An Encomium for Jonathan Lear....and Other Books

I did not mean to leave so large a gap on here, having posted nothing since March. I have several times gestured wanly in the direction of my laptop and the piles of books which sit uneasily near it at all angles and with varying degrees of instability, and on at least two occasions sat down to draft posts (one of which is nearly done and will focus on 3 or 4 books on mentalization I have been wrestling with this year). But for reasons I will not bore you with, my energy this year has been reduced and taken up with other things, and thus every time I sat down to write something the desire vanished almost instantly--until now. 

Anyway, in no especial order, here are some thoughts on books that you might find beneficial, edifying, and even enjoyable to some degree. 

Jonathan Lear: 

I begin with Jonathan Lear, whose death in September occasioned grateful commentary as well as mourning and melancholia in the worlds of academic philosophy and clinical psychoanalysis. I read his Imagining the End: Mourning and Ethical Life in early 2023 and before that his Freud, published in the Routledge Philosophers Series. It is, I submit, the best philosophical treatment of Freud since Ricoeur's 1977 landmark book Freud and Philosophy: An Essay on Interpretation. 

Therapeutic Action: An Earnest Plea for Irony (2003) is a languid book that showcases Lear as a philosopher asking question after question in service of, and search for, an answer to his central question, which is: what is the therapeutic action of psychoanalytic treatment? Since this book was published more than two decades ago, there has been an increasing body of literature investigating this question and not just in psychoanalytic circles either. It remains a question that continues to fascinate me and will be the focus of some attention in my next book: what is the action of psychotherapy that provokes change by and in and with the patient? 

Lear's contribution to this is based on a wonderful and close re-reading not just of Freud but also of Lear's own mentor, Hans Loewald. He begins by reminding all of us that "therapeutic action does not describe a process, like getting a tattoo, which has a fixed end point. Once you've gotten a tattoo, you've got a tattoo; indeed once you've had an analysis, you've had an analysis, but therapeutic action goes on and on. Analysis has a termination: therapeutic action does not. Ideally one continues one's own process of therapeutic action as a lifetime project" (p.33). In this Lear very much reminds me of one of Adam Phillips's aphorisms that "the cure can only begin once the treatment has ended." 

Later on Lear briefly discusses termination in treatment, and the need to have that firmly in mind as a clinician from the moment treatment begins. (My first supervisor taught me that in introducing the question of goals, he often used the question "What would done look like?" as a way to get the new patient thinking about how their life would have to be changed for them to feel justified in letting treatment be done, be finished.) Lear compares this to good parenting, saying that both, to be healthy, have to consist in a progressive withdrawal because "psychoanalysis is aimed at promoting a person's freedom [and] part of the freedom is freedom from the need to keep coming to the analyst" (p.56), a key principle both Erich Fromm and D.W. Winnicott have previously articulated. 

Lear's compatability with the thought of other clinicians shows up in numerous points in the rest of the book. When he turns to a discussion about whether a psyche can be said to have a "core," he notes, in a vein that strikes me as very similar to Philip Bromberg's incredibly rich and important book, that "the core is the elementary capacity of the psyche to hold itself together" without resorting to a ruthless superego-induced attempt at purging or synthesizing (p.118).

He returns to this issue at the end of his third chapter, "Internalization," where he seems to nod clearly in the direction of mentalization (as Fonagy and Bateman have famously called it) or the creation of a "psychoanalytic mind" (as Fred Busch has called it) by saying that "while superego internalizations may well occur at various levels of sophistication and primitiveness, even in the termination phase of the analysis, one is also fostering the internalization of a capacity for analyzing these unconscious forms of internalization." In other words, if the analyst has been internalized as a good object (a "benign superego figure" in Lear's phrase) then ipso facto the patient will have also internalized the analyst's mentalizing capacity for use after the analysis has ended, and such a process "properly constitutes the therapeutic action of psychoanalysis" (p.133).

The next chapter, "Love as a Drive," contains some fascinating reflections that could too easily be dismissed as insider baseball, or as reviving old controversies nobody has cared about for decades, but in line with Bettelheim and Laplanche (on whose Freud and the Sexual see below) Lear insists that swapping out "instinct" for "drive" in translating Freud's German is misleading and unhelpful. Lear insists, with ample documentation from Freud, that this is a bigger issue for him than any of his biographers or scholars and clinicians after him have been willing to allow, and that it remains a great unsolved issue: the drives, especially of sex and death, have been rather quickly and quietly bundled off the stage so as to allow our genteel and ever so much more socially respectable conversations about developmental, relational, and now traumatic challenges to take over the entire show. 

In the context of this discussion, Lear calmly revisits the old polemics--from enemies and defenders of Freud alike--about the role the "sexual" drive occupies in Freud's writings, noting that both sides miss a crucial philosophical point that Lear explicates: his understanding is not focused on copulation and he denies that the sexual drive and the sexual object have a more intimate connection than they actually do. To this extent, then, Freud is not saying--Lear argues--that at our most sexual we are also at our most animalistic. Au contraire: human sexuality has so many features, expressions, and pecularities that it is here more than anywhere else that we are not like other animals. In Lear's by-now familiar refrain, "human sexuality makes us all candidates for irony" (p.156).

Additionally, drawing on Plato, Freud noted in 1924 ("The Resistances of Psycho-Analysis: SE 19: 213-224) that when psychoanalysis refers to sexuality, it "had far more resemblance to the all-inclusive and all-embracing love of Plato's Symposium." Lear the philosopher leaps on this and spends the rest of the chapter wondering aloud about why Freud, having said this, then spent the rest of his life running away from serious sustained reflection on love as a drive. In doing so, Lear charges, Freud fails to develop a crucial line of reflection that would have a direct bearing on therapeutic action. We cannot, Lear implies, understand efficacious therapeutic action except as being a process motivated by love (as Freud first conceded in that off-hand comment to Jung in a letter of December 1906). 

What might this love look like and how might it be a driver (if not the driver) of therapeutic action? What might a "loving" treatment result in? Lear suggests--but does not really develop the thought--at a couple of points that loving therapeutic action will result in the analysand's enlarged capacity for "greater psychological complexity" (p.170). (Once again there are clear echoes of this in others, including Phillips, Busch, Bion, and many others.) But the analyst does not impose this on the patient, or demand that he develop or "perform" complexity. The analyst merely provides a place to do so without getting pushy about it. Indeed, Lear defends fairly traditional understandings of neutrality at this point, saying that "the analyst's holding herself in this 'neutral' position is itself an act of love."

Towards the end of this chapter and nearing the end of the book, Lear asks a question that I have not seen anyone else do: is the fear Freud had about discussing a "love drive," a fear that virtually every clinician since him has replicated and never challenged, born out of a philosophically impoverished understanding of what "science" is and does? (Contemporary psychology's ignorance of the philosophy of science remains a constant source of serious vexation to me.) "One reason Freud's theory of love has been ignored is that it seems ridiculous to take seriously the idea that love is really a basic principle of nature. Surely we need to turn to natural scientists to find out what the basic principles of nature are. But what if we think about second nature?" (p.172). 

At this point Lear the philosopher emerges to the fore again, and he reminds us of our need to return to moral philosophy in Plato and especially Aristotle, but also in our own time the works of such as Bernard Williams and Alasdair MacIntyre. The development of our second, more properly human nature--our nature as philosophers, one might say, over and above our animal nature--cannot avoid questions of "character, personality, and psychological structure" (p.173). These can only have a chance of developing well if they do so in the context of relationships motivated by love that abjure moralizing while insisting on asking what Lear terms the ethical question: "How shall I live?" (174). 

Analysts, finally, cannot avoid such questions, either in themselves, or in their work with patients. In pursuing such questions with love they propel the therapy forward to successful action, defined as "structural change" understood not as a "once-and-for-all achievement" but instead a "perpetual undermining of rigidifying and thereby alienating pretenses" incapable of ironic reflection on oneself (p.177). 

For this rich and important book, and for his others, it is certain that Jonathan Lear's memory will remain a blessing.  

Memory of and Desire for more Bion?

We seem to be entering an era in which books about W.R. Bion, who died in 1979, are emerging at an ever increasing pace. I know for many of us he has been a difficult read, and our feelings about him are suitably ambivalent. His claim that each session should unfold with the clinician refraining from "memory and desire" has often been seen as a problematic counsel of perfection, but there are very solid reasons for striving to do this as I have learned the hard way more than once. In fact, I would say that mistakes I have made in a recent case are almost entirely because I failed to refrain from memory and desire and instead been too keen to demand the patient discuss certain things he is manifestly not ready to discuss. Pacing remains a crucial technique still in need of refinement.

Beyond his reflections on attention, memory, and desire, I have long found Bion enormously useful for his two essays on the psychotic mind. Using Bion, I built my chapter, "Men and Schizophrenia," which I was asked to write for the forthcoming Oxford Textbook of Men's Mental Health, part of the Oxford University Press imprint Textbooks in Psychiatry. The better known of Bion's essays, "Attacks on Linking" (1959), I now believe, is really the second part of, or a continuation of, his 1957 essay “Differentiation of the Psychotic from the Non-Psychotic Personalities.” The two really must be read together, and both are to be found in several places, but conveniently reprinted together in E.B. Spillius, ed., Melanie Klein Today: Developments in Theory and Practice, Vol. 1 (Routledge, 1988). 

But now we have new books on Bion, and in this case Donald Meltzer as well, with whom I was completely unfamiliar prior to reading Avner Bergstein, Bion and Meltzer's Expeditions into Unmapped Mental Life (Routledge, 2019). This is a very useful introduction to the two authors in the title, rendering Bion especially much more accessible than he was himself in some of his writings. The chapters on obsessionality, as well as on the psychotic personality, render Bion's thinking on both topics lucid and accessible without any dilution of their explanatory power. 

The final chapter, "The Ineffable," looks briefly at Bion's familiarity with both Christian and Jewish mysticism before arguing that "Bion seems to present us with non-religious mysticism": p.172), a judgment I would agree with. Part of what Bion appears to have taken from both of these mystical traditions is captured in his famously misunderstood phrase about refraining from memory and desire: "The psychoanalytic attitude, much like the mystical one, is a deliberate conscious act of discipline which depends on an active suspension of memory and desire" in order to exercise an "act of faith" that "truth exists" and can be discovered in the clinical encounter (p.166). 

Psychosis and Schizophrenia: 

While on the topic of psychosis, I must mention the following books which I have found not merely edifying but actively encouraging in what is so often a bleak landscape of poor and inadequate treatment and resources for psychotic patients: David Garfield and Daniel Mackler, eds., Beyond Medication: Therapeutic Engagement and the Recovery from Psychosis offers a number of essays from scholars and clinicians around the world looking at a range of options, while Therapeutic Communities for Psychosis, John Gale et al., eds., is looking at non-medical, quasi-institutional, but voluntary and community-based outpatient options for residence and care. 

Perhaps the best known (relatively speaking) example of this are the Soteria houses, which have fascinated me for some time. Only in September did I get around to finally reading Soteria: Through Madness to Deliverance. I find that I read all such books with a mixture of awe and respect for what was attempted but also some regret and amazement at how poorly supported such initiatives seem to be--and also with a wish that we might continue to build such places for there is a long track record and very impressive evidence base that they work. (See below for the evidence.)

I have a number of must-read books I recommend to other clinicians when they consult with me about working with psychotic and schizophrenic patients, starting with Michael Garrett and Andrew Lotterman's books. To that I will now insist on adding a third which, despite being the oldest of the three, is still incredibly relevant, timely, and useful: Michael Robbins, Experiences of Schizophrenia: An Integration of the Personal, Scientific, and Therapeutic.

Finally for books in this category we come to Courtenay Harding, Recovery from Schizophrenia: Evidence, History, and Hope. Please, please, please buy this book! I get nothing for saying that, and have never met the author, but I will hope for some small satisfaction that by encouraging a wide reading of this book then perhaps the long-standing, deceptive, indolent, and destructive narrative about schizophrenia that I first encountered in 1991 as an undergraduate, and which seems still to be propagated today to the detriment of many, may eventually die an overdue death. That narrative, of course, is the one that tells patients and their families that schizophrenia is a lifelong sentence of suffering for which there is no cure and which can, at best, be only partially ameliorated by neuroleptic medications (with notorious, intolerable, and sometimes irreversible side-effects). The fatalism and hopelessness in this narrative is just crushing to patients and their families, but it is infuriating to those of us who know that with the right treatment patients can and do get better!

That is not just an anecdotal claim based on a tiny, non-representative sample of one clinician, but has been backed up by empirical studies of hundreds of patients in different countries going back 75 years. It is to Harding's everylasting credit that she has tracked down patient records and long-forgotten studies of schizophrenic patients, including some of the most rigorous longitudinal studies we have of any psychiatric population, and published them in one place. In rendering so important a service to scholarship and patients alike, she has allowed us to see that, with multi-modal treatment, many patients have recovered. That is, three-quarters of a century ago now we already knew that merely medicating a patient is far from sufficient. Medication might be useful, but so too is intensive psychotherapy (see, e.g., Frieda Fromm-Reichmann's practice, or Harry Stack Sullivan) combined with vocational counseling, social supports, access to supportive, low-cost, outpatient housing, and a team of people (psychiatrists, nurses, therapists, social workers, dieticians, and others); but who today is willing to fund such treatments? 

How to Listen:

Salman Akhtar's short book, Psychoanalytic Listening: Methods, Limits, and Innovations is a wonderful addition to the literature, filling a gap that goes back at least thirty years. 

My debts to, gratitude and affection for, and frequent quotation of Nina Coltart are no secret. I have long maintained that nobody, in my experience, has surpassed her cogent description of therapeutic listening as a process of: 

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 Toward Bethlehem, 119). 

A little later in that unforgettable book she returns to all that is going on when the clinician is listening therapeutically:  

the need for consistent scanning and judging, not only of what the other person says, but of what we are about to say, and are saying; and with this scanning, the need for rapid continuous thinking, which may be only half-conscious; the need for repeated moral and technical decision-making; and yet if it is to convey truth, and more importantly, authenticity, in our style of speech we must also master intuitive, unlaboured spontaneity. This is an extremely demanding and complex requirement...[and]...it depends, for success...on...the combination of unselfconscious self-forgetfulness with deep self-confidence (Ibid., 145). 

Since reading this description of listening more than 30 years ago, I have found nobody who unpacked these dense descriptions until Akhtar's book, which is a gem. I now regard it as required reading for my students. 

It is not especially long, and it is written in clear, cogent, accessible prose with good but not overwhelming use of clinical illustrations. In addition, there is a commendable modesty in the author, who freely and frequently confesses his own errors about listening in the wrong way, or tolerating silence when speech was called for, or vice versa. He also notes, with admirable restraint, the difficult circumstances under which listening might and even should be refused--not least when outside of clinical contexts, when psychotherapeutic listening could be used manipulatively or destructively (he gives examples of doing this early in his marriage and watching how frustrating his family members found his doing so). 

In keeping with Coltart, he writes appreciatively on types of and purposes for silence, and he recognizes the degree of "faith" (also a concept Coltart explored in a non-theistic way) required to sit and wait, confident that if something is important, it will show up, and not once but repeatedly. Finally, he has some throwaway comments on several topics, including supervision ("supervision is more than teaching and less than treatment" he quotes A.J. Solnit's 1970 article in the International Journal of Psychoanalysis as saying). 

Laplanche, Freud and the Sexual. 

I have not read Laplanche nearly enough, and so on my last research trip to the library of the Cincinatti Psychoanalytic Institute, with less than an hour before I was to leave, I pulled all his books off the shelf, and slightly manically tore through them to decide which I really needed to read in a ranked order of urgency or importance. Apparently (this was 18 months ago now at least) I decided it was going to be Freud and the Sexual at the top of my list. Having just finished it, I must say frankly that I'm not sure what I saw in it. The book is a collection of articles on several topics, many of which feel quite like unfinished first drafts; much space is given to arcane arguments with translators of Freud from German into French and English; and when Laplanche finally turns to the topic of the sexual, his main insight seems to be confined to insisting that we should stop fighting over whether "instinct" or "drive" is the best translation for Freud's Urtriebe and recognize the utility of both terms in English.

On Buddhism and Philosophy:

Todd McGowan, Embracing Alienation: Why We Shouldn't Try to Find Ourselves is a new book that I read in January as presidential transition was taking place and a sense of alienation was mounting. 

I came upon McGowan close to a decade ago now in reading his book on the death drive. Enjoying What We Don't Have is one of the richest and most rewarding reflections on the death drive I have read in English. 

His new book on alienation makes the simple point in several places that by abandoning quests to find ourselves, or our "true" selves, we stop wasting time and energy that could be better put to projects of solidarity with each other in challenging the myriad instances of injustice in the world today. Embracing our alienation, in other words, has an "emancipatory quality" (p.7). In this way, then, McGowan manages to avoid the problem of a paralyzing despair at being alienated, and to avoid the temptation to fantasize about some prelapsarian paradise from which we are estranged but which we should struggle to find out way back to. There is no such paradise, McGowan says, and a good thing too.

The "alien" that we need to embrace is not some vague existential angst or a sense of estrangement we have from scrolling on social media and reading about all the horrors of strangers being snatched off the streets by fifth-rate opéra bouffe thugs in masks. The alien, rather, is within: it is our unconscious mind. As Freud first argued, and McGowan heartily agrees, each of us is alienated from ourselves. Our minds are divided and we live in a state of perpetual psychic alienation. If we stop fixating on "solving" this problem, and instead learn to forget our alienated selves, we will not only have more time and energy to work toward a better world, but we will also discover freedom and even some measure of happiness by focusing on helping others instead of chasing after our own "identity." 

And that word, in McGowan's hands, is clearly (and rightly) to be regarded as a bogus, deceptive, self-indulgent idol of our time, perhaps more than ever thanks in part to social media. Being preoccupied with finding and then defending our true "identity," McGowan shows through a close reading of Hegel, is actually a form of slavery we must emancipate ourselves from by learning self-forgetfulness. In doing so, he says in conclusion, "becoming reconciled to one's alienation is not a way of accepting oppression as inevitable" (p.148). McGowan's welcome book, then, is not a counsel of despair or an example of pietism or quietism, but instead a call for a new kind of politics. 

McGowan's theme of forgetting ourselves is also treated in several of Mark Epstein's books, which I have read over the past year, but these deserve a post of their own, so before Christmas I hope to offer some thoughts on Advice Not Given: A Guide to Getting Over Yourself and at least two other of his books. I have been propelled into an unexpected exploration of Buddhism and psychotherapy because of Nina Coltart's own immersion in that tradition as seen in her wonderful concept of "bare attention," an ascetical discipline (so I would say) we must all cultivate moment by moment and hour by hour with each patient. More on that anon. 

Notes from Christmastide Reading: Schizophrenia, Case Formulation, Ogden, Self-Supervision, and Dead Analysts

The only time I can permit myself not to work is when I am traveling. If I am on my academic Christmas break, then I must be reading, writing, and editing. Herewith a few notes on some new, and new-to-me, books that I have recently finished over the break.

On Schizophrenia:

This is a very workmanlike little book that I immediately decided to adopt for my students in my psychopathology course. We do a special extended unit on psychotic illnesses, and I've not hitherto found a suitable book for this part of the course, making do with several articles.

I would quibble with the author for her bias that only the "medically qualified, Psychistry-trained Psychoanalyst" (titles she always capitalizes) is really equipped to handle schizophrenia--a clunky, snobby phrase used several times in a short book. I have no medical training but have nonetheless worked with cases of schizophrenia for years now. To her credit, she is aware that those with psychoanalytic training, which I do have, are also able to handle schizophrenic patients. 

Case Formulation/Conceptualization:

A supervisor of mine lamented for years that the art of case conceptualization had largely been lost, and I rather agree that in many cases it has. It is important, if only in the clinician's mind, to be able to have a relatively coherent, but dynamically flexible, succinct vision of who the patient is, what the presenting issues are, how they are bound up with personality structure and personal history, and what goals and direction treatment is taking, including its transference and counter-transference manifestations. The lack of all this immediately puts the clinician at risk for what I call therapeutic drift. 

To prevent that along comes the psychiatrist and psychoanalyst Mardi Horowitz with a handy little book suitable for students and trainees: Formulation As a Basis for Planning Psychotherapy Treatment. This is a very short workmanlike little book that would be suitable for students and trainees early on. 

André Green and Dead Parents:

Despite being once fluent in the language, I have read little of French psychoanalysis in that lovely language. Indeed, apart from the notorious (and largely unreadable) Lacan, I have had only some knowledge of a tiny number of figures such as Françoise Dolto, Élisabeth Roudinesco (author of several useful biographies, including of Freud and Lacan, and of the very valuable little book Why Psychoanalysis?), and André Green. But my ignorance of Green is slightly less deep after reading not just his most famous essay "The Dead Mother" (found in this collection) but also a book of essays devoted to that theme, The Dead Mother: The Work of André Green, ed. Gregorio Kohon. Among the virtues of this collection are essays by three of my favourite analytic writers today, Adam Phillips, Christopher Bollas, and Thomas Ogden. 

Green's concept of the dead mother has been helpful in understanding early struggles of several of my own patients. It was also very helpful in my own psychoanalysis to understand not just the emotional deadness of my mother but my father too because of several miscarriages prior to my birth, and other sudden family deaths, especially of my father's hugely idealized older brother when I was a small child. 

Thomas Ogden on Not Being Alive:

The theme of aliveness is one found in many of Ogden's writings (which, on this theme at least, bear striking similarities to Adam Phillips, as I showed here), including the essay published in 1999 in the above-noted collection. He has returned to it in his latest book, released just a few weeks ago: What Alive Means: Psychoanalytic Explorations. 

Having written many appreciative, almost fulsome, essays on Ogden, having recommended him more times than I can count to students and interns, and having bought all his other books (save for his novels), I think I am allowed at least one occasion to remark that this newest book of his is a dud. It says little he has not said elsewhere (always a danger as an author ages and his opera omnia becomes every larger, stretching back several decades), and most of this book is a rather diffident series of short commentaries on Winnicott's writings. My love of Winnicott, too, is second to none; but at some point this ground has been gone over so much by Ogden himself (to say nothing of others) that the freshness and, well, sense of aliveness that so marks Ogden's previous books, which I found exhilarating to read, is absent here, alas. Those new to Winnicott and Ogden alike might well find something useful or nourishing here, but I was quickly bored and disappointed. 

Self-Analysis and -Supervision: 

Freud, of course, first discussed and attempted to practice self-analysis and other authors, including Karen Horney, have written at length on the topic. There is some interesting recent research (which so often lags behind demonstrating what psychoanalytic clinicians have known for decades) on the reflective capacity of the clinician being a key component to the success or failure of treatment. Such a capacity is just what self-analysis and -supervision should be focused on. 

Marc Lubin and Jed Yalof have a new publication Self-Supervision Psychodynamic Strategies which offers some useful tips to clinicians. It is not a long or complicated book, making itself accessible to those new to this topic and trying to sort out some of the challenges of engaging in a self-supervision. 

Self-analysis and -supervision show up in Fred Busch's latest book How Does Analysis Cure: Essays on Psychoanalytic Method, Psychoanalytic Organizations, and Psychoanalysis. 

I have been a fan of Busch's earlier book Creating a Psychoanalytic Mind, as I showed here and here. So I hope it will not be thought an impertinence on my part to say that this new book is a bit of a mess, and only parts of it can be recommended. (The entire second and last section of the book has an infelicitous feel as Busch complains--almost gossips in public--about some rough handling by callow editors at psychoanlytic journals, and problems within psychoanalytic institutes, none of which are at all new or any great surprise to those of us paying attention since, say, 1941 or thereabouts. I am not at all clear how airing all this in public does anything to solve the problems or increase the esteem in which already battered and often justly ridiculed institutes, hidebound places of orthodoxies where none should be found, are held.) 

If we overlook the final section of Busch's book, we have some rich reflections, including the first chapter ("How Analysis Cures"--the short answer is mentalization, a word that Busch seems at pains to avoid for some reason), and the chapter on silence, as well as a chapter on self-analysis. Here, too, however, my complaint about several of these chapters is that they are too short and say too little. One has the distinct impression of an author losing steam from the beginning of this book. 

One thing that is clear in treatments of self-analysis and self-supervision is that these two are never to be exclusive substitutes for an actual personal psychoanalysis and work with a supervisor. One of the many things I admire about both Glenn Gabbard and Nina Coltart is how, even late in life, after decades of practice, they both flatly and humbly admitted, in an almost off-handed way, that with certain cases they sought out supervisors because the clinical issues were very tricky. This is something we must all consider doing when needed. 

Mechanisms of Change in Psychotherapy:

These two new books belong in the curricula of teaching institutes and graduate programs, for they contain a wealth of research, much of it quite sobering. 

I work with personality disorders, including borderline personalities as well as obsessional and compulsive personalities, about which see here for some invaluable resources. Despite being in the second-largest city in the state of Indiana, I seem to be among a very tiny handful of clinicians who treat these issues, which are, so far as I can tell, rarely discussed in the standard graduate training program in this country. (Every clinician's website I'm on seems to say the same thing: "I specialize in depression, anxiety, and trauma!" But how can it be a specialization when everybody is doing it?) So I picked up Understanding Mechanisms of Change in Psychotherapies for Personality Disorders by Ueli Kramer, Kenneth N. Levy, and Shelley McMain with great interest, and it would lend itself to incorporation into training programs.

This question of what mechanisms of change are in psychotherapy is a fascinating one in part because answering it raises some very formidable challenges to the empirical researcher. Those questions are given very substantial treatment in an enormously valuable collection edited by Louis Castonguay and Clara Hill, Becoming Better Psychotherapists: Advancing Training and Supervision. 

Particularly alarming are the several chapters devoted to exposing how little research we have on what constitutes good and useful supervision. Supervision, of course, is a standard requirement for graduation and licensing nearly everywhere, but who trains the trainers, and then who evaluates that training and those trainers? Few do, it seems. If we are to have better psychotherapists--and God knows we have nowhere to go but up on this score, as the hugely depressing, almost disgusting, data revealed by Francis Martin in Therapy Thieves has shown--then we need to train not just them but also their supervisors. But trained in what, and how, and by whom? Once again these are formidable questions without easy or quick answers. But they are crucial questions we need to be asking, and this book does so in unspairing and unsentimental ways, which we must be thankful for. 

Let me--feeling slightly sadistic--close by recommending you pick up Martin's book. He's done the heavy lifting of surveying thousands of clinicians in the United States to ferret out all the rubbish, all the chicanery, that gets passed off under the guise of "therapy." I was aware of just a handful of woo-woo examples--chakra therapy, singing bowls--but there are hundreds more, each more absurd than the last. Perhaps especially sobering is that regulating psychotherapy does little to control the growth of this nonsense. Once a clinician has a license, there seems in most if not all jurisdictions to be a tacit acceptance that whatever they want to do they can. Complaints against a license are common in custody cases, and of course for reasons of violating sexual boundaries or breaking confidentiality. But when was a clinican last challenged or brought before a disciplinary hearing for practicing (just to pick four random examples from thousands Martin has documented) bright light therapy, Shifaa soul counseling, Reiki womb therapy, or equine ecosomatics? One scarcely knows whether to laugh or throw up. 

This notion of being "evidence-based" smuggles in all sorts of covert philosophical and hermeneutical assumptions ("evidence" is never self-evident, but only ever a result of a process of interpretation which is personal and inescapable), and the refusal to recognize this is very vexing to me. So, having finished Stephen Toulmin's helpful Return to Reason over Christmas (which criticizes clinical psychology’s habit of wanting to base studies of the mind on Newtonian physics whence some wish to derive universal “laws” to the total exclusion of the case study method), my reading this spring will continue to mine the hermeneutical literature, starting with Richard Rorty's landmark book Philosophy and the Mirror of Nature; and then Paul Ricoeur's Hermeneutics and the Human Sciences: Essays on Language, Action and Interpretation. I've been reading Ricoeur off and on for more than twenty years, but never in a sustained and systematic way, as I hope to continue to do. 

Inculcating Psychological Mindedness for Use After Treatment

As so often happens, a comment on Twitter makes me think of a book I read that may have something useful to offer the conversation. In this case, it was a question about post-treatment goals in and for therapy, and whether they diverge that much between CBT and psychoanalytic practitioners. In particular, it was asked whether both traditions seek to create a capacity for what (following Nina Coltart) I would call a healthy psychological mindedness (a lack of which during intake bodes ill, as she says, and my experience confirms, for successful treatment). 

The question of post-treatment goes back, of course, to Freud's very late essay, "Analysis Terminable and Interminable," and its welcome ambivalence about whether one can ever be truly and totally and completely analyzed. I was very heartened precisely by his ambivalence in this essay. I also found it edifying that Freud seemed to recognize benefits might continue on even after analyst and analysand formally cease to meet together for sessions. 

In this regard, I often think of something Adam Philips (he whose books are so essentially aphoristic in nature) once said, which I have found incredibly true in my own life: "the cure can begin only after the treatment has ended." More recently, he has returned to the whole vexed question of cure in what I think is one of his best and most important books, The Cure for Psychoanalysis, which captures in one place a theme he has often advanced in just about every one of his previous books: about the sad irony that psychoanalysis has become--in many places, not least training institutes--a hidebound ideology instead of a means to free people from the prison of ideologies. 

For me, my first analysis (four times a week on the couch for almost seven years) ended in late July 2000 but I have found myself living from that in some useful ways ever since. And in fact I think the "returns," far from diminishing, actually grew in the years after treatment came to a formal end. (I would say the same thing of my second analytic therapy, which is ongoing.)

One person who has thought about this in an elegant and useful way is Fred Busch in his 2013 book, Creating a Psychoanalytic Mind: A Psychoanalytic Method and Theory.

Busch seems a very interesting fellow, and quietly understated pioneer of some sort. As he recounts in the introduction to this book, Busch was one of the first clinical psychologists to be admitted in the 1970s to psychoanalytic training at an American institute. American institutes, unlike those in Canada, the UK, and parts of Europe and elsewhere, generally have been extremely reluctant to admit any but psychiatrists or those with medical degrees. 

In this, they deplorably and unjustifiably take a different tack from what Freud recommended in The Question of Lay Analysis, a book where Freud memorably says two groups should most certainly keep their hands off psychoanalysis: doctors and clergy! He also coins a memorable phrase about analysts being "secular pastoral workers," a phrase to which I gave some attention elsewhere. 

I will not go into Busch's entire book, which I encourage everyone to read, but simply make a few brief observations based on notes I took years ago when first reading it.

Busch understands analysis to consist of three phases:

1) The first phase is when the patient comes to be familiar with his own inhibitions and restrictions that keep him from living: until the patient can wonder about his lack of wondering, wondering is not possible. This phase, later in the book, is called one of self-observation. 

2) The middle phase of an analysis is the creation of a "psychoanalytic mind," that is, learning to observe one's own mind and its sequence of free associations. Such a psychoanalytic mind is necessary if the analysis is to bear long-term sustainable fruits in one's life. It is necessary, that is, if the patient is to be freed from the "slavery of repetition compulsion" and instead freed to "think about thinking." Later in the book Busch calls this phase one of self-reflection. 

3) The terminal phase of an analysis consists of a deeper psychoanalytic mind more completely free from deceptions in understanding one's associations with greater veracity. Here the analysand can "play, muse, reflect, and interpret her own associations." This phase Busch later calls self-inquiry. 

Busch says that part of his practice consists in seeing patients for a second analysis. They have benefited from their first analysis, but from that largely derived only knowledge of their unconscious--an "object," as it were, rather than a process. And for Bush, "the process of knowing is as important as what is known." This, for me, is the very obvious difference between my first analysis (which I wanted simply to know what was unconscious and bring it forth for rational scrutiny and, especially, control!) and my second, which has focused much more on the process of knowing and far less on the contents. 

Busch continues in this vein, saying that he offers a different goal for analysis which, classically, has held up the importance of a state of knowing rather than a process of knowing. In the former, we come to know consciously what was previously unconscious. In the latter, the patient gains an understanding of how his mind works and how it affects him. Both offer freedom, albeit of a different degree and type, but Busch suggests the freedom of a psychoanalytic mind, with a process of knowing--in addition, and perhaps even preferable, to--what is known, may be of greater long-term benefit. I would heartily agree. 

The Therapist's Therapy

When psychoanalysis came to Canada, it retained more of its European and originally Freudian ideas and practices in some respects than it did when it came to the United States. One glaring example of this is in training requirements: Americans until recently required medical training before application to analytic training; Canadians never did. 

When I was an undergraduate in psychology in Ottawa in the 90s seriously contemplating analytic training, I knew I was not cut out for, nor did I have any interest in attending, medical school. Fortunately, following the model Freud first put forth in The Question of Lay Analysis, I knew there was an open path for me, allowing me to combine my scholarly interests with the clinical: I would obtain a doctorate--whether in history, psychology, religious studies, or possibly philosophy was not clear to me then--and then train as an analyst at the institute in Montreal. Many others had done this before me and it was long since commonplace in Canada as across most of Europe and elsewhere. In that book, Freud in fact spoke of the ideal analyst as being neither a priest nor a physician but a "secular pastoral worker," a very curious phrase which was, and remains, inspiring to me. 

The other requirement, of course, universally adopted--even in the US--was that analysts had first to be analysands, and thus undergo a training analysis. 

Moreover, Freud recognized very late in life, in "Analysis Terminable and Interminable," the need for ongoing treatment. Freud has reassuring words when he counsels that "Every analyst ought periodically himself to submit to analysis, at intervals of, say, five years, without any feeling of shame in so doing." (One of the things I admire about Nina Coltart, is her regular reminders throughout her books of the need for analysts and therapists to go back into therapy even occasionally or to "get a bit of supervision" as she puts it flatly if the counter-transference is getting out of hand or other difficulties arise.) 

Since returning to the clinical field more recently, and this time in the United States, I am frankly amazed not just at how long it took American institutes to admit more than just physicians, but to a broader phenomenon across the entire mental health field and outside of analytic institutes: the lack of any sort of requirement for personal therapy on the part of those who train to be therapists in other programs--clinical social workers, mental health counsellors, etc. 

I am aware, having read more than a few stories of abuse, that the requirement for therapy necessitates very careful handling so that it does not end up reinforcing certain existing ideological prejudices or power structures while hiding behind clinical concerns. Not unlike certain professors holding up their doctoral students because of "political" disagreements with other members of the jury (which I have seen first hand), certain analysts could hold up certain trainees as being "insufficiently analyzed" or "resistant" when in fact these trainees just disagreed with their analyst, or were more inclined to, say, a Kleinian or Adlerian or Freudian approach that did not sit well with their supervisors. 

So there are dangers to be avoided, but avoiding them is far from an insurmountable problem. This returns me to my original question, phrased in the following words in the introduction to a very absorbing, richly researched, and important book on an unjustly neglected topic: Jesse D. Geller, John C. Norcross, and David E. Orlinsky, The Psychotherapist’s Own Psychotherapy : Patient and Clinician Perspectives (Oxford University Press, 2005). Here in their introduction these authors ask how and why is it that "in most European countries, a requisite number of hours of personal therapy is obligatory in order to become accredited or licensed as a psychotherapist" but "in the United States, by contrast, only analytic training institutes and a few graduate programs require a course of personal therapy" (p.5)?

Much of the rest of this book--a collection of essays from people in many countries and operating from a variety of traditions--seeks to begin to look at the frequency of, resistance to, and unique aspects uncovered in, the psychotherapy undertaken by those who are themselves therapists of some sort, noting that "many important questions about the psychotherapy of psychotherapists have not been answered or even asked by empirical investigators" (7). 

I was especially interested in a chapter by the late Harry Guntrip on being in analysis with Fairbairn and Winnicott, two of the most important figures in the British object-relations school that I have read the most about and for whom I have enormous respect. For Guntrip, the trauma of losing a brother at 3 was "softened up" by his 2 analyses but not solved: that happened after. In this, he seems a perfect illustration of something Adam Phillips said when he noted that "The cure can begin only after the treatment has ended." One can certainly debate that, but I have found it very true in my own life. 

By this I think we must include the realization not only that the analysis itself helped directly, but it also gave one the skills to carry on a regular self-analysis and create what Fred Busch called a "psychoanalytic mind."

Guntrip, Fairbairn, and Winnicott--and more recently Phillips--remain hugely important and valuable to me in very large part because they illustrate how valuable a "psychoanalytic mind" is to avoiding the dangers of rigid ideological thinking, including those too attached to one theoretical orientation! As Guntrip puts it, theory can be "a useful servant but a bad master, liable to produce orthodox defenders of every variety of the faith" (63). 

So this book varies across theoretical persuasions, but is able to draw some generalizations, noting, e.g., that "therapists enter personal treatment an average of two to three times during their careers—and probably for and during developmentally propitious crises." What is curious to me is the further reporting that even as therapists enter their own therapy, with, presumably, some self-awareness into the dynamics of resistance that they themselves see in their own patients, they cannot resist these dynamics when they are the patient: "Directly and indirectly, all of the therapist-patients in this book reported that no matter how intellectually prepared they were to collaborate, they could not 'resist resisting'" (6). 

That resistance may keep some from entering therapy, which I would regard as a great pity. More than that, I would have to wonder: how much (to speak in a Kohutian way) of a usable self do you have available for your patients whom you hope to treat in therapy? If you are one of those blessedly free but vanishingly rare people with enormous reserves of the self available, and few to no traumatic memories to work through, then praise God. But for the rest of us, the answer to the question of the psychotherapist's own psychotherapy should be: "Yes, please, let us have some more!" 

Creating an Analytic Mind

Some discussion on Twitter this week with Jonathan Shedler and others about what we hope patients will be left with after therapy is over put me in mind two books I often find myself returning to. (Shedler deals handily and powerfully with the old and tiresome slanders that psychoanalytic/dynamic therapy are somehow less effective and less "evidence-based" than the CBT methods seemingly so beloved by governments and insurance companies today. See the invaluable articles at his website above, but also see this new book which I am looking forward to reading.)

The first is by Adam Phillips, who, like Shedler, is always worth reading. I have read all but one of Phillips' books, and would be hard-pressed to rank them, but if I had to, then On Kissing, Tickling, and Being Bored: Psychoanalytic Essays on the Unexamined Life would probably be in my top three, if only for its essay "Psychoanalysis and Idolatry," which I drew on in my own recent book on the sex abuse crisis in the Catholic Church. 

Anyway, Phillips has a lovely little aphorism in this book: "The cure can begin only after the treatment has ended." One can certainly debate that, but I have found it very true in my own life. As Luis Izcovich has recently argued, psychoanalysis leaves lasting "marks" in certain often distinguishable ways--a point stated even more dramatically by François Roustang almost forty years ago now. 

The second book that came back to mind this week is by Fred Busch. I read it several years ago, but it pays re-reading. He argues very much in favour of the idea that psychoanalysis and analytic therapy should leave the person with a re-structured mind as a permanent and positive after-effect: Creating a Psychoanalytic Mind: A Psychoanalytic Method and Theory (Routledge, 2013). 

Busch writes in a low-key manner with a refreshing lack of ideological rigidity, jargon, or hubris. He interpolates passages from well-known literary works with short case-studies from his own practice to illustrate what he means. This is a rewarding book that pays re-reading. 

As he recounts in the introduction to this book, Busch is something of a pioneer in psychoanalytic technique and training, being one of the first clinical psychologists to be admitted in the 1970s to psychoanalytic training at an American institute. (This restriction has never made any sense to me. I grew in Canada, underwent analysis there, and planned to finish a doctorate in the humanities and then embark on a training analysis at the Institute in Montreal. I was able to do this because unlike American institutes, those in Canada, the UK, and parts of Europe and elsewhere, generally have had no problem following Freud's recommendations in The Question of Lay Analysis.) 

As he looks over the course of an analysis, Busch understands it to consist of three phases:

1) The first phase is when the patient comes to be familiar with his own inhibitions and restrictions that keep him from living: until the patient can wonder about his lack of wondering, wondering is not possible. This phase, later in the book, is called one of self-observation. 

2) The middle phase of an analysis is the beginning of a "psychoanalytic mind," that is, learning to observe one's own mind and its sequence of free associations. Such a psychoanalytic mind is necessary if the analysis is to bear long-term sustainable fruits in one's life. It is necessary, that is, if the patient is to be freed from the "slavery of repetition compulsion" and instead freed to "think about thinking." Later in the book Busch calls this phase one of self-reflection. (In my experience this ability to "think about thinking" has remained a constant and constantly valuable gift bequeathed by analysis.) 

3) The terminal phase of an analysis consists of a deeper psychoanalytic mind more completely free from deceptions in understanding one's associations with greater veracity. Here the analysand can "play, muse, reflect, and interpret her own associations." This phase Busch later calls self-inquiry. 

Classically, it was thought by some that the main goal of an analysis was insight into the contents of the unconscious.  But for Bush, "the process of knowing is as important as what is known." Here Busch pioneers a different goal for analysis, giving greater emphasis to the patient gaining an understanding of how his mind works and how it affects him. Busch suggests the freedom of a psychoanalytic mind, with a process of knowing in addition to what is known, may be of greater long-term benefit.

This, it seems to me, is a very noble goal for a clinician to work towards: not merely to leave a patient with certain tips or techniques that may come in handy in some future struggle, but to help in the creation of a mind that can now think much differently. And one thing that newly recreated mind will likely have--dare we say should have?--is an awareness of its ongoing need for the help of others. Here I would return to Freud in noting that the creation, and nourishing, of such a mind is never going to be complete, but will require perhaps ongoing or perhaps periodic work. As he says in his "Analysis Terminable and Interminable": "Every analyst ought periodically himself to submit to analysis, at intervals of, say, five years, without any feeling of shame in so doing. This is as much as to say that not only the patient's analysis but that of the analyst himself is a task which is never finished." 

In conclusion, I would simply note that Busch has a new book coming out in November which I am looking forward to reading. The publisher tells us this about it: 

In this first-of-kind book, senior psychoanalysts from around the world offer personal reflections on their own training, what it was like to become a psychoanalyst, and what they would like most to convey to the candidate of today.

With forty-five personal letters to candidates, this edited collection helps analysts in training and those recently entering the profession to reflect upon what it means to be a psychoanalytic candidate and enter the profession. Letters tackle the anxieties, ambiguities, complications, and pleasures faced in these tasks. From these reflections, the book serves as a guide through this highly personal, complex and meaningful experience and helps readers consider the many different meanings of being a candidate in a Psychanalytic Institute.

Perfect for candidates and psychoanalytic educators, this book inspires analysts at all levels to think, once again, about this impossible but fascinating profession and to consider their own psychoanalytic development.