Creative Engagement in Psychoanalytic Practice: Further Thoughts
(I wrote and published this on 9 September 2023; but learned colleagues on Twitter, especially Jayce Long and Kristian Kemtrup--always gracious interlocutors from whom one learns much--offered an important challenge to my principal critique of Markman and I saw at once how right they were, and how their argument about reading Markman's ideas of surrender through Emmanuel Ghent's crucially important treatment of the topic makes brilliant sense, largely dissolving my difficulty. I have therefore amended the review at the place noted below.)
Introduction:
I'd never heard of this author until perhaps May, and, perusing the book on Amazon, found myself mildly interested. But I then I reviewed a mss for Routledge this summer and agreed, as always, to take payment in books; and so, to get to the total amount allotted to me, I (somewhat diffidently) put Henry Markman's Creative Engagement in Psychoanalytic Practice onto my list of desired books.
Wow. Did I ever severely underestimate the wisdom in this book and the grace of its author. If one can judge the import and impact of a book by the intensity and extent of the marginalia (underlining, double-underlining, starring, check-marking, uncharacteristically promiscuous use of exclamation points, and writing commentary up and down the page) it inspires then Markman's book is at moderate-to-severe flood stage, not quite drowning in suitably green (is anyone else quite so weird as to coordinate the colour of their ink relative to the colour of the book's cover?) ink from my second-favourite fountain pen of all times, but close to it.*
For me the impact of this book is twofold: it has forced--is forcing--me to rethink some things, though I do not know if in the end I will be in complete agreement (in other words, questions remain, and the chief of those are to be found below); and then there is much of the book that confirms and strengthens the argument for certain "techniques" that I (a nobody of very minor achievements) have more or less just found myself falling into doing, without ever seeing these cited or taught anywhere. (Perhaps some of them have been repeated by me as a result of being unconsciously imprinted on me by both of my psychoanalysts?)
The contents of this book are impressive indeed, and the writing is usually excellent; but what is the most outstanding feature of all is the manifest modesty of the author. Given the title we might have expected some "creative" fireworks and some preening by the author of how unique his methods of engagement are. But in fact what the author proposes seems to me a sort of engagement that bears strong resemblances to Winnicott and Ogden and their offering of "ordinary good enough" care for the patient. (In a time when even the basics of psychotherapy seem to have been utterly degraded or never taught, I mean that as very high praise.)
The biographical sketch at the bottom of the back cover only gives us the bare minimum. Inside, and very casually, the author also tells us he is a trained psychiatrist with wide and extensive experience in numerous settings. He has obviously read widely--Freud, Bion, Ferenczi, and Winnicott are the major interlocutors here but there are several others I had not heard of but am now seeking out. All this learning is worn very lightly, with the result that the book is a near-miraculous production: it lacks any indulgence in jargon or theoretical defensiveness. When reading it, I thought quite sincerely: Jonathan Shedler would approve of this book, for he has often--rightly--lamented how needlessly obscure much psychoanalytic writing is, a failing that Shedler totally avoids in his wonderful article "That Was Then, This Is Now: Psychoanalytic Psychotherapy For The Rest Of Us," copies of which I now give to our interns and my students.
In short, the miracle of this book is, I daresay, that even those with little or no clinical background could pick it up and immediately get a sense of how psychoanalysis and psychotherapy unfold with Markman, gaining insight into not just the patient's struggles, but how Markman is present with and attuned to them in far-reaching ways.
The Contents:
Right. Down to business. I shall only comment on select chapters, leaving readers to encounter the others for themselves. My commentary is driven largely by the need to continue metabolizing this book, and also to air some real questions I have.
The Importance of Play:
The author begins very promisingly when he recounts his early clinical experience with adolescents, and how this "changed how I worked with adult patients: I became more playful" (p.13). This, of course, is a very Winnicottian theme I greatly welcomed here.
Equally influential was his own experience as an adolescent patient who found his analyst had a "warm, calm, and capacious presence" and this was a key part of the "transformation" he experienced: "I strongly felt his loving care" (p.14).
This theme of love shows up in the first chapter: "Love is expressed in our desire to know, understand, and recognize the singularity of a patient in a deep way that fosters intimacy." This should not, he cautions, lead us into a facile belief about needing nothing more than love. "In fact, ongoing serious emotional work and self-interrogation are needed by the analyst" (p.23).
The Importance of Authenticity:
Ch.2 focuses on the authenticity of the clinician. Its epigraph is a well-known saying of Bion's about "the analyst you become is you and you alone." This, in turn, is a theme picked up by Ogden, as I noted here. Markman notes that authenticity and spontaneity are not license to do and say what you want--there is no "wild analysis" here. Everything is in service of our "care and empathic understanding of our patients" (p.46).
On Embodied Presence and its Obstacles:
Ch.3, on embodied presence, opens by drawing on French thought--Marcel and Merleau-Ponty in particular. The former's thought on disponibilité has clearly captured Markman's imagination: "putting oneself at another's disposal" is the translation he prefers. This leads into a discussion of how one manifests such availability through presence in the session. Though he does not cite her and appears unfamiliar with her work, Markman reminds me here of Nina Coltart's reflections on "bare attention." Here he also briefly invokes Ferenczi on the "language of tenderness."
There are, as the author recognizes here and elsewhere in the book, "emotional obstacles," as he calls them, to maintaining presence with our patients--and a fortiori a presence of tenderness one assumes. Here is the first of several discussions about such obstacles. In especially difficult cases, we may lose our sense of emotional equilibrium and thus struggle to maintain presence and attention. This is fairly commonplace, but the author presses the point to its (to my mind) most troubling extreme: those times when "we can be taken over by the patient's emotions and states, losing our analytic place, becoming ill with the patient for some time as described by Borgogno and Bollas" (p.67).
On Going Mad with Our Patients: How Much and How Far? And: How Helpful?
Others have also written of this, including Harold Searles and Philip Bromberg: what does it mean to say that with some patients you have to be willing to let them drive you at least a little bit mad? Markman argues that allowing yourself to get a bit sick, to go mad with the patient, can be "possibly...curative." (That adverb is bearing rather too much weight for me! And Markman never returns to this point to offer the fuller argument I think it very much deserves.)
Lest this quickly degernate into idealism and omnipotence, and all the dangers inhernet in those two, Markman later on explicitly recognizes that "we cannot fully make up for the deprivations in our patient's childhood. A 'basic fault' remains. There is a limit to how much we can repair or restore in the patient" (p.85). Our acceptance of this "basic fault" (as Balint called it) can help the patient mourn it.
How do we do it, and how does it help? Markman continues: "What use do we make of these emotions that help the patient? Paradoxically, by not resisting these states, by surrendering, relaxing, and living within them (i.e., containing them), we restore presence in ourselves and for the patient". Very similar language shows up again later on p.86, raising the same questions for me once again.
His use of "containing" here takes him into a brief excursus on Bion's use of that phrase, and Markman clarifies that containing = metabolizing. You take something in and contain it, and do not often give it back to the patient, at least not in the form you received it. Sometimes you may need to hold on to it permanently.
This chapter's introduction of the importance of surrender and relaxation is discussed in detail in the next chapter, "The Analyst's Work of Surrender and Mourning." I read it the first time and felt almost stricken into silence. A few days later I re-read it, sent some comments about it to friends, and then tried to read more. Even now, my third or fourth tour through this chapter, it feels deeply challenging.
Markman says here that effective therapeutic presence requires "surrender ('internal relaxation') and mourning. Mourning is the struggle to give up and let go of attachments that protect yet constrict us--attachments that do not allow for openness to the patient's inner world, being with and living within their experience. This is not the scary prospect it may sound when contemplated directly and abstractly like this, Markman suggests: "we are permeable to the emotions of others, at times even before they are aware of their own feelings" (p.77). So we may be "surrendering" in some ways without making a fuss of it. He brings in Bollas and Borgogno on this point, suggesting that such surrendering is, in essence, the greatest and most intensive form of empathic identification with the patient.
The Importance of Self-Forgetfulness:
This is not facile surrendering. Though Markman is not explicit on this point, he does seem quietly to recognize the risks and costs when he writes that "surrender is the necessary first emotional step. We give up the hard and clear boundaries that separate us from the patient, we give up our sense of control and surety....Mourning is the actual emotional work of letting go of such attachments that block surrendering" (p.82). A little later he is explict in seeing that such surrender and mourning brings with it "two painful states--loneliness and alterity."
Why do this? A little later Markman again brings in Gabriel Marcel's thought to argue against being "'encumbered with one's own self'." There is, I would add here, a lovely and lively freedom that comes from being forgetful of one's own self (in, of course, non-masochistic ways). I think this is very much what Coltart had in mind in speaking (ascetically, I would argue) of "bare attention," attention that is forgetful by and of the clinician's self. Such an approach not only frees oneself up to do deeper and more effective clinical work, but to do so in a way, I would suggest, that allows for you to be used, used up, and even destroyed, as Winnicott put it in his profoundly important essay on "The Use of an Object," without suffering as much "collateral damage" in the process.
On the Uses and Abuses of Masochism (updated):
On this question of masochism--about which he has authored a chapter elsewhere--Markman differs from Maroda later in the book when he outright says "we need to surrender to the particular and intense needs of the patient that may feel self-depriving, even masochistic" (p.192).
Markman appears to justify this masochistic surrender by returning to Ferenczi, who apparently wrote that "'transformation of the patient depends unequivocally on the willingness of the analyst to be transformed in and by the analytic process'." (p.198) But Ferenczi says nothing here about masochistic surrender, and on this point I was initially unconvinced and somewhat disconcerted by this argument. I do wish Markman had developed this point in more detail.
But after discussion with colleagues, noted above, much of my anxiety here is reduced by being reminded by them of Emmanuel Ghent's crucial distinction between surrender, on the one hand, and masochistic submission on the other. (Ghent, "Masochism, Submission, Surrender—Masochism as a Perversion of Surrender," Contemporary Psychoanalsis 26 [1990] :108-136.). I am inclined to give Markman the benefit of the doubt here, and thus to read him through Ghent and thereby feel much less anxious about his idea of surrender. But the remaining issue is: Ghent is nowhere cited in Markman's book--not in the text, notes, bibliography, or index!
Collapse of the Therapeutic Space?
Another important and somewhat disconcerting question Markman does not entertain here or anywhere in the book so far as I can tell is whether this process of surrender and mourning, leading to such intense indentification with the patient, does not carry the very real risk of collapsing the therapeutic space. There must, as Ogden has put it, be room for the "third." But the strong emphasis on mourning and surrender--which in the main I find deeply compelling and refreshingly challenging--almost seems to make the therapist too passive in some ways, perhaps too closely identified with the patient.
Instead, I am far more comfortable with the kind of "split mind" that Nina Coltart advocates than I am with an emphasis on mourning and surrender that seems (unless I have severely misread this book) to run unnecessary risks of minds merging, as it were--of overidentification with the patient. (I am not opposed to surrender at all--this I long ago learned from Winnicott theoretically, and practically from my own psychoanalysis. And I firmly believe mourning is always a crucial component of therapeutic work with everybody.) In her words, we must at any moment in a session be engaged in:
sharply focusing, and scanning; complex involvement in feelings, and cool observation of them; close attention to the patient, and close attention to ourselves; distinguishing our own true feelings from subtle projections into us; communicating insight clearly, yet not imposing it; drawing constantly on resources of knowledge, yet being ready to know nothing for long periods; willing the best for our patients and ourselves, yet abandoning memory and desire; a kind of tolerant steadiness which holds us while we make innumerable, minute moral decisions, yet steering clear of being judgmental (Slouching, p.119).
To his credit, Markman entertains some brief consideration of the dangers of the approach he advocates, but only much later in the book. On p.146, he briefly mentions the risk of "a narcissistic misuse of the patient." He also stresses (something Andrea Celenza does in her excellent book, discussed here) that we can never, ever forget the inescapably and profoundly assymetrical nature of our relationship with our patient. This must always be kept in the forefront of our mind, and we must always "interrogate our own actions and states of mind as our own responsibility....We are never off the hook, and that is a good thing" (146-47).
On Acknowledging our Own Needs of the Patient:
Markman also introduces an admission rarely encountered--Karen Maroda being the only obvious exception I know of: "unconsciously we need things from the patient." Inter alia, we "seek in our work reassurance of our goodness, capacity to repair, narcissistic needs for love, and early omnipotent feelings of power and control" (p.82). What he does not say here--but later reflections invite one to go on to this speculation--is whether some clinicians also need to feel the pleasures of masochism.
I do not wish to end on a quarrelsome note, for I have found this a deeply right book in almost all of its instincts, and deeply convicting in many ways. The author has written in a powerfully compelling way about some crucial, and crucially neglected, topics in clinical work today, including the centrality of mourning in diverse forms (which Nancy McWilliams also reminds us of).
In sum this is the very rich sort of book one feels wholly inadequate to metabolizing on one, or even the first several, sittings. I will doubtless pick it up profitably many times in the months and years ahead.
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* You naturally wonder: what is the most favored of all times? My favourite pen is a purple Krone from decades ago, so grand it travels in an enormous velvet case only slighly less posh than that which the Crown Jewels presumably travel in. Moses himself wanted to use it to write the 10 Commandments, but God told him He was giving it to me instead. Of course--to allay your further wondering--this pen is charged with purple ink. I inherited it from a dear friend upon his death the day after Christmas in 2010.