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Psychoanalytic training in South Africa: attending to the marginalia.

Introduction

Recent calls to reflect on the relevance of current models of psychoanalytic psychotherapy training in South Africa (Smith, 2014) and internationally (Kernberg, 2011) are of significant value in ushering in opportunities to take a meta-perspective, particularly for those, like myself, who are integrally involved in training programmes for clinical and counselling psychologists. Re-assessing the extent to which our current training programmes (across disciplines) that offer training in psychoanalytic work are able to address the challenges we face in contemporary South Africa has led to an emphasis on providing training in short term psychoanalytic psychotherapy models and on prioritising research on the efficacy and effectiveness of psychoanalytic psychotherapy (Smith, 2014). While these emphases are important and identified areas of much needed growth, in this paper my aim is to pay attention to issues that could be described as 'haunting' these directives for psychoanalytic training in South Africa. Here I am specifically using Frosh's (2013) recent reference to hauntings or ghostly transmissions as 'a presence that we are aware of, sometimes overwhelmed by, that embodies elements of past experience and future anxiety and hope, and that will not let us be' (p. 3, original emphasis). Paying attention to what 'haunts' these reflections on psychoanalytic training in South Africa is a specifically psychoanalytic endeavour because, Frosh argues, haunting and psychoanalysis go together: the latter 'refuses to allow its subjects to escape their ghostly remainders, the things that are left over from past happenings, or left out of conscious recognition' (2013, p. 3, original emphasis). The first part of this article describes and argues for the value of a different approach to thinking about psychoanalytic training in South Africa. Such an approach is concerned with the marginalia of the current narratives of psychoanalytic psychotherapy training, with 'the inconsistencies and incongruities appearing alongside the main text' (Nobus & Quinn, 2005, p. 28). The second part of this short paper engages with these elements which are argued to be lurking in the margins, and with identifying the possible unconscious libidinal attachments to these elements.

Hauntings and interruptions

It seems to me important to place our current concerns regarding 'the state of peril in which psychoanalysis finds itself today' (Smith, 2014, p. 27) in a broader context. In particular, I would like to draw attention to a global context within which psychoanalysis is being deployed outside of the therapy room to think about politics (e.g. Butler, 2003), gender (e.g. Gough, 2004), development studies (e.g. Kapoor, 2014), teaching and learning (e.g. Bibby, 2010), amongst numerous other 'non-psychological' concerns. This wider employment of psychoanalysis internationally can equally be found in our South African context (e.g. Hayes, 2012; Hook, 2012; Long, 2011). Certainly, employing psychoanalysis within these traditionally social rather than psychological spheres is not new. However, there is evidence of a growing impetus and organisation of this body of work in the past two decades under the term 'psychosocial studies'. Psychosocial studies specifies an approach or way of theorising that challenges the traditional divide between the social and the psychological; frequently employing psychoanalysis as a tool to traverse the division (Frosh & Baraitser, 2008). It is in light of this body of work that I want to argue for the value of reflecting on how psychoanalysis might be used to interrogate the ways in which the unconscious structures our current psychoanalytic training desires, debates and dilemmas. Rather than adding to the already existing and important directives for the future of psychoanalytic psychotherapy training in South Africa, I would like to look at what disturbs this way forward and at what is absent from this way forward, in a reflective move that is consistent with psychoanalysis 'in its most radical form' (Nobus & Quinn, 2005, p. 29).

Lacanian theory is a useful resource in conceptualising this endeavour which might be further articulated as an attempt to replace an understanding of the needs for psychoanalytic psychotherapy training with disrupting the representations of the future of psychoanalytic psychotherapy training in South Africa. Elliott (1994, p. 28) succinctly describes the Lacanian stance as follows:
   The distinguishing feature of poststructural
   psychoanalysis is the launching of a sustained critique
   on the very notion of 'self. The problem of
   contemporary experience, it is argued, is not located in
   the failure of autonomy itself but rather in the idea that
   a stable, personal self is attainable at all. What this
   means, at least in its more thoroughgoing versions, is a
   complete deconstruction of subjectivity. In
   contemporary psychoanalytic perspectives, the
   deconstruction is characterized by unconscious
   contradiction, dislocation, and polyvalency.


Drawing from the above, this reflective paper is premised on the unattainability of a unified, coherent argument for the future of psychoanalytic psychotherapy training in South Africa and the necessity of being critical of the extent to which psychoanalysis itself structures what it argues it should become in a kind of closed system (Parker, 2005). Smoothing over, resolving and identifying a way forward for training amongst debates and contentious issues is not the goal; rather the very things that disturb a clear way forward or are absent from the narratives for a way forward are what require our attention.

A useful conceptualisation of such a position is illustrated through Lacan's mirror stage which he argued was formative of the I function: the infant seeing him/herself in the mirror identifies with this image. Lacan (1949/2006) argues that this is experienced as a 'transformation' (p. 76). In opposition to the experience of the self as an amalgamation of non-unitary desires and impulses, the infant is presented with a coherent, unified gestalt. Lacan (1949/2006) makes it clear that this form presented to the infant from the outside ' situates the agency known as the ego ... in a fictional direction' (p. 76) and is the first of many instances of misrecognition, providing the illusion of autonomy. Applying this misrecognition to the current concern, we might think that we can forge a future for ourselves as psychoanalytic practitioners, but this is an illusion; rather our future forges us through representations of psychoanalytic work and through our (conscious and unconscious) investments in these representations, investments that belie what might be difficult to know. It is with these representations, the assumptions that 'haunt' these representations and our attachments to them, that I am chiefly concerned.

Importantly, the mirror stage also covers over a lack of being which returns at the level of the unconscious:

We sense that we are not beings like the other unified beings we see around us; there is as yet nothing we can point to as a discrete total being (something that can be counted as a One). Instead, there is a conspicuous lack of being; being as such is missing prior to the anticipatory action of the mirror stage (which creates a One where there was none). This is why Lacan tends to associate the ego with false being (Fink, 2004, p. 100).

This ego is a distortion or misunderstanding, covering over the infant's experience of him/herself as an uncoordinated conglomeration of emotions and sensations. Applying this to reflections on training in psychoanalytic psychotherapy, one might conceptualise the various attempts to identify dilemmas and debates in order to envision a way forward that is coherent and consistent as on the side of the imaginary. This is not to say, however, that this imaginary does not play an important role--something about feeling unified (even if it is false) can be incredibly comforting and enabling of agency. It is precisely because arguments for a way forward in psychoanalytic psychotherapy training exist that my aim is to interrupt these arguments in order to offer 'not a sense of holistic closure, but rather a set of provoking questions' (Frosh, 2008, p. 11). In other words, the desire to critically punctuate training directives at this juncture is dependent on the existence of these directives in the first place; it is only through the accumulation of knowledge that a position aimed at the 'fall of knowledge' is possible (Nobus & Quinn, 2005).

In summary then, a psychoanalytic reflection on training that draws on Lacan resists the line of the imaginary in making sense of the various debates and dilemmas which only serves to limit and fix training directives in an illusory way. Rather, a psychoanalytic reading that I am after always disrupts and deconstructs, focusing closely on the way language works in and around the representations of psychoanalytic psychotherapy and its training, and on the things outside of these representations that remain un-representable and yet haunt us in structuring ways.

Psychoanalytic psychotherapy under threat

Having set out some psychoanalytic parameters for reflecting on psychoanalytic training in South Africa, I now turn to some of the marginal elements in perspectives on psychoanalytic training that I argue may actually hinder future psychoanalytic trajectories in our locale.

The first assumption haunting at the margins of representations of the future of psychoanalytic training in South Africa is that psychoanalytic work needs to be done through psychotherapy and that it is psychoanalytic psychotherapy training that needs to be reflected upon and revisioned. What is absent in these formulations is the conceptualisation of psychoanalytic theory and practice as playing a valid role outside of the clinic, a role that may be preventative rather than remedial, and may look quite different to the one-on-one work traditionally associated with psychoanalysis. Certainly, within the context of clinical and counselling psychology training, where a large proportion of training programmes historically have taught psychoanalytic psychotherapy there is increasingly a recognition of the importance of the promotion of community mental health through less traditional roles such as providing support and training to primary mental health workers, and getting involved in advocacy initiatives, public information campaigns and policy work (Ahmed & Pillay, 2004; Kagee, 2006; Pillay, Ahmed & Bawa, 2013). Yet, I argue that psychoanalytic training within South Africa has not managed to embrace these less traditional roles within psychological practice in any sustained or integrated way. Despite examples of how psychoanalytic theory might be usefully employed in these ways of working (see Swartz, Gibson & Gelman, 2002) the absence of thinking psychoanalytically outside of psychotherapy haunts significant and useful works that foreground the ways in which psychoanalytic concepts and theories are applied within often widely varying and challenging contexts in contemporary South Africa. For example, a recent edited book by Smith, Lobban and O'Loughlin (2013) makes an important call for 'the need for a new kind of psychoanalytic theory and practice in South Africa which is relevant to its unique problems' (p. 273) and yet falls back on developing 'a new form of psychoanalytically oriented psychotherapy' (p. 273), with the vast majority of its contributors focusing on traditional clinical cases within therapy rooms. This consistent foregrounding of psychoanalytic work as psychotherapy, while often explicitly 'clinically' focused and certainly showcasing psychotherapies that are contextually sensitive to issues of race, class, gender and ethnicity, nevertheless contributes to the marginalisation and absence of less traditional psychoanalytic practices that arguably have more of a role to play in the South African mental health context. It is important to clarify here that the argument I am putting forward is not the same as saying that people of lower socioeconomic class are not good candidates for individual psychotherapy (although I believe that this argument is still worryingly prevalent within many South African mental health settings). Rather, as Altman describes, 'the office-based setup may be too unfamiliar and alienating to poor patients, and (that) the therapist must be open to a more community-based involvement in order to engage poor patients' (2010, p. 85).

Certainly, compared to the cognitive therapies, for example, psychoanalysis is particularly well placed to offer 'inner frames' (Berg, 2014) for community work that are socially, rather than individually, orientated. With a growing theoretical base that points to the usefulness of employing psychoanalysis to think about the contextual challenges in South Africa (see, for example, Hayes, 2012; Hook, 2012; Long, 2011) it is up to training institutions and current practitioners to begin taking these up in our practice alongside research on the effectiveness of these ways of practicing. Particularly important would be to continue to conceptualise this work as 'clinical', a term that tends to be reserved for traditional psychotherapy work. Within the area of contemporary attachment theory, it is significant to note that a book entitled Mentalizing in Clinical Practice (Allen, Fonagy & Bateman, 2008) includes the employment of mentalizing in group work, psychoeducational work, systemic work in schools, as well as individual psychotherapy, without the former being 'relegated' to a section or book on community work.

One possible interpretation of this continued (and arguably exclusive) investment in psychotherapy training is linked to psychoanalysis' continued representation as a marginalised profession that is under attack (Smith, 2014; Wallerstein, 2012). Relative to global developments, psychoanalytic work continues to be fairly mainstream in South Africa, certainly amongst psychologists: to my knowledge most mental health training programmes which are located in universities in South Africa provide some training in psychoanalytic or psychodynamic understandings which is not always the case for other therapeutic modalities. Yet, current representations and responses within South Africa have very much adopted a stance that mirrors international feelings of being under threat or in a 'perilous state' (Smith, 2014, p. 27). While there is no doubt that the context in which psychoanalytic work is being practiced in contemporary South Africa is quite different to the context within which it was practiced twenty years ago, the extent to which therapeutic modalities adapt and change to socio-historical forces is well established, particularly in the history of psychoanalysis. These adaptations are frequently highly productive such that the current representations of threat and tyrannical plagues are curious. These threats are represented as coming from many different sources including managed care, popular culture and cognitive behaviour therapy and culminate in what is described as a 'loss of prestige' (Smith, 2014, p. 30). Given this emphasis, and the historical lack of prestige or status afforded to community psychology comparative to clinical psychology in South Africa (Seedat & Lazarus, 2011), one could interpret the investment in psychotherapy within reflections on psychoanalytic training as a very particular response to a perceived threat, a response that holds even tighter onto what is considered a property that is exclusively psychoanalytic. For while other therapeutic modalities are indeed largely in the business of offering psychotherapy between two people within four walls, psychotherapy and particularly the psychotherapeutic relationship is chiefly represented as the hallowed ground of psychoanalytic work. As noted by Fonagy (1999): 'Psychoanalysis is more than the creation of a narrative, it is the active construction of a new way of experiencing self with other' (p. 218).

A lateral tangent: Being and having the same

In order to think about these 'hauntings' of psychoanalysis that impact on the ways in which psychoanalytic work (past, present and future) is represented within South Africa, I want to argue that it is helpful to take a small detour into the psychodynamics of sibling relations. Reading and rereading the accounts of threat within psychoanalysis, I am reminded of sibling relationships and documented responses to rivalry in these lateral relationships that have increasingly drawn the attention of psychoanalytic writers (e.g. Coles, 2003; Mitchell, 2000).These concepts of sibling envy or rivalry can be traced back to Freud:

The dread relates to the child's mother, and later to other familiar persons, and it is the expression of an unfulfilled desire, which the child does not yet know how to deal with in any way except by turning it into dread ... Something like it grows up first of all, in a nursery containing many children, out of the children's relations to their parents, and it does so as a reaction to the initial envy with which the elder child would certainly like to put its successor jealously aside, to keep it away from the parents, and to rob it of all its privileges (Freud, 1921, p. 195).

Certainly, the representations of threats to psychoanalysis described earlier conjure up this dread which Freud here links to a tendency in us all to wish we were the only child. For Freud, these hostile feelings were transformed into identification with the sibling in order, ultimately, to protect her/himself from the wrath of his/her parents for not loving the child their parents so obviously love. According to Freud this led to a demand for 'social feeling', for no difference--'every one must be the same and have the same' (Freud, 1921, p. 196).

Something of this might be present in calls within psychoanalytic practice to develop our entrepreneurial skills so as to be able to compete (the same as everybody else) alongside cognitive therapists (for example) for medical aid benefits (Smith, 2014). Remaining critical of the place for entrepreneurship within psychoanalytic training in South Africa is, I argue, essential for psychoanalysis to contribute to increasing access to mental health as a social justice project. Certainly, the global financial crisis in 2008 has led to interesting reflections on money from within psychoanalysis (e.g. Berger & Newman, 2012) but these reflections remain concerned with the meaning and function of fees in analysis or psychotherapy. A social justice emphasis goes much further than this to trouble the extent to which our health system in South Africa continues to serve two different countries, the rich South Africans and the poor South Africans, and the extent to which psychoanalytic work challenges or reinforces this.

From this perspective, it is crucial that psychoanalytic training continues to take place within mental health professional trainings (1) that require an internship in a public health setting, and that psychoanalytic trainings respond to these settings such that psychoanalytic practice resists the mainstream pull inherent in the 'social feeling of sibling relationships', and holds onto its critical, marginal, revolutionary possibilities. Such mental health professional trainings have been called to include an emphasis on social justice and policy in increasing recognition of the challenges facing mental health contexts internationally (Chu et al, 2012) and nationally (Young, 2013). Psychoanalytic training within South Africa needs to equip its students to join such conversations and in particular to think about the specific psychoanalytic contributions to such dialogues without conceptualising these as 'non-clinical'. The work that the South African Psychoanalytic Confederation has done and continues to do in developing a working relationship with the Department of Health certainly provides an important model of the kinds of skills future psychoanalytic practitioners will need. However, the importance of negotiating beyond individual access to mental health through psychotherapy needs to be recognised. Therefore, it behoves training institutions where psychoanalytic practice is taught to prepare trainees to work in the public sector, working in ways that make psychoanalysis more flexible, beyond short term approaches to systemic and group work. Such possibilities can be found in Altman's (2010) argument that 'psychoanalysis can be used to reinforce the status quo on personal and social levels' (p. 327) but that psychoanalysis can also more helpfully serve a subversive function:
   Instead of accepting unreflectively a location in the
   capitalist, medicalized world of private practice, we can
   explore how psychoanalysis can be more broadly
   applied socially (p. 327).


It is with this social application of psychoanalysis, through theory and practice, that I argue training programmes need to be most concerned.

Another lateral tangent: Mourning, subjecthood and serial diversity

Related to this argument is the second assumption reflected in future perspectives on psychoanalytic training that I would like to interrogate, which is that being on the outside, being on the margins, is necessarily undesirable--that we should be aspiring for greater status and prestige in order to get 'in'.

Again, this might be understood as a particular response to threats from 'siblings'. Juliet Mitchell (2000, 2003), who has made significant contributions to our understanding of sibling or lateral relations within psychoanalysis, argues that ' an actual sibling is the concrete embodiment of a general condition in which no human being is unique--he can always be replaced or repeated by another' (2000, p. 25-26). The sense of displacement that this ushers in is experienced as catastrophic by the sibling, as an annihilation--the terror of disappearing--and as a danger of non-existence: I

I suggest that the child begins to know about death and therefore that one must not kill one's brother, because the very existence of that brother in the first place has been experienced as a death of the subject's self (Mitchell, 2003, p. 34).

It is certainly possible to hear the hauntings of these kinds of experiences in those documented within psychoanalytic circles regarding the current status of psychoanalysis in light of its siblings (other modalities, particularly cognitive therapy, managed health care and media culture) all of whom have displaced psychoanalytic psychotherapy in some way or another and might even be responsible for its 'death' (see Bomstein, 2001).

Nevertheless, Mitchell's theorising about siblings is helpful in thinking through a different kind of response to one that yearns for prior prestige and is necessarily located in therapy rooms. She argues that if we are able to resist our murderousness, despite our feelings of annihilation, if we experience the 'death' of the self (read psychoanalysis) with the arrival of these competitors and mourn the loss of this narcissistic, unique self (read psychoanalysis) then we achieve a symbolic representation of 'subjecthood'. In other words, Mitchell argues that to establish subject differentiation, the subject itself must be lost. It is precisely this symbolic representation of psychoanalysis that may be important to focus on here, as a symbolic representation does not require holding on tightly to a space or place (the therapy room for example) but rather allows that symbolic representation of psychoanalysis to be used, transformed, integrated along with other representations so that the places within which it might be used are numerous (theoretical, community settings or educational settings, for example).

An important part of this symbolic representation of psychoanalysis is, I argue, its marginal status. Perhaps it is this revolutionary capacity that can differentiate psychoanalysis from its siblings jostling for places of their own. In her argument Mitchell (2003) refers to the sibling experience, where the other is experienced first and foremost as the same:
   Hatred is for one who is the same, it is this hatred for
   a same-ness that displaces which then generates the
   category of 'other' as a protection. It is the one who
   can now be imagined to be utterly different, who can
   thenceforth be loathed or loved (p.21).


What Mitchell coins as 'the law of the mother' is what emphasises this difference. The law of the mother refers to the mother's injunction that as children siblings are the same, they cannot have babies like adults can, but as siblings they are also different and there is space for one, two, three or four (seriality).Thus the hatred for sameness is negotiated through emphasising difference--'I hate you, you are not me' (Mitchell, 2003, p.27). This implies serial diversity rather than replication.

Taking a lead from this, it may be productive to think about psychoanalysis' increasing position on the margins as something which helpfully sets it apart. Certainly, within psychoanalysis there are those who have argued for the value of being 'on the outside' and against the mainstream therapeutic employment of psychoanalysis which brings to the fore its politically regressive tendencies (Frosh, 2010). Occupying a marginal position arguably allows for greater reflexivity, not reflexivity on how we might cure social systems or know subjects better, but reflexivity on the relation between the body of knowledge that is psychoanalysis and those of us who claim to think psychoanalytically combined with an acknowledgement of the incompleteness of both sides (Parker, 2012).

Conclusion

This paper has offered a reflection on the extent to which directives on psychoanalytic psychotherapy training are being conceptualised within a very particular dynamic, in this case a sibling dynamic, that takes the form of dominant attitudes and practices which may be serving defensive purposes rather than enhancing the psychoanalytic project.

In particular, I have argued that it is not the absence of theorising outside of the therapy room using psychoanalysis that is of concern as there are numerous examples that point to this flourishing; rather it is the continued emphasis on psychotherapy and on the training of therapists in an exclusively two (sometimes three) person model that remains problematically prevalent in future conceptualisations of training programmes in South Africa. In addition, I have queried the usefulness of a call for entrepreneurship in favour of social justice models within psychoanalysis. Finally, I have argued that there are theoretical benefits to psychoanalysis occupying a marginal stance.

Certainly, these reflections are challenging of the status quo for psychoanalytic training and practice in South Africa. I am acutely aware, as I conclude, of Altman's (2010) reminder that 'it is important to not delude ourselves that these forms of commitment to the status quo will ever disappear, but at the same time, they are always questionable' (p. 325, original emphasis).

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Lisa Saville Young

Rhodes University

(1) There continues to be no standalone qualification as a psychoanalytic psychotherapist in South Africa. Rather these skills are taught within a medical training, psychiatric training, social work training or psychological professional training.

Lisa Saville Young is an Associate Professor and co-ordinator of the clinical psychology training programme in the Department of Psychology at Rhodes University, South Africa. She qualified as a clinical psychologist in South Africa before studying in the UK towards a PhD that adopted a psychosocial approach to reading interview texts on men's relationships with their brothers. She has since published journal articles and book chapters on reading texts using a psychosocial framework, drawing on relational psychoanalysis, Lacan and, more recently, contemporary attachment theory. She teaches and supervises psychoanalytic psychotherapy and has a small private practice.
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