Overlapping Boundaries of the Work with Clients in Social Work, Psychotherapy, Somatic Psychotherapy and Psychoanalysis by Alison Ball.
This paper was presented by Alison to the Social Workers Psychoanalytic Interest Group meeting in November 2003.
Introduction.
In 2002 Juliet Hopkins wrote a paper titled “Failure of the Holding Relationship: Some effects of physical rejection on the child’s attachment and inner experience.” In this paper Hopkins explores aspects of the therapist’s provision of actual physical holding and body contact in child psychotherapy, for infants whose mothers may have been present but physically rejecting. She draws attention to the fact that Freud advocated abstinence and intended that “language and interpretation should suffice” (p.196). She notes however that Winnicott believed that, at times, actual physical holding was necessary although Winnicott qualified this when he said that it was only necessary when “there is a delay in the analyst’s understanding which he can use for verbalizing what is afoot.” In her paper Hopkins extends this notion and proposes that “there may also be a delay in the child’s understanding which needs to be bridged by physical holding”. Hopkins suggests that this may be the case with children who are avoidantly attached, when not to respond physically to them when distressed, may simply be repeating their rejecting experience of the mother. This she says might “nip a new beginning in the bud”. Hopkins backs this up with Main’s idea that what was of most meaning to an infant regarding physical contact with the mother was “her physical accessibility in response to his initiative”.
I have begun with this excerpt from Hopkins as a way of illustrating that the issue of active techniques and actual physical holding is sometimes explored in the psychoanalytic literature. In this paper tonight I will be using the hot potato of physical holding and touch to illustrate some of the points I will make, but this paper is essentially not about that. While being an extreme example, physical touch and holding is only one of the many supportive techniques generally eschewed by psychoanalysis. I have explored the issues of physical touch and holding to some degree in my Masters thesis on the subject. I have bought a couple of copies of the little book which Psychoz Publications very kindly published from my thesis. It is primarily a literature review of what is said about the issue in the psychoanalytic literature and, in this second edition has a little to say also about my view as a Somatic Psychotherapist.
But to come back to Hopkins. In my opinion, what Hopkins proposes makes eminent commonsense and it comes as a relief to me that she has opened up this area for possible discussion. In my mind I imagine that Hopkins knows that within psychoanalysis she treads on dangerous territory with an opinion here regarding the value of some degree of actual physical holding even though it is with children. Dangerous, I think, because if the door is opened in this way to legitimating some physical touch under some circumstances with some children then maybe the door is opened to questioning the rigid boundaries of no physical contact with adult patients. As will become clear in my paper tonight, unlike Hopkins and psychoanalysis in general, I think such thoughts about the value of actual physical holding cannot be limited to work with children.
The Issue.
My idea for this paper has undoubtedly come out of my own personal and professional experience. In broad terms for the purposes of this paper, the issue which particularly interests me in my work as a psychotherapist is that of the importance or otherwise of the concrete, of action and of actual and real life experience as against the symbolic, the verbal and the internal life of the patient. I mean this in relation to the way in which the patient’s material is viewed and also in what it means for the mode of working, the stance of the analyst and the range of possible interventions.
My ideas are by no means fully formed and writing this paper is one way for me to clarify the issues in my own mind. I hope that my explorations are of interest to you and do not come over as purely self indulgent. I do think that it is an issue which is likely to be of much more importance for the likes of myself who is a psychotherapist on the fringes of the psychoanalytic world. It is perhaps of less interest to Social Workers in the public sector where in general the work is accepted as more action oriented and legitimately deals with real life experience. As well, it is probably not so intriguing for those of you who are clear in you identity as psychoanalytic psychotherapists. So I hope you will bear with me.
Regarding my own experience;it is of being a mature age entry into Social Work in 1975 and 10 years of working as a social worker. From 1984 I began training in Somatic Psychotherapy. This included eight plus years of weekly psychotherapy with a senior Somatic Psychotherapist and concurrently 6 plus years of a particular form of massage for therapeutic purposes with another senior Somatic Psychotherapist. From there I had a gradual introduction to psychoanalytic ideas through supervision and reading, participation in a twice weekly psychoanalytic group for 5 years and beginning during that time, a Masters in Psychoanalytic Studies at Monash which included an infant observation and the minor thesis. I completed that in 1999.
My experience in general, has led me to a position where I greatly value my roots in social work and also the understanding of the bodily concomitants of psychic and emotional life which I gained from my training in Somatic Psychotherapy. But, over the years my excitement about and my experience of the value of psychoanalytic concepts in my clinical work, continues to fuel my quest for psychoanalytic knowledge as it feels for me like the deepest and most rich gold mine of on-going learning treasures.
My excitement comes from the fact that just because psychoanalysis concerns itself with the unconscious, the insights it gives into what might be going on in the clinical session is absolutely invaluable and I am continually excited and challenged by those insights. On the other hand, I also know that psychoanalytic ideas and psychoanalysts act as my super-ego and take the place in my mind of the judgmental God of my childhood. This is particularly so when I dare to question, as I am tonight, the absolute necessity of invariably striving to maintain the strict psychoanalytic stance of neutrality and abstinence on the part of the analyst. That stance precludes not only touch and actual physical holding but also support, education, advocacy, practical help, teaching of skills, advice and all of those actions, such as admitting someone to rehab or hospital, which Winnicott put in the class of “Management” (Winnicott 1975, 1958). He said that in these instances we act as the functioning ego for the patient and he thought that this was sometimes necessary.
However, Winnicott aside, with my psychoanalytic judgmental God inside my head I have extremely sensitive antennae for even the most slight raising of an eyebrow or stifled gasp of surprise or horror when I might venture to “confess” what, I think are to my God analysts, my sins of commission. Amongst my worse sins in this regard are those rare occasions when I decide that I might actually sit near to and physically hold a particular patient. Being so concrete is anathema to the psychoanalyst and most particularly when such action involves physical touch. So while I am talking about this please try to suspend your judgement so that my paranoia does not find fertile ground in the element of truth in what I fear is in your mind.
The boundary of “Real Psychoanalysis”.
As I understand it, in what I call “real” or “pure” psychoanalysis the base line focus of study is the inner world of the patient and the primary means used to facilitate the exploration of that world is through the relative neutrality and abstinence of the analyst in much the same way as was originally laid down by Freud (1915). This stance was spelled out recently by Milton (2001) who writes that it is not intended to “harden into rigidity and arrogance” (p.439) but it is intended to “allow disturbed aspects of the patient to come right into the room, with all their passion and irrationality, loving, hating, destroying and so on”. Milton goes on to say that not only the patient but the analyst as well, will be under constant pressure to “collapse” this stance largely because it is “counterintuitive and less socially acceptable”. However, even though collapses of the stance are inevitable the analyst must constantly “work it through in the countertransference, and re-establish its counter-intuitivness and complexity again”. All this is to enable the patient to find in the analyst “a truly surprising and new object” which is available for internalization and “who can bear and reflect upon the patient’s projections, rather than quickly disowning them.”(p.435)
The provisions of the environment that set the frame for this stance above are the set and regular time, the fee for which the patient becomes responsible whether or not they attend the session and the requirement that the patient free associate and speak out all that comes to mind. Within the session the analyst is guided by his own knowledge and countertransference and uses as his primary tool verbal interpretations based largely on the manifestations of the transference and aimed at elucidating the patient’s inner world.
In saying this I am not dismissing the fact that within psychoanalysis there are many, many shades in the spectrum- many versions of what constitutes psychoanalysis and of how theory is interpreted and used in clinical work. I have not for instance, gone into the very different approach of self-psychology or intersubjectivity. Outside these however, I think it is reasonable to say that the notion is fairly widely accepted that the maintenance of the analytic stance along with language, the verbal, the symbolic and the inner object or phantasy world of the patient is primary. On the other hand, the day to day real life experience of the patient or his or her real experience of attachment or say, of childhood trauma is not the major focus. Rather these are regarded as secondary, perhaps a diversion from the real work or as material that is to be interpreted so far as it relates to the transference or the patient’s inner world.
Some of this emphasis is also bourn out historically and currently. For example, if we think of how John Bowlby, himself a psychoanalyst, and his attachment theory was virtually shunned by psychoanalysis. Or we can take a current body of burgeoning knowledge; that of psychoneurobiology and what it tells us of the actual structures of the brain that form the mechanisms for emotional development and the capacity for language and reflection itself. This psychoneurobiology also tells us of the ways in which those structures and capacities are shaped by the day to day attachment experiences with the primary care-givers. As far as I can see, this knowledge and the consequent implications for all of us in the helping professions is of massive importance but to many psychoanalysts, this knowledge along with Attachment Theory itself, is regarded only as useful background knowledge but is not seen as belonging to “real” psychoanalysis.
In that pure view it means that, what is critical to the work is not the real life experience itself but what has the patient made of his or her experience in their own mind. It is out of this belief that say, Freud could decide to put to one side, real life sexual abuse; Melanie Klein could dismiss the fact that a child patient had an actual psychotic mother or mean that someone could have gone through years of psychoanalysis without the fact of their holocaust experience being addressed. I might say that it is also out of this belief that an experience of psychoanalysis can, under the best of situations, become one of the most profound and rich inner journeys and bring about deep structural change in the personality.
My Concerns and The Continuum.
For now I will concern myself with the issue of what the above view means for me personally and to my somatic psychotherapist colleagues, in relation to our mode of work, our stance and the interventions we might make. Psychotherapists such as myself may work in the more pure psychoanalytic way with some patients all the time and with most patients some of the time. We do this in spite of the fact that the pure view would say that if we do not begin in that psychoanalytic way with a patient we will have already compromised our neutrality and the method as a whole, making it very difficult to turn to it later in the course of the psychotherapeutic process.
We also work this way in spite of the purest view of all which I always recall hearing about in 1988 from Tristan Cornes; that of Robert Langs who thought that if patients were not ready for the pure psychoanalytic approach then they would be better off without any psychotherapy at all. But I really do not buy that. I think there are real questions to be thought about regarding the clinical value of rigidity or elasticity of boundaries as Ferenczi (1949) has called it. And these days, I am much more at home with the fact that I am not trained as a psychoanalyst.
What I want, is to be able to call on and use as seems appropriate to me, this more pure psychoanalytic mode, the knowledge, the theory and the understanding it gives of the workings of the mind. I also want to use it as a lens through which I can understand the meaning of the work that I do, and in this I often feel frustrated. To take my most provocative stance I think that the main problem with the raised eyebrow or the slight gasp when such matters as physical contact is mentioned, is that it can prevent any real thought being given to the issues for the client that are raised by such action and a frame that can allow for it.
It is difficult under the fear of judgement to consider whether there may or may not have been a wise clinical decision in taking the action and to really look at the consequences of taking that action. I once commented to someone that I was really sad that Winnicott did not write more about the work that he did when he actually held, touched and sometimes rocked patients. He has written just little snippets while one of his patients, the psychoanalyst Margaret Little wrote a couple of paragraphs about him working in this way with her. Winnicott had also written about how upset analysts got when he mentioned physically touching a patient, so I have assumed that he did not think it wise to write more on the subject. However, the person I was talking to said, “What makes you think he had anything more to say on the subject?” I find it incredible to think that such a critical issue would not be worthy of more thought, hence my pleasure in Hopkins again raising the issue.
I actually find that the pure psychoanalytic view is extremely seductive. Oh to be that pure!! But when I read Caper (1999) or Money-Kyrle (1978) or Milton (2001) then I am completely seduced and believe all over again that it is the only and the best way. And as I have said, I have that psychoanalytic judgmental God in my own head, so I always have questions for myself regarding the value of my psychotherapeutic work that is underpinned by my personal and social work proclivity for action but informed by psychoanalysis. I often wonder for instance, am I enacting something simply because I am unable to sit with the not knowing or the unbearable nature of what is happening with my client? Am I avoiding the negative transference or am I polluting or distorting the transference and thus precluding a depth of work that may ultimately have been possible if I had, in someone else’s words, said to myself “Don’t just do something, sit there!”
I also think about the purpose of my work. Are we there to try to facilitate people to function day to day and to help make their lives bearable? Do we think in terms of re-parenting, a corrective emotional experience, of healing, of curing, of fixing or of empowering people? Or do we believe as a modern day Kleinian psychoanalyst Robert Caper (1999) has said, that we are there solely to understand the patient and to enable the patient to understand themselves and to untangle their own internal objects from those of the analyst? In this view any cure or help or healing is regarded as almost co-incidental. As I have indicated I personally believe that some patients need one thing while others need something different but, on the whole I believe that all of us do a certain degree of reparenting and it is more a matter of how we go about doing that.
I think of this whole field of psychoanalysis, psychotherapy and social work as some sort of continuum, maybe an overlap of paradigms or simply, close knit specializations in the ways of working with clients or patients. I personally have always found myself somewhere in the middle of that continuum as I am sure have many of you. This Social Workers’ psychoanalytic interest group, in my mind, is an effort to acknowledge the value of the whole continuum but I often think about what are the real differences in the work that is done or is possible along and at either end of the continuum? I think, for instance of the undoubted value of the work I did in one off sessions or around the kitchen table with clients as a new social worker. But then I know I also felt limited at times and did not have the skills or the permission to address deeper layers. So I wonder, am I just talking about different layers and levels of work.
But I also think that maybe there are different modes of work that are most suitable for different patients or clients at different stages of their lives and which will be for those particular patients at that time the only way for them to get on with the journey toward those deeper layers. I think it is primarily about readiness. Winnicott thought that the decision about what a patient most needs is a matter of fine discrimination and I think there could be very fruitful work done in the area of real diagnosis that could determine which patients would profit best from what sort of help at what stage of their lives. Neither Winnicott nor Ferenczi for that matter, ever doubted that the essential long term goal was to thoroughly work through the material in the verbal and symbolic way of psychoanalysis. Winnicott, said that even though he had to sometimes “Manage” his patients and/or physically hold them, that it should not be confused with psychoanalysis. Ferenczi said, and I quote:
“Freud is right when he teaches us that it is a triumph for analysis when it succeeds in substituting recollection for acting out but I think it is also valuable to secure important material in the shape of action (my emphasis) which can then be transformed into recollection.” (1994 131)
Stages of Development
For the purposes of this paper, I would argue only that some patients are simply not yet ready for that total emphasis of psychoanalysis on the verbal and the symbolic and nor are some able to tolerate the strict psychoanalytic stance.
I do not and cannot know either, whether I, as a Somatic Psychotherapist, get referred to me patients who, as a group, are quite different from those who may be referred to a psychoanalyst. Personally I see many people who, I think, could just as easily have gone to a psychoanalyst or psychoanalytic psychotherapist. And, just as I know people who have had a long therapy with a Somatic Psychotherapist who then go into analysis, we sometimes get patients who have been in psychoanalysis of one sort or another and who then come to work with one of us. None of us can be all things to all people and we, as therapists can only offer what we can offer. However, over the years I know I and my colleagues have seen many clients who would never have gone near a traditional psychoanalyst or psychoanalytic psychotherapist, or who have been totally intimidated when they have. Alternately some of them may never get past first base in being considered suitable for psychoanalysis.
I would really like to know a whole lot more about why this is so and what it is that makes the difference in what either attracts someone to psychoanalysis or to my sort of psychotherapy. Milton (2001) gives some ideas she has about this matter. She thinks that some people just simply cannot tolerate “the sort of knowing and understanding that psychoanalysis offers.” (p.439). Others she thinks would not survive having their much needed defenses threatened. Alternatively of course, I think there are some who seem to almost “fall in love” with the psychoanalytic method and its emphasis on the verbal as some sort of defense.
I also wonder whether or not it is about levels of development of the mind of which the psycho-neurobiologists are researching apace. I think their ideas may eventually throw some light on why some people may do well with the more elastic frame of a Somatic Psychotherapist or alternatively do better in psychoanalysis.
On this subject, members of our association in recent years have been much interested in the research and writings of people such as Allan Schore, Peter Fonagy, Stanley Greenspan, Henry Krystal and Daniel Siegal. I do not pretend to have much understanding of this work but find it fascinating. Trying to get hold of it is not at all easy. However, when my colleagues and I read their work it makes a great deal of sense for us. We feel like we learned all this but here is a more credible theory base for our work. Perhaps too, it suits us well because it is very concrete and brings us back to the biological substrates of our psychic life. But I do believe that this research is invaluable and I think we must all allow it to influence our work and the way we view the material presented to us by our clients.
The work of the psycho-neurobiologists raises important issues such as the timing in the life of the infant, of the capacity to symbolize and the many hurdles that may get in the way of its development. Greenspan (1997), for instance posits six levels in the development of the mind. He thinks that psychoanalysis makes certain assumptions which may not be valid for a lot of adults. He writes:
“A particularly important (assumption) relates to the central role of verbal discussions of “represented” experience…. Verbal insight (he says), relates to the mind’s capacity for symbolic or representational thinking. It deals with the “content” of affects, wishes, fantasies and thoughts.”(p.44-48)
Greenspan says some people, get stuck at much more primitive levels in the development of the mind. They may never have developed the self regulatory capacities to contain overwhelming sensations. Many will never have experienced the empathic attunement which would allow them to have even put names to sensations and feelings let alone reflect upon their meaning. And if they cannot operate at these most basic developmental levels then they are unlikely to have felt the security needed to reach out to others and lay the foundations of empathy and love which in turn would allow the infant to recognize that there is intent behind the actions of themselves and others and to separate themselves from the other. All these stages must come before symbolic thought is really possible. Greenspan says of the fourth of these preliminary stages:
“Though symbols and language still lie far into the future, in the second half of their first year babies begin actively using gestures and expressions to participate in pre-verbal dialogue.” (1997 55)
It is only at Greenspan’s last two levels of development that symbolization comes to the fore in the good enough experience. This starts, he says with “increasingly complex, pre-symbolic communication” (p.60) where “the awareness of self and others for the first time involves social and emotional expectations.” (p.73). It is only now in the second and third year of life that Greenspan says:
“The child who has mastered the ability to create patterns of intent, behavior, emotion and expectation can move ahead … to the stage of true symbolic expression” …He or she can learn to deal with ideas as well as behavior and “grasp that one thing can stand for another, that an image of something can represent the thing itself.” (p.75)
He elucidates on this growing internal life:
“Wishes and intents are now represented internally by multisensory images. We begin to play out behavior in our minds before we carry it out. We learn to solve problems through thought experiments. We “picture” relationships, dialogues, and feelings, gradually creating new images to express our growing range of emotions. Together these images begin to create an inner world.” (p.74)
And finally the child who has had a good enough beginning can “make connections between affects and ideas (which) grows with maturity into the capacity to step back from and reflect on one’s own emotions, to deal with them at the level of their meaning rather than of the behavior that embodies them.” (p.86)
As we can see, prior to the development of any real capacity to symbolize or reflect verbally on one’s own or another’s emotions, wishes or phantasies, there is much potential for damage to have been done to the child’s psyche and capacities. In our experience, with some patients who are probably stuck at Greenspan’s most basic levels the whole of the work for years may be all about recognizing and then naming sensation in the body or contacting and knowing they have feelings. Or therapy may for a long time be all about learning to contain overwhelming feelings and sensation and then teaching the patient how to regulate that affect without numbing themselves or blocking it out with drugs or alcohol or other crazy acting out behavior. On the other hand some patients may be quite touch starved and/or unable to grasp anything through verbal means until they are actually literally in touch with themselves as an embodied ego. I am not suggesting that psychoanalysts do not do all of this. As I have said I think that we all do a certain amount of re-parenting at all sorts of levels.
However, I think it is in these areas of deficit that my middle of the road sort of psychotherapy may be at its most useful. I think that for some clients or patients, it is only after these deficits have been addressed and hopefully set on the road of development that they can tolerate the stricter privations of psychoanalysis. These people are often too frightened to lie on a couch, perhaps quite disintegrated, extremely concrete and non-verbal. The requirement of psychoanalysis to operate in the verbal, symbolic level is simply not understood by some of these patients, it is I think, developmentally out of their reach. They may have, as described by Marshall (2002), what the Self Psychologists and others would call Severe Self Disorders. Sometimes, along with more active techniques with some of these patients I find that what works best for me and for them is a more intersubjective/ self-psychological approach. In this what is critical is empathic attunement, mirroring, and a willingness to address therapeutic disjunctions and take responsibility for my own part in those disjunctions.
Conclusion
So for all the power of the judgmental God for me, in all these years I have never given over totally to the most tight boundaries of psychoanalysis and psychoanalytic psychotherapy. And in conclusion I want to mention two favorite arguments from the psychoanalytic literature against supportive techniques and in particular with one, physical touch. The first is Freud’s famous letter to Ferenczi (Gabbard 1995), regarding his elastic boundaries. This letter has been used by generations of psychoanalysts in favor of abstinence and worried about the “slippery slope”. (READ LETTER)
The second reference was first shown to me in 1988 and since that time I have been referred to this paper by Casement over and over and over again until it seemed to me that it must be the only evidence against physical touch in the psychoanalytic literature. In writing my thesis I found this was not quite so but, in fact very little else has ever been written on the subject by psychoanalysts.
In the paper Casement outlines a case where he was tempted to touch a patient and agreed with her that he would. Over the weekend Casement changed his mind and told her so. The resulting rage and fury from the patient made Casement decide once and for all that he would never touch a patient. This paper by Casement is used constantly as strong evidence against physical contact with patients as if it gives clinical proof that those feelings of rage would not have been expressed had he touched the patient.
However, it never convinces Somatic Psychotherapists who mostly shrug their shoulders as they think about the rage and fury expressed by their patients whether or not they have been physically touched. I think that hold her hand on that occasion or not, sooner or later he would have let her down in some other way and her rage would have been expressed anyway.
Winnicott has said just that. No matter how much we give to our patients, sooner or later we fail them and they make use of our failures. Ultimately, even if we wanted to be, we can never be the perfect substitute parents they long for. However, I find it also quite interesting that Casement himself wrote that it is likely that the patient’s rage would not have eventuated at all on that occasion if, in fact he had not actually at least been willing to consider the possibility of physically holding her. So I then wonder what may never be addressed if we have a blanket embargo on such action as physical touch, or advice, or support, or education of our clients.
Finally, I also think that we must bear in mind it is a decision to take action to even make an interpretation. Likewise, it could be thought that the decision to suggest that a patient lie on the couch or is to be seen four times per week or even to be seen at all as a patient is also taking action. But usually these matters are seen by psychoanalysts as simply setting up the frame and provisions of the environment.
That for me is fine but perhaps with some patients the way into the depths of their psyches is only found when the frame is a little more elastic. And just as those frame issues above can be thought about, interpreted and worked through, so in my experience, can the fact that I may have taken some more active or supportive measure. It is the “working through” that is always critical. And to end on a really provocative note, I think that primarily what the strict guidelines of psychoanalysis do is draw that line in the sand about what actions are acceptable and creates a very safe environment not only for the patient but also for the analyst.
References:
Caper, Robert (1999) A Mind of One’s Own: A Kleinian View of Self and Object. Routledge London & New York.
Fonagy, Peter (2003) The Development of Psychopathology from Infancy to Childhood: The Mysterious Unfolding of Disturbance in Time in Infant Mental Health Journal, Vol.24(3), Ps.212-239.
Ferenczi, Sandor (1994/1955) Final Contributions to the Problems and Methods of Psycho-Analysis. Karnac Books.
Ferenczi Sandor (1949). Confusion of the Tongues Between the Adults and the Child—(The Language of Tenderness and of Passion) International Journal of Psycho-Analysis, 30:225-230
Freud, Sigmund. (1915) Observations on Transference Love: Further Recommendations on the Technique of Psychoanalysis. S.E. X111. ps.159-173, Hogarth Press, London.
Greenspan, Stanley (1997) The Growth of the Mind: And the Endangered origins of Intelligence. Perseus Books Cambridge Massachusetts.
(1997) Developmentally Based Psychotherapy. International Universitites Press, Madison Connecticut.
Hopkins, Juliet (2002) Failure of the Holding Relationship: Some Effects of Physical Rejection on the Child’s Attachment and Inner Experience. Chapter 10 in Surviving Space. Ed. Bricks?
Marshall, A. (2002) Empathy and Therapeutic Touch in Severe Self Disorder. Unpublished Paper for 4th year Advanced Diploma at the Australian College of Psychotherapists Ltd. Petersham NSW.
Milton, J. (2001) Psychoanalysis and Cognitive Behavior Therapy – Rival Paradigms or Common Ground. International Journal of Psychoanalysis 82, 431.
Money-Kyrle,R (1956) Normal Countertransference and some of its Deviations in The Collected Papers of Roger Money-Kyrle (1978) Clunie Press, Strath Say, perthshire, ps.330-340
Siegal J. Daniel (2003) The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. The Guildford Press, New York, London.
Winnicott, Donald (1975, 1958) Through Paediatrics to Psychoanalysis. Karnac, London.