"Crisis
at Adolescence", Edited
By Sally Box, with Beta Copley, Jeanne Magagna & Errica
Moustaki-Smilanski. 1994. Aronson. Pp.268. £32.00
This
is the updated version of Box et al’s seminal work on a psychoanalytic
way of working with Families This home page announcement is for
patients, professional carers or interested lay individuals who would
not otherwise have access to this book, or know where to get it.
This book is a reissue of the only substantial British account of a
psychoanalytic model of family therapy. The new edition has been updated
and has three additional chapters. It is therefore, even more than
before, essential reading for anyone interested in applying
psychoanalytic understanding to their work with families. The book
consists of a collection of chapters by authors who are or have been
members of the psychoanalytic family therapy workshop in the Adolescent
Department of the Tavistock Clinic. For this reason much of the clinical
material concerns families of adolescents, and examines the impact of
adolescence on the dynamics of family life. Within this framework the
richness and range of the clinical illustrations is astonishing. There
are accounts of work with families, couples and professional networks.
Problems include mental illness, bereavement, suicide, and there is a
fascinating chapter by Roger Kennedy and Jeanne Magagna which describes
work with a family in the aftermath of a murder.
For me
the most important unifying feature of this book was the issue of change
in families. What sort of change are we aiming for and how are we going
to bring it about? These are pressing questions for social workers, and
are discussed in a helpful epilogue by the editor, Sally Box. This model
of family therapy, which emphasises change from within, is in stark
contrast to the facile prescriptions for behavioural change found in so
many child protection plans. This view is not a theoretical preference,
but a practical one. There is a growing body of evidence that
participation in psychotherapy can break intergenerational cycles of
child abuse. (e.g. Egeland et al 1988). The absence of both literature
and training opportunities for those who want to work psychoanalytically
with families is in some ways a curious one. Freud’s case histories
are full of fascinating accounts of his patient’s families. Yet until
recently psychoanalytic concepts have been applied mainly to the
understanding and therapy of groups and institutions. The book contains
two useful introductory chapters which describe the history of family
therapy, including the more recent attempts to develop a psychoanalytic
model. It does seem that modern British psychoanalytic concepts have
lent themselves particularly well to work with families. These
influences have crossed the Atlantic in the work of the Scharffs and
Zinner & Shapiro. The authors of "Crisis at Adolescence"
acknowledge a debt to the work of Melanie Klein and her followers,
particularly Wilfred Bion, as well as those analysts who have applied
these ideas to groups and institutions. Reference is also made to modern
work on narcissism and borderline states, although this theory is not so
clearly integrated into the clinical and theoretical discussions.
Klein’s
concepts of an unconscious world of internal objects and projective
identification are particularly helpful in understanding the dynamics of
family life. When a couple come together to form a family, each brings
not only their objective experience of family life, but an unconscious
world which has been so beautifully described by Joan Rivière as,
"..A world of figures formed on the pattern of the persons we first
loved and hated in life, who also represent aspects of ourselves.."
(Rivière 1952). If this internal world is filled with figures who are
damaged or in conflict this is a source of what may be felt to be
unbearable emotional pain. One way of dealing with this is by
externalising the difficulties. The mechanism by which this takes place
is projective identification, an unconscious phantasy that a part of
ourselves can be split off and located elsewhere. However, as Bion
points out, this phantasy can have a very real effect on the recipient.
In some ways this is the familiar concept of the ‘scapegoat’, but
Klein’s concepts allow us to conceptualise family relationships in a
more complex way, as the re-enactment of the internal conflicts and
shared unconscious anxieties of the family members. In order to get in
touch with these issues the psychoanalytic family therapist pays
attention not only to what the family says and does, but also to their
own experience of the family, their countertransference. This is
described very clearly by editor Sally Box. (page 72), "The task of
the therapist, then, is to be available to play a part in his
patient’s phantasy scenario, but rather than enacting the projections
as he is implicitly invited to, it is to monitor his minute by minute
experience in order to try and understand what part he is being required
to play and to transform it..". The process whereby the
transformation takes place can be understood in terms of Bion’s
concept of containment. The therapist receives the unbearable experience
The therapist receives the unbearable experience and processes it in
their own mind, so that it can be returned to the family in a
‘detoxified’ form. Hopefully repeated experiences of this sort will
enable the family to internalise this containing function for
themselves, and manage painful feelings which previously had to be split
off and disposed of. It seems to me that this approach is more truly
‘empowering’ than those models of family work where the therapist
stage manages structural change. It will also be clear from this rather
laboured account of mine that psychoanalytic family therapy is both
conceptually and theoretically demanding for the therapist, and this may
be even more so in families of very young children where the family
scene may be further complicated by play and other sorts of activity.
Not all
the chapters in this book are exclusively about family therapy. In
keeping with their psychoanalytic perspective the authors are open to
the possibilities of individual therapy for parents or children, or the
possibility that this approach will not suit every family. The
exploration of these possibilities makes fascinating reading,- Beta
Copley’s chapter, for example, on ‘Introducing families to family
work’. These types of decisions are often made, if not so self
consciously, by field social workers. The chapter on ‘Making a space
for parents’ by Anna Dartington and Jeanne Magagna illustrates what
powerful feelings are aroused for parents when their child is seen
separately even under relatively benign circumstances. In a book of such
richness it seems churlish to complain, but I was sorry there were not
more glimpses of families where there were younger children as well as
adolescents. In this area the value of the psychoanalytic model in
understanding the symbolic significance of play has obviously a great
deal to offer. The sensitivity of young children to family dynamics is
quite astonishing, and this may be an important route to getting in
touch with feelings that are sensitive issues for the parents. There is
a vivid example of this in the chapter by Margot Waddell, in which she
describes how a very young baby monopolised the therapists’ attention
in a very similar manner to his parents. It was the therapists’
comments on the child’s behaviour which allowed the father to look at
this aspect in himself. It is usually accepted without question that
family therapy works best if there is more than one therapist. Yet the
clinical material in this book illustrates the considerable demands that
working in this way makes on the therapists’ mutual trust and capacity
for insight, particularly when examining the different
countertransference feelings they pick up from the family. There is,
however, a very refreshing chapter by Beta Copley on the advantages of
being a single therapist. In view of the increasing number of small,
single parent families that many of us are seeing, and shrinking staff
numbers in many clinics, this approach seems to me to have a lot to
recommend it, particularly if there is good supervision or a regularly
meeting workshop.
There is
one chapter in this book which extends some of these ideas outside of
families and into the professional network. ‘Re-enactment as an
unwitting Professional Response to Family Dynamics’, by Ron Britton,
describes how different professionals and even institutions can be drawn
into a re-enactment of family dynamics. He shows how this re-enactment
can serve as a substitute for ‘realisation’ or real change and
development. As he puts it, the cast changes but the plot stays the
same, and since the activity appears to be ongoing professional business
it may be some time before the real situation is recognised. Anyone who
attends child protection conferences will be extremely familiar with
this phenomenon, often expressed through violent professional
disagreements, inappropriate inertia or precipitate action. At a case
conference I attended recently there was concern about a father’s lack
of involvement in the family. At this point the father’s psychiatrist
walked out saying that he had nothing to contribute! Recognising such
phenomena can enormously increase our understanding of a family, in
particular our awareness of what cannot be accepted or borne within the
family itself. As Britton points out, this may lead to painful or
necessary decisions being taken, or accepting that only small changes
may be made. At this point I would like to return to my earlier
observation about the scarcity of literature or training in family
therapy in Britain. (The situation seems to be rather different in the
USA). Is this simply because the major training institutions such as the
IFT are mainly systemic in their orientation? Is it to do with the
technical difficulties of this approach? My own view is that this is
related to the pressure on all therapeutic and social work agencies for
ever briefer forms of intervention. Systemic Family Therapy, Cognitive
Analytic Therapy and many other techniques offer the prospect of
relatively quick change. Yet those of us who work psychodynamically with
individuals are only too aware of the painful slowness of change from
within. I think in our hearts many of us would like to believe that
there must be some way of achieving change quickly, and this has been
part of the attraction of systemic family therapy for psychotherapists.
Approaching families with a psychoanalytic understanding brings us face
to face again with the enormous resistance we have to facing the pain,
anxiety and conflict that real psychic change entails. This is not to
advocate lengthy treatments. Indeed there are several families described
in this book, for example the ‘Langs’ in Margot Waddell’s chapter,
who in a few sessions achieve a new awareness which allows a more
constructive way of relating to develop. Perhaps we need to look more
carefully at the types of changes which are possible for each particular
family. The psychoanalytic model will not suit every family or every
family therapist, but Box and her colleagues demonstrate that it has
valuable insights to offer to family therapists whatever their
persuasion. At £32 this book is not cheap, but costs a great deal less
than a good pair of shoes and can be guaranteed to provide many years
excellent service!
Marion
Bower
"Unimaginable
Storms: A Search for Meaning in Psychosis.",
By Murray Jackson
& Paul Williams. 1995. London: Karnac Books. Pp.232. £16.95
A
recent, inexpensive and accessible book by two British psychoanalysts,
Murray Jackson and Paul Williams, on the treatment of psychosis has
received widespread praise in the psychiatric and psychoanalytic
literature. This home page announcement is for patients, professional
carers or interested lay individuals who would not otherwise have access
to this book, or know where to get it. Details of the book are given
below, with an extract of its contents, and a contact point if you need
help or information in trying to arrange psychotherapeutic treatment for
yourself or for a psychotic or seriously disturbed person.This book is a
distillation of many years' work on a therapeutic milieu in-patient ward
at the Maudsley Hospital, London, in which psychotic and other disturbed
patients were treated with an integrated combination of psychiatric and
psychological care anchored in the use of advanced psychoanalytical
concepts of psychosis. This highly unusual approach involved a minimal
use of medication and extended use of other, more social therapies,
especially psychotherapy - individually and in groups - to help in the
understanding of the meaning of patients' illnesses or disturbances. The
engagement of patients in their own recovery was held to be a very
important step. Compelling clinical material is reproduced to help
illuminate the meaning of illnesses such as paranoid schizophrenia,
catatonia, psychotic anorexia and manic-depression. Detailed
commentaries demonstrate how many patients may be understood in great
depth through the sensitive use of psychoanalytical concepts and, when
these concepts are part of a comprehensive psychiatric care plan, how
significant improvements are possible. Several extended and vivid depth
interviews of patients are reproduced.
Reviews of 'Unimaginable
Storms'
Professor
Robert H.Cawley, Emeritus Professor of Psychological Medicine in the
University of London:- "In this important book, Jackson and
Williams illustrate methods of psychodynamic assessment and treatment
with unique clarity by recorded interviews. The authors point the way
towards developing optimal treatment procedures - multidisciplinary in
the true sense. The implications for psychiatrists and health services
are challenging. The routine treatment of schizophrenia entails rapid
neuroleptisation, early discharge into the community and a strong
likelihood of relapse, readmission and deterioration. Optimal treatment
offers a better deal: suffering may be reduced, relapse rates lowered
and the patient's quality of life is likely to be immeasurably
enhanced." James S Grotstein MD, Psychoanalyst and Author
"Jackson and Williams have undertaken a painstaking and an in-depth
research effort which is elegantly detailed in this work. The lay
public, the mental health public, and future victims of schizophrenia
are in their debt for the authors' convincing efforts. They have done
for schizophrenics and other psychotics something similar to what was
done in the Menninger Research Program for the Study of the Treatment of
Borderline States thirty years ago, which established the efficacy of
psychoanalytically-informed psychotherapy for these cases." Michael
Feldman MD, Consultant Psychotherapist, Maudsley Hospital, London
"This book is an important and impressive description of an
approach to the understanding and management of severely disturbed
patients which incorporates the authors' psychoanalytic knowledge. The
vivid and moving detailed descriptions of interviews with the patients
offers a unique insight to their experience, and an understanding of the
powerful and disturbing underlying processes." Extracts from
'Unimaginable Storms': "Psychotic disorders bring immense suffering
to victims and relatives and constitute the heaviest burden on Mental
Health services throughout the western world. Although a great deal is
known about the nature of these devastating disorders, many conjectures
are still to be confirmed or refuted and much remains to be understood.
Whilst the definition of psychosis is generally agreed upon the same
cannot be said for schizophrenia, and these two orders of classification
bear examination. Psychosis encompasses a wide group of mental disorders
which have in common a serious impairment of the individual's capacity
to remain in contact with reality. They are often accompanied by
confusion and disorders of thought and perception which can find
expression as delusional thinking and hallucinatory experiences. The
causes of an individual psychotic episode or of long-term vulnerability
are to be sought in biological, social or psychological factors. Each of
the related disciplines has its own language and method of
investigation. Bridges, conceptual and operational, between these
disciplines may be difficult, sometimes impossible, to construct. Yet
each discipline is relevant, individually or in combination, to the
acquisition of a deeper understanding of the nature and treatment of
psychosis. The cooperation of different specialists is also needed if
the needs of the psychotic individual are to be met fully. It would seem
reasonable, under these circumstances, to expect practitioners skilled
in particular specialities or sub-specialties to acquire a level of
general understanding of, or contact with, other disciplines to permit
constructive debate to take place. In practice, cooperation appears to
be the exception rather than the rule. This book will argue for a change
in this position... ...The view that schizophrenia is a neuro-developmental
disorder of organic origin is based on research findings that are sound
and impressive. However, the application of these findings as general
truths about the nature and treatment requirements of schizophrenia can
be quite misleading. Studies of brain pathology reveal statistical
significance only, and the common disorders detected in the
'schizophrenic brain' are by no means confined to schizophrenia. It is
not yet known how frequently such disorders occur, or how often they
have pathological consequences for personality development and
psychological functioning. Genetic studies of schizophrenia have proved
to be more complex than many had imagined. The essential fact that genes
represent tendencies, and thus may be modifiable by favourable early
environmental conditions, has been demonstrated by studies which show
that where a genetically predisposed infant is born into a secure and
mature family the genetic effects may be neutralised (Tienari 1992a,b).
Lewontin, speaking of the 'doctrine' of DNA, criticises the current
tendency to overemphasise the role of genetics in human development. He
points out that 'genes affect how sensitive one is to the environment,
and environment affects how relevant one's genetic differences may be' (Lewontin
1993 p30). ... An attempt to reach a patient emotionally from the
earliest moment involves: exercising empathy, discerning the
non-psychotic part of his personality, attempting to understand his life
(external and internal, present and past), searching out the meanings of
his disturbance in relation to his history and prevailing phantasies,
considering his experience of the interviewer and of providing him with
the experience of being understood. Such a formidable list indicates a
specialised activity in which competence can only come with training and
experience. However, even a basic knowledge of psychodynamic principles
coupled with an attitude of respectful curiosity and a belief in the
patient's resources can prove to be of great benefit. If this attitude
is carried over into long-term individual psychotherapy with an
experienced therapist, impressive results can follow. By comprehending
the psychotic person's experiences in his terms, we discover an
existential coherence and emotional logic to his communications. These
may be confused or hard to follow, but they are his own ways of
expressing his crisis. If we succeed enough in understanding him we
reach levels of meaning which offer significant explanations of the
phenomena under observation.'Understanding' in the way we describe takes
many forms, not least unconditional acceptance, tolerance and the
withstanding of the patient's communications. It is shorthand for the
practitioner's progressive recognition of the patient's experience, its
relation to his life story and of the way he has needed to control his
severe underlying anxieties. Control requires the use of unconscious
mental defence mechanisms to deal with otherwise unmanageable feelings
arising particularly when he tries to achieve emotional closeness to
others. In severe psychotic conditions these mechanisms have been active
since infancy and may have led to structural changes within the
personality. These can appear obvious when the onset of psychosis is
early or they may be slow and insidious, or present as limitations of
personality which may not be obvious. Any improved awareness of his life
problems and the causes of his limitations will help the patient
integrate the meaning of his psychosis. The search for meaning and
understanding may be thought of as an attempt to help a sane and
cooperative part of the patient's mind to acquire an interest in how his
mind works. We must try to find out why a part of his mind has become
psychotic, and why the patient maintains a preference for the psychotic
world with all its confusion and sometimes terror, to the pains of the
world of dependent relationships. Important contact can sometimes be
achieved at the first encounter, as we have demonstrated, depending upon
the evolutionary stage of the psychosis. If a high degree of integration
is subsequently acquired as the result of long-term individual
psychotherapy or psychoanalysis, the quest for self-knowledge can become
an enduring motive for the patient, and an unswerving ally of
sanity."
'Unimaginable
Storms: a search for meaning in psychosis" (ISBN 1 85575 075 9) is
obtainable from Karnac Books Ltd., 58 Gloucester Road, London SW7 4QY
England (Telephone: [+44] 0171 584 3303 or Fax: 0171 823 7743). The cost
is 17.95 sterling + 3.30 post and insurance. In USA, you can also
contact Brunner Maazel Publishers in New York.
