Ferro said that in the few days of this weekend conference he had not tried to convey concepts.  He is grateful for all the models he has learned over the years (Bion, Klein, Winnicott, Ogden), but what matters to him most is the democracy of models; for instance, Ogden’s “the analytic third” can be thought of as being a concentration of “the field” and an equivalent to the concept of “the link” introduced by Pichon-Riviere and elaborated by the Barangers. At this moment Alpha function and Beta elements are not so important to him.  He said that what matters is to have an experience together, to share our ideas, and to think about how the mind works.  His aim in this workshop was to show us how to create an atmosphere that allows the patient to come alive and be creative and then to co-construct an experience that is transformative. Ferro said that he appreciated the warm, free atmosphere at the International Psychotherapy Institute in which we could dream together and create a narration.  He likes the group affective model developed at the International Psychotherapy Institute and hopes to export it to his own teaching.

“I appreciate the warm, free atmosphere at the International Psychotherapy Institute in which we can dream together and create a narration.  I like very much the group affective model developed at the International Psychotherapy Institute and I want to export it!”  Antonino Ferro, President, Italian Psychoanalytic Association.

Having studied the analytic process as one in which the Beta elements are represented in images (pictograms) and then in narrative form, we moved on to look at the process that occurs in reverse, in Frederico Fellini’s dream book.  Fellini had a daily habit of writing down his dreams and then drawing the image that came to mind. Ferro showed us that the drawing serves as the interpretation of the dream—no further narration, and no analyst in sight—and that completed the process until the night when the next dream could occur. Looking at a sequence of Fellini’s dream-text-picture records, we saw a progression from terror and loss to manic defense and resolution with acceptance of depressive anxiety. Like Fellini, we face the risk of plunging into depression, but we can use the fuel form the energy of the paranoid-schizoid position to arrive at a state of integration that is full of life. As we discussed this material in the large group, many minds were brought to bear on the dreams and the relevance to self-analysis and analytic therapy with patients. In Ferro’s way of putting it, based on Bion, the group brings many Alpha functions to bear on puzzling material, a super-Alpha function that he calls Gamma function, and this allows for a much richer appreciation of the material presented to us, richer for us, and for him.

Ferro showed us how to think of the history as a collection of facts or as a dream dreamt by the presenter of the case history. When a patient describes an avoidant attachment to a withdrawn and unresponsive mother, we can think of her as a dead mother. The patient may react by feeling dead or exploding in rage because all the messy, needy feelings of the baby cannot be taken in and metabolized, but return like a boomerang that misses its target and settles in the mind of the baby. The mother is dead to the infant’s need for having its Beta elements taken care of, but since she is alive in general she cannot be mourned. This problem has to come alive in the field for any transformation to occur. In the clinical situation, the person with this history has to find a way in to the field, but has no entry strategy. So the person may shut down and give up trying or may explode into the therapist’s mind, unless the therapist is able to open the door and allow entry. This opening of the door is more effective than making interpretations that penetrate the vulnerable, withdrawn or raging infant mind and are felt as persecutory rather than understanding.

Distinguished analyst Antonino Ferro, president of the Italia Psychoanalytic Association, opened our April Weekend Conference by presenting his unique approach to the clinical situation as a waking dream. The therapist receives unmetabolized proto-emotions generated in the here-and-now of the therapeutic relationship and contains them, first as a pictogram (image), until he/she can present them as a narrative. How does the therapist develop and enlarge the capacity to contain? This is the topic we will explore for the rest of this intensive weekend conference with our special guest, Antonino Ferro.

 Couple and Family Psychoanalysis Around the World

Monica Vorchheimer (BA), Mary Morgan (UK), Elizabeth Palacios (Madrid), Félix Velasco Alva (Mexico); John Zinner (Washington); Karen Proner (New York), Lin Tao (London and Beijing); and Susana Muszkat (San Paulo) who participate in an IPA working group chaired by David Scharff came to join IPI faculty and guests as presenters or discussants in couple and family psychoanalysis at the February core program weekend and its preconference day co-sponsored by IPI and the IPA working group.

Photo 1. Weekend conference on couple and family psychoanalysis

 The weekend conference co-chaired by David Scharff and Janine Wanlass looked at difference and similarity in theory and practice around the world, and particularly at beginnings – beginnings of sessions, of treatments, new beginnings within treatments that became moments of change.

Photo 2: IPI and IPA presenters

Back Row: David Scharff. Rich Zeitner (USA), Susana Muszkat (Brazil), Karen Proner (USA), Monica Vorchheimer (Argentina), John Zinner (USA), Lin Tao (UK and China), Jill Scharff (USA)

Front Row: Hanni Mann-Shalvi (Israel), Teresa Popiloff (Argentina), Mary Morgan (UK), Elizabeth Palacios (Spain), Delia de Cierda (Mexico), Yolanda Varela (Panama), Félix Velasco Alva (Mexico)

100 participants gathered to teach and learn about the differences among European, North and South American approaches to theory and practice of couple and family therapy.  We heard clinical examples that showed transference and countertransference noted at the beginning of contact and evolving over the months of treatment; difficulty in dealing with a hidden agenda in two beginning sessions; opening the space for discussion of trauma and shame in a consultation; how the initial conditions affected the outcome of a couple therapy; and ambivalence in making a first appointment as a displacement from ambivalence over reconnecting with a wife after renouncing an affair that gave the partners the illusion that they were stabilizing a marriage.

Photo 3. Felix Velasco and Delia de Cierda (presenters) Lea Setton (session chair), Caroline Sehon (discussant)

We explored the value of theory and looked for similarities and differences among couple and family analysts around the globe.  We compared and contrasted projective identification (from British object relations) and link theory (from Pichon- Rivière in South America) as concepts applied to couple and family work.  We presented those theories as quite different, and yet it was hard to establish clear lines of difference because of individual variation in how our concepts are defined, both concepts being polyvalent.  We presented differences in technique in terms of how much data various analysts want to have before delving into process and how comfortable others are with waiting and not knowing versus intervening to be helpful, whether in a presentation or in a therapy session.  Some analysts prefer to ask about history in a routine manner, while others ask only at moments of affective exchange.  There was a trend towards seeing the South American approach as one more comfortable in the present moment, while the American one was seen as more data driven, more directive.

These differences were presented as culturally determined, and yet we noted individual variations within each culture.  In any case, I felt that our differences were far outweighed by our similarities in valuing containment of anxiety, invitation to inquiry, following the affect, interpretation, and above all, developing a therapeutic relationship and tuning in to the unconscious as the route to therapeutic action.   We presented cases in a variety of ways – case summary and overview of analytic process, process notes, and video – in order to provide various points of access for various learning styles.  Taken together the diverse methods of presentation and the varying ways of offering entry into therapeutic process, offered a more whole object for contemplation.  We’re looking forward to more collaboration between IPI and the IPA at the Congress in Boston 2015, and possibly before then in Buenos Aires.

Book Launch at IPI

Overseas guests Mary Morgan and Lin Tao were joined by local IPI faculty who had authored chapters in the new book Psychoanalytic Couple Therapy, edited by David and Jill Scharff, with the collaboration of David Hewison, Christel Buss-Twachtmann and Janine Wanlass, for the USA launch of this book, a joint effort by the International Psychotherapy Institute (IPI) and Tavistock Centre for Couple Relationships.(TCCR). The book is based on the jointly offered course given over the last four years by video link, which has had participants from the United States and overseas in the UK, Central America, Israel, South Africa, Turkey and Hong Kong.

Photo 4. Chapter authors celebrating at the launch of Psychoanalytic Couple Therapy (left to right) Lea Setton, Yolanda Varela (Panama), Jill Scharff, David Scharff (USA) Damian McCann, Mary Morgan (UK), Mike Stadter, Janine Wanlass and Richard Zeitner (USA)

Photo 5. Psychoanalytic Couple Therapy book

Comments about Psychoanalytic Couple Therapy:

• “Shows the mental functioning of couples and families as fantasmatic organisms, the intertwining of intrapsychic and interpersonal levels, and the new frontiers opened by this approach.” Anna Maria Nicolo, President, Italian Society for Psychoanalysis of Couple and Family

• “Numerous, lively, in-depth clinical examples which bring the couples and the clinical dilemmas to life” Joanna Rosenthall, Tavistock and British Psychoanalytic

• “An updated, sophisticated approach to the diagnosis and effective treatment of the broad spectrum of couples’ difficulties.” Otto Kernberg, Past President, International Psychoanalytical Association

Scharff, J. S. (2013).  Book review of Shrink Rap.  In Psychodynamic Psychiatry 41(3): 473-477. Posted by permission of Guilford Press.

 Shrink Rap, by Dinah Miller, Annette Hanson, and Steven Roy Daviss, Johns Hopkins University Press, Baltimore, MD, 2011, 255 pp.

As a psychoanalyst, I was not drawn to the title of this book, Shrink Rap, or to its focus on psychiatry with barely a mention of psychoanalysis. As a psychiatrist, I was not drawn to it either, given I had already been immersed in psychiatry and had left it behind. Once into the book, I found plenty of useful information, and I quite enjoyed its survey of the field. This book, however, is not intended for professionals. It is for consumers of psychiatric services. A trade book! Surely an unconventional choice for an academic press, I thought, until I realized that Johns Hopkins Press includes similar titles in its catalogue. As an academic publication, Shrink Rap falls short in that, although there is an index, a list of further reading, and any research or literature drawn from is mentioned in the text, there is no bibliography as one might expect in a book from an academic press. Nevertheless, as a trade book, Shrink Rap is well written, well crafted, accurate, and forthright. In being clear, comprehensive, informative, and impartial, it is scholarly in its own way. True to their mission, the authors write as thoughtful friendly guides to the psychiatric system, respectfully explaining the competencies of various mental health professionals in relation to the book’s main focus—the practice of psychiatry from outpatient to inpatient setting, clinic to private practice, voluntary to involuntary treatment, severe mental illness to personality disorder. It interested me to read the book from the point of view of patients who face this array when they present with a problem, as well as from my own perspective as an analyst. Where would psychoanalysis fit in the scheme of things?

Written for patients and their families, Shrink Rap is a wealth of information, clearly presented. After years of experience writing a blog and creating podcasts, three Maryland physicians—Dinah Miller, a general outpatient psychiatrist, Annette Hanson, forensic psychiatrist, and Steven Roy Daviss, consultation-liaison psychiatrist and specialist in clinical informatics—know the needs and concerns of patients and their families and how to address them clearly and simply. Now they have distilled their collective wisdom and experience in this book. Readers can ask questions and post comments about the book and engage with the authors and other patients and families on the authors’ blog. The authors, who express their academic authority in a friendly professional voice, have constructed a really well written, easily accessible, reliable consumer guide with access to follow-up discussion. In short, Shrink Rap is a well-supported trade book, offered, however, by an academic press.

Accompanying the authors on this walk through the system are fictional patients. I always have a problem with this device because it cannot accommodate the movement of the unique individual unconscious. The “patients” are composites put to the service of representing types of illness such as attention deficit disorder, delinquency, depression, addiction to drugs and pornography, panic and eating disorders, bipolar depression, and schizophrenia, and illustrating various approaches by psychiatrists who vary from remote to effusive, respectful to exploitative. Patients and psychiatrists working in treatment demonstrate the strengths and weaknesses of the system, the therapeutic relationship, pharmaceuticals, and newer invasive therapies. At one end of the spectrum of satisfactory care, there’s Tara, her panic disorder treated successfully with drugs and weekly supportive and exploratory psychotherapy, and at the other end there’s Becca who bounces from one psychiatrist to another, feeling misunderstood, rejected, embraced, and eventually betrayed. There’s the fictive Brandt family whose members are given to suffer individually—Stuart from grief reaction, Jack with hallucinosis found to be caused by a brain tumor, rapid cycling bipolar disorder (that’s Becca), Richard addicted to pornography, and Frank who is simply in a developmental transition. Later we meet Mitchell who is receiving hospital care for relapsing schizophrenia, and orphaned, hyperactive Eddie who is followed from the juvenile justice system to his incarceration as an adult drug user and sex offender in a setting where at last he could develop into a responsible adult.

Shrink Rap is such an omnibus of information and possible scenarios that it is surprising to note a few omissions. The next edition might include telepsychiatry in which psychiatrists deliver quality mental health care direct to patients who live remote from specialist centers and provide consultation or supervision to their local physicians and therapists via videoconference. Perhaps the authors do not endorse this innovation, but it is a growing part of the field of psychiatry and therefore a significant omission. Conjoint therapies are also overlooked. Why, I wonder, did no psychiatrists recommend couple therapy for Richard and his wife, or family therapy for the whole Brandt family? Readers are not given enough information about the parents, the previous generation, and the current sociocultural setting to guess at the Brandt family unconscious that connects to individual psychopathology. There is little but a passing mention of psychoanalysis, the foundation for understanding human conflict that underlies symptoms. The authors do refer to the childhood history of each patient and its effect on perception and feeling toward the treating psychiatrist but they do not apply this knowledge fully in their clinical narratives. I regret that patients and their families cannot use this book to learn how their situation has arisen or how to work through to a better adjustment. To be fair, the authors do not claim to write a guide to self-help treatment, only a guide to the system. Their fictional patients and treatment situations do serve to illustrate what can happen to people who must traverse the ins and outs of psychiatric services. But the authors could have done more to encourage reflection on the patient’s self.

I appreciate that the authors are scrupulously and refreshingly honest. Their chapter featuring Becca and her troubled course of treatment with a series of psychiatrists—of whom none were quite right and one of whom broke professional boundaries to feed her own narcotic habit—is so chilling that they might have excluded it to save face, but they wisely left it in as a cautionary tale. They present and illustrate the ethics of psychiatry even-handedly, acknowledge ethical dilemmas candidly, and discuss questionable decisions in a nonjudgmental way, always recognizing the grey areas. They acknowledge areas of debate and controversy in psychiatry. Their examples show that any of the psychotherapies for mental illness take second place to the prescription and management of psycho-pharmaceutical agents, and they ac- knowledge that drug management earns the doctor much more money in 15-minute increments than can be made in a 50-minute therapy hour. The authors admit to not knowing. They confront ignorance and uncertainty in many aspects of this new and inexact science. They mention inadequacies among practitioners, limitations of research, discrimination in insurance reimbursement policy, and difficulties arising in diagnosis and treatment. They discuss the risks and benefits of a national health information data storage system. In short, they give an accurate, comprehensive, unvarnished overview of the medico-legal-psychiatric system.

Reading as a mature psychiatrist I came away with a refresher on areas of the field from which my subspecialty has taken me away. Reading as a psychiatry trainee, one would find Shrink Rap useful in that it provides a detailed, comprehensive view of the field, a description of many of the psychoactive drugs in use, and a nonjudgmental account of the three major forms of psychotherapy. Trainees who identify with the authors’ approach will come away with a broad perspective on issues in the field and a humane, respectful, ethical stance. They will be encouraged to develop curiosity about the emotional life of their patients and their histories, but they will not develop any analytic sensibility or deep understanding of the human condition.

Reading as a psychoanalyst, I was sad, but not surprised to note the tiny place psychoanalysis has in the mind-set of the general psychiatrist. Shrink Rap reflects current perceptions that drive psychiatric residency training and mental health insurance policy. Psychoanalytically informed treatment has been slow to subject itself to research because the psychodynamic therapeutic relationship is too complex to reduce to simple criteria ready for measurement, but attachment research and neuroscience are now showing how the therapist’s capacity for empathy, containment, and attunement provide conditions conducive to affect regulation and brain growth. Intensive psychotherapy, however, calls for a big investment of time and money by patient and therapist in training. Consequently, psychodynamic or insight-oriented psychotherapy, once the staple of psychiatry, is now less often prescribed than quicker, evidence-based, results-focused methods with circumscribed goals that can be subjected to quantitative research. As a psychoanalyst, having been an analysand myself, I know from professional and personal experience that an open-ended psychodynamic, interpretive approach that takes account of the dynamic unconscious and its effect on the therapeutic relationship offers insight out of which personal growth develops. But I do not find this value embodied in this book. Psychoanalysis receives a mention as an option for those who seek to know themselves better to fulfill their potential, especially as psychotherapists, but it is not fully described, illustrated, or applied to the discussion of vignettes.

Psychoanalysis is most visible by its absence in Shrink Rap. Reading this book is a hard lesson for the psychoanalyst and psychodynamic psychotherapist. It serves up a sharp dose of reality and a painful reminder of how society has come to view mental illness and the means to wellness.

Jill Savege Scharff, M.D.

6612 Kennedy Drive

Chevy Chase, MD 20815-6504

Jill Scharff, Caroline Sehon, Janine Wanlass

The International Psychotherapy Institute  (IPI) and Westminster College are the proud recipients of a research grant award from the International Psychoanalytical Association (IPA) in support of our jointly conceived Research Grant Proposal on Teleanalysis.  This proposal, written by Janine Wanlass, Principal Investigator, was submitted to the IPA by Caroline Sehon, chair of the teleanalysis working group of the International Institute for Psychoanalytic Training (IIPT) at the International Psychotherapy Institute (IPI) on behalf of IPI and Westminster College, Salt Lake City.

At the September meeting of the Teleanalysis Group, Janine Wanlass reviewed the history of the research grant proposal to the IPA.  She described learning about the IPA grant, gaining the interest and expertise of her colleagues Jen Simonds and Ellen Behrens at Westminster College, and discussing the collaboration between our group and Westminster College.  She then gave an overview of the study design.  The practice of teleanalysis – conducting psychoanalysis through the assistance of the telephone or other high quality video connection system – is described in case studies and anecdotal accounts but lacks an empirical research base.  The current study proposes development of a questionnaire to assess the frequency, format, rationale, experience, and scope of teleanalysis practice by IPA analysts.  Based on these research findings, a subset of analysts will be interviewed using a grounded-theory approach to further investigate analysts’ perceptions, experiences, and challenges in practicing psychoanalysis via the use of technology.  The findings from this mixed-methods approach will be presented with implications for current practice and future research.  For instance, we hope to expand our research to the study of psychotherapy via technology as another arm of the project. 

Janine explained that the grant money will be allocated against research expenses (such as data entry, translation of interview data, and computation) and that no researchers, interviewers, or interviewees will be paid for their participation in this study.  In response to interest shown by all members of the group, Janine stated that her next step will be to invite our group over the next couple of weeks to contribute ideas that would inform the questionnaire design. Janine looks forward to collaborating with the group, and to receiving direct and specific input from project participants along the way. We anticipate that it could take three to four months to design the questionnaire needed for Stage 1, obtain IRB approval, and pilot the questionnaire.  The award funds will be released as soon as we are ready to send documentation of IRB Approval from Westminster College to the IPA.

One IPA reviewer said, “This project is carefully planned and it promises to get data about teleanalysis which are not known up to now. Furthermore it is conducted in conjunction with two appropriate sponsoring institutions and with a group of experienced psychotherapeutic and psychoanalytical researchers. So it has a good basis…..”   IPI’s affiliation with Westminster College was a critically important factor in the success of this research submission, as it has been in many other clinical and educational aspects of training programs at IPI and Westminster College.

Robert Galatzer-Levy, chair of the Evaluation and Research Proposals and Results Committee of the IPA wrote that the IPI/Westminster College grant application “received a very high ranking in a highly competitive field. The grant will be funded in the amount of $5,000 to support your research project. This award reflects limitations in the funds available to support research.”   We are delighted with the amount of the award, because it corresponds exactly with the amount requested.  IPI Board member James Finkelstein expressed the view that the honor of receiving the award is much more significant than the amount of the award.  The IPI Board was unanimous in extending congratulations to faculty responsible for this successful submission.

Caroline Sehon complimented Janine Wanlass on her “hard work, keen analytical and research perspectives, and her collaboration with her research colleagues, Jen Simonds and Ellen Behrens, at Westminster College.”  Sharon Dennett, Chair of the International Institute for Psychoanalytic Training (IIPT), the analytic training program at IPI, thanked the teleanalysis group “for this considerable and productive work” and offered help in whatever way IIPT could provide support.
This is a tremendous accomplishment for all, and a testament to what can be achieved when a team of many individuals and two institutions came together, working at high intensity and lightning speed to meet a rapidly approaching deadline, all with the solid support of Geoff Anderson (IPI’s Director), Jill Scharff (co-founder of IPI, past chair of the teleanalysis group, and Board member) and David Scharff (co-founder of IPI and Board Chair), Doug Dennett, Sharon Dennett and Stan Tsigounis (IPI and IIPT at IPI), Colleen Sandor (Westminster College and IPI), and last but not least, Anna Innes, Executive Administrator of IPI.

This recent article in the New York Times is an important admission by the psychiatric community that the notion of having the biological answer to mental illness is a myth.  What biological psychiatry is still missing is the important biological evidence that is revealed in affective neuroscience and developmental psychology about the underpinnings of the development of the unconscious relational self in attachment, affect regulation, and mentalization.  By looking for cellular level structure problems they are missing the idea that the human brain develops primarily after birth in a relational matrix.  It is encouraging to see a step back from the certainty that biological structure determines behavior and that there are deeper mysteries to yet be explored.

CNN has recently posted a very interesting article about psychoanalysis in Argentina and how it is thriving there.  If you would like to see the article follow this link:http://www.cnn.com/2013/04/28/health/argentina-psychology-therapists/index.html.  A very interesting cultural difference in attitudes to the analytic therapies.