Learning From Our Mistakes: Beyond Dogma In Psychoanalysis And Psychotherapy (Book Review)

Author:  Casement, Patrick
Publisher: New York: Guilford Press, 2002
Reviewed By: Susan Demattos, Winter 2003, pp. 61-63

Learning from Patrick Casement

In Learning from Our Mistakes, Patrick Casement is still carefully listening to his patients and supervisees. “I have chosen to be informed by an awareness of the unconscious,” he writes in the introduction (p. xvi), “together with a recognition of transference and the power of phantasy, and to be guided by a sense that the past is often found to be dynamically present in the patient’s current life and in the consulting room.” In this slim volume Casement also gives us the opportunity to hear and learn from how he listens. Casement writes in an open, accessible idiom. He eschews jargon, but he clearly practices what he teaches and creates an attitude of openness toward the unknown.

Casement’s clear, accessible writing creates a space where the reader can learn. It is therefore not a surprise that Casement’s 1982 clinical case should have been commented on by so many different psychoanalytic writers representing so many different theoretical perspectives over the past twenty years. One of the pleasures of reading Casement’s new book is a chapter revisiting that case.

I will briefly review topics covered by Casement and describe some of the methods he offers for learning from the patient how to recognize and repair our mistakes in treatment. But my main focus will be on how Casement’s description of the treatment of Mrs. B. (in which he carefully listens to what she is saying, consciously and unconsciously, and in which he learns from his mistakes) has created a space in which psychoanalytic writers from diverse backgrounds have been able to dialogue and use his work to illustrate diverse psychoanalytic concepts.

In nine chapters Casement explores the paradox that psychoanalysis has the potential to free the mind but also to bind it if we rely on dogma rather than developing our own disciplined way of working. He offers contrasting examples of mistakes and suggests ways we might recognize and utilize them. Casement (p. 18) suggests that “because it is not possible for analysts to avoid making mistakes, it is important that there is always room for a patient to correct the analyst, and for the analyst not only to be able to tolerate being corrected but also to make positive use of these corrective efforts by the patient.” He recommends trial identifying with the patient before we speak as a way of not provoking a patient into being defensive. Casement expands Langs’ notion of unconscious supervision by the patient into four forms of unconscious criticism by the patient: unconscious criticism by displacement (where criticism of someone else alludes to something that has gone wrong in the analysis), unconscious criticism by contrast (where others are praised for doing something that we may not be doing well in the analysis), unconscious criticism by introjective reference (where the patient takes the blame for something caused by someone else in a way that may be commenting on the analysis), and unconscious criticism through mirroring (where the patient holds something up to the analyst by unconsciously imitating it, for example, by following the analyst in a deflection to the past or to another person).

Casement devotes a chapter to the experience of a single session, randomly chosen, as an example of his own use of internal supervision. Casement (p. xviii) describes internal supervision “as an internal dialogue by which analysts and therapists can monitor, moment by moment, what is happening in a session and the various options open to them, the various ways they might respond to this and the implications for the patient in each.” Casement then explores some of the problems that arise from trying to be helpful in therapy and offers clinical material to illustrate how a patient can use the analyst’s mistakes to reach more of what is unconsciously searched for.

In the chapter, “Re-enactment and resolution,” Casement draws on Winnicott’s (1963, p.344) observation that “so in the end we succeed by failing–failing the patient’s way” to introduce an example of how a repeating pattern of mistakes by the analyst allowed the patient to give expression to feelings that had formerly been thought of as too much for anyone.

Casement (p. 48) notes, in his chapter on psychoanalytic supervision, “I frequently find it useful to think of practising with a clinical vignette, as a musician might practise scales, in order to develop a greater fluency in thinking about clinical issues.” Casement illustrates this point by returning to his clinical vignette about Mrs. B. I was again impressed by the way Casement’s writing about cases invites greater fluency in thinking about clinical issues.

Two and a half years into analysis, soon after the summer holiday, Mrs. B. brought a dream to her session: She had been trying to feed a despairing ten-month-old child. Mrs. B. had been severely scalded by boiling water at age eleven months and had had to have surgery under local anesthesia at age seventeen months to loosen scar tissue. In exploring what the dream might mean, Casement noticed Mrs. B.’s rising anxiety and made an interpretation that Mrs. B. “seemed to be afraid of finding any element of bad experience during the time before the accident” (p.130). Casement also described repeating this interpretation even after Mrs. B. raised her hand for him to stop. The next day, a Friday, Mrs. B. came to her session “with a look of terror,” refused to lie down on the couch, and stated that she did not know if she could continue to explore these memories or stay in analysis unless she knew she could, if necessary, hold Casement’s hand. The rest of Casement’s paper explores how he and Mrs. B. negotiated and utilized this pressure for physical contact during the reliving of an early trauma.

In choosing to summarize Casement’s clinical vignette about Mrs. B., I have revealed, as have all the other commentators on this case, what struck me as important (the dream, the patient’s anxiety, a potential mistake in repeating and forcing an interpretation on the patient, a request to bend the rules at the end of the week). Casement himself began his 1982 paper, by focusing on the question of how tightly we are bound to the classical rule of abstinence, which would prohibit physical contact with the patient. And he plays this theme or scale again in the first chapter of this book.

Others have been able to use Casement’s vignette to play other themes. Richard Fox (1984) used the vignette to reconsider the principle (as opposed to the rule) of abstinence. He notes that Casement is one of the few writers who describes “any sense of option or conflict within the analyst about the management” of requests for gratification. Fox uses Casement’s case to show how balancing demands for gratification (from the patient) and for frustration or distance (from the principle of abstinence) can “create the conditions for the development of an interpretable transference” (Fox, p. 233). Axel Hoffer (1991) uses Casement’s clinical vignette to demonstrate the immediate relevance of the Freud-Ferenczi debate on the issues of “the role of abstinence and the relative importance of remembering the past through reconstruction (insight) versus reliving the past (experiencing) in the analytic situation” (Hoffer, pp.465-466). Stephen Mitchell (1991, p. 154) heard Casement’s vignette as a fascinating description of how Casement’s willingness to consider holding Mrs. B.’s hand and eventually deciding not to comply both seemed crucial in furthering the analytic inquiry. For Lewis Aron (1992), Casement’s vignette teaches important lessons about technique as well as theory:

I want to emphasize the way that his interpretations contain and convey a great deal of his personal subjectivity and, in particular, the way that they express his own conflict about his relationship with the patient. In my view, it is only when he conveys explicitly to her his own struggle, hope, and despair about ever reaching her and, in so doing, sharing his psychic reality with her, that she is able to emerge from the psychotic transference. It seems that what was therapeutic in this case was not that Casement walked the tightrope of abstinence, as Fox would have it, but rather that he fully engaged the patient by sharing with her his own psychic reality in the form of an interpretation that clarified both his own and the patient’s psychic functioning as well as the intersubjective engagement that had developed between them. (Aron, pp. 497-498).

At a 1990 APA panel (the report by Blum and Ross was not published until 1993) Casement himself revisits the case of Mrs. B. to illustrate clinically Winnicott’s concepts of regression to dependence, fear of break down, use of an object, and infant’s “going on being”, and the trauma derived from “breaks in continuity.” Nevertheless, Casement continued to stress that he took his cues from his patients rather than strictly adhering to Winnicottean theory. A new piece of information also emerged in this telling of the case: Casement mentions that Mrs. B. had to be barrier-nursed after the scalding and that she could not be held by her mother. Suddenly Mrs. B.’s dream of the distressed child takes on more poignancy and the possible toxic nature of touch is also introduced.

By 1993 Ralph Roughton is able to use Casement’s 1982 case to explore acting out, repetition, enactment, and actualization. Roughton (p. 456) sees Casement’s vignette as “sharply and evocatively” drawing “a distinction between the use of reliving in an analytic way and the unanalyzed gratification of a patient’s insistent demands for a mutual enactment.” Roughton applauds Casement’s refusal to collude in acting out and his indication of concern for the patient’s dilemma.

In 1998 Dale Boesky, W. W. Meissner, and Gil Katz comment on Casement’s 1982 case in three separate articles in the same volume of the Journal of the American Psychoanalytic Association. Boesky (p.1016) focuses on an interaction overlooked by other commentators: Casement repeating his interpretation after the patient asked that he stop. Boesky uses the patient’s associations to argue an alternative hypothesis that the patient “experienced the analyst’s insistence on his own view as the actualization of her unconscious fantasy of a sadistic sexual assault rather than the reexperiencing of a traumatic memory” (Boesky, p.1016). Meissner is able to use Casement’s case to rehabilitate the concepts of abstinence and neutrality. Katz uses Casement’s case to make three points: 1. That Casement’s interactions with the patient around abstinence were shaped by enacted processes (Katz, p.1161), 2. That these enactments are defined as processes that are unintended but meaningful deviations from abstinence and neutrality (Katz, p.1161), and 3. That both verbally symbolized and enacted transference experiences are critical dimensions of analytic process, and analytic treatment is most effective during these periods, as demonstrated in Casement’s case, when they can be brought together to create the kind of emotionally based, experiential insight that produces meaningful psychoanalytic change (Katz, p.1162).

Again in 2000 there were eight comments about Casement’s 1982 case in Psychoanalytic Inquiry. Kati Breckenridge focused on an exchange in which she felt Casement was not listening to his patient and argued that physical touch should be considered in the same way as other interactions in the analytic relationship. James Fosshage uses Casement’s case to review and assess the classical theory on precluding touch in psychoanalysis and offers some guidelines for the uses of touch in the analytic setting. Alex Holder questioned whether the ordeal that Casement and Mrs. B. went through was necessary if there had been sufficient emotional involvement and working through. James McLaughlin challenges what he sees as Casement’s theoretical and technical certainty about proscribing touch and cautions that theory can blind Casement to the patient’s concerns (a point one can well imagine Casement making). Barbara Pizer criticizes Casement for embodying a “distinctly authoritarian, one-person psychology” by unilaterally withdrawing the agreement to let the patient hold his hand. Pizer sees this as only one of many instances in which he collapses or forecloses potential space. Ellen Ruderman writes that Casement presented his case in a sensitive and honest manner without leaping to a reliance on formula. She then explored how analysts might be most receptive to the needs and tolerances of patients while keeping in mind their own subjectivities and tolerance levels. Morton Shane et al, taking a developmental systems self psychology perspective, note that Casement’s decision was based upon context, upon the analyst’s personality and theory, and upon how the patient’s request was understood by the analyst. Herbert Schlesinger and Ann Appelbaum then note that the responses illustrate a broad range of attitudes about nonerotic physical contact in analysis.

Casement returns to the case of Mrs. B. in this new book and responds to many of these comments. He emphasizes his decision to withdraw his hand was not made based on adherence to any rule of abstinence, but on “following the patient at a deeper level than just that of her surface communications to me” (Casement, 2002, p.88). In response to Breckenridge, Casement noted that holding open the possibility that Mrs. B. could hold his hand felt like a much safer course than taking that possibility away. Casement allows the reader to listen to his internal supervision over the weekend. He also reveals that he arranged a consultation with Paula Heimann who was familiar with his work on this case over that weekend. I suddenly had a sense of how large Casement’s analytic space could be: not only did he utilize internal supervision in his sessions and think about the case over the weekend, he also reached out to a trusted supervisor to help him think about how best to hold and help his patient. Heimann also confirmed Casement’s sense that holding open the possibility of Mrs. B. taking his hand would be an avoidance (for both of them) of the intensity of her feelings and imply that her feelings were unmanageable. When Casement worried with Heimann that he did not know how he could bring withdrawing the offer into the treatment, Heimann agreed that he should not introduce that topic. Instead, Heimann said, let the patient lead you, she will show you the way (Casement, 2002, p.92). Rather than being the unilateral decision Pizer posited, Casement points out that the patient brought him both a dream and a waking extension of that dream as messages about why touch in this case would be detrimental.

It is only much later in this analysis that Mrs. B. finds out that her mother’s decision to “barrier nurse” (i.e., not holding or touching her except with sterilized gloves) her may have saved her life. Whatever she did, the mother must not pick up her baby, however much she cried for this. For, if the mother did pick her up it might lead to her baby dying from infection, and there was no antibiotic treatment available at that time. What a parallel! So, we can imagine the agonies her mother must have gone through as she cared for her, whilst having to inhibit the natural impulse of a mother to hold her distressed baby to herself, to give her hugs that are meant to “make it better.’

Strangely, I had gone through similar agonies in my countertransference, in being there for my patient’s distress, wishing so strongly that my patient could at least have had the reassurance of my hand to help her through that experience. (Casement, 2002, pp.93-94.)

There is still an immediacy and aliveness to Casement’s writing about this case twenty years later. He is still open to learning from the patient and those who have written about the case. Casement’s experience-near description of interactions between himself and his patient, combined with his openness and curiosity, invite others to trial identify with him and Mrs. B. and to enter into practicing internal supervision with this case. Casement had been willing to learn from his mistakes with Mrs. B. and other patients. Just as his supervisor Paula Heimann had seen countertransference as one of the most important tools in analytic work, so Casement, following Winnicott, has discovered that mistakes and failures can be used to further our analytic understanding and work.

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