What is "Psychological Mindedness"?

The timing is always curious: in both my Introduction to Psychotherapy/Counseling course this week, and also on Twitter at the same time, questions were raised about how you might assess someone's suitability for psychotherapy, especially psychodynamic treatment. I told my students last night of one disastrous situation in which I ignored my own doubts about a particular patient and took this person into treatment anyway even though during the intake and first several sessions I could detect no serious "psychological mindedness." I had--I now realized--foolishly told myself that it was probably just very hidden and there was a chance it could emerge or even develop. It didn't and I discharged the patient with what I regard as very little change, alas. 

But what, my students rightly persisted, does "psychological mindedness" actually mean and look like in concrete ways? We were very nearly at the end of our time, so I gave them a quick three-sentence summary last night with a promise of more practical details next week. Here are those details, drawn, as so often happens with me, from the incomparable Nina Coltart's second chapter of Slouching Towards Bethlehem: and Further Psychoanalytical Explorations. "Psychological mindedness" is, in fact, her phrase in that chapter. (It was, in fact, this chapter that convinced me, in the fall of 1994, that I had the requisite ability to undertake psychoanalysis myself, and so when I say she changed my life, it is this that I mean more than anything.) 

Coltart gives some preliminary considerations before launching into a list of 9 things to watch for. These "preliminaries" include, during an intake, watching out for "intelligence, moral character, and money." Here is where she is at her most practical and also Freudian, noting how the great master said you cannot work with people who have no capacity for insight or understanding, who lead morally repellent or even criminal lives, and who are too poor to pay your fee. 

Beyond these things, she says to watch out for the following, which I have summarized under my own headings and with some detail or elaboration as appropriate. 

1) Emotional Distance on the Self: This she says is also known as the "autonomous ego" or the "observing ego." The would-be patient must have some capacity to take even a modest distance on his/her struggles to be able to talk about them. Obviously, she stresses, this must be "nicely judged" as you do not want a patient who is prone to "severe denial, splitting, or repression."

2) Elaboration and Extension: If, she says, you allow pauses, gaps, and silence in the intake (which I always do: a preliminary sense of how a patient can handle silence is invaluable to me), can the patient go beyond the mere narration of facts into a deeper elaboration of various emotional dynamics? Even a few minutes into an intake, if you are listening with the "bare attention" she elsewhere discusses in the book, may for the first time prompt the patient to take the risk of elaboration. If this is totally absent, she says, it may indicate "severe inhibitions" that prevent, in whole or in part, free association from happening.

3) Affectively Charged Memories: Can the would-be patient bring forth different memories with different affects that are more or less appropriate? A lot of memories without affect are suspect, as is a total lack of the same. 

4) Relationship between Past and Present: Can the patient see any connections, however tentative, between past experiences and present difficulties? Can they see, as Bollas might put it, how the shadow of the objects of one's past, including past relationships, falls on present ones? (As a former supervisor of mine once succinctly put it: is this person a reliable historian?)

5) Internal and External Worlds and their Conflicts: Does your would-be patient have an ability to see connections between their internalized objects and outer relationships and conflicts? Do they see conflicts in their mind? And do they have a capacity to tolerate difference from and conflict between inner objects and the therapeutic relationship and working alliance? (In other, more classical, terms, can they develop a transference neurosis?)

6) Curiosity and Playfulness: Coltart says the would-be patient must show even a scintilla of curiosity about their inner world and its intra-psychic conflicts (and those with external parties) and a capacity to play with those in a "lively" way. Do they show signs of being glad to obtain greater insight? Are they curious about how their mind works, and how it plays a part in current problems? Absent this, Coltart warns, you should not proceed with a recommendation for psychodynamic therapy, which has "nothing to offer a patient who only wishes to be relieved of his suffering." Instead, the would-be patient must show "some real pleasure in finding out some tiny thing about himself." This, she says, "is one of the best criteria for the analytical approach." This curiosity will be an invaluable adjunct to and support of the working alliance when things turn difficult and the transference is at its trickiest. 

7) Imagination and Fantasy: Can they even mention a fantasy, detailed or not? Or, better, still, a dream, which Coltart says you should jump on immediately to see what they can do with it. This indicates great promise for psychological mindedness during treatment. 

8) Self-Deception: Do they consent to recognize that we may in fact be divided, opposed to ourselves, and deceiving ourselves? Are they aware that they may not in fact have a complete or completely accurate sense of their own mind and desires, but are willing to work to increase such? 

9) Success or Achievement in Some Area: She reiterates the "truism" that if the would-be patient has not succeeded in some area--work, school, relationships--then they will not succeed at psychodynamic therapy. 

8 Theses from Thomas Ogden on Reverie

I have, once more, my friends on Twitter to thank for introducing me to the psychiatrist and psychoanalyst Thomas Ogden, about whom I have recently written here and here. Once I understood his style, and how to respond and work with it, I have found him an enchanting writer. So I decided to keep working my way through his books as time and energy allowed.

The past few days, before being thrown into the whirligig of a new semester, which begins tomorrow, I sat down and read through one of his first books, Reverie and Interpretation: Sensing Something Human (Jason Aronson/Rowman and Littlefield, 1997). Among its several virtues is one I was especially delighted to see: how many times Ogden quotes Nina Coltart, whose work was then brand new but never, then or since, widely known (alas). 

It is in some ways perhaps incommensurate with how Ogden writes and thinks that I have chosen to extract from this book eight "theses," if you will. Perhaps "aphorisms" is a better way to think of these ideas, which are embedded in a book with great masses of clinical material from his patients. I have summed them up in my own words and added a bit of reflection as appropriate.

First, there is no such thing as a mind. This, of course, is Ogden's riff on Winnicott's famous declaration that "there's no such thing as a baby." What both men have in mind to emphasize here is that no mind exists of itself or by itself. A mind, Ogden says, is always created and maintained (as well as harmed) intersubjectively. 

Put negatively, the idea of an "independent mind" existing in its solipsistic splendour, untouched by and not linked to other minds, not only does not exist but, as Bion might say, is a psychotic illusion. 

Second, both minds are different after analysis/therapy. Patient and therapist alike think differently after spending time working together. I am sometimes startled by how much differently my mind works thanks to my patients. I think if I had stuck to my original plan of full-time clinical practice in the 1990s, when I was still in my 20s, I had then a very rigid mind and most likely would have been a rigid and presumably inflexible clinician. Now I feel, with not just training and experience, but my own psychoanalysis and ongoing analytic psychotherapy, and many years of living, far more comfortable with the changes that are necessary. I can allow myself to be pulled and pushed in various ways without the fear I had earlier in life that I would be toppled over or destroyed.

For this reason, I now greatly resonate with Ogden saying in this book--and all the others I have read so far--that each course of therapy, indeed each session, has to be different with each unique patient, and that if patients could eavesdrop on other sessions they would well wonder "Is this really the same Dr Ogden/DeVille as the one I see and hear and talk to?" 

Third, Ogden took me back to reading a Jesuit psychotherapist to whom I was introduced in high-school in the 90s (who has since been revealed to have been an abuser), who used to quote St Irenaeus of Lyons famous line about the glory of God is a human being fully alive. For Ogden, several times in this book, he says quite compellingly: every form of psychopathology represents "a form of unconscious self-limitation of one's capacity to experience being alive as a human being" (p.18). 

Once more, of course, the debts here to Winnicott are obvious, including what his wife wrote of after his death: the "prayer" he sometimes used, asking "Oh God! May I be alive when I die." 

Fourth, sexualization is an attack on mentalization. Ogden does not use the latter term, Fonagy's work  (and that of others like Jon Allen) on it not being then widely known. But I have found this a helpful way to think of some issues in treatment which Andrea Celenza also addressed in her invaluable book Erotic Revelations: Clinical Applications and Perverse Scenarios, which I wrote about here. 

Fifth, alter the 'fundamental rule' to permit greater freedom for reverie and also patient privacy. The academic editor in me has long been at war with the psychoanalyst in me, finding that true and literal application of the rule makes for a chaotic session, almost quasi-psychotic at times, and strick application of the rule can be an attack on the capacity to dream and think. I know in my own therapy I once very deliberately, and with gleeful malice, went on a 'wild' spree of free associating to run out the clock in the last 15 minutes of a session to avoid talking about a very embarrassing dream. 

Sixth, quoting Freud's 1914 paper "On the History of the Psycho-Analytic Movement," Ogden reminds us that "any line of investigation which recognizes...these two facts [transference and resistance] and takes them as the starting-point of its work has a right to call itself psycho-analysis." This, blessedly, releases us from silly and interminable debates about use of a couch and number of sessions being somehow exclusively indicative of psychoanalytic treatment.  

Seventh, simply listen. This is from Freud's 1912 paper "Recommendations to Physicians Practicing Psycho-Analysis." By this Ogden says that Freud meant engage in that evenly hovering attention precisely to catch the drift of, to tune into, the unconscious mind of the patient. This puts me in mind of Coltart's exhortation to practice bare attention. 

Eighth, quoting Winnicott, psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist.