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,
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."
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.
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."
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.
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."
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.
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."
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.
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