Ogden and Phillips on Reclaiming Unlived Life

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Right. So much for Phillips. Onto Ogden.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Schizophrenia: Is the Past Prologue? Is the Future Condemned to a Repetition Compulsion of Failed Treatments?

Preface:

Every fall I teach my history and historiography of psychology course and for the last few years have struggled to help students come to understand that the history of any and every discipline is fluid and that certain categories and concepts--in psychology as in other disciplines--were not handed down on Sinai or at Delphi in a once-for-all manner eternally fixed and beyond us mortals to question. Ideas have a history, but such intellectual history properly so called is nowhere taught to undergraduates so far as I can tell. As a result, it is a real struggle for them to conceive of several things, including psychiatric nosology, as having a history. 

Additional complications abound: More than a third of our student body are nursing students, and so the perceived fixity of medical-diagnostic categories is a great comfort to many of them. But introduce to them the idea that psychiatric diagnostic categories do not enjoy just a biological basis, and are therefore much more fluid, and students are suddenly all at sea. 

I am hopeful that two new books might help us in this task of understanding the shifting history of diagnosis, and of nosology, starting with what has been called the poster-child for psychiatry, viz., schizophrenia.  

The first is Orna Ophir's new work, Schizophrenia: An Unfinished History. Just published last month by Polity, it is cogently written in a manner accessible to those with little background while also being grounded, in an unobtrusive way, in serious scholarship which is deftly handled. Because of these virtues, and because I cannot of course have my students read a history of every major disorder, and because schizophrenia is often described as the most serious and difficult concept and diagnosis in all of psychiatry and psychology, I have assigned this book to my students. I am eager to see what they make of it! 

Introduction:

In promoting her new book, the author recently published a short essay about it on Slate. As invariably happens, the title chosen by her editor and the spin given to the article immediately made Ophir's work sound more inflammatory and "radical" than I very much think it to be. And as also invariably happens in this social media age, people were immediately projecting into that article's title their own ideas and then criticizing Ophir for her apparent disagreement with them. It's all very tiresome. 

To come directly to the question thus raised on-line: does the author have an "agenda"? Almost certainly, but of which author is this not true? Is Ophir (a psychotherapist and psychoanalyst in private practice who also teaches at Cornell and NYU) crusading for the abolition of schizophrenia as a diagnosis, indeed even flatly denying that it is a disorder causing enormous distress for some patients? Not at all. (If she were, I would not assign such a book to my students because I would have to agree with a sentiment denied to me by my own private practice with psychotic and schizophrenic patients, whose suffering has stared me in the face.) 

These two questions cause enormous controversy: should the diagnosis of schizophrenia, which has changed greatly through five editions of the DSM, each of which she reviews carefully, as we shall see, be altered or even abolished? And should we make such an abolition because schizophrenia does not actually exist as a disease in the way we might say diabetes or cancer exist as diseases or disorders? 

Ophir handles both questions with skill and sympathy, after long reviews of the history and previous answers (going back to Greek antiquity, the Hebrew scriptures, the Latin Middle Ages, late Medieval and early-modern Europe and Byzantium, and right up through DSM-V). Her own highly provisional answers, are, to my mind, eminently defensible and worthy of ongoing discussion and debate. The singular virtue of this book is the author's lack of ham-fisted dogmatism in any of the matters she handles. Like a good psychoanalytic therapist, her practice of those sometimes misunderstood notions of "neutrality" and "abstinence" is well honed and expertly used throughout the book so that the reader never feels hammered by the author's views or compelled to agree with her. In that sense, her book is poor fodder for social media outrage and click bait, but excellent scholarship. 

As such, it will also give no comfort to those who wish to get up on their hind legs and shout at the rest of us--either in favour of retaining current names and nosology, or as a way of pushing for the abolition of the same. Ophir says--rightly--that all of us involved in these discussions should participate with humility and a lack of defensiveness (p.238), and we should be asking ourselves what the "prudent--indeed, ethically responsible" ways of proceeding are so that we do not leave people in the lurch. Even as we can see problems with current diagnostic criteria and categories, and even as we might want to change those, we must "acknowledge that so many of its elements, of its debris, and scattered building blocks...remain of importance for us" (p.239). Thus--as she concludes the book, perhaps a touch too neatly--she says that those involved in this discussion must ourselves be "of two minds" (!) in seeing what is good and conserving it, while discarding what is not good in search of better alternatives (p.244). 

Status Quaestionis:

But let us return to the beginning. The author begins by noting that for at least two decades now around the world more and more people have been wondering whether what we have (since 1911 only) called schizophrenia is in fact a distinct disease entity or not. There is not, she notes, any kind of objective test for it. There is no universal and unchanging agreement on what symptoms might--might--constitute sufficient evidence to make a diagnosis. Indeed, as she shows in detail, there is not even agreement on how to conceive of it in a basic nosological sense: should schizophrenia be seen as something radically other, a state or disease or disorder that in essence breaks with ordinary human experience and places one outside the realm of quotidian "reality"? Or is it a continuum on which people move around from time to time in life, never quite managing totally to leave shared human experience as they do? 

For some, she says, what are described as symptoms of that disease are, rather, "extreme versions of normal human experience" (xi). She here notes that some parts of the world--notably Japan, to which she will return late in the book--have attempted to take account of that and change the name from schizophrenia to something else, a move that a few other countries (also briefly noted below) have also undertaken. That global behemoth, the American Psychiatric Association, has, however, not followed suit even though it has been inundated with hundreds of possible changes to the name and diagnosis since the 1990s. 

History: From Ancient Israel through Byzantium and the Enlightenment:

Ophir begins the history section of her book (ch.1) with understandings of madness in Greek antiquity and in the Old Testament or Hebrew scriptures. Here she notes that for the latter text, the line between being cast as a "madman" and a "prophet" is vanishingly thin. The former is "other," likely under demonic influence, and often needs to be run out of town and destroyed. The latter, whose behavior is, curiously, often extremely similar to the former, will come to be seen--also after much suffering in many cases--as being divinely inspired and appointed rather than demonically disordered. 

She has a very brief section on this thin line between madness and sanctity in the Byzantine and later East-Slavic figure of the "holy fool," to which I have elsewhere many years ago paid not a little attention. Scholars of that phenomenon agree that it is never easy, and often impossible, to tell if holy fools are indeed "mad" in a pathological sense, or "mad" in the sense of being "possessed" by the divine and having a righteous mission whose oddness is reflected in the audience's profound estrangement from divine and holy purposes. Holy fools, then, are usually thought merely to look mad: underneath they are (ostensibly!) the ones who are truly rational in that they are at one with the Logos himself--though this is never demonstrated with complete certainty, leaving the figure a perpetually ambivalent and ambiguous one, which likely explains their enduring attraction. 

When she comes to the second millennium and the advent of what will come to be called the Scientific Revolution and the Enlightenment, Ophir notes that modern psychiatric nosology's problems begin here in attempting to pattern notions of mental disease after botanical classifications. At this point she introduces a metaphor that repeats regularly throughout the book: psychiatry's attempt to "carve nature at its joints." This, it will become plain, is--and perhaps only could be--a failed project. As she later puts it, "strictly speaking...there is no such thing as a single, stable object that corresponds to the word 'schizophrenia.' Rather, there is a complex description that has evolved through time (and does so to this very day)" (p.115). 

Psychoanalysis and Schizophrenia:

In her description of various ways over the last century to understand schizophrenia, the author tips her hand just a bit in the review of several psychoanalytic theoreticians, who include Freud and Jung. But Ophir seems to suggest that Melanie Klein's notion of splitting might have been, and yet remain, one of the most important theoretical concepts to help us conceive of what might happen in a schizophrenic mind. Others of note here include Harry Stack Sullivan and Silvano Arieti, who gets a very brief mention, along with equally brief mentions of Harold Searles and Frieda Fromm-Reichmann. But Klein predominates and of her Ophir says that she "does not see schizophrenia as a different natural kind or disease entity" (p.106). 

From here Ophir undertakes a careful, chronological review of each edition of the DSM.: Given the various axial configurations, DSM-IV could give us, she enumerates, 114 ways to be "schizophrenic"! For her DSM-V is only a slight improvement on this in some ways, but has other problems (p.148). 

Ophir's chapter on stigma--primarily, but not exclusively with schizophrenic patients--is very powerful and deserves much wider discussion than I will attempt here. There is one sobering thing she has unearthed that merits additional mention: she documents various ways in which empathy for severely mentally ill people can be increased in the general population, but a mere increase in empathy does not seem to correspond to a change in the problem of social distancing and isolation. In other words, I might learn to feel for and with "these people" but I still do not seek them out or necessarily want them around--a kind of very bloodless empathy. 

Ophir's careful handling of the Hearing Voices movement is fascinating and deserves deeper discussion. Equally fascinating were her reviews of the countries that have attempted name changes, including Japan (changed in 2002 to "integration disorder") and China. The new names are not without problems, to my mind, but Ophir does not really consider those. To be fair, I find it almost impossible to imagine that any change in nomenclature would not bring new or different problems. 

There is, however, perhaps one way around some of these difficulties, and here she quotes two British psychiatrists, Mohammed Abou-Saleh and Helen Millar, who suggested we simply rename schizophrenia "Kraepelin's disease" (p.226) on the same model of Alzheimer's disease (etc). On this point, see the recent and suggestive paper by two other British clinicians arguing we not quite jettison Kraepelin's categories just yet. 

Criticisms: 

It is never acceptable to fault an author for not writing the book you think they should have written, or for not writing a book they never said they were going to right in the first place. But it is entirely within the bounds of legitimate criticism, in the constructive and scholarly sense, to suggest that when an author says they will do something, and stresses the importance of that thing in the book, but then fails completely to deliver on it, that they be called to account for such a lacuna. And this is the case with Ophir, who more than once (e.g., p.242) says we must attend to forms of treatment for schizophrenia, but then signally fails to enter into any substantial discussion of treatments and their efficacy. Perhaps she lost steam, or her editor told her the book would be rendered far too long, if she also looked in greater detail at the history of treatments? I would not fault her for failing to do this if she had not raised hopes early in the book that she would attend in some detail to treatments, but does not. Overall, this is a rather minor weakness, easily remedied elsewhere. 

For such a remedy, we will have to turn to our second book, which does do this in some helpful ways, thus making this second book a very useful and important complement to Ophir's otherwise excellent text, which I am very grateful to have read and have profited greatly in doing so. It will bear re-reading and careful thinking about several important things. 

That second book is Matthew M. Kurtz, Schizophrenia and Its Treatment: Where is the Progress? To read this book with Ophir's is to find them very complementary. There is a bit of overlap in one or two areas, but Kurtz also goes much more into two areas that Ophir only skims: the results of decades of neurological research on schizophrenia, and how fascinating but largely clinically useless it has been; and then certain recent treatments--beyond psychopharmacology--that are showing promise in the psychotherapy of schizophrenic and psychotic conditions.

Kurtz is also, in both tone and conclusions, much less hopeful than Ophir is, and this is already telegraphed in his subtitle: Where is the progress, indeed, in treating schizophrenia? A cursory review of the data are not encouraging. We shall return to this later.

Kurtz says in his preface he will ask, and seek answers to, four questions, and he does this with admirable cogency and clarity throughout the book: what is the history of the category of 'schizophrenia' and how was it derived? What does neurology tell us about the brains of such patients? What does cognitive and affective science tell us about such a condition and its patients? And finally what psychotherapies are there that actually work? 

Already by the end of the brief preface, Kurtz says that "there remains no clear neural or psychological signature that is specific to the disorder of schizophrenia" (p.x). He hastens to add a little later--and will repeat this--that he is in no wise undermining or outright denying the idea that for some people this is a useful diagnosis. Kurtz is no anti-psychiatry radical--far from it: he attacks such zealots more than once (e.g., p.6). 

The first chapter is devoted to the first question noted above, and opens with some sobering statistics about how many homeless in the US are schizophrenic; about how the WHO lists "schizophrenia as one of the top 10 leading causes of disability among adults worldwide"; and perhaps most appalling of all, "rates of improvement have been less than 50% and largely unchanged since the 1890s"! 

From here Kurtz introduces an interesting discussion that Ophir did not: is schizophrenia actually one disease entity? He suggests that "there may not be a treatable core disease pathology in schizophrenia at all" (p.6). He will return to this later in suggesting possible reconfigurations in how certain symptoms might be considered and treated transdiagnostically. The chapter ends by asking how improvement in patients' lives might be meaningfully conceptualized and measured, and then how much (measured) hope we might have about possible progress and development of treatments. He cautions that any work on new or improved treatments cannot and must not be designed by academics and clinicians in isolation: here he nods to the Recovery Movement, and seems to agree with their slogan "no research on us, without us" (p.14). 

Chapter two is the most historical and usefully reviews several large-scale long-term studies in the US, including the Iowa 500 study, the Chestnut Lodge studies, studies in Vermont, and in Western Europe. He pays particular attention to the Chicago Prospective Longitudinal Study, saying that at the "15-year follow-up nearly half of the schizophrenia sample...had experienced at least a year of recovery" (p.23). The upshot of this literature review is his recognition that "it is clear from the data collected to date that initial conceptualizations of schizophrenia as a disorder that has a largely downward course is clearly not supported. Recovery is very much possible" (p.27). 

Ch.3 is devoted to the actual diagnosis of schizophrenia, noting that "the criteria for diagnosis...have changed radically over the past 100 years" before reviewing the five editions of the DSM and their indebtedness to Bleuler and Kraepelin. All this is situated within a broader context and wider consideration of psychiatric nosology. Kurtz says--somewhat staggeringly--of the early attempts to understand schizophrenia (roughly corresponding to DSM-I and DSM-II) that "accurate diagnosis was not seen as an essential first step for treatment" (p.44). 

The chapter that unfolds from here is not quite as detailed in some periods as Ophir, especially on Hebrew scriptures and Greco-Roman antique notions of madness, but it is still quite serviceable. It also includes gratuitous and amusing mentions (without, alas, elaboration!) of such things as "wedding night psychosis" and "masturbatory insanity" (p.37). When he gets to the 20th century and America, Kurtz is indebted to Richard Noll's 2011 book American Madness: the Rise and Fall of Dementia Praecox. Kurtz claims--based on Noll--that Kraepelin's classification scheme "took the United States by storm" and has exerted a lasting, and perhaps unduly strong, hold ever since. Others who have had influence here include John Feighner and Kurt Schneider, he of the (infamous?) first-rank symptomology.

The result of this lengthy and fair-minded survey is to claim that "there remains no reliable medical test for diagnosing schizophrenia or any other psychotic disorder" (p.52). But from this it does not follow that schizophrenia necessarily disappears as an actual disease: at most he says we can claim to have "modest evidence that an underlying disease entity might exist" (p.53). With equal care he ends this third chapter by arguing that "critiques of the category must balance calls for new nomenclature with the potential cost of losing a label that, with all of its limitations, rapidly identifies a group of individuals a large proportion of whom have profound disability and need for care" (p.58).

The fourth chapter reviews early (pre-revolutionary onward) asylums and treatments in the United States, including many things that rightly horrify us today. But he returns here to Bleuler and Kraepelin to make note that the latter "devoted only 5 out of 328 pages of text to treatment" and the former was little better: Bleuler's nearly 500-page text offered a scant 18 pages devoted to treatment of dementia praecox. 

Kurtz then looks at postwar developments, beginning, of course, with the invention in France of what became the first generation of neuroleptics. Psychoanalytic approaches get a wholly inadequate and totally unsatisfactory look-in here, along with R.D. Laing and Harry Stack Sullivan. 

Chapter 5 is devoted to biological mechanisms and the fascinating research that has been done here in the last several decades. Ch.6 is focused on the cognitive and affective dimensions of schizophrenia. This reviews data on neurocognitive functioning and testing before turning to recent attempts to theorize and treat schizophrenia as a disorder of self-cognition. This leads Kurtz to end the chapter with a brief look-in at a new approach developed largely here in Indiana with which I have some familiarity. 

This part of the book already needs updating in light of the ongoing research into metacognition, which is indebted to and very similar in some (not all) ways to Fonagy's famous mentalization treatments. Lysaker and others have been publishing at an impressive clip as they amass randomized control trials around the world to test their metacognitive approach, which is nicely outlined in the handbook linked at left. I have read it once, and want to read it again when I have time. 

Ch.7 looks at somatic treatments, reviewing the famous dopamine hypothesis and others. Along the way he notes what is already notorious: how huge numbers of patients in clinical trials discontinue their neuroleptics on their own because of absolutely intolerable side-effects. 

Ch.8 looks at psychological and psychosocial treatments of schizophrenia, and is perhaps the most hopeful chapter of the book. What Kurtz calls "evidence-based psychosocial treatments" include family interventions, social skills training, and CBT. He claims here, without any evidence, that "in recent years, the psychoanalytic approach has been supplanted by CBT." 

I do not buy that and the history does not bear Kurtz out on this. There are dynamic psychotherapies being successfully used right now, including those I discussed in some detail here, here, and here; and those developed by Andrew Lotterman; and then mention must also be made of the integrated approach of Psychotherapy for Psychosis: Integrating Cognitive-Behavioral and Psychodynamic Treatment by Michael Garrett. Still others could be mentioned, most notably and encouragingly those outlined in Downing's invaluable book. 

The chapter ends by noting--too briefly to be helpful--that international models, including that of Hans Brenner in Switzerland, might point the way to show us what future therapeutic models need to include. Kurtz then moves into a very brief epilogue where he laments the "profound lack of services available to so many people," especially in the US (p. 183) where "the science-to-practice gap has vastly widened" and where there is an appalling "absence of even minimal housing and institutional supports for people with schizophrenia" and equally appalling "very low rates of reimbursement provided for treatment of the...severely mentally ill" (p.184). 

Taken together, both of these are carefully written books by Ophir and Kurtz who have judiciously weighed competing theories and evidence, and done so with real concern for suffering human beings. They are not anti-psychiatry zealots, nor blind apologists for biological psychiatry either. Both books overlap but only modestly, and thus both books must be seen as more complementary than anything. Both books are at their most useful in reminding us of the appalling long-standing gaps in treatment and the fact that far from making progress, treatment seems to be stalled or even regressing (where, that is, it even exists at all). There is much work to be done if the past is not to be prologue to a future of continued, repeated failure. 

Karen Maroda on Theory, Challenge, and the Therapist's Needs

The Analyst's Vulnerability: Impact on Theory and Practice by Karen J. Maroda (Routledge, 2022, x+215pp.) is such a disarming book. I think that is the most apt word for it.

It advances some potentially challenging if not controversial theses but does so in a cogent, humble way free of fulgurating fireworks and polemics. Indeed I rather think that Maroda, aware of the defensiveness likely to be aroused by some things she advocates, has deliberately written them in as low-key a way as possible. The effect, for me at least, was to make her book more powerful than I was expecting. Indeed, I feel that in at least two important areas it has forced me to rethink some basic assumptions and feel my way towards some changes in my clinical practice. 

I previously wrote about one of her other books, Psychodynamic Techniques, which contains similarly sensible material serenely expressed in useful ways. (I have also read her first book The Power of Countertransference, which was decent but I did not find it as useful as works on that topic by Kernberg, Searles, Bion, and Coltart, all of them discussed elsewhere on here.) 

The Analyst's Vulnerability is, notwithstanding the title, a book that admits of wide utility to all manner of psychotherapist and counselor for the issues discussed in it are largely universal in many respects. Her opening claim at the start of the first chapter makes that plain when she says that anyone who has chosen to become a therapist "is keenly aware that there is something deep and primitive about the decision that eludes understanding" (p.5). I was aware that there were some primitive forces afoot in my move back into clinical work after a long detour but it has taken me quite some time to catch glimpses of what they could be. Following Freud I have no problem admitting that motives for most things are a mixture of the noble and the more primitive and self-seeking, as mine certainly are. 

Ambivalence about Motives and Fit:

Maroda also immediately goes on here to acknowledge this, as she will throughout the book, saying that we have "positive and obvious reasons for our choice" to become clinicians, but that there are also "deeper needs being met by doing therapy" (p.6). These needs, as she will elaborate later on, often include the need for gratification which, she quite straightforwardly says here and will develop later, we must stop pathologizing and being so highly suspect of: "The topic of the analyst's gratification should not be one of guilt and shame" (p.14). 

A little later in the first chapter she notes how most therapists report being the caregivers and peacemakers in their families, and this has stamped us inexorably for good and ill. We cannot shy away from that: "accepting our inevitable ambivalence toward both the work itself...and often toward our patients as individuals could provide the necessary momentum to advance both our theoretical formulations and our clinical interventions" (p.10).    

Weaving relevant clinical and autobiographical material into each chapter, Maroda here introduces some lessons learned from supervising other therapists, saying that in problematic cases, "I almost always see indications of their [other therapists'] reluctance to be assertive" (p.11). This likely comes, as she just noted, from the primal familial role of being peacemakers and caregivers

On that topic of ambivalence, Maroda notes here--as she did in her earlier book that I discussed--it is alright to feel some of that in taking on a new patient, but you must never martyr yourself to a bad fit or a patient you have absolutely no interest in. Repeatedly she says that therapists "shouldn't treat anyone that they are not interested in" (p.16). There has to be something, however small, that sparks some curiosity and compassion in you. If there isn't, if the patient simply bores you or you feel strongly that they are not a good fit, you ill serve both them and yourself if you do not refer elsewhere. 

This is such eminently sensible and obviously good advice that I am amazed at people who do not follow it and act surprised when I bring it up. Lest we miss the point, she again makes it directly later in the chapter: "the best therapist for someone is the therapist who can most freely experience the patient's reality, as well as their own" (p.22). 

Getting Ready to Rumble!

By the midpoint of the first chapter, Maroda is seeding some of the challenges she will advance throughout the book. These include, I will admit straightaway, some ideas and authors beloved to me. She tackles some ideas that I have myself resonated with strongly, but her challenges are welcome and make a great deal of sense. 

On Not Knowing:

The first example is her going after what she sees as an overpopular emphasis in analytic circles on "not knowing." While there is wisdom in admitting this, she says in her experience it "discourages analysts from claiming any real knowledge of skill" (p.18). The flip side of this is that "'knowing' has become a synonym for arrogance and reductionism" (p.19). I'm not entirely convinced of this second claim and have not seen it advanced in such stark terms, but then I do not have the decades of experience Maroda has nor have I moved in the circles she has. 

On Anger and Hostility:

Maroda expresses her debts to Harold Searles several times in this book. I have also written about him on here and benefited from reading him. For Maroda perhaps the most important thing he did was to be, and write about how he was, "free to understand and use his negative feelings toward his patients rather than bury them" (p.23). This is a theme she will develop at length in several subsequent chapters, as we will presently see.

On Not Holding and Containing Too Much or Too Long:

Late in the book Maroda tosses off a memorable line: "we need a statute of limitations on this holding and nurturing behavior" (p.197) among psychotherapists who do not sufficiently challenge their patients nor engage in healthful, careful conflict with them en route to their actually changing, getting better, and eventually going away. In this, she reminds me of nobody so much as Jonathan Shedler, who regularly makes this point on Twitter and from whom I have learned much.

Managing the Therapist's Needs:

As she moves into the second chapter, she returns to the discussion, telegraphed above, about the need for gratification and the importance of not submitting to self-induced suffering. Here she asks two straightforward questions: "how are we to discern when our needs are being met in the interests of the patient or at his or her expense? And when does health self-sacrifice devolve into masochistic submission?" (p.34). In this context she mentions a justly celebrated paper by Emmanuel Ghent on masochism and the need for "distinguishing between emotional surrender and masochistic submission" (p.39).

She forces us to consider these questions together, saying that doing so may yield new insights: "the greatest obstacle to integrating these two ways of being is the erroneous assumption that ongoing personal gratification of the analyst's needs is automatically at odds with doing right by the patient." 

Maroda uses an interesting phrase from Shulman: "Unavoidable satisfactions." We may feel guilty about it, or sheepish, or disdain its discussion as "unprofessional," but the fact is that we as psychotherapists do find the work gratifying and satisfying and should simply be honest about it. (In that spirit, I will note that my gratification is greatest, most of the time, with the most difficult cases--psychosis, schizophrenia, and borderline personality disorder.) 

In reading this declamation of hers, I was immediately put in mind of a book by the great Anglo-Welsh psychoanalyst Adam Phillips: Unforbidden Pleasures. (I have rather regularly and gratuitously with students, and very infrequently and diffidently with two patients--who asked me specifically--recommended this book and everyone has found it very edifying and helpful.)

Later in the book Maroda mentions "the notion that the patient helps the analyst to change" (51) but does not especially elaborate on this. It made me, of course, think of a paper I have often returned to in understanding one particular memory of my first psychoanalysis: Harold Searles, "The Patient as Therapist to His Analyst."  I think this topic would lend itself to a great deal more writing if we as clinicians were willing to be honest about how much our patients have taught us and helped us. 

Narcissistic Needs and Wounds:

In the next chapter, Maroda makes one suggestion I heartily agree with, and one question I am distinctly ambivalent about. The former is on p.76 when she writes that "for all our conversations about self-care I think more emphasis early in training on constructive gratification of our narcissistic needs would be more specific and germane to the question of how much we need our patients." That, too, is a topic inviting much more reflection by others responding to Maroda.

Her question: "if we cannot be wounded by our patients, how involved are we?" (p.83). I think this is a question that requires very careful handling to avoid some of the masochistic guilt and enactments she later speaks of in the book. 

Conflict and Negative Countertransference:

This is the most challenging and welcome material in the entire book.

She begins with a very important question: "Do we overidentify with our suffering patients, wanting more to soothe and comfort them rather than confront them" (p.97). Shortly after this, she moves into a discussion about Winnicott's famous 1947 paper on "Hate in the Counter-Transference," noting that his treatment of hate is too antiseptic (my word, not hers) and perhaps, she hints broadly, unrealistic. Winnicott portrays his hatred as being safely locked away and not at all disruptive. Maroda rather strongly suggests this is not realistic for lesser mortals. 

Later in the chapter she suggests that we cannot predict when hatred and anger and conflict will erupt in a patient, stimulating such feelings in our counter-transference without advance warning. She says we need to be open to recognizing how these feelings are awakened, and to do so with "greater self-acceptance and minimizing guilt and shame" (p.100). But to recognize and work with those feelings in the consulting room requires, she says, some skills that need to be learned. 

Prior to that, however, we must accept that "the only solution...is for therapists to actually embrace their rage and desire to retaliate against the patient" (101). If I may permitted to intrude a personal word here, I would say that I have been able to learn (not completely, not easily, and not perfectly!) how to do this largely because of a wonderful supervisor. I was open with him about my anger and disgust towards a very reactionary religious patient who would rant with anger and hatred about their gay son who is--it was claimed--going to hell according to their reading of Catholic theology, which has also been used to justify shunning him from family life. Being open about my countertransference response from the outset with my supervisor, and processing it with him, allowed me enough emotional space and relative freedom to work with this patient. 

Psychotherapists who are open about our own negative reactions, Maroda continues, citing several studies, consistently "had more successful outcomes than therapists who were not" aware of their negative emotions (p.111). 

Maroda says that we need, as psychotherapists, to learn how to engage in "constructive conflict" with our patients (p.106) and what she later calls "creative rage" (113). We have seen, she says, more than 30 years of talk about countertransference but little actual concrete reflection on what it means to deal with, and productively use, our rage and hostility. As she will caution in a later chapter on enactments, "there is no simple answer to this question" of "how do we harness negative countertransference emotions in the interests of furthering the treatment?" (p.129). 

Before we can harness such emotions, she says late in the book, we must stop pretending we are above them, and stop "denying our capacity for aggression" (p.161). Once such denial has ceased, we may be in a position to find some "willingness to express negative feelings to our patients" on the understanding that doing so "provides essential feedback and relief for them" (p.202). 

Conflict Among Psychotherapists:

In the final pages of the book, Maroda not only advocates that we get more comfortably familiar with conflict in our consulting rooms, but also in our conferences and publications. For too long, she implies, we have avoided conflict in order to leave certain psychoanalytic orthodoxies in place, or at least beyond real scrutiny and necessary criticism and possible development and emendation. I am entirely in accord with this view, which has long been maintained by others, including perhaps preeminently Adam Phillips in, e.g., The Cure for Psychoanalysis. 

Stated otherwise, it has long seemed obvious to me that the last people on the planet who would be guilty of building heavily defended ideological enclaves and avoiding conflict would be psychoanalysts, but ironically as we all know--thanks to the work of Phillips, but before him of others, including Paul Roazen--that has not been the case. So much time and energy has been sadly wasted defending Kleinian and Jungian, Freudian and Lacanian enclaves, inter alia. How very silly and unproductive that has been. 

In conclusion, I think we owe Maroda one or several responses to the challenges she has outlined in this excellent book. She has raised compelling and substantial points that I, for one, find necessary and sufficiently deep challenges to my own clinical practice. Her gracious, cogent, restrained, no-nonsense writing style has aided her greatly in this regard, and I hope going forward we can indeed begin to talk more about our gratification, our needs, and our attempts constructively to challenge and to harness our own aggression and anger in the service of our patients and in the building up of psychoanalytic theory and practice that we all love. 

A Note on Harold Searles on Counter-Transference

Having, as you will see here, paid my debts to Harold Searles for his fascinating and often useful work on schizophrenia (and before that his essay on "The Patient as Therapist to His Analyst"), I must now register a complaint that his book Countertransference and Related Subjects: Selected Papers (International Universities Press, 1979), ix+625pp. is misleading from the outset. That is, the book is badly named: only on p.373 do we get first discussion of counter-transference, and it is not developed in any useful detail but remains superficial. The rest of the book virtually ignores any serious discussion of countertransference and is instead an assorted collection of articles, most having to do with schizophrenia. It should therefore have appeared under the title Collected Papers on Schizophrenia Vol. II, as a complement to the other volume bearing that title. 

Having been an academic editor for twenty years now for presses and journals in two languages and three countries, I am perhaps more critical, and less forgiving, than some. I find it serves nobody well when publishers allow authors to throw everything into a book without any attempt even so much as to organize the chapters coherently. Those chapters then ramble on with excessive detail and clinical illustrations that run for so many pages as to lose their point very quickly. In short, this book should have been at least 25% shorter than it is. (The editor who gave me my first editorial job in 2002 said "We pay you for one thing only: to be ruthless!" There is always room to cut--sensibly and intelligently, without blindly hacking away--and myriad opportunities to put things more compactly and cogently.) 

That said, there are little nuggets here and there one must dig out, as here:

Finding Your Own Psychotic Elements:

I liked early on in the book when Searles noes that at the end of a successful treatment of schizophrenia or psychosis, the patient has achieved individuation and ego integration to whatever possible degree, but, Searles says, the psychotherapist has also gained something: he is much closer to, and on much easier terms with, his own psychotic elements, and, in future, will not have to travel so far or so hard to experience them in the next case that comes along. 

This is a point he reiterates at the very end of the book (pp. 596ff.) with brief reference to Harry Stack Sullivan, noting that if the psychotherapist has reflected philosophically on the fact that the differences between 'sanity' and 'insanity' are not so great he will, in Sullivan's famous words, be able comfortably to see and accept that "we are all much more simply human than otherwise" and thus the psychotic person is not some strange 'other' we must race to rescue and 'fix.' 

What Might Psychosis Have to Teach Us?

It still seems sadly common to deride psychotic disorders as a descent into utterly meaningless gibberish and irrational gestures ('word salad' etc.) but I simply cannot believe that to be the case all the time. And so with Searles, in this book as in his other one, I think he is onto something significant when he claims that "Schizophrenia is, in a sense, the shadow cast by the emotional deficiencies of our culture" (26). 

Even more strongly, Searles speaks of his schizophrenic patient thus: "because he, perforce--not by choice--has been living on the sidelines of humanity he is in a position to tell us some important things which we have been too immersed in 'normal' living to see" (p.26). This accords very much with what patients have felt and described to me, too--like they are coming back to report on things nobody wants to hear but which they regard (and I agree) as being vitally important to think about by way of acknowledging the suffering and isolation at the heart of the human condition, and the oft-unfulfilled longing for communion and connection. 

The Rewards: 

I was heartened to read that Searles reports feeling "unclean" with guilt, and "perverse" in his fascination with his patient's delusions and hallucinations--until he allowed himself to see them as high art, as products of a highly creative mind. I was also impressed (albeit uneasily) the first time delusions and hallucinations were described to me in very careful and exacting detail, feeling like I was watching a painter very deliberately decide on which brush, colour, and location on the canvas for each stroke and detail.

Having overcome his guilt, in the end Searles sees "one of the endlessly rewarding, exciting aspects of this work" to be found precisely in the unpredictability and singularity of each individual. I fully agree! 

A Caution Against Cures:

Searles, however, is at pains in his lengthy chapter on "The Dedicated Physician" not to go about putting pressure on patients to achieve the sense of satisfaction the psychotherapist needs in watching patients get better. As he elsewhere noted, and others have as well, pressure to be 'cured' can in fact be highly suspect and unhelpful--and may arise from omnipotent and sometimes sadistic elements in the psychotherapist's mind. Searles notes how often the overly zealous and over-eager therapist infantilizes the patient by his insistence on a cure, by his omnipotent desire to help which robs the patient of his autonomy. Sometimes you do this to avoid having a competitor or even superior in the patient, whose health or strength is suddenly greater than yours. 

Regardless of your motive, he says you must not imprison the patient with your desire to see him cured. In this he joins with Nina Coltart, Adam Phillips, and others in swearing off the idea of 'cure,' and I am glad to learn from them on this score, as I also have from Searles, albeit not as much as one might expect in a book of 625 pages!

Karen Maroda on the Therapeutic Relationship

I've previously read some of Karen Maroda's work and found it helpful. I've just had a chance now to finish her 2012 book Psychodynamic Techniques: Working with Emotion in the Therapeutic Relationship and found parts of it very helpful and insightful. Herewith some notes on it:

Figuring out Fit:

She begins in a way that puts me in mind of the great Nina Coltart, whose Slouching Towards Bethlehem talks about how to figure out whether you and a new patient are a good match, and how to figure out when to refer to someone else. Thus Maroda writes of what to look for: "Ideally a good match includes compatible styles of relating--just enough shared early emotional experience to make for a connection, but not so much as to blur the distinctions between therapist and client" (p.7). This might still seem a bit abstract so she has some even more practical counsel: Watch how you feel when the prospective patient walks in. What does your gut say? If you have an instant and strong negative reaction that does not abate, that is a strong sign not to be ignored. 

Do not, she goes on to say, tough it out and assume initial dislike will go away or be surmounted in an heroic burst of empathy: this almost always fails. Remember, she continues, that "it is not a good idea to engage in therapy, even short-term work, with someone you are either not interested in or dislike" (p.8). If therapists attempt to engage in such work anyway with people "who do not elicit their curiosity and whom they do not like [they] are doing an injustice to the clients as well as to themselves" (ibid).  

What, then, to do? Refer, of course, and do not be reluctant or neurotic about it. She says that while you might feel uncomfortable broaching the topic of a referral elsewhere, you should "keep in mind that if you know this person is not a good match with you, at some level the client knows it too" (p.11).

Mining the Intake's Several Veins:

Maroda reviews the data we are all familiar with, showing that drop-out rates are high, and this often occurs after a handful of sessions. Why? One reason she highlights is a rupture in the alliance, which never really had a chance to get off the ground, and this may be due in significant measure to how you conduct your intakes: do not, she says, put people off by taking notes, a principle I first learned from Coltart who is adamant about never taking notes with a patient in the room, which practice I also abhor. 

Maroda further says that you need, in that crucial first interview, to avoid asking rote questions, dealing extensively with insurance, etc. Your job is to help them get comfortable ASAP to start talking about themselves. To put it crudely--which she does not, but which I have heard others say--the point of the first session is to have a second session. 

As you are further considering fit, and whether this prospective relationship has any chance of success, Maroda recommends that you ask about the patient's existing and past relationships: the patient without any, especially sustained over the long-term, is a very poor prospect for successful therapy.

Don't be so high-minded during the first session to overlook the more mundane factors revealing much about the person and the prospects and direction of therapy. Here she says that much is revealed in the first session by such things as how they first greet you--she comments on the quality of handshakes, which apparently used to happen back in those pre-Covid days we can all scarcely remember now--and how and where they sit, whether they make eye contact, etc.

Once you agree to begin treatment, do not leap in too far and too soon and so overlook the importance of educating new patients on therapeutic process: let them know that "what they defend against feeling is exactly what they need to feel to get better....Paraphrasing Winnicott, I say that we always fear most what has happened to us already" (p.20).  

Don't Overdo the Empathy:

Maroda makes an almost off-hand comment that reminds me of much of what I have been reading recently about working with psychotic and schizophrenic patients: there's such a thing as too much affirmation and empathy. She says that if you have people who have difficulty accepting empathy, she advises that "the fewer words the better, and the less dramatic the better" (p.20).

Confrontations:

I really liked Maroda a lot for calling us out on how poorly most of us do with confrontation. I know this is a weakness I have to watch out for and am working on. Once again she puts me in mind of Coltart, who writes about the one and only time she "bawled out" a patient for what she said was a sustained and lethal attack on the treatment and relationship. This startling and singular action turned out to be the pivotal moment needed to prevent outright treatment collapse. 

Maroda notes that most therapists never learned how to do confrontation well. She illustrates this nicely with a story about how she confronted a man with herpes who slept around and put a lot of people at risk. In confronting him over this she diverged from what she says is the problem whereby "too many therapists masochistically submit rather than risk real emotional vulnerability" (p.191) which confrontation, done well, invites.

Dealing with Anger:

In this part of the book, she makes an obvious point that nonetheless needs stressing: Don't become a martyr by sacrificing yourself unduly as it only breeds fierce and seething resentment. I've learned that the hard way! 

We must respond to angry outbursts and not just suck it up in silence for, she insists, "no therapy is taking place when the therapist pacifies or silently withdraws from an angry client" so don't just sit there and let them rant at you! Instead, you "should struggle hard...to get out of the position of masochistic submission". A failure to respond will usually make the patient either contemptuous or feel hurt and abandoned. Find your own voice and style to respond, but respond. These can be moments of deep change because deep emotions are engaged (p.193). 

Hatred in the Counter-Transference:

I have often quoted D.W. Winnicott's 1947 paper "Hatred in the Counter-Transference" but Maroda is right to remind us that "we have given short shrift to the benefits of acknowledging anger and hatred in the countertransference when a stable, positive attachment between therapist and patient exists." As she goes on to note, DWW's classic paper is cited here, but rarely developed, discussed, or implemented.

If you are going to do this, and the relationship is stable and positive overall, try, before expressing anger, to verify whether the patient has any sadomasochistic relationships in the past or any personality tendencies in either direction. If they have pronounced masochistic tendencies, your getting angry may be an unwittingly gratifying thing they are seeking. Finally, ask yourself if you are feeling the need to punish the patient before you say or do anything.

Overall she offers the following concrete guidelines:

• be reasonably in control while manifesting emotion
• direct, honest, and non-defensive anger is what you are aiming for
• admit if you did something to make the patient angry
• don't get snarky or passive aggressive. Say something like "I'm getting tired of your insults and anger and I won't tolerate them any more. What I want is for you to talk about what lies behind those angry insults."

The Importance of Gratification:

Finally, Maroda has some very welcome words that bring out the importance of gratification and stress that it is not something therapists should be ashamed or embarrassed about. She notes that some gratification is not bad but in fact necessary to keep the relationship moving forward. As with the ideas developed at the outset about determining fit, you need to work with patients who interest you and whom you find it gratifying to help. 

This is, of course, as she says a "delicate balance" because you can never be totally gratified: that must always be denied to both patient and therapist alike--even as you pursue the limited gratification appropriate to your respective roles (p. 211). She refers to Searles here who freely admitted that he felt at least a little bit in love with every patient at some moment, but he never mentioned this to them or acted on it: here, Maroda observes, is someone who had good affect management, which we should aim for as well.