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Jeremy Holmes is a psychiatrist and psychoanalytic psychotherapist who works in the British National Health Service. He has written extensively on the political, economic and clinical challenges associated with the provision of psychoanalytic therapy, particularly in a public service setting. His paper was made available for free downloading at the IJPA Web Site at ijpa.org on 28 April 1998 (complete issues of the International Journal are now also available for free viewing via the same site address). Unusually for this discussion group, the initial response to the paper was slow—in fact, silent—and this is taken up by a number of contributors (see below). There then ensued an unusually long discussion!
What follows is only a précis of Holmes's paper: the full paper must be read if its detailed argument is to be understood. Holmes is concerned to relate traditional psychoanalytic ideas regarding aims and outcomes to the financial, theoretical and technical factors that affect and characterise contemporary psychoanalytic psychotherapy. For example, there is an emphasis today on splitting rather than repression, on issues of attachment and on achieving realistic goals. Cognitive behavioural psychotherapy shows possible areas of overlap with psychoanalytic psychotherapy. Attachment theory proposes that patient-therapist attunement is likely to be a key variable in outcome (Holmes wishes to stress the importance of this attachment perspective). He opens by quoting John Stuart Mill, who never renounced Bentham's utilitarianism, but who at the same time sensed that a society that aimed directly at happiness would be unlikely to achieve it. For Mill, autonomy and choice were goods in themselves, producing benefits as important as pleasure. Happiness, he believed, could not be legislated for: it was always a by-product of some other activity. Holmes sees parallels in the Bentham-Mill divide with the problem of aims and ‘aimlessness’ in the current deb