On Mentalization

I can't remember when or where I first came across Peter Fonagy's work on mentalization, but I'm glad I did because--when distilled down, which is my sole task below--it's clinically useful. Fonagy has on many occasions teamed up with other co-authors, including Anthony Bateman and Jon Allen. These three wrote a helpful book I discussed here. There is also a forthcoming volume later this August that I am keeping an eye on. 

In addition to reading the two books at that link, I have now finished re-reading two more, discussed below. Much as I like these authors and their books, they make high demands of the reader by writing often densely layered and very lengthy, detailed books with not a little repetition and redundant material in them. (It seems every book begins with enormous background on mentalization, somehow diffident about the reader's likelihood of having encountered this material before.) Ruthless and unapologetic academic editor that I am and have been for more than twenty years, I have no problem in saying that both books could have been cut down by at least 20%.  

But let not that detract from the considerable achievements amply on display in, first, Psychotherapy for Borderline Personality Disorder: Mentalization Based Treatment (Oxford UP, 2004), and then Mentalization-Based treatment for Personality Disorders: A Practical Guide (Oxford, 2016). The latter admits of wider application, though even here the authors concentrate almost entirely on borderline and anti-social personality disorders. I have found, however, that deficits in mentalization show up in nearly every condition--some more than others--and assessing for the ability to mentalize (perhaps especially with couples) is a useful part of my intake process when I'm looking for the nine signs of "psychological mindedness" Nina Coltart first so helpfully laid out. 

In what follows, I have continued my usual method of ransacking without apology and plundering with good cheer to extract material for use in my consulting room on a daily basis. I have therefore left behind all the vast quantities of material in both books on the underlying theory of mentalization, its relationship to attachment theory, and its comparisons to other approaches, including DBT, Kernberg's transference-focused treatment, and other modalities. 

In Psychotherapy for Borderline Personality Disorder, the authors begin by noting some of the important qualities of the psychotherapist, which they group under the rubric of "high boundaries" (p.xxiii). They don't elaborate on this much but seem to suggest--as others, such as Kernberg have long argued--that treating BPD requires a certain level of firmness, regularity, and stability in the clinician and this must be clearly and regularly communicated to the patient and firmly maintained. This is made more explicit later in the book (pp.169f) when the authors argue in favour of keeping the frame firmly in place. 

After a very great deal of preliminary and comparative material, the authors finally, in ch.7, turn to "Strategies of Treatment" and here note that 

the mentalizing stance is an ability on the therapist's part to question continually what internal mental states both within his patient and within himself can explain what is happening now (p.203). 

The authors further recommend that given such a focus on the here-and-now and the I-and-thou relationship, clinicians should recognize from the outset of treatment that countertransference enactments will happen, and to treat these in a "non-self-persecutory" way. 

Later in the book the authors (here echoing but not explicitly discussing others, it seems to me, including Kohut and Winnicott) suggest that "a focus in the mind of the therapist about the interpersonal aspects of treatment will ensure that a similar process begins to develop in the mind of the patient" (p.265).

Later in the book, in a section on "establishment of stable representational systems," the authors recommend that in individual sessions, clinicians should do several things, here paraphrased and summarized thus:

i) Continually encourage the patient to explore their understanding of the motives of others;

ii) Identify what effects such an understanding has on the patient's sense of self and his or her relationships;

iii) Use the transference to bring to light evidence that conflicts with the patient's own consciously articulated or claimed motives;

iv) Challenge faulty interpretations or distortions by the patient in light of the contrary evidence provided by the transference and counter-transference, including whether and how the patient participates in the session.

Let us turn now to the newer and much richer book, Mentalization-Based Treatment for Personality Disorders. 

Definitions and Deficits:

The book begins with defining mentalization and noting the problems created by mentalizing deficits. The authors claim that "mentalizing is a fundamental psychological process that has a role to play in all major mental disorders" (my emphasis). They further define it thus:

mentalizing is the ability to understand actions by both other people and oneself in terms of thoughts, feelings, wishes, and desires; it is a very human capability that underpins everyday interactions. 

Stated more succinctly, "mentalizing is seeing ourselves from the outside and others from the inside" (p.5).  

Deficits in a capacity for mentalizing mean there can be:

• no robust sense of self
• no constructive social interactions
• no mutuality in relationships, and
• no sense of personal security

Moving beyond a general and universally applicable definition of mentalization, Bateman and Fonagy now get more specific in what makes up (or thwarts) mentalization, including

Four Components of Mentalizing:

Different types of psychopathology are linked to impairments in one or more of the following forms of mentalizing:

1) Automatic vs. controlled
2) Mentalizing the self vs. others
3) Mentalizing internal vs. external features
4) Cognitive vs. affective mentalizing.

Controlled vs. Automatic:

The former is more conscious, deliberate, painstaking, and time-consuming; it is a deliberate reflective function often done in session. The latter happens with great speed, often barely consciously. A sign of good health is the ability to move between these two modes with facility. 

Cognitive vs. Affective:

The former is more intellectual in nature and can lead to "mind-reading" and what they will later call pseudomentalizing. The latter can result in an "oversensitivity to emotional cues" and a feeling of being overwhelmed by emotions. One wants a mixture of both for there to be healthy mentalizing. 

Unhealthy or at least unhelpful mentalizing, that is non-mentalizing, typically manifests in three  

Non-Mentalizing Modes:

Ideally in doing an intake, one assesses for mentalization as part of taking a larger history in which special attention to attachment history should be paid. Later in the book the authors recommend some tools if you wish, including the Reflective Functioning Scale they developed in the late 1990s. (I have used a version of it only 2 or 3 times and found it rather unwieldy.) There is also a relatively simple check-list available here from the Anna Freud Centre. 

As you are assessing, you want to watch out for non-mentalizing, which typically shows up in three forms:

Psychic Equivalence: this is where there is a kind of fusion between my mind and the world, so that they are taken to be coterminous. What is thought is taken to be real--too real, and thus overwhelming for some, leading to a collapse in ability to mentalize; doubt is suspended; and little ability to see any other perspective is present; typical of the very primitive infantile mind up to c. 20 months. 

Teleological Mode: this is where states of mind are conceivable and believable only if there is some sort of physical demonstration of them; this is an overly concretized attempt at thinking that may lead to acting out precisely to provoke the very physical demonstrations the patient feels are lacking. In essence, thoughts and minds do not exist here: only actions are real. 

Pretend Mode: derealization and dissociation are forms of pretend mode; children who invent pretend friends or entire fantasy worlds are clear examples of this failure to mentalize. 

The authors here return again to some discussion of pseudomentalization or hypermentalization. This they note--and my clinical experience confirms--is often characteristic of borderline patients. In both cases, they attempt to talk about states of mind, but do so in an abstract, ethereal way that tends to involve agonizingly lengthy descriptions of extraneous material with little real feeling or affect involved (except, often, paranoia). Opaqueness is never respected when in a pseudomentalizing mode. 

One classic hallmark indicating that you are in the presence of one or more of the above non-mentalizing modes is that of projective identification: the splitting off of undesired parts of the self, and their subsequent externalization in others. 

Internalized Self-Images:

The authors here note that those who struggle to mentalize may not have themselves 'been mentalized' as it were by their primary caregivers when young children. There has been, they say, a lack of "parental mirroring" (p.20) in place of which the child internalizes the image of the caregiver as part of their self-representation. This is so obvious in one of my toughest cases, where selfobject deficits are massive and widespread to a degree that sometimes shocks me. 

For me one way to start to bring this to light consists in listening with that "third ear" to the patient's language. You can usually get a sense when they slip into a different register, or use a hackneyed phrase in a too-facile fashion whereupon I pounce: "Whose language is that?" I usually ask, because it certainly does not feel indigenous to the person before me. Then gradually the two of us can begin to piece together rather alien introjects from others that are almost invariably savage and self-destructive. 

This lack of mirroring can lead to what the authors a little later call "epistemic mistrust" (p.26) in compensation for which some engage in epistemic vigilance, leading to a kind of furious hypermentalizing, which is a form of pseudomentalizing. One way clinicians can help patients move through and past this is by showing your mind: this is not an occasion for indulging in gratuitous self-disclosure, but a very focused intervention in which you talk about how you mentalize the patient both in and out of the session, and how you mentalize the session and even moments between the two people in the room. You are gently giving an example of another mind and its capacity for distance-taking and perspective-forming, as well as its limits and its acceptance of uncertainty. 

This cannot be done too definitively, however. A key part of mentalization is opaqueness: the recognition that minds are never 100% transparent and accessible to us and you must therefore be relatively comfortable with not knowing certain things, or knowing them incompletely. If you can convey to the patient your own relative comfort with not knowing things completely, this can function as an edifying example for them initially to borrow and then to immitate en route to recovering their own capacity to mentalize. 

Good Mentalizing about Others:

The authors briefly highlight things to watch out for that may be taken as signs of high levels of good mentalization (p.117). In such people, one finds that they can, when considering the thoughts and feelings of others, readily recognize and acknowledge:

1) Opaqueness: I can never totally know what others are thinking, but neither am I totally baffled: some things can very plausibly be discerned.

2) Absence of Paranoia: I can acknowledge others' thoughts, including angry and hostile ones, without thinking they necessarily have it in for me.

3) Contemplation and Reflection: I can reflect in a relaxed way on the minds of others without becoming compulsive about doing so. 

4) Perspective-Taking: I can placidly accept that things look very different based on the other's upbringing, culture, history, social context, and other factors. 

5) Genuine Interest: I can be curious about others' thoughts both for their content but also their form. 

6) Openness to Discovery: I can hold myself back from overspeculating in an attempt at omniscience, being pleased at new discoveries or having my assumptions challenged and changed. 

7) Forgiveness: I can tolerate and forgive someone once I recognize that, say, they acted in ___ fashion because their mind was clouded by grief or pain from their broken leg or whatever.

8) Predictability: I can be generally comfortable most of the time with most people in believing that their actions are predictable given knowledge of what they think and feel. 

Good Mentalizing about Myself:

In addition to the above, Bateman and Fonagy give us a further 8 characteristics or hallmarks of healthy mentalization about myself, which always involves humility and moderation, and a healthy comfort with limits and not knowing. It also requires prompt and non-defensive acknowledgement of one's errors. 

As with the above, I use their terms below in italics, but supply my own summary and examples:

1) Changeability: As I change, I can change my views of others. 

2) Developmental Perspective: As I developed and develop, my views of others changed and can still change. 

3) Realistic Skepticism: I see that my own feelings are sometimes confused and confusing. 

4) Acknowledgement of Preconscious Function: I see that at any given time I may not be aware of all my feelings, especially in conflictual situations. 

5) Conflict: I know that within me are sometimes incompatible ideas and feelings.

6) Self-inquisitive Stance: I have good-natured curiosity about myself. 

7) An Interest in Difference: I want to discover how minds different from my own work. 

8) Awareness of the Impact of Affect: I recognize and affirm that affect can distort my self-understanding. 

Finally (this having gone on much longer than I expected!), I have extracted from across the book what I will call 

Clinical Strategies

"Paying attention to your patient's mind is at the heart of mentalizing" (p.185), both authors reassure us. Your job is to be the "monitoring clinician" who is also the overtly self-correcting clinician, saying such things as "How was it that I so badly misunderstood you?" and thereby showing the patient your own capacity to reflect on your own lapses in mentalization. Authenticity and transparency are indispensable for your success: the patient must have access to your mind in a real way.

Stop, Rewind, Explore: This is something I have found very useful. If you are suddenly thrust into a non-mentalizing mode, or a rupture develops, the job is explicitly for you to call a halt in the session and ask to go back to where you think things seized up or went off the rails. Rewind to that point, and begin again from there to see if you can recover. I was very nervous the first time I did this with a borderline patient, but it turned out to make a huge difference and I was relieved and gratified. 

Typically early in the treatment one begins with the following strategies in this order, but these can be used again, and may have to be used again, after ruptures or mistakes:

1) Empathic Validation: always start here and do not go further if this is not established, or re-established after some kind of rupture. 

2) Basic Mentalization: clarification and exploration chiefly but with some limited and judiciously chosen challenge (which should be used sparingly in more severe borderline cases). 

    a) Challenge can take several forms, the more light-hearted the better in most cases (what they call counterintuitive, "whacky," and humourous or mischievous statements). In more serious cases, however, including suicidal ideation or boundary violations by the patient, challenge involves "frank but fair" discussion in which the clinician should feel no compunction about being direct, resolute, and authoritative, seeking firmly to preserve the patient and treatment from what may be a dire or even lethal threat.  

3) Basic Mentalization: focus on identifying affect

4) Mentalizing the Relationship. Later in the book the authors clarify that mentalizing the relationship involves here-and-now dynamics between this patient in this moment with me as the clinician; it does not involve mining the transference for clues about childhood attachment patterns or problems with parents.

I end here. There is much more material in the book--chapters on mentalizing groups, families, and systems--but I have the remnants of a lovely day to go enjoy.

Notes on Kernberg and Borderline Patients

I have of course been aware of Otto Kernberg's work for years, and read the occasional essay or article of his, but nothing more. Though he is well into his 90s now, Kernberg apparently has another book coming out this year, Hatred, Emptiness, and Hope: Transference-Focused Psychotherapy in Personality Disorders. 

Kernberg is, and has been for decades, especially well-known for his pioneering efforts in transference-focused psychotherapy for borderline personality disorder. I have known of this work for a while but only recently had occasion to read some of it, starting with the chapter "Psychotherapy with Borderline Patients: An Overview," which is available free of charge at this wonderful site. What follows are my notes from reading Kernberg's overview, which is very cogently written and useful. (This was originally published in 1980, so I will expect to see later developments as I read more recent works by Kernberg and others on BPD.) 

Prevalence of Sadistic Transferences:

Though he is too elegant to say it, Kernberg early on issues what amounts to a blunt warning that will be echoed several times: prepare for hard and painful sailing. This is likely to begin almost immediately--no leisurely leaving of harbor in bright, sunny skies for this therapy! Thus he notes that after psychotherapy has begun, there will be increased effort by the patient "to defend himself against the emergence of the threatening primitive, especially negative, transference reactions by intensified utilization of the very defensive operations which have contributed to ego weakness in the first place. One main 'culprit' in this regard is probably the mechanism of projective identification" (p.20), which of course goes back to Melanie Klein.

The transference will be one of intense distrust of the therapist and an attempt to "control" him in a "sadistic, overpowering way" (21). The patient's aggression and attempts to control will, Kernberg calmly warns, almost certainly provoke a counter-transference respond of like kind. 

But the relationship will not be steady or move in one direction only. The inner instability means that borderline patients tend to oscillate (sometimes rapidly in the same session) between projecting object representations and self-representations. Kernberg gives the example here of "a primitive, sadistic mother image may be projected onto the therapist while the patient experiences himself as the frightened, attacked, panic-stricken little child; moments later, the patient may experience himself as the stern, prohibitive, moralistic (and extremely sadistic) primitive mother image, while the therapist is seen as the guilty, defensive, frightened but rebellious little child" (p.21).

Breakdown of Ego Boundaries and Possible Psychosis:

Such oscillations bespeak a breakdown of ego boundaries and reality testing. Its most severe form is something Kernberg strikingly calls a "transference psychosis" in which delusional material appears that does not, however, appear to affect the patient's functioning outside of session.

Slow Progress and Shallow Pseudo-Insights:

The acting out of the transference is the biggest obstacle to progress, according to Kernberg. The transference very closely mirrors past conflicts. But do not, he cautions, mistake repeated transference material and manifestations for "working through." The repetition of these dynamics may in fact be precisely as a means of getting sadistic needs met through and from you and doing so in a way that overruns your capacity to "maintain a climate of abstinence" (23).

Don't fall for false and shallow insights! If the insight comes without three things Kernberg highlights--effort, change, and concern by the patient for the obvious pathology--it won't count for or do much. Authentic insight is a combination of the intellectual and emotional and it takes some work and costs something. 

The Here and Now:

Point out transference reactions regularly in the here-and-now without trying to link to the past, as the patient probably has little capacity for that. 

Firm and High Boundaries:

You must as therapist maintain firm and high boundaries to preserve neutrality and your freedom to act. Do not allow extra sessions, or running over, or extra calls, etc. The patient's acting out of a transference of neediness must be contained as much as possible by and within the session.

Three Steps to Handling Transference Material:

Transference, Kernberg recognizes, ordinarily reflects infantile object relations and the infants needs, defenses, and deprivations. These can usually be discerned as semi-coherent at least. 

Not so with BPD: it's just fragments and extreme distortions all the time. Your job is to take the baseless distortions and move them closer to actual experiences and reality in childhood. This is not easy as such patients cannot integrate libidinal and aggressive impulses and representations. Massive splitting is found here with strong defenses against integrating good and bad objects.

The work here may take years. It has three steps for the therapist:

First, you need to help reconstruct and evaluate, from the fragments and chaos, what "is of predominant emotional relevance in the patient's present relation with him [the psychotherapist], and how this...material can be understood in the context of the patient's total communications" (p.27).

Second, seek to clarify emerging self and object images and the interaction between them.

Third, surface and begin to integrate other part self objects, leading to greater unity of the true self.

Summed up, these three steps entail "integration of self and objects, and thus of the entire world of internalized object relations, is a major strategic aim in the treatment of patients with borderline personality organization" (p.28). 

Three Types of Negative Therapeutic Reaction

Repeatedly Kernberg lets the reader know this work will be slow-going at best. BPD patients may go for years with little change, and a lot of negative therapeutic reaction may regularly be present which thwarts change. Most of this shows up in attacks on the therapist driven by:

1) masochism and guilt at the unconscious level;

2) envy and the need to destroy the therapist because of it;

3) primitive sadism and the need to destroy the therapist because object relations can only be maintained in a situation of suffering.

All these, Kernberg says, reveal the "deepest levels of human aggression" (p.35). Such aggression is not at all above trying to destroy the therapist's love with cruelty, which is projected onto the therapist. 

Overcoming Attacks and Threatened Collapses:

Such negative reactions and threatened collapses may be alleviated by four things Kernberg recommends:

1) Extended patience over the treatment but decisive impatience in the session directed at any attempts to attack the work. The patient's acting out of severe aggression needs to be actively countered by the therapist without loss of neutrality.

2) Though he doesn't quote him here, Kernberg's second counsel puts me in mind of Winnicott's famous "Hate in the Counter-Transference" paper where he says you must get a firm grip on and be able to contain your aggression and not let it become action, but only fruit for reflection. The temptations here, however, will be considerable, and the risk of counter-transferential enactments a regular danger. 

3)  Kernberg has an interesting point I've not seen elsewhere about BPD and the relationship to time. He says that as therapist you need to "focus sharply on the patient’s omnipotent destruction of time. The therapist needs to remind the patient of the lack of progress in treatment, to bring into focus again and again the overall treatment goals established at the initiation of treatment and how the patient appears to neglect such goals" (p.36). Balance this by sharp focus on immediate reality.

4) Finally and consistently you need to interpret all attempts at destroying the patient's life and treatment. (He says elsewhere that in any given session the order of items addressed must always be, first, any suicidal ideation or attempts; second, any attacks on the treatment; and third anything else the patient brings up.)

Counter-Transference Reactions:

Rather early on you will experience a sense of chaos from the patient. That makes the counter-transference "an important diagnostic tool," allowing insights into that chaos and into the degree of regression in the patient, their emotional relationship to you, and any changes in that relationship (p.37).

In general, Kernberg cautions the psychotherapist, you should expect to react sooner, and more intensely and chaotically, than with just about anybody else (outside of psychosis). You will get a sense of primitive object relations here. 

Accept Ambivalence Everywhere:

Finally--and wisely, it seems to me--Kernberg says that you must accept your own ambivalence, and recognize its prevalence in all human relationships, which is precisely something the BPD patient often struggles greatly with: "the therapist’s thoroughly understood awareness of the aggressive components of all love relations, of the essentially ambivalent quality of human interactions, may be a helpful asset in the treatment of extremely difficult cases." (p.40).

Sadomasochism in Everyday Life

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Vamik Volkan Discussing His New Book

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

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

AD: Tell us a bit about your background

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Yes.


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

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


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

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

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

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

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

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

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

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

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