Betty Joseph on Psychic Change

As so often happens, my friends on Twitter [some insolent rabble in the gallery: "He has friends?"] convince me finally to read people of whom I have been aware, often for decades, without having actually read their works. In this case, it was a quotation from Betty Joseph. Finding it compelling, I ordered, and have now read, Psychic Equilibrium and Psychic Change: Selected Papers of Betty Joseph, eds. Michael Feldman and Elizabeth Bott Spillius (Routledge, 1989).  

Joseph lived to nearly 100, dying just a decade ago after a very long clinical career in England. (A short biographical sketch is available here.) My first analyst in Canada was a Kleinian and I vaguely recall her mentioning Joseph at one point but I never investigated farther. 

The Hard to Reach Patient:

Like all collections, Psychic Equilibirum is uneven. It contains papers originally published as far back as the late 1950s. Every chapter is fairly brief and follows a standard format. I perused the table of contents and decided, after reading the editors' introduction, to jump around, beginning with the chapter that first grabbed me most strongly, viz., no.5, "The Patient Who Is Difficult to Reach." I have at least one such right now and whenever I read a chapter like this--or any chapter by clinicians citing their own case material--I always hope (surely I am not alone in this?) that what they describe will be exactly what my patient is like so that, at last, I can stop thinking and reading and wondering and working to figure out the treatment they need, and instead copy the example cited by this manifestly masterful clinician. Thus does one see the very real attractions of manualized therapy!

But, of course, my patient is at least 90% different from Joseph's. (And thus does one see the massive limitations of manualized therapy!) So I ended this chapter somewhat disappointed, to be honest, finding it only partially useful. (That is also true of much of the book: I found only 2 or 3 chapters particularly useful, but read all of them, and found threaded through each and every one a common theme, noted below.)

But then, trying (at risk of sounding pious or sycophantic, both of which I abhor) to reflect over the whole chapter by means of a kind of reverie, which 'method' I learned from reading the great Thomas Ogden, I put the book down and stared across the coffee shop and out the window to the river, and found myself focusing on nothing in particular but allowing my mind to range back over the entire chapter as it tried to weave in one case in particular. At that moment I came to a rather startling insight about what now seems to me a technical mistake or perhaps an 'enactment' I have allowed to happen. I was aware of what I was doing, and thought it justified, but now in light of Joseph's chapter I see differently.

What, in particular, provoked this small epiphany? There are three lines in the chapter that were bracing to me.

First, she begins by talking (as others I have read would later do--I think in particular of Christopher Bollas here) about those patients eagerly proffering "pseudo-cooperation aimed at keeping the analyst away from the really unknown and more needy infantile parts of the self" (p.76). That latter phrase--more needy infantile parts--especially struck home and inched me toward greater understanding of a case in which my countertransference imagery has been utterly plagued for months with nothing but images of my cradling my (adult) patient as a babe-in-arms. 

This first line of Joseph's I immediately linked up with a passage a few paragraphs later in which, continuing the theme, Joseph speaks of the really needy part of the patient needing "the experience of being understood, as opposed to 'getting' understanding" (p.79). That, of course, echoes one of her contemporaries, Frieda Fromm-Reichman, and the latter's famous observation that the patient needs an experience, not an explanation. Here I came uncomfortably close to a second acknowledgment of a near-mistake in a case in which I have sometimes found, in my impatience, doing what Joseph warns against: offering 'an explanation,' a thing, rather than an overall experience--and doing so prematurely, in a way the patient could not use at the time. 

In doing so, I am now rebuked not just by her, but also by a passage of Winnicott I have not always heeded. In "The Aims of Treatment" from 1962, he speaks of the necessity of "economical" interpretations, rightly warning that "I never use long sentences unless I am very tired. If I am near exhaustion point I begin teaching." In my case it's not just a moment of exhaustion but also sometimes of frustration which I have done a poor job of controlling. At such a moment I lapse into professor and academic mode, giving a paragraph-length explanation, an understanding, an interpretation: these rarely go over well. 

At the very end of the chapter in the third passage of Joseph that I found challenging, she advises that with patients hard to reach, we must keep our interpretations, our understandings, "immediate and direct" (p.87; her emphasis). In other words, she explictly says, do not offer some kind of historical explanation or interpretation, linking together themes or events from years or months or even weeks past: stick closely to what is going on in that moment in that session in your consulting room. Here is where (as she'll make clear elsewhere in the book) Bion is handy: abandon memory of past events and sessions, and a desire to escape the present moment, and instead plunge right in to your immediate experience of and with the patient, and they of you. (Bion's famously difficult and confusing counsel is examined in a bit more detail here.)

I admit this--discussing what is happening in the moment--was enormously hard for me to do for a time, but working with borderline patients has in essence forced me to do it. I remember very clearly the first time, with enormous trepidation, I attempted it and how it proved to be so pivotal to treatment. Once I figured out my own idiom for doing it after that, and became (in part thanks to my own analyst) much more comfortable with the risks I felt I was running in doing this, it has begun to flow more easily now. I think the key for me was once again Winnicott. In that most invaluable of essays, "The Use of an Object," he helped me to see that I could allow patients to bring their rage out into the open of the immediate moment and try to destroy me but that I would not in fact be destroyed. 

The Patient Addicted to Near-Death:

The other outstanding chapter in this collection is "Addiction to Near-Death." Here she refers to patients engaged in "a type of mental activity consisting of a going over and over again about happenings or anticipations of an accusatory type in which the patient becomes completely absorbed." (In my experience this is characteristic of certain obsessional-compulsive personality styles, about whose treatment I wrote in some detail here.) For such patients their "seeing of the self in this dilemma [as] unable to be helped is an essential aspect." 

As a Kleinian, Joseph mentions projective identification and splitting in every chapter, and here notes that the splitting characteristic of these patients is such that "the pull towards life and sanity" (p.128) is projected almost entirely into the clinician. (I have found myself in this position but, being an ignorant fool at least once a day, rather blithely told myself--here vaguely calling to mind some exculpatory aphorism of Yalom--that it was simply me being "the bearer of hope" until such time as the patient could be more hopeful.....except they never assumed one bit of that burden, and acidly disdained any expressions of hope!) 

Joseph returns to this later in the chapter, speaking in more forthright terms than in many other chapters as she speaks of this splitting, and the clinician taking up the role of one who is hopeful about and pushing for change, as being a "collusion" in which a "major piece of psychopathology is acted out in the transference." If you are put into this position of bearing the hope and desire for change then "the patient constantly is pulling back towards the silent kind of deadly paralysis and near-complete passivity" in significant measure to avoid having to recognize and deal with their own "ambivalence and guilt" (p.136). 

The "patient's apparent extreme passivity and indifference to progress" is based in part on, and heavily reinforced by, the fact that "the near-destruction of the self takes place with considerable libidinal satisfaction." These patients enjoy the "deeply addictive nature of this type of masochistic constellation" (p.128). At the chapter's end, she will return to this in graphic terms, speaking of the patient as having "withdrawn into a secret world of violence, where part of the self has been turned against another part" and where "this violence has been highly sexualized" (p.137).  

A word is here introduced by Joseph, giving an excellent definition to a term I first encountered I don't know where some time back: chuntering. The chuntering patient goes "over and over again in some circular type of mental activity" that consists of endless grumbling, complaining, fault-finding. Sometimes, however, such chuntering is silent: Joseph mentions those patients who, passively and silently, will destroy whatever you are doing, apparently listening to your thoughts but all the while mocking them with silent contempt.

Given such powerful libidinal rewards for their self-destruction, it is no wonder that working with such patients is going to be very difficult. Joseph ends this chapter with no clear or simple fixes, saying simply that "it is very hard for our patients to find it possible to abandon such terrible delights for the uncertain pleasures of real relationships" (p.138). 

Once more the only thing Joseph counsels is taking a "moment to moment" approach in the session, monitoring the changes in transference (which for her is never static, never fixed, never permanent, but a live thing, a dynamic, living, changing experience) and counter-transference.  As a result the same behavior can have a difference transferential import: Sometimes the patient may be engaged in what appears to be chuntering, but doing so out of real psychic pain at some legitimate thing they need you to know about; at other times they may be trying to drag you into a masochistic enactment. You need to get clear as to which is which, and these can even shift within the same session.

Finally: What is the Change We Seek?

If it is hard for these patients to change, which patients find it easy? For Joseph the answer is itself easy: none. Nobody finds it easy to change for we are all shot through with ambivalence and conflicting desires, and all our struggles--whatever they are--are bound up with our personality structures (a point so helpfully made more recently by Jonathan Shedler and Nancy McWilliams, inter alia). Our personality defenses, Joseph notes here, are "very tightly and finely interlocked elements" (p.193). To change even one thing is to risk a cataract of other changes, and thus to provoke multiple defenses at every step: this is the theme of Joseph's fourteenth chapter ("Psychic Change and the Psychoanalytic Process"), the last on which I shall comment. 

How might we define change? What are its hallmarks? Here Joseph is very reluctant to get into details or to over-promise. Indeed, throughout this book one gets the sense that she is in constant, unwavering control of her omnipotent and omniscient desires, never overpromising or indulging in messianic fantasies about dramatic changes. 

"Moment-to-moment shifts and change" in the transference is what we should be paying attention to, Joseph says, without much regard for anything outside it. If such changes happen, then we are permitted to "hope" that such are "eventually going to lead to long-term, positive psychic change. I do not think that the latter long-term psychic change is ever an achieved absolute state but rather a better and more healthy balance of forces within the personality, always to some extent in a state of flux and movement and conflict" (p.194). This last sentence, to my mind, sounds very much like Philip Bromberg avant la lettre. (This chapter was originally published in 1986, a dozen years before Bromberg's Standing in the Spaces, an outrageously rich collection I hope to finish and write about next week. Bromberg cites this passage of Joseph's on p. 272.) 

From here Joseph expands somewhat outward, first noting what Freud said about change ("where id was, there ego shall be") before adducing what Klein added to this, and then, in sum, writing that psychic change consists in "greater integration between ego and impulses, love and hate, superego and ego" and that as an analysand moves toward greater health, this will be seen in an ability "to bear both his love and his hate at the same time and towards the same person. His perception of human beings then becomes more real, more human....This step, or rather, minute series of steps, forward and backward, towards integrating love and hate, brings with it momentous changes within the personality." (This theme of taking up love and hate will find powerful expression in Glen Gabbard's book of that name.)

Such changes may be seen in a greater ability to acknowledge and not flee from "guilt and concern" for others as we come to "take responsiblity" for our "own impulses" and how we may have harmed or attempted to destroy the objects of our life. If we take such responsibility, "there opens up the possibility of feeling for and repairing the object. With this there is also relief and a deepending of emotions" (pp.194-95). All of these changes emerge, Joseph stresses again and again, not in grand Damascus-like moments of blinding conversion, but often in the very minute, moment-by-moment changes in the transference, where it all begins; and if it doesn't begin here, it will never begin. 

This is a humbling note on which to end, but a salutary one. If we are always looking for external affirmations and grand signs of change and progress, we may risk overlooking, perhaps even disdaining, the quotidian ones in the transference.  We need to be content eating bread and butter as a regular diet rather than lusting after prime rib every day. 

We also need to be comfortable recognizing that the mind, Joseph says in conclusion, is a scene of perpetual conflict--even when progressing in the 'right' direction. If we leave our patient pretending otherwise, even as they progress in change and grow in freedom, then we have returned them to a very primitive form of splitting which, to Joseph, is anathema. 

Creative Engagement in Psychoanalytic Practice: Further Thoughts

(I wrote and published this on 9 September 2023; but learned colleagues on Twitter, especially Jayce Long and Kristian Kemtrup--always gracious interlocutors from whom one learns much--offered an important challenge to my principal critique of Markman and I saw at once how right they were, and how their argument about reading Markman's ideas of surrender through Emmanuel Ghent's crucially important treatment of the topic makes brilliant sense, largely dissolving my difficulty. I have therefore amended the review at the place noted below.)

Introduction:

I'd never heard of this author until perhaps May, and, perusing the book on Amazon, found myself mildly interested. But I then I reviewed a mss for Routledge this summer and agreed, as always, to take payment in books; and so, to get to the total amount allotted to me, I (somewhat diffidently) put Henry Markman's Creative Engagement in Psychoanalytic Practice onto my list of desired books.

Wow. Did I ever severely underestimate the wisdom in this book and the grace of its author. If one can judge the import and impact of a book by the intensity and extent of the marginalia (underlining, double-underlining, starring, check-marking, uncharacteristically promiscuous use of exclamation points, and writing commentary up and down the page) it inspires then Markman's book is at moderate-to-severe flood stage, not quite drowning in suitably green (is anyone else quite so weird as to coordinate the colour of their ink relative to the colour of the book's cover?) ink from my second-favourite fountain pen of all times, but close to it.*

For me the impact of this book is twofold: it has forced--is forcing--me to rethink some things, though I do not know if in the end I will be in complete agreement (in other words, questions remain, and the chief of those are to be found below); and then there is much of the book that confirms and strengthens the argument for certain "techniques" that I (a nobody of very minor achievements) have more or less just found myself falling into doing, without ever seeing these cited or taught anywhere. (Perhaps some of them have been repeated by me as a result of being unconsciously imprinted on me by both of my psychoanalysts?)

The contents of this book are impressive indeed, and the writing is usually excellent; but what is the most outstanding feature of all is the manifest modesty of the author. Given the title we might have expected some "creative" fireworks and some preening by the author of how unique his methods of engagement are. But in fact what the author proposes seems to me a sort of engagement that bears strong resemblances to Winnicott and Ogden and their offering of "ordinary good enough" care for the patient. (In a time when even the basics of psychotherapy seem to have been utterly degraded or never taught, I mean that as very high praise.) 

The biographical sketch at the bottom of the back cover only gives us the bare minimum. Inside, and very casually, the author also tells us he is a trained psychiatrist with wide and extensive experience in numerous settings. He has obviously read widely--Freud, Bion, Ferenczi, and Winnicott are the major interlocutors here but there are several others I had not heard of but am now seeking out. All this learning is worn very lightly, with the result that the book is a near-miraculous production: it lacks any indulgence in jargon or theoretical defensiveness. When reading it, I thought quite sincerely: Jonathan Shedler would approve of this book, for he has often--rightly--lamented how needlessly obscure much psychoanalytic writing is, a failing that Shedler totally avoids in his wonderful article "That Was Then, This Is Now: Psychoanalytic Psychotherapy For The Rest Of Us," copies of which I now give to our interns and my students. 

In addition to the clarity and cogency of the prose, this book also succeeds in demonstrating its independence of thought without being ostentatious or obnoxious about it. In at least two places it quietly makes a reference to "orthodox" thought or practice...and then even more quietly steps away from that with ample justification for independence of mind and practice. (In this he reminds me of nobody so much as Nina Coltart.) The book borrows, adapts, creates from across the various "schools" of analytic thought, intertwining all this with winsome reflections on the author's own clinical and personal development, and illustrated with material from his patients. Therein lies the creativity suggested in the book's title, which is not at all any sort of radical heterodoxy as far as I can see but instead a gentle pursuit of its own path.

In short, the miracle of this book is, I daresay, that even those with little or no clinical background could pick it up and immediately get a sense of how psychoanalysis and psychotherapy unfold with Markman, gaining insight into not just the patient's struggles, but how Markman is present with and attuned to them in far-reaching ways. 

The Contents:

Right. Down to business. I shall only comment on select chapters, leaving readers to encounter the others for themselves. My commentary is driven largely by the need to continue metabolizing this book, and also to air some real questions I have. 

The Importance of Play:

The author begins very promisingly when he recounts his early clinical experience with adolescents, and how this "changed how I worked with adult patients: I became more playful" (p.13). This, of course, is a very Winnicottian theme I greatly welcomed here. 

Equally influential was his own experience as an adolescent patient who found his analyst had a "warm, calm, and capacious presence" and this was a key part of the "transformation" he experienced: "I strongly felt his loving care" (p.14). 

This theme of love shows up in the first chapter: "Love is expressed in our desire to know, understand, and recognize the singularity of a patient in a deep way that fosters intimacy." This should not, he cautions, lead us into a facile belief about needing nothing more than love. "In fact, ongoing serious emotional work and self-interrogation are needed by the analyst" (p.23).

The Importance of Authenticity:

Ch.2 focuses on the authenticity of the clinician. Its epigraph is a well-known saying of Bion's about "the analyst you become is you and you alone." This, in turn, is a theme picked up by Ogden, as I noted here. Markman notes that authenticity and spontaneity are not license to do and say what you want--there is no "wild analysis" here. Everything is in service of our "care and empathic understanding of our patients" (p.46). 

On Embodied Presence and its Obstacles:

Ch.3, on embodied presence, opens by drawing on French thought--Marcel and Merleau-Ponty in particular. The former's thought on disponibilité has clearly captured Markman's imagination: "putting oneself at another's disposal" is the translation he prefers. This leads into a discussion of how one manifests such availability through presence in the session. Though he does not cite her and appears unfamiliar with her work, Markman reminds me here of Nina Coltart's reflections on "bare attention." Here he also briefly invokes Ferenczi on the "language of tenderness." 

There are, as the author recognizes here and elsewhere in the book, "emotional obstacles," as he calls them, to maintaining presence with our patients--and a fortiori a presence of tenderness one assumes. Here is the first of several discussions about such obstacles. In especially difficult cases, we may lose our sense of emotional equilibrium and thus struggle to maintain presence and attention. This is fairly commonplace, but the author presses the point to its (to my mind) most troubling extreme: those times when "we can be taken over by the patient's emotions and states, losing our analytic place, becoming ill with the patient for some time as described by Borgogno and Bollas" (p.67). 

On Going Mad with Our Patients: How Much and How Far? And: How Helpful? 

Others have also written of this, including Harold Searles and Philip Bromberg: what does it mean to say that with some patients you have to be willing to let them drive you at least a little bit mad? Markman argues that allowing yourself to get a bit sick, to go mad with the patient, can be "possibly...curative." (That adverb is bearing rather too much weight for me! And Markman never returns to this point to offer the fuller argument I think it very much deserves.) 

Lest this quickly degernate into idealism and omnipotence, and all the dangers inhernet in those two, Markman later on explicitly recognizes that "we cannot fully make up for the deprivations in our patient's childhood. A 'basic fault' remains. There is a limit to how much we can repair or restore in the patient" (p.85). Our acceptance of this "basic fault" (as Balint called it) can help the patient mourn it. 

How do we do it, and how does it help? Markman continues: "What use do we make of these emotions that help the patient? Paradoxically, by not resisting these states, by surrendering, relaxing, and living within them (i.e., containing them), we restore presence in ourselves and for the patient". Very similar language shows up again later on p.86, raising the same questions for me once again.

His use of "containing" here takes him into a brief excursus on Bion's use of that phrase, and Markman clarifies that containing = metabolizing. You take something in and contain it, and do not often give it back to the patient, at least not in the form you received it. Sometimes you may need to hold on to it permanently. 

This chapter's introduction of the importance of surrender and relaxation is discussed in detail in the next chapter, "The Analyst's Work of Surrender and Mourning." I read it the first time and felt almost stricken into silence. A few days later I re-read it, sent some comments about it to friends, and then tried to read more. Even now, my third or fourth tour through this chapter, it feels deeply challenging.

Markman says here that effective therapeutic presence requires "surrender ('internal relaxation') and mourning. Mourning is the struggle to give up and let go of attachments that protect yet constrict us--attachments that do not allow for openness to the patient's inner world, being with and living within their experience. This is not the scary prospect it may sound when contemplated directly and abstractly like this, Markman suggests: "we are permeable to the emotions of others, at times even before they are aware of their own feelings" (p.77). So we may be "surrendering" in some ways without making a fuss of it. He brings in Bollas and Borgogno on this point, suggesting that such surrendering is, in essence, the greatest and most intensive form of empathic identification with the patient. 

The Importance of Self-Forgetfulness:

This is not facile surrendering. Though Markman is not explicit on this point, he does seem quietly to recognize the risks and costs when he writes that "surrender is the necessary first emotional step. We give up the hard and clear boundaries that separate us from the patient, we give up our sense of control and surety....Mourning is the actual emotional work of letting go of such attachments that block surrendering" (p.82). A little later he is explict in seeing that such surrender and mourning brings with it "two painful states--loneliness and alterity." 

Why do this? A little later Markman again brings in Gabriel Marcel's thought to argue against being "'encumbered with one's own self'." There is, I would add here, a lovely and lively freedom that comes from being forgetful of one's own self (in, of course, non-masochistic ways). I think this is very much what Coltart had in mind in speaking (ascetically, I would argue) of "bare attention," attention that is forgetful by and of the clinician's self. Such an approach not only frees oneself up to do deeper and more effective clinical work, but to do so in a way, I would suggest, that allows for you to be used, used up, and even destroyed, as Winnicott put it in his profoundly important essay on "The Use of an Object," without suffering as much "collateral damage" in the process.  

On the Uses and Abuses of Masochism (updated):

On this question of masochism--about which he has authored a chapter elsewhere--Markman differs from Maroda later in the book when he outright says "we need to surrender to the particular and intense needs of the patient that may feel self-depriving, even masochistic" (p.192). 

Markman appears to justify this masochistic surrender by returning to Ferenczi, who apparently wrote that "'transformation of the patient depends unequivocally on the willingness of the analyst to be transformed in and by the analytic process'." (p.198) But Ferenczi says nothing here about masochistic surrender, and on this point I was initially unconvinced and somewhat disconcerted by this argument. I do wish Markman had developed this point in more detail.  

But after discussion with colleagues, noted above, much of my anxiety here is reduced by being reminded by them of Emmanuel Ghent's crucial distinction between surrender, on the one hand, and masochistic submission on the other. (Ghent, "Masochism, Submission, Surrender—Masochism as a Perversion of Surrender," Contemporary Psychoanalsis 26 [1990] :108-136.). I am inclined to give Markman the benefit of the doubt here, and thus to read him through Ghent and thereby feel much less anxious about his idea of surrender. But the remaining issue is: Ghent is nowhere cited in Markman's book--not in the text, notes, bibliography, or index!

Collapse of the Therapeutic Space?

Another important and somewhat disconcerting question Markman does not entertain here or anywhere in the book so far as I can tell is whether this process of surrender and mourning, leading to such intense indentification with the patient, does not carry the very real risk of collapsing the therapeutic space. There must, as Ogden has put it, be room for the "third." But the strong emphasis on mourning and surrender--which in the main I find deeply compelling and refreshingly challenging--almost seems to make the therapist too passive in some ways, perhaps too closely identified with the patient. 

Instead, I am far more comfortable with the kind of "split mind" that Nina Coltart advocates than I am with an emphasis on mourning and surrender that seems (unless I have severely misread this book) to run unnecessary risks of minds merging, as it were--of overidentification with the patient. (I am not opposed to surrender at all--this I long ago learned from Winnicott theoretically, and practically from my own psychoanalysis. And I firmly believe mourning is always a crucial component of therapeutic work with everybody.) In her words, we must at any moment in a session be engaged in:

sharply focusing, and scanning; complex involvement in feelings, and cool observation of them; close attention to the patient, and close attention to ourselves; distinguishing our own true feelings from subtle projections into us; communicating insight clearly, yet not imposing it; drawing constantly on resources of knowledge, yet being ready to know nothing for long periods; willing the best for our patients and ourselves, yet abandoning memory and desire; a kind of tolerant steadiness which holds us while we make innumerable, minute moral decisions, yet steering clear of being judgmental (Slouching, p.119). 

To his credit, Markman entertains some brief consideration of the dangers of the approach he advocates, but only much later in the book. On p.146, he briefly mentions the risk of "a narcissistic misuse of the patient." He also stresses (something Andrea Celenza does in her excellent book, discussed here) that we can never, ever forget the inescapably and profoundly assymetrical nature of our relationship with our patient. This must always be kept in the forefront of our mind, and we must always "interrogate our own actions and states of mind as our own responsibility....We are never off the hook, and that is a good thing" (146-47). 

On Acknowledging our Own Needs of the Patient:

Markman also introduces an admission rarely encountered--Karen Maroda being the only obvious exception I know of: "unconsciously we need things from the patient." Inter alia, we "seek in our work reassurance of our goodness, capacity to repair, narcissistic needs for love, and early omnipotent feelings of power and control" (p.82). What he does not say here--but later reflections invite one to go on to this speculation--is whether some clinicians also need to feel the pleasures of masochism. 

I do not wish to end on a quarrelsome note, for I have found this a deeply right book in almost all of its instincts, and deeply convicting in many ways. The author has written in a powerfully compelling way about some crucial, and crucially neglected, topics in clinical work today, including the centrality of mourning in diverse forms (which Nancy McWilliams also reminds us of). 

In sum this is the very rich sort of book one feels wholly inadequate to metabolizing on one, or even the first several, sittings. I will doubtless pick it up profitably many times in the months and years ahead. 

___________

* You naturally wonder: what is the most favored of all times? My favourite pen is a purple Krone from decades ago, so grand it travels in an enormous velvet case only slighly less posh than that which the Crown Jewels presumably travel in. Moses himself wanted to use it to write the 10 Commandments, but God told him He was giving it to me instead. Of course--to allay your further wondering--this pen is charged with purple ink. I inherited it from a dear friend upon his death the day after Christmas in 2010. 

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!). 

Harnessing--And Using!--Your Aggression in Psychotherapy: A Catena of Clinicians

Preface: 

There's a great bunch of psychotherapists on Twitter from whom I continue to learn much. The discussion over the past few days has been about clinicians who comfort but do not challenge; who soothe but never summon up the guts to push patients to change. This has made me go back and revisit some thoughts on here written over the past few years.

My love for and debts to D.W. Winnicott should surprise nobody who reads anything I write. Using his thrilling 1947 paper, "Hate in the Counter-Transference" with students ignited some of the best discussions I've had with students in a quarter-century of teaching. All credit should go to him for advancing the discussion of counter-transference (then still undertheorized) in general, and in particular for his blunt acknowledgement that parents hate their children just as therapists hate their patients sometimes, and both are not only normal but sometimes even justified.

But I'm increasingly coming to question aspects of his paper that might--however inadvertently--reinforce the notion that psychotherapy and psychoanalysis are never about direct challenges to the patient but consist largely in soothing and comforting. This is a point Jonathan Shedler has often made on Twitter, and I am very grateful that he keeps making it.

My rethinking of Winnicott is inspired directly and recently by reading Karen Maroda's new book, which I discussed in some detail here. The most memorable line in the entire book comes quite late: "we need a statute of limitations on this holding and nurturing behavior" (p.197) among psychotherapists who do not sufficiently challenge their patients nor engage in healthful, careful conflict with them en route to their actually changing, getting better, and eventually going away.

Maroda says that we need, as psychotherapists, to learn how to engage in "constructive conflict" with our patients (p.106) and what she later calls "creative rage" (113). As she will caution in a later chapter on enactments, "there is no simple answer to this question" of "how do we harness negative countertransference emotions in the interests of furthering the treatment?" (p.129). 

I took Maroda's challenge in that book as something of a rebuke to misreadings (or, perhaps better, misapplications) of Winnicott. For all his courageous and welcome bringing out of hatred from the closet, Winnicott's treatment of hatred in that essay no sooner brought it out before domesticating and stuffing it back in the cupboard again: E.g., early on he says that "hate that is justified in the present setting has to be sorted out and kept in storage for eventual interpretation." 

I do not find much in the essay to indicate that hatred became a present, this-day object of discussion with his patients: it is either always locked away for future interpretation or else, when it appears on the scene, is described as something in the past, safely overcome and no threat to patient or therapist right now: E.g., he writes that "It was indeed a wonderful day for me (much later on) when I could actually tell the patient that I and his friends had felt repelled by him, but that he had been too ill for us to let him know."

Winnicott goes on to give a rather nervous list of five reasons how and why analysts will of course keep their hatred on a very short leash in "ordinary analytic work"--in contrast to that with psychotic and anti-social disorders, which is his primary focus here. Most of the time, he rather blithely says, analysts will see that their hatred is "easily kept latent." 

But then all of a sudden he immediately shifts into saying that patients need "objective" hate and need to be able to access it in the therapist. I regard this sentence as the pivot of the article and indeed its most important claim:

If the patient seeks objective or justified hate he must be able to reach it, else he cannot feel he can reach objective love.

He must be able to reach it! Just when readers like me are starting to wonder about hatred and aggression being too domesticated, Winnicott brings us up short with this reminder: your hatred might be safely stored away for future use, or as a relic of past feeling, but in fact you need to have it in the therapy with your patient who needs it now. You might, in other words, have been amply supplying a lot of soothing, comforting "love" of some sort, but without feeling and accessing hatred, how much of that love you think you are offering is really being received and used well? (Indeed, that "love" you are offering might itself be fueling deeper hatred, or at least fear and anxiety, in your patient! Certainly there seems to be some evidence of this being true with psychotic patients.) 

Winnicott in this essay does not really offer specifics about handling hatred and aggression, but his final sentence is a severe warning that avoiding the use of hatred and aggression may well lead to treatment collapse: "Only in this way can there be any hope of the avoidance of therapy that is adapted to the needs of the therapist

rather than to the needs of the patient."

So let us say--as all good clinical practice demands--that the patient's needs are paramount, and yet one of those needs is to be challenged to change and grow, not merely to be soothed and comforted. They might hate you (at least right now) for your challenge to them to change and grow, and their hatred in turn might spurn your own hatred in the counter-transference. Without having had in-depth therapy of your own, can you handle this as a clinician? Can you be courageous enough to challenge and to hold the line when the patient resents or hates you for it? Or will you--as research suggests--revert to the familiar and familial role of comforter which many therapists learned to play as children with psychologically damaged parents?

I know I am not very good at this, but am constantly trying to learn to be better at it. But instead of just trying, as Winnicott suggests, to contain that hatred for future use, can you canalize, capture, or harness some of it for sound and careful clinical use in the here and now? 

Winnicott seems to imply that you can without showing how. So here is where I turn once again to Nina Coltart, that most independent-minded and bluntly outspoken of all the British analysts of the post-war period. With characteristic brevity and boldness, Coltart says a therapist should "harness our aggression skillfully in the service of clinical work" and that so doing is a "strongly positive factor" which patients will welcome. But such skillful use requires work in and by the therapist on him/herself so that it is done without fear or anxiety. (Famously or perhaps infamously Coltart gives an example of her using her own hatred in a very spectacular way with one patient who was, she said, utterly sabotaging treatment. Her outburst with him turned things around.) 

The other person who has done even more work than Coltart on this topic is Michael Karson (whose book is discussed in more detail here) Do not, he says, be that doctor who enlarged his practice by only pleasing, and never challenging or curing, his patients! You're going for patient improvement, not patient satisfaction. 

Karson says you do this by getting in touch with your aggression. One way you can do this, he suggests, is skillful use of interruption: "Good therapists are constantly disrupting their patients' master narratives" (6) and as a result are not in the business of merely supplying a comfortable environment to vent. The problem with merely being a person to whom I can comfortably complain is that "comfort seeking impedes growth" (7).

Rather than merely providing comfort, your job is to challenge patients and their faulty narratives. You do this by something that Karson later calls virtuous aggression (29). He gives such examples as challenging bad ideas, collecting the fee, and ending sessions on time. "These things all injure patients, as they should."  There is no point pretending otherwise. 

I admit I found that last bit very refreshing and straightforward. To drive the point home further, Karson says: consider the surgeon. He or she would not deny that cutting someone open and removing and replacing an organ is not injuring them in service of a cure. Would he or she flinch from saying: I have this slot on the surgical theatre's schedule, and these many minutes, for the procedure, and at the end of it, I am getting paid? 

Later in the book Karson says  too many therapists tiptoe around and try to avoid conflict. Bluntly he insists that "the overarching lesson about conflict in therapy is that it is better to approach conflict than to avoid it" (90). In fact, you cannot avoid it for "rupture and repair" always happens in therapy. If you are distinctly unc0mfortable with such things, and if you aren't comfortable making mistakes and then examining them, you have no business being a therapist. 

Some--perhaps much--of this is not necessarily sophisticated. Some of the conflicts that should not be avoided are around age-old things like the frame and the fee. Karson stays that to start and end on time regardless of joy or sorrow says that all is welcome here to be treated equally. It also refuses to infantilize the patient, and says that you have hope and confidence in them to be able to handle themselves and move on with their day. As Karson says, "patients need therapists to be not only loving but also strong, and time management denotes strength" (124). So whether in laughter or tears, the session ends on time.

This all still sounds a touch too abstract and theoretical. I am, as noted above, far from an expert on these matters, but as someone who has had to learn, and is still learning, to observe that statute of limitations on all this comforting business, and to become more comfortable challenging patients to change, I will continue to read on and think about these things. 

In the meantime, I can report the following have been helpful to me when tempted to collude with patients seeking comfort over change. This is far from a rigorous and tested list! It merely represents some very modest gleanings from that "constant feedback loop" which Shedler talks about in psychotherapy: I have tried these things and found them useful. My samples are very small and not verified by anybody other than my supervisor, and I do not suggest these are the only, or even best, practices: merely what has worked for me in particular sessions. 

With delusional and histrionic patients: Indirect challenges seem to bear more fruit. Frontally challenging deeply held ideas, in my experience, results in easy deflection and dismissal of the challenge. Looking for underlying components, and assessing their relative strength and importance to the patient, may direct you towards the proverbial Achille's heel which, when pressed upon, may yield in the direction of conceding something to be untrue and thereby moving closer to reality. 

With deeply sexually traumatized patients: I have had blunt discussions with such patients about the idea of a frame and how that--far from being a sign of my lack of care when I do not extend sessions, or have sessions with them over coffee in a shop of their choosing--is a protection to them, and a reminder to us both that we are here to do work and not merely commiserate. 

With psychotic and borderline patients: One thing I have learned from both mentalization and metacognition approaches to therapy (for the latter, see the MERIT approach in this book, which I have read but not written about yet) is that providing an environment encouraging unstructured and completely free association may be counterproductive. Rather, ask them early in the session what they want to work on that day, and then keep challenging them to return to that. (Stated differently, I have learned from my own psychoanalytic therapy that free association can itself be a defense mechanism! I ran out the clock on one session with almost sadistic glee wildly and knowingly associating all over the place to a rather unremarkable dream I had in order to avoid talking about something difficult from the previous session!)

With enmeshed and abused adolescents and adults: I've learned to challenge their near-constant deferring to the dominant authority figures in their life even though this makes them acutely uncomfortable. I could have colluded in keeping them comfortable but instead I would gently but repeatedly press, "But what do you want to do?" until I got a first-person answer that seemed genuine. (This requires careful handling, of course, so that they do not merely shift their submissive instincts from parents to you in a fairly obvious transference.) They were awkward and uncomfortable finding their voice, but once they had voiced their own views and desires, the relief and sense of increased autonomy was palpable.  

This approach reminds me that I have found the use of questions, rather than statements, and these delivered in a gentle tone with as much curiosity as possible, will almost always go farther with the patient in inviting open reflection than declarative statements. (I wish I could do this as well as my own analyst, who has this incredible capacity to deliver a simple question--"I wonder why that is?"--absolutely saturated with curiosity.)

With just about everybody: Thanks to Adam Phillips and--as we saw above--Michael Karson, I find myself routinely challenging master narratives. If you listen carefully (that third ear!) you will hear patients switch registers or voices, and give you material that is clearly a "received notion" (from family, typically). I regularly ask "Whose phrase is that" or even more bluntly "Says who?" if they give me something like "I know I am a real pain" or "this is such a stupid thing to bring up." 

I especially do this with patients who come in pre-loaded with diagnostic terminology: "I'm very OCDish" or "my mother says I'm bipolar." I always invite a deeper discussion here about what that label means to them, or might mean, and about the larger meaning of a diagnosis as such. Some find it welcome relief after a period of uncertainty; others find it a prison and stigma to bear. 

A few other thoughts: if I can feel (as my grandmother would say) when my dander is up in a session, I find myself returning to Winnicott to ask: does this aggression need to be held for another time? Or (with Coltart et al): Can I safely draw on a bit of it now in a productive way? If I feel I cannot--if I feel I might lose control and say more than would be helpful--I keep silent and process it in supervision. This does two things: it allows someone I respect hugely, who has had a wide and varied practice of 40 years, a chance to weigh in; and it also gives me a cooling-off period. Then when I go into the next session, I can, more coolly and with greater precision and control (and thus comfort!), talk about the previous session and open with the challenge. I try to do this right at the outset of the next session (as I also try to do if I feel there has been a rupture or I've made a mistake) so that I do not lose courage and dither!

Mary Jo Peebles on Psychotherapy and the Wisdom Found in its Impasses and Uncertainties

I previously wrote at length about the wisdom gained from reading Mary Jo Peebles' 2002 book Beginnings: The Art and Science of Planning Psychotherapy. 

Her name was recently brought back to mind by Jonathan Shedler on Twitter, from whom I continue to learn a great deal. He was favourably quoting from her new book, so that meant I had to get a copy and read it, which I did earlier this month. 

So let us turn our attention to her newest book, released late last year, When Psychotherapy Feels Stuck (Routledge, 2021), 164pp. I finished reading it last weekend and found it a profitable read, not so much for any new ground it breaks as for the many useful reminders it offers.

She starts off by very calmly advising that not knowing where to go next in treatment can be a very good thing: "I want you to be unafraid to not-know" (xiii). This, as I have written about often on here, is a familiar and welcome counsel, going back--for me--to at least the early 1990s when I read Nina Coltart's break-out book Slouching Towards Bethlehem, about which I wrote at length here. 

Towards the end of her preface, Peebles returns to this, writing winsomely that not knowing about your patient, or where to go with a patient, can in fact be a gift: 

feeling stuck and not-knowing...is a gift we are given to be able to learn something new. It is a sacred trust we hold when we invite our patient to share themselves with us. I want you to feel less of the fear and more of the wonder and sacred trust when you feel tense or confused. I want you to come to appreciate that if we listen, the knowing will come (xv).

She will return to these themes--of the sacred and of gift--in the concluding pages of the book, as we will presently discover. 

Her first chapter, "Change Takes Time," is one of those messages that needs to be heard more than ever today. The pressures from insurance companies and other agents of iniquity to shorten psychotherapy are notorious. Helpfully Peebles here launches straightaway into an analogy about learning a language and how much work and time that takes. In many ways, she shows, good psychotherapy is about learning how to talk (think, feel, etc.) about yourself in a different way so why should we expect that to be quick and easy? "Change that lasts is incremental," she reminds us (p.5), and such change is compared to compound interest: "our investment of time compounds over time" (p.9). (In this, she reminds me of a line from one of my favourite of Adam Phillips' books where he says of psychoanalysis that "the cure can begin only after the treatment has ended.")

"How We Say It Matters" is the second chapter and I confess I found it gratifying for such a seasoned clinician to be advocating a practice that I had just found myself falling into without having read about it before or seen it sanctioned elsewhere: "Perhaps you involuntarily wince when a patient excoriates himself. Let that show." This might be through body language or a simple "Ouch!" voiced aloud, shaking the patient's "obliviousness" (p.250). 

I can confirm that this is very effective if the timing and tone are right, though with some patients it needs to be done semi-regularly until their hitherto relentless super-ego attacks begin to lessen and they develop their strength and ability to stand "Against Self-Criticism."

Ch.3, "The Value of Awareness" contains a helpful list of questions, some of which I have used before--either in thinking of a case or in supervision, or both. All of these are very worthwhile and should be considered regularly to avoid epistemic closure and unjustified certainty. Peebles says (my paraphrase) we should be asking:

• Are there other ways for me to understand this?
• How would others of different theoretical persuasions see this?
• What am I missing or ignoring?
• Have I made assumptions about my patient instead of asking them questions?
• Am I discounting or dismissing something the patient said because of theoretical or clinical priors?
• Am I in danger of seeing the same symptoms and diagnosis in too many people? 

Ch.4, "Transforming the World Within," was perhaps the most challenging for me. Here she issues a number of welcome reminders, including this splendid aphorism: "the goal of psychotherapy...is to rattle our patient's certitude about his conclusions" (p.49). To do this, we must enter their world, and we must enter not just via their mind--their intellectual world--but above all their emotional world: "we must focus as therapists on our patient's sensations, not just on his ideas" (ibid). Peebles says that therapists who struggle to do this need to be in their own personal therapy. (I do, and am!)

Ch.5, "Learning to Not-Know," begins with an epigraph from W.R. Bion and his infamous "Notes on Memory and Desire," about which I essayed some thoughts here. Peebles quotes him thus: "'the only point of importance in any session is the unknown'." 

This is not easy to do! I find that to be especially difficult in working with psychotic disorders. The drives to know and control and fix--what Phillips talks about as our desires for omnipotence and omniscience--are strong! They are stronger still when under pressure from the parents of adolescent patients who, naturally enough, want a cure and want a guarantee that their children will never suffer another psychotic break ever again. 

Bion presents (so I thought until recently) especial difficulty with his insistence that the psychotherapist "must aim at a steady exclusion of memory and desire" and must also "aim at achieving a state of mind so that at every session he feels he has not seen the patient before." At first, I regarded these as counsels of perfection, absolutist and almost suspiciously totalizing in their demands and largely unachievable in most practices in this country today. But I must report that I have rethought my suspicion of him on this point recently, and was startled to realize in one case that Bion was right and I needed to do what he advised! Suddenly one day instead of thinking I was out in front waiting for a patient where we had ended the last session, I realized they had moved unexpectedly and thus surpassed me and I was playing catch-up: my memory of past sessions had deceived me, just as Bion predicted it would! 

To return to Peebles, she says there are two significant gifts which not knowing can offer: first, it can allow for creative thinking to emerge, for new ways of looking at and working on something. Second, "when therapists are able to tolerate uncertainty, the therapeutic alliance strengthens" (p.80). (This has been confirmed by my own recent experience with one patient in particular.)

A toleration of uncertainty, she continues later in the chapter, is connected to "being humble about the limits of our knowledge." We need to cultivate humility, but not of a masochistic kind: "humility is the child of self-assuredness" (p.81). In other words, as I have heard others put it, you can be certain of yourself as a person, but uncertain as a therapist as to what to do, and both are not just okay but exist in necessary relationship. 

A toleration of uncertainty goes well with a spirit and practice of playfulness in psychotherapy. This--though she does not cite him--is very much in keeping with Winnicott's ideas, as I noted here. 

Peebles ends this chapter with another timely reminder and reiteration of her central point: "the more comfortable we are with not having answers or next steps right away, the more opportunities we will afford our patients to resist concluding, endure not-knowing,...and master uneasiness" (p.91). This, in turn, will pay dividends in allowing patients to be freed from the often restricting, infantilizing, or even paralyzing certainties with which their lives have been ruled hitherto. 

Ch.6, "Relationship," focuses not just on the therapeutic alliance, but on negative emotions in that alliance. This was, for me, the most useful part of the chapter. She brings in some of the greats here--Winnicott, of course, on hate in the counter-transference; but also Searles on counter-transference; and others I was not familiar with but whose works I am now tracking down. She focuses not just on hate, but on what might perhaps be called lesser negative emotions, and how to deal with those. Her advice is masterful: "talk with our patient about the negative energy with the calm and respect that comes from knowing how to learn from negative process rather than be railroaded by it" (p.102). 

Timing, she says later in the chapter, is crucial here. Watch for, and even anticipate where possible, ruptures and outbursts of negative emotion, and handle them calmly and promptly. Left untended, they can damage the alliance and relationship. But handled quickly and well, the alliance can in fact be strengthened. 

Other useful and familiar reminders abound here: about the importance of good supervision; about self-care; about taking "cool soundings" (Coltart) from the counter-transference; and once again about the importance of the therapist having his or her own psychotherapy.

This chapter ends by compiling a list (quoting from this article) about the qualities of  master therapists properly so called, who are described as "'voracious learners, curious, reflective, and valued cognitive complexity and ambiguity; they were emotionally receptive, self-aware, non-defensive, and open to feedback'" (pp.112-13). 

The last chapter, Creating Meaning, takes us back to where we began: the costs and challenges of change, and the resistances to it which crop up. Noting that change brings loss and ambivalence, and takes time, Peebles concludes her worthwhile and helpful book with what I would call an existentialist turn, reminding us of past luminaries such as Viktor Frankl  and the present challenge of creating space where patients might explore questions such as the meaning of suffering, the questions about grief ("grieving is not giving up," she flatly asserts late in the book [p.132]) provoked by losses associated with change, and more broadly "spiritual" questions. 

In this final chapter, Peebles is also undertaking what I would call an implicit rebuke of instrumentalist or purely pragmatistic views of psychotherapy as means of overcoming "disease" or "disorder" in order to get back to being a quiet, compliantly cheerful employee and obedient citizen. Her view, rightly, is much more expansive than that, and reminds one of others, including Michael Eigen, not least in his book The Psychoanalytic Mystic.

Thus she says that "psychotherapy presents the opportunity for a mystical journey, however brief the encounter or modest the epiphanies" (p.124). On this felicitous note we take our leave of When Psychotherapy Feels Stuck, grateful for the wisdom of the author and her eminently useful book.