Sexualities and Identities:

It is the fate of collections to be often wildly uneven, and that is true with Sexualities: Contemporary Psychoanalytic Perspectives, eds. Alessandra Lemma and Paul E. Lynch (Routledge, 2015), xiii+244pp. There are two outstanding chapters, and two very good chapters; and then a great deal of other material some readers might find interesting or helpful but I did not. 

I read this book first for general interest, then because I work with adult and adolescent sex offenders ordered by the courts into treatment, and finally because I am working on an essay about the erotic in transferences and counter-transferences. 

I begin with Part III, "Homosexuality" and the first essay in this section by Peter Fonagy and Elizabeth Allision, "A Scientific Theory of Homosexuality." To my mind, this is the most outstanding essay in the book both for the cogency of the writing and for the challenging arguments it offers. The entire chapter--or at least the first half of it--plays something of a trick on the reader who, under that title, is led to expect something the authors very severely put to the question in the chapter's second half. That is, the first part is a brief review of the history of attempts to conjure up a theory of homosexuality (that history has recently been treated more expansively, but not entirely successfully, in a book I discussed here). 

Fonagy, of course, is the founder of the tradition of mentalization-based therapy, about which see here and here. He has also published on possible connections between infantile experiences and attachment, and the development of sexuality. 

With Allison, the burdern of the second half of their co-authored chapter is introduced and encapsulated by the claim that "normal sexual desire is inherently unknowable....Part of the essence of desire is that there is something anti-conceptual, something indefinite and unknowable about it" (p.133). This, in turn leads to one of the other major claims by these authors: "neither homosexuality nor heterosexuality are 'normal' and...neither can be an identity."

I rather imagine that both claims will immediately set some teeth on edge, but both are for me so straighforwardly obvious and true they cease to require additional argumentation. 

These claims are not, of course, entirely original to these two authors. Adam Phillips, for one, has argued something similar about the inherent unknowability about sexual desire and identity, especially in his 1997 book Terrors and Experts, where he has repeatedly noted that "there is nothing like sexuality...for making a mockery of our self-knowledge. In our erotic lives, at least, our preferences do not always accord with our standards." Later in the book he continues by arguing that "from a psychoanalytic point of view, nobody can know about sexuality" in part because "we are never one thing or another, but a miscellany. (For how long in any given day is one homosexual or heterosexual, and can you always tell the difference?)" 

The, uh, desire to have definitions and identities clearly nailed down is, Phillips suggests, an expression of our "wish to be defined [which] is complicit with the wish to be controlled." Additionally, the ham-fisted insistence on clear and sharp definitions runs the very real risk that "too much definition leaves too much out." Too much definition, in other words, undermines mystery and freedom alike. 

This, too, is very similar to what Fonagy and Allison argue: "the essence of desire is its indefiniteness." Indefiniteness means that we can have no legitimating theories of human sexuality, and these authors end their essay by suggesting that such theories in the past have functioned in an anti-mentalizing fashion, shutting down the ability to think about ourselves in ways that take account of our complexity and messiness: "it behooves us to be suspicious of ourselves when our wish for simplicity begins to override out respect for the complexity of subjective experience that our patients engender and bring with them in relation to their experience of their sexuality" (p.135). 

Anyone who has done clinical work for more than a week will immediately realize the profound truth of that last statement. And it shows up in several other essays, as well, including the moving and somewhat melancholic "Intimacy and Shame in Gay Male Sexuality" by Paul E. Lynch: "the beauty of working with patients instead of theories is that they are not so determinedly insistent on conclusions about their own sexuality, and are more often trying to find some way to make sense of themselves, their bodies, their pains and pleasures, and their relationships" (p.146). (Briefly towards the end of his chapter, Lynch suggests that "transgressive sexual behaviors may be an enactment or embodiment of un-represented, un-symbolized, or unformulated early experience," a theme that Adam Phillips has also briefly touched on, and before them both found in the works of Robert Stoller, including Perversion: the Erotic Form of Hatred.)

Earlier in the collection, Mary Target suggests that "fully expressed adult sexuality, regardless of dominant gender identity or orientation, incorporates unconscious bisexuality and bluring of the gender role of self or other." All of these authors, of course, are merely echoing what Freud first postulated in his infamous 1905 Three Essays on the Theory of Sexuality:

Since I have become acquainted with the notion of bisexuality I regarded it as the decisive factor, and witout taking bisexuality into account, I think it would scarcely be possible to arrive at an understanding of the sexual manifestations that are actually to be observed in men and women.

Lynch's claim about un-represented forms of sexual desire and behavior shows up in the last two chapters of this collection, the first written by Avgi Saketopoulou, who has also recently published Sexuality Beyond Consent, which I hope to read over the Christmas break. Her chapter here is entitled "On Sexual Perversions' Capacity to Act as Portal to Psychic States that Have Evaded Representation." 

She grapples with the continued use of the word "perversion," before arguing that we might retain it because it "captures the phenomenology of sexuality that blends anguish and/or pain with pleasure." Those who work clinically, as I do, with patients whose desires have been judged (often by courts, but sometimes by parents or themselves) as perverse and illegal know well this unique, and uniquely difficult, blend of anguish and pain: the desire that is unwanted, that has brought such trouble and left a streak of such devastation, is also a desire not without a certain frisson. Rather than condemn all such desires a priori and totally, we must, if we are to be of any help clinically at all, recognize that in some cases there may be real attempts to grapple with things that were unthinkable to the developing mind. As she puts it, "some sexual perversions...may be understood as proto-attempts towards figuration" (p.214). In the process of trying to figurate such experiences and desires, we must, she concludes, "always be aware" that some things are "eternally inaccessible to us, impossible to bring into knowable experience." Once more those with even modest clinical experience will at once recognize this as true.

Finally, Heather Wood concludes the book with her "Working with Problems of Perversion," and takes a much more practical approach, showing how many and how often perversions function as defensive measures to keep at bay the ever-threatening peril of intimacy and its possible engulfments. Drawing on Glasser's earlier work, Wood argues that "sexual perversions have very little to do with sex...but are about the use of sexualization as a defence to deal with primitive terrors in relationships" (p.224).  Such terrors include an uncertainty about whether the patient's own aggression can be controlled in a relationship or whether it will give rise to sadism and destruction. 

Wood also offers some helpful counsel about working in the transference with such patients, and dealing with counter-transference reactions. Many of us are anxious about sexualized transferences, and perhaps even more sexualized counter-transferences (a topic I'm writing a paper about just now), but she calmly suggests that if we keep in mind her claim above--that sexualization is a defense mechanism like other defenses--it should help us be less anxious about it. We must still, however, examine closely our own reactions as well as the transference to see whether they are about: control? sadism? anxiety? intrusion? seduction? taming a frightening object? fear of abandonment? a defense against destructive urges? a desire for merger which is intolerable and must be defended against? 

In some cases, Wood suggests, after the above forms of sexualization have been worked out, one occasionally might then begin to see less defensive sexual feelings emerge toward the clinician: "it may be important that these feelings are tolerated rather than viewed as defensive if true integration of sexuality and dependency are to occur" (p.228). 

This note has only touched on some of the essays in this rich collection. Anyone interested in sexuality and psychoanalysis will want to have this book on their shelf. 

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.

On Treating Obsessive Compulsive Personality Disorder

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

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

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

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

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

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

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

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

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

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

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

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

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

        Mirroring:     To be recognized

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

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

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

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

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

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

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

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

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

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

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

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

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

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

David Wallin on Attachment in Psychotherapy

This book, Attachment in Psychotherapy, has something of a legendary status in the field it seems to me, so it was on my long-term list of things I knew I must read at some point. But one of the things I learned from Nina Coltart is that clinical work has a way, largely unconsciously, of bumping things up your priority list depending on whom you are treating at any given moment. So with several new cases presenting with what seems to me dismissive and avoidant attachment histories that immediately seemed a threat to treatment even beginning, never mind proceeding successfully, I felt I had to do more work in both attachment and mentalization. So with gratitude and relief I picked up David Wallin's Attachment in Psychotherapy. 

The book begins with the ultimate hook to scholar-clinicians such as I: "How does psychotherapy enable people to change" (p.xi)? Whose blood is immediately not set aracing by such a crucial and intriguing question? 

He immediately posits that an answer to such a question almost certainly has something to do with giving a relational connection and context not unlike that of primary attachment figures in early life, here mentioning to me the surprising claim that Bowlby, famous for his attachment theory, was much more of a clinician than academic, seeing a considerable number of patients who seem to have occupied more time than I ever realized.  

Much of attachment begins at the most primitive, per-verbal levels, and Wallin here calls to mind Christopher Bollas and his notion of the unthought known. This is especially true for disavowed or dissociated experience, which may well end up, Wallin says, being enacted, embodied, or evoked in others. The therapist skilled in mentalization, Wallin says--here tying his own work to that of Fonagy (given his own chapter--#4) which I have also found, and continue to find, so very helpful--will help the patient see these three patterns and begin to reflect on and own them. The therapist who exhibits and encourages such mentalization will likely have a "contagious quality," helping the patient's capacities to expand and grow outside the consulting room.

Wallin also brings in the work of metacognition, which bears a good deal of similarity to mentalization, though the former term was primarily developed in the US while the latter in the UK. In the US Paul Lysaker is most associated with the term in my mind, and his work on metacognition in psychotic disorders informs my own clinical work and has proven very helpful. 

Ch.2, The Foundations of Attachment Theory, covers not just John Bowlby but also Mary Ainsworth's equally important pioneering work here. The gist of this is to show that "an abundance of follow-up studies has tended to show that the attachment patterns of infancy have long-term effects" (p.23). Another number of studies suggest that parents replicate with their infants and children their own attachment patterns and struggles.

Ch.3 focuses directly on Ainsworth, noting that "without a functioning capacity for metacognition, we may for the moment find ourselves in a particular state of mind; lacking such a capacity, it's as if we simply are that state of mind" (p.40). Helping my patients appreciate this has in several cases proven a turning point in treatment. They had hitherto felt helpless in certain affective states, as though controlled by them: Fonagy calls this "embeddeness." But being able to reflect on them, to sit with and observe them as they come and go, has been very helpful. 

As we move into ch.6 of Wallin's book, he makes a useful caveat that perhaps cannot be stated enough: "the fact is that their [patients'] complexity can never be adequately captured by a single descriptor--secure, dismissing, preoccuped, or unresolved" (p.96). Do not, in other words--as I constantly tell my students--expect to see people show up in your consulting room straight out of central casting, with clear, precise, unambiguous clinical presentation allowing you easily and immediately to tick some theoretical or diagnostic box--avoidant! bipolar! OCD! Rare are such patients. 

Ch.8 focuses explicitly on Bollas and the unthought known, emphasizing that patients who cannot put certain things into words will show us by their actions, and that enactments in therapy will also be crucial forms of communication. Here and in many other places in the book, Wallin stresses that with patients whose ability to communicate their struggles in words is limited, "we must tune in to our own subjective experience" (p.129). Such experience includes all of us: Wallin cautions that the "taking cure" must not be limited to "talking heads," but include the whole body. 

Resuming themes of mentalization, Wallin goes on to state quite clearly that "helping patients change their stance toward their own subjective experience depends, in part, on our explicit mentalizing." Lest some think this insufficient--where's the homework? work-sheets? skills building? breathing exercises?--he insists a little further down the same page that "rather than any particular understanding, it is the experience in which the patient feels understood--and inspired to understand herself--that is ultimately most therapeutic" (p.157). 

He resumes this theme later in the book, noting that "for patients who are unresolved the therapeutic relationship is the therapy" (p.244) and such therapy provides an "incremental achievement of a sense of safety in relation to the therapist," and to that extent may heal previously traumatic relationships. Put in classical terminology, psychotherapy that provides "the patient with a secure base" is offering him or her "a corrective relational experience that may be healing in its own right" (p.257).  

Ch.10 brings in the work of Phillip Bromberg, to whom I was recently introduced. His idea of multiple self-states, and of change being something more than a static end-point at which we arrive and stay, has been extremely illuminating for me. Wallin draws on him in this chapter as well as Bion's notion of helping the patient contain "disowned thoughts, feelings, and desires" which can be reintegrated once they have been held in mind by the psychotherapist (p.183). 

Wallin goes on to argue something that I have recently been learning (not without struggle!) from the new book of Karen Maroda (and before her from Nina Coltart and others): the need sometimes less for containment (pace Bion) and more for confrontation and challenge. As Wallin puts it simply, "it must be understood that our patients at times need confrontation more than they need empathy" (p.200). He seems to suggest a little later that this is especially so with those who exibit a predominantly avoidant and dismissive attachment style, clues about which can be found in a tendency to lapse into irrelevancies and to exhibit certain things bodily. For such patients, we need to combine "empathic attunement with confrontation" so that the dismissing patient is led to see "how he gets to us" (p.212). 

We do this, of course, not via a "barrage of honesty" but in a way that the "patient can make use of." In doing so, Wallin cautions toward the end of the book (repeating a theme throughout), we communicate usefully using words, but in other ways as well. If we are not attuned to non-verbal communication, our utility to the patient is going to be limited to just that extent. Thus we must cultivate what he calls "open presence" (310) and earlier "bare attention" (the exact phrase I first learned from Nina Coltart). Such bare attention, Wallin notes at the end of the book, should be offered with in "calm, quiet" ways, quoting one of Freud's technical papers from 1912 (to which Coltart says clinicians should return regularly). 

When we are communicating via words, Wallin hints that it is better to use observation statements than questions: "Generally I prefer to simply comment on what I think I see, letting the meaning emerge from the joint exploration the comment usually elicits" (p.299). 

In the end, we do all this, he says in a neat summary of the book, because "in the new attachment relationship we aim to provide for our patients, repeated experiences of disembedding through mindfulness as well as mentalizing can establish a competing centre of organization in both the mind and brain. In this way such experiences can potentially replace the patient's insecure working models with 'earned secure' ones" (p.337). 

On Mentalizing and Attachment

I have been aware for some time of the work of Peter Fonagy in England. But it was only more recently that I discovered his American colleague Jon G. Allen. Both have written about "mentalizing" as important in therapy. The pair of them have teamed up together with Andrew Batemen to write Mentalizing in Clinical Practice (APA Books, 2008). I mined this book for some good insights, and was not disappointed. Herewith a few of them:

Mentalizing: What Is It?

In their introduction they offer several quick, simple definitions of mentalization, including:

holding mind in mind

attending to mental states in yourself and in others

understanding misunderstandings

seeing yourself from the outside while seeing others from the inside

In the concluding appendix, they return to offer another simple definition of mentalizing: "You are mentalizing when you're aware of what's going on in your mind or someone else's" (311). Examples of this might include asking yourself "Why did I do that?" or "Why did she say that hurtful thing?" 

Practical Recommendations:

These authors offer some very practical recommendations in trying to increase the capacity for mentalization in patients: take your time; don't rush this; don't get out of step with your patient. If in doubt, confirm first (the patient's thoughts/experiences) and challenge later. 

Why do this? Why is mentalizing important? They find that its lack is almost always related to an attachment failure, early abuse or trauma, or substance abuse. Restoring the ability to mentalize can be both healing in itself but also open up further depths to be explored in therapy. The whole point of therapy is to open up alternate interpretations and to insert spaces where there were none before. This extends to allowing and encouraging the pt. to mentalize the transference: to look at this relationship now and imagine what might be going on in the therapist's mind while also discussing what is going on in your mind as a patient. 

Without Memory or Desire:

These authors offer what I would characterize as some very Bionian counsel: Be very at home in not knowing, not having memory or desire. Do not be an expert, for you are not an expert in the patient's mind! 

If you are trying to be mindful of their mind, then they recommend that the therapist make contrary moves: if the patient is excessively introspective, invite them to consider how another mind might see something; if they are obsessed with how others see it, invite them to offer their own thoughts from their own mind. 

As you and they offer such thoughts, watch the adverbs! Avoid using such terms as clearly, only, obviously, just, etc. If your patient uses them, you might want to challenge them gently, especially if such adverbs precede significant minimization of major events or issues or pain. 

Ask for feedback if a conflict is brewing: What have I just said/done that seems to be making you more and more agitated and upset?

I read Mentalizing in Clinical Practice after having finished Allen's Restoring Mentalizing in Attachment Relationships: Treating Trauma With Plain Old Therapy. Let me next offer some comments about this book which was also valuable. 

I confess that anyone who uses the phrase "plain old therapy" is going to command my attention rather immediately and easily. I further confess my ever-increasing lack of interest in, and sometimes scorn for, the mad rush of a lot of people to coin and then copyright acronyms and to trademark modalities. Allen has little interest in such things, and I am at one with him here. 

Neither of us, however, is willing to dismiss evidence or defend things merely because we have theoretical preferences. I do not doubt for a moment that in some cases some of these things (DBT, EMDR) work, but it seems clinical psychology is engaged in a frenetic and relentless chase after commodification of its services in a way that is profoundly off-putting, and usually for one of two reasons at least: either much of what is proffered is just needlessly complicated manual therapy like DBT, or recycled earlier approaches. 

In the foreword to this book, Peter Fonagy says that "plain old therapy [is] a mentalizing relationship in which the therapist's empathy allows the patient no longer to feel alone in emotional pain" (xiii). This approach, both he and Allen recognize, antedates all forms of psychotherapy, going back thousands of years and still being practiced today in regular forms of relationship with friends and family who help us by and with their empathy as we struggle. 

This approach, he further recognizes, has much in common with the ever-popular mindfulness today, but he distinguishes them thus:

Mindfulness is attention to and acceptance of present experience

Mentalizing is attention to and acceptance of mental states (mindfulness of mind).

Trauma and the Failures of Attachment:

For Allen, as for Fonagy, a failure of mentalizing often lies behind trauma, attachment failures, and substance abuse. What these situations have in common is that the person is left psychologically alone in distress, and so much find maladaptive ways of coping, including substances, disorganized attachment, or other personality disorders. 

In traumatic failures of attachment, especially situations of childhood abuse and neglect, those attachment failures always get re-enacted in other relationships, showing that re-enacting is always a failure of mentalization (what Freud called "remembering" in his invaluable essay "Remembering, Repeating, and Working Through").

Allen uses an interesting metaphor in working with severely traumatized patients: what were and are their "islands of security"? Find them, explore them, and then see if you can get them off the tiny island and onto a more secure mainland in their own mind. 

Importance of I Statements:

Two final words of counsel I found helpful, and have already seen work well in my consulting room: the first (which other therapists I have read, including Yalom, also recommend) is to give voice to struggles in the session and relationship by using I statements: e.g., "I seem to wonder if we are not going around in circles" and leave it at that. This method often sees the patient pick this up and elaborate, or adopt your view and allow themselves to be carried forward. 

Another effective version of such a statement that I have used with success marries what Allen recommends with what Nina Coltart also recommends: take cool soundings from the counter-transference, paying special attention to images or nick-names that your unconscious throws up. I have found myself saying things like "I have this image of you in mind" or "I'm wondering why I want to give you the nick-name of Invisible Man." Both of these opened up new depths and directions to be explored. 

Minds inside Minds:

Finally Allen notes that the patient has to be able to find him/herself in the therapist's mind just as the therapist has to be in the patient's mind. I think the former might be especially important around those notoriously destabilizing transition moments--a summer holiday or Christmas break, say. For some patients the knowledge that their therapist holds them in mind outside the session can be helpful and healing in itself, especially if they had no significant early attachment figures. 

Diana Fosha on the Transforming Power of Affect

David Arute contacted me on Facebook and initiated a lovely discussion about numerous things. He heads (with his wife) his own psychotherapy clinic outside of Chicago, where they are doing some very interesting work indeed. You can read all about that here. I mention this to give him credit for introducing me to Diana Fosha and her book The Transforming Power of Affect: A Model for Accelerated Change, published by Basic Books more than 20 years ago now. 

I confess that until this conversation I had never even heard of Fosha, but I am grateful to have had that ignorance now challenged, and to have been introduced to her book, which I have read with great interest. My interest grew even stronger upon reading of her background and some of her key theoretical influences. 

Fosha was born in Romania but trained in the US, including time learning with and from Habib Davanloo, whose books I have and have been meaning to read for coming on a year now, without finding the time. Davanloo was a pioneer in a intensive short-term dynamic psychotherapy, an approach that Patricia Coughlin (whose books I also have, but have not had time yet to read) has continued to make known. It is an approach that fascinates me, and once I get around to reading those books, will have plenty to say about it on here! 

As I noted not too long ago, the idea that analytic therapy has to take years is a relatively late development. The very first generation around Freud specialized in short courses of therapy, so the desire to return to those today is not entirely or even primarily born of the usual horrid capitalist demands for brevity and "efficiency." 

I must say this book hooked me with the first lines of an unlikely page: the acknowledgements, where Fosha begins by acknowledging her debts to the great D.W. Winnicott, whose thought I have been drawing on more and more for the past few years, most especially in my essay here on Hating the Church. (In the next breath she acknowledges Davanloo's influence.)

After these, she mentions David Malan, whom I have also marked to read, in my continuing exploration of short therapy; and then, inter alia, Paul Wachtel, whose Therapeutic Communication, Second Edition: Knowing What to Say When I actually have finished reading but not yet posted my thoughts about. 

So, to Fosha then. Having started to read Bowlby, Winnicott, and attachment and object relations theory more than twenty years ago now, I found that her first five chapters were well written if somewhat underwhelming--a refresher for me, but valuable introductory material for those without the theoretical background.  

There were two outstanding insights in this section.

First, I especially appreciated Fosha--after reviewing the literature on defense mechanisms (including Anna Freud's well-known treatment of them)--arguing that defenses should be understood not just as negative barriers (I build a wall to protect myself against anxiety or trauma), but as also leaving a positive residue, which goes some way to explaining their power and hold over us: the wall reduces my sense of anxiety and allows me to feel a bit better, a bit less anxious, perhaps even good about myself. Anything that plays such a pivotal and powerful dual role--protecting me and allowing me to feel if not good then at least less anxious--is very likely going to become deeply rooted in most of us. 

In that sense we must not condemn defenses even if we now see that they are maladaptive and unhelpful. Once more I'm put in mind here of Auden's poem "In Memory of Sigmund Freud," and these verses especially: 

but he would have us remember most of all 

to be enthusiastic over the night,

     not only for the sense of wonder

   it alone has to offer, but also

because it needs our love. With large sad eyes

its delectable creatures look up and beg

     us dumbly to ask them to follow:

   they are exiles who long for the future

that lives in our power, they too would rejoice

if allowed to serve enlightenment like him.

The second insight here is a familiar one to readers of Yalom: Fosha's very strong emphasis on the here-and-now of therapy, on the moment-by-moment affective experience going on in patient and therapist, and between them. This is well captured at the end of chapter six, when she says that "what we discover...is that when dynamically understood, the structure of the sweeping patterns of a lifetime resemble the moment-to-moment dynamic shifts of the current relationship with the therapist" (136). 

Earlier in chapter six, this has become the explicit focus as Fosha argues that the clinician needs to be closely attentive to those micro ruptures and alterations in affect that take place within the session moment by moment. She highlights some of the differences between resilience and resistance in dealing with psychic conflict and anxiety. 

Anxiety, in turn, is linked with affect and attachment, these latter two attempting abatement and regulation of the former. But we must not, Fosha seems to be saying, focus only on anxiety and defenses. There is also a "desire to grow, connect, and feel authentic" (109). The therapeutic task, of course, is to create the environment and conditions where this may happen more fully. 

In chapter seven, Fosha focuses on the patient's love and compassion, and what may have happened to those if they were thwarted, rejected, mocked, or insufficiently received by their intended objects. She notes--as I have seen Harold Searles and others do--that the patient does not just have a need to be healed, but also to able to offer healing to others, including the therapist: "when...empathy is directed toward the therapist, it is extremely important that she acknowledge it" (145), especially in those patients whose empathy more easily and generously extends to others than to themselves. 

A little later on (152-53) this discussion about empathy leads to an interesting analogy: is there such a thing as an unprovoked bear attack? You might think you did everything right to avoid provoking the bear, but it is the bear, not you, who decides whether he is feeling provoked or not! The same is true for the patient, who decides whether he finds you, as therapist, empathic and understanding, warm and accepting, or not. 

Chapter 8's reflections on meta-therapeutic processing includes this useful reminder given to public speakers: tell your audience what you are going to do, do it, and then tell them what you've done. In a similar way, the therapist facilitates the therapeutic environment, names the experience, and then with the patient explores his or her experience of the therapy. This experience of reflecting on one's own experience, Fosha says, is "strongly related to resilience and psychic health" (163), an insight she draws in part from the work of such as Peter Fonagy. Practiced long and well enough, these experiences can lead to a level of emotional mastery whose marks may often persist long after treatment has ended. 

In reflecting on and working through the suffering and losses of one's past, mourning arises and will be greatly aided, Fosha says, by the therapist making manifest and making use of "her own grief and sadness for what the patient has had to endure" (169). Later on she notes that therapy is off to a good start after the "sacred" first session if it is clearly established that "the patient feels safe and the therapist brave" (213) by being willing to become emotionally vulnerable with and for the patient. 

How Are We Doing? 

Much as Yalom suggests, Fosha also later notes that the very first session should not end without the patient "spending some time processing the patient's reaction to being and talking with the therapist" (238). As she elsewhere notes, this should be an entirely open conversation about good and bad: "We try to help the patient verbalize the experience of closeness and distance. Talking about what is happening--good and bad--intensifies the sense of closeness" (220). Here Fosha notes she explicitly departs from a more "traditional" analytic approach that eschews focus on positive transference in favour of the negative. Nothing should be off the table, allowing her to suggest these two questions are central:

• How do you feel here with me?
• What is your sense of me? (Or: how do you experience me?)

If the answers to those questions are genuinely positive, then here as elsewhere Fosha says the therapist must not, because of "ill-placed modesty" downplay the discussion of those positive interactions: rather the courage you need, mentioned above, must be brought to bear here for this discussion about positive feelings and interactions is just as therapeutically important, allowing both patient and therapist to ask themselves "could it be that I'm not bad?" (221).

On the Working Alliance:

Next drawing on research into the centrality of the working alliance as crucial to the success of therapy, Fosha notes that therapist's must regularly, consciously, and deliberately engage in "empathic prizing," showing the patient how much their experience is valued and validated (223), both the suffering but also their positive strengths and gifts. The therapist must offer encouragement to keep going, showing a hopeful way forward; and must also offer positive feedback and commendation for whatever progress or successes the patient enjoys, especially calling out and lauding any actions by the patient toward self-care and affirmation. 

Sometimes doing this is a both-and exercise, Fosha suggests: the praise may often be met by a defensive downplaying by the patient, and the therapist's empathy should call both dynamics out, validating the need for the defenses while also encouraging the further taking of risks in precisely this area. 

When it comes to the therapist's feedback and even more his or her self-disclosure, Fosha has an interesting take, noting that especially for those "patients [who] have rarely felt that they have an impact on the significant others of their early life," knowing they are having an impact on the therapist can be transformative (230). This is also true when it comes to acknowledging errors by and limitations of the therapist, and any vulnerabilities. Fosha uses a striking phrase here, noting how the therapist's "self-disclosure [can] counteract therapeutic omnipotence" (231) as well as strengthen the patient's belief that he or she has valuable contributions to make to the welfare of the other. For patients whose relational style is that of learned helplessness, rising to the challenge of helping another can be an important lesson to learn. For patients (and therapists, I might add!) whose relational style tends towards the very intellectual or even quasi-schizoid, asking these sorts of questions, and offering these sorts of reflections, can prove to be "the ultimate corrective emotional experience" (243). 

Working with Defenses:

Noting that explicit challenges to defenses are a hallmark of Davanloo's work and all who come after him in the short-term dynamic psychotherapies, Fosha differentiates between "soft" and "entrenched" defenses, noting that the latter require some form of "restructuring" (247). (In addition to challenging defenses, all these approaches also share another goal and technique: the learning to bear previously unbearable affect in the here-and-now of the working alliance.) Her approach here is refreshingly straightforward: "using empathy," simply begin by talking about the role of defenses with the patient, offering "nonjudgmental feedback to the patient of what it is like to be on the receiving end of his defenses," thereby allowing him or her to become aware of the impact those defenses have on others. 

After this an appreciative reframing of the defenses can take place. But before this, some patients can respond by trying to do too much too fast, overcoming defenses almost by sheer willpower in a given moment, which may lead to frustration. It is important for the therapist to call out this self-pressure and allow it to deflate. 

As work with defenses proceeds, other relational patterns may emerge to be worked on, reflecting patterns in the patient's wider life outside the consulting room. From here the work may proceed to a recasting of the narrative of the patient's life. Specifity and detail are often key here, Fosha says, not least in getting through intellectualization defenses: the more a patient can remember and describe about an experience the more he is likely to be close to what he felt about it, too.