Book Review: Further Learning From the Patient. The Analytic Space and Process by Patrick Casement

Portrait of a Patient in Saint-Paul Hospital – Van Gogh

I wrote this review as part of a diploma course in Psychoanalysis a number of years ago. Two other reviews written for that course of ‘Understanding the Borderline Mother‘ and ‘John Bowlby & Attachment Theory‘ have proved incredibly popular. Hence I’m posting this review as it might be of use to some readers, especially therapists interested in countertransference based diagnostic and treatment approaches, often at odds with more interpretative approaches. A review of Casement’s first book is available here.

Review: Further Learning From The Patient.

Casement’s second volume represents an examination of working with transference and countertransference (CT) as the means to understand a client’s current experience, early development. The book also deals with the use of countertransference to re-parent the client through containment and interpretation. Casement fuses this emphasis on CT with a person centred approach to psychoanalysis.

Casement begins by outlining the development of many of the ideas he discussed in depth in Learning From The Patient (Casement, 1995); including trial identification, the internal supervisor, and the mechanics of transference.

Early theological investigations disabused Casement of the idea of a single unitary and accessible truth. The discomfort of not knowing (cognitive dissonance) blinds us to the contradictions at play in the world. For Casement, dogmatism suffuses psychoanalytic claims to understand the mind. Transference occurs because of a mirror between internal or external reality and past experiences (pp7) – hence it is not always merely the patient’s projection, but also can reflect aspects of therapists own behaviour and self presentation.

Casement was initially wary of interpretation – intuiting that it could mask the client’s own experience; and this led him to develop a more client centred form of interpretation. (pp6)

Ignorance = Fear – Keith Haring

Casement classifies transference as ‘unconscious hope’ (pp7) a signal reaching from the client indicating their disordered thinking and desire for understanding. But is unconscious transference a kind of communication? It can certainly be understood as communicative (and informative as to the client’s prior experience), but given that transference is a part of everyday life (outside the therapeutic encounter) it is perhaps merely indicative of learned role / behaviour in response to a perceived aspect of another person or situation – rather than an effort at communication. Casement distinguishes incidental and intentional communication (pp110). Hope (the assumption of environmental reliability) arises initially from the meeting of infant needs during the omnipotent stage of development. In client work, it’s always present (even if repressed by the client) and may need to be held for the client by the therapist when its dissonance with felt despair is too great (although the clients negative emotions must also be felt and tolerated simultaneously) (pp122).

Casement distinguishes between client developmental needs (appropriate containment and empathy) and libidinal demands (satisfaction of desire – more practical needs) (pp91). He differentiates client needs (for appropriate therapist response and containment) from their attested wants – e.g.: for answers, control, power over the analyst (pp114).

Grief Head Boquilha – Amadeo De Souza-Cardoso

I question Casement’s belief that clients seek a firmness in reaction to their anger (pp115) – rather than an acknowledgement of what is being communicated by it – the intolerability of the internal experience. Although I do find his acknowledgment of the secondary benefits of social deviance / attention seeking / cruelty useful (pp123).

Casement distinguishes internal supervision (as a critical, pre-conscious way of thinking about ones contribution to the session) from an internalised supervisor (the introjected advice, opinions and attitudes of a real world supervisor) (pp9, 15).

Casement argues for the value of maintaining openness ‘not knowing’ alongside expertise. This is an openness to the client’s dynamic reality in the individual session, rather than theory or existing knowledge alone. Interpretation is something to be tentatively, playfully worked towards in collaboration with the client, (pp12) gradually scaffolding their disclosures (pp28), avoiding the appeal of trite, theoretically driven, falsely certain universalities (pp17). A client’s reaction to interpretation is as important as the clues that drive it initially – and in this way mistakes can become beacons to new understanding (pp20). Clients provide clues to their experience in the therapeutic relationship, and their emotional response to interpretation that Casement (citing Lands) describes as ‘unconscious supervision by the patient’. They may employ ‘communication by impact’, acting so as to provoke unacknowledged, or inexpressible feelings through the therapist’s projective identification (pp24). Interestingly, Casement notes that even accurate interpretations can serve as intellectualisations blocking engagement, when provided to the client rather than discovered with them (pp28). However, the example he provides – of a client’s repressed memories of abuse being screened by oedipal phantasy, is not the support for psychoanalytic theory Casement attests. Rather it evidences real abuse: The seduction hypothesis abandoned by Freud (Robinson, 1993), substituted for by the concept of the oedipal complex.

Interpreting the Torah – Alexander Roitburd

For Casement the role of the therapist is not necessarily a re-parenting one – in the transference clients can need the therapist to take the part of negative presences in their life. This can be an object relation that is bound, and indeed needs to fail – for that primeval failure to be recognised and overcome. However, the therapeutic encounter can become a replication of earlier dynamics, providing an opportunity for reconciliation of inadequate parenting (pp26). The client may use the therapist in a variety of ways – as a whole or part object, as subject of positive or negative transference, as a container and so on (pp105).

Therapist countertransference is both the creation of the client, and involves the contribution of the analyst. Others have proposed a variety of therapist contributions to the countertransference, as well as admixtures of client and therapist material. These include classical CT (the therapists own neurotic material), complementary identification (identifying with the clients disavowed / projected material), concordant identification (identifying consciously or unconsciously with the id, ego or superego of the client), indirect countertransference (introjection from supervision and other third parties), institutional countertransference (introjecting an institutions relation to a client), stylistic countertransference (self presentation effects), and ecological countertransference (aspects of the therapists own life) (Geddes & Pajic, 1990); any of these forms of countertransference could potentially be ego syntonic or dystonic for the client.

Interpretation

Hair Washing – Stefan Luchian

In Casement’s work with a child client, he initially expresses an admirable reluctance to provide the child with a readymade ‘symbolic language’, seeking to remain more reserved about unconscious assumptions. The parents had already labelled their prepubescent child ‘very sexual’, and compounded this interpretation by framing her behaviour in the context of seduction. At the same time, her mother behaved in a rejecting manner, while her father overindulged her. Casement employed play therapy with this client; despite his avowed reluctance to interpret, his (primarily sexual) analytic hypothesis fly thick and fast. Although he holds back some interpretations, Casement does provide the child with a theoretical frame – through his selective focus on sexual interpretations, and his provision of a narrative of secret collusion (pp39). The issue with this kind of interpretation is that humans cannot help but recognise patterns – even where none exist, and clients (especially children) are likely to provide a narrative that meets the (consciously and unconsciously expressed) expectations of the interpretive encounter. In this client’s disclosure we can see themes of penis envy (pp35, 37, 39), vagina dentata (pp39), camouflage (pp41), masculine violence (pp 39, 40) and so on, but it’s important to remember the selective, interpretative nature of Casements account; and to acknowledge his ‘coaching’ of his client through constant tentative interpretations (of her drawings).

Rather than working with the client’s parents to directly address her exclusion within the family system, Casement is preoccupied with discovering the hidden content of her disclosures. Thus there is a co-production of meaning at work – as seen in the mutual letter game Casement and his client develop (pp46); in which Casement serves not merely to understand, but despite himself, to build a context – through selective reflection, suggestion (e.g: theme of ‘secrets’ which could be revealed in confidence), fixation (e.g.: on genitalia), tentative interpretation etc. Another therapist might have focused on – and hence elaborated, other aspects of the client’s fantasy world – for example the archetypal figures of the threatening ‘great condor / eagle’ (pp54), or the cared for ‘coal baby’ (pp56). Casement by contrast, focuses on eliciting explicitly sexual / gender related themes with the client – even as he gradually comes to accept her need for age appropriate freedom and ‘messy’ regressed escape from control, and simultaneous desire for appropriate boundaries (pp50, 56, 58). Casement finds success when he models behaviour (playing word games), rather than directing it; developing the creative alliance in a way that’s more productive than interpretation (pp46, 48). His fixation on penis envy, and his interpretation regarding his client’s confusion over her own gender / family place, eventually produce the desired response in the child – who begins to respond in the terms and through the metaphors Casement has provided. This does not convince as an archaeology, but rather suggests an identification by the child with Casement’s own projected material (pp61). This creates a desire for the child to please the seductive partner, by producing the reading behaviour that he desires – as demonstrated when she later makes Casement’s baby ‘her baby’ (pp63). Casement disagrees – suggesting that he has gradually come to follow the child’s lead in addressing (explicitly sexual) matters that he was initially uncomfortable with; ultimately allowing the child to explore her own gender, and providing a space for reading ‘after her own more urgent needs had been attended to’ (pp63).

Communication Lines in 1004 Flats – El Anatsui

Countertransference Impact

Casement uses another case to examine client communication by impact, and how to differentiate neurotic from diagnostic transferences (pp65). Such communication cannot be interpreted in isolation, but must triangulate with explicit client communication (pp66). Casement details the treatment of a client horrendously abused by the medical establishment. Casement’s CT feelings concerned boredom at her rote deadened disclosures – and he identified this as a ‘role responsiveness’ re-enactment of the clients relationship with her withdrawn father. Rather than directly disclosing, and further distancing – Casement raises the issue from the client’s perspective – using trial identification. Later Casement identifies an erotic interest in the patient, hypothesising that it is the clients disowned erotic feelings, intruding on the session; he confirms this by asking the client about her sexuality (rather than disclosing his own feelings), unlocking a series of connections between sexuality and punishment (pp73). This case study provides not only a pragmatic examination of how to work from CT impact without disclosing inappropriately; but also a startling illustration of the biomedical treatment (and iatrogenic worsening) of hysteric symptoms.

My grandparents, my parents and me – Frida KahloTraumatic Transference

Discussing trauma, Casement highlights that it can be gradual or one trial learning, and aroused in the here and now of the session through associations with the original event or circumstances (pp 76). Casement’s use of the concept of signal anxiety, parallels the idea of the conditioned stimulus on behaviourism (Wyricka, 2000). What differentiates this psychodynamic account is that the anxiety can be provoked through unconscious associations with the original trauma (which can itself result from unconscious associations), rather than simply through direct replication of traumatic circumstances / stimuli (pp79). Casement identifies the differences between trauma and current transference as what make the transference endurable (and catharsis possible) (pp79), and hence inadequate / overly identified transference may block the work (pp81). Rather than attempting to ‘re-parent’, the therapist should maintain both the ‘as if’ transference illusion, within boundaried containment (pp82). In Casement’s previous volume (Casement, 1995), he revealed the extent to which he would risk client psychosis to avoid tempering this illusion (pp87) – which he sees as potentially retraumatising (along with potential similarities between traumatic childhood treatment and the analytic encounter). All this points out the difficulty of working in the transference – the necessity of being sensitive to parallels between inadequate parenting and the therapy, without seeking to reactively correct them. Casement argues against the ‘corrective emotional experience’ recommended by Franz Alexander, suggesting that the ‘good’ object in therapy is not reparative but needs to survive the client originated attempt at destruction described by Winnicott (Winnicott, 1971). It’s questionable whether this complete rejection of the concept of corrective emotional experience, and the implied necessity of abreaction / re-living of trauma as always necessary or sufficient to recovery (Lopez, 2011).

Casement discusses the intersubjectivities of therapist and client, both laid down (according to Casement) in early childhood experience (pp126). The therapeutic relationship hence acts as a re-enactment of the clients early disturbed object relations, aspects of the therapist related through in the transference as the previously failing care giver. If supportively contained, accurately trial identified and interpreted and provided sufficient boundaries, the client can find in the analysis the reparative relationship needed to heal early trauma (pp129), passing from antagonism, to dependence and finally independence – transcending the need for the therapist (pp131). Casement’s recognition that the therapist’s counter-transference can block this process, if unaddressed, is valuable.

My Grandparents, My Parents and Me – Frida Kahlo

Usefulness

By rejecting the ‘corrective emotional experience’, Casement distances his analytic technique from the intervention styles of behaviourist therapies – and their demonstrable efficacy in certain domains of psychopathology (Butler, Chapman, Forman, & Beck, 2006). However Casement’s issue seems to be more with the alliance damaging, transference provoking technique advocated by Alexander, than with the corrective utility of new emotional / social experiences themselves (provided they are client directed). Contemporary cognitive therapies frequently work to provide clients with the tools to meet their own needs – and while this can potentially fixate on the presenting problem, it also provides an agency and a willingness to accept client directed growth, lacking in a Casement’s singular focus on transference as a clue to developmental trauma which needs to be reworked. Casement tackles this contradiction directly when he talks about a case where therapist affirmation had helped solve a client’s immediate depression and purposelessness, but failed to tackle her deeper existential dilemma – by providing a ‘false self’ image that was not derived from the client (pp101). However, psychoanalytic interpretation too can provide a frame or self for the client that may not be wholly authentic. Further, as pointed out in my previous review of Casement’s first volume, there is a fallacious essentialism at work here – an assumption that there is a singular ‘true self’ (hypothesised by Winnicott), existing apart from influence and capable of destruction (Foucault, 1984).

Self Portrait in distress – Edvard Munch

Casement advocates waiting until the therapeutic alliance is developed to begin transference interpretations (pp95); therapists need to provide appropriate (emotional and physical) space, without impingement on or role-responsiveness to the client. Further, insight is of limited utility until it is experienced as transference (pp103). This is an important point, and I feel provides the powerful advantage of impact / transference based object-relations approaches. Emotional experience, rather than intellectual comprehension, is the domain of change and insight. The part I find challenging is the attested efficacy of interpretation during emotional experience (pp104) – isn’t this merely confining emotional reality into a new configuration of the symbolic order? Casement himself questions the power of naming (pp108) and the importance of the content of interpretation vs the communication of having understood the client (pp109), even while arguing for its utility. However research does seem to indicate the efficacy of interpretation, even apart from the other therapeutic aspects of analysis (the real relationship etc) (Høglend et al, 2008).

I found a number of Casement’s incidental ideas to be illuminating. For example, his definition of self-respect, self-esteem etc, as products of ways in which others have related to the self (pp98). This is another way of stating Roger’s utility of unconditional positive regard (Rogers, 1961) – in providing a space for reflection and acceptance of unmanageable communicated emotions often absent in the primary parenting relationship (pp99). Casement’s reframing of ‘negative therapeutic reaction’ in terms of ‘pain of contrast’ provides a way of understanding why clients might reject new positive experiences (pp106).

In treating narcissistic wounds, Casement recommends attending to the meaningful content of the symptom, rather than attempting to treat its abrasive aspect (out of intolerant defensiveness) – which may re-enact happened in the parental relationship (pp132). Narcissism as a defensive position, may occlude internal self loathing, and be perceived as un-repentant, resulting in projective identification criticism from the therapist – worsening defences / re-wounding the client (pp133).

As with Casement’s previous volume, there were moments when his treatment of clients in his care seemed worrisome. For example in his physical restraint of a misbehaving child client and his exclusive focus on sexual interpretations of the child’s play behaviour. With an adult client Casement recounts the uncovering of ‘repressed’ memories of sexual abuse (pp135) – which is an enormously problematic area, vulnerable to the construction of detailed false memories based on unconscious therapist suggestion (Rubin, 1999).

Conclusion

Marionettes – Raphael Kirchner

As with Casement’s first volume (Casement, 1995) there is a strong contradiction between his explicitly stated desire to ‘follow’ the client in interpretation, and the leading behaviour demonstrated in his case studies. However, Casement’s explanation of handling countertransference impact is a practical guide to handling the extreme emotional restimulation and regression that can occur in therapy.

This volume clarifies concepts established in Casement’s first book, such as the nature of the internal supervisor, the efficacy of transference work, and the methodology of trial identification.

For me, Casement’s approach is broadly a person centred psychoanalysis. Trial identification mirrors Rogerian empathy, while acceptance is another way of framing unconditional positive regard, and interpretation of the CT impact / the acknowledgement of mistakes in therapy are both example of deepening the therapeutic alliance through congruence. The innate orientation towards growth in humanistic models, is reflected in Casement’s belief that the client continually seeks to meet ‘unmet needs’ (pp105) through ‘unconscious hope’ (pp111). Finally, the client directed nature of person centred therapy, is mirrored in the focus on the clients own search for ‘therapeutic experience’ through transference (pp107), and the importance of tracking the client’s needs, intercommunicative style and experience of the therapeutic process.


References

Butler, A. C., Chapman, J. E., Forman, E. M., Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clinical psychology review, 26(1), pp17–31.
Casement, P. (1990). Further Learning From the Patient. The Analytic Space and Process. Routledge: London.

Casement, P. (1995). On Learning From the Patient. UK: Routledge.

Foucault, M. (1984). The Foucault Reader. UK: Pantheon.

Geddes, M.J., Pajic., A.K. (1990). A multidimensional typology of countertransference responses. Clinical Social Work Journal, Vol. 18(3), pp257–272.

Høglend, P., Bøgwald, K.P., Amlo, S., Marble, A., Ulberg, R., Sjaastad, M.C., Sørbye, O., Heyerdahl, O., Johansson, P. (2008). Transference interpretations in dynamic psychotherapy: do they really yield sustained effects? American Journal of Psychiatry. Vol. 165(6), pp763-71.

Lopez, G. (2011). Why verbal psychotherapy is not enough to treat Post Traumatic Stress Disorder: a Biosystemic approach to stress debriefing. Body, Movement and Dance in Psychotherapy, 6(2), pp129–143.
Robinson, P. (1993). Freud and his Critics. USA: University of California Press.

Rogers, Carl. (1961). On Becoming a Person. Great Britain: Constable.

Rubin, D. C. (1999). Remembering Our Past: Studies in Autobiographical Memory. UK: Cambridge University Press.
Winnicott, D.W. (1971). Playing and Reality. UK: Tavistock Publications.

Wyrwicka, W. (2000). Conditioning: situation versus intermittent stimulus. UK: Transaction Publishers.

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