Alessandra Lemma

Introduction to the practice of psychoanalytic psychotherapy

About the Author. Preface. Acknowledgements. Introduction: Psychoanalysis in the Twenty-First Century. 1. An Overview of the Schools of Psychoanalysis: Theory and Practice. 2. The Process of Psychic Change. 3. The Analytic Frame and the Analytic Attitude. 4. Assessment and Formulation. 5. Unconscious Communication. 6. Defences and Resistance. 7. Transference and Countertransference. 8. Working with Endings. References. Index.

A mentalization-based approach to the understanding and treatment of functional somatic disorders

Patients with functional somatic disorders (FSD) represent a sizeable group in our health care system. FSD are associated with high health care use and considerable personal and economic costs. Evidence-based treatments for FSD are only modestly effective in a large subgroup of patients, particularly in the long run, which emphasizes the need to develop more effective treatments rooted in extant knowledge about the nature of FSD. This paper presents a contemporary psychodynamic perspective on the conceptualization and treatment of patients with FSD rooted in attachment and mentalization theory. First, we review animal and human research demonstrating the close relationships among attachment, stress regulation, and immune and pain-regulating systems. We highlight research findings concerning the high interpersonal and metabolic costs associated with the use of insecure secondary attachment strategies (i.e. attachment deactivating and hyperactivating strategies) leading to increased vulnerability for stress. Next, we review evidence for the role of impairments in (embodied) mentalization in patients with FSD both as cause and consequence of functional somatic complaints, leading to the re-emergence of so-called non-mentalizing modes, i.e. modes of subjectivity that antedate the capacity for full mentalizing. Based on these views, a novel brief psychodynamic intervention for patients with functional somatic complaints is presented.

The Development of a Brief Psychodynamic Intervention (Dynamic Interpersonal Therapy) and Its Application to Depression: A Pilot Study

This paper describes a protocol for a brief psychodynamic intervention (Dynamic Interpersonal Therapy; DIT) for use with depressed patients and a pilot study set out to test its acceptability and compatibility with session-by-session monitoring as a prelude to a future randomized controlled trial. Sixteen consecutively referred, depressed patients (aged 20-53) were offered 16 sessions of DIT. Patient outcomes were collected pre-post, and on a session-by-session basis, using the PHQ-9 and GAD-7. Therapist and supervision feedback indicates that this structured psychodynamic treatment could be effectively taught, and that the key competences involved were acquired and demonstrated in the clinical work supervised. Patients found the treatment acceptable and relevant to their problems. The treatment appeared compatible with session-by-session monitoring of symptoms of anxiety and depression. DIT was associated with a significant reduction in reported symptoms in all but one case, to below clinical levels in 70% of the patients. Random regression models revealed highly significant linear and quadratic components, confirming the decrease in reported symptom severity but cautioning about slight increase in symptoms around the ending phase of the treatment. The results suggest that DIT is promising in its acceptability and effectiveness with an unselected group of primary care patients, and is easily acquired by psychodynamically trained clinicians.

The development of a brief psychodynamic protocol for depression: Dynamic interpersonal therapy (DIT)

This paper outlines the development of a manualized, brief (16-session) psychodynamic intervention – Dynamic Interpersonal Therapy (DIT) 1 – for the treatment of depression. DIT is based on a distillation of the evidence-based brief psychoanalytic/psychodynamic treatments pooled together from manualized approaches that were reviewed as part of the competence framework for psychological therapies first commissioned by Skills for Health. DIT has now been selected as the brief psychodynamic protocol that will be provided nationally in the UK as part of the IAPT programme. This paper will first describe the methodology underpinning the competence framework followed by an overview of the model, its relevance to depression, and finally its strategies and techniques.

The Power of Relationship: A study of key working as an intervention with traumatised young people

This paper explores the role of the key working relationship in helping traumatised and characteristically hard-to-reach young people. A grounded theory approach was used to analyse data from 18 semi-structured interviews carried out with both key workers and young users in a community-based, innovative project in Inner London, Kids Company. The following four codes emerged: titrating intimacy, the power of relationship, the therapeutic function of hope and ‘knowing your own ghosts’. As well as supporting the important therapeutic function of the key working relationship, this paper draws on the analysis of the data to outline a three-phase model of intervention (fostering place attachment–homeostatic attunement–disruptive attunement) when working with traumatised and often hard-to-reach young people.

An order of pure decision: growing up in a virtual world and the adolescent's experience of being-in-a-body.

Technological advances and the dominant values of contemporary culture make it possible and acceptable to alter, extend, or altogether bypass the body and its functions in actuality and in virtual space. This has contributed to a split between the body and the self, leading to a disembodied subjectivity that may encourage a neglect of the body’s unconscious meaning for the individual. Due to the psychic requirement during adolescence to accommodate the reality of the changing body, some vulnerable adolescents are especially primed for the seductions of virtual space—a “space” that is nowadays not only culturally sanctioned, but also idealized. The use of cyberspace can become a psychic refuge from the challenge of integrating the reality and meaning of the sexual body into the image of the self. Two case examples illustrate how for some vulnerable adolescents it is through the use of cyberspace that confusion about the real body can be denied or disavowed; for them the integrity of the self is sustained through pseudorepresentations of the body defensively experienced in terms of “play” rather than pathology.

The perversion of loss : psychoanalytic perspectives on trauma

The authors identify trauma as a life threatening experience (either actual or perceived) which impacts powerfully on the mind. This impact is specific and particular to each individual reflecting how people give meaning to their life experiences. The authors emphasise how human responses are shaped by both external and internal realities and that both internal psychic realities as well as external events contribute to a trauma. They pay particular attention to how trauma often fosters convictions, conscious or unconscious, about malignant agents or persecutors who are responsible for their suffering. They focus on four themes which they see as central to understanding trauma responses: trauma as an attack on attachment relations; trauma as a perversion of mourning or loss; the impact of trauma on identifications and the breakdown of symbolic functioning consequent to trauma.

The body one has and the body one is: Understanding the transsexual’s need to be seen

The transsexual individual confronts the analyst with a disturbing otherness. How this otherness is understood, that is, how the analyst ‘looks’ at the patient through her distinctive theoretical lens impacts, in turn, on the patient’s experience and what transpires between them. In this paper the author outlines a developmental model rooted in attachment and object relations theory to provide one alternative way of ‘looking’ at some of these patients’ experiences in the clinical setting. It is suggested that in some cases of transsexuality the primary object(s) did not mirror and contain an early experience of incongruity between the given body and the subjective experience of gender: it remains unmentalized and disrupts self‐coherence leading to the pursuit of surgery that is anticipated to ‘guarantee’ relief from the incongruity. Through an account of work with a male to female (MtF) transsexual who underwent surgery during her five years of psychotherapy, the author explores how a focus on the transsexual’s experience of ‘being seen’, that is, of being taken in (or not) visually and mentally by the object in their state of incongruity, affords another window through which to approach the transsexual’s experience in the transference–countertransference dynamics.

Does psychoanalysis have a valuable place in modern mental health services? Yes

Peter Fonagy and Alessandra Lemma say that the psychoanalytical approach can provide a useful and unique contribution to modern healthcare (doi:10.1136/bmj.e1211), but Paul Salkovskis and Lewis Wolpert argue that it may have no place there at all

The many faces of lying

In this paper the author explores the psychic functions of lying and draws on Glassers (1979) notions of self‐preservative and sadistic violence to identify three selfobject configurations. Each of these is associated with specific anxieties to which the lie offers an apparent solution. The first configuration is sadistic lying. Here the intent is to attack and triumph over the duped other. The lie allows the object to be controlled and humiliated. This gratifies the self by reversing an earlier humiliation. The second and third configurations are both forms of self‐preservative lying, where the lie may be best conceived as a symptom of hope (Winnicott, 1985). In the second configuration, the object is felt to be unavailable or inscrutable. The lie may be used to create an attractive self that will elicit the objects love, admiration and concern. In this way, the lie serves to eliminate doubt about the objects intentions towards the self. In the third configuration, the object is felt to be intrusive, and the dyadic relationship is overpowering. Here the lie can represent an attempt to insert a third into the relationship.