yorke

Clifford York was one of the leading Freudians of his generation. As Anna Freud's close colleague, he was also one of the last remaining links to the theoretical and clinical tradition set by her father, Sigmund Freud. Clifford Yorke was a prolific writer and played a very active role in the scientific life of both the British Society of Psychoanalysis and the Anna Freud Centre. The Anna Freud Centre was the foremost international centre for training to work psychoanalytically with children in the Freudian tradition. Clifford Yorke belonged to the tradition not just by training but by temperament. To be a psychoanalyst, as Freud saw it, required more than a knowledge of science. Unless the psychoanalyst is at home with literature, the arts and mythology, for example, he or she will not be able to make sense of much that patients bring to their analyses. He was a leading psychoanalyst and close associate of Anna Freud. I would like to comment mostly on three aspects of his work: his knowledge and use of Anna Freud's Diagnostic profile, his work with alcoholics and drug addicts, and his use of metapsychology.
For many years, as medical director, he chaired the Tuesday afternoon diagnostic meetings at the Anna Freud Centre. For most of the time, he listened patiently to the diagnostic profile some of us presented and occasionally he would also. One of them, particularly, comes to my mind as an excellent example of the clinical advantages of the profile, a servant to the diagnostician, never a master, as he used to remind us constantly. By this he meant the profile was a way of thinking, rather than a compendium of headings and concepts, a metapsychological and sophisticated way of reflecting psychoanalytically about patients of all ages, a guide to a psychoanalytical formulation. In his own words, '...the indispensable concept behind the use of the Profile is 'profile thinking', profile making being then a secondary matter'. The aim of the profile, according to him, is to bring together, in a readily assimilable form, the raw data available to the diagnostician at the time of the assessment. That is followed by a metapsychological formulation of the case. It is also important to follow this with some indication of factors which have a bearing on treatability, for example, progressive versus regressive forces, frustration tolerance and the like. Finally, he adds, since metapsychology based on a conceptual model of the mind and its functioning is several steps removed from clinical observation and inference (a fact which is partly responsible for its unpopularity), it is important, in the closing section, to translate the metapsychology back into flesh and blood, in the form of a psychoanalytic formulation of the case. In order to make it more accessible, he suggests that the metapsychology section could examine the case from the standpoint of the id, the ego and the superego. It could follow this by attempting to describe, in terms of object relationships and the relationship towards the self, the ways in which these three major agencies interact to bring about a particular outcome. In this context, he says, we should take into account that the profile provides a metapsychological cross-section of the case set against the background of a hypothetical developmental norm. It may be worth, he says, considering whether or not the value of the crosssection could be enhanced by a developmental assessment based on the Developmental Lines¹, which certainly do not lose their usefulness just because one is over the age of 5. It may be that the use of developmental lines adds a vertical dimension to the horizontal dimension of the Profile, and thus facilitates the psychoanalytic formulation which should constitute the diagnostic statement. While he always welcomed any initiatives one could take on this matter, he remained highly suspicious of innovation for the sake of innovation... The rigorous and disciplined approach represented by the Profile is something that once learnt one never abandons and in the Profile I alluded to earlier, he beautifully illustrates the point. Without following the traditional headings, experimenting with the traditional format but clearly keeping profile thinking in mind, he constructed the profile of a 14½ year old boy who presented, apparently, as a severe case of obsessional neurosis. With great skill, he lists, little by little, the reasons why, in his opinion, what presented as a severe case of adolescent obsessional neurosis contained intimations of a more severe non-neurotic developmental disorder of borderline psychopathology. To do so, he looks not only at the drive development of the patient, but at the vicissitudes of his object relations. He used to be irritated with the frequent criticism according to which the profile did not deal with the latter and wondered often, somewhat jokingly, if the critics believed that drives floated in the air without any attachment to objects...
The diagnostic profile is simply a mental framework for thinking about the assessment of patients. Its aim is to prompt the diagnostician to think about all areas of life and development to arrive to a balanced view of normal as well as pathological functioning. Yorke, like Anna Freud, was very concerned about the misdiagnoses which might occur if too much emphasis was placed on symptoms only, without taking into account the multiplicity of developmental factors affecting psychopathology or when the diagnostician is biased by particular beliefs, interests or adherence to currently fashionable diagnoses.
He was not a rigid fundamentalist, in fact he was a much more creative and original thinker than he gave himself credit for. This was clear to his analysands and supervisees. Patient and kind to newcomers, he was not so with those he saw as pretentious and arrogant.
In the early 70s Clifford Yorke became ostensibly interested in the field of addictions, not a favoured subject among psychoanalysts in our Society, with the exception of Rosenfeld, Limentani and I. He initiated a study group at the Hampstead Clinic to re-emphasise that a psychoanalytic diagnosis was neither more or less than a metapsychological diagnosis, and that it might therefore be profitable to devise a methodology by which Anna Freud's Diagnostic Profile (1962a, pp.149-158) could be used to clarify some of the nosological problems involved (Anna Freud 1965a, pp.140-147). Anna Freud's concept of the Profile was to use the mass of data gleaned in the assessment process and subject this to the consideration of careful psychoanalytic thinking, judging the value of each element of the material not independently but in relation to the rest.
In drawing up a Profile, the assessment information is organized by 'the investigating psychoanalyst into a comprehensive picture of the patient, in metapsychological terms, in terms of dynamics, genetics, economies, structure and adaptation, in an attempt to assess the relevant contributions of a large number of variables to the personality and presenting clinical picture'. Clifford Yorke considered the Profile was an appropriate systematic method for investigating problems of personality development and function (or malfunction)-that it opened up an investigative method which has a coherent theory, psychoanalysis, which is both its rationale and its organising and defining basis and was thus suited to the evaluation of a chosen group of heroin addicts. Systematically the method and technique of metapsychological assessment of the Diagnostic Profile would be applied.
Clifford Yorke joined forces with Stanley Wiseberg and Pat Radford in a new project whose aim was to research into heroin addiction.
The group chose ten people addicted to intravenous injections of heroin for their research. The patients were admitted to an in-patient unit for the treatment of heroin addiction along therapeutic community lines, though in carrying out their study Yorke, Wiseberg and Radford had no responsibility for the treatment program or the hospital care. All patients had been previously withdrawn from drugs, though one or two had minor lapses. They restricted their choice of patient to those cases where an independent early history was available. The diagnostic team embarked on a pilot series of Profiles, all of them based on detailed interviews and detailed social histories. Each piece of material from each interview was examined, discussed and eventually fitted into the appropriate section of the Profile: possible environmental factors, libidinal and aggressive drive organisation with the appropriate phase development, cathexis of the self, of the objects, ego development (reality testing, internalisation of objects, structured integration), defence organisation, super ego structure, etc.
Clifford Yorke published three related papers in the 70s: A critical review of some psycho-analytic literature on drug addiction in 1970 and subsequently, with Radford and Wiseberg A study of 'main-line' heroin addiction: A preliminary report and Aspects of self cathexis in 'mainline' heroin addiction.
In his 1970 review he drew our attention to some of the problems underlined by the study of Drug addiction:
Not all writers distinguished between the psychological effects of taking a drug and the psychic consequences of its pharmacological actions. Idiosyncratic views, he felt, could sometimes obscure otherwise useful clarifications of existing knowledge. Many papers failed to supply convincing clinical evidence to support their assertions and, he adds, there was 'a good deal of diagnostic disarray'. He disagreed with Rosenfeld who equated depressive affect and its relief with manic-depressive states as he was also critical of those who mistook the compelling character of addictions for obsessive-compulsive states. He also emphasised 'the remarkable refusal of a number of writers to acknowledge the contributions of their colleagues and predecessors and even less to make use of them' (Radford, Wiseberg & Yorke, 1972, p.157).
In later years he undertook again his research with Pat Radford's help but his illness and his death interrupted that project. Two more papers however were written by him: Jaak Panksepp's response: Commentary by Clifford Yorke in 1999 and Commentary on 'Understanding Addictive Vulnerability' in 2003, in response to Professor Khantzian's paper whose views he profoundly disagreed with. In his comment he summarizes most of his views on Drug addiction using many of the findings of his work with Radford and Wiseberg. Some of them I have been familiar with since he supervised my first intensive psychoanalytically oriented therapy case, a heroin addict whom I started seeing in the late 70s, when I started my psychoanalytic training here. He strongly felt we were not concerned with a homogeneous group of disorders and frequently commented on how different addicts were from each other. In some heroin addicts, for example, who otherwise would inhibit their aggressive inclinations, the drug intensifies or even liberates anger or rage. But in others, heroin may sharply reduce aggressive behaviour and that may be the unconscious reason for which the person uses it. In talking about aggression he had in mind not only destructive aggression but also the capacity to use aggression forcefully and constructively for adaptation and mastery.
Some heroin addicts whose anxieties have been aroused by their libidinal urges find their libido sufficiently damped down by the drug to obviate these anxieties; and when sexuality is a source of shame, the taking of the drug heightens their self esteem and feelings of well being. There was, he felt, no consistent response in different patients.
While trying to reply to the question asked by Freud in 1930 as to why people took morphia, cocaine, etc. Radford, Wiseberg and Yorke pointed out that when the use of such drugs increased self esteem, 'this might be felt by some to outweigh the dangers, especially so by those who have a defect in reality testing, however circumscribed, and who, on that account, do not fully appreciate the danger to which they subject themselves. Those whose egos are weak in other respects may also discount or set aside the danger'. In some of their cases though there were no indications that the use of the drug had any such effect on self-esteem. In other cases, where there was an apparent rise in self-esteem, the reasons for this were not consistent from case to case. They did not simply function as a source of narcissistic supplies. There are, in Yorke's opinion, other ways in which the use of heroin may appear to enhance self-esteem. The modification of critical super ego functioning, temporary changes in the defensive organization, redistribution of drive energy, the approval of other addicts, all these may increase the addict's self esteem, at least while the drug is operative.
There are many other reasons for taking drugs – for kicks and sexual gratification among them – and for addicts of this kind the 'buzz' is what really matters. And for some 'mainline' users the injection, he reminds us, the use of the needle, is of special importance.
In his last written comment on Drug addiction, in 2003, Clifford Yorke talks also about 'addictions' not intrinsically involving drugs, such as gambling, kleptomania, 'flashing', 'cottaging', 'stalking', compulsive masturbation, shoplifting, food addiction, and even multiple murders as in the case of Harold Shipman's actions of which the addictive nature raised many unanswered questions.
Although in later years he played a less active role in the running of the Society, he continued to be in touch with what was going on and remained very interested in all things until the end of his life. One of his concerns was related to the changes in policy he saw in the Society, many of them, he felt, more due to a wish for political correctness than to a deep understanding of the issues which were, in his opinion, somewhat thoughtlessly in the process of being changed. In a collection of radio talks entitled Childhood and Social Truth, presented at one of the Child Analysis Today meetings at the British Psychoanalytical Society and reproduced in The Bulletin of the Anna Freud Centre (vol.18, 47-74, 1995), Clifford Yorke displays his masterly command of Freudian metapsychology. Drawing on his experience as a child psychoanalyst, he makes observations which are very pertinent to our understanding of psychoanalytical truth. To illustrate my point I shall comment on the third of these radio talks: The triumph of a wish.
He starts with the example of a little patient of his, a three-year old girl who, whenever he started to say something she did not want to hear, would run up to him and clamp her fingers across his mouth, and when, at the end of a session, she did not want to leave, she would try to fasten his feet to the floor with sticky tape. Using this example, Clifford Yorke reminds us that every child analyst is familiar with manoeuvres of this kind, stratagems that try to keep an inconvenient or painful reality at bay but which are, in all the circumstances of a disobliging world, bound to fail. There is, too, he points out, behind the little girl's actions, a degree of concrete and magical thinking discarded by most grown-ups but proper to her age.
After sharing with us that clinical vignette, Yorke speaks about widely disseminated doctrines which have sought to justify and encourage widespread social and family changes over the past twenty or thirty years. The growing replacement of the traditional family by cohabitation without commitment, he tells us, the rapid spread of divorce with its many different outcomes including the single parent family, single parenthood chosen in preference to partnership, and many other styles of life, have been seen and presented as equally acceptable forms of personal and social organization that reflect the free and rational choice of the emancipated adult.
Drawing a parallel between these observations and the story of his little patient, Yorke shows us how both tell us something important about the nature and function of fantasy, and about the conditions under which considerations of reality can be set aside. 'There is no need to emphasise the part fantasy plays in the behaviour of my little patient, he adds, where its fulfilling character is perfectly plain. But the contemporary social pressure groups that promulgate the changes to which I have referred depend to a significant extent on fantasy, on denial of reality'.
Social changes that affect children inevitably involve the relationship between men and women, and those relationships are at the centre of his discussion. I quote him: 'No subject more strongly attracts the attention of social pressure groups, and many of them base their appeal, however unconsciously, on wish-fulfilling fantasies of sexual identity. It is, for instance, undeniable that men and women have a great deal in common and that feminine traits are to be found in men and masculine traits in women even though, in the majority of cases, the balance is decisively weighted on one side or the other. But it's quite a different matter to imply that men and women are interchangeable; that the only difference between the sexes is a formal, genital one. But that is a position increasingly taken by those who confuse equality with identity, and explains in part why some militant feminists and homosexuals find themselves in common cause'.
If homosexuality is thought of as no more than an alternative life style with no implications beyond the sexual identity of a preferred partner, Clifford Yorke points out that reality is set aside in that assertion and evident belief. The relatively recent and heated debate on the age of consent for homosexual activity produced a striking example of the belief in the interchangeability of male and female. Many participants compared, perhaps with unwitting naivety, the legal position, in respect of sexual intercourse, of heterosexual girls with that of homosexual boys. They did not, as did some others, draw a comparison between the legal rights of heterosexual boys and homosexual boys. And it was striking, too, how many discussants referred to sixteen year old adolescents as hetero or homo-sexual men and women. That denied reality too.
In one form or another, confusions of sexual identity, he reminds us, are universal in early childhood. But it is a fact long forgotten in the conscious minds of adults. Social doctrines are often proclaimed with passion, but the degree of primitive fantasy that informs them goes unrecognised. And they're all the more powerful for that. There is nothing more dangerously impervious to argument, he says, than a strong conviction of unknown origin. Its wish-fulfilling force exerts the powers of rationalization to the full by those who pursue what they take to be adult liberation at all costs.
Many men and women who are genuinely fond of children have what might be called an intuitive grasp of their needs. But others, he warns us, do not; and for them it is remarkably easy to set those needs aside when their adult requirements seem imperative. The need for mothers to work has intensified the demand for Nursery education, but the interests of children are not always paramount in the matter. If they were, every mother would need to ask herself whether the child were ready for such a placement. This is not simply a matter of chronological age. It concerns the child's physical and psychological readiness for such an adventurous step. Bearing in mind Anna Freud's developmental lines, Yorke reminds us that if the child is to be able to leave the safety and familiarity of his home for short periods, and to give up for a spell the close availability of his mother, he needs to have reached a point in his development where he can keep a positive image of his mother in mind, securely aware that she will return for him. He is, of course, referring here to the capacity for object constancy, without which the child may all too easily feel the distress of abandonment.
A parent who knew intuitively what it felt like to be taken to a nursery school for the first time would, perhaps, find these requirements selfevident. But why are these childhood needs often so hard to assimilate ? There are, Yorke believes, two principle and powerful reasons. The first is the fact of childhood amnesia, the general inability of adults to remember more than a few isolated details from the first five years or so of life. It is this factor that shuts away so many tempestuous and dramatic psychological events that characterize the move, in a very short spell of time, from total helplessness and dependency to the capacity to join the socially civilized world of school and playground. It is this amnesia that makes permanently unavailable for most people the sexual and aggressive vicissitudes of childhood, forces that though tamed and modified in so many respects, continue to cast an unrecognized influence on all future behaviour. It is, above all, the childhood amnesia that tends to divorce the adult from his own past.
The second factor is a related one. The forgotten childhood past intrudes into the adult present to influence ways of thinking and feeling. Early childhood thinking is motivated above all by a wish for pleasure, and wish-fulfilling fantasy plays an active part in life, a part that only gives way, slowly and reluctantly, to the recognition of unwelcome demands of reality. But if wish-fulfilling fantasy operates too strongly in the adult's mental life, it may be reflected, in however restricted and selective a way, in his view of the world about him. The fantasies of a small child who has yet to acknowledge the full force of reality play an undue part in his social thinking, and adult rationalization conceals the Weltanschauung of an infancy long since inaccessible.
After making these points, Yorke turns again to the example of his little patient who, through the enactment of her fantasies, tried to alleviate the pain of unwelcome perceptions and the need for parting. But she was, after all, barely three years old; and although she could draw distinctions between fantasy and reality, the boundaries were more readily blurred than they would be in an older child, much less an adult. An older child can often use fantasy in more effective ways than the very young patient, even though the capacity to test reality is more soundly established.
In this chapter Yorke reminds us of the famous example given by Anna Freud (1936) many years ago of the 7 year old boy who owned, in fantasy, a tame lion devoted to him, and who used denial as a way of coping with disappointing, threatening, even humiliating features of reality. Older children who have recourse to fantasies of this kind do not of course believe that reality has been changed. Their sense of what is real and what is not is fairly well developed. At its most advanced, this ability takes years to acquire. But even his little patient knew there was something to try to shut out, and that sticky tape did not really hold you to the floor and keep you there. But for Anna Freud's patient the capacity to distinguish fantasy from reality was far more clearly established. So why were his fantasies of such great value to him when, objectively, he knew that his daydreams and their enactments were at odds with the true situation ? The fact is that, at his age, the two faculties-awareness of reality and the readiness to take pleasure in seemingly contradictory fantasy-can comfortably co-exist. The child who cared for his fantasized lion knew very well that the lion was not really his father, but the objective awareness was intellectual. The feeling state, on the other hand, that the fantasy maintained, had an opposing but comforting quality and restored the good spirits of which the awareness of reality alone would have deprived him.
As development proceeds, the capacity to maintain a split of this kind declines. In the adult, the counterpart to these stratagems of childhood would raise suspicions of mental illness. For most people a daydream readily gives way to the disappointing realities of life. The capacity to deal successfully with painful feelings by the substitution of pleasurable fantasy is substantially reduced. Some try to look at the world through the altered perceptions induced by alcohol and drugs, but that is another matter.
Primitive thinking, Clifford Yorke reminds us, does not disappear from adult life, though it is generally better controlled and it plays an adaptive part in dreams and creative art. Unhappily, its everyday importance is not restricted to these valuable roles. In its adherence to the search for pleasure, he adds, in its peremptory demand for instant satisfaction, in the total absence of the word 'no', it is always at hand to set aside the claims of reality and 'take the waiting out of the wanting'. So it is a great deal to do with contemporary hedonism, he concludes, the belief that life should be continuously pleasurable, and the conviction that someone else, in the form of society, is to blame if it is not.
In concluding, I hope that I have shown throughout his work, be it clinical, diagnostic or theoretical, that metapsychology formed the bedrock of his psychoanalytic thinking as it was for this that he was often sought out by students and qualified analysts both from the British Society and the Anna Freud Centre.

[1]Developmental lines is a metaphor of Anna Freud from her developmental theory to stress the continuous and cumulative character of childhood development. They combine Freud's drive model with more recent object relation theories of development, which emphasise the importance of parents in child developmental processes. They are not a substitute for the metapsychological approach to assessment, but an additional metapsychological point of view to be added to the dynamic, genetic, economic, structural and topographic. The lines have a marked focus on the role of the child's object relations.

BIBLIOGRAPHY

FREUD, A. (1936) The Ego and the Mechanisms of Defence, London: Hogarth Press. (Rev. Ed, 1976), pp.74-75.
FREUD, A. (1962a) Assessment of childhood disturbances, Psychoanalytic Study of the Child 17: 149-158.
FREUD, A. (1965a) Normality and Pathology in Childhood: Assessments of Development, London: Karnac 1989.
FREUD, A., NAGERA, H. and FREUD, W.E. (1965) 'Metapsychological assessment of the adult personality: the adult profile', Psychoanalytic Study of the Child, XX: 9-41.
EDGCUMBE, R. (2000) Anna Freud: A view of Development, Disturbance and Therapeutic Techniques, London: Routledge.
LAUFER, M. (1965) 'Assessment of Adolescent Disturbances: The Application of Anna Freud's Diagnostic Profile', Psychoanalytic Study of the Child, XX: 99-123
YORKE, C. (1970). 'A critical review of some psycho-analytic literature on drug-addiction', Brit. J. Med. Psychol., 43: 141-159.
RADFORD, P., WISEBERG, S., & YORKE, C. (1972) 'A study of 'mainline' heroin addiction: A preliminary report', Psychoanal. Study of the Child, 27: 156-180.
WISEBERG, S., YORKE, C., RADFORD, P. (1973) 'Aspects of self cathexis in 'main-line' heroin addiction'. In: Studies in Child Psychoanalysis Pure and Applied, Mongr. 5, New Haven, CT: Yale University Press.
YORKE, C. (1995) Childhood and Social Truth, The Bulletin of the Anna Freud Centre, 18: 47-74.
YORKE, C. (1999b) 'Jaak Panksepp's response: Commentary: literature on drug addiction. British Journal of Medical Neuro-Psychoanalysis, 1: 251-254.
YORKE, C. (2003) 'Commentary on 'Understanding Addictive Vulnerability'. Neuro-Psychoanalysis, 5:42-53.