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. 

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. 

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.

Schizophrenia: Is the Past Prologue? Is the Future Condemned to a Repetition Compulsion of Failed Treatments?

Preface:

Every fall I teach my history and historiography of psychology course and for the last few years have struggled to help students come to understand that the history of any and every discipline is fluid and that certain categories and concepts--in psychology as in other disciplines--were not handed down on Sinai or at Delphi in a once-for-all manner eternally fixed and beyond us mortals to question. Ideas have a history, but such intellectual history properly so called is nowhere taught to undergraduates so far as I can tell. As a result, it is a real struggle for them to conceive of several things, including psychiatric nosology, as having a history. 

Additional complications abound: More than a third of our student body are nursing students, and so the perceived fixity of medical-diagnostic categories is a great comfort to many of them. But introduce to them the idea that psychiatric diagnostic categories do not enjoy just a biological basis, and are therefore much more fluid, and students are suddenly all at sea. 

I am hopeful that two new books might help us in this task of understanding the shifting history of diagnosis, and of nosology, starting with what has been called the poster-child for psychiatry, viz., schizophrenia.  

The first is Orna Ophir's new work, Schizophrenia: An Unfinished History. Just published last month by Polity, it is cogently written in a manner accessible to those with little background while also being grounded, in an unobtrusive way, in serious scholarship which is deftly handled. Because of these virtues, and because I cannot of course have my students read a history of every major disorder, and because schizophrenia is often described as the most serious and difficult concept and diagnosis in all of psychiatry and psychology, I have assigned this book to my students. I am eager to see what they make of it! 

Introduction:

In promoting her new book, the author recently published a short essay about it on Slate. As invariably happens, the title chosen by her editor and the spin given to the article immediately made Ophir's work sound more inflammatory and "radical" than I very much think it to be. And as also invariably happens in this social media age, people were immediately projecting into that article's title their own ideas and then criticizing Ophir for her apparent disagreement with them. It's all very tiresome. 

To come directly to the question thus raised on-line: does the author have an "agenda"? Almost certainly, but of which author is this not true? Is Ophir (a psychotherapist and psychoanalyst in private practice who also teaches at Cornell and NYU) crusading for the abolition of schizophrenia as a diagnosis, indeed even flatly denying that it is a disorder causing enormous distress for some patients? Not at all. (If she were, I would not assign such a book to my students because I would have to agree with a sentiment denied to me by my own private practice with psychotic and schizophrenic patients, whose suffering has stared me in the face.) 

These two questions cause enormous controversy: should the diagnosis of schizophrenia, which has changed greatly through five editions of the DSM, each of which she reviews carefully, as we shall see, be altered or even abolished? And should we make such an abolition because schizophrenia does not actually exist as a disease in the way we might say diabetes or cancer exist as diseases or disorders? 

Ophir handles both questions with skill and sympathy, after long reviews of the history and previous answers (going back to Greek antiquity, the Hebrew scriptures, the Latin Middle Ages, late Medieval and early-modern Europe and Byzantium, and right up through DSM-V). Her own highly provisional answers, are, to my mind, eminently defensible and worthy of ongoing discussion and debate. The singular virtue of this book is the author's lack of ham-fisted dogmatism in any of the matters she handles. Like a good psychoanalytic therapist, her practice of those sometimes misunderstood notions of "neutrality" and "abstinence" is well honed and expertly used throughout the book so that the reader never feels hammered by the author's views or compelled to agree with her. In that sense, her book is poor fodder for social media outrage and click bait, but excellent scholarship. 

As such, it will also give no comfort to those who wish to get up on their hind legs and shout at the rest of us--either in favour of retaining current names and nosology, or as a way of pushing for the abolition of the same. Ophir says--rightly--that all of us involved in these discussions should participate with humility and a lack of defensiveness (p.238), and we should be asking ourselves what the "prudent--indeed, ethically responsible" ways of proceeding are so that we do not leave people in the lurch. Even as we can see problems with current diagnostic criteria and categories, and even as we might want to change those, we must "acknowledge that so many of its elements, of its debris, and scattered building blocks...remain of importance for us" (p.239). Thus--as she concludes the book, perhaps a touch too neatly--she says that those involved in this discussion must ourselves be "of two minds" (!) in seeing what is good and conserving it, while discarding what is not good in search of better alternatives (p.244). 

Status Quaestionis:

But let us return to the beginning. The author begins by noting that for at least two decades now around the world more and more people have been wondering whether what we have (since 1911 only) called schizophrenia is in fact a distinct disease entity or not. There is not, she notes, any kind of objective test for it. There is no universal and unchanging agreement on what symptoms might--might--constitute sufficient evidence to make a diagnosis. Indeed, as she shows in detail, there is not even agreement on how to conceive of it in a basic nosological sense: should schizophrenia be seen as something radically other, a state or disease or disorder that in essence breaks with ordinary human experience and places one outside the realm of quotidian "reality"? Or is it a continuum on which people move around from time to time in life, never quite managing totally to leave shared human experience as they do? 

For some, she says, what are described as symptoms of that disease are, rather, "extreme versions of normal human experience" (xi). She here notes that some parts of the world--notably Japan, to which she will return late in the book--have attempted to take account of that and change the name from schizophrenia to something else, a move that a few other countries (also briefly noted below) have also undertaken. That global behemoth, the American Psychiatric Association, has, however, not followed suit even though it has been inundated with hundreds of possible changes to the name and diagnosis since the 1990s. 

History: From Ancient Israel through Byzantium and the Enlightenment:

Ophir begins the history section of her book (ch.1) with understandings of madness in Greek antiquity and in the Old Testament or Hebrew scriptures. Here she notes that for the latter text, the line between being cast as a "madman" and a "prophet" is vanishingly thin. The former is "other," likely under demonic influence, and often needs to be run out of town and destroyed. The latter, whose behavior is, curiously, often extremely similar to the former, will come to be seen--also after much suffering in many cases--as being divinely inspired and appointed rather than demonically disordered. 

She has a very brief section on this thin line between madness and sanctity in the Byzantine and later East-Slavic figure of the "holy fool," to which I have elsewhere many years ago paid not a little attention. Scholars of that phenomenon agree that it is never easy, and often impossible, to tell if holy fools are indeed "mad" in a pathological sense, or "mad" in the sense of being "possessed" by the divine and having a righteous mission whose oddness is reflected in the audience's profound estrangement from divine and holy purposes. Holy fools, then, are usually thought merely to look mad: underneath they are (ostensibly!) the ones who are truly rational in that they are at one with the Logos himself--though this is never demonstrated with complete certainty, leaving the figure a perpetually ambivalent and ambiguous one, which likely explains their enduring attraction. 

When she comes to the second millennium and the advent of what will come to be called the Scientific Revolution and the Enlightenment, Ophir notes that modern psychiatric nosology's problems begin here in attempting to pattern notions of mental disease after botanical classifications. At this point she introduces a metaphor that repeats regularly throughout the book: psychiatry's attempt to "carve nature at its joints." This, it will become plain, is--and perhaps only could be--a failed project. As she later puts it, "strictly speaking...there is no such thing as a single, stable object that corresponds to the word 'schizophrenia.' Rather, there is a complex description that has evolved through time (and does so to this very day)" (p.115). 

Psychoanalysis and Schizophrenia:

In her description of various ways over the last century to understand schizophrenia, the author tips her hand just a bit in the review of several psychoanalytic theoreticians, who include Freud and Jung. But Ophir seems to suggest that Melanie Klein's notion of splitting might have been, and yet remain, one of the most important theoretical concepts to help us conceive of what might happen in a schizophrenic mind. Others of note here include Harry Stack Sullivan and Silvano Arieti, who gets a very brief mention, along with equally brief mentions of Harold Searles and Frieda Fromm-Reichmann. But Klein predominates and of her Ophir says that she "does not see schizophrenia as a different natural kind or disease entity" (p.106). 

From here Ophir undertakes a careful, chronological review of each edition of the DSM.: Given the various axial configurations, DSM-IV could give us, she enumerates, 114 ways to be "schizophrenic"! For her DSM-V is only a slight improvement on this in some ways, but has other problems (p.148). 

Ophir's chapter on stigma--primarily, but not exclusively with schizophrenic patients--is very powerful and deserves much wider discussion than I will attempt here. There is one sobering thing she has unearthed that merits additional mention: she documents various ways in which empathy for severely mentally ill people can be increased in the general population, but a mere increase in empathy does not seem to correspond to a change in the problem of social distancing and isolation. In other words, I might learn to feel for and with "these people" but I still do not seek them out or necessarily want them around--a kind of very bloodless empathy. 

Ophir's careful handling of the Hearing Voices movement is fascinating and deserves deeper discussion. Equally fascinating were her reviews of the countries that have attempted name changes, including Japan (changed in 2002 to "integration disorder") and China. The new names are not without problems, to my mind, but Ophir does not really consider those. To be fair, I find it almost impossible to imagine that any change in nomenclature would not bring new or different problems. 

There is, however, perhaps one way around some of these difficulties, and here she quotes two British psychiatrists, Mohammed Abou-Saleh and Helen Millar, who suggested we simply rename schizophrenia "Kraepelin's disease" (p.226) on the same model of Alzheimer's disease (etc). On this point, see the recent and suggestive paper by two other British clinicians arguing we not quite jettison Kraepelin's categories just yet. 

Criticisms: 

It is never acceptable to fault an author for not writing the book you think they should have written, or for not writing a book they never said they were going to right in the first place. But it is entirely within the bounds of legitimate criticism, in the constructive and scholarly sense, to suggest that when an author says they will do something, and stresses the importance of that thing in the book, but then fails completely to deliver on it, that they be called to account for such a lacuna. And this is the case with Ophir, who more than once (e.g., p.242) says we must attend to forms of treatment for schizophrenia, but then signally fails to enter into any substantial discussion of treatments and their efficacy. Perhaps she lost steam, or her editor told her the book would be rendered far too long, if she also looked in greater detail at the history of treatments? I would not fault her for failing to do this if she had not raised hopes early in the book that she would attend in some detail to treatments, but does not. Overall, this is a rather minor weakness, easily remedied elsewhere. 

For such a remedy, we will have to turn to our second book, which does do this in some helpful ways, thus making this second book a very useful and important complement to Ophir's otherwise excellent text, which I am very grateful to have read and have profited greatly in doing so. It will bear re-reading and careful thinking about several important things. 

That second book is Matthew M. Kurtz, Schizophrenia and Its Treatment: Where is the Progress? To read this book with Ophir's is to find them very complementary. There is a bit of overlap in one or two areas, but Kurtz also goes much more into two areas that Ophir only skims: the results of decades of neurological research on schizophrenia, and how fascinating but largely clinically useless it has been; and then certain recent treatments--beyond psychopharmacology--that are showing promise in the psychotherapy of schizophrenic and psychotic conditions.

Kurtz is also, in both tone and conclusions, much less hopeful than Ophir is, and this is already telegraphed in his subtitle: Where is the progress, indeed, in treating schizophrenia? A cursory review of the data are not encouraging. We shall return to this later.

Kurtz says in his preface he will ask, and seek answers to, four questions, and he does this with admirable cogency and clarity throughout the book: what is the history of the category of 'schizophrenia' and how was it derived? What does neurology tell us about the brains of such patients? What does cognitive and affective science tell us about such a condition and its patients? And finally what psychotherapies are there that actually work? 

Already by the end of the brief preface, Kurtz says that "there remains no clear neural or psychological signature that is specific to the disorder of schizophrenia" (p.x). He hastens to add a little later--and will repeat this--that he is in no wise undermining or outright denying the idea that for some people this is a useful diagnosis. Kurtz is no anti-psychiatry radical--far from it: he attacks such zealots more than once (e.g., p.6). 

The first chapter is devoted to the first question noted above, and opens with some sobering statistics about how many homeless in the US are schizophrenic; about how the WHO lists "schizophrenia as one of the top 10 leading causes of disability among adults worldwide"; and perhaps most appalling of all, "rates of improvement have been less than 50% and largely unchanged since the 1890s"! 

From here Kurtz introduces an interesting discussion that Ophir did not: is schizophrenia actually one disease entity? He suggests that "there may not be a treatable core disease pathology in schizophrenia at all" (p.6). He will return to this later in suggesting possible reconfigurations in how certain symptoms might be considered and treated transdiagnostically. The chapter ends by asking how improvement in patients' lives might be meaningfully conceptualized and measured, and then how much (measured) hope we might have about possible progress and development of treatments. He cautions that any work on new or improved treatments cannot and must not be designed by academics and clinicians in isolation: here he nods to the Recovery Movement, and seems to agree with their slogan "no research on us, without us" (p.14). 

Chapter two is the most historical and usefully reviews several large-scale long-term studies in the US, including the Iowa 500 study, the Chestnut Lodge studies, studies in Vermont, and in Western Europe. He pays particular attention to the Chicago Prospective Longitudinal Study, saying that at the "15-year follow-up nearly half of the schizophrenia sample...had experienced at least a year of recovery" (p.23). The upshot of this literature review is his recognition that "it is clear from the data collected to date that initial conceptualizations of schizophrenia as a disorder that has a largely downward course is clearly not supported. Recovery is very much possible" (p.27). 

Ch.3 is devoted to the actual diagnosis of schizophrenia, noting that "the criteria for diagnosis...have changed radically over the past 100 years" before reviewing the five editions of the DSM and their indebtedness to Bleuler and Kraepelin. All this is situated within a broader context and wider consideration of psychiatric nosology. Kurtz says--somewhat staggeringly--of the early attempts to understand schizophrenia (roughly corresponding to DSM-I and DSM-II) that "accurate diagnosis was not seen as an essential first step for treatment" (p.44). 

The chapter that unfolds from here is not quite as detailed in some periods as Ophir, especially on Hebrew scriptures and Greco-Roman antique notions of madness, but it is still quite serviceable. It also includes gratuitous and amusing mentions (without, alas, elaboration!) of such things as "wedding night psychosis" and "masturbatory insanity" (p.37). When he gets to the 20th century and America, Kurtz is indebted to Richard Noll's 2011 book American Madness: the Rise and Fall of Dementia Praecox. Kurtz claims--based on Noll--that Kraepelin's classification scheme "took the United States by storm" and has exerted a lasting, and perhaps unduly strong, hold ever since. Others who have had influence here include John Feighner and Kurt Schneider, he of the (infamous?) first-rank symptomology.

The result of this lengthy and fair-minded survey is to claim that "there remains no reliable medical test for diagnosing schizophrenia or any other psychotic disorder" (p.52). But from this it does not follow that schizophrenia necessarily disappears as an actual disease: at most he says we can claim to have "modest evidence that an underlying disease entity might exist" (p.53). With equal care he ends this third chapter by arguing that "critiques of the category must balance calls for new nomenclature with the potential cost of losing a label that, with all of its limitations, rapidly identifies a group of individuals a large proportion of whom have profound disability and need for care" (p.58).

The fourth chapter reviews early (pre-revolutionary onward) asylums and treatments in the United States, including many things that rightly horrify us today. But he returns here to Bleuler and Kraepelin to make note that the latter "devoted only 5 out of 328 pages of text to treatment" and the former was little better: Bleuler's nearly 500-page text offered a scant 18 pages devoted to treatment of dementia praecox. 

Kurtz then looks at postwar developments, beginning, of course, with the invention in France of what became the first generation of neuroleptics. Psychoanalytic approaches get a wholly inadequate and totally unsatisfactory look-in here, along with R.D. Laing and Harry Stack Sullivan. 

Chapter 5 is devoted to biological mechanisms and the fascinating research that has been done here in the last several decades. Ch.6 is focused on the cognitive and affective dimensions of schizophrenia. This reviews data on neurocognitive functioning and testing before turning to recent attempts to theorize and treat schizophrenia as a disorder of self-cognition. This leads Kurtz to end the chapter with a brief look-in at a new approach developed largely here in Indiana with which I have some familiarity. 

This part of the book already needs updating in light of the ongoing research into metacognition, which is indebted to and very similar in some (not all) ways to Fonagy's famous mentalization treatments. Lysaker and others have been publishing at an impressive clip as they amass randomized control trials around the world to test their metacognitive approach, which is nicely outlined in the handbook linked at left. I have read it once, and want to read it again when I have time. 

Ch.7 looks at somatic treatments, reviewing the famous dopamine hypothesis and others. Along the way he notes what is already notorious: how huge numbers of patients in clinical trials discontinue their neuroleptics on their own because of absolutely intolerable side-effects. 

Ch.8 looks at psychological and psychosocial treatments of schizophrenia, and is perhaps the most hopeful chapter of the book. What Kurtz calls "evidence-based psychosocial treatments" include family interventions, social skills training, and CBT. He claims here, without any evidence, that "in recent years, the psychoanalytic approach has been supplanted by CBT." 

I do not buy that and the history does not bear Kurtz out on this. There are dynamic psychotherapies being successfully used right now, including those I discussed in some detail here, here, and here; and those developed by Andrew Lotterman; and then mention must also be made of the integrated approach of Psychotherapy for Psychosis: Integrating Cognitive-Behavioral and Psychodynamic Treatment by Michael Garrett. Still others could be mentioned, most notably and encouragingly those outlined in Downing's invaluable book. 

The chapter ends by noting--too briefly to be helpful--that international models, including that of Hans Brenner in Switzerland, might point the way to show us what future therapeutic models need to include. Kurtz then moves into a very brief epilogue where he laments the "profound lack of services available to so many people," especially in the US (p. 183) where "the science-to-practice gap has vastly widened" and where there is an appalling "absence of even minimal housing and institutional supports for people with schizophrenia" and equally appalling "very low rates of reimbursement provided for treatment of the...severely mentally ill" (p.184). 

Taken together, both of these are carefully written books by Ophir and Kurtz who have judiciously weighed competing theories and evidence, and done so with real concern for suffering human beings. They are not anti-psychiatry zealots, nor blind apologists for biological psychiatry either. Both books overlap but only modestly, and thus both books must be seen as more complementary than anything. Both books are at their most useful in reminding us of the appalling long-standing gaps in treatment and the fact that far from making progress, treatment seems to be stalled or even regressing (where, that is, it even exists at all). There is much work to be done if the past is not to be prologue to a future of continued, repeated failure.