Three Associating: Adventures in Relational Psychoanalytic Supervision

In this episode, Andrew gives new meaning to Winnicott's idea of “playing with reality” as he tries to help his patient into a more social reality through the medium of play.  In the session, Andrew⁠ and Gill reflect together on the fact that in a long-term therapy both the patient and the therapist develop beyond where they started and that the match between them needs to be re-thought in the light of this. 

In the beginning of the supervision, Andrew⁠ finds himself making a division in his head between work and play but then comes to realise that while the play is the work, there nevertheless is still room to transform the mode of play. In this way, the possibility of thinking about elided topics such as sexuality opens up. In addition, there is an opening up to a more enlivened way of working in the transference. 

In this episode, Andrew deals with the poignancy of the premature death of his patient. His presenting problem in the supervision is whether or not he should go to the funeral. While this is indeed a dilemma to be reckoned with, as the session unfolds it becomes clear that there are many other issues and feelings that are masked by Andrew’s focus on the issue of the funeral.  

One of the issues Andrew is struggling with underneath the tangible funeral issue is allowing himself to feel both his sadness at the death of the patient as well as his own significance to her.  In the course of supervision, Andrew⁠ finds that he is caught in a dynamic that is familiar to him where it is easier for him to go to conflict than to go to more tender feelings. 

Andrew⁠ explores some of the unconscious ploys that he uses to avoid certain feelings and comes to acknowledge the Lacanian claim that feelings can lie.  Thus one feeling for example guilt can be used to cover over another for example mourning. This frees ⁠Andrew⁠⁠ to more thoughtfully approach the issue of whether or not to go to the funeral and to understand the deeper meaning of his dilemma. 

In this episode, Rachael takes on a number of important questions including when is it appropriate to bypass defences by uniting with the patient’s perspective and when to try to get under the defences and how to do this . Similarly, Rachael explores the question of when to push against resistance and when to work around  resistance or go to a third option of analysing the resistance. 

Rachael also comes up against the fact that her memory of the patient in a previous phase of therapy is affecting her ability to simply be present with the patient in the current moment.

Following Bion's dictum to try to be without memory or desire, Rachael is able to reappropriate the value of working in the transference-countertransference matrix as it is unfolding in the room. She is also able to share with the patient the load of reflection and thought by asking questions and directing the treatment rather than doing all the work herself.  

In this episode, Andrew encounters a patient whose stated objective is to own her own competence and self assuredness and to be more like him. Andrew anticipates encountering a people pleaser and is surprised when he encounters a lack of it. The patient stonewalls him in particular moments  She resists his attempts to move closer by masking her anger and collapsing into tears and shutting him down. 

In response, Andrew⁠ consciously carries her denied anger but denies his own unconscious envy of her freedom to collapse. This leads him to subtly undercut her anger while consciously intending to invite it. 

In this interplay of the patient’s and therapist’s joint unconscious denials, affect heightens and thought decreases. Through supervision, a better balance between feeling and thought is achieved and Andrew⁠⁠ moves forward taking ownership of his own envy in the gender wars. 

In this episode, Rachael gets tangled up in her own anger and hostility towards her patient on behalf of the patient’s daughter. While trying to distance herself from the patient's enmeshment with the daughter she inadvertently gets enmeshed herself in the patient’s dynamic. 

By more fully accessing her anger with the patient and realising that in her mind she has been treating the daughter rather than the patient, she is able to recenter herself more clearly with the patient in the room.

The importance of feeling into the therapy and not only thinking into the therapy is emphasised, with the end point of integrating both. Rachael⁠ must own her murderous rage towards the mother/patient and to reflect on its meaning and beyond that have the capacity to articulate it in a form which can be heard by the patient.  By the end of the session, Rachael⁠ is able to achieve this.

In this episode, Andrew struggles with the question of therapy terminable and interminable. He faces an ethical dilemma as to whether continuing therapy with a particular patient who has made considerable gains would be in some way unethical.

Andrew⁠ is thoughtful about the issue of fostering dependence which is an important issue to consider. However, he finds through supervision that he has unconsciously stepped into enacting the role of the patient's authoritarian father who imposed separations on the patient as a child.

Andrew⁠ comes to see he has engaged in a subtle power struggle and has unconsciously used psychoanalytic premises as an anti analytical third that blocks thought rather than facilitates it. Interestingly, Andrew⁠’s awareness of the enactments in therapy are discovered through a parallel process that emerges in the supervisory relational field.

In this episode, Rachael struggles with her own feelings about her therapy being cut across by a psychiatrist who seems to be opposed to long term therapy. 

She feels activated especially as the patient has asked her to intervene and contact the psychiatrist. 

In supervision, she engages with her frustration at the interference in her treatment and her therapeutic relationship and also her anger in relation to the zeitgeist that opposes in-depth therapy. 

Rachael⁠ recognises that in her activation she gets pulled into focusing more on the zeitgeist and less on the patient and is hooked by the emergence of her own sibling rivalry . 

These are not enacted with the patient but they interfere with Rachael⁠’s ability to think about the analytic meaning of the patient’s request. Through supervision, she is able to see that she is inadvertently being invited into a split and while activated is loosing the opportunity to explore the psychodynamic meaning of the patient’s request. Through this understanding she returns to her analytic position. 

In this episode, Andrew presents an unusual situation where a patient requires his partner to be present in his therapy not to work on couple dynamics, but as a benign observer. 

Andrew finds himself unable to resist this demand both because Andrew is ideologically opposed to imposing his will on the patient and because he can’t in the moment think why the patient’s preference should be resisted. 

Andrew consciously accepts the patient’s narrative that therapy should take place in the threesome but unconsciously resists it. This resistance manifests in an insistent thought that the therapy will be short term. 

In supervision, he realises that the thought is a wish covering over his frustration at being manoeuvred into working in a way that is restrictive and recognises that he is in the presence of a merger.  

Andrew comes to see this merger as less sweet and more problematic than he had thought and he determines to use his frustration to challenge the merger and negotiate a different therapeutic frame. 

In this episode, Rachael struggles with her impulse to be castrating when she encounters what she experiences as an impenetrable patient, a Citadel.  She is irked by the patient constantly batting away her interventions and seemingly needing to know better than her.

In this episode, she and Gill discuss a stinging intervention that Rachael made. The problem was less the intervention itself than Rachael’s  desire to cut the patient down, a desire she recognised and asked for help to resist.  Through supervision Rachael was able to be more in touch with the patient’s vulnerability and developmental age and to move past the power struggle the patient evoked and to think about how to engage his vulnerability. 

In this episode, Rachael plumbs the mysteries of the erotic, both in the transference and the countertransference; mysterious because it occurs in liminal or transitional space as Winnicott would say. It is a space of illusion and disillusion where it is not clear what belongs to who. Both Rachael and her patient playfully enjoy the experience, while both in their own way bring in a third to dilute the experience. Rachael becomes aware of her own loss in this and is able both to observe and experience it while also observing and experiencing her patient's change. Together with Gill, the associators conclude that sometimes it is better to settle the waters by not stirring them. The erotic is often beyond words, and thus leaving the erotic known but unarticulated is, in this instance, a good option.