Betty Joseph on Psychic Change
As so often happens, my friends on Twitter [some insolent rabble in the gallery: "He has friends?"] convince me finally to read people of whom I have been aware, often for decades, without having actually read their works. In this case, it was a quotation from Betty Joseph. Finding it compelling, I ordered, and have now read, Psychic Equilibrium and Psychic Change: Selected Papers of Betty Joseph, eds. Michael Feldman and Elizabeth Bott Spillius (Routledge, 1989).
Joseph lived to nearly 100, dying just a decade ago after a very long clinical career in England. (A short biographical sketch is available here.) My first analyst in Canada was a Kleinian and I vaguely recall her mentioning Joseph at one point but I never investigated farther.
The Hard to Reach Patient:
Like all collections, Psychic Equilibirum is uneven. It contains papers originally published as far back as the late 1950s. Every chapter is fairly brief and follows a standard format. I perused the table of contents and decided, after reading the editors' introduction, to jump around, beginning with the chapter that first grabbed me most strongly, viz., no.5, "The Patient Who Is Difficult to Reach." I have at least one such right now and whenever I read a chapter like this--or any chapter by clinicians citing their own case material--I always hope (surely I am not alone in this?) that what they describe will be exactly what my patient is like so that, at last, I can stop thinking and reading and wondering and working to figure out the treatment they need, and instead copy the example cited by this manifestly masterful clinician. Thus does one see the very real attractions of manualized therapy!
But, of course, my patient is at least 90% different from Joseph's. (And thus does one see the massive limitations of manualized therapy!) So I ended this chapter somewhat disappointed, to be honest, finding it only partially useful. (That is also true of much of the book: I found only 2 or 3 chapters particularly useful, but read all of them, and found threaded through each and every one a common theme, noted below.)
But then, trying (at risk of sounding pious or sycophantic, both of which I abhor) to reflect over the whole chapter by means of a kind of reverie, which 'method' I learned from reading the great Thomas Ogden, I put the book down and stared across the coffee shop and out the window to the river, and found myself focusing on nothing in particular but allowing my mind to range back over the entire chapter as it tried to weave in one case in particular. At that moment I came to a rather startling insight about what now seems to me a technical mistake or perhaps an 'enactment' I have allowed to happen. I was aware of what I was doing, and thought it justified, but now in light of Joseph's chapter I see differently.
What, in particular, provoked this small epiphany? There are three lines in the chapter that were bracing to me.
First, she begins by talking (as others I have read would later do--I think in particular of Christopher Bollas here) about those patients eagerly proffering "pseudo-cooperation aimed at keeping the analyst away from the really unknown and more needy infantile parts of the self" (p.76). That latter phrase--more needy infantile parts--especially struck home and inched me toward greater understanding of a case in which my countertransference imagery has been utterly plagued for months with nothing but images of my cradling my (adult) patient as a babe-in-arms.
This first line of Joseph's I immediately linked up with a passage a few paragraphs later in which, continuing the theme, Joseph speaks of the really needy part of the patient needing "the experience of being understood, as opposed to 'getting' understanding" (p.79). That, of course, echoes one of her contemporaries, Frieda Fromm-Reichman, and the latter's famous observation that the patient needs an experience, not an explanation. Here I came uncomfortably close to a second acknowledgment of a near-mistake in a case in which I have sometimes found, in my impatience, doing what Joseph warns against: offering 'an explanation,' a thing, rather than an overall experience--and doing so prematurely, in a way the patient could not use at the time.
In doing so, I am now rebuked not just by her, but also by a passage of Winnicott I have not always heeded. In "The Aims of Treatment" from 1962, he speaks of the necessity of "economical" interpretations, rightly warning that "I never use long sentences unless I am very tired. If I am near exhaustion point I begin teaching." In my case it's not just a moment of exhaustion but also sometimes of frustration which I have done a poor job of controlling. At such a moment I lapse into professor and academic mode, giving a paragraph-length explanation, an understanding, an interpretation: these rarely go over well.
At the very end of the chapter in the third passage of Joseph that I found challenging, she advises that with patients hard to reach, we must keep our interpretations, our understandings, "immediate and direct" (p.87; her emphasis). In other words, she explictly says, do not offer some kind of historical explanation or interpretation, linking together themes or events from years or months or even weeks past: stick closely to what is going on in that moment in that session in your consulting room. Here is where (as she'll make clear elsewhere in the book) Bion is handy: abandon memory of past events and sessions, and a desire to escape the present moment, and instead plunge right in to your immediate experience of and with the patient, and they of you. (Bion's famously difficult and confusing counsel is examined in a bit more detail here.)
I admit this--discussing what is happening in the moment--was enormously hard for me to do for a time, but working with borderline patients has in essence forced me to do it. I remember very clearly the first time, with enormous trepidation, I attempted it and how it proved to be so pivotal to treatment. Once I figured out my own idiom for doing it after that, and became (in part thanks to my own analyst) much more comfortable with the risks I felt I was running in doing this, it has begun to flow more easily now. I think the key for me was once again Winnicott. In that most invaluable of essays, "The Use of an Object," he helped me to see that I could allow patients to bring their rage out into the open of the immediate moment and try to destroy me but that I would not in fact be destroyed.
The Patient Addicted to Near-Death:
The other outstanding chapter in this collection is "Addiction to Near-Death." Here she refers to patients engaged in "a type of mental activity consisting of a going over and over again about happenings or anticipations of an accusatory type in which the patient becomes completely absorbed." (In my experience this is characteristic of certain obsessional-compulsive personality styles, about whose treatment I wrote in some detail here.) For such patients their "seeing of the self in this dilemma [as] unable to be helped is an essential aspect."
As a Kleinian, Joseph mentions projective identification and splitting in every chapter, and here notes that the splitting characteristic of these patients is such that "the pull towards life and sanity" (p.128) is projected almost entirely into the clinician. (I have found myself in this position but, being an ignorant fool at least once a day, rather blithely told myself--here vaguely calling to mind some exculpatory aphorism of Yalom--that it was simply me being "the bearer of hope" until such time as the patient could be more hopeful.....except they never assumed one bit of that burden, and acidly disdained any expressions of hope!)
Joseph returns to this later in the chapter, speaking in more forthright terms than in many other chapters as she speaks of this splitting, and the clinician taking up the role of one who is hopeful about and pushing for change, as being a "collusion" in which a "major piece of psychopathology is acted out in the transference." If you are put into this position of bearing the hope and desire for change then "the patient constantly is pulling back towards the silent kind of deadly paralysis and near-complete passivity" in significant measure to avoid having to recognize and deal with their own "ambivalence and guilt" (p.136).
The "patient's apparent extreme passivity and indifference to progress" is based in part on, and heavily reinforced by, the fact that "the near-destruction of the self takes place with considerable libidinal satisfaction." These patients enjoy the "deeply addictive nature of this type of masochistic constellation" (p.128). At the chapter's end, she will return to this in graphic terms, speaking of the patient as having "withdrawn into a secret world of violence, where part of the self has been turned against another part" and where "this violence has been highly sexualized" (p.137).
A word is here introduced by Joseph, giving an excellent definition to a term I first encountered I don't know where some time back: chuntering. The chuntering patient goes "over and over again in some circular type of mental activity" that consists of endless grumbling, complaining, fault-finding. Sometimes, however, such chuntering is silent: Joseph mentions those patients who, passively and silently, will destroy whatever you are doing, apparently listening to your thoughts but all the while mocking them with silent contempt.
Given such powerful libidinal rewards for their self-destruction, it is no wonder that working with such patients is going to be very difficult. Joseph ends this chapter with no clear or simple fixes, saying simply that "it is very hard for our patients to find it possible to abandon such terrible delights for the uncertain pleasures of real relationships" (p.138).
Once more the only thing Joseph counsels is taking a "moment to moment" approach in the session, monitoring the changes in transference (which for her is never static, never fixed, never permanent, but a live thing, a dynamic, living, changing experience) and counter-transference. As a result the same behavior can have a difference transferential import: Sometimes the patient may be engaged in what appears to be chuntering, but doing so out of real psychic pain at some legitimate thing they need you to know about; at other times they may be trying to drag you into a masochistic enactment. You need to get clear as to which is which, and these can even shift within the same session.
Finally: What is the Change We Seek?
If it is hard for these patients to change, which patients find it easy? For Joseph the answer is itself easy: none. Nobody finds it easy to change for we are all shot through with ambivalence and conflicting desires, and all our struggles--whatever they are--are bound up with our personality structures (a point so helpfully made more recently by Jonathan Shedler and Nancy McWilliams, inter alia). Our personality defenses, Joseph notes here, are "very tightly and finely interlocked elements" (p.193). To change even one thing is to risk a cataract of other changes, and thus to provoke multiple defenses at every step: this is the theme of Joseph's fourteenth chapter ("Psychic Change and the Psychoanalytic Process"), the last on which I shall comment.
How might we define change? What are its hallmarks? Here Joseph is very reluctant to get into details or to over-promise. Indeed, throughout this book one gets the sense that she is in constant, unwavering control of her omnipotent and omniscient desires, never overpromising or indulging in messianic fantasies about dramatic changes.
"Moment-to-moment shifts and change" in the transference is what we should be paying attention to, Joseph says, without much regard for anything outside it. If such changes happen, then we are permitted to "hope" that such are "eventually going to lead to long-term, positive psychic change. I do not think that the latter long-term psychic change is ever an achieved absolute state but rather a better and more healthy balance of forces within the personality, always to some extent in a state of flux and movement and conflict" (p.194). This last sentence, to my mind, sounds very much like Philip Bromberg avant la lettre. (This chapter was originally published in 1986, a dozen years before Bromberg's Standing in the Spaces, an outrageously rich collection I hope to finish and write about next week. Bromberg cites this passage of Joseph's on p. 272.)
From here Joseph expands somewhat outward, first noting what Freud said about change ("where id was, there ego shall be") before adducing what Klein added to this, and then, in sum, writing that psychic change consists in "greater integration between ego and impulses, love and hate, superego and ego" and that as an analysand moves toward greater health, this will be seen in an ability "to bear both his love and his hate at the same time and towards the same person. His perception of human beings then becomes more real, more human....This step, or rather, minute series of steps, forward and backward, towards integrating love and hate, brings with it momentous changes within the personality." (This theme of taking up love and hate will find powerful expression in Glen Gabbard's book of that name.)
Such changes may be seen in a greater ability to acknowledge and not flee from "guilt and concern" for others as we come to "take responsiblity" for our "own impulses" and how we may have harmed or attempted to destroy the objects of our life. If we take such responsibility, "there opens up the possibility of feeling for and repairing the object. With this there is also relief and a deepending of emotions" (pp.194-95). All of these changes emerge, Joseph stresses again and again, not in grand Damascus-like moments of blinding conversion, but often in the very minute, moment-by-moment changes in the transference, where it all begins; and if it doesn't begin here, it will never begin.
This is a humbling note on which to end, but a salutary one. If we are always looking for external affirmations and grand signs of change and progress, we may risk overlooking, perhaps even disdaining, the quotidian ones in the transference. We need to be content eating bread and butter as a regular diet rather than lusting after prime rib every day.
We also need to be comfortable recognizing that the mind, Joseph says in conclusion, is a scene of perpetual conflict--even when progressing in the 'right' direction. If we leave our patient pretending otherwise, even as they progress in change and grow in freedom, then we have returned them to a very primitive form of splitting which, to Joseph, is anathema.