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.