Some Thoughts on the Death Drive

 I was moderately heartened to see that as the centenary of the publication, in 1920, of Freud's most neglected and professionally disliked book, Beyond the Pleasure Principle, approached, we saw a renewed interest in its most controversial idea: the death drive. The sputtering bewilderment proffered by psychoanalysts and others in the face of this theory finally seemed, after a century, to be giving way to some actual substantial engagement with Freud's text--albeit mostly by non-clinicians. The fact that anyone, clinician or otherwise, reacted so strongly to this theory has long been itself bewildering to me for evidence of a human propensity towards repetitive self-destruction (and the unconscious pleasure, or at least purpose served by such destruction) seems constantly on offer in consulting rooms around the world, and in so many other places.   

I do concede the point that part of the reaction may have been to Freud's suggestion that the death-drive might in fact be an actual "biological" drive. Unlike some, I think you can leave that out of Freud's theory without fatally (!) weakening its overall claims. 

The fact that discussions of Freud's notion of a death drive, which were few and far between even while Freud was alive, and were often politely ignored by much if not most of the psychoanalytic establishment for decades after his death, have taken off nearly 80 years after his death puts me in mind of Adam Phillips' argument from some time ago that the best time to re-examine Freud is precisely now, when nobody thinks much of him anymore and there are fewer and fewer professional establishments rushing to "protect" him from being critically scrutinized, or rushing to enforce some orthodox line or other:

This is certainly a good time for psychoanalysis: because it is so widely discredited, because there is no prestige, or glamour, or money in it, only those who are really interested will go into it. And now that Freud’s words are so casually dismissed, a better, more eloquent case needs to be made for the value of his writing ("After Strachey," London Review of Books vol. 29 no. 19, 4 October 2007, p.36) 

So scrutiny is returning to several parts of Freud's project, but noticeably his late-period "cultural works." Thus, earlier this year, as I discussed here in some detail, there was Benjamin Fong's fascinating new book Death and Mastery: Psychoanalytic Drive Theory and the Subject of Late Capitalism.

And before him, in 2013, in one of the most richly provocative books I've read in a long time, there was Todd McGowan's Enjoying What We Don't Have: The Political Project of Psychoanalysis, which I discussed in detail in three parts when I was attempting to demonstrate that much psychoanalytic thinking should be welcomed by theologically minded Christians, especially Catholics. 

In addition to Fong and McGowan, nobody has written as much about the death drive as Todd Dufresne, whose works I have enjoyed and through whom I discovered the wonderful work of his Doktorvater, the late Paul Roazen.

Roazen's Meeting Freud's Family is a thoroughly charming book. His Freud and His Followers was a groundbreaking and controversial work which fills in very important gaps in the historiography. And I have found his Encountering Freud: The Politics and Histories of Psychoanalysis useful in surveying what religious and theological responses were made over the history of psychoanalysis to the 1990s.

Dufresne's work on the death drive is found first in his Tales from the Freudian Crypt: The Death Drive in Text and Context and then, more recently and succinctly, in his introductory essay to the Broadview translation of Beyond the Pleasure Principle. It is the Broadview translation that I require of my students when I assign this text in classes. 

To my enormous surprise and puzzlement, neither of these books shows up anywhere in one of the heftiest recent books devoted to the topic, Repetition, the Compulsion to Repeat, and the Death Drive: An Examination of Freud's Doctrines, co-authored by M.A. Holowchak (a philosopher) and Michael Lavin (a clinician) (Lexington Books, 2018, viii + 163pp.). It is a very useful, crisply written, and largely clearly argued work.

 There are several virtues to this book, including its relative brevity, and the arrangement of each chapter, which aids in reading. More broadly the book will be useful if it is received as the history it is, tracing out the trajectories of the concepts of repetition, compulsive behavior and thinking, and the death drive across the Freudian canon. As such it goes back to 1895 and Studies in Hysteria, co-authored by Freud and Breur, and then forward past Beyond the Pleasure Principle to works in the last period of Freud's life, often referred to as his "cultural" or "meta-psychological" period. Along the way it also notes such "watershed" publications as Freud's 1914 paper, "Remembering, Repeating, and Working Through" as well as his essay on anxiety from 1932, by which point he seems to have moved from the very tentative and speculative writing of Beyond the Pleasure Principle 

Further virtues include the fact that this is neither an attack on Freud--though it advances important, serious, and considered criticisms of his theory--nor a glorification of him enforcing a certain "orthodox" line. It agrees with Freud in places, argues with him in others, and gives evidence in still others for where Freud may have been wrong, or subsequent research does not bear out his often highly tentative and speculative claims in Beyond the Pleasure Principle. 

On the latter score, it notes problems with Freud's attempting to find phylogenetic evidence for a death drive and compulsive repetition. The question remains: can his theory be rescued if the evidence he claimed to find for it in the biological sciences does not exist, or can be explained by other theories? In answer to that question the authors diverge somewhat, and candidly acknowledge this in the conclusion. For my part, I see few problems in separating out and sustaining most of the theory from insufficient "natural" evidence, and again the authors seem--albeit somewhat uneasily--inclined to agree, especially in a clinical setting, noting that clinicians rarely take their theory pure and whole.

All that having been said, the drive to destroy, including the self, is often a repetitive one, and we are faced with the question of why that is when such a drive brings terrible anguish, suffering, and consequences to the self and to others. Part of the answer may lie in the fact that the drive for pleasure and the death drive are not always operating in mutual and exclusive opposition. As the authors admit flatly, "eros and the death drives do not function independently of each other" (85). In fact, one of Freud's key insights here and in other areas was the admixture of experiences and emotions. In this light, one can, as he himself wrote, find in destructive repetitions the "pleasure of mastery or revenge," including against childhood traumas, enemies, or frustrations.

Such an understanding also goes some way towards accounting for what is perhaps Freud's clearest clinical evidence for compulsive repetitions and self-destructive behaviors: the regularly observed fact that patients get bogged down in treatment, and come actively to undermine the very thing that may help them get better through attacks on the therapist and the therapeutic alliance. In this regard, as D.W. Winnicott put it, attacks on a therapeutic analysis may be understood to reflect the fact that for many of us, "health is much more difficult to deal with than disease." In our perverse ways, we like being sick, we like being punished, and though we do not always admit this to ourselves consciously, our unconscious repetitions-in-action bear this out.

By chapter 6, it seems the authors' patience is wearing a wee bit thin, as they sum up the "view in the secondary literature...that the death drive creates more problems than it solves" (98). I think this overstates the case and the authors themselves have not provided absolutely conclusive evidence to support this judgment. Moreover, they fear that Freud's insistence on the death drive runs the "risk of throwing his metapsychology into a state of chaos" (108).

Here is precisely the point where an engagement with Todd Dufresne, mentioned above, would have been crucial. Dufresne's argument is that BTPP is a deliberate act of sabotage on Freud's part, undermining his theories of sexuality and much else. As Dufresne puts it, "metapsychology subverts psychoanalysis," whether "playfully or otherwise," inflicting from a position within the movement a "trauma" on psychoanalysis. 

Dufresne does not elaborate much on why he thinks Freud may have done this, but I would speculate--following Adam Phillips--that this may have been done precisely to keep the analytic movement from becoming a closed, rigid ideology with enforced orthodoxies and a putative epistemological omniscience. Already there were clear signs of this (some of them demanded, or at least supplied, by Freud himself!) before the great man's death in England in 1939. Alas, they seem only to have gotten worse after his death. If psychoanalytic institutes today complain (as they have for years) of their declining fate, much of the responsibility for that is entirely their own for they have too long been hidebound places demanding loyalty to certain orthodoxies that Freud himself was more open to questioning. (One of the virtues of Roazen's scholarship is the documentation it supplies whereby Freud was often rather free-wheeling in his own clinical practice, but often much more strict in what he recommended in writing.) 

Freud was certainly aware of the dangers in this direction (and had himself on occasion contributed to it), especially if analysis remained in the hands of psychiatrists or other medical doctors alone. He was forced to address this problem in 1926 in The Question of Lay Analysis, a work I would also see (as, again, Adam Phillips has) as pushing back against analysis becoming a closed system with a closed caste of expert "professionals," especially if those medical professionals were Americans, of whom he thought very little and whom he regarded with enormous skepticism. Such a resistance reflects Freud's own compulsive concerns in some ways, for he was clearly desperate for respect and acceptance for most of his life, but late in life seems to have come to regard such desires with disdain and begun to resist them and call for others to do likewise.

In the end, Holowchak and Lavin conclude there is not a lot that can be salvaged from Freud's death drive, but they do themselves a great service by noting that many other prominent analysts, including Klein, Lacan and Laplanche, disagree with them. Laplanche, it seems to me, takes the most sensible route forward by arguing that if the theory is stripped of biological concepts, if it is seen as exclusively human, and if it is seen as operating not independently but bound up with other drives and desires, it can be rescued. This remains my own view (for whatever that's worth). I will say more about it in later reviews of some of the other books on the death drive that have been helpfully published in the last 3 or 4 years. 

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

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

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

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

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

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

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

Others are much more critical and dismissive of Bion. 

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

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

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. 

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

Preface: 

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

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

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

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

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

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

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

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

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

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

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

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

rather than to the needs of the patient."

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Inculcating Psychological Mindedness for Use After Treatment

As so often happens, a comment on Twitter makes me think of a book I read that may have something useful to offer the conversation. In this case, it was a question about post-treatment goals in and for therapy, and whether they diverge that much between CBT and psychoanalytic practitioners. In particular, it was asked whether both traditions seek to create a capacity for what (following Nina Coltart) I would call a healthy psychological mindedness (a lack of which during intake bodes ill, as she says, and my experience confirms, for successful treatment). 

The question of post-treatment goes back, of course, to Freud's very late essay, "Analysis Terminable and Interminable," and its welcome ambivalence about whether one can ever be truly and totally and completely analyzed. I was very heartened precisely by his ambivalence in this essay. I also found it edifying that Freud seemed to recognize benefits might continue on even after analyst and analysand formally cease to meet together for sessions. 

In this regard, I often think of something Adam Philips (he whose books are so essentially aphoristic in nature) once said, which I have found incredibly true in my own life: "the cure can begin only after the treatment has ended." More recently, he has returned to the whole vexed question of cure in what I think is one of his best and most important books, The Cure for Psychoanalysis, which captures in one place a theme he has often advanced in just about every one of his previous books: about the sad irony that psychoanalysis has become--in many places, not least training institutes--a hidebound ideology instead of a means to free people from the prison of ideologies. 

For me, my first analysis (four times a week on the couch for almost seven years) ended in late July 2000 but I have found myself living from that in some useful ways ever since. And in fact I think the "returns," far from diminishing, actually grew in the years after treatment came to a formal end. (I would say the same thing of my second analytic therapy, which is ongoing.)

One person who has thought about this in an elegant and useful way is Fred Busch in his 2013 book, Creating a Psychoanalytic Mind: A Psychoanalytic Method and Theory.

Busch seems a very interesting fellow, and quietly understated pioneer of some sort. As he recounts in the introduction to this book, Busch was one of the first clinical psychologists to be admitted in the 1970s to psychoanalytic training at an American institute. American institutes, unlike those in Canada, the UK, and parts of Europe and elsewhere, generally have been extremely reluctant to admit any but psychiatrists or those with medical degrees. 

In this, they deplorably and unjustifiably take a different tack from what Freud recommended in The Question of Lay Analysis, a book where Freud memorably says two groups should most certainly keep their hands off psychoanalysis: doctors and clergy! He also coins a memorable phrase about analysts being "secular pastoral workers," a phrase to which I gave some attention elsewhere. 

I will not go into Busch's entire book, which I encourage everyone to read, but simply make a few brief observations based on notes I took years ago when first reading it.

Busch understands analysis 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 creation 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. 

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. 

Busch says that part of his practice consists in seeing patients for a second analysis. They have benefited from their first analysis, but from that largely derived only knowledge of their unconscious--an "object," as it were, rather than a process. And for Bush, "the process of knowing is as important as what is known." This, for me, is the very obvious difference between my first analysis (which I wanted simply to know what was unconscious and bring it forth for rational scrutiny and, especially, control!) and my second, which has focused much more on the process of knowing and far less on the contents. 

Busch continues in this vein, saying that he offers a different goal for analysis which, classically, has held up the importance of a state of knowing rather than a process of knowing. In the former, we come to know consciously what was previously unconscious. In the latter, the patient gains an understanding of how his mind works and how it affects him. Both offer freedom, albeit of a different degree and type, but Busch suggests the freedom of a psychoanalytic mind, with a process of knowing--in addition, and perhaps even preferable, to--what is known, may be of greater long-term benefit. I would heartily agree. 

A Note on Four Psychoanalytical Biographies

I have been a tireless reader of biographies at least as far back as the seventh grade. Since the summer began, I've had a chance to read four biographical studies, none exhaustive, and each in most cases covering terrain I was at least moderately familiar with. But they were enjoyable nonetheless, each in their own way, and each also filled in some gaps in a welcome way, so I thought I'd offer a few notes on each in case others might wonder about the wisdom of picking any of these up.

I begin with Joel Kanter, ed., Face to Face with Children: The Life and Work of Clare Winnicott. I should confess two biases at the outset: first, anything with the word "Winnicott" in the title is invariably going to attract my attention. Second, Joel Kanter is one of the conveners of an international study group on psychosis that it has been my very great privilege and delight to be part of.

That said, this book fills a huge lacuna. Clare Winnicott's husband Donald Woods is of course world renowned. But her own life as a clinical social worker and writer has been largely left in his shadow, which is completely unjustifiable given the scope of her contributions in their own right--to say nothing of the huge and countless ways she helped her husband achieve so much. 

Kanter has assembled a worthy cast of people to write about her works, and has reprinted several of them which were originally published decades ago in obscure places. But the crowning glory of this book is the 90-page biography he writes at the outset, which is superb. Buy and read the book if only for that reason. 

I have been very interested in reading more of Sandor Ferenczi for some time, and recently stumbled across Sandor Ferenczi: Reconsidering Active Intervention by Martin Stanton. It is a unique book: in fact I would call it a prolegomenon to a proper scholarly biography. That diminishes Stanton's labours not a whit, and in fact he himself more than once says he is merely trying to lay out the parameters of what a full biography of Ferenczi needs to wrestle with. 

There are at least two significant gifts offered by this book. First, Stanton has performed a very great task by merely assembling a chronology of the Hungarian analyst's life, farcing into each entry not just significant events in Ferenczi's own life, but also significant developments in the wider psychoanalytical movement in the opening decades of the last century. Thus we see when and where Freud and Ferenczi first meet, and Jung and Ferenczi, and so on.

Second, he has put together thematically named chapters that introduce the reader to some of the concepts and practices unique to Ferenczi, with liberal quotations of his writings as well as reactions, where known, to his writings from Freud and Jones, Jung and Klein, and others.

Next up is Gérard Bléandonu's Wilfred Bion: His Life and Works. It is an odd book in some ways, starting with the fact that a French psychiatrist wrote the first biography of an English psychiatrist and psychoanalyst, which was then translated from French. As someone who, many years ago, worked in scholarly translation of works between French and English (dealing, at the time, with Canadian governmental policy on HIV/AIDS), I know what a vastly time-consuming and painstaking process it is. I also learned that it's generally inadvisable to translate from translations. 

Nevertheless, in a way not entirely dissimilar to the Ferenczi study noted above, Gérard Bléandonu has written a life that spends most of its time discussing Bion's texts. I would have welcomed more integration of the theoretical chapters with Bion's life, which seems very much confined to the introduction to the book. By the end of the book one does not feel that one has penetrated very far at all beneath the surface of Bion's life, which is perhaps how he wanted it. 

So I would not consider this the definitive study of Bion by any means, and once again wonder: is anyone working on such a biography? If I had time and money I'd gladly fly to England (and anywhere else!) to luxuriate in archives and private collections of letters and whatever else I could lay my hands on in order to write about Bion. (For some unanalyzed reason, I have long wanted to write a biography. I thought at one time I might do the moral philosopher Alasdair MacIntyre, but a new study of his life has just been published--once more first in French!) 

Finally we come to Brett Kahr, The Legacy of Winnicott: Essays on Infant and Child Mental Health. I picked this up not only because I respect Kahr and have enjoyed previous works of his, but for two other reasons at least: the inclusion of an interview with Winnicott conducted by no less a figure than Paul Roazen; and then a really compelling essay by Susie Orbach, "The False Self and the False Body." 

If you do not know Roazen's work, then you should. He bids fair, more than a decade after his death, to retain (to my mind at least) the post of doyen of historiographers of psychoanalysis, at least in the anglophone world. Several of his books have been utterly fascinating, not least his Freud and His Followers as well as Meeting Freud's Family. 

It was Roazen, if I recall correctly, who back in the 1960s discovered and published the then hugely scandalous fact that Freud had analyzed his own daughter Anna, which by that point almost everyone was at pains to conceal, not least since she didn't die until 1982. On the topic of Anna, I've read two biographies: the one by Robert Coles (which is workmanlike but all of his biographies tend to feel just a shade too beige in some ways) and the more comprehensive one by Elizabeth Young-Bruehl, in an updated second edition from 2008.

I have known of Orbach's work for a while, but not read much. Still her essay in this collection is extremely valuable for its steely eyed critique of Winnicott's ideas of the true and false self. Orbach argues that too much of the reception and use of these ideas by and after Winnicott posit some kind of chasm (bad!) between them, on the one hand, or some kind of magical integration on the other (good!). But, she argues convincingly, we cannot and must not allow them to be seen as thus divided because in reality aspects of the true and false selves are always mixed up with each other. The therapeutic task thus becomes not a perfectionistic one (how very unWinnicottian!) whereby we totally separate or totally integrate the two, but rather an asking of the question: how ought they to be together, and what can be realistically disentangled and perhaps changed, and what cannot? 

In sum, each of these books was interesting, though none, admittedly, was as moving and fascinating as the last major biography I read, Gail Hornstein's lovely study of Frieda Fromm-Reichmann (about which a few brief comments here though I really should go back and write more about her). 

Next up: I will likely shift away from psychoanalytical biographies for a bit as I've just ordered Simon Sebag Montefiore's Stalin: The Court of the Red Tsar. I was tempted to do so after this highly entertaining (can one say that?) interview with the author here.