In the two previous chapters I described the‘affirmative’ atmosphere in which the inculcation of conservative therapeutic dispositions takes place. By the circumscription of the theoretical body, by the appeal to shared concepts of personhood which legitimate role asymmetries, and by the devices of secondary elaboration, and the successful management of doubt, trainees are institutionally coaxed into embodying a professional habitus which builds upon the foundational dispositions of‘partiality’ and‘imagining psychodynamically’, discussed in chapters two and three. In offering these comments I have argued that instances of dissent, no matter how infrequent, always presuppose a greater force against which the mutiny is levelled—in this case, an institutional consensus born from a kind of‘social contract’ of conformity, peer-fellowship, and a union of aims between novice practitioners and the initiated. I have further argued that such consensus is buttressed by the devices and preferences of psychoanalytic socialisation which finds it difficult to tolerate individual transgressions of institutional boundaries and valued beliefs.
While in the next chapter I intend to further highlight the institutional factors by which this consensual or‘affirmative’ atmosphere is nurtured, in this chapter I have two central aims to first achieve: to illuminate the psychoanalytic understanding of aetiology, and to provide an insight into the next stage of training— clinical supervision.As to why I select the topic of aetiology for especial attention this follows from the dominant place aetiological concepts assume in the therapeutic craft. The psychoanalytic understanding of causality constitutes a kind of omega point around which the whole practice of therapy—I believe—revolves, as all therapeutic action is predicated upon key assumptions about causes of distress. I believe by assessing how therapists’ assumptions are subtly affirmed in clinical supervision, we will come to learn how a central disposition guiding the therapist’s craft is inculcated.
Before setting down our case study of clinical supervision, let me first introduce the psychoanalytic conception of causation; this discussion will complement the case study of clinical action soon to follow.
Following the historical methodology of Collingwood (2002 [1940]), Evans-Pritchard (1961) and more recently Mark Hobart (2000), if we wish to expose the foundations of psychoanalytic ideas of causation then it would be useful to explore certain socio-cultural influences bearing upon the movement’s founding father. Thus we must first ask whether Freud’s attitudes, values, and presuppositions were all things upon which the social circumstances of his day left their mark. In order to consider this question more closely let us first try to gain an impression of the surrounding so-cio-cultural atmosphere of the European intellectual classes in the decades before the First World War—the period during which Freud advanced most of his foundational ideas.
In Central Europe peace had largely reigned since 1871, and the middle classes were increasingly benefiting from developments in industry, trade and science; developments which were securing their social, political and moral hegemony. Universal suffrage and education were being widely instituted, promising an end to the disenfranchisement and inequality of the early nineteenth century; and from these developments (it was thought) would inevitably spring an improved situation for the underprivileged classes. Thus, despite the global inequalities which deeply marred international economic and political relations, a global inequity which appeared remote and abstract to most middle-class Europeans, the fruits of various political, ecclesiastical and economic reforms back home had put many in the middle classes into a state of considerable optimism (Fromm 1974). The era of irrational authority and social injustice was thought in abeyance, being replaced by the rule of law, democracy and the steady march of enlightenment values. In this atmosphere of general hopefulness a political and ideological positivism was taking firm root, consistent as it was with the social experience of the European middle classes.
The fact that Freud himself was a child of such enlightenment optimism I shall argue stands out in his personality. As is illustrated by many close studies of his life, Freud was a conventional man of his day; a man representative of middle-class Vienna who largely accepted the central mores of the society in which he lived.121 While at face value this representation of Freud’s relationship to his social world seems inconsistent with the popular view that Freud was highly at variance with social convention, if we probe deeper we notice that Freud, apart from opposing a strong social taboo on sex, accepted most of his society’s dominant values uncritically. We can infer this acquiescence from both his practice and his writing. His positivism and objectivism, his views on the patriarchal family, his dichotomising of the rational/irrational and championing of the former, and his acceptance of the economic values of the middle classes, are all attitudes that betray themselves in his writing and way of life.122
An important consideration that these reflections raise is whether Freud’s general outlook coloured how he understood the causation of suffering. This is to say, so far as Freud regarded the society from which his patients largely came as healthy (modern bourgeois Vienna), was he therefore more prone to locate the causes of personal distress in his patients’ psychology rather than in the society of which he generally approved? An interesting en-trée into this question is to recall the reasons why Freud abandoned his theory of childhood‘seduction’ (which implied a corrupt social world); replacing it with his theory on childhood‘phantasy’ (one shifting the cause of distress to the realm within).
As is well known, Freud originally traced the aetiology of hysteria to actual traumatic events in childhood, usually to the child’s seduction by an adult. This was often seduction of a daughter by a father, as is illustrated in the case of Katharina in his Studies of Hysteria (1977 [1905]). It was believed that if patients could recall cathartically the original abuse then the repression and the symptom would automatically lift. Freud’s use of his seduction theory lasted until around 1900 (his letter to Fliess in 1897 heralding its end), at which point he slowly embarked upon a radical reformulation of his aetiological vision. This finally led to the new conclusion, as he tells us,
…that the neurotic symptoms were not related directly to actual events but to wishful phantasies, and that as far as the neurosis was concerned psychical reality was of more importance than material reality. (Freud 1977: 34)123
In other words, the stories of trauma which his patients confessed were now not to be interpreted as descriptions of real events, as had earlier been the case, but as fantasies motivated by their childhood libidinal desires. The various disclosures of his female patients were therefore not to be read as genuine recollections, but as fabricated actions and stories. And while this did not diminish the importance of these memories, it did alter their mean-ing—for now they spoke of psychic, not social, happenings.
The question of why Freud abandoned his seduction theory has been the subject of much controversy, but as this debate is only tangential to my current concerns, let me treat it only briefly here. Certain scholars such as Jeffery Masson argued that Freud’s revision ignored the considerable clinical evidence, even material from Freud’s own patients, that the abuse he repudiated as fantasy was actual and real (Masson 1984: 27). Indeed Masson’s claims seem to be supported not only by a thorough reading of the Fliess-Freud letters, edited by Masson (1989 [1985]) himself, but also more widely by later psychiatrists and social researchers who have subsequently revealed that childhood sexual abuse was far more prevalent than Freud supposed.124
Masson explains Freud’s abandonment of the seduction theory as owing to his reluctance to further outrage the psychiatric community with his findings. And although this explanation may in some measure account for his revision, it seems improbable that it explains it entirely. For in the first place, it appears highly inconsistent with Freud’s well-known disregard of conventional psychiatric explanations as well as with his evident nonchalance, often in spite of himself, concerning aggravating the psychiatric community. But more importantly it overlooks Freud’s considerable social conservatism which could only have been threatened by what his own seduction theory implied: as ever more patients came to him with hysterical symptoms he was forced to conclude that not only was childhood sexual abuse disturbingly common, but that it regularly occurred in the most‘respectable’ sectors of society. Even his own father seemed potentially guilty since Freud noticed hysterical symptoms in both his own brother and sister (Storr 1989: 18). In fact, in a letter to Wilhelm Fliess dated September 21st 1897, Freud clearly admitted that as hysteria was so common it could not possibly be caused by childhood abuse, since, as he says,‘surely such widespread perversions against children are not very probable’ (Freud 1989: 264). Thus with the growing numbers of patients came his growing disbelief and doubt, which, rather than settling on the upright world of Vienna, settled on his own theoretical con-struct—the seduction theory that he consequently abandoned. In other words, the consequences of his seduction theory being correct were too much at variance with his social conservatism, which, apart from opposing the rigid sexual mores of the day, supported the paternal social structure which he saw as integral to civilised life.125
However we decide to interpret his discarding of the seduction theory, what is most important to note for our current argument it is that after its abandonment Freud would habitually assume that what were reported by patients as real events were actually products of phantasy—phantasies that pointed to the existence of a childhood sexual life (hence the birth of his psycho-sexual stages of development). In fact this shift in orientation was perfectly consistent with another tendency that was clearly pronounced in his early case studies—namely, Freud’s need to help patients return to conformity with their social surroundings, rather than empower them to criticise or alter the potentially damaging social circumstances to which they were subject. In this sense Freud advocated adjustment to, rather than reform of, the social world in which his patients found themselves.
If we accept that Freud’s attitude to the dominant mores of the day influenced his concept of aetiology, then allow me now to illustrate how by implication this orientation influenced all subsequent developments within the field of mainstream psychoanalytic psychotherapy in Britain—setting in train a discourse psycho-centric in orientation; one that cast suffering in ever more psychological terms, and one diametrically opposed to the more social vision of human suffering prevalent in much social science today.
To acknowledge how Freud’s psycho-centric orientation influenced later theoretical developments, we must start by discussing the distinction between‘analytical’ and‘interpersonal’ or‘object-relations’ orientations in British psychoanalytic psychotherapy. At the outset of psychoanalysis Freud’s therapy was highly‘analytic’, with the‘interpersonal’ or‘object relations’ orientation only emerging in the latter half of the twentieth century. While this new‘interpersonal’ approach never constituted an overthrow of the analytic stance (it kept as axiomatic basic analytical ideas), for many analysts it gradually replaced the‘need for pleasure’ as the dominant human drive, with the‘need for healthy relationship’. For those who accepted this change not only was the analytic understanding of transference and counter-transference altered, but so too was the analytic understanding of aetiology.
The key difference with the new interpersonal or object relations approach was that it particularly emphasised, as Freud did not, the child’s attachment to its primary caregiver. Therapists such as Fairbairn, Winnicott, Bowlby, Klein and Balint, all unequivocally saw the origins of much pathology as arising from various kinds of loss of intimacy children had suffered with their parents—espe-cially with their mother. A special interest was therefore taken in the mother/child relationship, as its disruption was believed to damage the child’s potential for maturation. Thus for the new object-relations theorists neurosis did not only spring from the repression of disturbing fantasies, but from real deprivations, from real events.
With these changes object relations analysts returned to an earlier vision of aetiology that Freud had largely abandoned along with his theory of seduction: they reinstalled a respect for real rather than imagined events as causes. But instead of seeing the traumatic events as‘sexual abuses’, they also saw them as‘relational deprivations’ occurring within the first few months and years of the child’s life: if the child was denied sufficient‘mothering’ or‘mirroring’ it would develop a maimed sense of self. This could engender psychological complications in adulthood from‘schizoid’ or‘narcissistic’ personality traits, to obsessive/compulsive or phobic disorders, etc.
While both object-relations and Freudian orientations debated how far the causes of suffering were real or imagined, both still unequivocally agreed that early childhood was the key phase of human biography. One subsequent result of this has been that both orientations have instinctively learnt largely to favour early rather than present events in their explanations of current suffering. Current troubles are seen as inevitable given the childhood history of the person in question. The present malady has its roots in a personality that was structured in childhood.
Many commentators have argued that this vision has led on occasion to a form of reductionism which has not helped psychoanalysis in the political domain. Andrew Samuels, for instance, has argued that this reductionism has been partly responsible for why government policy makers have largely ignored the insights of therapists:
In asking the world why it didn’t turn up for the first session, we need to acknowledge the seemingly incurable psychotherapeutic reductionism and triumphal-ism that parallels that of the media. Psychotherapists write articles for newspapers about the phallic symbolism of cruise missiles going down ventilator shafts in Baghdad or they call Mrs Thatcher a restorative container for British greed… What is the point of this? Maybe the world was right not to turn up. (Samuels 2000: 8)
Other theorists have asserted that developmental reductionism inhibits theorising about how the present or more recent continuous social environment affects the person’s current functioning (Kleinman 1998, Littlewood & Kareem 1992). By not taking account of these later experiences, others have argued that strictly developmental psychoanalysts have downplayed the role of social factors in the causation of illness. As Peter Fonagy and M. Taget write:
Although infant research confirms some speculation and informal observation, the developmental argument of a linear evolution from infancy to adulthood cannot be sustained. Human development is far too complex for infantile experiences to have direct links to adult pathology. In fact the extent to which research is available, longitudinal studies of infancy suggest that personality organisation is subject to reorganisation throughout development based on significant positive and negative influences. (2003: 162)
The aforementioned scholars regard much developmental thinking as prone to underestimate how later and current‘living’ styles, which might have been socially rather than developmentally induced, affect the individual’s capacity for healthy living. Furthermore, their work raises the concern that so far as developmental thinking bypasses the question as to what extent the developmental dyad is part of a family system that is itself structured by a wider social system, it underplays how a socially conditioned change in the family influences the developmental dyad and through this, the child’s development. In this sense, to the degree that the dyad is considered in abstraction from the wider social scene, it omits the relevance of society at a second stage of influence.
To clarify these two points, then, the two broad orientations now widely applied in British psychoanalysis rest upon an understanding of aetiology that is circumscribed both spatially and temporally. Spatially, since the search for causes stops at the boundaries of the family (especially the developmental dyad), overlooking the manner in which different socio-cultural systems can structure and influence these primary ties. Secondly it is circumscribed temporally, since events in childhood, rather than later events, are privileged as the main determinants of adult suffering. In short, with these two perspectives at its heart, the psychoanalytic vision of aetiology prevalent in Britain today is largely psycho-centric in that it privileges psychological over social causes of suffering. This general perspective, as I have suggested, can partly be traced to Freud’s attitude to the social mores of his day, which, by disposing him to regard in modern Vienna few things of reprehensibility, led him to locate the sources of his patients’ discontent in their psyches rather than in the general social conditions to which they were forced to adjust.
With this brief introduction to psychoanalytic aetiology in place, we must now venture forth from the sphere of principles into that of facts. The following empirical discussion provides an instance of what an understanding of causation might entail when applied to the treatment of patients. The case discussed is based on the transcript of an audiotape recording—this was of eight clinical supervision seminars held at a training institute in London. The three seminars presented here are sessions 2, 5 and 7 of this series of 8.126
As is standard for clinical supervision, these seminars are intimate affairs, in our case involving only three trainees and one supervisor. Like theoretical seminars they are usually held once weekly at the institute and in the evenings. They differ from the theoretical seminars in terms of the content discussed: each week a different trainee‘brings to the group’ the case of a training patient with whom he or she is currently working. These cases are assessed by the supervisor (trainer) who decides on the basis of the trainee’s presentation whether he or she is proceeding correctly. Structurally speaking, in terms of the affirmative context and devices employed, clinical supervision and theoretical seminars are comparable, as here too the roles between trainer and trainee are clearly defined, while critical reflection falls less on either the truth or falsity of psychodynamic ideas than on whether they are being correctly applied in practice.
To turn now to the people involved, the Supervisor in question is a middle-aged male psychoanalyst (trained at the Institute of Psychoanalysis in London) whose research interests are cultural issues in the therapeutic encounter. Two of the three trainees are British males (early thirties) in their first year of clinical supervision; while our final trainee, who is the student presenting the case, is a forty-two year-old woman from India, who has previously trained in India in CBT (cognitive behavioural therapy). The patient she discusses is a twenty-one year-old Indian girl (Punjabi), whom I shall call Arya.
The trainee therapist starts by informing the group that her patient, Arya, came to England one year ago to live with her British-Indian husband (Gujarati, thirty-one years old) whom she had married three months earlier in India. Her problems started four months after she had arrived—her husband became increasingly critical of her domestic mistakes. At this time his possessiveness and jealousy also began to grow. He started to prohibit Arya from going out and from mingling with the rest of his family. Over the next few months the abusive episodes worsened, becoming physical and more frequent. After seven months he was hitting her‘on most days’ and becoming very aggressive sexually. For the next few months Arya‘lived in misery’ until finally, on an evening when he was particularly abusive, she‘escaped’ through a window to stay with an aunt whom she had recently visited. Her husband contacted her two days later to say he had filed for divorce and that she should never return. It was two months after this event that Arya was referred to our trainee therapist by her GP She described herself as feeling depressed, heartbroken, and extremely lonely.
The trainee relays to the group what she felt to be the important themes of her last session with Arya. Three themes in particular stand out. Firstly, Arya’s ambivalence for her ex-husband: at the beginning of the session Arya expressed a desperate hope that her husband would take her back, while at the session’s end, when asked how she might win him back, Arya’s immediate response was:‘No, no, I want a divorce, definitely divorce; I never want to go back, if I do he will be fine for a few days then he will start beating me’.
The second theme concerned Arya’s astonishment at the change in her husband’s behaviour, from a wooing lover (sending gifts to her from London) to‘the cruel man he became’. Arya said,‘I did ask him why his behaviour changed so much and he said that he was always like this, that he had two sides to him, that he could be soft and angry.’
The third theme concerned how he treated her in public. The trainee quotes Arya:‘My husband would not let me speak to any of his brothers. Once we had to go to his brother’s house for a function, he was hurrying me to get ready. And as I came down the stairs his older brother was waiting in the hall. I asked him whether he wanted tea or coffee. Immediately my husband pushed me into the kitchen and shouted at me for speaking to his brother’. At other Gujarati gatherings Arya was told she could not talk to certain women and certainly to no men at all.
Supervisor: In this session she clearly indicates that she felt cheated and deceived; that he represented himself as one thing and turned into something different. He even accepted that he has two sides to him… What was surprising is that at the beginning of the session she wants a second chance, to go back to him, while at the end she is adamant that she is not going to return. So is it one or the other?
Trainee Therapist: In the previous session she was longing for him to call her back. Also she hoped that the elders would intervene and improve things, that both families would talk and demand a harmonious reconciliation. This was her hope. But then, yes, by the end of this session she wants the separation; she has even had her lawyer request her belongings to be returned.
Supervisor: Do you know what is going to happen financially because I would imagine it plays quite an important part. Will he return whatever she gave to him?
Trainee Therapist: She is not quite sure about that…
Supervisor: Not that you should be concerned about this, it is not the therapist’s concern as such, but it is indirectly as I would imagine it would have many implications for what her condition is going to be… One thing that is striking about the session, really, is that the emphasis is on external things; you know you ask a question and she gives you some information about the husband or about the family. But there is really very little emphasis on her experience, on what it feels like for her to be in this situation.
Trainee Therapist: Yes, she repeatedly says that she is depressed and feels like crying; yet she says these things in a dissociated way.
Student One: So she was not angry?
Trainee Therapist: No, the anger was not expressed through her body or tone of voice, it was passive anger:‘I am feeling angry, I am angry towards my husband’, but nothing else…
Student One: She is talking about being angry, but you sense no anger in the room.
Trainee Therapist: Y e s , Y e s … [ Silence]
Student One: I was wondering whether that could have been explored?
Trainee Therapist: Yes, but then I was feeling that there is a cultural element here too. I am uncertain about Punjabi culture, but in the culture I come from as a woman I cannot express my anger very much. As a woman you have to be very soft, and even if you have anger you should learn to hold yourself and not express it. This posed a problem for my own therapy here, actually. When I was going through some difficulty, my therapist expected me to get really angry and made me practice verbalising my anger [she laughs] and so I can sympathise with Arya’s hesitance [silence].
Student Two: Does your issue with anger prevent you from exploring hers?
Trainee Therapist: OK. Good question. I need to think about that. [Silence.]
Supervisor: She is clearly indicating that she has felt trapped, not just physically in the sense of being locked in and not being allowed to talk to anybody, but also in the sense that she found herself in a position from which she couldn’t quite see a way out. She says more than once that she has done her best to please her husband, and so cannot understand why she has been treated in this way. She feels that whatever she does she will fail.
Trainee Therapist: Two things still surprise me. She doesn’t want to go deeper into what motivated her into marrying a man after one glance at a photograph; a man she had not seen and rarely spoken to, that is one thing. The other thing is that she never considers her part in all of this—what she has contributed to this situation.
Supervisor: [Eagerly] Right, yes.
Student Two: [In agreement] I noticed this.
Trainee Therapist: I feel that there is a block somewhere. [General agreement.]
Supervisor: I think these are two very valid points. Regarding the first one we could speculate that her wish to get away from India, from her family, or from her parents is very strong indeed to the point that she would almost marry anybody who was offering. It happened to be this man who also seemed to be nice, to write kind letters, to give her nice gifts and so on. Or then again maybe it’s due to her wish to come to England, her wish to leave her family, her wish to have children, who knows. Whatever is the case there is something else underneath this specific wish to be married to this man—it is not about him in other words. Yes, and the second point, I think it would be fair to assume that she might have played her part, but that is not to justify the way he seems to have behaved, but to try and understand it… so she may have played a part by being too passive, by provoking him, we are not sure.
Trainee Therapist: Y e s , Y e s .
[Omission.]
Supervisor: [Closing the session.] At the moment we are given facts‘my uncle did this, my husband did that’, but we don’t know enough about what it feels like for her. It might be possible as you say that anger is not one of those feelings that, culturally speaking, a woman of her age is able to get hold of; but I am sure that she has feelings of one sort or another. If she does not experience it as anger, she might experience it as humiliation or as a feeling of being deceived or whatever. I mean I think one should try to focus a bit more on the current form of words, let’s put it that way, rather than on what she should do or what he has done. These kinds of facts might be of more interest to a social worker, or to a biographer who had to write a story of what happened to her; but this is not the job of a therapist, which is about trying to understand the internal world and to somehow create the conditions where the subjective experience can be expressed and shared with you, so that it can be understood and interpreted. [Turning to a student.] You wanted to say something?
Student Two: I agree, I mean so far there has been a lot of talk about situations or events happening external to her, but not much talk about her internal reaction to these. I mean it is understandable; I am not blaming her, of course, but all the more reason for someone to draw attention to that fact that there are other ways of approaching these things—she needs to go into herself for answers, so to speak. [General agreement.]
At the beginning of the seminar, the group is evidently moved by the description of Arya’s circumstances, circumstances which, from another standpoint, would seem to provide explanation enough for her suffering. But instead of discussing whether therapy is appropriate for Arya (to what extent is her pain due to unfortunate circumstance rather than pathology?), the group still works to analyse her inner workings—a search which, after all, therapists see as their remit to undertake. Arya’s subjective problems are insinuated with comments such as:‘she only focuses on external events not her reactions to them’ (in psychodynamic parlance such behaviour could be expressive of an‘avoidant personality’). One student points out that,‘her anger is passive and not expressed’ (a characteristic of the‘schizoid’ character).127 And there were questions that all agreed were important:‘what was her motivation for marrying this man?’—and,‘what did she contribute to this situation?’ While these comments and questions overtly declared very little, they implied very much—namely, that a part of Arya might be conspiring against herself (e.g. unconscious motivations or needs perhaps).
Another feature of the seminar is the absence of any technical instruction from the supervisor. Although this is unusual, in this instance it seems understandable: while the nature of Arya’s distress still remains unclear, it is difficult to decide upon any curative strategy. The supervisor feels we need to know Arya a little better before a strategy can be decided upon, but there are two impediments to this—Arya’s focus on external events (which the supervisor sees as problematic), and the fact that certain behaviours can be accounted for on cultural rather than psychological grounds (e.g. her emotional‘repression’ being due to a cultural rather than psychological prohibition). The questions whether other factors too have cultural explanations also inhibits discussion—as one of the group mentioned to me after the session:‘there are many cultural themes here that I do not understand and this makes defining her problems much more complicated’. With these comments in mind, let us turn to our next transcribed seminar.
The first theme discussed is Arya’s longing for her husband. Yet she also wants him to return her belongings and passport (symbolic of her desire for independence). This contradiction is unravelled when it becomes clear that more than wanting the belongings themselves, she desires the contact that his returning them will necessitate.
The second theme is trust. Arya said,‘I usually trust people, but no longer; I have learnt a good lesson, I cannot trust anyone on this earth.’ The therapist asked Arya whether she can trust her, Arya responds:‘No, no, no, I don’t mean you, really you help me; I mean other people like my husband and in-laws. If my husband can betray me, how can I trust others?’
The final theme is about separation, for while Arya is happy to be away from the abuse (sexual, physical, verbal), she still misses her husband and his family:‘There were people like his brothers who were good to me and I loved his family members, because once I got married I treated all his relatives as mine own’. She continues,‘I still remember all the places where things were kept (the dishes and clothes) sometimes these memories are so vivid and comforting—I have to struggle to detach myself from them’.
Supervisor: [Addressing the group.] Any thoughts?
Student One: What struck me about all this was how she spoke about her husband’s good qualities and how she is going to miss him. This contradicts very much the representation she offered a few weeks ago; and also the original representation she gave of his family [General agreement—Arya had been angry with the family for siding with her husband and not criticising his treatment of her.]
Trainee Therapist: Yes, she now feels that there are many people she is going to miss. I think there is a sort of fear about letting this family go, no matter how bad they have been.
Supervisor: I suspect there is something else too. I wouldn’t want to be on the wrong track, you are more familiar than me with the cultural rules, but I wonder if when a young woman leaves a family to marry, in a sense she rejects her own family, in order to belong to a new one I mean. But now she has been rejected from the new family, well, she now doesn’t belong anywhere. She doesn’t belong in Britain, she doesn’t belong in India. She does not belong with her family. She doesn’t belong with her in-laws. And at that point (and I am just speculating here), at that point she is entirely on her own.
The other thing is that although she mentioned passports, I take the passport as being a symbol of her identity (it has her name, picture, address etc.) and the fact that she has no access to her passport is disturbing not just because she doesn’t have a visa, and is unable to travel, but because she has almost been deprived of her sense of identity, of who she is, by whoever holds her passport. And so she belongs really nowhere; and she is quite desperate. I think a lot of her depression and a lot of her tears are partly to do with that. She needs to find a place where she can settle, where she can be, where she can, so to speak, get her passport back, her identity back. But of course this isn’t the whole picture.
Trainee Therapist: Yes, the passport symbolises a lot. [Pause.] Another thing that is still a mystery to me is why she would agree to such a radical overhaul of her identity; why this man, why this country?
Supervisor: So she might have been more calculating than you thought?
Trainee Therapist: Yes, yes.
Supervisor: It wasn’t just because he was sending her nice presents.
Trainee Therapist: Exactly, and normally if a girl has a problem and the parents are open to receiving her back the girl will return. But she wants to remain in Britain and be independent.
Student One: This is interesting, isn’t it?
Trainee Therapist: Yes, because she grew up in a very close and loving environment the parents were very protective, but after marriage she has suffered so much here; but the desire to get back to her parents is not uppermost.
Supervisor: At the moment we don’t know why she has no desire to go back, but let us put this aside for right now because there is something else I think we might discuss here: I thought that you were right to notice that when she said that she couldn’t trust anybody she meant you as well, her emphatic denial‘no I mean everybody but you’, would not convince me. You know she might consciously, but I think somewhere there must be some ambivalence. I mean if she sees herself as being so inept at assessing and judging other people, why wouldn’t she be deceived by you? Indeed, you might be giving her a nice place in which to express herself, and nice interpretations and so on, but what is the difference between this and the nice presents her husband gave her? So while I think it was right to point out that she might find it difficult to trust you, I would not have taken her flat denial too literally… I think she could trust you more deeply if you allowed her to see that there is a part of her that actually does not trust you. You become more trustworthy if you make her face the fact that there is a part of her that cannot trust anybody; I mean she has been so massively disappointed and betrayed and so on…
Student One: I wonder how much she has been deceived in her life prior to these recent events?
Supervisor: Quite. We don’t really know much about her relationship with her parents for instance—to what extent she feels that they have let her down and betrayed her.
Trainee Therapist: She has an inflated vision of them; they are very nice and gave her everything, etc.
Supervisor: [Smiling.] Y e s , b u t …
Trainee Therapist: That she doesn’t want to go back to her parents does tell us something.
Student One: One could say that the reason that she isn’t going back is because it would be shameful to do so.
Trainee Therapist: Yes, maybe she doesn’t want to go back because she does not wish to bring shame to the family, etc. I am not suggesting it is her fault but she might feel it is.
Student Two: But would shame account entirely for her not wanting to return?
Trainee Therapist: Perhaps, maybe, but not entirely.
Supervisor: The suggestion is that she does not really trust her parents, that is why she does not want to go back. We don’t really know what was going on in her family.
Student Two: And do we really know how far she consented to the marriage?
Trainee Therapist: Well she told me she wanted the marriage.
Supervisor: But did she give her consent because she felt that she couldn’t let her parents down after they had arranged things? The point is we should question the idea of how free her decision really was. In theory she could say yes or no, but in reality did she really have a choice?
Student One: And if she didn’t have a choice, assuming that, and assuming that her parents knew she would accept it, why did the parents choose a man in England rather than a man down the road —I mean it is a huge distance to send your daughter.
Supervisor: A man from a different background, who lives in a different country, and who turned out to be so inappropriate for her.
Student Two: And why did the parents choose a man in London? This choice is surely significant.
Therapist: You are implying that if the parents choose someone in England for her, then the parents in a sense wanted to get rid of her…
Trainee Therapist: So maybe it is my assumption that she wanted to come to England and marry an Englishman—perhaps I have read too much Austen. [General amusement.]
Supervisor: It seems that the truth is very complex; wanting to get away from her family, wanting to come here, wanting to get married, wanting to obey her family’s wishes.
Student Two: [After a protracted silence.] She seems a very sad young lady.
Supervisor: [Regretfully.] It is a very sad story. I am sure not uncommon, but sad, yes.
[Omission.]
Supervisor: Look we are coming to the end now, so let’s round up. We are not sure at the moment what restraints she has internalised. Rather than discuss this at the moment, let’s say that it is probably a mixture of family pressure, external pressures, psycho-pathology of her own, education, you name it. What would be more useful would be to try in the following sessions to move her away from the external reality of things—is she going to get divorced or not, and so on. Rather try to read the whole thing at a more internal level—forget about the external events and try and see and understand her experience of them—this will reveal to us the landscape of her internal world. How does it feel for her to be in this situation now? What part she might or might not have played in finding herself here? How does she feel about you and talking to you about certain things? I think one is very tempted whenever there is a clear series of external events, for instance in the case of people who have been traumatised, abused or tortured, to focus entirely on that and to forget what her own individual personal experience of it was, which I am sure will be very different from person to person. So if the focus can be redirected towards her internal world rather than to the events then perhaps she would really begin to benefit and trust you rather than just say that she trusts you. Yo u are there for a different purpose other than healing her external life, that is what is special in a sense about what you have to offer her.
Student One: And do you think that by taking that approach which is therapeutic rather than a social worker’s approach you will be getting her to focus on her relationship to these events and to get her to reflect upon herself?
Supervisor: And where she comes from, and how she finds herself in this situation, and what part she has played in it.
Student One: And what part she can play to get out of it. [General agreement.]
What stands out in this seminar is that while the participants might be framing diagnostic interpretations privately, they have yet to reach a diagnostic consensus. This delay takes place for two reasons. Firstly, the cultural barrier—in many ways Arya’s world is unfamiliar (the patients of most therapists are British and middle-class), and that the training therapist is herself Indian obliges more sensitivity. Thus the students and the supervisor seem reluctant to draw conclusions until all the key cultural facts are in (e.g. in the omitted sections there were many questions asked about Arya’s values and beliefs, about arranged marriages, etc.)
Secondly, the external events to which Arya has been subject make it difficult for the trainees to look beyond these for an explanation of her suffering. The supervisor senses this, and yet while he acknowledges the impact of external events by saying,‘the depression could be a lot to do with having lost her identity’ he still concludes that‘this of course is not the whole picture’. He implies that there might be something else behind these events, some precipitating‘motivation’ which possibly helped lead Arya, unbeknown to herself, into this situation. Furthermore, by suggesting that Arya discloses her‘inner experience’, the supervisor is in fact requesting the type of data (fantasies, fears, inner contradictions and internal objects) from which a diagnosis of her problem and‘personality structure’ can be drawn. Thus what are being sought-for here are very specific kinds of subjective facts. This preference for the personal over the external and collective, anthropologists have argued may well serve to legitimate the application of psychodynamic interpretation and intervention where they might not be required.
For instance, cross-cultural clinicians have argued against gathering data of psychodynamic interest alone, since it privileges‘universal’ inner experience over external socio-cultural meanings, symbols, and events. Jadhav, Littlewood, and Raguram (1999), for instance, have critiqued this psycho-centric tendency of psychody-namic practice:
The process of deliberately filtering off cultural components of patients’ narratives to yield symptoms and signs, including defence mechanisms… is considered credible and meritorious [in psychodynamic psychotherapy]. We argue that this relates to an effort on the part of alienated health professionals attempting to approximate their patient’s stories as stories to Western therapeutic narratives, to arrive at some sort of goodness-of-fit with the latter. (Jadhav, Littlewood & Raguram 1999: 102)
While these authors are specifically talking here of how therapists recast patients’ narratives in therapeutic symbols (a usage overlooking that patients often better respond to understanding their world in its own symbolic terms) their comments have application to the manner in which the psychodynamic concept of aetiology might ignore other aetiological considerations. This is to say, not only might certain indigenous symbolic meanings be filtered away, but so might also certain aetiological perspectives which are irreconcilable with a psycho-centric vision of suffering.
The main theme of this session is that at its end the therapist sets her patient, Arya, some‘homework’ (some exercise between the sessions which may help increase the patient’s self-esteem). Setting homework is taboo in psychodynamic therapy. The trainee’s actions were thus more in accord with the principles of CBT (cognitive behavioural therapy) of which she possessed much knowledge and which encourages that therapists be more didactic than exploratory with their patients. The therapist made this suggestion because she felt Arya’s‘self-deprecatory feelings were inhibiting her from taking steps to improve her situation’.
The second theme concerns Arya’s reluctance to tell her parents of her unhappiness. Arya says,‘You know I do not share any of my deeper feelings with others. I fear that if I unburden my heart my family will suffer. I do not want them to suffer.’
Supervisor: You felt you had to set her some homework?
Trainee Therapist: Yes, I felt I had to ask her to sit and write a list of her good qualities as a kind of re-balancing. I felt that it would be good for me to counter her self-deprecation.
Supervisor: How do you feel about alternatives?
Trainee Therapist: Not giving her homework?
Supervisor: Yes. Look, it seems to me that it is more important to understand why she feels she has no good qualities, than to get her to make list of them. But I do understand—it really depends on which type of framework you see yourself working with. [The supervisor is aware that this trainee is referring to CBT ideas.] As a psychoanalyst, I would work in a non-directive way and therefore would not give instruction. Another colleague might say at the end of a session‘we must stop now but we could talk about this next time’? But I would not even do that because that is also giving some kind of instruction. Of course, if there is something that was incredibly important to her and she doesn’t return to it, I might interpret her avoidance, but I wouldn’t instruct her to come back to it —do you see the difference? I mean, there is nothing intrinsically wrong about getting someone to think about their good qualities and write them down—by doing this you won’t damage her or anything like that. It is really all to do with what you see your role as being and what your therapeutic attitude towards your client is. Is it a more directive one? [The trainee remains silent.]
Let me put it this way, if someone is very quiet in the session, I don’t think it would be the job of the therapist to make them talk, but it would be our job to understand why it is difficult for them to talk. After all, they’ve travelled here, they’ve paid their money, they sit in the chair or lie down in order to tell you things, so why can’t they? This suggests that there is some kind of problem, some issue, some anxiety about you or the situation or something else. So it is that conflict, that issue, which I would want to explore—I would not tell them that they must talk and that I cannot help them until they do. [Pause.] Actually, this analogy is useful because she has a problem with talking. Does she talk much with the aunt she lives with?
Trainee Therapist: Apparently not. And I was concerned why she couldn’t say anything to her parents either, although they call her.
Supervisor: But again, we do not know what relationship she has with them so it is difficult to know why she doesn’t tell them things. Say, if her parents were quite elderly and fragile it would be different than if they could just take things in their stride. [Pause.] But how depressed is she?
Trainee Therapist: She is improving. From my point of view she wants to move forward despite her inclination to move back, and moving around and filling the whole session with her sob story…
Supervisor: [Interrupting.] What concerns me here, and I think this is central, is that she doesn’t seem to feel that she can get her life back in her own hands and get what she wants; I mean there is something about that which suggests she doesn’t have or cannot quite find the internal resources to improve her situation. And alright, perhaps she could go to her parents and they might help, some other people might, but it seems to me that, although I wouldn’t describe her as a definite suicide risk, I wouldn’t rule that out altogether. So some attention should be paid to that because it is an option for her as for anyone at any point in our lives. But she seems to be perhaps a little closer to choosing that option than some of us might be.
Student One: [Slightly distressed.] Yes, she feels herself to be very restricted and determined by other things, external things; she experiences herself as very powerless.
Supervisor: Right, yes she feels this, so what would you see the role of the therapist as being then, what could you as a therapist do to help someone like her now? What should you take from that session and look at further?
Trainee Therapist: [Pause.] Perhaps her difficulty with sharing her burden with her parents, perhaps with her insisting that she is to blame for the failure in the marriage?—although, after all, she is the one who decided that she couldn’t stand it any longer. Perhaps the fact that she feels bad is because she hasn’t conformed to what is expected of her, in marriage, work, etc.? But most importantly, I feel that she hasn’t got an identity of her own, so she conforms to that identity or the idea or the expectation placed upon her by somebody else.
Supervisor: Right, good. So she has to be what others expect her to be because she doesn’t know who she is—that is something. But I am after something else. There is another clue here vital to unravelling what is going on. [Protracted silence.] Think of what you did. This is important.
Trainee Therapist: [Hesitatingly.] Instructing her?
Supervisor: Exactly! In that is the clue. By instructing her you end up colluding with her belief that she cannot know who she is, so you are going to tell her or give her a task that would allow her know. But by doing this in a sense you become like the husband who gives her instructions to do her sari up—I am exaggerating here, but you see what I am trying to say. As a therapist it is very easy to fit the role that the patient expects you to play. This is very clear for instance when you work with patients who have some sort of perversion, not necessarily a fully flown sexual perversion, but who have a certain masochistic tendency to put themselves in situations where they suffer—and as this is familiar to them they almost enjoy it—the familiarity. Well, now, when you have such a patient you will find yourself, whether you like it or not, and however hard you try, being quite sadistic towards them. It might just be in the sense that you arrive a couple of minutes late or that you make them choose the more uncomfortable chair, or that in your voice something will emerge when offering an interpretation, or you interrupt them—something minimal but something nonetheless that will reinforce the sado-masochistic pattern that they are used to and you find yourself in the sadistic position.
Or the other way round, the sadistic patient might make you feel passive and persecuted and oppressed. These are clear examples of how in the transference and counter-transference those personality traits or perverse traits or whatever they are, are re-enacted in the therapeutic relationship. And it is important not to allow yourself to fall into the trap, to set the homework so to speak, in order to then be able to reflect on this. So when you find yourself acting sadistically towards a patient, and this is the last thing you wanted to do, then the patient’s masochism becomes palpable, and now you can work on it and understand it, and link it with early events in this patient’s life or link it with early experiences—you notice the repetitions they live.Student One: So from how our patients make us feel we sense the tone of the patient’s personality.
Supervisor: Yes, that is right; we fit their personality and become that which is familiar to them, even if what is familiar is harmful. This is why so many people who have been abused as children end up as abusers themselves, for instance, or end up being abused again as adults. It is as if they only knew that way of relating to other people. This is why they relate this way to the therapist, and a therapist will inevitably fall into making this possible by adopting consciously or unconsciously the complementary attitude. But unlike others, you are in the very privileged position of being able to think about it and use it to understand the internal world of your patient and the internal objects of your patient, which also gives you a lot of responsibility. As you all know, the concept of the internal object is an important one and it has to do with the parents we carry inside ourselves—who are quite different from the parents we have had out there; they might be more benign or angrier or more difficult or more neurotic or more generous than the real parents really were. There are often parents who are more harsh and forbidding than the actual parents—so these internal objects govern the self-concept.
Student Two: They are both related and they both communicate to you at the same time…
Supervisor: Yes, yes, so to come back to Arya; her internal parents seem very fragile people who might be very upset or angry or anxious, while actually her real parents might be nothing of the sort. In fact her parents might be quite worried of having a daughter who never talks to them. So why does she think she is protecting them, when in fact she is worrying them more. You see, what we are really concerned with is her fantasies not the reality. And the main part of the therapeutic task is to explore these things, these objects, and to question them, to challenge them, so that hopefully those internal objects will be less persecutory or less depressing or less maddening than they really are. People who already have good internal objects are unlikely to come to us, they don’t need it. They are fine, yes of course, people go through loss of marriage, loss of friends, of illness, etc. but if they have sufficient inner resources to deal with it then somehow they cannot get on successfully. But those who cannot need therapy. Do you feel that we understand our patient a little better now, as well as what we can do with her?
Before studying further the implications of psychodynamic aetiology in the next chapter, let me draw some preliminary observations from the case-study discussed. This final seminar is to be distinguished from the previous sessions for two important reasons. Firstly, here a partial diagnosis is finally hinted at (i.e. masochism) a diagnosis which later becomes explicit, since the supervisor later suggests that Arya suffers from masochistic traits.128 This was inferred from the‘relational dynamics’ between patient and therap-ist.129 The‘sadistic’ act of setting homework was seen to be provoked by the patient’s need to settle in her familiar masochistic position, a position requiring a sadistic complement to be actualised. This diagnosis was supplemented by the supervisor’s suggestion that the patient has poor‘internal objects’. This was thought to explain not only the existence of her masochism, but also why Arya was unable to manage her situation adequately; a situation with which people possessing healthier internal objects would cope better.
The second reason why this session differs from the previous two is due to the group’s mood being different. In this session the supervisor is more decisive, more earnest than in previous sessions, perhaps because he feels he has a firmer grasp on what he suspects are Arya’s problems. The trainees respond gratefully to this new authority, they appear more engaged, less frustrated, more eager to learn. The mood remains buoyant in the halls once the session has ended where they express their satisfaction:‘we got somewhere today’, says one;‘very interesting, great session, he’s very good’ says another. While the trainee who analysed Arya commented to me later in interview:
This was a really helpful session; he has given me a lot to work with. After the other sessions I felt slightly unsatisfied, things were not really clear, actually I felt quite confused…
‘So now do you have a better grasp of Arya’s problem?’
‘Yes, I was just groping about before, but now I have formulated a clearer objective—I am looking forward to our next session.’
Talking informally to the supervisor the following week, he said:
‘I would advise [the trainee] to stay with these relational clues, because we now have something that we can work with.’
‘And her external situation?’
‘As therapists we can do nothing about this directly, but we can alter her reactions to it and also the inner tendencies that compel people (unconsciously) to search out disasters. What we need to do now is work to release her from her any compulsion she might have to repeat this situation in the future.’
In sum, as the trainees now feel they possess some kind of general diagnostic insight; they have a clearer understanding of the clinical steps to be taken. If Arya’s‘masochism’ is in part responsible for her compulsion to seek a sadistic‘other’, then the clinical task is now to expose to Arya the roots of this masochism through interpreting the‘material’ she presents, and through revealing the relational dynamics she manifests with the therapist. These clinical techniques, which are employed to repair through‘insight’ and the‘corrective relationship’ early relational deprivations, will also be used to treat the patient’s negative‘internal objects’ (i.e. her‘internal’ parents rather than her real parents’). These internal objects might be the real source of the masochism. These objects sabotage the patient’s ability to communicate and deal successfully with trauma. Thus with clearer diagnostic understanding comes the therapist’s conviction about how best to proceed clinically. The therapist now knows the aims of her clinical action—action, as I shall further explore in the next chapter, which opts to alter the patient’s inner-world rather than the social circumstances in which the person is embedded.
121 See the biographies on Freud by Webster (1995) and Ferris (1997).
122 Erich Fromm (1959) has eloquently explored all these factors in his book Sigmund Freud’s Mission which constitutes a psychosocial invest igation of Freud’s character.
123 See Standard Edition of the Complete Works of Sigmund Freud (1977) Vol. 20: 34.
124 For instance, Diana Russell’s influential study conducted in 1986 showed that sexual abuse occurring under the age of 18 affected al most 38 per cent of the female population. Her definition of sexual ab use was‘any kind of exploitative sexual contact that occurred between relatives’ (p.145). These are figures for the United States.
125 Freud’s views on patriarchy are well documented. I refer the reader to works by Webster (1996) and Gallop (1985).
126 This series of clinical supervision took place in early 2005.
127 See S. Johnson’s (1994: 21-54) discussion of‘character styles’ where ‘avoidant’ and‘schizoid’ personalities are discussed in depth.
128 Although this supposition is only hinted at in this transcribed session (the supervision speaks of masochism more generally rather than of Arya’s masochism) it was clear from my discussion with him after the session that he felt exploring Arya’s submissive and masochistic tend encies would constitute a large part of the work. This belief was made more explicit and accepted by the trainees in the following supervision session.
129 ‘Inspecting’ the relationship is a key diagnostic device in psychody- namic psychotherapy—in this case study we find two diagnostic devices at work: via inference on the one hand from the patient’s ma terial, and on the other from her relational style.