CORE Student Reflection on French Psychoanalysis

In preparing to write this blog on our recent weekend exploring French Psychoanalytic thought and its contribution to understanding psychotic and borderline states, I found myself worrying about using too many “I” statements in my reflections. This urge to avoid writing “I” too many times in this composition, I think speaks to the theme and tone of this past weekend. Alain Gibeault described Freud’s theory of psychosis as de-cathexis from worldly objects and the psychotic terror of being engulfed or consumed by an object. Additionally, he discussed the concept of “the blank,” a space between matter and nothingness. We then watched a recording of an institutionalized patient, François, describe murdering an elderly woman, Jeanette, whom he had cared deeply for. He described Jeanette and himself being up on separate pillars with “something growing up between us.” I was struck by the terror of this image, being alone on a pillar, surrounded by the blank, with something terrifying growing up between François and Jeanette.

This material along with Dr. Gibeault’s discussion of psychodrama led into our small group discussions. During our group affective learning, fear and safety and their relation to individuals, patients, our group, and IPI were central themes. As the group went on, I felt myself feeling strangely disengaged and detached.  Initially, I defended myself as bored.  However, upon reflection, like François I was gripped by a psychotic fear of vulnerability, of being engulfed by the group or by IPI.  I too, had in a sense de-cathected from the horror of the material and was existing in the blank.

I’d like to say that the psychodrama of our small group facilitated my re-cathexis with the material, but I found myself struggling to stay focused on Saturday as well.  On Saturday afternoon, a colleague in the CORE program gave a fascinating presentation on a boy that he had been working with. The presentation was rich with symbolic meaning and beautifully captured the theme of terror of being engulfed that was running throughout the weekend. During one of the sessions presented, the boy was playing with a dollhouse. The presenter described this patient arranging the dollhouse in such a way that there was a “sealed off room, full of drawers” upstairs. For the second time during the weekend, I was struck by the rich imagery described by a patient. During plenary, themes of fear and violence were discussed. The ambivalence concerning feeling for and treating psychotic patients, like François, and recognizing the horror of the acts that they sometimes commit. Jill Savege Scharff brought up confronting gun violence, hate crime, toxic partisan politics, and climate change that are terrifying realities of our daily lives. It was during this dialogue that the image of the “sealed room, full of drawers” popped back into my consciousness.

I wonder if my feelings of detachment and the theme of unease that seeped into the weekend conference acted as a defense against the sealed room, full of drawers inside of all of us. I began to think of these drawers as full of rage, panic, lust, and violence, terrifying emotions/drives that are walled off inside me, but in reality would take little to provoke. In relation to my small group: would these terrifying affects/emotions kill my group? In relation to psychotic or borderline patients: does the fear of violence or panic in myself incline me to split them off as different and distance myself from them? In thinking about the didactic material or engaging with IPI: am I de-cathecting at times and existing in the blank in order not to experience frightening emotions? This weekend spent thinking about French psychoanalysis and psychodrama provided the opportunity to think about borderline and psychotic states and the terrifying moods and affects associated with those states as positions along a continuum on which we are all precariously perched.

 

Thomas Ringwood Jr., NP –  1st year student in 2-year Object Relations Theory and Practice Program (CORE) December 1, 201

Analytic Student Reflection on French Psychoanalysis

During the November 8th through 10th weekend of 2019, the International Psychotherapy Institute hosted the French psychoanalyst Alain Gibeault. French analytic writing is often criticized by British and American analysts as overly abstract, lacking in clinical detail, and often difficult to follow; nonetheless, Dr. Gibeault’s presentation, particularly the video recordings of his patient Francois – a man who was legally committed to mental health treatment following his murder of an elderly woman during a psychotic break – gave us a first-hand look at how French psychoanalytic thought can be applied in the treatment of people with overwhelming psychotic terror. In Francois’s case, psychodrama was used by Dr. Gibeault and his colleagues to provide a mediator for the patient to begin to make sense of his otherwise unrepresentable mental state.  Rather than applying direct interpretation in an analytic dyad, which is the usual clinical approach in most psychoanalyses, Dr. Gibeault and his team allowed Francois to choose characters among the hospital staff to play out, in real time, the dramas that were occurring in his mind. That part of Francois that killed an elderly woman in his psychosis was re-presented to Francois in a session of psychodrama by an ‘actor-therapist’ who improvised a murderous old woman that Francois ran into while riding on a commuter train.  In another session, Francois’s brother was depicted as a carefree, somewhat envious character with whom Francois could interact – and at as much distance as the mediation of the psychodrama would allow. In this way Francois could experience aspects of murderous rage and envy, as represented by the actor-therapist, rather than having to own it as a direct aspect of himself.  In other words, rather than attempting to understand and interpret to Francois the unconscious derivatives of his intense envy and murderous rage in a two-person analytic relationship – an approach that Dr. Gibeault believed would probably be too overwhelming for Francois given his inherent engulfment and fusion anxieties that lay at the heart of his psychosis – the mediation of the multiple actors in the psychodrama allowed Francois to begin to think about his experience in a way that he could tolerate.

As I reflect on this particular weekend at IPI, I find myself drawn to the idea of the Group Affective Model as a kind of psychodrama.  The Group Affective Model – or GAM group – is a unique aspect of training at IPI that brings to life, much like in psychodrama, the often very complex theoretical and clinical material that participants are trying to digest.  Though not itself a “therapy group”, participants in small GAM groups of between four and let’s say ten individuals, are nonetheless encouraged to bring in their own affective material, often derived from their personal lives or immediate experiences of the weekend. By interacting in this way the GAM group works to understand, as a group, the different facets of the material under discussion. As such, what is learned at an IPI weekend is never only theoretical. Rather, it comes to life in some form or another as a memorable emotional experience from which any and all of the members of the group can learn – each in their own way. Given that this weekend was on the terror of non-representative states and the defensive use of psychosis as a way of negotiating the horror of experiencing psychic “nothingness”, it is not surprising that groups would get in touch with psychotic aspects of themselves as a group.  It was so in my own GAM group as well as in others’ groups that I had heard about.  This is not something to be concerned about as much as it is an opportunity to think about, particularly après coup – in the context of the theoretical material being presented over the weekend.

In thinking about the GAM group at IPI, I am also reminded of Dr. Gibeault’s discussion of the necessity of “the director” of a psychodrama (or of a GAM group, or even of an institute as a whole) as a representative of the ‘thirdness’ – or the analytic third – of the group.  The director serves as a container and a mediator, a kind of Perseus’ shield between the raw experience of group members and their distance from the material under discussion. With a good enough “director”, the experience of the psychodrama can be mediated in a way that makes it possible to appropriately reflect upon what is occurring in order that it can be learned from as an experience.  Obviously, there is nothing quite so good as a “good enough” anything. In that way, we struggle, as indeed we did once again this past weekend, to understand the ideas presented during the weekend in the context of our own unique clinical experience as well as in ourselves in ever new and enriching ways. Taken in its entirety, this was once again my experience of an IPI weekend – and one that will remain as my own experience in the learning group of analytic training at IPI over the last several years.

 

Matthew H. Rosa, M.D. – 4th Year Analytic Candidate

Alain Gibeault speaking at IPI, Saturday November 7, 2019

True to the traditions of French psychoanalysis, IPI’s visiting guest speaker Alain Gibeault, formerly secretary general of the IPA, bases his theory and clinical practice on the metapsychology of Freud. He approaches the first interview with a new patient with four questions in mind.

  1. What kind of meeting is appropriate for this patient — psychoanalytical or something else?
  2. What indications are there that a psychoanalytic approach to treatment could be useful?
  3. How do patient and analyst work together in this interview?
  4. What has triggered the request for help?

Gibeault’s intention is to explore the conscious, pre conscious and unconscious layers of the mind. In keeping with Freud’s topographical approach, he assesses the psychic functioning, faces the emotional storm, and contains the affect that arises as he works to open a psychoanalytic space, giving access to the unconscious and tracing the structural connections between superego, ego and id.

When treating the psychotic patients he sees in a clinic attached to a hospital, Gibeault, inspired by Lebovichi who introduced psychodrama to France, expands his psychoanalytic technique by including a team of seven psychodramatists (a luxury we can hardly imagine in the USA).  He also arranges for a psychiatrist to treat the patient as well, keeping medication, follow up, risk assessment, and medical responsibility separate from the psychoanalytic perspective.  The point of the profusion of therapists is to spare the patient the threat of engulfment by a single object.  Instead, the transference is spread laterally among psychoanalyst and psychodramatists and the task of containment is shared by the team. The introduction of such a third in this way reduces the threat and diminishes the defense of splitting as a defense against engulfment or intrusion by the single therapeutic object.

Neurotic patients can symbolize their distress and keep it internal and so we can treat them in private practice.  Psychotic patients cannot do that and so they need a hospital setting and a team approach that includes psychodrama to create for them an external image for contemplation.  These patients can address this externally created image more easily than trying to use words to reach insight, while dealing with the stress of looking at a single therapist.  The psychodramatists take on the characters assigned to each of them by the patient but they do not wait for role induction.  They spontaneously react in ways that do not try to recreate the patient’s experience. Instead they offer something different.  This construction of something new in the third reduces the dissociation from which the psychotic patient suffers.  Unlike Klein who teaches us to interrupt the negative transference in the first session, Gibeault recommends that we must respect idealization and only later interpret aggression. Only then is it possible to interpret the negative transference — which must be done before termination can be possible.

 

Submitted by Jill Scharff  Saturday November 9th

Alessandra Lemma: The Effect of the Internet on Sexuality and Identity

Jill Savege Scharff, October 5, 2019.

I am here at the International Psychotherapy Institute weekend conference Technology and Ethics in Treatment and Training: Best Practices. I am sitting in the audience of 60 people at a hotel conference room while the guest speaker talks with us via proZoom. It is now Saturday October 5, 2019. There on a large screen is Alessandra Lemma, Fellow of the British Psychoanalytical Society and Consultant-Clinical Psychologist at the Anna Freud Centre for Childrenand Families, Honorary Professor of Psychological Therapies at the School of Health and Human Sciences at Essex University, and Visiting Professor, Psychoanalysis Unit, University College, London. She is presenting on the impact of Internet pornography on development. We can see and hear Alessandra. She can see us in general and can hear each one in particular who comes to the microphone and web camera to speak to her. When she moves away or looks down we may miss the end of a word, and she may have to ask us to repeat a word, but by and large we can follow her talk. Some of us would rather interact with her in person, but she lives in London and cannot spare the time to travel here for a weekend conference or for one lecture. This way we are deprived of her actual physical presence but not of her humanity. We have the gift of her presentation, and we get to interact with her and her ideas. And we get to know her as a presenter beyond our experience of her as a writer from reading her book The Digital Age on the Couch. Technology isn’t perfect but it gives access to her knowledge. So what am I taking away from her talk?

I learn that Internet pornography, which obviously fundamentally interferes with sexual desire and development in adolescence, is now leading to sexual dysfunction in young people of the digital generation. Why is this happening in this age of enlightenment about sexuality? They spend their life online and pornography is not only regularly available but also jumps out at them. Ready access to pornography stimulates desire and leads to the delivery of instantaneous satisfaction. There is no need of delay. Under normal circumstances desire experiences a delay before there is the delivery of satisfaction. But in internet pornography there is no need of a journey towards gratification all because it is already there. This collapse of time and space incurs a stultification of psychic development. Psychic development requires delay of gratification, which leads to psychic movement across time, the unconscious mind at work developing its representations of desire and its gratifying objects of satisfaction. Furthermore, pornographic images do not only receive existing fantasies but also project other people’s fantasies violently into the viewer’s body and mind where they take over, creating a “not-me” experience and foreshortening the consolidation of sexual identity.

What makes an adolescent vulnerable to exploitation by pornographic images on the Internet? Alessandra suggests that we need to look backwards to the kind of infancy when an endless sensory, erotic experience occurs without the cognitive resources to make sense of it. Then it falls to the mother to reflect the sexuality of the infant and give the infant time to make sense of it. She delays gratification, which gives the body time to organize its response and fulfill its role as the link between desire and satisfaction, self and other. She develops cycles of frustration and satisfaction that shape the infant’s rhythms, which later underpin the expression of desire in later stages of development. When she fails to do this, the child develops an incoherent mental representation of the body.


Then in adolescence there is a desperate search to find a mirror that will reflect the sexual self accurately and confirm the adolescent’s sexual identity. In the pre-Internet era this was provided by peer groups and teen media during the infinitely lengthy waiting period that was adolescent sexual awakening. Now however the adolescent has been bombarded by sexual imagery in childhood and is now driven to look for reflection in the “black mirror” of the handheld device. The upside is that easy availability of such online mirroring brings a benefit of inclusiveness for those whose sexual proclivities place them in minority groups. The downside is that the adolescent looking for this type of reflection and peer affiliation stumbles upon an orgy of intoxicating sexual possibilities that re-create a view of the primal scene, now constantly open for access. Like an infant in an endlessly sensory state of being, the adolescent does not have the ego development to deal with the overstimulation alone. What is needed is the care and responsiveness of a living breathing other person.

Young people who look for instant, impersonal gratification do not know the value of the work of desire. When they are locked in to a habit of getting aroused and gratified online instantly, they feel that they triumph over desire. In fact they are killing desire. They do not recognize its value in creating movement towards the other. They do not know to wait for that. Learning to derive pleasure from waiting requires psychic work towards maturation. As therapists we can offer a reflective mirror and a relationship that will help these adolescents recover desire, experience anticipation, wait for pleasure, and ultimately enjoy a sexual experience with a partner.

 

And what about us? How is our digital learning experience different from that of the porno-addicted adolescents? Obviously this is not porn. We are watching and looking at an image, but our desire is for the gratification of learning. It is not a solo activity, and it is not hidden. True, Alessandra arrives the click of a mouse but she appears by careful selection and mutual arrangement. But in this case, there actually is delay between desire and delivery. We have been waiting to work with Alessandra Lemma since April two years ago when she was with us for a whole weekend. She could not offer that amount of teaching and travel given other commitments at this point in her life. So we signed up for the conference on technology and ethics at which she would speak by Zoom. We knew to expect a technology-mediated lecture: It does not intrude on us unbidden.

Looking at the screen and listening to Alessandra is not immediately gratifying: In fact it is slightly frustrating as we strive to catch every word. The image on the screen is inviting but not overstimulating. Yes, the content of the presentation is inducing desire for more, but we share the experience with others in a group setting. With technology, we get to “be with” Alessandra again, sharing with colleagues her brilliant ideas, empathy and responsiveness, and outstanding clinical technique.

The Contribution and Influence of Enrique Pichon Riviere

Lea Setton and David Scharff

 

David Scharff steps back into presenter mode this morning. He is talking about Pichon Rivière’s concept of el vinculo, translated as “link”.  David is excited to have found a theory that goes beyond Freud who sees development as instinctually driven, linear and predestined in the individual, and beyond object relations theory which sees development arising from the need to relate expressed in internal relationships being built in interaction in external relationships to Pichon Rivière’s more encompassing view of individual and group, self and society. Pichon Rivière focused on the area between two people as well. David tells that Pichon Rivière described the link as a feature of the inside, the outside and the area in between, all connected with experience of previous and future generations on the perpendicular post of a cross and connected to social and cultural associations in the present on the horizontal arm of the cross.  We can imagine the link as a network of connections, an endless, interlocking dynamic ring spinning around in space and along time, and it is into this link people are born, and which they change and are changed by as they express their needs for love, safety, nurture and knowing.

IPI faculty prepare for the weekend’s work with guest Joachin Pichon Rivière

 

Introducing Joachin Pichon Rivière, social psychologist and organizational consultant (and son of Enrique), David announced that in tomorrow morning’s open lecture, Joachin will present Pichon Rivière’s concept of the link in what he called “operative groups” (work and affiliate groups) in institutions.

Jim Poulton weekend cochair asks a question responded to by Lea Setton, David Scharff (presenters) and Karen Greenberg (session chair) on the panel and Joachin Pichon Rivière in the audience.

Until then, we are following Lea Setton’s application of Pichon Rivière’s theory in family therapy.  She shows how a family suffers from a major loss. Various family members from time to time become the spokesperson or the symptom bearer for the family wide loss in the present and its reverberations in past trauma and predictor of fears of future failure and shame. Over the years, the family engages with the analyst as the depositary for the family legacy and potential. Their therapy follows a spiral process in which the analyst relates to the symptom, the existent fixed pattern of reaction, makes interpretation which creates a disruption, after which the family enters an emergent pattern with new possibilities for reaching understanding and transformation.

IPI Program Graduates

Congratulations to our IIPT (analytic) graduate Michele Kwintner and our Core (object relations) graduates, and our clinical consultation program graduates.

cake

 

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Suzanne St. John and Karen Fraley announce the names of the Clinical Consultation Program graduates.

 

 

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Graduation Dinner

 

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Caroline Sehon (IIPT chair) Michelle Kwintner (graduate) and Janine Wanlass (IPI Director)
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Two Year Core Students preparing for their last weekend small group as a cohort (Henriette van Eck, Kelly Seim, Steven McCowin, Christie Dietz)
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The graduates acknowledge the support given to them by their group leader (Lorrie Peters)
Core graduates present their group leader with a blanket made of patchwork saris.
Core graduates present their group leader with a blanket made of patchwork saris.

 

Settings and Modalities in Family and Couple Treatment

Thursday Feb 1,2018

Panel: David Scharff, Jeanne Magagna, Caroline Sehon
Panel: David Scharff, Jeanne Magagna, Caroline Sehon

 

Jeanne Magagna is speaking about working with parents to help their difficult and unhappy children. Of course parents expect the child therapist to be trained in child development and parent effectiveness preparation. But no matter how well trained, the therapist cannot help the child without the parents. She NEEDS the parents to help her treat their child. Together they can build a thinking space where the parents can observe their child more fully, develop a shared narrative of their child and her role in the family, and make links from their experiences as children to their child’s life now. From there, parents at home create a daily routine review of their child’s day, and they can all explore the connections among the child’s experiences and the family history and social setting. In this way the parents build a sturdy emotional cradle in which they hold their child. Feeling secure in this loving, reflective parental cradle, the child grows in self regulation, curiosity and connectedness.

 

Saturday Feb 3, 2018

 

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We heard from the Scharffs about a brief encounter with a Chinese family. The index patient was a boy who could not make any decision or speak up for his own choices, caught between the unresolved differences of his parents. We heard the therapists describe working with them in an academic setting with a translator and a large audience. They spoke about the boy’s symptom as a distillation of family dynamics and they showed how playing spontaneously with him and his sister could help the boy to find a voice. Then Li Zhen and Mary Morgan discussed the cultural context and the treatment/teaching setting. We usually think of treatment as an intensely private matter but even in this strange setting a therapeutic exchange could occur. Mary Morgan pointed to the importance of the therapists’ internal setting enabling them to relax, engage in word and play, and make a safe, containing therapy space. Li Zhen viewed this family as one that represents not just the parents’ internal conflict but also the generational conflict between grandparents who live by Confucian principles of filial piety and young people who are looking for a way to live in the new China.

 

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Sunday Feb 4, 2018

As the discussion on settings and modalities continues, differences among various approaches are becoming clear. The therapist of an under-5 year old may usefully also do parent counseling or couple therapy with her parents. Others see this as a distortion of the frame. Some of us who begin work with a couple will see only the couple. Others will see whichever part of the couple shows up for the appointment. Those couple therapists with a family orientation may include the children (or even a newborn) for some sessions to explore the couple-as-parents, work on coalitions that replace the vital marital bond, and relive childhood experience that can inform current couple relating. Those with a couple orientation would never break the couple frame like that.

 

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Today Rich Zeitner showed that even though we hold a firm frame for meeting with a couple, we may find ourselves doing individual therapy in the presence of the partner, a difficulty encountered when one partner is identified as mentally ill. It is as though two people are living in one person, said Leora Benioff, and Mariangela Mendes de Almeida advised attending to the theme and the affect that connects them rather than to the projections of internal object relations. Mary Morgan reminded us that a projective identification system like this exists to protect the couple from aspects of themselves that they are frightened of. Mary Morgan reminds us that therapist needs to be patient in allowing the defensive process to continue until it is no longer needed. Damian McCann responded that the modifications in the frame can be an acting out, an acting-in of the transference for subsequent analysis, or a spontaneous or surprising intervention that reflects a shift in the therapist that could release the couple from their entrapment in paranoid-schizoid functioning to depressive concern.

The take away message is that various ways of maintaining and modifying the frame can be helpful or destructive, but the main point is that the therapist needs to examine the impact of any shifts in the frame and use it for therapeutic understanding.

 

Final Thoughts

Another way to think about the value and meaning of a change in modality or setting is to consider it in terms of whether the therapist is expressing a defensively caretaking function or a truly adaptive containing function. We might also ask if the change made is an innovative movement forward or a regression to a traditional modality out of guilt.
There are individual, couple and family levels of organization. We can intervene at any level but we need to keep in mind what we are doing and where we are going. We want to keep a multiocular vision on individual, couple and family in any of these treatment settings.

 

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And technical considerations aside, within the secure setting we create we are subject to unexpected external forces, liable to error, but willing to acknowledge mistakes and make reparation. We identify with our preferred settings, work from an internal setting that is firm but flexible when deviations are called for, and feel free to engage as a thinking, feeling human being.

 

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The Dream Factory: New Ways of Listening and Interpretting in Psychotherapy and Psychoanalysis

Friday, October 14, 2016

Today at the International Psychotherapy Institute, we are listening to Giuseppe Civitarese from Italy, or perhaps I should say dreaming along with him, as he begins a weekend workshop on listening and interpreting in psychotherapy and psychoanalysis. He asks us to consider the treatment setting as a field with a body which patient and analyst share and co-construct in the intersubjective area between them. The body of the setting is felt in the body of the patient and in the body of the analyst as a kind if somato-implicit-procedural impression of what is going on in the session. The analyst’s bodily experience often takes the form of a breach in the setting.

Mike Stadter, Doug Dennett, and Giuseppe Civitarese
Mike Stadter, Doug Dennett, and Giuseppe Civitarese

The mother helps her child develop a mind not through words, but through the music of language and rhythm of movement that gets installed in the body. Interruptions in that rhythm are also installed on the body.

In unexpected unconscious breaches in the setting, trauma is reproduced and experienced as sensorial and bodily manifestations on the way towards representability of dissonance in the rhythm of relating to the maternal object. When the surprise of the breach is encountered in the analyst’s reverie, the analytic pair arrives at a starting point for transformation. From the vertiginous multiplicity of past and current impressions in the analyst’s reverie, meaning will arrive if we have confidence in the sublime potential of psychoanalysis.

Jill Scharff

On the Body: IPI lecture by Vincenzo Bonaminio

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     Patrizia Pallaro, Vincenzo Bonaminio, and Janine Wanlass

Analysis emerged from Freud’s study of the body as he worked with women’s neurological symptomatic expressions of emotional conflict and reaction to societal attitudes about them. Alessandra Lemma has brought the body back into psychoanalysis in her study of the prepubertal body. Winnicott wrote of the importance of the integration of mind and body and thought of psychopathology as a rupture between them. IPI’s distinguished guest speaker Vincenzo Bonaminio shifts the focus to the body of the analyst and its impact on the analytic work as his stomach rumbles, as he shifts to achieve a better listening  or observing position or to ease a discomfort, as he and the patient pass on the way into or out of the waiting room, or inadvertently touch.

Vincenzo Bonaminio

Vincenzo Bonaminio

In the countertransference he described a memory and a dream of losing and reviving his daughter that he later discovered was in resonance with his patient’s trauma history and dream of infusing life into the body of a parent’s lost child. An analyst may respond impulsively to a patient’s physical presence with a care-taking action. This type of physical action is an enactment that avoids thought and feeling and yet, as Winnicott said, can provide a clue that leads right to the patient’s earliest maternal environmental failure.

From Jill Scharff

The Infant-Parent Dyad with Björn Salomonsson, MD

We’ve been fascinated this weekend at IPI by Dr. Björn Salomonsson’s account of his psychoanalytic treatment of infants with their parents. To develop an effective theory and technique for helping infants in distress we need to look beyond attachment research and developmental theory to include analytic theory and technique in our approach. It’s easy to believe that the analyst’s words communicate understanding to the parent. But Dr. Salomonsson believes that he can communicate directly with the baby. Many argue that you can’t analyze a baby because analysis is a talking therapy and babies can’t understand words. Others have argued that they do. But here it is important to distinguish between the lexical and the linguistic. True, babies do not understand the words but they respond to the patterns of the language, words, the rhythm of the speech, the affective tone, the authenticity and integrity of the analyst’s interest and reach the baby and give meaning to the experience. The analyst recognizes the baby’s distress, offers calm interest and concern, and conveys hope that the unmanageable distress can be understood and coped with through a process of co-thinking between baby and analyst and between baby and parent. The analyst recognizes the competence and responsibility of the baby to become a partner in the process of recovery.

– Jill Savege Scharff, M.D.

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