BookREVIEW: Introduction to the Practice of Psychoanalytic Psychotherapy (second edition)
Reviewer Tessa Ettedgui
I was interested in Lemma’s admission, in the first edition of the book, that her initial brush with psychoanalysis was ‘hostile’ (p.1). Her on-going belief in the relevance of psychoanalysis today is therefore all the more convincing, as here is someone who seems to leave no stone unturned in challenging and questioning the status quo. This personal attitude is further informed by the challenges of her work in the public health sector, and by her experiences of teaching psychoanalysis to clinicians from different mental health backgrounds which, she acknowledges, forces her to ‘revisit cherished assumptions’ (p.xi). Lemma advocates, and I agree, reading her book sequentially, as ideas and concepts are put forward and built upon layer by layer.
This is a book that models accessibility, inclusivity, and pragmatism, as Lemma aims to ‘demystify psychoanalytic practice’ (p.xii). Lemma suggests that ‘[as] evidence-based practice, as a primary driver in healthcare, is here to stay’ (p.15) it is less a question of if you can’t beat them join them, but more about being on the inside, and contributing to the discourse. To critics who may view this as a dilution of ‘the real thing’ she suggests that it is about development rather than dilution, and about accepting the inevitability of change and loss. She says that it is less about simulating a CBT-type set of skills, but more about adapting to the current reality of a healthcare driven by cost considerations, and making sure that psychoanalysis remains relevant rather than becoming obsolete. To this end Lemma, together with Target and Fonagy, developed Dynamic Interpersonal Therapy (DIT), a 16-week model of psychodynamic intervention for use in the NHS (2011).
Accounts of psychoanalysis can tend, in my experience, to assume familiarity with schools of psychoanalysis and their theories. Rather like my experience of learning to drive and finally understanding how the tube stations all linked up, Lemma rather satisfyingly maps out how these schools connect, how the concepts were born and developed, and how they fit into the modern day. A self-confessed ‘synthesiser’ she pulls in ideas from several psychoanalytic theories, and demonstrates how ideas from attachment theory and research, intersubjectivity theories, and cognitive, affective and social neuroscience have influenced what constitutes psychoanalysis today. She is clear about the fact that her view is inevitably filtered through her own understanding of theory, and also through her clinical practice.
The book moves from the more general – in terms of the background and theories of psychoanalysis – to the more specific, in examining more closely aspects such as what constitutes psychic change, and identifying key analytic assumptions which distinguish it as a theory from other therapeutic modalities. Nine chapters cover all the main aspects of psychoanalysis: Brave New Worlds – A Psychoanalysis Fit for the Twenty-First Century; An Overview of the Schools of Psychoanalysis; The Process of Psychic Change; The Analytic Setting and the Analytic Attitude; Assessment and Formulation; Unconscious Communication; Defences and Resistance; Transference and Countertransference; Working with Endings. Each chapter is broken down into sub-sections, making the book accessible and easy to follow, greatly aided also by Lemma’s clear writing style and her use of clinical vignettes to illustrate concepts.
Lemma has a knack for linking up theory and practice in a very organic way and, like the book overall, each chapter moves from the general to the more specific. For example, in ‘Assessment and Formulation’ Lemma begins with an overview of the topic and raises interesting questions about what assessment and formulation entail. She then introduces sub-headings which address the particularities of the assessment procedure, including aims and boundaries, ‘History Taking versus History Making’ and ‘Suitable Criteria and Contraindications for Psychoanalytic Therapy’. These sections provide clear guidelines on both techniques and process, and helpfully provide tables which distil main points and concepts into a quick ‘how to’ guide for future reference.
This is a book which I really enjoyed reading and would recommend. I was drawn in by the accessible and clear way in which it is laid out, and the author’s intelligently eloquent writing style. It manages to explore a wide range of complex ideas in a straightforward way, without being simplistic. Lemma references a wide range of historic and contemporary theorists, which I have already made a mental note to explore further. I would have appreciated reading it during the earlier years of my training, but also find that a few years into private practice there is much to be gleaned from it. Lemma conveys a love for, and conviction in, the relevance of psychoanalysis – and to Object Relations in particular – which is infectious, and I found myself using the book as a yardstick for re-evaluating my own theoretical outlook and clinical practice.
I found any lurking ‘hostility’ of my own evaporating in the face of Lemma’s manifest belief in having the best interest of the patient at heart, as well as the rigorous critique of potentially negative aspects of psychoanalysis, with perhaps the most obvious cliché being the analyst as a non-collaborative and mostly silent expert, engaging in a double bind technique of interpretation. This is particularly illustrated by the chapter on unconscious communication which highlights, for instance, the potentially seductive nature of interpretations, which might simply end up contributing to the analyst’s sense of omnipotence or omniscience rather than aid the patient, who indeed may feel shamed, alienated, or intruded upon, especially if the interpretation is ill-timed.
Lemma does acknowledge that neither books nor lectures can ultimately replace the experience of personal analysis, but her style of writing, as well as the content of the book, leads to my conclusion that she does a very good job of replicating aspects of the process involved.