Optimal Responsiveness: A Short Note on Howard Bacal's Book

I begin with a confession: So much of what many authors in this collection, and above all the rather self-impressed and heavy-handed editor himself (who not only writes an introduction to the book, but also superfluous and sometimes condescending introductions to every chapter, including the two chapters he himself wrote) are enthralled with (viz., the concept of optimal responsiveness) seems very commonplace to me now. To avoid such impatience on my part, I had constantly to remind myself while reading Optimal Responsiveness: How Therapists Heal Their Patients, ed. Howard Bacal (Jason Aronson, 1998) that a quarter-century is a very long time in psychotherapeutic history, and that in 1998 when the book was published (and in years earlier in that decade as these chapters were being written) the things we take for granted today--being on this side of the rise of two-person, interpersonal, relational, and self-psychology changes in our theorizing at the hands of people like Thomas Ogden especially--were, in fact, rather novel. 

But I firmly believe books have to be read in their original context as well as our own, and so I can see how valuable many of these chapters may have been 25 years ago. And, as I shall briefly show, some of them remain very valuable today.

For me, the largest overall value comes from how much of self-psychology, including Kohut's writings themselves, this book very skillfully manages to make clear. In doing so, it helps me finally find valuable material in him after struggling for close to a decade to read him, including a stint in 2018-19 when I was on a fellowship at his very own Chicago Psychoanalytic Institute, some of whose analysts on faculty also admitted (sotto voce) they could hardly understand his leaden and jargon-riddled Teutonic prose.

The book's virtues extend beyond making Kohut generally clearer into showing some key parts of his thought that are of direct clinical use to me in one of my hardest cases. I always remain grateful to authors who give practicing clinicians ways of reconceptualizing a case and adjusting their techniques for trying out in that ongoing feedback loop that Jonathan Shedler memorably talks about. 

Bacal's opening chapters lay out the idea of "optimal responsiveness" which seems to have begun as an explicit challenge to very early ideas of "optimal frustration" of various drives. Two of the chapters do an excellent job laying out the genesis and historical development of this latter concept from Freud who seems to have been reacting not just to patients but also his rather more careless colleagues, not least Jung and Ferenczi who instead of frustrating or denying patients' desires for more intimate contact, indulged those to sometimes disastrous effect. 

Bacal argues that "optimal" does not mean perfect, but means instead means "most favorable natural conditions for growth" and thus can include all kinds of responses by the therapist in the moment. Thus if the patient needs you to be mirroring or affirming, you do it; if withholding is indicated, you do that; if something needs to be directly challenged rather than "contained" then you do that. In some ways, as I noted above, this idea of such flexibility is more commonplace today than it seems to have been in the 1990s, when Bacal wrote that "optimal responsiveness of the analyst is determined by the position of the patient on the developmental line of self-selfobject relations, and on his position on the developmental line of internalization of, and capacity for, empathy" (p.32). 

Overall several authors in the book usefully reminded me that in some cases with serious developmental deficits, there are in essence holes in the internal self-structure and until and unless these are repaired, or at least attended to in the best (optimal!) way, little progress will be made, especially if the idea of progress is heavily insight-dependent. Thus Kenneth Newman's chapter (drawing on Winnicott's famous essay "The Use of an Object") reminds us that some patients cannot use the therapist adequately when they have such deficits (I immediately thought here of obesessive-compulsive personality disorders, about which I wrote at some length here, and Shedler brillantly discusses here). 

I joined this up with a much later chapter by Lynne Jacobs who offers a helpful caution that some "patients need to forcefully blot out the subjectivity of analysts in order to ensure that there is room for their own" (p.200). A little later she says that sometimes with some patients (and I again think of OCPD patients here) the therapist's independent existence needs to be "sturdy enough to be left in the background for long periods of time, to be refound at a later point unharmed and available for engagement" (p.201). 

In other words, to use a famous passage she does not quote here, therapists themselves need to remember that it can be a "joy to be hidden" and is not necessarily a disaster not to be found (for a while!). 

On Treating Obsessive Compulsive Personality Disorder

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

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

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

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

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

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

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

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

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

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

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

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

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

        Mirroring:     To be recognized

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Self Psychology and Psychosis

While looking for something else--as so often happens--I stumbled upon this useful little book by Ira Steinman and David Garfield: Self Psychology and Psychosis : The Development of the Self During Intensive Psychotherapy of Schizophrenia and Other Psychoses (Routledge, 2019), 192pp.  

Steinman (whose website is here, with some excerpts of his writing) trained with R.D. Laing and for a time worked at Chestnut Lodge. Garfield is also a psychiatrist and psychoanalyst, recently retired from the Chicago Psychoanalytic Institute. Both have teamed up to write a book that usefully agrees with other similar treatments, including those of Atwood and Bollas, already noted on here, and then especially with Bion in particular. At the same time, however, this jointly authored effort also differs from other treatments in bringing to bear aspects of self-psychology, most of them drawn from Heinz Kohut. 

I have several of Kohut's books, and have struggled to profit by them. The fellowship I did at the Chicago Psychoanalytic Institute in 2018-2019 helped break down some of his thought and make it somewhat more clear; but one always feels the need to keep a glossary close at hand because he uses, in some cases, ordinary language in quite singular ways and it is easy to misunderstand him when he does this. 

Since I'm mentioning him, let me also put in a plug here for Charles Strozier's excellent biography, Heinz Kohut: The Making of a Psychoanalyst, which I read several years ago. I owe several intellectual debts to Strozier (a Harvard-trained historian as well as practicing psychoanalyst), who was very kind in sending me drafts of papers and reviewing some of mine. It was also he who introduced me to the invaluable work of Vamik Volkan, whom I have previously interviewed on here, and whom I will again interview early next year when his new book Schizophrenia: Science, Psychoanalysis, and Culture appears, jointly authored with his son. 

But back to Steinman and Garfield, and their useful contribution to the literature. They begin with a few caveats we would do well to recall:

Some Initial Caveats and Requirements:

First, psychosis is not a unitary phenomena. Patients still retain all their uniqueness here as elsewhere. So do not make lazy generalizations, assuming that you've "seen it all before." Equally, do not assume that some successful piece of work in the past may stay in the past, or some issue you feel the patient has overcome will not re-appear. Here both authors remind us of the basic principle Freud first articulated: in the unconscious mind, there is no time. And schizophrenia is especially adept at destroying a coherent sense of temporality. 

Second, at every stage as you are working with these patients, the key thing is hope. If you can confidently but carefully cultivate some hope, that will aid both the working alliance and also the overall progress and prospects of the therapy. 

Learning to Speak Schizophrenese: 

These two authors echo what others have said about making the effort to understand the patient's use of language and symbolism, and impairments to the same: "One extremely important factor in my work with very disturbed people is the importance of understanding a patient’s symbolism, as contained in hallucinations and delusions. A good working alliance aids in helping the person make sense of confusion and distortions of reality. The closer one gets to the 'lost heart of the self' the easier it is to make sense of previously indecipherable and upsetting material" (p.xxi; the internal reference is to Guntrip).

Whereas some clinicians have dismissed, often patronizingly (as I have heard directly in one consult I was part of years ago) the schizophrenic patient's language and symbolism as the notorious "word salad," these authors insist--rightly in my view--that "speaking schizophrenese, making sense of psychotic productions, is the glue that makes therapy with the most disturbed work" (p.xxi). Neither here nor at any other point in the book do they downplay how difficult this can be in some cases, and how much patience is required by the psychotherapist over the long haul. But the therapist is helped by understanding that hallucinations and delusions are like a loud-hailer or sound amplifier for the self, perhaps especially the fragmented and painful parts that are projectively identified with external objects. 

How could one go about understanding those objects and their meaning? How could one begin to enter into a world that seems fragmented, confused and confusing, perhaps even hostile and bewildering? Here they turn immediately to the founder of self-psychology in this country: "Kohut suggested instead that through 'vicarious introspection' the analyst must look inside and find 'a taste' of what the patient is experiencing" (p.xxv) This is very similar to something Christopher Bollas has said about seeking to find the lost patient, and discovering that something of him is hiding within the therapist.  

The Paradoxical Protections Offered by Delusions and Rages:

For Kohut destructiveness and rage are the products of a disintegrating self that has sustained some injury. They thus have quite a "thick" meaning, as it were, and one must work carefully in trying to disarm the forces of destruction and rage without leaving the patient feeling overwhelmingly vulnerably exposed. Delusions are "both fragile and rigid" (p.104). Their rigidity has been helpful in giving even a minimal sense of security to the patient and holding back a totalized experience of fragmentation. Thus these authors recognize later in the book that "a delusional system is a compensatory structure that prevents fragmentation" (p.98).

In addition, delusions and fantasies have a self-protective, self-soothing or self-enhancing purpose and taking them away may have serious unintended consequences. Frontal attacks--and this seems a point of universal consensus so far in what I have read, which admittedly is not much yet--on delusions are a complete waste of time, and may in fact backfire. It is within the working alliance, and the transference, that you may begin to help someone see that their views are mistaken. As they come to mentalize more, and to understand things from a second-person perspective, the hold delusions have may begin to lessen. 

One tip the authors offer here is to take a history from the delusional figure. E.g., in one fascinating case they discuss, a woman believed she received messages from a "Good Angel.” Alright. So ask that angel for its history, then. How did it grow and develop, at what point, and in what circumstances? What purpose is it trying to fulfil? As you seek out all this material, gaps ("epistemological trauma," in Atwood's words, discussed here) may emerge in the history, or purpose, or message, that can be usefully wedged between the patient and the delusion. 

A great deal of case material makes up the book, and I will not annotate that here. I would, however, encourage interested readers to peruse it for themselves.

Instead let me turn to an earlier work of just one author, Ira Steinman, and his 2009 book from Karnac in London, Treating the "Untreatable": Healing in the Realms of Madness.

Steinman beings autobiographically, but with a searing self-criticism that extends and applies to his guild, as well. Here and elsewhere he will criticize American psychiatry, as he already telegraphs in his title and its dismissive labeling of schizophrenics as "untreatable." He tackles this bogus charge at the outset of the book: 

I have found over the last 40 years of psychiatric practice, however, that a number of these allegedly 'unresponsive' and 'untreatable' severely disturbed patients, diagnosed as suffering from schizophrenia, paranoid delusional disorder and multiple personality disorder, have responded to an in-depth exploratory psychodynamic psychotherapy. In a number of cases, antipsychotic medication has been titrated down and stopped (p.xiv).

He returns to the self-criticism in the last chapter, which frankly and critically admits US psychiatry is to blame for abandoning schizophrenic patients and psychotics and regarding them as untreatable, and thus justifying itself in not treating them at all. Such criticism is advanced without any self-righteousness. If anything, Steinman is at pains to stress that there was and is nothing fancy or heroic about what he did and does: he simply offers plain old psychotherapy to help patients find meaning behind terrifying voices, hallucinations, etc. And space to begin to integrate and defragment. 

After some introductory material, the book is largely made up of case material drawn from about 12 schizophrenic or delusional patients. 

That introductory material includes several useful bits of advice: 

Dreams:

Like numerous other authors (perhaps none so clearly and forcefully as the psychiatrist Andrew Lotterman in this excellent and useful article), Steinman notes the importance of one part of the counter-transference in particular: your own dreams. He suggests that useful dreams you have about your patient may be judiciously shared: patients tend to like that you think of them outside sessions, and these dreams can often illuminate certain things or open up good lines of exploration. 

Patience and Hope:

Again we hear sounded the refrain that the patient isn't the only one who needs patience! The clinician must keep in mind that, in most cases, "the period of psychotherapy aimed at helping the patient overcome a schizophrenic or delusional orientation will be a long and arduous one, with change measured in infinitesimally small increments. Long intervals of seeming stasis must be tolerated by both patient and therapist in the face of what may appear to be gridlock, if the process is to bear fruit" (p.8).

Steinman firmly believes an intensive psychodynamic approach works, and his book is evidence of that. The overall task consists, in part, of proving Freud right: Where id was, there shall ego be. That is all the more important in schizophrenic patients whose ego seems barely intact and needs a great deal of clarifying and strengthening. And such tasks, Steinman notes rather scornfully, cannot be done, and are not done, by so-called supportive psychotherapy, which he regards as often useless: it doesn't touch the underlying psychic conflicts and pain, leaving the delusions fresh untouched terrain to ravage and revisit. 

The Nature and Purpose of Delusions:

Speaking of delusions, he sees that they are usually a sign of great pain and terror. It is easier to believe you are Jesus, or to live in fear of Mafia, than acknowledge internal pain and terror that both delusions mask. Thus delusions have a function, and often he sees that as being "a creative compromise," albeit often unrecognized as such (p.3). This makes giving up delusions hard if it means being in contact with a painful reality.

Methods:

How does one go about doing that--beginning to move past delusions? Here as elsewhere the alliance is key; the setting is also important as a holding environment where, bit by bit, patients may feel safe and supported and open up. Steinman elaborates, however, noting that "the patient’s trust in the therapist and in his reliability as a consistent object, although extremely important, is not sufficient by itself to help the patient through the morass of delusions and psychosis......Clinical improvement occurred only when a more interpretive, psychoanalytically oriented approach was attempted" (p.26). So do not just hold and soothe, but work! 

More concretely he offers us the following methods:

1) Get a good history! Find out when psychotic material began. Also, here or later, take a history from the delusional figure. E.g., Judith's Good Angel: what was the angel saying, why, and when did it start? Can the angel answer unexpected questions put to it, or does the angel begin to fall apart? 

2) See what meaning this material--delusions, etc.--has. This goes to the book's fundamental "conviction that delusional and psychotic behaviour not only had unconscious meaning to the patient but could be made understandable to the patient in the form of a healing exploratory dynamic psychotherapy, in conjunction with antipsychotic medication used in a judicious fashion" (p.185).

This latter point bears underscoring: Steinman, and virtually everybody else I have read so far, is not against the judicious use of anti-psychotics--though he argues very strongly that it is possible for these to be titrated downward for some, and in others eventually to be discontinued entirely without relapse of symptoms. 

3) Reconstruct the feelings behind the origins of the psychosis, delusion, etc. 

4) Slowly move towards the hurt, undefended lost heart and inner core

5) Let them sit with their rage, hurt, abandonment.

6) Transference reactions not only happen, but are usually more extreme. This, in itself, can be revelatory to patients, as they can gradually come to see their reaction is disproportionate, and to begin to wonder why. One memorable example he gives here is that his own calm and containing presence sometimes provoked rage in those who had no such thing and were jealous: they tried to up the ante with violence towards him. 

A Quick Word on Self-Care:

You must have time and plenty of interests away from psychotic patients. (I have only two patients at present with psychotic symptoms, and I enjoy them hugely, but I have realized that--as with victims of sex abuse, whom I also treat--I could not have a full practice devoted just to them for it would become exhausting and overwhelming.)

Finally, I would note that Treating the "Untreatable" contains an Appendix that sums up lots of international studies on recovery rates from schizophrenia. Keep this close to hand for those impertinently crowing about how their preferred treatment is "evidence-based" while psychodynamic psychotherapy is not. 

The Therapist's Use of the Self

When I was on sabbatical in 2018, I spent part of it on a fellowship at the Chicago Psychoanalytic Institute. There for the first time, in one of our seminars, I actually felt like I began to understand some of the thought of Chicago's most famous analyst, Heinz Kohut, pioneer of so-called self psychology. Prior to this, I had tried several times to read at least two of Kohut's books. And I did manage to read Charles Strozier's lovely biography of him, Heinz Kohut: the Making of a Psychoanalyst. But none of his theory was especially accessible or attractive until we read K. Newman's 2007 article, "Therapeutic Action in Self Psychology," The Psychoanalytic Quarterly 76. Newman managed to put Kohut's ideas into much clearer and far less jargon-riddled prose than Kohut seems able ever to have done. 

It was, I seem now to recall, in our discussion of this article afterwards where I first began to learn about the idea of how much of the therapist's usable self is available for the patient in the working alliance--how, that is, in Kohutian terms, the therapist becomes a selfobject [sic] to the patient. (In some ways this just strikes me as a needlessly complicated reworking of object-relations theory, and in far less felicitous English, but let that pass.)

I have been thinking about that concept of the usable self for a couple of months now, and this led me to pick up John Rowan and Michael Jacob's book, The Therapist's Use of Self (2002). 

It's not the book I thought it was going to be, but it is valuable nonetheless. I think my very mild irritation with the book comes from it being in some ways a literature review disguised as a monograph. I was anticipating more decided and conclusive views from the authors, who instead spend most of the book surveying about four different theoretical schools for their thoughts on such things as counter-transference, abstinence, self-disclosure, and related issues.

But this should not be allowed to detract from the overall utility of a relatively short and straightforward text written in clear and workmanlike prose. The fact that it makes good use of British object-relations theory--including Guntrip, Winnicott, Balint, Bollas, and especially Bion (whom I've come to appreciate a lot more this year)--only increases the value of the book in my view. 

The authors begin by noting that the will explore how the therapist might make use of his self in the therapeutic relationship, and then posit three ascending levels of such selfhood so used: the Instrumental self, the Authentic self, and the Transpersonal self. (I pictured these here like Maslow's famous hierarchy, with Instrumental on the bottom, and Transpersonal on the top.)

In their chapter on the Instrumental self, which they suggest may be the most common of the three approaches, they make a striking observation that, in slightly different ways, has come to me in the past six months or so of training: therapists "appreciate the fact that what they do...does not ask them to change themselves as much as it invites them to come closer to their best and frequently unrealized selves" (11-12). This has been an unexpected but reassuring realization for me this year. (This is augmented later in the book with a passage from Harry Guntrip: "real psychotherapy does as much for the therapist as for the patient.")

Judicious Soundings from the Counter-Transference:

It is within this chapter that they get into some very useful detail about the origins and development of the notion of the counter-transference. I have for some time been influenced in this area by Harold Searles, Otto Kernberg, and then especially Nina Coltart, who advises the therapist to take judicious soundings from the counter-transference as it may offer otherwise inaccessible clues to what is going on in the patient. But how is that possible? Isn't the idea of counter-transference that it pertains to what is going on inside the therapist? How, then, can it offer clues to what the patient might be thinking, feeling, avoiding, or even totally unaware of? Moreover, how certain can we be that what the therapist's mind throws up is in fact reliable or accurate or truthful at all? Maybe it's anxiety from almost getting run over during lunch hour a few minutes ago while fetching the pizza now giving one dyspepsia and making one long for the sweet release of violently expelling the offending food. 

Such questions have long haunted me. How does one know--can one know?--that what one thinks one knows is in fact reliable and real, truthful and objective, and not merely the convoluted production of ones own issues? 

In this light, perhaps the most useful part of this chapter--indeed, book--is the sixfold typology Rowan and Jacobs offer of unhelpful or unreliable counter-transfer reactions that are most likely unreliable and liable to lead the therapist astray: 

Defensive: esp. related to the therapist's unresolved issues around sex, aggression, etc.

Attachment: those that evoke the therapist's need to be admired, successful, loved, powerful, etc.

Transferential: when the therapist responds as though the patient's parent or sibling.

Reactive: when the distortions of the transference neurosis are taken to be true by the therapist who reacts accordingly

Induced: when the therapist is induced to take on the role of giving advice

Identification: when the therapist overidentifies with the patient and/or the patient's child

Displaced: when feelings from other parts of the therapist's life come to be placed onto the patient. (This would be the pizza-induced dyspepsia in my example above.)

The above strikes me as something useful to run through your mind as you are trying to discern your own reactions to the patient to see what might be reliable and trustworthy in them. Later on, drawing on the late Jungian theorist Michael Fordham, the authors note that even if your counter-transference reactions prove illusory, that is valuable nonetheless insofar as it may teach the therapist something about himself. 

In the next chapter, the authors draw on Winnicott (not least his thrilling 1947 essay "Hate in the Counter-Transference"), who apparently modified that 1947 view in the 1960s by insisting that one distinguish between a reaction to a patient and a full-blown counter-transference. It is not entirely clear here what the difference is, though to me it seems plausible that a reaction may be momentary or short-lived, or discreetly focused on one particular thing, and a counter-transference may be a more wholistic, longer-term "package" of reactions. 

Presence and Analysis:

The authors note that the therapist must strive to overcome whatever blocks his ability to be fully present in the session. At the same time, and elsewhere in the book, they equally insist that the therapist cannot become totally lost in his immersion in the patient's world, but must do that all the while maintaining a critical eye, maintaining his critical-observational self. To capture this, they quote the late American therapist James Grotstein who apparently once said the posture of the therapist here is like that of the Pieta: Mary holding the tortured body of her son! 

The challenge of remaining present is perhaps higher today than when these authors wrote thanks to our electronics-addled brains. This is a topic I want to think more about and return to another time.