Mentalization, insightfulness, and therapeutic action: The importance of mental organization

Continuing debates over the relative importance of the role of interpretation leading to insight versus the relationship with the analyst as contributing to structural change are based on traditional definitions of insight as gaining knowledge of unconscious content. This definition inevitably privileges verbal interpretation as self-knowledge becomes equated with understanding the contents of the mind. It is suggested that a way out of this debate is to redefine insight as a process, one that is called insightfulness. This term builds on concepts such as mentalization, or theory of mind, and suggests that patients present with difficulties being able to fully mentalize. Awareness of repudiated content will usually accompany the attainment of insightfulness. But the point of insightfulness is to regain access to inhibited or repudiated mentalization, not to specific content, per se. Emphasizing the process of insightfulness integrates the importance of the relationship with the analyst with the facilitation of insightfulness. A variety of interventions help patients gain the capacity to reflect upon and become aware of the intricate workings of their minds, of which verbal interpretation is only one. For example, often it seems less important to focus on a particular conflict than to show interest in our patients' minds. Furthermore, analysands develop insightfulness by becoming interested in and observing our minds in action. Because the mind originates in bodily experience, mental functioning will always fluctuate between action modes of experiencing and expressing and verbal, symbolic modes. The analyst's role becomes making the patient aware of regressions to action modes, understanding the reasons for doing so, and subordinating this tendency to the verbal, symbolic mode. All mental functions work better and facilitate greater self-regulation when they work in abstract, symbolic ways. Psychopathology can be understood as failing to develop or losing the symbolic level of organization, either in circumscribed areas or more ubiquitously. And mutative action occurs through helping our patients attain or regain the symbolic level in regard to all mental functions. Such work is best accomplished in the transference. The concept of transference of defense is expanded to all mental structure, so that transference is seen as the interpersonalization of mental structure. That is, patients transfer their mental structure, including their various levels of mentalizing, into the analytic interaction. The analyst observes all levels of the patient's mental functioning and intervenes to raise them to a symbolic one. At times, this will require action interpretations, allowing oneself to be pulled into an enactment with the patient that is then reprocessed at a verbal, symbolic level. Such actions are not corrective emotional experiences but are interpretations and confrontations of the patient's transferred mental organization at a level affectively and cognitively consistent with the level of communication. Nonetheless, the goal becomes raising the communication to a symbolic level as being able to reflect symbolically on all aspects of one's mind with a minimum of restriction is the greatest guarantee of mental health.

Re-searching for therapy: the ethics of using what we are skilled in

Narrative inquiry as a qualitative research method appears to be growing in popularity among mental health nurses. This paper argues that there are a number of parallels between narrative inquiry and psychotherapy, and mental health nurses familiar with the practice of therapeutic engagement need to be mindful of these when using this approach to research. The symbiotic relationship between those engaged in narrative inquiry and those engaged in psychotherapeutic practice is explored in order to provide greater understanding of some of the ethical issues involved and how new researchers, supervisors and practitioners might better respond to the complexities inherent in using narrative inquiry which may itself be therapeutic. Our focus for this paper is the tensions experienced by the mental health nurse while working as a researcher when the research encounter provides a trigger that would normally elicit a therapeutic response for both participant and nurse. Using a selection of psychoanalytic theories and principles this paper explores the relationship between the processes of psychotherapy and narrative inquiry. This discussion paper is based on the authors' own research experiences of using narrative inquiry to explore a number of sensitive issues and many years of supervisory relationships with students and practitioners alike.

A shadow concept

The author focuses on the significance of preconscious thinking, and its relationship to what we think of as unconscious fantasies. He reopens Freud's forgotten struggle with preconscious thinking, while he explores preconscious thinking as the basis for thinking about psychoanalytic treatment. This includes our goals in bringing an idea to the analysand's attention, and the role of transitional space where thoughts and feelings can be played with.

Finding and refinding the therapeutic alliance: on thinking and thirds

This article represents an attempt to clarify some of our thinking about the component aspects of the analytic relationship as they enter into and play their role in the analytic setting and process. The interaction between transference and alliance generates a dual mental perspective within which the patient experiences and thinks about the analysis and the analyst experiences and thinks about the patient. Concepts of an analytic third, by displacing aspects of the alliance component of this dual relational perspective into either a separate transitional mental space or subjective third, have arisen in the attempt to shed light on the multiplicity of interactional perspectives in analysis: these are discussed and evaluated. The argument concludes that resort to the concept of an analytic third effectively dilutes the direct interpersonal involvement and responsibility of both analyst and patient for transactions within the therapeutic alliance.

"Nothing could be further from the truth": the role of lack in the analytic process

It is an oft-noted clinical phenomenon that the analyst's mistakes are beneficial to the analytic process. Although the analyst's mistakes, misunderstandings, and faulty functioning have been described by psychoanalysts of various theoretical persuasions, no overall theory has been advanced to account for this clinical phenomenon. To address this theoretical lacuna the central Lacanian notions of lack and desire are brought to bear. In particular, lack, or nothing, is presented as an essential working condition of the analyst, one that if understood, recognized, and tolerated can positively inform the analyst's attitude. By contrast, theoretical biases that privilege presence can obscure lack as an important contributor to the analyst's attitude. A clinical case demonstrates that both analyst and patient struggle with deep anxieties generated by lack, and that both are repeatedly tempted to solve these struggles by settling for obsessional solutions.