Attachment and New Beginnings

Reflections on Psychoanalytic Therapy

Jonathan Pedder, Gary Winship

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367106171
• eBook ISBN: 9780429911040
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This collection of written pieces plots the work of an NHS psychotherapist, Jonathan Pedder, turning the science of psychiatry into human encounters. He had a career teaching and inspiring colleagues and students with psychoanalytic ways of thinking, encouraging and supporting them in the challenges of contemporary psychiatry. In his work he made the world of psychoanalysis accessible to non-analysts, and this book augments the textbook on psychotherapy which Pedder wrote with Dennis Brown. Pedder was a quiet visionary influential in offering a pathway for mental health workers from many disciplines to find their way to the psychoanalytic ideas that illuminate their patients/clients.'- Professor R. D. Hinshelwood, Author of Clinical Klein and Dictionary of Kleinian Thought.

Commentary (GW)* on Chapter One: The role of space and location in psychotherapy, play, and theatre

The start of therapy is framed as an initial encounter that might be considered in terms of the drama of a theatrical performance. Pedder compares the moment of the curtain-raising in the theatre with the opening moments in a therapy session. Both are experiences which are characterized by anxiety and anticipation, some of which is unavoidable, and some of which is necessary to achieve a level of focus. As one observes the drama unfold in the plot of a play, so the process of therapy begins to move towards a deeper encounter with the patient’s internal world; the plot thickens, as they say. Pedder adopts a well-known quote from the New Testament; “through a glass, darkly” which is usually interpreted to mean that people have an imperfect perception of reality. The sentiments here are clear enough: that psychotherapy orientates a clearer grasp of reality for the client. But it is not in a cognitive or rational sense of orientating the client, rather, Pedder’s idea is that it is through pleasure and play that we learn about the world, as we did in childhood and then onwards. The suspension of reality in drama and creative enterprise is the frame from which the role of play in psychotherapy is conceptualized.

Winnicott’s (1971) ideas about potential space in Playing and Reality are mainstay here. There are resonances also of The Drama of Being a Child, by Alice Miller (1987), and Theatres of the Mind, by Joyce McDougall (1985). Pedder’s assertion is that the role of drama and play in therapy is essential to fostering a milieu where creativity can flourish. In this day and age, where therapy has become increasingly businesslike, for instance, in cognitive-behaviour therapy (CBT), we do well to remember that many of our clients have lost the capacity to play, or may not have learnt it in the first place. How many current professional trainings in the field of mental health these days prepare practitioners with the requisite resources to foster creative potential space and play with clients? Moments of joy, relaxation, and play are as crucial to therapeutic progress as thinking and rationalization. Whereas some therapies today tend to exert exacting clinical procedures with manualized and measurable interventions, with “homework” to be completed at certain times by patients, Pedder reminds us that the intention of therapy might be followed along a different path. There is something of the lively independent tradition in psychoanalysis that runs through the ideas here.

The challenge for the therapist is to permit a measured suspension of familiar formalities in order for the patient to unfold their imaginings, metaphors, and visualizations in the potential space of the therapy room—the “as-if-ness” of transferential encounter where previous patterns of relating can be brought alive in the here and now. The idea of a freed dramatic encounter gives light to the way in which Freud’s idea of free association can be applied. Pedder does not offer an account of how the physical environment should be established to create the most conducive conditions for interaction, that is to say, how the room should look, should there be artefacts, and so on. Although, there is no account of artistic material (paints, clay, etc.); instead, the space is presented as a mental space of creative encounter. Pedder is careful to deal with the situation where reality can collapse into unreality for some clients, in the case of psychosis, for instance, where the sense of as-if-ness might be lost. He offers several exemplars, from the child who loses a sense of reality about the pretend Peter Pan game with the crocodile, to an anecdote about seeing a play where the actors were in the audience, conflating the distance between audience and actor in a way which was unexpected and challenging. These experiences are used to demonstrate the way in which the margins between playing and reality can sometimes be fused. With further examples from literature and drama (Pirandello, Burnett, Carroll, Shakespeare), Pedder does not stoop to provide guidelines on how the therapist manages clinical situations; instead, he leaves the space for us to reflect on how we and our clients might experience, or have experienced, such situations ourselves.

There are several points of debate here: for instance, Pedder’s assertion that all art is illusion. Pedder’s point is, to be fair, rather about art appreciation than about how an artefact might vitalize or revitalize an experience in the viewer. Like Socrates, Pedder seems to suggest that there is, after all, nothing new, and this does seem rather to inhibit the notion that art can synthesize experiences into new realities. Notwithstanding these points of debate, the chapter offers an inspiring reclamation of a more fluid role for play in the process of therapy with clients. It is in the encounter of creative energies, where the medical model of the clinical surgical theatre is superseded by the dramatic theatre of the mind, that the client can experience new ways of being.

References

McDougall, J. (1985). Theatres of the Mind: Illusion and Truth on the Psychoanalytic Stage. New York: Basic Books.

Miller, A. (1987). The Drama of Being a Child: The Search for the True Self. London: Virago.

* The commentaries that precede each chapter have been written by the editor, Gary Winship.

CHAPTER ONE

The role of space and location in psychotherapy, play, and theatre

“When I was a child, I spake as a child, I understood as a child, I thought as a child: but when I became a man, I put away childish things. For now we see through a glass, darkly; but then face to face ...

(1 Corinthians 13:11, 12)

This paper explores common links between psychotherapy, play, and theatre, especially where they take place and what conditions are necessary to bring them to life, so that we can see through the glass less darkly. Trainee therapists beginning psychotherapy either individually or in a group ask, “Do we begin the session, or do we leave it to the patients and remain silent?; should we look at patients or avoid their gaze either in individual therapy or in a group when singled out for a communication at the beginning?” The question of technique here is, “What is the right level of tension needed to set psychotherapy going”.

Prominent among my various starting points was the work of Winnicott that developed out of his original paper, “transitional objects and transitional phenomena” (1953), leading to the series of studies assembled in his book Playing and Reality (Winnicott, 1971). A further starting point for me arose from reflecting on the increased skill needed by actors in the modern theatre when they are not sheltered or framed by the traditional proscenium arch, with its obvious parallel problem for the therapist when not sheltered by traditional medical frames of reference such as uniforms or institutions. This discussion of psychotherapy is initially tallied to what is variously known as dynamic, analytically orientated, interpretative, or insight-orientated psychotherapy. However, the concept of insight is fraught with difficulties, as pointed out by Aubrey Lewis (1934). Here, the older meaning he gives is relevant: “originally it meant internal sight, that is to say, seeing with the eyes of the mind, having inner vision and discernment”. Yet, how can we see into other people’s minds? As Hayman (1974) said, “Unlike the sciences—the humanities, history and many other disciplines—what we constantly discuss are things that we literally cannot see or visualize”. That is why some feel more comfortable with a presentation of repertory grids where an attempt is made to present a patient’s inner world in pictorial terms that we can all see and measure. As a surgical colleague once said, “Surgery is so satisfying because you can look and see if your diagnosis is right.”

The word “theatre” has intersecting origins—a place for looking—and so it came to be used in the “anatomy theatre” with its tiers for spectators and, hence, also in the “operating theatre”. Two assumptions are made about psychotherapy and theatre: in dynamic psychotherapy, the essential task of the therapist is to help his patient get in touch with those aspects of his inner psychic world which have hitherto been denied, suppressed, or disowned. The task of the theatrical director is to help his actors bring to life the creation of the inner psychic world of the dramatist, as it is revealed through his characters in the play. Until psychotherapy begins, the inner world of the patient may remain largely hidden and unconscious until it is brought to life in the play of psychotherapy. Until rehearsals of a play begin, the inner world of the dramatist remains hidden in the script and out of public consciousness until brought to life on stage. During rehearsals, the producer encourages his players to mine within themselves to discover feeling states which resonate with those intended by the author’s inner world; during psychotherapy the therapist’s task is to help the patient mine within his own inner world.

Both therapist and director must create and facilitate the conditions necessary for this to occur: another expression of Winnicott’s (1965) comes obviously to mind; the “facilitating environment”. The question to be pursued is: what is the “location” of psychotherapy and theatre and what are the best facilitating conditions to foster each? What sort of space do we need, in which something can be brought to life for us to see? Clearly, there is another overlap here, with the whole subject of children’s play, on which Winnicott (1971) has written so illuminatingly. “Play”, he writes, “is neither a matter of inner psychic reality nor a matter of external reality”; “if play is neither inside nor outside, where is it?” (ibid., p. 96). His answer is that it takes place in an interpsychic encounter, a “potential space between the individual and the environment, that which initially both joins and separates the baby and the mother” (ibid., p. 103). In other words, play is no longer a mere daydream or fantasy, nor yet real in the everyday sense, but something in-between: inner world imaginings brought to life in the space between the child and his environment.

Winnicott (1971) writes similarly of psychotherapy:

Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist. Psychotherapy has to do with two people playing together. The corollary of this is that where playing is not possible then the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play. [ibid., p. 38]

In other words, what has hitherto been more or less denied as inner fantasy is brought to life in the space between patient and therapist. It is suggested that in the theatre, too, the inner fantasy of the dramatist is brought to life in the potential space between the author and the audience, the space which the actors inhabit. Winnicott (1953) originally used “the terms ‘transitional objects’ and ‘transitional phenomena’ for designation of the intermediate area of experience, between the thumb and the teddy bear, between oral eroticism and the true object-relationship” that was imagined (mouth and mother). He repeatedly asked for the paradox of the transitional object to be respected. We must never ask, “did you conceive of this or was it presented to you from without?” (p. 12). We are in the field of illusion. “Gradual disillusionment” (p. 13) is one of the normal tasks of growing up in which a baby needs mother’s help. Normally healthy people must undergo the same process of disillusionment each morning on waking from a dream. I can remember the day I sadly realized as a child that the coals in the fire were not fiery castles with magic caves between, but mere coals. Yet the capacity to return to the enjoyment of such illusions is essential for the appreciation of all forms of art.

We know that the actors in a play are real people, yet we believe in them as the characters they portray. We suspend disbelief. We tolerate the paradox. Good theatre depends on it. If the actors cannot make us believe in the part they are playing, the drama does not work. On the other hand, when we have no means of checking on the reality of the actors (for example, in radio productions) we may be more than convinced, or even deluded, about the reality of the fiction. This happens in a mundane way when people send presents to the characters in a radio serial, such as The Archers (BBC Radio 4), or, more alarmingly, when people believed that the radio broadcast of H. G. Wells’ story War of the Worlds was for real. The same paradox is apparent in a child’s game. A child knows you are both Daddy and the crocodile chasing him (in Peter Pan, of course, the crocodile eats the bad Daddy, Captain Hook, of the dream and becomes both). But a small, two- or three-year-old may suddenly become overwhelmed by the reality of the play and fear being eaten, so real Daddy must re-emerge quickly. This again is a question of the right level of tension. As Winnicott (1971, p. 52) says, “playing is inherently exciting and precarious” but “the pleasurable element in playing carries with it the implication that the instinctual arousal is not excessive”.

Again, in formal psychotherapy, the paradox is needed. In analytic psychotherapy (individual or group), one sets up a relationship or working alliance (Greenson, 1965) between the therapist and the healthy adult part of the patient to investigate the way in which this relationship is distorted by the less mature child part of the patient; the distortion of the relationship we call transference, or the way in which our current perception of people in relationships is distorted by residues of feelings about important people in the past, and in particular parents. Pontalis (1974) refers to the “private theatre” of transference. Interpretative analytic psychotherapy can only work when the patient has sufficient capacity or ego strength to recognize and tolerate the paradox that though he may have intense feelings towards the therapist “as if” he were a parent, yet in reality he is not. In Winnicott’s (1971) words, “psychotherapy is done in the overlap of the two play areas, that of the patient and that of the therapist” (p. 54). When the “as if” quality is lost, we say the transference has become psychotic.

Anna Freud (1936) was possibly getting at the same idea when she wrote,

The ego is, in fact, requested to be silent and the id is invited to speak and promised that its derivatives shall not encounter the usual difficulties if they emerge into consciousness. Thus we have to play a double game with the patient’s instinctual impulses, on the one hand encouraging them to express themselves and, on the other, steadily refusing them gratification—a procedure which incidentally gives rise to one of the numerous difficulties in the handing of analytic technique. [p. 12]

Freud is often quoted as saying that psychoanalysis was impossible with psychotic patients because no transference developed. This view derives from his theory of narcissism (Freud, 1914c), according to which psychotic patients had withdrawn all libido from external objects and redirected it towards their own ego; therefore, it appeared to follow that there was no libido available for the outgoing development ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Acknowledgements
• About the Author and Editor
• Foreword
• Editor’s Introduction
• Editor’s commentary on Chapter One
• Chapter One The role of space and location in psychotherapy, play, and theatre
• Editor’s commentary on Chapter Two
• Chapter Two Attachment and new beginnings
• Editor’s commentary on Chapter Three
• Chapter Three Failure to mourn and melancholia
• Editor’s commentary on Chapter Four
• Chapter Four Fear of dependence in therapeutic relationships
• Editor’s commentary on Chapter Five
• Chapter Five Termination reconsidered
• Editor’s commentary on Chapter Six
• Chapter Six Reflections on the theory and practice of supervision
• Editor’s commentary on Chapter Seven
• Chapter Seven A brief history of psychotherapy in the British National Health Service: how can psychotherapists influence psychiatry?
• Editor’s commentary on Chapter Eight
• Chapter Eight Lines of advance: increasing access to psychoanalytic therapy
• References
• Index