Psycho-analytic Psychotherapy in South Africa

In this paper, we are concerned with the relevance of psychodynamic therapy in the South African context, where treatment is often brief, interrupted and conducted in compromised conditions. We present the case of Lana, a 25 year old South African coloured woman, who was diagnosed with depression and who sought psychotherapy at a university clinic. We aim to illustrate how focusing on the specificity of the case (the dynamics of the patient and therapist and their particular process) over and above the psychiatric diagnosis of the patient, was helpful therapeutically. It is our contention that understanding one’s patient from a psychodynamic perspective can have value in the South African public sector. After introducing the case, we present the psychodynamic formulation which draws on McWilliams’s notion of psychodynamic diagnosis and Fairbairn’s object relations theory. We then discuss the ways in which the formulation facilitated an idiosyncratic approach to understanding and working with Lana over the course of therapy, and how this led to positive therapeutic outcomes. We argue that focusing on the specificity of cases is important in facilitating effective therapeutic interventions, and that this may be particularly true in contexts where a compromised treatment structure and power differentials can lead to therapist paralysis or other enactments.

In keeping with much of the psychoanalytic literature of his time, Bion did not write about the shame affects, at least, not by name. After a brief review of some of the central issues that shame dynamics raise, some key theoretical ideas put forward by Bion are developed towards an understanding of shame as linked to a terror of emergence in ‘becoming’ one’s self. The formulation rests on three main ideas. Firstly, shame is understood to be an emergent emotion existing in a ‘shame-space’ between Bion’s bi-polar formulation of narcissistic and socialistic tendencies. Secondly, pathological shame is understood to develop from repeated denial of normal projective identifications and the painful rejection of the infant’s curiosity, vitality and capacity for communication in the eyes of the other. This leads to an acute sense of disorientation caused by the breakdown or loss of conception of the self. Finally, the defensive organisation linked to pathological shame is considered, with emphasis given to phantasies of ‘possessing O’ and the imitation of ideal forms. A case is used to illustrate the realisation of these ideas.