o f the m a i n purposes o f the therapeutic endeavour is t o break tin

defensive barrier.

A note on the interpretation of defence

I n terms o f attachment t h e o r y anxiety is m a i n l y related t n
attachment insecurity. T h e origins o fanxiety cannot be r e d u i t d
t o i n t e r n a l sources. A n x i e t y h a s t ob e located i n a n interpcrson.il
c o n t e x t . B e c a u s e a n x i e t i e s a r e d i f f i c u l t t o b e a r , t h e y a r e l i k e l y i
originate defences.
A n i n d i v i d u a l m a y u s e s o m e d e f e n c e m e c h a n i s m s agaiii'-t
anxiety i n a transient way. B u t s o m e defences c a n b e c o m e p.u t
o f t h e person's character organization. T h e y m a y influence i n
a predominant a n d continuous w a y t h e individual's pattern o l
responses o rbehaviour. A v o i d a n t behaviour, o m n i p o t e n t attitudi-s
a n d m a n y other features o f a person m a y b e the result o f defensive
organization.

G H A P T E R 1 2

On latrogenia
When the Wrong Clinical
Intervention Causes Harm

Introduction: the persecutory therapist

A certain analytic style emphasizes t h e need t o interpret

defences as t h e y m a n i f e s t i n t h e a n a l y t i c r e l a t i o n s h i p . T h i s is all
w e l l a n d good. T h e p r o b l e m is that w h e n defences are identified
w i t h o u t understanding t h e p a i n f u l situation that created t h e
u n d e r l y i n g anxieties, the analytic w o r k m a y b e c o m e r i s k y I shall
explain w h a t I m e a n . T h e r e are m a n y accounts o f analysts telling
their patients: ' Y o u feel o m n i p o t e n t ' o r ' Y o u avoid intimacy w i t h
me.' S u c h remarks - m a d e i nthis w a y - give a description, n o t a n
explanation. F u r t h e r m o r e , they m a y b e perceived b yt h e patient
as a t t a c k s o n h i s s e l f - e s t e e m . H o w e v e r , i f t h e a n d y s t p r o c e e d s
to investigate t h e possible sources o f these defences a n d s h o w
e m p a t h y f o r t h e patient's early pUght, t h e interpretation o i
defence w i l l b e m o r e adequate a n dt h e analysand m a y feel m o r e
accompanied. I n other words, i f w e interpret the defence together
w i t h the u n d e r l y i n g anxiety, a n d t h e n invite the patient t o explore
w a y s o fm a k i n g sense o fthese anxieties i nt h e c o n t e x t o f early
interpersonal experiences, w e m a y b e h e l p i n g the patient t o achieve
greater insight over his psychic f u n c t i o n i n g w h i l e a tthe same t i m e
offering a n empathic response.

S o m e therapists m a y behave i n w a y s t h a t can cause h a r m . I n t h e

m e d i c a l w o r l d t h e t e r m iatrogenia is u s e d t o classify h a r m f u l c U n i c a l
interventions (sometimes made w i t h good intentions).The concept
d o e s n o t i n c l u d e gross m a l p r a c t i c e , s u c h as d i f f e r e n t f o r m s o f o v e r t
and easily identified abuse (for example, sexual e n g a g e m e n t w i t h
the patient). I a mreferring t o interventions that can b e damaging
to t h e patient b u t a r eo f t e n disguised as 'therapeutic'. I n s o m e
respects m a n y o f these i n t e r v e n t i o n s c a n b e r e g a r d e d as a f o r m o f
abuse o r b u l l y i n g b u t t h e y are v e r y r a r e l y i d e n t i f i e d as s u c h a n d t h e
perpetrators are n o t referred t o a professional ethics c o m m i t t e e .
M e a r e s a n d H o b s o n (1977), i n a very i m p o r t a n t article o n
iatrogenia i n psychotherapy, stated t h a t i t w o u l d b e foolish t o
imagine that psychotherapy, w h e n i t is n o tbeneficial, is m e r e l y
ineffective. I n fact i tm a y d o h a r m . I w o u l d l i k e t o use t h i s c h a p t e r
as a n i n t r o d u c t i o n t o t h i s t o p i c .
M e a r e s a n dH o b s o n d r e w a t t e n t i o n t o t h e fact t h a t research
in t h e field o fpsychotherapy was, i n 1977, a t i t s beginnings. I t
perhaps still is. T h e r e isa great deal o f w o r k t o b e d o n e i n relating
reliable measures o f the m a n y variables i n the therapeutic process t o
valid assessment o f outcome. However, clinical observations made
over m a n y years c a n perhaps p r o v i d e m o r e t h a n m e r e anecdotal
accounts.

218

219

<>t ; i n i j i l i l \ ,

.IIKI

i a t r o g e n i c a n d t h a t a t t a c h m e n t t h e o r y c a n i n f o r m t h e dc-tc> i i i u i

W d o n e at

I 111-

and analysis o f iatrogenic techniques. T h e evidence

experience.

believe that some

psychotherapeutic

treatments

Ciiii

COMICS

1"

IIMIM

s e v e r a l c l i n i c a l s o u r c e s , w h i c h I p r e f e r n o t t o n a m e f o r t h e sn k i .1
discretion.
Meares

a n d H o b s o n focused

their study o n certain

kin'l-

o f t h e r a p e u t i c t e c h n i q u e w h i c h e v o k e i n t h e p a t i e n t f e e l i n ; , . ' ; . !
persecution. These

techniques

contain strong elements

use of intrusive

interpretations,

probing

Kisi

awarencss a n d this

o f invalidating t h e patient's

cannot
subjective

False neutrality.
T h i s is t h e stance o fa n 'opaque' therapist,
who pretends that clean w i t h d r a w a lf r o m the intersubjective
experience o f t w o people i n a n analytic relationship is
possible.

o f thi

following:
Frequent

rMciuHiig

or question!

n-

T h i s m a y involve forcing confessions. H o w e v e r , t h e i n o i

c o m m o n f o r m o f i n t r u s i v e n e s s i n a n a l y s i s o c c u r s w h e n ili>
analyst is interpreting every 'corner' o fthe patient's

miml

M e a r e s a n d H o b s o n a l s o d e s c r i b e t h e untenable
situation.
T h i s is reached w h e n t h e therapist's c o m m u n i c a t i o n t o t h e
patient renders h i m helpless, conflised and unable t o explore
a n d l e a r n . I t is p r o m o t e d b y l a c k o f c l a r i t y a b o u t t h e s t r u c t u r e
o f therapy, i m p o s i n g impossible requirements, giving
conflicting messages and m a k i n g conflicting demands.

in a persistent way. S u c h a technique is often justified h \

Finally, there

sophisticated theoretical claims.

c a n b e a persecutory

spiral,

w h i c h is a n

escalation o f destructive interaction i n w h i c h b o t h therapist

Frequent
his

use of derogation.

patient while

T h e therapist

considering

m a y derog.iic

his interpretations

'confrontations' o r 'insight-giving'. Meares

ID I "

and Holi-mi

a n d p a t i e n t are, o r feel, persecuted. A m b i v a l e n c e o r h a t r e d

may

d o m i n a t e t h e r e l a t i o n s h i p a n d n e i t h e r can leave. T h i s is

made worse w h e n the therapist is self-righteous.

s h o w e d that telling a patient that h e is angry o r that Inwishes t o dominate m a y be a covert w a y o f calling liim
n a m e s . T h i s d e r o g a t o r y attitude t o w a r d s patients is o l t m

A review of dysfunctional therapeutic styles

seen i n clinical seminars w h e r e emphasis

It m i g h t b e possible t o d r a w parallels b e t w e e n dysfunctional

parental styles a n d d y s f u n c t i o n a l therapeutic styles. I n t h i s c o n t e x t
it m i g h t also b e p o s s i b l e t o f o r m u l a t e a h y p o t h e s i s . I f , as A n n a
Freud, Selma Fraiberg, J o h n B o w l b y and others propose, w e tend
to t r e a t o t h e r s as w e h a v e b e e n t r e a t e d b y i m p o r t a n t p e o p l e i n o u r
past, t h e n w e c a n assume t h a t a n analyst m a y treat h i s patients
as h e h a s b e e n t r e a t e d , p a r t i c u l a r l y i f h i s o w n a n a l y s i s f a i l e d t o
investigate i ndetail t h epatterns o f interaction that characterized
his e a r l y r e l a t i o n s h i p w i t h h i s p a r e n t s o r caregivers. F o r i n s t a n c e ,
a n a n a l y s t w h o - as a c h i l d o r a d o l e s c e n t - w a s o f t e n s u b j e c t e d
to d e r o g a t o r y c o m m e n t s ( n o r m a l l y d i s g u i s e d as w e U - i n t e n t i o n e d
and helpful communications), m a y d o t h e same t o h i s patients.
M a n y examples o f this sort c o u l d b e given t o illustrate the process
to w h i c h I refer. T h i s process resembles t h e i n t e r g e n e r a t i o n a l
transmission of disturbed patterns o f attachment. However, i n this
case, t h e p e r s o n w h o i s e x p o s e d t o t h e i n t e r g e n e r a t i o n a l t r a g e d y i s
the patient and not the child.

is p u t o n t i n '

patients' destructiveness a n d e n v y t o t h e neglect o f po^iti\l

or w e l l - f i i n c t i o n i n g aspects o f these analysands.
By

subtle o r even brutal means t h e patient is m a d e i n

feel t h a t h e is 'bad', 'ill' a n d a b n o r m a l a n d hence c o m p l c t d v

different f r o m the therapist.
By definition, a patient who

s e e k s t h e r a p y is t r y i n g t o i l c . i l

w i t h a greater o r lesser degree o f i n s e c u r i t y o f attachnu-iii,

w h i c h always carries a b u r d e n o f l o w self-esteem. Theri:t()i<-,
derogation

i n psychotherapy,

because o f i t s detrimciit.il

effect o n the patient's self-esteem, is anti-therapeutic.

Invalidation
of experience.
T h i s m i g h t occur w h e n tint h e r a p i s t considers t h a t w h a t h i s p a t i e n t says does n o i
m e a n w h a t t h e latter t h i n k s i t means. There is a n imiilicii
suggestion t h a t t h e ' r e a l ' m e a n i n g lies elsewhere. T h i s is n u i
a n u n u s u a l situation, since psychotherapy is characterized , i .
a search f o r 'deeper'explanations. H o w e v e r , analysis con-i' i >

220

221

T h e iatrogenic analyst m a y have h a d years o f analysis ;md

g o n e t h r o u g h a t h o r o u g h t r a i n i n g . H e m a y have years o f cliiiiral
experience a n d be able t o e x p l a i n his t e c h n i q u e i n a substantial a n d
c o n v i n c i n g m a n n e r . Hovi^ever, i n t h e i n t i m a c y o f h i s consulting',
r o o m he m a y treat his patients (all o f t h e m or some o f t h e m ) in
a w a y t h a t is c o n s i s t e n t l y o r i n t e r m i t t e n t l yl a c k i n g i n e m p a t h y o i
sensitive responsiveness.
M a n y analysts w h o w o r k i n a n i a t r o g e n i c w a y d o so b y m e a n s
o f verbal c o m m u n i c a t i o n s w h i c h involve one o r m o r e o f tlic
f o l l o w i n g characteristics:
T h e y disconfirm the patient's real perception o f other
people (including the analyst) by emphasizing the influence
that projection and unconscious phantasy have i n causing
perceptual distortions.
T h e y invalidate the patient's subjective experience b y m a k i n g
i n t e r p r e t a t i o n s w h i c h i m p l y : ' W h a t y o u f e e l o r e x p e r i e n c e is
n o t w h a t y o u actually say b u t w h a t I t h i n k y o u actually feel
or experience.'
T h e y use double-binding, for instance b y m a k i n g the
patient feel g u i l t y and t h e n saying that the patient's internal
w o r l d is d o m i n a t e d b y g u i l t , b y i n d o c t r i n a t i n g t h e p a t i e n t i n
subtle ways and t h e n c l a i m i n g neutrality,by d e m a n d i n g that
the analytic relationship be central and t h e n interpreting
excessive d e p e n d e n c y o r b y increasing t h e patient's sense o f
v u l n e r a b i l i t y a n d t h e n t r e a t i n g i t as p a t h o l o g y .
T h e y i n h i b i t e x p l o r a t o r y b e h a v i o u r a n d a u t o n o m y . T h i s is
often achieved b y constantly interpreting the patient's search
f o r a u t o n o m y as a n a r c i s s i s t i c d e f e n c e a g a i n s t d e p e n d e n c y
a n d m o s t a c t i o n s t h a t t h e p a t i e n t t a k e s as ' a c t i n g o u t ' .
T h e y a l w a y s m a k e t h e p a t i e n t feel at f a u l t . T h i s is achieved
by m a k i n g 'fault-finding' interpretations, n o r m a l l y a i m e d at
d e m o n s t r a t i n g that any failure or conflict i n the patient's
i n t e r p e r s o n a l life is t h e sole r e s u l t o f h i s p s y c h o p a t h o l o g y o r
u n c o n s c i o u s d e t e r m i n i s m . I n t h i s w a y adversity is i n v a r i a b l y
reduced t o the patient's i n t e r n a l fault.

222

T h e y treat t l i e j M l i e i i l w i t h r i g i d i t y . I n t h i s case t h e t h e r a p i s t
m a k e s intcr]))vt;iiioi)s w i t h a n iixioraatic sense o f validity,
t h a t i s t o say, h i s v i e w s c a n n o t b e q u e s t i o n e d .

T h e y create i n the patient a sense o f d i s e m p o w e r m e n t . T h i s

can be d o n e b y c o m b i n e d use o f s o m e o f the techniques
d e s c r i b e d above. A s a result o f t h e i r use t h e p a t i e n t feels
increasingly unsure about his capacity to m a k e g o o d e n o u g h
d e c i s i o n s , t o assess r e a l i t y , t o p e r c e i v e o t h e r s , t o m a k e
realistic choices, t o establish realistically a m b i t i o u s aims, t o
be i n c o n t r o l o f h i s Ufe. T h e p a t i e n t feels e m o t i o n a l l y w e a k ,
h i s s e l f - e s t e e m is d e c l i n i n g a n d h e m a y e n t i r e l y d e l e g a t e a n y
sense o f w i s d o m t o his analyst.
Patients can be trapped i n analysis t h a t has s o m e o f these
c h a r a c t e r i s t i c s as d o m i n a n t f e a t u r e s . I n m a n y c a s e s t h e p a t i e n t
remains i n analysis for extremely l o n g periods o f t i m e because he
feels v e r y d e b i l i t a t e d a n d u n a b l e t o w a l k t h r o u g h Ufe w i t h o u t t h e
c r u t c h t h a t h i s a n a l y s t is s u p p o s e d l y p r o v i d i n g .
T h e r e seem t o be s o m e interesting a n d c o m m o n characteristics
i n t h e b e h a v i o u r o f m a n y i a t r o g e n i c analysts. F i r s t , t h e y are
dismissive o f their patients' attachment histories. Second, they
tend t o m a k e the patient feel vulnerable and weak, w h i l e they do
not recognize any vulnerability or weakness i n themselves.
B o t h characteristics - a dismissive attitude towards the
s i g n i f i c a n c e o f a t t a c h m e n t h i s t o r i e s a n d a t e n d e n c y t o see
vulnerability and weakness i n others rather than i n themselves c a n b e s e e n as c h a r a c t e r d e f e n c e s a g a i n s t i n s e c u r i t y o f a t t a c h m e n t
( a s i s o f t e n t h e c a s e with p e o p l e w h o h a v e b e e n b r o a d l y c l a s s i f i e d
a s avoidant
o r dismissive).
O f course, a c h i e f defence m e c h a n i s m
h e r e is projective i d e n t i f i c a t i o n : m a k i n g t h e o t h e r p e r s o n feel w h a t
o n e is r e s i s t a n t t o f e e l i n g . T h i s t y p e o f b e h a v i o u r r e m i n d s m e o f t h e
behaviour o f avoidant schoolchildren described by A l a n Sroufe i n
M i n n e s o t a (see C h a p t e r 4 ) . T h e s e are c h i l d r e n w h o s h o w a false
sense o f s e c u r i t y a n d s u p e r i o r i t y , w h o are n o r m a l l y tense, w h o
find i t d i f f i c u l t t o a d m i t p e r s o n a l f a i l u r e o r t o s a y ' s o r r y ' , w h o i n
s i t u a t i o n s o f i n t e r p e r s o n a l c o n f l i c t are m o r e l i k e l y t o p l a y t h e r o l e
o f v i c t i m i z e r t h a n t h a t o f v i c t i m . T h e y also have t h e capacity t o
m a k e t h e i r a m b i v a l e n t m a t e s w e a k e r a n d a c t t o w a r d s t h e m as i f
signs o f weakness deserve n o t h i n g b u t aggression a n d c o n t e m p t .

223

ATTACHMENT AND

INTERACTION

I n t h e f o l l o w i n g pages I shall t r y t o describe i ngreater detail

s o m e d y s f u n c t i o n a l c o m m u n i c a t i o n s m a d e b y t h e r a p i s t s as w e l l
as a t t i t u d e s l a c k i n g i n s e n s i t i v e r e s p o n s i v e n e s s . I s h a l l a l s o t r y t o
p i n p o i n t similarities w i t h parental c o m m u n i c a t i o n s o fthe same
sort.
L a c k o f w a r m t h i s s h o w n n o n - v e r b a l l y as w e l l as v e r b a l l y . I t
appears i n t h ef o r m o f a cold attitude w h e n greeting t h e patient
at t h e b e g i n n i n g o ft h e session o r w h e n saying goodbye. I t also
appears i n t h e f o r m o f l o n g silences o n t h e p a r t o f t h e analyst o r
in his tone o f voice w h e n m a k i n g a n interpretation. H o w e v e r , the
m o s t s t r i k i n g f o r m o f coldness occurs w h e n t h epatient is g o i n g
t h r o u g h a crisis o r needs c o m f o r t a n d w h a t h e gets i s a 'clean'
interpretive response devoid o f genuine empathy.
I n clinical seminars lack o f w a r m t h is o f t e n justified. I t is
seen as a protective shield w h i c h t h e analyst m u s t u s e against
the patient's 'seduction' o r m a n i p u l a t i o n . I t is o f t e n held that t h e
p a t i e n t is a l w a y s t r y i n g t o p l a y t r i c k s i n t h e a n a l y t i c r e l a t i o n s h i p , t o
seduce t h e analyst, t o m a k e h i m b e friendly, sot h a t t h e analysand's
destructive o r nasty elements r e m a i n h i d d e n a n d are i g n o r e d .
J o h n B o w l b y firmly believed that t h e starting a n d ending
p o i n t o fa n y analysis s h o u l d b e t h e analyst's stance o f b e i n g o n
t h e patient's side. T h i s requires f r o m t h e analyst a basic t r u s t i n
therapeutic relationships, compassion f o r t h e patient's plight,
a d e e p sense o f respect f o r t h e p a t i e n t a n d , as a r e s u l t , a c e r t a i n
w a r m t h . T h e n , o f course, i t s h o u l d b e possible t o explore t h e
patient's h o s t i l i t y a n d d y s f l i n c t i o n a l strategies.
T h e r e a r e p e o p l e w h o s h o w m o r e o r less w a r m t h i n t h e i r
everyday life. T h i s ist o d ow i t h personality a n d cultural influences.
I n t e r m s o f p s y c h o p a t h o l o g y , i n s o m e cases l a c k o f w a r m t h m a y
be a m a n i f e s t a t i o n o f character defences. H o w e v e r , t h e type o f
w a r m t h ( o r lack o f i t ) t o w h i c h I a m r e f e r r i n g here relates m o r e
specifically t o the attitude the analyst has i n relation t o his patient
and t othe theoretical justification f o u n d for such a n attitude.
L a c k o f w a r m t h o n t h epart o f the analyst m a y reactivate i n
certain patients early m e m o r i e s o f lack o f parental w a r m t h . This
i s a n i m p o r t a n t p o i n t b e c a u s e a n u m b e r o f s t u d i e s i n t h e field
o f a t t a c h m e n t ( e . g . F r a n z et al. 1 9 9 4 ) r e l a t e p a r e n t a l w a r m t h t o
acceptance a n d a f f i r m a t i o n o f t h e child's w o r t h . O v e r a l l rating
o f affection displayed i n parentchild interactions w a s inverscU'
proportional t o hostility or rejection in tlxv.c ifi.ili(>ii:;lii|)s. I laving

ON

IATROGENIA

had a difficult childhood correlated w i t h lack o f maternal w a r m t h .

M e a n w h i l e , h a v i n g a t least o n e w a r m parent w a s associated w d t h
better social a c c o m p U s h m e n t i n later life, w h i c h i n t u r n w a s
correlated w i t h a variety o findicators o fgeneral psychological,
interpersonal and psychosocial functioning.

On support and assurance

T h e r e are analysts w h o consider that support a n d assurance have
n o role t o play i n analysis. A patient w a s g o i n g t h r o u g h a v e r y
difficult period i nhis life a n d expected support i nhis therapy. I n
response, the analyst said w i t h a disapproving tone o f voice: ' M r
X , y o u w a n t r e a s s u r a n c e ! T h i s i s a l l y o u w a n t ! ' R e s e a r c h i n t h e field
o f attachment highlights t h e value o f support i n relationships
and shows h o w unsupportive communications m a y have a
d e t r i m e n t a l effect o n psychic f i x n c t i o n i n g . F u r t h e r m o r e , there is
n o clear evidence t o substantiate t h e hypothesis t h a t support is
incompatible w i t h analysis.
Support is a w a y o f s h o w i n g the patient that one understands
his p l i g h t , t h a t o n e is essentially o n h i s side a n d is prepared t o
listen a n d see t h e w o r l d f r o m h i sp o i n t o f v i e w . T h e therapeutic
alliance is essentially b u i l t o n t h e analyst's capacity t o offer
sensitive responsiveness a n d support. I t is o n t h e basis o f such
an alHance that t h etherapist c a nhelp t h epatient t o explore h i s
denial o f reality, splitting, perceptual distortions, manipulations,
dysfunctional strategies t o g e ta t t e n t i o n , h o s t i l i t y a n d s o o n .
A t t a c h m e n t research h a s s h o w n that there is a difference
b e t w e e n lack of support
a n d unsupportive
behaviour.
Lack o f
s u p p o r t i m p l i e s a p o o r response t o a person's care-eliciting
communications. Unsupportive behaviour involves a derogatory or
accusatory response t o a person's distress. A n e x a m p l e o f t h e latter
w o u l d b e a patient o f m i n e w h o reported that, t h r o u g h o u t her life,
e v e r y t i m e she f a i l e d as a c o n s e q u e n c e o f u n w i s e decisions she h a d
made, her mother w o u l d exclaim i na harsh and pimitive tone o f
voice: ' Y o u m a d e y o u r b e d , y o u l i e i n it!' or: ' I t serves y o u r i g h t l ' T h e
k e y aspect o f u n s u p p o r t i v e b e h a v i o u r is t h a t t h e p e r s o n i n distress,
instead o f g e t t i n g a reflective response, gets a n attack o n his o r her
self-esteem.
Unfortvmately, unsupportive behaviour c a n occur i n analysis.
A y o u n g patient w h o failed his exams was t o l d b y his analyst: ' Y o u

messed i t u p l ' E v e n i fthere w a s a n e l e m e n t o f t r u t h i n t h e aiiiilvst'

r e m a r k , as t h e p a t i e n t d i d n o t s e e m t o p e r f o r m as w e l l as h e e o u l t l
because o f his o w n anxieties and inhibitions, this explanation u m
o n l y refer t o a n aspect o f a m o r e c o m p l e x interpersonal sitiiation
Therefore such a r e m a r k , said w i t h o u t reference t o o t h e r factors ,ii
play, b e c o m e s reductionistic. W e shall briefly discuss reductionii.tn
i n the next section.
O v e r t o r covert derogatory a n d accusatory elements i n the
analyst's c o m m u n i c a t i o n s a r e o f t e n disguised as 'interpretations'.
N o t i n f r e q u e n t l y , i n c l i n i c a l s e m i n a r s o r s u p e r v i s i o n g r o u p s , ;tii
analyst's b e h a v i o u r is justified i n fashionably c o u c h e d t e c h n i c i l
t e r m s . H o w e v e r , t h e s e t e r m s c a n b e r o u g h l y t r a n s l a t e d as: ' I t is nil
the patient's fault.'

Reductionism and de-contextualization

I h a d m y first t r a i n i n g i n p s y c h o a n a l y t i c t h e r a p y i n A r g e n t i n a , i n
the tradition o f Jose Bleger a n d E n r i q u e P i c h o n Riviere. Blegci
insisted that behaviour is always m o t i v a t e d b y m o r e t h a n o n e
factor, all these factors converging t o produce a n e n dresult. Tliis
is w h a t h e called 'policausality'. P i c h o n R i v i e r e conceptualized
h u m a n b e h a v i o u r i n a g i v e n s i t u a t i o n as a n 'emergent', s o m e t h i n g ;
that emerges o u t o f the intersection b e t w e e n a person's h i s t o r y and
personality (he called i t the 'verticalline') and the context o f current
social i n t e r a c t i o n s ( t h e ' h o r i z o n t a l l i n e ' ) . T h i s t y p e o f t h i n k i n g is
compatible w i t h Foulkes' group analytic propositions a n d w i t h
a t t a c h m e n t t h e o r y . I t is also c o n g e n i a l w i t h Freud's c o n c e p t o f
c o m p l e m e n t a r y series ( 1 9 1 6 - 1 9 1 7 , S E 1 6 ) , w h e r e b y 'exogenous'
a n d ' e n d o g e n o u s ' factors w e r e s e e n as c o m p l e m e n t a r y i n t h e
aetiology o fneurosis. F r o m this p o i n t o f view, a n analyst s h o u k l
help t h ep a t i e n t realize t h a t his b e h a v i o u r a n dm e n t a l states m a y
be the result o f a n u m b e r o f factors c o m i n g together. A m o n g these
factors, t h e effect o f social interactions m u s t b e considered. N o t t o
d o this m a y l i m i t a n d i n h i b i t the broader reflective processes t h a t
are r e q u i r e d t o achieve m e t a c o g n i t i v e k n o w l e d g e . H o w e v e r , there
are analysts w h o start t h e i r i n t e r p r e t a t i o n s b y saying, ' T h e reason
w h y y o u d o that is...'
O f t e n , t h e analyst does n o t give e n o u g h consideration t o t h e
possibility that disturbed
fimctioning
o n t h e part o fthe patient
could b e a reaction t o unfavourable interpersonal situations - past

226

or p r e s e n t . I t c a n h a p p e n , loi instance, t h a t w h i l e a p a t i e n t ' s u s e o f

proj<;ctive itientificafion is froipRiitly a n a l y s e d , t h i s s a m e p a t i e n t
is n o t a s s i s t e d i n r e c o g n i z i n g s i t u a t i o n s i n w h i c h h e i s t h e a c t u a l
r e c i p i e n t o f s o m e b o d y else's p r o j e c t i v e i d e n t i f i c a t i o n s .
M r Y ,a m a n i n his late-30s living i n England, missed his native
country, w h e r e people are m o r e expansive and the sun shines m o r e
often. D r N , h i s analyst, was convinced that this patient ( w h e n
referring t o h i s nostalgia for a better place t o live) w a st r y i n g t o
convey i na symbolic a n ddefensive w a y the n o t i o n that i f he was
w i t h expansive people under a sunny sky h i s hidden depression
w o u l d disappear. A subsequent analysis revealed t h a t this patient
had genuine reasons t o miss h i s c o u n t r y o forigin a n d that t h e
'depression t ow h i c h D rN referred was actively induced b yD r N
himself, w h o was constantly u n d e r m i n i n g the patient's self-esteem
and self-confidence.

invalidation of the patient's subjective experience

I n t h e case o f M r Y , t h e m a n I m e n t i o n e d i n t h e p r e v i o u s section,
it c o u l d have been possible t h a t h e w a s i nfact l o n g i n g f o r a better
m e n t a l state, s y m b o l i c a l l y represented b y g o o d w e a t h e r a n d nice
people. H o w e v e r , D r N's denial o f the possibiUty that t h e patient
h a d g o o d reasons t o miss h i sc o u n t r y was a n invaUdation o f the
patient's subjective experience.
T h e same patient, M rY , whose parents lived i n h i s country
o f origin, once said t o his analyst: ' I t h i n k t h a t m yageing parents
need m e . M a y b e I should g o back.' D r N responded: ' N o , M r Y !
Y o u r parents d o n o tneed you. Y o u need them!' I n this w a y t h e
a n a l y s t i n t e r p r e t e d M r Y ' s s t a t e m e n t as a p r o j e c t i o n o f h i s o w n
dependency needs.
M r Y ' s subsequent analysis, w i t h a different therapist, s h o w e d
that: (1) M r Y had a genuine concern for his parents'well-being and
his appreciation o f their needs w a s accurate; a n d(2) nevertheless,
i n his early years M r Y was subjected t oa m i l d f o r m o f role reversal
i n relation t o b o t h parents, w h o i n a subtle w a y m a d e h i m feel
s o m e h o w responsible for their e m o t i o n a l well-being. I f there was
some p a t h o l o g y i n M r Y , this was specifically related t o a moderate
d e g r e e o f r o l e r e v e r s a l i n h i s a t t a c h m e n t h i s t o r y a n d n o t o n l y (as h i s
previous analyst claimed) t o a projection o f disowned dependency
needs. A s M e a r e s a n d H o b s o n ( 1 9 7 7 ) p o i n t o u t , i n cases H k e t h i s :

227

ATTACHMENT A N D INTERACTION

t h e t h e r a p i s t b e h a v e s as i f t h e p a t i e n t i s c o m m u n i c a t i n g i n a
c u r i o u s k i n d o f c o d e , w h i c h i t i s t h e d u t y o f t h e t h e r a p i s t t o b r i ,\\
U n d e r t h e s e c i r c u m s t a n c e s , t h e p a t i e n t finds h i s w o r d s a i ij^c
H o w e v e r m u c h h e s t r i v e s t o find h i s f r e e d o m t h r o u g h t h e m I n
is i m p r i s o n e d b e h i n d t h e i r o n b a r s o f a n e x p l a n a t o r y s t e r e o t y p e .
(p.352)
T h e p a t i e n t m a y perceive t h i s s t y l e o f i n t e r p r e t a t i o n as n o r s i
than oversimplification a n d reductionism, particularly w h e n
i n t e r p r e t a t i o n s are d i r e c t e d u n r e m i t t i n g l y t o h i s 'unconscious':
W h e n h e protests that h e is unaware o f the feelings attributed
t o h i m a n d h i s p l e a i s d i s m i s s e d as a r e s i s t a n c e , h e m a y s e n s e
a g r o w i n g failure a n d unreality - a n alienation f r o m h i s o w n
thoughts. T h a t w h i c h h e felt h e k n e w is uncertain, a n d w h a l
s e e m e d s u b s t a n t i a l , a m e r e figment. H e e n t e r s a s t a t e o f i n c r e a s i n g ,
b e w i l d e r m e n t , despair, a n d helplessness associated w i t h a sense of
unreality, (p.352)

The stereotyped approach

Peterfreund (1983, Part I ) defines a 'stereotyped psychoanalytic
a p p r o a c h ' w h e r e b y t h e a n a l y s t c o n s t a n t l y t r i e s u n i l a t e r a l l y t o fit t h e
patient's material i n t o h i so w n theoretical f r a m e w o r k . Typically,
those w h o w o r k i n a stereotyped m a n n e r believe that they
u n d e r s t a n d t h e case w e l l a n d t h a t t h e y h a v e i m p o r t a n t clues about
i t f r o m t h e o u t s e t . T h e r e f o r e t h e y t e n d t o fit t h e c a s e i n t o t h e o r y . T n
this c o n t e x t m e a n i n g s are a s s u m e d r a t h e r t h a n discovered.
T h e p s y c h o a n a l y t i c process i s n o t v i e w e d as a m u t u a l l y c o
o p e r a t i v e p r o j e c t t o search f o r t h e t r u t h b u t as t h e analyst's a t t e m } i l
t o g e t h i s p a t i e n t t o accept as correct, a n d h e n c e u n d e r s t a n d , h i s
h y p o t h e t i c a l f o r m u l a t i o n s . A l t h o u g h t h e p a t i e n t i s a s k e d t o 'free
associate', data presented b y t h e p a t i e n t are a l l t o o o f t e n selectively
filtered
t o fit t h e f o r m u l a t i o n , o r e l s e a r e m e r e l y f o r c e d o r c o l l a p s e d
i n t o t h e f o r m u l a t i o n . A l t e r n a t i v e possible interpretations o f the
data presented are neglected a n d m a y n o t e v e n b e recognized. T h e
'analysis' is t h e n r e d u c e d t o a p r o c e s s o f s u b t l e i n d o c t r i n a t i o n .
N e x t t h e patient's
u n d e r s t a n d t h e analyst's
t u r n t h e resistance m a y
stereotyped model. B u t

difficulty t o accept a t face value a m i

i n t e r v e n t i o n s i s r e g a r d e d as resistance. I n
be interpreted according t o yet anotliciw h a t could b e w o r s e is that tlie analyst.

J7R

ON

IATROGENIA

i n order t o m a k e the patient m o r e receptive t o his interpretations,

m a y insist t h a t t h e patient's i n a b i l i t y t o see t h eanalyst's p o i n t o f
view stems f r o m h i s o w n psychopathology. Therefore a w a y t o
p r o c e e d is t om a k e t h e p a t i e n t feel ill. D r N p e r s i s t e n t l y said t o M r
Y i n the course o f his analysis: ' Y o u have
fiindamental
problems!'
and: ' Y o u don't have a n y sense o f illness!'
A t some p o i n t M rY began t o feel increasingly bewildered,
confiised, despairing and lacking i nself-confidence. Therefore h e
began t o t a l k t o h i sfriends about his analysis and, o f course, t o
D r N about these conversations w i t h friends. H i s friends gave
h i m support a n dadvised h i m t o change analyst. I n response D r
N c o n c l u d e d t h a t M r Y w a s fixed i n t h e s c h i z o - p a r a n o i d p o s i t i o n
and began t o interpret that the patient had transformed his friends
i n 'all-good' a n d h i s analyst i n 'all-bad'. T h e degree o fsplitting,
D r N suggested, was such that h e w o u l d r e c o m m e n d that M r
Y abandon ambitious professional plans because h e w a s n o t
p s y c h o l o g i c a l l y fit t o c a r r y t h e m o u t . A t t h i s p o i n t , M r Y d e c i d e d
a b r u p d y t o t e r m i n a t e his long-standing analysis w i t h D r N a n d t o
seek another therapist.

On the importance of being wrong

Peterfreund ( 1 9 8 3 ) said that there is a s t r i k i n g tendency for t h e
stereotyped therapist t o believe t h a t h epossesses a n u n d e r s t a n d i n g
o f the 'truth'; that h e h a s a privileged awareness o f the nature o f
the patient's deep unconscious. Tolerance o f uncertainty a n d
a m b i g u i t y is n o t a h a l l m a r k o f his w o r k . H e tends t o present
formulations dogmatically. H e attributes cliche-ridden meanings
to highly complex phenomena, w h i c h m a y actually have multiple
meanings that m a y even change over time. I n this context, o f
course, t h e patient c a n o n l y play a m i n i m a l role i n establishing
the truth o f w h a t m a y be going o n o r o f w h a t has happened t o
h i m . T h e therapist does n o t v i e w t h e p a t i e n t as a n e q u a l w o r k i n g
partner, capable o f c o n f i r m i n g , revising o r refuting suggested
interpretations, capable o f evaluating w h a t h ehears a n d capable o f
arriving at insights independently.
T h e analyst persists i n m a k i n g circular, s e l f - c o n f i r m i n g
f o r m u l a t i o n s i n w h i c h r e f u t a t i o n has n o place o r i s t a k e n as a s i g n
o f p a t h o l o g y . T h i s t y p e o f analyst is u n a b l e t o engage i n a d i a l o g u e
w i t h t h e (Wticnt a n d n e g o t i a t e w i t h h i m any d i f f e r e n c e o f o p i n i o n .

ATTACHMENT AND

INTERACTION

I n this w a y t h e therapist presents a m o d e l o f identification that

is u n r e a l i s t i c , f o r t h e p a t i e n t m a y b e g i n t o feel t h a t i n o r d e r t o
b e c o m e h e a l t h i e r a n d m o r e m a t u r e h e h a st o b e c o m e as d o g m a t i c
as t h e t h e r a p i s t .
M a n y years a g o I gave a lecture a t t h e L o n d o n C e n t r e f o r
Psychotherapy under the title "The I m p o r t a n c e o f B e i n g W r o n g ' ,
in w h i c h I suggested that a therapist w h o can a d m i t that at times
he m a y b e w r o n g has e n o r m o u s advantages over t h e dogmatic
therapist w h o believes h e is always right. H a n s C o h n , w h o acted
as m y d i s c u s s a n t , s a i d :
Psychoanalytic interpretations tend to conclude some unconscious
A f r o m a n apparent B . W h e n s o m e o n e is late for a session, t h e
a n a l y s t m a y i n t e r p r e t t h i s as a resistance t o analysis. I s t h e a n a l y s t
r i g h t o rw r o n g ? I s there a necessary c o n n e c t i o n b e t w e e n lateness
a n d resistance? I d o n o t t h i n k there is. T h e r e are a n u m b e r o f
reasons w h y s o m e b o d y m a y b e late f o r a session, a m o n g t h e m
n o d o u b t also resistance. A c o n t e x t h a s t o b e established w i t h i n
w h i c h o n e reason is seen t o b e m o r e likely t h a n another. A n
interpretation, i n m yview, is essentially n o ta statement b u t a
question.
I o f t e n s a y t o m y p a t i e n t s : ' L o o k , l i s t e n i n g t o w h a t y o u say, I r e a l i z e
that a part o f myself responds i n this w a y and another part o f myself
in this other way. Perhaps w e need t ohave a 'group discussion w i t h
all these voices, i n c l u d i n g yours, t o negotiate a solution.'
I believe that i tis i m p o r t a n t t o s h o w h u m i l i t y and honesty i n
engaging a patient i na shared project. W i t h o u t these conditions
w e c o u l d e a s i l y lose o u r w a y a n d e v e n t r e a t t h e p a t i e n t as h e m a y
h a v e b e e n t r e a t e d b y h i s p a r e n t a l figures, w h o s e d y s f i i n c t i o n a l s t y l e
m a y u l t i m a t e l yexplain w h y the patient has c o m e t o therapy.
A patient w h o has experienced i n his c h i l d h o o d a dysfiinctional
f o r m o f p a r e n t a l t r e a t m e n t i s l i k e l y t o b e firrther d a m a g e d b y a n
analyst w h o , even i n subtle o r disguised ways, repeats t h e abuse.
T h e result m a y be that the patient becomes m o r e fragmented and
depressed o r t h a t h e reinforces h i s false self structure a n d gains
some stability through i t w i t h o u t a n y
fiindamental
change at a
deeper level.

ON

IATROGENIA

Iatrogenic influences in supervision

I have heard o f m a n y instances i n w h i c h a therapist i n t r a i n i n g was
t r e a t i n g a p a t i e n t w i t h sensitive responsiveness a n d c o m m o n sense,
w h i l e being instructed by the supervisor to frame the interventions
w i t h i n a different model, resulting i n difficultiesi n the therapeutic
relationship i f n o t itstotal breakdown. T h e m o d e l advocated b y
the supervisor contained several o f the f o l l o w i n g elements: (1) a
tendency n o t t o believe t h e patient's account; (2) a tendency t o
disregard t h e analysand's a t t e m p t t o explore his attachment history;
(3) a tendency t o collapse t h e understanding o ft h e interaction
into a v e r y n a r r o w v i e w o fthe transference-countertransference
interplay (whereby the 'here-and-now'is allthat matters); and (4) a
tendency constantly t o interpret the 'badness' o f the patient (that
is, t o say h i s defensive traits a n d d y s f u n c t i o n a l strategies w i t h o u t
examining the context i n w h i c h they were formed).
I n o n e case t h e p a t i e n t w a n t e d t o t a l k a b o u t h i s e a r l y p a t t e r n
o f interaction w i t h h i sparents a n d t h e trainee w e n t along w i t h
this. I n response t h e supervisor said: ' Y o u m u s t n o t accept t h e
patient's account o fhis history. Y o u s h o u l d o n l y t r y t o seet h e
h i s t o r y as i t appears i n t h e transference a n d countertransference.'
I t is a curious fact t h a t s o m e supervisors actively discourage t h e i r
supervisees f r o m accepting patients' detailed accounts o f their
experiences outside therapy (particularly past experiences) w h i l e
at t h e same t i m e d e m a n d i n g a v e r y detailed account o f each
analytic session. T h e u n d e r l y i n g a s s u m p t i o n seems t o b e t h a t a
supervisee's account o f events t h a t occur outside t h e s u p e r v i s i o n
( n a m e l y the session conducted b y t h e supervisee) isu n d i s t o r t e d b y
definition w h i l e the patient's account o f interactions w i t h others is
inherently untrustworthy. A s a consequence o f this t h etrainee is
indoctrinated into believing that: (1) t h e meticulous retrieval and
analysis o f t h e patient's life events is clinically insignificant; a n d
(2) that t h e patient deserves t o b e treated - b y v i r t u e o f being a
p a t i e n t - as s o m e o n e w h o s e c o m m u n i c a t i o n s c a n n e v e r b e t a k e n
f o r w h a t t h e y m e a n . I n a n o t h e r case t h e t r a i n e e e x p l a i n e d t o h e r
supervisor t h a t she accepted t h e reason her patient gave f o r m i s s i n g
t h e previous session. T h e p a t i e n t ( b e i n g a m o t h e r ) said t h a t s h e
h a d t o miss t h e session because h e r c h i l d h a d a temperature. I n
these circumstances she decided n o t t o send t h e child t o school
and t o stay a t h o m e t o l o o k after h i m . This, inevitably, resulted i n
her h a v i n g t o miss h e r analytic session. A f t e r h e a r i n g this report.

J i t

ATTACHMENT AND

INTERAOTON

the supervisor exclaimed: ' Y o u seem totally imable t o interpret

resistance!'
I n a t h i r d example, t h epatient was trying t o cope w i t h t h r
consequences o f a v e r y adverse social situation: s h ew a s a femali
j o u r n a l i s t w h o h a d r e c e n t l y t a k e n refuge i n t h e U Kafter beinji,
seriously threatened b y Islamic fundamentalists i n h e r native
c o u n t r y (particularly because she w a s a w o m a n w h o dared t o
publish h e ro w n independent ideas). T h e supervisor c o m m e n t e d :
' H o w are w eg o i n g t o h e l p t h i s p a t i e n t t o deal w i t h t h e p s y c h o t i i
part o f her personality ( w h i c h is our priority) i fit ismatched with
a m a d political situation?'The supervisor m a d e these comments
well before h e k n e w m u c h about this patient.
I t is n o t u n c o m m o n f o r trainees t o find themselves i n serious
difficulties w h e n they t r y t o deal w i t h a conflict b e t w e e n their
h u m a n responses and t h etechnique and style that the supervisor
demands. These difficulties often result i n t h e trainees being
constantly upset, feeling persecuted b y t h e training institution,
losing confidence i n their abilities, o b t a i n i n g negative responses
f r o m t h e i r p a t i e n t s a n d n o t b e i n g able t o i n t e g r a t e - as t h e y
s h o u l d c o m m o n - s e n s e w i t h a m o r e s o p h i s t i c a t e d a n d clcaianalytic understanding o f the patient and events i n the therapeutic
relationship.

CHAPTER 13

Attachment Theory and

Group Psychotherapy
Theoretical aspects
G r o u p analysis a n d a t t a c h m e n t t h e o r y share s o m e essential
principles ( M a r r o n e 1 9 9 4 ) . S . H . F o u l k e s , f o u n d e r o f group analysis
i n B r i t a i n , s a w t h i s d i s c i p l i n e n o t o n l y as a m e t h o d o f t r e a t m e n t b u t
also as a n e v e r - e v o l v i n g t h e o r e t i c a l b o d y b a s e d o n t h e c o n f l u e n c e
o f psychoanalysis w i t h sociology a n d other disciplines. T h r o u g h o u t
its d e v e l o p m e n t , g r o u p analysis h a s defined a n d m a i n t a i n e d i t s
o w n theoretical and methodological identity.Yet, at the same time,
group analysis h a s created f o r itself a t e r r i t o r y w h i c h is capable o f
a c c o m m o d a t i n g a n d integrating a n interplay o f different perspectives
(Marrone and Fines 1990).
G r o u p analysis is based o nt h e n o t i o n t h a t t h e essence o f m a n
is s o c i a l , n o t i n d i v i d u a l . E a c h o n e o f u s o c c u p i e s a n o d a l p o i n t i n
a f a m i l y n e t w o r k a n d society. T h e great forces o f conscious a n d
unconscious psychological dynamics are transmitted through
groups and social n e t w o r k s a n d w e aredeeply i m p r i n t e d b y these
great forces, t h r o u g h t o o u r v e r y core. I n o t h e r w o r d s , t h e m a i n
c o n c e r n o f g r o u p analysis, as a t h e o r e t i c a l b o d y , i s t h e l o c a t i o n
o f psychic f u n c t i o n i n g i n a developmental a n d social context.
A s N i c o l a D i a m o n d ( 1 9 9 6 ) points out, group analysis n o t o n l y
represents a m o v e m e n t away f r o m one-person psychology t o a
m u l t i - p e r s o n psychology, b u t also contains, fixndamentally, a n
i n t e r p e r s o n a l c o n c e p t i o n o f t h e h u m a n b e i n g as a l w a y s s i t u a t e d i n
relations w i t h others.
F o u l k e s ( 1 9 9 0 ) said t h a t psychological processes a r e n o t
created b ythe individual i n isolation, purely i n accordance w i t h his