Book Review: Being and Relating in Psychotherapy: Ontology and Therapeutic Practice

This book is an attempt at widening the lens of contemporary psychodynamic psychotherapeutic practice with its psychoanalytic foundations to considerations of what it means to be human in a wider context of life. Thus, the various authors consider not only the intrapsychic (drives, instinct, conflict and tensions within) but also pay attention to the relationship and situate it within the wider connections and influences of both the social and the cultural.

It is structured in three different parts, the first part looks at the therapeutic relationship per se by considering briefly ontology, the healing aspect of the therapeutic relationship, considerations on the 'talking cure' and what might be going on when clients 'refuse' to speak, and an introduction into Buber's concept of the I-Thou. The second part explores themes such as love, shame, loneliness and mortality. And finally, in the third part the net is cast wider into social and cultural dynamics by considering the nature of the self, diversity, sexuality, the artist in psychotherapy, religion and time.

The majority of the authors of this book have an association with the WPF (the Westminster Pastoral Foundation), a charity that came into existence in the late 1960s within the Methodist Church, as a way of supporting the community and pastoral work with the insights of psychotherapy, the psychodynamic and psychoanalytic in particular. It has become a provider for psychodynamic counselling, therapy and training and most authors of the chapters have been or are involved with WPF in the capacity of a training or supervisory role. It is not made clear in the book as to why there is this link between the authors and the training institution leaving the reader wondering about that.

To consider ontological questions invariably requires an attitude of openness that allows for those fundamental questions about our way of being and relating both in and outside of the therapeutic sphere to unfold. This is challenging because it looks at what it means to be alive, what it means to exist, what existence is, who does the existing and how this being that exists can reflect on itself and its own way of being. The question as to how to approach an understanding of human existence inevitably becomes also a question about methodology. How best do we arrive at an understanding of ontological questions?

Psychodynamic theory and the psychoanalytic body of thought in general rely on an interpretative method in order to make sense of client material. The theory takes centre stage and presentations of problems, or conflicts, which form a central idea, are relayed back to the theory, thus representing a closed, rather than an open, system.

Psychoanalytic theory has been hugely influential in the field of human psychology and in therapeutic practice. It began with Freud at the end of the 19th century, who developed both theory and treatment methods and branched out into a wide array of models, such as Jungian psychology, ego psychology, object relations theory, Kleininianism, post-Kleininianism, Winnicottism, self-psychology which amounts to a babel tower of orientations (Rycroft, 1995). Most of the authors seemed to be influenced by many of these and largely denote a moving away from the solely intrapsychic, to the interrelational and spiritual realms of being.

One could say that all psychotherapeutic practices of today took Freud as the starting point and developed into their own systems of thought. There is no doubt that the drama of being born, of having to go through developmental stages that necessarily involve separation, therefore loss and pain, the utter helplessness of the infant in its dependency on a good enough carer/mother is certainly a powerful thing and Freud's writings, and subsequent thinkers like Melanie Klein or Donald Winnicott have captured people's experiences and their imagination, giving words to the dramatic conflicts of being that are universal. All humans are born, and there is a universal need to be loved and to be seen, and to be able to express oneself in one's own right.

How we understand this drama of living and being, what we make of it in a wider context of social and cultural forces is clearly a complicated matter. In reading the book I was struggling with feeling a connection between the psychodynamic and analytic theory and the ontological questions it was attempting to ask. In a sense it felt that the intrapsychic level of enquiry was ever so present, with the interrelational and social taken as a given, without an unpacking of language or terminology. The relational world and the interconnection of beings in context is taken as a given in the existential body of thought and this is clearly more of a challenging leap to make from a psychodynamic model.

The chosen structure of the book was not helping. It might have been useful to start off with Chapter 10, an Exploration into the Nature of the Self, rather than have it in the third part of the book alongside for example Chapter 13, The Artist's Fear of the Psychotherapist, where the title already alerts the reader that this is not tackling an ontological question but rather works on the premise of an assumption.

In fact the lack of clarity in structure and the place of ontological questions could be seen as evidence for an epistemological crisis of the authors. How do they know? Are they trying to get to an objective truth – or is truth subjective? Human nature and understanding of human existence continues to be a conundrum both within philosophy and psychology. There are ongoing debates around whether there is something that exists or comes before existence or whether existence precedes essence as Sartre claimed. We have by all means not arrived at a full understanding yet of this complex state of affairs.

Lets look then at some chapters in the book, in no particular order, and I will start with Chapter 10 that explores questions about the nature of the self. Some examples and ideas around the nature of self evoked in the reading of this chapter are that it encompasses both body and mind, is a totality of being, is constructed, is relational, is viewed and imagined through the eyes of the other, can be altered by brain damage, by mood, is evident through behaviour, posture, way of talking, appearance, who we are surrounded by, our roles, and outward changes require an assimilation to an inward sense of self, or perhaps the other way round, and that there is a sense of a cosmic self in the face of death and the awe of the unknown of existence.

The Healing Relationship in Chapter 2 takes the starting point of self, perhaps of life even, as originating and unfolding in the relationship between mother/primary carer and child. Attachment theory and neuroscience is taken as a given and seen as providing evidence that this first relationship is crucial in influencing negatively or positively the development of the infant into adulthood. Is it possible to question this premise? Is it possible that in this complex web of relationships and existence it is the primary relationship alone that makes or breaks a person's development? Attachment theory has been criticised for putting undue blame and responsibility on the mother, yet strangely the mother seems to take a subordinated place in psychoanalytic thought.

Chapter 12 offers an important challenge to the male-centric and phallus oriented world-view of psychoanalytic thought where the female is subordinated and seen as lacking in the possession and the power of the penis, where both the female and the male have to identify with the father to resolve inner conflicts of sexual nature, which are at the basis of human development and intentions. An interesting body of thought is presented drawing on the French Feminist, philosopher, linguist, psychoanalyst and cultural theorist Luce Irigaray (born 1930) who 'insists that a self-reflective psychoanalysis needs to be able to situate itself historically, accept its limitations and articulate a subjectivity which is both embedded and embodied within history and culture' (Greally, p 150). Irigaray starts from the fact that all human beings have been born from a mother, a fact that has been denied in psychoanalysis and amounts to symbolic matricide and misogyny. Women's and mother's subjectivity is denied and Irigaray warns against the danger of normative presumptions leading to clinical impasses.

Even though the feminist movement has come a long way, as a society we still struggle to accept and understand difference and discrimination whether based on gender, race, sexuality, age or religion. The author of Chapter 11 discusses diversity and argues that psychoanalysis has rejected Freud's liberal stance on homosexuality and has remained to this day quite homophobic because of its reliance on the Oedipal complex theory. The idea being that homosexuality or transgender or non-binary identifications are due to an unresolved conflict in the Oedipal phase. The author argues that remaining in an intrapersonal stance risks objectifying the client. By contrast moving into an intersubjective and relational stance, by paying attention to the experience between and within people, whilst exposing both the therapist and client to the perils of uncertainty and uncomfortable feelings, opens up the possibility of an interesting creative co-creation.

I like the conclusion of this chapter, which leaves me with a sense of openness and possibility, which stands as a counterpoint to this sense that the psychoanalytic central idea of internal conflicts, that have to be overcome and resolved, leaves little room for the possibility of an experience of self in relation to an other that is not suffused with conflict. Sometimes connecting to another feels cooperative, feels like something flows, feels inspirational and opens up questions about other ways and possibilities of being.

The possibility of such an encounter gets picked up in Chapter 4 where Buber's philosophy is looked at, which situates people and their way of being necessarily in relationship and not in isolation, from a relationship to the natural world, to that between people where spoken language inevitably is part of the encounter, to a connection to the spirit world, which does not necessitate language but connects in the form of creating, thinking and acting with our being. Healing in Buber's context happens in the encounter where the other is appreciated as a whole and not treated as a part or an object (I-it). The author in this chapter is not sure that such an encounter is possible but can be aspired to in the therapeutic encounter. The I-thou encounter seems possible to me, but it is not a permanent state of affairs.

The second part of the book, entitled the Personal and the Interpersonal, looks at various topics of great importance in relation to both therapy and life. It felt hard to contain the ins and outs of those themes within one chapter alone. Generosity, love, shame, loneliness, mortality from a psychodynamic perspective seemed to be first and foremost situated as intrapsychic, and then interpersonal conflicts that need to be resolved first in order to arrive at a stage of maturity or greater freedom, and their experience as a given of existence did not come across easily. There was little discussion of these themes as existential givens. Mortality is the one thing that can't be resolved, and the authors suggest needs to be fully engaged with, in an embodied and authentic way. I agree, but how do we do that? How can we face the terror of death? And for some death does not represent terror.

Some people feel a deep religious or spiritual connection to something bigger than themselves and this faith pulls them through the most distressing and harrowing experiences. They feel it gives them a meaning that goes beyond cruelty and helps them to be loving and generous to others around them. Religious values, the denial of it by Freud and still some psychoanalytic thinkers, gets tackled in Chapter 4 and the author argues for its value as giving the believer an ethical outlook on life. The author also rightly points out the long history of some religions, in this case Buddhism, and how they have over millennia led people to think deeply about existence and ethical matters. To deny this seems a little careless.

The authors' and the WPF's attempt at bringing ontological questions into the realm of psychotherapeutic theory and practice is commendable, but I wonder whether psychoanalytic theory as a whole necessarily fails in that attempt, because of its deterministic and positivistic outlook on human experience. This stands in direct contrast to a constructivist outlook of existential therapy and philosophy, where the experience of being and existing is created and constructed in the relationship.

The existential-phenomenological body of thought attempts to apprehend human existence in an as wide and open way as possible. In the realm of psychiatry, Ludwig Binswanger and Medard Boss were both associated with Freud or closely following his line of thought but incorporating philosophical ideas, those of Martin Heidegger in particular. The resulting body of thought, Daseinsanalysis, as well as later writings within the radical psychiatry of R.D. Laing, were attempts at encountering the human being and their existence in an intersubjective world of being and as a totality of being in its embodied form that is in a continuous process of becoming. The client's understanding of their existence is central and challenges diagnostic labels and interpretative reasoning. A careful encountering of the other through the method of phenomenological enquiry, which endeavours to describe phenomena as they arise in the relationship, by trying to leave assumptions aside as much as possible and piece information together, with no hierarchical imposition, to arrive at an as close understanding as possible of any given experience and the associated world-views.

The way a person experiences themselves and their world can be mapped onto four dimensions of life, which can serve as a guide of enquiry within psychotherapy (van Deurzen-Smith, E., and Young, S., 2009); the physical (Umwelt), the social (Mitwelt), the psychological (Eigenwelt) and the Spiritual (Überwelt). In response to the questions around the nature of the self of Chapter 10, I feel that these four dimensions can also be seen as senses of self that are developing, emerging and interacting with others and the outside world in different ways. The dimensions also give a framework onto which the psychoanalytic body of thought can be mapped, where for example the idea of the instincts and drives belong to the physical dimension, or internal conflict on the psychological dimension, leaving still space for other experiences and senses to be examined and understood on the other dimensions such as the social and the spiritual.

The book was a frustrating read and I feel that it has not managed to open up to ontological questions. The overall flavour of the book felt like a community that by and large struggles to free itself from the shackles of its own paradigm. The book perhaps is relevant to readers training at WPF or prospective trainees wishing to embark on training in this model. A better way of approaching this project might have been to enter into a dialogue with existential philosophy beyond Martin Buber, and to consider ideas from contemporary existential psychotherapists such as Yalom, Spinelli and van Deurzen. A dialogue between psychoanalysis and existential philosophy/therapy is possible, but necessitates openness and a willingness to be with questions that have the potential to dismantle firmly held beliefs, on both sides, and a desire to enter the creative realm of intersubjective truth-finding that opens the space up to how living and being is experienced without excluding an approaching of the why it may be so.

To find a framework that does justice to the complexity of human experience is important and on a larger scale will continue to be debated. The funding of therapy and the understanding of human suffering and dilemmas depends on that and in the long run becomes a crucial project since the well-being of people, or the lack thereof, is costing humanity and the health of this planet a great deal. Perhaps we have reached a point in history where it is time to lay to rest rivalries and competitions between psychotherapeutic approaches, to enter into the realm of dialogue and sharing in order to find a paradigm that assists the understanding of ever evolving ways of being human in today's world.

References

Greally, B. (2013) Sexuality and Therapeutic Practice, in Being and Relating in Psychotherapy, Ontology and Therapeutic Practice. London: Palgrave Macmillan.

Rycroft, C. (1995). A Critical Dictionary of Psychoanalysis. London: Penguin Books.

van Deurzen, E., & Young, S. (2009). Existential Perspectives on Supervision, Widening the Horizon of Psychotherapy and Counselling. London: Palgrave Macmillan.

Sara Angelini