This chapter provides an introduction to psychodynamic theory as applied to settings outwith the specialist psychotherapy clinic, paving the way for the chapters that follow in Part 4. An individual’s internal world affects how they relate to others. Others may be unconsciously invited into playing old roles that are familiar to the individual (such as rejecting, not listening, criticising), even though these roles bring difficulty and distress to both sides. This chapter explores how these powerful but sometimes ‘invisible’ interpersonal dynamics may play out between service users and staff in settings where the human relationship is at the fore (such as schools, social service agencies, and hospitals). We also discuss splitting within a clinical team and other system dynamics. In circumstances where services and professionals can sustain a good-enough therapeutic environment in the face of unconscious invitations to repeat a problematic relationship, trust may develop between service user and service and many people are able to discover new ways of forming relationships. This depends partly on the capacities and current state of the person using a service, but also, crucially, on the capacity of the professionals and services to observe and be reflective about both sides of the relationship.

This chapter describes two types of projective identification, acquisitive and attributive, which dominate relating towards self and other in the most severe and complex interpersonal difficulties commonly diagnosed as ‘personality disorder’. These difficulties are defined in psychoanalytic terms as narcissistic. These two forms of projective identification result in a distorted psychosomatic sense of what belongs to whom in the internal world, relating to others and relating to the body. This leads to complex somatic symptoms such as eating disorders and psychosomatic presentations. They also drive the pattern of service use: acquisitive projective identification leading to a pattern of medical or mental health hospitalisation and a requirement for 24-hour care; and attributive projective identification resulting in disengagement and denial of need. The chapter describes the patterns of interpersonal engagement and conflict commonly found in those with the most severe and complex problems in inpatient settings. Furthermore, a psychodynamic formulation is provided to aid teams in understanding these interpersonal dynamics, provide clarity in planning long-erm care, and to identify adaptations of technique required in psychotherapeutic work.

This chapter provides an overview of current thinking regarding the supporting theory of psychodynamic psychotherapy. Rather than going through theoretical constructs in historical order of when each theory was proposed, they are presented as a composite of past and present thinking that the authors have found to be clinically relevant. It commences by describing theories on the early development of the infant and the creation of the internal world and object relations. The chapter them moves on to the issue of accommodating to the world as it is experienced by the infant, outlining circumstances leading to adaptive and less adaptive development. The chapter then outlines ‘core theory’ which covers more traditional psychodynamic concepts such as conflict, resistance, and defence mechanisms with an emphasis on projective identification. The role of this latter defence mechanism is linked with the theoretical constructs of transference and countertransference. There is a section on the narcissistic constellation in order to help the reader negotiate later sections in the book. Finally the chapter concludes with an introduction to theories as to how change is effected in psychodynamic psychotherapy.

We live in a multiplicity of personal worlds, all connected through the power of our unconscious mind and its capacity for trance. This vast unconscious, far larger than conscious awareness, appears to initiate all our movements. The cognitive unconscious, with its perceptual-cognitive abilities, automated motor skills, and implicit memory, facilitates creative expression while clinically, our unconscious emotions, internal conflicts, and repressed desires drive the inspiration and passion of a creative trance. Relinquishing conscious control in the creative process can be a type of artistic projective identification. As the visual artist Joan Mitchell says, “the painting tells me what to do.” Unlike the slow sequential thinking of the conscious mind, the unconscious is a parallel processor quickly integrating multiple variables to bring depth and complexity into the creative process. It carries out multipart repeated behaviors that become automatic fluid expertise, as in the violinist no longer concentrating on finger positions and the archer instinctually positioning a bow.

Melanie Klein was the first child psychoanalyst who delineated the rich and astounding inner lives of infants and young children and demonstrated the fundamental importance of mothers’ roles in human development. She was one of the founders of the “object relation theory” school, and her concepts – including “projective identification,” “depressive position,” and “paranoid-schizophrenic position” – have remained influential in clinical practice. Klein grew up in an impoverished immigrant family and suffered from multiple losses during her childhood and young adulthood, including the death of her father and two of her siblings. During most of her adult life, she was weighed down by a very difficult marriage, as well as estrangement from her own children. Her decades’ long fights with Anna Freud made life even more difficult for her (and for others). Yet, she survived it all and went on to make major contributions. This chapter provides a sketch of Klein’s life, focusing on various difficulties confronting her throughout her life, and their relationship with her insights and contributions.

The chapter finds in Joyce’s ‘The Dead’ a radical problematization of idiolect, one that creates a specific form of unstable narrative practice. It finds within these problematics a demand for what will be called the Loyolan Position: a mental stance towards the crises both Loyola and Joyce mobilize. The chapter is marked by a fresh, sustained close reading of one of the most well-read and well-analysed stories in English.