Desire: An Enigma Wrapped In Riddles Inside Mystery

Introduction:

I learn such things on Twitter. 

I forget to whom exactly to give credit for introducing me to Galit Atlas and her book, The Enigma of Desire: Sex, Longing, and Belonging in Psychoanalysis (Routledge, 2016). It may well have first been Adam Rodriguez, but I know it was even more forcefully Taylor Zimmerman, whom I met with great delight in Indianapolis in April at the celebrated day with Jonathan Shedler. Over the coffee hour and in subsequent correspondence, Taylor strongly encouraged me to read Atlas, so I am grateful to him as to Adam. 

Atlas is the third person in an ongoing series of clinicians in whom I am finding much wisdom with regard to erotic dynamics in psychotherapy, especially in the transference and countertransference. The first of these was, and is, Andrea Celenza, about whom I first wrote here, and more recently here. 

She and Glen Gabbard are arguably the two leading scholar-clinicians writing on sexualized boundary violations in professional contexts, including clinical and clerical contexts. Given the power of their writings, and the fact these topics are almost universally ignored in all training programs, and even by licensed professionals, I am at the point now where I just flatly tell anyone who asks, and even more who don't, that they should buy all of Gabbard's books and all of Celenza's and read them. Were I in charge of training programs in this country for future clinicians of all sorts, I would absolutely make these two authors mandatory reading. 

Into this group I now can bring Galit Atlas, who writes in a different style and with a different focus than Gabbard and Celenza, but with them is still broadly in the field--hitherto often terribly overlooked or denied--of erotic dynamics in treatment. Her book, The Enigma of Desire, puts me in mind of another recent treatment by another psychoanalyst, Carlos Dominguez-Morano (whose utterly irreplaceable Belief After Freud should also be required reading, not least by Christians still talking bollocks about Freud), The Myth of Desire: Sexuality, Love, and the Self, which I have to go back and re-read. 

Right, down to business. 

Atlas on Maternal Erotics:

Atlas begins punchily enough in her introduction by arguing that "In treatment, adopting the role of a nurturing mother can function as the therapist's way to avoid the erotic material that emerges between her and the patient." This I take to be just another version of the important warning (echoed by Shedler, Maroda, McWilliams, and many others) that being too much of a "container" (Bion) or providing little more than a "holding environment" (Winnicott) will mean you ultimately fail your patient who is there because something is wrong and something needs to be changed, not merely contained. 

A second related warning follows from this later in the book (p.80): "our patients' traumatized self-states may collude with our own in order to protect the tender parts of the self, the other, and the treatment from damage by the aggressive parts." (This, of course, is reason #23689 for the psychotherapist to have had his or her own in-depth and intensive long-term psychotherapy, and to engage in regular supervision and consultation.)

Also early in her book Atlas makes plain her own debts to what she calls Kleinian mothers, who have led her to be able "to trust the mind to lead us to the most unknown truths and to believe that the ability to tolerate those tensions allows us to live and to love." She also mentions her debts to Laplanche and Kristeva, and Jessica Benjamin, especially this: "I do not believe we can definitely know what belongs to us and what belongs to our patients." 

This point, of course, puts one in mind of Thomas Ogden's celebrated notion of the analytic third, and of the inability, as he has also recognized, to know where the patient's experience ends and the clinician's begins. 

The Erotics of Writing:

There is a sensuous quality to Atlas's writing itself, not least in her case studies, which are presented here in ways that are less stilted and bloodless than one so often finds. That is to say, there is still a warm pulse in the people she writes about. 

Moreover, and more interesting for me who has long loved to write and cared deeply about the felicities and rewards of style, and who has often felt a flush of excitement in the exchange of ideas, she openly acknowledges that "While writing, I found myself...swinging from feeling overaroused and exposed to using ideas as a way to distance, process, and regulate" (p.30). Lest we miss the point, a bit later she quotes a famous 1989 paper of Ronald Britton in which he recounts a patient demanding: "'Stop that fucking thinking'!" From this Atlas deduces that "thinking is a form of the therapist's internal intercourse" (p.32). Just so! 

I can relate to that outside the consulting room, but also in, which she captures with equal candor: "I notice the movement between moments of sexual stimulation and arousal to use of theory....I believe we often experience the same movement as analysts trying to regulate ourselves and our patients when the erotic pervades the analytic space" (p.30). Guilty as charged! (If I find myself becoming very theoretical, or subjecting the patient to a lecture, than I know my intellectualized defenses have led to such an enactment, and, following Fonagy's counsel, I need to rewind the session back to the point where I was able to mentalize before the defenses were, uh, aroused.)

The Enigmatic and the Pragmatic:

The unique contribution that Atlas make, so far as I can see at this point, is her stress on what she calls Enigmatic and Pragmatic knowing. Much more could be said about this, but I don't want to give all of the book away, so suffice it for me to say that the enigmatic and pragmatic are tied to her dual understanding of the origins of, changes in, and different desires manifested in sexuality: "the erotic comes into existence when the sexuality that at the start was based exclusively on nourishment and satisfaction of hunger moves away from the functional and toward play" (p.41). 

Do not, she warns later, be too enchanted (as some of us who love Winnicott are inclined to be) by notions of play, for these, too, can be used to displace certain important things: "playfullness can be a seductive way to express erotic and aggressive contents...but it's important to note that it can also serve to obstruct erotic transference and countertransference" (p.81). Yes it can, as I've noticed in some sessions after the fact, and not without some chagrin! 

Sexual Longing and Erotic Manifestations and Their Dangers:

Her mention of the erotic obstructing transference material takes us back onto more familiar ground, also covered by Gabbard and Celenza, and then by David Mann, whose two books on the topic I began last weekend, and about which I will have a very great deal to say later (O lucky reader!). 

Rightly does Atlas note early in the book that "sometimes we underestimate how dangerous it feels to be part of a dyad." I try to remind myself of that at least a few times a week, and (for some reason) it always happens at the last turn of the corridor immediately before bringing a patient into my consulting room. In those seconds as I usher them in, I cast my mind back to the first time I ever met with a psychotherapist (a pastoral counselor as I recall) in my teen years (to discuss sexual matters, too!), and how anxious I felt: I try to get a feel for whether this person with me is also a bit anxious, which is an entirely understandable feeling for, as Atlas continues a bit later, "being a patient is a dangerous position" for the patient may feel "he is forced back into the powerless position of being a child to a seductive mother who penetrates and excites him, feeds him but also controls his food and will certainly abandon him, leaving him overexcited, humiliated, and alone" (p.37). 

Strong stuff! No wonder people on Twitter lose their bloody minds when you speak such thoughts aloud; no wonder my undergrads had a collective meltdown at the mention of any hint of anything remotely "erotic" in the therapeutic relationship; no wonder even licensed professionals shy away from these discussions at best, and at worst become amusingly and revealingly hyper-defended. 

Why would anyone submit to this humiliating penetration and abandonment? Later she notes some of its rewards: "Allowing yourself to be penetrated means embracing a more fluid structure that is based on unsolidified boundaries....This is not exclusively a feminine process" (p.69). Indeed not. 

Precisely my attraction to psychoanalytic thinking, starting with Freud, more than three decades ago now was because it seemed to be quite at home with the idea of the fluidity, the complexity, the ambiguity and ambivalence--the sheer messiness--of human sexuality. I have always been highly suspicious of anyone who wants to put it into neat boxes, or map it out on a linear continuum or Kinsey scale. None of us is ever "straight." 

Before going further, she reminds us that for many of us, we had (referring to Kohut) no "mirroring" of the erotic and sexual growing up: "sexual feelings are unique in that caregivers systematically ignore them and they are therefore unmirrored" (p.115). This will and will not show up in a variety of ways in life, and in therapy. 

For some this lack of mirroring can leave the terror of such feelings in place, and that is where you must begin in therapy: "are there ways to listen for, and to, the unique accents of the language of sex." And if those accents are ones of fear, then, nodding towards Bion, Atlas says that an early task of the second mind in the room is to help the first mind bear to think about those fearful desires and terrifying thoughts.

As you think about them, some of the difficulty of such feelings comes from the fact that "sexual longing presupposes a sense of loss and a hope of refinding." 

That refinding is not a straightforward path from infantile attachment to adult sexual longings. It is often much more complicated than that, and thus the clinician needs to proceed with due caution: "the secret psychoanalytic touch is always about tolerating the erotic in the room while not adding to the stimulus." 

Earlier, she notes that we can and probably should do more than that: "we try to hold the unknown darkness with them, tolerate the 'too muchness' of excitement, joy, horror, and shame." Later she will speak of the "suffering of pleasure, of the excess that the body and the mind cannot contain," to which some might give the name "lust" while others (here Melanie Klein) prefer to speak of "human yearning for an 'unattainable perfect internal state'." 

Enactments Made and Redeemed:

Atlas is making what seems to me a very significant advance on how we think about therapeutic enactments. That word is almost universally taken as a sign of danger and enactments seem almost always to be treated sternly. This mirrors, it seems to me, the early Freud and his unidimensional warnings about the dangers of transference and countertransference especially. Only after 1950 did we start to get some limited reflection on what positive things countertransference might contain, and only much later--that is, within the relational movement of which Atlas is a significant part--do we start to see people recognize that countertransference can often be a positive good and contain much valuable information.

Similarly, Atlas is, in the last section of the last chapter of her book, opening up new territory by arguing that enactments are not just "a return of past dissociated memories but rather as the threshold for the introduction of emergent ways of being, of an opening toward new relational possibilities" (p.150). Enactments thus "work toward the future."

They do more than that, as becomes clear in her attempted definition: "enactments may well be a central means by which patients and analysts enter into each other's inner world and discover themselves as participants within each other's psychic life" (p.150). This does not guarantee, of course, that all enactments will always have a positive outcome, but it does begin to help them lose some of their fear, just as we have overcome fear from a century ago of countertransference as a sign of an insufficiently analyzed analyst. 

A concluding word that reminds us of how demanding our vocation as psychotherapists is, for we "must straddle a paradox, always skeptical, questioning, seeking hidden meanings, searching for unconscious dynamics at play, the trailing edge, a hermeneutics of suspicion--while also, paradoxically, trusting unconscious process and surrendering to the continuous flow of the enactive dimension of analysis, relying on a hermeneutics of faith" (here referencing Ricoeur).

A Note on Bruno Bettelheim on Freud and Man's Soul

I was first introduced to Bruno Bettelheim in high-school by a wonderful English teacher who had first introduced us to Freud and Jung in order to read Robertson Davies' Deptford trilogy. I read with great fascination Bettelheim's The Uses of Enchantment, and in fact had great fun with a friend using that book to analyze various fairy tales we had both grown up hearing and reading.

It was many years later when I thought about Bettelheim again, and read Bettelheim: A Life And A Legacy by Nina Sutton. By then certain egregious details about Bettelheim, in both his Austrian and American periods, were notorious and his reputation nosedived. Sutton's book appeared not long after a lot of those revelations came to light, and attempted reasonably well to grapple with them and to judge him judiciously.

At some point, too, I read his Freud and Man's Soul. This remains a vitally important and likely overlooked book, though my circle of wonderful psychotherapists on Twitter have this week been ordering copies and discussing it, which compelled me to go back and read it again. 

When I first read it, I paid the most attention to Bettelheim's compelling and disturbing examples of the many and serious problems of translation, especially by the Strachey circle, of Freud. I am speculating--but I think on very firm ground in doing so--that these translation decisions were very largely motivated by the politics and early historiography of psychoanalysis (here my debt is chiefly to Paul Roazen's revealing books, including Freud and His Followers as well as others) as well as an overly anxious concern for its reception, and corruption, in American circles. Having seen how the Great War very nearly destroyed psychoanalysis in Mitteleuropa, and how by the 1920s analysts were already emigrating to anglophone countries, Freud (as I've briefly touched upon elsewhere) could already see that psychoanalysis was going to survive most widely in America, but that it would be captured by American physicians and to that extent domesticated and even, one might say, denuded of its more critical and far-reaching potential. 

It would also need--again to an American audience then in increasing thrall to a rising crescendo of American behaviorist psychology--to appear as "scientific" as possible, and to that end a new language had to be invented. This is captured perhaps most notably in what can only be described as the deliberate and ruthless efforts to render the German into abstract pseudo-scientific-sounding English purged of any and all references to the "soul," a point Bettelheim makes with more power than anyone else I have read. I will return to this point presently. 

The Tripartite Model:

The most immediate problems are with the invention of Id, Ego, and Superego (totally foreign to the German, as Bettelheim shows with such devastating cogency, but also to the French: le moi, le ça, le surmoi). If we keep close to Freud's often poetic German (for which, remember, he won the Goethe Prize), then his famous phrase is re-translated by Bettelheim as "Where it was, there should become I."

The problem with these English renderings, Bettelheim shows, is that the bleed out all the deeply personal and individual feelings of das Ich and das Es, introducing a level of estrangement precisely where Freud is attempting to maintain an intimate and personal understanding of the mind. 

Thus a good translation would look like this:

das Ich = the it 

das Es = the I

Über-Ich = the over-I. 

On this latter point Bettelheim says Freud's motive was to stress to us that "it is the person himself who created this controlling institution of the mind" (p.58), thus underscoring again Freud's metapsychological point that the human mind is estranged from itself. (All this is worked out prior to his last phase, the 'cultural phase,' as it were, when he writes of broader estrangement in, e.g., Civilization and its Discontents and Moses and Monotheism.)

The Oedipal Story:

I had forgotten about this part of Bettelheim's book, but on reading it anew saw what a powerful point this was. The translators took it for granted Freud's anglophone readers would understand the details of Oedipus and not need the story presented to them to grasp Freud's point about how little we understand our motives, how blind we often are both to our desires and their sometimes devastatingly destructive consequences (for ourselves and those we hold closest and love most dearly), and how those most blind are often rendered as such because of childhood traumata, all of which the original story of Oedipus make abundantly clear. Oedipus is a deeply wounded child rejected by his family of origin and cast into adoptive and abusive relationships--points we should all have great familiarity with today, making the story as timeless for us as Freud thought it was.

Instead, we get some farrago of nonsense attributed to him. As Bettelheim reminds us, that story is "boys lust after their mothers and want to kill their fathers to have her to themselves for perverse sexual ravishment." This tiresome and transparently tendentious rendering of Freud seems designed only to ensure he is ridiculed ab initio without having to read him any further.  

Freud the Libertine:

Bettelheim opens his book by taking aim directly at another wildly popular but misleading rendering of Freud: that he is some kind of libertine. (Roazen's book Meeting Freud's Family shows in charming detail what rubbish this is.) This has led--in my experience--many religious folks to scathing skepticism or outright dismissal of Freud as some kind of dangerous revolutionary. But this is to miss his point entirely! And that point is that "Know thyself" is not a blank cheque, and does not justify the total absence of (as we would say today) emotional regulation and self-restraint, especially when it comes to erotic desires and sexual practices. 

Freud the Dogmatic Interpretation Machine:

Bettelheim reminds us that problems with translation go back to Freud's most famous book, almost invariably called The Interpretation of Dreams. That title, of course, suggests, not least by using the definite article, that it has oracular powers to divine the meaning of all the productions of the unconscious mind we call dreams. But this is very wide of the mark, Bettelheim says: the German is far more tentative and far less ambitious. Better renderings supplied by Bettelheim would include:

A Search for the Meaning of Dreams (my preference)

or

An Inquiry into the Meaning of Dreams (which Bettelheim prefers).

This corresponds with my reading of Freud's works, and especially his correspondence. Though there are undoubtedly parts of him that occasionally appear as "dogmatic" (but of whom could that not be said at least some of the time? As Adam Phillips has shown, we are all prepared to become unbalanced fanatics about things we truly care about!), I am struck time and again by far more numerous and sincere examples of his hesitancy, his tentativeness, his self-aware putting forth of ideas about which he himself is not completely convinced. Let us recall here how many of his writings were not monographs but essays, and that verb's infinitive in French, of course, means to try.

To pick the most controversial example, the death drive, which appears in Beyond the Pleasure Principle (do read the Broadview translation!): I defy any reader to get through the introduction to that and not be struck repeatedly by how open Freud is to criticism. He seems to go out of his way to underscore his own hesitations, and with good reason. 

The Deletion of the Soul:

"Of all the mistranslations of Freud's phraseology, none has hampered our understanding of his humanistic views more than the elimination of his references to the soul (die Seele)" (p.70). I take this to be the most crucial point of Bettelheim's plaidoyer. On this I think him absolutely correct in ways nobody else has bothered to consider.

In my view (working as I am on a book about the reception of Freudian and psychoanalytic thought in Christian circles), this is the most unforgivable sin committed by virtually all the English translators. For it has fed into the rabid dismissal by Jewish, Muslim, and Christian believers of Freud as a "godless Jew" (to use his own, albeit wry and perhaps ironic, phrase) who, with Marx and Nietzsche (the three "masters of suspicion" famously so called by Ricoeur) is, we are endlessly told, out to "destroy Western civilization" (a phrase whose utterance automatically marks the speaker down as a fundamentally lazy and unimaginative reactionary).  

Bettelheim goes into wonderful detail about how many examples of the soul show up across Freud's writings. I would document some of these, but I have to get off to another meeting, and I want to write about this more in an essay of its own--and finally my long-suffering readers were promised "a note" on the book, not a 10,000 word treatise!

Finis (pro tem).

K.R. Smith on Ethics and Psychotherapy

It was, if I recall correctly, Jason Blakely (whom I interviewed here) who put me in touch with Kevin R. Smith, author of two recent books: Therapeutic Ethics in Context and in Dialogue (Routledge, 2020, 108pp) and The Ethical Visions of Psychotherapy (Routledge, 2020), 112pp. I have read both of these books with great profit, and found them much more philosophically enriched and enriching than anything else I have to read currently in the area. I might even be bold enough to say here that clinicians who are only clinicians, that is who have never done any hard work in philosophy, have no business lecturing the rest of us on topics they scarcely understand themselves. Happily, Smith is not like that, coming at these books with a wide-ranging background that shows up in both books to great profit. 

Following my usual practice, I e-mailed him some questions for an interview about these books, and with heroic patience (such a key virtue for clinicians!) he has waited 

AD: Tell us a bit about your background:

KRS: My path is not the standard one for professional psychologists. I was not a psychology major as an undergraduate. While I had some good psychology classes at Berkeley in the early 1970’s, the program was influenced by positivist and behaviorist conceptions of psychology that missed the complexity and richness of human experience. As an alternative to a psychology major I took advantage of the option available at Berkeley to construct an interdisciplinary major that included classes in psychology, other social sciences, and the humanities. 

After a master’s degree in religious studies at the University of California at Santa Barbara, I entered the doctoral program in clinical psychology at Duquesne University. I had been exposed to the work of Ricoeur and Heidegger at Berkeley and Santa Barbara, and was excited to be studying psychology from the perspective of existential phenomenology. This program deepened my appreciation for the implicit philosophical assumptions often present in psychological theories that purport to be based upon objective data alone. 

But finding work where this alternative perspective on psychology was even known, let alone valued, was not easy. I worked in various settings (community mental health, a rehabilitation hospital, and a large psychiatric institution, and research center) where I gained further experience and training before starting my own practice. In retrospect, I’m glad I have had experience in these work settings, where mainstream ways of understanding and practicing therapy and conceptualizing psychopathology were dominant. 

But the sense was always there that something was amiss with the standard approaches. I have been struggling ever since to articulate what seemed wrong, and what the alternative might be. I have had help along the way from fellow therapists who wanted to understand people and their psychological difficulties in depth. Pittsburgh provided me a continued connection to the human science approach to psychology at Duquesne, experience with psychotherapy research at Western Psychiatric Institute and Clinic, and a series of seminars organized by Bill Cornell that exposed me to a variety of perspectives on psychodynamic therapy.

AD: You had me hooked on the first page of The Ethical Visions of Psychotherapy when you wrote this: "Therapy is also a social practice that enacts some perspective on what constitutes a good life, human well-being, or flourishing." And yet you note later on (ch.5) that "therapists rarely allow themselves to use the language of ethics in a full sense. They are often more comfortable with the language of repair." Why does it seem that virtually every school of psychotherapy wants to run from this question of the good, of flourishing--even as it smuggles in such assumptions through the backdoor?

KRS: There are a number of reasons why therapists avoid explicitly acknowledging that they are promoting ideas about the good. One category of reasons has to do with the nature of the goods that therapy promotes. These are often some variant of personal freedom or authenticity that is frequently understood to have its source in the individual. Whether this is viewed as a personal choice of how to live one’s life, or as fidelity to some core, authentic self, it often leads therapists to assume that they ought not to interfere with the patient’s free choice, or that their task is simply to free up an authentic self that has been buried, blocked, or distorted by social constraints and internal defenses. These ideals can often be valuable guides for practice, but therapists are mistaken when they think that there is no vision of a good life on offer here. Autonomous self-direction and authenticity are ethical ideals.

Another category of reasons for reticence about the promotion of some picture of human flourishing in therapy is the history of therapeutic efforts to challenge or undo the damage done by the excesses of conscience. Many people seek out therapy because they feel they are failing at life in some important respect. For some of these people, there is a recognition in therapy that they have been suffering from excessive demands to meet standards for a good life. 

Psychoanalytic ideas about relieving the relentless character of superego demands and rational-emotive therapy’s challenge to the oppressive “oughts” and “musts” under which people labor are both examples of the way that therapy seeks to undo the damage done by alienating expectations of doing well or being good. As a consequence, many therapists are wary about proposing another set of obligations for patients to live up to. Nevertheless, an ethical ideal is still present here, one that emphasizes the need for people to find their own way to live rather than take on what family, church, society, or their therapist have said their aims should be (even as the therapist is here promoting an ideal).

Both these reasons to steer away from open discussion of human flourishing receive support from yet another quarter. This has to do with the effort to give therapy scientific credentials. Often this effort is built upon a conception of science as only giving us information about what is the case, not about how things should be (the “fact-value dichotomy”). To the extent that therapists think of themselves as intervening in disorders or patterns of behavior based upon a scientific understanding of their causes, they can claim that they are simply agents who help to change circumscribed problems, not proponents of a particular set of ideas for how to live well. 

This view of therapy as technical intervention can hide from view the ways that therapy also functions as a social practice that instantiates various ideas about living well. Consider the different ways that psychological disorders are defined. If one compares the Diagnostic and Statistical Manual of Mental Disorders with the Psychodynamic Diagnostic Manual, for example, it is clear that there are different conceptions of the difficulties in living that people bring to therapy, conceptions that imply different ideas about what is important for human well-being. The DSM model implies that disorders are impediments to people getting on with their lives as they have decided to live them--the ideal is some form of autonomous self-direction. The PDM proposes a thicker set of ideals regarding a complex set of capacities for self-reflection, affective attunement, and interpersonal engagement, with autonomous self-direction as only one of many valued characteristics of psychological health. 

AD: You write early on that "the central thread that runs through this book is the philosophy of Charles Taylor." I've been reading Taylor for years, and drew on him in my recent book about the Catholic sex abuse crisis. Tell him why he's important for your work, and what ideas of his you find especially useful.

KRS: Taylor’s philosophical anthropology makes a great deal of sense to me, and helps to highlight many of the dead ends of current conceptions of therapy. A central theme of Taylor’s work on human science is his critique of claims to naturalistic objectivity and ethical neutrality. Insofar as persons are “self-interpreting animals” in Taylor’s sense, it is not possible to understand their actions as the result of objective influences alone. 

People do much of what they do because of how they understand themselves and the dilemmas and difficulties that arise in the effort to live a form of life they aspire to. To aspire to a form of life is to assess what one does and how one lives against a set of standards that one feels called to answer to, it is to be what Taylor calls a “strong evaluator.” 

An enormous range of questions can arise in this context that go far beyond removing obstacles to pursuing a life one has chosen. One can question whether the way one has been living one’s life is basically misguided. Do I hold myself to an impossible standard of perfection? Have I misunderstood what I am aiming for? Why do others keep responding to me as though I were someone different from whom I understand myself to be? Is the life I’ve been trying to live possible for me, truly my own, or an alienating imposition from family or culture? Questions like these are often an essential context for understanding particular psychological problems like panic disorder or depression. The level of discourse in which such questions are framed and addressed cannot be derived from a set of findings about which technical interventions bring about changes in particular symptoms.

Further, it is not just the difficulties that patients struggle with that point to deeply held evaluative assumptions. In the effort to assist people with their difficulties each therapy also promotes a particular take on what is essential to a life well-lived. The role of ethics in therapy is not always acknowledged. Sometimes the failure to acknowledge an implicit ethic is based upon therapists’ assumptions that their ideas about well-being are so basic or universal that there is no need to justify or reflect upon them. 

It is here that Taylor’s work on the modern identity in Sources of the Self, The Ethics of Authenticity, and A Secular Age is enormously helpful. In identifying the particular socio-cultural context for many of the modern ideas about human flourishing that are evident in the psychotherapies Taylor provides a platform from which to begin see that ideals like authenticity, interpersonal intimacy, rational self-mastery, or liberation from social constraints are not universally desired components of a good life.

AD: You note the importance of examining "ethics" in the eyes of psychology and psychotherapy and all the assumptions therein--as well as what is missing. You note that every form of therapy has some implicit ethical or moral notions: CBT people implicitly value what they call rationality (to which I'm always wanting to retort with MacIntyre's famous question: Whose Justice? Which Rationality?); psychoanalysts place great store on freedom; and of course everybody, including mainstream medicine, stresses "patient autonomy." Why is it important to call these out and examine them? What happens, in other words, if we continue to leave these notions of rationality and freedom unexamined?

KRS: To see that various assumptions about living well only make sense in socio-cultural context makes it possible to begin to question those assumptions. This is important, even if at the end of this questioning a decision is made to re-affirm those views, now not as unquestioned assumptions but as having some situated rationale. For example, it is not difficult to locate different therapies in relation to Taylor’s exploration of two distinct versions of the modern “inward turn.” 

There are traces in contemporary therapy of both the stance of rational, disengaged reflection descending from Descartes and Locke and the more immersive self-exploration running from Montaigne through Rousseau and the Romantics. As Taylor spells out the history of these two forms of modern inwardness he also points to the ethical rationales that have been given in support of them. In Taylor’s view, neither of these has definitively won the day nor proven the other to be simply mistaken. The differences between them are not such that there is likely to be a resounding defeat of one by the other, even if mutual critique is illuminating.

The situation is similar with regard to the therapeutic orientations that derive from them. Failing to consider the fundamental ethical differences between different therapies leads to the mistaken idea that one type of therapy can be vindicated by simple empirical evidence regarding a narrowly defined efficacy at symptom reduction. But it also leads to avoidance of the richer ethical language necessary to grapple with what is at stake between the therapies. Moreover, any particular view of what it means to live well can have an enormous range of variations, even within one therapeutic orientation (consider the variations between the different schools of psychoanalysis). Autonomy, authenticity, liberation, and rationality can all come in many forms that deserve careful examination.

AD: You note at one point something that has long bugged me: The very idea of finding more "efficient" means of therapy contains within it a conception of the good life. And then Ch.5 opens with: "If one type of therapy works better than another, why should we care about its underlying view of flourishing?" Tell us a bit more about your thinking here about issues of efficiency and efficacy, and why it is important to analyze such seemingly unobjectionable ideas while also taking account of human flourishing?

KRS: The emphasis upon efficacy and efficiency in many discussions of therapy can introduce one notion of living well that deserves consideration, but it cannot simply be assumed to be definitive. There are nested domains in which this language appears. The most common one is the call for efficient and effective therapy, that is, for therapy whose value is measured in terms of how well, how quickly, or sometimes, how lastingly, it reduces concrete measures of disorder, like symptoms, self-report measures of distress, or associated measures of functioning, life satisfaction, etc. At a “meta-level” are arguments to develop methods to effectively disseminate these effective therapies, that is, to effectively and efficiently train therapists to do these therapies. 

Fundamental to all of this is a sort of utilitarian ethic that attempts to develop a sort of calculus of suffering and scientifically founded methods to reduce that suffering. There clearly can be value in this project. It has motivated the development of therapies that have benefited many people. Reducing the fear about and frequency of panic attacks or decreasing suicidal ideation are not trivial improvements in people’s lives. 

But to think about the benefits of therapy only in these terms is to ignore other ways of thinking about how therapy helps people to live well. It is simply not a forgone conclusion that therapy is the removal of impediments to living whatever life people want to live. For many, their psychological problems point to something amiss in their reigning assumptions about a good life, assumptions that are now open for re-examination. One risk of a focus on effective removal of symptoms is that it can imply: “Get rid of your symptoms, then exercise your free agency to choose whatever form of life you like. After all, there can be no real answer as to what makes for a good life. It’s simply a matter of personal preference.” What is suggested here is that what really matters is an unencumbered freedom to choose. That is the ultimate good. But that leaves no reason for one’s choice, for there is no good outside of my preferences that I answer to, or that can give some confidence or grounding to my choice. 

AD: If I was cheering earlier, I was on my feet for a standing ovation when you recognized that "the evidence to warrant the designation 'empirically supported therapy' is far weaker than is routinely claimed, especially for the short-term manualized therapies." Apart from Jonathan Shedler's invaluable work, yours is one of the only other voices I've come across recently calling out the dangers of excessive deference to that talismanic phrase "evidence-based," which tendentiously smuggles in all sorts of ideological assumptions hidden under philosophical naiveté. Tell us a bit more about the problems and assumptions built into claims to be "evidence-based."

KRS: It is certainly reasonable to ask if a therapy does any good. But the usual criteria for a treatment to be considered evidence-based are a truncated form of this question. The appeal of this way of assessing therapy is that it lends itself to empirical evaluation. The results are not always impressive. Shedler and other researchers have noted that the measurable symptomatic improvements of the short term therapies are often small and temporary. 

Further, different types of therapy can achieve similar results according to standard measures of symptom reduction. The question then arises as to whether different therapies might offer different benefits beyond symptom change. One danger of the evidence-based practice movement is that it implies the irrelevance of questions about the relative value of a broad range of goods or benefits that may be on offer in therapy. 

To use a simple example, if both Dialectical Behavior Therapy and mentalization-based psychodynamic treatment have some success in measurable outcomes in the treatment of borderline personality disorder, how do we assess the relative value of the dialectic of self-acceptance and change that is part of DBT against gains in mentalization?  There is something internal to these distinct therapies, something that is part of their particular views about what matters most for living well that deserves consideration on its own merits, not just in terms of symptomatic improvement. As an analogy, suppose one were to decide whether to be a Presbyterian, an Episcopalian, a secular humanist, or a Marxist based upon research showing that the members of one of these groups had statistically higher measures of  self-reported happiness, or higher levels of functioning.  To choose one form of life over another upon such bases is to ignore the distinct views of the good internal to each. 

Therapies designed and tested against the criteria to be evidence-based may well provide significant benefits. But the talisman of “evidence-based” can obscure a number of other important considerations about the value of therapy.

AD: At one point after comparing DBT and psychodynamic approaches to treating borderline personality disorder, you note that "common factors are operative across technique and problem. They do not subsume and dissolve all specifics into one common therapy for all disorders." This leads me to a worry I have about those calling for psychotherapy integration, not unlike appeals for "Americans to come together" after the election: what notions--potentially problematic and objectionable notions--of the good life are being smuggled in behind these appeals to unity and integration?

KRS: Efforts to bridge the differences between the therapies by integrating different components of practice or theory are not necessarily misguided. It can be part of a laudable effort to develop therapy in new directions, and can lower the temperature of debates between competing schools. 

But there are dangers. Under the guise of integration, one perspective can be subsumed within another, with the loss of what is distinctive about what has been subsumed. The aim should not be to move the many schools and sub-schools of therapy to a unified theory and practice, but to engage in a more vigorous debate about the competing aims of the therapies. There is value in respectful engagement with the diversity of approaches. Dialogue here includes debate and critique—agreement may not be the outcome. But at least with regard to the debates between different schools of therapy there should be some protection of the right for all to be part of the debate. This is far more valuable than unity.

AD: At the end of ch. 5 I felt very much called to account when you write that "adherence to favored therapeutic orientations is influenced by the appeal of the particular picture of flourishing, of how to live life well and fully." This very much undergirds my continuing allegiance (but not uncritical, or unappreciative of other approaches) to psychoanalysis and its picture of flourishing as freedom which disrupts various forms of repression--individual and social alike (as we see in a recent book A People’s History of Psychoanalysis: From Freud to Liberation Psychology by Daniel José Gaztambide, whom I interviewed here). Is part of your argument that therapists need to be more open about their adherence, and more willing to subject it to searching examination to analyze underlying moral claims?

KRS: Absolutely! Adherence to a particular approach to therapy often has complicated sources: experience with being a patient or therapist in a particular therapy, or the way that a particular therapy matches one’s intellectual or cultural assumptions and style. And there’s nothing wrong with therapists finding a home in one school rather than another, even if that means they are limited in what they have to offer patients. None of us can be all things to all people. But it is problematic to let the justifications for a favored approach lead to definitive conclusions or institutionally enforced policies regarding which therapies are legitimate. Therapists’ reflection upon and debate with others about their underlying moral claims can not only protect against hubris--it may also help them to amend or even fortify their ethical assumptions. 

AD: If that's the case, then I'm wondering whether training programs do not need a whole lot more serious philosophy courses built into them, so that "ethics" is no longer a single course telling prospective therapists what their professional association's code forbids and requires, but instead gives them a level of facility and insight so that philosophical debates about human flourishing can be much richer than they are now?

KRS: I would love to see greater discussion of these issues within training programs. Unfortunately, ethics is often presented in training programs simply in terms of how not to avoid missteps in one’s professional duties. As valuable as those considerations are, they overlook important questions. For example, the American Psychological Association’s code of ethics promotes fundamental principles of beneficence and nonmaleficence, principles which enjoin therapists to offer something of benefit and to avoid doing harm. But if the benefits are understood only in terms of standard ideas about effective treatment a wide range of fundamental ethical questions are overlooked, or worse, they are assumed to already be definitively answered.

AD: Sum up your hopes for the books and who especially would benefit from reading them.

KRS: I hope that these questions get a wider hearing, and certainly there are others who are raising them, like Philip Cushman, Frank Richardson, Blaine Fowers, Brent Slife, Donnel Stern, Donna Orange, Robert Stolorow and others. 

But the culture of therapy, which is shaped by the larger culture of modernity, has certain built-in impediments to recognizing the salience of these questions, so I think the effort to gain recognition for them will be an uphill battle for some time to come.

My hope is that the books would have a readership beyond those who are already interested in philosophical questions about therapy. I think any therapist, regardless of theoretical orientation or stage of career, can have questions from time to time about more fundamental issues about therapy, about what it is, what its fundamental aims are, what good it might do, what therapeutic aims are most worth pursuing, and why. I hope that these books provide some specificity to and justification for asking such questions. I have tried to be respectful to therapeutic orientations other than my own because I do respect them, but also because I want to encourage therapists across the spectrum of different schools to consider these more fundamental questions.

AD: Having finished both books, what projects are you at work on now?

KRS: I’m currently working on a paper for a special issue of International Journal of Philosophical Studies dedicated to Taylor’s legacy and possible future impact. I am also working with a group of analytically oriented psychotherapists in Pittsburgh to develop a new program for education in psychoanalytic psychotherapy, the Western Pennsylvania Community for Psychoanalytic Studies.