On the 25th Anniversary of Her Death: Nina Coltart on Vocation and Faith in Psychotherapy

For reasons I will not bore you with, my mind has long had an acute awareness of anniversaries and dates of various sorts. So it dawned on me a week or so ago that next month will mark the 25th anniversary of the death of Nina Coltart, perhaps the one psychoanalyst whose influence on me continues to grow even today--if that is a possible and defensible claim of a woman I never met. I wrote here a bit about how her influence began with me thirty years ago (!!) now, and has returned in very helpful ways as I've gotten back into clinical work after a long academic "detour" as it were.

In being aware of the anniversary of her death, and of all that I feel I still owe her, I began to wonder about writing something to commemorate her death in 1997 on June 24th (death of John the Baptist, which somehow seems significant though not in ways I can defend). But where to publish such a piece, and who would be interested, especially an essay written by a nobody and devoted to someone who only became somewhat well-known in the last five years of her life and has now been gone a quarter-century?

But then all of a sudden this week the psychotherapist and philosopher Kristian Kemtrup on Twitter, who authors some of the most insightful questions and richly reflective discussions on a medium often famed for doing anything but, asked the following:

I’m curious what people think: What are the causes of some therapists finding the job to be unbearable? What causes them to burnout and quit.

How do some therapists avoid this? How do we advise others to help them avoid it?

My instincts in answering that question, as I said on Twitter, went immediately to Coltart, and so I thought I'd post some longer reflections in answer to these questions and by way of reflecting with real gratitude for her life and work. 

If I return to her very often, it is because, I now realize, of three things at least: first, she led me (via her first book Slouching Towards Bethlehem) to take the plunge into a four-times-a-week psychoanalysis on the couch for nearly seven years with the late Dr Louise Carignan. That would change my life in countless ways from which I continue to benefit (as Adam Phillips says, "the cure can begin only after the treatment has ended"). 

Second, Coltart, in the last interview she gave about six months before her death, noted that she was the most independent minded member of the Independent Group within the British Psychoanalytical Society, and she encouraged others to be very true to themselves and very independently minded as well. I have never been a joiner, and long resisted being put into, and putting others into, boxes and categories, so this (somewhat schizoid?) spirit of hers appeals very strongly to mine. 

Third, Coltart has a very practical focus that I find eminently useful on a near-daily basis, and so let me elaborate here four concrete ways I've found, and find, her coming to mind at opportune moments in clinical work with a view to answering Kristian's questions above: survival-with-enjoyment; faith; a strong life outside the consulting room; and vocation. Let me reflect briefly on each. (I will elaborate in much more detail on all four in a book I'm working on.)

Survival-With-Enjoyment:

This is a theme she writes about crisply in her second book, How to Survive as a Psychotherapist. Here she stoutly insists that the notion of 'survival' often seems to mean, at least in a British context, a kind of grim, mirthless carrying on, as in Surviving the Blitz. 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. She doesn't cite Winnicott here as I expected, but this, of course, is very similar to his claim that one must be able, as both psychotherapist and patient, to play and enjoy each other; I wrote a bit about that here. 

I wonder if those who find the therapeutic job unbearable or who appear to burn out (I've seen three therapists, all much younger than I, leave the field in the last month alone after less than a decade) from it ever thought that they could, and should, enjoy it. Or was that an impermissible thought? Were there (as Coltart would phrase it) some super-ego elements of guilt or masochism contaminating their ability to enjoy the work? This is entirely speculative and I offer no judgment here at all, not having any intimate knowledge of the people who leave the field. 

But as a full-time academic in psychology who is aware of the (deplorable and often unbelievably vacuous) state of training in undergraduate and graduate programs, I think I am on surer ground in saying that the idea of survival with enjoyment is almost certainly rarely if ever even thought, let along vigorously discussed openly and appreciatively. Students are admitted by universities interested only in keeping students in seats with vague promises of an 'interesting career' in the 'helping professions.' Little is said beyond that, I wager. Certainly notions of 'enjoyment' would be beyond the pale of many who might regard such discussions as impermissible or purely private concerns. 

Faith:

To hope that you not just survive, but also enjoy the work, takes me to the second notion that Coltart unapologetically proffers: faith. This, of course, is an even more 'impermissible' thought in virtually all clinical training programs except, perhaps, those in Christian academic contexts (where the uses and abuses of 'faith' are legion). 

Coltart notes in several places that she was an Anglican (as I was also when I first read her, which perhaps adds an additional reason to the affinity I felt with her) for part of her life before coming out of that to embrace Buddhism. But in any event she would defend the notion of faith, in a non-theological sense, for the rest of her life. For her that is defined as "faith in ourselves and in this strange process which we daily create with our patients." Such faith constitutes, with love, the only "trustworthy container" for the "hatred, rage, and contempt for varying periods of time" that patients might bring (or we in turn might feel). This idea of faith is one where she explicitly cites the influence of Bion, especially his book Attention and Interpretation.

There will be dark and difficult days, setbacks and anger and aggression and hatred in the transference and counter-transference. There will be patients you cannot reach, patients whose progress seems minimal at best. All the while the demands for treatment are relentless across this country and almost everywhere else, and they are only going up. In such a context, all this can be greatly discouraging to those who do not have deep training, their own personal psychotherapy, good supervision, and faith that you can and will make a difference and people can and will get better. Absent these four factors (at least), I can see how people might easily burn out and leave. 

An Extra-Therapeutic Life:

Faith without works--to cite a tedious Reformation debate--is not entirely useless, but it doesn't get you very far in psychotherapy. You need some concrete work and works outside of your consulting room to go along with faith so that both might help you to survive and enjoy the work.

In her last interview, published in the charming collection Freely Associated: Encounters in Psychoanalysis with Christopher Bollas, Joyce McDougall, Michael Eigen, Adam Phillips and Nina Coltart that Anthony Molino put together, Coltart spends some time justifying her decision to not just retire in 1994 but to resign her membership in the British Psychoanalytical Society, which astonished a lot of people and caused some of them to wonder if she wasn't becoming depressed or demented or something. She says quite simply that her life as a psychoanalyst was over, and she had no need of the Society any more, and thus no need for any badges of identity such as membership conveyed. 

Vigorously in retirement, but also in her life decades before that, Coltart enjoyed travel, extensive reading (of anything and everything outside psychoanalysis, she says, which seems key!), gardening, keeping up with friends, and other things. She had a very clear sense of her own life and pursued it with zest outside her consulting room, and bluntly encouraged other therapists to do the same thing as when, e.g., she writes: 

take it seriously when I say that you need to attend with real care to rest, relaxation, and refreshment, wherever you personally find it. Don't let your devotion to the job become too contaminated by superego elements and certainly don't let guilt percolate into any of your forms of relaxation and rest.

If you do these things, she concludes this passage in The Baby and the Bathwater, you will help preserve your ability to see and feel that "we have the most interesting job in the world." 

Certainly for me--whatever that's worth--I have longstanding academic and other interests outside of psychotherapy, and these are not only valuable in themselves, but they are crucial adjuncts in sustaining my faith, my ability to enjoy the work, and my sense of vocation. They 'inoculate' me against some of the vicarious traumatization characteristic of our work, and allow me to return to it refreshed each week. 

Doing clinical work no more than 20 hours a week at most also helps enormously to keep time open for other interests as well as teaching. People who do not have this luxury--as I honestly recognize it to be--who must work 40 or more hours just to try to survive (since the pay in most places, outside perhaps of private practice, is so abysmal) could easily find it harder to stay in this vocation long-term and could burn out sooner.

Vocation: Apart from the above passage, Coltart seldom uses the word 'job,' however. Instead she makes a case in this last book of hers for seeing psychotherapy as a vocation, another traditionally theological term that she removes from that context for her own use, saying that vocation has five features:

• giftedness
• belief in the power of the unconscious
• strength of purpose
• reparativeness
• curiosity

I am not at all sure that many training programs today talk about any of these above, let alone see them as worthy goals. My experience in higher education in Canada, Ukraine, and the US has all been within Catholic institutions, so the idea of 'vocation' comes more naturally and easily on such campuses--but beyond them? I'm not so sure.

Nevertheless, for me the idea of vocation--to both teaching and psychotherapy alike--has been absolutely sustaining through brutal cut-backs, devastating loss of morale in the last few years, very poor pay, endless bureaucratic encroachments, pestilential administrators and insurance companies, and other issues. I have looked many times at other 'careers' with much greater pay (Walmart is now paying its truck drivers a starting salary of $110,000 per annum!), but because I enjoy both of my vocations greatly and have faith in the process of teaching and therapy alike, I remain. But if I did not have this sense of vocation, I would have bailed a long time ago and I do not in any way for even a moment blame those who do bail out. 

All these put together--a sense of faith in oneself and the process, a sense of vocation, a sense of enjoyment, and an unapologetic life outside the consulting room--function, for me if for nobody else, as very strong supports to keep doing this difficult and unpredictable work with delight and curiosity and love. (Questions for another time: can these things be made requirements of admission into training programs? Can training programs themselves be restructured to focus on or even inculcate these where lacking?)

Outing Myself as Schizoid:

But there is--again for me if not for others--one other factor here I cannot fail to mention. Let me conclude here with an additional response to Kristian's questions drawn not from Coltart but from someone else I've learned a great deal from and read with real profit and gratitude: Nancy McWilliams (on whom I last wrote at length here). (I like to think she and Coltart would probably have found each other quite compatible in many ways.) McWilliams' paper on schizoid dynamics is, quite simply, the best thing I've read in the literature going all the way back to Fairbairn. It shows what is best and useful and creative about these personality traits and dynamics, and does so in a way that explicitly rejects the pathologizing approach of the DSM. 

In answer to how some therapists avoid being burnt out or driven from the profession, I would, in all honesty, have to say for myself alone that having fairly pronounced schizoid tendencies in the way that McWilliams so brilliantly captures has, in addition to all the foregoing (faith, vocation, etc.), been an unintended gift. When she writes that "psychoanalysis is a profession by schizoids for schizoids," I stood and cheered. And when she further notes that some research out of Australia on the personality dynamics of therapists has revealed that "although the modal personality type among female therapists is depressive, among male therapists, schizoid trends predominate," I again felt gratified and, perhaps ironically, less alone. 

She continues that schizoid types are ideally suited for practicing psychotherapy because they "are not surprised or put off by evidence of the unconscious.  That is, they have intimate--and at times uneasy--familiarity with processes that in most people are out of awareness, an access that makes psychoanalytic ideas more accessible and commonsensical to them than."

Using perhaps more familiar and less freighted terminology, McWilliams continues:

Schizoid people are temperamentally introspective; they like to wander among the nooks and crannies of their mind, and they find in psychoanalysis many evocative metaphors for what they find there.  In addition, the professional practice of analysis and the psychoanalytic therapies offers an attractive resolution of the central conflict about closeness and distance that pervades schizoid psychology.

I could quote acres of her paper but will not. Go and read it--it's very rich and repays regular re-readings--and her equally excellent books. 

I hope her thoughts, and those of Coltart, along with my own, might be of some use in continuing to reflect upon those excellent questions Dr Kemtrup posed this week. Certainly these thoughts of mine do not pretend to any great wisdom, nor to being any sort of panacea, but perhaps they might at the very least function as a worthy commemoration of and tribute to a psychotherapist and psychoanalyst from whom I have received much. May Nina Coltart's memory continue to be a blessing.

Karen Maroda on Theory, Challenge, and the Therapist's Needs

The Analyst's Vulnerability: Impact on Theory and Practice by Karen J. Maroda (Routledge, 2022, x+215pp.) is such a disarming book. I think that is the most apt word for it.

It advances some potentially challenging if not controversial theses but does so in a cogent, humble way free of fulgurating fireworks and polemics. Indeed I rather think that Maroda, aware of the defensiveness likely to be aroused by some things she advocates, has deliberately written them in as low-key a way as possible. The effect, for me at least, was to make her book more powerful than I was expecting. Indeed, I feel that in at least two important areas it has forced me to rethink some basic assumptions and feel my way towards some changes in my clinical practice. 

I previously wrote about one of her other books, Psychodynamic Techniques, which contains similarly sensible material serenely expressed in useful ways. (I have also read her first book The Power of Countertransference, which was decent but I did not find it as useful as works on that topic by Kernberg, Searles, Bion, and Coltart, all of them discussed elsewhere on here.) 

The Analyst's Vulnerability is, notwithstanding the title, a book that admits of wide utility to all manner of psychotherapist and counselor for the issues discussed in it are largely universal in many respects. Her opening claim at the start of the first chapter makes that plain when she says that anyone who has chosen to become a therapist "is keenly aware that there is something deep and primitive about the decision that eludes understanding" (p.5). I was aware that there were some primitive forces afoot in my move back into clinical work after a long detour but it has taken me quite some time to catch glimpses of what they could be. Following Freud I have no problem admitting that motives for most things are a mixture of the noble and the more primitive and self-seeking, as mine certainly are. 

Ambivalence about Motives and Fit:

Maroda also immediately goes on here to acknowledge this, as she will throughout the book, saying that we have "positive and obvious reasons for our choice" to become clinicians, but that there are also "deeper needs being met by doing therapy" (p.6). These needs, as she will elaborate later on, often include the need for gratification which, she quite straightforwardly says here and will develop later, we must stop pathologizing and being so highly suspect of: "The topic of the analyst's gratification should not be one of guilt and shame" (p.14). 

A little later in the first chapter she notes how most therapists report being the caregivers and peacemakers in their families, and this has stamped us inexorably for good and ill. We cannot shy away from that: "accepting our inevitable ambivalence toward both the work itself...and often toward our patients as individuals could provide the necessary momentum to advance both our theoretical formulations and our clinical interventions" (p.10).    

Weaving relevant clinical and autobiographical material into each chapter, Maroda here introduces some lessons learned from supervising other therapists, saying that in problematic cases, "I almost always see indications of their [other therapists'] reluctance to be assertive" (p.11). This likely comes, as she just noted, from the primal familial role of being peacemakers and caregivers

On that topic of ambivalence, Maroda notes here--as she did in her earlier book that I discussed--it is alright to feel some of that in taking on a new patient, but you must never martyr yourself to a bad fit or a patient you have absolutely no interest in. Repeatedly she says that therapists "shouldn't treat anyone that they are not interested in" (p.16). There has to be something, however small, that sparks some curiosity and compassion in you. If there isn't, if the patient simply bores you or you feel strongly that they are not a good fit, you ill serve both them and yourself if you do not refer elsewhere. 

This is such eminently sensible and obviously good advice that I am amazed at people who do not follow it and act surprised when I bring it up. Lest we miss the point, she again makes it directly later in the chapter: "the best therapist for someone is the therapist who can most freely experience the patient's reality, as well as their own" (p.22). 

Getting Ready to Rumble!

By the midpoint of the first chapter, Maroda is seeding some of the challenges she will advance throughout the book. These include, I will admit straightaway, some ideas and authors beloved to me. She tackles some ideas that I have myself resonated with strongly, but her challenges are welcome and make a great deal of sense. 

On Not Knowing:

The first example is her going after what she sees as an overpopular emphasis in analytic circles on "not knowing." While there is wisdom in admitting this, she says in her experience it "discourages analysts from claiming any real knowledge of skill" (p.18). The flip side of this is that "'knowing' has become a synonym for arrogance and reductionism" (p.19). I'm not entirely convinced of this second claim and have not seen it advanced in such stark terms, but then I do not have the decades of experience Maroda has nor have I moved in the circles she has. 

On Anger and Hostility:

Maroda expresses her debts to Harold Searles several times in this book. I have also written about him on here and benefited from reading him. For Maroda perhaps the most important thing he did was to be, and write about how he was, "free to understand and use his negative feelings toward his patients rather than bury them" (p.23). This is a theme she will develop at length in several subsequent chapters, as we will presently see.

On Not Holding and Containing Too Much or Too Long:

Late in the book Maroda tosses off a memorable line: "we need a statute of limitations on this holding and nurturing behavior" (p.197) among psychotherapists who do not sufficiently challenge their patients nor engage in healthful, careful conflict with them en route to their actually changing, getting better, and eventually going away. In this, she reminds me of nobody so much as Jonathan Shedler, who regularly makes this point on Twitter and from whom I have learned much.

Managing the Therapist's Needs:

As she moves into the second chapter, she returns to the discussion, telegraphed above, about the need for gratification and the importance of not submitting to self-induced suffering. Here she asks two straightforward questions: "how are we to discern when our needs are being met in the interests of the patient or at his or her expense? And when does health self-sacrifice devolve into masochistic submission?" (p.34). In this context she mentions a justly celebrated paper by Emmanuel Ghent on masochism and the need for "distinguishing between emotional surrender and masochistic submission" (p.39).

She forces us to consider these questions together, saying that doing so may yield new insights: "the greatest obstacle to integrating these two ways of being is the erroneous assumption that ongoing personal gratification of the analyst's needs is automatically at odds with doing right by the patient." 

Maroda uses an interesting phrase from Shulman: "Unavoidable satisfactions." We may feel guilty about it, or sheepish, or disdain its discussion as "unprofessional," but the fact is that we as psychotherapists do find the work gratifying and satisfying and should simply be honest about it. (In that spirit, I will note that my gratification is greatest, most of the time, with the most difficult cases--psychosis, schizophrenia, and borderline personality disorder.) 

In reading this declamation of hers, I was immediately put in mind of a book by the great Anglo-Welsh psychoanalyst Adam Phillips: Unforbidden Pleasures. (I have rather regularly and gratuitously with students, and very infrequently and diffidently with two patients--who asked me specifically--recommended this book and everyone has found it very edifying and helpful.)

Later in the book Maroda mentions "the notion that the patient helps the analyst to change" (51) but does not especially elaborate on this. It made me, of course, think of a paper I have often returned to in understanding one particular memory of my first psychoanalysis: Harold Searles, "The Patient as Therapist to His Analyst."  I think this topic would lend itself to a great deal more writing if we as clinicians were willing to be honest about how much our patients have taught us and helped us. 

Narcissistic Needs and Wounds:

In the next chapter, Maroda makes one suggestion I heartily agree with, and one question I am distinctly ambivalent about. The former is on p.76 when she writes that "for all our conversations about self-care I think more emphasis early in training on constructive gratification of our narcissistic needs would be more specific and germane to the question of how much we need our patients." That, too, is a topic inviting much more reflection by others responding to Maroda.

Her question: "if we cannot be wounded by our patients, how involved are we?" (p.83). I think this is a question that requires very careful handling to avoid some of the masochistic guilt and enactments she later speaks of in the book. 

Conflict and Negative Countertransference:

This is the most challenging and welcome material in the entire book.

She begins with a very important question: "Do we overidentify with our suffering patients, wanting more to soothe and comfort them rather than confront them" (p.97). Shortly after this, she moves into a discussion about Winnicott's famous 1947 paper on "Hate in the Counter-Transference," noting that his treatment of hate is too antiseptic (my word, not hers) and perhaps, she hints broadly, unrealistic. Winnicott portrays his hatred as being safely locked away and not at all disruptive. Maroda rather strongly suggests this is not realistic for lesser mortals. 

Later in the chapter she suggests that we cannot predict when hatred and anger and conflict will erupt in a patient, stimulating such feelings in our counter-transference without advance warning. She says we need to be open to recognizing how these feelings are awakened, and to do so with "greater self-acceptance and minimizing guilt and shame" (p.100). But to recognize and work with those feelings in the consulting room requires, she says, some skills that need to be learned. 

Prior to that, however, we must accept that "the only solution...is for therapists to actually embrace their rage and desire to retaliate against the patient" (101). If I may permitted to intrude a personal word here, I would say that I have been able to learn (not completely, not easily, and not perfectly!) how to do this largely because of a wonderful supervisor. I was open with him about my anger and disgust towards a very reactionary religious patient who would rant with anger and hatred about their gay son who is--it was claimed--going to hell according to their reading of Catholic theology, which has also been used to justify shunning him from family life. Being open about my countertransference response from the outset with my supervisor, and processing it with him, allowed me enough emotional space and relative freedom to work with this patient. 

Psychotherapists who are open about our own negative reactions, Maroda continues, citing several studies, consistently "had more successful outcomes than therapists who were not" aware of their negative emotions (p.111). 

Maroda says that we need, as psychotherapists, to learn how to engage in "constructive conflict" with our patients (p.106) and what she later calls "creative rage" (113). We have seen, she says, more than 30 years of talk about countertransference but little actual concrete reflection on what it means to deal with, and productively use, our rage and hostility. As she will caution in a later chapter on enactments, "there is no simple answer to this question" of "how do we harness negative countertransference emotions in the interests of furthering the treatment?" (p.129). 

Before we can harness such emotions, she says late in the book, we must stop pretending we are above them, and stop "denying our capacity for aggression" (p.161). Once such denial has ceased, we may be in a position to find some "willingness to express negative feelings to our patients" on the understanding that doing so "provides essential feedback and relief for them" (p.202). 

Conflict Among Psychotherapists:

In the final pages of the book, Maroda not only advocates that we get more comfortably familiar with conflict in our consulting rooms, but also in our conferences and publications. For too long, she implies, we have avoided conflict in order to leave certain psychoanalytic orthodoxies in place, or at least beyond real scrutiny and necessary criticism and possible development and emendation. I am entirely in accord with this view, which has long been maintained by others, including perhaps preeminently Adam Phillips in, e.g., The Cure for Psychoanalysis. 

Stated otherwise, it has long seemed obvious to me that the last people on the planet who would be guilty of building heavily defended ideological enclaves and avoiding conflict would be psychoanalysts, but ironically as we all know--thanks to the work of Phillips, but before him of others, including Paul Roazen--that has not been the case. So much time and energy has been sadly wasted defending Kleinian and Jungian, Freudian and Lacanian enclaves, inter alia. How very silly and unproductive that has been. 

In conclusion, I think we owe Maroda one or several responses to the challenges she has outlined in this excellent book. She has raised compelling and substantial points that I, for one, find necessary and sufficiently deep challenges to my own clinical practice. Her gracious, cogent, restrained, no-nonsense writing style has aided her greatly in this regard, and I hope going forward we can indeed begin to talk more about our gratification, our needs, and our attempts constructively to challenge and to harness our own aggression and anger in the service of our patients and in the building up of psychoanalytic theory and practice that we all love.