What is "Psychological Mindedness"?

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

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

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

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

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

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

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

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

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

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

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

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

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

Michael Garrett on Treating Psychotic Disorders: Part the First

Back in the early summer, outside the pressures of the academic year, I ordered a half-dozen books on psychosis and schizophrenia, thinking, in my slightly manic way, that I'd have abundant time and energy to "read, mark, and inwardly digest" each of them in great detail (to borrow one of Cranmer's genteel phrases from my Anglican childhood in Canada that doesn't quite describe how I often brutally ransack books like some kind of shameless Vandal), and perhaps even to re-read some of them. 

Well that didn't happen, but I did make steady, though much slower, progress on two of them, including Michael Garrett's Psychotherapy for Psychosis: Integrating Cognitive-Behavioral and Psychodynamic Treatment (Guilford, 2019). xiv+354pp. 

Part-way through the book, I learned on Twitter that Dr Garrett would be leading a 9-hour training workshop on Zoom discussing cases and techniques--both CBT and psychodynamic--for treating patients with psychotic disorders, whom he has had some considerable success in treating over the decades. So I signed up, and just completed it with him in early November. It was very useful in all sorts of ways, and in fact the week after the first session, I had occasion to meet with a heavily delusional patient and the "peripheral questioning" technique Garrett described in both the book and the seminar were extremely useful in beginning to chip away slowly at the delusional thinking. 

What follows, then, are my initial thoughts on the first third of the book (I won't have time profitably and deeply to read the rest until my Christmas break) farced with some comments and examples of his from the training, and my thoughts in response to that.

Garrett endeared himself to me in the first paragraph of the first page of the book in which he said (with no false modesty evident here or in person in our seminar) that "I make no claim to have invented a new therapy." To which let all the masses say: Amen! Alleluia! Blessing and Glory and Thanksgiving Be to Our Author! Later, at the end of ch.1, he will further outline a second important caveat that "I make no claim that the approach outlined in this book will be useful with all patients" (p.26). 

Instead of attempting to invent something de novo, he says his approach in the book will be to "fix two existing therapies together" (p.1). This he does by drawing in a careful and respectful way on longstanding training in both CBT and psychoanalytic methods. For those who are immediately nervous about such an approach, which has been attempted in the past by some apologists for therapy "integration," and often seems to end up trying to jam (one is tempted to write repress) dynamic ideas and practices into a Procrustean CBT bed, rest assured this is most certainly not Garrett's approach. He is, after all, first trained psychoanalytically long before he did CBT training. And second, he's married to the incomparable Nancy McWilliams (to whom he dedicates this book), arguably one of the great psychoanalytic psychotherapists practicing today in the anglophone world, whose praises I sang here. 

Aware that pulling two traditions together, especially in service of psychotic disorders, may seem a tall order, Garrett rightly says that "psychotherapy for psychosis should be ambitious" (p.1, his emphasis), and a little later on notes that the lack of ambition means many, perhaps most, patients are drugged and given little beyond that to help. Their suffering is relatively unabated by clinicians who are not ambitious enough on their behalf, seeking little more than symptom control via neuroleptics.

Garrett's approach is, as noted, twofold, and in the book and seminar he noted that it is usually important to begin with CBT methods in the first phase of treatment to try to "examine the literal falsity of delusional ideas" before trying, via psychodynamic methods and theory (especially that of object relations) to "examine the figurative truth (specific personal meaning) contained in psychotic symptoms" (p.2). Garrett thus takes his place alongside others we have noted on here who believe that "psychotic symptoms are a symbolic expression of the psychotic person's mental life" (p.3). 

In putting CBT and dynamic practices together, he will later argue in the book that there are "many differences of terminology rather than substance" (p.24). His one caution about integrating them is again the timing, noting that a weakness of dynamic therapists is to interpret the unconscious meaning of symptoms too early in the treatment. Doing so before a well-established foundation of trust is laid means that the therapist is likely to fail to help for the simple reason that "it isn't a clever point of logic that proves the delusion wrong and wins the therapeutic day; rather it is the patient's trust in the therapist" (p.25). 

Also in the introduction Garrett notes that as a prescriber he is not opposed to neuroleptics, but he rightly insists we should be aware of at least two things: first, that "the longitudinal data indicate that in the majority of patients long-term neuroleptics do not restore premorbid functional capacity" and second that "some individuals can recover without medication" (p.4). If treatment should be ambitious, then it should be open to using drugs where necessary, but even more it should be committed to long-term intensive psychotherapy for the latter lacks the notoriously nasty side-effects of neuroleptics. 

To argue for such intensive therapy requires that we counter the "discrediting myths about psychotherapy for psychosis," which he does very smartly and without polemics or fireworks in the the last half of the introduction to the book. I will not repeat those arguments here for I am utterly convinced by them and would regard their demonstration as tedious. But for those who are less convinced (e.g., most of mainstream psychiatry it seems), this is important reading.  

The first chapter begins with challenging head-on another excuse for avoiding psychotherapy with psychosis: that it is too difficult. Au contraire, he says: "it is doable and is often no more difficult than psychotherapy with people who have severe personality disorders" (p.17). I would second this based on my limited clinical experience. I find psychotic disorders more straightforward than the histrionic and borderline conditions I have attempted, with little success so far, to treat.

The chapter ends with Garrett saying something that I find so refreshing about work with psychotic patients: their directness and earnestness. "When a psychotic person talks in earnest with a clinician, there is no idle chit-chat...[or] half-truths and social niceties....The conversation is densely meaningful" (p.26). I find this very true, which is why I find myself greatly looking forward to seeing my psychotic patients.

Ch.2: "Biological and Psychological Models of Psychosis" does not pretend to be exhaustive, but it is wide-ranging and fair-minded enough to give readers with little background a good introduction to various theories. Like other authors, he notes that psychosis often begins with a prodromal period in which things begin somehow to feel 'off.' (This put me in mind of Christopher Bollas' image of When the Sun Bursts which I discussed here.) 

The prodromal phase may, he told us in the seminar, be brought back to mind in taking a history by asking such questions as "have you noticed any changes in the way your thoughts come to you lately?" Often, he says, patients "hear" their thoughts more than think them per se. Often, too, this phase is marked by a more intense awareness of the environment--its colours are more intense, or its suns and planets (cf. Bollas) more prominent in odd ways. 

In putting this chapter together, Garrett ranges widely, back to Harry Stack Sullivan and Karl Jaspers. An important sign of this prodromal phase, Garrett says, may be found in patients who report no longer thinking their thoughts, but instead "perceiving their thoughts." This, to put it into Fonagy's terms, could be described as a collapse of any ability to mentalize. Or to put it in Lysaker's terms--with which Garrett shows some familiarity at several points in the book--we see the inability to engage in any sort of metacognition. (One of these days, dear longsuffering reader, I will get around to writing about Lysaker's very rich and dense book, which I read nearly a year ago now.) 

As for the question of how to define psychosis--is it a 'disease' that is 'other' than or radically breaks with, common human experience, or is it on a continuum (Ophir's book examines these issues with great skill), Garrett reviews the evidence that "roughly 20% of the general population report transient psychotic experiences of some sort, which indicates that psychotic states exist along a continuum with ordinary mental life" (p.46). I like to scandalize my students by following Bion and altering Freud's famous phrase to say to them that the dream is the royal road to the psychotic mind, and to the extent we all dream, we all experience our own 'psychotic' minds. If nothing else, this claim of mine usually momentarily rouses the sleepers and Instagramers in the back of the room to raise their heads to lodge some desultory protest ("Whaddya mean we're all psychotic?") I laugh at with a little bit of smug sadism. 

Ch.3 advances Garrett's argument that psychosis is "an autobiographical play staged in the real world" (p.58). As compelling as I found this metaphor upon initially hearing it, I challenged him (in an amicus curiae sort of way) in our seminar, saying that I found Bion's argument about "Attacks on Linking" very powerful, and to just that extent wondered how a psychotic patient could link together his or her life in such a way as to mount a play that an audience could follow with some coherence and facility. In our exchange, which was very helpful and cordial, he was able to 'rescue' the metaphor, as it were, by suggesting that the play might make sense and cohere, more or less, to the patient, but of course would do so far less to the 'audience' (clinician, etc.). The job of the clinician, then, is partly to help the patient recover the ability to make sense not just to himself but especially to others, thus overcoming much of the profound isolation that so often marks psychotic disorders. In other words, the recondite meaning of the psychotic play needs, via psychotherapy, to become gradually more and more apparent and understandable to others. 

Also in this chapter Garrett advances his argument that delusions of grandeur exist in part to "fend off self-hatred and shore up self-esteem" (p.68). Thus, instead of rolling your eyes (as Garrett of course rightly said in our seminar a good psychotherapist should not do) at a patient who reports being a messenger of the divine, or perhaps even God himself, we can instead see this as valuable material, testifying to how little self-regard the patient has for him/herself: the more grandiose the delusion, perhaps the more depleted the sense of self.

Following the same logic, MG later in this chapter says that command delusions point to ambivalence in the patient: if they are uncertain about about a course of action, the delusion might resolve this for them in a kind of 'absolutist' way that you can decipher to find the uncertainty behind it. In other words, the more demanding the delusion, the more there might lurk ambivalence and confusion behind it in inverse proportion. 

On the topic of delusions, our seminar noted that one key hallmark here is the background becoming foreground, and things usually not noticed in daily life (e.g., the particular colour of cars in a parking lot) become hyper-salient details, perhaps revealing hidden meaning (apophenia). In addition, any sense of self disappears into the background and thoughts are no longer something I have, but malignant and persecutory outsiders that come to me unwanted and unbidden. 

Finally for this chapter, MG notes that any thespian metaphors are time-limited and prone to instability: "clinicians should not regard psychosis as essentially a static mistaken idea or cognitive bias. Psychosis is more like an ongoing improvisational drama, with unexpected twists and turns in the plot and an expanding cast of characters" (p.82). 

In Ch.4 MG notes that an important thing to keep in mind is that figurative language is almost always replaced by very concrete language and metaphors. We will return to this point later.

Well, that's it for now. I hope to finish the book in December and post the next part then.

Some Thoughts on the Death Drive

 I was moderately heartened to see that as the centenary of the publication, in 1920, of Freud's most neglected and professionally disliked book, Beyond the Pleasure Principle, approached, we saw a renewed interest in its most controversial idea: the death drive. The sputtering bewilderment proffered by psychoanalysts and others in the face of this theory finally seemed, after a century, to be giving way to some actual substantial engagement with Freud's text--albeit mostly by non-clinicians. The fact that anyone, clinician or otherwise, reacted so strongly to this theory has long been itself bewildering to me for evidence of a human propensity towards repetitive self-destruction (and the unconscious pleasure, or at least purpose served by such destruction) seems constantly on offer in consulting rooms around the world, and in so many other places.   

I do concede the point that part of the reaction may have been to Freud's suggestion that the death-drive might in fact be an actual "biological" drive. Unlike some, I think you can leave that out of Freud's theory without fatally (!) weakening its overall claims. 

The fact that discussions of Freud's notion of a death drive, which were few and far between even while Freud was alive, and were often politely ignored by much if not most of the psychoanalytic establishment for decades after his death, have taken off nearly 80 years after his death puts me in mind of Adam Phillips' argument from some time ago that the best time to re-examine Freud is precisely now, when nobody thinks much of him anymore and there are fewer and fewer professional establishments rushing to "protect" him from being critically scrutinized, or rushing to enforce some orthodox line or other:

This is certainly a good time for psychoanalysis: because it is so widely discredited, because there is no prestige, or glamour, or money in it, only those who are really interested will go into it. And now that Freud’s words are so casually dismissed, a better, more eloquent case needs to be made for the value of his writing ("After Strachey," London Review of Books vol. 29 no. 19, 4 October 2007, p.36) 

So scrutiny is returning to several parts of Freud's project, but noticeably his late-period "cultural works." Thus, earlier this year, as I discussed here in some detail, there was Benjamin Fong's fascinating new book Death and Mastery: Psychoanalytic Drive Theory and the Subject of Late Capitalism.

And before him, in 2013, in one of the most richly provocative books I've read in a long time, there was Todd McGowan's Enjoying What We Don't Have: The Political Project of Psychoanalysis, which I discussed in detail in three parts when I was attempting to demonstrate that much psychoanalytic thinking should be welcomed by theologically minded Christians, especially Catholics. 

In addition to Fong and McGowan, nobody has written as much about the death drive as Todd Dufresne, whose works I have enjoyed and through whom I discovered the wonderful work of his Doktorvater, the late Paul Roazen.

Roazen's Meeting Freud's Family is a thoroughly charming book. His Freud and His Followers was a groundbreaking and controversial work which fills in very important gaps in the historiography. And I have found his Encountering Freud: The Politics and Histories of Psychoanalysis useful in surveying what religious and theological responses were made over the history of psychoanalysis to the 1990s.

Dufresne's work on the death drive is found first in his Tales from the Freudian Crypt: The Death Drive in Text and Context and then, more recently and succinctly, in his introductory essay to the Broadview translation of Beyond the Pleasure Principle. It is the Broadview translation that I require of my students when I assign this text in classes. 

To my enormous surprise and puzzlement, neither of these books shows up anywhere in one of the heftiest recent books devoted to the topic, Repetition, the Compulsion to Repeat, and the Death Drive: An Examination of Freud's Doctrines, co-authored by M.A. Holowchak (a philosopher) and Michael Lavin (a clinician) (Lexington Books, 2018, viii + 163pp.). It is a very useful, crisply written, and largely clearly argued work.

 There are several virtues to this book, including its relative brevity, and the arrangement of each chapter, which aids in reading. More broadly the book will be useful if it is received as the history it is, tracing out the trajectories of the concepts of repetition, compulsive behavior and thinking, and the death drive across the Freudian canon. As such it goes back to 1895 and Studies in Hysteria, co-authored by Freud and Breur, and then forward past Beyond the Pleasure Principle to works in the last period of Freud's life, often referred to as his "cultural" or "meta-psychological" period. Along the way it also notes such "watershed" publications as Freud's 1914 paper, "Remembering, Repeating, and Working Through" as well as his essay on anxiety from 1932, by which point he seems to have moved from the very tentative and speculative writing of Beyond the Pleasure Principle 

Further virtues include the fact that this is neither an attack on Freud--though it advances important, serious, and considered criticisms of his theory--nor a glorification of him enforcing a certain "orthodox" line. It agrees with Freud in places, argues with him in others, and gives evidence in still others for where Freud may have been wrong, or subsequent research does not bear out his often highly tentative and speculative claims in Beyond the Pleasure Principle. 

On the latter score, it notes problems with Freud's attempting to find phylogenetic evidence for a death drive and compulsive repetition. The question remains: can his theory be rescued if the evidence he claimed to find for it in the biological sciences does not exist, or can be explained by other theories? In answer to that question the authors diverge somewhat, and candidly acknowledge this in the conclusion. For my part, I see few problems in separating out and sustaining most of the theory from insufficient "natural" evidence, and again the authors seem--albeit somewhat uneasily--inclined to agree, especially in a clinical setting, noting that clinicians rarely take their theory pure and whole.

All that having been said, the drive to destroy, including the self, is often a repetitive one, and we are faced with the question of why that is when such a drive brings terrible anguish, suffering, and consequences to the self and to others. Part of the answer may lie in the fact that the drive for pleasure and the death drive are not always operating in mutual and exclusive opposition. As the authors admit flatly, "eros and the death drives do not function independently of each other" (85). In fact, one of Freud's key insights here and in other areas was the admixture of experiences and emotions. In this light, one can, as he himself wrote, find in destructive repetitions the "pleasure of mastery or revenge," including against childhood traumas, enemies, or frustrations.

Such an understanding also goes some way towards accounting for what is perhaps Freud's clearest clinical evidence for compulsive repetitions and self-destructive behaviors: the regularly observed fact that patients get bogged down in treatment, and come actively to undermine the very thing that may help them get better through attacks on the therapist and the therapeutic alliance. In this regard, as D.W. Winnicott put it, attacks on a therapeutic analysis may be understood to reflect the fact that for many of us, "health is much more difficult to deal with than disease." In our perverse ways, we like being sick, we like being punished, and though we do not always admit this to ourselves consciously, our unconscious repetitions-in-action bear this out.

By chapter 6, it seems the authors' patience is wearing a wee bit thin, as they sum up the "view in the secondary literature...that the death drive creates more problems than it solves" (98). I think this overstates the case and the authors themselves have not provided absolutely conclusive evidence to support this judgment. Moreover, they fear that Freud's insistence on the death drive runs the "risk of throwing his metapsychology into a state of chaos" (108).

Here is precisely the point where an engagement with Todd Dufresne, mentioned above, would have been crucial. Dufresne's argument is that BTPP is a deliberate act of sabotage on Freud's part, undermining his theories of sexuality and much else. As Dufresne puts it, "metapsychology subverts psychoanalysis," whether "playfully or otherwise," inflicting from a position within the movement a "trauma" on psychoanalysis. 

Dufresne does not elaborate much on why he thinks Freud may have done this, but I would speculate--following Adam Phillips--that this may have been done precisely to keep the analytic movement from becoming a closed, rigid ideology with enforced orthodoxies and a putative epistemological omniscience. Already there were clear signs of this (some of them demanded, or at least supplied, by Freud himself!) before the great man's death in England in 1939. Alas, they seem only to have gotten worse after his death. If psychoanalytic institutes today complain (as they have for years) of their declining fate, much of the responsibility for that is entirely their own for they have too long been hidebound places demanding loyalty to certain orthodoxies that Freud himself was more open to questioning. (One of the virtues of Roazen's scholarship is the documentation it supplies whereby Freud was often rather free-wheeling in his own clinical practice, but often much more strict in what he recommended in writing.) 

Freud was certainly aware of the dangers in this direction (and had himself on occasion contributed to it), especially if analysis remained in the hands of psychiatrists or other medical doctors alone. He was forced to address this problem in 1926 in The Question of Lay Analysis, a work I would also see (as, again, Adam Phillips has) as pushing back against analysis becoming a closed system with a closed caste of expert "professionals," especially if those medical professionals were Americans, of whom he thought very little and whom he regarded with enormous skepticism. Such a resistance reflects Freud's own compulsive concerns in some ways, for he was clearly desperate for respect and acceptance for most of his life, but late in life seems to have come to regard such desires with disdain and begun to resist them and call for others to do likewise.

In the end, Holowchak and Lavin conclude there is not a lot that can be salvaged from Freud's death drive, but they do themselves a great service by noting that many other prominent analysts, including Klein, Lacan and Laplanche, disagree with them. Laplanche, it seems to me, takes the most sensible route forward by arguing that if the theory is stripped of biological concepts, if it is seen as exclusively human, and if it is seen as operating not independently but bound up with other drives and desires, it can be rescued. This remains my own view (for whatever that's worth). I will say more about it in later reviews of some of the other books on the death drive that have been helpfully published in the last 3 or 4 years. 

Self Psychology and Psychosis

While looking for something else--as so often happens--I stumbled upon this useful little book by Ira Steinman and David Garfield: Self Psychology and Psychosis : The Development of the Self During Intensive Psychotherapy of Schizophrenia and Other Psychoses (Routledge, 2019), 192pp.  

Steinman (whose website is here, with some excerpts of his writing) trained with R.D. Laing and for a time worked at Chestnut Lodge. Garfield is also a psychiatrist and psychoanalyst, recently retired from the Chicago Psychoanalytic Institute. Both have teamed up to write a book that usefully agrees with other similar treatments, including those of Atwood and Bollas, already noted on here, and then especially with Bion in particular. At the same time, however, this jointly authored effort also differs from other treatments in bringing to bear aspects of self-psychology, most of them drawn from Heinz Kohut. 

I have several of Kohut's books, and have struggled to profit by them. The fellowship I did at the Chicago Psychoanalytic Institute in 2018-2019 helped break down some of his thought and make it somewhat more clear; but one always feels the need to keep a glossary close at hand because he uses, in some cases, ordinary language in quite singular ways and it is easy to misunderstand him when he does this. 

Since I'm mentioning him, let me also put in a plug here for Charles Strozier's excellent biography, Heinz Kohut: The Making of a Psychoanalyst, which I read several years ago. I owe several intellectual debts to Strozier (a Harvard-trained historian as well as practicing psychoanalyst), who was very kind in sending me drafts of papers and reviewing some of mine. It was also he who introduced me to the invaluable work of Vamik Volkan, whom I have previously interviewed on here, and whom I will again interview early next year when his new book Schizophrenia: Science, Psychoanalysis, and Culture appears, jointly authored with his son. 

But back to Steinman and Garfield, and their useful contribution to the literature. They begin with a few caveats we would do well to recall:

Some Initial Caveats and Requirements:

First, psychosis is not a unitary phenomena. Patients still retain all their uniqueness here as elsewhere. So do not make lazy generalizations, assuming that you've "seen it all before." Equally, do not assume that some successful piece of work in the past may stay in the past, or some issue you feel the patient has overcome will not re-appear. Here both authors remind us of the basic principle Freud first articulated: in the unconscious mind, there is no time. And schizophrenia is especially adept at destroying a coherent sense of temporality. 

Second, at every stage as you are working with these patients, the key thing is hope. If you can confidently but carefully cultivate some hope, that will aid both the working alliance and also the overall progress and prospects of the therapy. 

Learning to Speak Schizophrenese: 

These two authors echo what others have said about making the effort to understand the patient's use of language and symbolism, and impairments to the same: "One extremely important factor in my work with very disturbed people is the importance of understanding a patient’s symbolism, as contained in hallucinations and delusions. A good working alliance aids in helping the person make sense of confusion and distortions of reality. The closer one gets to the 'lost heart of the self' the easier it is to make sense of previously indecipherable and upsetting material" (p.xxi; the internal reference is to Guntrip).

Whereas some clinicians have dismissed, often patronizingly (as I have heard directly in one consult I was part of years ago) the schizophrenic patient's language and symbolism as the notorious "word salad," these authors insist--rightly in my view--that "speaking schizophrenese, making sense of psychotic productions, is the glue that makes therapy with the most disturbed work" (p.xxi). Neither here nor at any other point in the book do they downplay how difficult this can be in some cases, and how much patience is required by the psychotherapist over the long haul. But the therapist is helped by understanding that hallucinations and delusions are like a loud-hailer or sound amplifier for the self, perhaps especially the fragmented and painful parts that are projectively identified with external objects. 

How could one go about understanding those objects and their meaning? How could one begin to enter into a world that seems fragmented, confused and confusing, perhaps even hostile and bewildering? Here they turn immediately to the founder of self-psychology in this country: "Kohut suggested instead that through 'vicarious introspection' the analyst must look inside and find 'a taste' of what the patient is experiencing" (p.xxv) This is very similar to something Christopher Bollas has said about seeking to find the lost patient, and discovering that something of him is hiding within the therapist.  

The Paradoxical Protections Offered by Delusions and Rages:

For Kohut destructiveness and rage are the products of a disintegrating self that has sustained some injury. They thus have quite a "thick" meaning, as it were, and one must work carefully in trying to disarm the forces of destruction and rage without leaving the patient feeling overwhelmingly vulnerably exposed. Delusions are "both fragile and rigid" (p.104). Their rigidity has been helpful in giving even a minimal sense of security to the patient and holding back a totalized experience of fragmentation. Thus these authors recognize later in the book that "a delusional system is a compensatory structure that prevents fragmentation" (p.98).

In addition, delusions and fantasies have a self-protective, self-soothing or self-enhancing purpose and taking them away may have serious unintended consequences. Frontal attacks--and this seems a point of universal consensus so far in what I have read, which admittedly is not much yet--on delusions are a complete waste of time, and may in fact backfire. It is within the working alliance, and the transference, that you may begin to help someone see that their views are mistaken. As they come to mentalize more, and to understand things from a second-person perspective, the hold delusions have may begin to lessen. 

One tip the authors offer here is to take a history from the delusional figure. E.g., in one fascinating case they discuss, a woman believed she received messages from a "Good Angel.” Alright. So ask that angel for its history, then. How did it grow and develop, at what point, and in what circumstances? What purpose is it trying to fulfil? As you seek out all this material, gaps ("epistemological trauma," in Atwood's words, discussed here) may emerge in the history, or purpose, or message, that can be usefully wedged between the patient and the delusion. 

A great deal of case material makes up the book, and I will not annotate that here. I would, however, encourage interested readers to peruse it for themselves.

Instead let me turn to an earlier work of just one author, Ira Steinman, and his 2009 book from Karnac in London, Treating the "Untreatable": Healing in the Realms of Madness.

Steinman beings autobiographically, but with a searing self-criticism that extends and applies to his guild, as well. Here and elsewhere he will criticize American psychiatry, as he already telegraphs in his title and its dismissive labeling of schizophrenics as "untreatable." He tackles this bogus charge at the outset of the book: 

I have found over the last 40 years of psychiatric practice, however, that a number of these allegedly 'unresponsive' and 'untreatable' severely disturbed patients, diagnosed as suffering from schizophrenia, paranoid delusional disorder and multiple personality disorder, have responded to an in-depth exploratory psychodynamic psychotherapy. In a number of cases, antipsychotic medication has been titrated down and stopped (p.xiv).

He returns to the self-criticism in the last chapter, which frankly and critically admits US psychiatry is to blame for abandoning schizophrenic patients and psychotics and regarding them as untreatable, and thus justifying itself in not treating them at all. Such criticism is advanced without any self-righteousness. If anything, Steinman is at pains to stress that there was and is nothing fancy or heroic about what he did and does: he simply offers plain old psychotherapy to help patients find meaning behind terrifying voices, hallucinations, etc. And space to begin to integrate and defragment. 

After some introductory material, the book is largely made up of case material drawn from about 12 schizophrenic or delusional patients. 

That introductory material includes several useful bits of advice: 

Dreams:

Like numerous other authors (perhaps none so clearly and forcefully as the psychiatrist Andrew Lotterman in this excellent and useful article), Steinman notes the importance of one part of the counter-transference in particular: your own dreams. He suggests that useful dreams you have about your patient may be judiciously shared: patients tend to like that you think of them outside sessions, and these dreams can often illuminate certain things or open up good lines of exploration. 

Patience and Hope:

Again we hear sounded the refrain that the patient isn't the only one who needs patience! The clinician must keep in mind that, in most cases, "the period of psychotherapy aimed at helping the patient overcome a schizophrenic or delusional orientation will be a long and arduous one, with change measured in infinitesimally small increments. Long intervals of seeming stasis must be tolerated by both patient and therapist in the face of what may appear to be gridlock, if the process is to bear fruit" (p.8).

Steinman firmly believes an intensive psychodynamic approach works, and his book is evidence of that. The overall task consists, in part, of proving Freud right: Where id was, there shall ego be. That is all the more important in schizophrenic patients whose ego seems barely intact and needs a great deal of clarifying and strengthening. And such tasks, Steinman notes rather scornfully, cannot be done, and are not done, by so-called supportive psychotherapy, which he regards as often useless: it doesn't touch the underlying psychic conflicts and pain, leaving the delusions fresh untouched terrain to ravage and revisit. 

The Nature and Purpose of Delusions:

Speaking of delusions, he sees that they are usually a sign of great pain and terror. It is easier to believe you are Jesus, or to live in fear of Mafia, than acknowledge internal pain and terror that both delusions mask. Thus delusions have a function, and often he sees that as being "a creative compromise," albeit often unrecognized as such (p.3). This makes giving up delusions hard if it means being in contact with a painful reality.

Methods:

How does one go about doing that--beginning to move past delusions? Here as elsewhere the alliance is key; the setting is also important as a holding environment where, bit by bit, patients may feel safe and supported and open up. Steinman elaborates, however, noting that "the patient’s trust in the therapist and in his reliability as a consistent object, although extremely important, is not sufficient by itself to help the patient through the morass of delusions and psychosis......Clinical improvement occurred only when a more interpretive, psychoanalytically oriented approach was attempted" (p.26). So do not just hold and soothe, but work! 

More concretely he offers us the following methods:

1) Get a good history! Find out when psychotic material began. Also, here or later, take a history from the delusional figure. E.g., Judith's Good Angel: what was the angel saying, why, and when did it start? Can the angel answer unexpected questions put to it, or does the angel begin to fall apart? 

2) See what meaning this material--delusions, etc.--has. This goes to the book's fundamental "conviction that delusional and psychotic behaviour not only had unconscious meaning to the patient but could be made understandable to the patient in the form of a healing exploratory dynamic psychotherapy, in conjunction with antipsychotic medication used in a judicious fashion" (p.185).

This latter point bears underscoring: Steinman, and virtually everybody else I have read so far, is not against the judicious use of anti-psychotics--though he argues very strongly that it is possible for these to be titrated downward for some, and in others eventually to be discontinued entirely without relapse of symptoms. 

3) Reconstruct the feelings behind the origins of the psychosis, delusion, etc. 

4) Slowly move towards the hurt, undefended lost heart and inner core

5) Let them sit with their rage, hurt, abandonment.

6) Transference reactions not only happen, but are usually more extreme. This, in itself, can be revelatory to patients, as they can gradually come to see their reaction is disproportionate, and to begin to wonder why. One memorable example he gives here is that his own calm and containing presence sometimes provoked rage in those who had no such thing and were jealous: they tried to up the ante with violence towards him. 

A Quick Word on Self-Care:

You must have time and plenty of interests away from psychotic patients. (I have only two patients at present with psychotic symptoms, and I enjoy them hugely, but I have realized that--as with victims of sex abuse, whom I also treat--I could not have a full practice devoted just to them for it would become exhausting and overwhelming.)

Finally, I would note that Treating the "Untreatable" contains an Appendix that sums up lots of international studies on recovery rates from schizophrenia. Keep this close to hand for those impertinently crowing about how their preferred treatment is "evidence-based" while psychodynamic psychotherapy is not. 

Psychotherapy for Schizophrenia

Continuing on with an exploration begun here, I turn now to two other works devoted to schizophrenia. I think it was Mark Ruffalo who again was helpful in recommending further resources to read about psychotherapy for patients with schizophrenia, including this book Psychotherapy of Schizophrenia: The Treatment of Choice Hardcover by Bertram P. Karon and Gary R. VandenBos (Rowman and Littlefield 2004/1981), which I discuss first before turning to Harold Searles. My approach to both books is very modest: what might I learn from them that may be useful in clinical work? 

The authors start from a premise I fully share, but which many others, alas, seem not to: "the schizophrenic patient is treatable. He or she may not be easy to treat, but is not impossible to treat" (p.33). 

Several times in the book the authors clearly seem to suggest that one cause of schizophrenia and psychosis may be massive childhood trauma, asking rhetorically (p.40) of one of the patients they see (a young man choked by his mother and repeatedly anally raped by his father), "wouldn't anyone be psychotic living such a life?" 

Language:

These authors, along with others discussed previously, and with Searles below, all seem to believe that under stress the schizophrenic patient (henceforth: SP) may revert to using language in a way more typical of earlier life, or in a dream. The SP's thinking can alternate between concrete and abstract according as which best protects against anxiety. 

If you encounter the infamous word salad and regard it as incomprehensible that is only because you've not yet made the effort to understand it! 

Hallucinations and Delusions:

Even more strongly than some of the other authors reviewed on here, these two recommend that you seek to understand hallucinations as Freud did dreams, but even more so given the motivation required to produce a dream while awake: "the hallucination has exactly the same structure as a dream" (177). Treat it as such, inviting associations and linking it to the pt's life. These can in fact be easier to interpret insofar as the pt. has worked hard to produce the hallucination.

They also advise doing something similar with delusions: look at them through the eyes of the pt. What does it mean? What sense might it make in the patient's life? Be careful before labeling or dismissing something just because it's weird. Perhaps it's a lack of understanding of how something works. And don't be afraid to test out some of them (e.g., a claim that God will end the world in 5 minutes or whatever) if it is immediately possible. 

Lack of Feedback is to be Expected:

As with Searles and others, these authors recommend that you do not expect the SP to tell you that you are helping them lest that be used against them! The SP excels at non-communication. You must go for a long time without much useful or positive feedback. Do not, however, let this inhibit you. Don't be afraid to make mistakes--this will be helpful to a psychotic patient to see you are not omnipotent. Also don't be afraid to be spontaneous and a bit free-wheeling--much better this than being stilted and overly scripted. Whatever you do, be yourself: "Your tool in effective psychotherapeutic work will always be your own personality" (139).

Defusing Threats:

The authors argue that the SP feels multiple threats on many fronts, and you need to pay attention to them and try to defuse them, some immediately, and others over the long term. Immediately: "for many schizophrenic patients it is extremely useful somewhere in the first hour to say that you will not let anyone kill him (or her)" (p.153). Ongoingly: the SP is often one whose "consciousness...is dominated by the unconscious" (142). (See below for more on this under Ego Boundaries.) 

Perhaps most paradoxically, the one threat the SP fears is the very raison d'etre for the therapy: we are told that "the patient is threatened by the possibility that the therapist will take away the psychosis" (145)!

This leads into a wider issue in which the therapist needs to reassure the SP that the former is not a taker of anything. The typical SP has felt emotionally deprived his whole life. It is therefore very important that the therapist come across as "a giver, and not a taker and to be perceived as a nonpunisher and nonpoisoner" (165). This includes requests for information or co-operation: stress that this is only to be helpful to the SP. 

What is it that you, as clinician, can give? The authors say that there are many SP "to whom the therapist need only say 'All I have to offer you is understanding, but that is a really great deal' and they react to it as if he had offered them the Holy Grail" (167).

Freedom:

Perhaps that is a bit too ungenerous, however. For you also have the ability to offer the SP freedom These authors recommend that the clinician stress from the outset the freedom to talk about anything. Nothing is taboo. While doing so, however, it is important to stress, too, that thoughts and actions, and feelings, are different and one does not necessarily lead to the other.

Anger:

These authors note that Harry Stack Sullivan and Frieda Fromm-Reichman both thought problems with anger and loneliness in the schizophrenic were much more serious than sexual problems. Anger may come out in a projected hallucination because that is the only permissible way to deal with it. 

Insults and Threats: Interpret Upward!

Later this discussion of anger comes up again as "murderous rage" (189). Talking about this or other feelings makes it easier for the SP to see that it need not lead to action. 

If, however, anger and rage do manifest in threats and insults, these authors have an intriguing approach: interpret upward. E.g., "I want to suck your cock!" = "You must really admire me!" or "I'm going to kill you!" = "you must really think I'm important enough to bother getting rid of."

The final bit of counsel I took from Karon and VandenBos is one that is, of course, generally and widely applicable in psychotherapy with patients of all sorts and conditions: to learn to tolerate not knowing. Thus they counsel that "the therapist must teach the attitude of being able to tolerate not knowing. The patient needs to learn to live with uncertainty rather than leaping to premature closure" (p.246). (This is one lesson imparted to me many years ago by Nina Coltart.)

Let us turn next to Harold Searles and his Collected Papers on Schizophrenia and Related Subjects.

I came across Searles some time back--I cannot recall exactly when or how--but immediately found his writing on counter-transference enormously helpful ("Concerning Transference and Counter-Transference"). Indeed, Searles, together with Otto Kernberg and then especially Nina Coltart remain the three most helpful people I've found so far in trying to understand and untangle counter-transferential reactions to patients. 

Perhaps even more moving to me was Searles' 1975 paper "The Patient as Therapist to His Analyst," which I only found many years after my analysis ended but which immediately helped me to understand one particular part of it in ways I could not at the time nor for many years afterwards.  

All this prolegomena is but to say I come primed to like and learn from Searles in this book on schizophrenia, and there is a lot to like and learn from--indeed, rather too much. It is, after all, a collection of previously published works, and thus runs the very real risk, much in evidence in this book, of repetitions and redundancies that strain the reader's patience. A careful editor would easily have pruned at least 25% of what is here. 

But what is here is born of an admirable willingness to try to see and understand the reality of his patients without any attempt to fit them into a Procrustean bed of theory: as he says in the introduction, "To the extent that these papers contain valid insights, they are a measure of the degree to which I have been able to relinquish any preconceptions and allow my patients to convey these insights to me" (p.10). This is not just Searles congratulating himself in advance, but it is a view confirmed by R.P. Knight in his preface, where he observes that "There is no armchair flavour in these papers, and the reader often feels that he is being permitted to be a genuine observer of clinical work," a feeling I very much had throughout (p.17).

With these preliminaries out of the way, let us turn to some of the practical observations Searles makes. Given the vast swaths of material in this book, I simply offer some selected gleanings here as they struck me as particularly insightful or clinically useful. The reader will also note that I tend to highlight where Searles is in agreement with, or at least manifests substantial overlap with, Atwood, Laing, and Bollas in my previous essay. 

Mistakes and Limitations:

Searles notes early on--an entirely appropriate way to begin--that mistakes will come up and you may in fact be able to put them to profitable use, but with the caution that the schizophrenic patient (henceforth: SP) will more readily forgive a mistake of the head than of the heart. You need to be vulnerable with them, and that is not easy to do.

Later in the book he several times makes an observation that, to my mind, applies to every patient in any condition: "One cannot formulate detailed rules which are applicable to the complex and changing conditions of a therapeutic relationship.. Nevertheless, as he continues a little later on the page, "there are several general principles which I have found to be consistently useful guides" (p.139).

One such principle is to remember the frame and humbly acknowledge what you can and cannot attempt to do--with an SP or any patient, it seems to me: "The therapist's major task is not to attempt to make up to the patient for past deprivations, but rather to help the patient to arrive at a full and guilt-free awareness of his dependency needs" (ibid). The best way to be able to do this is if "the therapist can freely accept his own human limitations, he can help the patient to relinquish his infantile omnipotence and accept his human dependency needs" (p.140). (That theme of omnipotence and its destructive potential is much observed in many of Adam Phillips' books, too, I would note in passing.) 

Dependency:

Searles argues repeatedly in much of the book that this theme of dependency may be one of the most central in schizophrenia, and may manifest itself pathologically: "Every schizophrenic possesses much self-hatred and guilt which may serve as defences against the awareness of dependency feelings" (p.116). What to do with these needs? Searles returns to this problem later and says you should neither gratify nor reject, but investigate. 

Signally, this hatred of dependency may manifest itself in what he calls "competitiveness and contempt" toward the therapist. Such feelings may also lie behind a sudden request to change therapists after months of work: you may then be on the cusp of a breakthrough which the SP finds intolerably anxiety-provoking and wants to shut down by means of removing the therapist, requiring, if the request is granted, a rewinding of the clock. As Searles puts it much later in the book, the SP is threatened by change and any idea of progress (p.461).

Compulsion to be Helpful: Watch the Counter-Transference!

Searles spends time on the anxiety aroused in the therapist whose own dependency needs are awakened in the counter-transference, which, he says, is found after a while in just about all therapists working with SPs. For both patient and therapist, these needs may be very early, almost primitive. 

For the therapist, this will show up in a "compulsion to be helpful" and a feeling of guilt that the therapist is not. This may be a disguised attempt to avoid feeling the patient's unmet dependency needs in the transference. It may also threaten the therapist's felt need for omnipotence, leading to a cycle of guilt over not meeting the patient's needs. However, Searles says in a very reassuring passage, "there is much evidence to indicate that it is this very problem with regard to infantile and early- childhood dependency needs which forms one of the strongest motivations, in therapists, for undertaking this kind of work and for persisting in it" (p.133). 

On Sexuality:

Exploring sexuality as a thread from infancy onward can "help to link otherwise patternless data and to reveal continuity" (429). 

For some, perhaps many, SPs who are precariously integrated, the experience of "being possessed by sexual lust, such as is so essential to orgiastic experience, is frighteningly similar to being possessed by--their behaviour uncontrollably governed by--introjects from one source or another" (436). As a result, the SP may live chronically under the threat of these "distorted representations of people which belong, properly speaking, to the world outside the confines of his ego, but which he experiences--insofar as he becomes aware of their presence--as having invaded his self" (467). 

Neither Too Much nor Too Little:

Don't be a literalist, and allow time for silence so that the pt. can expand upon his symbolic understanding of contents. A voracious curiosity by the therapist will threaten the patient. Thus you must finely judge how and when to probe or ask for more detail. You must be even stingier and abstinent with volunteering your own thoughts.

At the same time, however, Searles says you need to avoid smothering, permissiveness, etc. These are not helpful. Sometimes firmness is. Concretely this means that you should not accept violence or outbursts leading to it. SPs, he says, generally loathe the therapist who lets them get away with these things. 

Towards the end of the book, Searles further notes that "the schizophrenic patient needs from us not only the kind of intense emotional responsiveness which makes for comparatively dramatic clinical papers, but an equally liberal measure of neutral, and related, responses: responses of inscrutability, imperturbability, impassivity and, on many occasions, what can only be called indifference" (p.637). Earlier in the book he recounts a rather amusing case where indifference to a patient's hostility proved to be the turning point in a breakthrough. 

Ego Boundaries and Unconscious Processes:

The ego boundaries of the SP are so incomplete that they can be the recipients of massive introjections as well as initiator of massive projections: the "schizophrenic experience and behaviour consists, surprisingly frequently, in the patient's responding to other people's unconscious processes" (p.192) so that any conscious sense of self is highly porous, fragmented, and confused. It should not, therefore, surprise us when the SP manifests a delusion of being "magically 'influenced' by outside forces (radar, electricity, or what-not)," for such a delusion "is rooted partially in the fact of his responding to unconscious processes in people about him (p.192). Thus, Searles notes later, the SP is often impaired both with regard to ego integration as well as differentiation (304). 

On Communications and their Contents:

Given such fragmentary and porous ego boundaries, the SP's forms of communication often manifest the following defense mechanisms:

displacement;

projection;

introjection;

condensation;

isolation; and 

Fragmentation: skipping words, etc. this may reveal a very fragmented interior life. Searles recounts one case of a girl who, asked to read the writing on a bubble-gum wrapper, selectively skipped several words in each phrase/sentence but did so in a way and reflecting a pattern he would only later discern. 

All this often takes place in highly regressed people who have not matured to the stage of differentiating between metaphorical/symbolic and concrete thinking. As a result things are often highly disguised in part because the "archaically harsh, forbidding superego of the patient is another basic factor which helps to account for his heavily disguised and often fragmentary communications" (p.407). One way to understand such communications is to rely on your capacity to "bear intense and contrasting feelings" in both your preconscious and unconscious mind (p. 416).

Here, naturally enough, my mind returned once more to Winnicott's famous essay on "Hate in the Counter-Transference." In addition to Winnicott I also think of others (including once more Coltart as well, more recently, as Michael Karson), who counsel the therapist to know how to contain, channel, and sublimate your own aggression appropriately in service of the patient. 

Though Searles does not come out and explicitly recommend it (remember, he was writing many of these papers more than a half-century ago when analytic training was both widespread and absolutely premised upon years of an extensive personal analysis 4-5x a week) it is clear that a therapist working with SPs who has not had his or her own in-depth therapy is probably going to be of very little use here. The aggression and other bewildering emotions--the infantile dependency especially--may be overwhelming and intolerable if you have not plumbed your own depths. And even then it will not be easy-going which strongly suggests to me--though Searles does not say so--that getting good supervision here seems crucial. 

If I may interject an autobiographical note here, I would say that one of the lasting gifts of my analysis was a marked comfort with ambiguity and ambivalence, and a relatively serene awareness (to use a Jungian idiom for a moment) of the permanent nature of our shadow side. Moreover, I think--following Bollas again--that the whole notion of "madness," insofar as it has any coherent and transcendent definition at all (and I am not sure that it does), exists on a continuum and all of us move towards and away from it with some regularity. Some may find this terrifying, but I am not among them. 

One of the benefits of that analysis, as well as regular therapeutic work since then (remember that Freud recommended the therapist submit again to analysis every five years without fuss or shame--a regularly scheduled "tune-up," as it were) has been to create what I would call emotional kenosis to be at the service of the other in the consulting room. It is on this note that we read one more passage from Searles and thus take our leave from him:

Only if the forces of liberation and growth in the therapist are more powerful than those tending towards constriction, stasis, and psychological paralysis, can the patient by turn--partially through identification with the therapist--live, grow, and become progressively well (p.418).