Overcoming the Super-Ego, Ego Ideals, and Blind Spots

I reviewed a manuscript for Routledge in July, and as always took my payment in the form of books, two of which have now reached me. I hope to finish the second book, Psychoanalytic Credos, and post longer thoughts on the weekend. 

I will offer just a brief note on the first of these, Vic Sedlak, The Psychoanalyst's Superegos, Ego Ideals, and Blind Spots (Routledge, 2019). My brevity is largely dictated by the fact that my academic year begins next Monday and thus my time is becoming severely compressed; but also because this particular book has a rather meandering style (which is quite charming and works well with the content) and largely covers some (to me) fairly well-known territory. So in lieu of a lengthy discussion I shall give you a summary in Four Theses:

1) Avoid Moralization: 

Those of us trained with some notion of "neutrality" or "abstinence" (as Freud sometimes called it) are familiar with the idea of not proferring opinions on controverted moral questions or on most aspects of a patient's life, and of not giving advice on, say, whether to marry or divorce or change careers. But Sedlak advocates going beyond this to say that while we all have moral views, and these are natural, we must do a better job of preventing them from sneaking in to the therapeutic relationship in order to judge, say, a patient's marital situation or sexual fantasies or other choices. The patient's unconscious can pick up on these judgments even if you feel yourself to be sedulous about keeping them out of open discussion. (As someone who works with adolescent and adult sexual offenders, as well as those plagued by sadomasochistic fantasies, I found this a salutary reminder and challenge.)

Moralization is the result of an untamed super-ego, and much of this book's burden is to call for the therapist to work not on the patient's super-ego in the first instance, but on their own, replacing some of its harsh moralizing with what Hanna Segal called kindness and respect. In doing so, Sedlak says, you will end up helping the patient moderate their super-ego as well. 

This is especially important when it comes to failures--our own, and those of the patient. Here Sedlak openly says we have to challenge ourselves to find a way of discussing such things--including therapeutic ruptures and mistakes--"without writing a morality play" (p. 64). We also--here and elsewhere--have to keep in mind that none of us is ever permanently free from the "daemonic power that can fuel one's sadism" (p.68).

2) Avoid Colluding to Exclude Hatred:

In a chapter with the striking title "Contemplating Analytic Failure," and later in another chapter "Hostility Terminable and Interminable," Sedlak, with commendable and not frequently encountered candor in other clinicians, tells us of a case which he regards as a significant failure on his part. It was a huge blind spot for him. (The theme of blind spots does not come up as often as I wished in this book.) In essence he colluded with a patient to keep anger and hatred out of the treatment, and to that extent failed the patient. He challenges us not to make his mistake. (He does not give much by way of practical detail on how to do this, alas.) 

He prefaces this by wondering aloud as to how successful Winnicott was in really tolerating the hatred in his patients that he is sometimes credited with doing. I also ventured some doubts about DWW on this very point nearly a year ago now. 

Here he cites familiar but disturbing data (from Linda Hopkins' invaluable scholarship) on how Winnicott failed to deal with hatred and aggression in Masud Khan, his sometime analysand and editor. (F.R. Rodman's biography of Winnicott, which in my view is far and away the best of the biographies of DWW extant, is even more critical of DWW's handling of the Khan scandal.) Perhaps if DWW had dealt more forthrightly with Khan, the latter's abuses of his patients could have been avoided. DWW seems to have also avoided treating hostility with two other well-known patients: Harry Guntrip, and Margaret Little whose treatments have been written about extensively in the literature.

Sedlak is under no idealistic illusions about handling anger, hatred, and hostility. He says it will require constant maintenance and monitoring by the clinician, and you should have no ego ideals about your own ability easily to do this, or about the patient's willingness to give up hostile or unhealthy attacks on you, himself, or the treatment. 

This brings us to our third thesis:

3) Always Examine and Restrain Your Ideals about 'Cure':

One of the things I first learned from the great Nina Coltart is that you really have to ride ruthlessly on your ideals and hopes about "cure." 

Coltart was also--more than Sedlak is in this book--quite open about advocating that you not only allow for aggression to emerge, but that you figure out a way to draw on your own aggression and use it productively. In this I think she goes somewhat beyond both Sedlak and before him Winnicott. I wrote about this here. 

Sedlak says that completely giving up ideals about curing your patient is not only impossible but also at least partly inadvisable. You may need them to keep you motivated during a tough slog. So you need your ideals, but you need to not be ruled by them. If you are, he warns in several places, your patient may pick up on this and hold you and the treatment hostage by refusing to get better. Negative therapeutic reation, he says, may come from a patient denying you the power to "make" them better. In other words, the patient will want from you a demonstration that you love them unconditionally--without them getting better first--and only if they obtain that will they then allow treatment to proceed. 

Quoting a 1978 article from D Widlöcher, Sedlak warns of how unexamined ideals can ensnare therapist and patient alike, leading to treatment collapse:

the more the psychoanalyst's ego is dependent on his own ego ideal, the more dependent he is on his patient, and conversely the more dependent on the patient he feels, the more he accentuates his dependence in relation to his ego ideal and reinforces his own superego demands in order to detach himself from this dependence--a genuine vicious circle which introduces the problems of narcissism into the...countertransference. 

4) To Suffer the Illness Rather than Suffer From:

With, it seems to me, Bion in the background, Sedlak several times says that one of the aims of treatment is to help the patient suffer the illness rather than suffer from it. He's not entirely clear on this point, but what seems clear enough is that you do this by accompanying the patient so that, as Bion noted, the painful and horrifying--and thus often psychotically warded off thoughts and memories--can now be endured ("suffered") precisely because there is another there to help you do so, thereby preventing you from being alone and suffering from the malady entirely on your own. "Suffering from," in other words, is solitary and miserable; "suffering" is with another, and to that extent potentially very powerful. (To be alone in the presence of another person, as Winnicott so memorably taught us, is an enormous developmental achievement and never to be taken for granted.)