Psychoanalytic Psychotherapy in Institutional Settings. Edited by Julia Pestalozzi, Serge Frische, R D Hinshelwood & Didier Houzel.  Karnac. Pp  222. £18.95.

This book links together eleven articles written by authors from eight different countries, mostly within the European Union. All are working within institutional settings set up to treat individuals with severe and enduring mental health difficulties. I begin with some general comments about the book and then proceed to elaborate some common themes running through each chapter. Most of the authors are not writing in their first language. This leads to a rather forced style at times, and a language which struggles to contain and symbolise the concepts being explored. At other times, the language is flowing and poetic but is suddenly jolted by harsh, cruel realities. Initially, I felt ready to criticise the book on these grounds. However, the more I have thought about it the more I realise that such criticisms or comments apply to my own work at the Cassel Hospital. Here too we struggle to contain the pain, distress and fragile emotions of our patients. Finding a common enough language, that facilitates communication rather than thoughtless action, is part of the everyday work here.

It is not easy to condense the thoughtfulness of this book into the space of a book review. There are, however, a number of common themes. First, patients recreate their difficulties within the relationships they form. Each institution must struggle to tolerate complex transferences. Within an institution, transference is often divided, split, refracted and/or defracted in a way that makes living through it tolerable. Individuals (staff and other patients) may serve within rôle and/or within their own personalities as attracters or collectors of particular forms of transference. The everydayness of life in institutions is a screen for projections. It is important to be able to tolerate the countertransference feelings evoked. Patients often enact their difficulties with a level of intrusion and force that may lead to dangerous counter-aggressive measures from staff. Institutional responses