Book Review
 – “On learning from the Patient” – Patrick Casement

ISBN 0 415 02553 2 Price £9.50

It can be no accident that the title of Casement’s book echoes the dedication of D W Winnicott’s Playing and Reality, “To my patients who have paid to teach me”, since he uses the work of the older therapist so frankly to inspire the main thesis of his work. Having however acknowledged the dangers of trying to emulate the thera peutic styles of “genius analysts such as Freud and Winnicott who learned naturally how to learn from their patients” (pxii) Casement goes on to suggest an outline for an ”internal supervisor” which a therapist could cultivate within himself, whose specific role would be to make “trial identifications” with the client or patient. In this way the therapist would remain open to “learning from the patient”. For most of the book, Casement expounds this idea, giving lucid examples both from his own practice and from his work as a supervisor. The process brings him gradually closer and closer to a number of key concepts from Winnicott’s work, such as “containment” and “analytical holding” which he notes clearly and he also includes an appendix of vital quotations from both Winnicott and Bion.

I found Casement’s approach strikingly honest and fresh. The open acknowledge ment of his fears, the exposure of his own mistakes in practice and the way in which he tells us exactly how his patients have communicated the mistakes back to him make this an unusually enjoyable book on analytical practice. There are inevitably places where therapists of other persuasions may feel frustrated with the analytical phraseology; for example, Casement displays an almost dogmatic dread of “counter- transference” even while he is in a sense discovering a whole lot of positive aspects of similar unconscious responses from the therapist. But on the whole his work is free of jargon and mere complicatedness. He seems almost to have inherited some of Winnicott’s directness.

The central theme of the book, the therapist’s “internal supervisor”, raises issues about the therapist’s process during sessions and this is rather an unusual undertak ing. Casement speaks of “feeling rebuked” by a patient or of “receiving confirmation of (his) interpretation”. Evidently there is no guarantee that the “internal supervisor” will always be right, but the very decision to allow this extra commentary within the session seems to enable him to hear his patients more thoroughly. For instance it is the “internal supervisor” who often notes body-language and facial expression:

Internal supervision : What was most striking during the telling of this terri ble sequence of pain and loss was that Mrs T’s face remained wooden and lifeless.” (P79)

By acknowledging the ways in which the patients’ communications affect him, Casement gains insight into their defences, projections and so on and he demon strates how these insights can help the therapist to make himself appropriately available to the patient in the therapy. Thus, continuing from the case I quote above, Casement realises that this woman is generating in him the tears she cannot shed herself (“projective identification”) and so he is able to act appropriately:

I felt sure that, if Mrs T could be helped to be in touch with her own cry ing….she would not need her body to continue to be in pain. The subsequent course of her brief therapy fully confirmed this diagnostic impression. As she became able to bear to be in touch with the previously repressed psychic pain, her gynaecological pains began to fade away.” (P80)

Throughout the book, Casement is meticulous in maintaining the theoretical basis for his ideas. Yet I feel that the major value of the book for me lay not so much in the theoretical as in the practical area. Time after time, it is his examples which make the clearest sense. I suspect that he would not object to my view – even on the vexatious and complicated issue of the counter-transference, he takes a pragmatic stand:

It is a sound principle that counter-transference should not intrude upon the analytic process: but this should not deter us from using our resonance to the patient to aid our further listening.” (P99)

My own “internal supervisor” noted with appreciation the shift from the imper sonal to the personal within that sentence.

The special quality of this book stems from Casement’s own integrity as an analyst which comes through so luminously in the examples and in the overall design of the argument. It is a book which I feel every type of therapist, no matter how anti-analytical, could read with benefit.

Mary Montaut