How to Survive as a Therapist or Singing the Praises of Nina Coltart (I)
I went to my local bookstore and had them order me a copy at once. When it arrived I could scarcely know the delight that book would hold for me, or the change it would bring to my life. It was, in many ways, a decisive moment for me because her chapter on "analytic suitability" (combined with a discussion with a wonderful professor of mine in our Psychoanalysis and Literature class) convinced me to seek out psychoanalysis, which I began in 1994 with the late Dr. Louise Carignan.
Ever since, I have referred back to that book more often than I can count. Happily, the excellent Phoenix Publishing Company is bringing out new editions of all three of Coltart's books in October of this year. Investing in all three will be very much worth your while! (Incidentally, Phoenix has many other excellent books, old and new, on their lists, and they are definitely a website to keep a regular eye on.)
It was, however, only this year that I managed to read Coltart's other two books, which are both excellent, showing all the virtues that first endeared her to me: crisp and cogent prose; a no-nonsense approach to many things; a refusal of jargon and ideological defensiveness; and convincing arguments about the therapeutic enterprise as a vocation of love, about the role of faith in that enterprise, and about the ability to laugh with our patients sometimes. The first of her two remaining books I want to focus on here is How to Survive as a Psychotherapist (London: Sheldon Press, 1993), ix+120pp.
Coltart begins with a very brief introduction (less than a page) which functions as something of an apologia for her use of "survival" and cognates. As someone whose own life was massively traumatized during the Second World War (when her parents were killed in a train accident en route to visit Nina who was thought to be mortally ill at the time), and who is keenly aware of how the wartime generation spoke of survival--especially with reference to the experience of those managed to survive the Holocaust--she is aware that the word often seems to mean, at least in a British context, a kind of grim, mirthless carrying on. Instead, she wants to insist--without in the least being pollyannish about it--that the survival of a psychotherapist has to be shot through with enjoyment. That, in fact, is the title of her first chapter: Survival-With-Enjoyment.
Her first chapter shows a keen awareness of the challenges posed to therapists in training: they are usually often well into their 30s or 40s, holding down other employment, extremely pressed for time, and sometimes such people are indeed barely surviving but not thriving or enjoying themselves. She makes it clear (here returning to a theme I first saw in her Slouching Towards Bethlehem) the only way candidates and trainees under such strain can hope to have a worthwhile life is if they see that psychotherapy is not (or not just) a career, but very much a calling. To be a psychotherapist is very much to have, as she often says, a vocation. She is skeptical (as are others I have read) that a therapist can long survive if it is indeed little more than a career and not also, and perhaps primarily, calling.
Coltart, as she made clear in her first book, abandoned the Anglican Christianity of her youth for Buddhism later in life, so she is aware of the theological connotations around vocation, but steers clear of them. At the same time, in all her books she notes that Freud's assumption that all religious practice is ipso facto a sign of pathology is wrong, and in fact those analysts who might still hold to such a view Coltart regards as unjustifiably bigoted. We will return to this again later in the book when she rehabilitates another word--"faith."
Ch.2 is "Psychoanalysis vs. Psychotherapy?" I found it perhaps the most challenging and therefore worthwhile chapter in the book. Coltart was a physician who trained as a psychoanalyst, but had a mixed practice of both psychotherapy and psychoanalysis. At her height, she was one of the most respected consultants in London who did, she estimates, over 3000 consultations and referrals over a quarter-century and more. This gave her a very finely grained sense of who might benefit from which type of therapy and with which clinician. Most of the time her own practice was full so there was little self-interest in this, and in fact she says she felt she could give patients greater and more careful attention if she knew she was not assessing them to take them into her own practice.
She adheres here to a fairly standard if rather superficial differentiation between therapy and analysis, noting that the former usually only has patients coming 1-2 times a week (and sitting up) whereas the latter has normally been 4-5 sessions a week on the couch. (When I was in analysis in Canada I was told that nobody did 5 times a week anymore, so I went Monday to Thursday.) But Coltart notes that this differentiation tells us rather little, and in fact she notes she had one patient who came but once a week while insisting on using the couch; and another, a long-term analysand who came five times a week but insisted on sitting up.
I was a little surprised--but should not have been--by her declaration that "insofar as there are differences between 'doing psychoanalysis' and 'doing psychotherapy,' my first love has always been psychotherapy" (p.12). After a potted history of the first pioneers--Freud, Adler, Jung, Ferenczi, Rank et al--and their different methods to try to heal people, she notes that all analysis is therapeutic, but not all therapy is analytic. So what is the difference for her? Inter alia she says in therapy she can:
- be more direct in making interpretations
- be quite overt in listening for the gaps in what patients are saying and not saying
- be more spontaneous and freer in her emotions
- make use of both extra-transference and counter-transference materials
- be quite ready to laugh and joke with patients
Much of especially "classical" analysis (but who does that nowadays?) does not make huge, overt, obvious demands on the analyst. Coltart recognizes this later in the chapter when she says that those who straddle the two practices must be very clear that they are not using analytic technique to justify doing little to help a patient who "is genuinely in need of help, and it is up to us to exert ourselves and offer it. It is not appropriate, and it is not good therapy, to sit in lofty 'analytic' silence and watch the whole enterprise floundering, secure in our narcissistic self-satisfaction that we are doing" just whatever it is we think analytic training told us to do (p.21). From this, Coltart concludes that one needs to keep the differences clearly in mind because one's view of what one is doing profoundly influences how one does it.
Showing what she has picked up from Bion, Coltart advises that a therapist best serves patients by beginning each session with a tabula rasa, "turning a blank and receptive surface towards every patient in every session" (22). This "spacious stillness" together with a healthy reliance on one's intuition are some of the basic techniques she recommends.
I cheered her third chapter for one simple reason: she shares my intense dislike of the word 'client.' We both regard it as an ugly commercialization of the relationship which downplays the "dignity" of suffering found in one who bears such suffering patiently.
Her third chapter, Apparent Trivia, emphasizes the need for, inter alia, good furniture: do not stint on the couch, on the patient's chair, nor especially on the therapist's chair. (Coltart, late in life, had regular back pain most likely caused by decades of sitting listening to patients.)
Ch.4, Paradoxes, begins with a reassuring claim: "psychotherapists are trained from their weaknesses." She also gives advice I have heard from others, including Otto Kernberg: to pay careful attention to the counter-transference, not least because it gives insights into what is going on in the patient. This requires fine handling, because one has to be both emotionally tuned into the patient while also making careful, cool, clinical observations of the patient and of oneself. Attending to the counter-transference will help us discern bits of projection and projective identification from the patient.
I wonder if her next claim in this chapter is perhaps harder for Americans to understand and accept than it may be for others. Coltart here speaks of the need for the therapist to engage in the very hard task --"and yet perhaps the most vital"--of paring away any and all "ambition we may have that he get 'better.'" This has to be done away with, she continues, because our idea and the patient's idea of 'better' are probably very far removed from each other. Indeed, she recognizes--as everyone from Freud onward has--the patient may want for a very long time not to get better; he may have significant secondary reasons for remaining sick, even to the point of undermining the treatment. As Winnicott famously said, "health is ever so much more difficult to deal with than disease."
One of the difficulties of a 'disease model,' as Coltart and many others--including Adam Phillips--recognize is that the temptation is strong to slap a diagnostic label on something. But this, she warns, can have a "restricting power" whose effect is to "close the mind."
Chapters 5 and 6 are devoted to Assessment, in which, as noted above, Coltart has long experience. She notes that to do this well you need two full hours with a person, and then another hour to write up a report and make contact with those to whom one is making the referral. But sometimes, she says, these one-time appointments are all a small minority of people need--they have, she says, one bit of work that needs doing and if it gets done, both patient and therapist may in fact rightly conclude that no referral is needed and nothing further should be undertaken.
She further offers two very practical bits of advice in these chapters: first, get as much of the patient's history as you can because it will prove invaluable later. Second, do not, in regular sessions, take notes.
Her final chapter, Leisure and Living, in its last few pages, returns to the questions of vocation and faith first mentioned at the outset. She has treated these in her first book and does so here again but much more briefly, drawing in part on several of the works of Neville Symington.
She insists that 'faith' is not meant as a theological construct but rather describes an important quality a therapist must have precisely to achieve survival-with-enjoyment. The faith of the therapist is faith in the process (during which time one often has very little idea of where one is, or is going!), and in oneself. Both are necessary for both the therapist and for the patient to make progress. Doubt by the former in either the process or the self will inevitably be picked up by the patient, and Coltart regards this as damaging and unproductive to the outcome of the therapy.
There are other insights in this valuable and worthwhile little book, How to Survive as a Psychotherapist, and some often charming and amusing clinical vignettes and case-studies, making this short book very worth your while, and marking out Coltart as just the sort of therapist from whom one can learn a very great deal.
In a future entry, we will turn to the third of her three books, The Baby and the Bathwater before concluding with a discussion of the charming Festschrift that was issued after her death: Her Hour Come Round at Last: A Garland for Nina Coltart.
Continues.
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