The Online Journal of the American Association for Psychoanalysis in Clinical Social Work

Book Excerpt: From “Learning from Life: Becoming a Psychoanalyst” by Patrick Casement (Routledge, 2006)

Editor’s Note: With the kind permission of Patrick Casement and Routledge, his publisher, Beyond the Couch is publishing an excerpt from Chapter 3 (Finding a Place for Theory) from his most recent book, Learning from Life: Becoming a Psychoanalyst. This chapter reflects on Patrick’s experiences as an agency social worker before becoming a psychoanalyst and thus has special relevance for social work clinicians.

Finding a Place for Theory: Introduction

As I moved from my various training courses into social work, and later into psychotherapy and psychoanalysis, I encountered many clinical situations that seemed to illustrate theories I had been learning about. But I still had to find out how to apply them. Too often I was tempted to impose theory, making it seem to fit.                                    

Anyone can slip into being driven by theory rather than being guided by an inner sense of what feels true. Of course, we aim not to be as absurd as I was being in the following example. But even in psychoanalysis it is possible for the practitioner to become absurd in different ways, applying theory too confidently. Analysts may feel proud of their skills of understanding while the patient may still not feel understood.

Applying theory straight from training

I shall never forget the first time I was asked to provide a court report as a student probation officer. I was on duty in court, along with my supervisor, when a man (I shall call him John Macmillan) was about to be sentenced for the latest of many offences. He was currently charged with minor theft. Standing in the dock he shouted at the magistrate: "Give me a chance, guv. I've never had probation." The magistrate remanded him in custody for two weeks, to allow time for a court report to be prepared. My supervisor allocated the case to me, my first case as a student probation officer.

I was given John's known details and previous convictions. He was aged 54 at the time and had been sentenced for 47 previous offences, the full list being provided. The first offence was for stealing blankets and this latest was for "stealing a manhole cover valued at 12 shillings and sixpence." Being straight out of college after my social studies course, which had included psychology and some reading of basic psychoanalytic theory, I was wondering about the possible symbolism of these offences. I determined to explore this when I met the client.

I was given a note from my supervisor to allow me into Pentonville Prison, where John was being held in custody. My supervisor had written:

"The bearer of this note is Patrick Casement, a student probation officer under my supervision, who is required to provide a report on John Macmillan, at present being held in custody at Pentonville Prison."

The officer at the main gate of the prison took one look at this note and said: "Casement, eh? We hanged one of you. Come in. There is surely room for another." 1

I was conducted to the cell where John Macmillan was being held. Outside his cell was a prison officer who was noisily turning the pages of The Eagle, a children's comic. The door was kept open throughout my time with John, making it even more difficult for me to conduct this, my first ever, social enquiry — feeling overheard by someone very likely to be critical of much that I had in mind to say to this prisoner.

The prison authorities had inexplicably chosen to see John as someone who might try to escape – he of all people! He had therefore been deprived of his trousers "to make it more difficult for him to escape without being noticed" . So I had to interview this man while he was bizarrely sitting before me in his underpants.

After some preliminaries, I got round to my grandiose idea of preparing a "psychological profile" on this prisoner. Warming to my subject, I said to him: “I see your first offence was stealing blankets. Were you in need of blankets at the time?” 

I felt primed by my training to enquire into this, as his first offence might have indicated some maternal deprivation. Perhaps he had lacked emotional warmth and/or security at home. John replied to my enquiry with well deserved scorn: “Don't be daft, Guv. I used to sell them by the hundredweight.” I quickly abandoned any further idea of psychological profiling with this man.

Before the court hearing at which John was to be sentenced, I went to see the magistrate to discuss my recommendation. His name was Mr McGelligott, a name burned into my memory because of what followed. Trying to use the language of court to cover my shyness with this magistrate (the first I had ever had to speak to) I said: “You asked me to see you after preparing my report on the man you remanded in custody two weeks ago; the man you might remember as an incorrigible rogue.”

He replied: “Maybe, but what is his name?”

I, feeling flustered, said: “McGelligott. No. I'm so sorry, sir. No. His name is Macmillan.” Fortunately the magistrate thought my slip of the tongue more funny than offensive.

I then explained that I had studied John Macmillan's history and found that, in the last 35 years, the longest time he had remained out of prison had been two weeks. “So, if we are able to keep him out of prison for longer it might be some kind of progress.”  Mr McGelligott made a two-year probation order, requiring John to report to me on a regular basis, at a frequency to be decided by me.

For the first three weeks John reported whenever I required him to. He was then apprehended again by the police, having stolen a large quantity of lead from a church roof. He had dragged this lead along Old Street, past the probation office where nobody noticed him, past the magistrate's court where nobody noticed him, to the door of the police station where he collapsed — unable to go any further. The police finally got the message. He was begging to be taken back into prison, the only place of security he had known during those many past years. He had stayed out for longer than two weeks, but was this progress?

I had a long way to go before I was to find the value in discovering connections between life and theory, rather than trying to apply theory by making connections. But I have found it useful to recall this misuse of theory as a caution against being too ready to apply theory to what I hear from patients.

Another absurd use of theory

Some years after this, when I had become a principal social worker, I had a consultation with my line manager on a matter affecting the running of the office. I was to discover that he had been deeply influenced by Kleinian thinking.

I had been trying to explain an administrative matter for which I was seeking some practical help, bringing facts and figures in support of my request. Finally, instead of agreeing to any practical solution to the problem I had outlined, my manager chose to make an interpretation: “You are projecting your impotence.”

As I could not see how he had got to this, I challenged him: “Where does that come from?”

He replied: “From the tingling in my fingers.” (Pause)  ”I always know that, when I feel a tingling in my fingers, the other person is projecting their impotence.”

I felt infuriated by this trite dismissing of the reality in my request and I no longer felt inclined to respond politely. I replied: “Well that is most interesting. I thought the tingling I am now feeling in my fingers was because I have my elbow leaning on the hard arm of this chair. But, as you say, maybe you are projecting your impotence into me.” The end of this exchange was, finally, that my request for a practical solution to the problem was granted, but it had been hard work to get there.

This interchange left me with a useful suspicion of any theory that could be automatically applied. Another consequence was that I remained cautious about any use of the notion of projective identification, until I was with a patient where this was the only way in which I could begin to understand what I was experiencing. That was in the example I have given before (Casement,  1985:77-80, 1990: 68-72) when I was feeling tears in myself that belonged much more clearly with the mother who had lost her two babies. She had only been able to relate to me the details of those painful deaths, not showing any of her own feelings about them. I then came to understand that she was unconsciously provoking me to feel what she could not bear to feel, partly to get rid of her pain but also to communicate it in order to get some help with her own most painful feelings.

It had taken me a long time until then before I could accept the notion of projective identification as a real and useful concept. But it was worth all of that waiting, for me to have arrived at this understanding as clinically meaningful rather than routinely using it on the authority of others.

Communication through violent behaviour

Another probation enquiry concerned a boy who, along with others, had caused many thousands of pounds of damage in the park of a car sales showroom. The boys had gained access to this locked car-park and found rows of new cars, each with the doors unlocked and the keys in the ignition. They had driven these cars around with increasing recklessness, bumping into other cars as if they were at a fairground. The damage had been appalling.

When I met the parents I was struck by the timid quietness of the father. He appeared to be a gentle soul, more feminine than masculine, and apparently lacking in aggression — as if he might be afraid of it. He and his wife were at a loss to understand how their son could have been involved in anything like this. I was told he was always a quiet boy, never getting into fights, always nice to people and never joining in with the rough lot at school.

I didn't yet have any idea why this costly outbreak of violent behaviour had happened, but I recommended a probation order so that I would have time to get to know this boy and his family, with the hope of understanding this better.

In the course of the son's time on probation I came to know more about the parents. I learned that the father had been in the Gurkhas. In fact he still had his Gurkha knife, which he sometimes sharpened just as he used to during the war. It was a knife for killing as well as for cutting a way through the jungle. When he showed it to me he became uneasy about keeping it in the house. Would I please take it away, to find a place of safety for it? He was now seeing his son in a new light, as perhaps capable of untold damage, even killing, which he had never before imagined possible.

I began to have a sense that this boy had grown up in a family where there was a marked split in relation to aggression. The father, once strongly identified with his Gurkha knife and all that went with it, seemed to have backed away from his own aggression. He now regarded any aggression as dangerous. At the same time, his continuing to sharpen the knife seemed to be a way of remaining connected with it. The atmosphere in the family was one in which all aggression had been taboo.

I felt the son may have been giving expression to some of the excitement in aggression that he could sense in his father, but which was always kept locked away just as the knife had been. So, along with others, the boy had reached beyond locked gates and become thrilled with the excitement he discovered in being destructive. I felt both father and son needed help with their aggression, to find it could become manageable and be kept within safe bounds, rather than disowned and repressed until it exploded.

Still needing to come to terms with my own aggression and my fear of it

There was an interesting sequel to this probation case, about which I continued to reflect and to learn. The father had got me to take away the Ghurkha knife, to find a safe place for it, but then I too didn't know what to do with it. For a long time I kept it in the door-pocket of my car until I realized that if a police officer ever caught sight of it there I could be charged with being in possession of an offensive weapon. I then took it into my rented flat where I put it out of reach on top of a wardrobe. (I was distancing myself from what this knife had come to represent for the father and then for me.) When I later vacated that flat I decided to leave the knife there, as if I had forgotten it, but my landlady found it and asked me to remove it. So I had the knife back in my possession, still not wanting to have it around me or knowing what to do with it.

I told the story of this knife to a colleague, a Jungian analyst, from whom I was then renting a consulting room. I discovered that he collected knives, so the Ghurkha knife ended up with him — he evidently being more at home with his aggression than I was at that time.

Insight for management

When I was working as a family social worker I was asked to see Miss A. In her present life Miss A had multiple medical problems. She was seriously diabetic. She also had scoliosis, a spinal deformity, one result of which was that she quite often felt unable to administer her insulin injection to herself, without which she could go into a coma. At such times she would take herself round to the nearest hospital, demanding to have the injection given to her. Then, if anyone showed a reluctance to take her at her word, that she could not give this to herself, she would start screaming: “Do you want to kill me?” Not infrequently this behaviour resulted in her being seen by someone from the psychiatric department of whichever hospital she had taken herself to. There, in each case, she was understandably diagnosed as paranoid.

Miss A had a most disturbing childhood history. She had been the first child born to an anxious mother, who had become seriously depressed after her birth. Early in Miss A's second year her mother was pregnant again, becoming even less available to this anxious child. According to the case notes, the mother had fallen down the stairs during this pregnancy, as a result of which Miss A had become even more clinging than she already was. The mother had died in childbirth and so had the baby.

My reading of this history was that Miss A may have come to believe, from various family comments, that she had been responsible for the death of her mother. It might also have seemed to her that it had been the intensity of her dependence on her mother which had caused her death, and that her jealousy might also have seemed to have killed the baby. She was now spreading her dependence across many people, as if no one would survive the full weight of it in a single relationship. With her dependency spread amongst many, she had set up a kind of insurance against loss. Some people might leave, one or two had even died in recent years, but while her dependency was spread in this way there would always be others to turn to.

This formulation made some sense with regard to the possible management of this case, but I decided definitely not to interpret any of this to Miss A. She had already been made to feel she had killed her mother. I could also see from the file that earlier attempts with this interpretation had only added to Miss A's unbearable sense of guilt, as if the previous social worker had been confirming her own conviction that she had been the cause of her mother's death. I therefore called a case conference of the people most involved in her continuing drama.

Over several years, Miss A had built up a network of some 12 or more social workers, who had each tried to deal with aspects of her multiple problems, and almost as many doctors or psychiatrists. Her drama had snowballed to such an extent that she had become a "fat file" case in numerous hospitals, all this being very time-consuming and costly.

At the case conference I suggested that I could be used as the principal worker in the care of Miss A, everyone else being invited to pass on to me whatever "crisis" was brought to them during the week, dealing only with such medical states as might need immediate attention. I undertook to visit Miss A regularly every Monday at 2.0 pm (I still remember the time of those visits even after all these years), whether she was in crisis when I visited or not. I would then look at whatever problems had been reported to me during the week, and try to understand what the underlying communication in each might be.

During the two years that I was seeing Miss A her claims upon the others, from whom she had previously been demanding so much attention, noticeably calmed down. She became containable with the regular contact she had from me. She was also beginning to find that her demands could after all be focused on one person without this either destroying me or driving me away.

However, Miss A managed to keep up a high level of drama. For instance, on one occasion I arrived for my usual visit to find typing paper plastered all over the door of her flat, a door that faced down a balcony where it could be seen by anyone walking towards the stairs at her end. She had written in huge letters:

KEEP OUT
EVERYONE HAS FAILED ME
(except Mr Casement)
I HAVE NO WAY OUT OF THIS
EXCEPT BY KILLING MYSELF

The proviso, directed at me, was in very small writing. The meaning of this notice, at 2:00 PM on a Monday, was very obvious. “KEEP OUT” was clearly addressed to me, meaning “COME IN.” I got the caretaker to open the door, through which Miss A appeared, screaming: “Can't you even let me die in peace?”

I found that Miss A had spent the previous ten minutes trying to find a way of turning out the pilot light in her oven. Every time she tried to gas herself the oven had kept on lighting. She had not been able to get as far into her attempted suicide as she had wished. 2

Miss A knew that I would be there. She also knew I would not stay outside. I would come in. She also knew we would then spend the time of my visit looking at the latest crisis that had brought her to make this suicide gesture.

I was later to regret that I did not oppose Miss A's plan to move to be near a friend in another borough. I knew her move would relieve me, passing the problems on to someone else. The gains made during those two years were then mostly lost and she became as uncontained in the new borough as she had been before I started working with her. I also think my acquiescence with her plans to move fed into her longstanding view of herself as too much for her mother, and therefore too much for anyone. For a time I had seen to it that I would not let her be too much for me, but in the end she had begun to be a burden I was glad to do without.

This experience subsequently led me to be very careful, in my analytic work, to do whatever is possible to survive the attacks and demands we are likely to get, especially when patients are testing us, driven by an inner conviction that they will be too much for anyone. I have always aimed to “see it through” with a patient, seeking consultation to get support and help in surviving when necessary.

In one instance, I came to think my continuing to be available to a patient (Mrs Y), regardless of how I was being treated, was possibly playing into some sadism towards me. I felt it to be important that I set a clear limit to how much of this I would be prepared to tolerate. In the end I accepted the patient's own view that I seemed not to be able to help her any further, and gave her notice that I would not continue to be available. Much later this patient let me know that, however hurt she had been at the time when I stopped seeing her, she had subsequently come to realize that she had needed me to draw a line beyond which I would not let her go. That ending, she now knew, had been necessary.

An invitation to collude
                                               
While I was still with the Family Welfare Association we sometimes had visitors come to see us, interested to learn more about how we worked. During one of those visits we put on a live supervision, a member of my staff bringing some work I had not previously heard about, work with a couple she had been seeing.

I was told that my colleague had been offering marital therapy, husband and wife coming for joint sessions. Then the husband had stopped coming. For a time my colleague had been holding to her contract with the couple, being reluctant to see the wife on her own, writing to the couple to encourage them both to come back, to talk through what had been getting in the way of them coming together. After several failed appointments my colleague felt she had no choice but to see the wife on her own, especially as she was now saying she needed some particular help from her caseworker.

During the interview that was presented for this supervision, the wife had been putting pressure upon my colleague to help her with an application for divorce. The wife was saying she had given up on the marriage and was now wanting to divorce the husband. Therefore, as my colleague knew her situation quite intimately, the wife said it would help her case against her husband if she would give evidence in her divorce. Would she agree to this? My colleague was able to resist, saying she would like to see the wife again the following week. My colleague was now asking me what she should do.

As I was listening to this presentation a number of things stood out as unusual. My colleague knew I was most unlikely to be giving her advice, on what she should do about her client and yet she was asking me to tell her. Her client also knew that her caseworker didn't usually give advice. So what was going on?

As we looked at this, it became clear that the wife was putting pressure on my colleague to enter into a collusion, to give evidence on her behalf even though the therapeutic contract had been with the couple. Also, why would the wife need to have support in making her case? She was an intelligent woman, well able to stand up for herself. So why was she behaving as if she could not do this on her own?

Gradually, we came to see that the pressure on this caseworker was probably motivated by the wife's continuing indecision about the marriage. Was she really as single-minded about proceeding to a divorce as she was claiming? Maybe she was wanting the caseworker to side with her against the marriage in order to silence her own uncertainty about ending it. Perhaps she didn't altogether wish to end it. We were then able to see that this wife might still be looking for help with the difficulties in her marriage, even though she was acting as if it was all over. 3

After this discussion my colleague felt able to make a clearer stand on behalf of the marriage. Perhaps she had unwittingly begun to take sides with the wife and this could have been picked up by the husband. This may have been part of what he was communicating by staying away. Was there any point in him coming for these joint sessions if his wife was more readily heard than he was?

The caseworker felt able to write a letter to this couple that stated again her wish to be there for both of these clients, resisting the pressure on her to take sides. The husband then began to feel he was once more being taken into account in this marital work and he came back. The couple got through this difficult phase in their relationship and the marriage continued.

We might have missed the clues here if we had not been listening to the communication implicit in the wife's behaviour and in the husband's staying away, which seemed also to be reflected in some parallel process engaged in by the caseworker and myself in the supervision. It was only after we had sufficiently re-focused our attention on the couple, not only on the wife's side of things, that the marital counselling began to be fruitful again.

Finding a limit to understanding

My experience as a social worker helped me to realize that we often get into being critical of others when we are losing sight of the need to understand.that we often get into being critical of others when we are losing sight of the need to understand. In my new clinical work then as a psychotherapist, and in my continuing work as a social worker, I was often able to turn a corner in my understanding of people, whom I would otherwise have been wanting to criticize, through recovering my analytic curiosity as to what might lie behind their difficult behaviour. But it does not always work like that.

Before ending this chapter I wish to share my experience with a man I shall call Mr C. It was while I was seeing him that I had to learn we cannot use any particular approach as if it is going to fit all cases — however useful we may have found this to be elsewhere.

In my capacity as social worker, I had been seeing a family with a really terrible-sounding marriage. The wife was being kept seriously short of money while struggling to look after several small children. The husband seemed to do nothing to help her, either practically or financially. I also learned that he was quite well off, but he continued to keep his wife very short of money. Meanwhile he remained engrossed with his shares, and how to make more money, seeming to be totally self-absorbed and uncaring of anyone but himself.

Wondering about this man's selfishness, but wanting to understand it, I had been trying to find out about his childhood for any clues that might help to explain his behaviour. But however much I looked for clues, I was finding nothing that threw light on any of this.

One day, when I was visiting the home, Mr C was yelling at those around him while doing absolutely nothing to help his over-wrought wife with the children, or with anything that needed to be done in the house. At the same time he was letting off steam about his stockbroker who, he said, had missed the chance of a lifetime for making a considerable amount of additional money for him. He had missed the optimum moment for selling shares before they had suddenly crashed in value. He became so excited while telling me about this that his false teeth fell into his lap. At this point my analytic curiosity became exhausted. I just found this man utterly despicable. I could not wait to leave the home, wishing that I would never have to meet him again.

I knew that Mrs C had, on a number of occasions, expressed similar feelings to me about her husband, so I was not surprised that I was responding to him in this way. But I continued to wonder about the dynamics here and what they might be indicating, thinking that I might still be able to make some sense of this.

Before I was next due to visit this family, I received a message to say that Mr C had continued to be highly excited about having lost that opportunity on the stock market. But when he was once more shouting at his stockbroker he had collapsed with a heart attack and died.

I now had a completely different therapeutic task. How might Mrs C be now that her openly expressed wish, to be rid of her husband, had seemingly been granted? I went round to see her as soon as I could. To my surprise she was not upset by any of this. She felt as if God had taken care of her. She was at last free of this dreadful man. She would also be better taken care of now that he was dead. His money, for the first time, would be available to the family.

I still worried about the possibility that Mrs C might fall into depression, perhaps even a melancholic depression, or she might suffer guilt over her husband's death. But though I visited her several times in the following months, she continued to be transformed by her release from this terrible husband. Even the children seemed to be happier now that there was no longer the constant fighting and tension in the family.

I didn't see the family for long enough to know how lasting Mrs C's recovery was, but this experience did make me think more carefully about applying theory in any universal way. Perhaps some people really do not react as theory suggests to us that they might.

I know that much of what I have been describing here may be more directly of value to social workers or counsellors, but I believe that the matter of applying theory, and of listening to behaviour for what it communicates, is also a central issue in therapy and in psychoanalysis.