Psychoanalytic Thinking in Occupational Therapy

Symbolic, Relational and Transformative

Lindsey Nicholls, Julie Cunningham-Piergrossi, Carolina de Sena-Gibertoni, Margaret Daniel

• Publisher: Wiley-Blackwell
• Year: 2012
• ISBN:
  9781118511848
• Edition: 1
• Topic: Medicina
• Subtopic: Terapia ocupacional

Divided into three overarching themes, theory, application and research, this cutting edge book explores the influence of psychoanalytic theories on occupational therapy practice and thinking. It incorporates a new conceptual model (the MOVI) to guide practice, which uses psychoanalysis as a theoretical foundation for understanding therapeutic relationships and the 'doing' that takes place in clinical practice.

Using practice models and incorporating many clinically applied examples in different occupational therapy settings, this introductory text to psychoanalytic theory will appeal to students and practising clinical and academic occupational therapists worldwide and from different fields of practice from paediatrics and physical disability to older adult care and mental health.

• The first book in fifty years to concentrate entirely on a psychoanalytic approach to occupational therapy
• Distills cutting edge theory into clinically relevant guidance
• Features clinical examples throughout, showing the links between psychoanalytic theory and occupational therapy practice
• Written by an experienced international team of authors

1

Introduction

Lindsey Nicholls, Julie Cunningham Piergrossi, Margaret Daniel and Carolina de Sena Gibertoni

There is a saying for people who plan to undertake the long-distance walking route known as the ‘Way of St James’: it states that the Camino de Santiago¹ begins when you first think of it. That is how the book began; we began to think of it. Since 2006 we have exchanged our thoughts in emails and initial writings, and used a process of peer editing to learn from each other and produce this book. We have found ways to meet in person and listen to each other's presentations (at Brunel University Master Class events and international conferences in 2009, 2010 and 2011), and this had led to our connecting with many other occupational therapists who have been using (i.e. thinking and working with) psychoanalysis as a theory and method within their clinical practice.

It has been a rich and rewarding time where each of the authors, at different times and/or in relation to certain specialist topics, has taken the lead. Although we come from diverse professional and personal backgrounds, we share a conviction in the importance of using psychoanalytic theory in occupational therapy. In this we have been good companions and learnt much from each other's clinical work and theoretical discussions. This book is a result of our collaborative desire to make this work available to scholars and clinical therapists, to form a wider ‘community of practice’ (Wenger, 1998), where new projects, clinical discussions and writing can emerge.

At its heart the book discusses the work that we have practised, learnt, thought about and carry within as we engage with clients, students and colleagues. Our hope is that the book will provide a basis for serious study by therapists who are interested in psychoanalytic theory and may have begun their own journey into the internal landscape of the emotional understanding of people and what they ‘do’.

There are 13 chapters in all (including this one) and the book has been divided into three overarching themes; theory, application and research. The first section takes the classic psychoanalytic theories (e.g. Freud, Klein, Bion, Winnicott and Bowlby) and considers their influence on occupational therapy practice and thinking. The second section is devoted to an explanation of a psychoanalytic occupational therapy model (MOVI) and this is followed with further discussions of psychoanalysis in clinical occupational therapy practice. The final section describes research methods and projects that have incorporated psychoanalytic thinking in occupational therapy.

Each chapter could be read as an extended case study but we hope there is sufficient cross-reference between the different contributions to make for a coherent whole. In many ways it has been hard to choose the order of work for the linear structure that the book offered. The core of the book lies in understanding MOVI (Chapter 7), an occupational therapy model, and we would suggest that readers develop a duel vision where MOVI can be held in mind as they refer to the earlier chapters on Freud, Klein and Bion (Chapter 3), Bowlby (Chapter 5) and the therapeutic use of self (Chapter 2).

There are certain terms in current occupational therapy literature which have gained professional ascendance – for example, using the term ‘client’ rather than ‘patient’, and ‘occupation’ not ‘activity’ – which we have decided to use interchangeably. This is not a form of political rebellion against the discussions on client-centred practice or the value of understanding occupation, but belongs to the eclectic theoretical background we have used to develop an integration of psychoanalytic thinking in occupational therapy.

We are very grateful for the encouragement that Katrina Hulme-Cross, Rupert Cousens and Sara Crowley-Vigneau, the health sciences commissioning editors at Wiley-Blackwell, have given us during this time. Without their active support we might still have been thinking about writing the book and not have completed it!

Finding our Way

In this section, each author introduces themselves to the reader, saying how it was that they began establishing a link between psychoanalysis and occupational therapy. We hope these brief introductions will provide an illustration of our individual (even idiosyncratic) and shared interests in using psychoanalytic thinking in our work as occupational therapists.

---

Lindsey Nicholls

In 2002, after my rather clumsy presentation at a mental health conference on the use of dreams in clinical work, I was generously invited by Jennifer Creek to contribute a chapter on my work for her forthcoming book, Contemporary Issues in Occupational Therapy (Creek and Lawson-Porter, 2007). It was a professional lifeline for me as I had recently moved to the UK from South Africa and found myself floundering in a discourse full of positive affirmations and seemingly (only) conscious intensions. Any consideration of the unconscious aspects of clients and professionals had been subsumed by an emphasis on partnership working and recovery. I attempted to give voice to my concerns about this loss of thoughtfulness about the unconscious:

I have had an interest in and involvement with a psychoanalytic view of occupational therapy for so much of my professional life that I can no longer see clearly without these conceptual lenses.² It has been a concern to me that over the past 40 years a psychoanalytic discourse in occupational therapy has almost completely disappeared from our professional literature, except for a few voices (Banks and Blair, 1997; Cole, 1998; Collins, 2004; Daniel and Blair, 2002a; 2002b; Creek, 1997; Hagedorn, 1992), and it has been my wish to persuade occupational therapists to consider (or reconsider) what psychoanalysis can offer us in our endeavour to alleviate the suffering of our clients and support their sense of purpose in day to day life.

(Nicholls, 2007, p. 58)

When I wrote this entreaty to the profession, much admiring and quoting Margaret Daniel's work, I didn't know we would meet, that she worked as a clinical specialist psychodynamic occupational therapist in Glasgow and that we would become friends. I didn't known that Julie Cunningham Piergrossi and Carolina de Sena Gibertoni were working in Milan, Italy, using an ‘occupational play space’ in which children and adolescents could discover aspects of themselves through their choice of objects and activity in the containing presence of a psychoanalytic occupational therapist.

Then a wonderful synchronistic event took place. In 2006 I was the first speaker in a group of four papers at the World Federation of Occupational Therapy (WFOT) in Sydney, Australia. My paper used the layered story from the book Life of Pi (Martel, 2003) as an illustration of the concerns I had with some of the concepts in ‘client-centred practice’: that it can ignore unconscious motives, ambivalent emotions and contradictory behaviour (see Chapter 2). The paper seemed to go well and when I sat down a woman moved to the seat next to me, clasped my wrist and asked me where I was going. I was a little alarmed at the strength of her grip and told her I would be staying until the end of the session. ‘Good,’ she said. ‘I didn't want you to disappear.’ It was Julie and she gave the last talk in the group of four papers.

Julie's presentation described the response postgraduate students had to learning about the MOVI model (see Chapter 11). MOVI incorporates an understanding of the conscious and unconscious choices, actions and words of patients within the containing environment of a ‘play space’; a room full of activity choices and a therapist. While hearing about their work in Italy, delivered in Julie's eloquent, measured voice, I began to cry. This work took into account the conscious and unconscious aspects of the client and therapist, through the communication involved in ‘doing’ something together. MOVI captured a way of thinking and working that was an alternative to the highly contested ground taken by other practice models (e.g. the MOHO, KAWA and CMOP). But in truth, my tearful response to her talk was because I no longer felt alone.

It was through Julie that I met her colleague and collaborator, the Italian author Carolina de Sena Gibertoni, and this completed the initial learning group. Carolina's knowledge and application of core psychoanalytic theory in occupational therapy has been important in locating the book in the classic psychoanalytic texts. I have valued what each author has contributed in their understanding of theory as lived through the experience of working with clients and activities in the intimate relational space of emotions.

Perhaps I can end my introduction with where I began: by paying attention to the unconscious. It has been in my personal analysis that I have found an inner coherence and capacity for creativity. My experience of psychoanalytic psychotherapy has given me a deep belief in the efficacy of this approach to working with others.

I have never doubted the existence of the unconscious; in fact it was quite a relief when I realised during my first experience of an analysis, at the age of 23, that my dreams, thoughts and feelings were a language that I had not yet learnt to understand, but that were available to me as a guide to my internal life. Perhaps it is this investment in one's own internal life that is the most daunting and fulfilling in working within a psychoanalytic framework with clients. Bion (1991), an analyst who is considered a prodigious and original thinker, wrote in his autobiography that having recognised his most primitive self, capable of almost any heinous crime, he could better understand his clients and their struggles.

(Nicholls, 2010, p. 32)

---

---

Julie Cunningham Piergrossi

The event that started out the adventure of this book for me was my meeting up with Lindsey Nicholls (already described by her) in 2006 at the World Congress in Sydney. By pure chance we were presenting our papers in the same session and she spoke before I did. I remember listening to her psychoanalytic discourse and being both astounded and delighted at how it fitted together with my own thoughts. At the same time she was opening my mind to new ideas and I remember running up to her immediately afterwards and asking her not to leave until I had spoken, that I needed to talk to her. I was afraid she would be lost in the more than 2000 therapists present and that I would never find her again. In the general discussion following my talk she asked me two pertinent and thought-provoking questions which are always such a gift in a situation like that. Later we began to talk together and we haven't stopped since.

My interest in psychoanalysis began when I studied occupational therapy in the USA back in the 1960s and has never wavered since, even though my profession has changed immensely in the intervening years.

When I arrived in Italy in 1969 I became part of a group of psychoanalysts called ‘Il Ruolo Terapeutico’, with whom I began my training which is still ongoing. My case presentations, in supervision together with colleagues who are psychoanalysts, have always aroused curiosity in some and consternation in others. It was difficult when I heard people I respected tell me that the presence of the activities and the materials during the therapy sessions could be an impediment to the therapeutic process. In 40 years of working together things have changed as I have learned to put words to my ‘doing’ and my colleagues have accepted the fact that baking a cake can have psychoanalytic potential.

‘Ruolo Terapeutico’ was instrumental in making clear for me the importance of the structure of the therapy as a container for the process, a concept which led to the understanding of choice as part of the setting (the structure) of the occupational therapy experience using the Vivaio Model (MOVI).

I am especially grateful to Sandro Bonomo for his continual support of my work. It was Sandro who helped me to really understand the emotions around choices, especially concerning the complex aspects of unpredictability and its therapeutic value. My psychotherapist colleague, Elisabeth de Verdiere, was another strong supporter of occupational therapy with a psychoanalytic theory base and helped Carolina and myself in the founding of ‘Il Vivaio’ and in developing and carrying out the training programme for MOVI. The constant exchange with Carolina during the development of our model is a natural part of my existence, and much of my learning has come from her. Supervision, written contributions to a professional psychoanalytic journal, reading groups, seminars and my own personal psychoanalysis have helped me on my way, and of course my best teachers have always been the children and their families who came to me for help.

I can never think about myself as psychoanalytically trained without thinking first about myself as an occupational therapist. I think I have been an occupational therapist from when I was a child playing with my grandmother's box of odds and ends. I have always loved ‘doing’: cooking, sewing, woodworking and just making and fixing things. Being able to use ‘doing’ (which has always been therapeutic for myself) for helping others has been a privilege and a huge stroke of luck in enabling me to have a job I love. Because occupational therapy did not exist when I arrived in Italy, part of my time has always been dedicated to developing and teaching the basic profession. I have always strongly stressed the importance of keeping occupations in occupational therapy.

As an American living and working in Italy I have had the privilege of knowing two cultures well. The Italian influence on my life and work has been enormous, and living in a country wit...