Thérèse – first I want to welcome you back to Ireland Patrick, and to say how great it is to have this opportunity for a conversation with you. Without any real agenda, maybe I can begin by just asking about the direction your work is taking. I understand you’re no longer taking on patients…
Patrick – I stopped seeing patients altogether when I was seventy, five years ago. I gave three years notice to all my patients because I didn’t want to die in harness, and even more I didn’t want to go on working for years after I died like some of my colleagues.
Thérèse – can you say more about this?
Patrick – well, I met an ex-supervisee in Waitrose, aged about eighty-seven, and she couldn’t remember who I was even though she’d been to me for supervision. After I reminded her of who I was and that she did know me, she said; oh yes, of course. I’m glad I met you as I’m still taking patients so please refer…’ And I think some people carry on much too long – as an alternative to a pension plan…
Thérèse – so was it always your plan to finish seeing patients when you turned seventy?
Patrick – yes, I planned to finish at seventy, largely in order to have the freedom to travel and not be tied to fixed holiday times. My wife had put up with that for forty plus years. We have grandchildren in Australia, so now we can just jump on a plane and go. I still do some supervision on the understanding that it’s when I am in London and available; and when I’m not, I’m not – and it doesn’t have the same structure as would be there if I was seeing patients.
Thérèse – staying with supervision, what are some of your thoughts around the role of the supervisor?
Patrick – I think the supervisor has a particular function in being somebody who hopefully believes in their supervisee as a therapist to their patient, rather than behaving as if the therapist is not competent – but with a lot of nagging might become competent, which is undermining rather than supporting. There needs to be what I call a supervisory triad; a supervisor helping to ‘hold’ the therapist who is ‘holding’ the patient. This notion is really a parallel to the notion I attribute to Winnicott (even though I can’t actually find it in Winnicott) – the nursing triad, where the mother needs to be supported by somebody who believes in her as mother; not by somebody who offers themselves as a better mother, which is always undermining.
Thérèse – I’m curious as to what your response might be should you find yourself wondering about the competency of a supervisee, or about their competency around a particular aspect of their therapeutic work?
Patrick – if I do hear that something personal might be getting in the way of the work, I would never allow myself to wear the therapist’s hat with a supervisee. I might confront. I might say I think there is something personal here and I think you might need to do some homework on it, maybe with your therapist or someone but not with me. I also ask the question, who is putting what into the analytic space, and if it is something from the therapist that does not come in response to something already brought by the patient, then that could be a sign that there is something being brought into the space that doesn’t necessarily belong to the patient, and could be imposed on the patient by the therapist. But I know that I am not exactly answering your question about competence.
If a therapist brings in something from outside a current session, this can often hijack the session so that it then goes around what the therapist has brought in, but I think it can deflect the analytic process – the process that belongs to the patient rather than one that is influenced by the therapist. The same is true if therapists bring in something from their own experience. I don’t think a use of one’s own experience directly with a patient is advisable. One can draw on it. One can make some general comment perhaps, that sometimes people experience something in a particular way, rather than say how I might experience it. That, in effect, invites a patient to become curious about the therapist, which I think is counter-productive.
With a supervisee I think the boundary is a bit different. In supervision I do sometimes draw upon my own experience, as I don’t personally see the supervision process as a direct parallel to the therapeutic process. I don’t see myself behaving as a model to the supervisee – as I would be with a patient – because I am not with a patient; I’m with a supervisee. So sometimes I will allow myself to free associate to something the supervisee has brought – in a way that I wouldn’t with a patient. For instance, yesterday I was supervising somebody and I said, the problem with your patient brings to mind something I encountered with a patient of mine, and I gave an example which threw some light on the supervisee’s case. This turned out to have been useful because the example illustrated it so vividly. So I think, with a supervisee, there is a place for some careful use of one’s own experience.
Thérèse – there have been times as a supervisor, I find myself offering what I can only really describe as an educative piece to the supervisee and I’m curious about what you think of the idea of supervision as, in part, an educative space?
Patrick – I think that a lot of my work with supervisees could be regarded as educative in that, a lot of the time I am practising with clinical moments, when a clinical moment is being presented and it could have been handled differently. Now there is no value in saying, I think you should have said such and such because that moment is gone and it just makes the supervisee feel bad. On the other hand, I might take a moment to say; I think it’s useful to practice with this for another time, because you will have a patient presenting something like this and so, if you respond the way you did here, we could consider how the patient might experience that, perhaps not in the way you intended. If we practice here we might find other ways of handling it.
For instance, in the area of reassurance, a very useful teaching example that I have used is trying to work with a client or patient who is in black despair, and trying to help the client or patient feel better by saying something like, I do promise you that there is light at the end of the tunnel. Now if we listen to that from the patient’s point of view it’s very clear to the patient where the therapist is and where the therapist is not; the therapist is not in the tunnel, in the blackness with the patient. The therapist is in the light and saying, it’s nice out here, why don’t you join me? That is of very little use – if anything – to the client or patient. It just underlines how distant the therapist is from being alongside the patient.
Thérèse – I hear something about tolerance and the capacity of a therapist to be with what may feel intolerable for their client, and to journey alongside them through this.
Patrick – this is certainly part of what I am saying and I’m also trying to consider something that I find to be a useful way of thinking about trauma – as that which cannot be borne alone – because it helps us to find a function alongside the person who has been in trauma. Because, if we can make anything different at all it’s by being with them, alongside them as they engage further with their trauma, so that they’re not now so alone with it.
If a patient is in pain and we’re not also in pain, then we are defending ourselves. It’s to do with surviving the worst in a patient, but there are two very different ways of surviving it. One is leaning back in one’s chair and pontificating about what the patient is going through, and we’re then light years away from the patient. We’re protected from the pain and, of course, we can go on functioning – thinking we’re being clever but we’re not being useful. So when I’m with a patient who is in pain, emotionally if not literally, my position is to be on the edge of my chair. And when it’s the blackest of times, the only thing that has actually helped at times like that, with a number of patients I can think of, is when I share my sense that there is nothing that I can do or say to change this. The only thing I can offer is to be alongside you in this, for however long. When I’ve found a moment where that’s been true and I’ve said it, it’s actually changed things for a patient.
I also want to say a word or two about tears. I mention this in my last book, Learning from Life – in the chapter on Mourning and Failure to Mourn – where I was with somebody who had lost a baby as a result of having a test to see if the baby was alright; a test because of her age. The test was fine but the baby died because of it. She was in the most acute and relentless pain, and she needed to just pour out her pain in unbearable crying. She couldn’t use the couch. She needed to be on a chair. And I was sitting on the edge of my chair just watching her, being with her; not able to say anything meaningful, just sometimes making a sort of, I’m still with you sort of noise. And in the third of these sessions it was so painful that I realised that tears were forming in my eyes. But I believe that we need to be able to contain our difficult feelings in a session so that they do not intrude upon a patient. The place to process that is outside the session. We therefore need to contain it as well as we can inside a session. So I didn’t risk drawing attention to the tears forming in my eyes, as by wiping a tear away, because I didn’t want to deflect from her own pain by bringing attention to my crying. I just let what was happening happen, and at the end I said to her what I’ve already indicated, I know there’s nothing I can say that could change any of this, or make any of it feel any better, but I can still offer to be with you in this. And she said; you don’t need to say anything; your face has said it all.
So, I think it’s not inappropriate for a patient to be aware of the fact that we are sometimes in difficulties alongside their difficulties, but they need to have a sense that we are able to bear it. If we indicate anything that could be read as us not been able to bear it, then they will feel somehow that their distress could be too much even for the therapist. So it’s a difficult balance.
If we are engaging with something that is extremely difficult for a patient, I’d expect it to be difficult for me. And I know that if it’s not being difficult for me, then I would have to ask myself, why am I keeping myself at a distance from this?
Thérèse – that’s clear and so I guess a balance can be drawn from our experience and our ability to attune to the quality of the resonance, holding and responding appropriately.
Patrick – if I give a brief example, somebody who had been very seriously traumatised and abandoned by what happened in his childhood when he was two, and he was very much locked into his head. He had never cried in any session. The childhood problems were talked about but never re-experienced, that I could see. We came to the third long summer break and I made some cliché sounding interpretation about it being difficult, and he responded with absolute scorn – saying, well of course, analysts always say that. So I felt jogged into re-thinking. I then said to him, I’m glad you challenged me because it’s helped me to realise that if I listen to this from the point of view of the two year old in you, I think the two year old could feel that if I really understood what my going away could mean to that child, I would not be able to go away. And, for the first time, he cried. Now, I wasn’t offering to not go away, I was trying to get across some sense of being in touch with the quality of this absence for the two year old and at that moment, he felt that I had.
Thérèse – as you’re talking at different times Patrick I can see the tears form in your eyes and can clearly hear the emotion in your voice…
Patrick – well there are several reasons for that. One, as I said earlier, is that the place for processing the most difficult clinical experiences is not in the room with a patient but afterwards. I now find that when I’m talking about these things I’m still processing what I was having to contain at the time. So that’s the first thing. The other is that I don’t think it’s always to do with painful things that I might find tears in my eyes, because actually one of the things that really moves me is the relief of finding that something has become possible that might never have been possible. So it’s like tears of joy.
I think another kind of tears, which we sometimes meet in a patient and don’t always understand, that I have described in my last book, is from the time when I came across what I now call the pain of contrast. In what had seemed to be a perfectly normal session, my patient suddenly started crying, and very deeply crying, and I couldn’t think what had brought this about. It took a long time before she could say anything; and when she could speak she just said, it’s your voice. I thought how strange is my voice that it makes her cry like this? After more crying she eventually managed to say, your voice is kind. She had bumped into a realisation that she couldn’t recall a single time in her childhood when either her mother or father had ever spoken to her with kindness. So she didn’t know what it was like. And then, suddenly experiencing it for a first time, she was flooded with an awareness of what she’d missed that she’d never had.
Thérèse – I’m reminded of what is often referred to as a missing experience and the joy and pain that can be felt in the experiencing of something, perhaps for the first time.
If it’s okay I’d like to change tac a little and ask you something about your own journey and the move from psychotherapy to psychoanalysis. I know that my approach to this work reflects something of my own process, my journey and my way of being in the world. I’m curious about the move you made and how you might describe the qualitative difference between therapy and analysis for you.
Patrick – I find it very difficult to be meaningful in describing the difference because I don’t think it’s just a matter of frequency. I think that with the analytic training, where there is an insistence upon the frequency of sessions, we have the opportunity to discover the potential of psychoanalysis maybe in its truest/fullest sense. But I don’t think that it’s only with frequency that that’s possible. I think that if one has had the experience of being able to recognise what’s around at depth, and to work with it at depth, we can do that sort of work with somebody who is not coming as frequently; and I’ve done some seriously important depth work with patients who have only come once a week. But I don’t think I would have been able to do that had I only ever worked infrequently. It’s drawing on my experience of working at depth that allowed me to be able to work at depth with people who could come only once or twice.
Thérèse – maybe it’s not so much about difference, maybe it’s more about the quality of and our capacity for being with our clients.
Patrick – well I also want to keep alive a realisation that a good analysis does not end when the patient stops going to the analyst. I think a good analysis is when the analytic process has been sufficiently started and established, for that process to continue way beyond the end of the analysis. So I think that if we can get into that inner process, keeping it alive and drawing on it, we may often find that we get far beyond where we had got to in our own analysis. It’s not limited by what we actually achieved with the analyst. John Klauber used to say, it takes at least ten years for an analyst to become an analyst after they have finished training; and my version of that is, it takes a lot of people ten years to recover from their training.
For instance, a very well established analyst from Europe sometimes comes to me for consultation, and on one occasion he was speaking about a patient who had come for analysis four times a week throughout his third year of analysis but for the last six months had not spoken a word. I got the feeling that the analyst felt somehow obliged to wait for the patient to speak first, as learned in his training, and I just simply put it to him that even though I believe in letting the patient begin the session, in whatever way the patient begins – and sometimes they start with silence – sometimes there is communication in the silence. So, if we sense some of that non-verbal communication, I think it’s right to have a shot at indicating something of what we’re picking up. At least then the patient has a sense of being with someone who can work beyond words, rather than only with words. Once I got this across to this quite senior analyst, who I was surprised hadn’t recognised this for himself, within three days the patient was talking. So in that sense, this was someone who had not yet recovered from his training.
Thérèse – I’m reminded of my own analysis and the part silence played in this, remembering the times when my analyst would offer something and my felt sense of when this was spot on or when it felt that it was more about her anxiety or intolerance to remain with me in the communication of the silence.
Patrick – I had a patient who recently said to me that sometimes she felt I tried too hard to understand, and then she came for a session that was totally in silence and it felt that I should respect it and not risk spoiling it by speaking. I simply said at the end of the session that what had helped me to stay silent was what she’d said previously about me trying too hard to understand. The next day she came for another session which was fifty minutes of total silence, and I didn’t need to explain where I was. And the day after that she was profoundly grateful because she felt that I had allowed her the first experience she could remember of actually being free to be herself, rather than always trying to fit in with the other person. So she felt she had a real experience of being rather than just trying to please. I think that only worked because it was based on an understanding from the patient that allowed me to listen to the silence in that way, rather than thinking it might be a good thing to do.
Thérèse – earlier you spoke about re-experiencing and I felt a response that I recognise is attached to the idea of re-experiencing trauma in therapy and how this can sometimes translate into a client feeling re-traumatised. It seems to me that we have a responsibility to our clients to understand the complexity of this re-experiencing something in the present that may have its origins in the past.
Patrick – I’m using the word re-experiencing because of an ambiguous meaning in that word. Winnicott in his wonderful and very brief paper called Fear of Breakdown talks about people who have experienced trauma at such an early age that the mind could not engage with it and survive; the infant mind had detached itself from the experience as if it hadn’t happened. So in one sense it’s happened but, in another, the mind has not engaged with the experience of it. And the unconscious hope seems to be that the time will come when there is better holding around, and the mind is more mature, when it might just be possible, with help, to unfreeze the experience and to engage with it in a way that feels almost like for the first time; a first time of fully experiencing it.
Now, with my burned patient (described in my first book), a lot of people felt that I should have limited her to talking about the early trauma whereas she actually got into re-experiencing it. A key part of her experience of it with me was around the mother, who had been holding her hand when the surgeon had been cutting around her burn scars when she was seventeen months. The mother had been holding her hand, until she fainted because she couldn’t bear being reminded. So, the infant was left with this man with a knife doing something to her that she felt might kill her, and totally terrified by it, and full of dependent need for her mother and rage at mother for not being there; and yet feeling that somehow her neediness might have killed her mother.
When this patient got to this point in her analysis, when she began to experience me as the surgeon, the most obvious intuitive response (from me) was when she pleaded with me that, if it ever got that bad again, would I hold her hand? I naturally agreed. It just seemed like the only human thing I could do. But it soon became more and more clear that she immediately began to experience my agreement to this as my confirming her worst fears, that nobody could bear to stay around with the intensity of feelings that were around at that time. I then knew that, if I kept my promise (to hold her hand if it ever got so bad again), then we could always keep the worst of that experience out of the room, leaving it with the mother and not actually have it in the room with me. So, I felt I had to withdraw that offer. Inevitably, in her mind, I then became the fainted mother who wasn’t holding her hand; and she raged at me for many, many months, because of that perception of me. But she then came across the extraordinary discovery that, even with all her rage focussed onto me, I was still there; and she had always assumed that the other person would collapse or die if she ever became that needy of them, or that angry with them, and I hadn’t.
This is what Winnicott means about the important and complex idea of the survival of the object. The object is destroyed in the mind but in reality is found to have survived being destroyed. So, in her mind, she was killing me all that time and yet she came across the reality that I hadn’t been destroyed by it. This transformed, for her, her lifelong dread of her own neediness and dependence, her anger and intense feelings. All of that became possible for her to engage with, and to be alive with, rather than feeling that she had to be forever protecting the other person from all of that. She had always felt she had to. Now if I had done the corrective emotional experience thing, by offering to be the better mother – continuing to hold her hand, we would not have got into any of that and it would not have helped her.
Thérèse – so staying in the gap and creating the containment and safety necessary for what could be described as a negative transference to unfold.
In your work Patrick, I’m wondering where in analysis you feel there is the space for the physical imprints, the sensate memories or the echo’s that are so implicit in both traumatic wounding and developmental wounding.
Patrick – okay, now interestingly, some psychologists have been very critical of me and they have attacked my work with the burned patient on the basis that, at the time of the burning – when she was eleven months, they claim the mind had not developed enough of a capacity for memory to be able to recall the experience; but I’m absolutely certain that there is something else, which I call body memory. Because this burned baby had the pain of having been burned, today and the next day, and the next day after that, and the week after and the month after that, and so on. This would have been imprinted deeply into her mind. She didn’t need somebody to remember it for her; her body was remembering it for her until she was old enough to draw on her own re-collected memory of that.
Now what was so interesting, which I go into in my third book (Learning from our Mistakes) when I revisit my work with that burned patient. What neither of us knew at the time was what lay behind that focus on the moment when the mother had fainted, when the patient was seventeen months. All the time, it has seemed as if it had been simply that moment of not being held that she had been raging about. But when the patient realised she had really recovered from that trauma, and had become alive in herself, she wanted to re-negotiate her relationship with her mother to celebrate her recovery. Her mother (until then) had never recovered from this, still blaming herself. So the patient described this to her, and had told her that the most amazing thing of all, which had also helped her most, was that her analyst had found the courage to go through the surgical experience with her – without holding her hand; so all the rage was there for somebody not holding her. She described to her mother that long period of the analysis. And, during so much of that (though she did not know it then) I had been struggling with myself thinking, am I causing her more pain than I should, more pain than she can bear; maybe I’ve made a mistake, maybe I should bring it to a halt. But something made me not do that. Many times I had struggled with myself over that.
The mother had then said to my patient, but there is another “not holding” that you don’t remember. This had happened in wartime Europe and there was no hospital able to offer sufficient sterility for a baby that badly burned. Also there were no antibiotics then or pain relief for a baby of that age. The doctor had therefore said to the mother, the only chance of saving your baby’s life is if you (the mother) barrier nurse her, which means sterile gloves, sterile instruments, and you must only handle her in a totally sterile environment. Also, the one thing you must never do is to give into your instinct to pick up your crying baby, to make her better, because that would infect her and she would then inevitably die. So, without knowing it at the time. what had been in the room between my patient and me was that endless experience of not being held, with a mother person wanting to do whatever would seem necessary and, of course, wanting to hold the patient to make her feel better.
But something had held me back from doing that, and it was such a vivid example of what Freud called a screen memory. She had been working at the not being held at the level her mind could engage with, whilst in the room – between us – had also been this timeless experience of not being held, plus this tension between her being in such distress and me as a mother person struggling not to infect her. So, if I had given into this impulse to hold her, to relieve her of the most immediate pain, it would have simply confirmed forever her belief that, sooner or later, her distress would be too much for the other person, and she would have to go back forever to the habit of self-holding and protecting the other person.
Thérèse – what was it like for you when you heard about this missing piece because as therapists we don’t often get to hear what may only come into the light post therapy.
Patrick – utterly amazing, it was such a confirmation of everything we had been through. Both she and I suddenly knew that was what had been in the room between us even though we couldn’t actually name it.
Thérèse – this seems to me to be a wonderful example of the not knowing, when we trust what may be a felt sense of what we do not know!
Patrick – quite extraordinary and relief; again the tears of relief. It was such an extraordinary experience.
Thérèse – your passion is clear and I’m wondering have you always felt this, have you always felt the passion and compassion within you that feels so real and alive even in this moment?
Patrick – it’s not so real, it is real. And I know where some of it comes from because, although I don’t spell it out fully in my last book, I do touch on it in the first chapter. I was a child who was frozen off from all feeling. I then couldn’t think why children were crying at the boarding school. What were they crying about? Missing home? What was there to miss? I had somehow insulated myself from that attachment and it was only much later that, with the help of my analyst, I discovered why I had once, all of a sudden, collapsed in profoundly deep crying. I won’t go into this here but I describe that in the first chapter of Learning from Life.
So of course I had and have a passion for my work. I think I was very fortunate in being with the analyst I was with, because he was not a man of many words and a lot of the communication was beyond words. I have since found myself working with patients far more intuitively than I otherwise might have done, not relying very much, if at all, on the models that have been around that we can imitate; the way to interpret; the good interpretation, all those things. I much rather struggle to find words, however inarticulate they may be at the time, but struggling to engage with something, trying to understand it with a patient – to try and finds words for it. I think a lot of patients feel there is something more genuine in that struggle, rather than being with somebody who says, oh of course what’s happening here is… and out comes another cliché.
Thérèse – it’s good to hear you speak about working more intuitively and I guess for me a great deal of what I believe engages the unconscious is beyond words; where using integrative bodywork and the choreography of movement the emerging experience for a client is supported, processed and integrated at the physical, emotional and cognitive realms and there is a sense of moving through or sequencing through, layer after layer.
Patrick – I have great respect for that work. I don’t have that skill but I can see the value in it, and we get to where we need to get to with patients by different routes; whatever is most true for you with a patient or whatever is most true for me with a patient. I think it’s being true for the therapist is more important than having the idea that there is one model that is better than another.
Thérèse – I value the integrity of your response and feel how respectful this is. You’ve written about your experience with, I think, your first therapist and how in that therapeutic relationship you felt blocked (my words) in getting to experience your own feelings of anger because your therapist herself had unresolved issues (again, my words) with anger.
Patrick – I could never be angry with her. She so needed, for her own reasons, to be appreciated; needed to be thought well of so that her need there was blocking off whatever, in me, needed to come into the work with her. And I went to her as a failed suicide. If somebody is so angry that they try to kill themselves, there is always anger around; and why has it been turned against the self, and why can nobody engage with it? I therefore had a therapist who, for seven years, clearly couldn’t engage with my anger. This just confirmed my worst fears of what anger could do. So, I had to find somebody who wasn’t going to be afraid of my anger.
And because of my time with her, my first patients were all seeming to get better but all, I felt, for the wrong reasons; getting better to please me, thinking I was a nice person and being so helpful, and all that sort of stuff. But there wasn’t room with me as I was then, for them to bring what might be described as a negative transference; to use me to represent the worst in their lives, rather than have somebody who seemed to be better than those people by whom they felt they had been most let down.
I’m not now seeing patients but there are two exceptions. I now see just two people that I do not regard as patients, who come to see me for consultation. The first person, who is in his late seventies, had a history of seeing therapists or analysts for almost all of his life, which hadn’t done much good; and yet he wanted to have another go at it. However, I felt it might be the worst thing I could do, to refer him to another one of these people because they might take him into analysis or therapy. I’d already made it clear that I wasn’t taking patients, so what could we do? I said; I’m not going to think of you as a patient. You’ve had enough analysis. Instead, I think you now need to discover that you can get along without seeing a therapist or an analyst. So, if you like, you can come to see me from time to time to tell me how you’re getting on without one of those. He does this and he’s getting on much better. There’s one other person I see on a similar basis, and I think of myself as supervising these two people in relation to their own analysis, rather than have me doing it.
Thérèse – and finally, your books, workshops, seminars etc. have the potential to influence and impact on the lives of many others, most of whom you may never actually meet and I’m curious about how you keep it real for yourself?
Patrick – So, how do I stay real, having discovered that it’s possible to become real? Well I would rather die than lose that realness, and I think it may have influenced me away from taking my work to clinical seminars where I feared there might be too much interference in my work, from people who work differently. Yes, I could always learn from other people’s ways of working, but I have become very protective of a way of working with patients: learning from patients. That has taught me almost everything I know, and I just didn’t want to have that process interfered with by too much preconception coming at me from other people.
One thing I also try to remember to say at any teaching day, because I know that I could sometimes have a more powerful influence on others than I intend, is; please don’t do anything differently next week just because of what you’ve heard from me. That would not be using your own thinking. It would be using somebody else’s thinking. If, however, you find something from me that seems to be of value to you, you’ll come across it again later – sometime when you’ve had time to digest it.
Thérèse – thanks Patrick, it’s been lovely having this time and opportunity to speak with you.
Patrick – okay and thank you. I also wish to say that I like your journal’s title – Inside Out – because one of the things I’ve most been able to celebrate in my last forty-five years is being able to let out what had before been so locked in.
Patrick Casement obtained his degree at Cambridge University, in Anthropology and Theology. He then trained to become a social worker, subsequently training as an analytical psychotherapist and then as a psychoanalyst. Until he retired he was a training and supervising analyst of the British Psychoanalytical Society. His first book On Learning from the Patient, published in 1985, became an international best seller in the field of psychoanalysis, now in over twenty languages. A later book, Learning from Our Mistakes, published in 2002 was awarded a Gradiva Award in America for its contribution to psychoanalysis. His last book Learning from Life: becoming a psychoanalyst (2006) is partly autobiographical – an unusual step for an analyst but one he feels able to take now that he is retired.