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.) 

Harnessing--And Using!--Your Aggression in Psychotherapy: A Catena of Clinicians

Preface: 

There's a great bunch of psychotherapists on Twitter from whom I continue to learn much. The discussion over the past few days has been about clinicians who comfort but do not challenge; who soothe but never summon up the guts to push patients to change. This has made me go back and revisit some thoughts on here written over the past few years.

My love for and debts to D.W. Winnicott should surprise nobody who reads anything I write. Using his thrilling 1947 paper, "Hate in the Counter-Transference" with students ignited some of the best discussions I've had with students in a quarter-century of teaching. All credit should go to him for advancing the discussion of counter-transference (then still undertheorized) in general, and in particular for his blunt acknowledgement that parents hate their children just as therapists hate their patients sometimes, and both are not only normal but sometimes even justified.

But I'm increasingly coming to question aspects of his paper that might--however inadvertently--reinforce the notion that psychotherapy and psychoanalysis are never about direct challenges to the patient but consist largely in soothing and comforting. This is a point Jonathan Shedler has often made on Twitter, and I am very grateful that he keeps making it.

My rethinking of Winnicott is inspired directly and recently by reading Karen Maroda's new book, which I discussed in some detail here. The most memorable line in the entire book comes quite late: "we need a statute of limitations on this holding and nurturing behavior" (p.197) among psychotherapists who do not sufficiently challenge their patients nor engage in healthful, careful conflict with them en route to their actually changing, getting better, and eventually going away.

Maroda says that we need, as psychotherapists, to learn how to engage in "constructive conflict" with our patients (p.106) and what she later calls "creative rage" (113). As she will caution in a later chapter on enactments, "there is no simple answer to this question" of "how do we harness negative countertransference emotions in the interests of furthering the treatment?" (p.129). 

I took Maroda's challenge in that book as something of a rebuke to misreadings (or, perhaps better, misapplications) of Winnicott. For all his courageous and welcome bringing out of hatred from the closet, Winnicott's treatment of hatred in that essay no sooner brought it out before domesticating and stuffing it back in the cupboard again: E.g., early on he says that "hate that is justified in the present setting has to be sorted out and kept in storage for eventual interpretation." 

I do not find much in the essay to indicate that hatred became a present, this-day object of discussion with his patients: it is either always locked away for future interpretation or else, when it appears on the scene, is described as something in the past, safely overcome and no threat to patient or therapist right now: E.g., he writes that "It was indeed a wonderful day for me (much later on) when I could actually tell the patient that I and his friends had felt repelled by him, but that he had been too ill for us to let him know."

Winnicott goes on to give a rather nervous list of five reasons how and why analysts will of course keep their hatred on a very short leash in "ordinary analytic work"--in contrast to that with psychotic and anti-social disorders, which is his primary focus here. Most of the time, he rather blithely says, analysts will see that their hatred is "easily kept latent." 

But then all of a sudden he immediately shifts into saying that patients need "objective" hate and need to be able to access it in the therapist. I regard this sentence as the pivot of the article and indeed its most important claim:

If the patient seeks objective or justified hate he must be able to reach it, else he cannot feel he can reach objective love.

He must be able to reach it! Just when readers like me are starting to wonder about hatred and aggression being too domesticated, Winnicott brings us up short with this reminder: your hatred might be safely stored away for future use, or as a relic of past feeling, but in fact you need to have it in the therapy with your patient who needs it now. You might, in other words, have been amply supplying a lot of soothing, comforting "love" of some sort, but without feeling and accessing hatred, how much of that love you think you are offering is really being received and used well? (Indeed, that "love" you are offering might itself be fueling deeper hatred, or at least fear and anxiety, in your patient! Certainly there seems to be some evidence of this being true with psychotic patients.) 

Winnicott in this essay does not really offer specifics about handling hatred and aggression, but his final sentence is a severe warning that avoiding the use of hatred and aggression may well lead to treatment collapse: "Only in this way can there be any hope of the avoidance of therapy that is adapted to the needs of the therapist

rather than to the needs of the patient."

So let us say--as all good clinical practice demands--that the patient's needs are paramount, and yet one of those needs is to be challenged to change and grow, not merely to be soothed and comforted. They might hate you (at least right now) for your challenge to them to change and grow, and their hatred in turn might spurn your own hatred in the counter-transference. Without having had in-depth therapy of your own, can you handle this as a clinician? Can you be courageous enough to challenge and to hold the line when the patient resents or hates you for it? Or will you--as research suggests--revert to the familiar and familial role of comforter which many therapists learned to play as children with psychologically damaged parents?

I know I am not very good at this, but am constantly trying to learn to be better at it. But instead of just trying, as Winnicott suggests, to contain that hatred for future use, can you canalize, capture, or harness some of it for sound and careful clinical use in the here and now? 

Winnicott seems to imply that you can without showing how. So here is where I turn once again to Nina Coltart, that most independent-minded and bluntly outspoken of all the British analysts of the post-war period. With characteristic brevity and boldness, Coltart says a therapist should "harness our aggression skillfully in the service of clinical work" and that so doing is a "strongly positive factor" which patients will welcome. But such skillful use requires work in and by the therapist on him/herself so that it is done without fear or anxiety. (Famously or perhaps infamously Coltart gives an example of her using her own hatred in a very spectacular way with one patient who was, she said, utterly sabotaging treatment. Her outburst with him turned things around.) 

The other person who has done even more work than Coltart on this topic is Michael Karson (whose book is discussed in more detail here) Do not, he says, be that doctor who enlarged his practice by only pleasing, and never challenging or curing, his patients! You're going for patient improvement, not patient satisfaction. 

Karson says you do this by getting in touch with your aggression. One way you can do this, he suggests, is skillful use of interruption: "Good therapists are constantly disrupting their patients' master narratives" (6) and as a result are not in the business of merely supplying a comfortable environment to vent. The problem with merely being a person to whom I can comfortably complain is that "comfort seeking impedes growth" (7).

Rather than merely providing comfort, your job is to challenge patients and their faulty narratives. You do this by something that Karson later calls virtuous aggression (29). He gives such examples as challenging bad ideas, collecting the fee, and ending sessions on time. "These things all injure patients, as they should."  There is no point pretending otherwise. 

I admit I found that last bit very refreshing and straightforward. To drive the point home further, Karson says: consider the surgeon. He or she would not deny that cutting someone open and removing and replacing an organ is not injuring them in service of a cure. Would he or she flinch from saying: I have this slot on the surgical theatre's schedule, and these many minutes, for the procedure, and at the end of it, I am getting paid? 

Later in the book Karson says  too many therapists tiptoe around and try to avoid conflict. Bluntly he insists that "the overarching lesson about conflict in therapy is that it is better to approach conflict than to avoid it" (90). In fact, you cannot avoid it for "rupture and repair" always happens in therapy. If you are distinctly unc0mfortable with such things, and if you aren't comfortable making mistakes and then examining them, you have no business being a therapist. 

Some--perhaps much--of this is not necessarily sophisticated. Some of the conflicts that should not be avoided are around age-old things like the frame and the fee. Karson stays that to start and end on time regardless of joy or sorrow says that all is welcome here to be treated equally. It also refuses to infantilize the patient, and says that you have hope and confidence in them to be able to handle themselves and move on with their day. As Karson says, "patients need therapists to be not only loving but also strong, and time management denotes strength" (124). So whether in laughter or tears, the session ends on time.

This all still sounds a touch too abstract and theoretical. I am, as noted above, far from an expert on these matters, but as someone who has had to learn, and is still learning, to observe that statute of limitations on all this comforting business, and to become more comfortable challenging patients to change, I will continue to read on and think about these things. 

In the meantime, I can report the following have been helpful to me when tempted to collude with patients seeking comfort over change. This is far from a rigorous and tested list! It merely represents some very modest gleanings from that "constant feedback loop" which Shedler talks about in psychotherapy: I have tried these things and found them useful. My samples are very small and not verified by anybody other than my supervisor, and I do not suggest these are the only, or even best, practices: merely what has worked for me in particular sessions. 

With delusional and histrionic patients: Indirect challenges seem to bear more fruit. Frontally challenging deeply held ideas, in my experience, results in easy deflection and dismissal of the challenge. Looking for underlying components, and assessing their relative strength and importance to the patient, may direct you towards the proverbial Achille's heel which, when pressed upon, may yield in the direction of conceding something to be untrue and thereby moving closer to reality. 

With deeply sexually traumatized patients: I have had blunt discussions with such patients about the idea of a frame and how that--far from being a sign of my lack of care when I do not extend sessions, or have sessions with them over coffee in a shop of their choosing--is a protection to them, and a reminder to us both that we are here to do work and not merely commiserate. 

With psychotic and borderline patients: One thing I have learned from both mentalization and metacognition approaches to therapy (for the latter, see the MERIT approach in this book, which I have read but not written about yet) is that providing an environment encouraging unstructured and completely free association may be counterproductive. Rather, ask them early in the session what they want to work on that day, and then keep challenging them to return to that. (Stated differently, I have learned from my own psychoanalytic therapy that free association can itself be a defense mechanism! I ran out the clock on one session with almost sadistic glee wildly and knowingly associating all over the place to a rather unremarkable dream I had in order to avoid talking about something difficult from the previous session!)

With enmeshed and abused adolescents and adults: I've learned to challenge their near-constant deferring to the dominant authority figures in their life even though this makes them acutely uncomfortable. I could have colluded in keeping them comfortable but instead I would gently but repeatedly press, "But what do you want to do?" until I got a first-person answer that seemed genuine. (This requires careful handling, of course, so that they do not merely shift their submissive instincts from parents to you in a fairly obvious transference.) They were awkward and uncomfortable finding their voice, but once they had voiced their own views and desires, the relief and sense of increased autonomy was palpable.  

This approach reminds me that I have found the use of questions, rather than statements, and these delivered in a gentle tone with as much curiosity as possible, will almost always go farther with the patient in inviting open reflection than declarative statements. (I wish I could do this as well as my own analyst, who has this incredible capacity to deliver a simple question--"I wonder why that is?"--absolutely saturated with curiosity.)

With just about everybody: Thanks to Adam Phillips and--as we saw above--Michael Karson, I find myself routinely challenging master narratives. If you listen carefully (that third ear!) you will hear patients switch registers or voices, and give you material that is clearly a "received notion" (from family, typically). I regularly ask "Whose phrase is that" or even more bluntly "Says who?" if they give me something like "I know I am a real pain" or "this is such a stupid thing to bring up." 

I especially do this with patients who come in pre-loaded with diagnostic terminology: "I'm very OCDish" or "my mother says I'm bipolar." I always invite a deeper discussion here about what that label means to them, or might mean, and about the larger meaning of a diagnosis as such. Some find it welcome relief after a period of uncertainty; others find it a prison and stigma to bear. 

A few other thoughts: if I can feel (as my grandmother would say) when my dander is up in a session, I find myself returning to Winnicott to ask: does this aggression need to be held for another time? Or (with Coltart et al): Can I safely draw on a bit of it now in a productive way? If I feel I cannot--if I feel I might lose control and say more than would be helpful--I keep silent and process it in supervision. This does two things: it allows someone I respect hugely, who has had a wide and varied practice of 40 years, a chance to weigh in; and it also gives me a cooling-off period. Then when I go into the next session, I can, more coolly and with greater precision and control (and thus comfort!), talk about the previous session and open with the challenge. I try to do this right at the outset of the next session (as I also try to do if I feel there has been a rupture or I've made a mistake) so that I do not lose courage and dither!

Karen Maroda on the Therapeutic Relationship

I've previously read some of Karen Maroda's work and found it helpful. I've just had a chance now to finish her 2012 book Psychodynamic Techniques: Working with Emotion in the Therapeutic Relationship and found parts of it very helpful and insightful. Herewith some notes on it:

Figuring out Fit:

She begins in a way that puts me in mind of the great Nina Coltart, whose Slouching Towards Bethlehem talks about how to figure out whether you and a new patient are a good match, and how to figure out when to refer to someone else. Thus Maroda writes of what to look for: "Ideally a good match includes compatible styles of relating--just enough shared early emotional experience to make for a connection, but not so much as to blur the distinctions between therapist and client" (p.7). This might still seem a bit abstract so she has some even more practical counsel: Watch how you feel when the prospective patient walks in. What does your gut say? If you have an instant and strong negative reaction that does not abate, that is a strong sign not to be ignored. 

Do not, she goes on to say, tough it out and assume initial dislike will go away or be surmounted in an heroic burst of empathy: this almost always fails. Remember, she continues, that "it is not a good idea to engage in therapy, even short-term work, with someone you are either not interested in or dislike" (p.8). If therapists attempt to engage in such work anyway with people "who do not elicit their curiosity and whom they do not like [they] are doing an injustice to the clients as well as to themselves" (ibid).  

What, then, to do? Refer, of course, and do not be reluctant or neurotic about it. She says that while you might feel uncomfortable broaching the topic of a referral elsewhere, you should "keep in mind that if you know this person is not a good match with you, at some level the client knows it too" (p.11).

Mining the Intake's Several Veins:

Maroda reviews the data we are all familiar with, showing that drop-out rates are high, and this often occurs after a handful of sessions. Why? One reason she highlights is a rupture in the alliance, which never really had a chance to get off the ground, and this may be due in significant measure to how you conduct your intakes: do not, she says, put people off by taking notes, a principle I first learned from Coltart who is adamant about never taking notes with a patient in the room, which practice I also abhor. 

Maroda further says that you need, in that crucial first interview, to avoid asking rote questions, dealing extensively with insurance, etc. Your job is to help them get comfortable ASAP to start talking about themselves. To put it crudely--which she does not, but which I have heard others say--the point of the first session is to have a second session. 

As you are further considering fit, and whether this prospective relationship has any chance of success, Maroda recommends that you ask about the patient's existing and past relationships: the patient without any, especially sustained over the long-term, is a very poor prospect for successful therapy.

Don't be so high-minded during the first session to overlook the more mundane factors revealing much about the person and the prospects and direction of therapy. Here she says that much is revealed in the first session by such things as how they first greet you--she comments on the quality of handshakes, which apparently used to happen back in those pre-Covid days we can all scarcely remember now--and how and where they sit, whether they make eye contact, etc.

Once you agree to begin treatment, do not leap in too far and too soon and so overlook the importance of educating new patients on therapeutic process: let them know that "what they defend against feeling is exactly what they need to feel to get better....Paraphrasing Winnicott, I say that we always fear most what has happened to us already" (p.20).  

Don't Overdo the Empathy:

Maroda makes an almost off-hand comment that reminds me of much of what I have been reading recently about working with psychotic and schizophrenic patients: there's such a thing as too much affirmation and empathy. She says that if you have people who have difficulty accepting empathy, she advises that "the fewer words the better, and the less dramatic the better" (p.20).

Confrontations:

I really liked Maroda a lot for calling us out on how poorly most of us do with confrontation. I know this is a weakness I have to watch out for and am working on. Once again she puts me in mind of Coltart, who writes about the one and only time she "bawled out" a patient for what she said was a sustained and lethal attack on the treatment and relationship. This startling and singular action turned out to be the pivotal moment needed to prevent outright treatment collapse. 

Maroda notes that most therapists never learned how to do confrontation well. She illustrates this nicely with a story about how she confronted a man with herpes who slept around and put a lot of people at risk. In confronting him over this she diverged from what she says is the problem whereby "too many therapists masochistically submit rather than risk real emotional vulnerability" (p.191) which confrontation, done well, invites.

Dealing with Anger:

In this part of the book, she makes an obvious point that nonetheless needs stressing: Don't become a martyr by sacrificing yourself unduly as it only breeds fierce and seething resentment. I've learned that the hard way! 

We must respond to angry outbursts and not just suck it up in silence for, she insists, "no therapy is taking place when the therapist pacifies or silently withdraws from an angry client" so don't just sit there and let them rant at you! Instead, you "should struggle hard...to get out of the position of masochistic submission". A failure to respond will usually make the patient either contemptuous or feel hurt and abandoned. Find your own voice and style to respond, but respond. These can be moments of deep change because deep emotions are engaged (p.193). 

Hatred in the Counter-Transference:

I have often quoted D.W. Winnicott's 1947 paper "Hatred in the Counter-Transference" but Maroda is right to remind us that "we have given short shrift to the benefits of acknowledging anger and hatred in the countertransference when a stable, positive attachment between therapist and patient exists." As she goes on to note, DWW's classic paper is cited here, but rarely developed, discussed, or implemented.

If you are going to do this, and the relationship is stable and positive overall, try, before expressing anger, to verify whether the patient has any sadomasochistic relationships in the past or any personality tendencies in either direction. If they have pronounced masochistic tendencies, your getting angry may be an unwittingly gratifying thing they are seeking. Finally, ask yourself if you are feeling the need to punish the patient before you say or do anything.

Overall she offers the following concrete guidelines:

• be reasonably in control while manifesting emotion
• direct, honest, and non-defensive anger is what you are aiming for
• admit if you did something to make the patient angry
• don't get snarky or passive aggressive. Say something like "I'm getting tired of your insults and anger and I won't tolerate them any more. What I want is for you to talk about what lies behind those angry insults."

The Importance of Gratification:

Finally, Maroda has some very welcome words that bring out the importance of gratification and stress that it is not something therapists should be ashamed or embarrassed about. She notes that some gratification is not bad but in fact necessary to keep the relationship moving forward. As with the ideas developed at the outset about determining fit, you need to work with patients who interest you and whom you find it gratifying to help. 

This is, of course, as she says a "delicate balance" because you can never be totally gratified: that must always be denied to both patient and therapist alike--even as you pursue the limited gratification appropriate to your respective roles (p. 211). She refers to Searles here who freely admitted that he felt at least a little bit in love with every patient at some moment, but he never mentioned this to them or acted on it: here, Maroda observes, is someone who had good affect management, which we should aim for as well.