Mary Jo Peebles on Psychotherapy and the Wisdom Found in its Impasses and Uncertainties

I previously wrote at length about the wisdom gained from reading Mary Jo Peebles' 2002 book Beginnings: The Art and Science of Planning Psychotherapy. 

Her name was recently brought back to mind by Jonathan Shedler on Twitter, from whom I continue to learn a great deal. He was favourably quoting from her new book, so that meant I had to get a copy and read it, which I did earlier this month. 

So let us turn our attention to her newest book, released late last year, When Psychotherapy Feels Stuck (Routledge, 2021), 164pp. I finished reading it last weekend and found it a profitable read, not so much for any new ground it breaks as for the many useful reminders it offers.

She starts off by very calmly advising that not knowing where to go next in treatment can be a very good thing: "I want you to be unafraid to not-know" (xiii). This, as I have written about often on here, is a familiar and welcome counsel, going back--for me--to at least the early 1990s when I read Nina Coltart's break-out book Slouching Towards Bethlehem, about which I wrote at length here. 

Towards the end of her preface, Peebles returns to this, writing winsomely that not knowing about your patient, or where to go with a patient, can in fact be a gift: 

feeling stuck and not-knowing...is a gift we are given to be able to learn something new. It is a sacred trust we hold when we invite our patient to share themselves with us. I want you to feel less of the fear and more of the wonder and sacred trust when you feel tense or confused. I want you to come to appreciate that if we listen, the knowing will come (xv).

She will return to these themes--of the sacred and of gift--in the concluding pages of the book, as we will presently discover. 

Her first chapter, "Change Takes Time," is one of those messages that needs to be heard more than ever today. The pressures from insurance companies and other agents of iniquity to shorten psychotherapy are notorious. Helpfully Peebles here launches straightaway into an analogy about learning a language and how much work and time that takes. In many ways, she shows, good psychotherapy is about learning how to talk (think, feel, etc.) about yourself in a different way so why should we expect that to be quick and easy? "Change that lasts is incremental," she reminds us (p.5), and such change is compared to compound interest: "our investment of time compounds over time" (p.9). (In this, she reminds me of a line from one of my favourite of Adam Phillips' books where he says of psychoanalysis that "the cure can begin only after the treatment has ended.")

"How We Say It Matters" is the second chapter and I confess I found it gratifying for such a seasoned clinician to be advocating a practice that I had just found myself falling into without having read about it before or seen it sanctioned elsewhere: "Perhaps you involuntarily wince when a patient excoriates himself. Let that show." This might be through body language or a simple "Ouch!" voiced aloud, shaking the patient's "obliviousness" (p.250). 

I can confirm that this is very effective if the timing and tone are right, though with some patients it needs to be done semi-regularly until their hitherto relentless super-ego attacks begin to lessen and they develop their strength and ability to stand "Against Self-Criticism."

Ch.3, "The Value of Awareness" contains a helpful list of questions, some of which I have used before--either in thinking of a case or in supervision, or both. All of these are very worthwhile and should be considered regularly to avoid epistemic closure and unjustified certainty. Peebles says (my paraphrase) we should be asking:

• Are there other ways for me to understand this?
• How would others of different theoretical persuasions see this?
• What am I missing or ignoring?
• Have I made assumptions about my patient instead of asking them questions?
• Am I discounting or dismissing something the patient said because of theoretical or clinical priors?
• Am I in danger of seeing the same symptoms and diagnosis in too many people? 

Ch.4, "Transforming the World Within," was perhaps the most challenging for me. Here she issues a number of welcome reminders, including this splendid aphorism: "the goal of psychotherapy...is to rattle our patient's certitude about his conclusions" (p.49). To do this, we must enter their world, and we must enter not just via their mind--their intellectual world--but above all their emotional world: "we must focus as therapists on our patient's sensations, not just on his ideas" (ibid). Peebles says that therapists who struggle to do this need to be in their own personal therapy. (I do, and am!)

Ch.5, "Learning to Not-Know," begins with an epigraph from W.R. Bion and his infamous "Notes on Memory and Desire," about which I essayed some thoughts here. Peebles quotes him thus: "'the only point of importance in any session is the unknown'." 

This is not easy to do! I find that to be especially difficult in working with psychotic disorders. The drives to know and control and fix--what Phillips talks about as our desires for omnipotence and omniscience--are strong! They are stronger still when under pressure from the parents of adolescent patients who, naturally enough, want a cure and want a guarantee that their children will never suffer another psychotic break ever again. 

Bion presents (so I thought until recently) especial difficulty with his insistence that the psychotherapist "must aim at a steady exclusion of memory and desire" and must also "aim at achieving a state of mind so that at every session he feels he has not seen the patient before." At first, I regarded these as counsels of perfection, absolutist and almost suspiciously totalizing in their demands and largely unachievable in most practices in this country today. But I must report that I have rethought my suspicion of him on this point recently, and was startled to realize in one case that Bion was right and I needed to do what he advised! Suddenly one day instead of thinking I was out in front waiting for a patient where we had ended the last session, I realized they had moved unexpectedly and thus surpassed me and I was playing catch-up: my memory of past sessions had deceived me, just as Bion predicted it would! 

To return to Peebles, she says there are two significant gifts which not knowing can offer: first, it can allow for creative thinking to emerge, for new ways of looking at and working on something. Second, "when therapists are able to tolerate uncertainty, the therapeutic alliance strengthens" (p.80). (This has been confirmed by my own recent experience with one patient in particular.)

A toleration of uncertainty, she continues later in the chapter, is connected to "being humble about the limits of our knowledge." We need to cultivate humility, but not of a masochistic kind: "humility is the child of self-assuredness" (p.81). In other words, as I have heard others put it, you can be certain of yourself as a person, but uncertain as a therapist as to what to do, and both are not just okay but exist in necessary relationship. 

A toleration of uncertainty goes well with a spirit and practice of playfulness in psychotherapy. This--though she does not cite him--is very much in keeping with Winnicott's ideas, as I noted here. 

Peebles ends this chapter with another timely reminder and reiteration of her central point: "the more comfortable we are with not having answers or next steps right away, the more opportunities we will afford our patients to resist concluding, endure not-knowing,...and master uneasiness" (p.91). This, in turn, will pay dividends in allowing patients to be freed from the often restricting, infantilizing, or even paralyzing certainties with which their lives have been ruled hitherto. 

Ch.6, "Relationship," focuses not just on the therapeutic alliance, but on negative emotions in that alliance. This was, for me, the most useful part of the chapter. She brings in some of the greats here--Winnicott, of course, on hate in the counter-transference; but also Searles on counter-transference; and others I was not familiar with but whose works I am now tracking down. She focuses not just on hate, but on what might perhaps be called lesser negative emotions, and how to deal with those. Her advice is masterful: "talk with our patient about the negative energy with the calm and respect that comes from knowing how to learn from negative process rather than be railroaded by it" (p.102). 

Timing, she says later in the chapter, is crucial here. Watch for, and even anticipate where possible, ruptures and outbursts of negative emotion, and handle them calmly and promptly. Left untended, they can damage the alliance and relationship. But handled quickly and well, the alliance can in fact be strengthened. 

Other useful and familiar reminders abound here: about the importance of good supervision; about self-care; about taking "cool soundings" (Coltart) from the counter-transference; and once again about the importance of the therapist having his or her own psychotherapy.

This chapter ends by compiling a list (quoting from this article) about the qualities of  master therapists properly so called, who are described as "'voracious learners, curious, reflective, and valued cognitive complexity and ambiguity; they were emotionally receptive, self-aware, non-defensive, and open to feedback'" (pp.112-13). 

The last chapter, Creating Meaning, takes us back to where we began: the costs and challenges of change, and the resistances to it which crop up. Noting that change brings loss and ambivalence, and takes time, Peebles concludes her worthwhile and helpful book with what I would call an existentialist turn, reminding us of past luminaries such as Viktor Frankl  and the present challenge of creating space where patients might explore questions such as the meaning of suffering, the questions about grief ("grieving is not giving up," she flatly asserts late in the book [p.132]) provoked by losses associated with change, and more broadly "spiritual" questions. 

In this final chapter, Peebles is also undertaking what I would call an implicit rebuke of instrumentalist or purely pragmatistic views of psychotherapy as means of overcoming "disease" or "disorder" in order to get back to being a quiet, compliantly cheerful employee and obedient citizen. Her view, rightly, is much more expansive than that, and reminds one of others, including Michael Eigen, not least in his book The Psychoanalytic Mystic.

Thus she says that "psychotherapy presents the opportunity for a mystical journey, however brief the encounter or modest the epiphanies" (p.124). On this felicitous note we take our leave of When Psychotherapy Feels Stuck, grateful for the wisdom of the author and her eminently useful book. 

A Note on Harold Searles on Counter-Transference

Having, as you will see here, paid my debts to Harold Searles for his fascinating and often useful work on schizophrenia (and before that his essay on "The Patient as Therapist to His Analyst"), I must now register a complaint that his book Countertransference and Related Subjects: Selected Papers (International Universities Press, 1979), ix+625pp. is misleading from the outset. That is, the book is badly named: only on p.373 do we get first discussion of counter-transference, and it is not developed in any useful detail but remains superficial. The rest of the book virtually ignores any serious discussion of countertransference and is instead an assorted collection of articles, most having to do with schizophrenia. It should therefore have appeared under the title Collected Papers on Schizophrenia Vol. II, as a complement to the other volume bearing that title. 

Having been an academic editor for twenty years now for presses and journals in two languages and three countries, I am perhaps more critical, and less forgiving, than some. I find it serves nobody well when publishers allow authors to throw everything into a book without any attempt even so much as to organize the chapters coherently. Those chapters then ramble on with excessive detail and clinical illustrations that run for so many pages as to lose their point very quickly. In short, this book should have been at least 25% shorter than it is. (The editor who gave me my first editorial job in 2002 said "We pay you for one thing only: to be ruthless!" There is always room to cut--sensibly and intelligently, without blindly hacking away--and myriad opportunities to put things more compactly and cogently.) 

That said, there are little nuggets here and there one must dig out, as here:

Finding Your Own Psychotic Elements:

I liked early on in the book when Searles noes that at the end of a successful treatment of schizophrenia or psychosis, the patient has achieved individuation and ego integration to whatever possible degree, but, Searles says, the psychotherapist has also gained something: he is much closer to, and on much easier terms with, his own psychotic elements, and, in future, will not have to travel so far or so hard to experience them in the next case that comes along. 

This is a point he reiterates at the very end of the book (pp. 596ff.) with brief reference to Harry Stack Sullivan, noting that if the psychotherapist has reflected philosophically on the fact that the differences between 'sanity' and 'insanity' are not so great he will, in Sullivan's famous words, be able comfortably to see and accept that "we are all much more simply human than otherwise" and thus the psychotic person is not some strange 'other' we must race to rescue and 'fix.' 

What Might Psychosis Have to Teach Us?

It still seems sadly common to deride psychotic disorders as a descent into utterly meaningless gibberish and irrational gestures ('word salad' etc.) but I simply cannot believe that to be the case all the time. And so with Searles, in this book as in his other one, I think he is onto something significant when he claims that "Schizophrenia is, in a sense, the shadow cast by the emotional deficiencies of our culture" (26). 

Even more strongly, Searles speaks of his schizophrenic patient thus: "because he, perforce--not by choice--has been living on the sidelines of humanity he is in a position to tell us some important things which we have been too immersed in 'normal' living to see" (p.26). This accords very much with what patients have felt and described to me, too--like they are coming back to report on things nobody wants to hear but which they regard (and I agree) as being vitally important to think about by way of acknowledging the suffering and isolation at the heart of the human condition, and the oft-unfulfilled longing for communion and connection. 

The Rewards: 

I was heartened to read that Searles reports feeling "unclean" with guilt, and "perverse" in his fascination with his patient's delusions and hallucinations--until he allowed himself to see them as high art, as products of a highly creative mind. I was also impressed (albeit uneasily) the first time delusions and hallucinations were described to me in very careful and exacting detail, feeling like I was watching a painter very deliberately decide on which brush, colour, and location on the canvas for each stroke and detail.

Having overcome his guilt, in the end Searles sees "one of the endlessly rewarding, exciting aspects of this work" to be found precisely in the unpredictability and singularity of each individual. I fully agree! 

A Caution Against Cures:

Searles, however, is at pains in his lengthy chapter on "The Dedicated Physician" not to go about putting pressure on patients to achieve the sense of satisfaction the psychotherapist needs in watching patients get better. As he elsewhere noted, and others have as well, pressure to be 'cured' can in fact be highly suspect and unhelpful--and may arise from omnipotent and sometimes sadistic elements in the psychotherapist's mind. Searles notes how often the overly zealous and over-eager therapist infantilizes the patient by his insistence on a cure, by his omnipotent desire to help which robs the patient of his autonomy. Sometimes you do this to avoid having a competitor or even superior in the patient, whose health or strength is suddenly greater than yours. 

Regardless of your motive, he says you must not imprison the patient with your desire to see him cured. In this he joins with Nina Coltart, Adam Phillips, and others in swearing off the idea of 'cure,' and I am glad to learn from them on this score, as I also have from Searles, albeit not as much as one might expect in a book of 625 pages!