Notes from Christmastide Reading: Schizophrenia, Case Formulation, Ogden, Self-Supervision, and Dead Analysts

The only time I can permit myself not to work is when I am traveling. If I am on my academic Christmas break, then I must be reading, writing, and editing. Herewith a few notes on some new, and new-to-me, books that I have recently finished over the break.

On Schizophrenia:

This is a very workmanlike little book that I immediately decided to adopt for my students in my psychopathology course. We do a special extended unit on psychotic illnesses, and I've not hitherto found a suitable book for this part of the course, making do with several articles.

I would quibble with the author for her bias that only the "medically qualified, Psychistry-trained Psychoanalyst" (titles she always capitalizes) is really equipped to handle schizophrenia--a clunky, snobby phrase used several times in a short book. I have no medical training but have nonetheless worked with cases of schizophrenia for years now. To her credit, she is aware that those with psychoanalytic training, which I do have, are also able to handle schizophrenic patients. 

Case Formulation/Conceptualization:

A supervisor of mine lamented for years that the art of case conceptualization had largely been lost, and I rather agree that in many cases it has. It is important, if only in the clinician's mind, to be able to have a relatively coherent, but dynamically flexible, succinct vision of who the patient is, what the presenting issues are, how they are bound up with personality structure and personal history, and what goals and direction treatment is taking, including its transference and counter-transference manifestations. The lack of all this immediately puts the clinician at risk for what I call therapeutic drift. 

To prevent that along comes the psychiatrist and psychoanalyst Mardi Horowitz with a handy little book suitable for students and trainees: Formulation As a Basis for Planning Psychotherapy Treatment. This is a very short workmanlike little book that would be suitable for students and trainees early on. 

André Green and Dead Parents:

Despite being once fluent in the language, I have read little of French psychoanalysis in that lovely language. Indeed, apart from the notorious (and largely unreadable) Lacan, I have had only some knowledge of a tiny number of figures such as Françoise Dolto, Élisabeth Roudinesco (author of several useful biographies, including of Freud and Lacan, and of the very valuable little book Why Psychoanalysis?), and André Green. But my ignorance of Green is slightly less deep after reading not just his most famous essay "The Dead Mother" (found in this collection) but also a book of essays devoted to that theme, The Dead Mother: The Work of André Green, ed. Gregorio Kohon. Among the virtues of this collection are essays by three of my favourite analytic writers today, Adam Phillips, Christopher Bollas, and Thomas Ogden. 

Green's concept of the dead mother has been helpful in understanding early struggles of several of my own patients. It was also very helpful in my own psychoanalysis to understand not just the emotional deadness of my mother but my father too because of several miscarriages prior to my birth, and other sudden family deaths, especially of my father's hugely idealized older brother when I was a small child. 

Thomas Ogden on Not Being Alive:

The theme of aliveness is one found in many of Ogden's writings (which, on this theme at least, bear striking similarities to Adam Phillips, as I showed here), including the essay published in 1999 in the above-noted collection. He has returned to it in his latest book, released just a few weeks ago: What Alive Means: Psychoanalytic Explorations. 

Having written many appreciative, almost fulsome, essays on Ogden, having recommended him more times than I can count to students and interns, and having bought all his other books (save for his novels), I think I am allowed at least one occasion to remark that this newest book of his is a dud. It says little he has not said elsewhere (always a danger as an author ages and his opera omnia becomes every larger, stretching back several decades), and most of this book is a rather diffident series of short commentaries on Winnicott's writings. My love of Winnicott, too, is second to none; but at some point this ground has been gone over so much by Ogden himself (to say nothing of others) that the freshness and, well, sense of aliveness that so marks Ogden's previous books, which I found exhilarating to read, is absent here, alas. Those new to Winnicott and Ogden alike might well find something useful or nourishing here, but I was quickly bored and disappointed. 

Self-Analysis and -Supervision: 

Freud, of course, first discussed and attempted to practice self-analysis and other authors, including Karen Horney, have written at length on the topic. There is some interesting recent research (which so often lags behind demonstrating what psychoanalytic clinicians have known for decades) on the reflective capacity of the clinician being a key component to the success or failure of treatment. Such a capacity is just what self-analysis and -supervision should be focused on. 

Marc Lubin and Jed Yalof have a new publication Self-Supervision Psychodynamic Strategies which offers some useful tips to clinicians. It is not a long or complicated book, making itself accessible to those new to this topic and trying to sort out some of the challenges of engaging in a self-supervision. 

Self-analysis and -supervision show up in Fred Busch's latest book How Does Analysis Cure: Essays on Psychoanalytic Method, Psychoanalytic Organizations, and Psychoanalysis. 

I have been a fan of Busch's earlier book Creating a Psychoanalytic Mind, as I showed here and here. So I hope it will not be thought an impertinence on my part to say that this new book is a bit of a mess, and only parts of it can be recommended. (The entire second and last section of the book has an infelicitous feel as Busch complains--almost gossips in public--about some rough handling by callow editors at psychoanlytic journals, and problems within psychoanalytic institutes, none of which are at all new or any great surprise to those of us paying attention since, say, 1941 or thereabouts. I am not at all clear how airing all this in public does anything to solve the problems or increase the esteem in which already battered and often justly ridiculed institutes, hidebound places of orthodoxies where none should be found, are held.) 

If we overlook the final section of Busch's book, we have some rich reflections, including the first chapter ("How Analysis Cures"--the short answer is mentalization, a word that Busch seems at pains to avoid for some reason), and the chapter on silence, as well as a chapter on self-analysis. Here, too, however, my complaint about several of these chapters is that they are too short and say too little. One has the distinct impression of an author losing steam from the beginning of this book. 

One thing that is clear in treatments of self-analysis and self-supervision is that these two are never to be exclusive substitutes for an actual personal psychoanalysis and work with a supervisor. One of the many things I admire about both Glenn Gabbard and Nina Coltart is how, even late in life, after decades of practice, they both flatly and humbly admitted, in an almost off-handed way, that with certain cases they sought out supervisors because the clinical issues were very tricky. This is something we must all consider doing when needed. 

Mechanisms of Change in Psychotherapy:

These two new books belong in the curricula of teaching institutes and graduate programs, for they contain a wealth of research, much of it quite sobering. 

I work with personality disorders, including borderline personalities as well as obsessional and compulsive personalities, about which see here for some invaluable resources. Despite being in the second-largest city in the state of Indiana, I seem to be among a very tiny handful of clinicians who treat these issues, which are, so far as I can tell, rarely discussed in the standard graduate training program in this country. (Every clinician's website I'm on seems to say the same thing: "I specialize in depression, anxiety, and trauma!" But how can it be a specialization when everybody is doing it?) So I picked up Understanding Mechanisms of Change in Psychotherapies for Personality Disorders by Ueli Kramer, Kenneth N. Levy, and Shelley McMain with great interest, and it would lend itself to incorporation into training programs.

This question of what mechanisms of change are in psychotherapy is a fascinating one in part because answering it raises some very formidable challenges to the empirical researcher. Those questions are given very substantial treatment in an enormously valuable collection edited by Louis Castonguay and Clara Hill, Becoming Better Psychotherapists: Advancing Training and Supervision. 

Particularly alarming are the several chapters devoted to exposing how little research we have on what constitutes good and useful supervision. Supervision, of course, is a standard requirement for graduation and licensing nearly everywhere, but who trains the trainers, and then who evaluates that training and those trainers? Few do, it seems. If we are to have better psychotherapists--and God knows we have nowhere to go but up on this score, as the hugely depressing, almost disgusting, data revealed by Francis Martin in Therapy Thieves has shown--then we need to train not just them but also their supervisors. But trained in what, and how, and by whom? Once again these are formidable questions without easy or quick answers. But they are crucial questions we need to be asking, and this book does so in unspairing and unsentimental ways, which we must be thankful for. 

Let me--feeling slightly sadistic--close by recommending you pick up Martin's book. He's done the heavy lifting of surveying thousands of clinicians in the United States to ferret out all the rubbish, all the chicanery, that gets passed off under the guise of "therapy." I was aware of just a handful of woo-woo examples--chakra therapy, singing bowls--but there are hundreds more, each more absurd than the last. Perhaps especially sobering is that regulating psychotherapy does little to control the growth of this nonsense. Once a clinician has a license, there seems in most if not all jurisdictions to be a tacit acceptance that whatever they want to do they can. Complaints against a license are common in custody cases, and of course for reasons of violating sexual boundaries or breaking confidentiality. But when was a clinican last challenged or brought before a disciplinary hearing for practicing (just to pick four random examples from thousands Martin has documented) bright light therapy, Shifaa soul counseling, Reiki womb therapy, or equine ecosomatics? One scarcely knows whether to laugh or throw up. 

This notion of being "evidence-based" smuggles in all sorts of covert philosophical and hermeneutical assumptions ("evidence" is never self-evident, but only ever a result of a process of interpretation which is personal and inescapable), and the refusal to recognize this is very vexing to me. So, having finished Stephen Toulmin's helpful Return to Reason over Christmas (which criticizes clinical psychology’s habit of wanting to base studies of the mind on Newtonian physics whence some wish to derive universal “laws” to the total exclusion of the case study method), my reading this spring will continue to mine the hermeneutical literature, starting with Richard Rorty's landmark book Philosophy and the Mirror of Nature; and then Paul Ricoeur's Hermeneutics and the Human Sciences: Essays on Language, Action and Interpretation. I've been reading Ricoeur off and on for more than twenty years, but never in a sustained and systematic way, as I hope to continue to do. 

Creative Engagement in Psychoanalytic Practice: Further Thoughts

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

Introduction:

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

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

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

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

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

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

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

The Contents:

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

The Importance of Play:

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

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

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

The Importance of Authenticity:

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

On Embodied Presence and its Obstacles:

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

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

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

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

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

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

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

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

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

The Importance of Self-Forgetfulness:

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

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

On the Uses and Abuses of Masochism (updated):

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

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

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

Collapse of the Therapeutic Space?

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

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

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

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

On Acknowledging our Own Needs of the Patient:

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

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

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

___________

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

On Bare Attention: Notes on Ascetical Practice in Psychotherapy

I'm trying to teach my students this semester what it is required of clinicians if you are to open yourself to a patient in psychotherapy and listen to them at depth and in a way nobody else does. Such listening has, of course, gone under a number of phrases, starting with Freud's "evenly hovering attention." He posits this as the equally demanding practice expected of the analyst to correspond with the "fundamental rule" of free association. Both are deceptively simple on paper, but fiendishly difficult to practice regularly. 

I've never forgotten the first time that phrase came back to mind as a life-preserver as it were. It was during my internship and I was listening to my first-ever patient to report childhood sexual abuse in the Catholic church. It was a horrifying tale of systematic gang rape in essence lasting many years. As detail after detail poured forth, I found myself fixating on each fresh revelation, trying to sustain an equal level of horror and compassion for every new item. But after about 15 minutes of this, I felt my mind (in what I now regard as a protective-defensive manoeuver to protect me from this demonic horror) starting to disbelieve the patient and think she must be joking. Horrified at this, I realized I had to pull back, as it were, and allow my attention evenly to hover over the entire story rather than immersing myself in the bloody and dark gore of each detail. This allowed me to listen with less inner perturbance and with a greater distance on the scene, which, of course, is what the patient needed for she already knew how horrifying it was, and my constatnly saying so added nothing useful. 

I felt twinges of guilt as I pulled back, as though not being constantly horrified at each detail was somewhow to fail at being compassionate. But I've learned over the years that you cannot be over-identified with your patients. That does not, in the end, help them. They need you to be more objective, to have greater distance, and to offer a perspective that differs from all others in their life. 

How do I know this? They tell me, very explicitly! People will note how their friends will rush to offer them heaps of support and unquestioned sympathy, but they themselves know they need more and other than that, which is why they present for therapy in the first place. 

From this one can derive a technical rule: Don't try to outdo their friends, thinking this is what "empathy" is! As my first supervisor pounded into my head, "The fact you get paid means you will never be friends with your patients!" Thus, I tell my students, you need to listen in ways that go well beyond what friends and family do. Listen for the gaps, the pauses, the inconsistencies, the contradictions; listen for the darker emotions their friends and family did not hear and could not handle. 

From this a second technical rule can be derived: do not collude, especially unconsciously, in hating the people your patient hates. You need to be free to see what might be good in the person (typically parents or spouses) they claim to hate, and how that hate is invariably closely bound up with more tender emotions, including those of love. Your colluding in hate will preemptively destroy any space for ambivalence to emerge and breathe. 

How can you do such things, avoiding such entanglements as over-identifying and hating? At this point I introduce to my students the concept of "bare attention," which is a Buddhist-inflected concept found in the works of Nina Coltart. What does that mean?

Fittingly, Coltart offers only a very minimal definition, saying that to practice bare attention requires that we "teach ourselves so continuously to observe, and watch, and listen, and feel, in silence that this kind of attention becomes--in the end--second nature to us." But what does that look like? She does offer two highly complex paragraphs (quoted here) trying to explain this, which I have my students "meditate" upon as it were. But for the time being I want to advance the thesis that "bare attention" and "evenly hovering attention" are both practices I can only describe using explicitly theological language: they are ascetical practices.

Now "ascetical," for those who remember their Greek, is not in fact theological in origin, but simply pertains to that form of "training" or, as the OED has it, "ἀσκεῖν to exercise." Thus listening with "bare attention" requires the same sort of exercise, training, or practice as you would expect Olympiads to put in to train for a marathon or comparable exercise. 

The sheer physicality of this training should not escape us. It means--as I have learned by trying to ignore some of these things--that you have to take seriously the following as inescapable components of your training:

Food: don't skip meals or hydration in order to see more patients. Your practice of "bare attention" will be severely weakened as you pay more attention to your growling stomach or fantasies of how large a steak you will grill for dinner. (I've learned to keep "good" snacks in my desk--fruit and nuts usually, but also dark chocolate, along with a large pot of tea.)

Exercise: Coltart learned to her great cost that years of sitting without exercise can bring on severe back pain. Do not stint on getting up and walking around between sessions, and working in as much physical movement as you can outside of your clinical schedule. (For me running 15 miles a week is the bare minimum I need to sustain my attention as well as clear my head of the "vicariously traumatic" details of my patients' lives.) 

Timing and Scheduling: Figure out what works for you. If late afternoon or early evening appointments mean you are very tired, but are wide awake for an 8am appointment, then adjust your schedule if you can. There's no attention--bare or otherwise--paid to your patients if you are nodding off! 

Furniture in your consulting room: Again, Coltart was a cautionary tale for me: crappy chairs for you to sit in (including a lack of the fabled ottoman!) will induce discomfort that make your practice of "bare attention" much more difficult. Don't stint here! 

Sleep: You can't pay attention to anything or anyone if you are exhausted all the time. Get good sleep and don't stint on this to work in a few extra appointments.  

Your own Psychotherapy: I think for me likely the single-biggest factor on this list is my own first full psychoanalysis and then ongoing analytic psychotherapy which has allowed me to feel sufficient "ego strength" as it were that I can open myself up to my patient in a self-denying way without feeling threatened or deprived. To put it in "oral" terms, their slaking their needs through me does not leave me starving and resentful. 

These practices require a commitment to training or physical exercise, a form of discipline, a type of "rule of life" known to monastics of antiquity. Observing these things requires a form of self-discipline, indeed of self-denial and self-emptying. 

Such language may make some uncomfortable. Perhaps they will be reassured by learning that no less a figure than Thomas Ogden, in his book Reclaiming Unlived Life, on which I reflected a bit here, calls for such self-denial: 

the analyst must engage in an act of self-renunciation. By self-renunciation I mean the act of allowing oneself to become less definitively oneself in order to create a psychological space in which analyst and patient may enter into a shared state of intuiting and being-at-one-with a disturbing psychic reality that the patient, on his own, is unable to bear.

Ogden does not make the point explicit, but I have to think he would be adamant here that none of this self-renunciation is to be done masochistically.

Here I think Ogden would gladly join hands with Karen Maroda who, echoing Emmanuel Ghent, has rightly called for  "distinguishing between emotional surrender and masochistic submission" (p.39) in the therapeutic dyad. If you are masochistically foregoing food or sleep or other basic needs in order to spend more time with your patients, perhaps you need to ask whether this is really helping you practice the "bare attention" they need and want from you? 

In the end, then, the paradox of self-renunciation is that it helps not just the patient but you as the psychotherapist. After all, which of us does not want to be well-fed, well-rested, decently mobile and fit, and reasonably comfortable in our consulting rooms? Perhaps in the end "self-renunciation" is a disguised synonym for that sometimes infelicitous phrase "self-care"?

8 Theses from Thomas Ogden on Reverie

I have, once more, my friends on Twitter to thank for introducing me to the psychiatrist and psychoanalyst Thomas Ogden, about whom I have recently written here and here. Once I understood his style, and how to respond and work with it, I have found him an enchanting writer. So I decided to keep working my way through his books as time and energy allowed.

The past few days, before being thrown into the whirligig of a new semester, which begins tomorrow, I sat down and read through one of his first books, Reverie and Interpretation: Sensing Something Human (Jason Aronson/Rowman and Littlefield, 1997). Among its several virtues is one I was especially delighted to see: how many times Ogden quotes Nina Coltart, whose work was then brand new but never, then or since, widely known (alas). 

It is in some ways perhaps incommensurate with how Ogden writes and thinks that I have chosen to extract from this book eight "theses," if you will. Perhaps "aphorisms" is a better way to think of these ideas, which are embedded in a book with great masses of clinical material from his patients. I have summed them up in my own words and added a bit of reflection as appropriate.

First, there is no such thing as a mind. This, of course, is Ogden's riff on Winnicott's famous declaration that "there's no such thing as a baby." What both men have in mind to emphasize here is that no mind exists of itself or by itself. A mind, Ogden says, is always created and maintained (as well as harmed) intersubjectively. 

Put negatively, the idea of an "independent mind" existing in its solipsistic splendour, untouched by and not linked to other minds, not only does not exist but, as Bion might say, is a psychotic illusion. 

Second, both minds are different after analysis/therapy. Patient and therapist alike think differently after spending time working together. I am sometimes startled by how much differently my mind works thanks to my patients. I think if I had stuck to my original plan of full-time clinical practice in the 1990s, when I was still in my 20s, I had then a very rigid mind and most likely would have been a rigid and presumably inflexible clinician. Now I feel, with not just training and experience, but my own psychoanalysis and ongoing analytic psychotherapy, and many years of living, far more comfortable with the changes that are necessary. I can allow myself to be pulled and pushed in various ways without the fear I had earlier in life that I would be toppled over or destroyed.

For this reason, I now greatly resonate with Ogden saying in this book--and all the others I have read so far--that each course of therapy, indeed each session, has to be different with each unique patient, and that if patients could eavesdrop on other sessions they would well wonder "Is this really the same Dr Ogden/DeVille as the one I see and hear and talk to?" 

Third, Ogden took me back to reading a Jesuit psychotherapist to whom I was introduced in high-school in the 90s (who has since been revealed to have been an abuser), who used to quote St Irenaeus of Lyons famous line about the glory of God is a human being fully alive. For Ogden, several times in this book, he says quite compellingly: every form of psychopathology represents "a form of unconscious self-limitation of one's capacity to experience being alive as a human being" (p.18). 

Once more, of course, the debts here to Winnicott are obvious, including what his wife wrote of after his death: the "prayer" he sometimes used, asking "Oh God! May I be alive when I die." 

Fourth, sexualization is an attack on mentalization. Ogden does not use the latter term, Fonagy's work  (and that of others like Jon Allen) on it not being then widely known. But I have found this a helpful way to think of some issues in treatment which Andrea Celenza also addressed in her invaluable book Erotic Revelations: Clinical Applications and Perverse Scenarios, which I wrote about here. 

Fifth, alter the 'fundamental rule' to permit greater freedom for reverie and also patient privacy. The academic editor in me has long been at war with the psychoanalyst in me, finding that true and literal application of the rule makes for a chaotic session, almost quasi-psychotic at times, and strick application of the rule can be an attack on the capacity to dream and think. I know in my own therapy I once very deliberately, and with gleeful malice, went on a 'wild' spree of free associating to run out the clock in the last 15 minutes of a session to avoid talking about a very embarrassing dream. 

Sixth, quoting Freud's 1914 paper "On the History of the Psycho-Analytic Movement," Ogden reminds us that "any line of investigation which recognizes...these two facts [transference and resistance] and takes them as the starting-point of its work has a right to call itself psycho-analysis." This, blessedly, releases us from silly and interminable debates about use of a couch and number of sessions being somehow exclusively indicative of psychoanalytic treatment.  

Seventh, simply listen. This is from Freud's 1912 paper "Recommendations to Physicians Practicing Psycho-Analysis." By this Ogden says that Freud meant engage in that evenly hovering attention precisely to catch the drift of, to tune into, the unconscious mind of the patient. This puts me in mind of Coltart's exhortation to practice bare attention. 

Eighth, quoting Winnicott, psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist.

Ogden and Phillips on Reclaiming Unlived Life

I have read all of Adam Phillips' books (that is not a vulgar boast so much as a reflection of deeply ingrained scholarly habits, which are often nearly indistinguishable from semi-obsessive or slightly manic tendencies leading one to devour, and ideally to own, an author's opera omnia); and I have newly set for myself the goal of reading if not all then certainly several more of Thomas Ogden's books, to whom I was introduced this fall. I found his style enchanting, but even more some of his arguments--which I have never encountered in 30 years of reading psychoanalytic authors--are wonderfully capacious and hospitable, allowing me to think things about my own analysis and now my own clinical practice that are freeing--and topped, ever so slightly, with a frisson of the forbidden or, better, the "unthought known." 

It occurs to me that Phillips and Ogden have a lot in common. Surely someone else less dim than I has long ago noticed this? I am always a Johnny-come-lately to these things. 

But there is more than a superficially titular resemblance between the Ogden book I read this week--Reclaiming Unlived Life: Experiences in Psychoanalysis, from 2016--and Phillips' Missing Out: In Praise of the Unlived Life.  Both include (here as elsewhere) liberal and loving lashings from literature and poetry; both write in an often lyrical style; and both hold and expound views that, even at this late stage, still seem somehow to sit uncomfortably within "orthodox" psychoanalysis (if one can still speak coherently of such a thing). I have no data to confirm this, but it remains a strong impression. Nonetheless, I think we're all the richer for their perhaps sui generis views and would not have it otherwise. 

I will say that of all Phillips' books, Missing Out perhaps comes back to mind most readily, and has occasioned very profitable discussion with students in this Covid era. Let me tidy up a few old thoughts about it here, and then set him alongside Ogden. 

The appropriate place to begin is with Phillips flatly declaring that "reality matters because it is the only thing that can satisfy us" (25). This will get developed in the rest of the book's realist, anti-fantasist stance in which Phillips clearly comes out against spending time imagining what could have been--what sort of life we could have had, or worse, could yet have if we but overcome our limitations and frustrations. For to give ourselves over to such disordered fantasizing, to wondering after would-be satisfactions in some imaginary future, is to open ourselves to an endless frustration with our life, which is itself an enormous problem insofar as "frustration may be the thing that we are least able to let ourselves feel"(27); and again: "There is nothing more opaque about ourselves than our frustrations" (28).

Phillips is saying this as an adult, and directing it at his readers who will all presumably be adults. But how much more difficult is this for children and adolescents! How many "conduct disorders" and "adjustment disorders" are the results, at least in part, of an inability to bear frustration? How many arise in response to demands to produce facile "solutions" to our frustrations--which end up serving nobody well? 

One danger of children trying or being required to achieve over-mastery of frustrations, as Phillips hints, but Winnicott made explicit, is that of precocity, famously treated in an essay I wrote about here. On that topic, let me put in a plug for an unjustly neglected but invaluable collection, The Mind Object: Precocity and Pathology of Self-Sufficiency, eds. Edward G. Corrigan and Pearl-Ellen Gordon.

Frustrations, if allowed--as Evagrius recognized long before Freud came along--to take root in our mind can become, as Phillips nicely puts it, "intractable because their satisfaction is too exactly imagined" (32) and as a result "there can only be unrealistic wanting" (33). To have "realistic wanting" seems a good enough goal for therapy as for life. It may well require mourning what is unrealistic, and grieving those wants that can never be satisfied. 

I admit that such too easily imagined satisfactions and unrealistic wantings strike me whenever, as last week, NPR told me that the Powerball had grown to a billion dollars or whatever. Hearing this, on the tedious last stretch of some highway or other, I imagine the house I would build (the library would be multi-tiered, sound-proofed, and have a massive fireplace in it with floods of light from huge windows on all sides; all other design details are trivial and uninteresting), and the scholarships I would endow, and the training program I would build to graduate the finest psychodynamic psychotherapists in the country; and so on. 

But Phillips is not done with our frustrations, and not willing simply to dismiss them because they are too easily imagined. Instead, he says that "We need...to know something about what we don't get" (33). This, of course, immediately raises practical if not moral problems: "But how...would you teach someone to not get it?....Teaching them how not to conform without trying not to conform?" (48-49). 

As an academic and a clinician, I find this is a tricky balance to pull off, and today's undergraduates seem especially frustrated and suspicious as you attempt to do so. With understandable bewilderment, they want to know how it is that they are taking an (often required) course only to be told by the professor that one of his most important goals for them is that they understand more deeply what they do not know, what their blind spots are, and what value uncertainty, ambiguity, and ambivalence all have as scholars of any and all disciplines, but especially psychology. But I try nonetheless to inculcate this in them, saying that if they are the sort of logic choppers and hermeneutic naïfs with a raging and uncontrolled desire for omniscience, who have to know everything and have it mapped out in advance, and cannot find uncertainty anything but paralyzing and disdainful--well, then, they need to exit from a clinical career immediately and go build bridges or something. 

As we teach others about the importance of not always "getting it" we need ourselves to be, as it were, convinced of the benefit of doing so, asking ourselves and others: "In which area of our lives does not knowing, not getting it, give us more life rather than more deadness?" (80). 

Incidentally, these are questions profitably examined from a variety of angles in another unjustly neglected collection, Knowing, Not-Knowing and Sort-of-Knowing, ed. Jean Petrucelli

Since reading this passage in particular, I have often thought of my foolish desire in my 20s that psychoanalysis would grant me access to knowing the entirety of my mind, unconscious drives and all. At the end of a full and successful analysis, there would be no surprises and all would be known and mastered, laid bare to the cool eye of reason. My second analysis has moved me quite unexpectedly away from that desire. I now find it more freeing to not pursue every detail of my mind but instead simply to recognize within myself that "I contain multitudes." That is, I hope, not just some tawdry bit of Whitman on the cheap; nor is it meant to be self-congratulatory in the least, but instead an increasing acceptance of the undrainable reality and complexity of any human mind still living. 

One of Phillips' great lines comes in this book when he says that a good goal for psychoanalysis is to help us "make sense of our lives in order to be free not to have to make sense" (63). In other words, we might have "good enough" insights (Phillips' wrote an early biography of Winnicott, which is decent, but the Rodman bio is much better) into ourselves, and, being content with those, feel free to stop pursuing further insights and instead go off and do something else like write poems or make black raspberry jam. As he puts it here and elsewhere (and this clearly echoes Winnicott), one good therapeutic outcome of analysis is that you can forget your treatment, your "symptoms," and the problematic narratives that brought you in in the first place, and simply get on with living. (I recall with great relief Nina Coltart saying in an off-handed way that she could hardly remember a single word of her multi-year analysis with Eva Rosenfeld.)

Being aware of, and comfortable with, what we do not understand is nowhere more important, Phillips counsels, than with sex: "When it comes to sexuality, we don't get it....It means that when it comes to sex we are not going to get it. We may have inklings about it....We can know the facts of life, but nothing else. We may, as we say, have sex, but we won't get it" (77). And again: "What psychoanalysts mostly know about sex is the strange ineffectuality of so much of their knowledge" (79).

Thinking these things with Phillips is very helpful, I find, to maintaining "evenly hovering," that is non-judgmental attention in any discussions about sex. It seems to shock some patients that I am not shocked when they discuss certain things about their sexual life. So many people come in preloaded with all sorts of judgment, and can hardly sit still if you do not immediately express some kind of stern judgment, or at least mildly clucking distaste, for whatever their "issue" is. They seem startled by having everything welcomed for discussion. I suspect a few of them secretly believe I must be faking it--and silently racing to retch into the rubbish bin as soon as they leave!

Right. So much for Phillips. Onto Ogden.

Reclaiming Unlived Life is a collection of essays, as several of Ogden's books seem to be (and as most of Phillips' books are too). Unlike Phillips' book, Ogden's is not so focused on this theme of the unlived life. The title, in fact, seems to come from a single chapter devoted to a late essay of Winnicott. We will come to that presently. Other chapters range widely. I will confine my thoughts to the first five chapters, and to the last one, with which I start.

That chapter is an interview Ogden gave to Luca Di Donna. It gives interesting background, as one would expect, but perhaps the best nugget--hidden just beneath the surface, and not mentioned explicitly, but seemingly obvious to me--is that Ogden desires no disciples. And perhaps even more impressive is his sangfroid about others using his works and disagreeing with him: "the fact that I don't recognize my own thinking in another person's interpretation of the concept of the analytic third is an event that I welcome because it means that the interpretation of the concept has been nutriment for another person's thinking--that, after all, is the principal point of writing of any sort" (p.169). 

The second gift in this interview is a point Ogden has made in other books: the importance of "tailoring" (not the best word--not a good fit!--but I cannot think of another just now) each treatment to each person to such an extent that each patient finds a very different Ogden. He reports rather cheerfully that he wants and would expect his patients to be astonished if each of them could listen to how different he sounds in speaking to all the others, and far from being disorienting this is a good thing. In other words, Dr Ogden with Patient A would sound very different than Dr Ogden with Patients B through H. 

The final point in this chapter is that knowledge alone is a very poor outcome of therapy. It availeth nought toward psychic change: "There is nothing mutative or growth-promoting about the acquisition of greater knowledge about oneself. What is mutative, I believe, is the experience of oneself in the context of being with another person who recognizes you to be the person you are and the person you are in the process of becoming. (It is precisely this experience that has made my second therapeutic analysis so valuable in such unexpected ways.)

This last chapter, and this discussion in particular, link up very nicely with the first: "Truth and Psychic Change." Here Ogden makes several points, including--to my amazement and relief, being the first time I have heard such a thing uttered--that the fundamental rule of psychoanalysis "compromises the patient's right to privacy, which is necessary for the freedom to dream in session" (p.2). I found, and find, this very freeing. Equally liberating in this regard is his claim in Ch.5 that you can only become a therapist based on your own unique gifts: "you have to respect the uniqueness of your own personality" (p.93) and not rely so much on interpretations and theory and whatever you imbibed from your own therapist. In all these things, and in his other books I read recently, there is a very strong welcome made to individuality and creativity in an atmosphere of radical freedom. I suspect Ogden and Fromm would have been good friends. 

The chapter next explores how to pursue truth in analysis in ways that the patient can bear. If done too soon or too zealously, before trust is achieved, truth will carry little water and may drive the patient backwards. And it might always be a dialogic process--not a top-down "interpretation" imposed by the clinician. 

Ch.3, "Fear of Breakdown and the Unlived Life" is an obvious reference to Winnicott, whose very short 1974 paper "Fear of Breakdown" was published three years after his death. This is the central essay in the book and it seems characteristic of Ogden's peculiar gifts that he can find so much material to comment on so profitably in what was not just an unfinished paper of Winnicott's but also a very short one in its original publication. 

In any event, Ogden says that this paper is one of a half-dozen that have been most influential on his overall thinking--along with essays by Freud, Klein, Loewald, Bion, and Fairbairn (always nice to see that neglected Scotsman get some attention! For more on him, Jock Sutherland's Fairbairn's Journey into the Interior is a decent place to begin.)

Ogden talks about how moving it is to read Winnicott, here as elsewhere. Though he doesn't quite put it like this, I have long felt that you could, through Winnicott's words, gain a strong and felicitous feeling for what it must have been like to be in his warmly welcoming consulting room. Doubtless he would have scandalized many on Twitter by his occasional offer to some patients of a cup of tea, which I find very charming indeed.

This essay, Ogden says (and cf. below my comments on Searles and psychosis), allows you to feel compelled to join Winnicott in getting in touch with our own feelings of fear of breakdowns: "to be an adequate therapist we must make use of our own personal knowledge of 'what it feels like'--what 'insanity' feels like--even though we are not in the full grip of a particular 'detail' of that insanity at a given moment" (p.50). 

For Winnicott, a breakdown begins as a loss of defenses against the psychotic parts of our mind. The crucial difference, he suggests (and Ogden rightly notes how much of this paper is Winnicott thinking aloud in not entirely coherent ways), is that patients fear breakdown now when they lack the "container" or "holding environment" of the mother-infant bond. Ideally, of course the therapist and therapeutic frame provide this, but Winnicott and Ogden both say that the patient needs to know you understand not just their breakdown but feel the fear of it, and have some experience with it. To guard too much against these feelings in yourself will not help your patient and their feelings of being trapped by some "primitive agony."

Ch.4 dares to tackle the hermeneutics surrounding one of the most enigmatic and controversial essays of the last half-century: Bion's infamous "Notes on Memory and Desire," to which I've given not a little attention on here (and here). 

Ogden confesses he's tried to read and understand it for decades without success until he realized Bion did not want people to agree, but instead to think about these questions with him. And the question, Ogden asserts, is not about memory or desire, but about the proper and overlooked role of intuition and the unconscious in the analytic process--which desire and memory can mask and distort. 

Ogden comes close to saying--but does not seem to do so--that the problem with memory and desire is that they are, as it were, a false floor. We might think we are grounded on them, but in reality they cover over a yet deeper level where the truth is more likely to be found (cf. pp.77-78). I catch glimpses of this in my own life when I can allow myself sometimes to try to get behind certain memories or desires to discover that they might not in fact mean what I have long thought they did. (We are, as Phillips might say, too easily satisfied literalists!) If Ogden is correct on this, then it is both a little alarming and a little liberating: alarming because it suggests our capacity for self-deception is much deeper and more thorough-going than first realized; but liberating in that we might not quite be prisoners of our desires after all. This will bear continued thinking about. 

We can circumvent memory and desire, he suggests, by dreaming in the session, by reverie, though to do so may require that "the analyst engage in an act of self-renunciation. By self-renunciation, I mean the act of allowing oneself to become less definitively oneself in order to create a psychological space in which analyst and patient may enter into a shared state of intuiting and being-at-one with a disturbing psychic reality that the patient, on his own, is unable to bear" (p.79). 

This passage immediately put me in mind of working with psychotic and borderline conditions, both of which I have found require that I become for a time something more or other than what I seem to be. I really do think Harold Searles (whom I discussed a bit here) was right that in working with such patients, you have to be willing to allow yourself to be a little bit psychotic--or at least be somewhat comfortably, if only for a time, in the neighborhood of your own psychotic elements. These patients are so split, so fragmented so much of the time, that trying to keep them all together, or to put them together, too soon does not, it seems to me, help them learn how to bear what they cannot bear right now. 

How can you do that--allow yourself to be a little bit psychotic? I doubt I could have even entertained the thought when I was younger. It is not easy, and it can be a little bit frightening. But now I rely heavily on a strong frame along with good supervision, supportive colleagues, and my own psychotherapy. I think having patience is also crucial: if you get in touch with those terrifying psychotic elements, you can do so more easily knowing that (as Christopher Bollas has suggested, among others) it is possible to dip into and out of "madness" without getting stuck in it, and the dark and difficult experiences will pass. (Here I really do believe Ophir's recent arguments that "madness" is on a continuum, and not some radically "other" state or "disease entity" that is totally separate from ordinary human experience). 

 Speaking of schizophrenia and psychotic disorders, I have a half-dozen new books to read over my Christmas break, so I suppose I will have to frustrate my desires to order some more Ogden until I get through at least part of that pile. Of course, my super-ego can sometimes be overpowered or ignored, so who knows. But I will certainly read more of him when I can (and also, come to think of it, write more about Phillips' two newest books).