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