘Yes, but . . .’, the ‘but’ standing for correction, refinements, precisions, ampli- fications. The judgements may be ‘value-judgements’ but they are in intention universal. (Leavis 1975, p. 17)

Leavis is straining here with the problem that good criticism is always a per-

Downloaded by [New York University] at 12:48 14 August 2016 sonal response to the text, but this emphasis on individual response under- mines the critic’s claim to authority and universality of judgement. The critic is in a similar position to the analyst who ‘knows’ his perception of the case is ‘right’, but lacks any absolute criterion by which to establish his correctness. Somehow he has to hold to this view while knowing that alternative formulations, both within psychoanalysis and from different psychotherapeutic approaches, can be shown to be no less convincing or therapeutically effective. The implicit dialogue in the Leavisite approach to the text, in which the judgement is offered in a form that can be modiﬁed or contradicted, parallels the

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culture of a psychotherapeutic session: interpretations are offered in ways that are both authoritative and tentative – coming authentically from the therapist’s inner being, yet, in the spirit of mentalising, ever- open to correction by the patient. Leavis’ solution to this problem was to endow the critic with a special dis- criminatory sensibility which, in relation to the novel, meant considering only a small number of selected authors – Austen, Eliot, Dickens, James, Lawrence and Conrad – as inheritors of the ‘great tradition’ and more or less dismissing the rest as being of secondary value. A similar tendency towards exclusivity can be observed in some psychoanalytic circles. The critic then becomes a member of a Coleridgean ‘secular clerisy’, a defender of the Faith, an arbiter of taste not in the ephemeral dilettante sense, but as one who knows what is good and bad, what is valuable and what is dross. Leavis’ social vision is in the tradition of enlightened individualism, where the critic occupies a special place within the university and society in general; his job is to defend standards and values in a secular world characterised by moral chaos. Leavis saw literature as a ‘third realm’, neither public nor private, creating an invisible community between writer, reader and critic to all responding to ‘the black marks on the pages’: ‘a product . . . of human creativity’ with ‘an essentially collaborative nature’ (Leavis 1975, p. 93). There are parallels here with Winnicott: the concept of culture as occupying a transitional space between private and public: words on the page, like a transitional object, coming to life as an act of primitive creativity; the essential value of the psychoanalytic encounter in its creation of an ‘invisible community of two’ to use Philip Rieff ’s phrase (Rieff 1979, p. 204); learning to read a text, like ‘learning to play’, a vital ingredient in any culture. As suggested in Chapter 1, in Winnicott and other independent psychoanalysts we see, the convergence of the Romantic tradition with psychoanalytic thought, a breaching of the careful barriers put up by Freud against Romanticism in his quest for scientiﬁc credibility and his ﬁerce rejection of German mysticism (Turner 2004). Leavis’ approach, then, continues the Romantic tradition of creativity, individualism and a questionable nostalgia for a pre-industrial past. He harks back to a community of artisans, based on the neo- medievalism of William Morris and the early socialists. He rejects the Marxist ideals of a classless society and

Downloaded by [New York University] at 12:48 14 August 2016 espouses individualism and deﬁant inequality, quoting Lawrence:

We are all different and unequal in spirit – it is only the social differences that are based on accidental material conditions. We are all abstractly and mathematically equal, if you like. Every man has hunger and thirst, two eyes, one nose and two legs. We’re all the same in point of number. But spiritually there is pure difference and neither equality nor inequality counts. (Leavis 1962, p. 55)

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Lawrence’s distinction here between the social and spiritual defines a territory vacated by religion that psychoanalysis has increasingly come to occupy. The emphasis on the primacy of individual experience prefigures psychoanalytic objections to the head-counting and statistical obsessions of contemporary scientific psychiatry which has come to afflict even their own discipline (Hoffman 2009). At the same time it opens the way for a social vision in which, in Rieff ’s startling phrase: ‘psychoanalytically speaking, there were free slaves in Athens, as there are enslaved citizens in Manhattan’ (Rieff 1979, p. 205). Let’s now consider the case of Miss EW.

There are no hints here of psychosis or self-harm. Miss E is an attractive, comfortably off twenty-two-year- old, lively and intelligent: an ideal training case for psychotherapy perhaps. She lives in the country with her kind but ineffectual and hypochondriac father. Her mother died when she was ten, and her much older sister married several years ago. The precipitant of her seeking ‘treatment’ was the marriage of her governess and companion, Mrs W. Miss E felt inexplicably troubled and bereft by this, despite the power and status of her parentiﬁed role in relation to her elderly father. She has no boyfriend or lover and has vowed that she will ‘never marry’. She has a ‘therapist’, a Mr K, a man in his forties, with all the features of what Bollas (2007) calls a ‘transformational object’. He is strong, detached, slightly mysterious; available for a variety of transferential projections as brother, father and lover; taking a benign interest in his ‘patient’, but well able to resist her manipulations. He is sensitive to and critical of the latter, principally her tendency is to match- make and meddles in the affairs of other young people and to try to pair them off.

Emma Readers will have realised that this ‘patient’ is none other than Emma Wood- house, living in the village of Hartﬁeld. Its author, Jane Austen, herself remained single and arranged many marriages for her characters in her novels. Emma’s ‘therapist’ is Mr Knightley, who discusses her case in ‘supervision’ with Mrs Weston:

Downloaded by [New York University] at 12:48 14 August 2016 ‘There is an anxiety, a curiosity, in what one feels for Emma. I wonder what will become of her.’ ‘So do I,’ said Mrs Weston gently, ‘very much.’ ‘She always declares she will never marry, which, of course, means just nothing at all. But I have no idea that she has yet ever seen a man she cared for. It would not be a bad thing for her to be very much in love with a proper object. I should like to see Emma in love, and in some doubt of a return; it would do her good.’ (Austen 1816/1929, p. 32)

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I have suggested that there is a parallel between implicit psychoanalytic ethic and the Leavisite notion of literature as the basis and bastion of moral development in a secular world. Let us follow Emma’s progress through the book with a psychodynamic eye, starting with the notion of mild deprivation or therapeutic abstinence. As Kohon (1986, p. 91) puts it ‘the analysand will have to reconcile himself with the fact that the primary object will never be found again’; Emma’s difﬁculties and character disturbance arise in part from delayed mourning for her dead mother, and partly a consequence of the Oedipal short- circuit resulting from this bereavement, so that she becomes the ‘mother’ of the house and the quasi- spouse of her father, without having to face, and overcome, envy. Emma’s disavowed sexuality is projected into her socially inferior protégé, Harriet Smith, an orphan who is a friendly, attractive but rather simple girl, without apparent depth. Emma mistakenly decides that Harriet and the local curate, Mr Elton, would be ideal partners. Emma starts to paint Harriet’s portrait and when Elton comes to watch she imagines her plans are developing nicely. But it is the painter, not the painted whom Elton desires. Emma’s authorial exemption (paralleling Jane Austen’s) is challenged. She discovers she is object as well as subject; when Elton proposes to her she is furious, not least because it conﬁrms what Knightley has insisted all along – that she has displaced her own sexuality into meddlesome marriage-making for others. But this disappointment leads to a reconciliation with Knightley and, with his help, the beginnings of an appreciation of inner differentiation between her envious ‘vain spirit’ and her stage- of-concern ‘serious spirit’. At the same time she begins to experience the stirrings of sexuality when, at a dance, she sees Knightley in a new light:

‘Does my vain spirit ever tell me I am wrong?’ ‘Not your vain spirit, but your serious spirit. If one leads you wrong, I am sure the other tells you of it.’ . . . ‘Whom are you going to dance with?’ asked Mr Knightley. She hesitated a moment, and then replied, ‘With you, if you will ask me.’ ‘Will you?’ said he, offering his hand. ‘Indeed I will. You have shown that you can dance, and you know we are not really so much brother and sister as to make it at all improper.’

Downloaded by [New York University] at 12:48 14 August 2016 ‘Brother and sister! – no indeed.’ (p. 297)

This moment of awakening sexuality has profound consequences for Emma. She begins to emerge from her omnipotent narcissism, and to face the problems of rivalry, competition, envy and jealousy which she has hitherto avoided. An important point of similarity between psychotherapy and ‘English’, in the Leavisite sense, is the way in which change and self-knowledge can grow out of apparently trivial events – a session which starts a few minutes late, a bill

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wrongly paid, a slip of the tongue – which, acting as sudden unexpected windows into the unconscious, reveal key issues in a person’s life. Like the beat of a butterﬂy’s wing which, according to chaos theory, can change a whole pattern of prevailing weather, mutative moments are often built on apparently minor episodes around which plot and character crystallise and turn: Proust’s petite Madeleine; what happened or did not happen in Forster’s A Passage to India (1924/1988) in the Marabar Caves; and, in Emma, the Box Hill episode.

Box Hill A picnic, to be held at Box Hill, is agreed upon by the Hartfield gentry. The movement from house to open air, from village to open country, is an important backdrop to this momentous episode in Emma’s moral development. Feelings are loosened, the reins of respectability relaxed. Emma’s parentified status has hitherto shielded her from rivalry and competition, but now she begins to experience intense discomfort in relation to Jane Fairfax, an attractive, talented but enigmatic young woman, secretly engaged to the eligible Frank Churchill with whom Emma has had a flirtation. Jane Fairfax is, like Harriet, an orphan but lives with her grandmother and with her aunt, the kindly but rather dim Miss Bates. Emma proposes a Victorian parlour-game based on quotations; Frank Church- ill conveys her suggestion to the assembled company:

‘She only demands from each of you, either one thing very clever, be it prose or verse, original or repeated; or two things moderately clever; or three things very dull indeed; and she engages to laugh heartily at them all.’ ‘Oh! very well,’ exclaimed Miss Bates; ‘then I need not be uneasy. “Three things very dull indeed.” That will just do for me, you know. I shall be sure to say three dull things as soon as ever I open my mouth, shan’t I? (looking round with the most good-humoured dependence on everybody’s assent). Do not you all think I shall?’ Emma could not resist. ‘Ah! ma’am, but there may be a difﬁculty. Pardon me, but you will be limited as to the number – only three at once.’

Downloaded by [New York University] at 12:48 14 August 2016 Miss Bates, deceived by the mock ceremony of her manner, did not immediately catch her meaning; but, when it burst on her, it could not anger, though a slight blush showed that it could pain her. (p. 334)

Emma’s barb has struck home; Miss Bates is momentarily humiliated. But why is this tiny moment of aggression so signiﬁcant? Emma has no mother and a useless father. For her, there is no one to contain and transmute her Oedipal stirrings of sexuality and rivalry. Jane Fairfax, adored by her aunt and grandmother,

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loved by Frank Churchill, admired by all for her beauty and talent, arouses Emma’s envy, her rivalry, awakening in her an awareness of her own mother’s absence, and perhaps, too, feelings of anger towards her dead mother, all of which fuel her subtle but psychologically deadly attack diverted onto the easy target of Miss Bates. But if Emma can own these feelings she can change. She can abandon her narcissism (‘one thing very clever’) and accept moderation, even dullness. Knightley is at hand to help with this. His rebuke – ‘it was badly done indeed!’, especially because ‘she is poor’ – leaves Emma mortiﬁed and speechless:

How could she have been so brutal, so cruel, to Miss Bates! How could she have exposed herself to such ill opinion in anyone she valued! (p. 339)

We see here the beginnings of the depressive position, the stage of concern:

Time did not compose her. As she reﬂected more, she seemed but to feel it more. She never had been so depressed. (p. 339)

The novel now moves speedily to its climax. Emma discovers that her protégé Harriet has designs on Mr Knightley and believes her feelings may be returned. Threatened with the loss of the loved object, Emma feels the full force of desire for the ﬁrst time. Suddenly, in the famous phrase:

It darted through her with the speed of an arrow, that Mr Knightley must marry no one but herself. (p. 372)

Awareness of longing, the possibility of loss, of envy, of her position in relation to Harriet and Miss Bates opens her to the self- knowledge that she has hitherto avoided.

It was this knowledge of herself which she reached. She was ashamed of every sensation but the one revealed to her – her affection for Mr

Downloaded by [New York University] at 12:48 14 August 2016 Knightley. Every other part of her mind was disgusting. With insuffer- able vanity had she believed herself in the secret of everybody’s feelings; with unpardonable arrogance proposed to arrange everybody’s destiny. (p. 372)

Emma begins to reconcile herself to the conviction that she has lost Knightley for ever; and the beginnings of some sort of calm descend upon her with this acceptance of loss, of banishment from a longed for country:

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Consolation or composure could be drawn from the resolution of her own better conduct, and the hope that, however inferior in spirit and gaiety might be the following and every future winter of her life to the past, it would yet ﬁnd her more rational, more acquainted with herself, and leave her less to regret when it were gone. (p. 380)

But help is at hand to alleviate the misery of this painful maturity, to move her on through the pricked bubble of her narcissism, in the shape of the English weather, Ruskin’s ‘pathetic fallacy’, so vital a metaphor of shifting feelings, such an important aspect of life in the countryside:

The weather continued much the same all the following morning; and the same loneliness, and the same melancholy, seemed to reign at Hart- ﬁeld; but in the afternoon it cleared; the wind changed into a softer quarter; the clouds were carried off; the sun appeared; it was summer again. With all the eagerness which such a transition gives, Emma resolved to be out of doors as soon as possible. Never had the exquisite sight, smell, sensation of nature, tranquil, warm, and brilliant after a storm, been more attractive to her. She longed for the serenity they might gradually introduce. (p. 381)

Emma is at last ready to receive Knightley. She no longer possesses him; he is no longer a fantasised brother, father, an extension of her needs and controlling desires. He appears diffident, uncertain, different. She can approach him, for the first time, as an equal. A space exists between them, intimating uncertainty and mystery, but also creativity, possibility. Using metonymy, they can speak at last of what is on both their minds, through a reference to the impend- ing marriage of Frank Churchill and Jane Fairfax. The possibility of marriage, prefigured in the reader’s mind throughout the book, just as the Oedipal situation prefigures mature sexual longings in the course of psychological development, can declare itself at last as Emma and Knightley take a turn in the garden: Downloaded by [New York University] at 12:48 14 August 2016 They walked together. He was silent. She thought he was often looking at her, and trying for a fuller view of her face than it suited her to give. And this belief produced another dread. Perhaps he wanted to speak to her of his attachment to Harriet; he might be watching for encouragement to begin. She did not, could not; feel equal to lead the way to any such subject. He must do it all himself. Yet she could not bear this silence. With him it was most unnatural. She considered, resolved, and, trying to smile, began –

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‘You have some news to hear, now you are come back, that will rather surprise you.’ ‘Have I?’ said he quietly, and looking at her; ‘of what nature?’ ‘Oh, the best nature in the world – a wedding.’ (p. 381)

But now at last Emma can relinquish another’s wedding, her Oedipal bondage, and inhabit her own consummation, her ‘union’, present and future. Knightley proposes; Emma, of course, accepts. The book ends, as early nineteenth-century novelistic convention demands, with Emma and Knightley’s marriage:

The wedding was very much like other weddings, where the parties have no taste for finery or parade . . . But in spite of these deficiencies, the wishes, the hopes, the confidence, the predictions of the small band of true friends who witnessed the ceremony, were fully answered in the perfect happiness of the union. (p. 437)

As psychotherapists, we can’t help hoping for happy endings for our patients and ourselves. We too are ‘a small band of true friends’ who know that what counts is not ﬁnery or parade, but moral strength and maturity, often based on suffering overcome; we acknowledge the pain and anxiety entailed in letting go of parental bonds, ﬂoating free towards the uncertainty of ‘horizontal’ spousal, as opposed to ‘vertical’ parent–child attachment; we know too that this development cannot be forced, but must be allowed to emerge from silence, spontaneously, playfully, within the trajectory of the analytic setting.

The two cultures It is usually unwise, and certainly unfair, to accuse a writer of what they have not said, of what has been left out. And yet, as psychotherapists, it is precisely such gaps in our patients’ narratives that interest us. Alongside the great psychological insight and accuracy of Emma, is there perhaps something wrong, something missing? For a start, by staying within the formula of ‘happy-ever-after’ Austen leaves unexamined what happens after marriage and, if the analogy is accepted, Emma ends up marrying her analyst! If

Downloaded by [New York University] at 12:48 14 August 2016 Mr Knightley is Emma’s transformational object, so too, in Middlemarch, is Dorothea’s Mr Casaubon. Fifty years on from Jane Austen, a George Eliot, or a Gustave Flaubert, could take marriage, and a disastrous one, as a starting point for the exploration of sexuality, fulﬁlled and unfulﬁlled, and the possibilities both for growth and destruction which the accommodation and compromise entailed in real relationships produce. Another silent area in Emma derives from the fact that it was written and published during the Napoleonic wars, in the aftermath of the French Revolution, and yet no hint of these momentous events are to be found anywhere in the book.

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The little community of Hartﬁeld remains isolated and insulated from the world stage, as indeed it may realistically have been: the historical and political context is never allowed to disturb the tranquillity of the gardens and houses where the action is played out. Third, there is the problem of Jane Austen’s restricted class palate, the fact that her observations are conﬁned to a small section of society. As Raymond Williams puts it:

Neighbours in Jane Austen are not the people actually living nearby; they are the people living a little less nearby who, in social recognition, can be visited. What she sees across the land is a network of propertied houses and families, and through the holes in this tightly drawn mesh most actual people are simply not seen. To be face-to-face in this world is already to belong to a class. No other community, in physical presence or in social reality, is by any means knowable. And it is not only most of the people who have disappeared . . . it is also most of the country, for the rest of the country is weather, or a place for a walk. (Williams 1973, p. 74)

Jane Austen for all her sensitivity and moral integrity appears never to question a world that is in some respects incestuous; neglects social and political reality; and is conﬁned in its concern to the problems of a particular and numerically limited social class. And this brings us back to the ‘two cultures’, to Leavis and Snow, and for our purposes to psychoanalytic psychotherapy – at which these charges could also, with at least some justiﬁcation, be levelled. Leavis, it will be remembered, was defending values, discrimination, individualism, the complexity of culture, against what he saw as the crassness and moral irrelevance of science. Against this, Snow was defending the aesthetic value of science: arguing that the second law of thermodynamics was no less a thing of beauty than a Grecian urn. But Snow’s message, put with a certain banality, was also a social and political one. He was struggling against the marginalisation and isolation of the intelligentsia – against Pascal’s ‘we die alone’, or Conrad’s variant ‘we live, as we dream – alone’ to make a point about the transformational power of science to overcome poverty, inequality and injustice:

Downloaded by [New York University] at 12:48 14 August 2016 Each of us is solitary. Each of us dies alone: alright, that’s a fate against which we can’t struggle – but there is plenty in our condition which is not fate, and against which we are less than human unless we do struggle. Most of our fellow human beings for instance are underfed and die before their time. In the crudest terms, that is the social condition. There is a moral trap which comes through the insight into man’s loneliness: it tempts one to sit back, complacent on one’s unique tragedy, and let the others go without a meal. (Snow 1959, p. 129)

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Snow was thus trying to link the problem of the ‘two cultures’ – the division between arts and science – with that of the ‘two nations’ – the rich and the poor – described by Disraeli in his novel Sybil (1845/1980). The same debate has re- emerged recently in Wilkinson and Pickett’s (2009) analysis of the links between income inequality and social fragmentation. Coherent, caring societies are those where the gap between rich and poor is modest – whether through redistributive taxation, as in Scandinavia, or, as in Japan, a culture where it would be seen as obscene for managers to be paid a factor of more than a hundred times those of poor. Looking back on the Leavis–Snow controversy, and considering the implications of the debate for psychotherapy, we might conclude that each is both right and wrong. Leavis was right because of his emphasis on the importance of the individual; because he resists the melting down of differences into a featureless mass of humanity to be shaped by social forces; because he champions creativity and truth as central values in any culture. He is wrong because of his inherent elitism; because in the end the ‘English’ which he advocates is based on a nos- talgic wish to return to an arcadian pre-industrial past irretrievably lost; because of his cultural snobbery and intolerance of difference. Snow’s faults lie in his simplistic approach to the complexities of psychological and political reality. But he was surely right in his vision that without science there could be no solution to the problem of the ‘two nations’. And he was surely correct when he sensed the limitations of a culture which represents no more than the interests of a particular class; correct too in his realisation of the need to go beyond Emma (and, for our purposes, beyond psychotherapy as it is currently practised) to a wider vision. As Williams puts it:

What happens in Emma . . . is the development of an everyday uncom- promising morality which is in the end separable from its social basis . . . it is in this sense that Jane Austin relates to the Victorian novelists who had to learn to assume . . . that there was no necessary correspondence between class and morality . . . that cultivation, in its human sense had to be brought to bear as a standard against the social process of civilisation . . . Jane Austen provided emphasis which only had to be taken outside the park walls, into a different social experience, to become not a moral but a social criticism.

Downloaded by [New York University] at 12:48 14 August 2016 (Williams 1973, p. 75)

What, it might be asked, has all this to do with psychotherapy? This return to Jane Austen, to Leavis and Snow, has in part been a parable: an attempt to illuminate an ambivalence within psychoanalysis and psychotherapy about its status as a science or an art; its social role and its position as a source of moral or social criticism. Freud began his career as a medical scientist; medicine was the Trojan horse with which psychoanalysis inﬁltrated the citadel of science. Medical science,

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while providing a vehicle for psychotherapy, also embodies, through social medicine, an implication of universal applicability which psychotherapy has yet fully to embrace. Jane Austen’s awareness of the need for ‘cultivation’, for honesty, for self-knowledge and acceptance, for personal growth, for non-manipulative personal relationships, for respect and tolerance, for mature sexuality even, could if ‘taken outside the park walls’ become a morality with the potential for social transformation. So too the values of psychotherapy – its emphasis on autonomy, on the importance of intimacy in relationships, on the necessity for dealing with loss by grief and mourning, its acknowledgement of destructiveness and the possibility of transmuting hate into something positive through the use of a containing object (whether this is a parent, a therapist or an institution) – have potentially universal applications (Holmes and Lindley 1997).

Two nations: ‘adapting our techniques . . .’ Given that hope, we can now come on to some of the problems associated with a widened availability of psychotherapy, bearing in mind Melanie Klein’s contrast between the effects of excessive, and superable, envy:

When envy is excessive, the infant does not sufﬁciently build up a good object, and therefore cannot preserve it internally. Hence . . . he is unable to establish ﬁrmly other good objects in his inner world. But in children with a strong capacity for love the relation to the good object is deeply rooted and can, without being fundamentally damaged, withstand temporary states of envy, hatred, or grievance . . . when these negative states are transient, the good object is regained time and time again. (Klein 1957, p. 214)

Let us set against this Freud’s conﬁdence in the possibility of a widened availability of psychoanalysis:

One may reasonably expect that at some time or other the conscience of the community will awake and admonish [society] that the poor man has just as much right to help for his mind as he now has for the sur-

Downloaded by [New York University] at 12:48 14 August 2016 geon’s means for saving his life . . . the task will then arise for us to adapt our techniques to the new conditions. (Freud 1919, p. 15)

But the challenge of ‘adapting our techniques to the new conditions’ is far from simple. For once outside the park walls, psychotherapy encounters problems previously only encountered in symbolic form. ‘The poor’ do make a brief appearance in Emma. Just as Emma is beginning to experience sexual attraction for the ﬁrst time and is ﬂirting with Frank Churchill, Harriet, her sexual

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alter-ego, while out walking, is frightened by a group of rough, dirty gypsies, who demand her purse. Fortunately, Frank Churchill arrives in the nick of time and she is rescued. The gypsies have more psychological than social signiﬁcance here and represent not the real dispossessed, but rather an expression of fears of deﬂoration, dirt and dispossessed sexuality. What is the attitude of psychotherapy towards poverty? And what are the psychological implications when real deprivation reinforces envy? Do we, like Jane Austen, say, ironically perhaps, but emphatically:

Let other pens dwell on quiet and misery. I quit such odious subjects as soon as I can.

Or in E. M. Forster’s statement of this ironic dismissal:

We are not concerned with the very poor – they are unthinkable and only to be approached by the statistician or the poet. (Forster 1910, p. 47)

A ﬁrst necessity is to distinguish poverty as a reality, from ‘delusions of poverty in middle-class patients’ (Symington 1986, p. 66). Here emotional poverty, which is no less real, has to be separated from material deprivation, and may require different psychotherapeutic responses. Consider Sheila Ernst’s account of an analysis in which:

My analyst wore a suit, lived in a large house in a middle- class suburb with a neat garden, had a wife who didn’t work and a spotless child who went to private school. I still don’t know what his assumptions were about women’s role or what he thought about my attempts to combine being a student with taking most of the responsibility for the house and my small step- son, and being a trade union activist . . . He was not oppressive in the blatant way that feminist writers on therapy have documented. He didn’t try to seduce me, tell me I should use makeup or dress differently, accuse me of being incapable of real love because I didn’t have orgasms. The oppression lay in who he was, the questions he didn’t ask and

Downloaded by [New York University] at 12:48 14 August 2016 the material I didn’t present. It lay in the way I felt when I arrived at his house on my bicycle and he drew up in his large car; in the sense that I had that he must see his wife and family and home as normal and my household as a sign of my abnormality. To be cured would be to be capable of living like him. (Ernst and Goodison 1993, p. 39)

Are we not dealing here with questions which could be dealt with in the transference, with a developmental rather than a material gap between patient and

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analyst? And are Ernst’s complaints not merely a denial of Chasseguet-Smirgel’s (1985) double difference: the difference between the generations, and the difference between the sexes? Could they and similar demands for a democratic psychotherapy not be seen in terms of envy, of a false search for:

A balm for our wounded narcissism and a means of dissipating our feelings of smallness and inadequacy. This temptation can lead to our losing the love of truth and replacing it with a taste for sham. (Chasseguet- Smirgel 1985, p. 98)

Chasseguet- Smirgel sees a preoccupation with poverty, with dirt, as part of a regressive envy-based perversion in which authority and leadership are denied. She connects the psychology of sadism with the politics of the French Revolu- tion, the origins of which lie in the wish to escape the ‘paternal order’:

The pervert will attempt to give himself and others the illusion that anal sexuality (which is accessible to the little boy) is equal and even superior to genital sexuality (accessible to the father) . . . In reality, in order to have a genital penis and to procreate, it is necessary to grow up, to mature, to wait, whereas faeces are a production common to adult and child, woman and man. The two differences between the sexes and between generations are abolished at the anal level. Time is wiped out. (Chasseguet- Smirgel 1985, p. 101)

Chasseguet- Smirgel sees it as the job of psychotherapy to help patients to develop a necessary patience, so that the Oedipal task of discovery and acceptance of the ‘double difference’ can be successfully undertaken. But there is another set of differences, which psychotherapy is itself in danger of denying – the difference between the classes. And Chasseguet-Smirgel, however percep- tive in her account of envy, has little useful to say about how social change comes about. Unlike Winnicott, she cannot see the constructive aspect of hatred (Turner 1988). For her, the little boy who points to the unclothed Emperor is always regressively wanting to abolish differences, to see the powerful as no more than naked babies like himself, and from this perspective psychoanalysis seems inescapably linked to the established order, to stability, differentiation and

Downloaded by [New York University] at 12:48 14 August 2016 hierarchy. But the psychobiological realities of growth and development can be used as a cloak for social differences which are often arbitrary and mutable. The progressive potential of medical science, by this sleight of hand, is perverted, so that moral criticism is reduced to a pseudo-biological inevitability. The theoretical and technical problems which confront analytic psychotherapy if it is to become more widely available and yet remain true to itself are formidable, and are often underestimated by its enthusiastic champions. For example, in my own study of the referral process for psychotherapy from a deprived inner-city group practice, where there was a strong ideological bias

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towards positive discrimination for the underprivileged, working-class patients nevertheless formed no more than one- third of those who were referred (as opposed to the two-thirds that would have been statistically representative), and of those ﬁnally taken on for psychotherapy by experienced therapists (as opposed to medical students) only one in eight were from the working class (Holmes and Lindley 1997). Here is an example of one of these cases and of the technical problems posed by attempts to overcome the ‘two nations’ in psychotherapy.

The patient was a man of 28 taken on for weekly analytic psychotherapy. He had been brought up in the East End of London in conditions of emotional and material poverty. After leaving school he had worked for a while in a printing firm. When he was 18 his mother, who had been ill for many years, died of cancer. He became very depressed, gave up work and refused to leave the house where he lived with his father, a cantankerous respiratory cripple. A visiting psychiatrist diag- nosed schizophrenia, probably wrongly, and prescribed monthly injections of a major tranquilliser. The young man continued with these for three years, but remained confined to his house. One day he had a violent row with his father, and left to live in another part of the city. Through the Social Services Department he was housed in a bed-and- breakfast hotel, and eventually referred again for psychiatric help because of his obvious depression. As I got to know him it became clear that his entire worldview was based on mistrust and suspicion. ‘How can you expect me to trust anyone?’ he ranted. His father was a ‘bastard’, the psychiatrist who gave him the injections ‘ought to be locked up’, the social workers were ‘no good’ and kept offering him flats that were ‘unsuitable’: everyone let him down, kept him waiting, didn’t care. I tried to listen patiently to these tirades, and at first had no difficulty in empathising with his plight. I attempted, with little success, to steer the patient’s thoughts to his mother’s death and the anger and disappointment it had left him with. Feeling burdened by the bleakness and emptiness of the patient’s life (as I perceived it), and that the patient needed more than could be offered in once-weekly sessions, I thought that it might be helpful if he

Downloaded by [New York University] at 12:48 14 August 2016 were, in addition to his sessions, to attend a Day Hospital. The patient suddenly became furious. ‘How can you make suggestions like that?’ he shouted. ‘You don’t realise how difﬁcult it is for me even to come here to the hospital to wait in the waiting-room, let alone go into a new situation with strangers.’ I replied that perhaps he felt he was being passed on or got rid of, just as he may have felt abandoned when his mother died, and that perhaps this was what had made him so angry. The patient lost his temper: ‘You middle- class bastard, you don’t give a damn about me, sitting there with your well-paid job, your nice wife

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and kids, your comfortable home in the suburbs. What do the likes of you know about the way I live – in a damp room with no money, noisy neighbours, no job, walking the streets in the freezing cold?’ (it was a bitter November day). ‘You’re just doing your job, waiting to go home, you don’t care about me one bit.’ The force of this outburst was shocking. The attack hit home, leaving me speechless and feeling inadequate. In the end I replied that while I accepted the validity of what the patient had said, I also felt that he was using his misery in a self- destructive way. The patient’s no doubt accurate perception of my concerns for my own life should not be a jus- tiﬁcation for inertia, or become a way of avoiding the need to ﬁnd a future and to free himself from a paralysing attachment to his dead mother. The patient missed the next two sessions, but, rather to my surprise, did return, and work continued. Eventually he began to attend the Day Hospital and, while remaining on the fringes of ‘normal’ society, became less depressed and paranoid, survived the untimely death of his older sister, and formed a tenuous relationship with an ex-patient.

The Klein-in ﬂuenced American psychoanalyst Robert Langs (1978) is critical of the way in which therapists behave differently with ‘clinic patients’ (equivalent to UK NHS or Social Services-funded psychotherapy departments) compared with those they see in private practice. In his view, ‘frame violations’ are much more likely to occur: cancelled or changed appointments, sudden changes of tack, referrals (as in my case above) to other agencies, and he links these to the observation that drop- out rates are much higher among poor patients in free facilities, than for middle-class patients seen in private practice. From this perspective my inability to interpret, tolerate and transmute the patient’s rage, emptiness and envy led to the frame-violating Day Hospital referral, which in turn merely reinforced his deep sense of rejection and injustice rather than helping him to face and overcome it. No doubt my failure to interpret his envy was partly based on my own unana- lysed guilt, avoided by the easy privilege of the therapist’s position, just as Emma could avoid envy and guilt through her parentiﬁed position. But it must also be acknowledged that there was a real basis for his envy, one that could certainly not be overcome by analytic therapy alone. This leads on to an important

Downloaded by [New York University] at 12:48 14 August 2016 unexplored lacuna within psychoanalytic psychotherapy. For Freud, countertransference was the blind spot which meant that therapists, no less than patients, must subject themselves to analysis. Roustang (1980) and others have pointed to a further blind spot within this blind spot, one often collusively shared with the analyst’s analyst: the ‘unanalysable transference’ to psychoanalysis and Freud’s ideas themselves. My concern in this chapter has been with a third area of potential blindness within analytic psychotherapy, located at the boundary rather than the focus of our ﬁeld but, like peripheral vision, none the less central for all of that. This is a lack of outsight, an unawareness of the social position of therapy,

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without which psychotherapy remains conﬁned within its park walls, limited in its capacity to address the psychological problems of the poor, or to tackle the interplay between material and psychological deprivation.

Conclusions But what, even given outsight, is to be done? We know that simply to take psychoanalysis, unmodified, out of the consulting rooms and into the community mental-health centres, the GP practices, the psychiatric hospitals just does not work. To do so would be as unfeasible as to ask Jane Austen to centre her novel on the gypsies rather than the owner- occupiers of Hartfield. We know that assimilation is impeded by envy; and we know that envy is inevitably increased by deprivation and trauma. We also know that we cannot be all things to all men: it is in the nature of the Oedipal situation that by trying to be everything we end up as nothing; only when omnipotence is abandoned, is real potency possible. Only when Emma gives up her meddling, faces her envy and acknowledges her loss, can she make real choices and on that basis form new attachments. And yet, despite – perhaps even because of – her exclusivity, Jane Austen, as Raymond Williams implies, does have a message which can be more widely applied. Emma’s values of honesty, self- scrutiny, her distaste for finery and snobbishness as well as her love of fun and wit, stand against those of the Eltons and the Churchills and, within the community of Hartfield, may even have had a modifying influence. If we are searching for a contribution from psychoanalysis in the fight against arbitrary inequality and injustice, it may also be at the level of values and attitudes, alongside its limited role as a practicable treatment for the few. This is not to argue that psychoanalysis should not be much more widely available; that modified treatments do not have a great deal to offer or that far more state-funded therapy should not be provided for the less well off. Leaving aside these practical considerations, however, I shall conclude by touching on four key themes in which I see the clinical insights of psychoanalysis making a general contribution to the critique of an inequitable society. These are assimilation, pluralism, irony and the transformational image.

Assimilation

Downloaded by [New York University] at 12:48 14 August 2016 I have suggested that, from a sociological perspective, the function of psychoanalysis could be seen as a means of integrating outsiders excluded from a dominant culture. Freud’s genius was to take his own particular historical and cultural situation as a partially assimilated Jew and to develop a theory and technique that had universal applicability. Psychoanalysis recognises that we are all outsiders, none of us fully assimilated. Freud, as Lacan (1977) realised, saw the contradiction between a culture that is always excluding, which means that the ‘I’ is always a social construct, and therefore to an extent inherently alienating, and the necessity for integration into this socially constructed culture. The ironic

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transformation which follows from this is that the assimilated, differentiated ‘I’ acquires a freedom, including the freedom to challenge the values of the assimi- lating culture. This is Raymond Williams’ ‘cultivation’ which turns a wilderness into a garden; a wild, motherless, omnipotently meddling girl into a mature woman.

Pluralism The fashionable notion of pluralism is used by the Left as a justification for ‘anything goes’ absurdities; by the Right as a justification for the status quo – the rich man in his castle and the poor man at his gate remain pluralistically where they are. From a psychoanalytic perspective pluralism involves differences of position; but not of value. Pluralism is consistent with inequality, but not ineq- uity, and its developmental perspective implies that the more differentiated people are, the more equal they become. As Emma’s moral development proceeds, she moves from dependency to assume a unique position with her own special value and contribution, equal to, yet different from that of Knightley. Within the analytic setting, the patient comes to accept that there is no absolute distinction between himself and the analyst, simply a difference of role. At another level, acceptance of pluralism implies a lessening of envy so that, for example, psychoanalysis would accept the strengths and limitations of its position without the fear, which Freud expressed, of being assigned to the graveyard of ‘Methods of Treatment’ within psychiatry. Pluralism requires mutual respect between psychoanalysis and other forms of psychotherapy, cross fertilisation between them, and an acceptance of valid forms of scientific influence and evaluation, rather than a Leavis-like whole-scale rejection of science.

Irony The mature ego defence of irony is another central value of psychoanalysis with important general implications. The ironic vision sees through pretensions and defences – both of patient and therapist – to a deeper level of reality, but at the same time does not belittle the need for defence and protection; it acknowledges human vanity and self-centredness without trying to eliminate them. It is a moral, but not a proselytising vision. In its original meaning the ironist was a

Downloaded by [New York University] at 12:48 14 August 2016 dissembler – the intention of whose words conveyed the opposite of their surface meaning. The Christian slave who told the Roman guard ‘I am going to my father’s house’ was an ironist in this sense. This defensive dissembling later took on further meanings: paradox – a deep truth revealed by apparent surface incon- gruity – and, in tragic irony, a vision of the way in which peoples’ projects are confounded by events over which they have no control. The patient who became furiously depressed in her sixties when, at the end of a life in which she had waited dependently and expectantly for fun and attention from her hard-working husband when he retired, but whose mother then became ill and had to be looked

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after, and whose husband and mother had then died within a few weeks of each other, needed to be listened to with a sense of tragic irony. The ironic vision sees and accepts human folly; and in psychotherapy, through the notion of countertransference and mentalising, ensures that the therapist’s vision is never a ﬁxed Archimedean point, but has always to be questioned. The novelist too can include him or herself and the reader in an ironic self-scrutiny: as, for example, does George Eliot in the following passage from Middlemarch (Eliot 1874/2003, p. 81), relevant to our theme of whether poverty should be seen by psychotherapists as reality or fantasy:

I am led to reﬂect on the means of elevating a low subject . . . to observe that . . . whatever has been . . . narrated by me about low people may be ennobled by being considered a parable; so that if any bad habits and ugly consequences are brought into view, the reader may have the relief of regarding them as not more than ﬁguratively ungenteel, and may feel himself virtually in company with persons of some style.

The transformational image Finally, we must consider a fundamental value of psychoanalysis which brings us close to the process of thought itself, to what might be called (Bollas 2007) the transformational image. Change, at both a personal and a political level, often coalesces around an image. In therapy this can be a thought, a dream, a fantasy, an artefact, a transferential moment (as with the patient who shouted at me), or even a delusion which contains within it all the themes, conﬂicts and potential with which the patient is struggling. The capacity of such imagery to contain in a concentrated form both love and hate, and to act as a pivot around which transformation from bad to good can occur, forms a focus of opposition from psychoanalysis to a contemporary culture which tries to force false choices, divisions and exclusions. I shall end with a brief clinical example of such imagery.

The patient was a man in his thirties who had come into treatment because of chronic feelings of anxiety and inexplicable outbursts of anger. He had been brought up by a depressed and controlling mother,

Downloaded by [New York University] at 12:48 14 August 2016 his father having died when he was two. He dealt with his boredom, anger, fear, exhaustion and rejection by compulsively turning to alcohol, cannabis and watching ﬁlms on video, especially if mildly por- nographic. He found the early stages of treatment excruciatingly difﬁ- cult as he tried to avoid the empty space of therapy by attempts to fraternise, control, please or antagonise the therapist. Gradually he relaxed. During a break in therapy he acquired some money and thought he would buy some electronic equipment, but, rather to his surprise, found himself acquiring instead a large, beautiful dolls’ house,

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unfurnished and empty. He wondered what to put inside, and then had the idea of filling it with tiny clay erotic figures lying on couches, based on Indian sculpture. This transformation debased into more mature sexuality, the transferential reference to the therapeutic couch, the acceptance of the empty space of therapy and of his own less crowded mind, was marked by an intensification of his investment in therapy, an improved relationship with his wife and diminished outbursts of rage.

The words ‘country’ and ‘city’ in their origins both imply connections, unity. Country comes from ‘contra’, against: the landscape that lies against the eye, the essential Other that contrasts and complements the Self. City comes from ‘civitas’ ‘community’ (Williams 1973). This man, like many others, had moved from city to country life, to farming work in search of an ‘unspoiled’ garden, of a mother undiminished by loss, undamaged by envy, hoping she would yield her fruits to him. He saw the city he had left behind as no longer a community, more divided than ever into two nations; he experienced a countryside debased and polluted, his idealised mother-woman’s body defiled. Through the transformational image, he was able to acknowledge his own hand in destructiveness, but also to see how good could come out of evil. The empty dolls’ house which, like therapy, acted as, and symbolised the container within which he could put all his impulses, good and bad, and where transformation could take place. Underpinning this chapter lies an implicit ethical imperative towards the validation of feelings, and a position of moral equivalence which at the same time respects difference and diversity. Entailed in this is the assumption of an universal right to developmental conditions leading to secure attachment, the expression of affect and acquiring the capacity for self- reflection or mentalising. Literature and psychotherapy play their part in fostering these processes, and redressing their inevitable failures. Despite their elitist access and status in class- riven societies, both contain democratic potential. And both help guard against false hopes and facile programmes of social amelioration, and are fierce guard- ians of the inextricability of pain and gain. Downloaded by [New York University] at 12:48 14 August 2016

108 Part III

PSYCHOTHERAPEUTIC APPROACHES TO PSYCHIATRIC DIAGNOSES Downloaded by [New York University] at 12:48 14 August 2016 This page intentionally left blank Downloaded by [New York University] at 12:48 14 August 2016 9 ANXIETY Wagner’s Siegfried

We now move to the ways in which literature can help deepen our understanding of some common psychiatric conditions: anxiety, abnormal grief, dissociation and narcissism. These ‘labels’, or diagnoses, it should be emphasised, are seen merely as useful rubrics rather than fixed biological entities, which is not to say they do not have identifiable psychobiological correlates. Literature, and psychotherapy, although always concerned with individual lives and stories, nevertheless aspire to general truths about the human condition, occupying an intermediate zone between the uniqueness of the individual narrative, and the impersonality of universal scientific laws. Siegfried, the eponymous protagonist of the third part of Wagner’s Ring Cycle, is a typical conduct- disordered male adolescent. Boorish, rebellious and demanding, lacking all tenderness or consideration, he relentlessly humiliates his crippled foster-father Mime in whose sole control he has been since infancy. Yet this exasperating boy will, as the cycle proceeds, come to achieve manhood and heroic stature. From the scheming Mime’s point of view Siegfried has one indispensible quality: he knows no fear. Mime plans to use this to gain his objective. If Sieg- fried kills the terrifying dragon Fafner, Mime will reclaim the Ring and its power. Unbeknownst to Siegfried, his grandfather Wotan, ruler of the Gods, has decreed that for Fafner to be slain, Siegfried’s father Siegmund’s shattered sword Nothung (need) must be re-forged, and this can only be accomplished by one who knows no fear. Siegfried duly refashions Nothung, kills Fafner and then Mime. Now, tasting the dead dragon’s blood, he suddenly finds he can understand

Downloaded by [New York University] at 12:48 14 August 2016 the language of animals, and especially the song of the forest bird. Dimly sensing that something is missing, Siegfried wants at last to learn to feel fear, the idea of which leads to the previously unthinkable image of a vulnerable child in need of parental protection. Stimulated by bird’s song, he begins to wonder who his parents, and particularly his mother, might be. From the bird he learns that his task is to rescue a maiden who sleeps surrounded by ﬁre on a mountain top. Setting out, his path is barred by Wotan, but, Oedipus- like, Siegfried brushes the old man aside, breaks his staff and with it his world- power, and passes on upwards.

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There he encounters the Amazon-like Brunhilde, Wotan’s illegitimate daughter, asleep, surrounded, as predicted, by a ring of fire. Undeterred, he breaches the ring but now, finally, fear threatens to overwhelm him. Confronting womanhood for the first time since infancy, he unlooses Brunhilde’s breastplate and, amazed, calls out: ‘Das is kein Mann’.1 The otherness of the Other, and the reality of sexual difference, hit him for the first time, and he is terrified. Siegfried’s kisses have by now awakened Brunhilde, and she too, previously impregnable, is overcome with mortal terror. Mutually helping one another to transcend their new- found fear, they fall in love, ready now to move on to the final phase of the story. In devising this component of his music-drama, Wagner drew on the German folk tradition, assembled in the early part of the nineteenth century by the Brothers Grimm. Their collection contains two similar stories: The Prince who was Afraid of Nothing and The Youth who Learned what Fear was (Pullman 2012). In both there is an unfavoured second son, sent off into the world to seek his fortune, who comes at last to a castle complete with king and beautiful daughter. He is challenged by the king to spend the night alone in his castle. If he can survive three nights there without flinching, he can marry the princess. The fearless boy survives terrifying noises, attacks from goblins, pinching and beatings, and other trials and tribulations unscathed, and so wins the princess’s hand. But still he does not know what fear – or ‘shuddering’ as he calls it – is. However, on their wedding night the princess pours a bucket of live fish over the young man. Their twitching and tickling at last teach him what it is to ‘shudder’: ‘Oh how I shudder, dear wife! Yes, now I know what shuddering is’. A quasi-structuralist approach to these stories (cf. Leach 1982) suggests several points relevant to the theme of anxiety disorders.

• First, like psychoanalytic therapy itself, these are quest stories of searching and transformation. These entail tasks which have to be undertaken or undergone before change can take place. • Second, Siegfried’s is a story of trauma – the protagonist is a bereaved, abandoned and exploited child in search of a more healthy developmental pathway. • Third is the theme of the relationship between aggression and fear. Like any acting-out adolescent, however threatening and seemingly beyond redemption, behind Siegfried’s anger and cruelty lies a well of fear, too threatening for him to admit, given the fragility of his nascent manhood.

Downloaded by [New York University] at 12:48 14 August 2016 • Fourth, we are reminded of the protective function of anxiety. The imagination’s capacity to conjure up goblins and dragons and things that go bump in the night – and to take appropriate avoiding action – is evolution’s way of keeping us alive when threatened by invisible but potentially fatal predators. Siegfried and the young princess have to walk the adolescent tightrope between staying alive and rite- de-passage risk-taking. Suomi (1997) has shown that similar dilemmas affect adolescent rhesus monkeys as they have between clinging to their maternal troupe and seeking their sexual fortunes in another group.

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• Fifth, in the magical moment when, thanks to the female voice of the forest bird, Siegfried suddenly acquires understanding, we see the intimate connection between empathy and fear. The dragon’s blood opens Siegfried’s ears to the feelings of others, which, as a maternally deprived boy, has been so missing in his childhood. • Sixth, this process continues in Siegfried’s encounter with Brunhilde. Sol- diers, both, they cannot love one another without acquiring the capacity to feel fear. Fear of rejection, fear of hurting the other’s feelings and the capacity to experience fear oneself as a template for mirroring the other’s fear, is integral to the capacity for emotional closeness. Without it, proximity merely provides opportunities for exploitation and aggression. • Seventh, in both the Siegfried–Brunhilde encounter and the ‘shuddering’ story is the idea that, for men at least, the ultimate fear is not to be found on the battlefield, but in bed. Loving sex implies surrender: a degree of trust that the other will respect one’s vulnerability rather than use it to inflict harm. ‘Shuddering’ is a ‘switch word’ (Freud 1905/1953) signifying both orgasm and terror. • Eighth we see Siegfried beginning to develop feelings of mutuality in relation to the natural world. Previously, in his bear- killing narcissistic way, he regarded nature as a mere play- thing, there for his amusement and gratification. Respect for the forces of nature entails awe, a recognition of human frailty in comparison with the grandeur and power of nature. • Ninth, returning to the idea of the developmental quest, these stories are consistent with the Aristotelian notion that psychic health depends on affect- balance. We can be crippled by too much fear, or too little. A brave man is one who is said to be too frightened to run away from the battlefield. Sieg- fried needs his fear in order to love Brunhilde, but he also needs to master it in order to push aside the previous generation, to scale the heights – to feel the fire and do it anyway! • Finally, implicit in the story is also a message for therapy. In order to recover from his developmental trauma and steer a course consistent with his destiny, Siegfried has to accomplish three tasks. He must find who his parents are; grasp the role and importance of his sword, which is their legacy; then rebuild its shattered pieces so that he is no longer trapped in the past (Owen Lee 1998). Downloaded by [New York University] at 12:48 14 August 2016 All three aspects are relevant to the therapy of anxiety disorders. The primal fear is the fear of one’s helplessness, Winnicott’s ‘nameless dread’. The bulwark against this is the understanding that one would not have survived without attachment to one’s caregivers, however imperfect they may have been. Con- versely, one has then to come to trust oneself and one’s separateness, and capacity to survive, drawing on the internal support and security bequeathed by parental altruism. Finally one has to overcome the fear that nothing can be put right and that one is trapped in an endless cycle of danger and destruction.

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Note 1 A poignant moment, but one which usually raises an embarrassed titter(!) from the audience. Siegfried here is relying on ‘difference coding’ (Northoff 2014). His self-referencing means that he knows what Brunhilde is not, not what she is. In characterising female sexuality as dominated by an absence, or lack (in Siegfried’s case, even when confronted by her breasts), Freud was similarly phallocentric. Downloaded by [New York University] at 12:48 14 August 2016

114 10 SPLITTING Stevenson’s Dr Jekyll and Mr Hyde

The beginnings of psychoanalysis can be dated to a professional split that occurred in 1886 (Ellenberger 1970). Freud, just 30, newly married, returned from Paris full of Charcot’s ideas, and presented a paper on male hysteria to the Viennese Society of Physicians. The reception was less than enthusiastic. Aus- trian medical chauvinism was offended by his espousal of French ideas that, the medical elders claimed, contained nothing they did not know already. Freud, eager for fame, and in need of money to settle down, was discouraged by this rejection and the anti-semitism of the medical establishment. Turning away from the medical establishment, he began, with the help of ﬁrst Fliess and then Breuer, to invent the theory and practice of psychoanalysis.

Stevenson Meanwhile, also in 1886, another young man, a writer – this one Scottish rather than Jewish – also newly married and short of money, was living in Bournemouth in England (Holmes, R. 1985). Like Freud, he was in the habit of attending closely to his dreams, which he used to furnish him with plots for stories, a mysterious process he attributed to his ‘brownies’ (Harman 1992a). One night he dreamed of a respectable doctor sitting unhappily at the window of his house, approached by two friends who ask him to come for a walk. At ﬁrst he readily agrees, but suddenly he slams down the window ‘with an expression of such abject terror and despair as froze the very blood of the two gentlemen below’ (Harman 1992b, p. ix). The dreamer cried out so much in his sleep that, much to his annoyance, his wife woke

Downloaded by [New York University] at 12:48 14 August 2016 him up so that the rest of the story was lost. But the fragment was enough. He started writing furiously, and within three days the ﬁrst draft of Dr. Jekyll and Mr. Hyde – the author was of course Robert Louis Stevenson – was completed. Dr. Jekyll and Mr. Hyde (Harman 1992b) is the classic literary account of splitting, or, as Stevenson put it, of ‘man’s double being’ – multiple personality, somnambulism and hypnotism being topics much in vogue in the 1880s, in literary as well as medical circles. Looking at the story from a psychodynamic perspective, several themes immediately stand out. The episode at the window epitomises the schizoid

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dilemma: Jekyll, lonely and troubled, longs for closeness, to tell someone what is happening to him; yet, when the possibility of doing so arises, he is smitten with terror and slams down the shutters of communication; this is the quintes- sential claustro-agoraphobic dilemma (Rey 1994). The whole work, like a psychotherapeutic treatment, can be seen as a movement from secrecy and silence to open communication. The vehicle of this transformation is the quiet and receptive solicitor Utterson, whose name, like proper names in a dream is cryptogrammic: Hyde – hide is self-explanatory; Jekyll has jackal and kill hidden within its apparent innocuous respectability; their covert link revealed in the held-in-common ‘y’, or, perhaps, ‘why?’. It is Utterson’s consistent concern that enables Jekyll eventually to utter his terrible tale of utmost (‘utter’) horror. Ste- venson, too, was an ‘utter son’ – a puer eternus, always a son, later a step-father but never a biological father – whose espousal of atheism at the age of 19, and fateful break with his father’s Calvinism was one of the turning points in his life, but whose genius for utterance, in words and on paper, were his salvation. Utter- son’s silent psychotherapeutic unobtrusiveness has the effect on his friends of ‘sobering their minds in the man’s rich silence’ (Stevenson 1886, p. 34; cf. Deronda, Chapter 1), eventually enabling Jekyll to deliver his narrative in the form of a letter. Hyde’s crimes are usually thought of as murder, addiction and lasciviousness, but the story opens with a horrific act in which, curiously, no one is seriously hurt. Running down a street, Hyde collides at the corner with a little girl coming in the opposite direction and tramples on her. Her piteous screams and Hyde’s indifference to them are what first alert Utterson to his evil nature. Trampling on a child’s feelings, an adult’s indifference – this is the territory in which splitting arises. Jekyll, one might speculate, was somehow trampled on as a child and has split himself into two parts: the one respectable, compliant, law-abiding, the other hidden, vengeful, compulsively doing to others what was done to himself. These un-integrated parts are symbolised in the story by the many different rooms that Jekyll inhabits, interconnecting in ways that emerge as the story unfolds, with the locked door, or the ghastly operating theatre turned laboratory finally smashed open by Utterson at the denouement. The avoidant individual similarly inhabits a divided house in which dependency needs and his rage at their not being met are hermetically sequestered one from another. A striking feature of the story is the absence of female characters; the same is

Downloaded by [New York University] at 12:48 14 August 2016 true of Treasure Island (1883/2010) and Kidnapped (1886/2002). The characters all appear to be bachelors, inhabiting a fog- bound Dickensian world, a Gothi- cised version of the Edinburgh middle classes among whom Stevenson grew up: no wives, mothers or other children. The dynamic of Jekyll and Hyde is that of father and son. When Stevenson announced his atheism to his parents, his father responded by saying, ‘You have rendered my whole life a failure’ (Holmes, R. 1996). Hyde is consistently described as smaller than Jekyll, a child- man, who, at the end, unable to ﬁnd the ingredients for the potion that will turn him once more into his creator, dresses up in Jekyll’s clothes, which were

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enormously too large for him in every measurement – the trousers hanging on his legs and rolled up to keep them from the ground, the waist of the coat below his haunches, and the collar sprawling wide upon his shoulders. (Stevenson 1886, p. 32)

Here, unmistakably, is a little boy dressing up in father’s clothes. The struggle between Jekyll and Hyde as each tries to claim supremacy at the end is the struggle between son and father: ‘Jekyll had more than a father’s interest; Hyde had more than a son’s indifference’ (Stevenson 1886, p. 36). When Jekyll ﬁrst takes the potion he feels a surge of liberation.

Younger, lighter, happier in body . . . a heady recklessness, a current of disordered sensual images running like a mill-race in my fancy, a solution of the bonds of obligation, a leap of nature . . . this too was myself. . . . Strip off the lendings and spring headlong into a sea of liberty. (Stevenson 1886, p. 53)

This is in contrast to his bonded, dutiful, fettered self,

I saw my life as a whole; I followed it up from the days of childhood, when I had walked with my father’s hand, and through the self-denying toils of my professional life. (Stevenson 1886, p. 54)

Here we see Stevenson struggling with the irreconcilable split in his nature between ambition and pleasure, security and danger, between the wish for closeness but the fear of being trampled, the longing for freedom but the risk of being disinherited. Stevenson, a lifelong ТВ sufferer, ever conscious of the proximity of death, and the guilty possibility of punishment for his wish to escape from the coils of Calvinism, writes of ‘a creature eaten up and emptied by fever, solely occupied with one thought: the horror of my other self ’. But reconciliation requires a female principle. For Stevenson his love of Fanny Osbourne, ten years his senior, a woman, as described in his Chapter on

Downloaded by [New York University] at 12:48 14 August 2016 Dreams (Harman 1992a), married to another man, yet who loved him, but for whom he had to endure torture. A classical psychoanalytic interpretation of Dr. Jekyll and Mr. Hyde might focus on the Oedipal struggle between father and son, the fear of castration, guilt at his rebellious murderousness – ‘If I am the chief of sinners, I am the chief of sufferers also’ (Stevenson 1886, p. 56). A schizoid split emerges from the lack of a container for Jekyll’s rage and desire, which is therefore split off and projected into his alter ego. The innovator, the creative schizoid, creates his own new forms. For Steven- son, dreaming, creativity, the work itself, became the container that held together

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the discordant elements in his nature. Jekyll illustrates the dangers of the Frank- ensteinian project – the attempt to break the laws of nature by giving birth to oneself is doomed to failure. Only in death can the two split halves be united: ‘co-heir with him to death’ (Stevenson 1886, p. 61). A world without women – and for Stevenson, the lighthouse builder’s son, science was quintessentially a masculine enterprise – was doomed to perversity and horror:

That insurgent horror was knit to him closer than a wife, closer than an eye; lay caged in his ﬂesh, where he heard it mutter and felt it struggle to be born. . . . In the agonised womb of consciousness these polar twins should be continuously struggling. (Stevenson 1886, p. 63)

We see in Utterson, in Jim in Treasure Island and in David in Kidnapped, Ste- venson’s central ego, frail but determined, likable, loyal, ever- youthful and – with his Scottish father and English mother – struggling to hold the divergent elements of his nature together. Like Jekyll:

No more myself when I laid aside restraint and plunged in shame, than when I laboured, in the light of day, at the furtherance of knowledge or the relief of sorrow and suffering. (Stevenson 1886, p. 12)

In Stevenson’s adventure stories the reader’s sympathies are aroused more by the outlaws and blackguards (Silver and Breck and the highland clansmen) than with the forces of convention (Trelawny and the doctor, the Lowlanders and the King’s men). Innocents abroad, Jim and David are attracted first toward rebellion, and then reigned in by the need to survive and so conform. A similar polarity is played out between Jekyll and Hyde, which is no simplistic struggle between good and evil. Jekyll is portrayed, albeit sympathetically, as rather stuffy and a hypocrite: ‘I concealed my pleasures . . . committed to a profound duplicity of life’ (Stevenson 1886, p. 66). Utterson, though good, is weak – an observer rather than an actor. Jekyll is attracted – and the reader is fascinated – by his alter ego, as an addict might be by his drug. As Hyde, he is free from conflict and doubt and can pursue his ruthless selfishness and hedonism, untroubled

Downloaded by [New York University] at 12:48 14 August 2016 by conscience or guilt. Stevenson was not alone in his concern with man’s dual nature; the theme of the doppelgänger was part of the zeitgeist (Ellenberger 1970). While the splitting in Dr. Jekyll and Mr. Hyde is entirely psychological, the adventure books represent splitting at a social level. In Kidnapped the division is between the Highlanders and the Lowlanders, between Jacobites and Loyalists, the gulf between them symbolised by the Firth of Forth. It is only with the help of a pretty peasant girl – the only ‘love interest’ to appear in either book – that David and Breck manage to reach safety. The pirates in Treasure Island tear each other

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apart in their struggle to the death for the buried gold – the mother’s love, the breast, which these men deprived of women want above all – outwitted in the end by Ben Gunn, the holy fool, another projection of Stevenson’s, who as a sickly only child had access to his mother’s ‘treasure’, without having to win it by ﬁghting.

Freud Implicit in Stevenson is the idea that man’s dual nature is related in some way to the suppression of the female principle – his men are all in one way or another avoidant. They are out of touch with the feminine in themselves, just as avoidant children keep their distance from the nurturing object. Freud’s project was to reconcile his clinical experience of splitting as manifest in the hysterics he had encountered at the Salpetriere clinics and in his consulting rooms at Berggas- strasse, with the Helmholtzian ideal of a scientiﬁc psychology. His early theorising moved away from people and their interactions to the idea of psychic energy and its repression or expression. As Grotstein (1992) puts it:

Due to the constraints of his Cartesian logical positivism, [Freud] travelled down the biological road and not exclusively the psychological one. In brief, Freud took the vertical splits of the hysteric’s double consciousness and, in effect, rotated them to the horizontal plane, thereby imposing the System Consciousness atop the System Unconsciousness. (Grotstein 1990, p. vi)

The Freudian model was thus predicated on dominance and submission. The two sides of Freud’s nature – Freud the innovator and Freud the consolidator – can be seen in the shift in his thinking from his early topographical model of the mind with its emphasis on the liberation of repressed psychic energy, to his later tripartite model with its emphasis on the control of instinctual forces. For Freud the subversive, energy resided in the unconscious, kept at bay by the powers of repression (cf. Barratt 2012). The aim of therapy was the gradual releasing of repression, or at least ﬁnding a compromise between the pleasure-seeking unconscious and the castrating reality principle. With the tripartite model of the mind, Freud moved away from a purely energetic conception of the mind to one that

Downloaded by [New York University] at 12:48 14 August 2016 contained at least one prototypical person-like internal object – the superego, a residue of parental prohibitions and restrictions as imagined by the self. Now the therapeutic task is not so much lifting of repression as reducing the unrealistic demands of this superego and reclamation of the vast areas of submerged self expropriated by the unconscious: ‘Where id is there ego shall be’ (Freud 1933, p. 80). The therapeutic movement in Freud’s metapsychology is mainly in the vertical plane, uncovering deeper and deeper layers of the psyche. But already in 1921, the year Freud was writing The Ego and the Id, Yeats had seen in the

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horizontal plane how, in the face of increasing splitting, the ‘center cannot hold’. The beginnings of a signiﬁcant shift in the metaphors and ambiance of psychoanalysis was under way: from the subjugation of unruly impulses to the holding together of a fragmenting and incoherent system. Let us look at how two psychoanalytic inheritors – Bowlby and Fairbarn, both with strong Scottish connections – carried forward the story of splitting into the contemporary era.

Bowlby John Bowlby’s father came from exactly the class described by Stevenson. He was a successful London surgeon, a bachelor until he was 40, hard- working, God-fearing, practical and down- to-earth. Like Stevenson, Bowlby fils was rebellious and independent, but with an ambitious and conformist streak. During the war years Bowlby joined the War Officer Selection Boards, that ‘invisible college’ of psychoanalysts and psychodynamic psychiatrists, headed by Jock Sutherland, that laid the foundations for psychodynamic psychiatry and psychotherapy after the war. Here the atmosphere was of openness and collaboration, in contrast to the esotericism of the psychoanalytic society at that time. Sutherland insisted that the selection boards be chaired by soldiers rather than psychiatrists; with his intuitive feel for group processes he saw that this would avoid the tendency to split off and marginalise psychological advice, and would, paradoxically, give the psychiatrists greater rather than less influence. Sutherland and Bowlby emerged from the war as director and deputy director, respectively, of the Tavistock Clinic. They were a formidable pair: outstanding men in their different ways, close friends, at that time sharing a house together with their families in Hampstead. These were heady times of reparation and new vision. Sutherland soon set about building up the ‘Tavi’ as an internationally known centre for training in psychodynamic psychotherapy. While repression, as originally conceptualised by Freud, is essentially intrapsychic, the concept of splitting is necessarily interpersonal, since split- off emotions are projected on or into the subject’s significant others. The theme of splitting emerges strongly from experimental studies of insecure attachment, in which children in sub- optimal caring environments are forced to deny aspects of themselves – neediness in the case of avoidant insecurity, autonomy in the case of ambivalent attachment. Here we can see links between intrapsychic splitting

Downloaded by [New York University] at 12:48 14 August 2016 and its interpersonal context – between the Klein–Bion model, which focuses on the inner world, and the Bowlby–Ainsworth one, whose target is the interpersonal environment. To maintain some contact with his attachment ﬁgure the avoidant child has split off his wish for intimacy and anger about separation – the beginnings, in extreme cases perhaps, of a Jekyll and Hyde divide that may erupt in later life when the trampled turns the tables and becomes the trampler. A converse splitting occurs in ambivalently attached infants. On separation these children cling unhappily to their parent for fear of losing them again, splitting off competence and agency for fear of further rejection.

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Main (1995) suggests that in peer groups, avoidant and ambivalent children can form a system of mutual projection: avoidants tending to be bullies, while ambivalents are their victims. A similar pattern can be found in sadomasochistic marriages. Each person projects into the other the disowned part of oneself, which he or she both envy yet cannot relinquish. This aspect of interpersonal theory of splitting is illustrated by the following two examples.

Andrew: a present- day Hyde Andrew, a bricklayer, 40, spent 11 years in prison after he followed an unknown woman back to her house from a bus stop and brutally attacked her with a knife, leaving her for dead. She dragged herself to a neighbour and eventually recovered. Andrew gave himself up to the police the next day. Subsequently he had little recollection of the event – ‘I just can’t believe it was me that did that’ – but did admit that he had been drinking heavily. His childhood was deeply unhappy. There were eight children, four boys and four girls. His parents fought incessantly, and the children were recruited as allies, with the boys on their father’s side, the girls on their mother’s; neither side was permitted to speak to the other for days on end. When Andrew was 16 his mother developed lung cancer, and over the next two years he watched her die a horrible death. Soon after her death he wandered away from home and lost all contact with his family. He married and had a child, but was unhappy. As the rows with his wife escalated he started to drink and it was then that the offence occurred. After a few years in prison he was transferred to an experimental prison unit (Grendon Underwood) run on psychotherapeutic lines. There he learned that it was possible to talk about emotions. He discovered that he existed as a person, he said, and that other people also had feelings: ‘I went into Grendon Underwood an animal and came out a man.’ While he was there he fell in love with his prison visitor and after his release they married and had a daughter. He remained on indefinite parole. The marriage broke up, but they remained on good terms and he was devoted to his daughter. He asked for further help when he began to detect in himself the beginnings of the feelings of depression and violence, which he said had preceded the attack. Downloaded by [New York University] at 12:48 14 August 2016 Andrew’s attack contained the naked rage of a split- off infantile part of his personality when parted from his loved object – a typical avoidant/unresolved pattern. The separation started with the parental fights in childhood, and was tragically reinforced by his mother’s death. As his first marriage began to fail the same feeling of schizoid isolation re- emerged. The attack was also an enactment of the experience of violent rejection in childhood that often underlies avoidant attachment – like Hyde, trampled Andrew turned trampler, as the split- off part of himself suddenly erupted under the influence of alcohol and depression.

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Vivienne: the lady and the tramp Vivienne was in her mid- fifties, a highly respectable solicitor’s wife who had grown up in a large working- class family whose lives revolved around a fundamentalist religious sect. She was close to her mother, but had terrible fights with her father in her teens when she had wanted to wear makeup and go to discos. When at 16 he caught her kissing a boy good- night on the doorstep she was beaten mercilessly. The next day she left home, not to return until his death some ten years later. Mean- while she found a job in a solicitor’s office and gradually a new personality emerged in which, Galatea-like, she acquired the airs and graces of a lady. She married a junior partner in the firm and, despite his many inexplicable absences on business, was devoted to him. They got on well as companions, but their sexual relationship never worked: he seemed to hold back and she was unable to let him know how strongly she desired him. Gradually she began to feel discontented and depressed. Feelings were never discussed between them; they continued to have dinner parties, play golf and were stalwarts of the rotary club. She became convinced that her husband was having an affair with one of the secretaries at work. She challenged him about this but, as always, he remained silent. Word got back to her confirming her suspicions. She became wild with jealousy and fury, and tried to leave the marriage but could not bring herself to do so. Then, one evening, without really realising what she was doing she put on a scruffy duffle coat of her son’s, pulled a woollen cap over her head, donned some muddy boots and left the house. She found herself drawn inexorably to her rival’s home. There, outside her door, was a shining white car. She picked up a rock and scratched the car all the way around, ending by smashing the windshield. She was not found out and, emboldened, she continued to enact her alter ego from time to time, especially when upset, often going to supermarkets and shoplifting, sometimes going into rough pubs and picking up men. Finally, with the marriage in tatters, her husband insisted that they talk and seek help. The whole story came out, with much guilt and many tears, but also a note of triumph and glee in Vivienne’s demean- our. Notably, her husband had also split himself – ever kind and consid- Downloaded by [New York University] at 12:48 14 August 2016 erate on the surface, but full of misery and rage inside.

In her ambivalent attachment, Vivienne had clung to her avoidant husband while the rebellious side of her, which had erupted brieﬂy in her adolescence when she left home, was split off into the ‘tramp’ she enacted in the midst of her marital misery. In both cases it was only when a suitable container had been found that these patients could begin to tell their story – for Andrew it was a benign penal

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institution; for Vivienne it was the setting of psychotherapy. The process of therapy, the healing of splits, requires the finding of a centre that can hold – in Bowlbian terms, finding a secure base in which split- off affects can be first felt, and then put into words.

Fairbairn Bowlby and Fairbairn were struggling with the constricting atmosphere of religion and middle- class mores in which they had been brought up. They found in psychoanalysis a system of thought powerful enough to rival these values, which at the same time provided both an account of their rebellion and a therapy to help resolve it. Both men had powerful, rigid and successful fathers; their mothers showed features of ‘affectionless control’ (Parker 1983), which can be precursor of avoidant (or, in Fairbairn’s terms, schizoid) attachment (Sutherland 1991). Bowlby was essentially a man of action, more at home with observable behaviour than with hypothesised feelings. Fairbairn, by contrast, was a man of contemplation, who, because of his difficulty in micturition in public – a symptom he shared with his father and which neither managed to overcome – found it difficult to travel far away from home. But Fairbairn was a fearless inner traveller, and, in his relative isolation from the psychoanalytic mainstream, had no hesitation in discarding Freud’s ideas where he thought them wrong, produc- ing perhaps the most radical statement of object relations theory available (Greenberg and Mitchell 1983). Fairbairn discarded drive theory altogether. Anticipating the findings of developmental psychology (Stern 1985), he saw mother and infant interacting with one another from the moment of birth. Pleasure was a ‘signpost to the object’, rather than the other way about, as Freud originally conceived it. (It is perhaps significant that both Bowlby and Fairbairn tended to downplay the importance of pleasure and sexuality in their theorising.) Fairbairn saw splitting as a fundamental defence, not as Klein imagined due to innate destructiveness, but as a response to environmental failure. The child represses not just his own impulses (which was Freud’s view) but also internalised bad objects such as the mother who frustrates and rejects. Andrew’s attack could be seen not just as a desperate attempt to find a con-

Downloaded by [New York University] at 12:48 14 August 2016 tainer for his unprocessed feelings of rage, but also as an eruption into consciousness of the painful feelings about the rejecting and later dying mother, projected into the unknown woman. Similarly, women who have been sexually abused as children will often choose abusive men as partners, and may evoke a psychologically abusive transference with their caregivers. It is as though there is a compulsion to ﬁnd an object with whom the drama of attachment – however painful – may be re-enacted. For Fairbairn, what is repressed is not just an impulse, but a dynamic structure comprising the affect, the ego that feels and responds to it, the relationship

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to the object to which it is directed, and the resulting behaviours. Split- off dynamic structures cannot be modiﬁed by the impact of external reality, especially the soothing and modulating inﬂuence of the mother; they become sequestered, and when released they emerge in a primitive and often destructive form. For Fairbairn the split is within the ego itself, not between conscious and unconscious, or between ego and id. This splitting of the ego may be more or less organised, ranging from a vague sense of separate selves or parts of the self, through sub- personalities, to the Jekyll- and-Hyde- like phenomenon of multiple personality. Fairbairn’s position led him to a radically different view of dreams from that of Freud, more akin to Jung’s, and one perhaps that most analytic psychotherapists use in practice, whatever their theoretical allegiance. As Fairbairn (1952) puts it,

Dreams, and for that matter waking phantasies . . . [are] essentially dramatizations of endopsychic situations involving both (a) relationships between ego- structures and internalized objects and (b) interrela- tionships between ego-structures themselves. (p. 170, my italics)

Stevenson’s window dream dramatises his longing for closeness and companionship, and his dread of it – his wish to be close to his internalised mother, but his fear that to get close would unleash all the rage and fury he felt in response to her rejection. The pulled- down window represents the typical schizoid or avoidant defence. Fairbairn had been thoroughly thrashed by his mother as punishment for an episode of sexual curiosity with his cousin, and on another occasion for asking questions about a blood- stained sanitary towel. Had he dreamed Stevenson’s dream – as he well might – it would have encapsulated the schizoid conﬂict based on the feeling that his love is inherently destructive. Fairbairn disliked the term analysis, and thought synthesis would have been a better term for the integration of split selves that he saw as the essential therapeutic aim. For Fairbairn the neurotic is trapped within a closed system, and the task of the therapy is to transform this into an open interpersonal system. He emphasised the real contribution of the therapist – her empathic understanding, reliability, beneﬁcence and acceptance, leading to a reduction in hatred and

Downloaded by [New York University] at 12:48 14 August 2016 therefore a diminished need for splitting. Patient and therapist are seen as an attachment system, and the need for sensitive attunement is inherent in his view of the successful therapeutic process. Behind his closed window, Jekyll is a caricature of the evil genius of modern science. Fairbairn and Bowlby are good examples of ‘positive splitting’. By remaining geographically and intellectually at a distance from psychoanalytic hurly-burly, Fairbairn was able to develop his own conceptual framework open- mindedly, with no pressure to adopt any particular line or dogma. Similarly, Bowlby continued to use psychoanalytic ideas creatively throughout his working

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life, integrating them with those of systems theory and developmental psychology without being too concerned about whose vested interests he would be threatening.

Therapeutic implications In psychotherapy this hidden aspect of the self is evoked by the relationship with the analyst, who has to create sufﬁcient intensity for the split- off affect to be re- experienced but not to be overwhelming. If the therapist can then respond in an accepting, but not indulgent way, bad affects and roles no longer need to be disavowed but can be integrated into the personality. The therapist acts like an effective parent, neither intruding upon nor neglecting the patient’s feelings and, by her modulatory response, enabling affect to be contained within the envelope of the patient’s autonomous self. Katherine illustrates this point.

Katherine: the gendered self Katherine was all too aware of the futility to which Fairbairn was so sensitive. After splitting up with her husband in Australia she had returned to look after her octogenarian mother, with whom she found it impossible to communicate in any meaningful way, but to whom she still felt deeply tied. She had had an unusual and very unhappy rural childhood. Her parents had owned a small school, in theory idyllic, but the reality, at least for Katherine, was very different. In the course of therapy she began to recover some positive memories of her mother stroking her, but then she had been removed from her parent’s part of the house at the age of three and placed in the dormitory with other pupils: ‘I was cast into outer darkness’. Typically for ambivalent children, no protest was permissible. Her mother, who had been crippled with polio, became remote and unavailable; she refused to kiss or cuddle her own children, as she said this would make the other children jealous. Her father beat and sexually abused her, as he did several of the other pupils. The transference soon reproduced her family situation. The therapist was seen either as a cruel and heartless father who intruded on her and caused her unbearable pain with his interpretations,

Downloaded by [New York University] at 12:48 14 August 2016 or as a benign version of the all-powerful father who could, if only he would, set everything to rights with his perfect understanding, love and admiration. At other times he was the crippled mother who was indifferent to her daughter’s cries for help. On one occasion when she was again insisting that the therapist should help her more, she said that there was a ‘big part’ of her missing. The therapist commented that perhaps what she was out of touch with was her womanliness; she had been unable to identify with her mother’s femininity because of her rejection, and also because her mother had not felt conﬁdent with this

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aspect of herself. Perhaps what terriﬁed her was the thought that she might have some aspect of her abusive father alive inside her. Could ‘big part’ represent the genital that had abused her? She was amused by this, immediately having an image of herself wearing a codpiece; at the next session she said she had felt much more herself for a few days after this episode. Katherine exempliﬁes the clinical reality of splitting of the ego, the crippled mother self, the persecuting and persecuted self in relation to her father – and the way in which these were evoked in therapy. It illustrates the therapist’s attempt to help the patient get in touch with a central integrative self, which is almost invariably a gendered self. With the interpretation of her womanliness she moved from seeing herself as a woman to the thought ‘I am a woman’. Here, momentarily, was a true meeting of therapist and patient – it was the coming together of tone, timing, content and receptiveness that made this interpretation helpful. Similar things had been said before with little impact.

Jekyll’s monstrous creation of Hyde from within himself is an aberration, a schizoid defence against un-attuned desires. When, too late, he ﬁnally ﬁnds his voice in his last letter to Utterson, his two halves come together in death. At this therapeutic nodal point Katherine could see her split selves as springing from a secure unitary biological core; she could see the possibility of integrating the many false selves which she had created and to which, temporarily at least, she was no longer in thrall.

Conclusion Running through this chapter has been the view that the key to neurosis is not so much repressed sexual or aggressive impulses, as split-off feelings and their relational context. In infancy and childhood modulation leads to integration, while failure of maternal responsiveness results in defensive avoidance of feelings in order to maintain some sort of contact with the object. These feelings are thus not subject to the modifying inﬂuence of reality. This can result in later life in Hyde-like explosions of primitive affect; disowning of exploratory competence or projection of parts of the self, resulting in a hostile worldview and feelings of

Downloaded by [New York University] at 12:48 14 August 2016 inner impoverishment or futility. This leads to a model of psychotherapy in which regulation of affect becomes the central theme. ‘Where id is, there ego shall be’ is interpreted as bringing the impersonal ‘it’ (i.e. unmodulated, unprocessed affect) within the orbit of the autonomous active experiencing self via relational experience. The main function of transference is to evoke and re-experience split-off affect, which is then available to the modulatory inﬂuence of the therapeutic process. The timing and tone of interpretations is as important as their content since their therapeutic effect depends on their capacity to promote the modulation and maturation of

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primitive affective states. The modulatory inﬂuence comprises the impact of the setting, the soothing and accepting response of the therapist, and the efforts of the patient to comprehend painful feelings. The aim of therapy is, through the discovery of meanings, the integration of experience into a shared narrative between patient and therapist. Therapy oscillates between the formation of an attachment bond and the developing story of that attachment. Painful losses are neither denied nor allowed to become overwhelming. The importance of a shared narrative is underpinned by the observation that autobiographical competence is a mark of secure attachment. Narrative capacity requires a containing boundary and a sense of continuity across time – a movement from the past, however painful, through the present, toward the future. Splitting arises where no common ground between attached and attachment ﬁgure can be found, or where the rupture between the generations is so great that no continuity in time can be established. Downloaded by [New York University] at 12:48 14 August 2016

127 11 GRIEF AND LOSS Milton, Tennyson and Donne

There is no life without loss; yet loss can blight a life irreparably. Learning to live with, transcend, survive, be strengthened by loss and separation is an inescapable part of the developmental and maturation process. As discussed in Part I, death is a major poetic theme in poetry – ‘the poet’s trump card’ as Heaney puts it, in the tarot section of The Wasteland literally so. Poetry often attempts to bridge the irremediable gap between the living and the dead, the present and the departed, the past and the present. This chapter looks at the ways in which three of our greatest poets have tackled this subject. In each case there is a movement through pain and despair to the consolations of acceptance of the natural rhythm of connection and separation, and, through memory, despite external vanishment, the presence of an inner representation of the lost loved one. Milton’s Lycidas and Tennyson’s In Memoriam are both poems by young men about the loss of loved and valued fraternal comrades. It is debatable whether friendship (and sib-ship) fulfil the criteria of proximity seeking, secure-base effect and separation protest which are the hallmarks of a full-blown attachment relationship. Weiss (1982) distinguishes the companionship provided by friends from the intimacy of adult attachment typically to be found in a sexual partnership. He showed how wives who move because of their husband’s job to new towns felt cut off from their friends and bored, but did not experience the specific empty loneliness that widows or separated people feel when loss of a spouse first hits. By contrast, Heard and Lake (1986) write about the need for ‘likeminded companions of similar experience and stamina with whom to engage in mutually interesting and enjoyable activities’ as an essential part of the ‘attachment dynamic’.

Downloaded by [New York University] at 12:48 14 August 2016 The prime role of friendship seems to facilitate exploratory activity rather than to provide a secure base, although without a secure base no exploration is possible, and many intimate relationships, especially marriage, provide both. It seems likely that friendship or sib-ship does have a more central role as a source for a secure base in certain circumstances: in adolescence; among comrades in intense and isolated circumstances such as the armed services or mountaineering expeditions; and between siblings when the parental relationship is difﬁcult or defective. The latter was certainly the case for Tennyson, who had an extremely unhappy and tormented childhood which he survived mainly through his writing

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and intelligence (Hamilton 1986), and, from his teenage years, through his friendship with Arthur Hallam who, although two years younger, became his mentor, sponsor and champion. Hallam’s premature death when Tennyson was only 24 led to near- breakdown for the poet. In Memoriam was started within weeks of the loss, but was only completed and published some 13 years later.

Lycidas Milton’s Lycidas similarly ‘bewails’ the death of a ‘learned friend’ (Edward King) drowned in the Irish Sea – like Tennyson’s Hallam, a childhood companion and one who shared Milton’s radical anti- clericalism. Milton’s mother had also died a few months earlier; numbed, Milton had apparently been unable to write anything to mark her loss. The scene is pastoral and the two friends are depicted as shepherds. The need at times of grief to return to the good object (breast-hill) is evoked:

For we were nursed upon the self- same hill, Fed the same ﬂock by fountain, shade, and rill.

The centrepiece of the poem is the attack on the ‘corrupted clergy then in their height’, drawn as self- serving, ignorant shepherds. Like so many prematurely bereaved people, Milton rails against the injustice of fate: why has my loved one died, who did not deserve it and not those undeserving souls who live on?

How well could I have spared for thee, young swain, Enow of such as for their bellies’ sake Creep, and intrude, and climb into the fold! . . . Blind mouths! that scarce themselves know how to hold A sheep- hook . . . The hungry sheep look up, and are not fed, But swoln with wind, and the rank mist they draw, Rot inwardly, and foul contagion spread.

The inner world is contaminated and fouled by the anger and despair of the poet, then projected onto the corrupt priests (the hopeless shepherds) who are held to blame for the loss.

Downloaded by [New York University] at 12:48 14 August 2016 The action of the poem takes place in a single night in which the poet passes through the stages of sadness, despair, anger, blame and depression until he reaches acceptance, with the help of two images from the natural world. The ﬁrst are the garlands of ﬂowers with which to ‘strew the laureat hearse where Lycid lies’, and which serve to link the loss of Lycidas with the natural transience of beauty. In the second he pictures the sun setting over the ocean where Lycidas is drowned, only to rise again the next morning,

and with new spangled ore Flames in the forehead of the morning sky.

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An image of setting and rising, of separation and reunion, has replaced the sense of irretrievable loss. A secure base is re-established, mirroring perhaps the regular appearance and disappearance of the feeding mother. The poet can begin once more to explore, no longer enshrouded, but enveloped by a cloak that moves and lives:

At last he rose, and twitched his mantle blue: To- morrow to fresh woods and pastures new.

In Memoriam In In Memoriam we see many of the same themes. In recalling his love for Hallam, Tennyson is taken back to preverbal paradisial times before the loss, reminiscent of the mother’s attunement to her baby’s needs, which leads, in Winnicottian terms, to the opening out of a transitional space between them. The poet describes the two friends’ sense of intuitive, empathic understanding:

Dear as the mother to the sun More my brothers are to me Thought lept out to wed with thought Eere thought could wed itself to speech

But then the dreadful boat brings the dead body home. Tennyson contrasts his own empty hands and those reunited with their attachment ﬁgures:

Thou bring’st the sailor to his wife And travelled men from foreign lands And letters unto trembling hands And, thy dark freight, a vanished life.

Tennyson tackles the tragic implications of monotropism: attachments are not transferable, or only so by a slow and painful process of withdrawal and re- attachment. By contrast, nature becomes an indifferent mother who cares equally and indiscriminately for all of her ‘children’ and has no special affection for any one of them.

Are God and Nature then at strife, Downloaded by [New York University] at 12:48 14 August 2016 That Nature lends such evil dreams? So careful of the type she seems, So careless of the single life?

Despair strikes, meaning is destroyed, when the interplay of attachment, with its mutual reinforcement, its linking of inner world and outer reality, is disrupted:

‘So careful of the type’? But no. From scarped cliff and quarried stone

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She cries, ‘A thousand types are gone; I care for nothing, all shall go.’

Loss throws us back to our childhood, to our primary attachments: but what am I?

An infant crying in the night: An infant crying for the light: And with no language but a cry.

Tennyson begins to think on a new time-scale and to see the possibility of new attachments, as one generation succeeds another:

Unwatch’d, the garden bough shall sway, The tender blossom ﬂutter down . . . Till from the garden and the wild A fresh association blow, And year by year the landscape grow Familiar to the stranger’s child.

Finally he returns to the image of mother and child, to the hatching of individuality from their symbiotic mixed- upness (Balint 1964). The mother’s ‘roundness’ takes him round the corner of his developmental pathway towards a less despairing separation in which the inner world is strengthened and clariﬁed:

The baby new to earth and sky What time his tender palm is prest Against the circle of the breast Has never thought that ‘this is I’ So rounds he to a separate mind From whence clear memory may begin As through the frame that binds him in His isolation grows deﬁned.

So it is with grief where, if all goes well, can come a strengthening of the inner world, of memory and deﬁnition. The ‘roundness’ of the breast is preserved in

Downloaded by [New York University] at 12:48 14 August 2016 the inner world, his ‘separate mind’. Isolation, if deﬁned and contained, becomes bearable; it no longer permeates the entirety of mental space. The importance of telling a story, of ‘clear memory’, is central to the poet’s (and the psychotherapist’s) mission.

‘A Valediction: forbidding mourning’ For a third example of mourning, John Donne’s ‘A Valediction: forbidding mourning’ also concerns a sea voyage, and also uses the image of a ‘round’ or

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circle as an antidote to the abyss of loss and separation. Despite its admonitory title, it offers a model for the resolution rather than denial of mourning. It is a poem about anticipatory grief, given by Donne to his wife before setting sail for France in November 1611 (Gardner 1957). He starts by advocating a slipping away on parting, which he compares with death, rather than an abrupt and emotional separation:

As virtuous men pass mildly away, And whisper to their soules to goe Whilst some of their sad friends doe say The breath goes now, and some say no.

He contrasts their love with that of ‘dull sublunary lovers’, who lack a secure inner base and who therefore are dependent on one another’s physical presence. They

cannot admit Absence, because it doth remove Those things which elemented it. But we . . . Interassured of the mind, Care lesse, eyes, lips, and hands to misse.

If we can mentalise, if we can hold onto the mental representation of the loved one, then their physical absence becomes bearable. He pictures the invisible but precious bonds which link carer and cared-for, lover and beloved in an attachment relationship as slender threads of gold:

Our two souls therefore, which are one, Though I must goe, endure not yet A breach, but an expansion, Like gold to ayery thinnesse beate.

Then, in another brilliant metaphysical metaphor, he imagines the internal working model of self and other as the two ends of a pair of compasses:

Downloaded by [New York University] at 12:48 14 August 2016 Thy soule the ﬁxt foot, makes no show To move, but doth, if th’other doe. And though it in the center sit, Yet when the other far doth rome, It leanes, and hearkens after it, And growes erect, as it comes home . . . Thy ﬁrmnes makes my circle just, And makes me end, where I begunne.

The sexual imagery of this poem – despite appearances to the contrary ladies do move, perhaps ‘grow erect’ even, the lover ‘ending’ (that is, in orgasm) where

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he ‘begun’ (i.e. was born) – combines in a profound way sexuality and attachment. The rhythm of sexuality, of coming together and separating, is linked both with death and the parting of soul from body at the start of the poem, and with birth at the end. They are held together by the central image of the secure base or ‘inter- assurance’ of lover and beloved. Seen in this way, attachment is a unifying principle that reaches from the biological depths of our being to its furthest spiritual reaches. The inevitability of loss means that grief sometimes outshines attachment in importance, that psychoanalysis often seems to over-emphasise negative emotions in comparison with the positive, just as for the republican Milton, Satan and the underworld were more vibrant and interesting than the monarch, or even the kingdom of heaven. In our next chapter we once more enter this underworld, through the vehicle of narcissism, viewed as yet another manoeuvre aimed at avoiding the pain of loss. Downloaded by [New York University] at 12:48 14 August 2016

133 12 NARCISSISM Ovid and Wilde

Narcissism starts from mirrors – from the mirroring mother, whose gleaming eye and responsive smile reflects delight in her child, through the seductive yet claustrophobic ‘hall of mirrors’ of overprotective parents, the suicidal patient confronting the cold lifeless mirror of the empty bathroom, to the watery surface that shatters into a thousand pieces as Narcissus vainly reaches out to embrace his own reflection. We are all fascinated by mirrors. But who and what do we behold when we peer into them? Does what we see seem alien – a stranger whom we hardly recognise? Do we look ‘alright’ – do we say to ourselves ‘you’ll do’ as we make ready for a party? Do we secretly admire what we see, or collapse in horror and loathing like the fairy-tale dwarf seeing his deformity for the first time? Do we preen ourselves in front of the mirror, pirouetting with backwards glance, flirting with our own image? Or do we, like Rembrandt, gaze squarely at the face that stares back at us, trying with every fibre to penetrate the mysteries of the self – a self that is at once so familiar and so strange? Havelock Ellis, the late nineteenth-century sexologist, was the first to link the classical Narcissus myth with psychological difficulty, seeing homosexuality, then regarded as a sexual perversion, as a pathology of self-love; a man loves another man, a woman a woman, who is like (a reflection of ) him or herself, rather than the otherness of the supposedly appropriate opposing gender. The Oxford English Dictionary (1973) defines narcissism, a term coined by Wilhelm Nacke in reviewing Ellis’ work, as ‘morbid self-love or self-admiration’. Note the necessary qualifier, ‘morbid’ – self- love is not

Downloaded by [New York University] at 12:48 14 August 2016 necessarily problematic, and indeed, as self-esteem, is generally seen as a mark of psychological health. The term ‘narcissism’ can be used in a number of distinct ways. In a lay sense it tends to be synonymous with self- centredness or self- preoccupation, and is appropriately used in describing people whose speech is littered with the pronoun ‘I’; whose conversation tends to take the form of what one long- suffering spouse of a chronic narcissist dubbed ‘Radio Me’. For Charles Rycroft (1972, p. 116), narcissism is a variant of

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solipsism . . . the tendency to use oneself as the point of reference round which experience is organised. In this sense the discovery that one is not the only pebble on the beach and that the world was not constructed solely for one’s own beneﬁt involves a loss of narcissism.

There is an implicit value judgement, with developmental implications, here which, as we shall see, psychoanalysis tries to theorise: to be self-centred is normal and acceptable in the young, but, if ‘selfishness’ persists into adult life, it is maladaptive and liable to be frowned upon. Consideration for others and altruism are contrasted with the inability or refusal to see the world from anything other than one’s own point of view – to mentalise – with consequent potential for trampling on other’s feelings. The idea of narcissism has been used sociologically by authors such as Chris- topher Lasch (1979) to describe a constellation of attitudes characterised by extreme individualism, lack of interest in the past or future, disregard for others, preoccupation with personal relationships at the expense of political activity and lack of concern about social cohesion. People so described (no doubt not without a streak of puritanical envy) might be the ‘me generation’ of today’s young afflu- ent middle class, or the decadent and fin de siècle hedonists of the late nineteenth-century European upper classes, so beautifully depicted by Oscar Wilde (of whom more below). Collective or group narcissism underlies such diverse phenomena as delusions of racial superiority, and various cults and mes- sianic groupings in which individual narcissism may be either legitimised or submerged in devotion to a charismatic leader. Psychoanalytic ideas about narcissism fall under three distinct headings: libidinal narcissism, destructive narcissism and healthy narcissism. Freud saw ‘primary narcissism’ as a normal developmental stage in which the infant thinks only, and blissfully, of itself. This is a precursor of object relations, the capacity to relate to – ‘invest libido in’ – others. Freud believed that people suffering from paranoia and schizophrenia, and to some extent hypochondriacal illnesses, regressed, often in the face of loss, to a ‘secondary’ narcissistic state in which ‘libido’ (here conceptualised as a kind of psychic fluid) is withdrawn from the external world and reinvested in themselves and their own bodies. Britton (1998) calls this state of psychic withdrawal into the self ‘libidinal narcissism’. By contrast, Karl Abraham (1973), and later the Kleinian school (especially

Downloaded by [New York University] at 12:48 14 August 2016 Rosenfeld 1965 and Kernberg 1975), emphasise the destructive aspects of narcissism, in which the narcissist envies, hates and actively seeks to destroy the object, that is, the Other. Only the self can be allowed to exist. Rosenfeld uses the powerful metaphor of the ‘maﬁa gang’ which is imagined taking over the mind, ruthlessly insisting that no external relationship is permissible. This triumphant ‘thick-skinned’ narcissism is contrasted with ‘thin-skinned’ libidinal narcissism, which is more defensive than destructive. A third psychoanalytic approach to narcissism is associated with the self- psychology school of Kohut (1971) who saw narcissism, i.e. self-love and

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object-love, not as lying on a continuum, but as two distinct developmental lines which persist throughout life, each with its own characteristic features and pathologies. He emphasised the healthy aspect of narcissism, seeing such phenomena as parental adoration of their children, the child’s excitement in itself and its world, and ‘normal’ hopes, aspirations, ambitions and ideals as all belonging to the sphere of positive narcissism. In this model, as development proceeds, narcissism is not replaced by object- love but, rather, is tempered by gradual disillusionment so that in maturity it continues to underlie good self- esteem and realistic goals. ‘Secondary narcissism’, and the inability to progress along the path of moderated self- love, result from ‘narcissistic wounds’, often arising out of parental neglect or abuse. Here, lacking external validation of their narcissism, people fall back on self-love so that at least a modicum of hope and motivation may survive. Many of these psychoanalytic ideas are brought together in the psychiatric sense of narcissism contained in Kernberg’s (1975) notion of ‘narcissistic personality disorder’, in which the sufferer is self-centred and demanding, over- estimates his or her own abilities and specialness, is envious, exploitative and unable to consider others’ feelings. But underneath this bombastic self- importance, the sufferer is often deeply depressed and has profound feelings of emptiness. As we shall see, ﬁnding ways to help these individuals is a major challenge for psychotherapy.

Clinical manifestations of narcissism In this section I shall consider aspects of narcissism as they might arise in a psychoanalytic situation, which I divide, somewhat artiﬁcially, into ‘necessary narcissism’, everyday ‘clinical narcissism’ and ‘entrenched narcissism’. The most obvious example of necessary narcissism is to be found in normal parental fascination and pride in their children, which, as we shall see, is a prerequisite if children are to develop good self- esteem. As Freud (1914, p. 91) puts it:

Parental love, which is so moving and at bottom so childish, is nothing but parent’s narcissism born again, which, transformed into object-love, unmistakably reveals its former nature. Downloaded by [New York University] at 12:48 14 August 2016 Of course, most parents are able to temper their narcissistic over-investment with realism. They can also see their offspring as separate beings, with their own projects, whose purpose is not merely to fulﬁl their parents’ hopes and ambitions. Also, effective parenting involves a huge sacriﬁce of narcissism, putting aside one’s own self-centredness in order to concentrate on one’s child, and allowing that child access to one’s partner. There are, however, those individuals who cannot not talk about their children, especially if successful, thereby inducing a certain envy and weariness in

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the listener. Similarly, those whose conversation consists mainly of boasting about their own achievements, wealth, and the important and powerful people with whom they are connected, are often compensating for feelings of insignificance and inferiority. Their conversation is peppered with the pronouns ‘I’ and ‘me’ and ‘mine’; their primary need is to be centre stage, yet with little apparent interest in the lives and reactions of their audience. They may be entertaining and fascinating, or sometimes unbearable bores. Again, they may excite envy, since most of us have a well of residual narcissism which our developmental process has helped keep in check, but which is never fully abandoned, only partially transcended in favour of the more palpable satisfactions of object relationships. The rich and famous, and their attendant publicity machines, provide necessary icons into which the majority of us who lead mundane lives can project our own secret narcissistic hopes and desires. The ‘narcissistic bubble’ with its brilliant reflections floats tantalisingly above our heads; when it bursts, the occupant is left naked and pitifully vulnerable, while we lesser mortals, our envy momentarily replete, can triumphantly gloat until the next object of our projected narcissism moves into view. The therapist’s reactions are an invaluable guide to the presence of narcissistic phenomena. Often, there is a feeling of a lack of real contact or dialogue with the client, who may superficially agree with the therapist’s comments, but, with glazed and unresponsive eyes, return to his or her own preoccupations without showing any discernible impact once the therapist has had their say. As a therapist, one may feel bored or excluded, ‘mad’ or importuning (as though the therapy is for one’s own rather than the client’s benefit), or even envious of the client, whose life seems so much more colourful and exciting than one’s own. One of the more seductive manifestations of narcissism is to be found in clients who idealise and overvalue therapy and their therapists. They insist on being treated by the top man or woman, the best that is going: nothing less will do. The therapist becomes a saviour, imbued with special powers that compensate for the patient’s feelings of ordinariness and insignificance. One therapist, well known for outstanding writing in the field, decided never to take on clients who approached her after reading her work: she found they invariably had projected huge narcissistic longings into her that were often resistant to analysis, and which she was destined to disappoint, not being able to live up to the ideal

Downloaded by [New York University] at 12:48 14 August 2016 of the ‘perfect therapist’ that they thrust upon her. There are certain characteristic features of more severe narcissism to which we can now turn. In a paper ﬁrst published in 1922, Abraham focused on ‘negative narcissism’, in which, paradoxically, sufferers are not so much irredeema- bly pleased with themselves but, rather, are in a constant state of anxious self- dissatisfaction. What is ‘narcissistic’ about negative narcissists is that they are just as self-preoccupied as their grandiose cousins, but are locked into self- hatred rather than self-love. Abraham quotes from Leo Tolstoy’s Boyhood and Youth:

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[M]y occupations . . . included . . . much looking at myself in the glass, from which, however, I always turned away with heavy feelings of depression and even disgust. My outward appearance, I was convinced, was unsightly, and I could not even comfort myself with the usual consolation in such cases – I could not say that my face was expressive, intelligent, or distinguished. (Hamilton 1982, pp. 122–123)

Freud saw the ‘negative therapeutic reaction’, in which patients deteriorate rather than get better when offered an apposite interpretation of their distressed state, as a manifestation of negative narcissism. For these patients, the ‘ideal self ’ is so far removed from the ‘real self ’ that striving towards it may seem futile – the ideal is too far away to even contemplate. As nothing less than perfection will satisfy, any attempt to change – to lessen the gulf between where one is and where one would like to be – is resisted in order to preserve the relative comfort of the status quo. People are often frightened to change, tending to cling to what they already have, including the illusion that perfection is somehow possible, even if they themselves are forever out of its reach. There can be a perverse satisfaction in being miserable. The origins of such negative narcissism are often to be found in a harsh superego, internalised from parental strictures. One patient described how she came home from school one day, delighted with having achieved 99 per cent in a maths exam, only to be roundly criticised by her father for not getting 100 per cent! With his libidinal perspective, Freud saw narcissism as a staging post on the way from autoeroticism to object relationships. The unconscious sexual and masturbatory phantasies of narcissistic patients (as opposed to their conscious fantasies) are important clues to their pathology. In men, there may be a huge preoccupation with the penis, either their own or that of others. Sometimes the narcissist has abandoned hope of mutuality in relationships and relies instead on power and coercion to gain access to his objects, access that provides a sense of security and satisfaction. Sadomasochistic phantasies are common. In female narcissism, the whole body itself may become idealised, with terror and desperation whenever signs of imperfection appear. Fantasies of being made love to by rich and famous men in exotic locations are perhaps a harmless manifestation of

Downloaded by [New York University] at 12:48 14 August 2016 normal female narcissism, but some women are in thrall to powerful men, and remain so, however much they suffer as a result. Those who feel powerless and empty, and view themselves as objects to be used, have to meet their narcissistic needs as best they can. Grandiose fantasies are a normal aspect of adolescent narcissism, but may persist into adulthood, albeit in a highly concealed form. It is rare that a client will speak of such things until they feel they can fully trust the therapist, and, even then, may only do so with much embarrassment and hesitation. Such thoughts are deeply coloured with shame, which many, like Phil Mollon (1993),

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view as the crucial ‘narcissistic affect’. The patient may dream of being a famous pop singer, football player, artist, academic or politician, and of untold riches and power. The possibility of artistic success is particularly seductive to the narcissist because of the social construction of genius. The idea of ‘genius’ (despite the reality that almost all ‘geniuses’ have put in a vast amount of hard work – 99 per cent perspiration; 1 per cent inspiration) encapsulates the quintessence of narcissism – someone who is touched by the gods and who can effortlessly achieve great things. ‘Narcissistic rage’ is another important clinical phenomenon. The narcissist may have managed to construct a world that more or less meets their needs, and in which, to use Freud’s famous phrase, ‘his majesty the baby’ is waited on hand and foot by various courtiers, or at least has found ways to recreate momentary feelings of narcissistic bliss with the aid of drugs, alcohol or sex, or through the purchase of so-called luxury goods. But sooner or later reality will intrude. The sufferer discovers that his or her needs have to be balanced with those of others, that helpers are motivated not just by devotion but by the necessity of earning a living, or simply that reality has its own logic and does not always bend to the dictates of human will. A therapist may be on holiday just when the patient needs them, or bring a session to an end when the patient is in full ﬂow. Such phenomena, great or small, may trigger an outburst of narcissistic rage. The patient will metaphorically, or sometimes literally, stamp his foot, smash or trash precious things, or shout the place down. One such patient, whenever he was thwarted, regularly had appalling rows with workmen or fellow drivers who got in his way on narrow lanes. In therapy he appeared compliant and accepting, but it gradually emerged how much he deeply resented and took personally the therapist’s holiday breaks, which he felt were invariably calculated to come at a time when he was most in need of support and comfort. As a child he had hour- long outbursts in which he threw himself inconsolably to the ground and screamed himself sick. With un-empathic parents and having spent long periods in hospital during his childhood, he was enormously insecure, and was cata- pulted into ﬁts of rage whenever he felt threatened, as a form of ‘displacement activity’ (apparently irrelevant behaviours triggered by intense emotions that cannot be ‘directly’ discharged or dealt with at the time). The rage itself seems to provide a measure of security for the narcissist who is fundamentally so lonely and deprived of a secure base.

Downloaded by [New York University] at 12:48 14 August 2016 Beneath narcissistic rage lies what Mollon terms ‘narcissistic vulnerability’ or, as Kohut calls it, the ‘narcissistic wound’. The narcissist is caught in a bind whose limits are the universal need to feel special on the one hand, and the equally imperative need to adapt to reality on the other. An attempt is made to create a world which will boost the sense of specialness and importance, but underneath lurks despair and depression and feelings of insigniﬁcance. In these circumstances, the narcissist is vulnerable to even minor slights and rejections which disconﬁrm their specialness, as well as to the everyday, or sometimes extraordinary, mishaps and traumas which unrelenting fate decrees.

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Two contrasting clinical patterns of narcissism have been described. Rosenfeld’s ‘thick-’ and ‘thin-skinned’ narcissists become, in Gabbard’s (1996) terminology, the ‘oblivious’ and the ‘hypervigilant’. Oblivious narcissists appear to have little understanding of others’ feelings and ride roughshod with their arrogant and self-serving ruthlessness. They are grandiose and exhibitionistic in their manner. Hypervigilant types are shy, inhibited and self- centred in their sensitivity to rejection or criticism. They seem to have ‘one skin missing’, and are so easily emotionally bruised that their self intrudes in every encounter. Bateman (1998) argues that these stereotypes are not mutually exclusive and that the hypervigilant are far less fragile than they appear, with huge rage lying not far beneath their frailty, while seemingly oblivious people, once engaged in therapy, may ultimately reveal emptiness and despair.

Literary examples of narcissism

Ovid’s version of the narcissus myth Many contemporary ideas about narcissism can be found in embryonic form in the classical Narcissus myth which gave its name to the syndrome. Here, I follow the poet Ted Hughes’ (1997) powerful translation of the Ovid version. The story starts not with Narcissus but with Tiresias, the only person to have lived both as male and female, and whom Jove and Juno therefore called in to adjudicate their dispute over who derived the greater pleasure from the act of sex: man or woman. Tiresias’ vote was for women. (Although in some versions he diplomatically replies that while women experience ten times the intensity of pleasure, men experience it ten times more often!) Juno, inexplicably angry, strikes him blind, while to compensate, Jove opens Tiresias’ inner eye, giving him the gift of prophecy. Thus Ovid reveals the narcissistic themes of bodily pleasure, envy and the difﬁculty in knowing how another truly feels, especially when one is oneself consumed with desire. Narcissus was the product of his mother Liriope’s rape by the river- god Cephisus. Narcissus was outstandingly beautiful from birth, so much so that envious gossips came to Tiresias questioning whether a creature so beautiful could live for long. Here the profound theme of the transience of beauty, and of

Downloaded by [New York University] at 12:48 14 August 2016 the links between narcissism, envy and death is introduced. Tiresias answers enigmatically: he can live long, ‘unless he learns to know himself ’. The paradox turns on the fatal word ‘unless’. The terrible dilemma of the narcissist is thus elegantly summarised: either the narcissist remains trapped forever in the shadow world of self-love, or he is released from the bondage of self-unknowing (and by implication being unable to know others), but on price of death. Although the narcissist thinks only of himself, ironically he can never really know himself, since he cannot take a position outside himself and see himself as he ‘really’ is. The narcissist can never ﬁnd that essential inner vantage

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point which is the beginnings of the capacity to mentalise. If he could accept that beauty fades, then his loveliness would be something to celebrate; by grandi- osely denying the reality of loss and change, this beauty is transformed into monstrosity. Narcissus grows into a beautiful young man. Many fall in love with him, but he keeps his distance. Then the wood-nymph Echo sees him and is immediately stricken. Previously a chatterbox, she has lost her power of speech as punishment from her mother Juno who discovered that Echo was being used as a decoy by Jove to engage her in conversation while he was away chasing other women. All she can do is repeat the words she has just heard. How is she to declare her love? One day Narcissus is lost in the woods and calls out to his friends: ‘Come to me’. Echo reveals herself: ‘to me’, ‘to me’, she calls. Narcissus – terrified at the prospect of real object love, turns and runs: ‘I would rather be dead than let you touch me’. Echo is mortified, and slowly dies of lost love, until all that is left is her voice. Narcissists break hearts. They cannot see the impact of their actions on others. They attract flatterers and fawners, themselves narcissistically traumatised, hoping for reflected glory. Echo’s ‘God- mother’ (Juno) is so envious of her relationship with her ‘God-father’ (Jove) that she blights the father–daughter relationship so essential to healthy female narcissism – a relationship in which the adolescent daughter knows that her father sees her as beautiful, while remaining utterly respectful of her sexuality. Echo, the hypervigilant, becomes the mirror image of the oblivious Narcissus. He is untouchable; she eternally longs to be in his arms. He thinks only of himself and is ruthlessly selfish; she can only think of him, and her damaged self-esteem remains fragile even unto her death. He cannot identify with others and so make their voices his own, thereby enlarging the range of his personality; she has no voice of her own and is condemned to pale imitation. In attachment terms, both are insecurely attached: she clings insufferably to her object, he forever keeps his at a distance. Many others fall unrequitedly in love with Narcissus. Eventually one, in a crucial therapeutic move, has the courage to confront his tormentor. (It is a ‘his’ – there is a suggestion of bisexuality throughout the myth, Narcissus cannot be content with the love of only one sex.)

Downloaded by [New York University] at 12:48 14 August 2016 Let Narcissus love and suffer As he has made us suffer Let him, like us, love and know it is hopeless . . .

One day, thirsty from hunting, Narcissus ﬁnds a ‘pool of perfect water’ and there, as he stretches out to drink:

A strange new thirst, a craving, unfamiliar, Entered his body with the water,

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And entered his eyes With the reﬂection in the limpid mirror . . . As the taste of water ﬂooded him So did love.

He falls deeply in love with his own image. But the harder he tries to embrace himself, to kiss the lips that ‘seemed to be rising to kiss his’, the more frustrated and lovesick he becomes. He bemoans his fate. Eternally separated from his love-object, he experiences loss and grief for the ﬁrst time. At last he comes to know himself:

You are me. Now I see that . . . But it is too late. I am in love with myself . . . This is a new kind of lover’s prayer To wish himself apart from the one he loves.

He realises that he must die: ‘I am a cut ﬂower’, ‘Let death come quickly’. At last he feels compassion for another: ‘The one I loved should be let live. He should live on after me, blameless.’ But he knows this is impossible. When he dies, both he and his observing self die – and even as he crosses the Styx he cannot resist a glimpse of himself in the water. But at the moment of his death he is metamorphosed into a beautiful ﬂower. To this day, the narcissus, with its evanescent delicate trumpet and seductive fragrance, is a tribute to Tiresias’ prescience. Tiresias, like a good psychotherapist, knew that if we are to survive psychologically, we must outgrow our narcissism. If we can accept our own transience and mortality, then we can be transformed – our self-esteem will be secure and we will be blessed with an inner beauty. If not, we are condemned to a living or actual death, perhaps at our own hands, as our narcissism grows ever more demanding and insistent. We will grow a thick skin over the vulnerability which has made us shy away from relationships. Loving only ourselves we envy those who can relate to others, and do our damnedest to destroy them, using our beauty as a weapon.

Downloaded by [New York University] at 12:48 14 August 2016 Shakespeare: Sonnet 62 For Shakespeare’s protagonist, the act of writing is a process of self-discovery:

Sin of self- love possesseth all mine eye, And all my soul, and all my every part; And for this sin there is no remedy, It is so grounded inward in my heart. (62: 1–4)

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There is perhaps an ironic tone here. Is it really such a sin to love oneself? Well- founded healthy narcissism needs to be ‘grounded in the heart’ if it is to serve its purpose, and to keep us buoyant in the face of life’s tribulations. And yet the narcissist who has eyes only for himself is lost. He is consumed with envy, constantly having to boost himself by comparing himself with others. Like Snow White’s step-mother, he boasts:

Methinks no face so gracious is as mine . . . As I all other in all worths surmount. (62: 5, 8)

What is more – and here’s the rub – when age creeps in, all is lost, as self- love turns to self- loathing:

But when my glass shows me myself indeed, Beated and chapped with tanned antiquity, Mine own self- love quite contrary I read; Self so self- loving were iniquity. (62: 9–12)

The resolution comes in the ﬁnal couplet which, like Tiresias’ paradox, depends on a metamorphosis:

’Tis thee, my self, that for myself I praise, Painting my age with the beauty of thy days. (62: 13–14)

The solution to narcissism is to love another. But, unlike Narcissus who longs for some separation between lover and beloved, Shakespeare highlights the merging aspect of love. ‘Thee’ and ‘my self ’ form a unity in which there is no distinction between self and other, in which self- love and object- love come together, or as Freud put it:

[A] real happy love corresponds to the primal condition [i.e. of early infancy] in which object-libido and ego-libido cannot be distinguished.

Downloaded by [New York University] at 12:48 14 August 2016 (Freud 1914, p. 100)

Being in love both destroys and preserves narcissism, in the practical sense that to love is to escape from oneself, but also helps one to feel good about oneself; and in the theoretical sense that self-love passes over, and so is lost, via projective identiﬁcation, into the image of the beloved, where it is metamorphosed into a celebration of their existence. The ‘paint’ of the ageing, perhaps theatrical, narcissist – the makeup, rejuvenating creams and cosmetic surgery – is transformed by mutual happiness and the hue of the loved one.

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This sonnet was probably written to Shakespeare’s young and handsome noble patron. Thus while offering a partial solution to the inherent problem of narcissism – transience – it could be seen as narcissistic in that it is based on the love of a younger man by an older one, who projects all his own narcissism into youth. In Freud’s schema:

A person may love according to the narcissistic type:

(a) what he himself is (i.e. himself ) (b) what he himself was (c) what he himself would like to be . . .

Narcissus and the poet at the start of the sonnet are in category (a). The penulti- mate line of the poem suggests that all types of love – certainly all falling in love – contain an element of narcissism in that the beauty is as much in the eye of the beholder as in the separateness of the beloved. The last line suggests that movement from (a) to (b) or (c) may represent progress but still remains within the bounds of narcissism. Taken with Ovid, we can suggest that truly relational love depends on the capacity for both merging and separation. Unlike narcissistic and ‘echoistic’ love, such love is both eternal and transient, depending on the capacity simultaneously to trust and so entrust oneself to the Other, and to cope with difference and separation.

Wilde: The Picture of Dorian Gray All three of Freud’s varieties of narcissism are amply illustrated in Wilde’s novel The Picture of Dorian Gray (Wilde 1891/1985), which, like Stevenson’s novella (see Chapter 10), was stimulated by contemporary fascination with ‘alters’ and doppelgängers. It contains one of the classic images of narcissism – the diabolic pact in which the narcissist defeats ageing by presenting an eternally youthful face to the world, while the true horror of his inner self is depicted in a grotesque portrait, locked away in his innermost attic sanctum. The novel starts with a series of epigrammatic statements about art. These are essentially anti-puritanical celebrations of the ‘uselessness’ of art and the

Downloaded by [New York University] at 12:48 14 August 2016 supreme importance of beauty as a virtue in its own right. They represent another of the metamorphoses of narcissism. By transforming his narcissism into art, Wilde transcends its self- centredness, since ‘artistic beauty’ (as opposed to ‘real beauty’) does not fade and is a form of communication. Even destructive narcissism ﬁnds justiﬁcation: ‘Vice and virtue are to the artist materials for an art.’ The novel centres on three main characters, each of whom perhaps represents a facet of Wilde’s personality. Dorian – the golden boy – is an incredibly beautiful young man; Lord Henry Wotton, a forerunner of Algernon in The Importance of Being Earnest (1995/2002), is a witty and ruthless roué who takes Dorian

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under his wing; Basil Hallward is the painter touched with dangerous genius, whose portrait of Dorian has such magical properties. Dorian gazes at his portrait, and imagines a Faustian pact:

How sad it is! I shall grow old, and horrible and dreadful. But this picture will always remain young. It will never be older than this particular day of June . . . If it were only the other way! For that I would give everything . . . I would give my soul for that!

The novel turns on the interplay of Wotton and Dorian’s narcissism. Each is enormously excited by the other: Gray by Wotton’s intellect and social ease, Wotton by Gray’s looks and innocence, and by the fact that he is able to manipu- late him at will. Dorian falls in love with a pretty young actress, Sibyl Vane, but like a true narcissist he has no real feelings for her, and is merely excited by the idea of possessing someone who is so admired by everyone else. In this way she vicariously enlarges the scope of his narcissism, and her love for him is flatter- ing. But then, to his horror, he realises that others find her ordinary and lacking in talent. The mundane and socially inferior concerns of a real person begin to intrude, and he drops her. Mortified, she commits suicide, which tips Gray into a life of debauchery and viciousness. Rosenfeld’s mafia gang has taken over his personality, and there is no escape. While his looks remain unchanged, the secret portrait reveals the cruelty and ugliness of his soul. As the novel descends into gothic horror, Hallward visits Dorian in a vain attempt to get him to mend his ways. Gray reveals the omnipotence and grandiosity of the narcissist: ‘I shall show you my soul. You shall see the things you fancy only God can see.’ Then Gray confronts Hallward with the despair of the narcissist. Like Narcissus when he finally realises that his ever- elusive beloved is none other than himself, now Gray grasps how his pursuit of eternal youth has condemned him to cause and to suffer unutterable misery. Hallward offers him the chance to repent, but destructiveness takes over and Gray stabs the artist to death. Gray manages to escape the revenge of Sybil’s brother, and shows some slight stirrings of redemption as he decides not to exploit another lovesick woman, Hetty Merton. He revisits the picture in the hope that this act of charity will show in a softening of his image, but it is too late; his sins cannot be wiped out so easily. His final act is to plunge the murder knife into the magical canvas.

Downloaded by [New York University] at 12:48 14 August 2016 As he does this, he falls, stricken, so that in the morning his servants find an old and ugly man dead on the floor, with the portrait mysteriously intact, now depict- ing the bloom of youth from the moment it was painted 20 years before. The narcissist is likely to become suicidal at the moment of narcissistic collapse. Dorian Gray is grotesque because in it the normal relationship between fantasy and reality is reversed. The seductiveness of art lies in its capacity to create an artificial reality that is both an expression of narcissism and, through self-knowledge and communication with an audience, a partial release from it. Thus in Seamus Heaney’s (1998, p. 15) poem ‘Personal Helicon’, he describes

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his fascination with wells as a child, into which, ‘big-eyed Narcissus’, he would stare endlessly. He compares this with his adult activity as a poet in which: ‘I rhyme/To see myself, to set the darkness echoing’.

Theorising narcissism Theories about narcissism have stimulated ﬁerce debate within psychoanalysis and centre on two main issues. The ﬁrst concerns the relationship between primary and secondary narcissism, the second about the healthiness, or otherwise, of narcissistic phenomena in general.

Primary and secondary narcissism Freud differentiated primary narcissism, a normal developmental stage in early infancy en route to states of object relatedness, from secondary narcissism in which troubled individuals regressively take themselves as their primary love- object rather than another. Secondary narcissism is relatively uncontentious. It covers the range of different conditions described earlier in which people are pathologically self- preoccupied; unable to relate; approach others not as ends in themselves but as means to selﬁsh ends; resort to ‘self-soothing’ behaviours such as drug addiction, deliberate self- harm or promiscuous sex; become self- defeatingly self-reliant, and so on. The main debate has focused on the precise meaning of the term primary narcissism, and whether it refers to any real phenomenon. Freud’s original idea was that the child – after the stage of autoeroticism, but before becoming aware of his mother as a separate being, and therefore as someone to love (or ‘libidinally cathect’) in her own right – narcissistically invests himself with the love he had felt from his mother. Later, however, Freud used the term in a more general sense to denote an undifferentiated state of existence, occurring before the child has developed even a rudimentary ego or self. In this state, the infant basks in maternal tenderness and care, and is suffused with blissful feelings of love and being loved that are neither object- or self-directed, or are perhaps both at the same time. As psychoanalysis has moved from a libido-oriented to an interpersonal perspective this concept has been challenged. Balint (1968) and Fairbairn (1952)

Downloaded by [New York University] at 12:48 14 August 2016 argued that we are object related from the start of life, and research by Stern (1985) on infant behaviour seems to support this view. Infants interact inten- sively with their mothers from birth and can for example differentiate the smell of their own mother’s milk from that of others in the ﬁrst few hours of life. Melanie Klein argues that young babies have an ego that is actively involved in mental processes such as splitting, idealisation and denigration. In this schema there seems little room for the notion of primary narcissism. As Symington (1993, p. 120) roundly puts it, ‘the only narcissism that exists . . . is secondary narcissism’.

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Even the original conceptualisation of narcissism is questionable. Freud saw homosexuality, psychosis and hypochondria as examples of narcissism in which libido is directed inwardly to the self, rather than outwards to another. Today, few would argue that people suffering from schizophrenia do not form object relationships. They are, if anything, inter-personally over-sensitive. Similarly crude distinctions between homosexual and heterosexual types of loving are utterly outdated. Many homosexuals form mature loving relationships, and, conversely, heterosexual object choice is not infrequently narcissistic, in the sense of choosing a glamorous ‘trophy partner’ whose main psychological role is to boost the subject’s narcissism through stimulating envy in others.

Healthy versus pathological narcissism In the late 1960s, Kohut mounted an important challenge to the then conventional views on narcissism. Kohut argued that Freud’s idea – of a single developmental line from narcissism to object relationship – should be abandoned. For him, the growth and shaping of normal healthy narcissism is a separate and necessary developmental process in its own right. Rather than seeing narcissism as a ‘bad’ thing, to be found in the mentally ill, immature – and those not prop- erly analysed – he argued that healthy narcissism is a precondition of successful living, including object relating, and that the phenomena of secondary narcissism should be considered as representing ‘breakdown products’ of the normal process of narcissistic maturation. Kohut quotes Freud’s famous statement (Kohut and Seitz 1963, p. 20) that: ‘a man who has been the undisputed favourite of his mother keeps for life the feeling of a conqueror; that conﬁdence of success often induces real success’, and from a chapter entitled ‘Baby Worship’ in Anthony Trollope’s Barchester Towers (1857/2007) in which a mother is looking at her little boy:

‘Diddle, diddle . . . dum . . . hasn’t he got lovely legs?’ . . . Said the rap- turous mother ‘. . . He’s a little . . . darling, so he is; and he has the nicest little pink legs in all the world . . .’

This process appears to have gone wrong in the infancy of people destined later to suffer from narcissistic and Borderline Personality Disorders. Such sufferers

Downloaded by [New York University] at 12:48 14 August 2016 believe either that they were unwanted, or an ‘afterthought’, or were adopted; that their mothers had ‘terrible’ labours which made them determined never to have another child; that they were responsible for their mothers’ post-natal depression, or for causing their fathers to walk out. All this suggests how the potential for healthy narcissism can been blighted from birth. When things go right, the child begins to build up a sense of himself as special and lovable, and is able to enjoy healthy exhibitionism and grandiosity. A child aged three who jumps off a sofa onto a soft landing, shouting to his parents ‘Look at me, I can ﬂy!’, will be admired with affectionate pride. When

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that child goes to school a year or two later, his parents will collect him from the school gate with a ‘gleam’ in their eye – seeing their own child standing out from the crowd as though suffused with a special light. If parents cannot love their children in this way, then the seeds of shame and self-disgust are sown. Kohut coined the word ‘selfobject’ to describe this specialness of intimate relationships in which the other is neither fully part of the self, nor fully separate. A young child’s parents are selfobjects, in that they are experienced as extensions of the self which the child can to some degree control. This selfobject relationship can be seen as purely illusory and defensive – a way of avoiding the traumatic realisation of the helplessness and vulnerability of childhood. For Kohut, however, selfobjecthood is an antidote to the excessive preoccupation with autonomy and separateness which he sees as pathologically endemic in Western culture. As development proceeds, so infantile grandiosity (or ‘omnipotence’) and exhibitionism have to be tempered with reality and self- awareness. Kohut calls this ‘optimal frustration’, and states:

If the child is spoiled (not optimally frustrated), it retains an unusual amount of narcissism or omnipotence; and at the same time because it lacks actual skills, feels inferior. Similarly, overly frustrating experiences . . . lead to retention of omnipotence fantasies. (Morrison 1986, pp. 69–70)

Striking the right balance between necessary frustration, without inducing shameful awareness of helplessness is a skilful task, and one which, according to Kohut, is best done by more than one parent: from a classical Oedipal perspective, it is the father’s role to frustrate the child’s sense of exclusive possession of the mother. At the same time the father, or ‘paternal principle’ (which can equally be provided by the mother herself or a male relation), helps the child to metamorphose his grandiosity and exhibitionism into what Kohut calls the ‘bipolar self ’, whose twin poles are the ideals to which we strive, and ambition – a word Kohut uses for the sense of real potency (as opposed to delusions of omnipotent control) in achieving those ideals. It is noteworthy how frequently the childhood of Borderline patients is characterised by abusive, drunken or dis- appearing fathers – and often all three.

Downloaded by [New York University] at 12:48 14 August 2016 The ultimate blow to narcissism is the fact of our own death; coming to terms with death is a mark of maturity and wisdom. For Kohut, narcissism, successfully negotiated, leads to the capacity to accept mortality, to see oneself as one is without over- or underestimation, to develop a sense of creativity and humour and to trust one’s intuition and empathy. The paradox of this process is that narcissism needs to be healthily established before it can be given up. Winnicott wrote famously about a child’s use of a spoon during a consulta- tion: holding it, sucking it, hitting with it. Hamilton (1982) similarly emphasises the infant’s acquisition of the ability to grasp an object as illustrating both

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healthy narcissism and its transcendence. Grasping is a huge achievement for a small child and often seems to produce a sense of mastery and satisfaction – there is a triumphant look in the child’s eye as he manages to wrest his cup from the high-chair table and bring it to his mouth for the ﬁrst time. At the same time, grasping is an escape from the solipsism of infancy – an encounter with the real world that carries through into the metaphorical use of the word: to denote our ability to comprehend ideas. ‘Spoiling’ a child – helping too much, in a way that compromises autonomy – interferes with this process of discovery of the world, and paradoxically increases levels of stress hormones (Dozier et al. 2006). In the Kohutian schema, defective narcissism is as problematic as excessive narcissism, and pathology arises when normal selfobject development is inhibited. A modicum of what Britton’s (1998) ‘epistemic narcissism’ – an unshak- able belief in the rightness of one’s own ideas – is the mark of a creative and assertive self. For Britton however, as a follower of Rosenfeld, such epistemic narcissism is essentially defensive. In ‘destructive narcissism’ the sufferer feels so threatened by the existence of people outside himself upon whom he depends, and feels so envious of them, that in order to maintain his omnipotent position as ‘lord of all he surveys’, he must eradicate the object forthwith. The pathological aspects of narcissism – treating others as a means to an end, ruthless self- centredness, lack of empathy – are all manifestations of this envious need to deny the importance of the object. The mirror image of this thick-skinned narcissism is to be found in the utterly vulnerable patient who controls her object by remorselessly tugging at their heart strings. Sohn’s (1985) metaphor of the Pied Piper who lures all the healthy children into the mountainside, leaving only the crippled boy behind, captures the way in which such patients may present only the wounded part of themselves to the therapist, while the healthy aspects are inaccessibly sequestered, emerging perhaps unwittingly in dreams and scraps of creativity. Kernberg similarly emphasises the pathological aspects of narcissism, in which he postulates a ‘grandiose self ’ comprising a fusion of real self, ideal self and ideal object, and resulting in an idealised self- sufﬁciency, making the subject impervious to intimate relationships, including analysis. According to Kernberg, the narcissist is saying:

I do not need to fear that I will be rejected for not living up to the ideal

Downloaded by [New York University] at 12:48 14 August 2016 of myself which alone makes it possible for me to be loved by the ideal person I imagine would love me. That ideal person and my ideal image of that person and my real self are all one and better than the ideal person whom I wanted to love me, so that I do not need anybody else anymore. (Morrison 1986, p. 134)

Or, as the nursery rhyme has it; ‘I care for nobody, no not I, for nobody cares for me.’

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The radical self-suf ﬁciency of the narcissist is of course in direct denial of the inescapable fact of parental sex – the ultimate act to which we owe our existence and over which we have no control (‘I did not ask to be born’ is the despairing cry of depressed narcissism). The narcissist strives to think of himself as a ‘self- made man’, but may pay the price of inability to allow the free intercourse of unconscious parts of the mind (cf. Britton 1998). In sum, the narcissistic self comprises three layers of feelings: an outer denial of dependency and a consequent self- admiration; beneath this lies overwhelming rage and envy; and below that, a frustrated yearning for loving care.

Attachment approaches to narcissism Attachment theory brings an empirical approach to bear on psychoanalysis. It emphasises the importance of protection and security provided by the caregiver (usually the mother), for the child, who turns to a ‘secure base’ when threatened. Can attachment theory, with its emphasis on evidence and observation, help reconcile the Kernbergian and Kohutian perspectives? Attachment theory makes a clear distinction between healthy and sub-optimal developmental lines, which it sees as being established quite early in the course of psychological growth, so that by one year, children can be divided into those with secure and those with insecure attachment patterns. Insecure attachment is seen as a defensive response to sub-optimal parenting – a way of maintaining contact with a supposedly ‘secure’ base that is in fact rejecting, inconsistent or psychologically confused and unavailable. This produces the characteristic patterns of insecurity: avoidant, ambivalent (clinging) and disorganised. In secure attachment the mother is responsive and attuned. As Winnicott put it, her face is the mirror in which the infant begins to ﬁnd and know itself. Healthy narcissism starts from the warm responsive mirror-mother who is able accurately to reﬂect back the infant’s feelings which form the core of the self. Through the presence of another we can come to know and accept ourselves. Where attachment is insecure, this mirroring process is compromised. The mirror may be blank and unresponsive (leading to the avoidant pattern); suffused with the parent’s feelings rather than those of the infant (ambivalent pattern); or chaotic and confusing (disorganised pattern). Narcissus and Echo could be seen as typifying the avoidant and ambivalent

Downloaded by [New York University] at 12:48 14 August 2016 strategies. As her son was the product of a rape, Liriope may have had difﬁcult feelings about Narcissus from the start. This ‘ghost in the nursery’ (Fraiberg et al. 1975) meant that her helpless rage towards his father may have led to an aggressive care- giving pattern, in which Narcissus, seeking some sort of security, will have suppressed his loving feelings and tried to become emotionally self- sufﬁcient. He may have denied the reality of parental sex that led to his existence, and in fantasy seen himself as self-generated. His beauty ensured that this relationship with himself would always be available, but his suppressed rage about rejection by his mother meant that he could not trust an Other and thereby

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establish a secure base, preferring to use people in a punishing and coercive way instead. At school or with his peers, Narcissus would have been a bully, picking on victims like Echo as his prey. Echo, by contrast, illustrates ambivalent attachment: her self exists only in response to others, never as an active agent. Her narcissism is in this metamor- phic sense anti-narcissistic. Her only hope is to cling to the object in order to achieve a modicum of security. As development proceeds, so external attachment patterns with caregivers are internalised as representations of self, Other, and their varying relationships. These representations in turn colour relationships with significant others. This whole process depends on the caregiver’s capacity to mentalise: to see her child as a separate sentient being. For all their difficulties, at least Narcissus and Echo have coherent selves, albeit based around insistent self- sufficiency or compulsive caring, respectively. For the avoidant Narcissus, this will feed into a grandiose self; for the ambivalent Echo, a depleted self. Insofar as Narcissus denies the importance of the secure base and takes himself as his object, he will demonstrate clinical features of narcissism. Echo will be vulnerable to dependency and negative narcissism; her only security, in the sense of an internal object to which she can cling, is a denigratory superego – derived from Juno’s rage. Avoidant and ambivalent strategies involve either the absorption of some of the functions of the necessary Other into the self, or the ‘projection’ of self- characteristics onto the clung-to object, attributing to the Other one’s own qualities. By contrast, without a consistent means to achieve even partial security, the ‘disorganised’ individual resorts to bizarre methods to approximate to a secure base. Disorganised people lack a coherent representation of the Other, and have to rely on various forms of self- splitting to create a secure base effect. In ‘narcissistic’ phenomena such as cutting the body with razor blades (for example, in Borderline Personality Disorder), or self-starvation (in anorexia nervosa), the body becomes an ‘Other’ to which the sufferer relates, albeit in a pathological way. Psychological and to some extent physical survival depends on the ability to form a close attachment relationship and thereby to achieve an external secure base in reality, and an ‘internal secure base’ within the self. The relationship with this secure base is healthily narcissistic, in the sense that the Other is seen

Downloaded by [New York University] at 12:48 14 August 2016 to be there for the beneﬁt and security of the subject. The establishment of this base is a precondition for seeing the Other as a separate being, and for having fun together and exploring the world in a companionable way – in short, for establishing an object relationship. The clinical phenomena of narcissism can be seen as attempts to short- circuit the need for relationship. For the hypervigilant, ‘Echoic’, person this means taking the body and/or the self as the secure base, clinging to it in an escalating cycle, since the more it is clung to, the more questionable it seems as a source of security, and so the more insistent the clinging. The oblivious narcissist has

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taken a different route to partial security. Despairing of mutuality, he relies on coercion and power to maintain some sort of connection with others. To become aware of his own fundamental powerlessness creates unbearable envy, so, turning the tables, he evokes envy in others, and thus excites their attention, albeit from a distance.

An integrative perspective: the emergence and metamorphoses of narcissism Erik Erikson’s (1968) model of the growth of the mind visualises a series of stages, each with its own positive or negative polarity: basic trust versus mistrust; autonomy versus shame and doubt; industry versus inferiority; generativity versus stagnation; integrity versus despair. A comparable model helps integrate the various aspects of narcissism, both healthy and pathological. The stages described are necessarily artiﬁcial, and not superseded, merely added to, as development proceeds. Each can be activated at any time.

Stage 1: first year of life – secure sense of creative self in relation to a responsive Other The crucial issue here is parental attunement: empathy, mirroring and responsiveness. Treated with ordinary parental devotion, the child feels himself as ‘special’, unique, the centre of his own universe. He is a distinct sentient being, in relation to responsive Others. Knowing that his word is his caregiver’s command, he can begin to tolerate periods of frustration and separation. He is helped to reach out to the world and to trust that he will be met with acceptance and joy. Here the beginnings of good self- esteem, or healthy narcissism, are installed. Conversely, in the absence of parental attunement the child may experience feelings of inner emptiness, dread, insignificance, impotence and periods of inconsolable rage. A temperamentally difficult or physically imperfect child may be at particular risk here.

Stage 2: second year of life – narcissistic investment in the body and its growing powers

Downloaded by [New York University] at 12:48 14 August 2016 Healthy exhibitionism arises at this stage. Parents delight as their children reach developmental milestones, as they begin to walk, talk, gain sphincter control and to explore the world. The secure base is not just a source of security but of encouragement and approbation. The child invests his body with the glow of healthy narcissism, and enjoys the gleam in the parental eye as he enters the society of kin and friends. The stressed, depressed, aggressive, rejecting, overwhelmed or resentful parent will denigrate or fail to notice her child’s fumbling need to elicit gleam, leading to the beginnings of shame and self-disappointment that are so characteristic of the narcissistically wounded.

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Stage 3: third year of life – beginnings of optimal frustration Healthy narcissism knows its limitations. A child who is narcissistically entangled with his mother cannot test his hopes and ambitions against reality. The American ideal (and illusion) of ‘log cabin to White House’ has to be tempered with the ability to distinguish castles in the air from real dwellings. In the Lacanian schema, the ‘Nom (and ‘Non’) du Pere’ – the name and ‘no’ of the father – both set limits to narcissism, but also help the child to feel that he is part of his parent’s clan, and indeed the human race. Individual narcissism begins to be subsumed into social narcissism. Without this process, grandiosity and denial of reality threaten to persist.

Stage 4: adolescence – ideals and ambitions Narcissism is re-worked in adolescence. Healthy adolescents have their heroes, hopes, ambitions, fervent beliefs and secret dreams. The narcissistically wounded adolescent is in despair and depression, seeing the world as doomed, oppressed by death and either defying it with risky behaviour or shrinking from it into regressive avoidance. The body becomes a source of pleasure and pride, or else a hated encumbrance that fails to measure up to impossible ideals. An outpour- ing of creative energy is a mark of healthy self-belief, at this stage not needing to be evaluated or measured up. Rage and destructiveness express narcissistic feelings of failure to ﬁnd a mirroring ideal.

Stage 5: adulthood – transfer of narcissism to the next generation Omnipotence lessens as real potency takes over. The healthy adult begins to know his or her strengths and limitations. He feels good about himself, his relationships, family and society. His narcissistic hopes are invested in his children. Projects are conceived and brought to fruition. Frustrated ideals are replaced with love of truth. Failure is met with acceptance. Meanwhile, the unhealthy narcissist consolidates his self- centred world, either exciting envy or enviously undermining the possibility of intimacy with others. Sufﬁcient unto himself, he becomes more and more self-absorbed – either hyper-vulnerable to every slight or brutally bullying his way to a ‘top’ whose twin peaks are his own self- aggrandisement and the denigration of others. Downloaded by [New York University] at 12:48 14 August 2016

Stage 6: later life – the getting of wisdom For Kohut, the installation of healthy narcissism together with optimal frustration sets an individual on a road that leads to the ability to see the world as it is, to accept the reality of one’s own death, to trust one’s intuition and empathy, ﬁnd sources of creativity and humour, and ultimately to achieve a measure of wisdom. In the absence of these metamorphoses, the onset of middle age and

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beyond raises feelings of terror at one’s own inevitable extinction. Depression and hopelessness become ever-present possibilities. Narcissism may manifest itself in increasing hypochondria, endless ruminating on past achievements or failures, or a coercive tyranny in which power, rather than mutuality, dominates relationships. In this health/pathology model, the task of therapy, whatever stage is presented, is to ﬁnd the seeds of healthy narcissistic strivings, and to reduce the impact of pathological narcissism.

The psychotherapeutic treatment of narcissistic difficulties Critics of psychotherapy – perhaps motivated by the puritanism that Wilde so outrageously flouted – accuse it of being self-indulgent, a luxury occupation for those who have nothing better to do with their lives: in other words, of fostering rather than helping to overcome narcissism. Certainly, at its worst, psychotherapy can encourage aspects of psychological life that are typical of narcissism itself: self-preoccupation and interminable regression, an exaggerated sense of entitlement, unrealistic hopes that all past wrongs can be put to rights given sufficient therapeutic love and empathy. This tendency within psychotherapy to become the ‘disease of which it purports to be the cure’ is yet another of narcissism’s metamorphoses, the mirror image of Wilde’s self-conscious use of narcissism as an artistic device to overcome narcissism. A more positive view, one which Carl Jung was fond of advocating when contrasting Western with Eastern paths to enlightenment, is that it is necessary to find one’s self before contemplating the possibility of transcending it, and, as the popular phrase has it, you must love yourself before you can begin to love others. Working with narcissistic patients is difficult in many ways. Here are three vignettes illustrating some of the day-to-day dilemmas they raise for therapists.

Vignette 1 Bill, a 40-year-old barrister, came into hospital following a near-fatal suicide attempt. His career had been hugely successful, but the pleasures of success never seemed to last, and his death-wish came out of a deep sense of dissatisfaction in his marriage, and the realisation of just

Downloaded by [New York University] at 12:48 14 August 2016 how cut off he felt from his wife. This was a typical mid-life narcissistic crisis. A great sportsman, bon viveur, womaniser and money-maker, his life felt empty and meaningless. He was referred for psychoanalysis, but it was holiday time and no one could see him for several weeks. He was furious – ﬁlled with narcissistic rage. What right had the analysts to be away when he needed help now, not in a few weeks’ time? If that was the way he was to be treated, let his suicide be on his carers’ heads. His ward psychiatrist rang round again, but still to no avail. Bill insisted that he be seen. Why could not the psychiatrist see Bill himself?

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What was the psychiatrist to do? By agreeing to see Bill, would he be merely pandering to his own narcissism (‘only you can help me’) and, like all Bill’s conquests, dancing to his self-serving tune? But by refusing to comply with his request, would he not be reinforcing Bill’s deep-rooted feeling of not being listened to, throwing him back once more into alienated self-suf ﬁciency?

Vignette 2 Caroline was both hypervigilant and oblivious. Adopted, she had two older sisters who were her parents’ obvious favourites. Her mother became bed-ridden when Caroline was 13 and from then on she was expected to wait on her, and to satisfy her father’s sexual needs. She had major depressive breakdowns in her thirties and forties, and eventually entered weekly supportive psychotherapy which kept her out of hospital and brought some stability into her life. Ending treatment seemed difficult, as she idealised both therapist and therapy, and the compromise was to move to monthly sessions. One of Caroline’s characteristic patterns was to ‘bolt’ when she felt anxious or rejected; on one occasion she took a major overdose and locked herself in the boot of her car, and was only saved by a police helicopter search. Naturally these episodes, usually much milder, caused huge worry to her husband and children whenever she disappeared, and they would immediately start to look for her, not stopping until she was either found or reappeared of her own accord. In one session she was describing a recent example of these episodes, emphasising how unsympathetic her husband had been when eventually he found her. After many years of supportive work, the therapist was suddenly filled with boredom and weary irritation. Without much thought he suggested that perhaps her long- suffering husband was furious with her; he asked her to think about how it must feel for him when she disappeared. Caroline blanched, her lip trembled, she looked frightened and angry, as though she was about to walk out. There was five minutes’ silence. Eventually, she decided to stay and the session ended without mishap. At the end she had to pay her bill, and asked to borrow the therapist’s pen. She commented on what a nice pen it

Downloaded by [New York University] at 12:48 14 August 2016 was – without thinking, the therapist found himself offering it to her as an unwitting present.

Here we see how the thin-skinned narcissist’s anger is often projected into those around her; how difﬁcult and dangerous confrontation can be, how important it is to maintain therapeutic potency, how often the ‘father-principle’ is discarded in favour of a regressive ‘maternal’ collusion, and how guilty it can make the therapist feel when he does confront such patients as he or she walks the tightrope between collusion and realistic confrontation.

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Vignette 3 Peter, who had spent most of his childhood in children’s homes, was a classic and extreme case of oblivious narcissism, who had lived a life of ruthless selﬁshness until his late forties. It was not his depression, violence, alcoholism, lawbreaking habits, loneliness or declining physical attractiveness to women, but a thin-skinned hypochondria which had led his GP, who had exhausted every pill and physical specialist, to refer him for psychiatric help. As he walked down the corridor to the consulting room, he would invariably start each session by asking in a way that was at once challenging, aggressive, deferential and defensive: ‘How are you, doctor?’

Finding a way to interpret this apparent concern as another aspect of his narcissism – a need to control the therapeutic situation from the start, as a defence against the threat of relationship formation which being in therapy implied – without alienating and putting him down, was a tough technical challenge. These examples illustrate some of the common themes of therapy with such people: seductive excitation of the therapist’s own narcissism; rage and demandingness that can easily stimulate rejection, thereby reinforcing the patient’s sense of being let down by everyone; boredom, leading to a rejecting neglect of the patient’s underlying misery. Kohut and Kernberg advocate very different ways of handling these issues. Kohut describes three characteristic patterns of transference in therapy with narcissistic patients: mirror transference, idealising transference and ‘twinship’ transference. His advice to therapists is along the lines of acceptance and against premature interpretation. As W. B. Yeats (1972) put it:

I have spread my dreams under your feet; tread softly because you tread on my dreams.

The patient must feel able to invest the therapist and therapy with their hopes and dreams. ‘Persecutory therapists’ who interpret these phantasies as defensive too early and too crashingly, will merely reinforce the narcissistic wound which has led to the need for them in the first place. Kernberg, however, sees dangers in collusion, and emphasises the denigration that is the accompanying shadow of Downloaded by [New York University] at 12:48 14 August 2016 idealisation. He stresses the importance of dealing with negative transference and assisting the patient to develop appropriate concern and guilt for the objects that he uses so thoughtlessly. Patients must be helped to deal with their rage and disappointment, and should not be misled into thinking that therapy can in itself undo past wrongs. Being in therapy stirs up the basic conflicts and deficiencies that have already led to a narcissistic superstructure in the personality. This will arouse a measure of resistance at best, and at worst suicidal feelings. As Rosenfeld puts it:

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When he is faced with the reality of being dependent on the analyst, standing for his parents, particularly the mother, he would prefer to die, to be non- existent, to deny the fact of his birth, and also to destroy his analytic progress and insight representing the child in himself, which he feels the analyst, representing the parents, has created. (Rosenfeld 1965, p. 17)

Kernberg acknowledges, however, that for some patients this will prove too much and that in these cases, in order to maintain a therapeutic alliance, a more supportive approach may be necessary. I end by listing some key principles that can help in working with narcissism in its various manifestations.

• The therapist must be able to accept the idealisation of his relationship with the patient while at the same time not being afraid to challenge the patient’s denial of his covert denigration of others’ feelings and need for omnipotent control. • In challenging narcissism, the therapist must guard against using his own position of power and narcissistic superiority to bully and reinforce the patient’s low self-esteem. • A collusive relationship of mutual admiration must also be eschewed. • Supporting a patient’s narcissism can be a legitimate therapeutic strategy, especially in counteracting compulsive negative narcissism and self- denigration. The therapist must ﬁnd a positive ‘spin’ to counterbalance attempts by the patient to put himself down. • Disillusionment in the therapist and therapy is healthy, but should be gradual rather than traumatic. In time-limited therapy, the ending should be discussed and interpreted right from the start. • The therapist must be able to set limits both to the demandingness of the thin- skinned and the fury of the thick-skinned narcissist. • Creativity, humour, playfulness and the use of dreams are all positive manifestations of transformed narcissism and are crucial ingredients of therapy. • Curiosity about the therapist may be part of the omnipotent need to control or to enviously cut him down to size, but is also a potentially healthy escape from self- preoccupation into wishing to know about the world. • Gratitude comes late in the therapy of narcissism. • The gap between actual and ideal self is distorted in narcissism. In the

Downloaded by [New York University] at 12:48 14 August 2016 ambivalent, ‘Echoic’, negative, hypervigilant type, the gap is too great. In the ‘narcissistic’, thick- skinned, oblivious type, there is fusion of ego and ego- ideal. The therapeutic task is to narrow the gap in the former, helping the sufferer to ﬁnd and accept good things about himself; in the latter to open it up, helping the patient to come to terms with loss and failure. • The two types are not mutually exclusive. Beneath the thick skin of the narcissist, there is huge vulnerability and longing for closeness; below the fragility and pitifulness of the hypervigilant type, there is often ruthless self- centredness.

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• The narcissist seeks his object in the mirror, but is doomed to disappointment as the mirror is cold and lifeless and cannot rescue him from his loneliness. Therapy can transform narcissism through ‘mirroring’ – the playful, warm, responsive mirroring of the attuned Other.

Freud, narcissistically perhaps, saw psychoanalysis as the third of the three great blows that civilisation has dealt to man’s narcissism: the Copernican revolution, which displaced the earth from the centre of the universe; the Darwinian revolution, which dethroned man from his superiority over the rest of nature; and the psychoanalytic, in which the conscious mind is demoted to a servant of the unconscious forces that rule our lives. To this, an attachment perspective might add a fourth blow: the understanding of how, at a very fundamental level, our prized individuality arises out of our relationships with others. In each case, the miracle of transformed narcissism leads to deeper understanding: we see the beauty and simplicity of the universe; realise the extent to which we are linked with, rather than excluded from, nature; understand how we are psychologically all of a piece; and that, rather than divided and isolated selves, we are inescapably interconnected. Downloaded by [New York University] at 12:48 14 August 2016

158 Part IV

‘ONLY CONNECT’ Psychotherapy and psychiatry Downloaded by [New York University] at 12:48 14 August 2016 This page intentionally left blank Downloaded by [New York University] at 12:48 14 August 2016 13 MEANING V. MECHANISM Forster’s Howard’s End

In the remaining three chapters I struggle once again with the ‘two cultures’ discussed in Chapter 8. Here they manifest themselves with the continuing, but potentially mutually beneficial tension between mainstream, diagnostically oriented, managerial psychiatry on the one hand, and on the other, psychodynamic psychiatry, drawing on the Freudian tradition, but also with roots in literary culture. The first of these three chapters looks at this from an historical and philosophical perspective, while the final two return once more to poetry as a beacon of non-discursive communication that I believe psychiatrists need to incorporate into their therapeutic work, however ‘organic’ that may seem. On New Year’s Eve 1992, a man suffering from schizophrenia climbed into a lions’ cage at the London Zoo and was badly mauled. This event provoked a full- scale moral panic among the media and government, the tragedy seeming to violate many of the comfortable myths about progress in psychiatry, echoing the impact of the civil war in former Yugoslavia which had shattered the hope of an era of unbroken European peace following the end of the cold war. Whatever we may wish, in reality the lion does not lie down with the lamb. Daniel the visionary, the interpreter of dreams, the one who asserted that his God, the God of angels and saints with power over man and beasts would eventually endure, while all earthly kings were found wanting, emerged from the lions’ den unscathed – but secular, psychiatric, suffering, decarcerated, visionless, late-twentieth-century man does not. In Daniel the vision and the reality, the soothsayer and the king, are kept separate. The story of the triumph of spiritual powers is perhaps a compensatory fantasy expressing the aspirations of an oppressed and displaced Jewish nation.

Downloaded by [New York University] at 12:48 14 August 2016 In our society psychotherapists are cast in the role of visionaries, while psychiatry represents power and adaptation. Was the tragedy at the zoo emblematic of this divide? Could the disaster have been avoided if the insights of psychotherapy had been welded to the ‘outsight’ of psychiatry? The idea of a psychotherapeutically informed psychiatry seems such a simple and obvious one and yet the divide between psychotherapy and general psychiatry – between ‘brainlessness’ and ‘mindlessness’ (Eisenberg 1986) – has seemed unbridgeable. My aim here is to set this debate in its historical, philosophical and scientiﬁc context.

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The relationship between psychiatry and psychotherapy has been influenced by at least three interrelated historical processes: the decline of religion and the emergence of philosophical dualism, the sociology of professionalisation, and the demands of society, particularly in times of war. Although Freud saw psychoanalysis as the third of man’s great dethronings – a worthy successor to the Copernican and Darwinian revolutions – Kant had already proposed that personal knowledge is inevitably perspectival and that the self is irremediably finite. In response, the idealist philosophy of the Romantic movement celebrated mind as an autonomous sphere in which, in the imagination, all things are possible, a countervening power to balance the increasing materialism of nineteenth-century science and commerce. The emerging profession of psychiatry was keen to divest itself of idealist influence as a mark of respectability within the medical and scientific community. Hughlings-Jackson proposed his theory of concomitance: ‘Psychical symptoms are to medical men only signs of what is wrong in a material system’ (Hinshelwood 1991), thereby avoiding dualism by suppressing the notion of mind altogether. The Society for Psychical Research was set up to study the ways in which mind can affect events in the brain and, despite, to contemporary ears, its outré title, was taken seriously by a group of distinguished fin- de-siècle scientists, including Frederic Myers who, in 1892, was the first British advocate of Freud (Hinshelwood 1991). Freud under Charcot’s influence was initially a reverse Jacksonian, assuming the physical symptoms (at least in hysteria) were to psychoanalytic men signs of what is wrong in a psychical system. In his ‘Project’ (1899), unpublished in his lifetime, he tried to equate physical and psychical energy; later he abandoned the attempt and became increasingly interested in meaning and relationships rather than mechanisms. The pre-First World War years of the twentieth century saw both psychiatry and psychoanalysis trying to establish themselves as authentic disciplines, circling around one another, both interested and suspicious. A British Medical Association report on psychoanalysis in 1907 declared that ‘[it] usurps the confessional [and is] in most cases incorrect, in many hazardous, and in all dispen- sable’ (Pines 1991). But Bernard Hart, Consultant in Psychological Medicine at University College Hospital, based his influential The Psychology of Insanity on psychoanalysis, acknowledging ‘. . . the genius of Professor Freud of Vienna,

Downloaded by [New York University] at 12:48 14 August 2016 probably the most original and fertile thinker who has yet entered the field of abnormal psychology’ (Hart 1912). The impact of war exposed the therapeutic bankruptcy of conventional psychiatry. Psychiatrists were doctors rather than psychologists, combining a scientific (or pseudo-scienti fic) empiricism with pastoral support and/or admonishment based in the large mental hospitals and having little to offer to the thousands of traumatised cases who streamed away from the killing fields of France. The Cassel hospital was founded in response to the needs of shell-shock and several psychoanalytically influenced psychiatrists opened outpatient clinics with similar

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aims. The Brunswick Square clinic was directed by James Glover whose students included a group of women therapists all later to become analysts, including Sylvia Payne, Ella Sharp, Susan Isaacs and Marjorie Brierley. Perhaps the most famous of the shell-shock cases was Siegfried Sassoon who was sent by Robert Graves to be treated (rather than court- marshalled) by W. H. Rivers, one of the most gifted of the eclectic psychiatrists who were influenced by Freudian ideas (Pines 1991; Barker 2005). The relationship between psychiatry and psychotherapy can be divided into three phases, an early phase of blurring and overlap, a middle phase of standoff and separation, and a third contemporary phase of creative interchange. These can perhaps be compared with a developmental process of moving from undif- ferentiation and pluripotentiality of infancy, through identity formation of adolescence and early adulthood, into a more mature phase in which the individual feels secure enough to explore different aspects of him or herself – in Jungian terms the ‘shadow’. The middle phase of violent repudiation of the shadow began abruptly in the early 1920s when, possibly with Freud’s encouragement, both James Glover and Ernest Jones became strongly opposed to eclectic psychotherapy. The Brunswick Square clinic folded, the Tavistock was dubbed as the ‘parson’s clinic’, and the psychoanalysts set about establishing themselves as an independent force. An earlier moral panic had arisen in 1926 following the suicide of a young lawyer who was being treated psychoanalytically. This led to the BMA Committee on Psychoanalysis, which, thanks largely to the impassioned advocacy of Jones, acknowledged it as a recognised form of training and treatment, while remaining neutral as to its efficacy. The war years saw a continuation of the opposing tendencies towards isolation- ism and integration. On the one hand the psychoanalysts became inward-looking, locked in a war of succession following Freud’s death between the supporters of his daughter Anna and Melanie Klein; on the other, through the War Office Selec- tion Boards and the famous ‘Northfield Experiments’, psychoanalysts and psychodynamically minded psychiatrists (who included John Bowlby, Jock Sutherland, Tom Main, W. H. Foulks, Maxwell Jones and W. R. Bion) were increasingly involved in the mainstream of medical and psychiatric care. The post-war period in Britain saw the emergence of an entrenched divide between psychodynamic and conventional psychiatry, epitomised in London by

Downloaded by [New York University] at 12:48 14 August 2016 the Tavistock Clinic and the Maudsley under Aubrey Lewis. Elsewhere in the country things were more fluid, with, among others, Stengel, an implacable opponent of Lewis, establishing a psychodynamic department in Sheffield; Dicks who had left Tavistock to work with the psychoanalyst Harry Guntrip in Leeds; and Carstairs’ dynamically informed eclecticism in Edinburgh. At this stage the emerging community psychiatry movement, headed by Northfield veterans like Jones, was strongly psychodynamic in flavour. In the United States psychoanalysis reigned supreme in the 1950s, but in the ensuing two decades three factors were to emerge which changed the face of

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psychotherapy, which, in an attenuated form, filtered significantly across the Atlantic to influence psychiatric practice in the UK. The first was the so- called ‘cognitive revolution’ in psychology, particularly associated with the work of Bruner and Miller, which heralded the end of behaviourism. They had been influenced by the ideas of Kenneth Craik (1941) who, working in Cambridge, had, before his premature death, proposed the idea that external behaviour and adaptation depended on the organism carrying within itself a model of the world (later to become in John Bowlby’s version an ‘internal working model’). The significance of the cognitive revolution was, and is, that, at least potentially, psychoanalysts and scientific psychologists could begin to share a common language, since psychoanalysis had from the start postulated an inner or ‘representational’ (Sandler and Rosenblatt 1962) world. The emergence of cognitive therapy through the work of Aaron Beck was the clinical manifestation of the cognitive revolution, which, despite its declared opposition to psychoanalysis, was to become an important stepping stone across the gulf between dynamic and traditional psychiatry. Craik’s ideas had been influenced by the new science of cybernetics which had come out of the war effort, emphasising self- regulation, information and feedback. Gregory Bateson’s (1972) exposition of ‘systems thinking’ and the consequent emergence of family therapy provided an opportunity for a further widening of the psychotherapeutic base from the narrowly psychoanalytic approach of the 1950s. Leff and Hirsch’s definitive refutation in the early 1970s of the bold Batesonian assertion that schizophrenia was ‘caused’ by faulty family communication is an outstanding example of the creative conflict between the psychotherapy and psychiatry, and led, ironically, to the establishment of the importance of family work in the prevention of relapse in schizophrenia (Leff and Vaughn 1983). It might somehow be imagined that the ‘soft’ science of psychotherapy would be pushed aside in times of war. But we have already seen how, faced with the need for practical and effective solutions to emotional distress during and in the aftermath of both world wars, prejudice was cast aside and psychotherapeutic methods were widely accepted and used to treat war casualties. Psychotherapy was able to provide a language in which the overwhelming experiences of trauma and pain could be faced squarely rather than avoided. In the 1970s the Vietnam War produced a similar reaction in the United States; the need to understand and treat Post Traumatic Stress Disorders (PTSD) became urgent, leading

Downloaded by [New York University] at 12:48 14 August 2016 to the development of brief forms of psychotherapy. The ideas generated by PTSD were then brought to bear on the comparable situations on civilian life, especially the psychological impact of physical and sexual abuse and the effects on survivors of mass disasters (Garland 1991). The contemporary convergence of psychotherapy and psychiatry emerged not so much from war, but from the economic crisis which gripped the industrial nations of the West. Psychotherapy needs the social and scientiﬁc power of medical psychiatry if it is not to be marginalised as a ‘luxury’; psychiatry needs both the inspiration and the practical techniques of psychotherapy if it is to satisfy the

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criteria of public acceptability and relevance upon which the new climate insists. Professional rivalry plays a part too. The belated recognition by British psychiatry of the importance of psychotherapy has not a little to do with the challenge posed to psychiatry by clinical psychology. The divide and rule atmosphere created by the health ‘market’ may be deplorable, but is inescapable. Psychiatrists feel the need to be well trained in all aspects of their discipline, including psychotherapy, if they are to compete on equal terms with other professions in the new market economy in the scramble for contracts from purchasers. The psychotherapy/psychiatry split reﬂects the familiar mind/body or mind/ brain problem which philosophers have been wrestling for at least six centuries. This links with what Eliot (1975) called the ‘dissociation of sensibility’ – a gap between the ‘two cultures’ of art and science, imagination and reality, subjectivity and objectivity, which began at the renaissance. The debate between psychiatry and psychotherapy is located in one of the great geological fault lines of philosophy. It would be surprising if there were not occasional eruptions! As we have mentioned, Freud was, avowedly at least, a concomitantist. His gloss on the mind/brain debate was the concept of ‘Two principles of mental functioning’ (Freud 1911) – the primary and secondary processes, each with its own modus operandi, the one imaginative and wish- fulﬁlling, the other adaptive and reality- serving. He pictured their relationship in developmental terms, in which the lion-like primary processes were gradually tamed by the forces of socialisation. Freud’s contribution to the debate was original in that he saw the mind/brain problem as a biological reality rather than an unsolved philosophical conundrum, a problem as much for developmental psychology as for philosophy. The idealism of the primary processes is developmentally prior to secondary process realism. Object Relations Theory (Greenberg and Mitchell 1983) sees primary and secondary processes not so much in opposition as complementary, based on the Winnicottian (and Kohutian) notion of an area of overlapping interaction between mother and child in which imagination and reality coincide (Winnicott 1971). Stern (1985) has argued that Freud got it the wrong way round when he suggested that primary processes were developmentally prior to secondary processes. In Stern’s empirical model of early infancy, mother and infant are highly adapted to the realities of one another, and it is only later, with the advent of language, that imaginative (i.e. ‘primary process’) thinking could truly be said to be

Downloaded by [New York University] at 12:48 14 August 2016 possible. Minds emerge from brains, meanings from mechanisms. Freud faced a paradox in his view of secondary processes as superior to and superseding the primary. As Rycroft (1985, p. 11) puts it:

Since psychoanalysis aims at being a scientiﬁc psychology, psychoanalytic observation and theorising is involved in the paradoxical activity of using secondary processes to observe, analyse, and conceptualise precisely the form of mental activity, the primary processes, which sci- entiﬁc thinking has been at pains to exclude.

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The problem perhaps becomes less paradoxical if adaptation is seen, as in Stern’s model, to precede imaginative alterations of reality. Imagination is not, as in the Kleinian vision, a response to deprivation (‘no breast – therefore imagine a breast’ – see Bion 1962), but, rather, the fruits of satisfaction. The securely attached infant is free to play; the insecure infant clings or avoids in order to survive (Bowlby 1988). Thus if we characterise psychiatry as the domain of adaptation, psychotherapy that of imagination, there is a sense in which psychiatry takes precedence over psychotherapy, in that the patient needs to be contained and capable of understanding before meaningful psychotherapy can begin. With better awareness between the two disciplines the need for paranoid splitting becomes less and a real relationship can begin to develop. There seems to be a general agreement, in the spirit of Keatsian ‘negative capability’, to try to live with the paradox which Freud and his opponents strove unsuccessfully to resolve – to accept that a ‘mindless’ psychiatry and a ‘brain- less’ psychotherapy are both equally disadvantaged, and that neither can be subsumed within the other. Psychiatry needs to rehabilitate the mind, psychotherapy to cultivate its links with science. Barthes’ statement that ‘A writer’s greatest gift to a reader is to help him become a reader’ (Bruner 1986) applies equally to psychodynamic psychiatry and is echoed in Winnicott’s (1971) famous dedication ‘To my patients who have paid to teach me’. We are constantly learning how to ‘read’ patients, how to listen to their ‘text’, and to the ‘virtual text’, which comprises all the assumptions and preconceptions we have about them and about their world (i.e. our countertransferences). The familiar structure of psychodynamic training – ‘taking on’ a patient for regular sessions, weekly supervision, examining our own responses either in supervision or personal therapy – is designed to maximise the process of enhancing the student’s narrative skills, his ‘bottom up’ appreciation of meaning, as opposed to his ‘top down’ grasp of the principles of diagnosis and prescribing. Bruner argues that most worthwhile psychological activity contains narrative as well as ‘scientiﬁc’ elements. A favourite example to set alongside Kekule’s famous dream of snakes-biting-their- tails benzene rings is Bohr’s idea of complementarity in quantum theory – the impossibility of thinking simultaneously about the position and velocity of a particle – which came to him just after his son has confessed to shoplifting and he was contemplating seeing his son simul-

Downloaded by [New York University] at 12:48 14 August 2016 taneously in the light of both love and justice. Zukier and Pepitone (1984) con- ducted an ingenious experiment in which they presented their subjects with a description of a person – ‘Shy, bespectacled, helpful, slightly withdrawn, orderly’ – and then told them that it was drawn at random from a collection of 100 such character descriptions of which 70 were salespersons and 30 librarians. Who would not override ‘scientiﬁc’ probabilistic bias and, guided by narrative, decide that this had to be one of the librarians? One of the special – and for students both awkward and fascinating – features of psychology and psychiatry is that they are disciplines in which the narrative

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and scientific approaches overlap and frequently get in each other’s way. I shall now try to buttress the case for narrative with some supporting ‘scientific’ arguments. The first is the philosophical view that even scientific descriptions of the world are refracted through the mind and thus are models or stories – special sorts of stories admittedly, subject to the scientific method of refutation, controlled trial and so on – but because they are mental models, ‘stories’ nonetheless. In psychiatry good ideas – the view that schizophrenia might have something to do with faulty communication, the importance of low self esteem in depression, splitting in borderline personality disorder – often start as narratives based on psychotherapeutic observation and end up as established scientific facts – although many are of course discarded or modified along the way. Narrative is needed if the imagination is to generate useful hypotheses which can be put to scientific test. Second, we are beginning to understand more about the origins of narrative capacity, which seems to emerge from secure attachment in infancy. Securely attached infants, if followed up for ten years or so, and asked to describe their autobiography or to undertake picture completion tasks, are better able to tell coherent stories, including accounts of coping with painful events and resolving conflict than are their insecurely attached counterparts. Similarly, prospective parents who show secure autobiographical competence on the Adult Attachment Interview are more likely to have securely attached children at one year than those who are insecure (Fonagy et al. 1991). My third and fourth points concern what John Bowlby called the ‘kidnapping’ of the term ‘biological psychiatry’ by opponents of the psychodynamic psychiatry (Bowlby 1988). The story of evolution is a paradigm which underlies the entire science of biology. Psychodynamic ideas are, or should be, no less ‘biological’ than biochemical theories. Neo- Darwinism can be applied to psychotherapy in interesting and illuminating ways (Slavin and Kriegman 1992). For example, the notion of kin altruism helps to explain the attunement or ‘primary maternal preoccupation’ of Winnicott’s (1971) ‘ordinary devoted mother’, and the primary narcissism of the newborn, for whom, thanks to the overlapping interests of mother and child’s ‘selfish genes’, the world really is his or her oyster. But the ‘Oedipal’ child is in a very different situation. His genetic interests are no longer identical with those of his parents who will want to produce

Downloaded by [New York University] at 12:48 14 August 2016 other children as well as to maintain him, but this fact will be concealed from him, in order, Skynner (1976) argued, to protect him from unbearable envy. The ‘Oedipal’ child is entering a world familiar to biologists – of deceit and camou- ﬂage in which the ability to ‘read’ other’s intentions and to experience guilt and pain when one is thwarted, are essential to survival. If adult sexuality is imported into this arena of potential conﬂict between generations, especially via a biologically unrelated adult – i.e. step-parent, the stage is set for childhood sexual abuse, which is present (Herman et al. 1989) in such a high proportions of hos- pitalised psychiatric patients.

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Finally we are beginning to understand how social events can have direct structural effects on brain functioning. Suomi (1997) has studied the effects of maternal and peer separation on the development of rhesus monkeys. Monkeys reared in isolation have consistently lower levels of cerebral amines in their cer- ebrospinal fluid than those reared normally, and behaviour patterns in later life, especially social and sexual behaviour, are grossly disrupted. This work can be related to the emerging new paradigm of Edelman’s ‘neural darwinism’ (Edelman 1978). This suggests that learning and memory proceed by the interplay between random events and the strengthening of cortical neural pathways underlying useful behaviours by ‘value systems’ or ‘wired in’ reinforcers in the midbrain. It seems likely that maternal contact greatly enhances these reinforcing effects, and that this will be reflected in cerebral amine metabolism. Thus the random, or ‘narrative’ aspects of an individual’s unique biography is underpinned by a set of scientifically establishable sociobiological patterns.

A literary excursion Thus far I have tried to relate the psychotherapy–psychiatry debate to its historical and cultural context. A literary excursion may reinforce this effort. E. M. For- ster’s Howard’s End, published in 1910, but still with contemporary relevance and power, is perhaps the classic literary account of the two cultures debate. The novel centres around the cultural polarities of class, culture and gender, symbolised in various ways by the two protagonistic families – the Schlegels and the Wilcoxes. The Schlegels are female, Bloomsbury-style intellectuals, concerned about poverty and social injustice. The Wilcoxes are male dominated, business- rich, accepting and exploitative of their class position. Like psychiatrists, the Wilcoxes are practical people who make and do, while, like psychotherapists, the Schlegels are dreamers who feel and see. Forster summarises the tensions – sexual and literary – between the two principles, using images which evoke Drake and Shakespeare, projected onto the English landscape:

England was alive, throbbing through all her estuaries, crying for joy through the mouths of her gulls, and the north wind with contrary motion blew stronger against her rising seas. What did it mean? For what end are her fair complexities, her changes of soil, her sinuous

Downloaded by [New York University] at 12:48 14 August 2016 coast? Does she belong to those who have moulded her and make her feared by other lands, or to those who have added nothing to her power, but have somehow seen her, seen the whole island at once, lying as a jewel in a silver sea, sailing as a ship of souls . . .? (p. 173)

The movement of the novel is the working out of the interchange between these two principles. Mrs. Wilcox bequeaths Howard’s End to Margaret Schlegel, who later marries Henry Wilcox. In an ideal world the Wilcoxes and the Schlegels

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should complement and enrich each other, the lion should lie down with the lamb. For Margaret:

Only connect! That was the whole of her sermon. Only connect the prose and the passion and both will be exalted and human love will be seen at its height. Live in fragments no longer. Only connect, and the beast and the monk, robbed of the isolation that is life to either will die. (p. 203)

But reality never quite conforms to our ideals. Henry just could not connect, ‘for there was one quality in Henry for which she was never prepared . . . his obtuse- ness. He simply did not notice things . . .’, Helen becomes furious with him, his hypocrisy (frequenting prostitutes while refusing to allow Margaret’s single- parent sister into his house), his blindness to feelings: ‘ “Not any more of this” she cried. “You shall see the connection if it kills you, Henry!” ’ But it is Leonard Bast, the autodidact, the working class scholar and husband of Henry’s former call-girl who dies, symbolically crushed by a bookcase. Despite Margaret’s fury, and Henry’s failure to respond, the novel ends optimistically with a partial reconciliation between them, Margaret living at Howard’s End. Hope is symbolised by the new baby (despite being fatherless) and the promise of a bumper harvest. It is perhaps only this arcadian optimism that dates the book, since the conﬂict between liberalism and capital, not to mention the sexual hypocrisy of men in high places, is as relevant today as it was a century ago. The message from Howard’s End for psychiatry and psychotherapy centres on the essential complementarity of the psychiatric and the psychotherapeutic vision, and of the need for creative conﬂict as well as compromise between the two approaches.

Conclusion This leads to two concluding points. First if integration between psychiatry and psychotherapy is to be achieved each side will have to abandon traditional ways of thinking. Second, and perhaps paradoxically the greater the integration between psychiatry and psychotherapy, the more the need for a clearly deﬁned

Downloaded by [New York University] at 12:48 14 August 2016 boundary between them. It is all too easy to practice a mish- mash of basic psychiatry and half-baked psychotherapy – an antidepressant here, and anxiety management group there – without clearly defined roles, limits or objectives. Opening up one’s practice of psychiatry to psychotherapy can be confusing. Losing the certainties – however artificial – of a narrowly defined medical or psychotherapeutic approach, one can end up feeling neither fish nor fowl. Hybrid vigour yes – chimeras no. This brings us back to our beginning. The chimera is a creature with a lion’s head, a goat’s body, a serpent’s tail – a pluripotential creature representing both

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the fantasies of early childhood in which all is still possible – when the ‘double difference’ between the generations and between the sexes not yet fixed – but also a nightmare world of confusion and terror. Contemporary mental health care needs to move from a split between the fixed and stereotyped roles of psychiatrist and psychotherapist to a more fluid relationship, yet one in which each side retains its identity – striking a balance between containment and intervention, receptiveness and activity. I have tried here to relate a very practical problem – the relationship between psychiatry and psychotherapy – to the historical and philosophical forces shaping our everyday thoughts and professional behaviour. Philosophical dualism underlies the ‘two cultures’ split as it does the divide between ‘mindful’ psychotherapy and ‘brainy’ psychiatry. Yet our very notion of mind and brain may be in need of revision. Scientific advances in understanding the mechanisms underlying memory and the development of behaviour can help to reconcile what has hitherto been a seemingly unbridgeable gap. We can now begin dimly to envisage how the personal narratives of the mind are signposted and etched into the brain by sociobiological reinforcers (cf. McGilchrist 2011). The exploration of the logical, ethical, linguistic and cultural implications of these new scientific ideas represents an exciting challenge for future researchers and clinicians alike. Downloaded by [New York University] at 12:48 14 August 2016

170 14 TOUGHNESS V. ‘WETNESS’ Armitage

Some time ago I met for the first time a psychiatrist colleague whose articles I had enjoyed reading. I introduced myself, saying how impressed I was by his account of introducing cognitive-behavioural approaches in a tough inner- city general psychiatry setting. He responded graciously, saying ‘Oh, but you’re the psychotherapist fellow who writes those nice articles about poetry’. I felt slightly put down by this male banter, implying that there was something vaguely soppy and irrelevant about both poetry and psychotherapy. Keen to establish psychotherapy as a vigorous equal player with social and psychical treatment approaches, I was reminded of how easy it is to see psychotherapy as a frivolous luxury when compared with the ‘rock-face’ of general adult psychiatry – and how to view it as ‘poetic’ might merely reinforce that view. But poetry can be extremely tough – Kipling, Graves and Hughes are obvious twentieth century examples – as can psychotherapy, which often outmatches other psychiatric disciplines in the rigour of its research methods (Roth and Fonagy 2004) and strict- ness of its boundaries. Nevertheless, in considering links between poetry and psychotherapy I run the risk of confirming my new friend’s prejudices. In order to confound the idea that psychotherapy and poetry are essentially ‘wet’ (to use a favourite word from my public school past) I have deliberately chosen to consider a poem by one of these rather ‘masculine’ poets, Simon Armitage (1992), who spent many years working in a related field to ours, the probation service. Here is the poem in full.

Downloaded by [New York University] at 12:48 14 August 2016 The Catch The Catch Forget the long, smouldering afternoon. It is

this moment when the ball scoots off the edge

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of the bat; upwards, backwards, falling seemingly

beyond him yet he reaches and picks it out of its loop like an apple from a branch, the ﬁrst of the season.

It is hard to describe what makes this seemingly simple poem so moving. It is essentially an action-replay of a tiny yet significant moment in a cricket match. Like an action-replay it plays with time, slowing it down to a freeze-frame where the powerful feelings aroused by a batsman’s dismissal can be examined and absorbed. The event described takes place in a fraction of a second, yet the tone of the poem is languorous and sleepy – a typical afternoon in early summer, evoking the nostalgia of childhood, boring or forgettable perhaps, but punctuated by a single moment of beauty and brilliance where ball meets hand. Just as the affiliated sounds – full rhymes, half rhymes, internal and external to the line, assonances – reach out across the spaces between them – scoots/loop, falling/ ball, reaches/branch – so the arm finds itself in the right place at the right time – a miracle of skill. Then suddenly the poem turns on the reader with a striking simile that sends a shimmer back through the poem right up to its title. The hand that grasps the ball is the same hand that picks the apple – the forbidden fruit, the ‘catch’ that has caught mankind, the irresistible desire for knowledge, our undoing and what makes us human. Not just the batsman, but the catcher, is too ‘out’: out of the Garden of Eden, out in the cold. Now we feel that the reflex action of the man in the slips is not so much brilliant as driven by unconscious forces over which he has no control – he cannot not catch the ball, even though to do so may be his undoing.

Downloaded by [New York University] at 12:48 14 August 2016 What is poetry doing here and what can we learn from it, and what is its relevance to psychotherapy? First, as described in Part I, like psychotherapy, poetry has the capacity to home in on tiny moments of experience, to amplify them, put them under the microscope and so make them accessible to conscious awareness. Psychotherapy supervision may take a particular moment in a session, either in self-report, or audio- or videotape, and subject it to detailed discussion. The minutiae of interpersonal phenomena, the quicksilver of the unconscious that makes us get it ‘right’ or ‘wrong’, time and time again, move as fast as a cricket ball and with equally devastating or ecstatic results. As

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psychiatrists we are constantly deciding and acting in ways that deserve this kind of close scrutiny – or being blindly driven by our transference and countertransference. Poetry and psychotherapy can help us slow down and cultivate reflective function, in order to practise our art more truly, safely and deeply. Second, like psychotherapy, poetry is based on words, but words used in a very special way. Armitage’s poem starts at the Oval and ends up beyond Eden: the moment when the preverbal oneness of mother and infant comes to an end, the expulsion from the garden; but its sleepy rhythms and half rhymes remind us how things were before we were ensnared by our desires – to win the game, to cause an opponent’s downfall, to revel narcissistically in our skill. Third, in both poetry and psychotherapy (and cricket) there is a dialectic between form and content – the firm boundaries of the former allow for infinite variety of the latter. Like the all-important psychotherapy ‘setting’ – consistency of place, time, person and technique – poetry creates a structure, a container, a set of rules and parameters that allow feelings to arise spontaneously. The importance of these simple technical devices should not be underestimated. Just as the invention of the stave system of notation ushered in a new era in music, so Freud’s invention of the rules of therapy in the consulting room made it possible to put relationships and emotions under the microscope in ways that were impossible before. Despite its apparent simplicity, The Catch resists total explication; what exactly, for example, is the function of the word ‘forget . . .’ at the start of the poem? How often do we finish a session with a patient and say to ourselves ‘I really didn’t understand what was going on there’? We have to be able to tolerate the poem’s obscurity, and the consequent feelings of splitting and falling apart of meanings, secure in the knowledge that a resolution will emerge, given time and attentiveness and faith. Similarly, with patients we have to attune ourselves to their and our own feelings, without knowing in advance what they ‘mean’, or how they fit into a predetermined schema. Poetry, like psychotherapy, and healthy psychological functioning, enables us to reflect on the flux of life (faster than the flight of a cricket ball), penetrate its mysteries and learn from experience. Without an intersubjective perspective people suffering mental pain are stuck – trapped within their narcissism or nihilism (which is only a negative form of narcissism, see Chapter 12). Psychotherapy and poetry help us escape from this

Downloaded by [New York University] at 12:48 14 August 2016 cul-de-sac. Both put us in touch – physiologically, emotionally, cognitively – with creativity and with the living reality of the other. Psychiatry needs psychotherapy – and perhaps even poetry – if it is to go beyond a reductionism that excludes the mind and cannot theorise relationships. Just as psychotherapy needs to expose itself to the pain and difﬁculty of coalface psychiatry, so my bantering new-found friend needed to open himself to the poetry of his discipline. Without it he was in danger of being caught out.

173 15 FACTS V. FEELINGS Abse, Olds, Holub and Larkin

‘We are professionals. We have a job to do. We just go on autopilot and tackle the task in hand’. Thus the surgeon in charge of the casualty department receiv- ing the victims of a tragic massacre. We must be grateful for that autopilot, but once the technical job is done, the professional needs to reconnect with herself as a person. Now there is another kind of work to be done – to help with the impact of the trauma, the grief, the horror – and here, paradoxically, professional skills are needed to help professionals divest themselves of their professionalism – to become themselves once more, no longer automata. Feelings are facts. Psychodynamic psychiatry can help understand these facts and how they inﬂuence our patients and our professional responses to them, and so contribute to the ‘art’ of medicine. Psychodynamic understanding is an art, but it is also a science and a moral discipline. It is an art in that ultimately it is impossible to legislate for the tact, timing, sensitivity and creativity that makes up a helpful encounter between doctor and patient. It is a science in that psychology, psychoanalysis and child development inform our understanding of the dynamics of relationships. It is a moral discipline in that in our encounter with the patient we are always struggling to do and say the ‘right’ thing in the face of human suffering. This struggle is as much with our own inadequacies, negativ- ity, anxiety and pessimism as with those of the patient, even if we sometimes comfort ourselves with the thought that, via projective identiﬁcation, these arise in ‘the patient’ rather than ourselves.

Medicine as a moral challenge Downloaded by [New York University] at 12:48 14 August 2016 I sometimes like to think of the normal working day of a psychiatrist as a moral obstacle course. We are exposed each day to an enormous amount of suffering: to people who see no reason for living and wish to die, to those who have been brutally exploited and abused, to those for whom violence either to themselves or others has become a habitual way of living and coping with stress. Part of one’s job is to avoid emotional blunting and to remain sensitive to this mental pain, while at the same time remaining buoyant and cheerful. Mental health professionals have to deal with the unrealistic expectations

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placed upon them, both by society and by individual patients, without dashing their hopes or retreating into cynicism. Equally one has to endure one’s role as a ‘bad object’, being seen as the source of all that is wrong in the lives of some of our patients. This too has to be taken seriously, with good humour and with a realistic capacity to sift legitimate complaints from obvious misperceptions. For team-leaders it is vital to maintain morale, and, as Winnicott (1968, p. 112) put it, to help with the team’s triple task of ‘keeping alive, keeping well and keeping awake’. One has to maintain one’s boundaries – take much-needed breaks, while at the same time being flexible enough to allow for the unexpected. Space must be created within those boundaries so that the patient can feel safe enough to get in touch with feelings and to feel more creatively alive. One has to learn when necessary to say ‘no’, to draw a line, without being rejecting or irre- sponsible. One must learn to take account of the fact that some patients seem attractive and likeable, while others evoke fear or even loathing – these are all reactions that need to be noted, understood and worked with. One has to render unto the Caesar of the bureaucracy the necessary forms filled in – to acknowledge that they have a value, and yet not to see them as a substitute for the human encounter with the patient. One has, as the former tank-commander and psychoanalyst Bion stated, to keep one’s head under fire and to learn from one’s mistakes. One has to learn to think before acting – diagnosis before treatment as Balint (1964) put it – to ask oneself why this patient wants her medication changed, that one wants to be discharged, this one is heading for compulsory detention and so on. And to learn not to be paralysed into inaction by an excess of ratiocination.

The developmental tasks What then are the developmental tasks that young professionals must meet if they are to be ﬁt for this moral steeplechase? My non- comprehensive list is as follows:

1 Coming to terms with ambivalence – wanting to know, and fear of knowing, with compassion and revulsion; 2 Learning when necessary to dissociate facts from feelings, without losing

Downloaded by [New York University] at 12:48 14 August 2016 sight of either; 3 Coming to terms with the body, including sexuality – one’s own and that of others; 4 Retaining a personal vision, while feeling comfortable with the persona and role of a psychiatrist; 5 Acceptance of success and failure – learning to ‘treat those two imposters just the same’; 6 Coming to terms with loss, including – dare one say this? – the inevitability of suicide in some cases.

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Poetic examples I shall try to illustrate some of these themes by the work of four contemporary poets. My presumption and slight embarrassment about this is tempered by a paper (Horowitz 1996), unthinkable in today’s managerialist culture, in which, not a psychiatrist but a physician described starting his ward round with a brief literary interlude in which each member of the team in turn brought a poem for discussion. He reported positive effects on team morale and sensitivity. My ﬁrst poem is ‘X- Ray’ by Dannie Abse (1981), who, as emerges in the poem, is both a chest physician and a highly accomplished poet.

Some prowl sea- beds, some hurtle to a star and, mother, some obsessed turn over every stone or open graves to let that starlight in. There are men who would open everything.

Harvey, the circulation of the blood, and Freud, the circulation of our dreams, pried honourably and honoured are like all explorers. Men who’d open men.

And those others, mother, with diseases like great streets named after them: Addison Parkinson, Hodgkin – physicians who’d arrive fast and ﬁrst on any sour death-bed scene. I am their slowcoach colleague, half afraid, incurious. As a boy it was so: you know how my small hand never teased to pieces an alarm clock or ﬂensed a perished mouse.

And this larger hand’s the same. It stretches now out from a white sleeve to hold up. mother, your X- ray to the glowing screen. My eyes look but don’t want to: I still don’t want to know.

This moving poem captures for me the inherent terror and ambivalence of medi- Downloaded by [New York University] at 12:48 14 August 2016 cine – its power to make us feel small and to pronounce our fate. The dissociated white-sleeved hand of the last verse belongs to the man whose mother, we suspect, has a terminal illness, and can also sign her death- sentence. It captures the ‘reaction formation’ that underlies many medical careers: by becoming doctors and health workers we gain mastery over that which we most fear. Somewhere too there is an ‘Oedipal’ theme. The son who was once helpless and vulnerable is now in a position of power. However reluctantly, he has joined the company of those great men with whom he compares himself so unfavourably

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(Abse had two highly successful older brothers). Although he ‘doesn’t want to know’, he forces himself to look, and his voyage of exploration lies in the making of the poem, whose slow pace, coming in a roundabout way in the last verse to its almost unbearable point, is just as courageous, one might say, as the journeys of the men he admires. In Sharon Olds’ (1983) poem ‘The connoisseuse of slugs’ we again encounter the dynamics of the gaze, showing how intense scrutiny can disarm, turning something potentially frightening or even disgusting into an object of wonder and tenderness.

When I was a connoisseuse of slugs I would part the ivy leaves, and look for the naked jelly of those gold bodies, translucent strangers glistening along the stones, slowly, their gelatinous bodies at my mercy. Made mostly of water, they would shrivel to nothing if they were sprinkled with salt, but I was not interested in that. What I liked was to draw aside the ivy, breathe the odour of the wall, and stand there in silence until the slug forgot I was there and sent its antennae up out of its head, the glimmering umber horns rising like telescopes, until ﬁnally the sensitive knobs would pop out the ends, delicate and intimate. Years later, when I ﬁrst saw a naked man, I gasped with pleasure to see that quiet mystery reenacted, the slow elegant being coming out of hiding and gleaming in the dark air, eager and so trusting you could weep.

As a man, I ﬁnd this poem quite shocking, with its feminist reversal of the culturally sanctioned gaze of the male artist or advertiser on the naked body of a

Downloaded by [New York University] at 12:48 14 August 2016 woman. I respond with typical medical dissociation by reminding myself that what is being described are perfectly normal physiological phenomena. It reminds me that, when teaching medical students, we would discuss in the group how to cope when they or their patient developed an erection in the course of a medical examination – it seemed a relief to discuss such matters, once they too had got over the initial embarrassment. Olds, an American poet, writes about an eroticised and possible abusive relationship with her father, and the last line conveys the delicacy of the contrast with which we entrust our bodies to the hands of our parents, our lovers and our doctors, and hinting at how that power

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can be perverted. In medicine we learn to listen, to look, to feel, and yet how easy is it to take a history without really hearing, to glance without wonder, to palpate without feeling, to pour salt and make feelings shrivel (or shrink!). Learning medicine is about learning how to touch and feel; listening to our own feelings helps us to be touched by those of our patients. My third poem, ‘Pathology’ is by Miroslav Holub (1967), a Czech immunol- ogist of international repute as well as a well-known and much translated poet.

Here in the Lord’s bosom rest the tongues of beggars, the lungs of generals, the eyes of informers, the skins of martyrs.

in the absolute of the microscope’s lenses.

I leaf through Old Testament slices of liver, in the white monuments of the brain I read the hieroglyphs of decay.

Behold Christians. Heaven, Hell, and Paradise in bottles. And no wailing. not even a sigh. Only the dust moans. Dumb is history strained through capillaries.

Equality dumb. Fraternity dumb.

And out of the tricolours of mortal suffering we day by day

Downloaded by [New York University] at 12:48 14 August 2016 pull threads of wisdom.

This is perhaps a modern version of ‘Ozymandias’, or Cymbeline (‘golden lads and girls all must/like chimney-sweepers come to dust’), in which all beliefs and ideologies – the poem is as much an ironic commentary on communism as on Christianity – are dissolved by the merciless levelling of the pathologist’s table. A bosom is transformed into a marble slab, bodies of heroes are dismembered, and the only truths are the threadbare thoughts of the pathologist – and the poet.

178 FACTS V. FEELINGS

Holub’s poem is perhaps more daring than Abse’s in that he takes further the splitting and evacuation of meaning that medicine is capable of, and yet manages to make of it something arresting and beautiful. The poem is as disjointed as the bodies it describes, yet coheres with its careful step-by-step use of sparse but feeling-imbued language, so that by the end we have, like the pathologist, extracted a thread of wisdom – a diagnosis – from our dissection and micro- scopic scrutiny.

Identification Identification with parent-fi gures is an essential component in the development of a young person’s identity in late adolescence (Erikson 1968). One’s identity as a doctor is inevitably formed through identifications and disidentifications with the elders to whom one has been exposed in the course of training. A benefit of the Balint-type groups for psychiatric trainees is the proximity it provides between student and group facilitator, which fosters this process in a way that mass teaching cannot. The issue of identification is of course a much wider one than simply the running of a seminar for trainees. It is particularly difficult for adolescents to identify with parents who are themselves in the throes of a mid- life crisis. One strand of this crisis in contemporary psychiatry is the encroachment of a well- meaning but insidious bureaucracy. One is hemmed in by rules and regulations, and forms and paperwork. Not that this is all bad: doctors, like any professional group, need regulation and scrutiny. But the essence of a bureaucracy is that it requires no value system at its heart: it is self-perpetuating and self-justifying. Its procedures exist to produce more procedures, and so on. To counterbalance this we need value- based medicine as a counterweight to profit- based medicine. The question I have tried to pose in this book is whether we can become more aware of them through cultivation of psychodynamic reflection, which is, for me, akin to the poetic impulse. Whatever else they are, medical systems stand as an enormous social defence against anxiety. If one feels something is wrong, just seeing a doctor makes one feel better, even if there has been no apparent ‘evidence-based intervention’. I end with the opening and closing stanzas from Philip Larkin’s (1974) ‘The building’ in which he compares the district hospitals with medieval cathedrals, those magnificent and defiant expressions of negative

Downloaded by [New York University] at 12:48 14 August 2016 entropy, monuments of our resistance to death and dissolution:

Higher than the handsomest hotel The lucent comb shows up for miles, but see. . . . what keeps drawing up At the entrance are not taxis; and in the hall As well as creepers hangs a frightening smell. . . . All know, they are going to die. Not yet. Perhaps not here, but in the end.

179 ‘ONLY CONNECT’: PSYCHOTHERAPY AND PSYCHIATRY

And somewhere like this. That is what it means This clean-sliced cliff; a struggle to transcend The thought of dying, for unless its powers Outbuild cathedrals nothing contravenes The coming dark, through crowds each evening try With wasteful, weak, propitiatory ﬂowers.

Larkin touches here the paradox of medicine: its capacity both to remind us of our weakness, vulnerability, frailty and mortality, and at the same time its immense power to overcome and outwit disease, and to stave off death, at least for a while. The tone of the poem, as so often in his work, is pessimistic and elegiac; he seems self-depreciatingly to imply that his words are as weak and propitiatory as the relative’s ﬂowers. And yet this is a highly crafted longish poem, a tour de force of complex rhyme and structure – itself almost cathedral- like. It is perhaps the task of psychotherapy and psychiatry to keep alive awareness of the anxiety and fear that lie at the heart of the cathedral-building, medicine-making impulse. Without this balance, medicine is in danger of top- pling over into commerce and bureaucracy and denial. Like the poet we too have to celebrate our knowledge of the mind and spirit and of our skills in the crafting of words and ideas to express that understanding. Without psychiatry, medicine is, in Bettleheim’s (1969) striking image, in danger of being an empty fortress, an autistic world of function devoid of feeling – and the same could be said for a psychiatry which divested itself of dynamic psychotherapy. Psychiatrists, the popular joke has it, work with ‘castles in the air’. We should be proud of our knowledge of those castles, resist their dismissal. Like feelings, they are very real. Downloaded by [New York University] at 12:48 14 August 2016

180 POSTSCRIPT

Embarking on this book may have been a foolhardy enterprise. Assembling seemingly disparate writings over a 30-year period runs the obvious risks of appearing irrelevant, dated and/or repetitious. Against that, I would argue that psychoanalytic advance has generally been slow and tortuous, and progress in the arts – as opposed to the sciences – is often more cyclical than incremental. I therefore remain committed to the four overall themes that shape this work, although, like the shifting sands of the North Devon dunes where I am lucky enough to live, their contours have undoubtedly eroded and re- formed over the years. Curiously, the topic that stands almost unchanged since Freud ﬁrst began his excavations is the creativity of the unconscious mind, with its untold capacity to surprise and synthesise, harnessed by creative writers, and unleashed by the psychoanalytic process. With notable exceptions, the increasing emphasis on the therapeutic relationship in contemporary psychoanalysis, important though that is, has tended to downplay this aspect of the psychoanalytic project. A prime aim of this volume has been to rehabilitate the unconscious as celebrated in literature and psychoanalytic work as the very basis of human vitality, not excluding intellectual life. With the help of literature, I have tried to anatomise the creative unconscious in ways that complement psychoanalytic theorising. My second theme – the making and breaking of stories – is a product of the continuing rapprochement between attachment theory and psychoanalysis that is a striking feature of contemporary relationally inclined psychoanalysis (Slade and Holmes 2013). Bowlby insisted that one could be both biological and

Downloaded by [New York University] at 12:48 14 August 2016 psychosocial, and serve the masters of research and therapy without betraying either. ‘Story stem’ research has become a potent research tool in the attachment field that classifies the different kinds of stories children tell – calamity resolu- tions, augmentations, inconclusiveness – depending on their attachment disposition. Later, the Adult Attachment Interview (Main 1995; Fonagy et al. 1995) classifies, in a quasi- literary way, the style and manner of their telling. The idea of a ‘secure base script’ (Waters and Waters 2006) as an affect- regulating device, and standing for a safe self in relation to an empathic Other, is another emerging theme. If we can tell stories, we are at least half way to feeling OK.

181 POSTSCRIPT

Literature and consulting room narratives can both be seen as attempts to capture and tame the painful and evanescent flux of existence and turn them into manageable beasts. Thanks to the baleful influence of the ‘drug metaphor’ and of managerialism in health services, my third theme – the contribution of literature and psychotherapy to the question of psychiatric diagnosis – remains as salient as ever. Our paymasters demand specific therapies for specific conditions based on specific outcome studies, without which – no deal. But, argue the humanistically inclined, we are more than mere bundles of symptoms and ‘conditions’. People, ‘mentally ill’ or not, are coherent mentalising beings, agents, entities that refuse to be fragmented and arbitrarily dissected, however troubled. That rearguard action remains essential, and the richness that literature and psychotherapy bring to the debate indispensible. Finally, with the help of poetry, I try to address the divide within mental health provision between psychodynamic and narrow medical approaches to psychiatric disorder. Sadly, the terms of that debate have changed radically over the past two decades. Medical psychotherapy – the counterweight to the ‘biological psychiatry’ which Bowlby saw as a misnomer – is in retreat. Cognitive Behavioural Therapy (CBT) is now the dominant psychotherapy paradigm in mental health provision, typically practised by clinical psychologists rather than psychiatrists. CBT, which within its limitations has much to recommend it, is often a ‘flag of convenience’ under which, consciously or unconsciously, travel many highly interpersonally sensitive therapists. Nevertheless, today’s great divide lies between psychodynamic approaches and CBT. Ironically, psychodynamics now finds support from contemporary neuroscience, its former enemy (e.g. Strathearn et al. 2009; Holmes 2012a). Bartels and Zeki (2004) famously demonstrated that the same parts of the brain are activated in maternal and adult romantic love, consistent with psychoanalytic hypotheses about the importance of early relationships in determining the subsequent life- course. Or to take another rather delightful example, brain responses to threat are moderated depending on whether the sufferer holds a loved one’s hand or has to endure the pain on her own (Coan et al. 2006). In view of all of this, I stand firm to this book’s basic message. Poetry, an essential hand-holder in times of trouble, is as integral to psychotherapy’s identity as its science, and, as a third leg of the hybrid tripod, literature will continue

Downloaded by [New York University] at 12:48 14 August 2016 to be a boundless and continuing resource for its practitioners.

182 REFERENCES

Abraham, K. (1973) Selected Papers of Karl Abraham. London: Hogarth Press. Abse, D. (1981) Way Out in the Centre. London: Hutchinson. Ainsworth, M. (1982) Attachment: retrospect and prospect. C. M. Parkes and J. Sevenson- Hinde (Eds), The Place of Attachment in Human Behaviour. London: Routledge. Allen, J. G., Fonagy, P. and Bateman, A. W. (2010) The role of mentalizing in treating attachment trauma. R. A. Lanius, E. Vermetten and C. Pain (Eds), The Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic. New York: Cambridge University Press, pp. 247–256. Armitage, S. (1992) Kid. London: Faber. Auden, W. (1963) The Dyers Hand. Oxford: Oxford University Press. Austen, J. (1816/1929) Emma. London: Macmillan. Balint, M. (1964) Primary Love and Psychoanalytic Technique. London: Tavistock. Balint, M. (1968) The Basic Fault. London: Hogarth Press. Barker, P. (2005) The Ghost Road. London: Penguin. Baron- Cohen, S. (2003) The Essential Difference. London: Penguin. Barratt, B. (1984) Psychoanalytic Reality and Psychoanalytic Knowing. Hillsdale, NJ: Psychoanalytic Press. Barratt, B. (2012) What is Psychoanalysis: 100 Years after Freud’s Secret Committee. Hove: Routledge. Bartels, A. and Zeki, S. (2004) The neural correlates of maternal and romantic love. Neu- roimage, 21, 1155–1166. Bateman, Α. (1998) Thick- and thin- skinned organisations and enactment in borderline and narcissistic disorders. International Journal of Psycho-Analysis , 79, 13–26. Bateman, A. and Fonagy, P. (2004) Mentalisation based treatment of BPD. J Pers Dis, 8, 36–51. Downloaded by [New York University] at 12:48 14 August 2016 Bateman, A. and Holmes, J. (1995) Introduction to Psychoanalysis. London: Routledge. Bateson, G. (1972) Steps Towards an Ecology of Mind. Chicago: University of Chicago Press. Beebe, B., Jaffe, J., Markese, S., Buck, K., Chen, H., Cohen, P. and Feldstein, S. (2010) The origins of 12-month attachment: a microanalysis of 4-month mother–infant interaction. Attachment & Human Development, 12, 1–135. Beebe, B., Lachmann, F., Markese, S. and Bahrick, L. (2012) On the origins of disorganised attachment and internal working models: a dyadic systems approach. Psychoana- lytic Dialogues, 22, 253–272.

183 REFERENCES

Benoit, D. and Parker, K. (1994) Stability and transmission of attachment across three generations. Child Development, 65, 1444–1456. Bettleheim, B. (1969) The Children of the Dream. London: Thames & Hudson. Bettleheim, B. (1982) Freud and Man’s Soul. New York: Knopf. Bion, W. (1962) Learning from Experience. London: Heineman. Bion, W. (1997) Clinical seminars. Clinical Seminars and Other Works. London: Karnac. Birkstead- Breen, D. (2012) Taking time: the tempo of psychoanalysis. International Journal of Psycho-Analysis , 93, 819–835. Blake, W. (1977) The Complete Poems. A. Ostriker (Ed.). London: Penguin. Bloom, H. (1973) The Anxiety of Inﬂuence. Oxford: Oxford University Press. Bollas, C. (2007) The Freudian Moment. London: Karnac. Britton, R. (1998) Belief and Imagination. London: Routledge. Britton, R. (2003) The preacher, the poet and the psychoanalyst. H. Canham and C. Satyamurti (Eds), Acquainted with the Night: Psychoanalysis and the Poetic Imagina- tion. London: Karnac, pp. 113–132. Brockmeier, J. (1997). Autobiography, narrative, and the Freudian conception of life history. Philosophy, Psychiatry, Psychology, 4(3), 175–200. Bronowski, J. (1978) The Origins of Knowledge and Imagination. New Haven: Yale Uni- versity Press. Bruner, J. (1986) Actual Minds, Possible Worlds. Cambridge, MA: Harvard University Press. Canham, H. and Satyamurti, C. (2003) Acquainted with the Night: Psychoanalysis and the Poetic Imagination. London: Karnac. Casement, P. (1985) On Learning from the Patient. London: Tavistock. Cavell, M. (2002) Border crossing: the philosopher as analyst. J. Raphael-Leff (Ed.), Beyond Sessions and Beyond the Couch. Essex: CPS Psychoanalytic Publications, pp. 159–163. Chasseguet- Smirgel, J. (1985) Creativity and Perversion. London: Free Association Books. Chomsky, N. (2008) The Essential Chomsky. A. Arnove (Ed.). London: Bodley Head. Coan, J. A., Schaefer, H. S. and Davidson, R. J. (2006) Lending a hand: social regulation of the neural response to threat. Psychological Science, 17(12), 1032–1039. Coleridge, S. (1817/1983) Biographical Literaria. J. Engell and W. Bate (Eds). London: Routledge. Coleridge, S. (1827, 12 July) Table Talk 1821–1824. http://en.wikiquote.org/wiki/ Samuel_Taylor_Coleridge (accessed 14 February 2014). Conrad, J. (1899/2003) Heart of Darkness. London: Penguin. Craik, K. (1941) The Nature of Explanation. Cambridge: Cambridge University Press. Crittenden, P. (1988) Relationships at risk. J. Belsky and T. Nezworsky (Eds), Clinical Downloaded by [New York University] at 12:48 14 August 2016 Implications of Attachment. New York: Erlbaum. Dennett, D. (2006) Breaking the Spell. London: Allen Lane. Dimen, M. (2001) Deconstructing difference: splitting, gender and transitional space. Psychoanlytic Dialogues, 1, 335–352. Dirda, M. (2011) On Conan Doyle. Princeton, NJ: Princeton University Press. Disraeli, B. (1845/1980) Sybil, or The Two Nations. London: Penguin. Dozier, M., Manni, M., Gordon, M. K., Peloso, E., Gunnar, M. R., Stovall- McClough, K. C., Eldreth, D. and Levine, S. (2006) Foster children’s diurnal production of cortisol: an exploratory study. Child Maltreatment, 11, 189–197.

184 REFERENCES

Eagleton, T. (2007) How to Read a Poem. London: Blackwell. Edelman, G. (1978) The Mindful Brain. Cambridge, MA: MIT Press. Eisenberg, L. (1986) Mindlessness and brainlessness in psychiatry. British Journal of Psychiatry, 148, 497–508. Eliot, G. (1874/2003) Middlemarch. London: Penguin. Eliot, G. (1876/1986) Daniel Deronda. B. Hardy (Ed.). London: Penguin Books. Eliot, T. (1954) East Coker in Four Quartets. London: Faber. Eliot, T. (1969) The Complete Poems and Plays of TS Eliot. London: Faber. Eliot, T. (1975) Selected Prose. F. Kermode (Ed.). London: Faber. Eliot, T. (1986) Collected Poems. London: Faber. Ellenberger, H. F. (1970) The Discovery of the Unconscious. New York: Basic Books. Empson, W. (1930/2008) Seven Types of Ambiguity. London: Seabrook Press. Erikson, E. (1968) Identity, Youth and Crisis. London: Faber and Faber. Ernst, S. and Goodison, L. (1993) In Our Own Hands: A Handbook of Self- help Therapy. London: Paladin. Fairbairn, R. (1952) Collected Papers. London: Hogarth Press. Feeney, B. and van Vleet, M. (2010) Growing through attachment: the interplay of attachment and exploration in adulthood. J Soc Per Relat, 27, 226–234. Fenichel, O. (1946) The Psychoanalytic Theory of Neurosis. London: Hogarth. Ferro, A. (2012) Psychoanalysis as Therapy and Storytelling. Hove: Routledge. Fonagy, P., Steele, M. and Steele, H. (1991) The capacity for understanding mental states: the reflective self in parent and child and its significance for security of attachment. Infant Mental Health Journal, 12, 201–218. Fonagy, P., Steele, M., Steele, H. and Leigh, T. (1995) Attachment the reflective self, and borderline states: the predictive specificity of the adult attachment interview and pathological emotional development. S. Goldberg, R. Muir and J. Kerr (Eds), Attachment Theory: Social, Developmental and Clinical Significance. Hillsdale, NJ: Analytic Press. Foster- Harris, P. (1959) Basic Patterns of Plot. Norman, Oklahoma: University of Okla- homa Press. Forster, E. (1910) Howards End. London: Edward Arnold. Forster, E. (1924/1988) A Passage to India. London: Penguin Books Fraiberg, S., Adelson, E. and Shapiro, V. (1975) Ghosts in the nursery: a psychoanalytic approach to impaired infant–mother relationships. Journal of American Academy of Child Psychologists, 14, 387–422. Freud, S. (1900) The Interpretation of Dreams. Standard Edition, vol. 4, London: Hogarth, 1–627. Freud, S. (1905/1953) Three Essays on Sexuality. Standard Edition, vol. 7, trans. J. Stra- chey, London: Hogarth Press. Downloaded by [New York University] at 12:48 14 August 2016 Freud, S. (1911) Formulations on the Two Principles of Mental Functioning. Standard Edition, vol. 12, 215–217. Freud, S. (1914) On narcissism. Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 14, trans. J. Strachey, London: Hogarth Press, 1953–1973, p. 91. Freud, S. (1919) Lines of Advance in Psychoanalytic Therapy. Standard Edition, vol. 17, London: Hogarth. Freud, S. (1923) The Ego and the Id. Standard Edition, vol. 19, 7–109. Freud, S. (1928) Dostoevsky and Parricide. Standard Edition, vol. 21, London: Hogarth.

185 REFERENCES

Freud, S. (1933) New Introductory Lectures on Psycho- Analysis. Standard Edition, vol. 22, 3–182. Fuller, P. (1980) Art and Psychoanalysis. London: Readers & Writers. Gabbard, G. (1996) Psychodynamic Psychiatry in Clinical Practice. Washington: Ameri- can Psychiatric Press. Gabbard, G. (Ed.) (2001) Psychoanalysis and Film. London: Karnac. Gabbard, G. and Ogden, T. (2009) On Becoming a Psychoanalyst. International Journal of Psychoanalysis, 90, 311–327. Gardner, H. (1957) The Metaphysical Poets. London: Penguin. Garland, C. (1991) External disasters and the internal world. J. Holmes (Ed.), Textbook of Psychotherapy in Psychiatric Practice. Edinburgh: Churchill Livingstone, pp. 507–532. Gergely, G. and Watson, J. (1996) The social biofeedback theory of parental affect- mirroring. International Journal of Psycho Analysis, 77, 1181–1212. Green, A. (1997) The intuition of the negative in playing and reality. International Journal of Psycho-Analysis , 78, 1071–1084. Greenberg, J. R. and Mitchell, S. A. (1983) Object Relations in Psychoanalytic Theory. Cambridge, MA: Harvard University Press. Grosz, S. (2013) The Examined Life. London: Chatto & Windus. Grotstein, J. (1990) Introduction. M. Little (Ed.), Psychotic Anxieties and Containment. Northvale, NJ: Jason Aronson. Grotstein, J. (1992) Reﬂections on a century of Freud: some paths not chosen. British Journal of Psychotherapy, 9, 181–187. Grotstein, J. (2009) A Beam of Intense Darkness: Bion’s Legacy to Psychoanalysis. London: Karnac. Gurevich, H. (2008) The language of absence. International Journal of Psycho- Analysis, 89, 561–578. Hamilton, V. (1982) Narcissus and Oedipus. London: Routledge. Hamilton, V. (1986) Grief and mourning in Tennyson’s In Memoriam. Free Associations, 7, 87–110. Harman, C. (1992a) Introduction. Essays and Poems, RL Stevenson. London: Everyman. Harman, C. (1992b) Introduction. The Strange Case of Dr Jekyll and Mr Hyde. London: Everyman. Harris, A. and Bass, A. (2011) Nachtraglichkeit. Psychoanalytic Dialogues, 21, 239–242. Hart, B. (1912) The Psychology of Insanity. Cambridge: Cambridge University Press. Havens, L. (1982) The choice of clinical methods. Contemporary Psychoanalysis, 18, 16–42. Heaney, S. (1980) Preoccupations; Selected Prose 1968–1978. London: Faber. Heaney, S. (1998) Opened Ground: Poems 1966–1996. London: Faber and Faber. Heard, B. and Lake, D. (1986) The attachment dynamic in adult life. British Journal of Downloaded by [New York University] at 12:48 14 August 2016 Psychiatry, 149, 430–438. Heath, I. (2012) In memoriam. BMJ, 344, 2725. Herbert, G. (1991) Man in The Complete English Poems. J. Tobin (Ed.). London: Penguin. Herman, J., Perry, J. C. and van der Kolk, B. A. (1989) Childhood trauma in borderline personality disorder. American Journal of Psychiatry, 146, 490–495. Hinshelwood, R. (1991) Psychodynamic psychiatry before Word War I. G. Berrios and H. Freeman (Eds), 150 Years of British Psychiatry. London: Gaskell. Hobson R. (1985) Forms of Feeling: the Heart of Psychotherapy. London: Tavistock.

186 REFERENCES

Hobson, P. (1993) Autism and the Development of Mind. Hillsdale: Erlbaum. Hoffman, I. (2009) Doublethinking our way to scientific legitimacy: the desiccation of human experience. J Am Psychoanal Assoc, 57, 1043–1070. Hollis, M. (2011) Now All Roads Lead to France. London: Faber. Holmes, J. (1992) Between Art and Science: Essays in Psychotherapy and Psychiatry. London: Routledge. Holmes, J. (1993/2013) John Bowlby and Attachment Theory. London: Routledge. Holmes, J. (1996) Attachment, Intimacy, Autonomy: Using Attachment Theory in Adult Psychotherapy. New York: Jason Aronson. Holmes, J. (1997) Attachment Intimacy Autonomy: Using Attachment Theory in Adult Psychotherapy. Northvale, NJ: Jason Aronson. Holmes, J. (2010) Exploring in Security: Towards an Attachment-informed Psychoana- lytic Psychotherapy. Hove: Routledge. Holmes, J. (2012a) Psychodynamic psychiatry’s green shoots. British Journal of Psych- iatry, 200, 439–441. Holmes, J. (2012b) Storr’s The Art of Psychotherapy. London: Hodder. Holmes, J. and Lindley, R. (1997) The Values of Psychotherapy. London: Karnac. Holmes, R. (1985) Footsteps. London: Penguin. Holmes, R. (1996) Footsteps: Adventures of a Romantic Biographer. London: Vintage. Holmes, R. (1999) Coleridge: Darker Reflections. London: Flamingo. Holub, M. (1967) Selected Poems. Trans. I. Milner and G. Theiner. London: Penguin. Hopkins, G. (1967) Poems. H. Gardner and N. MacKenzie (Eds). Oxford: Oxford Univer- sity Press. Horowitz, H. W. (1996) Poetry on rounds: a model for the integration of humanities into residency training. The Lancet, 347, 447–449. Howard, G. (1991) Culture tales: a narrative approach to thinking, cross-cultural psychology and psychotherapy. American Psychologist, 46, 187–197. Hughes, T. (1997) Tales from Ovid. London: Faber. Hunt, J., Timoshkina, Y., Baudains, P. J. and Bishop, S. R. (2012) System dynamics applied to operations and policy decisions. European Review, 20, 324–342. Jones, E. (1948) The death of Hamlet’s father. International Journal of Psycho- Analysis, 29, 174–176. Keats, J. (1973) Collected Poems. J. Barnard (Ed.). London: Penguin. Kelly, M. (Ed.) (1998) Encyclopedia of Aesthetics. New York, Oxford: Oxford University Press. Kernberg, O. (1975) Borderline Conditions and Pathological Narcissism. New York: New York Universities Press. Klein, M. (1957) Envy and Gratitude: A Study of Unconscious Sources. London: Tavistock. Knox, J. (2011) Self- Agency in Psychotherapy. London: Norton. Downloaded by [New York University] at 12:48 14 August 2016 Kohon, G. (Ed.) (1986) Reflections on Dora: the case of hysteria. The British School of Psychoanalysis: The Independent Tradition. London: Free Association Books. Kohon, G. (Ed.) (1999) The Dead Mother: The Work of André Green. London: Routledge. Kohut, H. (1971) The Analysis of the Self. New York: International Universities Press. Kohut, H. (1984) How does Analysis Cure? Chicago: University of Chicago Press. Kohut, H. and Seitz, P. (1963) Three self psychologies – or one? A. Goldberg (Ed.), The Evolution of Self Psychology: Progress in Self Psychology, vol. 7. Hillsdale, NY: Analytic Press, p. 20.

187 REFERENCES

Lacan, J. (1977) Ecrits: A Selection. Trans. A. Sheridan. London: Tavistock. Langer, S. (1951) Philosophy in a New Key. New York: Mentor. Langs, R. (1978) The Listening Process. New York: Jason Aronson. Laplanche, J. and Pontalis, J.-B. (1980) The Language of Psychoanalysis. London: Hogarth Press. Larkin, P. (1974) High Windows. London: Faber. Lasch, C. (1979) The Culture of Narcissism. New York: Doubleday. Lawrence, D. H. (1989) Selected Poems. London: Penguin. Leach, E. (1982) Social Anthropology. Oxford: Oxford University Press. Lear, J. (2009) Technique and final cause in psychoanalysis: four ways of looking at one moment. International Journal of Psycho-Analysis , 90, 1299–1317. Leavis, F. (1962) Two Cultures? The Significance of CP Snow. London: Chatto & Windus. Leavis, F. (1975) The Living Principle. London: Chatto & Windus. Leff, J. and Vaughan, C. (1983) Expressed Emotion in Families. New York: Guilford. Leiman, M. (1995) Early developments. A. Ryle (Ed.), Cognitive Analytic Therapy: Developments in Theory and Practice. Chichester: Wiley. Lessing, D. (2007) Nobel Lecture. Available online at http://nobelprize.org/nobelprizes/ ligerature/laureates/2007/lessing-lecture_en.html (accessed 17 June 2009). Llosa, M. (1975) Aunt Julia and the Scriptwriter. London: Faber. Lowell, R. (1959) Life Studies. London: Faber. Luborsky, L. (1984) Principles of Psychoanalytic Psychotherapy. New York: Basic Books. Lyons-Ruth, K. and the Boston Change Process Study Group (2001) The emergence of new experiences: relational improvisation, recognition process and non- linear change in psychoanalytic psychotherapy. Psychologist/psychoanalyst, 21, 13–17. Main, M. (1995) Recent studies of attachment: overview with selected implications for clinical work. S. Goldberg, R. Muir and J. Kerr (Eds), Attachment Theory: Social, Developmental and Clinical Perspectives. Hillsdale: Analytic Press. Malan, D. (1979/2013) Individual Psychotherapy and the Science of Psychodynamics. 2nd Edition. London: Hodder. Marcus, S. (1974) Representations: Essays on Literature and Society. New York: Random House. Matte- Blanco, I. (1975) The Unconscious as Infinite Sets. London: Routledge. McGilchrist, I. (2011) The Master and his Emissary. New Haven: Yale University Press. McLuhan, M. (1964) Understanding Media: The Extensions of Man. New York: McGraw- Hill. Meares, R. (1993) The Metaphor of Play. New York: Jason Aronson. Medawar, P. (1975) Victims of psychiatry. New York Review of Books. 23 January. Downloaded by [New York University] at 12:48 14 August 2016 Meins, E., Fernyhough, C., Fradley, E. and Tuckey, M. (2001) Rethinking maternal sensitivity: mothers’ comments in infants’ mental processes predict security of attachment at 12 months. Journal of Child Psychology and Psychiatry, 42(5), 637. Milton, J. (1983) Selected Poems. London: Dover. Mollon, P. (1993) The Fragile Self. London: Whurr. Morrison, A. (Ed.) (1986) Essential Papers on Narcissism. New York: New York Uni- versity Press. Northoff, G. (2014) Unlocking the Brain: Vol 1 Coding. Oxford: Oxford University Press.

188 REFERENCES

Ogden, B. and Ogden, T. (2012) How the analyst thinks as a clinician and as a literary reader. Psychoanalytic Perspectives, 9, 243–273. Ogden, T. (1987) The Matrix of the Mind. Northvale, NJ: Jason Aronson. Ogden, T. (1994) The analytical third: working with intersubjective clinical facts. Inter- national Journal of Psycho-analysis , 75, 3–20. Ogden, T. (1997) Reverie and Interpretation. Northville, NJ: Jason Aronson. Ogden, T. (1999) The music of what happens in poetry and psychoanalysis. International Journal of Psychoanalysis, 80, 979–994. Olds, S. (1983) The Dead and the Living. New York: Knopf. Orange, D. (2011) The Suffering Stranger: Hermeneutics for Everyday Clinical Practice. New York: Routledge. Owen Lee, M. (1998) Wagner’s Ring. New York: Proscenium. Oxford English Dictionary (1973) Oxford: Oxford University Press. Palazzoli, M. S. (1978) Paradox and Counter- Paradox. New York: Jason Aronson. Parker, G. (1983) Parental ‘affectionless control’ as antecedent to adult depression. Arch Gen Psych, 40, 956–960. Parsons, T. (1951) The Social System. New York: Free Press. Pedder, J. (2010) Attachment and New Beginnings. G. Winship (Ed.). London: Karnac. Pines, M. (1991) The development of the psychodynamic movement. G. Berrios and H. Freeman (Eds), 150 Years of British Psychiatry. London: Gaskell. Plato (360 BCE) The Sophist. Internet Classics Archive. classics.mit.edu/Plato/sophist.html (accessed September 2013). Polti, G. (1916) The Thirty-Six Dramatic Situations. Trans. L Ray. Franklin, Ohio: Reeve. Pope, A. (1976) Pope Everyman Poety. J. Fuller (Ed.). London: Orion. Proust, M. (1941) Remembrance of Things Past. Vol 1 Swann’s Way. Trans. C. Scott Moncrieff. London: Chatto. Pullman, P. (2012) Grimm Tales. London: Penguin. Quinodoz, J.-M. (2006) Reading Freud. London: Routledge. Reik, T. (1948) Listening with the Third Ear: The Inner Experience of a Psychoanalyst. New York: Farrar Straus. Rey, H. (1994) Universals of Psychoanalysis in the Treatment of Psychotic and Border- line States. J. Magagna (Ed.). London: Free Association Books. Richards, I. and Ogden, C. (1923/1989) The Meaning of Meaning. New York: Harvest. Ricoeur, P. (1970) Freud and Philosophy: An Essay on Interpretation. New Haven, CT: Yale University Press. Rieff, P. (1979) Freud: The Mind of the Moralist. Chicago, IL: University of Chicago Press. Rosenfeld, H. (1965) Psychotic States: A Psycho Analytic Approach. New York: Inter- national Universities Press. Downloaded by [New York University] at 12:48 14 August 2016 Rotenberg, C. (1999) George Eliot: proto-psychoanalyst. Am J Psychoanal, 59, 257–277. Roth, A. and Fonagy, P. (2004) What Works for Whom. 2nd Edition. New York: Guil- ford. Roustang, F. (1980) Psychoanalysis Never Lets Go. Trans N. Lukacher. Baltimore: John Hopkins Press. Rusbridger, R. (2008) The internal world of Don Giovanni. International Journal of Psycho- Analysis, 69, 181–194. Rustin, M. (2001) The therapist with her back to the wall. J Child Psychotherapy, 27, 273–284.

189 REFERENCES

Rustin, M. and Rustin, M. (2002) Mirror to Nature: Drama, Psychoanalysis and Society. London: Karnac. Rycroft, C. (1968) Imagination and Reality. London: Hogarth. Rycroft, C. (1972) Critical Dictionary of Psychoanalysis. London: Penguin. Rycroft, C. (1979) The Innocence of Dreams. London: Chatto. Rycroft, C. (1985) Psychoanalysis and Beyond. London: Chatto. Sandler, J. and Rosenblatt, B. (1962) The concept of the representational world. The Psy- choanalytic Study of the Child, 17, 128–145. Schafer, R. (1992) Retelling a Life: Narration and Dialogue in Psychoanalysis. New York: Basic Books. Schore, J. R. and Schore, A. N. (2008) Modern attachment theory: the central role of affect regulation in development and treatment. Clinical Social Work Journal, 36, 9–20. Segal, H. (1991) Dream, Phantasy, and Art. London: Routledge. Shakespeare, W. (1911/1962) The Comedies of Shakespeare; The Histories and Poems of Shakespeare; The Tragedies of Shakespeare. W. Craig (Ed.). Oxford: Oxford Univer- sity Press. Sharpe, E. (1940) Psycho-physical problems revealed in language: an examination of metaphor. International Journal of Psycho-Analysis , 21, 201–213. Shedler, J. and Westen, D. (2007) The Shedler-Westen Assessment Procedure (SWAP): making personality diagnosis clinically meaningful. Journal of Personality Assessment, 89, 41–55. Skynner, R. (1976) One Flesh, Separate Persons. London: Butterworth. Slade, A. (2005) Parental reflective functioning: an introduction. Attachment and Human Development, 7, 269–282. Slade, A., Grienenberger, J., Bernbach, E., Levy, D. and Locker, A. (2005) Maternal reflective functioning, attachment, and the transmission gap: a preliminary study. Attachment and Human Development, 7, 283–298. Slade, A. and Holmes, J. (2013) Selected Papers in Attachment 1943–2012. London: Sage. Slavin, M. and Kriegman, D. (1992) The Adaptive Design of the Human Psyche. New York: Guilford. Snow, C. (1959) The Two Cultures. Cambridge: Cambridge University Press. Sohn, L. (1985) Narcissistic organisation, projective identification, and the formation of the ‘identificate’. International Journal of Psycho-Analysis , 66, 201–213. Spence, D. (1982) Narrative Truth and Historical Truth: Meaning and Interpretation in Psychoanalysis. New York: Norton. Stern, D. (1985) The Interpersonal World of the Infant. New York: Basic Books. Stern, D. B. (2009) Partners in Thought: Working with Unformulated Experience, Disso- ciation, and Enactment. London: Routledge. Stevenson, R. (1883/2010) Treasure Island. London: Collins. Downloaded by [New York University] at 12:48 14 August 2016 Stevenson, R. (1886/2002) Kidnapped. London: Scholastic. Stevenson, R. (1886) The Strange Case of Dr Jekyll and Mr Hyde. London: Everyman Edition. Strathearn, L., Fonagy, P., Amico, J. and Montague, P. R. (2009) Adult attachment pre- dicts maternal brain and oxytocin response to infant cues. Neuropsychopharmacology, 34, 2655–2666. Suomi, S. (1997) Early determinants of behaviour: evidence from primate studies. British Medical Bulletin, 53, 170–184. Sutherland, J. (1991) Fairbairn’s Journey to the Interior. London: Free Association Books.

190 REFERENCES

Symington, N. (1986) The Analytic Experience. London: Free Association Books. Symington, N. (1993) Emotion and Spirit. London: Karnac. Thompson, E. (1982) Writing by Candlelight. London: Merlin. Trilling, L. (1950) The Liberal Imagination. London: Secker & Warburg. Trollope, A. (1857/2007) Barchester Towers. London: Penguin. Turner, J. (1988) Wordsworth, Winnicott and the arena of play. International Review of Psychoanalysis, 15, 481. Turner, J. (2004) A brief history of illusion: Milner, Winnicott, Rycroft. J. Pearson (Ed.), Analyst of the Imagination: The Life and Work of Charles Rycroft. London: Karnac. Van de Kolk, B. and Fisler, R. (1996) Dissociation and the fragmentary nature of traumatic memories: overview. British Journal of Psychotherapy, 12, 352–361. Vygotsky, L. (1962) Thought and Language. Cambridge, MA: MIT Press. Waddell, M. (1989) Experience and identiﬁcation in George Eliot’s novels. Free Associ- ations, 1, 72–84. Waddell, M. (1998) Inside Lives: Psychoanalysis and the Growth of the Personality. London: Karnac. Waters, H. S. and Waters, E. (2006) The attachment working models concept: among other things, we build script- like representations of secure base experiences. Attach- ment & Human Development, 8(3), 185–197. Watson, P. (2010) The German Genius: Europe’s Third Renaissance, the Second Scient- iﬁc Revolution and the Twentieth Century. New York: Simon & Schuster. Waugh, E. (1938/2003) Scoop. London: Penguin. Weir, H. (1996) Analytic reverie and poetic reverie: a comparison. Free Associations, 6, 316–336. Weiss, R. (1982) Attachment in adult life. C. Parkes and J. Stevenson- Hinde (Eds), The Place of Attachment in Human Behaviour. London: Routledge. Wilde, O. (1891/1985) The Picture of Dorian Gray. London: Penguin. Wilde, O. (1995/2002) The Importance of Being Earnest. Oxford: Oxford University Press. Wilkinson, R. and Pickett, K. (2009) The Spirit Level: Why More Equal Societies Almost Always Do Better. London: Penguin. Williams, H. (1994) Dock Leaves. London: Faber. Williams, M. and Waddell, M. (1991) The Chamber of Maiden Thought: Literary Origins of the Psychoanalytic Model of the Mind. London: Free Association Books. Williams, R. (1973) The Country and the City. London: Chatto & Windus. Williams, T. (1993) A Streetcar Named Desire. Oxford: Heinemann. Winnicott, D. (1967) Mirror- role of mother and family in child development. P. Lomas (Ed.), The Predicament of the Family. London: Hogarth Press. Winnicott, D. (1968) The Maturational Processes and the Facilitating Environment. London: Tavistock. Downloaded by [New York University] at 12:48 14 August 2016 Winnicott, D. (1971) Playing and Reality. London: Penguin. Wordsworth, W. (1802/1954) Collected Poems. Oxford: Oxford University Press. Wordsworth, W. (1994) Ode on Intimations of Immortality in The Collected Poems of William Wordsworth. Hertfordshire: Wordsworth Editions. Wright, K. (1991) Vision and Separation. London: Free Association Books. Wright, K. (2010) Mirroring and Attunement: Self-realisation in Psychoanalysis and Art. London: Routledge. Yallom, I. (1989) Love’s Executioner and other Tales of Psychotherapy. London: Penguin.

191 REFERENCES

Yeats, W. B. (1972) He wishes for the cloths of heaven. Collected Poems. London: Mac- millan. Zeki, S. (2008) The Splendours and Miseries of the Brain: Love, Creativity and the Quest for Human Happiness. Chichester, UK: Wiley-Blackwell. Zukier, H. and Pepitone, A. (1984) Social roles and strategies in prediction: some determinants of the use of base rate prediction. J Pers Soc Psychol, 47, 342–356. Downloaded by [New York University] at 12:48 14 August 2016

192 INDEX

Abraham, K. 135, 137–8 model of 164; and narcissism 150–2, Abse, D., ‘X-Ray’ 176–7 158; and narrative 65–85; primary xiii, abuse, physical/sexual 74, 164 5, 8, 13; secure x, 53, 71, 72, 76, 108, action xiii, 5, 8, 11–12 127, 150, 166, 167; therapist’s style of action replay 47 83 active listening 18 attention, free ﬂoating 22, 30 adaptation 164, 166 attunement: cross-modal 53; maternal/ adolescence, narcissism in 153 parental 53–4, 70–1, 76, 152 Adult Attachment Interview (AAI) 71–2, Auden, W. H. 41, 42 167, 181 Aunt Julia and the Scriptwriter (Llosa) affect-balance 113 86–8 affect regulation 86, 126–7 Austen, J. 91, 100; Emma 92–8, 99, 100–1, afterwards-ness 47 106 agency 70 autism 11 aggression 78; and fear 112 autobiographical competence 18, 72, 127 Ainsworth, M. 71, 120 autonomy 18, 19, 100, 148 alertness, dynamic 22 availability of psychotherapy 100, 102–5 Allen, J. G. x avoidant attachment 71, 72, 73, 120, 121, ambiguity 37–9 123, 150, 151 ambivalent attachment 71, 73, 120, 121, awareness, unfocused 22 150, 151 analytic third 59, 60 Balint, M. 131, 146, 175 Ancient Mariner (Coleridge) 62 Barchester Towers (Trollope) 147 anorexia nervosa 151 Barker, P. 163 anxiety 111–14; protective function of 112 Baron-Cohen, S. 11 Armitage, S., ‘The Catch’ 171–3 Barratt, B. 3, 4, 8, 29, 31, 119 art in therapy 54, 60–2 Bartels, A. 182 artistic discovery: Heaney 20–4; Proust Barthes, R. 166 Downloaded by [New York University] at 12:48 14 August 2016 24–6 Bass, A. 47 assimilation 90, 105–6 Bateman, A. 13, 140 assonance 38 Bateson, G. 164 38 asymetrising 44 Baudelaire, C. 40 attachment x, xi, 7, 50–1, 58–9, 86, 88, beauty 144 128, 133, 181; ambivalent 71, 73, 120, Beck, A. 164 121, 150, 151; avoidant 71, 72, 73, 120, Beckett, S. 50 121, 123, 150, 151; disorganised 71, Beebe, B. x, 54 150, 151; insecure 71, 72, 73, 76, 120, Benoit, F. 72 150–2, 166, 167; internal working Bettleheim, B. 29, 180

193 INDEX

Bion, W. R. ix, 4, 12, 15, 18, 36, 50, 88, Conrad, J. 91, 98; Heart of Darkness 65 120, 163, 166, 175 conscious xi, 7, 39 bipolar self 148 containing object 100 Birkstead-Breen, D. 13, 19 contingency 70, 71 Blake, W. 37 countertransference xi, 11, 18, 48, 49, 104, Bloom, H. 22 107, 166 bodily functions 53 craft 23; poetic 20–1 Bohr, N. 166 Craik, K. 164 Bollas, C. 66, 79, 92, 107 creativity 20, 26, 91, 99 Borderline Personality Disorder 13, 51, 76, Crittenden, P. 71 147, 151 cybernetics 164 Bowlby, J. 123, 124–5, 163, 167; attachment theory 5, 71, 164, 166, 181; Daniel Deronda (Eliot) 5–8, 10, 11, 12, on splitting 120, 124 14 Boyhood and Youth (Tolstoy) 137–8 death 128, 140, 148 Breuer, J. 115 Dennett, D. x Brierley, M. 163 depressive position 59 British Medical Association (BMA) 162; description 19 Committee on Psychoanalysis 163 destructive narcissism 135, 149 Britton, R. ix, 4–5, 15, 56, 59, 135, 149, Dickens, C. 91 150 Dicks, H. 163 Brockmeier, J. 70, 76 Dimen, M. 4 Bronowski, J. 42 Dinner with my Mother (Williams) 44–5, Bruner, J. 69, 164, 166 46, 47, 48, 49, 50 Brunswick Square clinic 163 discovery 16, 18–19; scientiﬁc 19–20; ‘The building’ (Larkin) 179–80 see also artistic discovery discursiveness 28 Canham, H. ix, 10 disorganised attachment 71, 150, 151 Casement, P. 87 Disraeli, B., Sybil 99 ‘The Catch’ (Armitage) 171–3 dissonance 38 Catullus 37 ‘The Diviner’ (Heaney) 22–3 Cavell, M. xi, 32 Donne, J., ‘A valediction: forbidding change 86–8, 93–4 mourning’ 131–3 Charcot, J.-M. 115, 162 double bind hypothesis 38 Chasseguet-Smirgel, J. 102 Dozier, M. 149 children: inner speech acquisition 73–4; Dr. Jekyll and Mr. Hyde (Stevenson) narcissism in 135, 136, 147–9, 150, 115–19, 126 152–3; physical/sexual abuse of 74, 167; dream-interpretation 40, 60–1 theory of mind 74; see also infants dreams 124, 157 Chomsky, N. 40 drive theory 123 class 102–4 dynamic alertness 22 clinical imagination 4 clinical psychology 165 Eagleton, T. 49 Downloaded by [New York University] at 12:48 14 August 2016 Coan, J. A. 182 ‘East Coker’ (Eliot) 46 coexistence of opposites 37 Edelman, G. 168 Cognitive Behavioural Therapy (CBT) 182 ego 25, 53, 119; infant 146; splitting of cognitive revolution 164 124, 126 cognitive therapy 164 Eisenberg, L. 161 Coleridge, S. T. 4, 10, 13, 15, 20–1, 43; Eliot, G. 83, 91; Daniel Deronda 5–8, 10, Ancient Mariner 62; Frost at Midnight 9 11, 12, 14; Middlemarch 97, 107 compromise 39 Eliot, T. S. 4, 12, 34, 60, 165; ‘East Coker’ concomitance, theory of 162 46 ‘The connoisseuse of slugs’ (Olds) 177–8 Ellenberger, H. F. 115, 118

194 INDEX

Ellis, H. 134 119; The Interpretation of Dreams 4; emergent meaning 46 ‘Project’ 162 Emma (Austen) 92–8, 99, 100–1, 106 friendship 128 emotional poverty 101 Frost at Midnight (Coleridge) 9 emotional truth 69, 86 Frost, R. 23 empathy 8; and fear 113; parental 152 Fuller, P. xii Empson, W. 37 enactments 14, 60 Gabbard, G. xii, 22, 140 Enlightenment 15 gambling 52 envy 90, 100, 101, 102, 104, 105, 140 Gardner, H. 32 epistemic narcissism 149 Garland, C. 164 Erikson, E. 179 gendered self 125–6 Ernst, S. 101 genius 139 exploration 46 Gergely, G. 70, 71 exploration paradox x German Romanticism 3–4, 15 external–internal object 59 Glover, J. 163 Goodison, L. 101 failure, importance of 26–7 Graves, R. 163 Fairbairn, R. 123–5, 146 Green, A. 3 family therapy 164 Greenberg, J. R. 123, 165 fancy 9, 15, 21 grief 100, 128–33 fear 113; and aggression 112; and empathy Grimm, J. L. C. and Grimm, W. C. 112 113 Grosz, S. xii Feeney, B. x Grotstein, J. 12 female narcissism 138, 141 Guntrip, H. 163 female principle 119 Gurevich, H. 3 Fenichel, O. 53 Ferro, A. 4, 15 Hallam, A. 129 ﬁctions xii Hamilton, V. 129, 148–9 Fisler, R. 82 Harman, C. 115, 117 Fliess, W. 115 Harris, A. 47 Fonagy, P. 13, 68, 72, 74, 76, 167, 171, Hart, B. 162 181 hate 100 Forster, E. M. xiii, 101; A Passage to India Havens, L. 4, 10 94; Howard’s End 168–9 Hazlitt, W. 41 Foulks, W. H. 163 healing 41 free association xi, 4, 30, 74 Heaney, S. 20–4, 26–7, 128; ‘The Diviner’ free ﬂoating attention 22, 30 22–3; ‘Personal Helicon’ 145–6 Freud, A. 163 Heard, B. 128 Freud, S. ix, xi, 4, 8, 25, 28, 29, 34, 43, 47, Heart of Darkness (Conrad) 65 91, 99, 100, 105, 106, 115, 162; on Heath, I. 10 afterwards-ness 47; on conscious/ Herbert, G. 31 unconscious 7, 37; on Herman, J. 167 Downloaded by [New York University] at 12:48 14 August 2016 countertransference 104; on free hermeneutic school of psychoanalysis 70 association 30; on love 143; on Hinshelwood, R. 162 narcissism 135, 136, 138, 139, 144, Hirsch, S. R. 164 146–7, 158; on over-determination 32, Hobson, P. 74 40; on pleasure 123; on primary and Hobson, R. 47 secondary process thinking 39, 73, 165; Hoffman, I. 29, 92 on psychic energy 19; ‘Rat Man’ 31; on Holmes, J. 10, 14, 18, 34, 37, 40, 41, 51, splitting 119–20; on switch words 113; 70, 71, 72, 78, 83, 100, 103, 181, 182 on symbolisation 52–3; tripartite model Holmes, R. 4, 115, 116 of the mind 53, 119; The Ego and the Id Holub, M., ‘Pathology’ 178–9

195 INDEX

homosexuality 134, 147 Klein, M. 100, 120, 123, 146, 163 Hopkins, G. 58 Kleinian thought 50–1, 59, 135 Horowitz, H. W. 176 Knox, J. 11, 18 Housman, A. E. 37 Kohon, G. 18, 93 Howard, G. 66 Kohut, H. 34, 59, 135–6, 139, 147, 148, Howard’s End (Forster) 168–9 153, 156 Hughes, T. 31 Kriegman, D. 167 Hughlings-Jackson, J. 162 Hunt, J. 46 Lacan, J. 58, 105 hypervigilant narcissism 140, 151, 155, 157 Lake, D. 128 hypochondria 135, 147 Langer, S. 28, 43 hypothetico-deductive system 19–20 Langs, R. 104 language 19; shared 27 id 53, 119 Laplanche, J. 33 idealising transference 156 Larkin, P., ‘The building’ 179–80 identiﬁcation 8, 76, 179–80; projective Lasch, C. 135 143, 174 Lawrence, D. H. 58, 91–2 imagination 3–4, 166; clinical 4; poetic 4; Leach, E. 112 sympathic 41; see also therapeutic ‘leaning off’ 23 imagination Lear, J. 10, 13, 19 imaginative competence 34 Leavis, F. R. 90–1, 98, 99 In Memoriam (Tennyson) 128, 129, 130–1 Leff, J. P. 164 individualism 91 Leiman, M. 74 inequality 90, 91, 106 Lessing, D. 45 infants: attachment patterns 70–1, 72–3, Levinas, E. 8 76, 85, 120, 150, 166, 167; ego 146; Lewis, A. 163 narcissism 135, 146, 148–9, 150; see libidinal narcissism 135 also maternal attunement; maternal libido 135, 146, 147 mirroring; mother–infant relationship limitlessness 39 inner speech 73–4 Lindley, 37, 70, 100, 103 insecure attachment 71, 72, 73, 76, 120, listening, active 18 150–2, 166, 167 literary criticism 90–1 insecure–dismissive narratives 71, 72 Llosa, M., Aunt Julia and the Scriptwriter insecure–preoccupied narratives 71, 72 86–8 insight 18, 19 logos 5, 7, 10–11, 13–14 interconnectedness 39 loss 47, 51, 52–62, 100, 128–33 interpretations 39; of dreams 40, 60–1 love: of another 143, 144; narcissistic see intimacy 78, 100, 128 narcissism Intimations of Immortality (Wordsworth) Lowell, R., Waking the Blue 29–32, 33–4, 5, 54–8 35, 38, 39 irony 106–7 Luborsky, L. 78 Isaacs, S. 163 Lycidas (Milton) 128, 129–30 Lyons-Ruth, K. 49 Downloaded by [New York University] at 12:48 14 August 2016 James, H. 91 Jones, E. 163 Main, M. 71, 72, 78, 121, 181 Jones, M. 163 Main, T. 163 Jung, C. G. 4, 124, 154 Malan, D. 18 Marcus, S. 41 Kant, I. 4, 162 masturbation 52, 138 Keats, J. 4, 38, 80, 166; To a Nightingale 9 material deprivation 101–2, 107 Kekule, A. 166 maternal attunement 53–4, 70–1, 76 Kernberg, O. 135, 136, 149, 156, 157 maternal mirroring 53–4, 70–1, 72, 85, 150 Kidnapped (Stevenson) 116, 118 Matte-Blanco, I. 39, 43

196 INDEX

Maudsley Hospital 163 narcissistic personality disorder 136, 147 McGilchrist, I. 15, 170 narcissistic rage 139 McLuhan, M. 49 narcissistic vulnerability 139 meaning 29, 31, 48, 58, 59; emergent 46; narcissistic wounds 136, 139 making 86, 88 Narcissus myth 140–2, 150–1 Meares, R. 22, 73 narrative 166–7; and attachment 65–85; Medawar, P. 19–20, 37 competence 72; deconstruction medical science 99–100 dismissive 78–9; insecure–dismissive Meins, E. 43, 72 71, 72; insecure–preoccupied 71, 72; memories 24–5; changing the narrative science of 69–70; secure–autonomous context of 79–80; nodal 78–9; normal 71–2; style 71–2, 73, 83, 85; as a 82; traumatic 82 therapeutic technique 76–8; thread mentalising 11, 41, 43, 45–6, 47, 48, 50, 80–1; trauma 82, 83–4, 112; unresolved 51, 72, 107, 108, 135 71, 72 metaphor 25–6, 27, 32–7, 43–4 negative capability 4, 22, 30, 59, 80, 166 Middlemarch (Eliot) 97, 107 neural darwinism 168 Miller, G. A. 164 non-attachment 83–4 Milton, J., Lycidas 128, 129–30 non-discursiveness 28–42 miming of therapy 21, 27 Northﬁeld Experiments 163 mind-mindedness 43, 72 mind/brain problem 165 object-love 143 mirror transference 156 object relations 135, 146, 147 mirroring: maternal/parental 53–4, 70–1, object relations theory 123, 165 85, 150; and narcissism 158 objectiﬁcation 50–1, 77 Mitchell, S. A. 123, 165 oblivious narcissism 140, 151–2, 155, 156, Mollon, P. 138, 139 157 moral challenge 174–5 ‘Oedipal’ child 167 Morris, W. 91 Ogden, C. 30 Morrison, A. 148, 149 Ogden, T. 4, 10, 15, 22, 33, 47–8, 51, 59 mother–infant relationship 8, 49, 72–3, Olds, S., ‘The connoisseuse of slugs’ 123, 146, 165; see also maternal 177–8 attunement; maternal mirroring; primary Orange, D. 8 attachment outsight 90, 104–5 mourning 100, 131–3 over-determination 32, 40 Myers, F. 162 Ovid, Narcissus myth 140–2 Owen Lee, M. 113 Nacke, W. 134 narcissism 59, 134–58; in adolescence Palazzoli, M. S. 38 153; attachment approaches to 150–2, paradox 38 158; in children 136, 147–9, 152–3; paranoia 135 clinical manifestations of 136–40; paranoid-schizoid position 59 collective or group 135; destructive 135, parent–infant/child interaction 8; see also 149; emergence and metamorphoses of attunement; infants; mirroring; mother– Downloaded by [New York University] at 12:48 14 August 2016 152–4; epistemic 149; female 138, 141; infant relationship; parental healthy 135, 136, 147–9, 152, 153; responsiveness hypervigilant 140, 151, 155, 157; parental narcissism 136 libidinal 135; literary examples of parental responsiveness 72–3, 152 140–6; negative 137, 138; oblivious Parker, G. 123 140, 151–2, 155, 156, 157; pathological Parker, K. K. 72 147, 149–50; primary 135, 146–7; Parsons, T. 90 psychotherapeutic treatment of 154–8; Pascal, B. 98 secondary 136, 146–7; theories 146–54; A Passage to India (Forster) 94 thick- and thin-skinned 140, 157 paternal principle 148

197 INDEX

patient autonomy 18, 19 Rieff, P. 91, 92 Payne, S. 163 Rivers, W. H. 163 Pedder, J. 18, 32 Romantic movement 3–4, 15, 91, 162 Pepitone, A. 166 Rosenblatt, B. 164 ‘Personal Helicon’ (Heaney) 145–6 Rosenfeld, H. 135, 140, 156–7 philosophical dualism 162 Rotenberg, C. 5 Pickett, K. 99 Roth, A. 171 The Picture of Dorian Gray (Wilde) 144–6 Roustang, F. 104 Pines, M. 162, 163 Rusbridger, R. xii Plato, The Sophist 9 Russian dolls example 61–2 play/playfulness 18, 46; solitary 73 Rustin, M. 4 pleasure 123 Rycroft, C. 4, 28, 34, 42, 134–5, 165 pluralism 106 poetic imagination 4 sadomasochistic phantasies 138 poetic reality 33–4 Sandler, J. 164 poetic third 59, 60 Sassoon, S. 163 Pontalis, J.-B. 33 Satyamurti, C. 10 Pope, A. 37–8 Schafer, R. 70 Popper, K. 37 Schelling, F. W. J. 4 Post Traumatic Stress Disorder (PTSD) schizophrenia 135, 147, 164 164 science 98, 99–100; of narrative 69–70 poverty 100–2, 107; emotional 101 scientific discovery 19–20 primary attachment 5, 8, 13 Scoop (Waugh) 89 primary process thinking 39, 73, 165 secondary process thinking 73, 165 projective identification 143, 174 secure attachment 53, 71, 72, 76, 108, 127, Proust, M. 24–6, 94 150, 166, 167 psychic energy 119, 162 secure–autonomous narratives 71–2 psychic reality 33 Segal, H. 43, 51 psychosis 147 self 70; autobiographical 70; bipolar 148; psychotherapy–psychiatry debate 161–70 gendered 125–6; self-reflexive 77; sense of 53–4 quest stories 112 self-centredness 134, 135 Quinodoz, J.-M. 47 self-esteem 134, 136, 152 self-narrative 73 rage, narcissistic 139 self-object 59, 148 ‘Rat Man’ 31 self-psychology school 135–6 reaction formation 37 self-referentiality 49–50 real relationship 8 self-reflexive self 77 reality 20; poetic 33–4; psychic 33 self-soothing 76, 146 reality principle 53, 119 selfishness 135 reconciliation 39 separateness 148 recursiveness 46–7 separation 50, 71, 144 reflection 5, 8, 12, 14 sexual abuse 74, 164, 167 Downloaded by [New York University] at 12:48 14 August 2016 reflexive self-function (RSF) 72, 76 sexual metaphors 25 Reik, T. 30 sexual phantasies 138 religion, decline of 162 sexuality 123 repair 43–51 Shakespeare, W.: A Midsummer Nights’s repression 119, 120 Dream 3; Sonnet 62 142–4; Sonnet 111 responsiveness, parental 72–3, 152 7 reverie 4, 5, 7, 9–10, 13–14, 22, 47–8 shame 138–9 Rey, H. 116 Sharp, E. 163 Richards, I. A. 30 Sharpe, E. 4, 31 Ricoeur, P. 12, 33 Shedler, J. 70

198 INDEX

shell-shock 162–3 timelessness 39, 40 sib-ship 128 To a Nightingale (Keats) 9 Siegfried (Wagner) 111–14 Tolstoy, L., Boyhood and Youth 137–8 silence 18 tragic irony 106–7 Skynner, R. 167 transference 18, 19, 21, 23, 25, 26, 32–7, Slade, A. 51, 72, 181 49, 126; idealising 156; mirror 156; Slavin, M. 167 second-order 27; ‘twinship’ 156 Snow, C. P. 90, 98–9 transferential experience 19, 27 social role of psychotherapy 100, 102–5 transferential mode 32 Society of Psychical Research 162 transformation image 107–8 Sohn, L. 149 transitional object 59, 91 solitary play 73 trauma narrative 82, 83–4, 112 somato-sensory experience 47–8 traumatic memories 82 The Sophist (Plato) 9 Treasure Island (Stevenson) 116, 118–19 space: for mentalising 45–6; in therapy Trilling, L. 34 17–18 tripartite model of the mind (Freud) 53, Spence, D. 70 119 splitting 115–27 Trollope, A., Barchester Towers 147 Stern, D. 48, 53–4, 123, 146, 165 truth 69, 86, 99; emotional 69, 86; Stevenson, R. 124; Dr. Jekyll and Mr. narrative 70; objective or ‘historical’ 70 Hyde 115–19, 126; Kidnapped 116, 118; Turner, J. 4, 91, 102 Treasure Island 116, 118–19 ‘twinship’ transference 156 ‘story stem’ research 181 ‘two cultures’ debate 90, 98–100, 168, 170 strange situation studies 71, 72 Strathearn, L. 182 unconscious xi, 7, 37, 38, 39, 52, 53, 66, structure in therapy 17, 18 119, 158, 181 sublimation 39, 53 unfocused awareness 22 suicide rescue 5 unresolved narratives 71, 72 Suomi, S. 112, 168 superego 53, 119 ‘A valediction: forbidding mourning’ Sutherland, J. 120, 123, 163 (Donne) 131–3 switch words 113 valency 36 Sybil (Disraeli) 99 Van de Kolk, B. 82 symbolisation 52–3 Vaughan, C. 164 Symington, N. 101, 146 verisimilitude 69, 70 symmetrising 44 Vico 34 sympathetic imagination 41 Vygotsky, L. 73 systems thinking 164 Waddell, M. 4, 5, 83 Tavistock Clinic 163 Wagner, R., Siegfried 111–14 technique 21, 23 Waking the Blue (Lowell) 29–32, 33–4, Tennyson, A. 128–9; In Memoriam 128, 35, 38, 39 129, 130–1 watermarking 22–3 Downloaded by [New York University] at 12:48 14 August 2016 theory 34 Waters, H. S. and Waters, E. 181 theory of mind 74 Watson, J. 70, 71 therapeutic alliance 8 Watson, P. 4 therapeutic imagination 4–12; Waugh, E., Scoop 89 impediments to 12–15; in non- Weir, H. 4 psychotherapeutic settings 14–15 Weiss, R. 128 therapists: attachment style 83; Westen, D. 70 developmental tasks 175; narrative style wholeness 39–41 83 Wilde, O. 135, 154; The Picture of Dorian Thompson, E. P. 17 Gray 144–6

199 INDEX

Wilkinson, R. 99 Wordsworth, W. 16, 37, 47, 59, 60; Williams, H.: Dinner with my Mother Intimations of Immortality 5, 54–8 44–5, 46, 47, 48, 49, 50 working alliance 8 Williams, M. 83 Williams, R. 98, 99, 105, 106, 108 Yeats, W. B. 21, 119–20, 156 Williams, T. 8 Winnicott, D. 4, 10, 15, 23–4, 34, 84, 91, Zeki, S. 48, 182 113, 148, 165, 166, 167, 175; on Zukier, H. 166 maternal mirroring 70; on play 18, 73; Zweig, S. 52, 54 on transitional objects 59 Downloaded by [New York University] at 12:48 14 August 2016

200