Frieda Fromm-Reichmann's Life

I have been reading and re-reading Erich Fromm again for more than a year now, after having first read some of his works in the 1990s. Some of my notes from my ongoing reading of him may be found here. 

Quite all of a sudden last week I realized I knew nothing of his first wife, and so I ordered, and have happily begun, Gail Hornstein's biography, To Redeem One Person is to Redeem the World: the Life of Frieda Fromm-Reichmann.

Normally I would wait until I have finished a book to comment on it--and I shall be writing about this book upon its completion--but it is such a lovely and even thrilling book that I wanted to recommend it straightaway. Hornstein's elegant introduction alone is worthy of her subject, who rapidly emerges as a fascinating figure indeed. 

In particular, Fromm-Reichmann was able to restore to health several schizophrenics, whom orthodox Freudian analysis at the time thought untreatable, least of all by unmodified analytic technique. (Even today, alas, some people, far from Freud, nonetheless also think schizophrenics largely untreatable by any therapeutic technique except perhaps heavy use of psychotropics.) In this there are parallels between some of Fromm-Reichmann's unusual clinical successes and those of others I have read such as R.D. Laing and more recently Christopher Bollas, especially his When the Sun Bursts: the Enigma of Schizophrenia. Such stores always fascinate and inspire me, serving as a reminder not to assume in advance that anyone is beyond reach.  

Diana Fosha on the Transforming Power of Affect

David Arute contacted me on Facebook and initiated a lovely discussion about numerous things. He heads (with his wife) his own psychotherapy clinic outside of Chicago, where they are doing some very interesting work indeed. You can read all about that here. I mention this to give him credit for introducing me to Diana Fosha and her book The Transforming Power of Affect: A Model for Accelerated Change, published by Basic Books more than 20 years ago now. 

I confess that until this conversation I had never even heard of Fosha, but I am grateful to have had that ignorance now challenged, and to have been introduced to her book, which I have read with great interest. My interest grew even stronger upon reading of her background and some of her key theoretical influences. 

Fosha was born in Romania but trained in the US, including time learning with and from Habib Davanloo, whose books I have and have been meaning to read for coming on a year now, without finding the time. Davanloo was a pioneer in a intensive short-term dynamic psychotherapy, an approach that Patricia Coughlin (whose books I also have, but have not had time yet to read) has continued to make known. It is an approach that fascinates me, and once I get around to reading those books, will have plenty to say about it on here! 

As I noted not too long ago, the idea that analytic therapy has to take years is a relatively late development. The very first generation around Freud specialized in short courses of therapy, so the desire to return to those today is not entirely or even primarily born of the usual horrid capitalist demands for brevity and "efficiency." 

I must say this book hooked me with the first lines of an unlikely page: the acknowledgements, where Fosha begins by acknowledging her debts to the great D.W. Winnicott, whose thought I have been drawing on more and more for the past few years, most especially in my essay here on Hating the Church. (In the next breath she acknowledges Davanloo's influence.)

After these, she mentions David Malan, whom I have also marked to read, in my continuing exploration of short therapy; and then, inter alia, Paul Wachtel, whose Therapeutic Communication, Second Edition: Knowing What to Say When I actually have finished reading but not yet posted my thoughts about. 

So, to Fosha then. Having started to read Bowlby, Winnicott, and attachment and object relations theory more than twenty years ago now, I found that her first five chapters were well written if somewhat underwhelming--a refresher for me, but valuable introductory material for those without the theoretical background.  

There were two outstanding insights in this section.

First, I especially appreciated Fosha--after reviewing the literature on defense mechanisms (including Anna Freud's well-known treatment of them)--arguing that defenses should be understood not just as negative barriers (I build a wall to protect myself against anxiety or trauma), but as also leaving a positive residue, which goes some way to explaining their power and hold over us: the wall reduces my sense of anxiety and allows me to feel a bit better, a bit less anxious, perhaps even good about myself. Anything that plays such a pivotal and powerful dual role--protecting me and allowing me to feel if not good then at least less anxious--is very likely going to become deeply rooted in most of us. 

In that sense we must not condemn defenses even if we now see that they are maladaptive and unhelpful. Once more I'm put in mind here of Auden's poem "In Memory of Sigmund Freud," and these verses especially: 

but he would have us remember most of all 

to be enthusiastic over the night,

     not only for the sense of wonder

   it alone has to offer, but also

because it needs our love. With large sad eyes

its delectable creatures look up and beg

     us dumbly to ask them to follow:

   they are exiles who long for the future

that lives in our power, they too would rejoice

if allowed to serve enlightenment like him.

The second insight here is a familiar one to readers of Yalom: Fosha's very strong emphasis on the here-and-now of therapy, on the moment-by-moment affective experience going on in patient and therapist, and between them. This is well captured at the end of chapter six, when she says that "what we discover...is that when dynamically understood, the structure of the sweeping patterns of a lifetime resemble the moment-to-moment dynamic shifts of the current relationship with the therapist" (136). 

Earlier in chapter six, this has become the explicit focus as Fosha argues that the clinician needs to be closely attentive to those micro ruptures and alterations in affect that take place within the session moment by moment. She highlights some of the differences between resilience and resistance in dealing with psychic conflict and anxiety. 

Anxiety, in turn, is linked with affect and attachment, these latter two attempting abatement and regulation of the former. But we must not, Fosha seems to be saying, focus only on anxiety and defenses. There is also a "desire to grow, connect, and feel authentic" (109). The therapeutic task, of course, is to create the environment and conditions where this may happen more fully. 

In chapter seven, Fosha focuses on the patient's love and compassion, and what may have happened to those if they were thwarted, rejected, mocked, or insufficiently received by their intended objects. She notes--as I have seen Harold Searles and others do--that the patient does not just have a need to be healed, but also to able to offer healing to others, including the therapist: "when...empathy is directed toward the therapist, it is extremely important that she acknowledge it" (145), especially in those patients whose empathy more easily and generously extends to others than to themselves. 

A little later on (152-53) this discussion about empathy leads to an interesting analogy: is there such a thing as an unprovoked bear attack? You might think you did everything right to avoid provoking the bear, but it is the bear, not you, who decides whether he is feeling provoked or not! The same is true for the patient, who decides whether he finds you, as therapist, empathic and understanding, warm and accepting, or not. 

Chapter 8's reflections on meta-therapeutic processing includes this useful reminder given to public speakers: tell your audience what you are going to do, do it, and then tell them what you've done. In a similar way, the therapist facilitates the therapeutic environment, names the experience, and then with the patient explores his or her experience of the therapy. This experience of reflecting on one's own experience, Fosha says, is "strongly related to resilience and psychic health" (163), an insight she draws in part from the work of such as Peter Fonagy. Practiced long and well enough, these experiences can lead to a level of emotional mastery whose marks may often persist long after treatment has ended. 

In reflecting on and working through the suffering and losses of one's past, mourning arises and will be greatly aided, Fosha says, by the therapist making manifest and making use of "her own grief and sadness for what the patient has had to endure" (169). Later on she notes that therapy is off to a good start after the "sacred" first session if it is clearly established that "the patient feels safe and the therapist brave" (213) by being willing to become emotionally vulnerable with and for the patient. 

How Are We Doing? 

Much as Yalom suggests, Fosha also later notes that the very first session should not end without the patient "spending some time processing the patient's reaction to being and talking with the therapist" (238). As she elsewhere notes, this should be an entirely open conversation about good and bad: "We try to help the patient verbalize the experience of closeness and distance. Talking about what is happening--good and bad--intensifies the sense of closeness" (220). Here Fosha notes she explicitly departs from a more "traditional" analytic approach that eschews focus on positive transference in favour of the negative. Nothing should be off the table, allowing her to suggest these two questions are central:

• How do you feel here with me?
• What is your sense of me? (Or: how do you experience me?)

If the answers to those questions are genuinely positive, then here as elsewhere Fosha says the therapist must not, because of "ill-placed modesty" downplay the discussion of those positive interactions: rather the courage you need, mentioned above, must be brought to bear here for this discussion about positive feelings and interactions is just as therapeutically important, allowing both patient and therapist to ask themselves "could it be that I'm not bad?" (221).

On the Working Alliance:

Next drawing on research into the centrality of the working alliance as crucial to the success of therapy, Fosha notes that therapist's must regularly, consciously, and deliberately engage in "empathic prizing," showing the patient how much their experience is valued and validated (223), both the suffering but also their positive strengths and gifts. The therapist must offer encouragement to keep going, showing a hopeful way forward; and must also offer positive feedback and commendation for whatever progress or successes the patient enjoys, especially calling out and lauding any actions by the patient toward self-care and affirmation. 

Sometimes doing this is a both-and exercise, Fosha suggests: the praise may often be met by a defensive downplaying by the patient, and the therapist's empathy should call both dynamics out, validating the need for the defenses while also encouraging the further taking of risks in precisely this area. 

When it comes to the therapist's feedback and even more his or her self-disclosure, Fosha has an interesting take, noting that especially for those "patients [who] have rarely felt that they have an impact on the significant others of their early life," knowing they are having an impact on the therapist can be transformative (230). This is also true when it comes to acknowledging errors by and limitations of the therapist, and any vulnerabilities. Fosha uses a striking phrase here, noting how the therapist's "self-disclosure [can] counteract therapeutic omnipotence" (231) as well as strengthen the patient's belief that he or she has valuable contributions to make to the welfare of the other. For patients whose relational style is that of learned helplessness, rising to the challenge of helping another can be an important lesson to learn. For patients (and therapists, I might add!) whose relational style tends towards the very intellectual or even quasi-schizoid, asking these sorts of questions, and offering these sorts of reflections, can prove to be "the ultimate corrective emotional experience" (243). 

Working with Defenses:

Noting that explicit challenges to defenses are a hallmark of Davanloo's work and all who come after him in the short-term dynamic psychotherapies, Fosha differentiates between "soft" and "entrenched" defenses, noting that the latter require some form of "restructuring" (247). (In addition to challenging defenses, all these approaches also share another goal and technique: the learning to bear previously unbearable affect in the here-and-now of the working alliance.) Her approach here is refreshingly straightforward: "using empathy," simply begin by talking about the role of defenses with the patient, offering "nonjudgmental feedback to the patient of what it is like to be on the receiving end of his defenses," thereby allowing him or her to become aware of the impact those defenses have on others. 

After this an appreciative reframing of the defenses can take place. But before this, some patients can respond by trying to do too much too fast, overcoming defenses almost by sheer willpower in a given moment, which may lead to frustration. It is important for the therapist to call out this self-pressure and allow it to deflate. 

As work with defenses proceeds, other relational patterns may emerge to be worked on, reflecting patterns in the patient's wider life outside the consulting room. From here the work may proceed to a recasting of the narrative of the patient's life. Specifity and detail are often key here, Fosha says, not least in getting through intellectualization defenses: the more a patient can remember and describe about an experience the more he is likely to be close to what he felt about it, too. 

In Honour of D.W. Winnicott on the 50th Anniversary of His Death

Last week marked the 50th anniversary of the death of D.W. Winnicott. It seems with each passing year I find myself reading more of him, and benefiting in deeper ways from his many rich and often unusual insights. (I have an essay coming out this week that draws on him.) So I wanted to repost these reflections from last November so that we may continue to honour him in the best possible way: by reading him. 

Before you do that, you could do worse than to start here with this moving and fascinating reflection from his wife on how DWW understood death and wrote about the prospect of his own death. I have read it three times now and continue to learn different facets of him and of their marriage. His prayer "Oh God! May I be alive when I die" is one that repays careful reflection. (I will, in fact, have an essay about it coming out probably next month.) 

I recently noted an essay of D.W. Winnicott that I found very insightful. Now the BBC has published excerpts from various talks by, and about, Winnicott. It is a charming retrospective and will only take 10 minutes of your time. Have a listen here. 

I have not read all of Winnicott by any means, but my debts to him are noted in the above-linked piece and in other essays here (discussing his thrilling 1947 essay "Hate in the Counter-Transference") and here. 

For those who have the money and inclination, Oxford University Press recently published the entire opera omnia. 

For those who might find it useful, let me recommend a few individual books by and about him. There are many more, of course, but these are the ones I have read and in some cases re-read several times. 

For biographies, there are two I have read (and others I have not but hope to). The first is by Adam Phillips, titled simply Winnicott. It is one of Phillips' earliest publications, and is a relatively simple and straightforward book without some of the literary flourishes so common in his more recent books. 

The second is by Dodi Goldman, In Search of the Real: The Origins and Originality of D.W. Winnicott, published in 1989. It's somewhat more intellectually expansive than Phillips but generally complementary to his book. 

The Chicago Psychoanalytic Institute had a library sale a year or two back, and I was very glad to get my hands on Through Paediatrics to Psycho-Analysis: Collected Papers. That is a very rich collection despite the somewhat off-putting title. 

Next to this, his Playing and Reality is perhaps one of his most noteworthy books.

Winnicott's Home Is Where We Start From is somewhat mixed, but there are some good essays in there. 

Additionally, I'm only part-way through Psycho-Analytic Explorations, but it has many good essays in it, especially those on the uses of silence.

Though a bit dated now, Judith Hughes' Reshaping the Psychoanalytic Domain: The Work of Melanie Klein, W.R.D. Fairbairn, and D.W. Winnicott is useful for the wider context, and for showing the very important relationships between all three who, each in their own way and also together, form so much of the British object-relations tradition. I am always happy to see Fairbairn get some attention after his decades of more or less solitary Scottish labours in Edinburgh, far from the London scene where Winnicott and so many others made their name. Fairbairn's early essay on schizoid personalities remains one of the most illuminating things I have read on that score. 

Finally, I have started, but not yet finished, Stephen Parker's Winnicott and Religion. So far it's rather good, though not earth-shattering. Winnicott seems to have been comfortable, in that rather vague and pragmatic British way, being part of the Church of England though he was not especially demonstrative of it, least of all in his writings. 

On this score, one final book on my list to read: Ann Belford Ulanov Finding Space: Winnicott, God, and Psychic Reality. I confess to never having heard of Ulanov (a New York-based Jungian analyst and academic) until almost exactly a year ago when I interviewed Pia Sophia Chaudhari about her recent and fascinating book, Dynamis of Healing:  You may read that interview here.