Working with Violent and Sexually Harmful Children and Adolescents

This book is so new that it bears, on my copy, a copyright date of 2022 even though I have had it in my hands since late August 2021. (One might reflect that perhaps this confusion over dates reflects a rush to get into print a book that, alas, has not been copy-edited very well: I've found several typos and solecisms, which is not a thing one typically expects or encounters in Routledge books.)

In any event, it is a rich collection of articles from numerous clinicians in England associated there with the prestigious Portman and Tavistock clinics: A. Nathanson et al., eds., From Trauma to Harming Others: Therapeutic Work with Delinquent, Violent, and Sexually Harmful Children and Young People (Routledge), xxiii+172pp. In what follows, I simply put together some insights pulled from several (but not all) chapters. I do so in part because about half my current clinical work is with adolescents court-ordered into individual and group psychotherapy for various sexual offenses. This is not work I ever expected to find myself doing at this stage of my life. It was, to be frank, work I was faintly horrified by when I first learned of it. But now that I have been immersed in it for nearly a year, I have come very much to enjoy it in that Winnicottian sense I wrote about here. 

The introduction takes us into some of the theoretical underpinnings of the essays in the collection, and explicitly makes mention of someone whom I was introduced to through reading Adam Phillips: the late American psychiatrist and psychoanalyst Robert Stoller. His book Perversion: the Erotic Form of Hatred gets cited by the editors as a useful text, which I have also found it to be. Stoller has argued--in my view correctly--that often what is sought in sadomasochistic fantasies and enactments as an adolescent or adult is a triumph over childhood traumas. The authors and editors in this new book would also seem to share that view.

The other author they cite, unfamiliar to me, is Ismond Rosen, editor of a collection of articles, published by Oxford UP in its third edition (original: 1979) in 1995 as Sexual Deviation. 

The editors go on to be clear about things that in the popular imagination are often obscure, noting that "only a minority of adolescents who sexually harm others turn into habitual sex offenders" (xiv). This is confirmed in some of the case studies later in the book of adolescents who sexually harmed children not because of an attraction per se to children as such, but because in each case the child represented something the offender hated and sought to strike at to hurt someone else--chiefly a parent. 

The editors in the introduction, and many of the other authors in this collection, acknowledge that what has changed in their work over the years with this population is the Internet and the widespread and rampant access to pornography (and the related problem of other images on social media). 

Mariane Parsons has a brief chapter, "Key Concepts Developed at the Portman Clinic," whose conclusion is simply stated but, in my view, absolutely crucial for this kind of work: "to foster...and enhance the youngster's self-esteem and capacity to be curious about himself it is of vital importance to help him to feel seen by the therapist as a whole person with strengths that can be valued (as well as weaknesses that need help). This offers hope to the patient and is essential for a move towards a healthier future" (p.7). I have written at length elsewhere (in press) about trying to do exactly this and why it is so vital for clinician and patient alike, so I will say no more about that here. (The last chapter in the book, "The History of the Portman Clinic," brings us back to the introduction, but with more particular detail and less clinical material.)

Anne Alvarez, in her chapter "Motiveless Malignity," notes bluntly that clinicians, when working with patients of psychotic and psychopathic tendencies, must "look evil straight in the eye" but then also look at whatever good qualities may be starting to emerge in a patient as well. Sometimes these qualities will be very minimal and must not be overplayed or exaggerated. In some particularly damaged individuals the most we might ever see are "faint beginnings...of trust and faith" which may be remarked upon unsentimentally. Such patients also generally cannot handle symbolic interpretations ("in attacking me you are seeking to strike at your mother") so these must be used with great caution.

Donald Campbell's chapter, "Considering Perversion from a Portman Clinic Perspective," engages with Stoller and other recent clinicians after returning to Freud's 1905 Three Essays on the Theory of Sexuality. Campbell's chapter inspired me to return to that 1905 work also, and find in it some refreshingly blunt and straightforward claims, including that "sadism is the most common and the most significant of all the perversions." 

Campbell agrees with this, and notes that none of us should recoil from this because "all of us in one way or another are neurotic and have entertained perverse fantasies" (22). Much of the rest of the chapter is taken up with case studies and other clinical material. 

Toward the end he offers a welcome note of caution which it seems to me those running CBT-type treatments for sexual offenders might need to take deeper note of: whether in individual or group treatment, authoritarian and "macho" tendencies must be avoided in leaders who must also avoid focusing "exclusively on behavioral change without understanding the individual's internal conflicts and anxieties." Merely focusing on externals overlooks "the abuser's capacity to adopt language, concepts, and whatever is suggested as normative behavior," offering "simulated attitudes and behaviour" and a mere appearance of change (33). 

Graham Music and Heather Wood author the next chapter, which focuses on porn on the 'net. They begin by quoting a 2017 UK study to the effect that 65% of adolescent boys had not just seen porn on-line but "thought such images were realistic." Those who are emotionally fragile may gravitate towards porn and become fixated on it in part because of a pre-existing lack of connection to their own "bodily experiences and desires" (38). Continued use of it may be a defense mechanism against "core complex anxieties." One way to combat this, they aver later in the chapter, may come through developing greater capacity to mentalize, here drawing on Peter Fonagy's well-known work in this regard. 

The authors are commendably straightforward about what is offered by life in comparison to the endless fantasies of porn: compared to those images, reality must seem "very grey and dull" and it requires a perhaps unlovely "acceptance of ambivalence and imperfection" (39). Here I am put in mind of Adam Phillips again and his rather bald assertion that "reality matters because it is the only thing that can satisfy us." 

The ending of this chapter leads into the next, for both talk about porn in Winnicottian terms: as an object over-invested with meaning for some; as an object that attempts to replace human and fleshly contact because of past trauma; as an object to which one relates precisely to escape from the problem of relating to flesh-and-blood human beings. Thus do we come to John Woods' chapter on porn, "Seeing and Being Seen," which draws on Winnicott at length.  

Woods begins by commendably acknowledging the "contradictory messages from adult society" that children and adolescents get around sex and porn. On the one hand, we live in a libertarian world where "freedom of expression" is strongly encouraged and the right to sex, to sexual and gender identity, and to explorations of the same are all held up as goods that rights-bearing autonomous citizens have and which must not be impeded by censorious governments or others. But on the other hand, those of us who are working with adolescents and children, especially those court-ordered into treatment, operate with an inescapable and relatively clear moral imperative: certain forms of sexual exploration and expression are totally prohibited by the law, which punishes those who disobey, and our adolescent patients must be brought into compliance with this. 

Woods introduces another element here between competing moral and legal philosophies: the question of development. He believes that "unrestricted access to internet pornography undermines normal development" (56) and can contribute to the problem of voyeurism. On this topic, he draws on Winnicott's erstwhile analysand, the problematic Masud Khan (himself guilty of sexual boundary violations--inter alia--with patients), who notes that the intensity of pornographic arousal may be closely tied to how much of a need for "object relating" it provides. Additionally, the power of voyeurism may come from the fact that one believes one to be able to see anything and everything without consent.

Later in the chapter, Woods returns again to the moral problem of pornography, and is refreshingly candid in asking why "we are turning a blind eye to the very damaging effects of internet pornography in our society" (60) which he says should be regarded as a "Public Health issue" (61). He says clinicians should give support to parents who are fighting to maintain some control over what their children are exposed to, and that "the ideal of free expression and no censorship has to be questioned." Based on my own clinical experience watching how badly distorted some adolescents' views of sex are based on exposure to porn, and how many problems it has created in their life, I am firmly in agreement with Woods in all this.

Ariel Nathanson's chapter "Working with Mental Hackers and Backroom Thinkers" introduces the useful concept of having a mental backroom "as both a hiding place and a control centre" from which to exercise one's wishes for "omnipotence" (67). This chapter could have withstood some further development and elaboration, not least by drawing on what seems to me an obviously relevant body of literature: that of schizoid personality theory from Fairbairn, Guntrip, Winnicott, and most recently Nancy McWilliams. 

She reports confronting one patient with the rather colourful question: "are you making direct in-the-moment contact with me or do you use the sessions as a takeaway service, store my comments, and feed yourself elsewhere?" (76). If progress is made with such patients, then they may come to realize how much of life they are missing out from and thus they may come to leave their backroom, regarding it no longer as a "glorified control centre" but instead a "bleak addict's den" (77). 

In his chapter "Angels and Devils: Sadism and Violence in Children," Graham Music echoes several themes noted earlier about sadomasochism supplying unmet needs, or being a way to triumph over earlier traumas as well as various forms of "anxiety, stress," or "feelings of inadequacy" (86). Sometimes, however, the intensity of sadistic fantasies or enactments is precisely due to the patient having an internal world that is "empty and flat" with much deadening of feeling.

As we move into the later chapters in the book, some of the clinical material becomes darker and we see more severe cases of violent sexual acting out. This leads one of the authors in this section, Tim Baker, to reflect on the connection between aggression and the counter-transference. This becomes especially tricky to manage if one is working with an adolescent offender who was also himself victimized at some point. Baker's chapter on self-harm in adolescents offers some helpful vignettes to those struggling to understand such things as adolescents exposing themselves on-line or in school settings, or in public places, or those who admit to, but never carry out, sexual attacks on siblings. Much of this is discussed under the heading of Winnicott's aphorism that "it is joy to be hidden, but disaster not to be found." 

Patricia Allan's chapter, "Securing the Disaster Zone," offers some useful ways to think about initial contact, early assessment, and decisions for treatment with adolescents. She worked with a badly traumatized 8-year-old boy whose clinical presentation was of very considerable complexity and difficulty.

Ariel Nathanson's chapter closes out the book. She begins by presenting a case of a young man who admitted to using sadomasochistic pornography (of violent cuckolding) to masturbate to as a way of handling fights with and rejection from his girlfriend. He explicitly felt that this was a better way of handling things than giving in to his aggression towards her. The problem with such an approach, Nathanson says (here drawing, as numerous authors before her have, on the work of M. Glasser in the Rosen volume, Sexual Deviation, noted above) is that it rapidly becomes "both perverse and highly addictive" (139).

Nathanson's chapter is an attempt to synthesize "common themes and dynamics" across her many years of work with adolescent and young adult males presenting with sexual difficulties and offenses. Most of them wound up in long-term psychotherapy. All of them presented as "suffering, highly addicted to their destructive activities and feeling at the mercy of those, unable to free themselves, as they would desperately like to do in order to lead a normal life" (140). 

Central to every story, she says, is a theme of descending into a dark world. For many, this is a comforting and familiar world, a world where they can feel alive, where they feel their "real self" may be discovered, where their "real attachment" and "first love" abide (140). Such a world elides the problem of abandonment. It creates and welcomes plenty of bad objects which become perversely salvific.

Nathanson talks of how all her patients come sooner or later to a moment of realizing how and when their "fuck-it" button functions in life--that rapid moment of transition from one self-state to another which has previously been so rapid for them and so out of control that they find themselves back in addictive behaviors before they realize it, let alone attempt to control them or resist them. As one increasingly recognizes the dynamics of this process, she reports that patients notice things slowing down. The fuck-it button might still get pressed, but this time with a little more room for noticing, and perhaps very briefly tolerating, the anxieties that precede it.  

As this increases, patients realize how much they have ritualized, via negative behaviors, unintegrated anxieties, memories, feelings. Over time much of this can actually decrease: enactments may still happen, but with less intensity and frequency, and with greater realization and control: this is what she calls "emerging potency" (148). One patient noted "how not enacting sexually made him feel more potent, creative, and able to use his aggression to assert himself at work." 

Central to success in this work is an increasing "integration between the physiological and psychological, often reconfiguring the relationship between their bodies and their minds after many years of addiction and abuse" (149). 

In her conclusion, Nathanson affirms a practice that is central to the program I work in with adolescent sexual offenders: not just building a general relationship with each patient, but having each patient narrate in close and concrete and unsparing details the nature of their enactments and abuse. These are then "looked at carefully, under a microscope." 

Each of my patients struggles to do this, but it is key to all future progress. Such enactments, she says--echoing, of course, Bion--constitute "attacks on linking." The moment when the fuck-it button is identified is the beginning of the end of attacks on linking, the beginning of the restoration, in fact, of the capacity to see, and gradually to accept and tolerate, linking (between, that is, maladaptive behavior in the present along with anxieties and feelings from a traumatic past, which are now noticed and increasingly tolerated before being changed). 

Finally, Nathanson notes that responses to enactments are often much more effectively delivered by group therapy than individual. In the latter, responses from the therapist to enactments can seem authoritarian and punitive, shutting down the process of exploration and reinforcing the very habits of flight one is working to heal. A group, by contrast, offers different ways of exploring these enactments that eventually lead to their extinguishment (or at least very dramatically reduced number and nature).

In sum, then, From Trauma to Harming Others is a rich compendium of clinical experience that all those of us working with adolescents and young men struggling with sexual addictions and crimes can profit from with gratitude. 

In Praise of Nancy McWilliams: On Psychodynamic Therapy

I forget when I first stumbled upon Nancy McWilliams, but it was some time ago. I had started with W.R.D. Fairbairn's pioneering work on the schizoid personality, and then read Melanie Klein and Harry Guntrip on the same phenomenon.

It was, however, only when I came to McWilliams that I found an essay on the topic that is the clearest and most compelling treatment of them all. Not unrelated to this post, McWilliams in that essay quotes Harold Davis to the effect that “'psychoanalysis is a profession by schizoids for schizoids'.”

On the strength of that essay, and also very much respecting Jonathan Shedler, who regularly extolls McWilliams work on Twitter, I put her Psychoanalytic Psychotherapy: A Practitioner's Guide on my reading list, and have now had a chance to go through it very carefully. It is excellent, especially for those with little background in psychoanalysis. 

I appreciate her openness in the preface where she recognizes that there is a legitimate diversity of treatments, but that psychodynamic approaches are often neglected when it comes to studies of their efficacy. From here she notes that her approach in writing this book will be to emphasize what may be applied "to all clients," and not just those who have signed up for psychodynamic therapy. I take her to mean that psychodynamic theory is applicable and useful in understanding patients even if a given therapist operates predominantly from a tradition of CBT or DBT (etc.). 

In this she puts me in mind of the great philosopher Alasdair MacIntyre whose early work in the philosophy of science and the development of theoretical traditions--and the clashes between them--rightly reminds us that one mark of a stronger tradition is its capacity to more fully and helpfully account in a better way for the gaps in, or problems raised by, its rivals. 

The other welcome note in the preface is that McWilliams is not going to be a zealous crusader insisting that everyone must slavishly imitate her methods, or those of psychoanalysis more generally. Instead she speaks of the "need for therapists to honour their own individuality in the arrangements they make" (xiii). The preface ends by McWilliams recognizing her own debts to various figures, including Theodor Reik (he of the "third ear") and especially Frieda Fromm-Reichmann, whom I wrote about appreciatively and at length here. 

Later on she returns to this theme, insisting in several places that one should "integrate one's individuality into the role of therapist" (p.52) and that therapists are most successful when they "relax and let their unique personalities become their therapeutic instrument" (53). As she notes later, "when it goes well, psychoanalytic therapy feels to both parties like a conversation from the heart, not the head" (66).

The patient seeing you being genuine and open, and speaking from the heart, can find all this therapeutic. But we must, of course, do more than that--if a bit of warm listening and sincere opening up were all that a patient needed, then they would simply turn to a good friend or family member, not a psychotherapist. The uniqueness of the role is that we must also challenge patients to grow. 

Throughout the book one has the sense of serenity in McWilliams: she is not someone who defensively feels she must be a fierce advocate for or against any particular approach, or to challenge patients in an obnoxious fashion. In this, as I have remarked elsewhere, she stands firmly in Freud's line who, pace the myths talked about him, emerges in his correspondence and in Paul Roazen's original and invaluable scholarship, as very "liberal" in encouraging all sorts of methods of healing, not just psychoanalysis. 

In her discussion on the "American Medicalization of Psychoanalysis," McWilliams, in fact, emerges as a critic of the tradition she is defending and its "cult-like atmosphere," its often ideological and hidebound ways that have, perhaps more than anything else, contributed to the vastly diminished standing psychoanalysis has in this country. 

By contrast, she notes that contemporary psychoanalysis in this country, to the extent it remains viable and healthy, tends, rightly, to eschew tendencies towards "purity" of both theory and method, being comfortably eclectic in some ways ("I remain skeptical of orthodoxies, especially technical ones" [p.23]). 

In her first chapter she draws close to something I am working on in my next book: the increased openness towards spirituality in psychoanalysis today, and psychology generally. Here she references the work of Bion in particular, whom I discussed a bit here. 

What, if anything, distinguishes a psychoanalytic approach from any other? McWilliams begins by noting that there must be a "curiosity and awe" for the unconscious, and an awareness that most of our behavior, thoughts, and feelings are not in fact consciously determined. This requires of the therapist a willingness regularly to have what one thought one knew about the patient disconfirmed and disturbed. If, she suggests, one is attempting to practice some version of Freud's "evenly hovering attention," then this might not be so difficult for in that state one has not fixated on any one thing, least of all some notion of causation which might blind us to other factors in play. 

In her second chapter, McWilliams quotes Christopher Bollas from his first (and to my mind still his best) book, The Shadow of the Object: Psychoanalysis of the Unthought Known: "in order to find the patient, we must look for him within ourselves." 

She rounds out this chapter with a brief discussion on the role of faith--in the process, in ourselves, and in our patients--though there is no mention here of the extensive writings on the topic by Nina Coltart, who, to my mind, has covered this topic perhaps more forcefully than anyone else I know of. 

Chapter 3, "The Therapist's Preparation," begins by noting that we are going to make mistakes, and need to be okay with that. What happens after the mistake is often more crucial than the mistake itself. Will this lead to an enactment, or rupture, and if so, how is that handled? 

In her fourth chapter, McWilliams discusses the well-known findings about the centrality of the therapeutic or working alliance to the success (or failure) of all therapies. The patient cannot be expected early on to know to check in about this, so the therapist needs to make a regular point of asking  "How are you feeling about working with me?" or "Are you finding yourself comfortable talking with me?" (p.82). 

I have, so far, only once been scared by a patient, but I managed to wrestle control over my fear by, as it were, "channeling" the spirit of D.W. Winnicott (whom I last wrote about here), about whom it was often said that he refused to be afraid of his patients. I thought fear would be something you'd just have to get used to, if it came to that, but McWilliams addresses fear and threats of various sorts in several places in the book, and she helpfully reminds us that "the therapist's sense of safety is as important as the patient's" (80). 

Later on in a related vein she will note that protecting therapist and patient alike is also part of the reason for the frame, and one should never deviate from it lightly. If, she says, you ever feel uneasy about any request that seems to veer towards a boundary violation, trust your gut and err on the side of being conservative. Boundaries and frames, moreover, are crucial in managing the huge power differential that exists in therapy, of which we must ever be mindful. 

If a sense of safety on the part of the patient exists, and boundaries are in good working order, then the patient may begin to experience his capacity to express hostility and contempt toward the therapist without fear of retaliation. Handling this requires a deft touch so that you do not masochistically collude in diminishing yourself on the one hand, nor in reacting defensively and perhaps vindictively on the other. 

The topic of hate returns late in the book, when she notes that a therapist might well need to encourage a patient not merely to express that feeling, but even feel encouraged to enjoy it. 

Handling other requests also requires a deft touch. A bit earlier, in her section "The Art of Saying No" (p.126), she has some very useful advice which I had no sooner read then within a day or two had occasion to put it into practice, finding success on both occasions (to my considerable relief!). She refers to those sometimes awkward conversations one must have with patients, often over fees, or no-show policies, or other limits. Rather than give them a lecture on how such limits or policies are really in the patient's best interest, she finds it much easier to elicit co-operation if she presents those as helping to fulfill her needs. 

I did this with a patient who had sustained a serious injury and then not showed up to two appointments in a row. I could legitimately tell this person that I was worried they might have been hospitalized with worsening injuries and I was worried about them. This prompted a phone call the following week when another (different but serious) reason kept my patient from making the appointment. I think both of us felt relief that this was handled now openly and simply via this expedient manner. 

Chapter six ends with some welcome reflections on the nature of psychoanalytic love. Here, as earlier, she has returned to Freud's famous observation in a letter to Jung that psychoanalytic cures are, in the end, ones of love. This, she insists rightly, is not an infantilizing form of love but one of serious respect that takes account of all qualities, positive and negative, in the patient. It is not cheap sentimentality, and certainly never exploitative. 

Chapter 10 offers some brief comments on sexuality, noting "how sexually diverse people are," and learning this can often be a very freeing part of good psychoanalytic therapy: "the appreciation of sexual diversity and the capacity to own one's unique sexuality without apology are frequent 'nonspecific' outcomes" (pp.254-55). 

The final chapters of the book offer an array of more practical tips to therapeutic practice, with welcome comments on malpractice hearings and ethical violations, and how to handle them. The very last chapter is focused entirely on self-care, one form of which she advocates that I also greatly love doing: writing. Here she quotes Michael Eigen that "psychoanalysis is a writing cure, not only a talking cure. Writing helps organize experience of sessions, but it also helps discover and create this experience." 

In the end, McWilliams has a lovely answer as to why many of us might be, at least in part, motivated to do this work: "our patients heal us as we heal them" (p.281). 

How May We Say that Psychoanalytic Therapy Changes Us?

I freely admit that I've struggled for twenty years to read Lacan with any profit--nearly the same period as I've sought to discern the effects of my own psychoanalysis, which ran for seven years four times a week on the couch. So I am glad, finally, to have been exposed to enough of his writings to find some insightful and useful ideas therein for understanding my own experience as an analysand. 

At the same time, though, I am aware of violating my own practice of always seeking to read primary literature rather than secondary sources, which I have done in this case in the form of Luis Izcovich's recent book The Marks of a Psychoanalysis, trans. E. Faye and S. Schwartz (Karnac, 2017). Izcovich is a psychiatrist, psychoanalyst, and academic teaching and practicing in Paris, where he is a founding member of the School of Psychoanalysis of the Forums of the Lacanian Field. He has written several other books, most of which have not been translated into English. He quotes Lacan lavishly, especially in the latter half of the book, which was far and away the more valuable part to me. 

Part of the accessibility of this book, for me, was that it does not confine itself only to Lacanian thought. Chapter 10 takes me into deeply familiar territory: England, where Izcovich reviews the work of Winnicott and Guntrip. The latter was especially interested in the question at the heart of this book: how much change can anyone expect to experience after having been analyzed? 

Guntrip was first analyzed by the unjustly neglected Scottish analyst W.R.D. Fairbairn (about whom John Sutherland wrote an interesting if incomplete book, Fairbairn's Journey into the Interior) toward the end of the latter's life. Fairbairn--to the extent he is known at all today--is invariably introduced as a solitary Scottish analyst practicing in isolation in Edinburgh where he kept out of the Controversial Discussions and turmoil in the Klein-Freud feud around the English psychoanalytic scene down in London in the 1940s. Fairbarin, even in relative obscurity, remains, to my mind, important for his early and still valuable work on the schizoid personality type which others--Guntrip most notably--have expanded upon considerably. 

Guntrip felt there was still more work to be done, and so embarked upon a second analysis with Winnicott. He would recount details of both analyses later in writing, showing that he received different gifts from each analyst, but that Winnicott was able to take him farther than Fairbairn, but neither could go as far as Guntrip hoped and wanted. 

If neither analyst was able to effect the comprehensive cure that Guntrip seems to have wanted, he would nonetheless be led to ask a crucial question (which is also Izcovich's question): "How complete a result does psychoanalytic therapy achieve?" 

In one of his last essays, "Analysis Terminable and Interminable" (1937), Freud answered this question in a pessimistic way. Here Freud recognizes that almost all analyses will be incomplete in some way for diverse reasons. In some cases it may be that the analysis was broken off too soon; but in in others an analysis may have been successful, allowing for the patient to have a long period of health and freedom which may then be unexpectedly replaced by a return of old habits, or fresh suffering, requiring new therapeutic attention. Sometimes the analysis did all that it could, and new trauma, which nobody could anticipate, emerges, requiring new therapy. This is also true in a well analyzed analyst's life, leading Freud here to give his famous--and welcome--counsel that "every analyst should periodically--at intervals of five years or so--submit himself to analysis once more, without feeling ashamed of taking this step." 

Izcovich goes beyond Guntrip to ask additional questions: What are the marks of a successful and completed analysis? Can we see them clearly? 

When he finally and fully turns to these questions, Izcovich offers an attractively straightforward answer, at least for me: "without doubt the most salient (marquant) indicator of analytic progress is a very clear change in the intellectual inhibition that preceded the analysis" (121). This, he notes later on, does not have to be immediate and is not always calculable. 

A little later Izcovich writes in what seems to me reminiscent not only of Winnicott, but even more of Adam Phillips (whom he does not cite) when Izcovich notes that "one aspect of psychoanalysis is anti-identity" (135). As Dodi Goldman (inter alia) has mentioned, one of the most attractive aspects of Winnicott was his thwarting of ideology and identity in their essentialist guises, his refusal to be dogmatic about these and other matters. 

That, it seems to me, is an especially rare and important gift today--to be freed of the need to have have questions of "identity" solved in a clear and unambiguous way. At the same time, however, such freedom comes at a cost, which was well captured in Auden's haunting panegyric poem for Freud where he notes that "To be free/is often to be lonely." 

The answer to these questions--about the ends and marks of psychoanalysis--is not automatic, and Izcovich shows that Lacan would want us to remind us that the "crucial question concerns what use is made of the effects of an analysis" (213). It should not be assumed, he continues, that one effect is for the analysand to become an analyst "but rather it is what analysis changes in the way someone lives his life" (215). Such changes, however, do not result in having everything resolved sensibly and in understanding everything. Rather there is "discontinuity" at the end of the analytic journey, which leaves one--here Izcovich and Lacan quote Melanie Klein--with a renewed capacity for "solitude" (which is well treated in the contemporary English psychiatrist Anthony Storr's book Solitude: A Return to the Self.)   

In the end, then, Izcovich says that for Lacan "therapeutic analysis should clear the way, via a freedom in relation to the symptom, and, as a consequence, open up the most direct path in life to the realization of one's desire" (239) insofar as this can be known and accepted (for some people do not want what they desire, or do not want to desire at all!). In some cases, one's desire, after an analysis, has been re-directed: "libidinal redistribution implies the withdrawal of libido from certain partners in life in order that it be invested in new ones" (243). 

Izcovich's book did not offer all the answers I may have expected when I first picked it up, but it was and is a useful reminder (especially when joined to the chorus of others whom I love, particularly Nina Coltart but also Michael Eigen) that analysis begins and ends in mystery. 

The Therapist's Therapy

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

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

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

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

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

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

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

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

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

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

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

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

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