Divided into three overarching themes, theory, application and research, this cutting-edge book explores the infl uence of psychoanalytic theories on occupational therapy practice and thinking. It incorporates a new conceptual model (the MOVI) to guide practice and uses psychoanalysis as a theoretical foundation for understanding therapeutic relationships and the ‘doing’ that takes place in clinical practice.

Using practice models and incorporating clinically applied examples in different occupational therapy settings, this introductory text to psychoanalytic theory will appeal to students and practising clinical and academic occupational therapists worldwide and from different fields of practice from paediatrics and physical disability to older adult care and mental health.

• The fi rst book in fi fty years to concentrate entirely on a psychoanalytic approach to occupational therapy

• Distills cutting-edge theory into clinically relevant guidance

• Features clinical examples throughout, showing the links between psychoanalytic theory and occupational therapy practice

• Written by an experienced international team of authors

Related TitlesClinical Reasoning in Occupational Therapy: Controversies in PracticeEdited by Linda Robertson

ISBN: 978-1-4051-9944-5

Neuropsychology for Occupational Therapists: Cognition in Occupational PerformanceThird EditionJune Grieve and Linda Gnanasekaran

ISBN: 978-1-4051-3699-0

About the AuthorsLindsey Nicholls is a Lecturer at Brunel University, London, UK. Her doctorial study used psychoanalytic theory to explore the symbolic and relational encounters between occupational therapists and their clients in acute medical settings.

Julie Cunningham Piergrossi is a psychoanalytically trained Occupational Therapist in Milan, Italy.

Carolina de Sena Gibertoni is a psychoanalytically trained Occupational Therapist in Milan, Italy.

Margaret Daniel is a Clinical Specialist Occupational Therapist in Psychotherapy working in an NHS Psychotherapy Clinic in Glasgow, UK, and is a senior accredited counsellor with the British Association for Counselling and Psychotherapy.

Psychoanalytic Thinking in Occupational Therapy

Psychoanalytic Thinking in Occupational Therapy

Lindsey Nicholls | Julie Cunningham PiergrossiCarolina de Sena Gibertoni | Margaret Daniel

“Psychoanalytic Thinking in Occupational Therapy is unashamedly humanistic. It puts the humanity of the

client at the forefront of the professional agenda … This is how the psychoanalysis I love should be used

– to enliven, to ‘move’ and to make you think, the opposite of jargon or dogma.”

Professor Paul Hoggett, University of West of England

“This is a courageous book … [it] strives to help the reader develop their own sensitivity to others through

the provision of vignettes and this both helps deepen professional reasoning and links theory with

practice.”

Dr Sheena Blair, Dip COT, M Ed, Ed D, FHEA, FCOT

Nicholls, C

unningham P

iergrossi, de S

ena Gibertoni and D

aniel

Psychoanalytic Thinkingin Occupational Therapy

Psychoanalytic Thinkingin Occupational Therapy

Symbolic, Relational andTransformative

Dr Lindsey NichollsSchool of Health Science and Social Care

Brunel University, London, UK

Julie Cunningham PiergrossiThe Vivaio Centre: Practice, Training and Research in Psychoanalytic

Occupational TherapyUniversity of Milan, Milan, Italy

Carolina de Sena GibertoniThe Vivaio Centre: Practice, Training and Research in Psychoanalytic

Occupational TherapyUniversity of Milan, Milan, Italy

Margaret A. DanielClinical Specialist Occupational Therapist in Psychotherapy

Lansdowne Psychotherapy Service, Glasgow, UK

This edition first published 2013# 2013 by John Wiley & Sons, Ltd

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Library of Congress Cataloging-in-Publication DataPsychoanalytic thinking in occupational therapy : symbolic, relational, and transformative / Lindsey

Nicholls . . . [et al.].

p. ; cm.Includes bibliographical references and index.

ISBN 978-0-470-65586-3 (pbk. :alk. paper)

I. Nicholls, Lindsey.[DNLM: 1. Occupational Therapy–psychology. 2. Psychoanalytic Theory. 3. Psychotherapy.

WM 450.5.O2]

616.890165–dc232012027805

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1 2013

Contents

Foreword by Sheena Blair viiForeword by Paul Hoggett ixAcknowledgements xi

1 Introduction 1

Section 1 Psychoanalytic Theory Interwoven with Occupational Therapy 13

2 The ‘Therapeutic Use of Self’ in Occupational Therapy 153 An Occupational Therapy Perspective on Freud, Klein and Bion 324 The Function of ‘Doing’ in the Intermediate Space: Donald Winnicott

and Occupational Therapy 575 Beyond Bowlby: Exploring the Dynamics of Attachment 686 Re-awakening Psychoanalytic Thinking in Occupational Therapy:

From Gail Fidler to Here 87

Section 2 Psychoanalytic Occupational Therapy: A Relational PracticeModel and Illuminating Theory in Clinical Practice 103

7 MOVI: A Relational Model in Occupational Therapy 1058 Let the Children Speak 1289 Working with Difference 145

Section 3 Further Psychoanalytic Thinking: Research and Training 163

10 Psychoanalytic Thinking in Research 16511 Understanding the Use of Emotional Content in Therapy Using

Occupational Therapists’ Narratives 18612 Training Experiences to Develop Psychoanalytic Thinking 20213 The Relational Space of Supervision 222

Index 239

Foreword

From the day that I first learned about the work of Azima and Azima (1959) andFidler and Fidler (1963) whilst undertaking my occupational therapy course in themid to late 1960s in Glasgow, I was captivated. This work sought to explore andunderstand the meaning of what we do as human beings and how participation inoccupational therapy could offer another means of communication. The Fidlers alsocontributed one of the first andmost comprehensive approaches to activity analysis.I was fascinated by the links between psychoanalytic thinking and the practice ofoccupational therapy and was lucky enough in my early practice to work in a unitwhich was underpinned by the principles of group psychotherapy and the impor-tance of themilieu. Forty-five years later, I am equally engrossed by the ideas offeredin this text.

Over the years, I have reflected countless times on how the ideas, concepts andprinciples have informedmy understanding and work, whether that was in practice,education, management or research. Historically, there has always been a sustainedadherence to this way of understanding human beings within the occupationalliterature. Contrary to the popular view of some occupational therapy theorists whoconsidered that therapists who thought and practised in this way would lead to thedemise of the profession, I maintain that this form of thinking enhances ourrepertoire of knowledge and skill. I endorse the view that is taken in this bookthat occupation is symbolic, relational and transformative, and to facilitate under-standing of this we need to refer to the seminal work referred to in this text.

This is a courageous book. It bravely runs counter to contemporary discourse ofhealth and social care and reminds us of what it is to be a therapist by attending tomulti-layered communication and containing distress. Therapy is characterised byproviding emotional safety and containment. Often engagement with occupationprovides that safe space to begin to explore difficult issues. Throughout, the bookstrives to help the reader develop their own sensitivity to others through theprovision of vignettes and this both helps deepen professional reasoning and linkstheory with practice. This is the crux of good educational practice and enablesreaders to risk reflecting upon and considering their own interactions with others. Itis also courageous in adhering to the principles and mores of psychoanalyticalthinking instead of the more popular notion in occupational therapy literature ofpsychodynamic thinking.

The writers have outlined the links between psychoanalytical thought and thepractice of occupational therapy in a developmental way by revisiting seminalworks from both occupational therapy and psychoanalysis. Additionally, they have

offered a specificmodel to infuse practice with a celebration of the therapeutic use ofself and the pivotal contribution of emotion and relationships in the lives of humanbeings. The text covers work from childhood to later adulthood and reveals howthis way of working with people can facilitate the development of an emotionallanguage and enable emotional shifts to occur. It also covers how work of thisnature can revitalise supervision and develop organisations in a positive way. Thefinal chapters of this text concern psychoanalytic thinking in research and thisreveals how there has been a regeneration of interest in the contribution ofpsychoanalytical thinking within social science. As such the book unites theory,practice and research.

I have found this a refreshing text with the authoritative signature of stimulatingthe occupational imagination to creatively work with the unconscious. It encour-ages practitioners to strive to understand internal life, whether as a therapist,educator, researcher or manager. While it may only be possible for a small numberof occupational therapists to directly practise in this way, what this book offers is away to enhance professional reasoning, deepen understanding of the meaning ofoccupation and contribute to mental health and well-being.

Dr Sheena E. E. BlairDip COT, M Ed, Ed D, FHEA, FCOT

viii Foreword

Foreword

In the UK today we are experiencing a crisis in the quality of our care services withscandal after scandal surfacing in our hospitals, our residential homes and dayservices. In Europe, for two decades now, welfare services have struggled to developunder successive waves of management reforms which, under the banner ‘gettingmore for less’, have sought to increase the productivity of the public services. I thinkit is clear now that whilst in some cases we may have increased the volume ofthroughput, it has been largely achieved by a real decline in the quality of care. Thedanger is that as the OECD economies seek to regenerate private affluence on thebacks of public austerity, the quality of care is something that will be seen assomething we can no longer afford.

The appearance of Psychoanalytic Thinking in Occupational Therapy is there-fore very timely. For here is a book which has the courage to proclaim that qualitycounts and that ultimately the only guarantee of quality lies in the richness of therelationship that emerges between the professional and the client. I deliberately usethe unfashionable word ‘client’ rather than ‘service user’ because the latter hasbecome a degraded term, a piece of ‘carewash’ (like greenwash) which actuallycovers up the lack of care which now seems to accompany the bizarre mish-mash ofcentralised control, micro-management and breakdown of real accountabilitywhich makes up our increasingly fragmented welfare system. The concept of ‘client’(still used by architects, solicitors and many other professions) has those connota-tions of dignity, respect and status that we urgently need to rediscover to challengethe lack of care presently taking place.

Psychoanalytic Thinking in Occupational Therapy is unashamedly humanistic. Itputs the humanity of the client at the forefront of the professional agenda – theiremotions, frailties, eccentricities, strengths and mysteries. Indeed it pours out of themany vignettes and case studies that are such a marvellous feature of this book.Whilst the authors show great confidence in their use of psychoanalytic terms, theydo so in a way which illuminates rather than reduces the humanity of their clients.This is how the psychoanalysis I love should be used – to enliven, to ‘move’ and tomake you think, the opposite of jargon or dogma.

In contrast to the regimented, risk-averse and prescriptive techniques which havecome to dominate our thinking about professional practice, the authors of this bookoffer an entirely different way forward. Can we afford not to move in the directionthey point to? So much of our accounting these days is preoccupied with short-termefficiencies that the long-term costs of failing to think systemically pile up all aroundus. There are signs all about us that the citizen is no longer prepared to surrender

public welfare on the altar of economic austerity. We do indeed deserve more. Thekind of practices outlined in this book should lie at the heart of a welfare society, onewhich values human and non-human relations as intrinsic goods rather than meansto an end.

Professor Paul HoggettCentre for Psycho-Social Studies, University of West England

x Foreword

Acknowledgements

We would like to thank our clients, colleagues and students for their sincerity,patience and commitment to work that can only truly be done in the spirit ofcollaborative inquiry.

1 Introduction

Lindsey Nicholls, Julie Cunningham Piergrossi,Margaret Daniel and Carolina de Sena Gibertoni

There is a saying for people who plan to undertake the long-distance walking routeknown as the ‘Way of St James’: it states that the Camino de Santiago1 begins whenyou first think of it. That is how the book began; we began to think of it. Since 2006we have exchanged our thoughts in emails and initial writings, and used a process ofpeer editing to learn from each other and produce this book.We have found ways tomeet in person and listen to each other’s presentations (at Brunel University MasterClass events and international conferences in 2009, 2010 and 2011), and this hadled to our connecting with many other occupational therapists who have been using(i.e. thinking and working with) psychoanalysis as a theory and method within theirclinical practice.

It has been a rich and rewarding time where each of the authors, at different timesand/or in relation to certain specialist topics, has taken the lead. Although we comefrom diverse professional and personal backgrounds, we share a conviction in theimportance of using psychoanalytic theory in occupational therapy. In this we havebeen good companions and learntmuch from each other’s clinical work and theoreti-cal discussions. This book is a result of our collaborative desire to make this workavailable to scholars and clinical therapists, to form a wider ‘community of practice’(Wenger, 1998), where new projects, clinical discussions and writing can emerge.

At its heart the book discusses the work that we have practised, learnt, thoughtabout and carry within as we engage with clients, students and colleagues. Our hopeis that the book will provide a basis for serious study by therapists who areinterested in psychoanalytic theory and may have begun their own journey intothe internal landscape of the emotional understanding of people and what they ‘do’.

Psychoanalytic Thinking in Occupational Therapy: Symbolic, Relational and Transformative, First Edition.Lindsey Nicholls, Julie Cunningham Piergrossi, Carolina de Sena Gibertoni and Margaret A. Daniel.

� 2013 John Wiley & Sons, Ltd. Published 2013 by John Wiley & Sons, Ltd.

1 The 1000-year-old pilgrimage to the shrine of St James in the Cathedral of Santiago de Compostela is

known in English as the ‘Way of St James’ and in Spanish as the Camino de Santiago. Over 100,000pilgrims travel to the city each year from points all over Europe and other parts of the world (Wikipedia,

2012).

There are 13 chapters in all (including this one) and the book has been dividedinto three overarching themes; theory, application and research. The first sectiontakes the classic psychoanalytic theories (e.g. Freud, Klein, Bion, Winnicott andBowlby) and considers their influence on occupational therapy practice and think-ing. The second section is devoted to an explanation of a psychoanalytic occupa-tional therapy model (MOVI) and this is followed with further discussions ofpsychoanalysis in clinical occupational therapy practice. The final section describesresearch methods and projects that have incorporated psychoanalytic thinking inoccupational therapy.

Each chapter could be read as an extended case study but we hope there issufficient cross-reference between the different contributions to make for a coherentwhole. In many ways it has been hard to choose the order of work for the linearstructure that the book offered. The core of the book lies in understanding MOVI(Chapter 7), an occupational therapy model, and we would suggest that readersdevelop a duel vision where MOVI can be held in mind as they refer to the earlierchapters on Freud, Klein and Bion (Chapter 3), Bowlby (Chapter 5) and thetherapeutic use of self (Chapter 2).

There are certain terms in current occupational therapy literature which havegained professional ascendance – for example, using the term ‘client’ rather than‘patient’, and ‘occupation’ not ‘activity’ – which we have decided to use inter-changeably. This is not a form of political rebellion against the discussions on client-centred practice or the value of understanding occupation, but belongs to theeclectic theoretical background we have used to develop an integration of psycho-analytic thinking in occupational therapy.

We are very grateful for the encouragement that Katrina Hulme-Cross, RupertCousens and Sara Crowley-Vigneau, the health sciences commissioning editors atWiley-Blackwell, have given us during this time. Without their active support wemight still have been thinking about writing the book and not have completed it!

Finding our way

In this section, each author introduces themselves to the reader, saying how it wasthat they began establishing a link between psychoanalysis and occupationaltherapy. We hope these brief introductions will provide an illustration of ourindividual (even idiosyncratic) and shared interests in using psychoanalytic thinkingin our work as occupational therapists.

Lindsey Nicholls

In 2002, after my rather clumsy presentation at a mental healthconference on the use of dreams in clinical work, I was generouslyinvited by Jennifer Creek to contribute a chapter on my work forher forthcoming book, Contemporary Issues in OccupationalTherapy (Creek and Lawson-Porter, 2007). It was a professionallifeline for me as I had recently moved to the UK from South Africa

2 Psychoanalytic Thinking in Occupational Therapy

and found myself floundering in a discourse full of positiveaffirmations and seemingly (only) conscious intensions. Any con-sideration of the unconscious aspects of clients and professionalshad been subsumed by an emphasis on partnership working andrecovery. I attempted to give voice to my concerns about this lossof thoughtfulness about the unconscious:

I have had an interest in and involvement with a psycho-analytic view of occupational therapy for so much of myprofessional life that I can no longer see clearly withoutthese conceptual lenses.2 It has been a concern to me thatover the past 40 years a psychoanalytic discourse inoccupational therapy has almost completely disappearedfrom our professional literature, except for a few voices(Banks and Blair, 1997; Cole, 1998; Collins, 2004; Danieland Blair, 2002a; 2002b; Creek, 1997; Hagedorn, 1992),and it has been my wish to persuade occupational thera-pists to consider (or reconsider) what psychoanalysiscan offer us in our endeavour to alleviate the sufferingof our clients and support their sense of purpose in day today life.

(Nicholls, 2007, p. 58)

When I wrote this entreaty to the profession, much admiring andquoting Margaret Daniel’s work, I didn’t know we would meet,that she worked as a clinical specialist psychodynamic occupa-tional therapist in Glasgow and that we would become friends.I didn’t known that Julie Cunningham Piergrossi and Carolinade Sena Gibertoni were working in Milan, Italy, using an‘occupational play space’ in which children and adolescents coulddiscover aspects of themselves through their choice of objects andactivity in the containing presence of a psychoanalytic occupa-tional therapist.Then a wonderful synchronistic event took place. In 2006 I was

the first speaker in a group of four papers at the World Federationof Occupational Therapy (WFOT) in Sydney, Australia. My paperused the layered story from the book Life of Pi (Martel, 2003) asan illustration of the concerns I had with some of the concepts in‘client-centred practice’: that it can ignore unconscious motives,ambivalent emotions and contradictory behaviour (see Chapter 2).The paper seemed to go well and when I sat down a womanmovedto the seat next to me, clasped my wrist and asked me where I wasgoing. I was a little alarmed at the strength of her grip and told herI would be staying until the end of the session. ‘Good,’ she said. ‘I

2 The idea of theory (structure) being used as a lens throughwhich to view theworld – ‘a pair of spectacles

with a specially tinted filter’ – comes from Hagedorn (1992, p. 14).

Introduction 3

didn’t want you to disappear.’ It was Julie and she gave the last talkin the group of four papers.Julie’s presentation described the response postgraduate stu-

dents had to learning about the MOVI model (see Chapter 11).MOVI incorporates an understanding of the conscious andunconscious choices, actions and words of patients within thecontaining environment of a ‘play space’; a room full of activitychoices and a therapist. While hearing about their work in Italy,delivered in Julie’s eloquent, measured voice, I began to cry. Thiswork took into account the conscious and unconscious aspects ofthe client and therapist, through the communication involved in‘doing’ something together.MOVI captured a way of thinking andworking that was an alternative to the highly contested groundtaken by other practice models (e.g. the MOHO, KAWA andCMOP). But in truth, my tearful response to her talk was because Ino longer felt alone.It was through Julie that I met her colleague and collaborator,

the Italian author Carolina de Sena Gibertoni, and this com-pleted the initial learning group. Carolina’s knowledge andapplication of core psychoanalytic theory in occupational ther-apy has been important in locating the book in the classicpsychoanalytic texts. I have valued what each author has con-tributed in their understanding of theory as lived through theexperience of working with clients and activities in the intimaterelational space of emotions.Perhaps I can end my introduction with where I began: by

paying attention to the unconscious. It has been in my personalanalysis that I have found an inner coherence and capacity forcreativity. My experience of psychoanalytic psychotherapy hasgiven me a deep belief in the efficacy of this approach to workingwith others.

I have never doubted the existence of the unconscious; infact it was quite a relief when I realised during my firstexperience of an analysis, at the age of 23, that my dreams,thoughts and feelings were a language that I had not yetlearnt to understand, but that were available to me as aguide to my internal life. Perhaps it is this investment inone’s own internal life that is the most daunting andfulfilling in working within a psychoanalytic frameworkwith clients. Bion (1991), an analyst who is considered aprodigious and original thinker, wrote in his autobiogra-phy that having recognised his most primitive self, capableof almost any heinous crime, he could better understandhis clients and their struggles.

(Nicholls, 2010, p. 32)

4 Psychoanalytic Thinking in Occupational Therapy

Julie Cunningham Piergrossi

The event that started out the adventure of this book formewasmymeetingupwithLindseyNicholls (alreadydescribedbyher) in 2006at the World Congress in Sydney. By pure chance we were present-ing our papers in the same session and she spoke before I did. Iremember listening to her psychoanalytic discourse and being bothastounded and delighted at how it fitted together with my ownthoughts. At the same time she was opening my mind to new ideasand I remember running up to her immediately afterwards andaskinghernot to leaveuntil I had spoken, that I needed to talk toher.I was afraid she would be lost in the more than 2000 therapistspresent and that I would never find her again. In the generaldiscussion following my talk she asked me two pertinent andthought-provoking questions which are always such a gift in asituation like that. Later we began to talk together and we haven’tstopped since.My interest in psychoanalysis began when I studied occupa-

tional therapy in the USA back in the 1960s and has never waveredsince, even though my profession has changed immensely in theintervening years.When I arrived in Italy in 1969 I became part of a group of

psychoanalysts called ‘Il Ruolo Terapeutico’, with whom I beganmy training which is still ongoing. My case presentations, insupervision together with colleagues who are psychoanalysts,have always aroused curiosity in some and consternation in others.It was difficult when I heard people I respected tell me that thepresence of the activities and the materials during the therapysessions could be an impediment to the therapeutic process. In 40years of working together things have changed as I have learned toput words to my ‘doing’ and my colleagues have accepted the factthat baking a cake can have psychoanalytic potential.‘Ruolo Terapeutico’ was instrumental in making clear for me

the importance of the structure of the therapy as a container for theprocess, a concept which led to the understanding of choice as partof the setting (the structure) of the occupational therapy experi-ence using the Vivaio Model (MOVI).I am especially grateful to Sandro Bonomo for his continual

support of my work. It was Sandro who helped me to reallyunderstand the emotions around choices, especially concerningthe complex aspects of unpredictability and its therapeutic value.My psychotherapist colleague, Elisabeth de Verdiere, was anotherstrong supporter of occupational therapy with a psychoanalytictheory base and helped Carolina and myself in the founding of ‘IlVivaio’ and in developing and carrying out the training pro-gramme for MOVI. The constant exchange with Carolina duringthe development of our model is a natural part of my existence,

Introduction 5

and much of my learning has come from her. Supervision, writtencontributions to a professional psychoanalytic journal, readinggroups, seminars and my own personal psychoanalysis havehelped me on my way, and of course my best teachers have alwaysbeen the children and their families who came to me for help.I can never think about myself as psychoanalytically trained

without thinking first about myself as an occupational therapist. Ithink I have been an occupational therapist from when I was achild playing with my grandmother’s box of odds and ends. I havealways loved ‘doing’: cooking, sewing, woodworking and justmaking and fixing things. Being able to use ‘doing’ (which hasalways been therapeutic for myself) for helping others has been aprivilege and a huge stroke of luck in enabling me to have a job Ilove. Because occupational therapy did not exist when I arrived inItaly, part of my time has always been dedicated to developing andteaching the basic profession. I have always strongly stressed theimportance of keeping occupations in occupational therapy.As an American living and working in Italy I have had the

privilege of knowing two cultures well. The Italian influence onmylife and work has been enormous, and living in a country withpeople so relational and expressive of complex emotion hascontributed to my understanding of that part of myself whichin turn has helped me in my work with very sick children. At thesame time, my American part was always encouraged by Carolina,who never tired of pointing out to me the positive aspects of myfirst and formative culture and how important it was to combinethe two.This book is a continuation of my ‘conversations’ with Lindsey

and my exchanges with Carolina in an ongoing search for ways tofurther develop and implement clinical excellence in psychoana-lytically oriented occupational therapy.

Margaret Daniel

I remember being interviewed to become a member of the ScottishInstitute of Human Relations in Scotland and being asked how Iknew that I had an unconscious. This thought still stays with me asa question that I only manage to glimpse at in myself, but can seemuch more easily in someone else, through slips of the tongue,forgotten agreements or an off-the-cuff remark. I am curious toknow more about how our unconscious influences us, somethingwe cannot see or be aware of in ourselves, yet which has such animpact on our experiences and choices, professionally, organisa-tionally and socially.

6 Psychoanalytic Thinking in Occupational Therapy

My journey has been mainly based in Glasgow, where I am aClinical Specialist Occupational Therapist in Psychotherapy. Ihave worked for over 35 years in the NHS where my career hasbeen devoted to Mental Health and especially to the field ofpsychotherapy. I built up further training at the Scottish Instituteof Human Relations and I have attained senior accreditation as apsychodynamic counsellor with the British Association of Coun-selling and Psychotherapy (BACP). I went on to gain a Master’sdegree in Psychoanalytic Studies from the University of Sheffield,in which I attempted to unite the dialogue between psycho-dynamic thinking and occupational therapy. In expanding myunique post as a clinical specialist I needed to find a way toidentify and meet with other likeminded occupational therapists.This was limited in Scotland and an opportunity came about todevelop a website called the National Exchange for Psycho-dynamic Occupational Therapists (NEPOT), which is a self-regulating intranet community that is located within the NHSMental Health Specialist Library and aims to link and providesupport for occupational therapists interested in psychodynamicthinking.As aMember of the Scottish Institute of HumanRelations I have

been involved in the training of psychodynamic counsellors andworked in organisational consultancy projects which took psy-chodynamic thinking out into the voluntary and public sectors. Itis in keeping with its founder, Jock Sutherland’s philosophy oftaking psychodynamic thinking beyond therapy and into thecommunity. I was invited to become a Trustee of the SutherlandTrust, which carries on Sutherland’s ideas by supporting humanrelations work in health, education and social services through theapplication of psychodynamic ideas and practices. One of thelectures introduced me to Dr Una McCluskey and her researchwork on adult attachment. I decided to join one of her groups forprofessional caregivers and have gone on to do further training inYork in this approach and theory, which she developed in collab-oration with Dorothy Heard and Brian Lake (Heard, Lake andMcCluskey, 2009; Heard, McCluskey and Lake, 2011). Foroccupational therapists I believe this approach endorses howcreative activities can validate and restore a person’s sense ofwell-being. It also links with my work and interest in supervision,where a collaborative approach can enhance learning.My connections to the other authors came through a chance

meeting with the then Director of Occupational Therapy at BrunelUniversity, Christine Craik, who was my first Head OccupationalTherapist. She drew my attention to an article she thought mightinterest me, recently published by her colleague. I read Lindsey’sarticle (Nicholls, 2003) and excitedly made contact as I had

Introduction 7

discovered someone else who was writing about the influence ofthe felt experience. This toowas how I had felt on reading Julie andCarolina’s work (Piergrossi and Gibertoni, 1999) while studyingfor my Master’s. The chance of meeting and working with themwas an incredible opportunity that I would never have imaginedpossible and has led to a cross-fertilising of ideas and interests.I am ever indebted to the patience and generous feedback I

received from my colleagues in occupation therapy, nursing,counselling and psychotherapy. I am also appreciative of thetime that people took in reading over the material and helpingme to fine tune my thoughts. Special thanks go to SamanthaFlower, Sheena Blair, Sue Jervis, Eileen MacAlister, Una McClus-key and Paul Arnesen. I also need to thank my son, Kenny, for hissupport and endurance throughout this task.

Carolina de Sena Gibertoni

It was 1980 and I was visiting an Italian friend in London.Wewerehaving breakfast when her telephone rang and surprisingly it wasfor me. Who could be calling me in London? It was GiannaPolacco from the Tavistock Clinic, to whom I had written sometime back, and she was arranging an appointment with LinaGenerali Clements for an admissions interview for the Tavistocktraining programme inMilan. This was themoment that beganmytie to the institution which illuminated my path of knowledge andcontributed to transferring psychoanalytic concepts to our profes-sion (occupational therapy).Iwasworking inMilan togetherwith JulieCunningham(whohad

come to Italy from America) and Elisabeth de Verdiere, a psycho-analytic psychotherapist working with severely disturbed autisticand psychotic children and adolescents. Julie had introduced me tooccupational therapy using a model based on Gail Fidler’s work. Ibecame aware of areas of shadow, obscure aspects of what weweredoing, curiosities that seemed to demand responses.I had completed my own personal analysis and knowing myself

better helped me to establish a different kind of relationship withmy young patients and with their parents; it was as if theiremotions and mine were entering and demanding space in thesetting. I was continuing my training with Donata Miglietta eMirella Curi Novelli in analytic psychodrama, and participating inpsychoanalytic study groups with Corrao, Gaburri, Napolitaniand the Roman group connected with the journal Quaderni diPsicoterapia Infantile. The Italian world of psychoanalysis wasvery lively. However, child psychoanalysis in Italy was just

8 Psychoanalytic Thinking in Occupational Therapy

beginning. It was an experience that came from afar, particularlyfrom the British world, and I felt the need to know moreabout children, to begin a training course like that proposedby the Tavistock Clinic. The appointment with Lina Clementshad great importance for me, but how would the admissioninterview go?It was a foggy Milanese afternoon and I remember the surprise

when the door was opened by an elderly lady with a kind smile.She had me sit down and guided me easily into a conversation.After about an hour she told me I was suitable and could present arequest for admission either to the course which would be startingin Milan two years later or to the one in Rome, where all of theteachers would be coming from the London Tavistock Clinic,which would begin that same year. I did not hesitate: if myapplication was accepted, I would choose Rome.And that is how it all turned out. It was not easy for me. I was

working; I had a family with two young children; the trip to Romefrom Milan was long and costly; and there was an enormousamount of studying and preparation between one meeting and thenext. But it was worth it! I presented my weekly ‘Baby Observa-tions’ to Marta Harris and Donald Meltzer, and what I learnedwas often a surprise for me. Their seeming disagreements, freshand lively, revealed two different points of view, full of wisdom inrespect to how much movement could be seen in the observer, thebaby and the whole context. As meeting after meeting passed inBaby Observations, learning to observe, paying attention to detail,finding an emotional resonance, became the instruments thatwould accompany me in my whole working life.I took part in the Tavistock training for many years, attending

seminars with Francis Tustin, Jeanne Magagna, Gianna Polacco,Menzies Lyth and Anton Obholzer in a precise training for work-ing with groups. The Tavistock training, together with the Italiancontributions, permitted me that ‘fertile contamination’ withoccupational therapy which, up until then, was still confined tothe goal of functional independence. I felt that it was time torelease our occupational therapy from its medical constraints bygiving it the new role of contemplating the dynamics of relation-ships that are born during clinical practice.The rest is written in this book. For long decades Julie and I have

worked side by side, exchanging ideas and presenting at nationaland international congresses. We have had continuous interactionwith Italian colleagues, psychoanalysts and students both withinand outside of the university in therapy rooms and in variousinstitutions. The emotions that were discovered in our occupa-tional therapy practice found a specific theoretical location when arelational model of occupational therapy (MOVI) was born.

Introduction 9

In recent years, following the happy coincidence of their meetingthat Lindsey and Julie recount, we have participated in the BrunelMaster Classes on Psychoanalytic Thinking in Occupational Ther-apy (2009, 2010, 2011). This has been an enriching experience, anexchange of thoughts with a common base that the far-sightednessof Lindsey willed into a book. And I stop here.If I think about it, the English and American influence on my

working life was fundamental. And yet . . . I still cannot speakEnglish with the same fluid thoughts that my mind has allowed.

Finding the words

As we have said earlier, this book was written to begin a conversation with ourcolleagues. Since 2006, when the four of us established a correspondence, we havehad many contributions from – and lively discussions with – clinical and academictherapists, at the Brunel master classes and international conferences. Our bookoffers an opportunity to engage with the thinking and clinical work undertaken byoccupational therapists who engage with the relational and symbolic world of theclient. The case examples, embedded in every chapter, pay careful attention to theemotionally nuanced events that take place within and between therapist and client,and what is done (or not done) in the therapeutic encounter. It is within thisrelationship that a shift or change can take place in the inner world of the client.This is essentially slow, painstaking work where small emotional gains can bemeasured in the patient’s capacity for creative thought and/or play. It is deeplyrewarding work and, because therapists need to understand the conscious andunconscious experiences of the client, it is helpful for the therapist to have their ownpsychodynamic psychotherapy and supervision.

Conclusions

Once begun, the work of analysis through acknowledging feelings, thoughts,associations and reflections never ends. This work is the essence of relation-ships (love) and creativity (art, poetry and music). Freud stated that thatwherever his theory led him, he found a poet had already been there. T. S. Eliot(1959) captures the struggle to articulate what is known, learnt from expe-rience, better than any theoretical paper on the subject. As Palmer (1979)stated, using Eliot’s work from East Coker, ‘Trying to learn to use words, andevery attempt . . . Is a wholly new start, and a different kind of failure’ (p. 171).This quote seems to describe how difficult it is to articulate (find the words for)the discoveries of what it is to be human. This knowledge seems to be in a stateof being found and lost, only to be found again. We are hoping that psycho-analytic thinking, which was present in the early theoretical papers onoccupational therapy (Fidler and Fidler, 1963), will be found and enjoyedagain by a wide collection of therapists.

10 Psychoanalytic Thinking in Occupational Therapy

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Introduction 11