Creative Engagement in Psychoanalytic Practice: Further Thoughts

(I wrote and published this on 9 September 2023; but learned colleagues on Twitter, especially Jayce Long and Kristian Kemtrup--always gracious interlocutors from whom one learns much--offered an important challenge to my principal critique of Markman and I saw at once how right they were, and how their argument about reading Markman's ideas of surrender through Emmanuel Ghent's crucially important treatment of the topic makes brilliant sense, largely dissolving my difficulty. I have therefore amended the review at the place noted below.)

Introduction:

I'd never heard of this author until perhaps May, and, perusing the book on Amazon, found myself mildly interested. But I then I reviewed a mss for Routledge this summer and agreed, as always, to take payment in books; and so, to get to the total amount allotted to me, I (somewhat diffidently) put Henry Markman's Creative Engagement in Psychoanalytic Practice onto my list of desired books.

Wow. Did I ever severely underestimate the wisdom in this book and the grace of its author. If one can judge the import and impact of a book by the intensity and extent of the marginalia (underlining, double-underlining, starring, check-marking, uncharacteristically promiscuous use of exclamation points, and writing commentary up and down the page) it inspires then Markman's book is at moderate-to-severe flood stage, not quite drowning in suitably green (is anyone else quite so weird as to coordinate the colour of their ink relative to the colour of the book's cover?) ink from my second-favourite fountain pen of all times, but close to it.*

For me the impact of this book is twofold: it has forced--is forcing--me to rethink some things, though I do not know if in the end I will be in complete agreement (in other words, questions remain, and the chief of those are to be found below); and then there is much of the book that confirms and strengthens the argument for certain "techniques" that I (a nobody of very minor achievements) have more or less just found myself falling into doing, without ever seeing these cited or taught anywhere. (Perhaps some of them have been repeated by me as a result of being unconsciously imprinted on me by both of my psychoanalysts?)

The contents of this book are impressive indeed, and the writing is usually excellent; but what is the most outstanding feature of all is the manifest modesty of the author. Given the title we might have expected some "creative" fireworks and some preening by the author of how unique his methods of engagement are. But in fact what the author proposes seems to me a sort of engagement that bears strong resemblances to Winnicott and Ogden and their offering of "ordinary good enough" care for the patient. (In a time when even the basics of psychotherapy seem to have been utterly degraded or never taught, I mean that as very high praise.) 

The biographical sketch at the bottom of the back cover only gives us the bare minimum. Inside, and very casually, the author also tells us he is a trained psychiatrist with wide and extensive experience in numerous settings. He has obviously read widely--Freud, Bion, Ferenczi, and Winnicott are the major interlocutors here but there are several others I had not heard of but am now seeking out. All this learning is worn very lightly, with the result that the book is a near-miraculous production: it lacks any indulgence in jargon or theoretical defensiveness. When reading it, I thought quite sincerely: Jonathan Shedler would approve of this book, for he has often--rightly--lamented how needlessly obscure much psychoanalytic writing is, a failing that Shedler totally avoids in his wonderful article "That Was Then, This Is Now: Psychoanalytic Psychotherapy For The Rest Of Us," copies of which I now give to our interns and my students. 

In addition to the clarity and cogency of the prose, this book also succeeds in demonstrating its independence of thought without being ostentatious or obnoxious about it. In at least two places it quietly makes a reference to "orthodox" thought or practice...and then even more quietly steps away from that with ample justification for independence of mind and practice. (In this he reminds me of nobody so much as Nina Coltart.) The book borrows, adapts, creates from across the various "schools" of analytic thought, intertwining all this with winsome reflections on the author's own clinical and personal development, and illustrated with material from his patients. Therein lies the creativity suggested in the book's title, which is not at all any sort of radical heterodoxy as far as I can see but instead a gentle pursuit of its own path.

In short, the miracle of this book is, I daresay, that even those with little or no clinical background could pick it up and immediately get a sense of how psychoanalysis and psychotherapy unfold with Markman, gaining insight into not just the patient's struggles, but how Markman is present with and attuned to them in far-reaching ways. 

The Contents:

Right. Down to business. I shall only comment on select chapters, leaving readers to encounter the others for themselves. My commentary is driven largely by the need to continue metabolizing this book, and also to air some real questions I have. 

The Importance of Play:

The author begins very promisingly when he recounts his early clinical experience with adolescents, and how this "changed how I worked with adult patients: I became more playful" (p.13). This, of course, is a very Winnicottian theme I greatly welcomed here. 

Equally influential was his own experience as an adolescent patient who found his analyst had a "warm, calm, and capacious presence" and this was a key part of the "transformation" he experienced: "I strongly felt his loving care" (p.14). 

This theme of love shows up in the first chapter: "Love is expressed in our desire to know, understand, and recognize the singularity of a patient in a deep way that fosters intimacy." This should not, he cautions, lead us into a facile belief about needing nothing more than love. "In fact, ongoing serious emotional work and self-interrogation are needed by the analyst" (p.23).

The Importance of Authenticity:

Ch.2 focuses on the authenticity of the clinician. Its epigraph is a well-known saying of Bion's about "the analyst you become is you and you alone." This, in turn, is a theme picked up by Ogden, as I noted here. Markman notes that authenticity and spontaneity are not license to do and say what you want--there is no "wild analysis" here. Everything is in service of our "care and empathic understanding of our patients" (p.46). 

On Embodied Presence and its Obstacles:

Ch.3, on embodied presence, opens by drawing on French thought--Marcel and Merleau-Ponty in particular. The former's thought on disponibilité has clearly captured Markman's imagination: "putting oneself at another's disposal" is the translation he prefers. This leads into a discussion of how one manifests such availability through presence in the session. Though he does not cite her and appears unfamiliar with her work, Markman reminds me here of Nina Coltart's reflections on "bare attention." Here he also briefly invokes Ferenczi on the "language of tenderness." 

There are, as the author recognizes here and elsewhere in the book, "emotional obstacles," as he calls them, to maintaining presence with our patients--and a fortiori a presence of tenderness one assumes. Here is the first of several discussions about such obstacles. In especially difficult cases, we may lose our sense of emotional equilibrium and thus struggle to maintain presence and attention. This is fairly commonplace, but the author presses the point to its (to my mind) most troubling extreme: those times when "we can be taken over by the patient's emotions and states, losing our analytic place, becoming ill with the patient for some time as described by Borgogno and Bollas" (p.67). 

On Going Mad with Our Patients: How Much and How Far? And: How Helpful? 

Others have also written of this, including Harold Searles and Philip Bromberg: what does it mean to say that with some patients you have to be willing to let them drive you at least a little bit mad? Markman argues that allowing yourself to get a bit sick, to go mad with the patient, can be "possibly...curative." (That adverb is bearing rather too much weight for me! And Markman never returns to this point to offer the fuller argument I think it very much deserves.) 

Lest this quickly degernate into idealism and omnipotence, and all the dangers inhernet in those two, Markman later on explicitly recognizes that "we cannot fully make up for the deprivations in our patient's childhood. A 'basic fault' remains. There is a limit to how much we can repair or restore in the patient" (p.85). Our acceptance of this "basic fault" (as Balint called it) can help the patient mourn it. 

How do we do it, and how does it help? Markman continues: "What use do we make of these emotions that help the patient? Paradoxically, by not resisting these states, by surrendering, relaxing, and living within them (i.e., containing them), we restore presence in ourselves and for the patient". Very similar language shows up again later on p.86, raising the same questions for me once again.

His use of "containing" here takes him into a brief excursus on Bion's use of that phrase, and Markman clarifies that containing = metabolizing. You take something in and contain it, and do not often give it back to the patient, at least not in the form you received it. Sometimes you may need to hold on to it permanently. 

This chapter's introduction of the importance of surrender and relaxation is discussed in detail in the next chapter, "The Analyst's Work of Surrender and Mourning." I read it the first time and felt almost stricken into silence. A few days later I re-read it, sent some comments about it to friends, and then tried to read more. Even now, my third or fourth tour through this chapter, it feels deeply challenging.

Markman says here that effective therapeutic presence requires "surrender ('internal relaxation') and mourning. Mourning is the struggle to give up and let go of attachments that protect yet constrict us--attachments that do not allow for openness to the patient's inner world, being with and living within their experience. This is not the scary prospect it may sound when contemplated directly and abstractly like this, Markman suggests: "we are permeable to the emotions of others, at times even before they are aware of their own feelings" (p.77). So we may be "surrendering" in some ways without making a fuss of it. He brings in Bollas and Borgogno on this point, suggesting that such surrendering is, in essence, the greatest and most intensive form of empathic identification with the patient. 

The Importance of Self-Forgetfulness:

This is not facile surrendering. Though Markman is not explicit on this point, he does seem quietly to recognize the risks and costs when he writes that "surrender is the necessary first emotional step. We give up the hard and clear boundaries that separate us from the patient, we give up our sense of control and surety....Mourning is the actual emotional work of letting go of such attachments that block surrendering" (p.82). A little later he is explict in seeing that such surrender and mourning brings with it "two painful states--loneliness and alterity." 

Why do this? A little later Markman again brings in Gabriel Marcel's thought to argue against being "'encumbered with one's own self'." There is, I would add here, a lovely and lively freedom that comes from being forgetful of one's own self (in, of course, non-masochistic ways). I think this is very much what Coltart had in mind in speaking (ascetically, I would argue) of "bare attention," attention that is forgetful by and of the clinician's self. Such an approach not only frees oneself up to do deeper and more effective clinical work, but to do so in a way, I would suggest, that allows for you to be used, used up, and even destroyed, as Winnicott put it in his profoundly important essay on "The Use of an Object," without suffering as much "collateral damage" in the process.  

On the Uses and Abuses of Masochism (updated):

On this question of masochism--about which he has authored a chapter elsewhere--Markman differs from Maroda later in the book when he outright says "we need to surrender to the particular and intense needs of the patient that may feel self-depriving, even masochistic" (p.192). 

Markman appears to justify this masochistic surrender by returning to Ferenczi, who apparently wrote that "'transformation of the patient depends unequivocally on the willingness of the analyst to be transformed in and by the analytic process'." (p.198) But Ferenczi says nothing here about masochistic surrender, and on this point I was initially unconvinced and somewhat disconcerted by this argument. I do wish Markman had developed this point in more detail.  

But after discussion with colleagues, noted above, much of my anxiety here is reduced by being reminded by them of Emmanuel Ghent's crucial distinction between surrender, on the one hand, and masochistic submission on the other. (Ghent, "Masochism, Submission, Surrender—Masochism as a Perversion of Surrender," Contemporary Psychoanalsis 26 [1990] :108-136.). I am inclined to give Markman the benefit of the doubt here, and thus to read him through Ghent and thereby feel much less anxious about his idea of surrender. But the remaining issue is: Ghent is nowhere cited in Markman's book--not in the text, notes, bibliography, or index!

Collapse of the Therapeutic Space?

Another important and somewhat disconcerting question Markman does not entertain here or anywhere in the book so far as I can tell is whether this process of surrender and mourning, leading to such intense indentification with the patient, does not carry the very real risk of collapsing the therapeutic space. There must, as Ogden has put it, be room for the "third." But the strong emphasis on mourning and surrender--which in the main I find deeply compelling and refreshingly challenging--almost seems to make the therapist too passive in some ways, perhaps too closely identified with the patient. 

Instead, I am far more comfortable with the kind of "split mind" that Nina Coltart advocates than I am with an emphasis on mourning and surrender that seems (unless I have severely misread this book) to run unnecessary risks of minds merging, as it were--of overidentification with the patient. (I am not opposed to surrender at all--this I long ago learned from Winnicott theoretically, and practically from my own psychoanalysis. And I firmly believe mourning is always a crucial component of therapeutic work with everybody.) In her words, we must at any moment in a session be engaged in:

sharply focusing, and scanning; complex involvement in feelings, and cool observation of them; close attention to the patient, and close attention to ourselves; distinguishing our own true feelings from subtle projections into us; communicating insight clearly, yet not imposing it; drawing constantly on resources of knowledge, yet being ready to know nothing for long periods; willing the best for our patients and ourselves, yet abandoning memory and desire; a kind of tolerant steadiness which holds us while we make innumerable, minute moral decisions, yet steering clear of being judgmental (Slouching, p.119). 

To his credit, Markman entertains some brief consideration of the dangers of the approach he advocates, but only much later in the book. On p.146, he briefly mentions the risk of "a narcissistic misuse of the patient." He also stresses (something Andrea Celenza does in her excellent book, discussed here) that we can never, ever forget the inescapably and profoundly assymetrical nature of our relationship with our patient. This must always be kept in the forefront of our mind, and we must always "interrogate our own actions and states of mind as our own responsibility....We are never off the hook, and that is a good thing" (146-47). 

On Acknowledging our Own Needs of the Patient:

Markman also introduces an admission rarely encountered--Karen Maroda being the only obvious exception I know of: "unconsciously we need things from the patient." Inter alia, we "seek in our work reassurance of our goodness, capacity to repair, narcissistic needs for love, and early omnipotent feelings of power and control" (p.82). What he does not say here--but later reflections invite one to go on to this speculation--is whether some clinicians also need to feel the pleasures of masochism. 

I do not wish to end on a quarrelsome note, for I have found this a deeply right book in almost all of its instincts, and deeply convicting in many ways. The author has written in a powerfully compelling way about some crucial, and crucially neglected, topics in clinical work today, including the centrality of mourning in diverse forms (which Nancy McWilliams also reminds us of). 

In sum this is the very rich sort of book one feels wholly inadequate to metabolizing on one, or even the first several, sittings. I will doubtless pick it up profitably many times in the months and years ahead. 

___________

* You naturally wonder: what is the most favored of all times? My favourite pen is a purple Krone from decades ago, so grand it travels in an enormous velvet case only slighly less posh than that which the Crown Jewels presumably travel in. Moses himself wanted to use it to write the 10 Commandments, but God told him He was giving it to me instead. Of course--to allay your further wondering--this pen is charged with purple ink. I inherited it from a dear friend upon his death the day after Christmas in 2010. 

Credo: I Believe in What, Exactly?

I'm going to let you in on a couple of secrets from my previous life that bear directly on this book I shall be reviewing.

First, those of us with some scholarly background in religious studies and theology (especially its Christian variants) tend to hear the word credo and immediately have a set of fairly specific and rather clearly defined associations and connotations come to mind. In typical usage, a credo ("I believe" in Latin) is a very succinct and often dense statement comprised of propositions establishing belief on frequently contested points of doctrine. In some versions, after laying out the positive claims, a series of anathemas follow, establishing what beliefs are to be explicitly rejected as heterodox. 

In the book under review we have almost none of this at all. Given that we are talking about psychoanalysis and the authors are all analytically trained, it would be rather queer to find such statements being proffered too categorically for psychoanalysis, of course, seeks always to question definitive claims and probe what lies beneath the lust for certainty. 

While there are, as the eminent historian Jaroslav Pelikan and others demonstrated, many versions of such creedal statements within just Christianity, the most common example still in use today is the Nicene Creed, as it is usually called, though its fuller title is the Niceno-Constantinopolitan Symbol of Faith, reflecting the fact that the statement begun at Nicaea I in 325 was amended and added to at the first council of Constantinople in 381. Unlike the word "creed" and cognates, "symbol" in Greek is less a carefully and cogently constructed series of propositions but instead often translated as that which is thrown together.

I'm going to suggest straightaway that had the editor or contributors to this volume, Psychoanalytic Credos: Personal and Professional Journeys of Psychoanalysts, ed. Jill Salberg (Routledge, 2022) been aware of the etymological history I've just so roughly sketched, they would have called their volume Psychoanalytic Symbols of Faith or something along those lines instead of using the word credos, which promises a type of statement, and a corresponding level of certainty in its propositions, very nearly entirely absent from this volume. That is not a fatal flaw but merely a rather minor mismatch between title and contents. (Perhaps, they might reply, the subtitle, especially with its use of the word journeys, gives cover here, as indeed it does, for many authors seem to have written not tight compact creedal essays, but meandering autobiographical sketches, many of them quite banal and of very limited interest.) 

The second secret I shall let you in on also comes from my scholarly life organizing international conferences, editing two academic journals, and also being editor of scholarly collections and proceedings, several of which I have published. In every case, one often begins with a dream list of contributors, but then has to settle for those who actually say yes and show up. Roughly 15% will say yes and then drop off the face of the earth; roughly 35% will say yes and hold you hostage while they wickedly blow past all deadlines and may eventually get their submission to you months or even years after deadline; and the rest will usually be professional and accommodating in working with you to submit decent materials on time. The resulting collection, of course, is invariably going to be very uneven and even the most ruthless editing I could provide could never totally smooth it out entirely. Such is the fate of all collections. 

Sometimes it is fairly well accepted (though should not be) that especially "big names" may agree to give a paper or make a submission to your journal or book, but it will be some paper they've recycled four times already and couldn't be bothered publishing, or the paper was not really top-drawer stuff, but because of their status in the field they can pawn off second-rate materials and people will gladly take them because, of course, you want their name in your publication, and they know you want their name. Thus they send you some such material--not their best stuff because it may be incomplete, or the sources haven't been updated since they first gave the paper in 1998, or they wrote in sloppy haste--and you accept it even though it doesn't quite fit your focus. 

Similarly, if the "big name" really should be in your book or conference program--else people will sneer How could you publish on gravity without asking Newton for an essay?--but does not want to write something original, or finds you insufficiently important enough to think of writing something fresh for your focus, they may condescend to let you have a paper previously published that, they think after two seconds, clearly fits your focus (but doesn't really). Again, being glad to have this person, you will snatch up the previously published paper and include it in your collection even though it doesn't quite fit your focus.

There are, then, a number of prominent people in Psychoanalytic Credos who fit into this category. These essays, if not previosuly encountered, may be profitably and perhaps even enjoyably read here. I shall not name names nor pay them any attention in what follows.  

Rather, I am content to highlight a half-dozen chapters that offered some excellent insights. 

The first of these--it will come as no surprise--is Nancy McWilliams' chapter "Credo: Psychoanalysis as a Wisdom Tradition." I am, of course, greatly indebted to McWilliams, as I showed here. If I were the editor here, I'd have sent her chapter around to other contributors as a model of what to write: she begins with some autobiographical reflections and then, in a section labelled Credo, tells us how she believes psychoanalysis to be a wisdom tradition, and what that means. 

A central feature of her article, not encountered much elsewhere in the book or the wider literature, is that "much of the healing in analytic treatment seems to me to be essentially a grieving process...and deep acceptance of what cannot be changed" (p.74). What she does not say on this point, but clearly implies, is that such grieving can be a conduit to greater liberation and even to some change not possible until and unless grief happens first and is really worked through. 

The very next chapter is by the British analyst Michael Parsons. He gives us two gifts. The first is to remind us that "to be an analyst...is to lay oneself continually on the line," that is, clinicians (if they are to do what he calls "transformative" work) must "have their own psychic life at stake in an analysis." Only, he says, if you can tolerate this will you have the potential to be both changed and to help your patient change. (This theme is taken up in a later chapter by Lewis Aron, who suggests "the biggest thing getting in our way is that we're afraid to be bad objects, we're afraid to just let ourselves out.")

Parsons ends his chapter with a very striking suggestion: what if we conducted supervision or case consultation in a freely associative manner? How might this help the supervisor, supervisee, and patient? 

Jessica Benjamin (about whom I wrote a bit here) has a wonderful chapter which opens with the ringing declaration that "if psychoanalysis were a religion, I would be not only a practitioner but also a theologian"! She launches into a discussion about Winnicott on uses of an object, and the non-retaliatory stance of the clinician whose failures of the patient and ruptures in the alliance can be "developmentally necessary." 

She also draws on Emmanuel Ghent's celebrated distinction between submission and surrender to note that if the patient has to surrender to the clinical process, so too does the clinician, and the latter's surrendering first is a salutary model for the anxious patient to see that they are not alone (even if the level of surrender is, she notes, assymetrical).

To my mind, the best chapter in the book is, by far, Steven Cooper's "Credo: Playing and Becoming in Psychoanalysis." There is a refreshing candor in what he reports of how he talks to patients with great modesty:

"I have faith in your ability to grow even if I don't always know how to facilitate that. I believe that there is something unique about this setting and the two of us trying that can be useful. I would like to become useful in helping you with the process of becoming who you are." 

Cooper says that the key way he attempts to help patients is through play, which he learned from Winnicott, and about which published a book last year, Playing and Becoming in Psychoanalysis. 

Therapeutic play, Cooper argues, should help the patient to develop "elasticity," a term he borrows from Ferenczi. None of this should be thought easy; we cannot be seduced by the word 'play' into thinking of it as something facile. Instead Cooper says that "finding new forms of play is immensely messy and challenging" (p.106). Some of the challenge comes from patients who "hold on to bad, sometimes persecutory objects rather than feel alone or helpless." Only if they can play with you can they perhaps come to surrender those objects.

Echoing McWilliams, Cooper says that "the play of mourning" is crucial: "limit and mourning are just as constitutive of play as more frequently described forms." Mournful play, though, can facilitate movement "from the chains binding the self to an internal object toward new experiences with self and other" (109). 

Play is ultimately a form of love, Cooper briefly notes, quoting Hannah Arendt (who was herself writing about Augustine of Hippo) who said that love consists in saying "I want you to be." Play is useful here insofar as it expresses "the wish to appreciate the patient as he or she is." 

The last chapter I will note here is from Ken Corbett, "Credo: So Our Lives Glide On." He foregrounds the importance of freedom, drawing here on Freud (and not, as I expected, on Fromm) in several striking ways. Part of the freedom of the clinician, he suggests, is to not know, to not intrude with one's knowing too soon, and certainly to not talk too much: "too much talking is akin to wind drag, and slows the patient down" (p.162). 

He then links his discussion of freedom to "the eroticism of coming into existence" through periods and experiences of "libidinal turbulence." These striking phrases are not developed in any depth, alas, no doubt reflecting the limitations of a word count in a volume such as this. 

There are a few gems in almost every chapter of Psychoanalytic Credos, but I will not drag this on with more talking! 

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

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

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

1) Avoid Moralization: 

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

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

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

2) Avoid Colluding to Exclude Hatred:

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

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

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

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

This brings us to our third thesis:

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

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

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

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

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

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

4) To Suffer the Illness Rather than Suffer From:

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

Making Contact: Leston Havens on the Uses of Language in Psychotherapy

People for whom I have very great respect, and from whom I have learned and continue to learn much, have said very laudatory things about Paul Wachtel's book Therapeutic Communication: Knowing What to Say When. I have read it twice, and recommended it to students and interns albeit diffidently because I was sure I must have missed a great deal in the book because of my general dimness, laziness, or both. 

And yet, on both readings--three years apart--it has struck me as unnecessarily dense and prolix, needlessly complicated in places, and in want of more ruthless editing. The writing style is also entirely forgettable--it has little charm and even less humour. Does it have valuable things to say? Without doubt. Have I learned from it? Certainly. Does it fill a gap in the contemporary literature? Yes. 

But does it allow itself with some facility to translate memorably into clinical practice? No, it does not, at least for me.

Along comes a book treating the same issue but doing so in a way that is much briefer, written with greater cogency and accessibility, and occasionally has subterranean shots of sarcasm and the driest of dry humour, which we all know is the best kind. That book makes itself almost immediately clinically useful: it is by the late Harvard psychiatrist Leston Havens, Making Contact: Uses of Language in Psychotherapy (Harvard UP, 1986). 

Additional virtues abound in this book: the author name-drops almost never; his intellectual fireworks (as seen, e.g., in the use of jargon) are non-existent; the apparatus is very minimal and does not distract from the text; and he is that rarest of clinical writers in that his vignettes from sessions are usually a half-dozen lines at most. (I suspect I am very odd in finding it vexatious when clinical writers put acres and acres of session notes to illustrate one brief point. Others may benefit from this but I rarely do.)

The book consists of four chapters along with an introduction, the gist of which is that patients, being human, come in wearing disguises and leaving parts of themselves deliberately outside the door--absent, in effect, both consciously and unconsciously. Language has to find a way to outwit both of these phenomena. In order to find the other, the missing other, one employs the language of empathy, a succinct definition of which is given early on: 

empathy is best measured by the therapist's attempting inwardly to complete the patient's sentences. The more closely the therapist can match what the patient then says, the closer he is to the patient (p.19). 

Empathy will get broken down into different types as Havens proceeds through the book. These will then need to be deployed at the right time depending on what the patient presents with, and where they are with you in treatment. 

I: Immitative Statements: 

One begins with these. Havens says they are sometimes called 'doubling' as "in psychodrama and work with children." They consist simply in the therapist "speaking out loud for the patient," especially one who seems very lost, depressed, or to have little developed sense of self. Examples (there are many others):

Issue:                                                    Statement:

Fear:                                                    "Where does one find the courage?"

Doubt:                                                "How can I decide?"

Depression:                                        "What hope is there?"

Dominated:                                        "I have no rights." 

The utility of such statements is that they do two things: they demonstrate that the therapist is with and understands the struggles of the patient, but the therapist is also at something of a remove or a distance, which is important especially early on treatment when trust is not yet fully established and having someone close may be threatening. As Leavens puts it nicely, "the goal is to comfort by our presence, not to startle by our prescience" (28). There are echoes of Winnicott here, it seems to me, in his well-known call for patience in the therapist: "It appalls me to think how much deep change I have prevented or delayed...by my personal need to interpret. If only we can wait, the patient arrives at understanding creatively and with immense joy, and I now enjoy this joy more than I used to enjoy the sense of being clever."

In addition to foreclosing on the ability of the patient to get there before you, untested empathic statements can also be an imposition, Havens says, in forcing the patient to feel what you are feeling or what you feel the patient should feel. Instead you must create room for the patient to feel how and whatever they do. Thus in response to a patient's memory of being forced to eat what he hated because his mother dominated him, Havens said "I have no rights," an immitative statement that, the patient later said, made him realize: Havens is like me, and he also wants me to have rights.

II: Empathic Exclamations:

a) Nonverbal Sounds:

Havens says there is a whole range of these from simple to complex. The simplest of them are not words at all, but "nonverbal utterances" or empathic sounds, which "form an important supplement to what is usually considered the language of emotion, namely facial expression" (42). In 1986, when Havens published this book, he could not of course have forseen the rise of telehealth where, especially on the phone (less so in my limited experience on video calls), such sounds become vitally important. 

I admit I was gratified to read this section because I have found myself rather unselfconsciously making a number of these sounds as a patient is talking. In my experience the benefit is that they do not interrupt or prevent the patient from speaking. They convey not just interest but indeed empathy, but potentially many other things as well. In Havens' words, empathic sounds typically convey "ascent, protest, contentment, outrage, or sorrow." He gives an example of a patient weeping: while acknowledging that sometimes he, too, feels like weeping, what he finds himself instead doing is uttering "brief, low cries." 

b) Adjectival Exclamations:

These are what he also calls "translation statements" as you translate into words the feelings in or behind the story the patient is telling you. Such statements/exclamations are by definition very brief:  

Pain:                                     "Terrible!"   or    "How awful" 

Joy or Victory:                    "That's wonderful!"

Shock:                                   "Good God!"

If the shock strikes the therapist especially strongly, Havens--anticipating something Fonagy would recommend decades later, as I noted here--says you should freely request "Give me a moment to take that in" (p.44). Fonagy says the same thing: when you lose your ability to mentalize, you need to pause the session until you can recover. I've done this several times, especially with borderline and manic patients, and it is very helpful. 

Additional benefits are to be found in using these statements and sounds, chiefly that they can outwit the patient's defenses. They can also "normalize" (my word) what often feel like illegitimate feelings or a great deal of ambivalence in the patient. This is often the case early in treatment--or sometimes well into treatment--when "that rough beast, its hour come round at last, slouches toward Bethlehem to be born" in your presence for the first time. The patient tells you something they have not uttered to another living soul, and have scarcely allowed themselves to think, or feel much about. 

I find this especially in those who have been abused as children and do not, on first telling, know exactly what they are feeling, and whether they have the right to feel anything critical, hateful, or rageful in response to the abuser, especially if that person is still a part of their life. To these I often find myself saying something like "No wonder you were pissed!" (I deliberately use that language after a patient has told me that "We weren't allowed to swear" or "We got into trouble for cussing." My doing so conveys, without drawing too much attention to itself, that such language is fine with me. More important, of course, as Havens recognizes, it gives legitimacy, often for the first time, to the inchoate rage and hatred now heaving into view. 

c) Complex Empathic Statements:

All the statements and sounds Havens lays out for us have the twofold job of getting close to the patient and seeing the world from their eyes but not crowding them out or making them uncomfortable by your getting too close. Such statements as

"No one understands"

or

"No wonder you were frightened" 

have a way of accomplishing this twofold task. A "no one" statement "reconnoiters the field of blame," Havens says, while "no wonder" statements clear it. 

"Wonder" statements are very powerful in several ways, the author continues. As I suggested above, patients may have very covertly allowed themselves only the slightest bit of wonder at what happened ("was this normal? Should I be feeling like this?"), before shutting it down. Your use of such statements legitimizes the wonder and brings it out into the open. "No wonder" statements, Havens says, are a "denial of denial." If the patient has denied himself the right to feel something, your saying "No wonder you hate him!" now allows him to begin doing exactly that--if he chooses. That is an additional benefit here: you are not imposing what you feel, or what some abstract standard of feeling might insist the patient feel: you give them freedom and room now to feel something previously heavily warded off. 

No wonder statments can later on be supplemented or even supplanted by what havens sees as stronger expressions of empathy: "It is natural" statements. 

d) Bridging Statements:

In patients who are "supine" or who have hardly been allowed to live or develop a robust sense of self by parents or other overly dominating figures, or who are so severely depressed that there is little life in them at the moment, or who are heavily conflicted by their conflicting feelings (here I think of patients with obsessive-compulsive personality disorder--not OCD--about whom see some excellent resources here) you need to use bridging statements. These allow you to share the conflict around conflicting feelings, to be ambivalent with the patient in his or her ambivalence. They also, as he says later in the book, function as a form of "noninvasive closeness in which the patient has someone present on his own terms" (p.85).

Again using military metaphors (as Freud did in one of his most important papers, "Remembering, Repeating, and Working Through"), Havens says that in such patients you are entering a state of civil war, and you have to form a "provisional government" to deal with on the patient's behalf: "the seat of governance is found in an unexpected place: the patient's reaction to his own behavior." Precisely to the extent the patient finds his own behavior baffling or terrifying you have material to work with. (Here I am mindful of later developments in motivational interviewing in which you "roll with the patient's ambivalence.") By wading into an internally conflicted patient, the therapist gives both sides permission to acknowledge each other and begin talks toward integration.

Bridging statements to use here include "God knows": 

"God knows you must have wanted to escape from them!" (This, he says, lends support to the desire to get away while also subtly acknowledging problematic ties of authority holding the patient back.)

Another version of this to use is "God forbid you should try to escape." This, of course, is spoken "sarcastically" (p.62). In uttering it, you come alongside the patient in her desire to escape and to tell off the domineering authority figures. 

e) Causal Extensions:

One should not--I hope this is obvious to seasoned clinicians--use questions to demand of such patients as above "Why didn't you leave?" Those are very counter-productive approaches. Instead, Havens recommends causal extensions:

"If I say 'Why didn't you call?' I am judgmental, inquisitive, and assume that the patient knows. On the other hand, if I say 'You must have had some good reason for not calling,' I put myself with the patient and extend that empathy investigatively."

The above is, he says, a longer version of "no wonder" statements, but it does more work and opens onto a potentially longer line of inquiry. 

III: Good Management:

Later in the book, having fully convinced us of the need for all of the above, Havens then "rights the balance," as it were, by introducing some contrary factors to watch for. (On the very last page, he will later speak of "disciplined passion" so that your statements of empathy are not "empty display.") Here he says--in something that made me think immediately of Nina Coltart's open advocacy of the therapist always operating in "two minds"--the therapist cannot just be a tap pouring out empathy constantly. "Therapists must cultivate attitudes sharply opposed to one another," he bluntly puts it, reminding us that we have to enter into the patient's world via empathy, but we also cannot be "taken in" too much by that, losing our distance, our neutrality, our abstinence, our ability to mentalize. (There is little of clinical utility in my thinking empathy requires me to hate the patient's alcoholic mother or abusive husband as much as she does.) 

Remember, Havens says: "the object is the establishment of a working distance" (p.95) and both parties in the room have to be aware of the other and at the appropriate (and sometimes changing) distance from each other. If you collapse that distance and space--if there is, in Ogden's well-known terms, no room for an analytic third--then one has to wonder if any real work is going to get done. What will likely replace the work is some extended collusion-cum-enactment, and whom does that help? 

The Therapist's Authority:

Maintaining distance and space, however, does not mean a retreat to a preserve of therapeutic authority. Finding the balance here is, Havens freely acknowledges, one of "exquisite difficulty" (p.103). You need to likely have a greater sense of authority at the start so the work can begin, but as it progresses you need to relax that so that the patient does not come to be dominated by you, but to discover more freedom with and through your work together. (Havens is preaching to my choir here for I have long had in mind Erich Fromm's insistence from decades ago that in time a therapist has to be abandoned precisely so the patient's freedom can continue to expand, even by "disobeying" the therapist.) 

On Being Wrong and Acknowledging It:

One way Havens recommends doing this--and I was gratified to find I've just sort of fallen into doing this myself long before reading the book--is by your "willingness to be wrong" (p.105) and your inviting the patient to share whatever they feel, including critical or angry feelings towards or about you. Of course, merely telling the patient they can do this often cuts little ice. Instead, the author says think of what you have to do with frightened children: you yourself volunteer to go up to the barking dog and pet it, thereby revealing to the child that it is okay to do so. (Merely insisting "Go on--he won't bite you! Pet him! Come on!!" of course rarely works and often makes the child more upset.)

Another way to do this (which I have done) is to begin a session with an apology. I had let a patient, on a provisional basis, do something in session for about six weeks that I would not normally have encouraged and do not allow others to do. It became a ritualized part of the session and I half-forgot that it was supposed to be provisional. One weekend I realized it had long outserved whatever modest purpose it had and was now proving to be harmful to our work together. So I began the following session with an apology for letting it go on so long and explaining how I thought it was hindering the work. This so startled the patient that I saw a completely different, much more playful and emotionally fluid side of them that day, and slowly, haltingly, without any further encouragement from me, they began to venture more independent thoughts in session, and to disagree with me. I was delighted.

Projective Statements:

Additional ways to do this are by means of "projective statements." These put the "therapist's fallibility forward first" and reveal an example of your "happy receptivity" to being corrected.

One way I have found to do this is by using some version of the following prefaces:

"I could be wrong about this......."

"This may sound really off the wall, but I'm wondering if....."

"I really don't know if this is the best word for it, but I can't think of another at this point." (This often gets the patient thinking for a better one, and very often it is better and we happily agree on it.)

Havens suggests the utility of these projective statements with erotic and loving transferences, and his example of how to handle these is extremely close to the way that Andrea Celenza (as we saw here) recommends: by saying "You love me and naturally want me to love you." That normalizes things and goes some way to balancing them. But then you follow up with "Would that I could! Would that work made room for them both!" (p.107).

Counter-Assumptive Statements:

The goal here is to shake assumptions without getting drawn into a long debate about them. (They are especially useful if you find yourself caught in what I would call the agonies of an idealizing transference.) In brief, you do this by taking the patient's expectations and then "throw a dash of salt on those expectations" (p.115). Such disconfirming responses might include (only well after a solid alliance has been established!) saying "Yes, I know: you're a real idiot." Here you are sarcastically siding with the patient's inner prosecutor and the shock of your sarcasm, if done well and at the right moment and in the right way, can jolt them out of agreeing with that prosecutor. (I have done this many times and can report that it is very effective.)

I will pass over sections on counter-projective statements and others in the interests of wrapping this up.

Idealizing and Mirroring and Loving:

Some of the richest material in the book, for me, comes in the last chapter, and here again I thought of work with OCPD patients in particular. This leads Havens to reflect on the place of ideals and the therapist's use of what he calls Performative Statements: "the power of performatives is based on the therapist's authority and on the patient's need to be loved. Such statements evoke and then transform the need to be loved" (p.162). 

Havens gives the example of a deeply conflicted patient with internalized hateful objects that attacked the self, inhibiting a healthy self-love. So Havens sided with the kind, gracious aspects of the patient he saw, and called those out for attention, affirming them. The very "performance" of such affirmation ipso facto strengthened the kindness in the patient and allowed him increasingly to love that part of himself to the point he did not need external affirmation of it after a while. (As he puts it later in the book, "the therapist who finds something to admire in the patient creates the state of being admired.")

Such admiration is needed above all in those patients the author calls "supine." But once admired and loved--and my experience confirms this--they discover some inner resources and strength, so that the need to be admired does not become prolonged or pathological, but leads to real and important independent growth in a capacity for love and corresponding decrease in self-hatred. 

In the End, Love: 

This leads Havens into a very important clarification in the book, worth quoting in full and ending this review with:

Freud's cure through love did not mean any happy result that might spring from the love of a therapist for his patient. Quite the reverse....The cure through love...depends upon the therapist's finding in the patient a quality that can be admired, hoped, or wished for. It is the 'recognition of a promise.'

Psychoanalysis and Christianity

Prologue:

A tedious bit of autobiography: since 1990, when I was in gr. 12 first reading Freud and Jung and trying to decide, first, what I was to study at university the following year (psychology? theology? history?) and, second, whether to pursue clinical and then analytic training in Montréal, or priestly ordination into the Anglican Church of Canada, I have lived my life at the intersection of theology and psychoanalysis. When I went on sabbatical in 2018, my project was to finally write the book I had been carrying around in my head for nearly thirty years at that point, then tentatively titled "Theology After Freud." (Events intervened and I turned my sabbatical project to writing Everything Hidden Shall Be Revealed: Ridding the Church of Abuses of Sex and Power, where Freud features very prominently and unapologetically throughout). 

I may yet write that book, though increasingly with a much different focus. Some of its materials have in the last decade worked their way into lectures on the relationship between theology (especially Orthodox and Catholic theology) and psychoanalysis that I have gladly given before academic and ecclesial audiences in England and Wales, Canada, and in several places across these United States. A version of that lecture is available here as a podcast.

The other development in 2018 that swayed me against writing my book on psychoanalysis was the appearance of the most powerful theological engagement of Freud I have ever read. The Spanish psychotherapist and Jesuit Carlos Dominguez-Morano (who has published many books in his native tongue, few, alas, having been translated into English) published Belief After Freud: Religious Faith Through the Crucible of Psychoanalysis. That book is, and remains, a stunning work of far-reaching criticism of the most prominent manifestations of the massive psychopathology at the heart of Catholic Christianity. I could only salute the author's penetrating insights and great courage in writing a much more forceful book than I would have attempted. If you read nothing else on this list, read, mark, and inwardly digest this book. The Catholic Church would be a far less objectively disordered and sadomasochistic institution if Dominguez-Morano's proposals were taken at all seriously, which they won't be. (I wrote a bit about him for the Jesuit periodical America, and in more detail at an old blog.) 

If you read Morano and then want to read more in this area, I have, over the last three decades, read as many books about religion and psychoanalysis as I can lay my hands on--with many more to read! What follows are a few notes on disastrous books to avoid, a few that are "good enough," and a rare few that our outstanding. 

Books Fit for Burning:

Previously I noted on here one book that, had it been edited and published properly, would have been a handy collection to have. But it was so shoddily produced it's not fit for reading and the publisher should be ashamed to have foisted such slop on us. 

The other book is one I can only think of as psychotic: by that I mean Bion's theory of psychosis as the severance of all meaning-making links and possibilities for rationality and reality-testing. I cannot in all honesty discern any sort of rational purpose to the book as it staggers around vomiting out incoherent statements unconnected to any sort of discernible purpose--or to each other. The Freud who features here, and the "arguments" made, bear no relationship to reality. There is of course no end of attacks on Freud, and almost all of them are at least generally coherent (see, e.g., Frederick Crews), but this book could not even manage to rise to the level of childish diatribe. 

Mediocre Treatments:

Beyond such egregious examples, there are plenty of books in which others might quite rightly find value but I found to be very thin gruel indeed. Most of them were written in too general a way, and often very poorly edited. Under this heading I include Christianity & Psychoanalysis: A New Conversation, eds. Earl D. Bland and Brad D. Strawn; and Marie Hoffman's sprawling Toward Mutual Recognition: Relational Psychoanalysis and the Christian Narrative. Her premise and methods were good but the execution very poor. Other books along these lines could be mentioned but need not detain us further. 

Good General Treatments:

If you are new to the area, then a 30,000-foot overview provided by one of the great scholar-clinicians and social critics of the last century, Erich Fromm, is a good place to start: Psychoanalysis and Religion was originally delivered as part of the Terry Lectures at Yale. Like all Fromm's books, it is written at a very general and accessible level. (I discuss Fromm in a bit more detail here but keep meaning to get back to him at some point.) 

A more advanced but still general treatment may be found in William Meissner, the Jesuit psychiatrist and psychoanalyst I wrote about in my America piece, who authored several decent books, including Psychoanalysis and Religious Experience.

Two other collections merit mention: Soul on the Couch: Spirituality, Religion, and Morality in Contemporary Psychoanalysis, eds. Charles Spezzano and Gerald Gargiulo is decent. Even better is Psychoanalysis and Religion in the 21st Century: Competitors or Collaborators? ed. David M. Black.

Ana-Maria Rizzuto's Works:

The Argentine-born but American-educated Catholic psychiatrist and psychoanalyst remains too little known, in my view, but deserves to be for her first book in 1979, The Birth of the Living God, which was based on fascinating and highly original research with psychiatric inpatients and their internalized God objects. 

Then her 1998 book Why Did Freud Reject God?, published by Yale, is the most careful and respectful such treatment yet published of a topic that almost always sees authors descend to the level of puerile polemics and "pseudo-mentalizing" (to borrow a phrase from Fonagy). 

Only recently has Rizzuto come in for some attention in this decent collection: Ana-María Rizzuto and the Psychoanalysis of Religion: The Road to the Living God, eds. Martha J. Reineke and David M. Goodman.

Winnicott and Religion:

Back when I taught undergraduates theology, I came across the works of the scholar and Jungian clinician Ann Ulanov, author of such books as Finding Space: Winnicott, God, and Psychic Reality as well as Primary Speech: A Psychology of Prayer (which my students loved). 

Stephen Parker has written an unexpectedly excellent monograph (I say "unexpectedly" because works like this are often ploddingly dull, having all the vices of a doctoral dissertation and none of its virtues), Winnicott and Religion, which is very much worth your time if you love Winnicott half as much as I do. Winnicott, as always, has a lovely and useful phrase to describe his own relationship to the Methodism and Anglicanism in which he was reared: traditions to "grow up out of." That phrase admits of wider application today if much research (e.g., Stephen Bullivant's important new book Nonverts: The Making of Ex-Christian America is to be believed on declining practices. 

Highly Specialized Scholarly Monographs:

Under this heading I put two dense but worthwhile works: Peter Tyler's The Pursuit of the Soul: Psychoanalysis, Soul-making and the Christian Tradition; and then Marcus Pound's Theology, Psychoanalysis and Trauma. Pound's book has the virtue of making some of Lacan accessible--a figure whom I otherwise find needlessly and vexatiously obscure so much of the time (though I did find something useful in him as I argued here). 

One of the best books I have read is Pia Sophia Chaudhari's Dynamis of Healing: Patristic Theology and the Psyche. I discussed its virtues and interviewed her about it here. 

Let me end with a new book I forgot to mention in a recent post on On Bare Attention: it is a book by Paul Marcus entitled Psychoanalysis as a Spiritual Discipline: In Dialogue with Martin Buber and Gabriel Marcel. The book is a bit choppy in execution, but it draws out useful material from its two named interlocutors. I read some of Marcel and Bueber in writing my M.A. in moral philosophy at the end of the 1990s (when I read rather a lot more of Alasdair MacIntyre and Emmanuel Levinas, whose "ethics of the face" and critique of abstraction I still teach to my students). 

Marcus seems to suggest in this book that for people who both find themselves "ecclesially homeless" (to use a phrase of Stanley Hauerwas) or "deconstructing" their faith, or otherwise alienated from religious institutions, and are clinicians or interested in psychoanalysis, then the analytic tradition offers both insights and "disciplines" similar to ascetical practices found in Judaism, Christianity, and Buddhism. This allows him to say that "psychoanalysis can reasonably be conceptualized as a spiritual/moral venture." As such, it has practices of "communion" (to borrow a term from Marcel) or what Marcus calls "the five essential elements of psychotherapeutic support--presence, holding, caring, challenging, and confirming."