Sexualities and Identities:

It is the fate of collections to be often wildly uneven, and that is true with Sexualities: Contemporary Psychoanalytic Perspectives, eds. Alessandra Lemma and Paul E. Lynch (Routledge, 2015), xiii+244pp. There are two outstanding chapters, and two very good chapters; and then a great deal of other material some readers might find interesting or helpful but I did not. 

I read this book first for general interest, then because I work with adult and adolescent sex offenders ordered by the courts into treatment, and finally because I am working on an essay about the erotic in transferences and counter-transferences. 

I begin with Part III, "Homosexuality" and the first essay in this section by Peter Fonagy and Elizabeth Allision, "A Scientific Theory of Homosexuality." To my mind, this is the most outstanding essay in the book both for the cogency of the writing and for the challenging arguments it offers. The entire chapter--or at least the first half of it--plays something of a trick on the reader who, under that title, is led to expect something the authors very severely put to the question in the chapter's second half. That is, the first part is a brief review of the history of attempts to conjure up a theory of homosexuality (that history has recently been treated more expansively, but not entirely successfully, in a book I discussed here). 

Fonagy, of course, is the founder of the tradition of mentalization-based therapy, about which see here and here. He has also published on possible connections between infantile experiences and attachment, and the development of sexuality. 

With Allison, the burdern of the second half of their co-authored chapter is introduced and encapsulated by the claim that "normal sexual desire is inherently unknowable....Part of the essence of desire is that there is something anti-conceptual, something indefinite and unknowable about it" (p.133). This, in turn leads to one of the other major claims by these authors: "neither homosexuality nor heterosexuality are 'normal' and...neither can be an identity."

I rather imagine that both claims will immediately set some teeth on edge, but both are for me so straighforwardly obvious and true they cease to require additional argumentation. 

These claims are not, of course, entirely original to these two authors. Adam Phillips, for one, has argued something similar about the inherent unknowability about sexual desire and identity, especially in his 1997 book Terrors and Experts, where he has repeatedly noted that "there is nothing like sexuality...for making a mockery of our self-knowledge. In our erotic lives, at least, our preferences do not always accord with our standards." Later in the book he continues by arguing that "from a psychoanalytic point of view, nobody can know about sexuality" in part because "we are never one thing or another, but a miscellany. (For how long in any given day is one homosexual or heterosexual, and can you always tell the difference?)" 

The, uh, desire to have definitions and identities clearly nailed down is, Phillips suggests, an expression of our "wish to be defined [which] is complicit with the wish to be controlled." Additionally, the ham-fisted insistence on clear and sharp definitions runs the very real risk that "too much definition leaves too much out." Too much definition, in other words, undermines mystery and freedom alike. 

This, too, is very similar to what Fonagy and Allison argue: "the essence of desire is its indefiniteness." Indefiniteness means that we can have no legitimating theories of human sexuality, and these authors end their essay by suggesting that such theories in the past have functioned in an anti-mentalizing fashion, shutting down the ability to think about ourselves in ways that take account of our complexity and messiness: "it behooves us to be suspicious of ourselves when our wish for simplicity begins to override out respect for the complexity of subjective experience that our patients engender and bring with them in relation to their experience of their sexuality" (p.135). 

Anyone who has done clinical work for more than a week will immediately realize the profound truth of that last statement. And it shows up in several other essays, as well, including the moving and somewhat melancholic "Intimacy and Shame in Gay Male Sexuality" by Paul E. Lynch: "the beauty of working with patients instead of theories is that they are not so determinedly insistent on conclusions about their own sexuality, and are more often trying to find some way to make sense of themselves, their bodies, their pains and pleasures, and their relationships" (p.146). (Briefly towards the end of his chapter, Lynch suggests that "transgressive sexual behaviors may be an enactment or embodiment of un-represented, un-symbolized, or unformulated early experience," a theme that Adam Phillips has also briefly touched on, and before them both found in the works of Robert Stoller, including Perversion: the Erotic Form of Hatred.)

Earlier in the collection, Mary Target suggests that "fully expressed adult sexuality, regardless of dominant gender identity or orientation, incorporates unconscious bisexuality and bluring of the gender role of self or other." All of these authors, of course, are merely echoing what Freud first postulated in his infamous 1905 Three Essays on the Theory of Sexuality:

Since I have become acquainted with the notion of bisexuality I regarded it as the decisive factor, and witout taking bisexuality into account, I think it would scarcely be possible to arrive at an understanding of the sexual manifestations that are actually to be observed in men and women.

Lynch's claim about un-represented forms of sexual desire and behavior shows up in the last two chapters of this collection, the first written by Avgi Saketopoulou, who has also recently published Sexuality Beyond Consent, which I hope to read over the Christmas break. Her chapter here is entitled "On Sexual Perversions' Capacity to Act as Portal to Psychic States that Have Evaded Representation." 

She grapples with the continued use of the word "perversion," before arguing that we might retain it because it "captures the phenomenology of sexuality that blends anguish and/or pain with pleasure." Those who work clinically, as I do, with patients whose desires have been judged (often by courts, but sometimes by parents or themselves) as perverse and illegal know well this unique, and uniquely difficult, blend of anguish and pain: the desire that is unwanted, that has brought such trouble and left a streak of such devastation, is also a desire not without a certain frisson. Rather than condemn all such desires a priori and totally, we must, if we are to be of any help clinically at all, recognize that in some cases there may be real attempts to grapple with things that were unthinkable to the developing mind. As she puts it, "some sexual perversions...may be understood as proto-attempts towards figuration" (p.214). In the process of trying to figurate such experiences and desires, we must, she concludes, "always be aware" that some things are "eternally inaccessible to us, impossible to bring into knowable experience." Once more those with even modest clinical experience will at once recognize this as true.

Finally, Heather Wood concludes the book with her "Working with Problems of Perversion," and takes a much more practical approach, showing how many and how often perversions function as defensive measures to keep at bay the ever-threatening peril of intimacy and its possible engulfments. Drawing on Glasser's earlier work, Wood argues that "sexual perversions have very little to do with sex...but are about the use of sexualization as a defence to deal with primitive terrors in relationships" (p.224).  Such terrors include an uncertainty about whether the patient's own aggression can be controlled in a relationship or whether it will give rise to sadism and destruction. 

Wood also offers some helpful counsel about working in the transference with such patients, and dealing with counter-transference reactions. Many of us are anxious about sexualized transferences, and perhaps even more sexualized counter-transferences (a topic I'm writing a paper about just now), but she calmly suggests that if we keep in mind her claim above--that sexualization is a defense mechanism like other defenses--it should help us be less anxious about it. We must still, however, examine closely our own reactions as well as the transference to see whether they are about: control? sadism? anxiety? intrusion? seduction? taming a frightening object? fear of abandonment? a defense against destructive urges? a desire for merger which is intolerable and must be defended against? 

In some cases, Wood suggests, after the above forms of sexualization have been worked out, one occasionally might then begin to see less defensive sexual feelings emerge toward the clinician: "it may be important that these feelings are tolerated rather than viewed as defensive if true integration of sexuality and dependency are to occur" (p.228). 

This note has only touched on some of the essays in this rich collection. Anyone interested in sexuality and psychoanalysis will want to have this book on their shelf. 

Psychoanalysis and Homosexuality

This short new book, Psychoanalysis and Homosexuality: A Contemporary Introduction (Routledge, 2023, vii+164pp.) by two British clinicians, Leezah Hertzmann and Juliet Newbigin, is something of a useful handbook of (select) sources. It would be helpful to have on hand to refute those who still wish to criticize Freud and associate to him what are demonstrably later and far less felicitous attitudes towards homosexuality, which he never held. Such (often tendentious) criticism is rather tiresome and has long been known to be baseless by those of us who have actually read, and still regularly re-read, Freud (as I have done since 1990), either in German or in the authorized translation, or both. 

Hertzmann and Newbigin's book reads, in part, rather like a graduate student's lit review as part of a thesis requirement. The authors have provided decent lashings of (select) primary source material (always in translation, of course) farced not with scholarly analysis but rather with commentary of their own, which has its place. The style is admirably and immediately accessible and clear.

My hesitation with this book is threefold: first, it is never clear how they chose to pay attention to some figures and not others. It is never good to leave your readers guessing about your selection criteria. To my amazement, the radical views of Sandor Ferenczi (so much so that Freud himself, very "liberal" in his day on this question, was made uncomfortable by them) on homosexuality show up nowhere in this book.  It would have been good, at the very least, to have a look into Sandor Ferenczi: Reconsidering Active Intervention by Martin Stanton. Other important figures from that first generation--which, as a whole, was far more "liberationist" than their reactionary heirs in postwar America--are also overlooked. Why?

Second, the book attends in no significant way to significant historiographical issues in the composition and context of the texts they choose to include, and in those they exclude. I teach my history of psychology class every fall, and attending to how and why that history is written, and by whom--who is in, who is out, who does the choosing, and what are the subterranean currents to this choosing and composing we need to listen for with our third ear--is at least as important as any question of what was written. 

From this follows my third concern: the book pays insufficient attention to sociopolitical factors, especially in the United States in the postwar (=Cold War) period, where many of the developments we can now rightly deplore in psychoanalysis took root with a vengeance. Though these authors indicate a nodding familiarity with Dagmar Herzog's book Cold War Freud, they have not sufficiently integrated her arguments into this little book (or those of other scholars who are relevant here, including Todd McGowan and Paul Roazen). 

The problem--as Freud foresaw as far back as 1909--was that on questions of sexuality in general, America was a puritannical and hostile nation that could not handle his ideas. And this was confirmed after his death in 1939 and the end of the war in 1945 when American attitudes (many of them politically driven) towards many things argued by Freud were disastrously distorted or abandoned, including such things as the restriction of analysis to physicians (which he strongly denounced in The Question of Lay Analysis) and the rise of psychoanalysis as an ideology (the best recent book here is Adam Phillips, The Cure for Psychoanalysis) with orthodox beliefs and practices rigorously policed and enforced by training institutes that often existed in a state of excommunication from each other) rather than a method of treatment. Those institutes, of course, came to exclude homosexual candidates from training. 

Now, it is rightly objected--as I have objected in the past as both editor and reviewer--that one must not unfairly criticize authors for not having written the book the reviewer thinks they should have while overlooking the book they did in fact write. That would be a valid objection here if--again--we were given any sort of rationale for how this book was written, or what the purposes of composing this highly selective, almost idiosyncratic text were. It is certainly not a systematic or comprehensive history, but that does not deny its value and virtues, and the place it does fill as a very brief introduction to the topic. Scholars wanting a more thorough, searching, critical, historiographically sophisticated text will have to produce one themselves or wait for others to do so. 

Having offered such concerns, let me now end with some examples of the book's virtues. 

The third chapter does, in some ways, attend to postwar figures sometimes overlooked, including Sandor Rado who, with some of the Kleinians and others like Edmund Bergler, seem to have played significant roles in shaping views on homosexuality and trying to obtain a role in its "treatment." This chapter--drawing on Herzog--also notes (as more recent authors such as Andrea Celenza and Galit Atlas have done) that psychoanalysis as a whole became far less willing to consider the role of the erotic, in all its forms, and far more suspicious of it and intolerant of its ambivalences and ambiguities. 

The final chapter of the book is the richest, and here the authors turn again to the problem of the exclusion and suspicion of sexuality across the board in clinical work, noting--as others such as Celenza, Atlas, Maroda, and Gabbard have done--that most training programs deal insufficiently or not at all with questions of erotic transference and counter-transference, but that such questions are even more defended against when "the patient's sexual or gender orientation is different from that of the therapist" (p.133). Thus, they argue, one of the challenges going forward is to more fully recognize non-heterosexual forms of desire and how they show up in, and have an impact upon, treatment. 

Notes on Motivational Interviewing

Having here praised William R. Miller, whose book, co-authored with Theresa Moyers, was unexpectedly helpful, I realized I could now go back and read Miller's famous work on motivational interviewing. As so often seems to happen with me (a phenomenon first noted by Nina Coltart), current clinical work brings certain books back to mind and unconsciously nudges them up the priority list, on which reside, at any given moment, at least a dozen other works in various stages of being read, marked, and inwardly digested. So I found my copy of Motivational Interviewing and cracked it open again. 

Psychoanalytic snob that I have so often been, when I first heard that phrase years ago my eyes instinctively rolled so far back into my head they were able to watch old episodes of WKRP in Cincinnati. Herb Tarlek instantly came to mind--he who was always arrayed in a hideous jacket and had the oily demeanour of the salesman that he was. That is what I thought of "motivational interviewing": some smarmy technique devised by the more revolting apologists for "dollarland," Freud's acid nickname for America. 

But Adam Phillips taught me (this appears in many of his books, but perhaps most especially The Cure for Psychoanalysis) that ideological thinking is the antithesis of a psychoanalytic mind, and snobbery and defensiveness around it are both false to its promises and unnecessary to its survival (indeed, are fatal to its survival). 

My Canadian and Catholic instincts here further remind me that many differences are frequently exaggerated, and a careful work of "translation" will often reveal how similar things are. Though I have often thought the contemporary academy (especially in the humanities) is too enamoured of works of intellectual genealogy, they have their place, perhaps especially in the clinical sciences as we see just how much covert borrowing there is, especially by those (e.g., Aaron Beck, Marsha Linehan) who had analytic training but went to great pains to downplay or disown it in order to promote or tolerate the spread of myths of their own putative originality. 

Many concepts later "pioneered" (and trademarked and copyrighted) by others are demonstrably and indisputably analytic in origin. This is not noted smugly, but simply as a matter of honest intellectual history. Freud himself in several places notes how much he borrowed from others (Feuerbach, Schopenhauer), and I have myself noted his debts to monastic practices of late antiquity. There really is very little new underneath the sun. 

So if, in what follows--some selective, non-systematic notes on the second edition of Miller's Motivational Interviewing, bought years ago but left mostly unread--you find my taking particular pains to relate these to my analytic training, or to find psychoanalytic antecedents and analogues, you will understand why. (Others have done this with greater skill than I--Glen Gabbard for one, including in this article; see also Stanley Messer here; and perhaps most especially D. Westen's 1998 article--showing how often extremely similar techniques are to be found in differently labelled theories under different terms.) 

And the first note of significance comes at the start of the Acknowledgements page, where the authors note that "there is little that is truly original in motivational interviewing," referring to their debts to Carl Rogers in particular. 

It is an interesting exercise to return to this book after having read the more recent treatment of effective therapists. For much of that latter book is foreshadowed in Motivational Interviewing, as when they note already on p.6 that across different theories and types of treatment, common factors "frequently make a difference," and these factors are bound up with "certain characteristics of therapists." Therapists who consistently manifest empathy, avoid being high-handed, and do not infantilize their patients have better outcomes than those who view it as their mission to engage in "confrontation" and advice giving.  

I am also heartened that this book's second chapter is "Ambivalence: the Dilemma of Change." (Miller has a more recent book entirely on ambivalence.) Freud brought ambivalence to common awareness, though I sometimes fear it has largely disappeared from the clinical landscape, full as it often seems to be of much boosterish talk of techniques and tool boxes and work-sheets promising transformational change in 6 sessions or fewer (most of these barbaric self-promoters would write "less"). In any event, our authors note that ambivalence is universal and natural, and hectoring people who are ambivalent only serves to deepen the defenses and make change harder. 

Instead of that, you need to see what does motivate someone, for we are all motivated by something, and often several things. Discover what continues to motivate your patient even as they remain ambivalently attached to the thing they are trying to give up or alter. And while you're about it, do not--these authors strongly suggest--be a purist about this but a pragmatist: how much of the thing are they willing to give up? Go with that rather than pushing for total abstinence or complete change. (I am heartened to read this, because it seems to accord with something I've been calling "partial victories" with my patients who are inclined to totalized thinking.)

Developing Discrepancy: Our authors note that discrepancy is a good thing, and sometimes may actively need to be cultivated. Help the patient come to see the gap between where they claim to want to be, and where they are now. This then leads into what is called "change talk," which manifests itself in four ways:

1) Recognizing disadvantages of the status quo
2) Recognizing advantages of change
3) Hope for change
4) Intention to change.

This leads the authors to recognize the entire process of motivational interviewing is one led by the patient, and not an imposition on them--or a panacea either. It takes time and patience, and consists in the clinician giving space to talk through the ambivalence and bring patients to decide for themselves what they want to do. (That, of course, sounds very much like the kind of free and freeing environment that most of us try to create in psychodynamic treatment, which resists imposing our ideas upon, and thus infantilizing, the patient.) As they say a little later, the key here is "exploration more than exhortation" (p.34), and the exploration and decision-making sees the patient very much in the lead. 

All of this is premised upon something I have heard attributed to Rogers, and occasionally to Jung: "paradoxically, this kind of acceptance of people as they are seems to free them to change" (p.37). (So many people seem to come into my consulting room full of zeal for change which is motivated entirely by masses of self-loathing. They therefore find the idea of working from a place of self-acceptance utterly baffling.) Once people feel accepted as they are, and not forced prematurely into change by the therapist, then it is your next job with them to bring forward what they are already motivated by, and use that as a spring-board for action. Discovering a sense of self-motivation and self-efficacy will be key to everything that follows. 

At the outset of treatment the authors warn clinicians off the use of questions--closed are worse than open-ended, but both invite superficial and often defensive answers. (Other traps to avoid: labelling, instructing, playing the expert, taking sides, blaming, and going to fast--what a friend of mine calls a failure of pacing). 

At this stage, minimize the use of questions. Reflective listening and the use of statements are better. (In saying this, our authors remind me of Brodsky and Lichtenstein's useful article, "Don't Ask Questions.") Affirmation and elaboration are also useful techniques, particularly when the latter involves questions of values. Ambivalence can often be worked through if the desired change is in keeping with the patient's values.

Chapter 8: Responding to Resistance. I know that word has increasingly been avoided by some, but the authors note that no good alternatives have yet been found so they keep using it. Every time I hear it, I think of an example my first supervisor gave me. His besetting sin, he said, was getting too far out in front of the patient by moving too fast. He would look around and see how far behind him the patient was. Instead of chiding the patient for being a slow-poke, he realized he had gone too far too fast and had, he said, "humbly to walk back where they were and come along side them again." I think this example nicely illustrates Miller and Rolnick's ideas of resistance. Do not, they say, see this as something to blame the patient for: it is the fault of the clinician, just as my old supervisor recognized. 

So what do you do--how ought you to respond? You meet resistance with non-resistance. Shifting the focus (what I've heard called "lowering the anxiety temperature in the room" by changing the subject) is useful, along with exaggerated (but calm and sincere) reflection back are useful here. 

Ch.9: Enhancing Confidence: Not surprisingly, the authors recognize two traps at the outset to be avoided: one is to fall into the patient's totalized gloom-mongering and not have hope that things can change; the other is to be a mindless booster, offering cheap, soothing encouragement that is equally totalized and simplistic. You need to have and hold out hope for the patient, but it needs to be tempered and realistic hope. It also needs to be discerning enough that you know when to hope for change and when to gently bring the patient (as the Serenity Prayer reminds us) towards some reality-testing so they can see what is unlikely to change. 

Having found realistic hope, the process next moves on to actual planning of the change--lists of ideas, desires, hopes, obstacles, and strengths. At every stage this is led by the patient and your job as clinician is not to be the expert dispensing advice or telling them what and how to do something. This is repeated, along with many of the observations briefly noted above, throughout the first half of the book, which is easily twice as long as it needs to be. Overall, the summary of MI's "four general principles" occurs early in the book (p.36), thus:

1) Express empathy
2) Develop discrepancy
3) Roll with resistance
4) Support self-efficacy.

Part IV: Applications of Motivational Interviewing features nearly a dozen chapters by invited contributors focusing on specialized populations (groups, couples, adolescents, criminals et al) or issues. There are also chapters reviewing the evidence on the efficacy of MI and its application in medical and other contexts. 

A Note on Bruno Bettelheim on Freud and Man's Soul

I was first introduced to Bruno Bettelheim in high-school by a wonderful English teacher who had first introduced us to Freud and Jung in order to read Robertson Davies' Deptford trilogy. I read with great fascination Bettelheim's The Uses of Enchantment, and in fact had great fun with a friend using that book to analyze various fairy tales we had both grown up hearing and reading.

It was many years later when I thought about Bettelheim again, and read Bettelheim: A Life And A Legacy by Nina Sutton. By then certain egregious details about Bettelheim, in both his Austrian and American periods, were notorious and his reputation nosedived. Sutton's book appeared not long after a lot of those revelations came to light, and attempted reasonably well to grapple with them and to judge him judiciously.

At some point, too, I read his Freud and Man's Soul. This remains a vitally important and likely overlooked book, though my circle of wonderful psychotherapists on Twitter have this week been ordering copies and discussing it, which compelled me to go back and read it again. 

When I first read it, I paid the most attention to Bettelheim's compelling and disturbing examples of the many and serious problems of translation, especially by the Strachey circle, of Freud. I am speculating--but I think on very firm ground in doing so--that these translation decisions were very largely motivated by the politics and early historiography of psychoanalysis (here my debt is chiefly to Paul Roazen's revealing books, including Freud and His Followers as well as others) as well as an overly anxious concern for its reception, and corruption, in American circles. Having seen how the Great War very nearly destroyed psychoanalysis in Mitteleuropa, and how by the 1920s analysts were already emigrating to anglophone countries, Freud (as I've briefly touched upon elsewhere) could already see that psychoanalysis was going to survive most widely in America, but that it would be captured by American physicians and to that extent domesticated and even, one might say, denuded of its more critical and far-reaching potential. 

It would also need--again to an American audience then in increasing thrall to a rising crescendo of American behaviorist psychology--to appear as "scientific" as possible, and to that end a new language had to be invented. This is captured perhaps most notably in what can only be described as the deliberate and ruthless efforts to render the German into abstract pseudo-scientific-sounding English purged of any and all references to the "soul," a point Bettelheim makes with more power than anyone else I have read. I will return to this point presently. 

The Tripartite Model:

The most immediate problems are with the invention of Id, Ego, and Superego (totally foreign to the German, as Bettelheim shows with such devastating cogency, but also to the French: le moi, le ça, le surmoi). If we keep close to Freud's often poetic German (for which, remember, he won the Goethe Prize), then his famous phrase is re-translated by Bettelheim as "Where it was, there should become I."

The problem with these English renderings, Bettelheim shows, is that the bleed out all the deeply personal and individual feelings of das Ich and das Es, introducing a level of estrangement precisely where Freud is attempting to maintain an intimate and personal understanding of the mind. 

Thus a good translation would look like this:

das Ich = the it 

das Es = the I

Über-Ich = the over-I. 

On this latter point Bettelheim says Freud's motive was to stress to us that "it is the person himself who created this controlling institution of the mind" (p.58), thus underscoring again Freud's metapsychological point that the human mind is estranged from itself. (All this is worked out prior to his last phase, the 'cultural phase,' as it were, when he writes of broader estrangement in, e.g., Civilization and its Discontents and Moses and Monotheism.)

The Oedipal Story:

I had forgotten about this part of Bettelheim's book, but on reading it anew saw what a powerful point this was. The translators took it for granted Freud's anglophone readers would understand the details of Oedipus and not need the story presented to them to grasp Freud's point about how little we understand our motives, how blind we often are both to our desires and their sometimes devastatingly destructive consequences (for ourselves and those we hold closest and love most dearly), and how those most blind are often rendered as such because of childhood traumata, all of which the original story of Oedipus make abundantly clear. Oedipus is a deeply wounded child rejected by his family of origin and cast into adoptive and abusive relationships--points we should all have great familiarity with today, making the story as timeless for us as Freud thought it was.

Instead, we get some farrago of nonsense attributed to him. As Bettelheim reminds us, that story is "boys lust after their mothers and want to kill their fathers to have her to themselves for perverse sexual ravishment." This tiresome and transparently tendentious rendering of Freud seems designed only to ensure he is ridiculed ab initio without having to read him any further.  

Freud the Libertine:

Bettelheim opens his book by taking aim directly at another wildly popular but misleading rendering of Freud: that he is some kind of libertine. (Roazen's book Meeting Freud's Family shows in charming detail what rubbish this is.) This has led--in my experience--many religious folks to scathing skepticism or outright dismissal of Freud as some kind of dangerous revolutionary. But this is to miss his point entirely! And that point is that "Know thyself" is not a blank cheque, and does not justify the total absence of (as we would say today) emotional regulation and self-restraint, especially when it comes to erotic desires and sexual practices. 

Freud the Dogmatic Interpretation Machine:

Bettelheim reminds us that problems with translation go back to Freud's most famous book, almost invariably called The Interpretation of Dreams. That title, of course, suggests, not least by using the definite article, that it has oracular powers to divine the meaning of all the productions of the unconscious mind we call dreams. But this is very wide of the mark, Bettelheim says: the German is far more tentative and far less ambitious. Better renderings supplied by Bettelheim would include:

A Search for the Meaning of Dreams (my preference)

or

An Inquiry into the Meaning of Dreams (which Bettelheim prefers).

This corresponds with my reading of Freud's works, and especially his correspondence. Though there are undoubtedly parts of him that occasionally appear as "dogmatic" (but of whom could that not be said at least some of the time? As Adam Phillips has shown, we are all prepared to become unbalanced fanatics about things we truly care about!), I am struck time and again by far more numerous and sincere examples of his hesitancy, his tentativeness, his self-aware putting forth of ideas about which he himself is not completely convinced. Let us recall here how many of his writings were not monographs but essays, and that verb's infinitive in French, of course, means to try.

To pick the most controversial example, the death drive, which appears in Beyond the Pleasure Principle (do read the Broadview translation!): I defy any reader to get through the introduction to that and not be struck repeatedly by how open Freud is to criticism. He seems to go out of his way to underscore his own hesitations, and with good reason. 

The Deletion of the Soul:

"Of all the mistranslations of Freud's phraseology, none has hampered our understanding of his humanistic views more than the elimination of his references to the soul (die Seele)" (p.70). I take this to be the most crucial point of Bettelheim's plaidoyer. On this I think him absolutely correct in ways nobody else has bothered to consider.

In my view (working as I am on a book about the reception of Freudian and psychoanalytic thought in Christian circles), this is the most unforgivable sin committed by virtually all the English translators. For it has fed into the rabid dismissal by Jewish, Muslim, and Christian believers of Freud as a "godless Jew" (to use his own, albeit wry and perhaps ironic, phrase) who, with Marx and Nietzsche (the three "masters of suspicion" famously so called by Ricoeur) is, we are endlessly told, out to "destroy Western civilization" (a phrase whose utterance automatically marks the speaker down as a fundamentally lazy and unimaginative reactionary).  

Bettelheim goes into wonderful detail about how many examples of the soul show up across Freud's writings. I would document some of these, but I have to get off to another meeting, and I want to write about this more in an essay of its own--and finally my long-suffering readers were promised "a note" on the book, not a 10,000 word treatise!

Finis (pro tem).

Ogden and Phillips on Reclaiming Unlived Life

I have read all of Adam Phillips' books (that is not a vulgar boast so much as a reflection of deeply ingrained scholarly habits, which are often nearly indistinguishable from semi-obsessive or slightly manic tendencies leading one to devour, and ideally to own, an author's opera omnia); and I have newly set for myself the goal of reading if not all then certainly several more of Thomas Ogden's books, to whom I was introduced this fall. I found his style enchanting, but even more some of his arguments--which I have never encountered in 30 years of reading psychoanalytic authors--are wonderfully capacious and hospitable, allowing me to think things about my own analysis and now my own clinical practice that are freeing--and topped, ever so slightly, with a frisson of the forbidden or, better, the "unthought known." 

It occurs to me that Phillips and Ogden have a lot in common. Surely someone else less dim than I has long ago noticed this? I am always a Johnny-come-lately to these things. 

But there is more than a superficially titular resemblance between the Ogden book I read this week--Reclaiming Unlived Life: Experiences in Psychoanalysis, from 2016--and Phillips' Missing Out: In Praise of the Unlived Life.  Both include (here as elsewhere) liberal and loving lashings from literature and poetry; both write in an often lyrical style; and both hold and expound views that, even at this late stage, still seem somehow to sit uncomfortably within "orthodox" psychoanalysis (if one can still speak coherently of such a thing). I have no data to confirm this, but it remains a strong impression. Nonetheless, I think we're all the richer for their perhaps sui generis views and would not have it otherwise. 

I will say that of all Phillips' books, Missing Out perhaps comes back to mind most readily, and has occasioned very profitable discussion with students in this Covid era. Let me tidy up a few old thoughts about it here, and then set him alongside Ogden. 

The appropriate place to begin is with Phillips flatly declaring that "reality matters because it is the only thing that can satisfy us" (25). This will get developed in the rest of the book's realist, anti-fantasist stance in which Phillips clearly comes out against spending time imagining what could have been--what sort of life we could have had, or worse, could yet have if we but overcome our limitations and frustrations. For to give ourselves over to such disordered fantasizing, to wondering after would-be satisfactions in some imaginary future, is to open ourselves to an endless frustration with our life, which is itself an enormous problem insofar as "frustration may be the thing that we are least able to let ourselves feel"(27); and again: "There is nothing more opaque about ourselves than our frustrations" (28).

Phillips is saying this as an adult, and directing it at his readers who will all presumably be adults. But how much more difficult is this for children and adolescents! How many "conduct disorders" and "adjustment disorders" are the results, at least in part, of an inability to bear frustration? How many arise in response to demands to produce facile "solutions" to our frustrations--which end up serving nobody well? 

One danger of children trying or being required to achieve over-mastery of frustrations, as Phillips hints, but Winnicott made explicit, is that of precocity, famously treated in an essay I wrote about here. On that topic, let me put in a plug for an unjustly neglected but invaluable collection, The Mind Object: Precocity and Pathology of Self-Sufficiency, eds. Edward G. Corrigan and Pearl-Ellen Gordon.

Frustrations, if allowed--as Evagrius recognized long before Freud came along--to take root in our mind can become, as Phillips nicely puts it, "intractable because their satisfaction is too exactly imagined" (32) and as a result "there can only be unrealistic wanting" (33). To have "realistic wanting" seems a good enough goal for therapy as for life. It may well require mourning what is unrealistic, and grieving those wants that can never be satisfied. 

I admit that such too easily imagined satisfactions and unrealistic wantings strike me whenever, as last week, NPR told me that the Powerball had grown to a billion dollars or whatever. Hearing this, on the tedious last stretch of some highway or other, I imagine the house I would build (the library would be multi-tiered, sound-proofed, and have a massive fireplace in it with floods of light from huge windows on all sides; all other design details are trivial and uninteresting), and the scholarships I would endow, and the training program I would build to graduate the finest psychodynamic psychotherapists in the country; and so on. 

But Phillips is not done with our frustrations, and not willing simply to dismiss them because they are too easily imagined. Instead, he says that "We need...to know something about what we don't get" (33). This, of course, immediately raises practical if not moral problems: "But how...would you teach someone to not get it?....Teaching them how not to conform without trying not to conform?" (48-49). 

As an academic and a clinician, I find this is a tricky balance to pull off, and today's undergraduates seem especially frustrated and suspicious as you attempt to do so. With understandable bewilderment, they want to know how it is that they are taking an (often required) course only to be told by the professor that one of his most important goals for them is that they understand more deeply what they do not know, what their blind spots are, and what value uncertainty, ambiguity, and ambivalence all have as scholars of any and all disciplines, but especially psychology. But I try nonetheless to inculcate this in them, saying that if they are the sort of logic choppers and hermeneutic naïfs with a raging and uncontrolled desire for omniscience, who have to know everything and have it mapped out in advance, and cannot find uncertainty anything but paralyzing and disdainful--well, then, they need to exit from a clinical career immediately and go build bridges or something. 

As we teach others about the importance of not always "getting it" we need ourselves to be, as it were, convinced of the benefit of doing so, asking ourselves and others: "In which area of our lives does not knowing, not getting it, give us more life rather than more deadness?" (80). 

Incidentally, these are questions profitably examined from a variety of angles in another unjustly neglected collection, Knowing, Not-Knowing and Sort-of-Knowing, ed. Jean Petrucelli

Since reading this passage in particular, I have often thought of my foolish desire in my 20s that psychoanalysis would grant me access to knowing the entirety of my mind, unconscious drives and all. At the end of a full and successful analysis, there would be no surprises and all would be known and mastered, laid bare to the cool eye of reason. My second analysis has moved me quite unexpectedly away from that desire. I now find it more freeing to not pursue every detail of my mind but instead simply to recognize within myself that "I contain multitudes." That is, I hope, not just some tawdry bit of Whitman on the cheap; nor is it meant to be self-congratulatory in the least, but instead an increasing acceptance of the undrainable reality and complexity of any human mind still living. 

One of Phillips' great lines comes in this book when he says that a good goal for psychoanalysis is to help us "make sense of our lives in order to be free not to have to make sense" (63). In other words, we might have "good enough" insights (Phillips' wrote an early biography of Winnicott, which is decent, but the Rodman bio is much better) into ourselves, and, being content with those, feel free to stop pursuing further insights and instead go off and do something else like write poems or make black raspberry jam. As he puts it here and elsewhere (and this clearly echoes Winnicott), one good therapeutic outcome of analysis is that you can forget your treatment, your "symptoms," and the problematic narratives that brought you in in the first place, and simply get on with living. (I recall with great relief Nina Coltart saying in an off-handed way that she could hardly remember a single word of her multi-year analysis with Eva Rosenfeld.)

Being aware of, and comfortable with, what we do not understand is nowhere more important, Phillips counsels, than with sex: "When it comes to sexuality, we don't get it....It means that when it comes to sex we are not going to get it. We may have inklings about it....We can know the facts of life, but nothing else. We may, as we say, have sex, but we won't get it" (77). And again: "What psychoanalysts mostly know about sex is the strange ineffectuality of so much of their knowledge" (79).

Thinking these things with Phillips is very helpful, I find, to maintaining "evenly hovering," that is non-judgmental attention in any discussions about sex. It seems to shock some patients that I am not shocked when they discuss certain things about their sexual life. So many people come in preloaded with all sorts of judgment, and can hardly sit still if you do not immediately express some kind of stern judgment, or at least mildly clucking distaste, for whatever their "issue" is. They seem startled by having everything welcomed for discussion. I suspect a few of them secretly believe I must be faking it--and silently racing to retch into the rubbish bin as soon as they leave!

Right. So much for Phillips. Onto Ogden.

Reclaiming Unlived Life is a collection of essays, as several of Ogden's books seem to be (and as most of Phillips' books are too). Unlike Phillips' book, Ogden's is not so focused on this theme of the unlived life. The title, in fact, seems to come from a single chapter devoted to a late essay of Winnicott. We will come to that presently. Other chapters range widely. I will confine my thoughts to the first five chapters, and to the last one, with which I start.

That chapter is an interview Ogden gave to Luca Di Donna. It gives interesting background, as one would expect, but perhaps the best nugget--hidden just beneath the surface, and not mentioned explicitly, but seemingly obvious to me--is that Ogden desires no disciples. And perhaps even more impressive is his sangfroid about others using his works and disagreeing with him: "the fact that I don't recognize my own thinking in another person's interpretation of the concept of the analytic third is an event that I welcome because it means that the interpretation of the concept has been nutriment for another person's thinking--that, after all, is the principal point of writing of any sort" (p.169). 

The second gift in this interview is a point Ogden has made in other books: the importance of "tailoring" (not the best word--not a good fit!--but I cannot think of another just now) each treatment to each person to such an extent that each patient finds a very different Ogden. He reports rather cheerfully that he wants and would expect his patients to be astonished if each of them could listen to how different he sounds in speaking to all the others, and far from being disorienting this is a good thing. In other words, Dr Ogden with Patient A would sound very different than Dr Ogden with Patients B through H. 

The final point in this chapter is that knowledge alone is a very poor outcome of therapy. It availeth nought toward psychic change: "There is nothing mutative or growth-promoting about the acquisition of greater knowledge about oneself. What is mutative, I believe, is the experience of oneself in the context of being with another person who recognizes you to be the person you are and the person you are in the process of becoming. (It is precisely this experience that has made my second therapeutic analysis so valuable in such unexpected ways.)

This last chapter, and this discussion in particular, link up very nicely with the first: "Truth and Psychic Change." Here Ogden makes several points, including--to my amazement and relief, being the first time I have heard such a thing uttered--that the fundamental rule of psychoanalysis "compromises the patient's right to privacy, which is necessary for the freedom to dream in session" (p.2). I found, and find, this very freeing. Equally liberating in this regard is his claim in Ch.5 that you can only become a therapist based on your own unique gifts: "you have to respect the uniqueness of your own personality" (p.93) and not rely so much on interpretations and theory and whatever you imbibed from your own therapist. In all these things, and in his other books I read recently, there is a very strong welcome made to individuality and creativity in an atmosphere of radical freedom. I suspect Ogden and Fromm would have been good friends. 

The chapter next explores how to pursue truth in analysis in ways that the patient can bear. If done too soon or too zealously, before trust is achieved, truth will carry little water and may drive the patient backwards. And it might always be a dialogic process--not a top-down "interpretation" imposed by the clinician. 

Ch.3, "Fear of Breakdown and the Unlived Life" is an obvious reference to Winnicott, whose very short 1974 paper "Fear of Breakdown" was published three years after his death. This is the central essay in the book and it seems characteristic of Ogden's peculiar gifts that he can find so much material to comment on so profitably in what was not just an unfinished paper of Winnicott's but also a very short one in its original publication. 

In any event, Ogden says that this paper is one of a half-dozen that have been most influential on his overall thinking--along with essays by Freud, Klein, Loewald, Bion, and Fairbairn (always nice to see that neglected Scotsman get some attention! For more on him, Jock Sutherland's Fairbairn's Journey into the Interior is a decent place to begin.)

Ogden talks about how moving it is to read Winnicott, here as elsewhere. Though he doesn't quite put it like this, I have long felt that you could, through Winnicott's words, gain a strong and felicitous feeling for what it must have been like to be in his warmly welcoming consulting room. Doubtless he would have scandalized many on Twitter by his occasional offer to some patients of a cup of tea, which I find very charming indeed.

This essay, Ogden says (and cf. below my comments on Searles and psychosis), allows you to feel compelled to join Winnicott in getting in touch with our own feelings of fear of breakdowns: "to be an adequate therapist we must make use of our own personal knowledge of 'what it feels like'--what 'insanity' feels like--even though we are not in the full grip of a particular 'detail' of that insanity at a given moment" (p.50). 

For Winnicott, a breakdown begins as a loss of defenses against the psychotic parts of our mind. The crucial difference, he suggests (and Ogden rightly notes how much of this paper is Winnicott thinking aloud in not entirely coherent ways), is that patients fear breakdown now when they lack the "container" or "holding environment" of the mother-infant bond. Ideally, of course the therapist and therapeutic frame provide this, but Winnicott and Ogden both say that the patient needs to know you understand not just their breakdown but feel the fear of it, and have some experience with it. To guard too much against these feelings in yourself will not help your patient and their feelings of being trapped by some "primitive agony."

Ch.4 dares to tackle the hermeneutics surrounding one of the most enigmatic and controversial essays of the last half-century: Bion's infamous "Notes on Memory and Desire," to which I've given not a little attention on here (and here). 

Ogden confesses he's tried to read and understand it for decades without success until he realized Bion did not want people to agree, but instead to think about these questions with him. And the question, Ogden asserts, is not about memory or desire, but about the proper and overlooked role of intuition and the unconscious in the analytic process--which desire and memory can mask and distort. 

Ogden comes close to saying--but does not seem to do so--that the problem with memory and desire is that they are, as it were, a false floor. We might think we are grounded on them, but in reality they cover over a yet deeper level where the truth is more likely to be found (cf. pp.77-78). I catch glimpses of this in my own life when I can allow myself sometimes to try to get behind certain memories or desires to discover that they might not in fact mean what I have long thought they did. (We are, as Phillips might say, too easily satisfied literalists!) If Ogden is correct on this, then it is both a little alarming and a little liberating: alarming because it suggests our capacity for self-deception is much deeper and more thorough-going than first realized; but liberating in that we might not quite be prisoners of our desires after all. This will bear continued thinking about. 

We can circumvent memory and desire, he suggests, by dreaming in the session, by reverie, though to do so may require that "the analyst engage in an act of self-renunciation. By self-renunciation, I mean the act of allowing oneself to become less definitively oneself in order to create a psychological space in which analyst and patient may enter into a shared state of intuiting and being-at-one with a disturbing psychic reality that the patient, on his own, is unable to bear" (p.79). 

This passage immediately put me in mind of working with psychotic and borderline conditions, both of which I have found require that I become for a time something more or other than what I seem to be. I really do think Harold Searles (whom I discussed a bit here) was right that in working with such patients, you have to be willing to allow yourself to be a little bit psychotic--or at least be somewhat comfortably, if only for a time, in the neighborhood of your own psychotic elements. These patients are so split, so fragmented so much of the time, that trying to keep them all together, or to put them together, too soon does not, it seems to me, help them learn how to bear what they cannot bear right now. 

How can you do that--allow yourself to be a little bit psychotic? I doubt I could have even entertained the thought when I was younger. It is not easy, and it can be a little bit frightening. But now I rely heavily on a strong frame along with good supervision, supportive colleagues, and my own psychotherapy. I think having patience is also crucial: if you get in touch with those terrifying psychotic elements, you can do so more easily knowing that (as Christopher Bollas has suggested, among others) it is possible to dip into and out of "madness" without getting stuck in it, and the dark and difficult experiences will pass. (Here I really do believe Ophir's recent arguments that "madness" is on a continuum, and not some radically "other" state or "disease entity" that is totally separate from ordinary human experience). 

 Speaking of schizophrenia and psychotic disorders, I have a half-dozen new books to read over my Christmas break, so I suppose I will have to frustrate my desires to order some more Ogden until I get through at least part of that pile. Of course, my super-ego can sometimes be overpowered or ignored, so who knows. But I will certainly read more of him when I can (and also, come to think of it, write more about Phillips' two newest books).

On Sexualized Defenses, Transferences, and Counter-Transferences

Though I can remember almost none of my undergraduate professors at the University of Ottawa from the early 1990s, I have never forgotten Dr Arthur Blank, for both salutary and unsavory reasons. The salutary: I got to write a research paper in his Family Psychology class on what happens to families (such as mine) with a child who is chronically ill and then dies, and it was a profoundly revealing and helpful experience which earned me an A (not a grade I was anywhere near in my psychometrics or neurobiology classes that semester!), and gave me new and more sympathetic insights into what my parents faced and the choices they made to concentrate on my sister in the last six years of her life to the inevitable and unavoidable neglect of me and my younger sisters for most of our late childhood and nearly entire adolescence. 

The unsavory: a few months after class ended, he was in the papers on a regular basis being sued by former patients whom he had sexually abused in his private practice, including a woman who went into therapy with him to deal with having been sexually abused while growing up. He would be struck off the register of psychologists in Ontario and have to pay hundreds of thousands in damages to his ex-patients. I read the newspaper accounts with horror that a man could do such a thing to vulnerable patients. 

This coincided with living with a roommate, whom I knew slightly from my church (which very much encouraged his moving in), who had all kinds of issues with boundaries; we ended up having to ask him to leave. And it also coincided a few months later with my starting analysis and the great pains my analyst took to coax me onto the couch, which I was more than a little frightened of for the vulnerable position it places one in. ("What's she thinking back there watching me? What if she reaches around and touches me before I can see what she's up to and leap out of the way?")

Boundaries, then, have long been prominent in my mind. A few weeks back, I had occasion to read Glen Gabbard, "Lessons to be Learned from the Study of Sexual Boundary Violations" last week (American Journal of Psychotherapy 50, Summer 1996: pp.311-322). I posted insights from that on Twitter. He offers clear and concrete guidelines for avoiding boundary violations based on his work with more than 100 such cases. 

As important as his work in this essay is, he does not reflect on what might be useful in erotic transferences and counter-transferences and how to handle them in a profitable way that does not lead to disastrous outcomes. That crucial task falls to Andrea Celenza, Erotic Revelations: Clinical Applications and Perverse Scenarios (Routledge, 2014), who breaks the ice on these discussions (for me at least). As she notes, much of the clinical literature and likely almost all supervisory contexts avoid the topic because of the understandable fear and even shame such things evoke. 

I was not familiar with her work until Adam Rodriguez on Twitter mentioned how important her work is, and how she should be required reading in training programs. Having taken at least one lesson from her already, and used it in my own supervision, I would agree: she offers insights that begin a long overdue discussion, and we should be introducing that discussion to our students and supervisees. 

What do I mean by that? My take-away from her many insights is that there is a necessary difference between erotic attraction and sexual enactment, and that to feel and discuss the former without shame is not to necessarily risk the latter. Indeed, to put the point more strongly: perhaps the extent to which we feel more free to discuss erotic elements in the transference and counter-transference we may deprive them of the power of secrecy which so often masks and precedes boundary violations. Reading her book has in fact moved me along into feeling more comfortable discussing these things with my own supervisor, who has himself published on problems of sexual boundaries with certain populations, and discusses these with grace and good humour (not unlike Celenza's own supervisor as recounted in an hilarious anecdote on p. 69). 

The other crucial insight she offers is that sexual desire between patient and psychotherapist is always complex and complicated. Though Celenza is not so blunt on this point, I take her to be reminding therapists that if you think your patient really wants to just have sex with you in some straightforward manner, then you are deluded and have indulged in a self-serving and grossly reductionistic attempt to focus on only one thing: your desire. In this monomaniacal pursuit, you not only take your eye off the patient and his or her welfare, but you also fail to recognize that the patient's putative desire for you is highly ambivalent and complicated by many factors, and most certainly does not mean what you want it to. 

She puts it more elegantly and less compactly throughout the book, noting, first, that "being multiple selves is the human condition, and being multiple others to our patients is the analytic condition" (p.62). This multiplicity of self-states comes up several times in the book, and puts me in mind of a wonderful essay by Phillip Bromberg, "Standing in the Spaces," that I read recently and profitably. 

She continues in this vein, arguing, second, that "the gender that the analyst is...is not necessarily the only gender the analyst can be in the erotic transference" (ibid). I found this very revealing, opening up a new way of trying to understand same-sex erotic transference which baffled me in one particular case.

So the patient--whether male or female--could be responding erotically to us in a more maternal or masculine, or paternal or feminine role, or mixtures thereof; they could be responding from a younger and more childish part of the self, or (in our counter-transference) we to them from such multiple and entangled and ambiguous self-states of our own. Thus we see that the erotic response of patient to analyst, and therapist to patient, is not at all clear or straightforward, and responding as though it is will always invite disaster. (Celenza notes in an offhand passage something that Gabbard goes into in more detail: sexualized boundary crossings often happen when the therapist is engaged in "defensive efforts to manage our self-neglect" [p.67, with a reference to her 2007 book on the topic].)

Third, she states a little later that "the wish to know the analyst sexually is invariably complicated and usually highly conflicted. And if it is not, it should be, given the inherent power imbalances" in the therapeutic relationship (p.79). This theme of power imbalance is one she threads throughout much of the book, noting that it is inevitable no matter how much some misguided efforts might be made to flatten things and to insist patient and clinician meet on equal terms. We do not, and never will. 

I remember almost nothing else from one of my first supervisors, but he made damn sure to pound into my head one crucial point: We are not and never will be friends with our patients. A fortiori, we are never going to be lovers, either. As Adam Phillips says in one of his many wonderful books, psychoanalysis welcomes exploration of any and all topics no matter how emotionally and erotically laden and we can do this only because we agree never to have sex with each other.

On the question of sexual desires and their conflicts, I think the crucial passage in the entire book is this:

What do our patients want? They say they want our love, or more pointedly, to have sex--but do they really want that? We are many things to our patients simultaneously and equally important: analyst, woman, person, mother, father, sibling, and child....At any one time a plea for love or sex is a plea from within only one of those dimensions....The man may want a kiss, but the child does not. 

From this she follows up even more directly, insisting that "our patients do not really want us to gratify their erotic wishes, despite their vociferous protests to the contrary. But they do not want us to simply maintain our professional role either" (p.68-69). 

How, then, ought we to handle such things if it seems we are caught on the horns of a most serious dilemma? I confess I was gratified to read of her approach, which I stumbled upon myself before I had heard of this book. Celenza notes that if we cannot indulge patient desires, nor shut them down in a brutally "professional" way (for both responses harm patients in different ways), what is needed of us? Patients need us to respond to them as human beings, and so she said that sometimes a response like "I would if I could!" or "In another time or place" are just the sorts of responses "we need to convey to our patients" (p.69). (Quoted in this way, it may sound like Celenza is a bit flippant about such matters, but the force of her cogent book is quite to the contrary: she has clearly thought about such matters in depth and has hard-won wisdom abundantly displayed throughout the book.) 

I do not want to suggest this book is only devoted to these issues. Its other riches include good discussions in ch.1 especially on overly restrictive ideas of gender and on the uses of sexuality as a defense mechanism. Ironically, sexualized defenses and behaviors can often be used to stave off intimacy--a theme she devotes the entire second part of the book to in her focus on sadomasochistic and perverse habits and enactments. 

That final section, on sadomasochism, explicitly draws on a book I have half-finished right now: Robert Stoller's Perversion: The Erotic Form of Hatred. Celenza picks up where Stoller (whose work was published in 1975 but still has valuable insights for me at least in clinical work with sex offenders) leaves off and gives us a nuanced and balanced assessment before concluding that in her view sadomasochistic enactments are problematic insofar as they may be attempts to destroy any "tolerance of dependency, vulnerability, and self-revelation" (p.114) and may participate in "dehumanization of the other" (p.109). She notes that too often sadomasochistic habits may exist as a "closed feedback loop in which repetition and sameness is substituted for creativity and growth" (p.100). She gives an encouraging case study of one such patient who was finally able, after intensive analysis, to move into a much freer and more loving relationship with a woman who became his wife.