|
Kate Schechter interviews Patrick Casement
Editor’s Note: In April and May 2007, Kate Schechter, a member of the Editorial Board of Beyond the Couch, conducted an “interview” via email with Patrick Casement in response to the chapter excerpt published in this issue.
Kate Schechter: Your chapter ends with the comment that much of what you’ve said about the importance of paying attention to communication in behavior may be of most value to social workers. Why to social workers in particular? Would you comment on the distinction you are drawing between social work and psychoanalysis?
Patrick Casement: One of the problems that I have sensed at the interface of social work and psychoanalysis is that in the social work field some people are tempted to use inappropriate interpretation. In psychoanalysis I think there is a tendency to slip into inappropriate action.
In social work, some insight is better used for management. For instance, in the extract from my chapter three (taken from Learning from Life), I give an example of this in my work with the client I call Miss A. Instead of interpreting her unconscious belief that her needs would be too much for a single person to bear, hence her spreading of her demands between many different doctors and social workers, I offered myself as the single person upon whom her needs would be focused. Other people were invited to pass on to me this client’s other demands, when taken inappropriately to them, so that these would be attended to in my regular visits to Miss A instead of each demand being treated as if it were a crisis that had to be attended to immediately.
The client gradually became contained in this way. I never interpreted to her my analytic reasons for managing her like this, having other people reporting to me rather than trying to deal with each problem immediately as it was presented. Instead, I shared my reasoning with the team of social workers who had previously been caught into her web of demands.
I believe that it is also easy for social workers to get caught into seeing problems too concretely. It can be quite difficult for some to tune adequately into the internal world of their clients, to see the extent to which clients experience external reality in terms of their internal world. Internally others may be seen as ”not to be trusted,” “out to get them” or whatever, all of this based upon the objects in their minds who have come to be seen in these ways.
Equally, it is tempting for social workers to offer patients ‘solutions’ that are too concrete, trying to be a “better parent” in order to make up for bad experience in the patient’s past. What is then so often missed, in this well-intentioned endeavor, is the fact that those intense feelings that belong to the patient’s relationship with the “bad” parent(s) are often kept outside of the consulting room: the bad being still seen as concretely “out there” and the patient’s unconscious contribution to bad experience being overlooked.
By contrast, when a patient’s internal bad objects are put onto the analyst, if the analyst can stay with the projections, or the transference, in this, the patient can have the experience of someone being prepared for and able to engage with what may have seemed to be too much for anyone, like a monster in the mind. Only then do these apparent monsters begin to lose their power over the patient. Just talking about it, with the analyst still being protected from the intensity of what has seemed to be too much for anyone, can keep alive the patient’s sense of having to protect anyone who is important to them from that which they still assume will destroy that person.
One other problem with trying to offer a concrete reparative good experience is that a patient can see this as indicating the analyst’s need to be seen as good and giving, as if he/she – like others in the patient’s past – might need to be protected from the intense feelings the patient has for those who have been experienced as failing him/her. An analysis of that kind can end with both analyst and patient feeling good about the shared experience, with good feelings for the analyst predominating over bad, and it is sometimes only in a subsequent analysis that it becomes clear to what extent the patient had been protecting the good analyst from all that had been unconsciously feared as a threat to the good experience.
A common understanding in analysis is that the good analytic object is that which has survived being used to represent all that had been worst in the patient’s past experience. This is a difficult notion, especially for social workers. I think it is only when they have really been through an analytic experience of that kind that they can appreciate the profound truth in this understanding.
KS: So what would you say from your experience of being a social worker has been of particular value to you in analysis?
PC: I particularly came to recognize the value in recognizing communication in behavior. Communication does not have to be in words. This applies to adults too, not only to infants or children. As an example of that, I came to see the invaluable insight in Winnicott's notion "the anti-social tendency" whereby he noted that there is often an important communication in early delinquency, or what he called pre-delinquency. From this I came to recognize what I later called "unconscious hope", in that people (young and old), especially when disturbed or distressed, often go in search of what is needed -- usually indicating this through behavior.
I also came to recognize a crucial difference between "needs" and "wants." I came to see needs as needing to be met and wants as sometimes needing to be frustrated. This led me to discover the extreme importance of setting limits, illustrated in my first published paper "The setting of limits: a belief in growth." The content of the paper is all in the title. It was based upon Winnicott's observation that one of the most important but difficult responsibilities of a mother is to be able to offer her infant a "progressive failure to adapt" to demands, introducing the infant to its capacity to tolerate degrees of frustration that had not been possible earlier on.
KS: Regarding the supposed utility of frustration, I am most familiar with the movement in self psychology from “optimal frustration” to “optimal gratification” to” optimal responsiveness.” Would you tell me more about how you see the difference between "needs" and "wants" and how you came to draw and understand the distinction? How does frustration really work?
PC: I give an example in my latest book of a client who had been helped out of serious debt by a grant that I had raised for her, so that her most urgent debts could be settled and the remaining debts could be paid off by weekly amounts that would be manageable. It had been clear that she needed that initial help so that she could manage the debts that remained. However, when she later told me she wanted to spend a further big amount on something she didn’t actually need, but very much wanted, I made it clear to her that I would not make that decision for her. Instead, if she went ahead with this, she would have to find ways of paying off any new debt herself. I would not be able to just justify asking a charity for another grant to pay off something that we both knew she didn’t actually need.
It was this client who threw things at me when I stood firm on this. Later, when she had somehow managed to pay off that additional debt, I learned that she had taken something very important from my being firm. I had said “No” but I had continued to visit her each week. She realized that this was because I had cared enough to take her anger and to stand firm in my belief that she could find her own way to deal with this. She had likewise found that she could say “No” to her children when they had been demanding more sweets or presents, etc., which was how she had managed to pay off that new debt rather than spending money on the children in order to feel good through giving, as before. She had also discovered that stronger kind of love for her children, being able to bear being hated when she knew she was actually trying to be a good parent rather than a spoiling one.
From working with that client demanding money from me, when I had told her I would not be offering her an easy way out of her new debt, I came to realize that a good 'parent' is often tested to see if there is a sufficient love for a child, or caring for a client, to be able to withstand being treated is if he/she is a bad parent -- especially when faced by a tantrum in a child or manipulative behaviour in an adult. Even though these demands or requests might often seem to be quite innocent, they can sometimes be an invitation to avoid difficulties in the analytic relationship rather than actually attending to what most needs to be attended to. This led me to realize the truth in that saying about a good analytic object not being that which is better than what has been experienced before but someone who is able to survive being used to represent the bad objects in the patient's mind.
KS: I note that you always stay extremely close to data, and I am wondering if you also have a story about the "progressive" quality of the "progressive failure to adapt" that a mother offers her infant, thereby introducing the baby to his own capacity to tolerate degrees of frustration. When you are working with an adult, do you see the "progressive" quality as a cumulative series of developmental steps spread over time? How analogous is this process to development in childhood? Do you also find the concept of regression useful? It strikes me that the time dimension is an especially important part of your theory of practice, and in view of the demand today for brief, medicalized treatments, I think you have some very important things to say about time and temporality in treatment.
P.C. I have given above most of an answer to this, I think. In analysis, I came to realize that when a patient is in regression it may be necessary to allow the patient to be in control of the analyst – for a while. With my burned patient, Mrs. B (referred to in Learning from the Patient and further in Learning from Our Mistakes), I allowed her to control me for most of the opening phase of that analysis until I felt she was needing, and might be ready for, me to differentiate myself from her view of me as having to be under her control, or as apparently having to be protected from all that she had come to assume the other would not be able bear. It was when I did not stop, when she had (as often before) put up her hand to signal me to stop, that we then began to move into a new relationship in which she could discover that I had actually a strength in myself to survive, not still needing her always to protect me from all that she had formerly assumed would be too much for the other person.
KS: You say “until I felt she was needing, and might be ready for…” – could you tell us more about these transition points, the “untils” of a treatment process? How does one know one has arrived at such a moment? I believe that in the old days these were considered junctures where the “transference” had become a “resistance” and needed now to be addressed as such – do you think of this development at all in these terms? Regarding the value of preserving boundaries and saying no to demands, I see a man whose life has taken a turn for the busier -- from an extreme form of isolation and stagnation -- and he and I both view this movement from stagnation as a direct exemplification of his growth. Until recently I have tacitly complied with each of his requests for schedule changes, but lately I have noted a different, demanding, somewhat demeaning quality to these requests, and a feeling in myself that some of these are gratuitous and I am in some way being tested. In my view my patient is showing me his sturdiness and readiness to be confronted more directly with something that has been split off. My question for you is whether the "value of preserving boundaries" isn’t better put as a "value of knowing-when-to preserve (versus when to interpret) boundaries." As I see it this cannot be a normative matter in a treatment that has momentum. What do you think of this more relativistic view?
PC: I completely agree with this. I don’t mean to be understood as standing by boundaries as something that have to be fixed and rigid. However, I do believe that we need to recognize that issues to do with boundaries are always important. We therefore do need to move from making exceptions to recognizing when exceptions have themselves come to be regarded as the “norm”. When exceptions become a problem then, I believe, a patient is prompting us to re-think our position on exceptions or flexibility, to see that they may have outlived their therapeutic usefulness. But I don’t think in terms of “problematizing.” I prefer to address the fact that a reliance upon flexibility may itself have become a problem, which could indicate the need to firm up on the arrangements so that both analyst and patient can more clearly know where they are in relation to the arrangements – as in the example you refer to.
As I said earlier, with regard to analytic insight, with some clients I came to see the value of "insight for management" rather than just for interpretation. In analysis, insight may often be of value in helping us to manage ourselves, not necessarily for interpretation to the patient. Thus the need for internal supervision, learned from students who were internalizing me as supervisor, this then being experienced as if I had become an internal SUPER-visor leading them to feel disabled rather than enabled.
KS: Regarding "insight for management" -- when you say it can often be of most value in helping us manage ourselves, I presume you mean the kind of silent process of self-interpretation that you are known for in your work on internal supervision. How would you compare this to the more traditional idea of "self-analysis" as an ego function that one takes from one's own experience as an analysand? How conscious and cognitive a process would you say it needs to be? How do you see the learning from one's own analysis and the learning from one's work with clients to be related?
PC: I see these two as intimately interconnected but nevertheless somewhat different. Monitoring oneself from the view point of the patient is not necessarily an extension of one’s own analysis, but it may well throw up pointers for more self-analysis – as when we may have been stepping back from something difficult, or defensively interpreting something away from ourselves as if it were only transference, or in returning to the history rather than finding a way of staying more clearly with the issue between the patient and oneself as in the present – to be stayed with in the present.
I think of the process of internal supervision as becoming, with practice, mostly pre-conscious rather than conscious – as when a musician acquires a fluency in the fingers by practising scales. I believe that, with practice, we become more able to be fluent in our thinking in a session – more readily able to sense the implications of what we are hearing and in what we may have it in mind to say: or may already have said to the patient.
KS: In monitoring yourself from the viewpoint of the patient, how do you then work with material that is warded off or defended against?
PC: Another thing I came to recognize from social work regards working with unconscious guilt from a position of seeming to be not understanding why guilt is felt, rather than too readily offering to understand this at the cost of sounding as if we are seeing it as rational -- thus adding to the guilt rather than helping to ameliorate it. It is difficult to expand on this without an example. It was when I prematurely interpreted to a client, in social work, that I believed she was attacking herself (in the skin irritation that she had developed after her husband had died) because I thought she felt guilty about having so often and openly attacked her husband (in my presence too) before he had died of a heart attack.
This client heard what I said as if I were saying she should feel guilty. A colleague had commented, in a case discussion, that I had “merely added insight to injury” and I think she was right. My comment had been experienced more as an insult than as an interpretation. Instead, I might have waited until I could perhaps have drawn the client’s attention to what certainly looked like self-attacking, in her constant scratching that was often drawing blood, as if there was something under the skin she was trying to get rid of – but then wondering with her what this might be. I now think it is always better to be listening and speaking from a position that is more clearly an “ego position”, seeing a sense of guilt but wondering why it is there, rather than sounding as if we are speaking from a “superego position” – as if we are thinking the patient should feel guilty.
KS: I trust that we will hear more from you on this topic in the near future. Thank you, meanwhile, for this opportunity.
|
