Learning from the Patient ~:» ~:» PATRICK CASEMENT Foreword by Robert S. Wallerstein, M.D THE GUILFGRD PRESS New York London © Copyright 1985, 1990, 1991 by Patrick Casement by arrangement with Mark Paterson Published by The Cuilford Press A Division of Guilford Publicat;ions, Inc. 72 Spring Street, New York, N. Y. 10()12 All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, phot;ocopying, microlilming, recording, or otherwise, without written permission from the Publisher Printed in the United States of America This book is printed on acid-free paper Last digit is print number: 9 8 7 6 5 4 3 Library of Congress Cataloging-in-Publication Data Casement, Patrick. [()n learning from the pat;ient] Learning. cm. from the patient / Patrickj. Casement. lieprint (lst work). Criginally published: On learning from the patient. London; New York: Tavistock Publications, 1985 Reprint (2nd work). Originally published: Further learning from the pat;ient. London; New York: Routledge, 1990. Includes bibliographic references. Includes index. ISBN 0-89862-559-9 -ISBN 0-89862-157-7 (pbk.) 1. Psychotherapist and patient. 2. Psychoanalysis. 3. Psychotherapy. I. Casement, Patrick. Further learning from the patient. II. '1`itle. [l)NLM: 1. Physician-Patient Relat;ions. 2. Psychotherapy. WM 420 C33'75o] RC480.8.C38 1991 616.89'14-dc20 forDN LM/ Library DLC of Congress 90-14210 CIP To the many who have helped me to leafrn 'UZZZ LEARNING FROM YYJE PATIENT PART TWO: The Analytic Space and Process Introduction 187 11 Beyond Dogma 189 12 Interpretation: Fresh Insight or Cliché? 201 13 A Child Leads the Way 214 14 Countertransference and Interpretation 248 15 The Experience of Trauma in the Transference 258 16 The Meeting of Needs in Psychoanalysis 273 17 Unconscious Hope 293 18 Inner and Outer Realities 308 19 Trial Identification and Technique 319 20 The Analytic Space and Process 339 APPENDIX I: 357 Knowing and Not-Knowing: Winnicott and Bion APPENDIX II: 359 The Issues of Confidentiality and of Exposure by the Therapist Notes 361 References 373 Index 379 +$*+I+ Pre ace This volume combines my two books on the theme of its title, On Leafrningfrom the Patient (Tavistock 1985) (Part One) and Fufrthefr Learning from the Patient (Routledge 1990) (Part Two). In Part ()ne I examine the first principles of psychoanalytic practice as I see it, in terms of learning from the patient in the course of the analytic session. Indispensable to this is the technique of internal supervision by means of which analysts can monitor the interaction between themselves and their patients, and their im­ pact upon the analytic process. In Part Two I go further in explor­ ing the nature of the analytic process, and I illustrate the kind of results that can emerge when we follow it. I also suggest ways in which- we can help to preserve the analytic space from influences that can interfere with that process. Following the patient’s lead has always been an important prin­ ciple of psychoanalysis and analytic psychotherapy. But, in prac­ tice, there has been a tendency for some analysts to become inappropriately controlling through being dogmatic, which inter­ feres with the analytic process. Learning to learn from the patient provides a balance against this, helping to preserve the analytic space more clearly for the processes within it. I have come to regard the nature of the repressed unconscious as sometimes surprisingly positive and creative; even pathology may be seen as an indication of unconscious hope. What has been repressed is not necessarily dangerous, except in so far as it is thought to be so. There may be some inherent destructiveness in the primary unconscious, but I believe that we should not overlook our patients’ positive search for what they need, so often indicated by the unconscious prompts and cues they give to the analyst. ix x LEARNING FROM THE PATIENT I have become increasingly aware of the ways in which patients unwittingly seek out the help and experience they need for recovery and health. The manner of this unconscious search defies common sense but it can involve analysts in a process which represents what the patient is just becoming capable of facing in the analysis. The past, as it was, is reexperienced in the present but with a difference: the analyst neither collapsing nor retaliating, as past objects often had. For the analyst to be guided by the patient’s unconscious search, in this process, is not to be unjustifiably controlled by the patient: it is to be aided by the unconscious processes that interact within the analytic relationship. August 1990 PATRICK CASEMENT London °$'*I* Foreword There is by now a very respectable body of literature about both psychoanalysis and the varieties of psychoanalytic psychotherapies as treatment modalities, that is, as techniques for ameliorating mental and emotional disorders-enough so that one needs to look at new offerings in this category from the viewpoint of how they relate to the existing corpus and what novel or altered perspectives they bring to the subject. It is also true, however, that by and large the books in this area are theory driven; that is, they elaborate a theory of technique from within the larger framework of an overall general psychoanalytic theory of the mind, of its development, and of its normal and abnormal functioning. The theory of technique is then the derivative conceptual structure that guides the effort to restore mental functioning in desired directions in accord with the requirements for mental balance determined by that theory. Given this approach to the organization of most of our literature on psychoanalysis as therapy, it should be no surprise that this literature is almost entirely framed within the traditional kinds of one-body psychology to which, in erecting their understandings of the human mind, our various theoretical perspectives in psycho­ analysis are naturally disposed to a considerable extent (though Some will feel this to be an arguable assumption). This is true even when those theoretical perspectives are avowedly object-relational or interpersonal in their conceptions of the driving motivational forces in human personal and interpersonal functioning. It is just this fact that has always underpinned the uneasy dialectical tension between theory (theory in general, and its derivative theory of Uichnique in particular) and actual technique, that is the actual clinical operations in the consulting rooms with their “natural” xi xii LEARNING FROM THE PAYYENT two-body interactional language. Patrick Casement is not the first to call attention to this dialectic with his observation that, to the practicing clinician absorbed in the transference and countertrans­ ference interactions in the consulting room, the existence-in the background-of an explanatory theoretical structure serves often primarily as a shield against bewilderment and anxiety, rather than as a true guide to and determinant of our actual clinical operations. The link between theory qua theory and technique qua technique isjust too elastic and loosejointed. Perhaps out of fear of falling into the opposite difficulty in writing books on treatment, the risk of producing a reductive caricature of the complex psychoanalytic treatment process-a stereotyped “cookbook” akin to the listing of typical dream sym­ bols in pop psychology dream interpretation books-most psycho­ analytic authors have avoided writing about the nature of treat­ ment and the treatment process from the clinical phenomenal base of therapeutic interactions, building up to clinical theory, and even to overarching general theory, within which these phenomena can be convincingly enough and comprehensively enough ordered. Freud, who through his long and prolific career wrote so little about actual issues of clinical technique and treatment, had in fact warned against the difficulties of this task in 1913: “Anyone who hopes to learn the noble game of chess from books will soon discover that only the openings and end-games of an exhaustive systematic presentation and that the infinite variety of moves which develop after opening defy any such description. This gap in instructions can only be filled by a diligent study of games fought out by masters. The rules which can be laid down for the practice of psycho-analytic treatment are subject to similar limitations.” It is this daunting challenge which Casement has so successfully taken up, without making any claim to being a “master,” since it is central to his approach that psychoanalytic therapy is a process of “interactive communication” to which analyst and patient both bring their characters propensities, forged within the crucibles of their own personal histories, which both experience in ways that seem plausible and persuasive in the light of their own character­ istic expectations and apprehensions (with those of the analyst hopefully more governed by the present and less by the past than in the case of the patient), and in which both (but again, hopefully, more the patient) pull for a “role responsiveness” that actualizes wished for and/ or feared role relationship patterns. Given all of this, no one’s perceptions can always be veridical, analysts do­ being human-make mistakes of both understanding and of inter­ Foreword xiii vention, and no analyst need claim to be a “master,” only an open and forthright enough searcher who is willing to, in accord with the book’s title, “learn