Creating an Analytic Mind

Some discussion on Twitter this week with Jonathan Shedler and others about what we hope patients will be left with after therapy is over put me in mind two books I often find myself returning to. (Shedler deals handily and powerfully with the old and tiresome slanders that psychoanalytic/dynamic therapy are somehow less effective and less "evidence-based" than the CBT methods seemingly so beloved by governments and insurance companies today. See the invaluable articles at his website above, but also see this new book which I am looking forward to reading.)

The first is by Adam Phillips, who, like Shedler, is always worth reading. I have read all but one of Phillips' books, and would be hard-pressed to rank them, but if I had to, then On Kissing, Tickling, and Being Bored: Psychoanalytic Essays on the Unexamined Life would probably be in my top three, if only for its essay "Psychoanalysis and Idolatry," which I drew on in my own recent book on the sex abuse crisis in the Catholic Church. 

Anyway, Phillips has a lovely little aphorism in this book: "The cure can begin only after the treatment has ended." One can certainly debate that, but I have found it very true in my own life. As Luis Izcovich has recently argued, psychoanalysis leaves lasting "marks" in certain often distinguishable ways--a point stated even more dramatically by François Roustang almost forty years ago now. 

The second book that came back to mind this week is by Fred Busch. I read it several years ago, but it pays re-reading. He argues very much in favour of the idea that psychoanalysis and analytic therapy should leave the person with a re-structured mind as a permanent and positive after-effect: Creating a Psychoanalytic Mind: A Psychoanalytic Method and Theory (Routledge, 2013). 

Busch writes in a low-key manner with a refreshing lack of ideological rigidity, jargon, or hubris. He interpolates passages from well-known literary works with short case-studies from his own practice to illustrate what he means. This is a rewarding book that pays re-reading. 

As he recounts in the introduction to this book, Busch is something of a pioneer in psychoanalytic technique and training, being one of the first clinical psychologists to be admitted in the 1970s to psychoanalytic training at an American institute. (This restriction has never made any sense to me. I grew in Canada, underwent analysis there, and planned to finish a doctorate in the humanities and then embark on a training analysis at the Institute in Montreal. I was able to do this because unlike American institutes, those in Canada, the UK, and parts of Europe and elsewhere, generally have had no problem following Freud's recommendations in The Question of Lay Analysis.) 

As he looks over the course of an analysis, Busch understands it to consist of three phases:

1) The first phase is when the patient comes to be familiar with his own inhibitions and restrictions that keep him from living: until the patient can wonder about his lack of wondering, wondering is not possible. This phase, later in the book, is called one of self-observation. 

2) The middle phase of an analysis is the beginning of a "psychoanalytic mind," that is, learning to observe one's own mind and its sequence of free associations. Such a psychoanalytic mind is necessary if the analysis is to bear long-term sustainable fruits in one's life. It is necessary, that is, if the patient is to be freed from the "slavery of repetition compulsion" and instead freed to "think about thinking." Later in the book Busch calls this phase one of self-reflection. (In my experience this ability to "think about thinking" has remained a constant and constantly valuable gift bequeathed by analysis.) 

3) The terminal phase of an analysis consists of a deeper psychoanalytic mind more completely free from deceptions in understanding one's associations with greater veracity. Here the analysand can "play, muse, reflect, and interpret her own associations." This phase Busch later calls self-inquiry. 

Classically, it was thought by some that the main goal of an analysis was insight into the contents of the unconscious.  But for Bush, "the process of knowing is as important as what is known." Here Busch pioneers a different goal for analysis, giving greater emphasis to the patient gaining an understanding of how his mind works and how it affects him. Busch suggests the freedom of a psychoanalytic mind, with a process of knowing in addition to what is known, may be of greater long-term benefit.

This, it seems to me, is a very noble goal for a clinician to work towards: not merely to leave a patient with certain tips or techniques that may come in handy in some future struggle, but to help in the creation of a mind that can now think much differently. And one thing that newly recreated mind will likely have--dare we say should have?--is an awareness of its ongoing need for the help of others. Here I would return to Freud in noting that the creation, and nourishing, of such a mind is never going to be complete, but will require perhaps ongoing or perhaps periodic work. As he says in his "Analysis Terminable and Interminable": "Every analyst ought periodically himself to submit to analysis, at intervals of, say, five years, without any feeling of shame in so doing. This is as much as to say that not only the patient's analysis but that of the analyst himself is a task which is never finished." 

In conclusion, I would simply note that Busch has a new book coming out in November which I am looking forward to reading. The publisher tells us this about it: 

In this first-of-kind book, senior psychoanalysts from around the world offer personal reflections on their own training, what it was like to become a psychoanalyst, and what they would like most to convey to the candidate of today.

With forty-five personal letters to candidates, this edited collection helps analysts in training and those recently entering the profession to reflect upon what it means to be a psychoanalytic candidate and enter the profession. Letters tackle the anxieties, ambiguities, complications, and pleasures faced in these tasks. From these reflections, the book serves as a guide through this highly personal, complex and meaningful experience and helps readers consider the many different meanings of being a candidate in a Psychanalytic Institute.

Perfect for candidates and psychoanalytic educators, this book inspires analysts at all levels to think, once again, about this impossible but fascinating profession and to consider their own psychoanalytic development.

Neville Symington on The Making of a Psychotherapist

I spent several happy days in early 2018 at the Cincinnati Psychoanalytic Institute and their library, which I had the run of. There I had the first chance to begin to read some of the many works of several people, including the Anglo-Australian therapist Neville Symington, who has recently died. 

Part of my interest in him is for a book I'm working on that will look, in part, at the question of psychoanalysis and religion, especially Christian theology. Symington was for a time a Catholic priest before leaving the Church, marrying, undergoing analysis, and then training to become a therapist, first in London (where he was connected to the justly celebrated Tavistock Clinic) and later in Australia. He has many interesting insights on the analysis-religion relationship, and most of them are constructive if not positive, but we will not get into those here. 

In any event, I've been meaning to read more of him, and recently had a chance to read his The Making of a Psychotherapist (Routledge, 1997). Herewith some thoughts on that.

Symington notes early on that the goal for this book is to show "a psychotherapist in the making, so both the strengths and errors of the psychotherapist are laid bare for the reader to scrutinize. I hope that this might help psychotherapists who are trying to learn, as I am." And with commendable candor Symington, several times in his mini case-studies, does describe interactions with a patient that were not always productive and positive, and how he handled them, and what he learned from them. 

The first part of the book is, in my view, much richer than the second. By the second he seems to forget the rather sharp distinction he posited early on between psychotherapy and psychoanalysis, and the second half of the book is almost entirely focused on classical analytic issues and concepts.

Having recently written appreciatively about what I've learned, and am learning, from Yalom, I noted that Symington early on in this book takes issue with the notion of therapy providing corrective emotional experiences (which Yalom talks about in his chapter on interpersonal group therapy, where he notes that many of his insights originate with Harry Stack Sullivan and Franz Alexander). Such experiences, along with the therapist's empathy, are not in themselves sufficient to provide lasting healing according to Symington. 

Inner Creative Emotional Act:

Instead, he writes, "my own belief is that healing of a lasting kind is the product of an inner creative emotional act. This act is essentially free and cannot therefore be imposed upon the patient" (xvi). 

I was struck by this insofar as it rings true to my own experience as a patient, and describes my own approach to working with people. A lack of imposition was, and is, the largest part of my attraction to, benefit from, and continued defense of psychoanalytic therapy: it seems to offer maximum freedom to the patient and to resist imposing things on him or her. Some of the key insights I took from analysis came from that kind of inner emotional act. Does that mean they were singularly and solely mine, and that the analyst or therapist plays no role? Of course not.

Psychotherapy and the Moral Life:

Ch. 1 opens with the ringing declaration: "Psychotherapy means healing of the soul." This then leads into a brief discussion of Viktor Frankl and from here into an extended discussion about the "moral element to mental distress" which is not always entirely clear. I think what he is saying here--and it comes out more clearly at the very end of the book--is that none of us can escape certain judgments about the good life, and so even though we may try to preserve a certain level of neutrality with patients, nonetheless each claim about what constitutes "healthy" or "adaptive" or "appropriate" behavior or thought is ipso facto a moral judgment. It may, Symington seems to suggest, be profitable to be more explicit about this, especially with those patients who are asking explicitly moral, metaphysical, or existential questions. 

Of course, such engagements must be nicely judged to avoid moralizing or moral imposition. As Symington recognizes, 

If the psychotherapist does not understand the moral element to mental distress, then the patient will superficially sigh with relief but, at a deeper level, go away disappointed. There is no doubt that the theoretical models with which the trainee psychotherapist is equipped during the course of his training are essential tools of the trade. But of equal importance to this knowledge of theory is knowledge of when and how to apply it-which tool to use for a particular job.

Process Your Own Mourning and Melancholia:

Symington does not shy away from noting several significant challenges a therapist must continue to face. At the end of ch. 3 he says that the therapist's "task is to reach his own feelings," especially "feelings...[of] pain and loneliness." Why should any of us want to do that? The answer is quite simple: doing so is a win-win for both people in the relationship: "If... he reaches his own feelings, it frees the patient and favours his emotional development." This is not a one-and-done kind of thing, but, Symington says, an on-going task throughout the therapist's life. 

Take Courage!

Later in the book he recognizes that this task of the therapist recognizing his own feelings of pain and loneliness requires courage or, as he says, "moral fortitude is an essential quality in a psychotherapist if he is to endure the pain that reaching those feelings entails. In other words, moral courage is needed to deal with mental pain."

Keep Your Imagination in Good Working Order:

In ch. 4 Symington notes that very often "patients come to see us when things have broken down and when their lives no longer hold meaning for them." In such a situation many of them will "place implicit trust in the psychotherapist's ability to help them rebuild their world." A therapist will be useless at doing this "unless the imagination of the psychotherapist is in a healthy, functioning state." I know such arguments make some people very nervous, especially if they have been led to believe there is a manual for everything so that imagination becomes otiose. And I think Symington would be the first to agree that this, too, must be finely judged so that the therapist's imagination does not run riot, indulging in what Freud would call "wild analysis." 

Symington comes to this point a little later in the same chapter, when he says that it "is important that the psychotherapist should freely exercise his imagination while in the process of determining the most appropriate treatment programme for the patient." As he goes on to recommend, some of this can begin even "at the initial assessment interview" when, "as the patient is allowed to talk freely" the therapist then "relaxes into an inner attitude of free association," a process that "will frequently lead him to the area in which the patient has the greatest difficulty."

Your Office Matters!

In a separate, longer post sometime down the road, I will bring in some of the research I did this past semester on the arrangement of a therapist's office. That research, as it turned out, revealed that common arrangements (sometimes in textbooks referred to as the SOLER set-up) are very under-theorized and based more on assumptions.  There are gaps in the research here which are nonetheless covered over by common assumptions many people seem to copy almost mindlessly--chief among them that one must always sit squarely facing the patient. Knowing this, I was greatly cheered to read that Symington is also aware of the power of the environment to be (or not to be) "conducive to the free exercise of the imagination.... The interior decoration of the psychotherapy rooms and the whole psychotherapy department will, in itself, play an important part in both the activity of psychotherapy and the enjoyment of the results." 

Can You Paint Your Patient?

At the end of ch 4, Symington, who has written elsewhere about the British analyst Wilfred Bion, quotes the latter in a way that uses a really striking image: "When you have seen a patient, instead of going and writing up the session, why not instead go and make a painting of the next session." I can't paint (or draw) worth a damn, but I like this image in part because of what it seems to imply about the relatively freer mode of painting vs. the tendency to feel one has locked something down in writing, especially if one also happens to be, as I am, a longstanding academic editor with a ruthless intolerance of sloppy writing. 

But sometimes ruthlessly cogent writing can be its own kind of prison, and we need to break out of it at least to some degree. One of the many valuable lessons I have learned from Adam Phillips is that people may often come to therapy precisely when they feel the stories of their life have been too tightly, narrowly, pathologically written--by themselves and others--and need help finding a freer, newer story to inhabit. 

But the search for alternate or freer stories is always going to be challenged, perhaps most of all by ourselves. As Symington recognizes on this point, the process of therapy is a constant battle against patients who want to be cured but, at the same time, do everything in their power to avoid mental pain. Much effort, a good deal of it unconscious, will be spent trying to steer the therapist away from the patient's areas of pain. This, of course, has been known from the beginning when Freud saw resistance emerging almost minutes after a patient settled onto the couch for the first time. He wrote about it, and later his translator and sometime analysand Joan Riviere did also in her essay on negative therapeutic reaction. 

Sometimes the Complaint is Justified!

Symington is helpful in noting that not every bit of negative feedback from the patient is just projection or pathology. Sometimes they are right to be critical. As he says, the psychotherapist needs a finely tuned sensitivity in order to distinguish between the negative transference and straightforward justifiable negativity--as when, e.g., the therapist has been an ass or made a major mistake. 

The Importance of Neutrality:

For people personally inclined towards, and professionally trained in the practice of, empathy, it may be difficult to realize that one can go too far in trying to take the patient's side or in accepting uncritically what s/he tells you. This, I think, is especially tricky in cases of massive trauma. In such cases, Symington quotes Jung "'The patient does not feel himself accepted unless the very worst in him is accepted, too'." This has to be a comprehensive acceptance of the love and hate, the ambivalence, the admirable and despicable parts of the self. 

But Symington (and others I have read) is very clear in noting that acceptance must be contained within a broader neutrality of sorts. As he says, if the "psychotherapist puts himself entirely into the shoes of the patient and bases his understanding on the patient's own point of view, excluding all else, he will do nothing to solve the patient's basic problem." That is because, he continues, the patient comes to us in the first place "because his own point of view had not solved his problem. To be able to solve it, he needs the point of view of the Other."

Approaching Termination:

Many people have turned their hand to the question of when a therapy might be ended, or what signs or criteria one might use in judging whether a patient is approaching a terminal phase in the treatment. Symington also has done so in this book, noting two primary criteria which he regards as "particularly good indicators of whether emotional maturity has been achieved. These are the capacity to bear criticism and the capacity to manage confrontation."

But termination is not the end--far from it. As Adam Phillips has said, "the cure can only begin after the treatment has ended." (That may be more true for classical psychoanalysis than psychotherapy, but it seems to me that if either is good and worthwhile, its long-term effects will continue to be manifest almost if not daily. I certainly believe it to be in my own life.) And termination can leave in place certain skills that allow the patient to negotiate future struggles. As Symington notes in the book--with some hesitation--far from being in a crisis when you go to therapy, going to therapy is itself a crisis. If it is successfully survived, then this becomes a rich and significant source of strength to prevent collapse in future crises.

One final note here on the theme of termination, drawn from a fascinating book I read several years ago: Fred Busch's Creating a Psychoanalytic Mind: A Psychoanalytic Method and Theory. 

In that book, Busch divides the therapeutic relationship (as many do) into three phases: 

1) The first phase is when the patient comes to be familiar with his own inhibitions and restrictions that keep him from living: until the patient can wonder about his lack of wondering, wondering is not possible. This phase, later in the book, is called one of self-observation. 

2) The middle phase consists in learning to observe one's own mind and its sequence of free associations. Such a mind is necessary if the analysis is to bear long-term sustainable fruits in one's life. It is necessary, that is, if the patient is to be freed from the "slavery of repetition compulsion" and instead freed to "think about thinking." Later in the book Busch calls this phase one of self-reflection. 

3) The terminal phase consists of a mind more completely free from deceptions in understanding one's associations with greater veracity. Here the patient can "play, muse, reflect, and interpret her own associations." This phase Busch later calls self-inquiry.