Preface to the Third Edition

Psychoanalysis Inside Out

The first edition of this book was published over twenty years ago in 2003. It is a privilege to know that the book has been read by several generations of clinicians who have found something of value in it. Revisiting it for its third edition provides a welcome opportunity to reflect on the developments in the field over this extended period, and inevitably in my own practice too.

The core tenets of psychoanalysis as a model of the mind and as a form of psychological intervention have not substantially changed over the past twenty years. However, we now live in times when questions about race, religion, gender, sexuality and poverty are more present in the minds of psychoanalytic practitioners and their critics. The traditional analytic focus on the internal world is making room for a greater acknowledgement of the external world – real and virtual – and its impact on the mind of both therapist and patient.

At the time of writing in 2024, critics are knocking loudly at the door of the psychoanalytic establishment, urging it to take a close look at itself chiefly in relation to questions of diversity and inclusion. This was long overdue. To secure the credibility of our discipline and its relevance to current and future generations, we need to pay close attention to questions of diversity, for example, around gender and sexuality. Normative roles are somehow hardwired into psychoanalytic thinking, not least within the notion of the Oedipus complex, despite significant societal changes and new family configurations, all of which requires us to critically revisit cherished concepts. Reproductive technologies are fundamentally reshaping kinship categories and raise new possibilities for ‘non‐traditional’ family triangulations, but they also introduce new questions about the impact of our biotechnologically mediated ‘origins’ on psychic development (Marion, 2022; Raphael‐Leff, 2007). The classical psychoanalytic focus on vertical relationships, such as the parent–child, has also broadened to bring into view the importance of horizontal relationships such as those between siblings (Mitchell, 2023).

Despite challenges from feminist psychoanalytic theorists, psychoanalysis' phallocentric bias persists and contributes to the relative neglect in the literature, for example, of the meaning for both men and women of the biologically female procreative body (Balsam, 2019). Others have argued that there continues to be a misogynistic current not only within psychoanalytic thinking, but also in its institutions (Chamberlain, 2022). Approached from different angles, the message is clear: Freud's quest for universal theories needs revision. Our theories must engage with cultural, social, and embodied specificity in addition to what may be universal anxieties and conflicts. How psychoanalytic theory and practice engage with all these changes and new perspectives is a work in progress.

The shadow of psychoanalysis' historical pathologising of homosexuality hangs over the discipline (Hertzmann & Newbigin, 2023). Institutional apologies have now been issued worldwide. This is an essential part of the process of reparation for the normative violence perpetrated against both colleagues and patients. By virtue of their sexual orientation some colleagues were either denied the opportunity to train psychoanalytically or had to conceal their sexual orientation to do so (Drescher, 2008). Patients who were homosexual were de facto pathologised. No sooner did we begin to turn the corner in relation to homosexuality, the thorny question of transgender identities has now become the new focus of heated debate and controversy, once again provoking divergent perspectives amongst the psychoanalytic community (e.g., Blass, 2020; Bell, 2020; Saketopoulou, 2020; Lemma, 2022a).

The practice of psychoanalytic therapy involves an ongoing commitment to engage in a radical analysis of our psychic investments and our position in society without losing sight that such discourses are all the poorer if we fail to consider the operation of unconscious processes. This is nowhere more apparent than in relation to ‘identity politics’ that has become a dominant discourse and pressure point in many debates and institutions, including within psychoanalysis. The importance of factoring in our patients' social and cultural context cannot be disputed, but this recognition need not entail giving up on psychoanalysis' emphasis on the internal world, on unconscious processes, and how these shape individual subjectivities.1

As individual practitioners and as a discipline, we also need to consider how global events challenge our identities, beliefs and relationships. Pandemics, discrimination, wars, the rise of digital media usage, climate change, the increasing dominance of artificial intelligence in daily life – to name but a few of the realities and changes that we are all witnessing on a global scale – all need to be thought about in relation to how this positions us towards the patients with whom we work.

If we now turn to the place of psychoanalytic interventions in healthcare, over the past twenty years there has been steady change. Psychotherapy outcome studies have proliferated, and psychoanalytic approaches have fared well. This research is essential to secure the ongoing provision of psychoanalytic interventions within public health services. At the level of psychoanalytic technique, there is now greater openness to the need to adapt classical technique to make psychoanalytic interventions more accessible in a range of public health service settings, and to meet the needs of diverse patient groups, not least those patients who struggle with representing their experience and are prone to fragmentation and severe acting out.

Transference and countertransference remain central pillars of technique. However, the postmodern challenge to the notion of therapist neutrality,2 the increased acknowledgement of intersubjective processes operating on the analytic dyad, the impact of online work during the COVID‐19 pandemic on how we conceptualise the analytic setting, and the impact of digital technologies on the viability of maintaining the therapist's anonymity, are all examples of challenges that have encouraged a more critical approach to what it means to work psychoanalytically. This has opened the windows and let in some fresh thinking into the corridors of the psychoanalytic establishment.

As with any change, the revisions in theory, practice and institutional life are a slow and, at times, painful process. As we tread the path of necessary development, we must be careful not to throw out the psychoanalytic baby with the bathwater. I am critical of certain aspects of psychoanalytic theory and practice, as will become evident as you read this book. Even so, I have yet to find a more comprehensive and compelling account of the human mind that sheds important light on individual and group functioning and provides a rich method for intellectual and personal enquiry. And, of course, it provides a method of psychological intervention that can make a profound difference to people in psychic pain.

The psychoanalytic model may not have changed substantially since the first edition of this book, but I have evolved as a clinician, enriched by now 40 years of clinical experience and through my ongoing engagement with psychoanalysis and other disciplines. Since the second edition, I undertook a training in applied ethics that has helped me to approach psychoanalytic practice with a broader lens, enlivened by the questions that interdisciplinary dialogue promotes. This more recent influence on my thinking and practice will be apparent in the pages to follow.

About this Book

This book was originally inspired by teaching psychoanalysis to trainee clinical psychologists on the Doctorate in Clinical Psychology back in the 1990s at University College London and subsequently to other clinicians from different mental health backgrounds who were often approaching psychoanalysis with little knowledge or experience of it. Even so, many were primed to be critical of it based on prior learning or exposure to psychoanalytic interventions that had been experienced as unhelpful. I approach psychoanalysis in this book largely with this audience in mind, remembering some of the questions my students have put to me over the years and the criticisms they have voiced. However, this is not the only audience to whom this book is addressed. The book is intended primarily as a practical, clinical text for clinicians in the mental health field who are relative newcomers to the practice of psychoanalytic therapy and who are embarking on psychoanalytic training. It assumes a core background in one of the mental health professions, clinical experience with patients, and a degree of familiarity with the practice of psychotherapy and/or counselling more generally.

Teaching psychoanalysis has helped to remind me that when we are trained psychoanalytically it is all too easy to forget that our practice is based on so much that is taken for granted, and on the idiosyncrasies of our own personal analytic experiences with training therapists and supervisors, that it is unsurprising when the newcomer to it finds the ideas confusing and the theories difficult to translate into practice. Teaching is indeed a salutary experience – unless we teach the converted – since it forces us to revisit cherished assumptions. It has taught me to...