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. 

Some Thoughts on the Death Drive

 I was moderately heartened to see that as the centenary of the publication, in 1920, of Freud's most neglected and professionally disliked book, Beyond the Pleasure Principle, approached, we saw a renewed interest in its most controversial idea: the death drive. The sputtering bewilderment proffered by psychoanalysts and others in the face of this theory finally seemed, after a century, to be giving way to some actual substantial engagement with Freud's text--albeit mostly by non-clinicians. The fact that anyone, clinician or otherwise, reacted so strongly to this theory has long been itself bewildering to me for evidence of a human propensity towards repetitive self-destruction (and the unconscious pleasure, or at least purpose served by such destruction) seems constantly on offer in consulting rooms around the world, and in so many other places.   

I do concede the point that part of the reaction may have been to Freud's suggestion that the death-drive might in fact be an actual "biological" drive. Unlike some, I think you can leave that out of Freud's theory without fatally (!) weakening its overall claims. 

The fact that discussions of Freud's notion of a death drive, which were few and far between even while Freud was alive, and were often politely ignored by much if not most of the psychoanalytic establishment for decades after his death, have taken off nearly 80 years after his death puts me in mind of Adam Phillips' argument from some time ago that the best time to re-examine Freud is precisely now, when nobody thinks much of him anymore and there are fewer and fewer professional establishments rushing to "protect" him from being critically scrutinized, or rushing to enforce some orthodox line or other:

This is certainly a good time for psychoanalysis: because it is so widely discredited, because there is no prestige, or glamour, or money in it, only those who are really interested will go into it. And now that Freud’s words are so casually dismissed, a better, more eloquent case needs to be made for the value of his writing ("After Strachey," London Review of Books vol. 29 no. 19, 4 October 2007, p.36) 

So scrutiny is returning to several parts of Freud's project, but noticeably his late-period "cultural works." Thus, earlier this year, as I discussed here in some detail, there was Benjamin Fong's fascinating new book Death and Mastery: Psychoanalytic Drive Theory and the Subject of Late Capitalism.

And before him, in 2013, in one of the most richly provocative books I've read in a long time, there was Todd McGowan's Enjoying What We Don't Have: The Political Project of Psychoanalysis, which I discussed in detail in three parts when I was attempting to demonstrate that much psychoanalytic thinking should be welcomed by theologically minded Christians, especially Catholics. 

In addition to Fong and McGowan, nobody has written as much about the death drive as Todd Dufresne, whose works I have enjoyed and through whom I discovered the wonderful work of his Doktorvater, the late Paul Roazen.

Roazen's Meeting Freud's Family is a thoroughly charming book. His Freud and His Followers was a groundbreaking and controversial work which fills in very important gaps in the historiography. And I have found his Encountering Freud: The Politics and Histories of Psychoanalysis useful in surveying what religious and theological responses were made over the history of psychoanalysis to the 1990s.

Dufresne's work on the death drive is found first in his Tales from the Freudian Crypt: The Death Drive in Text and Context and then, more recently and succinctly, in his introductory essay to the Broadview translation of Beyond the Pleasure Principle. It is the Broadview translation that I require of my students when I assign this text in classes. 

To my enormous surprise and puzzlement, neither of these books shows up anywhere in one of the heftiest recent books devoted to the topic, Repetition, the Compulsion to Repeat, and the Death Drive: An Examination of Freud's Doctrines, co-authored by M.A. Holowchak (a philosopher) and Michael Lavin (a clinician) (Lexington Books, 2018, viii + 163pp.). It is a very useful, crisply written, and largely clearly argued work.

 There are several virtues to this book, including its relative brevity, and the arrangement of each chapter, which aids in reading. More broadly the book will be useful if it is received as the history it is, tracing out the trajectories of the concepts of repetition, compulsive behavior and thinking, and the death drive across the Freudian canon. As such it goes back to 1895 and Studies in Hysteria, co-authored by Freud and Breur, and then forward past Beyond the Pleasure Principle to works in the last period of Freud's life, often referred to as his "cultural" or "meta-psychological" period. Along the way it also notes such "watershed" publications as Freud's 1914 paper, "Remembering, Repeating, and Working Through" as well as his essay on anxiety from 1932, by which point he seems to have moved from the very tentative and speculative writing of Beyond the Pleasure Principle 

Further virtues include the fact that this is neither an attack on Freud--though it advances important, serious, and considered criticisms of his theory--nor a glorification of him enforcing a certain "orthodox" line. It agrees with Freud in places, argues with him in others, and gives evidence in still others for where Freud may have been wrong, or subsequent research does not bear out his often highly tentative and speculative claims in Beyond the Pleasure Principle. 

On the latter score, it notes problems with Freud's attempting to find phylogenetic evidence for a death drive and compulsive repetition. The question remains: can his theory be rescued if the evidence he claimed to find for it in the biological sciences does not exist, or can be explained by other theories? In answer to that question the authors diverge somewhat, and candidly acknowledge this in the conclusion. For my part, I see few problems in separating out and sustaining most of the theory from insufficient "natural" evidence, and again the authors seem--albeit somewhat uneasily--inclined to agree, especially in a clinical setting, noting that clinicians rarely take their theory pure and whole.

All that having been said, the drive to destroy, including the self, is often a repetitive one, and we are faced with the question of why that is when such a drive brings terrible anguish, suffering, and consequences to the self and to others. Part of the answer may lie in the fact that the drive for pleasure and the death drive are not always operating in mutual and exclusive opposition. As the authors admit flatly, "eros and the death drives do not function independently of each other" (85). In fact, one of Freud's key insights here and in other areas was the admixture of experiences and emotions. In this light, one can, as he himself wrote, find in destructive repetitions the "pleasure of mastery or revenge," including against childhood traumas, enemies, or frustrations.

Such an understanding also goes some way towards accounting for what is perhaps Freud's clearest clinical evidence for compulsive repetitions and self-destructive behaviors: the regularly observed fact that patients get bogged down in treatment, and come actively to undermine the very thing that may help them get better through attacks on the therapist and the therapeutic alliance. In this regard, as D.W. Winnicott put it, attacks on a therapeutic analysis may be understood to reflect the fact that for many of us, "health is much more difficult to deal with than disease." In our perverse ways, we like being sick, we like being punished, and though we do not always admit this to ourselves consciously, our unconscious repetitions-in-action bear this out.

By chapter 6, it seems the authors' patience is wearing a wee bit thin, as they sum up the "view in the secondary literature...that the death drive creates more problems than it solves" (98). I think this overstates the case and the authors themselves have not provided absolutely conclusive evidence to support this judgment. Moreover, they fear that Freud's insistence on the death drive runs the "risk of throwing his metapsychology into a state of chaos" (108).

Here is precisely the point where an engagement with Todd Dufresne, mentioned above, would have been crucial. Dufresne's argument is that BTPP is a deliberate act of sabotage on Freud's part, undermining his theories of sexuality and much else. As Dufresne puts it, "metapsychology subverts psychoanalysis," whether "playfully or otherwise," inflicting from a position within the movement a "trauma" on psychoanalysis. 

Dufresne does not elaborate much on why he thinks Freud may have done this, but I would speculate--following Adam Phillips--that this may have been done precisely to keep the analytic movement from becoming a closed, rigid ideology with enforced orthodoxies and a putative epistemological omniscience. Already there were clear signs of this (some of them demanded, or at least supplied, by Freud himself!) before the great man's death in England in 1939. Alas, they seem only to have gotten worse after his death. If psychoanalytic institutes today complain (as they have for years) of their declining fate, much of the responsibility for that is entirely their own for they have too long been hidebound places demanding loyalty to certain orthodoxies that Freud himself was more open to questioning. (One of the virtues of Roazen's scholarship is the documentation it supplies whereby Freud was often rather free-wheeling in his own clinical practice, but often much more strict in what he recommended in writing.) 

Freud was certainly aware of the dangers in this direction (and had himself on occasion contributed to it), especially if analysis remained in the hands of psychiatrists or other medical doctors alone. He was forced to address this problem in 1926 in The Question of Lay Analysis, a work I would also see (as, again, Adam Phillips has) as pushing back against analysis becoming a closed system with a closed caste of expert "professionals," especially if those medical professionals were Americans, of whom he thought very little and whom he regarded with enormous skepticism. Such a resistance reflects Freud's own compulsive concerns in some ways, for he was clearly desperate for respect and acceptance for most of his life, but late in life seems to have come to regard such desires with disdain and begun to resist them and call for others to do likewise.

In the end, Holowchak and Lavin conclude there is not a lot that can be salvaged from Freud's death drive, but they do themselves a great service by noting that many other prominent analysts, including Klein, Lacan and Laplanche, disagree with them. Laplanche, it seems to me, takes the most sensible route forward by arguing that if the theory is stripped of biological concepts, if it is seen as exclusively human, and if it is seen as operating not independently but bound up with other drives and desires, it can be rescued. This remains my own view (for whatever that's worth). I will say more about it in later reviews of some of the other books on the death drive that have been helpfully published in the last 3 or 4 years. 

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

Preface:

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

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

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

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

Introduction:

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

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

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

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

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

Status Quaestionis:

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

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

History: From Ancient Israel through Byzantium and the Enlightenment:

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

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

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

Psychoanalysis and Schizophrenia:

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

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

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

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

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

Criticisms: 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

W.R. Bion's Second Thoughts on Schizophrenia

Introduction: 

When I was discovering the Middle/Independent and object relations schools in Her Majesty's United Kingdom in the 1990s, Bion's name came up several times. Both then and since I tried, in an admittedly desultory way, to read a bit of him, but finding the experience infelicitous, did not persist in my attempts.

Recently, however, I have made some in-roads with him, and it is through his papers on schizophrenia, most of them collected in Second Thoughts, that I have found some material to latch onto as it were. My method in reading this book was admittedly rough: I ransacked it for only such material as struck me as being clinically useful and broadly in accord with what I have previously read, much of it noted on here already.

The chapters in this book that focus on schizophrenia draw their material from his work with six patients. Bion says he did not depart from analytic technique, taking note of positive and negative transference (about which more presently). 

Bion notes that Melanie Klein's work plays a central part in his attempt to understand schizophrenia, especially his insistence that the schizophrenic is making constant use of projective identification and splitting to navigate the world. This leads him to claim, early in the book, that "the peculiarity of the schizophrenic's object relations is the outstanding feature of schizophrenia" (p.23). 

Centrality (if not Singularity) of the Counter-Transference: 

Bion also notes  that "counter-transference has to play an important part in analysis of the schizophrenic" (p.24). Bion is writing this well over half a century ago, but his point has been given even stronger emphasis in a recent and fascinating essay I read tonight by the Columbia psychiatrist Andrew C. Lotterman ("Psychotherapy Techniques for Patients Diagnosed with Schizophrenia," American Journal of Psychotherapy 70 [2016]), who insists on the absolutely irreplaceable value of the counter-transference, saying that sometimes this may be the only tool the therapist has at his disposal for understanding fragmented speech, hallucinations, and other psychotic manifestations. Lotterman:

In many cases, the countertransference is the only place where some of the patient’s crucial emotions and fantasies will appear in the treatment. The patient often projects or induces these experiences into the therapist to rid himself of the burden of feeling them, and of the work of becoming conscious of them by capturing them in words or images.

Frequency of Splitting: 

Back to Bion, and so to Klein, on the centrality of splitting in the schizophrenic: he notes that they may often try to split the therapist in a variety of ways you might not appreciate for some time. Some examples: to overstimulate and to make you so drowsy you fall asleep; to ask two incompatible demands of you (longer and shorter sessions). Insofar as the patient can move from splitting to the depressive position, Bion says, we may see this as a sign of progress and increasing health. But the patient may fight this and return to a more primitive position precisely because of the inability to deal with the psychic pain of being in touch with 'reality' (which depresses us all, psychotic and non-psychotic alike!). 

It is not just that objects are split, but Bion insists that many objects are often pulverized into fragments, and then compressed and agglomerated: they cannot be synthesized. Insertion of them into the patient's mind is felt to be violation and an assault.

Later on Bion returns to this, advising the psychotherapist that you not allow yourself to be confused in thinking too high: that when a patient mentions and attacks an object, they have the full object clearly in mind. They do not. You, the clinician, would assume this, but in reality the patient does not have the full object clearly in mind. They are attacking only fragments, residues, etc. They resent these objects and do not have sufficient curiosity to investigate and know them in their fullness. 

Projective Identification:

For Klein, splitting is a key part of the phenomenon of projective identification, of which Bion makes much in this book. He says that for the schizophrenic, projective identification is widespread and key; it replaces repression. Ordinarily objects that are unpleasant may be repressed but the schizophrenic cannot do this and so the objects are split off and identified in particles in and with other objects. 

In turn, this makes the introjection of those objects impossible. One consequence of this is that excessive projective identification at an early stage prevents "smooth introjection and assimilation of sense impressions and so denies the personality a firm base on which the inception of pre-verbal thought can proceed" (p.61). 

Attacks on Linking:

I have previously read Bion's essay, "Attacks on Linking," but did not, at the time, pay attention to the fact that it was so focused on psychosis and schizophrenia. But now, having read it in this context, and in light of other recent reading, this chapter makes a very great deal more sense.

The patient attacks anything that feels like a link between objects. They may even attack links to such fragments of feelings they feel, or need to feel: thus they can hate their hatred, etc.

One helpful way to begin to notice these attacks on linking, Bion says, is the frequency with which they often resort to "it seems" language rather than such firmer declaratives as "it is" or "I think." 

Because it is difficult for the schizophrenic to accept links, Bion strongly advises (and others do, as we have seen) that the therapist avoid why questions: the patient will have little understanding of causation, those links having been severed also. So do not ask why or try to induce the patient to offer some speculation on how A might have caused B.

This lack of understanding of causation, on a much larger and 'structural' scale, comes up later in the book when Bion says we must not expect to meet material that has been filtered and mediated by the patient's personality:

Psycho-analysis of the psychotic personality thus has a quality which makes it so different from the analysis of the non-psychotic personality. Conversely, the relationship with external reality undergoes a transformation parallel to the relationship with psychic reality which lacks an intervening (or "interceding") model. There is no "personality" intervening between the psycho- analyst and the "unconscious" (p.147).

A Lack of Dreams:

Bion seems to accept--as other authors noted on here also do--that hallucinations and delusions are, and are to be discussed and treated as, wide-awake dreams. Their prevalence may explain the striking absence of actual nocturnal dreams. In some schizophrenic people, conventional nocturnal dreams might well be found to be rare: "The psychotic patient appears to have no dreams, or at least not to report any, until comparatively late in the analysis" (p.98). 

Primitive Disaster and Ever-Shifting Psychotherapy:

Bion engages in some useful repurposing of Freud's famous analogy, saying that "I suggested that Freud's analogy of an archaeological investigation with a psycho-analysis was helpful if it were considered that we were exposing evidence not so much of a primitive civilization as of a primitive disaster"(p.101). The problem, he elaborates, with the metaphor of an archaeological dig site is that it presupposes a static and settled site, but an analysis/therapy is no such thing: it is a moving thing of many parts. (A realization of this lies behind his strong deprecation of the therapist entering a session with memory or desire, which may weigh down and hold the session back from moving in the direction it wishes.)

In particular terms, Bion notes that this is true of the use to which hallucinations are put: such use is often constantly changing so one must not assume a once-and-for all grasp of the hallucinations and their purpose in the patient's life.  

In general, and overall Bion advises--as many others do--that the therapist prepare for lots of ambivalence: the patient may come, eventually in his own way, to manifest some gratitude that the therapy gives occasion for or provides things the pt. was denied growing up, but that same patient will also manifest resentment/hostility, also directed toward you, that he was deprived in the first place. 

So you are--in Kleinian terms--both the good and bad breast. This may well arouse in you a regular feeling of being uncertain and confused, as the patient will seek to attack your peace of mind, and any links in your mind between the work you are attempting and the changes you hope to see. Others I have read all make note of this, and advise that the clinician must be very comfortable with going for long stretches where things do not seem clear. 

Here is where Coltart's words come back to mind for me when she advocates that we have "faith; faith in ourselves and in this strange process which we daily create with our patients." Such faith will carry us through the long stretches of fog during which we long, in Newman's felicitous words, to see the "kindly light" but are denied it, instead being forced to accept "one step enough for me." 

To preserve and protect that faith, and even more the freedom of the patient, Bion, at the end of the book, it seems to me, goes on what I regard as a radical Fromm-like tear about absolutely respecting the freedom of all your patients, the schizophrenics especially. This requires your getting rid of any desire for "cure" or "improvements" or "results" in your patients (the neurotics as well as psychotics). If you have no such desires, then there is one less thing for the psychotic patient to attack. Moreover, of course, Bion thinks having those desires--whether they are attacked or not--is a hindrance to the patient and an impingement on her freedom. In this he is joined by other members of the British school, including Nina Coltart, who also strongly disdains the language of cure. 

Overall, for those undertaking this difficult and lengthy work with these types of patients, Bion's book offers some helpful counsel encouraging freedom and creativity: "The psycho-analyst who undertakes a schizophrenic analysis undergoes an experience for which he must improvise and adapt the mental apparatus he requires" (p.146). 

In Praise of Nancy McWilliams: On Psychodynamic Therapy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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