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Psychoanalysis in modern mental health practice

Article  in  The Lancet Psychiatry · March 2018

DOI: 10.1016/S2215-0366(18)30052-X

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THELANCETPSYCH-D-17-00649R2 Review
S2215-0366(18)30052-X
Embargo: 21 March 2018—23:30 GMT KiG
This version saved: 10:06, 14-Mar-18
Doctopic: Review and Opinion

Psychoanalysis in modern mental health practice

Jessica Yakeley

Like any discipline, psychoanalysis has evolved considerably since its inception by Freud over a century ago, and a Lancet Psychiatry 2018
multitude of different psychoanalytic traditions and schools of theory and practice now exist. However, some of Published Online
Freud’s original ideas, such as the dynamic unconscious, a developmental approach, defence mechanisms, and March 21, 2018
http://dx.doi.org/10.1016/
transference and countertransference remain essential tenets of psychoanalytic thinking to this day. This Review
S2215-0366(18)30052-X
outlines several areas within modern mental health practice in which contemporary adaptations and applications of
Portman Clinic, The Tavistock
these psychoanalytic concepts might offer helpful insights and improvements in patient care and management, and and Portman NHS Foundation
concludes with an overview of evidence-based psychoanalytically informed treatments and the links between Trust, London, UK
psychoanalysis, attachment research, and neuroscience. (J Yakeley FRCPysch)
Correspondence to:
Introduction which emphasise the two person nature of psychoanalytic Dr Jessica Yakeley, Portman
Clinic, The Tavistock and
Freud’s vision for psychoanalysis was ambitious. treatment and that knowledge or truth does not belong to Portman NHS Foundation Trust,
Psychoanalysis was not merely a mode of treatment, but the therapist, but is co-constructed during the interaction London NW3 5NA, UK
a metapsychology—a new scientific discipline in its between patient and therapist. [email protected]
own right—based on its “procedure for the investigation What relevance does this array of psychoanalytic
of mental processes that are almost inaccessible in any movements and their theories pose to modern mental
other way”.1 Although Freud did not discover the health practice? Although in the past 25 years many
unconscious,2 one of his greatest achievements was to substantial advances have been made in mental health
make it the main object of investigation. This research and practice—notably in the development of
unconscious is dynamic, comprised of shifting feelings, safer and more effective psychotropic drugs and of
fantasies, conflicts, memories, and desires that motivate evidence-based psychological therapies—such achieve­
our conscious thoughts and manifest behaviour, and ments can seem overshadowed by the numerous
which can be glimpsed through the window of dreams, challenges faced by publicly funded mental health
but are kept out of consciousness by the force of services today. These challenges include the following: a
repression because of their unacceptability to the social, shortage of financial investment compared with services
moral, and ethical values of civilised thought. Although for physical health; target cultures encouraging
its nature has been much debated, the existence of a inappropriate incentives; service reconfigurations
dynamic unconscious continues to constitute one of the resulting in fragmentation, poor continuity of care, and
fundamental underpinnings of psychoanalytic theory disruption of therapeutic relationships; the margin­
and practice to this day. alisation of psychosocial approaches; and high frequency
However, Freud’s own theories were not always unified, of staff sickness and burnout due to the stresses of
and psychoanalytic theory and practice subsequently working with patients with mental disorders, who might
evolved into many different psychoanalytic schools and participate in risky behaviour, in inadequately resourced
traditions. In the USA, these schools of thought have services.
included the ego psychology school of Heinz Hartmann, Psychoanalysis does not, of course, offer easy
influenced by Anna Freud, the self-psychology school of explanations or solutions for these long-standing and
Heinz Kohut, and the object relations theory of complex problems. However, psychoanalytic
Otto Kernberg. In the UK, the works of Melanie Klein conceptualisations of human psychological processes
and Donald Winnicott have been prominent, with and behaviour, psycho­ analytically informed develop­
Melanie Klein emphasising the role of innate envy, mental theories, and specific applications of psycho­
destructiveness, and primitive unconscious fantasies in analytic thinking and practice within mental health
early development, and Donald Winnicott the role of the services could be helpful in complementing other
mother and the environment. Their work formed the approaches within the field of mental health, in under­
basis of object relations theory, which expanded Freud’s standing the nature of these difficulties, and in initiating
focus on intrapsychic factors and individual autonomy by therapeutic change within complex systems of care. This
proposing that development takes place within a Review explores how key Freudian psychoanalytic
relational context, ideas that were further developed by concepts, such as unconscious mental processes, a
John Bowlby and his seminal work on attachment. developmental approach to psycho­ pathology, defence
Meanwhile, the French psychoanalyst Jacques Lacan mechanisms, transference and countert­ ransference
developed Freud’s earlier theories into his distinctive dynamics, and the elaboration of these concepts by
writings, which have been particularly influential in subsequent psychoanalytic theorists, could implicitly
France and South America. In the 1980s, a number of inform a clinician’s day-to-day work within the mental
postmodern schools of thought emerged, such as the health field, and offer insights and improvements in
relational, intersubjectivist, and constructivist schools, patient care. The Review concludes with a summary of

www.thelancet.com/psychiatry Published online March 21, 2018 http://dx.doi.org/10.1016/S2215-0366(18)30052-X 1

 Review

advances in the development of evidence-based psycho­ assessment process, and focusing on their individual
1
analytic psycho­therapies, and in the inter­
disciplinary experiences of their illness. The patient’s unique
dialogues between psychoanalysis, attachment studies, subjective experience, influenced by unconscious forces,
develop­mental research, and neuroscience. acts as a lens through which the determinants of their
5 mental illness shape the nature of their symptoms and
Reclaiming subjectivity in diagnosis and behaviours. Phenomeno­logical attention to the structure
assessment and form of a symptom is integral to the psychoanalytic
The development of psychiatry has been strongly conceptualisation of symptomatology in giving clues
influenced by a tradition of positivism and empiricism, about its underlying anxieties, conflicts, and defences;
an approach advanced most notably in the natural 10 however, psychoanalysis goes further in attributing
sciences. Positivism promotes a stance of objectivity in unconscious meaning to the patient’s manifest
which phenomena are accurately defined, externally symptoms and behaviours, and proposes that
validated, and reliably applied; by contrast, subjectivity— understanding this meaning might help both clinicians
that of perceptions, interpretation, and individual and patients within the therapeutic context.
narratives of past experience—is avoided, because it is 15
unreliable and obscures or distorts how things really are. Is there meaning in madness?
Challenges to the dominance of the positivistic paradigm The delusional world of patients with psychosis might
have not only come from psychoanalysts, but were also seem impenetrable to understanding, an attitude that is
one of the underpinnings of the antipsychiatry movement enshrined in Jaspers’4 concept of the so-called
in the 1960s;3 however, despite the growing acceptance of 20 un-understandable delusions of schizophrenia, and
the importance of service user involvement—the therefore attempts to decipher their meaning can seem
so-called lived experience and patient voice—the futile. Moreover, these patients’ concrete commun-
centrality of meaning, elucidation, sensibility, and ications, lack of affectivity, and poor capacity for symbolic
subjective experience within the therapeutic encounter and abstract thinking can inhibit meaningful dialogue,
arguably remain somewhat neglected in modern 25 and weaken the responses of mental health professionals
psychiatric practice. tasked with looking after them, whose responses can
The psychoanalytic approach is focused on subjective become as concrete (eg, form filling or administering
experience, exploring the vagaries and vicissitudes of the medication) as those of their patients.5
human mind, elucidating the patient’s internal world— Freud proposed that in neurosis, repression is partly
their fantasies, dreams, hopes, feelings, wishes, 30 successful, and disturbing thoughts and wishes emerge
motivations, anxieties, and defences—both conscious into consciousness under the guise of symptoms
and unconscious. The paradox of the psychoanalytic that cause distress, but do not completely destabilise
method is that its therapeutic instrument, unlike the ego functioning.6 Freud saw psychosis, however,
surgeon’s scalpel, is identical to the object of its as a failure of repression, which leads to the mind
treatment: the interaction of two minds, the emotional 35 being overwhelmed with disturbing thoughts and
distress of the patient contained by the emotional feelings arising from the unconscious, and delusions
receptivity of the therapist, unconscious communications as an attempt to repair a fragmentary inner world by
between the one listening and the other talking. The remodelling reality. Subsequently, Klein7 and Bion8
contents of the unconscious are fundamentally developed the idea that the symptoms in themselves
inaccessible, and are only revealed to us through dreams, 40 do not define psychotic illness, but are defences against
slips of the tongue, mannerisms, and symptoms. The underlying anxieties, which cannot be symbolised
enigmatic and fleeting nature of the unconscious is at or consciously reflected on. Lacan9–11 introduced the
odds with the concrete nature of bodily matter, in which idea that psychosis arises from foreclosure, a specific
illness can be detected, diagnosed, and treated according defence mechanism in which the so-called name of the
to a positivist model of medical science. Symptoms or 45 father (or paternal function) is rejected. Lacan proposed
behaviours represent adaptive distortions hiding that the father plays an essential role in structuring
unconscious drives, fantasies, conflicts, anxieties, the child’s inner world, and does so by intervening in
defences, and object relations that are deemed the dyadic relationship between mother and child to
unacceptable, or intolerable, to the conscious mind. facilitate separation by introducing the child to culture,
Their overt phenomenology is not a basis for 50 language, social reality, and meaning—the so-called
classification, as in the diagnostic systems of the DSM symbolic order. In psychosis, this process has been
or ICD, but represents the manifest indications of curtailed or foreclosed, and the individual remains
underlying psychic conflicts, which become the focus of within the so-called imaginary order, in which no
therapeutic intervention. meaningful symbolic sense can be made of experience,
Psychoanalysis does not reject the importance of 55 and psychotic delusions and hallucinations are the result
descriptive phenomenology but enhances its subjective of the individual striving to account for what he or she
perspective by explicitly engaging the patient in the experiences.

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 Review

Like Lacan, other psychoanalysts working with 1 delusions of being poisoned by maternal figures such as
psychotic patients in the UK and USA, notably nurses, who are meant to be caring but instead are
Winnicott,12 Stack Sullivan,13 and Searles,14 located the abusive in the delusion. Moreover, his internal conflicts
origins of their illness in early environmental deficits about his racial and masculine identity, stemming from
and traumas, particularly the very early relationship 5 his early experience of his abusive mother, inform the
between mother and infant. However, double bind theory content of his psychotic symptoms in his delusional
and the notion of the so-called schizophrenogenic mistrust of black female staff, and the voices that
mother, who causes her child to become psychotic in the undermine his masculinity. His vulnerability to the effect
context of contradictory communications within families of experiences of loss could be compounded by a genetic
of individuals with psychosis,15 made such families feel 10 predisposition to psychosis, because the patient had a
blamed, and this led to a rejection of the contribution first-degree relative with schizophrenia. From a Lacanian
of psychoanalytic thinking to understanding the cause of viewpoint, his psychosis had arisen in the context of
psychosis in favour of biological explanations. However, paternal absence, and without the symbolising function
evidence suggests that childhood trauma, neglect, and of the so-called name of the father, the patient continued
abuse could play a role in the origins and maintenance of 15 to have psychotic symptoms of persecutory delusions
psychotic illnesses.16 A meta-analysis of relevant studies and hallucinations.
published between 1980 and 2011 found that childhood The direct interpretation to the patient of the potential
sexual, emotional, and physical abuse, emotional neglect, unconscious meanings of his psychotic illness is likely to
bullying, and parental death increased the risk of be destabilising to him, and would disrupt the precarious
developing psychosis by almost three times.17 Individuals 20 defensive nature of his symptoms, which protect him
who were exposed to trauma and adversity at a younger against unbearable feelings of aggression, humiliation,
age or exposed to trauma over a prolonged period were at shame, and loss. However, a shared exploration within
a higher risk of developing psychosis.18 the staff group caring for the patient of the unconscious
A contemporary psychoanalytic or psychodynamic fantasies and fears that might underlie his psychosis
model of psychosis proposes that environmental events 25 could enable them to understand how his previous
and experiences interact with genetic and biological experiences have shaped the content and meaning of his
factors in the context of early attachment relationships to symptoms, and help the staff to offer compassionate care
increase a person’s vulnerability to psychosis. These and containment for a patient who might be rejecting
interactions alter the developing cognitive-affective them, without acting on their countertransference
schemas concerning relationships that develop between 30 feelings of anger and humiliation by rejecting the patient.
the individual and others, and interfere with the
development of the capacity to tolerate emotions, Countertransference, defences, and toxic
modulate impulses, and mentalise.19 Psychosis develops institutions
when current stresses overwhelm the mind’s capacity to Countertransference, the correlate of transference,
bear, reflect on, and integrate painful mental experiences 35 describes the therapist’s experiences of the patient, and
or, from a biological viewpoint, when external factors particularly those that are affective and somatic. Freud20,21
trigger endogenous and genetic vulnerabilities that alter originally viewed countertransference as an obstacle to
the structure and functioning of the brain. The impact therapeutic progress and a manifestation of unresolved
and experience of current stressors are also determined conflicts within the analyst. However, later psychoanalysts
by their meaning for the individual, which is influenced 40 such as Heimann,22 Racker,23 and Sandler24 highlighted
by previous life experiences. the utility of countertransference as a therapeutic
For example, a mixed-race patient presented with instrument by understanding the patient’s contribution
first-onset psychosis following the breakup of a to the therapist’s countertransference, in which the
relationship with his white girlfriend. His psychotic patient’s unwanted feelings are projected into the
symptoms consisted of persecutory delusions of being 45 therapist, who is then made to feel and act in ways that
poisoned by black female nursing staff, and third-person are unfamiliar. This view led to a change in psychoanalytic
auditory hallucinations accusing him that he was not a technique, in which close attention to transference–
real man. In his history, his father had a diagnosis of countertransference dynamics in the therapeutic
schizophrenia and left when he was a baby, leaving him relationship can give insights into the unconscious and
in the care of his white mother who repeatedly told him 50 internal object relationships of the patient, which are
that he was “bad like your black father”. Here we might repeated in their external relationships. More recent
formulate that the rejection from his girlfriend awoke conceptualisations of transference and counter-
previously repressed unresolved feelings of loss and transference from inter­ subjective and relational
abandonment towards his father and aggressive feelings perspectives emphasise equality and mutuality, whereby
towards his mother, which were intolerable to his 55 unconscious aspects of both the patient and therapist
conscious mind and therefore projected onto other interact and influence each other, and meaning and
people, and these feelings returned in the form of insight are co-constructed within the therapeutic

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 Review

relationship, rather than via the therapist’s objective 1 Various types of staff groups offering support and
observations of the patient’s projections.25–27 supervision, such as reflective practice, case discussion,
Reflection on the countertransferential feelings and and Balint groups, are available within mental health
reactions professionals have towards their patients can services, and provide a space for staff to think about their
help them to understand how they unconsciously 5 work with patients and reclaim their focus on good
distance and defend themselves from the anxieties that clinical care. However, case discussion groups tend to
come from working with patients with mental illnesses, focus on the diagnosis and formulation and management
by adopting particular attitudes and behaviours. of specific patients, rather than on the staff’s emotional
Unacknowledged and unchecked feelings such as anger, reactions to patients, and how these are enacted at
therapeutic nihilism, or despair towards difficult patients 10 both an individual and systemic level.32 Moreover, the
whom the professionals are managing in tough working provision of regular reflective multidisciplinary forums
environments, in which the expression of emotions is are often difficult to implement in a meaningful and
discouraged, could lead staff to unconsciously enact sustained way, and when they are available, they are often
aggressive responses towards their patients, such as not attended by senior staff, and are thought of as a
unnecessary seclusion, withholding leave, or boundary 15 luxury rather than essential to patient care and staff
violations. wellbeing. The reluctance of staff to engage in these
Not only do individual clinicians struggle during forums could be because they find it difficult to cultivate
encounters with their patients’ mental illnesses, but on a and sustain an attitude of awareness and reflection on
wider scale the staff group as a whole might also their emotional responses and how these might influence
unconsciously use organised pathological group 20 their work, and find it difficult to develop a capacity for
defences, such as ritualised form filling, scheduling self-reflection and emotional attunement with patients—
frequent meetings, or organising staff rotas, to distance ie, an attitude of affective subjectivity33—because this
themselves from having any prolonged emotional contact brings them closer to their own vulnerabilities and
with patients committed to their care. Bion28 described limitations. However, by pushing these thoughts out of
how latent defensive group cultures, or basic 25 awareness and repressing them into the unconscious,
assumptions, can develop as a defence against primitive the ability of staff to relate to patients, enter their
anxieties of dependence, aggression, and sexuality, and subjective world, and contain, understand and reduce
to block the more conscious and manifest work of the the distress of both individual patients and the
staff group. organisations that look after them is impeded.
On the basis of Bion’s ideas, and theories of social 30
defence systems,29,30 Hinshelwood31 and others have Evidence-based psychodynamic
shown how institutional dynamics, and small and large psychotherapies
dynamic group processes that occur between staff and One of the persistent criticisms of the psychoanalytic
patients within institutions, can hinder the effective discipline is that its concepts and treatments lack
functioning of the whole organisation. The psycho­ 35 empirical evidence. Historically, there have been various
pathology of patients seeps into that of the institution in challenges to undertaking methodologically sound
which they are detained, in a reciprocal exchange of studies of psychoanalytic or psychodynamic therapies,
destructive projections and defences between patients which have undergone little outcome and process
who are mentally ill who often engage in risky behaviour, research in the field. These challenges include the
and fragile and demoralised staff, who might have their 40 following: the poor methodology of many existing
own unconscious disturbances that become more evident studies, such as unclearly defined patient samples or
in conditions of stress. Damaging defensive practices treatment methods, absence of adequate controls, and
used by individual professionals become common insufficient monitoring of adherence to the treatment
practice in the institution where patients are siloed, and model and inter-rater reliability; resistance within the
the anxieties and tensions between staff and patients 45 psychoanalytic community to research methods such as
might lead to rivalry and splintering within the staff the manualisation of treatments, randomisation of
group. Staff who cannot endure the daily emotional patients, recording of therapy sessions, studying of
stress are more likely to require sick leave or to have narrowly defined research samples that are not
burnout; those who stay do so by adopting the same representative of clinical practice, and scepticism within
primitive defence mechanisms—such as denial, 50 the community as to whether unconscious conflicts,
splitting, and projection—and dysfunctional ways of defences, and fantasies can be measured; and, finally,
relating as their patients. The fragmentation of the difficulties in investigating longer-term treatments and
institution mirrors the fragmented minds of many of the outcomes.34
patients, a reflection of lives that might be chaotic and Although some empirical evidence can be found for
damaged, in which their early experiences of disturbed 55 the efficacy of psychoanalysis35–38 for complex mental
attachments, loss, abuse, or rejection are repeated by the disorders, most of the studies are not controlled, which
unconscious enactments of the staff. limits the interpretation of the results. More robust

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 Review

research has been done on psychodynamic psycho­ 1 following cessation of therapy than do short-term
therapies. The terms psychoanalytic psychotherapy and treatments,55 and that effect sizes might not become
psychodynamic psychotherapy are often used inter­ evident until some time after treatment has ceased,
changeably, but psychodynamic therapy is usually suggesting the need for longer-term follow up.56
considered to be a broader umbrella concept for 5 The previously mentioned findings should be viewed
psychotherapy modalities that have been adapted to with some caution. Consistent with the so-called dodo
different degrees from psychoanalytic principles, are less effect (ie, the notion that all psychotherapies have
intensive than treatment with psychoanalysis, and equivalent outcomes regardless of their differences),57,58
operate on an interpretive–supportive continuum. Many the comparison of psychodynamic psychotherapy with
of these modalities were initially developed for treating 10 active treatments rarely identifies psychodynamic
specific disorders—such as mentalisation-based therapy as superior to control inter­ventions, a finding
treatment39 or transference-focused therapy40 for that is usually explained by the real agents of change
borderline personality disorder, cognitive analytic being common factors—ie, techniques and mechanisms
therapy41,42 for depression, dynamic interpersonal common to all therapies. However, others argue that the
therapy43 for anxiety and depression, and panic-focused 15 dodo effect is due to a failure to measure real differences
psychodynamic psycho­therapy for panic disorder44—and between different therapies that exist but have eluded
some have been subsequently generalised to treat a wider detection because current measures are inadequate.49
range of conditions. These therapies tend to be time Nevertheless, competition between psychotherapies and
limited, have a clear theoretical basis, and are manualised. other types of psychological therapies, especially CBT, is
In the past two decades, an increasing number of 20 often unhelpful, and efforts would be better focused on
high-quality individual randomised controlled trials, defining conceptual similarities and differences in
meta-analyses, and systemic reviews assessing the therapeutic paradigms, and identifying which
efficacy of short-term and long-term psychodynamic psychological modalities are most appropriate for specific
psychotherapy have been done in a range of mental mental disorders within a complex context of treatment
disorders and have reported effect sizes as large as other 25 efficacy and effectiveness, cost-effectiveness, patient
evidence-based therapies such as cognitive behavioural choice, and availability of treatments.
therapy (CBT).45–48 These findings contradict the Moreover, a shift has occurred within psychotherapy
widespread belief that psychodynamic approaches are research, pioneered by researchers in the field of CBT,59–61
short on empirical support, a myth that could reflect the and later those within psychodynamic psychotherapy,
selective dissemination of robust research findings.49 30 from developing manualised approaches focused on
Corroborated by several meta-analyses, a systemic single disorders towards transdiagnostic and modular
review50 of psychodynamic therapy for specific mental treatments, which focus on similarities among disorders,
disorders identified 64 randomised controlled trials that particularly those in similar classes of diagnoses that are
provide evidence for the efficacy of psycho­ dynamic associated with a high risk of comorbidity, such as anxiety
psychotherapy in common mental health disorders, 35 disorders.48 This approach could be particularly suited to
including depressive and anxiety disorders, eating psychodynamic psychotherapy, because it is traditionally
disorders, complicated grief, somatoform disorders, less tailored to the symptoms of single mental disorders,
personality disorders, substance-related disorders, and rather than problems, especially in the relational sphere,
post-traumatic stress disorder. that are common to many mental conditions, and
Most of these studies investigated short-term 40 promotes a dimensional model of classification focusing
psychodynamic psychotherapies (eight to 40 sessions). on the core underlying processes of mental conditions.
However, some evidence suggests that long-term psycho­
dynamic psychotherapy (12–36 months) in complex Attachment, developmental research, and
mental disorders is effective. In several meta-analyses, neuroscience
long-term psychodynamic psychotherapy was 45 The interdisciplinary collaboration between psycho­
significantly more effective at improving target problems, analysis and attachment research has provided one of
general psychiatric symptoms, and personality and social the most convincing theoretical frameworks guiding
functioning than were shorter or less intensive forms of psychodynamic treatment and research today. The notion
treatment in patients with complex mental disorders, of attachment stems from the seminal work of the
defined as chronic mental disorders, personality 50 psychoanalyst Bowlby,62–64 who integrated psychoanalytic
disorders, or multiple comorbid disorders.51–54 These ideas with ethology and evolutionary theory to form a
findings are consistent with data on dose–effect relations, model of child development, in which the child’s earliest
which suggest that for many patients with complex relationships with caregivers lead to the development of
mental disorders, including chronic mental disorders internal working models, or cognitive-affective schemas,
and personality disorders, short-term psycho­therapy is 55 which guide the child’s perceptions, emotions, thoughts,
not sufficient.50 Moreover, some evidence indicates that expectations, and relationships in later life. Bowlby’s
long-term treatments have better longer-term outcomes ideas gained empirical validity in subsequent research

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 Review

showing that infants with insecure attachments, caused 1 difficult to differentiate and regulate.
by early disruptions in their primary relationships as a These findings from psychoanalytically-informed
result of separation, trauma, or loss, were more likely to developmental research have implications for clinical
experience psychopathology and relationship difficulties theory and therapeutic action. Psychotherapy can be seen
in later life;65,66 furthermore, representations of an adult’s 5 as being associated with the developmental framework of
attachment experiences have substantial influence on attachment theory, in which the therapist acts as a secure
their own children’s development and attachment base and temporary attachment figure who helps the
patterns, defining their socioemotional functioning in patient explore the link between past and current
adulthood.67 relationships. Within the therapeutic relationship,
These findings, based on the direct observation of 10 transference and countertransference can be used to
infants and children in relation to their caregivers, explore changes in the patient’s internal working models,
challenge traditional psychoanalytic theories of child to expose how the relationship with the therapist is linked
development that are based on retrospective inferences to external relationships, and to provide the opportunity
from adult psychoanalyses, such as classical Freudian for these working models to shift and adapt, allowing the
and Kleinian accounts, in which the baby is primarily 15 patient to feel and act in new ways based on current,
motivated by drive instincts. In the attachment model, rather than past, experience.78 Non-verbal communication,
the baby is considered relational from the start: the baby’s and other implicit relational and affective processes
mind is organised and oriented to the external world and within the intersubjective relationship between patient
human interaction from birth, and development is and therapist, are now recognised as crucial factors in
motivated by social relationships. Psycho­ analytically 20 initiating therapeutic change in psychoanalytic psycho-
oriented developmental infant researchers such as therapy, in addition to the traditional mutative role
Stern,68 Schore,69 Lyons-Ruth,70 and Tronick71 have shown assigned to the patient who gains a conscious insight into
that the intersubjective relationship between infant and their difficulties. Therapeutic techniques are now more
parent is the fundamental unit in which psychological directly linked to theories of therapeutic action, and have
development originates. In this relationship, the mutual 25 been systematised into manualised psychodynamic
processes of non-verbal communications, transmitted via psychotherapies developed for personality disorders and
motor activity, affect, and sensation between infant and other mental conditions, such as mentalisation-based
caregiver, are the core motivators and organisers of treatment, which is specifically based within an
experience, and drive the development of affect attachment framework, and in which the therapist’s
regulation, impulse control, autonomy, and sense of 30 points of view, attitudes, and skills are explicitly directed
identity, all of which constitute key elements of at increasing the patient’s capacity to mentalise.
the person’s emerging personality. Such research Finally, a growing number of practitioners and
affirms some basic assumptions of the psychoanalytic researchers are exploring the interface between
developmental approach, such as the formative role of psychoanalysis and neuroscience. Prominent psycho­
early life experiences, normal and disrupted development, 35 analysts such as Gabbard79 have explored the neuro­
a person-centred perspective, complexity of development, biological correlates of psychoanalytic psychotherapy,
and a focus on the inner world.72 with implications for diagnosis and treatment. The work
Fonagy and others73–75 have built on attachment of interdisciplinary researchers, such as Damasio,80
research, and have drawn from psychoanalytic theories of Panksepp,81 and Solms,82 highlight the association between
child development, such as those of Winnicott76 and 40 affective neuroscience and the psychodynamic domains of
Bion,77 to introduce the concept of mentalisation. emotion and instinctual drive, progress in neuro­
Mentalisation is an essential and uniquely human psychology with the discovery of mirror neurons83,84 and
psychological process that involves the capacity to reflect their links to psychoanalytic conceptualisations of
and understand the contents and processes of our own empathy and unconscious communication, and advances
and other people’s mental states, including thoughts, 45 in cognitive science in which traditional cognitive modular
beliefs, desires, affects, wishes, and intentions, and to be and computationalist views of the mind are shifting to
able to interpret our own actions and those of others as more complex models of neurocognitive organisation and
meaningful, and based on intentional mental states. In function, which might be compatible with psychoanalytic
normal development, the capacity to mentalise arises via models of dynamic mental processes.85
the intersubjective process of emerging psychological 50
awareness between the child and mother or caregiver, in Conclusion
the context of secure attachment. Disruptions in early Psychoanalytic studies have become more embedded in
attachment, through experiences of trauma, loss, abuse, empirical research and provide increasing evidence for
and neglect, interfere with the normal development of the validity of some psychoanalytic concepts and for the
mentalisation, and can lead to personality pathology in 55 effectiveness of psychoanalytic therapies, findings that
adulthood, such that the person’s representations of are important in ensuring that psychoanalysis and its
themselves and others are unstable, and affect states are insights, applications, and treatments survive in a rapidly

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 Review

1 11 Vanheule S. Conceptualising and treating psychosis: a Lacanian

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