Books

How Does Psychotherapy Work? (2005) (Karnac, London)

Distinguished psychotherapists from different schools of thought come together in this fascinating volume to address the question, how does psychotherapy work? Despite the wide variation of psychotherapeutic theory and technique, the contributors are united in finding the common denominator in successful psychotherapy. This is a thought-provoking dialogue on psychotherapy and its place in modern society.

Contributors include: Neil Altman, Roz Carroll, Sue Cowan-Jenssen, Nicola Diamond, Carol Holmes, Brett Kahr, Dianne Le Fevre, Susie Orbach, James Pollard, Jane Ryan, Joseph Schwartz and Robert Maxwell-Young

 

An extract from Roz Carroll’s chapter:

Rhythm, re-orientation, reversal: deep re-organisation of the self in psychotherapy

 ‘Life itself is an expression of self-organisation’ (Sardar, 77)

What makes psychotherapy work is a question which is both impossible to answer conclusively and yet necessary to address. In this chapter I propose that psychotherapy ‘works’ in the same way that life works (or evolves), only in a more concentrated form by intensifying and containing specific processes that occur in all living developing systems (from cells, to individuals, to communities etc).

Psychotherapy was once presented to the public as a detective story: clues to the unconscious expertly spotted by the therapist-sleuth leading to a reconstruction of traumatic events in childhood. In this linear account revelation brings catharsis, insight, and healing. Actually this search for a hidden story remains a fairly central feature of psychotherapy, but today’s version of therapy encompasses many more nuanced levels of information and interaction which are marked by non-linear cycles of disorganisation-reorganisation. The emphasis has moved from discovering the origins of neurotic patterns to working directly with relating as a human capacity. [i]

Before attempting to outline some of the intricacies that typify psychotherapeutic work, I want to make a brief comparison between psychotherapy and other life-changing experiences. What else brings about significant lasting constructive change in an individual? A very basic summary might include: relationships of all kinds (falling in love, becoming a parent, friendship…); creativity, sports, spiritual practice and work. It may also include encounters with phenomena in nature; witnessing or participating in significant social events, including upheaval and mass movements.  Any of these might bring about cumulative change, requiring learning, adapting, but if they to are lead to significant change they will usually include some or even many experiences of intensity, of feeling pushed beyond a threshold, and probably also phases of enduring uncertainty and even disillusion. Usually, in order for meaningful change to occur, there will be an assimilation of what has been intense or difficult, and an emergence of a different or expanded sense of oneself.

Psychotherapy is a complex, ambitious, multiplicitous process. A good chat with a friend, priest, or confidante can help complete an unfinished emotional cycle, it can lead to insight, and life-changing decisions. But psychotherapy goes beyond this by continuing to ask questions and listen for the intangible organising principles in a person’s life. These emerge and are re-organised within the therapeutic relationship via exchanges and insights paralleled by significant shifts in rhythm, perspective and orientation.

Psychotherapy is also different from the ongoing process of ‘life’ in that it is a specific form in which the practitioner attempts to maximize ‘openness’ in the therapeutic relationship within a set of formal constraints (boundaries of time, space, confidentiality etc) which close the system. The structure of the therapy enables a concentration of experience, with an opening out of meaning. This occurs in a non-linear way as trust and mistrust in the client are negotiated. Whilst at times this is characterised by deepening relaxation, at other times the work is intense and unpredictable. Periods (or moments) of assimilation interspersed with crises and transitions lead to more complex and differentiated ways of being.

Psychotherapeutic work rests on and wrestles within the paradox that deep change is spontaneous – it cannot be rationalised, prescribed or controlled (by either client or therapist). Rather it is through the dialectic of spontaneity and discipline (with the therapist taking much of the responsibility for discipline) that changes occur in the client which are simultaneously relational, bodily, perceptual and reflective.

In this chapter I want to explore aspects of the developing paradigm of contemporary psychotherapy, which is itself a product of social and cultural change and crisis. I will be focusing on the emergent principles – cutting edge practice across a number of psychotherapeutic approaches - rather than describing a generic model. Despite the variation  between them there are still some noticeably contemporary emphases, such as working with a greater appreciation of difference; a more relational, dialogic style; the use of the countertransference; more cross-fertilisation between psychoanalytic and humanistic thinking; and a greater attention to the body.

Psychotherapy works by utilizing various kinds of intervention to maximize feedback. The sheer variety  of interventions in psychotherapy have in common their aim to stimulate some shift in the client’s awareness of themselves. Dialogue and exploration are the core of most approaches, though the style may vary considerably. Interventions include: reflecting back the client’s own implicit formulations, challenging the client’s expressed perception, discovering new metaphors, formulating questions, hypotheses, transference interpretation. It may mean exploring and elaborating on symbols and fantasy occurring within the transference relationship and arising from dreams, made and found objects, sand tray, drawing, claywork. Interventions which emphasize the body may pay attention to the breath, track changes in sensation, or allow and follow spontaneous movements and gestures. Some therapies make use of structures and experiments, such as dramatic enactment, visualisation or Gestalt ‘chair work’.

Whatever the modality and theoretical model used by the therapist, the essence of psychotherapy is concentrated feedback, specifically cultivated, and operating in many varying ways. [ii] ‘Concentrated’ feedback means complex, multiplicitous, and spanning a whole range of phenomena; it goes far beyond ‘mirroring’ and is not neutral. This enables the client to acquire a more differentiated experience of life and more elaborated, varied responses to challenge and change.

The psychotherapist of today is often guided by the countertransference to formulate and engage in the relational dynamic, and perhaps to be more personal and explicit in their responses to the client. The discipline required of the therapist is to use their subjective experience (the countertransference) with some degree of objectivity (reflection) and to feed it back into the therapy relationally and in terms of interventions. (Orbach) The countertransference is itself self-organising: it emerges spontaneously, giving shape to the therapist’s necessarily conflicted and complex response to the client. (Soth)

What psychotherapy can offer above and beyond other relationships is that the therapist is dedicated to the task of holding and considering many levels of an interaction. Deep re-organisation of the self in psychotherapy occurs through the deepening and expansion of relational capacity in the client (and  the therapist). The client experiences a plurality not just of ‘mental’ attitudes but of embodied states in an intricate dance of reciprocal feedback between self and other. In this chapter I want to show how this capacity includes aspects such as rhythm, intensity, orientation, and reversal of perspective (shifts in perception) which embrace both verbal and non-verbal processes.

Rhythm, intensity and timing

“The magic of a dance, young man, is something purely accidental. The irony of this is that you have to work harder than anyone else for the accident to occur…( Mc Cann, 68)

Rhythm is intrinsic to our lives and permeates every aspect of our self-organisation. In the body there are, for example, hormonal, metabolic, and neural cycles, and over fifty ultradian rhythms, such as sleep-waking patterns. In relationships some of these rhythms are more explicitly involved in the dynamic between people: breathing, heart-beat, contraction-flexion of muscles; gait, gesture, eye contact. Rhythm underlies speech (pace, cadence) and conversation (turn taking, pausing, postural matching, de-synchronisation). Other typical rhythms are involved in habits and activities, lifestyle organisation and social exchanges, seasons and celebrations.

Rhythm is fundamentally organising, and it confers a degree of predictability, a structure to follow. It operates at every level in human engagement embodying nuances of connection, power, desire and fear. When we connect to our internal rhythm, we know who we are. How we connect to the rhythm of another defines our relationship with them in that moment. As much as we need regularity of rhythm, we also need graded differences, surprises, and new movements: and this is the basis for re-organisation, a development and expansion of the sense of self.

When a client comes for psychotherapy both parties need to establish a rhythm together – sometimes this is straightforward, perhaps deceptively so; at other times, there is a struggle or intense anxiety that makes for a staccato beginning. Timing and rhythm are generally not in focal awareness or under deliberate control yet it tells us much about the idiom of the client and the way they are relating to the therapist. (Beebe & Lachman)  Some clients find the therapist’s silences particularly disconcerting because they struggle with what seems to be an absence of rhythm to adjust to or interact with.

With one client, Fred, the difficulties we had with establishing a rhythm encapsulated the overall difficulties of the therapy. Fred’s anxiety to inform me, direct me, and get through to me his history in all its detail meant that it was almost impossible to find a gap in his talking to respond. I felt literally ‘in the firing line’. His talking was usually fast and loud: often volcanic, venomous, steely with contempt. One day, in an effort to get a word in, I implored him ‘shut up, Fred!’, and he fell at my feet with a salaam. It was a  comic moment, both of us were relieved by my interjection and his instant response. War became play, or rather, a temporary truce.

By talking non-stop Fred was literally holding onto himself, avoiding even momentary pauses that carried the risk that I would fail to be there, thus leaving him to drop into an abyss of terror and vulnerability. So, in an attempt to stay with rather than resist the pattern (it was hard not to become defensive in response to this volley), I took to really concentrating on watching his face and body very carefully and started to perceive points at which he seemed to ‘cohere’. These were fleeting but clear moments of repose amidst long sequences of rapid face changes which, observed closely, showed expressions of horror, disgust, hatred, and extreme anguish. My almost exclusive attentiveness to his body, putting aside the attempt to respond to his verbal challenges and exhortations, soothed him and evoked some gratitude. This was a first step in modifying his relentlessness pace, and allowed for the emergence of other registers, rhythms and tones: poignant, subtle, clever, passionate and desperately playful.

Finding the right rhythm with the therapist is reassuring, it gives some shape to emotional intensity. Losing it or letting go of it can be frightening or exciting and this happens as the client shifts from one state to another. The therapist’s work involves attunement to the client’s rhythm  and awareness of the impact the client’s rhythm is making on them. In addition, the therapist needs to consider how their interventions contribute to the shape and direction of the rhythm of the therapy.  Synchronising, counterpointing, emphasising, pausing, amplifying and slowing down  are finely calibrated aspects of the interaction with the client.

Rigidity or hypermobility in the client’s rhythm blocks deeper re-organisation and is the hallmark of difficulty with and fear of relating. Insight can lead to more spontaneity; so also can ‘experiments’, following a body process, active imagination with an image or symbol, working through conflicts, and finding unexpected support in the sustained empathy from the therapist. Timing, one of the least written about aspects of psychotherapy, is crucial. Therapists are skilful in gauging the degree of tension in the relationship, the depth of feeling that can be addressed at any given moment, and recognising defences and their function.

[   ]

Health is the capacity to tolerate, to maintain and to shift between a plurality of states. (Schore, Bromberg) ‘Psychological’ difficulties of any degree correlate with an incapacity to bear intensity of feelings, or to transition between one feeling state and another, or even to maintain any kind of stable state without it being fragmented by dissociation. Although  changes in emotional state are inevitable, when people are depressed, anxious, or traumatized the main experience is that ‘things stay the same’. There is a deadness and dryness and/or overwhelming intensity and chaos, which is experienced as unbearable.

Psychotherapy aims to create the space for deepening the cycles of disorganisation-reorganisation which can enhance the sense of richness, complexity and variation in the texture of experience. The length of time involved in psychotherapy is necessary  to slow down the frantic rhythms of trauma and stress to allow assimilation of what has happened and what is happening. It also takes time to facilitate the re-emergence of spontaneous rhythms – such as breathing – which have been suppressed in an attempt to control the pain of living and relating. (Totton 1998) Peaks and shifts do occur  because of the cyclical nature of bodily rhythms but may not lead to real change unless the wave itself is completed in a meaningful contact with another or with oneself. It is at these peaks – or troughs – that deep re-organisation can occur and a new pattern and a new orientation can emerge.

Countertransference  - the therapist’s orienting response

Two states differing by imperceptible amounts may eventually evolve into two considerably different states…  (Lorenz quoted in Sardar, 43 )

The use of the countertransference is the hallmark of many contemporary psychotherapies – and its discovery and elaboration have been fuelled because of the way it has been found to catalyse change and re-invigorate  therapeutic processes. Countertransference is a refined form of orienting response towards the emergent, drawing on information from subsumed levels of phenomena in the client’s verbal and non-verbal presentation. The perception of minute sometimes fleeting detail stimulates the cohering of an image, an idea, or an impulse. For example, one day with a client I became aware of the image of collecting eggs and putting them in a basket very gently, The image provides lots of food for thought: the need to be aware of fragility, of gathering pieces, and many associations to the idea of ‘putting all the eggs in one basket’. In this sense the image confirmed my sense that I needed to wait patiently for something to incubate and hatch.

Whatever the motivations holding a pattern of any kind in place, human processes – as with other living systems – will often be cyclic. When a cycle or Gestalt is incomplete, it tends to repeat in the same way, and can become ‘stuck’. New rhythms, waves or cycles may be inhibited. The therapist’s sensitivity to very slight fluctuations that indicate the potential for shifting can enable them to support transitions between states, sensing when to wait, how to intervene, to interpret or be silent. Sometimes the therapist supports the momentum of spontaneous change and at other times is actively challenging or disrupting certain fixed patterns.

Countertransference is characterised by an extreme sensitivity to relational cues  - the therapist has a capacity to resonate to such a degree that quite subtle states can be caught and amplified. Indeed, the therapist allows the client to evoke specific modes of relating in them. Typical modes might include high receptivity and openness, curiosity and humour, warmth, caution, or a sharper more focused use of therapist’s own emotional agency.

Whilst there are many factors influencing these modes (including training and the therapist’s character) they can help to differentiate emergent patterns in the relationship. These might be patterns organised on the basis of past experience or patterns which are new and creative responses to relationship in the present. The therapist’s response accents, highlights or modifies the client’s experience. The therapist may feel compelled to act, intervene or comment in a striking or dramatic way (as I did with Daniel, or Schwartz-Salant with Paula) which is, or comes close to, an enactment of a dynamic in the client’s history. Increasingly, in the debate on countertransference, it has been noted that enactment can operate on a fine edge between replaying or re-enacting a traumatic couple (such as parent-child) and transforming it by adding a new depth of holding and awareness. (Mitchell & Aaron) Such moments become possible, and bear fruit, when the intensity in the relationship reaches a threshold, the equivalent of a critical mass, but does not destroy the relationship. Traversing that threshold precipitates a reversal of perspective, position, and/or feeling in the client. This is like a moment of punctuation, which can catalyse a significant re-organisation of perception in the client.

Reversal: Getting More Than You Bargained For and Other Turning Points

We wish for a closely fought match containing many satisfying reversals (Mamet, 9)

Bifurcation point: a branch, where there are two distinct choices available to a system  (Coveney and Highfield, 424)

A huge body of metapsychological theorizing attempts to account for the recalcitrance of human beings to deep psychological change. The difficulty of achieving lasting and effective changes in clients and the arguments about the conditions and criteria for that are the subject of wide-ranging debate and conflict. (Totton 2004) It is important to understand that the human propensity to try to maintain equilibrium is not simply ‘mental’ or ‘psychological’ but bodily (neurophysiological) (Carroll 2001, 2003) It is also the case that cycles of behaviour, feeling and perception can reach a limit point, which is an opportunity for deep re-organisation. In this section I want to elaborate on a basic principle of process which is that deep internal structural change occurs when the system is ’far from equilibrium’.

In self-organisation theory the threshold for radical change is known as a bifurcation point and occurs as a system is reaching a state ‘far from equilibrium’:

At this moment of instability, the system may break down and follow an earlier pattern imprinted in its structure (repetition). Or as a result of its exquisite sensitivity to any fluctuation in the environment, it may break through to a new pattern of higher order and complexity. (Capra, 171)

At the bifurcation point the system goes back into a familiar cycle (a regression), or it shifts to a new level of organisation, a quantum leap (a progression). One of the trickiest aspects of psychotherapy is the tension between the need for equilibrium (which represents safety and stability, but also entrenched defenses) and loss of equilibrium (breakdown, breakthrough, dis-organisation). Much of the time change is facilitated, and  phases of regression may be supported, increasing the client’s trust and understanding of their needs. But at some points a movement to a new pattern is precipitated suddenley. The tension has been building until an aspect of the client’s life, relationship with the therapist, or inner world is far from equilibrium and the client arrives at a crossroads, the all or nothing, sink or swim, now or never. There are many phrases in our language for this bifurcation point because it is such a profound feature of human experience.

In terms of psychotherapy, the bifurcation point is a crisis, perhaps the ‘make or break’, where overwhelming intensity tests the limits of the therapeutic relationship. This can lead to the emergence of something new: a re-organisation of perspective (reversal), a more intense contact between client and therapist, the breaking down of barriers. Often it appears things are getting worse. The client may feel abandoned by the therapist, or turned on by them. They may attack or feel attacked. Both clients and therapists desire and fear these heightened, often dramatic, moments. A battleground may get marked out. Does the client need to win, or leave the therapy, to survive or maintain control at this point?

Lets illustrate this ‘bifurcation point’ with vignettes from two  brilliant and very different therapists - Joyce McDougall, a psychoanalyst based in Paris for half a century and Irvin Yalom, an existentialist therapist practicing in California. McDougall recounts a session with a patient who spends the session complaining that her analysis has failed to enable her to get a lover, earn enough money to buy a studio apartment, and that even the success of the analysis -  the alleviation of an old symptom of self-harming - is a nuisance because this had been an effective technique for calming herself down. As she is leaving the consulting room, the patient says ‘Well this weekend I shall commit suicide; there’s nothing left for me to live for!’ McDougall calls out after her retreating back, ‘If you do that I’ll never speak to you again!’ When the patient returns on Monday she confesses that she laughed all weekend and then adds ‘Perhaps for the first time I believed you really care for me.’ (25 McDougall in ed .Raphael-Leff)

The patient’s complaints are a repetition, a familiar way of organsising herself in relation to disappointment. McDougall doesn’t analyse the tone of the patient’s parting shot – perhaps it contained a nascent self-irony, a sense of her own ridiculousness, but the positive effect of McDougall’s response clearly indicates a ripeness for a new pattern, more sophisticated, more relational, more creative. We can also be in little doubt that years of a relationship marked by reliable holding and more typical analytical interventions enable this spontaneous rebellion on McDougall’s part to bear fruit. It is a turning point that precipitates a deep re-organisation: a reversal (of perspective, of behaviour); a change of rhythm (the session speeds up at the end with the exchange like a sudden flash of glinting swords) and re-orientation (a sudden recognition of the analysts love).

Laughter, like sobbing, losing one’s temper, or a startle reflex, is one of the hallmarks of re-organisation. It signals a shift in a fixed relational and situational dynamic. The dynamic intensity of the moment can bring therapist and client into a new level of contact with the other or precipitate  recoil from the other. There is a reversal of perspective, a coming together of opposites, as the client glimpses or feels the other side of the story.  As Eigen puts it, the client is ‘enlivened and quickened through the sense of difference’ with the presence of the other ‘no longer taken for granted but appreciated as coming through’. (8) The antithesis of reversal, in the sense I am using it, is splitting, which is a used to diminish intensity and protect a fragile self from the impact of experience.

[     ]

Rhythm, re-orientation and reversal: contemporary psychotherapy at the cutting edge

Containment is a paradoxical process, a relational dance, in which spontaneity transcends established structures and boundaries only to organise itself into a new contained shape. (Soth 2004)

The terms ‘rhythm’, ‘re-orientation’ and ‘reversal’ are not intended to describe a technique or approach but rather to suggest overarching phenomena which characterise a process of development in psychotherapy. I chose to focus on these functions because they reflect the inseparability of relational, bodily and perceptual processes. Over a sustained period of therapy, the client’s sense of self becomes wider and more differentiated neurophysiologically through the experience of ongoing re-organisation. Finding and changing rhythm, re-orienting, and surviving and surrendering to reversals becomes a more fluid process. The client experiences more frequent, subtle, tacit body shifts as part of a more spontaneous movement between a connection to themselves and a perception of the other.

Psychotherapy opens things out – undoes knots – in order to mitigate against some of the effects of time-gone-wrong, to allow re-organisation where time has stopped a process and encapsulated it. Paradoxically it is also highly concentrated, with elements specified by the context, which are witnessed, assimilated and anchored with the help of the therapist. This requires the therapist to maintain the dialectic of spontaneity and discipline which chararcterizes a relational approach to psychotherapy. Part of the shift in contemporary psychotherapeutic practice stems from the recognition that significant re-organisation of understanding is more likely to occur when the client is propelled experientially (and therefore bodily) into a new perspective.

The ideas developed in this chapter draw on a wide range of contemporary psychotherapy theorists, mostly at the more radical end of their field. My sources and influences include authors from body psychotherapy, creative arts therapies, Gestalt therapy, Jungian analysis, relational psychonanalysis and especially, neuroscience. [iii] I have de-emphasised language and insight deliberately in order to highlight the bodily and relational factors which are an essential component of psychotherapeutic change.



[i] For discussion of the development of the relational thread in psychoanalysis, see the Preface of Relational Psychoanalysis ed Mitchell & Aaron. For a humanistic perspective on the relational going back to Buber and Tillich, see Hycner & Jacobs.

[ii] For more detailed discussion of negative and positive feedback and the effect of transference as feedback and on feedback, see Carroll 2003

[iii] I am grateful to Jon Blend, Michael Soth, Linda Hartley, Graeme Galton and Ed Mayo for their feedback  and help in developing this chapter.

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