ISTDP and the Quest for Effective Fast Treatment

I have noticed several pecularities in my relationship with time: first, I have an absolute horror of being late, and under my maternal grandfather's influence early in my childhood (when he would take me to Boy Scouts or choir practice, etc.) developed the adamantine practice that if I do not arrive at least 15 minutes before the appointed time, then I am de facto late. Second, and perhaps somewhat in tension with the first, though not to a noticeable degree, I loathe being rushed. I plan out my schedule with its departures and arrivals well in advance with generous allowances for possible last-minute delays so that I can be where I need to be without racing in the door with 60 seconds to spare, huffing and puffing in disgusting display of wheezy and aging flesh. There is no faster (!) way to get me to sloooooooooooow right down than to try to jolly me along in a rush. 

When it comes to psychotherapy, it will not surprise you that I chose a more leisurely course of treatment for myself after trying some very short-term biweekly counselling in the student centre at the University of Ottawa, where I was an undergraduate trying to come to terms with the death of my sister five weeks into my freshman year far from home. After running out of allotted sessions, and frustrated that this counselling not only did not touch the issues I wanted to focus on but in fact denied that they were issues at all, I embarked upon a psychoanalysis of four times a week on the couch for nearly seven years. There was, in that work, never any urge to jolly me along to a speedy resolution of presenting issues. 

Now as a licensed clinician myself, I have, not surprisingly, been highly skeptical of the smug peddlers of things like the so-called Accelerated Resolution Therapy, or indeed many of the modern therapies promising dramatic results in a handful of sessions. Part of my skepticism is motivated by my awareness of the intractable nature of human habits and our resistance to change and deep ambivalence about it. So I refuse to over-promise to patients about how quickly they might begin to experience change.

At the same time, however, my own basic empathy--to say nothing of a "business" sense of survival--compels me to want to help patients begin to experience some change as fast as they can. Unlike my analysis from more than 30 years ago, which was fully covered by Ontario's healthcare system (my analyst was also a psychiatrist), I know patients feel financial pressure from their insurance company to find and finish a quick course of treatment. So none of us today, at least in the horrifying landscape of American mental health, can turn up our noses at real and legitimate desire to find some relief and some change as quickly as we can. 

As noted, many contemporary treatements have grown up around this pressure, including the one I am most interested in, Intensive Short-Term Dynamic Psychotherapy (ISTDP), whose roots go back a half-century now to the pioneering work of the Iranian-Canadian psychoanalyst and psychiatrist Habib Davanloo. 

Davanloo's work has been picked up and extended by others, including Diana Fosha, whose well-known book from more than a quarter-century ago now I reviewed here. 

More recently, Patricia Coughlin Della Selva, in her Maximizing Effectiveness in Dynamic Psychotherapy (Routledge, 2017), explictly extends Davanloo's project. Hers is a much more useful book than I expected it to be, and I learned a great deal from it. Unlike some other authors in the ISTDP world, she writes cogently and gets straight to the point, with an abundance of clinical illustrations of key techniques. She also has a disarming style that does not leave the reader feeling as though he's being bullied into submitting to the dictates of a manual--a process which ensures a book is flung onto a bonfire with indecent haste--or left entirely bereft to craft his own techniques while wondering if he's quite grasped things. 

I happened to be nearly finished Karen Maroda's new edition of Psychodynamic Techniques (about which more soon) when something prompted me to take a second look at Coughlin's works. I had previously picked up a couple of her books some years back but never pursued them. But this time around, I found a curious and striking overlap between Maroda and Coughlin in that both have a laser-like focus on the need for clinicians to be trained in techniques to provoke emotional change in psychotherapy if it is to be effective. 

Coughlin begins with the important and I think now indisputable research that good psychotherapy is marked by about a half-dozen common factors--common as in they are found across theoretical traditions or "modalities," to use that ugly word. Studies have been confirming this for a couple of decades now. I have previously written about some of those studies and their findings here. Attention should also be paid to the enormously valuable collection, How and Why Are Some Therapists Better than Others? Understanding Therapist Effects, eds. Louis G. Castonguay and Clara E. Hill (APA Press, 2017) 

Coughlin picks up where most of this research leaves off and argues stoutly and rightly that we need more than just these common factors--the working alliance; the revival of hope; the tactful, well-paced, but firm confrontation of problems; the development by the patient of a sense of mastery and agency; and the ability to attribute success to one's own actions. But few treatments include all these, she says, and fewer still use these common factors with specific factors or techniques promoting sustained and sustainable change. (The idea that all therapies using these common factors are equally effective is most likely a function, and flaw, of research study designs, a crucially underappreciated point in so much of the research on psychotherapy effectiveness. The use of a randomized control trial to study individual psychotherapy is a significant mismatch.) 

So we need a marriage of common and specific factors, and Coughlin argues that Davanloo's pioneering ISTDP has long been exactly that. 

Such a recognition that we need both has not, however, resulted in the kinds of training programs necessary to convey both: "over the past several decades, we have been neglecting the development of our trainees on a personal level, no longer requiring or even encouraging them to engage in their own therapies or other experiences designed to enhance self-awareness and growth" (p.11). Thus, Coughlin suggests, we cannot just develop new skills or specific techniques without attending to the development of the person who will be using them. I am completely in agreement with this view, and look at the problem of training in a book I am working on at the moment. 

The Initial Assessment:

Part of what attracts me to Coughlin's approach brings me back briefly to my grandfather: in addition to being utterly intolerant of lateness, he was also intolerant of chit-chat and time-wasting, frequently lavishing his admiration on people who got straight to the point, even if he didn't like the point or them. He was an admirably blunt man himself, and while that could at times ruffle feathers, he was humble enough to apologize with real feeling and sincerity when he had gone too far.

For Coughlin, the Initial Assessment should be as detailed and direct as possible, asking pointed and blunt questions about when and how the presenting issue developed, including current triggers, but also asking after psychological mindedness, willingness to do the work, and what strengths and capacities the patients bring. (There is much overlap here with what I learned from Nina Coltart many years ago, including doing one or two things in the assessment that are unexpected to see how the patient reacts and to gauge the strength of their defenses.) This initial data must then be used to develop a "clear and comprehensive case formulation" which is a key factor in producing superior results. This assessment is not merely or primarily descriptive and diagnostic in nature, nor historical and developmental. Instead what is needed is a monitoring of the patient to our interventions here and now. This requires that the therapist:

i) see the current problem "as the m0st recent example of a recurring conflict in the patient's life";

ii) deal "directly and swiftly with negative feelings in the transference"; and further requires that the

iii) patient responds "to the therapist's intervention in an affect-laden manner within the first four sessions" (p.17). 

The key here is to force or (in less defended patients) facilitate the immediate development (Davanloo, like my grandfather, seems to have been a man in a hurry!) of an internal crisis: Patients--as we have long known--are often on the verge of such a crisis, with the hopeful breakdown in defenses, when they present for treatment. This must be forced all the way open by means of putting pressure on the patient to be completely honest, emotionally available, and actively engaged while also challenged to abandon defenses of avoidance. This, Coughlin claims, permits "rapid entry into the unconscious life" (p.18) and requires:

1) detailed inquiry into presenting issue and triggers;

2) pressure to experience feelings of that issue right now in the room with you;

3) monitoring and assessing the level of anxiety;

4) identifying and blocking or challenging defenses to (2) above;

5) analyzing memories and dreams provoked by accessing feelings

6) manifesting links between feelings, anxiety, defenses, and presenting problems and current patterns of behavior (p. 19).

As you are gathering this history, do not accept vague or old examples but press for details. We must also not be content with reports of only external triggers, but press the patient to see what is triggered internally. Additionally, as this is happening, keep a close eye on body language: we must observe physical signs of anxiety and if see none inquire directly in part so that we can keep anxiety within a tolerable level: Too high = no change and too low = no change.

What you are trying to get at early on is what is called the Triangle of Conflict: Anxiety, Defense, Feelings. (To get good data about all three, and to begin to build a solid working alliance, Coughlin later in the book notes that the intake interview should be lengthy: Davanloo apparently advocated for three hours! I quite see the wisdom of that but of course I know of no insurance plan today that pays for more than an hour.)

Typically we see 3 types of patients: the small group of those who respond to pressure and discuss feelings; the larger group of those who "require restructuring of defenses" before accessing feeling; and a small group of "fragile patients....[who] need a more ego-building" beginning to treatment (29). It is important to have this sorted out at the very beginning of the work. 

Coughlin, like Maroda and others, recognizes that most forms of psychological distress are connected to problems with emotions, and therefore argues that from the beginning the clinician's goal is to probe "for feelings, monitoring anxiety, and blocking defenses," calling this "our essential psychodiagnostic procedure" (p.21). 

When asked about feelings toward someone currently, your patient will respond with feelings, anxiety, or defenses--or likely some tangled skein of all three. Our job is to roll with each. 

Feelings we should encourage; anxiety we should help regulate; and defenses we should point out with a view to decreasing them immediately. The sooner we tackle all three, the greater our chances of success. No coasting in the counter-transference here! 

Challenging Defenses Head-On:

What of the patient who presents as such a bundle of nerves, so tightly wound, or so riven with deep psychopathology, that they resist exploration of all three? Here Coughlin responds with what Davanloo famously called the head-on collision. This is a direct, blunt presentation to the patient of the defenses just seen along with their destructive consequences and the overall costs to remaining unchanged before presenting him or her with a question: do you want to stay like this?  The overall point is to make the defenses feel dystonic to the patient.

In more detail, it looks like this:

1) outline the therapeutic task: we are here to promote the change you said you want, yes?

2) clarify defensees and resistance and their consequences: I see you doing X,Y,Z and this mitigates against the task of change. Do you want to continue to resist change? 

3) acknowledge with empathy the patient's need to continue to suffer and fail: I understand why you continue to feel the need to do this. 

4) declaim any omnipotence as the therapist: I cannot and will not fix you if you don't want to be helped. 

5) emphasize patient's choice but encourage him to DO SOMETHING about the defenses and resistance that will prevent healing from happening.

If you get an "I don't know" in response, especially to questions 2 and 5, do not accept that at face value but continue to press the issue, pointing out costs but also the enormous relief that will come from finally changing, and the more hopeful future that beckons if the patient will do the work not alone but with the help of the therapist. Coughlin says that the response to this exercise will give you the "most accurate and timely information on his willingness and capacity to engage in psychotherapy"(22). It is also key to forming a treatment plan. 

Davanloo advocated identifying the defense, clarifying its function, and examining its consequences. Then patients must choose. We can't let them flounder or obsess or sit on the fence, but we also can't force them to face what they have avoided. We can, however, put some pressure on them to do something about the situation, reminding them of their courage to change and of our being there every step of the way. We are not neutral here: we take a stand against defenses because they are against the patient's health and flourishing, and as we all know they will get in the way of whatever work we are trying to do. 

What defenses do we typically see? Coughlin briefly mentions several in different categories including rationalization, minimization, intellectualization, and displacement: these can be problematic, of course, but usually indicate decent capacity for mentalization. 

Repressive defenses eliminate awareness of anxiety and these have to be dealt with immediately, as do what she calls regressive defenses: projection, acting out, dissociation, somatization, denial. 

Certain tactical defenses will need ongoing work and might not be immediately apparent in the first session. These include pushing against closeness with therapist: being helpless, avoiding eye contact, giving vague answers, laughing and joking, talking so much and so fast that there is no room for you to intervene. 

Moving further into the book, we come to the chapter that links Coughlin most closely to Maroda in my current reading:

Ch.5: A Focus on Feelings: Facilitating the Experience of Emotion

Most problems, Coughlin reiterates, are those of emotions: too much, too little, too maladaptive/outdated. "Given this, the effective therapist must develop specific skills and interventions designed to help patients identify their emotions" (p.110).

Davanloo, who pioneered the method of extensively taping and rewatching sessions, thought it important to recognize physiological activation of emotions in session, noting that certain emotions regularly show up in certain forms or parts of the body.

Anger: neck, jaw, shoulders, arms; heat and energy

Pain and grief: chest, heart, throat

Love and joy: chest, but lightness instead of grief's heaviness

Guilt: gut wrenching

But before we usually get to see these emotions, the other two parts of the Triangle are activated, and the defenses kick in to deal with the anxiety which crops up as soon as warded off or fearful feelings might remotely be detected. This makes our job clear: we must first regulate anxiety and then block defenses "so that the direct, visceral experience of the avoided feelings can be facilitated in a safe and tolerable manner" (113). Even helping people identify this threefold tangle can be very helpful. 

Openly processing feelings in session enables greater mentalization and change. Reactivating old feelings can unlock them for the first time. This involves four steps: targeting the symptom/presenting problem; reactivating consciously the emotional script from the past that undergirds the symptom; providing "contradictory experience or correcive emotional experience that disconfirms" previous experience; and repeating the new learning several times (115) to lay down new or rewritten memory tracks. 

As we are seeking to access feelings, Coughlin cautions that "All three levels of feeling--cognitive, physiological, and motoric--need to be present for the full and direct access to feelings to be achieved" (119). This is the "name it to tame it" approach. Careful assessment needs to be done to see which feelings can be/are experienced, and which avoided/denied. Some can admit to sadness but not rage; some to admiration but not longing; etc. 

Experiencing emotions in session will of course involve transference work and it is important that the therapist openly seek out the transferences and deal with them directly. Coughlin counsels that clinicians "convey confidence and determination in the quest for emotional truth and be willing to be the target of the patient's rage, pain, and thwarted desires for love" (124). Overcoming resistance to feelings about the therapist allows for "deeply buried memories from the past" to become "available for reworking" (130). 

Importantly, Coughlin recognizes that feelings are never solitary or single, so the task here is to work with mixed emotions. (In this regard, she reminds me of nobody so much as Winnicott and his wise insistence that bringing a patient to being able comfortably to live with ambivalence is about as far as psychotherapy can go.) 

It is important to act on transference feelings the moment they first appear: one must "deal with negative feelings in the transference in a calm and direct manner, as soon as they become apparent." If they are present but not taken up then "they contribute to the resistance" (135). She quotes no less a figure than Anna Freud, who apparently said that the clinician's ability to "respond to a patient's negative affect without flinching is a key aspect, sometimes the key aspect, of conducting successful psychotherapy." 

To be able to do this, Coughlin says, requires "courage, maturity, and a good deal of emotional awareness" on the clinician's part (p.135). I would also add that ongoing supervision and consultation can be hugely helpful here, and in the background, of course, one's own prior intensive treatment is (once again) crucial. I've never forgotten the moment I finally felt overwhelming rage and hatred for my (second) analyst, and then the session where we began to be able to talk about that. Her sangfroid and curiosity when I told her of the hatred was an absolutely pivotal moment for me to witness that someone could deal with some of the most intensive and potentially destructive feelings in a way that defanged them for me and gave me the ability to talk about the hitherto unspeakable. 

To deal with anger, Coughlin says we need to focus on the internal, visceral feeling of that anger in the body, but as we do so we must make sure anxiety is regulated here to avoid acting out. The patient needs, she claims, "direct eye contact with the therapist during this experience" (135). The patient needs to not just talk about past difficulties but also what emotions toward the therapist are felt right now? 

In doing all this, you are aiming to provide in the session what we might call as "transitional space" and a "holding environment" between defensive internalization of the anger, on the one hand, and acting out against you (externalization) in the session on the other. To 'hold' that anger together in this form of tension gives us an opportunity to deepen curiosity about it, to explore it, to connect it to past and present extra-therapeutic relationships and experiences, and then to begin to rework and get rid of it. As she puts it at the end of this chapter, experiencing strong emotions in the session, in detail with accompanying fantasies of enactment, will help us discover unconscious antecedents "and facilitate deep and lasting change" (p.144). This kind of real-time, intensive transference work is not a detached intellectual discussion of emotions while avoiding the same: it seeks deliberately to activate those emotions in session. 

Exploration of defenses and resistance, and then feelings, should be done from the very beginning, but later in the book (p.156) Coughlin does admit that doing so at any point can be helpful if treatment has stalled. 

Later chapters in Coughlin's book cover well-worn areas around creating, sustaining, and repairing the therapeutic alliance. If the book had ended with chapter 5, it still would have been and done enough. Based on the strength of this volume, I hope next to turn my attention to her new book, Intensive Short-Term Dynamic Psychotherapy (Routledge, 2026). 

Mentalization and its Discontents

I have been reading works on mentalization (some of them discussed here) for at least five years now, not long after I discovered how much of it was rooted in attachment and, more distantly, psychoanalytic theory. This theory and therapy come from England and the work of Peter Fonagy and Anthony Bateman, whom I respect enormously for their decades of work and research. 

Not long after, I made another discovery--this time  stateside: the work of Paul Lysaker (and others) on metacognition. I was more or less propelled into exploring both concepts and their clinical applications as I began taking on more severe cases of borderline personality disorder and especially schizophrenia and first-episode psychosis. (I had investigated DBT training but found its main manual profoundly off-putting and knew that operating from a manual--which also ruled out most CBT approaches--was antithetical to my own long therapeutic psychoanalysis and all my clinical instincts deriving therefrom.)

In 2022 I was able to do some training with Lysaker not long before his very unexpected and early death in 2023. I have since read at least twice his book, co-authored with Reid Klion, Recovery, Meaning Making, and Severe Mental Illness (Routledge, 2017). It is a dense but rich book and pays re-reading if you regularly treat, as I do, schizophrenic patients. (The MERIT institute founded by Lysaker recently put on a training for those who work with psychotic disorders, and I found it a very valuable refresher.) 

But unlike the metacognitive therapy outlined in the above book, which takes pains to be concrete in its discussions of clinical technique, all the works on mentalization I have read to date seem rather vexingly to follow the same format: great (and, after the first serving, increasingly tedious) lashings of history, theory, and review of the empirical evidence--which is very impressive indeed--of mentalization-based therapy (hereinafter: MBT), and often a good bit of detail on how to structure mentalization-based group therapy, but little to nothing on how this actually might play out in individual psychotherapy. 

This lack of focus on individual application bedevils every book on the topic I have read to date. I am now increasingly certain that this is a virtue of the mentalizing approach, but I will also say that the lack of discussion of individual technique is--if not a weakness--a significant lacuna. As a result, I have been forced to figure out, moment by moment in a session, how to try to help a patient mentalize, but I have never been much satisfied with this approach even though it does bear some fruit. Surely, I keep telling myself, there must be a wide array of much more effective clinical techniques of which I am--as so often happens--ignorant? Surely my on-the-spot efforts must be pretty weak sauce when set aside some smart list of sturdier and more effective applications developed by someone more experienced than I? 

In search of an answer to that question I have read such numerous and hefty volumes as those discussed here as well as others like this one, with very limited utility. Most recently I read Elliot Jurist's Minding Emotions: Cultivating Mentalization in Psychotherapy (Guilford, 2018), which never even bothers to turn to its titular challenge until well over half-way through the book. Only on p.97 (out of 168pp) does Jurist get around to asking "How can mentalization be enhanced by psychotherapy?" His answer is "mentalized affectivity," drawn from Fonagy's co-authored 2012 collection, Handbook of Mentalizing in Mental Health Practice, which I read some time back and found very little that was new or helpful in it after having read so many other extremely similar books by Fonagy and increasingly others. After six paragraphs on this mentalized affectivity, we are off to the races again with the next section on the psychometrics of measuring reflective function and then the rest of the book fails to address the question directly, instead offering some interesting history of mentalization as seen in earlier works of French psychoanalysis, and then in Winnicott and Bion. 

Thus I admit, in frustration, that in none of these books have I found the handy applications for individual treatment I have long wanted. I understand--to be sure--that mentalization, properly done, has a certain dynamic and creative nature to it so that it cannot always be prescribed in set forms in advance, but should arise organically inside the working alliance, and this, for me, is in actual fact a very attractive virtue of this approach; but at the same time all of us, no matter how creative or clever we think we are in the moment, can always benefit from the experiences of others and learn new techniques from them. 

In search of such enrichment, I picked up, and have now read twice, Carla Sharp and Dickon Bevington, Mentalizing in Psychotherapy: A Guide for Practitioners (The Guilford Press, 2022), 210pp. It repays re-reading and is, of all the books noted on here, the one that has done the most work to make itself practical and useful to the provider of individual psychotherapy. 

Amusingly and encouragingly the book begins with an incredibly humble and self-effacing foreword from Fonagy himself. He notes more than once that "it is undoubtedly the most clearly written and most easily accessible depiction of MBT that is available to date. ....I am deeply grateful to the authors...for doing something I know I could never have delivered"! 

That is not, I'm happy to report, merely the hyperbole typical of book blurbs by prominent scholars: it really is born out in the text which is indeed written with clarity and cogency and simplicity that sacrifices nothing of substance. 

The Mentalizing Stance:

Happier still I can report that it confirms my sense of the "withholding" nature of mentalization guidebooks insofar as--the authors readily admit early in the book--"mentalization-based interventions, by design, abandon specific techniques in favour of a generic therapeutic stance" (p.2). This mentalizing stance is, and cannot but be, non-authoritative and based not in the superior expertise of the clinician, but in the attachment relationship s/he has with the patient. This stance, embedded in that relationship, is what "drives therapeutic change" (p.xviii). We will return to this later. 

Necessary Virtues in the Clinician:

This stance requires at least five virtues (my word)--or what the authors call "personality characteristics" of the psychotherapist (p.4). These are:

• High cognitive flexibility
• Humility
• Adaptability
• Low rigidity
• High tolerance of uncertainty. 

In addition, the authors several times plainly and unapologetically admit that the mentalizing therapist is going to be more active in session than a classical psychoanalytic stance might encourage. (Lysaker's metacognitive therapy for psychosis also says and requires this.) The chief task for the clinician is to put his or her mind on the table and make it less opaque. This, I hasten to add, is not a recommendation to engage in wanton self-disclosure about any old thing. Instead, it is showing, by sincere and humble example, your own openness to learning with--and from!--the patient, to collaborating together on the problem of other minds and the dangers of thinking too much or too little (or not at all). 

Negative Capability:

The clinician must model what Bion (borrowing the phrase from the poet Keats) famously called "negative capability." (Bion develops this in his "Notes on Memory and Desire" and other words, discussed here. I know Bion is often disdained as a difficult read, as indeed he can be, but that short essay is invaluable, as are his two major essays from the 1950s on the psychotic mind. Everyone should read all three.) That is to say, the clinician must show a genuine ability to tolerate and be comfortable with uncertainty, ambivalence, ambiguity, and must not race to draw hasty and absolute conclusions. In modeling all this, the clinician is showing the patient how to live with ambivalence, but also how to collaborate together in finding out more about certain things in ways that increasingly abound with an often hitherto inaccessible or non-existent curiosity and playfulness. 

At the start of ch.2, the authors give us a succinct definition of mentalizing which they quote from Fonagy and others, stressing that it is an "imaginative mental activity" that tries to interpret human behavior as a result of "intentional mental states" (p.16). The authors reiterate the importance of understanding intentionality, saying that our thoughts and actions are not random but contain meaning which we need to discern.  Why be concerned about the mental activity and states of others and ourselves? The authors respond by noting that mentalizing is "profoundly about social connection" (p.28). An inability to mentalize is a recipe for isolation, loneliness, and a host of other problems. 

Mentalizing, as all authors in the field make clear, is not merely, nor only, an intellectual or cognitive activity--trying to figure out what I, or others, think. It is also, and equally important, about trying to discern and understand affective states as well--emotion and feeling. 

Slow Down!

How do we do all this? Here, in line with the best research in good psychotherapy, the authors note that it requires pacing and pausing: "if you commit to mentalizing, you commit to slowing down your interactions with others." Doing so allows us to understand them better, but also to understand ourselves better as well. From this the authors develop a practical rule that is especially useful when working with couples: one partner needs to stop and "reflect on what they want the other person to hear rather than what they want to say" (p.36). 

Developmental Difficulties:

Though he is not quoted, a Bionian theory of mind seems clearly operating in the background here as the authors reflect on how mentalizing develops, or fails to develop, from infancy onward. (For more on this, see Bion's "The Psycho-Analytic Study of Thinking," The Psychoanalytic Quarterly 82:2 (2013); originally published in 1962). In brief, an infant's mind only develops by interacting with a mentalizing mother or primary caregiver. The health of the developing infantile mind is directly affected by the mentalizing capacity of the caregiver. Weaknesses in the caregiver can be transmitted to the infant often through two major challenges: hypermentalizing or hypomentalizing. Both of these are common psychological struggles, and show up in all personality disorders. Both of these are problematic insofar as they rob the developing mind of the capacity for healthy independent agency--to become what the authors call an "agentic learner" (p.83). 

Measuring Mentalizing:

Though she died shortly before Fonagy's research really attracted attention, Nina Coltart's chapter on the nine signs of "psychological mindedness" (which I treated here) bear strong resemblance to mentalization. Her stress was on assessing for these before agreeing to take a patient into treatment, which is something I always do. I have on a number of occasions declined to take certain people into treatment when I could not see any signs of such mindedness. The few times I ignored my misgivings and agreed to try treatment did not end well when it became clear that self-reflection was really beyond a particular person and we were not making any progress. Sharp and Bevington argue that you should assess for mentalizing capacity not just during an intake process, but "throughout a session and throughout the course of therapy" (p.85). You are looking for the patient's overall capacity, but also their predominant mentalizing style (hyper/hypo) and their ability to mentalize both parts of the self-other, cognitive-affective, internal-external, and automatic-controlled dyads. 

None of us remains in only one state for very long, and so ongoing assessment of "Where are we now?" remains important in each session--not unlike the close monitoring of each session Betty Joseph advocated so many years ago now. Joseph talked about "pseudo-cooperation" with the clinician in session, and mentalization talks about pretend forms of mentalizing in similar ways. 

A Non-Technical Stance:

As I noted above, it has long haunted me that mentalization therapy remains non-specific with regard to clinical technique. Some of that is wise and inevitable, but it does not remove from one's mind the questions "Am I doing it well enough?" and "Are there other--more effective-- ways I could or should be doing this?" The authors returns to this later int he book noting that clinicians do not have to assess for every part of the patient's mentalizing style at every minute and "in a precise way" (p.95). 

When trying to make such assessments, simple questions will suffice: 

• Why do you think he said that?
• If your spouse/child/friend/boss were in the room, what do you think s/he would say about that?
• Could you make sense of why she did that?
• What do you think was probably on his mind before he blew up at you? 
• If we were watching this together on a screen as a movie, what would we be seeing? 

The point of trying to encourage mentalizing, and correct for unhelpful ways of doing it, or not doing it at all, is to return a sense of agency to the patient--especially those marked by personality disorders--but to do so in a way that helps us appreciate how and why "minds...are at play," that is, they are not "trapped in their fixed beliefs" but can be explored from a variety of angles (p.105). 

An additional and ongoing task here is for the clinician to point out instances of when the patient or others are engaged in healthy mentalization. This includes confession by the clinician of when we were not engaged in the right kind of mentalizing activity or failed to do so entirely. This is regularly referred to as putting your mind on the table and I have consistently found it helpful for patients to see that--especially my psychotic patients in a severe state of splitting and totalized, paranoid thinking with little to no ability to trust anything or anyone. For me to admit to doubt, or unsolved questions, and to be able to tolerate those is not a small thing for a psychotic person to witness. 

Some Additional Guidelines:

Regularly in several books, I have seen the following recommendations, some hinted at above:

Slow down! Mentalizing takes time. 

Call for a pause when needed--time to "rewind the tape." I have done this in sessions that were getting overheated with patients with borderline personality disorder. Any time I feel myself getting overwhelmed and losing a mentalizing stance, I will explicitly ("I need a moment here to think about what's going on") take time to recover before allowing the session to continue.

Interrupt: do not allow a long non-mentalizing or non-productive monologue to go on. Disrupt and redirect. I felt, and sometimes still feel, a bit rude when I do this, but I'd estimate that in 90% of cases, the patient has actually appreciated the redirection. And don't just take this from me or these authors but consider also Karen Maroda's new and wonderful book--which I'll review on here soon--advocates for doing so as well. 

Do not mentalize for the patient but instead invite them to do so.

Mentalize the patient's mind, especially, Sharp and Bevington say, when the patient is not mentalizing: "the most powerful way to invite, stimulate, or reawaken mentalizing in another mind...is to mentalize that mind." I regularly do this by saying something like "If I were you..." or "I was trying to imagine that fight from your perspective, and this is what crossed my mind." Very often this is quite effective, but on the occasions when it is not, we find out valuable information nonetheless. As the authors say, we still help the patient in our failures by showing our "enthusiasm to notice and learn from [our] failings" (p.124). 

Other phrases to use here, which I have found very effective, include what I call the "standard prefaces":

"This may seem totally off the wall, but I was just thinking of...."

"I don't know why this crossed my mind, but I was wondering about...." (My second analyst used this phrase with some regularity when we were trying to puzzle out parts of a dream.) 

"I don't know if this will make sense or help, but the word that came to mind for me was...."

Engage in Contrary Moves: If the patient is predominantly stuck in cognitive mentalizing, push for more affect; and vice versa. If they are struggling inside their own minds, push them to get outside by asking something like "What would your husband think about that?" If they are absolutely certain about something, mentalize the issue yourself in such a way that they see your own doubts and capacity to be comfortable with something less than total certainty. And finally, if affect in the room is too high or heated in the moment, then your contrary move is to change the subject until things cool off a bit because high affect makes mentalizing much more difficult. It requires, as psychotherapy so often does, finessing the degree of affect so that some is aroused, but not too much. 

In sum, Sharp and Bevington maintain, the "mentalizing stance is what drives therapeutic change" (p.147). 

Let us turn next, and finally, to another recent book by three German scholar-clinicians: Josef Brockmann, Holger Kirsch, and Svenja Taubner, Mentalizing in Psychodynamic and Psychoanalytic Psychotherapy: Basics, Applications, Case Studies (Routledge, 2025). Like the book by Sharp and Bevington, this one has a self-effacing preface from Peter Fonagy and then an introduction from the authors who ask Why Another Book on Mentalizing?

Their answer to that is that psychoanalytic practice differs most clearly from mentalizing therapy with regard to clinical technique and the level of activity of the clinician in session, and so this book sets out in part to explore those differences, suggesting that they are more of degree than kind in most cases.

Before doing that, the book commendably begins where the Sharp and Bevington book left off: by focusing on the question of the mechanisms of therapeutic change. These German authors assert that "improved mentalization creates a mental buffer between feelings and actions, allowing reflection on conflicting interpersonal experiences and complex affects. Patients learn to think before they act--to reflect befor they act" (p.10). Thus conceived, mentalization "indeed represents a significant change mechanism of psychotherapy" (p.12). A little later they will sharpen this point somewhat: "Mentalizing the therapeutic relationship is seen as the central mechanism of change" (p.30). 

Mentalizing the therapeutic relationship, as part of the change process, must include explicitly and regularly asking for feedback. Quoting the well-known but I think often ignored research on how much clinicians overestimate our effectiveness, these authors say that no good mentalizing clinician will want to fall into the trap of assuming they are doing well without verification of the same. 

For change to happen, these authors review the basic foundations of any successful therapeutic relationship: a strong working alliance; a "therapeutic setting pursuant to trust"; a theory or model of psychological disturbance or disorder; a model of change; and a set of techniques to pursue and enact that change. 

On that question of techniques, as I have noted already, mentalization therapy offers some but not many, and in every case strongly encourages clinicians "to explore creative ideas to improve mentalization" in each session (p.31). These authors then recommend many of the approaches noted above, but they also make explicit something only hinted at in other works on mentalization: psychotherapy is a "communication system" and mentalization, as a part of that, is always going to be concerned with communication both interpersonally and intrapsychically. 

They return to this point at the end of the book, reiterating that "psychotherapy as a threefold communication system" involves a theory of therapy, the actions of mentalization, and finally "restoring social learning (epistemic trust)" (p.157), a theme which shows up increasingly in the literature in the last decade, especially with regard to psychotic patients, delusional patients, and borderline patients. 

These two helpful books are good for both newcomers and those of us who need occasional or regular refreshers. 

On Therapeutic Drift or: Coasting in the Counter-Transference

There are certain books which may meander for several hundred pages, but have a single, simple thesis easily summed up in a paragraph or less and easily remembered thereafter; and then there are complex books that use all of their many pages to advance multiple points or explore multiple sources and contain so much content that re-reading on several occasions is required to master it all. Irwin Hirsch's book Coasting in the Countertransference: Conflicts of Self Interest between Analyst and Patient (The Analytic Press/Routledge, 2008) is very much in the former category, and that is very much a virtue. 

Hirsch's book (xv+220pp) is of standard length but really does advance a simple point that merely recalling the title is enough to remind you of the force of his argument. And his argument, his point, is an absolutely crucial one still too little talked about in the clinical literature after a century and a quarter of psychoanalysis and psychotherapy: the avoidance by too many clinicians of raising, and maintaining sustained and necessary focus on, conflicted and unsettling topics in therapy because the clinician would rather "coast" than run risks of patients becoming (more) angry or leaving therapy entirely to avoid painful topics. 

He states his thesis with pellucid clarity and simplicity on p.2: the clinician "can be said to coast in the countertransference, choosing comfort or equilibrium over creating useful destabilization." A little later on he notes further that "the quest for personal comfort and equilibirum with each unique individual patient is always potent" (p.4) for one of several reasons: I can't bear their rage/sorrow/other uncomfortable emotion; I can't bear the loss of income; I can't bear the loss of company in my lonely life. 

Hirsch zeroes in on a point others have remarked on: avoidance of conflict is an understandable weakness of most people, but it is not so understandable, and certainly not so justifiable, in clinicians who know--and ought to know--that until and unless difficult emotions are grappled with in the therapy, the process of change is very likely to remain dormant, weak, and ineffective. In other words, the absence of useful destabilization means the absence of meaningful and lasting change. 

On this point, I am, in reading Hirsch, at once reminded of my first encountering Karen Maroda some time back and, before her, of the incomparable Nina Coltart. Both of these outstanding women, from whom I have been learning for many years now (as I noted here and here), and to whom I continue to repair regularly, remind us that we need to do a much better job harnessing our aggression in clinical work and using it in these difficult situations where the attractions of coasting peacefully and passively down the quiet canal, rather than venturing out onto stormier bodies of water, remain strong. 

Maroda first broached this topic, if I recall correctly, in her book Psychodynamic Techniques and then more recently in The Analyst's Vulnerability, which I wrote about here. The former book, I should note, is coming out next week with much fresh and updated material, and I am planning on reading it at once. 

But back to Hirsch. He notes that one of the most common refrains from clinicians justifying coasting is that "the patient is not yet ready." Oh I can confess I've dined out on that in two cases simultaneously for months! In one case, I did and do believe it was justified, and that the patient was too heavily defended against hearing directly and clearly about a very strong transference dynamic which showed up immediately upon intake and was a constant (a highly vexatious constant, I would add!) for many months. This was also, not surprisingly, the thing that had destroyed so many relationships across three decades and led to an acute sense of isolation and, on occasion, serious thoughts of suicide. His effect on me in session was so strong that I deliberately and I think justifiably avoided confrontation until I could be certain that my reactions to him were under careful control. (Winnicott's warnings against retaliation echoed in my mind constantly.) 

"Strike while the iron is cold" was very much my watchword here, and when I finally did start to unpack with him what he had been doing to me in the transference, and had been doing with friends and family for decades, we were able to have a much less defensive discussion and make faster and more straightforward progress than I ever thought possible. At the end of treatment, he thanked me for being the only therapist in decades of trying who was actually able to help him understand his actions and feelings and help him to change them. 

Another case at the very same time brought me up short. I had also been saying "She's not ready" about this patient, who one day confronted me about this very topic and my avoidance of it! She pointed out that I had not gone back to a very painful topic she had raised about 4 or 5 months earlier, and I readily agreed that I had not. She quietly asked why I had not, and I said that in my estimation it seemed that she was not yet ready and I did not want to press too soon or too hard into matters that, months ago, seemed very tender and almost unbearable. 

"But couldn't you have asked me if I was ready!?" Her question had a real scales-falling-from-eyes effect on me, and I realized at once that she was right and I was wrong: I had made an assumption--my confidence in which was about 75 or 80%--and that seemed sufficient to me that I didn't need to verify it with her: I was about 80% confident she was not ready and so I continued to allow us to drift quietly down the canal rather than risk choppier waters.

I apologized to her for my presumption, and sincerely thanked her for teaching me an important lesson about not underestimating a patient's strength or overestimating her reluctance to engage a topic without first using the simple expedient of asking her if she was ready!

The beauty of Hirsch's book is that he is able to point out our tendencies to drift and coast without at any point sounding like a hectoring or sanctimonious moralist. He illustrates the book with many examples of his own failings--but these, too, are told without any tone of that moral masochism Freud first recognized. So we can feel challenged and confronted, but gracefully, humbly, and clearly because of a heartfelt desire "to be more useful to patients" (p.51).

In the end, the problem with drift or coasting is not one that can be permanently eliminated in advance, and the elimination of it should not be a process of constant recrimination from our superegos. Instead, it requires regular work on all our part, session by session, to ensure we are not allowing this to happen, but being both gracious and realistic about it when we discover it is happening. And such vigilance is required because of the all-important awareness that "patients change less from theoretically biased insights and procedures than from new and unpredictable affective relational experience" with their clinician (p.113). The supreme gratification of this work, in the end, is in watching people change in long-sought and often difficult ways, and we should set our boats to sail vigorously in that direction rather than drifting about inhibiting the progress we all seek. 

An Encomium for Jonathan Lear....and Other Books

I did not mean to leave so large a gap on here, having posted nothing since March. I have several times gestured wanly in the direction of my laptop and the piles of books which sit uneasily near it at all angles and with varying degrees of instability, and on at least two occasions sat down to draft posts (one of which is nearly done and will focus on 3 or 4 books on mentalization I have been wrestling with this year). But for reasons I will not bore you with, my energy this year has been reduced and taken up with other things, and thus every time I sat down to write something the desire vanished almost instantly--until now. 

Anyway, in no especial order, here are some thoughts on books that you might find beneficial, edifying, and even enjoyable to some degree. 

Jonathan Lear: 

I begin with Jonathan Lear, whose death in September occasioned grateful commentary as well as mourning and melancholia in the worlds of academic philosophy and clinical psychoanalysis. I read his Imagining the End: Mourning and Ethical Life in early 2023 and before that his Freud, published in the Routledge Philosophers Series. It is, I submit, the best philosophical treatment of Freud since Ricoeur's 1977 landmark book Freud and Philosophy: An Essay on Interpretation. 

Therapeutic Action: An Earnest Plea for Irony (2003) is a languid book that showcases Lear as a philosopher asking question after question in service of, and search for, an answer to his central question, which is: what is the therapeutic action of psychoanalytic treatment? Since this book was published more than two decades ago, there has been an increasing body of literature investigating this question and not just in psychoanalytic circles either. It remains a question that continues to fascinate me and will be the focus of some attention in my next book: what is the action of psychotherapy that provokes change by and in and with the patient? 

Lear's contribution to this is based on a wonderful and close re-reading not just of Freud but also of Lear's own mentor, Hans Loewald. He begins by reminding all of us that "therapeutic action does not describe a process, like getting a tattoo, which has a fixed end point. Once you've gotten a tattoo, you've got a tattoo; indeed once you've had an analysis, you've had an analysis, but therapeutic action goes on and on. Analysis has a termination: therapeutic action does not. Ideally one continues one's own process of therapeutic action as a lifetime project" (p.33). In this Lear very much reminds me of one of Adam Phillips's aphorisms that "the cure can only begin once the treatment has ended." 

Later on Lear briefly discusses termination in treatment, and the need to have that firmly in mind as a clinician from the moment treatment begins. (My first supervisor taught me that in introducing the question of goals, he often used the question "What would done look like?" as a way to get the new patient thinking about how their life would have to be changed for them to feel justified in letting treatment be done, be finished.) Lear compares this to good parenting, saying that both, to be healthy, have to consist in a progressive withdrawal because "psychoanalysis is aimed at promoting a person's freedom [and] part of the freedom is freedom from the need to keep coming to the analyst" (p.56), a key principle both Erich Fromm and D.W. Winnicott have previously articulated. 

Lear's compatability with the thought of other clinicians shows up in numerous points in the rest of the book. When he turns to a discussion about whether a psyche can be said to have a "core," he notes, in a vein that strikes me as very similar to Philip Bromberg's incredibly rich and important book, that "the core is the elementary capacity of the psyche to hold itself together" without resorting to a ruthless superego-induced attempt at purging or synthesizing (p.118).

He returns to this issue at the end of his third chapter, "Internalization," where he seems to nod clearly in the direction of mentalization (as Fonagy and Bateman have famously called it) or the creation of a "psychoanalytic mind" (as Fred Busch has called it) by saying that "while superego internalizations may well occur at various levels of sophistication and primitiveness, even in the termination phase of the analysis, one is also fostering the internalization of a capacity for analyzing these unconscious forms of internalization." In other words, if the analyst has been internalized as a good object (a "benign superego figure" in Lear's phrase) then ipso facto the patient will have also internalized the analyst's mentalizing capacity for use after the analysis has ended, and such a process "properly constitutes the therapeutic action of psychoanalysis" (p.133).

The next chapter, "Love as a Drive," contains some fascinating reflections that could too easily be dismissed as insider baseball, or as reviving old controversies nobody has cared about for decades, but in line with Bettelheim and Laplanche (on whose Freud and the Sexual see below) Lear insists that swapping out "instinct" for "drive" in translating Freud's German is misleading and unhelpful. Lear insists, with ample documentation from Freud, that this is a bigger issue for him than any of his biographers or scholars and clinicians after him have been willing to allow, and that it remains a great unsolved issue: the drives, especially of sex and death, have been rather quickly and quietly bundled off the stage so as to allow our genteel and ever so much more socially respectable conversations about developmental, relational, and now traumatic challenges to take over the entire show. 

In the context of this discussion, Lear calmly revisits the old polemics--from enemies and defenders of Freud alike--about the role the "sexual" drive occupies in Freud's writings, noting that both sides miss a crucial philosophical point that Lear explicates: his understanding is not focused on copulation and he denies that the sexual drive and the sexual object have a more intimate connection than they actually do. To this extent, then, Freud is not saying--Lear argues--that at our most sexual we are also at our most animalistic. Au contraire: human sexuality has so many features, expressions, and pecularities that it is here more than anywhere else that we are not like other animals. In Lear's by-now familiar refrain, "human sexuality makes us all candidates for irony" (p.156).

Additionally, drawing on Plato, Freud noted in 1924 ("The Resistances of Psycho-Analysis: SE 19: 213-224) that when psychoanalysis refers to sexuality, it "had far more resemblance to the all-inclusive and all-embracing love of Plato's Symposium." Lear the philosopher leaps on this and spends the rest of the chapter wondering aloud about why Freud, having said this, then spent the rest of his life running away from serious sustained reflection on love as a drive. In doing so, Lear charges, Freud fails to develop a crucial line of reflection that would have a direct bearing on therapeutic action. We cannot, Lear implies, understand efficacious therapeutic action except as being a process motivated by love (as Freud first conceded in that off-hand comment to Jung in a letter of December 1906). 

What might this love look like and how might it be a driver (if not the driver) of therapeutic action? What might a "loving" treatment result in? Lear suggests--but does not really develop the thought--at a couple of points that loving therapeutic action will result in the analysand's enlarged capacity for "greater psychological complexity" (p.170). (Once again there are clear echoes of this in others, including Phillips, Busch, Bion, and many others.) But the analyst does not impose this on the patient, or demand that he develop or "perform" complexity. The analyst merely provides a place to do so without getting pushy about it. Indeed, Lear defends fairly traditional understandings of neutrality at this point, saying that "the analyst's holding herself in this 'neutral' position is itself an act of love."

Towards the end of this chapter and nearing the end of the book, Lear asks a question that I have not seen anyone else do: is the fear Freud had about discussing a "love drive," a fear that virtually every clinician since him has replicated and never challenged, born out of a philosophically impoverished understanding of what "science" is and does? (Contemporary psychology's ignorance of the philosophy of science remains a constant source of serious vexation to me.) "One reason Freud's theory of love has been ignored is that it seems ridiculous to take seriously the idea that love is really a basic principle of nature. Surely we need to turn to natural scientists to find out what the basic principles of nature are. But what if we think about second nature?" (p.172). 

At this point Lear the philosopher emerges to the fore again, and he reminds us of our need to return to moral philosophy in Plato and especially Aristotle, but also in our own time the works of such as Bernard Williams and Alasdair MacIntyre. The development of our second, more properly human nature--our nature as philosophers, one might say, over and above our animal nature--cannot avoid questions of "character, personality, and psychological structure" (p.173). These can only have a chance of developing well if they do so in the context of relationships motivated by love that abjure moralizing while insisting on asking what Lear terms the ethical question: "How shall I live?" (174). 

Analysts, finally, cannot avoid such questions, either in themselves, or in their work with patients. In pursuing such questions with love they propel the therapy forward to successful action, defined as "structural change" understood not as a "once-and-for-all achievement" but instead a "perpetual undermining of rigidifying and thereby alienating pretenses" incapable of ironic reflection on oneself (p.177). 

For this rich and important book, and for his others, it is certain that Jonathan Lear's memory will remain a blessing.  

Memory of and Desire for more Bion?

We seem to be entering an era in which books about W.R. Bion, who died in 1979, are emerging at an ever increasing pace. I know for many of us he has been a difficult read, and our feelings about him are suitably ambivalent. His claim that each session should unfold with the clinician refraining from "memory and desire" has often been seen as a problematic counsel of perfection, but there are very solid reasons for striving to do this as I have learned the hard way more than once. In fact, I would say that mistakes I have made in a recent case are almost entirely because I failed to refrain from memory and desire and instead been too keen to demand the patient discuss certain things he is manifestly not ready to discuss. Pacing remains a crucial technique still in need of refinement.

Beyond his reflections on attention, memory, and desire, I have long found Bion enormously useful for his two essays on the psychotic mind. Using Bion, I built my chapter, "Men and Schizophrenia," which I was asked to write for the forthcoming Oxford Textbook of Men's Mental Health, part of the Oxford University Press imprint Textbooks in Psychiatry. The better known of Bion's essays, "Attacks on Linking" (1959), I now believe, is really the second part of, or a continuation of, his 1957 essay “Differentiation of the Psychotic from the Non-Psychotic Personalities.” The two really must be read together, and both are to be found in several places, but conveniently reprinted together in E.B. Spillius, ed., Melanie Klein Today: Developments in Theory and Practice, Vol. 1 (Routledge, 1988). 

But now we have new books on Bion, and in this case Donald Meltzer as well, with whom I was completely unfamiliar prior to reading Avner Bergstein, Bion and Meltzer's Expeditions into Unmapped Mental Life (Routledge, 2019). This is a very useful introduction to the two authors in the title, rendering Bion especially much more accessible than he was himself in some of his writings. The chapters on obsessionality, as well as on the psychotic personality, render Bion's thinking on both topics lucid and accessible without any dilution of their explanatory power. 

The final chapter, "The Ineffable," looks briefly at Bion's familiarity with both Christian and Jewish mysticism before arguing that "Bion seems to present us with non-religious mysticism": p.172), a judgment I would agree with. Part of what Bion appears to have taken from both of these mystical traditions is captured in his famously misunderstood phrase about refraining from memory and desire: "The psychoanalytic attitude, much like the mystical one, is a deliberate conscious act of discipline which depends on an active suspension of memory and desire" in order to exercise an "act of faith" that "truth exists" and can be discovered in the clinical encounter (p.166). 

Psychosis and Schizophrenia: 

While on the topic of psychosis, I must mention the following books which I have found not merely edifying but actively encouraging in what is so often a bleak landscape of poor and inadequate treatment and resources for psychotic patients: David Garfield and Daniel Mackler, eds., Beyond Medication: Therapeutic Engagement and the Recovery from Psychosis offers a number of essays from scholars and clinicians around the world looking at a range of options, while Therapeutic Communities for Psychosis, John Gale et al., eds., is looking at non-medical, quasi-institutional, but voluntary and community-based outpatient options for residence and care. 

Perhaps the best known (relatively speaking) example of this are the Soteria houses, which have fascinated me for some time. Only in September did I get around to finally reading Soteria: Through Madness to Deliverance. I find that I read all such books with a mixture of awe and respect for what was attempted but also some regret and amazement at how poorly supported such initiatives seem to be--and also with a wish that we might continue to build such places for there is a long track record and very impressive evidence base that they work. (See below for the evidence.)

I have a number of must-read books I recommend to other clinicians when they consult with me about working with psychotic and schizophrenic patients, starting with Michael Garrett and Andrew Lotterman's books. To that I will now insist on adding a third which, despite being the oldest of the three, is still incredibly relevant, timely, and useful: Michael Robbins, Experiences of Schizophrenia: An Integration of the Personal, Scientific, and Therapeutic.

Finally for books in this category we come to Courtenay Harding, Recovery from Schizophrenia: Evidence, History, and Hope. Please, please, please buy this book! I get nothing for saying that, and have never met the author, but I will hope for some small satisfaction that by encouraging a wide reading of this book then perhaps the long-standing, deceptive, indolent, and destructive narrative about schizophrenia that I first encountered in 1991 as an undergraduate, and which seems still to be propagated today to the detriment of many, may eventually die an overdue death. That narrative, of course, is the one that tells patients and their families that schizophrenia is a lifelong sentence of suffering for which there is no cure and which can, at best, be only partially ameliorated by neuroleptic medications (with notorious, intolerable, and sometimes irreversible side-effects). The fatalism and hopelessness in this narrative is just crushing to patients and their families, but it is infuriating to those of us who know that with the right treatment patients can and do get better!

That is not just an anecdotal claim based on a tiny, non-representative sample of one clinician, but has been backed up by empirical studies of hundreds of patients in different countries going back 75 years. It is to Harding's everylasting credit that she has tracked down patient records and long-forgotten studies of schizophrenic patients, including some of the most rigorous longitudinal studies we have of any psychiatric population, and published them in one place. In rendering so important a service to scholarship and patients alike, she has allowed us to see that, with multi-modal treatment, many patients have recovered. That is, three-quarters of a century ago now we already knew that merely medicating a patient is far from sufficient. Medication might be useful, but so too is intensive psychotherapy (see, e.g., Frieda Fromm-Reichmann's practice, or Harry Stack Sullivan) combined with vocational counseling, social supports, access to supportive, low-cost, outpatient housing, and a team of people (psychiatrists, nurses, therapists, social workers, dieticians, and others); but who today is willing to fund such treatments? 

How to Listen:

Salman Akhtar's short book, Psychoanalytic Listening: Methods, Limits, and Innovations is a wonderful addition to the literature, filling a gap that goes back at least thirty years. 

My debts to, gratitude and affection for, and frequent quotation of Nina Coltart are no secret. I have long maintained that nobody, in my experience, has surpassed her cogent description of therapeutic listening as a process of: 

sharply focusing, and scanning; complex involvement in feelings, and cool observation of them; close attention to the patient, and close attention to ourselves; distinguishing our own true feelings from subtle projections into us; communicating insight clearly, yet not imposing it; drawing constantly on resources of knowledge, yet being ready to know nothing for long periods; willing the best for our patients and ourselves, yet abandoning memory and desire; a kind of tolerant steadiness which holds us while we make innumerable, minute moral decisions, yet steering clear of being judgmental (Slouching Toward Bethlehem, 119). 

A little later in that unforgettable book she returns to all that is going on when the clinician is listening therapeutically:  

the need for consistent scanning and judging, not only of what the other person says, but of what we are about to say, and are saying; and with this scanning, the need for rapid continuous thinking, which may be only half-conscious; the need for repeated moral and technical decision-making; and yet if it is to convey truth, and more importantly, authenticity, in our style of speech we must also master intuitive, unlaboured spontaneity. This is an extremely demanding and complex requirement...[and]...it depends, for success...on...the combination of unselfconscious self-forgetfulness with deep self-confidence (Ibid., 145). 

Since reading this description of listening more than 30 years ago, I have found nobody who unpacked these dense descriptions until Akhtar's book, which is a gem. I now regard it as required reading for my students. 

It is not especially long, and it is written in clear, cogent, accessible prose with good but not overwhelming use of clinical illustrations. In addition, there is a commendable modesty in the author, who freely and frequently confesses his own errors about listening in the wrong way, or tolerating silence when speech was called for, or vice versa. He also notes, with admirable restraint, the difficult circumstances under which listening might and even should be refused--not least when outside of clinical contexts, when psychotherapeutic listening could be used manipulatively or destructively (he gives examples of doing this early in his marriage and watching how frustrating his family members found his doing so). 

In keeping with Coltart, he writes appreciatively on types of and purposes for silence, and he recognizes the degree of "faith" (also a concept Coltart explored in a non-theistic way) required to sit and wait, confident that if something is important, it will show up, and not once but repeatedly. Finally, he has some throwaway comments on several topics, including supervision ("supervision is more than teaching and less than treatment" he quotes A.J. Solnit's 1970 article in the International Journal of Psychoanalysis as saying). 

Laplanche, Freud and the Sexual. 

I have not read Laplanche nearly enough, and so on my last research trip to the library of the Cincinatti Psychoanalytic Institute, with less than an hour before I was to leave, I pulled all his books off the shelf, and slightly manically tore through them to decide which I really needed to read in a ranked order of urgency or importance. Apparently (this was 18 months ago now at least) I decided it was going to be Freud and the Sexual at the top of my list. Having just finished it, I must say frankly that I'm not sure what I saw in it. The book is a collection of articles on several topics, many of which feel quite like unfinished first drafts; much space is given to arcane arguments with translators of Freud from German into French and English; and when Laplanche finally turns to the topic of the sexual, his main insight seems to be confined to insisting that we should stop fighting over whether "instinct" or "drive" is the best translation for Freud's Urtriebe and recognize the utility of both terms in English.

On Buddhism and Philosophy:

Todd McGowan, Embracing Alienation: Why We Shouldn't Try to Find Ourselves is a new book that I read in January as presidential transition was taking place and a sense of alienation was mounting. 

I came upon McGowan close to a decade ago now in reading his book on the death drive. Enjoying What We Don't Have is one of the richest and most rewarding reflections on the death drive I have read in English. 

His new book on alienation makes the simple point in several places that by abandoning quests to find ourselves, or our "true" selves, we stop wasting time and energy that could be better put to projects of solidarity with each other in challenging the myriad instances of injustice in the world today. Embracing our alienation, in other words, has an "emancipatory quality" (p.7). In this way, then, McGowan manages to avoid the problem of a paralyzing despair at being alienated, and to avoid the temptation to fantasize about some prelapsarian paradise from which we are estranged but which we should struggle to find out way back to. There is no such paradise, McGowan says, and a good thing too.

The "alien" that we need to embrace is not some vague existential angst or a sense of estrangement we have from scrolling on social media and reading about all the horrors of strangers being snatched off the streets by fifth-rate opéra bouffe thugs in masks. The alien, rather, is within: it is our unconscious mind. As Freud first argued, and McGowan heartily agrees, each of us is alienated from ourselves. Our minds are divided and we live in a state of perpetual psychic alienation. If we stop fixating on "solving" this problem, and instead learn to forget our alienated selves, we will not only have more time and energy to work toward a better world, but we will also discover freedom and even some measure of happiness by focusing on helping others instead of chasing after our own "identity." 

And that word, in McGowan's hands, is clearly (and rightly) to be regarded as a bogus, deceptive, self-indulgent idol of our time, perhaps more than ever thanks in part to social media. Being preoccupied with finding and then defending our true "identity," McGowan shows through a close reading of Hegel, is actually a form of slavery we must emancipate ourselves from by learning self-forgetfulness. In doing so, he says in conclusion, "becoming reconciled to one's alienation is not a way of accepting oppression as inevitable" (p.148). McGowan's welcome book, then, is not a counsel of despair or an example of pietism or quietism, but instead a call for a new kind of politics. 

McGowan's theme of forgetting ourselves is also treated in several of Mark Epstein's books, which I have read over the past year, but these deserve a post of their own, so before Christmas I hope to offer some thoughts on Advice Not Given: A Guide to Getting Over Yourself and at least two other of his books. I have been propelled into an unexpected exploration of Buddhism and psychotherapy because of Nina Coltart's own immersion in that tradition as seen in her wonderful concept of "bare attention," an ascetical discipline (so I would say) we must all cultivate moment by moment and hour by hour with each patient. More on that anon.