Panic Focused Psychotherapy Study

By David E. Scharff, M.D.

Among the sessions I attended at the Winter Meetings of the American Psychoanalytic Association, one stood out on the findings of a randomized control trial of a new and manualized psychoanalytic treatment for panic disorder, overseen by its principal researcher, Barbara Milrod of Cornell Medical Center in New York City. The presentation was chaired by Stuart Hauser, a leading analytic researcher, and discussed by Peter Fonagy.

I’m writing about it here because it is a hopeful and beautifully done addition to our armamentarium concerning the efficacy of psychoanalytic therapy. It adds to studies being done by Fonagy, Target and their group in London on Mentalization-Based Therapy, and by Otto Kernberg’s group at Cornell, White Plains on Transference Focused Psychotherapy. The studies apparently have a good deal of overlap in their systematic use of transference and basic analytic techniques applied to a brief therapy that is therefore much easier to test for outcome.

In this study, Dr. Milrod and her colleagues treated Panic Disorder – including such symptoms of acute anxiety as intense fear, chest pain, heart palpitations, and shortness of breath — precisely because Panic Disorder has been a focus of CBT and medication outcome studies. Since these studies have been based on 12 weeks of treatment, she designed her Panic Focused Psychotherapy (PFP) study to conform to these parameters so they can be compared. PFP treatment is manualized in a manner similar to Kernberg’s Transference Focused Psychotherapy (TFP), but this is much briefer — 12 weeks of twice-weekly weekly as opposed to a year of therapy for TFP.

(Patients were left on medication if they were already on it at the time they began the study, so that is not in the comparison. Obviously, if they were on medication at the beginning of the study, it was not in itself curing the panic disorder because symptoms of panic attacks had to be present for a subject to qualify for the study.)

Panic Focused Psychotherapy begins with initial evaluation of the symptoms, relating them to the surrounding circumstances and attendant feelings, exploration of the personal meaning of symptoms and episodes. Then the therapist works to identify relevant psychodynamic conflict, focusing commonly on issues of separation, autonomy, and anger. In the first phase, therapy aims for panic relief and reduced agoraphobia.

The second phase of PFP explores panic vulnerability by addressing transference manifestations, and working through the many situations of conflict. In this phase, therapy hopes to result in improved relationships, less conflict and anxiety in the experience of anger, separation and sexuality, and reduced recurrence of panic. Finally, a termination phase permits re-experience of conflict around separation and anger themes in the transference, because a frequent temporary recrudescence of symptoms during termination allows for a review of problems that can again lead to an enhanced ability to manage separation and experience autonomy.

In a paper published in February of 2007 in the American Journal of Psychiatry (164:2 pp 265-272) Dr. Milrod and her colleagues reported on the preliminary study that showed 73% efficacy compared to 39% for Relaxation Therapy. This study prepared the research for later comparison to medication and CBT. But at the presentation in January, Dr. Milrod presented preliminary data on the comparisons going forward with CBT. So far and unofficially, PFP holds up well against CBT and especially shows a better capacity to maintain gains months after the completion of treatment. Although the treatment is “manualized” it is not a rote treatment. The manual offers a guide as to what issues to focus on in evolving phases of therapy. There are compromises with the way we practice analytic therapy that are required to construct such a manualized treatment, but anyone who has read Michael Stadter’s excellent book “Object Relations Brief Therapy” (Jason Aronson, 1996) will recognize the enormous overlap in methodology. Stadter’s model is one of a combined focus on the symptom and the dynamic unconscious structure that underlies it, all treated in the transference using working through and a late focus on termination and loss. Brief analytic treatments can be tested, while it is exponentially more difficult to do so with open-ended, long term therapy. These studies, done in ways that can be compared directly to CBT and medication, offer to give us the ammunition to defend our trade in clear and legitimate ways that have, until recently, been sorely lacking. Peter Fonagy spoke with deep appreciation of Barbara Milrod’s study, particularly noting how arduous and time consuming such studies are, and how thoroughly and rigorously she and her colleagues were in the conduct of this study.

Webb MD’s Denise Mann reported on January 17 that, “The psychodynamic psychotherapy regimen used in the study was so successful that the American Psychiatric Association is in the process of changing its guidelines to reflect the new findings, according to researcher Barbara Milrod.”(Until now the APA has only endorsed CBT and medication as treatments for Panic Disorder.)

This research and the few comparable studies now going on are a cause for hope for our way of thinking and practicing. I look forward to more results from Dr. Milrod and her colleagues.

Psychoanalysis in China, Part Two

By David E. Scharff, M.D.

May 15 and 16, 2007

Wuhan is not known for its sights, and among friends and acquaintances with whom we discussed our trip before coming, only those with experience in international business had spent time here. Others had come to board the cruise down the Yangtze River to the Three Gorges Dam without staying in the city. But we are growing fond of Wuhan. We have been to dinner at General Wu’s house, a grand although now dilapidated mansion, eating spicy long green vegetables and chickens’ feet (and some more palatable food) on the verandah two stories above the street, looking at a sign that read “Endless Midnight: Infinite is Overwhelmed with Emotion” over an abandoned store front. Wu was a powerful South China general early in the 20th century who refused to cede power to the occupying Japanese. So they made him an offer he couldn’t refuse. When he developed a virulent tooth infection, the Japanese insisted he accept the help of their dentist. He died immediately after the dentist’s visit.

Yesterday we tried to come to terms with the difficulty the audience had following our videotapes of an evaluation. The gap in understanding is greater than anyplace we have ever taught. Although we sent transcripts of the interview of the couple ahead for translation so that the audience could follow along, the cultural gap has proved to be too great for the interview to make sense to them without quite a lot of explication. Jill labored bravely to bridge the gap, but only got through eight minutes of this tape. It was dismaying because this has always been our most popular, and most easily understood vehicle for teaching. She changed tactics and had volunteers read the transcript for a kind of scripted role play, but thought that the audience would probably have preferred to do their own unscripted role play! Later we learned that the translation of idioms was part of the problem. For instance, when the woman in the couple begins the interview by telling us, “We have three shrinks between us,” the translation read, “We are three very small people.”

Jill struggled with another discrepancy: Dr. Qijai Shi, our host, had asked us to prepare an advanced curriculum, which we came to feel is what would most suit his interests. But now we can see that most members of the audience have no background in what we are teaching, and need the most basic concepts spelled out clearly.

Jill and I spent the next session consulting jointly to an extremely depressed and frequently suicidal young woman, a hospitalized teacher of Chinese language and literature who had lost her job, she said, because her students objected to her disciplinary methods, and who now only wanted to go home and stay with her parents. A sad situation! Dr. Jun Tong, the head of the Inpatient Unit, reports that this woman is actually much improved after some time in the hospital and several sessions of psychotherapy. Dr. Tong tells us that many of the teachers, themselves with little training in pedagogy, are quite harsh and therefore unpopular. Jill continued her teaching for the rest of the day, including a consultation to a case that was extremely well presented by an experienced therapist, while I was given my day off for a tour or two of the city.

Dr. Wu Xiaojan (who has chosen the English name Rose), a 26 year old woman psychiatrist, is Dr. Shi’s protégée. Graduated from the medical school of Wuhan University two years ago and about to complete her Masters Degree in psychotherapy, she will join Dr. Shi’s staff in July. Her English is excellent. She has been an able translator when Dr. Shi hands over to her, and on this occasion, she was tasked with giving me the tour of the city with a clinic car and driver. We went first to the Guiyuan Temple, an impressive although somewhat shabby sprawling structure that houses 500 painted life sized images of pupils of Buddha, each with a distinctive persona, some serious, some fearsome, some whimsical. In one main hall, a golden image of Guiyuan stands on a heavily decorated alter. A peace garden occupies one corner, and massive reconstruction is still taking place on other parts of the large site. What is most impressive is that this is a working religious operation, with monks teaching and ordinary Chinese coming to pray in various halls in the temple. The whole effect is perhaps marred by a lack of tiptop repair and decoration, but my interest was carried by the fact that I could easily see that despite more than two generations of repression of religion, this place still had day to day meaning for so many people. What we learn as we tour more of China is that the culture has not been dominated by a religious ethic for a long, long time. Although we are used to linking Confucianism and Buddhism with China, the country has been principally secular for perhaps a thousand years. There are active religions, including some Christianity, but the lack of a dominant religious ethic began long before the Communists came to power. Weddings, for instance, take place in restaurants, not churches or temples.

I was not prepared for how impressed I was by the next site, however, because the guide book is dismissive of the Hubei Provincial Museum, saying only that it is dedicated to artifacts excavated from the tomb of Marquis Yi who died in 433 B.C. What an understatement! This is one of the most impressive collections of tomb elements I have ever seen! Three years ago Jill and I saw the newly opened, magnificent “Lord of Sipan” tomb reconstruction in northern Peru when we visited one of our daughters who was working in Lima. This was every bit as impressive: Perfectly preserved bronze serving and drinking vessels, large and small, beautifully preserved arrow and spear heads with crossbows, bamboo spear shafts, full suits of lacquered armor, woven silk, massive group tombs to house those who were required to die with Marquis Yi. The collection of likenesses of animals is stunning, but the elaboration of fanciful animals, of one animal turning into another, of a tree that turns from frog to bird, of graceful antlers arising from the head of a bird is hauntingly beautiful. And most of all, a full orchestra perfectly preserved: a mounted collection of several dozen musical bronze bells, from large to very small along with zithers and wind instruments. Apparently, 2400 years ago, Marquis Yi liked music! The highlight of the visit is the concert. While the ancient instruments are all playable, to preserve the originals, the concert is given on a full replica set playing traditional Chinese music accompanied by fluid, graceful dancers, and a small fillip of modern Western music to show how flexible the orchestra is.

The next day, we woke to a grey rainy sky, an army of umbrellas held over motor scooters, bicycles and pedestrians crossing the huge intersection below our breakfast window. The ebb and flow of humanity rain or shine. We tried to adjust our teaching, to match it more appropriately to the mixture of experience in the audience, focusing on the rudiments of the frame required for therapy, a smattering of attachment theory and the way it could be used through assessment of the patient’s language and narrative, some neuroscience of the frontal lobes as the executive of emotional regulation, and the role of the face and mirror neurons in expression and reading of emotion in development and in psychotherapy.

It is odd to teach about non-verbal communication, when we are feeling that the audience is having such difficulty reading the non-verbal expression of our teaching tapes! On this day, while Jill had her turn to see the monastery and museum I had seen the day before, instead of playing a whole video, I played short segments and told the story of an interview with a couple with sexual difficulty who had delayed their marriage in order to get help. We discussed the role of sexuality in the formation of their bond, and of the trauma each of them had suffered growing up in structuring their relationship and their difficulty. We seem to have hit a better level of understanding for the group – but I didn’t think we managed a really good fit as yet.

Jill returned from seeing the temple and museum to share in conducting an interview of a family of a 17-year-old girl who acts up a good deal and whose declining school performance distressed her and her parents so thoroughly that she ended up in the hospital. It was an entertaining affair. The patient’s English was excellent. The English name she had chosen for herself was Elizabeth (altered here for her privacy), and when I went to ask her to participate in the live, observed interview to which her parents had already consented, she flippantly answered, “No sweat!” and headed down the hall to the interview room. Elizabeth translated (and actually often mistranslated) our comments for her parents, while Dr. Tong then corrected her adolescent attempts to mislead the parents, and we worked for 45 minutes to make an assessment of her ambivalent wishes to satisfy and thwart her parents’ ambitions for her. “All Chinese children are under pressure to live up to their parents’ high hopes for them,” Elizabeth said – and young Dr. Wu confirmed that it is so: places are so scarce in the good schools and the reward for success is so high, that all ambitious families are under enormous pressure. Since 1981, all urban families are held strictly to the one child policy, so that each family has but one precious child who is their hope for the future. (We learned of an exception later in Shanghai where negative population growth has led the government to allow two children.)

What makes things worse for the one child families like Elizabeth’s, is that the parents were usually denied a similar advantage because of the destruction of educational possibilities during the Cultural Revolution when Mao ordered young people to forego education and the children of professional and educated families were sent to the countryside. This happened to the parents of our young guide and translator, Dr. Wu, whose parents have been generously supportive of her growth and education, still paying the now expensive university costs and supporting her in the long slog before she becomes eligible for a salary for the first time later this year. But in the case of Elizabeth, the situation had become sadly complicated. Still, these were dedicated and worried parents who clearly would do whatever they could. And while Elizabeth was flamboyant and provocative, disguising and then flaunting her story of declining performance and erratic behavior over the last three years, she responded to our efforts and steadied down in the interview to show flashes of quite remarkable intelligence and insight. True she fell about on the floor and acted “crazy,” but she responded to limit setting and acted sanely again. At the end, in an oedipal enactment, she told me that she wanted my email (which I did not give) so that she could see me in America in three or four years, and immediately turned to tell Jill that she was beautiful. (Elizabeth had a remarkably young and beautiful mother.) We thought that, despite her hysterical psychosis, she had the potential to make good use of family and individual therapy, perhaps a mild learning disability in math, and a supportive, if baffled, family.

The exhausting day of teaching ended with Dr. Shi treating us and our two young guides to an hour’s foot massage, called “reflexology.” What a comic sight, the five of us lined up in a row in plush armchairs, with four young women and a young man for Jill, kneading, slapping, and massaging our feet, legs and shoulders for an hour until we relaxed thoroughly. Dr. Shi kept worked on a large sheath of papers throughout his foot massage.

May 17, 2007

In the teaching today we tried to make modifications based on the experience of the first three days. Jill began by taking questions, and the discussion therefore was much closer to the level of interest of the group. She had to go over the basic ideas of projective identification and transference, using simplified examples from her practice. Later in the day, we interviewed a middle aged couple while the audience watched by video feed to another floor. The couple was of particular interest because the wife was educated while the husband was not. She used her excellent English to exclude him from direct contact with us. We felt this gave a new version to the dynamic of their marriage in which she had chosen a much less educated husband who she felt was more emotionally available than her strict and controlling parents, only to later reject him because unconsciously he represented her denigrated self. Beginning with the pregnancy that produced their daughter, she had become emotionally provocative and he physically abusive. Later he spent money from his overtime work on prostitutes, resulting in her acquiring a gonorrheal infection. They had settled into a marriage marked by emotional distance and fighting. Both had considered divorce, but neither felt they were likely to find a better partner. Finally a friend of the wife had recommended that they seek psychotherapy. The interview was made immeasurably easier by Dr. Shi’s translation which gave him a role like an additional co-therapist. He and I worked to include the husband on a more equal footing to compensate for the way the wife kept trying to recruit Jill to her point of view. At the end of the interview, Dr. Shi offered to see the couple in marital therapy, and the husband, whom the wife had described as reluctant to come to therapy, seemed willing.

Dr. Shi left our afternoon teaching to meet his German colleague, Wolfgang Senf from the University of Ulm, at the Wuhan Airport. At a grand dinner in a private room in one of several Wuhan restaurants that seats 3000 people and is permanently set up for large weddings, we learned more about the alliance between the German-Chinese Cultural Alliance that has been the guiding hand in the establishment of the Wuhan Hospital for Psychotherapy. Dr. Senf, a psychoanalyst, has had a leading hand in the design of psychotherapy training in Wuhan. He has been coming to China for many years, and to Wuhan several times a year for the last 5 or 6. Bejing is only an enviable mere 9 hours from Frankfurt, so the trip is not more difficult than for us to go to Europe. Dr. Senf has set up psychotherapy training that spans the modalities and models of analysis, cognitive behavioral, and systems therapy, and has come to the conclusion that what is needed is not training in analysis or analytic therapy first and foremost, but basic training in doing all psychotherapy. He has developed a basic curriculum that the first generation of trainees can then implement with his and his colleagues help. In the place of individual personal therapy for the trainees, he offers sessions two or three times a year in “self awareness” in which he consults to their own process of self-examination which should continue in the intervals between his visits. The supervision and personal sessions Dr. Senf gives are augmented by local supervision given individually and in groups by Dr. Shi. The design stems from Dr. Senf’s conclusion that standard training and more intensive therapy and supervision are simply not possible in China at this point in the evolution of dynamic therapy, so that the question is comparable to one Winnicott posed in conceptualizing the provision of therapy to the large numbers of children seeking help — not how much can be done, but how little need be done to get the job done. This design contrasts sharply with the discussion Jill had with Elise Snyder before we came to China. She has been working in China for more than 20 years, and currently has a handful of Chinese professionals in analysis at very low fees in a program in which American analysts donate time and accept these fees. The fees cannot be taken out of China, she told Jill, so these analysts have to come to China to spend the money. The scope of influence seems entirely different.

The more I talked with Dr. Senf, the more I was impressed at the complexity of the problem of jump starting psychotherapy in China. The professional audience is eager and naïve. But they won’t wait the many years it would take to slowly build analytic psychotherapy skills to the level of practice of Europe and the Americas. What will practice and training be like in the wake of this kind of short-cut training? Will the level of practice ever reach even that of our mid-level trainees, or will it become a kind of analytically informed counseling? I felt that I had to withhold conclusion, and perhaps after experience in Shanghai at the conference Dr. Shi had partnered, I might feel I knew more about the problems.

May 19, 2007 Beijing

We have spent the last 2 ½ days touring in Beijing after a morning flight, met by Martin, our guide with Mr Jin, the driver of a Chinese make car rather like a down-market Lincoln Town Car. It was a hard working three days of touring, all the sights of the city including Tiananmen Square, the Forbidden City and the state precious objects, a teeming city now surrounded by six ring roads, construction everywhere in anticipation of the 2008 Olympics, more subway lines, highways, high rise apartment buildings, and ever more cars where there were almost none fifteen years ago. But the pollution is not bad, nothing like Wuhan, perhaps because, as Martin told us, industry has been moved out. The architecture of the years the Russians were building for the Chinese, and even after they left with bad feeling, is extremely . . . well, “pedestrian” would be high praise. It’s ugly and rapidly decaying in the way East Berlin is drab, even the relatively expensive apartments. Prices escalate the closer to the center of town, beginning with the 4th ring road, and by the 3rd ring road, only wealthy foreigners can afford the new apartments being built everywhere. The posh Peninsula Hotel doesn’t have the panache in its management that we have experienced in, say, Sydney, but it’s the best that is available we assume, given that the Kennedy Center Board is also staying there during their visit to Beijing.

The first day we visit the Temple of Heaven, a drum tower with ancient timekeeping drums and cymbals, and a bicycle-rickshaw visit through the part of Old Beijing that is being preserved and spruced up for the Olympics. A 73 year-old woman still lives in one of these ancient, not very attractive houses, not wanting to move. She keeps occupied by serving tea to visitors like us, and tells us about her three children, in their forties, each a high level professional with, of course, only one child apiece. They would never live in this old neighborhood, preferring the new high rise apartments, but they visit her and she them – especially when she took care of their newborns some years ago. I’d guess that in another ten years, this neighborhood will be the object of gentrification like Soho or Georgetown, and prices will skyrocket at the chance to get away from the anonymous new apartments.

Yesterday was the Ming Tombs, wonderful treasures from the Ming rulers, and the Great Wall. We climbed one portion of the 6000 mile national treasure, reconstructed after its destruction several times, most lately by the European assault on China in the 19th century and by the Japanese devastation of so many things from the 1930s until the end of World War II. This is true also of the Forbidden City where the Emperors lived from the beginning of the 15th century in the Ming and Quin dynasties, reconstructed after. But these, like Tiananmen Square, are not beautiful. Covered in grey brick, they are impressive, with rooms of precious objects and thrones, awe inspiring, but not beautiful. But there are wonders: the carvings of jade of all colors and from intricately small to large and towering landscapes, and especially a collection of clocks, mostly from Europe, with the most wonderful detail in all sorts of precious materials – gold, enamel, porcelain – and the most wonderful clockwork: the motions of the solar system, varying musical accompaniments to the hours, and one European looking scribe sitting at a desk who writes Chinese calligraphy of eight characters on fresh sheet of paper when set in motion. The Dowager Empress who reigned at the same time as Queen Victoria, and who is roundly believed to have been a selfish and cruel ruler, had a passion for clocks, and collected Chinese and European clocks that are marvels of the world.

This empress also loved the summer palace an hour’s drive from Beijing. Built around a large and wonderful man-made lake, the woods, the Buddhist pagoda tower, and most of all, the painted covered gallery along the side of the lake with thousands of painted images of myth, animals, birds, and country life are one of the most wonderful sights anywhere. The paintings line the crossbeams, the ceiling, and the outsides of the picture gallery walk, with occasional gazebos with stepped ceilings, all painted brightly. The Summer Palace is a beautiful, relaxing park, soon to be made easily accessible from downtown Beijing when the new subway line is finished for the 2008 Olympics.

Beijing is not itself beautiful. But it is teeming with a large and growing population, many of whom seem increasingly prosperous and middle class, growing numbers of tourists from elsewhere in China and abroad. Mixed in with this phenomenon of a seemingly middle class city, there remains a deference to Chairman Mao, at the same time there is gratitude to Deng Xiao Ping for reversing the destruction of the Cultural Revolution that, from 1966 to 1976 when Mao died, disrupted all intellectual and organized life in China, killed millions, kept people from going to university, and kept a generation from learning anything that would enable them to earn a useful living. Only in the last 15 years, has China opened up to the economic and technological progress that has brought it the rapid economic and intellectual gains, developed its enormous economic potential, and brought it to the world’s attention as an emerging presence on the world stage – and fueled it’s interest in psychotherapy.

Psychoanalysis in China, Part One

By David E. Scharff, M.D.

In May of this year, my wife, Jill Savege Scharff, and I made our first trip to China. The invitation to her came after a Chinese graduate student wrote her with questions about one of her books, which he was reading. After she had answered him, he wrote a kind of “by the way” email asking if perhaps she would consider coming to Wuhan, where he was then working and teaching. She wrote that she would. An invitation came from Professor Shi, the head of the Wuhan Hospital for Psychotherapy, and she agreed that I could accompany her. The report that follows is a first encounter with a remarkable group of people in an eagerly blossoming land, not by any means without its struggles and contradictions.

May 13, 2007

It’s a long trip to Wuhan. More than 21 hours of flying, a 30 hour trip in all by the time we change planes in Los Angeles and again in Hong Kong. It is not so much with romance as with anxiety that I think we are on a trip into the unknown. We’re not going to the tourist part of China, and our hosts are unknown to us except for a handful of polite emails of invitation, first from a student who had read one of Jill’s books, then from his professor. When we sent a set of options as proposals for teaching plans, Professor Shi suggested we should do them all. Meeting a new group always involves a slow process of getting to know each other. While we bring theories through lectures with power point and examples of how we work, we are struggling to get to know the audience as a group and as individuals. We want to know their level of understanding, their interest, their ability to understand what we are trying to say in order that we can pitch our teaching to their needs. And even more, we want to meet them as people, to understand their lives, their professional interests and the kind of patients they see.

In Wuhan, we are met by a senior trainee doctor, Wu Xiaojan who tells us her English name is Rose. We soon learn that young educated people in China all pick an English name themselves. Dr. Wu introduces us momentarily to our host, Professor Dr. med. Qijia Shi, Director of Wuhan Mental Health Research Institute and of the Wuhan Hospital for Psychotherapy, and a board member of the Chinese Association of Psychoanalysis, who has studied psychoanalysis and family therapy extensively in Germany for more than four years as he made his own transition from neurological researcher and clinician to psychoanalyst and family therapist. Soon we also meet Professor Dr. med. Jun Tong, who has studied in Boston at Harvard and Tufts, and heads the inpatient program of the hospital, where they treat a great many patients with severe personality disorders, borderline personality, and PTSD in in-patient stays with intensive psychotherapy, and in follow up outpatient psychotherapy. This whole university clinic is devoted to analytic psychotherapy. The staff have profited not only from the training the chiefs have had abroad during the last ten years, but through guest teaching from people like us. During the last fifteen years, the German-Chinese Cultural Institute has offered training in China in a variety of forms of psychotherapy – family systems, cognitive-behavioral, and not least, psychoanalytic psychotherapy. So we are not going into a totally naïve culture, but at the same time, we do not expect they will have any grasp of our particular way of understanding development and personality organization or how we teach the conduct of therapy.

Dr. Wu meets us at our hotel the next morning, and walks us to the hospital. Soon the teaching begins. We have sent our teaching materials ahead for translation. Jill began, speaking one or two lines at a time, followed by Dr. Shi’s intensely modulated Chinese translation that sounds nothing like what she said. Sometimes he spoke much longer than we had, sometimes after a rather lengthy explanation, he spoke rather briefly. The students had our PowerPoint slides in front of them, with the Chinese characters as puzzling to us as we assumed our explanations might be to them. Jill began by explaining the overall import of object relations approach, of a way of working that begins with listening and responding to unconscious messages behind the conscious communications, of tracking affect, and of working through interpretation towards understanding in depth, looking to understand the interferences in the achievement of developmental levels rather than focusing merely on symptoms and their relief. The students are looking down, writing as Dr. Shi translates. Jill moves on to specific aspects of theory, briefly outlining contributions from Fairbairn on the introjection of experience with the child’s mother, and the internal organization of the child’s mind. She hands the microphone over to me to continue with contributions of Melanie Klein of the stages of mental development from paranoid/schizoid to depressive position, adding in what we consider the crucial idea by Thomas Ogden on an earlier phase of development, the “autistic/contiguous position” when the child first begins to negotiate the coherence of a rudimentary self through the process of negotiating close contact with the parents while still maintaining the autonomy of a self across a distance. It is a difficult idea to get across that once these three positions begin to organize mind, they are all three present in a kind of continuous cycle. It’s one of those foundation ideas that has an elegant simplicity to it, and yet is one of the most complex ideas we might discuss. What are the prerequisites for understanding that the foundation on which personality is built is a cybernetic, ever fluctuating system of organization, not just a series of linear inputs? We teach it at the beginning, but we still have no idea how much the students are taking in.

Because of the time it takes Dr. Shi to translate each of our ideas, we make progress much more slowly than with an audience of native English speakers. I always wonder if that is not a good thing. These are difficult, basic concepts and the extra time may do as much to promote their absorption as anything. All of our slides are translated for them into Chinese, so we hope they have time to ponder them.

We’ve barely dented our theoretical overview, not yet introduced Winnicott or Bion whose ideas we need to put out, but we feel that the lecturing is in danger of going right over the heads of those from outside the Wuhan group, who, Drs. Shi and Tong tell us, have been introduced to these concepts. Those from outside may well be encountering them for the first time. And indeed, the last of our four days of teaching in Wuhan, the students who are not from Wuhan tell us heatedly that we have not been basic enough for them. It is disappointing to hear this late in the day when we are beyond our capacity to repair with this group of students.

So we decide to introduce a clinical experience to give a common element to the group’s experience. To ground the group, we show a video clinical interview. (It is important to note that this man, like any other video examples we use, has given full and knowing permission to use the video record of his interview for teaching. We are profoundly grateful to the volunteers who have contributed so generously to mental health education.) The young man Jill interviews in this video is a 26 year old student who has a past history of alcoholism, a difficult relationship to his mother, and a story of having almost blown up a dormitory inadvertently while drunk. It was this incident that caused him to give up drinking. The students have the translation of the interview into Chinese because we sent the transcript ahead, but now they can see the non-verbal aspects of the interview in the video. Jill interrupts every few minutes to describe her thinking as the interview had developed.

What I am trying to convey is how we have to feel our way in learning ourselves to teach this group of new students who come from such different worlds, getting a sense for what they already understand, what seems opaque to them, and what resonates with their ways of understanding. By using material that is familiar to us as a vehicle for teaching, we use the baseline of our previous teaching experience to see how this group expresses its capacity to take in, its way of puzzling at the material, the kinds of questions they ask to let us know where they are. We have at least two audiences in mind at the same time: The professors and experienced staff, who bring their own understanding and who need to feel that what we bring will suit their educational needs of their students, and the students and audience themselves, many of whom have little or no background.

Jill works with the reactions to the video, sharing her state of mind as she worked through the interview they watch. She discusses an episode the patient tells her in which he almost went to jail for banging two loaded propane tanks together while he was drunk in college. The story captures an unconscious image of destructive internal parents (the two tanks banging together represent the danger of bringing two parents together inside himself.), the hopes for more in his own life, and the way the confrontation with his destructiveness led to his recognition of a need for treatment for a legacy of shaky self esteem from a damaged and damaging self. We release the students at the end of the day, still unclear how much they can make sense of what we are trying to teach. We have come a long way to be so unclear about what we might have to offer.

All teaching involves this kind of ongoing assessment, but there is, of course, a much bigger cultural gap 10,000 miles from home and a world away. Yet in some ways the cultural gap seems less than we might have imagined. At the “ Red Passion Four Seasons” restaurant overlooking a small lake in the middle of Wuhan that night, the food was completely new to us – chicken cooked in a bag of bread, sliced spicy eel, the best fried tofu I ever tasted, melon strips unlike any at home and local beer. They marveled that we were comfortable with chop sticks, and we marveled that the excellent pianist played Western standards from the 40s and 50s, and that the dress was completely familiar jeans, shirts and blouses that would have looked completely ordinary on the Potomac River waterfront on a Sunday afternoon in Washington. The skyscraper bank buildings and new hotels that have gone up in Wuhan the last ten years look familiar too. Nothing of rural, strange China of that we might have imagined. This is a modern China, ever more cars, bikes, motor scooters everywhere. Except the pollution is pretty intense, and people wander across the street in the middle of traffic while cars, bikes and motor scooters weave miraculously as to miss them and each other. But while we are here, we come to understand that there are ever more cars, ever more smog, and a China heading for environmental confrontation with its own aggressive economic development.

The next morning, the traffic below the window at breakfast teems, flows, breaks up into eddies, a river of humanity on foot, scooter, motorbike, car and truck, and most of all bicycles, many with two riders, some with huge loads before or behind the rider. One has what seems to be an entire house full of goods loaded ingeniously on the back, chests and furniture all negotiating the river of pedestrians and vehicles mixing at this broad and unregulated intersection like eddying of currents when rivers meet the ocean. Passengers sitting side-saddle balance effortlessly over the rear wheel of bicycles, disembarking at a stoplight, hopping back on as the cycle picks up pace. A man pedals two children held in a tent contraption over the rear wheel. Perhaps he is bike-pooling the children to nursery school. A half hour later, he returns, the hutch now empty. A woman on a motor scooter with her small daughter riding in front of her, no helmets anywhere, seems to have been hit and a policeman emerges from nowhere to have a protracted discussion with her. She walks the scooter off to the sidewalk, the girl trailing alongside, and talks for a long time with other people. Finally, they disappear. The river of humanity is endlessly fascinating. We watch it every morning from our breakfast table, never tiring, like looking at a whirlpool or the never repeating pattern of flames from a campfire.

Yesterday afternoon Dr. Xiaojan Wu, who has never been outside China, presented a case to me. It was a nightmare of an experience. Dr. Wu’s English is good, although she seems at first retiring. We have become friendly since she met us at the airport. She presented in Chinese, while Dr. Jun Tong, head of the Outpatient Clinic, who has studied for two years in Boston at the New England Medical Center (where I did my own medical internship) and Cambridge Hospital where I also spent a small part of my training, translated. Dr. Tong excellent understanding of English, when given at lightning speed, was difficult for me to grasp, so I felt completely lost about the case. Not wishing to offend Dr. Tong, I struggled both to understand the case and to see how I could somehow more easily understand the case. Finally we realized that the thing to do was to have Dr. Wu tell me the case in English, and have Dr. Tong translate into Chinese for the audience. Only then could I relax into consulting to the case and using it to teach the principles that we had been lecturing about in the morning.

The case Dr. Wu presented was of a young man who had great difficulty speaking about himself. He told her a story of being able to go to University, where he helped a classmate study for an exam, only to find that the classmate did much better than he did himself. Not only that, but female classmates admired the other boy. He began to skip class as his resentment grew, his performance deteriorated, and in the end he had to leave university. In every way he painted a picture of himself as a victim, but he denied being angry and seemed to have no feeling about his situation. Dr. Wu found herself becoming more and more confused, telling him that of course he had to go to class and do his homework. This seemed to correspond to the image he had of his mother who told him what he should do in a way that made him feel criticized. In a recent session, he told her a story from a book about a composer who sent music he had written to a famous musician, only to later find the musician had made it famous, but as his own. The protagonist came home and destroyed his instruments. Telling his children never to play music, and he became alcoholic. One day he found that his youngest son had become a successful musician despite his bitter advice, and he died on the spot from agitation at this revelation. When Dr. Wu asked her patient how he felt in reaction to the story, he ignored her question and began to question her about her response, leaving her in renewed and continual frustration.

Since by now I felt in more direct contact with Dr. Wu, I turned to discuss how the patient had put the dynamics of his internal world into her, so that Dr. Wu came in the therapy to act like the critical mother at times, frustrated with her under-achieving son. At other times, she felt like the frustrated boy who could get no understanding. Meanwhile, in her confusion, she experienced the boy’s attacks on thinking and linking elements of experience to each other. I asked if she had been able to get supervision for her work with him? Supervision with Dr. Shi had indeed been helpful. She had a session with the patient last week in which, finally, he had become directly angry with her. She experienced this development with considerable relief. So now we could discuss how the months of psychological holding she had offered had come in due course to create a situation in which feeling, and especially anger, could form, and in which the young man could begin to trust her enough (in what I have termed the contextual transference) that he could bring the anger directly to her without overwhelming fear that she would abandon him just because he had dared to express it. A new phase of treatment looked as though it was finally going to be possible.

With considerable relief on all sides, Dr. Shi escorted us to his Volvo, and in caravan with Dr. Tong we left the hospital for a tour of the East Lake, one of the largest and most beautiful lakes in China. It was here that Mao Zedong would come to rest and write poetry, said Dr. Shi. He was a wonderful poet, and Dr. Shi wondered if I had ever read any of his poetry. We drove through the university district of Wuhan, divided from the commercial district of this burgeoning city, which suddenly is full of cars only in the last 10 years, to a vista of hills bordering the lake, small skiffs for pleasure rides – all framed by air clouded with smog. We strolled by the lake, then continued to restaurants across a causeway that were in the suburbs, serving country food, a completely different cuisine than last night’s. None of the food we ate here resembled any Chinese food we have ever had in the United States or Europe, and it was wonderful in its newness and variety, some mildly spicy, some not – cooked vegetables, duck, eel, cooked cucumber and cabbage, new and strange tastes, all in communal dishes to which we applied chopsticks. Forks were available for the asking, but we managed, sometimes with help from our friends, to serve ourselves without defaulting to Western implements. Every success, for instance in retrieving peanuts from the dish one by one, met with exclamations of admiration.

After dinner on the return to the city, Dr. Shi said that much has changed in the last ten years. Only now is it possible to learn psychoanalysis. While we were in China, and through reading books like Rob Gifford’s deeply informative book China Road, we came to understand that it is still rare to discuss politics in China, and not entirely safe. Fifteen years ago, it would not have been possible to have a discussion of the wisdom of the cultural revolution of the 1970s in which the young people were sent into the countryside because Mao recognized the danger of the young to his regime. There learning and idealism were stamped out ruthlessly, contributing to a second wave of devastation of intellectual growth. Our hosts did not take up these matters with us. But we did learn that the attack on beliefs and ideas had begun much earlier in China. Under the Qing Dynasty (pronounced ching) which began in Mongolia early in the 17th century, the conquering rulers had absorbed the Chinese culture steeped in Confucianism, Dao and Buddhism. With the Republican revolution of 1912 led by Sun Yat Sen, these ideas were attacked further, so that when Mao’s communist revolution attacked religion and Western ideas again at the defeat of Chiang Kai-shek’s Nationalist Party, most of the centuries of religious and intellectual tradition were already suppressed. The Cultural Revolution unleashed by Mao in the 1960s was another phase in this series of attacks, so that generations of Chinese lost connection to the rich heritage of civilization that predated so much of Western intellectual and cultural thought. But now, said Dr. Shi, there is an economic and cultural openness. It is unspoken but clear that political dissent is still unwise, but there is even official support for the gathering of ideas from the West towards the scientific and economic growth of China. Economic growth of the GDP is galloping at more than 10% annually – leading to increasing environmental pollution, but also to enormous expansion. Psychoanalysis is one of the areas of inquiry that have leapt onto Chinese radar. There is intense curiosity and a willingness to invest in finding out what the West has to teach that will improve mental health delivery in China. Wuhan is in the lead in this inquiry.

From Klein Forward

By David E. Scharff, M.D.

Psychoanalysis is in a state of evolution. It is almost as though if we don’t keep up with the advances in neuroscience, attachment theory or latest research on the validation of psychotherapy, we can’t do our daily work. But at the same time that there is such an explosion of research, one of the most important findings is precisely the validation of our work, of the basic kind of work that analysts and analytic therapists have been carrying on for the last hundred years. I believe that this hearkens back to Fairbairn’s thesis that the foundation of analytic potential lies in the therapeutic relationship itself, because without that, none of the other things that promote change have any effect. We can include in those elements of therapy that support growth the genetic reconstruction of early developmental experience, transference interpretation, the use of countertransference as a “global positioning system,” the patient’s acceptance of her own projective identifications, the understanding of the co-construction of emotional experience in therapy, and the support therapy offers for deficits in early experience. All of these are important. They are all building blocks for change. Even the offering of support and advice, long relegated to the mere ranks of supportive psychotherapy, can offer something to patients attempting analytic work, given at the right times and in the right dose. But fundamental to the whole system is that the therapist offers herself as a person – even though she is a person in a role – who is dedicated in that role to the growth of her client or patient. She is in the growth and development business in a very personal way, even when she is being most professional.

Today I want to go back to another element of our roots, to the work of Melanie Klein, whose work was for many years disparaged in the United States, only to be widely embraced in the last 30 years. Jim Grotstein, Jay Greenberg and Steve Mitchell, Otto Kernberg, Roy Schaefer and many others brought these ideas across the Atlantic. Jill Scharff and I followed Henry Dicks of London in applying her ideas to couple and family therapy, combining her discovery of projective identification with Fairbairn’s idea of a psyche made up of multiple self-object units, and since then have written extensively about projective and introjective identification in all aspects of development, pathology and treatment.

Today, I want to re-evaluate her contribution in the modern context. First her emphasis on early development. Klein posited an infant and young child whose mind was formed in bodily terms, and especially in terms of sexual conflict. She envisioned a child focused at first on her mother’s breast as good or bad, and soon seeing her parents locked in intercourse of an oral sort, the mother capturing the father’s over-valued penis. It was the dramatically worded body language that drew much attention, but the controversial parts also included the early dating of triangular conflicts – the early oral Oedipus – to times within the first year. So what do we think now of these controversial elements?

I think she was undoubtedly right that the young child, within the first year, does have an experience of the parents as a couple, and begins to “think” of herself in relationship to them as a pair. But are things so sexual? Probably not. Is the thinking in terms of bodies? Probably. The infant is very much body-based, and modes of thinking do echo the signals coming from inside her own body, and from its handling by the parents. But I think that Klein was analyzing children who were almost three years old – young by the standards then of course, but old enough that these children had already been sexualized from hormonal and cognitive development. Then she read the material from these relatively advanced children backwards into their infancy, and made an error of inference. So is early thinking triangular? Yes. Is it intensely sexual? Probably not. But early thinking does influence sexual thinking as it blossoms in the third and fourth years, and the sexual versions the child creates do reflect triangular thinking, which is sexualized from that point on.

Klein posited two modes of thinking that organize life from the earliest months: the Paranoid/Schizoid and Depressive Positions. In the first, the paranoid/schizoid, life is divided into good and bad, black and white, as absolutes. There isn’t much grey, and the object world is handled by the tendency to guard things inside or project them in paranoid or projecting mode into the outside. Persecuting inner objects are felt to offer persecution from the outside because of the child’s use of projection. It was in writing about this mode that Klein first understood projective identification – the mode of thinking in which the child (and actually all of us) locate parts of our own psychic processes in another person with whom we have established intimate emotional relations. Klein originally thought this process allowed the child to off-load an excess of aggression, to make his own inner world less toxic, but we now see it as an all-purpose mechanism of unconscious communication, in which each of us seeks to unconsciously communicate our emotions, fears, wishes, fantasies and inner organizations of self and object to the other person by finding unconscious resonance with her mind.

To this we have added an equal emphasis on introjective identification: that the mother or spouse takes in the unconscious communication, identifies with it, subjects it to her own processing (all still unconsciously) and feeds it back in a continuous cycle of mutual projective and introjective identification. I said a moment ago that Henry Dicks understood this to be the basis of marital intimacy and formulated it as the forerunner of a general theory of interpersonal communication. So did Wilfred Bion, who took this another step forward to make the continuous cycle of projective and introjective identification the basis for the origin of the infant’s mind. Mind is, we can now see, the product of continuous unconscious communication (mainly about affects and their regulation) between child and parent. Conscious communication, we now understand due to the neuroscience writing of Alan Schore and others, comes much later.

So here’s where the neuroscience comes in. In the last 20 years, Gallese and others have described the presence in the motor cortex of the brain of “mirror neurons” that mimic an observed action right next to the motor neurons that we fire if we actually perform an action. Now, since all emotions involve some sort of motor discharge (muscles, hormones, the autonomic nervous system,) this gives the mirror neurons a central role in the communication of emotion. The purpose of these mirror neurons, to paraphrase Gallese, is to instantiate a shared manifold of subjectivity – that is, the other person’s emotional experience is installed deep within our own mind in a way comparable to the way our own emotional experience is represented there. In short, Klein’s “wild ideas” about the communication of emotion have been fully upheld by modern neuroscience – and can now be seen to be the fundamental basis of the growth of mind.

When Klein posited her second fundamental state of mind, the Depressive Position, she wrote that it was the basis for a more integrated view of the other person. It includes the capacity for concern for the other, the ability to feel that the mother who has mistreated you is also the one who loves you, and a potential for guilt. It is a more mature position, but not a better one. We all need both. In the paranoid/schizoid position (aren’t the terms terrible?) we can sort things, divide, parse things, see qualities that contrast. In the depressive position, we can integrate and join affect with that more integrated view, we can work on healing rifts. Later Thomas Ogden added another position, which he thinks (and I think) comes before the paranoid/schizoid. He calls it the autistic/contiguous position, maintaining the penchant for obscure terms. But what he means by this is crucial: that the infant, and all of us throughout life, worry about the cohesion of our self, and we manage this psychically by pulling away from our objects into ourselves at times (the autistic pole,) and at other times by leaning against the edges of other people (the contiguous pole) and that we all move back and forth along this continuum. I do believe that self cohesion is a life long worry, and that it is at least equally fundamental to the other positions of mind. Ogden makes the convincing argument that all three positions exist all the time – all three groups of mental concerns exist all the time, but that at any one moment, one of them may be dominant and seen to be the principal organizing mode of someone’s psyche. This complex formulation fits with the most modern ideas of the organization of mind as a set of complex functions widely distributed throughout the brain and the mind, with the highest and most abstract functions overseen by executive function in the prefrontal lobes. The writing of Herbert Rosenfeld on pathological positions, and the subsequent work of John Steiner on what he called psychic retreats, both give us language for the perversion of these modes of thinking that represent a short circuiting of the normal fluidity between the three developmental positions in mental states of severe pathology.

There is much more of our work that derives from Melanie Klein’s ideas, all formulated from the 1920s through the 1950s: Her work on envy and gratitude that came late in her life, and her invention of ways of working with the psychological life of young children that was among her first contributions. But I think we have covered enough for one posting.

The Therapeutic Instrument

By David E. Scharff, M.D.

The psychotherapeutic instrument is, of course, the therapist – in all aspects of her or his personality – who has the unique capability of being honed by experience to create a relationship that helps other people grow, heal, and expand the range of possibilities in their lives. Fashioning your personality to fill a role isn’t unique to psychotherapists. Dancers, ministers, cops, business people all do it. But our field is right up there among those whose training is the most intensive and extensive – and it needs to be. We are unique in our ambitious goals of creating lasting change in our patients.

When I think of the therapeutic instrument, and of tuning that instrument, I consider all the elements that go into our work: The personality of the therapist, her growth and development, her well-being; her theoretical education; her treatment; her knowledge of all sorts of things that her clients and patients encounter. The job we do is complex, pretty much as complex as humanity itself, from the sociological and anthropological differences that now people our country, to the complexity of individual personality, to the more complex patterns of interaction in couples and families.

Because of the ultimate complexity of our work and the demands it can make on us as therapists, a wide variety of topics is relevant to getting us in tune. As we explore the process of therapy, I want to discuss issues having to do with theory and with technique, even though the boundary between these often blurs. I want to draw from diverse theoretical and scientific universes that can be brought to bear on understanding our patients. This is all with an eye to fine-tuning ourselves as therapeutic instruments.

The therapeutic instrument gets tuned by being open to influence from diverse fields that may, at first glance, seem to have nothing to do with our work and to be unrelated to each other: Chaos theory, literary theory, anthropology, large group psychology. And the obvious fields of neuroscience, psychoanalysis in its many forms (object relations, self psychology, relational, contemporary Freudian, Lacanian) systems theory, and strangely (from my point of view) cognitive and behavioral therapy. As John Sutherland, editor of the International Journal of Psycho-Analysis 40 years ago, used to say, “People are so complex that we need all the theories we can get to make sense of them.” We need diverse theories and models to expand our understanding of therapy, to help frame, contain, and to provide narrative to patients’ lives and interactions. So we need to learn, and to continuously relearn, how to draw on our own experience, cognitive and especially emotional, to sharpen our understanding, to catch the faint whiff of transient emotional trends that come and go between us and our patients. The complexities of human experience are always more than our comprehension. That daunting fact is also a lifelong invitation to continue our own growth endlessly towards fuller understanding. Tuning our therapeutic instrument is nothing less than tuning the whole of ourselves.

All of that is what this blog is about. I plan to write from as wide a variety of experiences as I can, and from time to time, will invite colleagues to contribute their experiences and special areas of understanding of diverse aspects of the wonderfully unfolding world of psychotherapy and psychoanalysis. That includes what we learn about the interest in and practice of psychotherapy around the world. I plan to write about psychotherapy in China in a posting soon, drawn from my recent trip there. Beyond that, we want to explore topics that interest us, writers who seem to have something new to say – or even something old restated in an original and fresh way.

I have found central support of my work in the contributions of the original Object Relations theorists, Klein, Winnicott, Bowlby, Bion, and especially Fairbairn. More modern contributions – those that take us beyond the original formulations from, say, 1940 through 1975, and into the dynamically evolving field that has come from the premises Fairbairn first spelled out – are just as pivotal. To the foundation work of what we might call ‘classical’ Object Relations theory, we have to add the rich elaboration by many others such as Sutherland, Guntrip, Kohut, Segal, Kernberg, Bollas, Steiner, Britton, McDougall, Mitchell, Fonagy and Target, Jacobs, Akhtar, on both sides of the Atlantic over the years. And recently there has come an explosion of new research and conceptual material that has enriched our thinking almost beyond our wildest hopes. Here I mean first the contributions of the study of affect, trauma, attachment theory, and neuroscience. Psychoanalytically we have been enriched by self psychology, the study of intersubjectivity, relational theory, self psychology and motivational systems theory, family and couple therapy, sex therapy and many other clinical areas of study. These fields of research overlap greatly and enrich each other, and the cumulative effect is to transform our thinking and our reach beyond object relations. I’ve used object relations as a foundation whose elaboration leads to areas that, while confirming the original insights of Fairbairn, Klein, Bion, Winnicott and Bowlby, offers new insights and newly penetrating and flexible ways of working clinically.

Object relations theory was the first theory that focused on the relationship between therapist and patient as the essential factor in psychological change, the heart of growth and development. But in recent years, I have also based my ideas on the model provided by chaos or complexity theory, also called the theory of dynamical systems. This modern theory began to be developed in the mid 1970s, and was formulated for a popular audience by Gleick in 1987. Since then it has been applied to neuroscience, psychoanalysis, and family systems theory. It has the paradoxical quality of being a set of real operating principles for the physical universe as well as the world of psychology, and at the same time being a useful metaphor that can help achieve a new vision clinically and theoretically.

I’m going to begin with the foundation because if you are unfamiliar with the basics of object relations, the rest won’t make so much sense. I take Fairbairn as the spine of object relations theory. He knew Freud’s work extremely well, from studying it and teaching it to medical and philosophy students, and he adopted Freud’s clinical method in his own practice. But he had questions about some logical inconsistencies in Freud’s theory. For instance, he could not see how the superego could be the agent of repression if it was repressed itself. And he worried about the absence of a clear theory of aggression, having refuted the idea of a death instinct. In place of these theories, Fairbairn said that when people acted clinically as though driven by either the pleasure principle or the death instinct, they were acting in a closed system cut off from dynamic influence of the wider social environment.

Fairbairn’s reformulation of basic theory began with the child’s need for a relationship with a primary caretaker – a mother (although we now see that fathers can fill this role too.) He thought this was central, and that the vicissitudes of that need dominated development and all of life, with the drives having meaning in the context of that need. Although we know now that there are aspects of development that are not centrally relational (learning motor skills, for instance), we can also see that the need for relationship still dominates psychological life and therefore is what is most important in our work.Fairbairn thought that when the mother inevitably disappointed the infant, he or she then introjected (that is psychologically incorporated) this disappointing experience with mother as a “bad internal object” – that is, an image of the mother as painfully disappointing, rejecting, neglectful or even persecuting. Introjection, however, creates the same painful experience inside that the child had outside just before, which then necessitates the next defensive maneuver: the splitting apart of the bad image of mother from the good, and repressing the bad image. Now these split-off bad images are more than just bad internal objects: they are actually parts of the ego organization, because they quickly become part of the self, capable of generating ideas and actions themselves. You can see what this means if you think of times you catch yourself acting like someone you don’t like, or who treated you badly. In such a case, you are acting in the image of your internalized “bad objects.” We all do that frequently, and perhaps most significantly, we do it when we act like our parents did when we resented them the most, when we swore we’d never act that way ourselves. So these aren’t just passive internal images. They are capable of organizing part of our actions. We all have multiple aspects of our selves in our psyche, and these parts are in dynamic relationship with each other. They monitor experience with the outer world, and determine how we understand the meaning of experience with others.

Fairbairn also realized that affect was the link between these internal aspects of self and object (or “other”), and therefore that affect was crucial theoretically and clinically. His ideas were forerunners of modern affect theory. And his realization that the psyche is a dynamic, complex system, always on the move internally, that also interacts with the world of people outside the self, made his work one of the precursors of the way we take advantage of chaos theory to understand the infinitely complex organization of emergent selves in interaction with the complex outer world.

Clinically, Klein and Winnicott wrote compellingly from an object relations perspective, and Bion offered theory that is a direct imaginative precursor to many modern developments, including chaos theory. Bowlby’s attachment theory, the elaborations in infant research, and the ideas of affect regulation and mentalization by Fonagy and Target give us further crucial elaborations on the theory Fairbairn began. But each of these is so rich that they deserve their own focus – which will come in subsequent postings.