Putting Theory into Practice: Struggling with Perversion and Chaos in the Analytic Process*

At the risk of stating the obvious, I would like to preface this paper by saying that psychoanalytic psychotherapy with disturbed patients is an extremely difficult and arduous process. Particularly when working in the NHS, with its increasingly stretched resources, psychoanalytically trained psychotherapists tend to see patients from the most extreme end of the spectrum of referrals. The pressures that these patients put on us and our way of working need frankly to be acknowledged and recognised by setting realistic and often limited treatment objectives. It is important to bear these considerations in mind constantly, so as not to become disheartened or surprised when faced with what at times seems to be insurmountable obstacles in the path of psychic change. In the light of the severity of many patients’ histories and presenting problems, it would be naive to expect otherwise.

Introduction

There are many occasions in clinical practice when the problem of “what to do” (within which I am including verbal doing), as opposed to understanding the question of “why”, raises great uncertainty in the therapist. I suspect that work with children and adolescents is particularly difficult in this respect as frequently so much of the analytic process is embodied in the manner in which the basic boundaries of the sessions are upheld, and then challenged by the patients. The therapists’ actions are more likely to be understood than their words. This puts an increased emphasis on the importance of many issues which could easily be regarded as matters of management rather than being central to the analytic process itself. What we actually “do” has to be distilled from clinical experience as well as from the theory which stimulates our thinking and understanding.

In this paper I would like to discuss the many questions that have been raised for me in the treatment of a sexually perverse child. These questions have made me wonder about the appropriateness of “classical” techniq