Spirituality and Therapy

One recent change I have noted since I began in psychology in 1991 is that the openness to and even basic awareness of the role that "spirituality" plays has grown very considerably in the last decade or so. A book just released this week will continue to break down the once-traditional hostility between psychology (especially psychoanalysis) and religious and spiritual practices and traditions: 
Spirituality in Mental Health Practice: A Narrative Casebook, eds.,Miriam Jaffe, Widian Nicola, Jerry Floersch and Jeffrey Longhofer (Routledge, 2020), 226pp. 

About this book the publisher tells us this:

This key text presents an accessible and diverse exploration of spirituality in mental health practice, broadening the definition of spirituality to comprise a variety of transcendent experiences.

Chapters include a brief history of the tensions of spirituality in mental health practice and consider a range of emerging topics, from spirituality among the elderly and energy work (Reiki), to spirituality in addiction recovery, incarceration, and hospice work. The book offers a close examination of the limits of the medical model of care, making a case for a more spiritually sensitive practice. Rich case examples are woven throughout, and the book is paired with podcasts that can be applied across chapters, illuminating the narrative stories and building active listening and teaching skills. Suitable for students of social work and counseling at master's level, as well as practicing clinicians, Spirituality in Mental Health Practice is an essential text for widening our understanding of how spiritual frameworks can enrich mental health practice.

Psychotherapy and Christianity in Scotland

My mother and her entire family were all from the west of Scotland, up and down the coast along the Firth of Clyde and into Glasgow. One day, God willing and the pandemic receding, I may get over to see it.

Partly because of that, but also partly because of a sense that events in London, as always, tend to outshine and overshadow others in the United Kingdom, I have cultivated for several years an interest in figures in Scotland who have been important and influential in the development of psychoanalysis and psychotherapy. E.g., W.R.D. Fairbairn's pioneering work on the schizoid personality type remains fascinating to me, as does his life, some of it covered in John Sutherland's 1989 book, Fairbairn's Journey into the Interior, which I read last year.

Even more fascinating, in part because more dramatic and "radical," is the life and work of the psychiatrist R.D. Laing, whose Wisdom, Madness and Folly: The Making of a Psychiatrist I read last year.

Along comes a new book to deepen our knowledge of Scottish developments in mental health in the last century. Set for release at the end of June is Miracles of Healing: Psychotherapy and Religion in Twentieth-Century Scotland by Gavin Miller (Edinburgh UP, 2020), 184pp.

About this book the publisher tells us this:

Although a tide of secularization swept over the post-war United Kingdom, Christianity in Scotland found one way to survive by drawing on alliances that it had built earlier in the century with psychoanalysis and psychotherapy. Psychoanalysis was seen as a way to purify Christianity, and to propel it in a scientifically rational and socially progressive direction. This book draws upon a wealth of archival research to uncover the complex interaction between religion and psychotherapy in twentieth-century Scotland. It explores the practical and intellectual alliance created between the Scottish churches and Scottish psychotherapy that found expression in the work of celebrated figures such as the radical psychiatrist R.D. Laing and the pioneering psychoanalyst W.R.D. Fairbairn, as well as the careers of less well-known individuals such as the psychotherapist Winifred Rushforth.

The New Books Network and Nancy Chodorow

I've just come across the channel devoted entirely to psychoanalysis at the New Books Network, which I commend to your attention for notices of books, podcasts with new authors, and such riches.

On there I spied a name I've not come across since I read some of her works when I was an undergraduate in psychology, and an analysand, in the 1990s in Canada: Nancy Chodorow, author of such works as The Reproduction of Mothering: Psychoanalysis and the Sociology of Gender and Feminism and Psychoanalytic Theory.

This year she has a new book out, about which the New Books Network interviews her: The Psychoanalytic Ear and the Sociological Eye: Toward an American Independent Tradition (Routledge 2020).

About this new book the publisher tells us this: 

In The Psychoanalytic Ear and the Sociological Eye: Toward an American Independent Tradition, Nancy J. Chodorow brings together her two professional identities, psychoanalyst and sociologist, as she also brings together and moves beyond two traditions within American psychoanalysis, naming for the first time an American independent tradition. The book's chapters move inward, toward fine-tuned discussions of the theory and epistemology of the American independent tradition, which Chodorow locates originally in the writings of Erik Erikson and Hans Loewald, and outward toward what Chodorow sees as a missing but necessary connection between psychoanalysis, the social sciences, and the social world.

Chodorow suggests that Hans Loewald and Erik Erikson, self-defined ego psychologists, each brings in the intersubjective, attending to the fine-tuned interactions of mother and child, analyst and patient, and individual and social surround. She calls them intersubjective ego psychologists―for Chodorow, the basic theory and clinical epistemology of the American independent tradition. Chodorow describes intrinsic contradictions in psychoanalytic theory and practice that these authors and later American independents address, and she points to similarities between the American and British independent traditions.

The American independent tradition, especially through the writings of Erikson, points the analyst and the scholar to individuality and society. Moving back in time, Chodorow suggests that from his earliest writings to his last works, Freud was interested in society and culture, both as these are lived by individuals and as psychoanalysis can help us to understand the fundamental processes that create them. Chodorow advocates for a return to these sociocultural interests for psychoanalysts. At the same time, she rues the lack of attention within the social sciences to the serious study of individuals and individuality and advocates for a field of individuology in the university.

How Much Light is in the SOLER System?

In discussing Neville Symington recently, I noted in passing his welcome comment about the importance of a therapist's office.

This is a question I spent some time investigating earlier this semester when one of our graduate classes introduced the so-called SOLER recommendations for doing therapy. (SOLER = Sitting Squarely while having an Open posture as you Lean in, maintain Eye contact, and have Relaxed body language.) 

I confess upon reading this that I immediately had questions, and so spent a happy few days ransacking the literature going back to the early 1970s to see what it said, and to see if there is a consistent evidence base justifying all these arrangements as a feature of a consulting room. It turns out--as they say in some Scottish trials--that the case is "not proven," or at least not proven to any degree sufficient to convince me. 

I do not pretend that what follows is an exhaustive literature review, but I can report the following: One early study (Broekmann and Moller, 1973) yielded ambiguous results, in part because, the authors say, their 30 randomly assigned test subjects were regular students, not patients in therapy. This study found that in some cases students preferred chairs side-by-side, rather than facing each other squarely, but in other situations preferred chairs facing each other squarely but with a large table in between them. 

Another old study found that room arrangements differed considerably between patients and therapists: “clients had different preferences for seating arrangements than did counselors. In general, clients preferred spatial arrangements that were more protected than those preferred by the counselors” (Haase and DiMattia, 1976, p.414). Once again, however, both groups of subjects in this experiment were American university students (and all men), not those in therapy, and they were assigned very particular cognitive tasks of learning and conditioning not always found in therapy, so I am not sure how useful these results are. Still, it did uncover that a larger room consistently invited longer verbalization by the subjects than a smaller room. But as for furniture and its arrangements, the results uncovered merely “a marginally significant effect due to furniture arrangements” (p. 419). The authors then conclude that “It would be desirable to replicate this study with a group of actual clients…in addition to analogue studies.”

Further analogue studies from the same time (e.g., Chaikin et al 1976) emphasized the need for a consulting room to be a “warm, intimate” place to facilitate greater self-disclosure. Another focused primarily on the therapist’s attire and office decorations, but said nothing about furniture and its arrangements (Amira and Abramowitz, 1979). More recent research (e.g., Miwa and Hanyu, 2006) also focuses on lighting and decorations while, again, saying little about furniture and its arrangement.

A 2011 study (Nasar and Devlin), also with students, uncovered several interesting findings: a warmer, more intimate space consists largely of using more classical wood materials rather than colder and harder steel and concrete, or brick; plants are very often a encouraging sign of vitality; the display of diplomas almost universally increases perceptions of the clinician’s trustworthiness and credibility; and a messy desk is rated more positively than an excessively neat one (which is seen as somewhat stiff and cold, or as Freud might say, anal retentive!). 

A significant difference in this study is that “We sampled real environments: 30 offices used by psychotherapists” (p.311). Test subjects were shown real photographs of offices, mostly in Manhattan. From this it emerged that subjects ranked matters thus: “Neatness and chair comfort were rated as most important, followed by order, space, style, and color. The first two items were judged significantly more important than were the rest” (p. 317). It’s important to note here that the “chair” in question is the therapist’s chair, pictures of which were shown to subjects in this study—the discussion of furniture here was limited to this one chair only. As they note in conclusion, “Although the therapist’s chair was the focus of the photograph that respondents viewed…client seating could be the focus of future study.”

A 2013 study (Devlin et al), using the same method as the study just mentioned from 2011, this time asked a cross-cultural group of subjects to look at pictures of the therapist’s chair and office surrounding it. Here it was found that among student populations in the US, Turkey, and Vietnam (more than 1/3 of whom had been to therapy at least once) there was consensus on things like colour, neatness, perceived “softness” and “orderliness” of the offices, but no substantial comment on furniture arrangement beyond noting that “participants rated chair comfort as highest in importance, and neatness and orderliness among the most important attributes in influencing their judgments” (p.15). Once again, the reference here is to the therapist’s chair only, and nothing was said about its position in the room.

Another 2011 study, a qualitative survey of practicing psychologists, has yielded fascinating data into how they see their offices, how they arrange them, and how strongly they have a desire to have control over such elements. The authors began by admitting that “psychologists’ offices have been largely absent from contemporary theoretical and methodological discussions of therapeutic environments.” They note that “in general, the therapeutic setting should be a holding environment; psychologists and their offices should provide comfortable and secure environments within which clients feel free to communicate sensitive information” (Watkins and Anthony, 2011, p.2). That use of “holding environment” is of course a signature idea of object-relations theory, which these authors explicitly reference several times, especially the works of Winnicott and Klein. I found it very encouraging that they admitted “If necessary, a few psychologists were even willing to rearrange furniture for specific clients” (p.8).

Three other studies recognize a lack of data. Gass (1984) has admitted with commendable candor that “Recommendations that concern the seating arrangement in therapy are based more on intuition than on empirical research,” which accords with my initial suspicions (see below).

In one of the longest and most comprehensive studies I’ve yet found, surveying a wide variety of clinicians (psychiatrists, social workers, counsellors, etc.) in many contexts, the author (Backhaus, 2008) noted that research over the last forty years has rarely focused on arrangements of furniture and related details in consulting rooms before going on to argue that “the seating arrangement in the therapeutic environment is perhaps the most controversial aspect of the physical environment of the therapy room. Based on results from several studies, there does not appear to be one recommended method for seating arrangement” (p.22). Whence comes this controversy she mentions? The author does not say. But it is noteworthy, and reassuring, that there is not one prescribed arrangement everybody must universally follow.

She does go on to tip her hand somewhat, nothing that “in intimate situations, both parties often sit next to each other versus across the room from one another” (p.23). Her most valuable suggestion, to my mind, is that clinicians should be “offering clients several seating options including chairs that can be easily moved” (p.22). I think this is extremely wise: flexibility and a focus on what the person prefers should be uppermost considerations in the design of a consulting room.

The most recent research by Jackson confirms the gap first noted by Gass in 1984. Jackson (2018) admits that “Despite its importance, the subject of the therapist's office has been largely absent from contemporary literature, with a few exceptions.” 

Interestingly, she does quote a 1988 book, Psychotherapy Tradecraft: The Technique and Style of Doing Therapy, by a former APA President Theodore Blau, who does have some concrete recommendations over furniture and its arrangement. She quotes him as having “encouraged thoughtful seating options that ‘consider comfort and convenience,’ and that ‘the most comfortable and orthopaedically correct seating possible is strongly recommended in order to avoid back problems’ for the therapist.” She also later avers to “the use of chairs that are moveable or large enough to allow clients to choose their positions, providing a sense of control over their environment” (p. 235). Once again, then, we see there is encouragement to be flexible and have one’s furniture be portable. I find this exactly right and most encouraging. 

Beyond peer-reviewed journals other reflections (e.g., Saari, 2002) remain vague about clinical environments, as do APA  and a handful of other professional blogs I have seen, which talk in generalities about office design and patient-therapist arrangements, always emphasizing that patient needs come first, which is exactly right. 

In sum, then, and putting this preliminary literature review together, then, and recognizing that it doesn’t pretend to be exhaustive but I think fairly representative nonetheless, I have thus far found very little specific, explicit, concrete, and repeated evidence (or even discussion) justifying SOLER. 

Given that I’ve not found much evidence so far, I can’t help but return to my original suspicion that perhaps SOLER arrangements began as a personal preference (from someone like Rogers perhaps?) that has then been simply copied by others without much thought or research precisely in the same manner as Freud’s famous couch was almost mindlessly copied with no comment, let alone deeper reflection or empirical study, in the psychoanalytic literature for the better part of a century. 

Only very recently, in fact, have two fascinating books been published looking critically at the role of couches: Kravis, 2017; and Gerald, 2019. He himself only justified the couch by saying that he could not stand being looked at for 8 hours a day, but otherwise wrote nothing about the couch, which seems to have been a holdover from his early attempts at using hypnotherapy.

Is it possible, then, that SOLER arrangements remain as undertheorized and under-researched as Freud’s couch? Gass, Backhaus, and Jackson all strongly suggest as much. I think, therefore, that there are strong arguments to be made about alternate arrangements, some of which, some of the time, for some people, may well prove to be more therapeutically effective than SOLER.

Here are my arguments and concerns with the presuppositions in the literature:

Constantly facing people square on presupposes that they want you to do that, that they are comfortable with such an arrangement, and that their progress in therapy will be helped, not hindered, by such an arrangement. I do not make those assumptions, and would want, as part of an intake process or after a preliminary session, to invite people to express their preferences and, at the next and subsequent sessions, to position themselves as they wish. If therapists are there to serve patients, then surely these latter need to have some choice as to posture and position in the consulting room.

Why do I say that? Four reasons. First, as Judith Herman’s Trauma and Recovery and other books in traumatology suggest, severely traumatized patients often feel like they have few or no choices, and feel profoundly disempowered. Giving them even modest choice and power to decide things, she says, is important in therapy.

Second, does SOLER presuppose a Western audience—and even within such an audience presuppose that every “Westerner” is comfortable with such an arrangement? Do we know if other cultures would be equally at home with such an arrangement? I've found little evidence that this question has even occurred to previous researchers apart from the Devlin et al study discussed above. Thus I have to wonder: Is it not possible that some cultures would find a SOLER arrangement if not threatening then at the very least considerably uncomfortable, perhaps so much so that therapeutic progress is attenuated?

Third, my own experience as an analysand of course enters here. I found the couch very helpful in recounting especially bizarre dreams or traumatic memories. These things were hard enough to vocalize to begin with, but I’m quite sure I’d never have gotten into them if I had to face my analyst. (Indeed, for our first three intake sessions, when facing her in a chair, I danced around a lot of stuff, speaking only in extremely vague generalities because I couldn’t talk about certain things while having to make eye contact. Once on the couch, however, it was easier to begin, however gingerly, to wade into deep and dark waters.)

Fourth, I have had difficult conversations with students on campus while walking side-by-side and not facing each other, as well as with my own son, neither of which would, I wager, have gone successfully and smoothly if my interlocutor was forced to look me in the eye the whole time.  

For all these reasons, then, I would invite people in my consulting room to one of three arrangements. First would be the SOLER arrangement—two chairs face to face. (Some people, I know, really do prefer that arrangement.) Second would be to have an additional chair placed beside my own, both facing the same direction, slightly angled and with a modest gap (e.g., small table) between them. Thus a person could choose to sit either across from or beside me. The third option would be a couch. And I would invite people to make use of both chairs and the couch as they saw fit, without requiring that they be consistent. Some days they might feel the need to lie down; others to sit but not face me; and still others, to see me and know I’m there. I'm quite happy with their doing whatever they need to from session to session. 

There are, I must confess in conclusion, some perhaps more "selfish" reasons connected to the fact that I know my own posture could be misinterpreted, and that my own tolerance for leaning in and constantly facing someone would be diminished if not exhausted after a time. For me, sitting with hands behind my head, or arms crossed, are often postures for me not of being closed, but of being more physically comfortable and thus freed up to listen more carefully. I find that when trying to listen more deeply with my “third ear” (Reik 1948) to hear what else the person might be saying unconsciously or trying to avoid saying, I sometimes find it very helpful not to lean in and maintain eye contact, but to sit back and look off into the distance or even close my eyes, trying to catch, in Eliot’s lovely words,

The voice of the hidden waterfall
And the children in the apple-tree
Not known, because not looked for
But heard, half-heard, in the stillness
Between two waves of the sea.

++++++++++++++++++

REFERENCES:

Amira, S. and Abramowitz, S.I. (1979). Therapeutic attraction as a function of therapist attire and office furnishings. Journal of Consulting and Clinical Psychology 1979, 47, 198-200.

Backhaus, K.L. (2008). Client and therapist perspectives on the importance of the physical environment of the therapy room: A mixed methods study. Doctoral dissertation at Texas Women’s University. 

Broekmann, N.C. and Moller, A.T. (1973). Preferred seating position and distance in various situations. Journal of Counseling Psychology, 20, 504-508.

Devlin, A.S. Nasar, J.L., and Cubukcu, Ebru (2013). Students’ impressions of psychotherapists’ offices: cross-cultural comparisons. Environment and Behavior, 20, 1–26.

Devlin, A. S., and Nasar, J. L. (2012). Impressions of psychotherapists’ offices: Do therapists and clients agree? Professional Psychology: Research and Practice, 43, 118-122.

Gass, C.S. (1984). Therapeutic influence as a function of therapist attire and the seating arrangement in an initial interview. Journal of Clinical Psychology, 40, 52-57.

Gerald, Mark (2019). In the Shadow of Freud’s Couch: Portraits of Psychoanalysts in Their Offices. London: Routledge.

Jackson, Devlin (2018). Aesthetics and the psychotherapist’s office. Journal of Clinical Psychology, 74, 233-238.

Kravis, Nathan (2017). The Couch: a Repressed History of the Analytic Couch from Plato to Freud. Boston: MIT Press.

Nassar, J. and Devlin, A. (2011). Impressions of psychotherapists’ offices. Journal of Counseling Psychology 58, 310 –320.

Reik, Theodore (1948). Listening with the Third Ear: the Inner Experience of a Psychoanalyst. New York: Farrar Strauss & Co.

Saari, Carolyn (2002). The Environment: Its Role in Psychosocial Functioning and Psychotherapy. New York: Columbia  University Press.

Yoshiko Miwa, and Kazunori Hanyu (2006). The effects of interior design on communication and  impressions of a counselor in a counseling room. Environment and Behavior, 38, 484-502.

Watkins, N.J. and Anthony, K.H. (2011). The design of psychologists’ offices: A qualitative evaluation of environment-function fit. 

Neville Symington on The Making of a Psychotherapist

I spent several happy days in early 2018 at the Cincinnati Psychoanalytic Institute and their library, which I had the run of. There I had the first chance to begin to read some of the many works of several people, including the Anglo-Australian therapist Neville Symington, who has recently died. 

Part of my interest in him is for a book I'm working on that will look, in part, at the question of psychoanalysis and religion, especially Christian theology. Symington was for a time a Catholic priest before leaving the Church, marrying, undergoing analysis, and then training to become a therapist, first in London (where he was connected to the justly celebrated Tavistock Clinic) and later in Australia. He has many interesting insights on the analysis-religion relationship, and most of them are constructive if not positive, but we will not get into those here. 

In any event, I've been meaning to read more of him, and recently had a chance to read his The Making of a Psychotherapist (Routledge, 1997). Herewith some thoughts on that.

Symington notes early on that the goal for this book is to show "a psychotherapist in the making, so both the strengths and errors of the psychotherapist are laid bare for the reader to scrutinize. I hope that this might help psychotherapists who are trying to learn, as I am." And with commendable candor Symington, several times in his mini case-studies, does describe interactions with a patient that were not always productive and positive, and how he handled them, and what he learned from them. 

The first part of the book is, in my view, much richer than the second. By the second he seems to forget the rather sharp distinction he posited early on between psychotherapy and psychoanalysis, and the second half of the book is almost entirely focused on classical analytic issues and concepts.

Having recently written appreciatively about what I've learned, and am learning, from Yalom, I noted that Symington early on in this book takes issue with the notion of therapy providing corrective emotional experiences (which Yalom talks about in his chapter on interpersonal group therapy, where he notes that many of his insights originate with Harry Stack Sullivan and Franz Alexander). Such experiences, along with the therapist's empathy, are not in themselves sufficient to provide lasting healing according to Symington. 

Inner Creative Emotional Act:

Instead, he writes, "my own belief is that healing of a lasting kind is the product of an inner creative emotional act. This act is essentially free and cannot therefore be imposed upon the patient" (xvi). 

I was struck by this insofar as it rings true to my own experience as a patient, and describes my own approach to working with people. A lack of imposition was, and is, the largest part of my attraction to, benefit from, and continued defense of psychoanalytic therapy: it seems to offer maximum freedom to the patient and to resist imposing things on him or her. Some of the key insights I took from analysis came from that kind of inner emotional act. Does that mean they were singularly and solely mine, and that the analyst or therapist plays no role? Of course not.

Psychotherapy and the Moral Life:

Ch. 1 opens with the ringing declaration: "Psychotherapy means healing of the soul." This then leads into a brief discussion of Viktor Frankl and from here into an extended discussion about the "moral element to mental distress" which is not always entirely clear. I think what he is saying here--and it comes out more clearly at the very end of the book--is that none of us can escape certain judgments about the good life, and so even though we may try to preserve a certain level of neutrality with patients, nonetheless each claim about what constitutes "healthy" or "adaptive" or "appropriate" behavior or thought is ipso facto a moral judgment. It may, Symington seems to suggest, be profitable to be more explicit about this, especially with those patients who are asking explicitly moral, metaphysical, or existential questions. 

Of course, such engagements must be nicely judged to avoid moralizing or moral imposition. As Symington recognizes, 

If the psychotherapist does not understand the moral element to mental distress, then the patient will superficially sigh with relief but, at a deeper level, go away disappointed. There is no doubt that the theoretical models with which the trainee psychotherapist is equipped during the course of his training are essential tools of the trade. But of equal importance to this knowledge of theory is knowledge of when and how to apply it-which tool to use for a particular job.

Process Your Own Mourning and Melancholia:

Symington does not shy away from noting several significant challenges a therapist must continue to face. At the end of ch. 3 he says that the therapist's "task is to reach his own feelings," especially "feelings...[of] pain and loneliness." Why should any of us want to do that? The answer is quite simple: doing so is a win-win for both people in the relationship: "If... he reaches his own feelings, it frees the patient and favours his emotional development." This is not a one-and-done kind of thing, but, Symington says, an on-going task throughout the therapist's life. 

Take Courage!

Later in the book he recognizes that this task of the therapist recognizing his own feelings of pain and loneliness requires courage or, as he says, "moral fortitude is an essential quality in a psychotherapist if he is to endure the pain that reaching those feelings entails. In other words, moral courage is needed to deal with mental pain."

Keep Your Imagination in Good Working Order:

In ch. 4 Symington notes that very often "patients come to see us when things have broken down and when their lives no longer hold meaning for them." In such a situation many of them will "place implicit trust in the psychotherapist's ability to help them rebuild their world." A therapist will be useless at doing this "unless the imagination of the psychotherapist is in a healthy, functioning state." I know such arguments make some people very nervous, especially if they have been led to believe there is a manual for everything so that imagination becomes otiose. And I think Symington would be the first to agree that this, too, must be finely judged so that the therapist's imagination does not run riot, indulging in what Freud would call "wild analysis." 

Symington comes to this point a little later in the same chapter, when he says that it "is important that the psychotherapist should freely exercise his imagination while in the process of determining the most appropriate treatment programme for the patient." As he goes on to recommend, some of this can begin even "at the initial assessment interview" when, "as the patient is allowed to talk freely" the therapist then "relaxes into an inner attitude of free association," a process that "will frequently lead him to the area in which the patient has the greatest difficulty."

Your Office Matters!

In a separate, longer post sometime down the road, I will bring in some of the research I did this past semester on the arrangement of a therapist's office. That research, as it turned out, revealed that common arrangements (sometimes in textbooks referred to as the SOLER set-up) are very under-theorized and based more on assumptions.  There are gaps in the research here which are nonetheless covered over by common assumptions many people seem to copy almost mindlessly--chief among them that one must always sit squarely facing the patient. Knowing this, I was greatly cheered to read that Symington is also aware of the power of the environment to be (or not to be) "conducive to the free exercise of the imagination.... The interior decoration of the psychotherapy rooms and the whole psychotherapy department will, in itself, play an important part in both the activity of psychotherapy and the enjoyment of the results." 

Can You Paint Your Patient?

At the end of ch 4, Symington, who has written elsewhere about the British analyst Wilfred Bion, quotes the latter in a way that uses a really striking image: "When you have seen a patient, instead of going and writing up the session, why not instead go and make a painting of the next session." I can't paint (or draw) worth a damn, but I like this image in part because of what it seems to imply about the relatively freer mode of painting vs. the tendency to feel one has locked something down in writing, especially if one also happens to be, as I am, a longstanding academic editor with a ruthless intolerance of sloppy writing. 

But sometimes ruthlessly cogent writing can be its own kind of prison, and we need to break out of it at least to some degree. One of the many valuable lessons I have learned from Adam Phillips is that people may often come to therapy precisely when they feel the stories of their life have been too tightly, narrowly, pathologically written--by themselves and others--and need help finding a freer, newer story to inhabit. 

But the search for alternate or freer stories is always going to be challenged, perhaps most of all by ourselves. As Symington recognizes on this point, the process of therapy is a constant battle against patients who want to be cured but, at the same time, do everything in their power to avoid mental pain. Much effort, a good deal of it unconscious, will be spent trying to steer the therapist away from the patient's areas of pain. This, of course, has been known from the beginning when Freud saw resistance emerging almost minutes after a patient settled onto the couch for the first time. He wrote about it, and later his translator and sometime analysand Joan Riviere did also in her essay on negative therapeutic reaction. 

Sometimes the Complaint is Justified!

Symington is helpful in noting that not every bit of negative feedback from the patient is just projection or pathology. Sometimes they are right to be critical. As he says, the psychotherapist needs a finely tuned sensitivity in order to distinguish between the negative transference and straightforward justifiable negativity--as when, e.g., the therapist has been an ass or made a major mistake. 

The Importance of Neutrality:

For people personally inclined towards, and professionally trained in the practice of, empathy, it may be difficult to realize that one can go too far in trying to take the patient's side or in accepting uncritically what s/he tells you. This, I think, is especially tricky in cases of massive trauma. In such cases, Symington quotes Jung "'The patient does not feel himself accepted unless the very worst in him is accepted, too'." This has to be a comprehensive acceptance of the love and hate, the ambivalence, the admirable and despicable parts of the self. 

But Symington (and others I have read) is very clear in noting that acceptance must be contained within a broader neutrality of sorts. As he says, if the "psychotherapist puts himself entirely into the shoes of the patient and bases his understanding on the patient's own point of view, excluding all else, he will do nothing to solve the patient's basic problem." That is because, he continues, the patient comes to us in the first place "because his own point of view had not solved his problem. To be able to solve it, he needs the point of view of the Other."

Approaching Termination:

Many people have turned their hand to the question of when a therapy might be ended, or what signs or criteria one might use in judging whether a patient is approaching a terminal phase in the treatment. Symington also has done so in this book, noting two primary criteria which he regards as "particularly good indicators of whether emotional maturity has been achieved. These are the capacity to bear criticism and the capacity to manage confrontation."

But termination is not the end--far from it. As Adam Phillips has said, "the cure can only begin after the treatment has ended." (That may be more true for classical psychoanalysis than psychotherapy, but it seems to me that if either is good and worthwhile, its long-term effects will continue to be manifest almost if not daily. I certainly believe it to be in my own life.) And termination can leave in place certain skills that allow the patient to negotiate future struggles. As Symington notes in the book--with some hesitation--far from being in a crisis when you go to therapy, going to therapy is itself a crisis. If it is successfully survived, then this becomes a rich and significant source of strength to prevent collapse in future crises.

One final note here on the theme of termination, drawn from a fascinating book I read several years ago: Fred Busch's Creating a Psychoanalytic Mind: A Psychoanalytic Method and Theory. 

In that book, Busch divides the therapeutic relationship (as many do) into three phases: 

1) The first phase is when the patient comes to be familiar with his own inhibitions and restrictions that keep him from living: until the patient can wonder about his lack of wondering, wondering is not possible. This phase, later in the book, is called one of self-observation. 

2) The middle phase consists in learning to observe one's own mind and its sequence of free associations. Such a mind is necessary if the analysis is to bear long-term sustainable fruits in one's life. It is necessary, that is, if the patient is to be freed from the "slavery of repetition compulsion" and instead freed to "think about thinking." Later in the book Busch calls this phase one of self-reflection. 

3) The terminal phase consists of a mind more completely free from deceptions in understanding one's associations with greater veracity. Here the patient can "play, muse, reflect, and interpret her own associations." This phase Busch later calls self-inquiry. 

The Centenary of the Death Drive

In December 2018, aware that the centenary of Beyond the Pleasure Principle would soon be upon us, I reflected on a number of books recently published that seemed to herald something of a revival of interest in Freud's most controversial and widely dismissed theory. I have assigned Beyond the Pleasure Principle in classes, and come to think and write about it a lot more in the last couple of years. 

Just this week Josh Cohen reflected on the interplay of the drives in a time of pandemic in an essay that is well worth your time (as everything from Cohen that I have read to date certainly is, including this recent piece).

A little later this summer, when I get several projects cleared off my plate, I hope to be able to read a new collection recently sent to me by the publisher: Contemporary Perspectives on the Freudian Death Drive: In Theory, Clinical Practice and Culture, eds. Victor Blüml, Liana Giorgi, and Daru Huppert (Routledge, 2019), xv+182pp. 

About this book the publisher tells us this: 

Contemporary Perspectives on the Freudian Death Drive provides a sustained discussion of the death drive from the perspective of different psychoanalytic traditions. Ever since Freud introduced the notion of the death drive, it has been the subject of intense debate in psychoanalysis and beyond. The death drive is arguably the most unsettling psychoanalytic concept. What this concept points to is more unsettling still. It uniquely illuminates the forces of destruction and dissolution at work in individuals as well as in society. This book first introduces Freud’s use of the term, tracing the debates and developments his ideas have led to. The subsequent essays by leading Viennese psychoanalysts demonstrate the power of the death drive to illuminate psychoanalytic theory, clinical practice, and the study of culture. Since this book originally arose from a conference in Vienna, its final segment is dedicated to the forced exile of the early Viennese psychoanalysts due to the Nazi threat. Due to its wide scope and the many perspectives it offers, this book is a tribute to the disturbing relevance of the death drive today. Contemporary Perspectives on the Freudian Death Drive is of special interest to psychoanalysts, psychotherapists, social and cultural scientists, as well as anyone intending to understand the sources and vicissitudes of human destructiveness.

Cometh the Hour, Cometh the Man--Again: Erich Fromm

I'm working feverishly to get an essay done before month's end for a project at Cambridge University on the sex abuse crisis in the Catholic Church, about which last year I published Everything Hidden Shall Be Revealed: Ridding the Church of Abuses of Sex and Power, which drew extensively on psychoanalytic thought.

For my current project I'm going beyond what I wrote last year thanks to a re-immersion in thought of Erich Fromm, to whom I will return again on this blog, but some of whose books I wanted to draw to your attention even now. I think he's perhaps more relevant than at any time since the 1940s when he made his breakout into the anglophone world. 

March 2020 passed--for obvious reasons--without much attention being given to the fact that it marked both the 120th anniversary of the birth, and the 40th anniversary of the death, of Erich Fromm (23 March 1900–18 March 1980). He was wildly popular for much of his life, his books regularly selling millions of copies and being read or quoted by popes and presidents and policy-makers, inter alia. If anyone demonstrated the sociopolitical uses of psychoanalytic thought, well beyond the consulting room, it was and is Fromm. 

Today what he may lack in popularity he more than makes up for in ongoing relevance, not least to the politics of these United States but also, as I will soon suggest elsewhere, the politics of the Catholic Church. In some ways we need to return to his thought now more than ever for his insights into the problems of power, authority, freedom, and submission remain perennially relevant. 

I bought his Escape from Freedom in the mid-1990s in a cramped used bookstore down the street from my psychoanalyst in Ottawa, where I was an undergraduate student in psychology at the time. That book, Fromm's first of many runaway best-sellers when it came out in 1941, has never left me, and within the past couple of years has come to inform my thinking more and more, aided in part by some similar themes in Adam Phillips. 

Like most of Fromm's books, Escape from Freedom was written in a rather loose, breezy, and, if you will, "popular" style, which goes some way to explaining why, as his most perceptive biographer Lawrence Friedman has shown, he was largely ignored at least by North American academics. 

But, says Friedman--who has been reading and writing about Fromm since the late 1950s--the 1941 book was and is “the deepest and most important of Fromm’s books.” 

I would not dissent from that, but only put in a bid to claim that his posthumously published 1981 book On Disobedience: Why Freedom Means Saying “No” to Power is a crucial, and more concrete, "second volume" if you will to the 1941 book. It is a very short book, but what it lacks in length it makes up for in more concrete and pointed insights, it seems to me, than those found in Escape from Freedom. 


In addition to these two books, I have for the first time just finished Fromm's The Anatomy of Human Destructiveness. It is an extremely wide-ranging book, but its sections on sadism and masochism are especially valuable. I will return to this S&M theme in the coming days with some further thoughts on Fromm and also on an outstanding collection, Essential Papers on Masochism, ed. Margaret Ann Fitzpatrick Hanly (NYU Press, 1995). 

The Gift of Yalom (I)

My clinical supervisor very off-handedly mentioned "Yalom" in class one day last year and everyone seemed to know what/who that was. I had no clue. I half-figured it was one of those myriad acronyms for some gimmicky "technique" modern psychology loves, if only for purposes of trade-marking and marketing and thus money-making.  

I have been happily rectifying my ignorance since then by reading several of Irvin Yalom's books, starting with his landmark work, which I used for a project in a group therapy class: The Theory and Practice of Group Psychotherapy, which is fascinating and so much better written than any textbook I've read so far in the area. I expect this will be the kind of book I shall return to often in the coming years. 

Next up I ordered The Gift of Therapy. It, too, will reward re-reading over the years. It is, in some respects, almost a collection of aphorisms, though most chapters are a little longer than the typical aphorism, and in that regard the subtitle is apt: An Open Letter to a New Generation of Therapists and Their Patients. 

The book's 85 chapters are thus seen as something longer than an aphorism but shorter than a really long letter: they are in fact short letters, some of them less than a page, and the longest of them just over six pages. Yalom writes with a light and often charming touch, so these are an easy read. 

That is not to say they are flippant in any way. Some of these letters strike me as such obvious counsel that they do not need saying (e.g., ch. 64, "Never be Sexual with Patients"), but clearly they do need saying as sexual abuse by clinicians is by no means unknown even today. One of the startling and disgusting experiences of my undergraduate days was finding out that a professor, whom I really liked, who had taught a class on personality theories, which was one of my favourite classes, was later tried by the College of Psychologists of Ontario and had his license stripped after on-going sexual relationships with several patients, to whom he was later ordered by the courts to pay extensive damages. 

Part of the motivation for writing this book, Yalom says in the introduction, is that "our field is in such crisis," in large part because (at least in America under its horrid and rapacious health insurance industry) of the pressure that all therapy be "brief, superficial, and insubstantial." Such pressures (ongoing in 2020, as this letter from Division 39 of the APA shows) mean that mental healthcare today is running the risk of being "deformed by economic pressures and impoverished by radically abbreviated training programs" (xv). It is for those who also want to resist these pressures, and learn how to offer a form of therapy that is deeper, longer, and open to exploring existential issues (about which Yalom has written elsewhere several times) that Yalom has written The Gift of Therapy. 

Part of what immediately endeared Yalom to me is that he makes it plain that his enemies are also mine: he is explicitly "against sectarianism" and in favour of "therapeutic pluralism in which effective interventions are drawn from several different therapy approaches" (xv). Some of his friends are also mine, and so I happily note his positive references to such existentialists as Paul Tillich and others, including Nietzsche. 

Even more delightful was to encounter a name I have not seen, nor read, since high-school: Rainer Maria Rilke, whose Letters to a Young Poet I read at a crucial time and have stayed with me all these years later as an example of what Christopher Bollas (in his first and, to my mind, still his best book, The Shadow of the Object) would recognize as a largely unconscious "transformational object." Rilke shows up again at the end of ch.3, where Yalom quotes his wise counsel: "Have patience with everything unresolved and try to love the questions themselves" to which Yalom himself adds "try to love the questioners as well."

Yalom's The Gift of Therapy exhibits an openness to the questions and insights from giants of the near-past without idolizing them: names like Karen Horney (who graces the first page of ch.1), Winnicott, Ferenczi, Fromm, Erikson, and of course Freud are cited here with critical appreciation. Given its nature ("this volume is in no way meant to be a systematic manual") it does not of course lend itself to a standard review, so instead I shall simply mosey around the book highlighting things that stand out. (This will be an on-going series of posts.)

Chapter 3 opens with an observation Yalom draws from the French novelist André Malraux about one of his characters: "there is no such thing as a grown-up person." That immediately put me in mind of Adam Phillips, the other person I have spent the last four years reading very closely, and who will feature on this blog regularly. He says in one of his many books that "we remain children for a very long time." In this light I am also minded to think of an observation I heard (perhaps in the Ken Burns' PBS series The Roosevelts?) someone make about Teddy Roosevelt to the effect that "you have to understand the president is, at heart, just a six-year-old boy." It's a pity too many of us would regard that as a fault or failing!

In ch.4 and elsewhere, Yalom offers a simple question I have started using with people and that is to ask them some version of this: As you are driving home today/leaving from here, what are you telling yourself about this conversation? What are you taking away? This, as he says later, is a useful window to help him see that he and the patient do not always "have the same experience during the hour." 

Ch. 5 offers one pithy bit of advice: "Don't be stingy" in offering positive feedback to patients. Too many today, Yalom fears, may in fact be stingy, and I would wonder if some of this does not go back to Freud's rule of "abstinence" in that the therapist was to leave the patient as undisturbed as possible by refusing to offer advice or feedback. But as Paul Roazen has demonstrated, Freud talking to fellow therapists comes across as strict and forbidding, but Freud's own clinical practice was often much more relaxed about the rules he laid down (and sometimes, as the correspondence with Ferenczi makes clear, this was not always to the good!). 

Ch. 7 deftly deals with statements from patients such as "you must be bored of me by now" by turning them around: "Is there a question in there for me? "

Ch.8 (without quoting her) sounds very similar to advice the great Nina Coltart (about whom I have a post coming) offers in allowing patients to matter to therapists, and not to be afraid to acknowledge that. This must be nicely judged, however, so that things do not get too awry and patients matter too much or the counter-transference gets out of hand. But to be totally unmoved, sitting in lofty and aloof silence, will help nobody.

Several times throughout the book Yalom says that therapists should just acknowledge a cock-up and deal with it openly: "I'm sorry I made a mistake" will help things get back on track more swiftly and successfully than pretending nothing happened.

Several times he also uses words like "spontaneous," "dynamic," and "ever-evolving" to describe how therapy should proceed, and in this way pushes back against the increasing tendency towards manualized, standardized "therapy."

Yalom's Ch.12, with which I shall end for now, contains what I regard as the central and most important insight and counsel in the entire book, captured by its title: "Engage in personal therapy." I am frankly amazed that plenty of people can enter the therapeutic vocation (as Coltart rightly calls it) without having undergone, and regularly undergoing, their own therapy. As I have argued elsewhere recently, a personal psychoanalysis has been the most transformational experience of my life and I remain profoundly grateful.