ON LEARNING FROM THE PATIENT: THE WORK OF PATRICK CASEMENT – Part 1

Leader: Paul Steinberg, MD

September 15, October 13, November 3 and December 1, 2017

This seminar series consisting of four three-hour seminars will focus on the importance of hearing and using feedback from our psychotherapy patients, especially when there is a difficulty or impasse in the work. Casement combines a relational approach with the theories of Winnicott and Bion. He expresses himself in plain English, free of psychoanalytic jargon. Casement outlined many important practical psychotherapeutic applications of the above theories. He consistently encourages the therapist to put her- or himself in the patient’s shoes, and try to see things from the patient’s point of view.

The seminar leader will begin each seminar by briefly summarizing some of the important points in the reading material assigned for that seminar. The major part of each seminar will consist of participants presenting clinical material for discussion, with a focus on the theme of the course, “learning from the patient”, attempting a specific focus on the assigned reading material. It is expected that 2 or possibly even 3 presentations will be made in each seminar.

This course is not focused on didactic teaching, but on the interaction between participants and leader, based on the notion that “many heads are better than one”, and that the experience of thinking together about our patients can generate ideas that we would be unlikely to come up with on our own. The Talmudic idea that if one wants to study, “First get a friend”, applies. An ongoing emphasis will be to explore what message or supervision the patient may be unconsciously providing us with, and looking at what may make it difficult for us to hear the patient. Of course, this will include a consideration of countertransference.

On Learning from the Patient (part of a book review essay published online in 2015 in Psychodynamic Practice) First edition published 1985. Routledge Mental Health Classic Edition: London & New York, 2014.

The author is writing explicitly about psychoanalysis, but what he says applies to psychodynamic psychotherapy, and to psychotherapy in general. The exception one could take to the claim in this book’s introduction, that Casement is a pioneer in relational approaches to psychotherapy, might be considered pedantic. This book was published three years before Stephen Mitchell’s Relational Concepts in Psychoanalysis. I would say that Casement was in the first full generation of relational therapists, and would reserve the term “pioneer” for Ferenczi, a very early forerunner and true pioneer in the sense of someone who cuts a path through uncharted territory. This is not to take anything away from Casement, who demonstrates many virtues as a psychoanalytic author. He writes in clear non-technical language unambiguous and unburdened by jargon, and is able to describe complex and difficult- to-understand theories in a simple and effective way. His writing is very supportive of therapists in training, for example, debunking the myth that the experienced analyst or therapist understands patients swiftly and unerringly. Each chapter is divided into very short units which are easily chewed on and digested. Casement makes it easy for us to learn from him.

In this volume, Casement focuses on the interactional processes in the analytic relationship to illustrate the patient’s unconscious contributions to the analytic work. He insists that theory is not just applied in clinical work, but is also rediscovered. In Preliminary Thoughts, Casement introduces the relational point of view, which he calls “interactional”. From the beginning, it is clear that Casement is heavily influenced by Bion and Winnicott, of whom he is an excellent and exceptionally clear exponent. He describes Bion’s concept of negative capability as preserving an adequate state of not knowing in order to be open to fresh understanding. It is refreshing to read an author familiar with Bion’s work, which is often difficult to understand, who expresses his ideas lucidly. There is no indication that Casement is familiar with the work of Irwin Hirsch (2008, 2014), although they have much in common, understanding patients being exposed to unacknowledged countertransference activity by therapists as therapists develop a relationship, not unlike a transference, to their own theoretical orientations. Both Casement and Hirsch also are very open regarding their countertransference and their mistakes. Casement creatively uses an arithmetic series to illustrate the danger of premature assumptions without verifying evidence from the patient’s associations. He invokes a comparisons between psychoanalytic supervision (the patient, the analyst/therapist, and the supervisor), and the nursing triad of (mother, infant and father), showing how the therapist in training, like the new mother, requires support in order to learn how to be a therapist.

In The Internal Supervisor, Casement remarkably combines denseness of theoretical ideas and clinical insights in an almost effortlessly readable idiom. This chapter is packed with gems of clinical wisdom. This book is an excellent practical guide to psychodynamic psychotherapy and psychoanalysis which trainees and experienced practitioners alike will find very useful. Casement describes his notion of unfocused listening, provides an example of the internal supervisor at work, and shows the basis on which he chooses from various interpretations. Internal Supervision: A Lapse and a Recovery describes a therapist’s lapse and recovery using internal supervision. This involves an excellent discussion of a series of countertransference lapses, and the patient’s “supervision” of the therapist with unconscious indicators which the therapist has to understand by interpreting extra-therapeutic references as referring to the therapeutic relationship. This chapter includes a concise but comprehensive discussion of countertransference and its communicative function. In Forms of Interactive Communication, Casement describes “communication by impact”, which appears closely related to projective identification. Casement repeatedly demonstrates an ability to express in simple terms concepts which many find difficult to understand, and to illustrate them with lucid case examples.

Listening from an Interactional Perspective provides a detailed analysis of a week of treatment. The author employs the concept of internal supervision to criticize his interventions and adds his hindsights, in an attempt to understand re-enactments growing from his unconscious responses to the patient’s unconscious cues. Casement shows himself capable of reflecting on and learning from his mistakes. He is open to discussing his unconscious motivations for interventions he made which interfered with the analytic process. In Key Dynamics of Containment, Casement uses internal supervision and trial identifications to examine some failures to contain. He deals with the ineffectiveness of reassurance, reminding us that reassurance never reassures. He shows how offering an extra session in crisis may be supportive or unhelpful, depending on the meaning of this to the patient.

In Analytic Holding under Pressure, Casement describes pitfalls to be avoided when pressure from a patient is extreme, including looking for security in a rigid adherence to the usual rules of technique. Patients do not feel secure with therapists being defensive this way. Another pitfall is to feel justified in stepping outside the analytic framework to accommodate special circumstances. However, patients sense therapists’ alarm when they resort to extraordinary ways of working. Casement provides an illustration of difficulty dealing when under pressure from a traumatized patient who accuses the therapist of re-traumatizing her. He noticed that he was offering to be a “better mother’ for the patient, his offer had been partly motivated by fear of losing the patient. However, if he acceded to her request, he would not help her re-experience the original trauma, reinforcing her perception of this being something too terrible ever to be fully experienced. Casement describes in detail his approach to resolving this.

Processes of Search and Discovery in the Therapeutic Experience explores the patient’s unconscious search for the therapeutic experience which is most needed, and how trial identification and internal supervision help the therapist to distinguish what is healthy in the search from what is pathological. Casement notes Strachey’s advice, that every mutative interpretation must be emotionally immediate; the patient must experience something actual. Casement illustrates some of the many ways in which patients contribute towards the shaping of the therapy and towards helping the therapist to provide the kind of therapeutic experience which they need, offering unconscious cues to the therapist to draw attention to when things are going wrong. Therapists may discover the gradual process whereby a patient unwittingly guides the therapist towards what is unconsciously sought within the therapeutic relationship, nudging the therapist back towards ways of working that are nearer to what the patient needs when something is amiss in the therapy. This chapter inspired me to think that this volume is so rich in clinical wisdom that it could be profitably read more than once by many clinicians. The Search for Space: An Issue of Boundaries provides an extended case example illustrating the importance of respecting therapeutic boundaries. Theory Rediscovered provides a summary of the book. Casement emphasizes that, to use my tailoring metaphor, therapy needs to be custom-made for each patient; a therapy off the rack will not suffice.

Already in this first volume the reader finds herself in good hands, the hands of an experienced guide who has learned a lot from his clinical experiences and is very well able to convey this in a manner which most readers of any health discipline can profitably digest. This book is so well-written and so packed with clinical wisdom that I was interested in how the author would develop his thoughts further in the next three books. While reading this book, it was a pleasure to return to it, like meeting old friend with whom one is so familiar and fond that one picks up where one left off in spite of the passage of years. This is not to say that most won’t find something new in it.

Readings:

All page references are from the Routledge Mental Health Classic Edition of On Learning from the Patient, 2014 {originally published by Tavistock Publications in 1985. This is not an inexpensive book, but is well worth re-reading. Copyright law prevents the book chapters from being distributed to the participants. Unfortunately, I think it will be difficult to find a cheap original edition of the book. The intention of the leader is within a year to continue with a second mini-course covering the second half of the book.

This series of seminars will utilize the first 4 chapters and 2 brief Appendices from Casement’s first book, On Learning from the Patient. The following readings are assigned:

September 15, 2017

Preliminary thoughts on learning from the patient, (pp. 1-24).

October 13, 2017

Chapter 2: The internal supervisor (pp. 25-49).

November 3, 2017

Chapter 3: Internal supervision: a lapse and a recovery (pp. 50-62);

Appendix I: Knowing and not-knowing: Winnicott and Bion (pp. 190-192);

Appendix II: The issues of confidentiality and of exposure by the therapist (pp 193-194).

December 1, 2017

Chapter 4: Forms of interactive communication (pp. 63-88).