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About this book

This book identifies and explores what is missing in therapy practice, namely the 'craft' aspects of skilled psychoanalytic work: how theories and models are actually used in practice, what kind of reasoning is employed in conducting a session, and how interventions are composed and evaluated.

The text shows how these features of clinical thinking, which normally operate below the level of awareness, can be identified and explored in clinical practice, in supervision and in teaching. This clear and vividly written book addresses the needs of practitioners and trainees moving beyond beginner level to more skilled and attuned practice.

Table of Contents

Introduction

Introduction

Abstract
By common consent, it takes a long time to become a competent psychoanalytic practitioner. Comparing his experience of learning to become a psychoanalyst to his time as a medical student in a neurology hospital, Ronald Britten describes how his medical chief assured him that “the complexity of the clinical picture and the laboriousness of anatomical diagnoses would, through familiarity, become easily recognized patterns” (2003, p.x). And within just a few months of seeing a large number of different patients each week, this is what Britton found. By contrast, learning to become a psychoanalyst involved a far longer timescale:
The patterns in analysis that eventually become familiar are those of the transference-countertransference relationship. It takes many years, however, to see enough patients and hear about more for these patterns to become very familiar. (Ibid. p.x)
“In the meantime,” Britton adds, “the authority of the teacher/manual is relied on” (ibid. p.x).
Laurence Spurling

Obstacles to Development

Frontmatter

1. The Developing Practitioner

Abstract
Writing this book has been the outcome of something that has puzzled me for a long time. As an experienced teacher and supervisor of psychoanalytic practitioners of various types, it has been no surprise to find that students starting out in their learning and practice typically feel deskilled and incompetent. This is well known in the literature on how psychotherapy students develop. For example, in an extensive research study of over 100 psychotherapy practitioners of different orientations and at different levels of development, the authors found the beginning stage characterized by a state of mind they termed “pervasive anxiety”. They accounted for this as follows:
In our research study … we noticed the large theory-practice gulf experienced by the student. The student is immediately exposed to extensive new theoretical and empirical information and is then expected to perform adequately in practicum. The student at this level naturally lacks the competency to perform professionally and is generally painfully aware of it, even though much energy is invested in concealing it. (Ronnestad and Skovholt, 1993, p.398)
Laurence Spurling

2. What Gets Missed Out in Analytic Accounts

Abstract
In order to look at the kinds of accounts of analytic work that developing practitioners rely on, I have taken an example of practice from a textbook called A Short Introduction to Psychoanalysis by Jane Milton, Caroline Polmear and Julia Fabricius (2011). I have chosen this book as it gives a coherent and authoritative description of the psychoanalytic method, with particularly vivid clinical examples of good psychoanalytic work.
Laurence Spurling

3. The Babelization of Psychoanalytic Language

Abstract
We saw in the previous chapter how Gabbard and Westen, in their account of the therapeutic action of psychoanalytic therapy, referred to a “pluralism unknown in any prior era”. Tracing the development of psychoanalytic theory and practice since Freud is an intrinsic part of any psychoanalytic training. All beginners learn to construct a genealogy of the main psychoanalytic schools, with their key ideas and figures, and their relationship with each other. This map can be drawn in many ways. My own version is shown in Figure 3.1.
Laurence Spurling

4. Why Theory Does Not Inform Practice

Abstract
When I started out as a practitioner, and, later, when I began teaching psychoanalytic theory and practice, I assumed a very close connection between theory and practice. As a teacher, I saw it as my task to first teach students the main psychoanalytic theories, and then help them “apply” the theories to their practice. But over time, I started to question the value of this way of thinking. What does it mean to “apply” a theoretical construct, concept or framework to a live piece of practice? It is certainly not like applying a coat of paint to a bare wall. Furthermore, what, precisely, was being applied — was it a wholesale theory, or bits of a theory? Probably the latter, but which bits and how would they cohere? These questions led me to doubt the value of this way of thinking about theory and practice. But if theory was not there simply to be applied, what was it meant to be doing?
Laurence Spurling

Psychoanalytic Practice as a Form of Craft

Frontmatter

5. The Craft Metaphor

Abstract
The argument of the previous chapters is that if we are to know how to develop as analytic practitioners, we need to know what practitioners do rather than what they think they do or ought to do. In so doing, we have started to think in terms of different images or metaphors to describe psychoanalytic practice, for example in the previous chapter comparing analytic work to the construction of a new house and the practitioner to a craftsman or artisan.
Laurence Spurling

6. Analytic “Rules” and Craft Practice

Abstract
One of the biggest sources of the intense and debilitating anxiety of the developing practitioner concerns the application of analytic “rules”. That is, practitioners often feel (or so they tell me) that they are not working in accord with these rules. Two in particular are often mentioned. The first is that they should not be imposing their own ideas on the patient, or determining the course of the session by choosing a focus for the work. The second idea, clearly related to the first, is that they should not be trying to “know” something about the patient, as that would seem to contradict the principle of “not-knowing”, which they have taken as a fundamental aspect of the analytic approach.
Laurence Spurling

7. Countertransference and Containment Revisited

Abstract
In the previous chapter, I looked at several so-called rules of analytic practice in terms of the craft skills needed to implement them. In this chapter, I will do the same thing with two of the most widely used clinical concepts, countertransference and containment. Since its introduction in the 1950s as a distinctive way of thinking about certain aspects of practice, the term “countertransference” has now become part of the psychoanalytic canon. It means simply taking one’s emotional reactions as a source of knowledge rather than as obstacles to the work. In her seminal paper “On Countertransference”, published in 1950, Paula Heimann observed that many analytic students felt the right way to work was to cut themselves off from their feelings, which were perceived as a “source of trouble” in the work: “If an analyst tries to work without consulting his feelings, his interpretations are poor. I have often seen this in the work of beginners, who, out of fear, ignored or stifled their feelings” (ibid. p.81)
Laurence Spurling

Describing the Craft: Examples from Practice

Frontmatter

8. A Session from an Intensive Therapy

Abstract
In the first two parts of the book, I have argued that many accounts of analytic work miss out an essential part of the process — the implicit clinical thinking that goes on in the background. This is what I shall try to describe in the next two chapters by looking at a piece of my own work in this chapter and the work of a colleague in the next. The question I will address is this: what would a description of ordinary clinical work look like if the practitioner’s clinical thinking is foregrounded? This means focusing on what normally remains hidden or obscured: the processes of practical and theoretical reasoning, the invocation of working models, the rhythm of problem-setting and problem-solving, the composing of interventions and all the other operations carried out which “produce” the practitioner’s way of working.
Laurence Spurling

9. Two Sessions from a Brief Therapy (with a Commentary by Dorota Jagielska-Hall)

Abstract
In this chapter, I will attempt to reconstruct the clinical thinking that has informed the work of a colleague, Dorota Jagielska-Hall, who is a qualified and experienced clinical psychologist. I have taken the first two sessions from a 16-session therapy which she conducted under my supervision in a National Health Service specialist psychotherapy outpatient department in which I work. In writing the account of the two sessions, I have relied on Dorota’s process notes of the sessions described. All the sessions were taped (apart from the first one) and Dorota wrote her notes after listening to the tape of that session. I have read Dorota’s notes from all of the sessions and listened to tapes from three of the sessions (although not of the two sessions described in this chapter). On the basis of this comparison between tapes and notes, I considered the process notes to be a reasonably reliable account of the sessions described, in the sense that they give an account of much of what was actually said between Dorota and her patient (certainly a much more reliable rendition than one dependent solely on memory and retrospective notes). Furthermore, the notes are written in a particularly open and transparent way, which leaves many traces and clues for a reconstruction of Dorota’s clinical thinking.
Laurence Spurling

Developing the Craft: Examples from Clinical Discussion, Supervision and Teaching

Frontmatter

10. Thinking About Interventions: An Example from a Clinical Discussion Group

Abstract
In the two previous chapters, we looked at examples of clinical work over a whole session or group of sessions in an attempt to reconstruct the clinical thinking of the clinician. We drew on the “comparative instrument” designed by the EPF Comparative Methods Working Group in looking at how each clinician’s internal clinical template is constructed. This involved looking at each intervention described in the sessions in order to decide on their purpose.
Laurence Spurling

11. How Working Models Inform Practice: An Example from a Supervision Group

Abstract
Traditionally in psychoanalytic teaching, supervision has been seen as a way of passing on the psychoanalytic tradition and helping the supervisee apply this correctly in their work. However, all too often this can lead to what Juan Pablo Jimenez, writing about clinical discussion groups, calls “a dialogue of the deaf”:
In presentations of material, the persons who present it are not usually concerned about explaining the reasons for which they intervened in the way they did and the discussant is not interested in elucidating the presenters’ reasons. Consequently what is produced is a dialogue of the deaf, who never meet on any shared ground, which thus leads to misunderstandings and a growing babelization. (2009, p.235)
But if one shifts perspective to seeing supervision as a way of acquainting the student with their own technique, their way of evaluating their own work and how they come to clinical decisions, the supervisee will then be in a better position to learn to supervise themselves. This positions the supervisor more as a participant in a dialogue than as an authority figure.
Laurence Spurling

12. Developing One’s Own Way of Working: An Example From Teaching

Abstract
If we think of the capacity to become more aware of one’s implicit clinical thinking and how this informs our practice as a key part of developing as a psychoanalytic practitioner, what might the implications be for the formal teaching of psychoanalytic practice? Traditionally, psychoanalytic trainings have emphasized the importance of unlearning. This means the student, especially at the beginning of their training, needs to give up on all previously acquired knowledge or methods of doing therapy which involve leading the patient towards any pre-determined ends. Only then will the trainee be in a position to acquire and maintain an analytic attitude, the capacity to listen in an unfocused way to the patient’s unconscious communications and to the unfolding of the transference (see Introduction, “The prevailing view of analytic practice”, pp.2–3).
Laurence Spurling

Concluding Remarks

Abstract
In a paper called “On Becoming a Psychoanalyst”, Glen Gabbard and Thomas Ogden reflect on the developmental task of how to become an analyst “in one’s own terms”. They remark that few analysts feel they know what they are doing when they complete their formal training: “we strive to find our ‘voice’, our own ‘style’, a feeling that we are engaging in the practice of psychoanalysis in a way that bears our own watermark” (2009, p.311). In order to illustrate this, Thomas Ogden describes how he came to notice, for a period in his work with one particular patient, that he would preface his remarks with the word “well”. When he thought about this, he realized he had adopted this mannerism from his first analyst. This led him to reflect on his relationship to authority and tradition. Gabbard and Ogden describe this relationship as one of tension between “inventing oneself freshly” and “creatively using one’s emotional ancestry”:
In the process of becoming an analyst, we must “dream up” for ourselves an authentic way of speaking that involves disentangling ourselves from our own analyst(s) as well as past supervisors, teachers and writers we admire, while also drawing on what we have learned from them. (ibid. p.315)
Laurence Spurling
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