Optimal Responsiveness: A Short Note on Howard Bacal's Book

I begin with a confession: So much of what many authors in this collection, and above all the rather self-impressed and heavy-handed editor himself (who not only writes an introduction to the book, but also superfluous and sometimes condescending introductions to every chapter, including the two chapters he himself wrote) are enthralled with (viz., the concept of optimal responsiveness) seems very commonplace to me now. To avoid such impatience on my part, I had constantly to remind myself while reading Optimal Responsiveness: How Therapists Heal Their Patients, ed. Howard Bacal (Jason Aronson, 1998) that a quarter-century is a very long time in psychotherapeutic history, and that in 1998 when the book was published (and in years earlier in that decade as these chapters were being written) the things we take for granted today--being on this side of the rise of two-person, interpersonal, relational, and self-psychology changes in our theorizing at the hands of people like Thomas Ogden especially--were, in fact, rather novel. 

But I firmly believe books have to be read in their original context as well as our own, and so I can see how valuable many of these chapters may have been 25 years ago. And, as I shall briefly show, some of them remain very valuable today.

For me, the largest overall value comes from how much of self-psychology, including Kohut's writings themselves, this book very skillfully manages to make clear. In doing so, it helps me finally find valuable material in him after struggling for close to a decade to read him, including a stint in 2018-19 when I was on a fellowship at his very own Chicago Psychoanalytic Institute, some of whose analysts on faculty also admitted (sotto voce) they could hardly understand his leaden and jargon-riddled Teutonic prose.

The book's virtues extend beyond making Kohut generally clearer into showing some key parts of his thought that are of direct clinical use to me in one of my hardest cases. I always remain grateful to authors who give practicing clinicians ways of reconceptualizing a case and adjusting their techniques for trying out in that ongoing feedback loop that Jonathan Shedler memorably talks about. 

Bacal's opening chapters lay out the idea of "optimal responsiveness" which seems to have begun as an explicit challenge to very early ideas of "optimal frustration" of various drives. Two of the chapters do an excellent job laying out the genesis and historical development of this latter concept from Freud who seems to have been reacting not just to patients but also his rather more careless colleagues, not least Jung and Ferenczi who instead of frustrating or denying patients' desires for more intimate contact, indulged those to sometimes disastrous effect. 

Bacal argues that "optimal" does not mean perfect, but means instead means "most favorable natural conditions for growth" and thus can include all kinds of responses by the therapist in the moment. Thus if the patient needs you to be mirroring or affirming, you do it; if withholding is indicated, you do that; if something needs to be directly challenged rather than "contained" then you do that. In some ways, as I noted above, this idea of such flexibility is more commonplace today than it seems to have been in the 1990s, when Bacal wrote that "optimal responsiveness of the analyst is determined by the position of the patient on the developmental line of self-selfobject relations, and on his position on the developmental line of internalization of, and capacity for, empathy" (p.32). 

Overall several authors in the book usefully reminded me that in some cases with serious developmental deficits, there are in essence holes in the internal self-structure and until and unless these are repaired, or at least attended to in the best (optimal!) way, little progress will be made, especially if the idea of progress is heavily insight-dependent. Thus Kenneth Newman's chapter (drawing on Winnicott's famous essay "The Use of an Object") reminds us that some patients cannot use the therapist adequately when they have such deficits (I immediately thought here of obesessive-compulsive personality disorders, about which I wrote at some length here, and Shedler brillantly discusses here). 

I joined this up with a much later chapter by Lynne Jacobs who offers a helpful caution that some "patients need to forcefully blot out the subjectivity of analysts in order to ensure that there is room for their own" (p.200). A little later she says that sometimes with some patients (and I again think of OCPD patients here) the therapist's independent existence needs to be "sturdy enough to be left in the background for long periods of time, to be refound at a later point unharmed and available for engagement" (p.201). 

In other words, to use a famous passage she does not quote here, therapists themselves need to remember that it can be a "joy to be hidden" and is not necessarily a disaster not to be found (for a while!). 

On Treating Obsessive Compulsive Personality Disorder

Given absurd federal regulations, we have to schedule courses and pick books nearly a year before teaching them. So it was last summer when I adopted Robert Feinstein, ed., Personality Disorders (Oxford University Press, 2021). We are finishing up the semester with that book, and recently focused on the chapter on Obsessive Compulsive Personality Disorder (OCPD), the epidemiology of which here and elsewhere often suggests it is perhaps the most widespread of all the personality disorders. 

In re-reading the chapter for class, I realized that a new case--which has been difficult to conceptualize coherently because psychological issues are intercalated with a rare and unpredictable multi-symptomatic cardiovascular condition about which medical science knows little to date--matched DSM-V criteria for OCPD.

Following this minor epiphany, I indulged my own OCD-ish tendencies by spending about 6 hours ransacking the databases to see what else I could find on OCPD that was useful. Herewith some results of that unsystematic survey.

In the first place, far and away the most helpful thing has been the chapter, "The Obsessive-Compulsive Patient" in The Psychiatric Interview in Clinical Practice by Roger A. Mackinnon, Robert Michels, and Peter J. Buckley. They have captured to an astonishing degree what I have seen, and highlighted two things I had seen but not thought clinically significant. They also give some very helpful recommendations on techniques, two of which I have already tried and found very fruitful. To read page after page of this chapter was to feel like pieces falling into place at long last, and a clarity which has frustratingly eluded us, "its hour come round at last," now emerging. To document all the insights of this article would take too long. Suffice it for me to say that if you can't read anything else noted here, read this!

After that chapter, I found my longstanding practice of returning to earlier writers never fails to pay dividends. Thus I read the late (d.2009) Georgetown psychiatrist Leon Salzman's article "Psychotherapy of the Obsessional," American Journal of Psychotherapy (1979). This then reminded me that I had, some time back, been given a copy of his 1968 book, The Obsessive Personality: Origins, Dynamics, and Therapy. I retrieved it and perused it. The whole thing seems to have held up very well, in my view, and is not only helpful and interesting but written in a remarkably accessible way. The last section of the book gives many similar technical recommendations as he did in the 1979 article linked above. 

E.g., he begins by noting the obsessional's "extraordinary capacity" to "evade, distract, obfuscate, and displace" in order to avoid confrontation and change. This is very much my experience to date. The author recommends ensuring a solid working alliance is in place before moving slowly and gently but firmly to confrontation of these maladaptive coping mechanisms, aware that the obsessional's perfectionism (about which see below) will make such confrontation slow-going, partial, and halting--but essential nonetheless.  

Psychodynamic clinicians, confronted with the relentlessly controlling and perfectionistic instincts of the obsessional, might be tempted, as I was early (too early!) in one treatment to encourage the patient to make great use of free association, but Salzman warns--and my mistakes again confirm!--that too heavy an insistence upon free association "might often aggravate the problem" by burying "the therapy under endless trivia." This is where some guidance may be necessary, and again some confrontation if the patient seems clearly to be free-associating in an obfuscating or evasive fashion. On this point Salzman bluntly advocates that "the therapist curtail techniques which defeat communication."

The broader metapsychological issue for the obsessive is the unwillingness or inability to deal with the universal human problems of ambiguity and ambivalence. These create a paralyzing anxiety in the obsessive, and the work of therapy will be centred here, helping the patient come to appreciate "the universality of anxiety" while stressing, and building up, the patient's inner capacity to handle this. Salzman says that in working on this issue it is best to stay in the moment and make use of "here-and-now" material. This is, in fact, a frequent technical recommendation he makes in this article and in his book: to draw on daily experiences, and the therapeutic relationship in the present, while gradually closing off the obsessive's recourse to past events.

In particular, the things that are frustrating about, and enraging in, treatment are especially to be focused upon: the therapist's mistakes (whether legitimate or perceived) as well as the patient's "feelings of distrust, dislike, or liking for the therapist" should be shared even though doing so is of course difficult. On this point Salzman says to watch out for the the obsessive's tendency to observe with exactitude, and externally comply with, the rituals and rules of therapy while seeking to defy them internally. This is the central bind of the obsessive--defiance vs. obedience or conformity, themes well covered in The Psychiatric Interview--and it will be particularly manifested in what he calls subtle, perhaps even petty, complaints about time, fees, office decor, the therapist's choice of dress, or similar matters. 

What these complaints mask is the patient's inability to make use (cf. Winnicott's understanding of use vs. exploitation) of the therapist in a deeper way at this point. Instead, the therapist will be confronted with the task of slowly but steadily wresting from the patient, one by one, his many defense mechanisms (cf. "Remembering, Repeating, and Working Through"), including the one that manifests as perfect outward compliance to the requirements of therapy. Some patients (a common theme in the literature, and also confirmed by my experience) will bring lists of things to each session they claim to want to remember to mention, or to prove how actively they are thinking about the session, or doing some apparent "homework" after the session. There is a strong consensus in the articles covered here that bringing such lists should be forbidden as soon as feasible. 

What you will rarely hear from the obsessive are warm, tender feelings or affectionate reactions. These are guarded against with characteristic fierceness, but as the therapy unfolds must gradually be encouraged and brought into view. One way I have found to "sneak" these in, as it were, is to invite the patient to share dreams. Many of them (and I have sometimes felt this in my own analysis) seem to have a curious distance on their dreams, as though they originated outside of their minds. So they will sometimes share warm, vulnerable, affectionate, moving dreams without being concerned or even very conscious of those dynamics. Such dreams can sometimes be processed in the moment or, as I have done, stored up in your memory for recall later at a more opportune moment when the alliance is stronger and the patient's capacity to experience warm emotions less heavily defended against. 

To do such things, Salzman says, you must help the patient "see how it will benefit him." They need to see, in other words, how becoming less angry and defiant, less controlling and more vulnerable, less cold and more warm, helps here and now. One way you can encourage such feelings to emerge more regularly (and here Salzman's advice shows up in other articles cited here) is to be more active and spontaneous in session as a clinician, changing parts of how sessions unfold to prevent them from becoming too ritualized and predictable, thereby reinforcing the obsessive's sense of control. You can also, he says, take some risks in sharing your own "doubts and uncertainties" as well as your own "weaknesses." Thus do not be afraid of "spontaneity, direct confrontation, and activity...to reduce distracting behavior."

From here we turn to Crayton Rowe, "Treatment of an Obsessive-Compulsive Personality Disorder: A Self Psychological Perspective," Psychoanalytic Social Work (2020). Rowe proposes, following Kohut, that "undifferentiated selfobjects" are the key to the development of various personality disorders, including OCPD. In particular detail, he highlights the threefold needs of such patients for:

        Mirroring:     To be recognized

        Idealizing:     To be aware of a new life, of new possibilities for living differently

        Twinship:      To experience companionship, in the therapist and beyond.

These (often insufficiently met developmental) needs are in competition with a developmental failure that left the patient often feeling "disappeared" early in life. This may lead some patients, he says, to come to therapy with notes, lists, and similar materials constantly written out in an effort to prove they exist. The use of such notes must gradually be discontinued while the therapy seeks to encourage a rediscovery of curiosity about the self and the patient's life. This goal will be constantly challenged by a patient "preoccupied with thoughts that are symbolic of disappearance." 

These dynamics are explored within the context of a case study about a patient in his 40s, an accountant, who had OCPD. Treatment was twice weekly for six years. Countertransference issues are briefly mentioned: these focus on a demand for instant results entirely engineered by the therapist, who thus feels enormous pressure to make the problems go away without any curious exploration of them. 

Two remaining useful articles include, first, Simone Cheli et al., "The Intertwined Path of Perfectionism and Self-Criticism in a Client with Obsessive-Compulsive Personality Disorder" in the Journal of Clinical Psychology (2020). This article and the one below are both Italian studies and both from a metacognitive perspective. 

I have been reading works in both mentalization and metacognitive therapy, much of which seems to have been pioneered here in Indiana at the IU School of Medicine down in Indianapolis. It has been useful for work with psychotic and borderline conditions, but also, in my experience, is useful in nearly every clinical case. Though some might cavil at this, and I would not stand by the comparison in every respect, it is, I think, quite justifiable to say that, broadly considered, metacognitive therapy is just the "American" word for what Fonagy in England has called "mentalization." 

These authors argue that perfectionism remains understudied in the literature. They describe a case treated for six months with metacognitive therapy. These authors usefully if briefly review some other treatments and the evidence for them, noting (as others I have read also do) that we do not have a lot of well-studied treatments for OCPD. The literature consists, based on my unsystematic survey, of a number of individual case studies, or very small comparison studies. From this highly limited evidence base, it seems that metacognitive, psychodynamic, and schema therapies show much promise, along with some CBT techniques. 

Similar countertransference issues show up here as noted above: the pressure the therapist feels to instantly produce a perfect solution to the patient's problems, solving them after a session or two. ("From a MIT point of view, what the therapist feels, perceives, and, generally speaking, experiences constitutes a core component of the intervention.") 

Much of the rest of this article consists of a single case-report of a young female patient (described as highly motivated and without comorbidities) whose progress was measured using a number of instruments, including the SCID-5-PD at the end of six months and again at a one-month follow-up. Two key parts of perfectionism were shown to be significantly reduced. In the end, she no longer met the criteria for an OCPD diagnosis, and her life was significantly improved across a number of measures after a six-month treatment that made regular use of guided imagery, rescripting, and behavioral techniques.

A 2011 article, Giancarlo Dimmagio et al., "Progressive Promoting Metacognition in a Case of Obsessive-Compulsive Personality Disorder Treated with Metacognitive Interpersonal Therapy," Psychology and Psychotherapy: Theory, Research, and Practice offers an awareness of the similarities between metacognitive and mentalizing stances, directly and frequently drawing on Fonagy's research. It begins by recognizing the failures of patients in this regard who suffer from personality disorders. Such failures include a lack of self-reflection, a lack of "understanding others' minds," and an inability to engage in "decentering," that is, an inability to remove the self from a dominating and obscuring place on center-stage so as to see more clearly what others might be thinking. 

Metacognitive techniques are tailored to the patient, and from the outset the authors caution that in highly intellectually defended and controlling obsessives, it is necessary to begin at a basic level of trying to help them recognize what emotions feel like in the body and to name them. Some are unaware of the meaning of even such seemingly simple gestures as facial blushing. 

From here they recommend that the therapist show the patient how many perceived problems are "internalized, i.e., a stable tendency to see others as critical and react by feeling ashamed and withdrawing" before trying to challenge this. Treatment is divided into two phases: "stage-setting and change-promoting." In the former, autobiographical incidents are invited as material to begin to reflect on, challenging old understandings and beginning to inculcate new ones based on the patient's developing capacity to think how others thought at the time. These authors are aware that at both phases of therapy ruptures to the alliance may occur, but their discussion and repair will prove especially salutary to OCPD patients, one of whom they spend much of the rest of the article focusing on. 

What worked with her is what will work, they recommend, with others: a patient process of promoting not just thinking differently about past patterns, but behavior change in the present, though change understood and promoted in a way that does not risk reactivating the perfectionistic tendencies that have hitherto been so problematic. In this the authors recommend that therapists will "not force them to use psychological knowledge they have no access to, but will gradually promote metacognitive growth." This is very similar to something Fonagy says: a non-mentalizing stance in the patient cannot be met with a mentalizing stance in the therapist. The latter must encourage the former to develop their own capacity to mentalize. 

This, they conclude, makes metacognitive and mentalization therapies as perhaps more time-consuming than other approaches. The treatment studied in this article ran for a year, which they take as a minimum to provoke new ways of mentalization and metacognition. 

Self Psychology and Psychosis

While looking for something else--as so often happens--I stumbled upon this useful little book by Ira Steinman and David Garfield: Self Psychology and Psychosis : The Development of the Self During Intensive Psychotherapy of Schizophrenia and Other Psychoses (Routledge, 2019), 192pp.  

Steinman (whose website is here, with some excerpts of his writing) trained with R.D. Laing and for a time worked at Chestnut Lodge. Garfield is also a psychiatrist and psychoanalyst, recently retired from the Chicago Psychoanalytic Institute. Both have teamed up to write a book that usefully agrees with other similar treatments, including those of Atwood and Bollas, already noted on here, and then especially with Bion in particular. At the same time, however, this jointly authored effort also differs from other treatments in bringing to bear aspects of self-psychology, most of them drawn from Heinz Kohut. 

I have several of Kohut's books, and have struggled to profit by them. The fellowship I did at the Chicago Psychoanalytic Institute in 2018-2019 helped break down some of his thought and make it somewhat more clear; but one always feels the need to keep a glossary close at hand because he uses, in some cases, ordinary language in quite singular ways and it is easy to misunderstand him when he does this. 

Since I'm mentioning him, let me also put in a plug here for Charles Strozier's excellent biography, Heinz Kohut: The Making of a Psychoanalyst, which I read several years ago. I owe several intellectual debts to Strozier (a Harvard-trained historian as well as practicing psychoanalyst), who was very kind in sending me drafts of papers and reviewing some of mine. It was also he who introduced me to the invaluable work of Vamik Volkan, whom I have previously interviewed on here, and whom I will again interview early next year when his new book Schizophrenia: Science, Psychoanalysis, and Culture appears, jointly authored with his son. 

But back to Steinman and Garfield, and their useful contribution to the literature. They begin with a few caveats we would do well to recall:

Some Initial Caveats and Requirements:

First, psychosis is not a unitary phenomena. Patients still retain all their uniqueness here as elsewhere. So do not make lazy generalizations, assuming that you've "seen it all before." Equally, do not assume that some successful piece of work in the past may stay in the past, or some issue you feel the patient has overcome will not re-appear. Here both authors remind us of the basic principle Freud first articulated: in the unconscious mind, there is no time. And schizophrenia is especially adept at destroying a coherent sense of temporality. 

Second, at every stage as you are working with these patients, the key thing is hope. If you can confidently but carefully cultivate some hope, that will aid both the working alliance and also the overall progress and prospects of the therapy. 

Learning to Speak Schizophrenese: 

These two authors echo what others have said about making the effort to understand the patient's use of language and symbolism, and impairments to the same: "One extremely important factor in my work with very disturbed people is the importance of understanding a patient’s symbolism, as contained in hallucinations and delusions. A good working alliance aids in helping the person make sense of confusion and distortions of reality. The closer one gets to the 'lost heart of the self' the easier it is to make sense of previously indecipherable and upsetting material" (p.xxi; the internal reference is to Guntrip).

Whereas some clinicians have dismissed, often patronizingly (as I have heard directly in one consult I was part of years ago) the schizophrenic patient's language and symbolism as the notorious "word salad," these authors insist--rightly in my view--that "speaking schizophrenese, making sense of psychotic productions, is the glue that makes therapy with the most disturbed work" (p.xxi). Neither here nor at any other point in the book do they downplay how difficult this can be in some cases, and how much patience is required by the psychotherapist over the long haul. But the therapist is helped by understanding that hallucinations and delusions are like a loud-hailer or sound amplifier for the self, perhaps especially the fragmented and painful parts that are projectively identified with external objects. 

How could one go about understanding those objects and their meaning? How could one begin to enter into a world that seems fragmented, confused and confusing, perhaps even hostile and bewildering? Here they turn immediately to the founder of self-psychology in this country: "Kohut suggested instead that through 'vicarious introspection' the analyst must look inside and find 'a taste' of what the patient is experiencing" (p.xxv) This is very similar to something Christopher Bollas has said about seeking to find the lost patient, and discovering that something of him is hiding within the therapist.  

The Paradoxical Protections Offered by Delusions and Rages:

For Kohut destructiveness and rage are the products of a disintegrating self that has sustained some injury. They thus have quite a "thick" meaning, as it were, and one must work carefully in trying to disarm the forces of destruction and rage without leaving the patient feeling overwhelmingly vulnerably exposed. Delusions are "both fragile and rigid" (p.104). Their rigidity has been helpful in giving even a minimal sense of security to the patient and holding back a totalized experience of fragmentation. Thus these authors recognize later in the book that "a delusional system is a compensatory structure that prevents fragmentation" (p.98).

In addition, delusions and fantasies have a self-protective, self-soothing or self-enhancing purpose and taking them away may have serious unintended consequences. Frontal attacks--and this seems a point of universal consensus so far in what I have read, which admittedly is not much yet--on delusions are a complete waste of time, and may in fact backfire. It is within the working alliance, and the transference, that you may begin to help someone see that their views are mistaken. As they come to mentalize more, and to understand things from a second-person perspective, the hold delusions have may begin to lessen. 

One tip the authors offer here is to take a history from the delusional figure. E.g., in one fascinating case they discuss, a woman believed she received messages from a "Good Angel.” Alright. So ask that angel for its history, then. How did it grow and develop, at what point, and in what circumstances? What purpose is it trying to fulfil? As you seek out all this material, gaps ("epistemological trauma," in Atwood's words, discussed here) may emerge in the history, or purpose, or message, that can be usefully wedged between the patient and the delusion. 

A great deal of case material makes up the book, and I will not annotate that here. I would, however, encourage interested readers to peruse it for themselves.

Instead let me turn to an earlier work of just one author, Ira Steinman, and his 2009 book from Karnac in London, Treating the "Untreatable": Healing in the Realms of Madness.

Steinman beings autobiographically, but with a searing self-criticism that extends and applies to his guild, as well. Here and elsewhere he will criticize American psychiatry, as he already telegraphs in his title and its dismissive labeling of schizophrenics as "untreatable." He tackles this bogus charge at the outset of the book: 

I have found over the last 40 years of psychiatric practice, however, that a number of these allegedly 'unresponsive' and 'untreatable' severely disturbed patients, diagnosed as suffering from schizophrenia, paranoid delusional disorder and multiple personality disorder, have responded to an in-depth exploratory psychodynamic psychotherapy. In a number of cases, antipsychotic medication has been titrated down and stopped (p.xiv).

He returns to the self-criticism in the last chapter, which frankly and critically admits US psychiatry is to blame for abandoning schizophrenic patients and psychotics and regarding them as untreatable, and thus justifying itself in not treating them at all. Such criticism is advanced without any self-righteousness. If anything, Steinman is at pains to stress that there was and is nothing fancy or heroic about what he did and does: he simply offers plain old psychotherapy to help patients find meaning behind terrifying voices, hallucinations, etc. And space to begin to integrate and defragment. 

After some introductory material, the book is largely made up of case material drawn from about 12 schizophrenic or delusional patients. 

That introductory material includes several useful bits of advice: 

Dreams:

Like numerous other authors (perhaps none so clearly and forcefully as the psychiatrist Andrew Lotterman in this excellent and useful article), Steinman notes the importance of one part of the counter-transference in particular: your own dreams. He suggests that useful dreams you have about your patient may be judiciously shared: patients tend to like that you think of them outside sessions, and these dreams can often illuminate certain things or open up good lines of exploration. 

Patience and Hope:

Again we hear sounded the refrain that the patient isn't the only one who needs patience! The clinician must keep in mind that, in most cases, "the period of psychotherapy aimed at helping the patient overcome a schizophrenic or delusional orientation will be a long and arduous one, with change measured in infinitesimally small increments. Long intervals of seeming stasis must be tolerated by both patient and therapist in the face of what may appear to be gridlock, if the process is to bear fruit" (p.8).

Steinman firmly believes an intensive psychodynamic approach works, and his book is evidence of that. The overall task consists, in part, of proving Freud right: Where id was, there shall ego be. That is all the more important in schizophrenic patients whose ego seems barely intact and needs a great deal of clarifying and strengthening. And such tasks, Steinman notes rather scornfully, cannot be done, and are not done, by so-called supportive psychotherapy, which he regards as often useless: it doesn't touch the underlying psychic conflicts and pain, leaving the delusions fresh untouched terrain to ravage and revisit. 

The Nature and Purpose of Delusions:

Speaking of delusions, he sees that they are usually a sign of great pain and terror. It is easier to believe you are Jesus, or to live in fear of Mafia, than acknowledge internal pain and terror that both delusions mask. Thus delusions have a function, and often he sees that as being "a creative compromise," albeit often unrecognized as such (p.3). This makes giving up delusions hard if it means being in contact with a painful reality.

Methods:

How does one go about doing that--beginning to move past delusions? Here as elsewhere the alliance is key; the setting is also important as a holding environment where, bit by bit, patients may feel safe and supported and open up. Steinman elaborates, however, noting that "the patient’s trust in the therapist and in his reliability as a consistent object, although extremely important, is not sufficient by itself to help the patient through the morass of delusions and psychosis......Clinical improvement occurred only when a more interpretive, psychoanalytically oriented approach was attempted" (p.26). So do not just hold and soothe, but work! 

More concretely he offers us the following methods:

1) Get a good history! Find out when psychotic material began. Also, here or later, take a history from the delusional figure. E.g., Judith's Good Angel: what was the angel saying, why, and when did it start? Can the angel answer unexpected questions put to it, or does the angel begin to fall apart? 

2) See what meaning this material--delusions, etc.--has. This goes to the book's fundamental "conviction that delusional and psychotic behaviour not only had unconscious meaning to the patient but could be made understandable to the patient in the form of a healing exploratory dynamic psychotherapy, in conjunction with antipsychotic medication used in a judicious fashion" (p.185).

This latter point bears underscoring: Steinman, and virtually everybody else I have read so far, is not against the judicious use of anti-psychotics--though he argues very strongly that it is possible for these to be titrated downward for some, and in others eventually to be discontinued entirely without relapse of symptoms. 

3) Reconstruct the feelings behind the origins of the psychosis, delusion, etc. 

4) Slowly move towards the hurt, undefended lost heart and inner core

5) Let them sit with their rage, hurt, abandonment.

6) Transference reactions not only happen, but are usually more extreme. This, in itself, can be revelatory to patients, as they can gradually come to see their reaction is disproportionate, and to begin to wonder why. One memorable example he gives here is that his own calm and containing presence sometimes provoked rage in those who had no such thing and were jealous: they tried to up the ante with violence towards him. 

A Quick Word on Self-Care:

You must have time and plenty of interests away from psychotic patients. (I have only two patients at present with psychotic symptoms, and I enjoy them hugely, but I have realized that--as with victims of sex abuse, whom I also treat--I could not have a full practice devoted just to them for it would become exhausting and overwhelming.)

Finally, I would note that Treating the "Untreatable" contains an Appendix that sums up lots of international studies on recovery rates from schizophrenia. Keep this close to hand for those impertinently crowing about how their preferred treatment is "evidence-based" while psychodynamic psychotherapy is not. 

Sadomasochism in Everyday Life

During the fall of 2018 I was on sabbatical and set aside plans to finish my book on Freud, and instead wrote what became Everything Hidden Shall Be Revealed: Ridding the Church of Abuses of Sex and Power, published the following year. 

Freud still featured in that unexpected book in important ways. I made the case for why Freud's theory of moral masochism was very helpful in explaining some of the continued cringe-making deference, indeed submission and subservience, to the "Holy Father" and pope of Rome and to all others bearing the title "Father" in the Catholic Church. Such submission is not a small factor in seeking to understand how and why this crisis of sexual abuse has gone on for so long and been so widespread across every continent on earth. 

Freud's 1924 essay "The Economic Problem of Masochism" was very helpful here, along with his other, better known works. That essay is available in this very rich collection: Essential Papers on Masochism. 

Since reading that book, and writing my own, I have had on my list of things to return to and investigate in more depth the topic of sadomasochism. Part of this is driven by clinical work with sexual offenders. 

But part of this is also driven by trying to understand certain dynamics within contemporary America, including contemporary American Christianity in its reactionary and "conservative" guises where the levels of cruelty have been revealed in the past few years in ways I still find astonishing both in number and degree. I am far from finished thinking through all these issues so I will say no more about them here.

Instead the purpose of this note is to draw your attention to a book I just finished this week which is very much worth your time if you are interested in these issues whether to understand your own life, or the life of your patients, or of parts of our culture, or perhaps all three. 

Before doing so, however, let me draw your attention very briefly to two other works I have found useful, and then a longer note about a third book in particular. 

The first book is one that R.A. Glick and D.I Meyers edited: Masochism: Current Psychoanalytic Perspectives, which was first published in 1988 and has a number of useful and insightful chapters by such well-known figures as Otto Kernberg and Roy Schafer. 

The second book is also an edited collection: The Clinical Problem of Masochism, eds. D. Holtzman and N. Kulish (Jason Aronson/Rowman & Littlefield, 2012). This work contains chapters again by Kernberg, alongside others such as Glen Gabbard, Stanley Coen, Harold Blum, and others. 

The book I want to focus on now has been published for nearly a quarter-century now, so some of its cultural references are a bit dated, but the overall discussion and analysis stands up very well indeed to the passage of time. The book is by a clinical psychologist and psychoanalyst in New York, John Munder Ross, and was published in 1997 by Simon & Schuster as The Sadomasochism of Everyday Life: Why We Hurt Ourselves--and Others--and How to Stop.

The sub-title and the fact of being brought out by a commercial publisher both suggest a certain "self-helpish" nature to the book, but the author, to his credit, largely steers clear of that. As author he's more a sober clinician than a gushing guru bidding for a spot on Oprah, and we can be thankful for that. At the same time, however, he manages to write as a clinician in a way that makes abundant use of examples from modern culture and describes them in ways those with little clinical or psychoanalytic background could easily grasp. 

Before diving into Ross, I went back to Freud's Three Essays on the Theory of Sexuality, and he does not equivocate in there when he argues that "the tendency to cause pain to the sexual object and its opposite, [is] the most frequent and most significant of all the perversions." And a little further on in this section he notes reassuringly that "sadism can be readily demonstrable in the normal individual" not least by looking at the forms of its "displacement" through aggression. And masochism, too, is equally widely to be found: "Masochism is nothing but a continuation of sadism directed against one's own person." (These views, of course, would be modified by some of Freud's later works, including the essay mentioned above, but the general point still stands in my view.) 

This is clearly where Ross picks up, too, as when, on the first page, he claims that "Scratch the most normal surface and you will find a little fundamental erotic sadomasochism in just about everybody" (p.11). Before we all run furiously to issue disavowals of this, note that Ross uses terms in the same way as Freud: "erotic," like "libidinal," is not the same thing as "sexual" and does not necessarily entail "genital activity." The former terms are used much more diffusely, and Ross gives examples that reassure us of this: the scab we were fascinated with picking as a child, or the neck-craning we do as adults at the scene of a motor wreck on the highway. Pain and suffering, both our own and that of others, often elicits a certain frisson in us, a soupçon of Schadenfreude if you will, however much admitting so is uncomfortable to us. But admitting so does not thereby entail copping to all of us having bondage dungeons in our basements! Ross's title here is important: everyday life. Dungeons are still a little outré for most of us!

Ross then brings to our attention people who, knowing what they are doing, and knowing the need to change, still engage in self-sabotage. In dramatic and large terms we know such people as, e.g., alcoholics who have lost jobs, children, marriages, even housing. But in smaller and more everyday terms, whom does he not describe? Which of us has not done this a little bit ourselves, and probably as recently as, oh, this week? Self-sabotage seems very much to be an everyday and a universal phenomenon. (It could have been something as banal as skipping on your workout this morning even though you know you need it after scarfing that entire bag of chips last night watching that old horror flick that always gives you nightmares and leaves you feeling anxious and fatigued the next day.)

Work with a patient once brought me back to Freud's little-known 1916 essay "Those Wrecked by Success" as a means of helping to understand how and why it is a person in the prime of life, who has achieved very widespread success and recognition, would descend into a fit of self-destruction. Ross also avers to this essay, which deserves more attention than it seems to have gotten.

Since the pandemic started, and more recently as it appeared to be winding down, how many stories have we been bombarded with about workers not returning? Restaurants are notoriously desperate for staff, truck-haulage companies as well, daycare institutions across the country, and just this morning a local story about 70 unfilled positions in the Indiana State Police after a rash of retirements and resignations. Everyone rightly focuses on the low wages in many of these occupations but in these and many (most?) other occupations, how much attention have we given to the power structures and their abuses? If, writing in 1997, Ross could claim this, it is surely a fortiori applicable today: "Nowhere in daily life is sadomasochism more constantly in evidence than in the institutions that constitute the workplace" (p.44). He expands on this a little later, noting that "surreptitious sadomasochism is to be found everywhere in the life of ordinary individuals and the institutions that organize their social lives" (p.47). 

Overt sadists are rare; so too masochists. Ross draws our attention to how often such phenomena are masked and only manifest clinically in compromise formations, therapeutic enactments, and of course the transference. For some particularly recondite sadomasochistic dynamics, I would follow Nina Coltart's lead and pay attention to whatever images, nicknames, or reveries thrown up in the counter-transference.

Much of sadomasochism, he says later in the book, must be seen as "obeying two basic principles of mental functioning: 'overdetermination' and 'multiple function.' In other words, it has many causes and, once it is in place, serves many ends" (p.160). Some of these manifestations and causes--and here Ross avers to the famous "third ear" of Reik--have to be listened and watched for in particular ways. 

Sadism and masochism may once have played a useful role in the child's development (Ross is familiar with the work of Klein and Winnicott in particular, and cites them later in the book), but he recognizes how "maladaptive" (96) such things usually become later in life. One manifestation in adulthood may be the lack of self-love: "Sadomasochists...lack the basic self-self with which to withstand the fact of their own repugnant but naturally ordained desires" (102). 

The reference here to self-love indicates that Ross is also familiar with, and occasionally quotes from, Heinz Kohut. I have not read as much Kohut as I feel I should, but Charles Strozier's biography is lovely and a worthy introduction to Kohut's life. (I suppose I should confess a bias here in that Strozier has been kind and helpful to me on a number of occasions in sending me drafts of stuff he was working on, and reviewing an article I was working on. It was through Strozier, moreover, that I was introduced to the enormously valuable work of Vamik Volkan.)

When I was on my fellowship at the Chicago Psychoanalytic Institute in 2018-2019, we did devote a day to Kohut and our teacher was very helpful in breaking down some of the recondite terminology and opaque jargon that Kohut seems to have unhelpfully delighted in. 

In addition to Kohut and the others, Ross also rightly draws on the work of Robert Stoller, to whom I was first introduced a few years back by the great Adam Phillips, from whom I have learned so much. Stoller's book Perversion: the Erotic Form of Hatred is one of the most insightful things I have read in this whole area. For Stoller many manifestations of masochism and sadism are "reparative" attempts by the adult self to turn childhood traumas into triumphs. 

Later in the book, Ross returns to Freud's views on moral masochism, and claims that "since neurosis is inevitable and universal, so, too, is moral masochism" (p.152). Here Ross links this back to one of Freud's last works, Civilization and its Discontents, suggesting that in some ways the price of civilized order is that we all must tolerate a certain degree of moral masochism. 

Moral masochism preoccupies the last two chapters of Ross' book. Chapter 9 ("Sadomasochism in the Treatment Setting: the Cure") argues that "the universality of moral masochism makes almost every course of treatment harder and longer than might otherwise be the case" (p. 185). Here, of course, our attention is drawn to negative therapeutic reactions, retrenchment, and so-called resistance. Here we are confronted, in some patients, with a high enough level of masochistic guilt that they keep themselves from betting better. (As Winnicott famously observed, "health is ever so much more difficult to deal with than disease.")

The therapeutic challenges are many, and Ross does not shy away from discussing them. He notes that people who punish themselves and are unable to allow themselves to get better do so because such reactions have many "internal and external masters" whose job is always to seek to maintain "the social status quo" (187). Thus for some, they really do prefer to remain in "an oppressive but contained and secure" environment of their own making--however painful it is to them and others. 

For the therapist inclined here, when faced with such patients, to resort to moral exhortation to grow past their masochistic masters, Ross rightly cautions us in no uncertain terms that 

The very act of offering advice runs counter to the ingenuity of psychoanalytic method [that]...is devised to draw out & then call into question the omniscience & omnipotence attributed to the practitioner by the patient & to analyze the sources of these illusions (191).

In saying this, Ross is echoing and in fact anticipating Adam Phillips, not least in the latter's recent book The Cure for Psychoanalysis (but see also his Terrors and Experts). 

What then, can the clinician, tempted to despair, actually do? Ross offers two things worth considering. The first has very strong echoes of Winnicott: "What is most significant for the resolution of masochistic conflicts...is the psychoanalyst's growing emphasis on the patient's capacity to be alone and to tolerate tension and uncertainty" (192). In increasing such an emphasis, the therapist has to find ways of gently but firmly thwarting the patient's desire for a panacea, for a clear-cut "fix" to all their problems. 

An additional way forward is here suggested by Ross: "in order to be free or independent, one must mourn one's past, refrain from taking the path of least resistance, and constantly act to impose one's will on oneself" (193). In saying this, Ross is rightly pointing out that the work rests on the patient. Here he reminds me of that constant refrain supervisors have given down through the ages: do not work harder than your patient. Ross makes this explicit thus when addressing the reader directly at the very end of his book The Sadomasochism of Everyday Life: Why We Hurt Ourselves -- and Others -- and How to Stop: "the responsibility for making changes is your own, and in a sense nobody changes anybody else's mind or heart" (220). 

The Therapist's Use of the Self

When I was on sabbatical in 2018, I spent part of it on a fellowship at the Chicago Psychoanalytic Institute. There for the first time, in one of our seminars, I actually felt like I began to understand some of the thought of Chicago's most famous analyst, Heinz Kohut, pioneer of so-called self psychology. Prior to this, I had tried several times to read at least two of Kohut's books. And I did manage to read Charles Strozier's lovely biography of him, Heinz Kohut: the Making of a Psychoanalyst. But none of his theory was especially accessible or attractive until we read K. Newman's 2007 article, "Therapeutic Action in Self Psychology," The Psychoanalytic Quarterly 76. Newman managed to put Kohut's ideas into much clearer and far less jargon-riddled prose than Kohut seems able ever to have done. 

It was, I seem now to recall, in our discussion of this article afterwards where I first began to learn about the idea of how much of the therapist's usable self is available for the patient in the working alliance--how, that is, in Kohutian terms, the therapist becomes a selfobject [sic] to the patient. (In some ways this just strikes me as a needlessly complicated reworking of object-relations theory, and in far less felicitous English, but let that pass.)

I have been thinking about that concept of the usable self for a couple of months now, and this led me to pick up John Rowan and Michael Jacob's book, The Therapist's Use of Self (2002). 

It's not the book I thought it was going to be, but it is valuable nonetheless. I think my very mild irritation with the book comes from it being in some ways a literature review disguised as a monograph. I was anticipating more decided and conclusive views from the authors, who instead spend most of the book surveying about four different theoretical schools for their thoughts on such things as counter-transference, abstinence, self-disclosure, and related issues.

But this should not be allowed to detract from the overall utility of a relatively short and straightforward text written in clear and workmanlike prose. The fact that it makes good use of British object-relations theory--including Guntrip, Winnicott, Balint, Bollas, and especially Bion (whom I've come to appreciate a lot more this year)--only increases the value of the book in my view. 

The authors begin by noting that the will explore how the therapist might make use of his self in the therapeutic relationship, and then posit three ascending levels of such selfhood so used: the Instrumental self, the Authentic self, and the Transpersonal self. (I pictured these here like Maslow's famous hierarchy, with Instrumental on the bottom, and Transpersonal on the top.)

In their chapter on the Instrumental self, which they suggest may be the most common of the three approaches, they make a striking observation that, in slightly different ways, has come to me in the past six months or so of training: therapists "appreciate the fact that what they do...does not ask them to change themselves as much as it invites them to come closer to their best and frequently unrealized selves" (11-12). This has been an unexpected but reassuring realization for me this year. (This is augmented later in the book with a passage from Harry Guntrip: "real psychotherapy does as much for the therapist as for the patient.")

Judicious Soundings from the Counter-Transference:

It is within this chapter that they get into some very useful detail about the origins and development of the notion of the counter-transference. I have for some time been influenced in this area by Harold Searles, Otto Kernberg, and then especially Nina Coltart, who advises the therapist to take judicious soundings from the counter-transference as it may offer otherwise inaccessible clues to what is going on in the patient. But how is that possible? Isn't the idea of counter-transference that it pertains to what is going on inside the therapist? How, then, can it offer clues to what the patient might be thinking, feeling, avoiding, or even totally unaware of? Moreover, how certain can we be that what the therapist's mind throws up is in fact reliable or accurate or truthful at all? Maybe it's anxiety from almost getting run over during lunch hour a few minutes ago while fetching the pizza now giving one dyspepsia and making one long for the sweet release of violently expelling the offending food. 

Such questions have long haunted me. How does one know--can one know?--that what one thinks one knows is in fact reliable and real, truthful and objective, and not merely the convoluted production of ones own issues? 

In this light, perhaps the most useful part of this chapter--indeed, book--is the sixfold typology Rowan and Jacobs offer of unhelpful or unreliable counter-transfer reactions that are most likely unreliable and liable to lead the therapist astray: 

Defensive: esp. related to the therapist's unresolved issues around sex, aggression, etc.

Attachment: those that evoke the therapist's need to be admired, successful, loved, powerful, etc.

Transferential: when the therapist responds as though the patient's parent or sibling.

Reactive: when the distortions of the transference neurosis are taken to be true by the therapist who reacts accordingly

Induced: when the therapist is induced to take on the role of giving advice

Identification: when the therapist overidentifies with the patient and/or the patient's child

Displaced: when feelings from other parts of the therapist's life come to be placed onto the patient. (This would be the pizza-induced dyspepsia in my example above.)

The above strikes me as something useful to run through your mind as you are trying to discern your own reactions to the patient to see what might be reliable and trustworthy in them. Later on, drawing on the late Jungian theorist Michael Fordham, the authors note that even if your counter-transference reactions prove illusory, that is valuable nonetheless insofar as it may teach the therapist something about himself. 

In the next chapter, the authors draw on Winnicott (not least his thrilling 1947 essay "Hate in the Counter-Transference"), who apparently modified that 1947 view in the 1960s by insisting that one distinguish between a reaction to a patient and a full-blown counter-transference. It is not entirely clear here what the difference is, though to me it seems plausible that a reaction may be momentary or short-lived, or discreetly focused on one particular thing, and a counter-transference may be a more wholistic, longer-term "package" of reactions. 

Presence and Analysis:

The authors note that the therapist must strive to overcome whatever blocks his ability to be fully present in the session. At the same time, and elsewhere in the book, they equally insist that the therapist cannot become totally lost in his immersion in the patient's world, but must do that all the while maintaining a critical eye, maintaining his critical-observational self. To capture this, they quote the late American therapist James Grotstein who apparently once said the posture of the therapist here is like that of the Pieta: Mary holding the tortured body of her son! 

The challenge of remaining present is perhaps higher today than when these authors wrote thanks to our electronics-addled brains. This is a topic I want to think more about and return to another time. 

Vamik Volkan Discussing His New Book

As I indicated earlier in the week, Vamik Volkan is a clinician and scholar from whom I have learned much. He has a new book out, Large Group Psychology, just published by Phoenix Books, whose website everyone interested in psychotherapy, psychoanalysis, and much else should keep a close eye on. Rare is the week that does not see Phoenix publishing something, or advertising books soon to be published, all of which look fascinating. 

I sent Dr Volkan some questions about his book. Here are his thoughts:

AD: Tell us a bit about your background

VV: I was born in 1932 to Turkish Cypriot parents on the Mediterranean island of Cyprus when it was a British Colony. The first humans on the island arrived about ten thousand years before the birth of Christ. As the centuries went by, invaders and traders multiplied. In my childhood I was exposed to people with different large-group identities: Cypriot Greeks, Cypriot Turks and, in much smaller numbers, Armenians, Maronites, people who considered themselves as descendants of Phoenicians and, of course, the British – all living side by side. Only much later I begin to wonder what history means for people with different large-group identities.

In early 1957 I came to the United States armed with my medical degree from the Ankara University’s Medical School in Turkey and only 15 dollars in my pocket, but I had a job at a hospital in Chicago. I became an American citizen a few years later. My departure to the United States was part of the phenomenon known as the ‘brain drain.’ The United States lacked medical doctors at this time and therefore attracted doctors from around the world. I had my psychiatric and psychoanalytic training in the USA.

In 1977, Egyptian president Anwar Sadat visited the Knesset and famously referred to a psychological “wall” between the Israelis and the Arabs—a wall that, he stated, accounted for 70 percent of the problems between them. In response, the American Psychiatric Association’s Committee on Psychiatry and Foreign Affairs, of which I was a member, brought influential Arabs and Israelis together for unofficial dialogues for six years to find out if this “wall” could be made permeable. This is how I started my decades-long work in unofficial diplomacy.

I met and had opportunity to spend time with many political and community leaders (For example, Jimmy Carter, Mikhail Gorbachev, Yasser Arafat, the Emir family in Kuwait, North Cyprus President Raif Denktaş, Turkish President Abdullah Gül, Estonia President Arnold Rüütel and Archbishop Desmond Tutu). This also helped me to study leaders-followers interactions and national, ethnic, religious and political large-groups’ psychology. As an academician, generally speaking, I stayed away from the news media. However, I believe that deeper knowledge about what lies behind what we see, hear and learn daily is useful for the public

AD: What led to the writing of Large Group Psychology: Racism, Societal Division, Narcissistic Leaders, and Who We are Now?

VV: I have been living in Charlottesville, Virginia since 1964. Following the deadly 2017 white supremacist rally in my city numerous fatal attacks on churches, synagogue and mosques occurred worldwide. In many countries, people are asking the metaphorical question “Who are we now?” and coming up with seemingly opposite answers. I could no longer ignore the urge to write a new book about large-group problems.

During my decades-long activities in the international arena I have learned that behind observable factors like politics, economics and law, the central psychological factor in starting and keeping alive large-group conflicts is the protection and maintenance of large-group identity. During my work I heard the subjective experiences of such large-group identities being expressed in terms such as “We are Palestinians,” “We are Lithuanian Jews,” “We are Russians living in Estonia,” “We are Polish,” “We are Communists,” “We are Sunni Muslims.”

AD: I visited Cyprus in October 1993 for an international ecumenical conference in Limassol devoted, in part, to overcoming division and conflict between Christians. As a young, naive kid from Canada I was almost entirely ignorant of the conflict until we were given a guided tour of Nicosia, getting as close to the DMZ/Buffer Zone as we were allowed. I've never forgotten the shock of seeing that, like a huge open scar right across the city streets. That division and its conflict are very personal for you, as you tell us in your moving first chapter. Is that conflict part of your own working through of the "rescue fantasy" (p.1) you speak of as motivating some therapists and clinicians?

VV: My arrival in America in 1957 coincided with the Cypriot Greeks’ struggle against British rule in order to unite Cyprus with Greece. The Greek Cypriots began to oppress Turkish Cypriots and an ethnic conflict was inflamed. I experienced a terrible stabbing pain six months after taking up residence in America. My father sent me a newspaper clipping with very grave tidings. My roommate, Erol, from the days when we lived in clapped-out lodgings in Turkey while attending the same medical school had returned to Cyprus to tend to his ailing mother. He was the nearest thing to a brother that I have had. A Greek terrorist shot him seven times, killing him, in a pharmacy where he was buying medication for his mother.

He was murdered in order to terrorize the ethnic group to which he belonged. After receiving the news of his death, I felt numb. I did not cry. I was in Chicago, in a foreign environment in which I was close to no one, so I did not share the news of my former roommate’s murder with any other person. Much later I would become aware how the murder of my roommate played a role in my involvement for finding ways for a more peaceful world.

Relationship between Cypriot Greeks and Cypriot Turks changed greatly since your visit to the island in 1993.  Border crossing points are now available. Due to COVID-19 there are the necessary cautions for border crossings.

AD: Your discussion of group psychology is, as of course you note at the outset, indebted to Freud and his book Group Psychology and the Analysis of the Ego.
One of the key points you repeat in your book is that group psychology exists "in its own right." Tell us a bit more what you mean by that and why it's important to be clear about this.

VV: Sigmund Freud and his followers (in the clinical setting) described what belonging to a large ethnic, national or religious group means for an individual and how an individual unconsciously perceives his or her large group as a symbol of a mother or father figure.

My work is very different. As a psychoanalyst I have studied the shared psychological processes within a large group and relationships between opposing large groups. Large-group psychology in its own right means making formulations about the conscious and unconscious shared past and present historical/psychological experiences that exist within a large group. Making such formulations enlarges our understanding of the emergence of present-day societal-political-religious events, and leader-follower relationships. 

Doing this allows us to look at the interactions between opposing large groups in depth. This is similar to a psychoanalyst making formulations about his or her analysands’ developmental histories associated with various conscious and unconscious fantasies in order to understand what motivates certain behavior patterns, symptoms and habitual interpersonal relationships.

AD: Two other key phrases recur in your book, reflecting some of your earlier work: "Complicated mourning" and "survivor guilt." From everything I'm hearing in this pandemic, there seems to be a lot of both being experienced by people today. Tell us a bit about those and how you understand them.

VV: I wrote about my roommate Erol’s murder above. Since I did not have family members or friends in Chicago at that time, I had no one to share my feelings and thoughts about my loss. My mourning process was complicated. 

Also, I was not aware of my “survivor guilt.” While I was safe in the US my family members in Cyprus were living under very difficult conditions and my former roommate was dead. Decades later I realized how I handled my “complicated mourning” and “survival guilt.” My first academic research was on these topics. I wrote papers and books on these subjects. My book (with Elizabeth Zinti), Life After Loss has been translated into several languages.

In the present book, the reactions to loss are seen in the  Addendum, which describes 16 analysands’ initial responses to the pandemic. These patients returned, consciously and unconsciously, to their childhood losses and re-experienced anxieties and old defense mechanisms and fantasies linked to such losses. Moreover, when I gave a seminar for 8,000 Chinese mental health workers on trauma due to COVID-19 pandemic on April 3, 2020 I encouraged them to study the psychology of mourning.

AD: You note (p.29) that an individual who has difficulty in mourning can often pass that on to succeeding generations, resulting in the transgenerational transmission of trauma. Is that also a dynamic we see at work in groups, indeed whole countries? Could it be said that some of the rage and grief today over police brutality and racism are at least partly due to America's never really having grieved the legacy of slavery and attempted to heal from it?

There are variations of transgenerational transmissions and all of them depend on the permeability of the psychological boundary between children and their mothers or other important caretakers. It is not only anxiety that travels from the mother or other primary caretaker to a developing child through the permeable boundary. Other psychological “messages” are also  given to the child.

Important adult persons may push their specific self- and object-images into the developing self-representation of the child. In other words, the “other” uses the child, mostly unconsciously, as a reservoir for certain self- and object-images that belong to that adult.

The experiences that created these mental images in the adult are not “accessible” to the child, but instead are deposited or pushed into the child, but without the experiential/contextual framework that created them.
In the psychoanalytic literature there are many papers and books that examine the psychology of the transgenerational consequences of the Holocaust for the children of the survivors as well as the perpetrators.

The rage and grief today over police brutality and racism are mostly due to America's never really having mourned the legacy of slavery. Mourning is a slow process related to remembering and relating to lost persons and things and, if everything goes Ok, saying “good bye” to such lost objects. What we see in the streets can be considered as an expression of shared mourning. I hope that it will take a positive course.

AD: In that vein, can we see your notion of a "linking object" as helpful in trying to understand some of the battles over statues, including over the removal of the Robert E. Lee statue in Charlottesville in 2017, which you say in your introduction was part of the motive for writing this book?

I described linking objects and linking phenomena in 1972. A linking object is an item chosen by an adult mourner that unconsciously represents a meeting ground for the mental image of the lost person or thing and the corresponding image of the mourner.   

Not every keepsake is a linking object; the item is a linking object if the mourner makes it “magical” and uses it as a “tool” for postponing the work of mourning. For example: after his father’s death, a young man picks up his father’s broken watch and hides it in a desk drawer.  For the young man, this broken watch becomes “magical.”  He becomes preoccupied with repairing the watch, but he never gets it repaired.

Some statues and monuments are shared linking objects. They connect many people to their ancestors’ losses or glories often without hurting or humiliating other large groups. But in the US some such shared linking objects humiliate another group (African Americans).

We are now more openly becoming aware that the beginning of American greatness was accompanied with the history of slavery. This reality now is hitting us openly. We need good leadership and open discussions to come up with ideas about what to do with some statues and monuments.

AD: Over the years, since discovering your work, I've found your concepts of "chosen trauma/glory" and "time collapse" enormously valuable. In this new book you introduce a concept I've not come across before in your work: "Entitlement ideology." Would you give us a sense of that and perhaps a current example?

Entitlement ideologies refer to a shared sense of entitlement to recover what was lost in reality and fantasy during the ancestors’ collective trauma. They deny difficulties and losses that had occurred during it, and imagine their large group as if it is composed of persons belonging to a superior species. Holding on to an entitlement ideology primarily reflects a complication in large group mourning, an attempt both to deny losses as well as a wish to recover them, a narcissistic reorganization accompanied by “bad” prejudice for the other.

The white supremacists openly verbalize their (fantasied and delusional) entitlement ideology, to have an America populated only by  white people from selected locations.

Some entitlement ideologies are known by specific names in the literature. What Italians call “irredentism” (related to Italia Irredenta), what Greeks call  “Megali Idea” (Great Idea) (an irredentist concept that expressed the goal of reviving the Byzantine Empire), what Turks call “Pan-Turanism” (bringing all the Turkic people together from Anatolia and Central Asia), what Serbs call “Christoslavism,” and what extreme religious Islamists of today call “the return of an Islamic Empire” are examples of entitlement ideologies.

We should remember the horrible consequences of the inflammation of the Serbian entitlement ideology (to have a greater Serbia) under Slobodan Milošević and be aware and careful about the inflammation of American white supremacists’ entitlement ideology.

AD: On pp.54-55 you speak of the "formal and informal systems of 'checks and balances' in a well-functioning democracy [that] prevent a leader's personality...from exerting undue influence over government and the governed." It seems ever more widely accepted by clinicians and observers today that such a system in this country is under the greatest and most severe strain ever. Is that an assessment you would share?

Yes.


AD: You refer to some of those clinicians (p.98) before, in ch.9, talking about "persons with exaggerated narcissism." Here you draw on the works of Kohut, Kernberg, and Jacobson. Tell us a bit more about this phenomenon of extreme or exaggerated narcissism. Is this a helpful way of understanding Donald Trump?

In my book I describe Charlottesville Psychoanalytic Study Group’s years-long study of persons with exaggerated narcissism.  An in-depth description of such individuals’ behavior patterns, need to be number one, language peculiarities, inability to have empathy and other characteristics help us to see observable personality characteristics of Donald Trump.


AD: Sum up your hopes for Large Group Psychology, and who especially would benefit from reading it:

VV: First, today we see a preoccupation with Donald Trump’s tweets, verbalizations, and behavior patterns. In the book the reader will learn about narcissistic personality organization, why it evolves and how it can lead to destructive or reparative societal processes. Such knowledge will help the reader to have a better understanding of Donald Trump and his influence on his followers.

Second, there are severe societal/political divisions in the USA. The reader will read why there is a need to have allies and enemies in human nature.

Third, racism, ethnic prejudice, removing or not removing some statues are discussed. In the book I describe the experience and views of an immigrant to the USA in late 1950s on these issues.

Fourth this book illustrates the need to have an in depth psychological/historical understanding of large groups and the meaning and the power of large group identity in order to find new solutions for political/societal problems.

Fifth, I wrote this book before the COVID-19 pandemic started to illustrate shared psychological processes of the Trump-era America and the world. The corona virus pandemic made me to realize that deeper knowledge of such psychological processes is sought by the reader. At the present time the personality of political leaders, racism, societal/political divisions and political propaganda preoccupy public interest. 

Sixth and finally, this book is written without my hiding behind technical psychoanalytic terms. It is easily readable.

AD: Having finished this book, do you have other projects on the go at the moment--other books in the works?

VV: I just finished writing another book. Soon I will send my manuscript to my publisher.  This one is on non-chemical addictions. I describe how some individuals remember their childhood traumas and their own “solutions” with compulsive actions. I hope that this book will also help the reader to have a deeper understanding of some political leaders’ repeating actions.