On Working Clinically with Sexual Offenders: An Interview with Dr James Cates

When I was first introduced to Dr James Cates about five years ago, it was in a lecture in which he talked about the unique challenges of doing clinical work with the abundant Amish population (third largest in the country) in northern Indiana. I was fascinated by this work in part because it focused on sexual abuse inside a religious community, and I had myself just finished a book on sexual abuse inside the Catholic Church. 

About a year later, I had the great good fortune to read his elegantly written and fascinating book, Serpent in the Garden: Amish Sexuality in a Changing World, about which I interviewed him here. 

I brought him to one of my classes this past semester to lecture on working with the Amish and it was then I learned his newest book was about to make its appearance in print. I eagerly ordered and read Offenders and the Sexual Abuse of Children (Routledge, 2024), and then asked him for an interview about it. His thoughts are below.  

AD: Tell us about your background

James Cates: I graduated with a master’s degree in clinical psychology from George Mason University in Fairfax, Virginia. Jobs were sparse, so I did a nationwide search, and wound up employed in Fort Wayne, Indiana. I planned to stay a couple of years and move back to Virginia.

That was 1982. I’m still in Fort Wayne, looking for the right job to move back. 

Meanwhile, I received my doctorate in clinical rehabilitation psychology in 1993, became a board-certified clinical psychologist, and moved into private practice. Somewhere along the line I began teaching part-time at Purdue University-Fort Wayne, first undergraduate, and more recently in the mental health counseling program. I became involved with the Amish, a culture that I love dearly and respect deeply. I am now semi-retired, and continue to write and to do psychological testing and consultation. 

AD: Your previous books marked you out as the leading scholar-clinician on Amish psychology, so a book on sexual offenders might seem a significant new direction to move in. Are there any connections between these worlds?

JC: Sadly, more connections exist between the Amish and sexual offending than would be preferred. All three of my books on their culture include chapters that address sexual abuse: Serving the Amish: A Cultural Guide for Professionals; Serpent in the Garden: Amish Sexuality in a Changing World; and Dancing on the Devil’s Playground: The Amish Negotiate with Modernity. And mainstream media has picked up the storyline of hidden sexual abuse among the Amish, as among so many groups today, as a social ill in desperate need of change. 

I credit my work with the Amish for helping to broaden my perspective on sexual offending. Their culture is collective, emphasizing a communal and cooperative lifestyle, so that very few actions occur outside public awareness. Their culture also emphasizes forgiveness as a Christ-like virtue, so that sins are to be forgiven and forgotten. Consulting with both social service personnel and Amish ministers on how to handle issues of sexual abuse within the church, and counseling with Amish victims of sexual abuse and those who have sexually offended has given me an appreciation for the interwoven complexities of this behavior, and its impact on the family and community. This fallout is too often obscured as the justice system grinds into gear in mainstream culture.  

AD: The first part of your book helpfully situates what is to come in its social and historical context, especially in the anglophone world. As you survey this history, are there 2 or 3 outstanding factors you unearthed to help explain shifting perspectives on sexual offenses? 

JC: The idea that history is written by the victors is most recently attributed to Winston Churchill. That is so true when considering perspective on sexual offenses. With the caveat that I am neither a historian by training, nor am I an amateur historian, these are my thoughts.

The anglophone response to sexual abuse through the 19th and earlier 20th centuries was dictated by class and caste systems far more than an advocacy to protect all children. As horrible an indictment as that sounds, it fits within the broader disinterest in the rights and well-being of those of lower socioeconomic status. In this country, the status of African-Americans is the most obvious example. As the Civil War became a cause to end slavery, even many who were fervent abolitionists failed to perceive people of color as equal to whites. And these attitudes continued to be codified in law well into the mid-20th century. The backlash to these prejudices became an embrace of equality, and demand that the rights of all people be respected. One of the lasting legacies of this principled backlash has been a strong advocacy for the safety of children. Unfortunately, those who sexually offend then become pariahs in their own right. 

Another rarely considered historical factor was political necessity in the early years of gay rights. That portion of the nascent movement driven by gay men was enmeshed with men attracted to young boys. This uneasy truce lasted until it became clear that an alliance between men attracted to men and men attracted to boys was a detriment to social and political ambitions for the former, who acted to distance themselves from those who would now be termed minor-attracted. While the gay movement did not actively denigrate those who were minor-attracted, the implication was clear: we do not support that type of sexual activity. In that implication, one denigrated sexual minority made a case for its own worth by keeping its distance from another. (And in fairness, at the time those advocating same-sex attraction to boys were also advocating for the freedom to act on their sexual desires, a much different social and political agenda than those currently seeking status as minor-attracted.)   

AD: One of the themes in the background of your book seems to be how much we like to paint sexual offenders as bright red grotesques, whose features and causes we confidently feel we can immediately identify, but you note "there appear to be too many variables that contribute to the ultimate behavior to reliably predict patterns of sexual offending" (p.23). Later you note that when it comes to the risk of recidivism for sexual offenses "nothing even approaching a definitive response exists" (p36). Given the enormous publicity that attends sexual offenses, one might expect this to be a heavily researched area. What helps to explain the many lacunae in the clinical literature on these topics? 

JC: The problems in predicting the behavior that leads to sexual offending are myriad. A parallel example from several years ago in the area of substance use exemplifies the dilemma. At that time, studies repeatedly found that among 18–25-year-olds, over 50% were binge drinking on a regular basis. The first problem with this statistic is that by definition, if an 18–25-year-old was not binge drinking, they were abnormal, since they were in the minority. The second problem with this definition became the criteria for binge drinking. As studies began refining the definition of “binge drinking,” using differing criteria for the number of drinks consumed at one time, or within a certain time period, the percentage of those identified as binge drinkers began to vary too. Alcohol use was not significantly changing. The way research defined it was. 

When research looks at sexual offending, the same problem with definitions applies. What is the age of the victim? Legally, a “sex offender” label applies to someone who has sex with a five-year-old, or someone a week younger than the legal age of consent. Do the same dynamics of sexual, emotional, and romantic interest apply to these two individuals? What is the age range of interest for someone who has sexually offended? How often, or under what circumstances do the sexual offenses occur? Do we apply the same criteria to the uncle who molests his niece on two occasions, and the serial offender who has sexually offended against both genders multiple times?  Is there an element of power and control, or do they exhibit a romantic or regressive emotional interest in the younger partner? Not only is this a complex topic, but we do little to encourage those who have sexually offended to be open and honest about their sexual and psychological experiences. 

Research on recidivism in sexual offending is hampered by the shame, guilt, and risks that attend honesty. Consider a standard field research protocol. Participants must be known to have sexually offended. There is no potential to circulate a call for participants, such as can occur at a local 12-step meeting for those struggling with substance abuse who might like to give back to the community. There is no potential to ask counselors to share with clients who would qualify as participants. No, the only participants available are those who have been charged and convicted of a sexual offense. And the majority of these (now) criminals have no incentive to be honest about their behavior, beyond the behaviors for which they have been convicted. If they are, they run the risk of having even more charges added, and facing lengthier sentences. The individual struggling with alcohol or drug abuse, including illicit drugs, can share stories of past use with impunity. Not so the individual who has sexually offended.

The most accessible participants then, are those who have served a period of incarceration and are released. And the most easily obtained outcome measure is recidivism. Have they been arrested post-release for a sexual offense? And again, there is no incentive to be honest if they have not been caught. For the probationer who relapses and watches child pornography but escapes detection, there is no incentive to share that fact. We are then left with no understanding of the emotional and psychological forces that become overwhelming and lead to the decision to risk prison once again in order to fulfill this sexual need. The probationer who shares with a counselor that they have used alcohol, violating the rules of their release, faces minimal expectation that the counselor will report them. But the probationer who shares with a counselor that they have sexually offended, violating the rules of their release? A report is almost inevitable. 

And there is a need – clearly, there is a need – to protect potential victims of sexual offending. But in acknowledging that need, we fail to take into consideration the vague definition that the outcome measure “recidivism” must inevitably become. As another example, studies vary in the types of crimes they define as recidivism. Any violent crime? Or only a sexual crime? If a defendant is initially charged with a sexual crime, but it is reduced by plea bargain to a misdemeanor battery with no sexual component, is that recidivism? These are the types of decisions about definitions that vary from study to study, and complicate meta-analyses.  

AD: One of the (to my mind) peculiarities in treatment of adolescent vs. adult offenders is, as you note, offering the former a "rehabilitative model rather than a punitive one" (p.38). The latter model, when applied to adults (who are often related to their victims), often causes even further unintended hardship (as you note on p.78) and suffering by imprisoning the offender, causing a loss of income to the family and other problems. Is there any argument to be made about adopting a more rehabilitative model across the board for all offenders? What is the evidence we have about rehabilitation and its efficacy? 

The question goes to the broader issue of American attitudes toward rehabilitation. The statistic is hard to pin down, but we rank among the highest per capita incarceration rates among developed countries. We are more comfortable locking away those who offend than finding ways to manage them within the community. 

Restorative justice, the concept that accountability and reparation are more important than retribution and punishment, is beginning to make inroads into the justice system. We see it in the formation of drug courts and mental health courts, designed to treat substance abuse and mental illness primarily as disorders, rather than crimes to be adjudicated. Still, the emphasis on protection for the community means that rehabilitative models for those who sexually offend are slower to develop and slower to be implemented than for other populations. 

Rehabilitation for a particular population will relate to that population’s standing. Those who engage in criminal behavior are placed at the intersection of politics and science. There is a grim reality to the frequency with which Americans incarcerate those who commit crimes. Reducing the number of people likely to commit crimes who are on the streets does indeed contribute to a lower crime rate. So, at some point the issue becomes philosophical: to what extent is the drug dealer/drug user/burglar/child pornographer/etc. deserving of rehabilitation and a return to mainstream society? Only the to extent that we believe that a given population deserves rehabilitation do we begin to emphasize rehabilitation for them. And only to the extent we emphasize rehabilitation is it funded, analyzed, refined, and measured for its efficacy. 

An argument for extending rehabilitation? For those of us who argue for the worth of the individual over the erosion of civil rights and the staggering costs of incarceration, it is well worth it. For those of us who argue for the safety of the community over the worth of the individual? Rehabilitation is secondary to confinement.  And the argument is obviously not that black-and-white. Argue within the shades of gray and it becomes a tumultuous argument, indeed. 

AD: I thought my cynicism about the legal system was approaching bedrock level, but I confess it fell still further as I watched you judiciously sift and sort through the evidence for geographical restrictions on offenders, state-mandated offender registries, and similar tools of social control. Given that, as you show, we have virtually no empirical evidence for their utility, how are we to explain their ubiquity today--are they simply the perverse fruits of moral panic, a kind of "quarantining" or ghettoization of undesirables we see throughout human history going back to biblical leper colonies? 

JC: The high-profile kidnapping, sexual assault, and murder of several children resulted in federal laws that have shaped social control of those convicted of sexual offending. To some extent, it was a perfect storm of events: the public was clamoring for a sense of safety due to multiple events on the world stage that led to unrest and feelings of unease; the media hyped stories of child abduction and murder in an endless loop as the public became increasingly interested, and the media fed that interest; and social science had little or nothing in the way of evidence to support or refute proposed legislation. 

Once legislation was in place, research was playing catch-up to determine how effective it might be. Laws continued to be modified, expectations for registries continued to evolve, and research needed to change to match current expectations. By the time research was demonstrating that registries had no deterrent effect and geographic limitations were ineffective, both of these safeguards were entrenched in the public psyche as “deterrent measures.” For legislators it was no longer a matter of what might be effective. It was a matter of public demand. 

A demonstration of just how little evidence-based practice impacts social policy can be seen by placing gun ownership and sexual offending side by side. Mass shootings have become a norm in the United States – including in schools - but no one is seriously considering gun control, despite the evidence that gun control would work to reduce senseless deaths. Meanwhile, registries and geographic limitations on habitation do nothing to reduce sex offending, but we cling to them like a drowning man to a life preserver.

AD: At the end of ch.9 you note that "the necessary, fundamental change is a better understanding of a person who sexually offends." This seems so simple as to be almost startling, but I think it true. And yet I know from my students that the one population they all say they would struggle the most to work with, some of them expressing horror at the very thought, is that of sexual offenders. What are some of the most startling or surprising insights for you working with sexual offenders--what have you learned from them?

JC: Let me start the answer to this question indirectly, and wind my way back. It strikes me as a political rather than a clinical statement that as a 68-year-old male, in my state of residence I can carry on a romantic/sexual affair with a 16-year-old, and not only be within the boundaries of the law, but there is no preponderance of research explaining what might be the hell wrong with me. And yet social science churns out article after article detailing the problems of a 20-year-old who deigns to fall madly in love with a 15-year-old. 

Now, a couple of quick clarifications to the paragraph above. I have no interest in a romantic or sexual liaison with a 16-year-old. Rather, my point is that empirical research does not bother to extensively study age differences in romantic interest across the lifespan; only between adults and children. And the example I use is one of the narrower age gaps that can occur that result in arrest, charge, and conviction leading to the label of “sex offender.” Obviously, 20-year-olds (and older) are also sexually abusing much younger children, a clinical problem in desperate need of research. 

The point however, is that between the black-and-white of inappropriate sexual acting out and sexually permissible behavior there is a wide, gray area that becomes codified in laws that may not be an accurate representation of how clinically disordered a person is. 

I give two brief examples in the book. Fleshing these out a bit gives a better sense of just how different the dynamics between two people who become “sex offenders” can be. 

One was a case in which I testified for the prosecution. This was an approximately 40-year-old man who had a history of arrests for various offenses. His apartment was filled with toys and games he used to entice children from the neighborhood. By the time he was arrested he had multiple victims, and from all potential observation, no remorse for his behavior. He appeared to exhibit an Antisocial Personality Disorder – that is, a lack of conscience or ability to empathize with others, and a willingness to disregard their rights. In his case, rehabilitation was far less of a concern than safety for the community. His is one extreme of those who sexually offend. He also had charges for various non-sexual felonies. His sexual offending was part of a larger pattern of disregarding the rights of others. 

At the other extreme was a young man with a severe addiction to marijuana. He began sexually abusing his young daughter. He hated himself for doing so, and after one incident said to her, “If I do this again, tell mommy.” He sexually abused her again, and in turn, his daughter told her mother. He did not contest the charges. While he waited for the justice system to proceed (it took 14 months for his sentencing hearing), he lived on house arrest with his parents. He found a job, and made voluntary child support payments on a biweekly basis. Despite his cooperation and behavior, he was given a sentence of 12 years. In counseling him as he waited for sentencing, and staying in touch with him during the time he has been in prison, it is clear to me that he is not attracted to children. The incidents with his daughter arose from a combination of reduced inhibitions due to drug use, tensions with his wife (the girl’s mother), and feelings of helplessness in his larger environment. 

In these two vignettes, from a legal perspective, the behavior is the same. A child under the age of 14 was touched for the purpose of sexual gratification. From a clinical perspective, they could not be more disparate. Regardless of the presenting problem, it is a profound reminder for those of us in the mental health field: there are multiple reasons for a behavior to occur. 

And the most surprising observations? Very few of my clients fail to offer me insights in some way. Sometimes, they are insights that leave me grieving the human condition. Sometimes, they are insights that leave me breathless with what the human condition can overcome. The most startling among those who sexually offend has been the integrity they can demonstrate. Knowing full well that they are now pariahs, despised by so many, relegated to wear the scarlet letter of the registry upon their release from incarceration, they carry on with a dignity and purpose that belies their pariah status. There are several that I am proud to call my friends.  

AD: Your historicizing tendencies in this book are never so powerful and disturbing as when you show that many of the treatments previously used to "treat" today's offenders were the self-same ones used not so long ago to try to "convert" mostly gay men into heterosexuality. Are there, in fact, any treatments we have today that are (a) not connected to those abuses and (b) effective? 

JC: Visualize a map of empirical study of effective treatments for sexual offending. There is a broad, well-traveled road that runs through the middle of the map. That is the history of Sexual Orientation Change Efforts (SOCE), as they are now called, the historical efforts to convert sexual minorities to heterosexuality. At some point, that road begins to narrow, and eventually becomes a minor path. But branching away from it is a path that broadens into its own road. And these are the efforts to create change among those who sexually offend. Same journey; different destination. 

Now, staying with that visual, imagine side trails leaving the main road, both from the original highway and the new branch. These are much narrower, and almost all of them dead-end. That is the history of alternative treatment efforts, for both SOCE and for sexual offending. Without sufficient funding or willingness on the part of the larger mental health community to explore them, they may hold potential, but the destination is a therapeutic dead end. 

In brief answer to your questions then, (a) no, nearly all of the interventions in use today have their genesis in SOCE approaches, and (b) their efficacy is based on outcome measures, and the inefficacy of those measures is discussed above.  

I devote a single chapter to the evolution of mental health treatment. The topic is worthy of an entire book itself. My hope is that the chapter spurs a healthy debate on the efficacy of treatment, and that the community of current mental health practitioners implementing and researching these treatments are called to critically analyze their approaches.   

AD: Your chapter on minor-attracted persons is perhaps the one where we see most acutely the limitations and short-comings of our research, knowledge, and clinical practice. Where would you like to see the research go? What future directions and changes do we need to investigate? 

Minor-Attracted People (MAPs) are a paradox. They again demonstrate the intersection of the clinical and political. Allyn Walker wrote extensively about MAPs in their book A Long, Dark Shadow: Minor-Attracted People and Their Pursuit of Dignity, only to be pressured to resign from their position as faculty at Old Dominion University because of it. On the one hand, there is increasing urgency to recognize the right of MAPs to express themselves as romantic and sexual human beings. On the other hand, there is the ongoing urgency to protect vulnerable children from any more exposure to adult romantic and sexual encounters than a socially toxic environment already allows. 

The fear is the “slippery slope” of acceptance. It took time, but from riots by street people outside the Stonewall Inn in 1969, gay liberation brought us to Obergefell vs. Hodges in 2015, the Supreme Court decision legalizing same-sex marriage. Some fear that embracing MAPs as a legitimate sexual orientation is an ultimate invitation to act on that desire, protests to the contrary notwithstanding. They point to the slow history of acceptance of same-sex couples as an example of how that can occur. 

It is here that social scientific research can be most helpful. Is minor-attraction a sexual orientation? Are there different manifestations of minor attraction? How often does minor-attraction as a sexual orientation coexist with other sexual orientations? If minor-attraction is only one of many reasons that individuals may desire to become sexually involved with a child, what clinical/emotional/psychological factors and traits contribute to minor-attraction as opposed to other reasons for focusing on children? And if a MAP chooses to embrace that attraction but remain abstinent from acting on the desires, what are the most effective means of assisting them in doing so?  

AD: Sum up your hopes for this book? Who should read it? 

JC: Bear with me for a moment – my dad was a Baptist minister, and some of those lessons linger. One of those lessons was the story of Elijah the prophet on the mountainside. God sent a message, but first he sent an earthquake, a huge wind, and a fire. The message wasn’t in any of these. And then, God sent the soft whisper of a voice. That has been an important lesson for me.

So much of what is written about sexual offending advocates for the victim and rails against those who offend. Less often, but still in print are those writings that advocate for those who offend and rail against the system. Offenders and the Sexual Abuse of Children is, unapologetically, an indictment of the mental health, social service, and justice systems as they attempt to protect victims and treat those who offend. But I strive to maintain a balanced perspective. The system is not in need of repair because of indifference. On the contrary, there is a desperate desire to protect the community and potential victims. My voice may rise above a whisper in these pages, but I strive to avoid the drama of frustration and anger that so often pervades these emotional arguments. 

I encourage anyone in the fields of mental health, social services, or criminal justice who work with those who sexually offend or their victims to read this book. I also encourage those who volunteer with organizations that support those who offend, their victims, or their families to read this book. And for those who have offended and their families, some may find this book of interest as well. As much as possible, I have stayed away from jargon, and maintain a readable style. 

AD: What are you at work on next? 

Back to the Amish, at least for a time! Several years ago, I was part of a program that offered psychoeducational classes for Amish youth arrested for drug and alcohol offenses in the Elkhart-LaGrange settlement of northern Indiana (the third largest Amish settlement). Over the 14 years the program ran, we collected data on almost 1000 participants. That data is ready for analysis, and I am working with several other professionals to begin that process.

I am also co-authoring another book on the Amish. This book examines the strengths and weaknesses of Amish culture, particularly as their social fabric comes under criticism from ex-Amish, the media, and the larger culture.  

And the response to Offenders and the Sexual Abuse of Children will guide my decisions about further work (article, book, etc.) in this area.  

Thank you so much, Dr. DeVille, for the opportunity to share on this blog! Always fulfilling to work with you as a colleague and a friend.

Summer 2024: An Omnium Gatherum

Introduction:

Can it have been eight months since I last posted on here? It is not for lack of materials, as you shall presently see! I read as greedily and voraciously as ever, rapidly eviscerating some books while with others slowly meandering through them repeatedly as I soak in their wisdom.

Instead, I have been busy with all the usual aacademic and clinical duties, and all spare energies have gone into writing not one but two books of my own this year. With one of them done, I have come up for breath and can say something brief about both (before reviewing books devoured this year to date). 

1) The first has morphed in my mind countless times. But now it has coherent shape, and would have been done this summer but for the unexpected instrusion of book #2, noted below. This first book will be more 'meditative' (for lack of a better word) and gives me a chance to develop some things I have been thinking about for thirty years now. The tentative title is On Being a Psychiatric Monk. It develops ideas my beloved Nina Coltart first laid out very sparingly, especially her notion of "bare attention" which the clinician must constantly cultivate.

Such a notion was drawn from her immersion in Buddhism, about which I have hitherto been ignorant. But she inspired me to start reading Mark Epstein's books, two of which I have now finished and want to re-read: first was Thoughts Without a Thinker: Psychotherapy from a Buddhist Perspective. This was followed by Going to Pieces without Falling Apart: A Buddhist Perspective on Wholeness.

In thinking about "bare attention," I returned to a fascinating woman I first read about in the early 1990s: Simone Weil. She has a very rich essay "Attention" that I read in Gravity and Grace. For context to Weil's essays I read The Subversive Simone Weil: A Life in Five Ideas by Robert Zaretsky (University of Chicago Press, 2021).

2) This second book of mine, which I had neither plans nor foreknowledge of, came roaring out of nowhere in the late spring, part of it decided upon simply by gathering the lecture notes I use for my Introduction to Psychotherapy/Counseling class every year. In that class I have had the students read a number of books (especially those of Lou Cozolino and Nina Coltart) and articles, especially those of Jonathan Shedler and Nancy McWilliams. But I decided I could write my own book not only as a short, accessible, suitable text for my students, but also (and here I must cite Kristian Kemtrup for this inspiring idea) as a rejoinder to the increasing number of right-wing critics of psychotherapy, of whom some American journalist named Abigail Shrier is most prominent just at the moment with her Bad Therapy: Why Kids Aren't Growing Up. Her book advances many of the usual romantic and reactionary fantasies ("chosen traumas" as Vamik Volkan calls them) about our present moment but it also, importantly, advances criticisms of the field of psychotherapy some of which deserve to be taken seriously. So that is what I spend the first chapter of the book doing: responding to, and in many cases agreeing with, Shrier about the many practices that constitute bad therapy. 

Nobody likes a scold, however, so I spend the rest of my book unfolding a more compelling vision of what psychotherapy could and should be like largely inspired from Winnicott's argument that “psychotherapy has to do with two people playing together.”

Here is the Table of Contents:

Introduction:

I: What Good Psychotherapists Do Not Do

II: What Good Psychotherapists Are and Do:

III: What Good Psychotherapy Requires: a Frame

IV: What Good Psychotherapy Requires: Psychologically Minded Patients   

Conclusion

Brief Annotated Bibliography

Acknowledgements.

I have been unable to decide on title for this book. There are four contenders at the moment, none of which I am entirely happy with. Your feedback, and additional suggestions would, dear reader, be gratefully appreciated:

A Short Guide to Finding a Good Psychotherapist Psychotherapy: A Playbook for Patients, Students, and Clinicians Psychotherapy: A Playbook for Patients and Professionals Alike On Not Giving Blow-Jobs to Stick Figures on White Boards: And Other Tales of Psychotherapy Gone Awry

Right. Now to briefly go through some of what I have been reading this summer in the hope that it might be useful to others:

Clinical Readings:

Having previously read two of her books, especially The Analyst's Vulnerability, which I wrote about here, I was eager to read another of Karen Maroda, and this July read Seduction, Surrender, and Transformation: Emotional Engagement in the Analytic Process. I began with her chapter on the use of touch in psychotherapy, of which I am not an advocate at all, while she came very carefully to moderate her previously negative views, too. But the richest part of the book is her reflection on how all psychotherapy is "grief work," to use that almost pedestrian phrase.

Self-Examination in Psychoanalysis and Psychotherapy: Countertransference and Subjectivity in Clinical Practice by William F. Cornell came out from Routledge in 2018. Perhaps this book might be useful for beginning students unaccustomed to self-examination and drawing on counter-transference reactions, but I found it very thin gruel.

That was also my reaction to The Language of Change: Elements of Therapeutic Communication by Paul Watzlawick (Norton, 1993). Much better books on this topic exist including Paul Wachtel's Therapeutic Communication: Knowing What to Say When and, even more than that, Leston Haven's invaluable Making Contact: Uses of Language in Psychotherapy, which I wrote about at length last summer and find myself returning to often.

Having been so taken by Haven's book, I decided I should read more of his. Reader, I was not impressed, but that is okay for I have long been aware that authors of more than one book usually have a dud or two in the mix. Thus I was rather disappointed by the thinness of A Safe Place: Laying the Groundwork of Psychotherapy (1989) and Coming to Life: Reflections on the Art of Psychotherapy (1994). Slightly more edifying were Haven's chapters in The Real World Guide to Psychotherapy Practice, eds., Alex N. Sabo and Leston Havens (Harvard UP, 2000).

Critical Analyses of the Field of Psychotherapy:

Because I am a neurotic academic anxious not to repeat what others have said before me, and even more anxious to ensure all my bases are covered, I decided, in writing the second of my books noted above, I had to look at recent critiques of psychotherapy from those within the field, and so I read and almost entirely agreed with Enrico Gnaulati's Saving Talk Therapy: How Health Insurers, Big Pharma, and Slanted Science are Ruining Good Mental Health Care.

Advancing Psychotherapy for the Next Generation, eds., Linda L. Michaels, Tom Wooldridge, Nancy Burke, and Janice R. Muhr (Routledge, 2023) deserves the widest possible audience for it publishes the results of one of the largest and best studies of what patients want and benefit from in psychotherapy. A study of this size has not been seen, as far as I know, since the 1995 Consumer Reports study. Here's a hint totally unsurprising to practicing clinicians: patients want to be listened to at depth to explore the dynamics of their minds and relationships. They do not want worksheets, breathing exercises, chakras, and the whole farrago of fatuities one so often encounters today.

Some Winnicott (of course):

I own all but one of Christopher Bollas's books so when he published another one recently I was of course going to get it: Essential Aloneness: Rome Lectures on DW Winnicott. Regular readers and re-readers of Winnicott, as I am, will not find a lot of new material here, but this book would make the best brief introduction to Winnicott I know of. It is cogently and compellingly written based on lectures which Bollas gave decades ago and, strikingly, did not feel the need to alter for publication. There is a freshness and liveliness to each of the short chapters.

This is one of those books I did not--could not--devour and eviscerate, but instead had slowly to read and re-read, and I expect I will go back to regularly: Steven Cooper, Playing and Becoming in Psychoanalysis. He picks up on Winnicott's argument, quoted above, about psychotherapy being a place for play to ask what that looks like. Happily Cooper does not give definitive answers to that question but writes in such a way as to invite the reader to imagine his or her own thoughts on the question, noting that you can never play with each patient in exactly the same way. (Another book on this theme of playing was a total disappointment--virtually worthless.)

Books Useful for Training or Recommending to Students:

If you are trying to teach your students or supervisees about the centrality of the working alliance, then this is a book to have in your back pocket: The Therapeutic Alliance: An Evidence-Based Guide to Practice, eds., Christopher J. Muran and Jacques P. Barber (Guilford Press, 2010).

In May I was asked to do some training for local clinicians on working with psychotic disorders, and just a few days before I did so, a brand new book arrived, which I tore through at the time but really must go re-read to benefit from. It is very rich and compelling: From Breakdown to Breakthrough: Psychoanalytic Treatment of Psychosis by Danielle Knafo and Michael Selzer (Routledge, 2024).

A Little Sex:

I still cannot overcome my dumbness to say anything about two books Avgi Saketopoulou. The first of these is her just staggering work Sexuality Beyond Consent, which I read back in mid-January. I have tried writing about it several times, but to no avail. She has forced me to re-think things in ways I would never have expected or been prepared to until quite recently.

The second is one she co-authored with Ann Pellegrini: Gender Without Identity It took requires more commentary than I can make here. Perhaps some day...

Speaking of sex, because I work with sex offenders clinically I ordered Brett Kahr's Who's Been Sleeping in Your Head: The Secret World of Sexual Fantasies to see what some of the international research says about types, themes, and prevalence of various fantasies. Kahr's book is very workmanlike. (A friend tells me he is currently enjoying one of Kahr's other books: Coffee with Freud.)

A Bit of Bromberg and Bach:

Once I take a liking to an author I usually have to devour all his or her works. So in January of this year I ordered the remaining books of both Philip Bromberg and Sheldon Bach that I did not own. I've read chapters in each of them, but hope to finish them by Christmas.

Non-Clinical Reading:

How boring it would be only to read books in one's field! Thus not all my reading is clinical: I confine that to daytime and weekday reading.

Bedtime and weekend reading lately has consisted of many other books (especially those about the canal systems of England and Wales, a curious obsession I cannot explain), including Adrienne Rich's poems, and Charles Moore's splendid Margaret Thatcher: The Authorized Biography, vol.3: Herself Alone. Though I found her politics repellent then as now, I was fascinated by her fierce and contradictory character and perhaps allowed myself a bit of a crush on her as I watched her final year in office when I was a teenager briefly toying with a possible career in law and politics. Moore is a much more judicious commentator and elegant writer than I was expecting, and the book, while a bit over-laden with detail sometime, is very gripping. Having finished the final volume, I'm about to go back and read the first.

Prior to finishing the Moore biography, I read the second of Steven Kotkin's studies of Stalin, Stalin: Waiting for Hitler, 1929-1941. Among its many virtues is its careful attendance upon and wise reflections on historiographical principles used and abused in telling the story of Stalin, who has been the subject of a myriad of biographies, some of which I have read.

Traveling this summer I perused used bookstores in North Carolina and West Virginia, and found Harry S. Truman, written by his only child Margaret. It's a charming biography of one of the most compelling men to occupy the White House. This has made me determined to re-read David McCullough's Truman, which I first read twenty years ago. Recently two new books about him have emerged which I may eventually read.

Truman's exact contemporary and man of similar temperament and politics, Clement Attlee, was the subject some years back of John Bew's splendid book Clement Attlee: The Man Who Made Modern Britain. These two men nearly alone of all politicians in the last century remind me that not all political leaders are mendacious, malevolent, and repellent creatures.

I am part-way through the very dense Early Auden, Later Auden: A Critical Biography by Edward Mendelson.

Once that is done, I will start another biography I found on my travels this summer: Jacques Lacan by Elisabeth Roudinesco. If you don't know Roudinesco's works, you should. Her Freud: In His Time and Ours is one of the best single-volume biographies of the great man (less idealistic and more gritty than Peter Gay's book, and far less officious, of course, than Ernest Jones' authorized three volumes) while her Why Psychoanalysis? is a short apologia which avoids special pleading.

With the academic year beginning Monday, time for reading and writing sharply diminishes and so it may well be December before I have time to pop back on here, but who knows....

Betty Joseph on Psychic Change

As so often happens, my friends on Twitter [some insolent rabble in the gallery: "He has friends?"] convince me finally to read people of whom I have been aware, often for decades, without having actually read their works. In this case, it was a quotation from Betty Joseph. Finding it compelling, I ordered, and have now read, Psychic Equilibrium and Psychic Change: Selected Papers of Betty Joseph, eds. Michael Feldman and Elizabeth Bott Spillius (Routledge, 1989).  

Joseph lived to nearly 100, dying just a decade ago after a very long clinical career in England. (A short biographical sketch is available here.) My first analyst in Canada was a Kleinian and I vaguely recall her mentioning Joseph at one point but I never investigated farther. 

The Hard to Reach Patient:

Like all collections, Psychic Equilibirum is uneven. It contains papers originally published as far back as the late 1950s. Every chapter is fairly brief and follows a standard format. I perused the table of contents and decided, after reading the editors' introduction, to jump around, beginning with the chapter that first grabbed me most strongly, viz., no.5, "The Patient Who Is Difficult to Reach." I have at least one such right now and whenever I read a chapter like this--or any chapter by clinicians citing their own case material--I always hope (surely I am not alone in this?) that what they describe will be exactly what my patient is like so that, at last, I can stop thinking and reading and wondering and working to figure out the treatment they need, and instead copy the example cited by this manifestly masterful clinician. Thus does one see the very real attractions of manualized therapy!

But, of course, my patient is at least 90% different from Joseph's. (And thus does one see the massive limitations of manualized therapy!) So I ended this chapter somewhat disappointed, to be honest, finding it only partially useful. (That is also true of much of the book: I found only 2 or 3 chapters particularly useful, but read all of them, and found threaded through each and every one a common theme, noted below.)

But then, trying (at risk of sounding pious or sycophantic, both of which I abhor) to reflect over the whole chapter by means of a kind of reverie, which 'method' I learned from reading the great Thomas Ogden, I put the book down and stared across the coffee shop and out the window to the river, and found myself focusing on nothing in particular but allowing my mind to range back over the entire chapter as it tried to weave in one case in particular. At that moment I came to a rather startling insight about what now seems to me a technical mistake or perhaps an 'enactment' I have allowed to happen. I was aware of what I was doing, and thought it justified, but now in light of Joseph's chapter I see differently.

What, in particular, provoked this small epiphany? There are three lines in the chapter that were bracing to me.

First, she begins by talking (as others I have read would later do--I think in particular of Christopher Bollas here) about those patients eagerly proffering "pseudo-cooperation aimed at keeping the analyst away from the really unknown and more needy infantile parts of the self" (p.76). That latter phrase--more needy infantile parts--especially struck home and inched me toward greater understanding of a case in which my countertransference imagery has been utterly plagued for months with nothing but images of my cradling my (adult) patient as a babe-in-arms. 

This first line of Joseph's I immediately linked up with a passage a few paragraphs later in which, continuing the theme, Joseph speaks of the really needy part of the patient needing "the experience of being understood, as opposed to 'getting' understanding" (p.79). That, of course, echoes one of her contemporaries, Frieda Fromm-Reichman, and the latter's famous observation that the patient needs an experience, not an explanation. Here I came uncomfortably close to a second acknowledgment of a near-mistake in a case in which I have sometimes found, in my impatience, doing what Joseph warns against: offering 'an explanation,' a thing, rather than an overall experience--and doing so prematurely, in a way the patient could not use at the time. 

In doing so, I am now rebuked not just by her, but also by a passage of Winnicott I have not always heeded. In "The Aims of Treatment" from 1962, he speaks of the necessity of "economical" interpretations, rightly warning that "I never use long sentences unless I am very tired. If I am near exhaustion point I begin teaching." In my case it's not just a moment of exhaustion but also sometimes of frustration which I have done a poor job of controlling. At such a moment I lapse into professor and academic mode, giving a paragraph-length explanation, an understanding, an interpretation: these rarely go over well. 

At the very end of the chapter in the third passage of Joseph that I found challenging, she advises that with patients hard to reach, we must keep our interpretations, our understandings, "immediate and direct" (p.87; her emphasis). In other words, she explictly says, do not offer some kind of historical explanation or interpretation, linking together themes or events from years or months or even weeks past: stick closely to what is going on in that moment in that session in your consulting room. Here is where (as she'll make clear elsewhere in the book) Bion is handy: abandon memory of past events and sessions, and a desire to escape the present moment, and instead plunge right in to your immediate experience of and with the patient, and they of you. (Bion's famously difficult and confusing counsel is examined in a bit more detail here.)

I admit this--discussing what is happening in the moment--was enormously hard for me to do for a time, but working with borderline patients has in essence forced me to do it. I remember very clearly the first time, with enormous trepidation, I attempted it and how it proved to be so pivotal to treatment. Once I figured out my own idiom for doing it after that, and became (in part thanks to my own analyst) much more comfortable with the risks I felt I was running in doing this, it has begun to flow more easily now. I think the key for me was once again Winnicott. In that most invaluable of essays, "The Use of an Object," he helped me to see that I could allow patients to bring their rage out into the open of the immediate moment and try to destroy me but that I would not in fact be destroyed. 

The Patient Addicted to Near-Death:

The other outstanding chapter in this collection is "Addiction to Near-Death." Here she refers to patients engaged in "a type of mental activity consisting of a going over and over again about happenings or anticipations of an accusatory type in which the patient becomes completely absorbed." (In my experience this is characteristic of certain obsessional-compulsive personality styles, about whose treatment I wrote in some detail here.) For such patients their "seeing of the self in this dilemma [as] unable to be helped is an essential aspect." 

As a Kleinian, Joseph mentions projective identification and splitting in every chapter, and here notes that the splitting characteristic of these patients is such that "the pull towards life and sanity" (p.128) is projected almost entirely into the clinician. (I have found myself in this position but, being an ignorant fool at least once a day, rather blithely told myself--here vaguely calling to mind some exculpatory aphorism of Yalom--that it was simply me being "the bearer of hope" until such time as the patient could be more hopeful.....except they never assumed one bit of that burden, and acidly disdained any expressions of hope!) 

Joseph returns to this later in the chapter, speaking in more forthright terms than in many other chapters as she speaks of this splitting, and the clinician taking up the role of one who is hopeful about and pushing for change, as being a "collusion" in which a "major piece of psychopathology is acted out in the transference." If you are put into this position of bearing the hope and desire for change then "the patient constantly is pulling back towards the silent kind of deadly paralysis and near-complete passivity" in significant measure to avoid having to recognize and deal with their own "ambivalence and guilt" (p.136). 

The "patient's apparent extreme passivity and indifference to progress" is based in part on, and heavily reinforced by, the fact that "the near-destruction of the self takes place with considerable libidinal satisfaction." These patients enjoy the "deeply addictive nature of this type of masochistic constellation" (p.128). At the chapter's end, she will return to this in graphic terms, speaking of the patient as having "withdrawn into a secret world of violence, where part of the self has been turned against another part" and where "this violence has been highly sexualized" (p.137).  

A word is here introduced by Joseph, giving an excellent definition to a term I first encountered I don't know where some time back: chuntering. The chuntering patient goes "over and over again in some circular type of mental activity" that consists of endless grumbling, complaining, fault-finding. Sometimes, however, such chuntering is silent: Joseph mentions those patients who, passively and silently, will destroy whatever you are doing, apparently listening to your thoughts but all the while mocking them with silent contempt.

Given such powerful libidinal rewards for their self-destruction, it is no wonder that working with such patients is going to be very difficult. Joseph ends this chapter with no clear or simple fixes, saying simply that "it is very hard for our patients to find it possible to abandon such terrible delights for the uncertain pleasures of real relationships" (p.138). 

Once more the only thing Joseph counsels is taking a "moment to moment" approach in the session, monitoring the changes in transference (which for her is never static, never fixed, never permanent, but a live thing, a dynamic, living, changing experience) and counter-transference.  As a result the same behavior can have a difference transferential import: Sometimes the patient may be engaged in what appears to be chuntering, but doing so out of real psychic pain at some legitimate thing they need you to know about; at other times they may be trying to drag you into a masochistic enactment. You need to get clear as to which is which, and these can even shift within the same session.

Finally: What is the Change We Seek?

If it is hard for these patients to change, which patients find it easy? For Joseph the answer is itself easy: none. Nobody finds it easy to change for we are all shot through with ambivalence and conflicting desires, and all our struggles--whatever they are--are bound up with our personality structures (a point so helpfully made more recently by Jonathan Shedler and Nancy McWilliams, inter alia). Our personality defenses, Joseph notes here, are "very tightly and finely interlocked elements" (p.193). To change even one thing is to risk a cataract of other changes, and thus to provoke multiple defenses at every step: this is the theme of Joseph's fourteenth chapter ("Psychic Change and the Psychoanalytic Process"), the last on which I shall comment. 

How might we define change? What are its hallmarks? Here Joseph is very reluctant to get into details or to over-promise. Indeed, throughout this book one gets the sense that she is in constant, unwavering control of her omnipotent and omniscient desires, never overpromising or indulging in messianic fantasies about dramatic changes. 

"Moment-to-moment shifts and change" in the transference is what we should be paying attention to, Joseph says, without much regard for anything outside it. If such changes happen, then we are permitted to "hope" that such are "eventually going to lead to long-term, positive psychic change. I do not think that the latter long-term psychic change is ever an achieved absolute state but rather a better and more healthy balance of forces within the personality, always to some extent in a state of flux and movement and conflict" (p.194). This last sentence, to my mind, sounds very much like Philip Bromberg avant la lettre. (This chapter was originally published in 1986, a dozen years before Bromberg's Standing in the Spaces, an outrageously rich collection I hope to finish and write about next week. Bromberg cites this passage of Joseph's on p. 272.) 

From here Joseph expands somewhat outward, first noting what Freud said about change ("where id was, there ego shall be") before adducing what Klein added to this, and then, in sum, writing that psychic change consists in "greater integration between ego and impulses, love and hate, superego and ego" and that as an analysand moves toward greater health, this will be seen in an ability "to bear both his love and his hate at the same time and towards the same person. His perception of human beings then becomes more real, more human....This step, or rather, minute series of steps, forward and backward, towards integrating love and hate, brings with it momentous changes within the personality." (This theme of taking up love and hate will find powerful expression in Glen Gabbard's book of that name.)

Such changes may be seen in a greater ability to acknowledge and not flee from "guilt and concern" for others as we come to "take responsiblity" for our "own impulses" and how we may have harmed or attempted to destroy the objects of our life. If we take such responsibility, "there opens up the possibility of feeling for and repairing the object. With this there is also relief and a deepending of emotions" (pp.194-95). All of these changes emerge, Joseph stresses again and again, not in grand Damascus-like moments of blinding conversion, but often in the very minute, moment-by-moment changes in the transference, where it all begins; and if it doesn't begin here, it will never begin. 

This is a humbling note on which to end, but a salutary one. If we are always looking for external affirmations and grand signs of change and progress, we may risk overlooking, perhaps even disdaining, the quotidian ones in the transference.  We need to be content eating bread and butter as a regular diet rather than lusting after prime rib every day. 

We also need to be comfortable recognizing that the mind, Joseph says in conclusion, is a scene of perpetual conflict--even when progressing in the 'right' direction. If we leave our patient pretending otherwise, even as they progress in change and grow in freedom, then we have returned them to a very primitive form of splitting which, to Joseph, is anathema.