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. 

Psychoanalysis and Homosexuality

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

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

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

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

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

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

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

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

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

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

Notes on Motivational Interviewing

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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."

 

On Love, Eros, and the Perverse

Introduction:

Recently with my students, I began a discussion about transference and counter-transference in psychotherapy, including erotic transferences and counter-transferences. The class seemed to cleave into two: those who regarded the idea of any sort of erotic feelings arising, in either direction, as "gross"; and those who didn't see what the big deal was. I'm not sure by whose response I am more disconcerted. 

Part of the difficulty turns on the wide variety of meanings attached to the term "erotic." I tried, following the ancients, to expand upon it as something much wider and more vital than the merely sexual or, narrower still, the genital. I brought in Freud's notion of the libidinal and its close links in to the notion of both "life" and "love." This gained traction with the students and also frank relief among them. At last they seemed to find a notion they could relate to: the erotic as something that excites deep and wide interest, even "passion," as people often say today, without necessarily implicating them in some sordid desire for sexual intercourse with whatever/whomever this objet is. 

In talking with them, I was of course drawing on what I've written previously about what I have learned, and am still learning, from Andrea Celenza, especially in her vitally important book Erotic Revelations: Clinical Applications and Perverse Scenarios (Routledge, 2014). I drew on her work with my students in attempting to illustrate the polymorphous ways in which erotic desire can arise in treatment. As Celenza shows, such desire, far from being avoided as it almost universally seems to be today, can in fact be helpful--but it can also lead to disastrous outcomes if not handled well. 

On the strength of how much I had learned from that book, I recently bought another of hers: Transference, Love, Being: Essential Essays from the Field (Routledge, 2022). There are riches scattered throughout this collection, one of whose chief virtues is that almost every chapter is 3 or at most 4 pages in length. 

The collection begins by reflecting on the disappearance of the notion of love in psychotherapeutic practice. And that reflection itself begins by referring to Philip Bromberg's work, who really deserves (and will one day achieve) an essay of his own on here. When someone introduced me, last fall, to his essay "Standing in the Spaces," it effected a sea-change in how I conceive of my own mind and the notion of selfhood and psychic change. It also changed for the good how therapy was progressing with one particular long-term case that seemed to be bogged down. 

Since then, I have used excerpts from his essay in a number of classes, and in every case it has stirred up lengthy and fascinating discussion. 

Celenza says that the splits in the self, which Bromberg focuses on, can be helped by reconsidering and reintroducing the notion and practice of love, properly understood, in the therapeutic relationship. 

Disappearing Love and Hidden Sexuality:

Along with the disappearance of any notion of love in contemporary practice, Celenza, in this book and her other one, has pressed the case more relentlessly and compellingly than anyone else I have read about the disappearance of sexuality and the erotic, citing a word-count Fonagy did some years back showing that terms like 'relational' are all over the literature today, but 'sexual' and cognate terms have taken a nose-dive. This leads Celenza to claim that "there is an unmistakable desexualization that pervades psychoanalytic theorizing...., an erasure of the natural erotic and sensual aspects of intersubjectivity" (p.75).

Celenza, later in this chapter, speculates that perhaps this disappearance has someting to do with the fact that, understood classically, "Eros is described as the son of Chaos, the original primeval emptiness of the universe" (p.76). She does not elaborate the point but the suggestion seems to be that therapy is often difficult enough without (one imagines some bedraggled, overworked, underpaid clinician moaning) introducing further potentially destabilizing and presumably difficult elements such as the erotic.

But at what cost do we exclude such things? In later chapters, she returns indirectly to the theme saying that "we must have the full range of affectivity at our disposal" in order for us to "help our patients...experience the excitements and mysteries within themselves" (113). These excitements, she notes a page later, "include allowing sexual desire to be present in our countertransference." The point of doing so, she repeatedly notes throughout the book, is to serve the patient: "the more we can acknowledge what we feel at work with our patients, the better we do." (Her earlier book, Erotic Revelations, has helped me greatly in seeing that such feelings can be stirred up within us in ways that unconsciously and blithely ignore our cultured notions of "gender" and "sexual orientation.") 

The Perverse and Sadomasochistic:

The essays in the final section are the ones I gravitated towards the most for I have for some time been engaged in trying to understand manifestations of what she calls "the perverse," including sadomasochistic fantasies and actions of some patients.

Some interesting work has been attempted here over the years, but there seems to have been gaps in the literature. Robert Stoller's book Perversion: the Erotic Form of Hatred, from the mid 1970s, seems to have been one of the first major works in the area. The topic comes and goes across the decades. There was renewed interest in the late 90s on the "perverse," and I have to say that it was a great surprise to see my first analyst's work in this area cited in Celenza's chapters and notes. (See also this essay by Dr. Louise Carignan, whose winsome necrology is here.) 

Celenza brings much (not all) of this literature together in chapters 30 and 31, which I found the richest in the book. She begins, rightly, by trying to define terms, offering "a contemporary definition of perversion that reveals a form of psychic functioning as a quality of being toward others, toward one's body, or toward internal objects" (p.139). This differs, she says, from past definitions which were almost always entirely behavioral in nature. She continues: "I propose that a perverse internal psychic mode is one where affective embodied and pre-reflective self-experience is split off or dissociated." 

Chapter 31 is perhaps the longest and most helpfully detailed in the book, and continues on these themes. She explicitly reviews the past literature to see what she finds still useful, discarding the rest. She says that any new attempt at defining the perverse must abandon "phallocentric and heteronormative assumptions." 

What does perversion look like in action? She begins by arguing that "persons engaging in perverse scenarios are attempting to imagine a one-person universe" (142). The tracks closely with cases I have seen clinically.

From here she lays out seven "characteristics that define a perverse quality of being." These are:

• Constriction and Constraint
• Repetition
• Objectification
• Sexualization
• Desire to Harm
• Means/End Reversal
• Absence of Symbolization. 

Taken together, these are usually brought to bear in constructing scenarios and fantasies to manage anxiety, ward off danger, and maintain control. As Stoller put it, sadomasochistic fantasies are usually ones of triumph that at some level are thereby trying to reverse the traumas of the past. They have a dead and deadening, self-reinforcing nature to them; their objects are sexualized to turn threats into pleasure; and there is very little ability to play with them in a symbolic register. She very helpfully elaborates on all these points in some detail, and with clinical material--as she does in nearly every chapter. 

Overall, then, Transference, Love, Being is a rewarding collection and I continue to be grateful for having been led to Celenza's work.