An Encomium for Jonathan Lear....and Other Books

I did not mean to leave so large a gap on here, having posted nothing since March. I have several times gestured wanly in the direction of my laptop and the piles of books which sit uneasily near it at all angles and with varying degrees of instability, and on at least two occasions sat down to draft posts (one of which is nearly done and will focus on 3 or 4 books on mentalization I have been wrestling with this year). But for reasons I will not bore you with, my energy this year has been reduced and taken up with other things, and thus every time I sat down to write something the desire vanished almost instantly--until now. 

Anyway, in no especial order, here are some thoughts on books that you might find beneficial, edifying, and even enjoyable to some degree. 

Jonathan Lear: 

I begin with Jonathan Lear, whose death in September occasioned grateful commentary as well as mourning and melancholia in the worlds of academic philosophy and clinical psychoanalysis. I read his Imagining the End: Mourning and Ethical Life in early 2023 and before that his Freud, published in the Routledge Philosophers Series. It is, I submit, the best philosophical treatment of Freud since Ricoeur's 1977 landmark book Freud and Philosophy: An Essay on Interpretation. 

Therapeutic Action: An Earnest Plea for Irony (2003) is a languid book that showcases Lear as a philosopher asking question after question in service of, and search for, an answer to his central question, which is: what is the therapeutic action of psychoanalytic treatment? Since this book was published more than two decades ago, there has been an increasing body of literature investigating this question and not just in psychoanalytic circles either. It remains a question that continues to fascinate me and will be the focus of some attention in my next book: what is the action of psychotherapy that provokes change by and in and with the patient? 

Lear's contribution to this is based on a wonderful and close re-reading not just of Freud but also of Lear's own mentor, Hans Loewald. He begins by reminding all of us that "therapeutic action does not describe a process, like getting a tattoo, which has a fixed end point. Once you've gotten a tattoo, you've got a tattoo; indeed once you've had an analysis, you've had an analysis, but therapeutic action goes on and on. Analysis has a termination: therapeutic action does not. Ideally one continues one's own process of therapeutic action as a lifetime project" (p.33). In this Lear very much reminds me of one of Adam Phillips's aphorisms that "the cure can only begin once the treatment has ended." 

Later on Lear briefly discusses termination in treatment, and the need to have that firmly in mind as a clinician from the moment treatment begins. (My first supervisor taught me that in introducing the question of goals, he often used the question "What would done look like?" as a way to get the new patient thinking about how their life would have to be changed for them to feel justified in letting treatment be done, be finished.) Lear compares this to good parenting, saying that both, to be healthy, have to consist in a progressive withdrawal because "psychoanalysis is aimed at promoting a person's freedom [and] part of the freedom is freedom from the need to keep coming to the analyst" (p.56), a key principle both Erich Fromm and D.W. Winnicott have previously articulated. 

Lear's compatability with the thought of other clinicians shows up in numerous points in the rest of the book. When he turns to a discussion about whether a psyche can be said to have a "core," he notes, in a vein that strikes me as very similar to Philip Bromberg's incredibly rich and important book, that "the core is the elementary capacity of the psyche to hold itself together" without resorting to a ruthless superego-induced attempt at purging or synthesizing (p.118).

He returns to this issue at the end of his third chapter, "Internalization," where he seems to nod clearly in the direction of mentalization (as Fonagy and Bateman have famously called it) or the creation of a "psychoanalytic mind" (as Fred Busch has called it) by saying that "while superego internalizations may well occur at various levels of sophistication and primitiveness, even in the termination phase of the analysis, one is also fostering the internalization of a capacity for analyzing these unconscious forms of internalization." In other words, if the analyst has been internalized as a good object (a "benign superego figure" in Lear's phrase) then ipso facto the patient will have also internalized the analyst's mentalizing capacity for use after the analysis has ended, and such a process "properly constitutes the therapeutic action of psychoanalysis" (p.133).

The next chapter, "Love as a Drive," contains some fascinating reflections that could too easily be dismissed as insider baseball, or as reviving old controversies nobody has cared about for decades, but in line with Bettelheim and Laplanche (on whose Freud and the Sexual see below) Lear insists that swapping out "instinct" for "drive" in translating Freud's German is misleading and unhelpful. Lear insists, with ample documentation from Freud, that this is a bigger issue for him than any of his biographers or scholars and clinicians after him have been willing to allow, and that it remains a great unsolved issue: the drives, especially of sex and death, have been rather quickly and quietly bundled off the stage so as to allow our genteel and ever so much more socially respectable conversations about developmental, relational, and now traumatic challenges to take over the entire show. 

In the context of this discussion, Lear calmly revisits the old polemics--from enemies and defenders of Freud alike--about the role the "sexual" drive occupies in Freud's writings, noting that both sides miss a crucial philosophical point that Lear explicates: his understanding is not focused on copulation and he denies that the sexual drive and the sexual object have a more intimate connection than they actually do. To this extent, then, Freud is not saying--Lear argues--that at our most sexual we are also at our most animalistic. Au contraire: human sexuality has so many features, expressions, and pecularities that it is here more than anywhere else that we are not like other animals. In Lear's by-now familiar refrain, "human sexuality makes us all candidates for irony" (p.156).

Additionally, drawing on Plato, Freud noted in 1924 ("The Resistances of Psycho-Analysis: SE 19: 213-224) that when psychoanalysis refers to sexuality, it "had far more resemblance to the all-inclusive and all-embracing love of Plato's Symposium." Lear the philosopher leaps on this and spends the rest of the chapter wondering aloud about why Freud, having said this, then spent the rest of his life running away from serious sustained reflection on love as a drive. In doing so, Lear charges, Freud fails to develop a crucial line of reflection that would have a direct bearing on therapeutic action. We cannot, Lear implies, understand efficacious therapeutic action except as being a process motivated by love (as Freud first conceded in that off-hand comment to Jung in a letter of December 1906). 

What might this love look like and how might it be a driver (if not the driver) of therapeutic action? What might a "loving" treatment result in? Lear suggests--but does not really develop the thought--at a couple of points that loving therapeutic action will result in the analysand's enlarged capacity for "greater psychological complexity" (p.170). (Once again there are clear echoes of this in others, including Phillips, Busch, Bion, and many others.) But the analyst does not impose this on the patient, or demand that he develop or "perform" complexity. The analyst merely provides a place to do so without getting pushy about it. Indeed, Lear defends fairly traditional understandings of neutrality at this point, saying that "the analyst's holding herself in this 'neutral' position is itself an act of love."

Towards the end of this chapter and nearing the end of the book, Lear asks a question that I have not seen anyone else do: is the fear Freud had about discussing a "love drive," a fear that virtually every clinician since him has replicated and never challenged, born out of a philosophically impoverished understanding of what "science" is and does? (Contemporary psychology's ignorance of the philosophy of science remains a constant source of serious vexation to me.) "One reason Freud's theory of love has been ignored is that it seems ridiculous to take seriously the idea that love is really a basic principle of nature. Surely we need to turn to natural scientists to find out what the basic principles of nature are. But what if we think about second nature?" (p.172). 

At this point Lear the philosopher emerges to the fore again, and he reminds us of our need to return to moral philosophy in Plato and especially Aristotle, but also in our own time the works of such as Bernard Williams and Alasdair MacIntyre. The development of our second, more properly human nature--our nature as philosophers, one might say, over and above our animal nature--cannot avoid questions of "character, personality, and psychological structure" (p.173). These can only have a chance of developing well if they do so in the context of relationships motivated by love that abjure moralizing while insisting on asking what Lear terms the ethical question: "How shall I live?" (174). 

Analysts, finally, cannot avoid such questions, either in themselves, or in their work with patients. In pursuing such questions with love they propel the therapy forward to successful action, defined as "structural change" understood not as a "once-and-for-all achievement" but instead a "perpetual undermining of rigidifying and thereby alienating pretenses" incapable of ironic reflection on oneself (p.177). 

For this rich and important book, and for his others, it is certain that Jonathan Lear's memory will remain a blessing.  

Memory of and Desire for more Bion?

We seem to be entering an era in which books about W.R. Bion, who died in 1979, are emerging at an ever increasing pace. I know for many of us he has been a difficult read, and our feelings about him are suitably ambivalent. His claim that each session should unfold with the clinician refraining from "memory and desire" has often been seen as a problematic counsel of perfection, but there are very solid reasons for striving to do this as I have learned the hard way more than once. In fact, I would say that mistakes I have made in a recent case are almost entirely because I failed to refrain from memory and desire and instead been too keen to demand the patient discuss certain things he is manifestly not ready to discuss. Pacing remains a crucial technique still in need of refinement.

Beyond his reflections on attention, memory, and desire, I have long found Bion enormously useful for his two essays on the psychotic mind. Using Bion, I built my chapter, "Men and Schizophrenia," which I was asked to write for the forthcoming Oxford Textbook of Men's Mental Health, part of the Oxford University Press imprint Textbooks in Psychiatry. The better known of Bion's essays, "Attacks on Linking" (1959), I now believe, is really the second part of, or a continuation of, his 1957 essay “Differentiation of the Psychotic from the Non-Psychotic Personalities.” The two really must be read together, and both are to be found in several places, but conveniently reprinted together in E.B. Spillius, ed., Melanie Klein Today: Developments in Theory and Practice, Vol. 1 (Routledge, 1988). 

But now we have new books on Bion, and in this case Donald Meltzer as well, with whom I was completely unfamiliar prior to reading Avner Bergstein, Bion and Meltzer's Expeditions into Unmapped Mental Life (Routledge, 2019). This is a very useful introduction to the two authors in the title, rendering Bion especially much more accessible than he was himself in some of his writings. The chapters on obsessionality, as well as on the psychotic personality, render Bion's thinking on both topics lucid and accessible without any dilution of their explanatory power. 

The final chapter, "The Ineffable," looks briefly at Bion's familiarity with both Christian and Jewish mysticism before arguing that "Bion seems to present us with non-religious mysticism": p.172), a judgment I would agree with. Part of what Bion appears to have taken from both of these mystical traditions is captured in his famously misunderstood phrase about refraining from memory and desire: "The psychoanalytic attitude, much like the mystical one, is a deliberate conscious act of discipline which depends on an active suspension of memory and desire" in order to exercise an "act of faith" that "truth exists" and can be discovered in the clinical encounter (p.166). 

Psychosis and Schizophrenia: 

While on the topic of psychosis, I must mention the following books which I have found not merely edifying but actively encouraging in what is so often a bleak landscape of poor and inadequate treatment and resources for psychotic patients: David Garfield and Daniel Mackler, eds., Beyond Medication: Therapeutic Engagement and the Recovery from Psychosis offers a number of essays from scholars and clinicians around the world looking at a range of options, while Therapeutic Communities for Psychosis, John Gale et al., eds., is looking at non-medical, quasi-institutional, but voluntary and community-based outpatient options for residence and care. 

Perhaps the best known (relatively speaking) example of this are the Soteria houses, which have fascinated me for some time. Only in September did I get around to finally reading Soteria: Through Madness to Deliverance. I find that I read all such books with a mixture of awe and respect for what was attempted but also some regret and amazement at how poorly supported such initiatives seem to be--and also with a wish that we might continue to build such places for there is a long track record and very impressive evidence base that they work. (See below for the evidence.)

I have a number of must-read books I recommend to other clinicians when they consult with me about working with psychotic and schizophrenic patients, starting with Michael Garrett and Andrew Lotterman's books. To that I will now insist on adding a third which, despite being the oldest of the three, is still incredibly relevant, timely, and useful: Michael Robbins, Experiences of Schizophrenia: An Integration of the Personal, Scientific, and Therapeutic.

Finally for books in this category we come to Courtenay Harding, Recovery from Schizophrenia: Evidence, History, and Hope. Please, please, please buy this book! I get nothing for saying that, and have never met the author, but I will hope for some small satisfaction that by encouraging a wide reading of this book then perhaps the long-standing, deceptive, indolent, and destructive narrative about schizophrenia that I first encountered in 1991 as an undergraduate, and which seems still to be propagated today to the detriment of many, may eventually die an overdue death. That narrative, of course, is the one that tells patients and their families that schizophrenia is a lifelong sentence of suffering for which there is no cure and which can, at best, be only partially ameliorated by neuroleptic medications (with notorious, intolerable, and sometimes irreversible side-effects). The fatalism and hopelessness in this narrative is just crushing to patients and their families, but it is infuriating to those of us who know that with the right treatment patients can and do get better!

That is not just an anecdotal claim based on a tiny, non-representative sample of one clinician, but has been backed up by empirical studies of hundreds of patients in different countries going back 75 years. It is to Harding's everylasting credit that she has tracked down patient records and long-forgotten studies of schizophrenic patients, including some of the most rigorous longitudinal studies we have of any psychiatric population, and published them in one place. In rendering so important a service to scholarship and patients alike, she has allowed us to see that, with multi-modal treatment, many patients have recovered. That is, three-quarters of a century ago now we already knew that merely medicating a patient is far from sufficient. Medication might be useful, but so too is intensive psychotherapy (see, e.g., Frieda Fromm-Reichmann's practice, or Harry Stack Sullivan) combined with vocational counseling, social supports, access to supportive, low-cost, outpatient housing, and a team of people (psychiatrists, nurses, therapists, social workers, dieticians, and others); but who today is willing to fund such treatments? 

How to Listen:

Salman Akhtar's short book, Psychoanalytic Listening: Methods, Limits, and Innovations is a wonderful addition to the literature, filling a gap that goes back at least thirty years. 

My debts to, gratitude and affection for, and frequent quotation of Nina Coltart are no secret. I have long maintained that nobody, in my experience, has surpassed her cogent description of therapeutic listening as a process of: 

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 Toward Bethlehem, 119). 

A little later in that unforgettable book she returns to all that is going on when the clinician is listening therapeutically:  

the need for consistent scanning and judging, not only of what the other person says, but of what we are about to say, and are saying; and with this scanning, the need for rapid continuous thinking, which may be only half-conscious; the need for repeated moral and technical decision-making; and yet if it is to convey truth, and more importantly, authenticity, in our style of speech we must also master intuitive, unlaboured spontaneity. This is an extremely demanding and complex requirement...[and]...it depends, for success...on...the combination of unselfconscious self-forgetfulness with deep self-confidence (Ibid., 145). 

Since reading this description of listening more than 30 years ago, I have found nobody who unpacked these dense descriptions until Akhtar's book, which is a gem. I now regard it as required reading for my students. 

It is not especially long, and it is written in clear, cogent, accessible prose with good but not overwhelming use of clinical illustrations. In addition, there is a commendable modesty in the author, who freely and frequently confesses his own errors about listening in the wrong way, or tolerating silence when speech was called for, or vice versa. He also notes, with admirable restraint, the difficult circumstances under which listening might and even should be refused--not least when outside of clinical contexts, when psychotherapeutic listening could be used manipulatively or destructively (he gives examples of doing this early in his marriage and watching how frustrating his family members found his doing so). 

In keeping with Coltart, he writes appreciatively on types of and purposes for silence, and he recognizes the degree of "faith" (also a concept Coltart explored in a non-theistic way) required to sit and wait, confident that if something is important, it will show up, and not once but repeatedly. Finally, he has some throwaway comments on several topics, including supervision ("supervision is more than teaching and less than treatment" he quotes A.J. Solnit's 1970 article in the International Journal of Psychoanalysis as saying). 

Laplanche, Freud and the Sexual. 

I have not read Laplanche nearly enough, and so on my last research trip to the library of the Cincinatti Psychoanalytic Institute, with less than an hour before I was to leave, I pulled all his books off the shelf, and slightly manically tore through them to decide which I really needed to read in a ranked order of urgency or importance. Apparently (this was 18 months ago now at least) I decided it was going to be Freud and the Sexual at the top of my list. Having just finished it, I must say frankly that I'm not sure what I saw in it. The book is a collection of articles on several topics, many of which feel quite like unfinished first drafts; much space is given to arcane arguments with translators of Freud from German into French and English; and when Laplanche finally turns to the topic of the sexual, his main insight seems to be confined to insisting that we should stop fighting over whether "instinct" or "drive" is the best translation for Freud's Urtriebe and recognize the utility of both terms in English.

On Buddhism and Philosophy:

Todd McGowan, Embracing Alienation: Why We Shouldn't Try to Find Ourselves is a new book that I read in January as presidential transition was taking place and a sense of alienation was mounting. 

I came upon McGowan close to a decade ago now in reading his book on the death drive. Enjoying What We Don't Have is one of the richest and most rewarding reflections on the death drive I have read in English. 

His new book on alienation makes the simple point in several places that by abandoning quests to find ourselves, or our "true" selves, we stop wasting time and energy that could be better put to projects of solidarity with each other in challenging the myriad instances of injustice in the world today. Embracing our alienation, in other words, has an "emancipatory quality" (p.7). In this way, then, McGowan manages to avoid the problem of a paralyzing despair at being alienated, and to avoid the temptation to fantasize about some prelapsarian paradise from which we are estranged but which we should struggle to find out way back to. There is no such paradise, McGowan says, and a good thing too.

The "alien" that we need to embrace is not some vague existential angst or a sense of estrangement we have from scrolling on social media and reading about all the horrors of strangers being snatched off the streets by fifth-rate opéra bouffe thugs in masks. The alien, rather, is within: it is our unconscious mind. As Freud first argued, and McGowan heartily agrees, each of us is alienated from ourselves. Our minds are divided and we live in a state of perpetual psychic alienation. If we stop fixating on "solving" this problem, and instead learn to forget our alienated selves, we will not only have more time and energy to work toward a better world, but we will also discover freedom and even some measure of happiness by focusing on helping others instead of chasing after our own "identity." 

And that word, in McGowan's hands, is clearly (and rightly) to be regarded as a bogus, deceptive, self-indulgent idol of our time, perhaps more than ever thanks in part to social media. Being preoccupied with finding and then defending our true "identity," McGowan shows through a close reading of Hegel, is actually a form of slavery we must emancipate ourselves from by learning self-forgetfulness. In doing so, he says in conclusion, "becoming reconciled to one's alienation is not a way of accepting oppression as inevitable" (p.148). McGowan's welcome book, then, is not a counsel of despair or an example of pietism or quietism, but instead a call for a new kind of politics. 

McGowan's theme of forgetting ourselves is also treated in several of Mark Epstein's books, which I have read over the past year, but these deserve a post of their own, so before Christmas I hope to offer some thoughts on Advice Not Given: A Guide to Getting Over Yourself and at least two other of his books. I have been propelled into an unexpected exploration of Buddhism and psychotherapy because of Nina Coltart's own immersion in that tradition as seen in her wonderful concept of "bare attention," an ascetical discipline (so I would say) we must all cultivate moment by moment and hour by hour with each patient. More on that anon. 

Overcoming the Super-Ego, Ego Ideals, and Blind Spots

I reviewed a manuscript for Routledge in July, and as always took my payment in the form of books, two of which have now reached me. I hope to finish the second book, Psychoanalytic Credos, and post longer thoughts on the weekend. 

I will offer just a brief note on the first of these, Vic Sedlak, The Psychoanalyst's Superegos, Ego Ideals, and Blind Spots (Routledge, 2019). My brevity is largely dictated by the fact that my academic year begins next Monday and thus my time is becoming severely compressed; but also because this particular book has a rather meandering style (which is quite charming and works well with the content) and largely covers some (to me) fairly well-known territory. So in lieu of a lengthy discussion I shall give you a summary in Four Theses:

1) Avoid Moralization: 

Those of us trained with some notion of "neutrality" or "abstinence" (as Freud sometimes called it) are familiar with the idea of not proferring opinions on controverted moral questions or on most aspects of a patient's life, and of not giving advice on, say, whether to marry or divorce or change careers. But Sedlak advocates going beyond this to say that while we all have moral views, and these are natural, we must do a better job of preventing them from sneaking in to the therapeutic relationship in order to judge, say, a patient's marital situation or sexual fantasies or other choices. The patient's unconscious can pick up on these judgments even if you feel yourself to be sedulous about keeping them out of open discussion. (As someone who works with adolescent and adult sexual offenders, as well as those plagued by sadomasochistic fantasies, I found this a salutary reminder and challenge.)

Moralization is the result of an untamed super-ego, and much of this book's burden is to call for the therapist to work not on the patient's super-ego in the first instance, but on their own, replacing some of its harsh moralizing with what Hanna Segal called kindness and respect. In doing so, Sedlak says, you will end up helping the patient moderate their super-ego as well. 

This is especially important when it comes to failures--our own, and those of the patient. Here Sedlak openly says we have to challenge ourselves to find a way of discussing such things--including therapeutic ruptures and mistakes--"without writing a morality play" (p. 64). We also--here and elsewhere--have to keep in mind that none of us is ever permanently free from the "daemonic power that can fuel one's sadism" (p.68).

2) Avoid Colluding to Exclude Hatred:

In a chapter with the striking title "Contemplating Analytic Failure," and later in another chapter "Hostility Terminable and Interminable," Sedlak, with commendable and not frequently encountered candor in other clinicians, tells us of a case which he regards as a significant failure on his part. It was a huge blind spot for him. (The theme of blind spots does not come up as often as I wished in this book.) In essence he colluded with a patient to keep anger and hatred out of the treatment, and to that extent failed the patient. He challenges us not to make his mistake. (He does not give much by way of practical detail on how to do this, alas.) 

He prefaces this by wondering aloud as to how successful Winnicott was in really tolerating the hatred in his patients that he is sometimes credited with doing. I also ventured some doubts about DWW on this very point nearly a year ago now. 

Here he cites familiar but disturbing data (from Linda Hopkins' invaluable scholarship) on how Winnicott failed to deal with hatred and aggression in Masud Khan, his sometime analysand and editor. (F.R. Rodman's biography of Winnicott, which in my view is far and away the best of the biographies of DWW extant, is even more critical of DWW's handling of the Khan scandal.) Perhaps if DWW had dealt more forthrightly with Khan, the latter's abuses of his patients could have been avoided. DWW seems to have also avoided treating hostility with two other well-known patients: Harry Guntrip, and Margaret Little whose treatments have been written about extensively in the literature.

Sedlak is under no idealistic illusions about handling anger, hatred, and hostility. He says it will require constant maintenance and monitoring by the clinician, and you should have no ego ideals about your own ability easily to do this, or about the patient's willingness to give up hostile or unhealthy attacks on you, himself, or the treatment. 

This brings us to our third thesis:

3) Always Examine and Restrain Your Ideals about 'Cure':

One of the things I first learned from the great Nina Coltart is that you really have to ride ruthlessly on your ideals and hopes about "cure." 

Coltart was also--more than Sedlak is in this book--quite open about advocating that you not only allow for aggression to emerge, but that you figure out a way to draw on your own aggression and use it productively. In this I think she goes somewhat beyond both Sedlak and before him Winnicott. I wrote about this here. 

Sedlak says that completely giving up ideals about curing your patient is not only impossible but also at least partly inadvisable. You may need them to keep you motivated during a tough slog. So you need your ideals, but you need to not be ruled by them. If you are, he warns in several places, your patient may pick up on this and hold you and the treatment hostage by refusing to get better. Negative therapeutic reation, he says, may come from a patient denying you the power to "make" them better. In other words, the patient will want from you a demonstration that you love them unconditionally--without them getting better first--and only if they obtain that will they then allow treatment to proceed. 

Quoting a 1978 article from D Widlöcher, Sedlak warns of how unexamined ideals can ensnare therapist and patient alike, leading to treatment collapse:

the more the psychoanalyst's ego is dependent on his own ego ideal, the more dependent he is on his patient, and conversely the more dependent on the patient he feels, the more he accentuates his dependence in relation to his ego ideal and reinforces his own superego demands in order to detach himself from this dependence--a genuine vicious circle which introduces the problems of narcissism into the...countertransference. 

4) To Suffer the Illness Rather than Suffer From:

With, it seems to me, Bion in the background, Sedlak several times says that one of the aims of treatment is to help the patient suffer the illness rather than suffer from it. He's not entirely clear on this point, but what seems clear enough is that you do this by accompanying the patient so that, as Bion noted, the painful and horrifying--and thus often psychotically warded off thoughts and memories--can now be endured ("suffered") precisely because there is another there to help you do so, thereby preventing you from being alone and suffering from the malady entirely on your own. "Suffering from," in other words, is solitary and miserable; "suffering" is with another, and to that extent potentially very powerful. (To be alone in the presence of another person, as Winnicott so memorably taught us, is an enormous developmental achievement and never to be taken for granted.) 

Michael Garrett on Treating Psychotic Disorders: Part the First

Back in the early summer, outside the pressures of the academic year, I ordered a half-dozen books on psychosis and schizophrenia, thinking, in my slightly manic way, that I'd have abundant time and energy to "read, mark, and inwardly digest" each of them in great detail (to borrow one of Cranmer's genteel phrases from my Anglican childhood in Canada that doesn't quite describe how I often brutally ransack books like some kind of shameless Vandal), and perhaps even to re-read some of them. 

Well that didn't happen, but I did make steady, though much slower, progress on two of them, including Michael Garrett's Psychotherapy for Psychosis: Integrating Cognitive-Behavioral and Psychodynamic Treatment (Guilford, 2019). xiv+354pp. 

Part-way through the book, I learned on Twitter that Dr Garrett would be leading a 9-hour training workshop on Zoom discussing cases and techniques--both CBT and psychodynamic--for treating patients with psychotic disorders, whom he has had some considerable success in treating over the decades. So I signed up, and just completed it with him in early November. It was very useful in all sorts of ways, and in fact the week after the first session, I had occasion to meet with a heavily delusional patient and the "peripheral questioning" technique Garrett described in both the book and the seminar were extremely useful in beginning to chip away slowly at the delusional thinking. 

What follows, then, are my initial thoughts on the first third of the book (I won't have time profitably and deeply to read the rest until my Christmas break) farced with some comments and examples of his from the training, and my thoughts in response to that.

Garrett endeared himself to me in the first paragraph of the first page of the book in which he said (with no false modesty evident here or in person in our seminar) that "I make no claim to have invented a new therapy." To which let all the masses say: Amen! Alleluia! Blessing and Glory and Thanksgiving Be to Our Author! Later, at the end of ch.1, he will further outline a second important caveat that "I make no claim that the approach outlined in this book will be useful with all patients" (p.26). 

Instead of attempting to invent something de novo, he says his approach in the book will be to "fix two existing therapies together" (p.1). This he does by drawing in a careful and respectful way on longstanding training in both CBT and psychoanalytic methods. For those who are immediately nervous about such an approach, which has been attempted in the past by some apologists for therapy "integration," and often seems to end up trying to jam (one is tempted to write repress) dynamic ideas and practices into a Procrustean CBT bed, rest assured this is most certainly not Garrett's approach. He is, after all, first trained psychoanalytically long before he did CBT training. And second, he's married to the incomparable Nancy McWilliams (to whom he dedicates this book), arguably one of the great psychoanalytic psychotherapists practicing today in the anglophone world, whose praises I sang here. 

Aware that pulling two traditions together, especially in service of psychotic disorders, may seem a tall order, Garrett rightly says that "psychotherapy for psychosis should be ambitious" (p.1, his emphasis), and a little later on notes that the lack of ambition means many, perhaps most, patients are drugged and given little beyond that to help. Their suffering is relatively unabated by clinicians who are not ambitious enough on their behalf, seeking little more than symptom control via neuroleptics.

Garrett's approach is, as noted, twofold, and in the book and seminar he noted that it is usually important to begin with CBT methods in the first phase of treatment to try to "examine the literal falsity of delusional ideas" before trying, via psychodynamic methods and theory (especially that of object relations) to "examine the figurative truth (specific personal meaning) contained in psychotic symptoms" (p.2). Garrett thus takes his place alongside others we have noted on here who believe that "psychotic symptoms are a symbolic expression of the psychotic person's mental life" (p.3). 

In putting CBT and dynamic practices together, he will later argue in the book that there are "many differences of terminology rather than substance" (p.24). His one caution about integrating them is again the timing, noting that a weakness of dynamic therapists is to interpret the unconscious meaning of symptoms too early in the treatment. Doing so before a well-established foundation of trust is laid means that the therapist is likely to fail to help for the simple reason that "it isn't a clever point of logic that proves the delusion wrong and wins the therapeutic day; rather it is the patient's trust in the therapist" (p.25). 

Also in the introduction Garrett notes that as a prescriber he is not opposed to neuroleptics, but he rightly insists we should be aware of at least two things: first, that "the longitudinal data indicate that in the majority of patients long-term neuroleptics do not restore premorbid functional capacity" and second that "some individuals can recover without medication" (p.4). If treatment should be ambitious, then it should be open to using drugs where necessary, but even more it should be committed to long-term intensive psychotherapy for the latter lacks the notoriously nasty side-effects of neuroleptics. 

To argue for such intensive therapy requires that we counter the "discrediting myths about psychotherapy for psychosis," which he does very smartly and without polemics or fireworks in the the last half of the introduction to the book. I will not repeat those arguments here for I am utterly convinced by them and would regard their demonstration as tedious. But for those who are less convinced (e.g., most of mainstream psychiatry it seems), this is important reading.  

The first chapter begins with challenging head-on another excuse for avoiding psychotherapy with psychosis: that it is too difficult. Au contraire, he says: "it is doable and is often no more difficult than psychotherapy with people who have severe personality disorders" (p.17). I would second this based on my limited clinical experience. I find psychotic disorders more straightforward than the histrionic and borderline conditions I have attempted, with little success so far, to treat.

The chapter ends with Garrett saying something that I find so refreshing about work with psychotic patients: their directness and earnestness. "When a psychotic person talks in earnest with a clinician, there is no idle chit-chat...[or] half-truths and social niceties....The conversation is densely meaningful" (p.26). I find this very true, which is why I find myself greatly looking forward to seeing my psychotic patients.

Ch.2: "Biological and Psychological Models of Psychosis" does not pretend to be exhaustive, but it is wide-ranging and fair-minded enough to give readers with little background a good introduction to various theories. Like other authors, he notes that psychosis often begins with a prodromal period in which things begin somehow to feel 'off.' (This put me in mind of Christopher Bollas' image of When the Sun Bursts which I discussed here.) 

The prodromal phase may, he told us in the seminar, be brought back to mind in taking a history by asking such questions as "have you noticed any changes in the way your thoughts come to you lately?" Often, he says, patients "hear" their thoughts more than think them per se. Often, too, this phase is marked by a more intense awareness of the environment--its colours are more intense, or its suns and planets (cf. Bollas) more prominent in odd ways. 

In putting this chapter together, Garrett ranges widely, back to Harry Stack Sullivan and Karl Jaspers. An important sign of this prodromal phase, Garrett says, may be found in patients who report no longer thinking their thoughts, but instead "perceiving their thoughts." This, to put it into Fonagy's terms, could be described as a collapse of any ability to mentalize. Or to put it in Lysaker's terms--with which Garrett shows some familiarity at several points in the book--we see the inability to engage in any sort of metacognition. (One of these days, dear longsuffering reader, I will get around to writing about Lysaker's very rich and dense book, which I read nearly a year ago now.) 

As for the question of how to define psychosis--is it a 'disease' that is 'other' than or radically breaks with, common human experience, or is it on a continuum (Ophir's book examines these issues with great skill), Garrett reviews the evidence that "roughly 20% of the general population report transient psychotic experiences of some sort, which indicates that psychotic states exist along a continuum with ordinary mental life" (p.46). I like to scandalize my students by following Bion and altering Freud's famous phrase to say to them that the dream is the royal road to the psychotic mind, and to the extent we all dream, we all experience our own 'psychotic' minds. If nothing else, this claim of mine usually momentarily rouses the sleepers and Instagramers in the back of the room to raise their heads to lodge some desultory protest ("Whaddya mean we're all psychotic?") I laugh at with a little bit of smug sadism. 

Ch.3 advances Garrett's argument that psychosis is "an autobiographical play staged in the real world" (p.58). As compelling as I found this metaphor upon initially hearing it, I challenged him (in an amicus curiae sort of way) in our seminar, saying that I found Bion's argument about "Attacks on Linking" very powerful, and to just that extent wondered how a psychotic patient could link together his or her life in such a way as to mount a play that an audience could follow with some coherence and facility. In our exchange, which was very helpful and cordial, he was able to 'rescue' the metaphor, as it were, by suggesting that the play might make sense and cohere, more or less, to the patient, but of course would do so far less to the 'audience' (clinician, etc.). The job of the clinician, then, is partly to help the patient recover the ability to make sense not just to himself but especially to others, thus overcoming much of the profound isolation that so often marks psychotic disorders. In other words, the recondite meaning of the psychotic play needs, via psychotherapy, to become gradually more and more apparent and understandable to others. 

Also in this chapter Garrett advances his argument that delusions of grandeur exist in part to "fend off self-hatred and shore up self-esteem" (p.68). Thus, instead of rolling your eyes (as Garrett of course rightly said in our seminar a good psychotherapist should not do) at a patient who reports being a messenger of the divine, or perhaps even God himself, we can instead see this as valuable material, testifying to how little self-regard the patient has for him/herself: the more grandiose the delusion, perhaps the more depleted the sense of self.

Following the same logic, MG later in this chapter says that command delusions point to ambivalence in the patient: if they are uncertain about about a course of action, the delusion might resolve this for them in a kind of 'absolutist' way that you can decipher to find the uncertainty behind it. In other words, the more demanding the delusion, the more there might lurk ambivalence and confusion behind it in inverse proportion. 

On the topic of delusions, our seminar noted that one key hallmark here is the background becoming foreground, and things usually not noticed in daily life (e.g., the particular colour of cars in a parking lot) become hyper-salient details, perhaps revealing hidden meaning (apophenia). In addition, any sense of self disappears into the background and thoughts are no longer something I have, but malignant and persecutory outsiders that come to me unwanted and unbidden. 

Finally for this chapter, MG notes that any thespian metaphors are time-limited and prone to instability: "clinicians should not regard psychosis as essentially a static mistaken idea or cognitive bias. Psychosis is more like an ongoing improvisational drama, with unexpected twists and turns in the plot and an expanding cast of characters" (p.82). 

In Ch.4 MG notes that an important thing to keep in mind is that figurative language is almost always replaced by very concrete language and metaphors. We will return to this point later.

Well, that's it for now. I hope to finish the book in December and post the next part then.

Musings on Reading Ogden

It was Adam Rodriguez on Twitter who convinced me to finally start reading Thomas Ogden. (At his recommendation I ordered Coming to Life in the Consulting Room and Rediscovering Psychoanalysis.) It is he who has further tempted (not convinced!) me to proffer, as he put it, some "primary process associations" in response to reading two of Ogden's books. This tempting invitation of his came in response to my saying I felt I needed to let these books steep for a few weeks or months, keeping silent about them. 

But, longing for a break from the tedium of marking nearly 100 mid-terms and essays, I decided to try to flesh out some reactions to Ogden. 

I am increasingly of the view that one is not ready for certain books until a certain time, which time may not be clear for many years, during which books will be attempted and abandoned. One is, moreover, going to read books differently at different periods of one's life, finding in some periods riches in the same books that were overlooked or unimportant on previous attempts. I've had all these experiences on several occasions. Perhaps the clearest recent example is finally being able to read some of Bion. I first learned of him from Nina Coltart, whom I started reading nearly 30 years ago, and to whom I now go back to regularly. Re-reading her is a wonderfully steadying but at the same time refreshing experience, not unlike re-reading Freud. 

Through Coltart, I quickly found my home in the British object relations and so-called Independent/Middle schools, where Bion looms large. But I simply could not make head or tails of the man until about two years ago, when his "Attacks on Linking" and his work on psychosis have proven extremely helpful in clinical work with both schizophrenia and an increasing number of cases of cannabis-induced psychosis. It was only after I started seeing psychotic patients that I could finally understand, almost all at once, what Bion meant by attacks on the links in the patient's mind, between objects, and between patient and psychotherapist. 

I tried, in a similarly desultory fashion, to read Ogden over the last few years. Given how many books he has published, I counted him a substantial figure and thought perhaps I might, some years hence, finally have time and feel inclined to tackle him, but his style, so far as I experienced it in one or two essays, rather put me off. 

Now, however, I am trying to rationalize blowing my remaining book budget for the year to buy all of his books. How can this be?

Firstly, the other clinicians I have found on Twitter have emerged in the last few months as a wonderful community from whom I continue to learn so much, and for whom I am so very grateful. So I trusted Adam's judgment enough to buy two of Ogden's books but then they sat on my shelf for a bit because I was uncertain of whether to begin them now or wait until I get some of the other half-dozen (at least!) books I have on the go finished first. Perhaps, I thought, Ogden really deserves to wait until the Christmas break when I'll have a bit of a clearer head. 

Once again clinical experience interposed itself and all of a sudden I dove in and read both Ogden books within a few days. It was a totally unexpected session with a patient that so deeply rattled me as to crack open some unexpected interior space to read and appreciate Ogden now. 

It was going to be a long five days until supervision the following week to process the session; but in the meantime--awkwardly, my super-ego evenly hovering with ever-attentive guilt at the ready for doing this because I have so many papers to mark and other books I should be finishing first--I found myself at first dipping into and then devouring Ogden's chapters in which he seems almost cheerfully to recommend doing something strange and admittedly uncomfortable: to "dream" the patient and the session, and to present both as a form of "fiction" ("Analytic Writing as a Form of Fiction"). Doing so, he hastens to add, is not a form of falsification, but arises out of the awareness that in sessions without notes or recording (neither of which I do), how do you present what happened afterwards?  

So I "dreamt" the story of this session several times on the treadmill in the following days, and it was very helpful to my own churning and processing of a session which, I said to my supervisor, felt very powerfully and disturbingly like my mind had been invaded in an attempted colonization. My counter-transference images in the session were of my first (last, and only!) MRI some three years ago, which was a nearly unbearable (and equally surprising) experience of captivity. 

The day after this exhausting session, another one with a different patient, I now see, also predisposed me to keep reading Ogden, especially his essay "Destruction Reconceived: On Winnicott's 'The Use of an Object and Relating through Identifications'." (Ogden's essay is masterful and deserves a response of its own. Perhaps I shall return to it again another time.)

I have read, and recently closely re-read, that Winnicott essay, but for all the warmth and light I constantly find in Winnicott, his essay is cold comfort when confronted with someone's vast reservoirs of white-hot rage. I need less theory here than Winnicott offers and more case material to see things in action. (I'm only half-joking when I say that as the product of a Canadian WASP family, mild irritation was the only permissible emotion tolerable in public display.) 

Winnicott, however, offers little of that here. Ogden, however, is more intellectually helpful. But surpassing both in concrete clinical helpfulness, to put it frankly, is being rooted in my own psychoanalytic therapy. My analyst's work with me is firstly grounding me, and then making me a more useful selfobject (to use the one, and only, bit of Kohutian terminology I even pretend to understand) by helping me to discover and create a deeper and wider inner emotional range (she's used the image of a metronome with me once and it's stayed with me as unexpectedly charming) in a quietly stabilizing way that allows for my working with, and not being totally swamped by, e.g., the full-force gales of psychotic mania and great masses of sadistic rage (and much else besides).

But to return for a moment to Ogden, I take him to be helpful to the extent that he suggests that what is destroyed by the child or patient is an image or illusion of the parent or therapist, and being able to sort this out and maintain this understanding is the crucial task during such destructive phases. This essay is so rich and inviting I could say much more about it, but I am now mindful of how long and ponderous and secondary-process-like this is becoming! That was not my intent at all here. 

I fear I cannot but do that in my own way of using, and using up, objects, including especially books. Else why have this blog? If nothing else, blogging is an exercise in indulging my "object hungers" as Sheldon Bach so memorably put it.

To avoid doing more of that here, I think I will just turn Ogden into a Magickal Aphoristical Cannon, shooting out bits that powerfully resonated with me and recording my most immediate thoughts upon reading them:

From Coming to Life in the Consulting Room:

Ogden: "We must invent psychoanalysis for each patient" 

Me: What a relief to know he does that so I don't have to feel guilty about having very different styles with each patient.

Ogden: "It is disturbing to recognize that, despite ourselves, we tenaciously hold to what we feel to be destructive aspects of ourselves, our internal and external parents, and of our social system and culture."

Me: Exactly right. This is why Freud first grabbed my attention in high-school, and why, for all its controversy, I still think his theory of the death drive has unmatched explanatory power. 

Ogden: "In dealing with the aspects of self that have been buried alive, it is of the utmost importance for the analyst to respect the patient's defenses."

Me: Yes. This puts me immediately in mind of Auden's lines from his panegyric for Freud where he writes of how Freud

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.

Ogden: "When I find myself asking questions that invite secondary process thinking on the part of either the patient or me, I pause to wonder, what is it about the unconscious aspect of what is occurring that is frightening to me?"

Me: Q.E.D.

Ogden: "It is incumbent upon me not to introduce or join the patient in 'parent-blaming'."

Me: Exactly right, and so important to remember with my adolescent patients where sometimes creating and having an enemy we can both hate is just a little too alluring, and a convenient way for me to collude in keeping the hatred safely out of the room. 

Ogden: "Psychic health, to my mind, is a reflection of the degree to which a person is able to genuinely engage in dreaming his lived experience."

Me: I'd get in trouble if I tried this regularly. Most people seem, when I ask about them, to regard nocturnal dreams, if they remember them at all, as some colossal irrelevancy and bizarre waste of time. How can I get them to dream while awake, to dream while in the session, to be curious enough about their day or night dreams to try to remember even fragments of them? American cultural ideals of productivity and efficiency are never so destructive as here, when talking about dreams.

And now for some from Rediscovering Psychoanalysis: Thinking and Dreaming, Learning and Forgetting.

Ogden: "I view it as my role to create...ways of talking with each patient that are unique to that patient in that moment....Talking with patients in the way I am describing requires that the analyst pay very careful attention to the analytic frame."

Me: I'm glad to know I do not have to achieve some weird scrupulous idea of 'consistency' with every patient as though we are in some manualized horror show. I'm also glad he mentions the frame here as that is so important, too, especially with this kind of freedom to be creative in each session. Gabbard's writings, which I've been reading on the frame and boundary violations, are now firmly impressed on my mind along with Ogden's.

Ogden: "It is at all times...the analytic task of helping the patient to become more fully alive to his experience, more fully human." 

Me: Yes! The spirit of Freud and Fromm lives on, and never more necessary in an age of 'skills building' and 'outcome measures.'

Ogden: "The analyst's ability to speak with humility from the uniqueness of his personality, from his own 'peculiar mentality,' lies at the core of what I am calling the analyst's style. It must be apparent by now that style is the opposite of fashion; it is also the opposite of narcissism." 

Me: What a relief! I know this to be confirmed by other research that your own style, and personality, can be a strength. Also humility, which seems to startle and even upset some patients when you tell them quite sincerely you are not an expert on their life and your job is not to 'fix' or 'cure' them. The longing for a guru is so strong in some people it startles and repels me. Perhaps I should do a better job of trying to get them to explore their longing for an authority figure to fix them? 

Ogden: "The analyst's task is first and foremost to allow himself to experience the full emotional intensity of all that he feels in the here-and-now of the analytic experience."

Me: Easier said than done! 

Ogden: "For many years I have enjoyed washing dishes."

Me: So do I! I think it's partly the same reason I enjoy cooking: it's something manual, which is so necessary when you're an academic and a clinician dealing with texts and abstractions and the unconscious world so much of the time. 

In conclusion, I've found Ogden a delightful writer in whom one finds much freedom to think and move. Doubtless I'll be returning to him again another time. (In fact, I had a recent relapse with my Visa card and two more Ogden books are arriving here Monday morning....)

A Brief Note on Bion's Los Angeles Seminars and the Problems of Memory and Desire

I tried for ages to read and understand W.R. Bion. His writing seemed so different from the very straightforward and concrete clarity of Winnicott or Coltart and others associated with the British independent tradition. Unlike them, he seemed to write in a cryptic, almost obscurantist way some of the time, reminding me much more of Lacan than of any anglophone analysts. 

When I finally did have some success in reading and appropriating some of what he has written, it proved to be enormously helpful for, e.g., treating schizophrenia, about which I wrote a bit here. His notion of "attacks on linking" is one I find myself calling upon and seeing more and more. Understood in the context of mentalization or metacognition, attacks on links in one's own mind become very problematic even outside of the psychotic patients Bion was focused upon. 

I also finally tracked down and read the original essay from which his claims about starting each session "without memory or desire" are so often extracted and often unhelpfully quoted. I wrote about that essay and book, Attention and Interpretation, here. 

Since writing that piece almost 2 years ago, I have had occasion to read his Los Angeles Seminars and Supervision, and at the very end is a reprint of the essay, "Notes on Memory and Desire" and then a slew of commentators taking issue with it, followed by his response. 

Respondents are therapists from England, Mexico, & the US. Their responses range from saying they find Bion's essay and idea utterly incomprehensible to a rather ambivalent and obviously shaky attempt to agree with him. One says perhaps we should merely regard the paper as "provocatively nihilistic" and that Bion's brevity and "aphoristic" style makes him very difficult to understand. 

Another said he was irritated by Bion, and ready to dismiss his idea but then a long analysis (7+ years, and this a second analysis for this patient) wwas stalled until the analyst abandoned his desires for the patient to get better and his memory of the treatment being in a quagmire, whereupon "to my astonishment, within a week, the analysis was revitalised with totally new and important insights appearing."

Others are much more critical and dismissive of Bion. 

He respond to them all graciously, admitting that his use of "memory and desire" was too ambiguous and he attempts to define these terms more precisely, but recognizing he's probably not going to do a good job of it. He also seems strongly to suggest doing all this only under supervision: "I must warn psychoanalysts that I do not think they should extend this procedure hurriedly or without discussion with other psychoanalysts." At this point he quotes Freud in a letter to Lou Andreas-Salomé, May 25, 1916: “I know that I have artificially blinded myself at my work in order to concentrate all the light on the one dark passage.” 

Finally Bion says nobody should abandon memory and desire who is uncomfortable doing so. I think here he recognizes that his own approach is very sui generis, making him manifestly uneasy with giving recommendations to others. That impression comports with what Michael Eigen and Nina Coltart have both said of him. Coltart, in the last interview she gave just months before her death, and published in Anthony Molino's delightful Freely Associated, said he was a "law unto himself" and that seems very clear here!