What is "Psychological Mindedness"?

The timing is always curious: in both my Introduction to Psychotherapy/Counseling course this week, and also on Twitter at the same time, questions were raised about how you might assess someone's suitability for psychotherapy, especially psychodynamic treatment. I told my students last night of one disastrous situation in which I ignored my own doubts about a particular patient and took this person into treatment anyway even though during the intake and first several sessions I could detect no serious "psychological mindedness." I had--I now realized--foolishly told myself that it was probably just very hidden and there was a chance it could emerge or even develop. It didn't and I discharged the patient with what I regard as very little change, alas. 

But what, my students rightly persisted, does "psychological mindedness" actually mean and look like in concrete ways? We were very nearly at the end of our time, so I gave them a quick three-sentence summary last night with a promise of more practical details next week. Here are those details, drawn, as so often happens with me, from the incomparable Nina Coltart's second chapter of Slouching Towards Bethlehem: and Further Psychoanalytical Explorations. "Psychological mindedness" is, in fact, her phrase in that chapter. (It was, in fact, this chapter that convinced me, in the fall of 1994, that I had the requisite ability to undertake psychoanalysis myself, and so when I say she changed my life, it is this that I mean more than anything.) 

Coltart gives some preliminary considerations before launching into a list of 9 things to watch for. These "preliminaries" include, during an intake, watching out for "intelligence, moral character, and money." Here is where she is at her most practical and also Freudian, noting how the great master said you cannot work with people who have no capacity for insight or understanding, who lead morally repellent or even criminal lives, and who are too poor to pay your fee. 

Beyond these things, she says to watch out for the following, which I have summarized under my own headings and with some detail or elaboration as appropriate. 

1) Emotional Distance on the Self: This she says is also known as the "autonomous ego" or the "observing ego." The would-be patient must have some capacity to take even a modest distance on his/her struggles to be able to talk about them. Obviously, she stresses, this must be "nicely judged" as you do not want a patient who is prone to "severe denial, splitting, or repression."

2) Elaboration and Extension: If, she says, you allow pauses, gaps, and silence in the intake (which I always do: a preliminary sense of how a patient can handle silence is invaluable to me), can the patient go beyond the mere narration of facts into a deeper elaboration of various emotional dynamics? Even a few minutes into an intake, if you are listening with the "bare attention" she elsewhere discusses in the book, may for the first time prompt the patient to take the risk of elaboration. If this is totally absent, she says, it may indicate "severe inhibitions" that prevent, in whole or in part, free association from happening.

3) Affectively Charged Memories: Can the would-be patient bring forth different memories with different affects that are more or less appropriate? A lot of memories without affect are suspect, as is a total lack of the same. 

4) Relationship between Past and Present: Can the patient see any connections, however tentative, between past experiences and present difficulties? Can they see, as Bollas might put it, how the shadow of the objects of one's past, including past relationships, falls on present ones? (As a former supervisor of mine once succinctly put it: is this person a reliable historian?)

5) Internal and External Worlds and their Conflicts: Does your would-be patient have an ability to see connections between their internalized objects and outer relationships and conflicts? Do they see conflicts in their mind? And do they have a capacity to tolerate difference from and conflict between inner objects and the therapeutic relationship and working alliance? (In other, more classical, terms, can they develop a transference neurosis?)

6) Curiosity and Playfulness: Coltart says the would-be patient must show even a scintilla of curiosity about their inner world and its intra-psychic conflicts (and those with external parties) and a capacity to play with those in a "lively" way. Do they show signs of being glad to obtain greater insight? Are they curious about how their mind works, and how it plays a part in current problems? Absent this, Coltart warns, you should not proceed with a recommendation for psychodynamic therapy, which has "nothing to offer a patient who only wishes to be relieved of his suffering." Instead, the would-be patient must show "some real pleasure in finding out some tiny thing about himself." This, she says, "is one of the best criteria for the analytical approach." This curiosity will be an invaluable adjunct to and support of the working alliance when things turn difficult and the transference is at its trickiest. 

7) Imagination and Fantasy: Can they even mention a fantasy, detailed or not? Or, better, still, a dream, which Coltart says you should jump on immediately to see what they can do with it. This indicates great promise for psychological mindedness during treatment. 

8) Self-Deception: Do they consent to recognize that we may in fact be divided, opposed to ourselves, and deceiving ourselves? Are they aware that they may not in fact have a complete or completely accurate sense of their own mind and desires, but are willing to work to increase such? 

9) Success or Achievement in Some Area: She reiterates the "truism" that if the would-be patient has not succeeded in some area--work, school, relationships--then they will not succeed at psychodynamic therapy. 

8 Theses from Thomas Ogden on Reverie

I have, once more, my friends on Twitter to thank for introducing me to the psychiatrist and psychoanalyst Thomas Ogden, about whom I have recently written here and here. Once I understood his style, and how to respond and work with it, I have found him an enchanting writer. So I decided to keep working my way through his books as time and energy allowed.

The past few days, before being thrown into the whirligig of a new semester, which begins tomorrow, I sat down and read through one of his first books, Reverie and Interpretation: Sensing Something Human (Jason Aronson/Rowman and Littlefield, 1997). Among its several virtues is one I was especially delighted to see: how many times Ogden quotes Nina Coltart, whose work was then brand new but never, then or since, widely known (alas). 

It is in some ways perhaps incommensurate with how Ogden writes and thinks that I have chosen to extract from this book eight "theses," if you will. Perhaps "aphorisms" is a better way to think of these ideas, which are embedded in a book with great masses of clinical material from his patients. I have summed them up in my own words and added a bit of reflection as appropriate.

First, there is no such thing as a mind. This, of course, is Ogden's riff on Winnicott's famous declaration that "there's no such thing as a baby." What both men have in mind to emphasize here is that no mind exists of itself or by itself. A mind, Ogden says, is always created and maintained (as well as harmed) intersubjectively. 

Put negatively, the idea of an "independent mind" existing in its solipsistic splendour, untouched by and not linked to other minds, not only does not exist but, as Bion might say, is a psychotic illusion. 

Second, both minds are different after analysis/therapy. Patient and therapist alike think differently after spending time working together. I am sometimes startled by how much differently my mind works thanks to my patients. I think if I had stuck to my original plan of full-time clinical practice in the 1990s, when I was still in my 20s, I had then a very rigid mind and most likely would have been a rigid and presumably inflexible clinician. Now I feel, with not just training and experience, but my own psychoanalysis and ongoing analytic psychotherapy, and many years of living, far more comfortable with the changes that are necessary. I can allow myself to be pulled and pushed in various ways without the fear I had earlier in life that I would be toppled over or destroyed.

For this reason, I now greatly resonate with Ogden saying in this book--and all the others I have read so far--that each course of therapy, indeed each session, has to be different with each unique patient, and that if patients could eavesdrop on other sessions they would well wonder "Is this really the same Dr Ogden/DeVille as the one I see and hear and talk to?" 

Third, Ogden took me back to reading a Jesuit psychotherapist to whom I was introduced in high-school in the 90s (who has since been revealed to have been an abuser), who used to quote St Irenaeus of Lyons famous line about the glory of God is a human being fully alive. For Ogden, several times in this book, he says quite compellingly: every form of psychopathology represents "a form of unconscious self-limitation of one's capacity to experience being alive as a human being" (p.18). 

Once more, of course, the debts here to Winnicott are obvious, including what his wife wrote of after his death: the "prayer" he sometimes used, asking "Oh God! May I be alive when I die." 

Fourth, sexualization is an attack on mentalization. Ogden does not use the latter term, Fonagy's work  (and that of others like Jon Allen) on it not being then widely known. But I have found this a helpful way to think of some issues in treatment which Andrea Celenza also addressed in her invaluable book Erotic Revelations: Clinical Applications and Perverse Scenarios, which I wrote about here. 

Fifth, alter the 'fundamental rule' to permit greater freedom for reverie and also patient privacy. The academic editor in me has long been at war with the psychoanalyst in me, finding that true and literal application of the rule makes for a chaotic session, almost quasi-psychotic at times, and strick application of the rule can be an attack on the capacity to dream and think. I know in my own therapy I once very deliberately, and with gleeful malice, went on a 'wild' spree of free associating to run out the clock in the last 15 minutes of a session to avoid talking about a very embarrassing dream. 

Sixth, quoting Freud's 1914 paper "On the History of the Psycho-Analytic Movement," Ogden reminds us that "any line of investigation which recognizes...these two facts [transference and resistance] and takes them as the starting-point of its work has a right to call itself psycho-analysis." This, blessedly, releases us from silly and interminable debates about use of a couch and number of sessions being somehow exclusively indicative of psychoanalytic treatment.  

Seventh, simply listen. This is from Freud's 1912 paper "Recommendations to Physicians Practicing Psycho-Analysis." By this Ogden says that Freud meant engage in that evenly hovering attention precisely to catch the drift of, to tune into, the unconscious mind of the patient. This puts me in mind of Coltart's exhortation to practice bare attention. 

Eighth, quoting Winnicott, psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist.

David Wallin on Attachment in Psychotherapy

This book, Attachment in Psychotherapy, has something of a legendary status in the field it seems to me, so it was on my long-term list of things I knew I must read at some point. But one of the things I learned from Nina Coltart is that clinical work has a way, largely unconsciously, of bumping things up your priority list depending on whom you are treating at any given moment. So with several new cases presenting with what seems to me dismissive and avoidant attachment histories that immediately seemed a threat to treatment even beginning, never mind proceeding successfully, I felt I had to do more work in both attachment and mentalization. So with gratitude and relief I picked up David Wallin's Attachment in Psychotherapy. 

The book begins with the ultimate hook to scholar-clinicians such as I: "How does psychotherapy enable people to change" (p.xi)? Whose blood is immediately not set aracing by such a crucial and intriguing question? 

He immediately posits that an answer to such a question almost certainly has something to do with giving a relational connection and context not unlike that of primary attachment figures in early life, here mentioning to me the surprising claim that Bowlby, famous for his attachment theory, was much more of a clinician than academic, seeing a considerable number of patients who seem to have occupied more time than I ever realized.  

Much of attachment begins at the most primitive, per-verbal levels, and Wallin here calls to mind Christopher Bollas and his notion of the unthought known. This is especially true for disavowed or dissociated experience, which may well end up, Wallin says, being enacted, embodied, or evoked in others. The therapist skilled in mentalization, Wallin says--here tying his own work to that of Fonagy (given his own chapter--#4) which I have also found, and continue to find, so very helpful--will help the patient see these three patterns and begin to reflect on and own them. The therapist who exhibits and encourages such mentalization will likely have a "contagious quality," helping the patient's capacities to expand and grow outside the consulting room.

Wallin also brings in the work of metacognition, which bears a good deal of similarity to mentalization, though the former term was primarily developed in the US while the latter in the UK. In the US Paul Lysaker is most associated with the term in my mind, and his work on metacognition in psychotic disorders informs my own clinical work and has proven very helpful. 

Ch.2, The Foundations of Attachment Theory, covers not just John Bowlby but also Mary Ainsworth's equally important pioneering work here. The gist of this is to show that "an abundance of follow-up studies has tended to show that the attachment patterns of infancy have long-term effects" (p.23). Another number of studies suggest that parents replicate with their infants and children their own attachment patterns and struggles.

Ch.3 focuses directly on Ainsworth, noting that "without a functioning capacity for metacognition, we may for the moment find ourselves in a particular state of mind; lacking such a capacity, it's as if we simply are that state of mind" (p.40). Helping my patients appreciate this has in several cases proven a turning point in treatment. They had hitherto felt helpless in certain affective states, as though controlled by them: Fonagy calls this "embeddeness." But being able to reflect on them, to sit with and observe them as they come and go, has been very helpful. 

As we move into ch.6 of Wallin's book, he makes a useful caveat that perhaps cannot be stated enough: "the fact is that their [patients'] complexity can never be adequately captured by a single descriptor--secure, dismissing, preoccuped, or unresolved" (p.96). Do not, in other words--as I constantly tell my students--expect to see people show up in your consulting room straight out of central casting, with clear, precise, unambiguous clinical presentation allowing you easily and immediately to tick some theoretical or diagnostic box--avoidant! bipolar! OCD! Rare are such patients. 

Ch.8 focuses explicitly on Bollas and the unthought known, emphasizing that patients who cannot put certain things into words will show us by their actions, and that enactments in therapy will also be crucial forms of communication. Here and in many other places in the book, Wallin stresses that with patients whose ability to communicate their struggles in words is limited, "we must tune in to our own subjective experience" (p.129). Such experience includes all of us: Wallin cautions that the "taking cure" must not be limited to "talking heads," but include the whole body. 

Resuming themes of mentalization, Wallin goes on to state quite clearly that "helping patients change their stance toward their own subjective experience depends, in part, on our explicit mentalizing." Lest some think this insufficient--where's the homework? work-sheets? skills building? breathing exercises?--he insists a little further down the same page that "rather than any particular understanding, it is the experience in which the patient feels understood--and inspired to understand herself--that is ultimately most therapeutic" (p.157). 

He resumes this theme later in the book, noting that "for patients who are unresolved the therapeutic relationship is the therapy" (p.244) and such therapy provides an "incremental achievement of a sense of safety in relation to the therapist," and to that extent may heal previously traumatic relationships. Put in classical terminology, psychotherapy that provides "the patient with a secure base" is offering him or her "a corrective relational experience that may be healing in its own right" (p.257).  

Ch.10 brings in the work of Phillip Bromberg, to whom I was recently introduced. His idea of multiple self-states, and of change being something more than a static end-point at which we arrive and stay, has been extremely illuminating for me. Wallin draws on him in this chapter as well as Bion's notion of helping the patient contain "disowned thoughts, feelings, and desires" which can be reintegrated once they have been held in mind by the psychotherapist (p.183). 

Wallin goes on to argue something that I have recently been learning (not without struggle!) from the new book of Karen Maroda (and before her from Nina Coltart and others): the need sometimes less for containment (pace Bion) and more for confrontation and challenge. As Wallin puts it simply, "it must be understood that our patients at times need confrontation more than they need empathy" (p.200). He seems to suggest a little later that this is especially so with those who exibit a predominantly avoidant and dismissive attachment style, clues about which can be found in a tendency to lapse into irrelevancies and to exhibit certain things bodily. For such patients, we need to combine "empathic attunement with confrontation" so that the dismissing patient is led to see "how he gets to us" (p.212). 

We do this, of course, not via a "barrage of honesty" but in a way that the "patient can make use of." In doing so, Wallin cautions toward the end of the book (repeating a theme throughout), we communicate usefully using words, but in other ways as well. If we are not attuned to non-verbal communication, our utility to the patient is going to be limited to just that extent. Thus we must cultivate what he calls "open presence" (310) and earlier "bare attention" (the exact phrase I first learned from Nina Coltart). Such bare attention, Wallin notes at the end of the book, should be offered with in "calm, quiet" ways, quoting one of Freud's technical papers from 1912 (to which Coltart says clinicians should return regularly). 

When we are communicating via words, Wallin hints that it is better to use observation statements than questions: "Generally I prefer to simply comment on what I think I see, letting the meaning emerge from the joint exploration the comment usually elicits" (p.299). 

In the end, we do all this, he says in a neat summary of the book, because "in the new attachment relationship we aim to provide for our patients, repeated experiences of disembedding through mindfulness as well as mentalizing can establish a competing centre of organization in both the mind and brain. In this way such experiences can potentially replace the patient's insecure working models with 'earned secure' ones" (p.337). 

A Note on Bruno Bettelheim on Freud and Man's Soul

I was first introduced to Bruno Bettelheim in high-school by a wonderful English teacher who had first introduced us to Freud and Jung in order to read Robertson Davies' Deptford trilogy. I read with great fascination Bettelheim's The Uses of Enchantment, and in fact had great fun with a friend using that book to analyze various fairy tales we had both grown up hearing and reading.

It was many years later when I thought about Bettelheim again, and read Bettelheim: A Life And A Legacy by Nina Sutton. By then certain egregious details about Bettelheim, in both his Austrian and American periods, were notorious and his reputation nosedived. Sutton's book appeared not long after a lot of those revelations came to light, and attempted reasonably well to grapple with them and to judge him judiciously.

At some point, too, I read his Freud and Man's Soul. This remains a vitally important and likely overlooked book, though my circle of wonderful psychotherapists on Twitter have this week been ordering copies and discussing it, which compelled me to go back and read it again. 

When I first read it, I paid the most attention to Bettelheim's compelling and disturbing examples of the many and serious problems of translation, especially by the Strachey circle, of Freud. I am speculating--but I think on very firm ground in doing so--that these translation decisions were very largely motivated by the politics and early historiography of psychoanalysis (here my debt is chiefly to Paul Roazen's revealing books, including Freud and His Followers as well as others) as well as an overly anxious concern for its reception, and corruption, in American circles. Having seen how the Great War very nearly destroyed psychoanalysis in Mitteleuropa, and how by the 1920s analysts were already emigrating to anglophone countries, Freud (as I've briefly touched upon elsewhere) could already see that psychoanalysis was going to survive most widely in America, but that it would be captured by American physicians and to that extent domesticated and even, one might say, denuded of its more critical and far-reaching potential. 

It would also need--again to an American audience then in increasing thrall to a rising crescendo of American behaviorist psychology--to appear as "scientific" as possible, and to that end a new language had to be invented. This is captured perhaps most notably in what can only be described as the deliberate and ruthless efforts to render the German into abstract pseudo-scientific-sounding English purged of any and all references to the "soul," a point Bettelheim makes with more power than anyone else I have read. I will return to this point presently. 

The Tripartite Model:

The most immediate problems are with the invention of Id, Ego, and Superego (totally foreign to the German, as Bettelheim shows with such devastating cogency, but also to the French: le moi, le ça, le surmoi). If we keep close to Freud's often poetic German (for which, remember, he won the Goethe Prize), then his famous phrase is re-translated by Bettelheim as "Where it was, there should become I."

The problem with these English renderings, Bettelheim shows, is that the bleed out all the deeply personal and individual feelings of das Ich and das Es, introducing a level of estrangement precisely where Freud is attempting to maintain an intimate and personal understanding of the mind. 

Thus a good translation would look like this:

das Ich = the it 

das Es = the I

Über-Ich = the over-I. 

On this latter point Bettelheim says Freud's motive was to stress to us that "it is the person himself who created this controlling institution of the mind" (p.58), thus underscoring again Freud's metapsychological point that the human mind is estranged from itself. (All this is worked out prior to his last phase, the 'cultural phase,' as it were, when he writes of broader estrangement in, e.g., Civilization and its Discontents and Moses and Monotheism.)

The Oedipal Story:

I had forgotten about this part of Bettelheim's book, but on reading it anew saw what a powerful point this was. The translators took it for granted Freud's anglophone readers would understand the details of Oedipus and not need the story presented to them to grasp Freud's point about how little we understand our motives, how blind we often are both to our desires and their sometimes devastatingly destructive consequences (for ourselves and those we hold closest and love most dearly), and how those most blind are often rendered as such because of childhood traumata, all of which the original story of Oedipus make abundantly clear. Oedipus is a deeply wounded child rejected by his family of origin and cast into adoptive and abusive relationships--points we should all have great familiarity with today, making the story as timeless for us as Freud thought it was.

Instead, we get some farrago of nonsense attributed to him. As Bettelheim reminds us, that story is "boys lust after their mothers and want to kill their fathers to have her to themselves for perverse sexual ravishment." This tiresome and transparently tendentious rendering of Freud seems designed only to ensure he is ridiculed ab initio without having to read him any further.  

Freud the Libertine:

Bettelheim opens his book by taking aim directly at another wildly popular but misleading rendering of Freud: that he is some kind of libertine. (Roazen's book Meeting Freud's Family shows in charming detail what rubbish this is.) This has led--in my experience--many religious folks to scathing skepticism or outright dismissal of Freud as some kind of dangerous revolutionary. But this is to miss his point entirely! And that point is that "Know thyself" is not a blank cheque, and does not justify the total absence of (as we would say today) emotional regulation and self-restraint, especially when it comes to erotic desires and sexual practices. 

Freud the Dogmatic Interpretation Machine:

Bettelheim reminds us that problems with translation go back to Freud's most famous book, almost invariably called The Interpretation of Dreams. That title, of course, suggests, not least by using the definite article, that it has oracular powers to divine the meaning of all the productions of the unconscious mind we call dreams. But this is very wide of the mark, Bettelheim says: the German is far more tentative and far less ambitious. Better renderings supplied by Bettelheim would include:

A Search for the Meaning of Dreams (my preference)

or

An Inquiry into the Meaning of Dreams (which Bettelheim prefers).

This corresponds with my reading of Freud's works, and especially his correspondence. Though there are undoubtedly parts of him that occasionally appear as "dogmatic" (but of whom could that not be said at least some of the time? As Adam Phillips has shown, we are all prepared to become unbalanced fanatics about things we truly care about!), I am struck time and again by far more numerous and sincere examples of his hesitancy, his tentativeness, his self-aware putting forth of ideas about which he himself is not completely convinced. Let us recall here how many of his writings were not monographs but essays, and that verb's infinitive in French, of course, means to try.

To pick the most controversial example, the death drive, which appears in Beyond the Pleasure Principle (do read the Broadview translation!): I defy any reader to get through the introduction to that and not be struck repeatedly by how open Freud is to criticism. He seems to go out of his way to underscore his own hesitations, and with good reason. 

The Deletion of the Soul:

"Of all the mistranslations of Freud's phraseology, none has hampered our understanding of his humanistic views more than the elimination of his references to the soul (die Seele)" (p.70). I take this to be the most crucial point of Bettelheim's plaidoyer. On this I think him absolutely correct in ways nobody else has bothered to consider.

In my view (working as I am on a book about the reception of Freudian and psychoanalytic thought in Christian circles), this is the most unforgivable sin committed by virtually all the English translators. For it has fed into the rabid dismissal by Jewish, Muslim, and Christian believers of Freud as a "godless Jew" (to use his own, albeit wry and perhaps ironic, phrase) who, with Marx and Nietzsche (the three "masters of suspicion" famously so called by Ricoeur) is, we are endlessly told, out to "destroy Western civilization" (a phrase whose utterance automatically marks the speaker down as a fundamentally lazy and unimaginative reactionary).  

Bettelheim goes into wonderful detail about how many examples of the soul show up across Freud's writings. I would document some of these, but I have to get off to another meeting, and I want to write about this more in an essay of its own--and finally my long-suffering readers were promised "a note" on the book, not a 10,000 word treatise!

Finis (pro tem).

Ogden and Phillips on Reclaiming Unlived Life

I have read all of Adam Phillips' books (that is not a vulgar boast so much as a reflection of deeply ingrained scholarly habits, which are often nearly indistinguishable from semi-obsessive or slightly manic tendencies leading one to devour, and ideally to own, an author's opera omnia); and I have newly set for myself the goal of reading if not all then certainly several more of Thomas Ogden's books, to whom I was introduced this fall. I found his style enchanting, but even more some of his arguments--which I have never encountered in 30 years of reading psychoanalytic authors--are wonderfully capacious and hospitable, allowing me to think things about my own analysis and now my own clinical practice that are freeing--and topped, ever so slightly, with a frisson of the forbidden or, better, the "unthought known." 

It occurs to me that Phillips and Ogden have a lot in common. Surely someone else less dim than I has long ago noticed this? I am always a Johnny-come-lately to these things. 

But there is more than a superficially titular resemblance between the Ogden book I read this week--Reclaiming Unlived Life: Experiences in Psychoanalysis, from 2016--and Phillips' Missing Out: In Praise of the Unlived Life.  Both include (here as elsewhere) liberal and loving lashings from literature and poetry; both write in an often lyrical style; and both hold and expound views that, even at this late stage, still seem somehow to sit uncomfortably within "orthodox" psychoanalysis (if one can still speak coherently of such a thing). I have no data to confirm this, but it remains a strong impression. Nonetheless, I think we're all the richer for their perhaps sui generis views and would not have it otherwise. 

I will say that of all Phillips' books, Missing Out perhaps comes back to mind most readily, and has occasioned very profitable discussion with students in this Covid era. Let me tidy up a few old thoughts about it here, and then set him alongside Ogden. 

The appropriate place to begin is with Phillips flatly declaring that "reality matters because it is the only thing that can satisfy us" (25). This will get developed in the rest of the book's realist, anti-fantasist stance in which Phillips clearly comes out against spending time imagining what could have been--what sort of life we could have had, or worse, could yet have if we but overcome our limitations and frustrations. For to give ourselves over to such disordered fantasizing, to wondering after would-be satisfactions in some imaginary future, is to open ourselves to an endless frustration with our life, which is itself an enormous problem insofar as "frustration may be the thing that we are least able to let ourselves feel"(27); and again: "There is nothing more opaque about ourselves than our frustrations" (28).

Phillips is saying this as an adult, and directing it at his readers who will all presumably be adults. But how much more difficult is this for children and adolescents! How many "conduct disorders" and "adjustment disorders" are the results, at least in part, of an inability to bear frustration? How many arise in response to demands to produce facile "solutions" to our frustrations--which end up serving nobody well? 

One danger of children trying or being required to achieve over-mastery of frustrations, as Phillips hints, but Winnicott made explicit, is that of precocity, famously treated in an essay I wrote about here. On that topic, let me put in a plug for an unjustly neglected but invaluable collection, The Mind Object: Precocity and Pathology of Self-Sufficiency, eds. Edward G. Corrigan and Pearl-Ellen Gordon.

Frustrations, if allowed--as Evagrius recognized long before Freud came along--to take root in our mind can become, as Phillips nicely puts it, "intractable because their satisfaction is too exactly imagined" (32) and as a result "there can only be unrealistic wanting" (33). To have "realistic wanting" seems a good enough goal for therapy as for life. It may well require mourning what is unrealistic, and grieving those wants that can never be satisfied. 

I admit that such too easily imagined satisfactions and unrealistic wantings strike me whenever, as last week, NPR told me that the Powerball had grown to a billion dollars or whatever. Hearing this, on the tedious last stretch of some highway or other, I imagine the house I would build (the library would be multi-tiered, sound-proofed, and have a massive fireplace in it with floods of light from huge windows on all sides; all other design details are trivial and uninteresting), and the scholarships I would endow, and the training program I would build to graduate the finest psychodynamic psychotherapists in the country; and so on. 

But Phillips is not done with our frustrations, and not willing simply to dismiss them because they are too easily imagined. Instead, he says that "We need...to know something about what we don't get" (33). This, of course, immediately raises practical if not moral problems: "But how...would you teach someone to not get it?....Teaching them how not to conform without trying not to conform?" (48-49). 

As an academic and a clinician, I find this is a tricky balance to pull off, and today's undergraduates seem especially frustrated and suspicious as you attempt to do so. With understandable bewilderment, they want to know how it is that they are taking an (often required) course only to be told by the professor that one of his most important goals for them is that they understand more deeply what they do not know, what their blind spots are, and what value uncertainty, ambiguity, and ambivalence all have as scholars of any and all disciplines, but especially psychology. But I try nonetheless to inculcate this in them, saying that if they are the sort of logic choppers and hermeneutic naïfs with a raging and uncontrolled desire for omniscience, who have to know everything and have it mapped out in advance, and cannot find uncertainty anything but paralyzing and disdainful--well, then, they need to exit from a clinical career immediately and go build bridges or something. 

As we teach others about the importance of not always "getting it" we need ourselves to be, as it were, convinced of the benefit of doing so, asking ourselves and others: "In which area of our lives does not knowing, not getting it, give us more life rather than more deadness?" (80). 

Incidentally, these are questions profitably examined from a variety of angles in another unjustly neglected collection, Knowing, Not-Knowing and Sort-of-Knowing, ed. Jean Petrucelli

Since reading this passage in particular, I have often thought of my foolish desire in my 20s that psychoanalysis would grant me access to knowing the entirety of my mind, unconscious drives and all. At the end of a full and successful analysis, there would be no surprises and all would be known and mastered, laid bare to the cool eye of reason. My second analysis has moved me quite unexpectedly away from that desire. I now find it more freeing to not pursue every detail of my mind but instead simply to recognize within myself that "I contain multitudes." That is, I hope, not just some tawdry bit of Whitman on the cheap; nor is it meant to be self-congratulatory in the least, but instead an increasing acceptance of the undrainable reality and complexity of any human mind still living. 

One of Phillips' great lines comes in this book when he says that a good goal for psychoanalysis is to help us "make sense of our lives in order to be free not to have to make sense" (63). In other words, we might have "good enough" insights (Phillips' wrote an early biography of Winnicott, which is decent, but the Rodman bio is much better) into ourselves, and, being content with those, feel free to stop pursuing further insights and instead go off and do something else like write poems or make black raspberry jam. As he puts it here and elsewhere (and this clearly echoes Winnicott), one good therapeutic outcome of analysis is that you can forget your treatment, your "symptoms," and the problematic narratives that brought you in in the first place, and simply get on with living. (I recall with great relief Nina Coltart saying in an off-handed way that she could hardly remember a single word of her multi-year analysis with Eva Rosenfeld.)

Being aware of, and comfortable with, what we do not understand is nowhere more important, Phillips counsels, than with sex: "When it comes to sexuality, we don't get it....It means that when it comes to sex we are not going to get it. We may have inklings about it....We can know the facts of life, but nothing else. We may, as we say, have sex, but we won't get it" (77). And again: "What psychoanalysts mostly know about sex is the strange ineffectuality of so much of their knowledge" (79).

Thinking these things with Phillips is very helpful, I find, to maintaining "evenly hovering," that is non-judgmental attention in any discussions about sex. It seems to shock some patients that I am not shocked when they discuss certain things about their sexual life. So many people come in preloaded with all sorts of judgment, and can hardly sit still if you do not immediately express some kind of stern judgment, or at least mildly clucking distaste, for whatever their "issue" is. They seem startled by having everything welcomed for discussion. I suspect a few of them secretly believe I must be faking it--and silently racing to retch into the rubbish bin as soon as they leave!

Right. So much for Phillips. Onto Ogden.

Reclaiming Unlived Life is a collection of essays, as several of Ogden's books seem to be (and as most of Phillips' books are too). Unlike Phillips' book, Ogden's is not so focused on this theme of the unlived life. The title, in fact, seems to come from a single chapter devoted to a late essay of Winnicott. We will come to that presently. Other chapters range widely. I will confine my thoughts to the first five chapters, and to the last one, with which I start.

That chapter is an interview Ogden gave to Luca Di Donna. It gives interesting background, as one would expect, but perhaps the best nugget--hidden just beneath the surface, and not mentioned explicitly, but seemingly obvious to me--is that Ogden desires no disciples. And perhaps even more impressive is his sangfroid about others using his works and disagreeing with him: "the fact that I don't recognize my own thinking in another person's interpretation of the concept of the analytic third is an event that I welcome because it means that the interpretation of the concept has been nutriment for another person's thinking--that, after all, is the principal point of writing of any sort" (p.169). 

The second gift in this interview is a point Ogden has made in other books: the importance of "tailoring" (not the best word--not a good fit!--but I cannot think of another just now) each treatment to each person to such an extent that each patient finds a very different Ogden. He reports rather cheerfully that he wants and would expect his patients to be astonished if each of them could listen to how different he sounds in speaking to all the others, and far from being disorienting this is a good thing. In other words, Dr Ogden with Patient A would sound very different than Dr Ogden with Patients B through H. 

The final point in this chapter is that knowledge alone is a very poor outcome of therapy. It availeth nought toward psychic change: "There is nothing mutative or growth-promoting about the acquisition of greater knowledge about oneself. What is mutative, I believe, is the experience of oneself in the context of being with another person who recognizes you to be the person you are and the person you are in the process of becoming. (It is precisely this experience that has made my second therapeutic analysis so valuable in such unexpected ways.)

This last chapter, and this discussion in particular, link up very nicely with the first: "Truth and Psychic Change." Here Ogden makes several points, including--to my amazement and relief, being the first time I have heard such a thing uttered--that the fundamental rule of psychoanalysis "compromises the patient's right to privacy, which is necessary for the freedom to dream in session" (p.2). I found, and find, this very freeing. Equally liberating in this regard is his claim in Ch.5 that you can only become a therapist based on your own unique gifts: "you have to respect the uniqueness of your own personality" (p.93) and not rely so much on interpretations and theory and whatever you imbibed from your own therapist. In all these things, and in his other books I read recently, there is a very strong welcome made to individuality and creativity in an atmosphere of radical freedom. I suspect Ogden and Fromm would have been good friends. 

The chapter next explores how to pursue truth in analysis in ways that the patient can bear. If done too soon or too zealously, before trust is achieved, truth will carry little water and may drive the patient backwards. And it might always be a dialogic process--not a top-down "interpretation" imposed by the clinician. 

Ch.3, "Fear of Breakdown and the Unlived Life" is an obvious reference to Winnicott, whose very short 1974 paper "Fear of Breakdown" was published three years after his death. This is the central essay in the book and it seems characteristic of Ogden's peculiar gifts that he can find so much material to comment on so profitably in what was not just an unfinished paper of Winnicott's but also a very short one in its original publication. 

In any event, Ogden says that this paper is one of a half-dozen that have been most influential on his overall thinking--along with essays by Freud, Klein, Loewald, Bion, and Fairbairn (always nice to see that neglected Scotsman get some attention! For more on him, Jock Sutherland's Fairbairn's Journey into the Interior is a decent place to begin.)

Ogden talks about how moving it is to read Winnicott, here as elsewhere. Though he doesn't quite put it like this, I have long felt that you could, through Winnicott's words, gain a strong and felicitous feeling for what it must have been like to be in his warmly welcoming consulting room. Doubtless he would have scandalized many on Twitter by his occasional offer to some patients of a cup of tea, which I find very charming indeed.

This essay, Ogden says (and cf. below my comments on Searles and psychosis), allows you to feel compelled to join Winnicott in getting in touch with our own feelings of fear of breakdowns: "to be an adequate therapist we must make use of our own personal knowledge of 'what it feels like'--what 'insanity' feels like--even though we are not in the full grip of a particular 'detail' of that insanity at a given moment" (p.50). 

For Winnicott, a breakdown begins as a loss of defenses against the psychotic parts of our mind. The crucial difference, he suggests (and Ogden rightly notes how much of this paper is Winnicott thinking aloud in not entirely coherent ways), is that patients fear breakdown now when they lack the "container" or "holding environment" of the mother-infant bond. Ideally, of course the therapist and therapeutic frame provide this, but Winnicott and Ogden both say that the patient needs to know you understand not just their breakdown but feel the fear of it, and have some experience with it. To guard too much against these feelings in yourself will not help your patient and their feelings of being trapped by some "primitive agony."

Ch.4 dares to tackle the hermeneutics surrounding one of the most enigmatic and controversial essays of the last half-century: Bion's infamous "Notes on Memory and Desire," to which I've given not a little attention on here (and here). 

Ogden confesses he's tried to read and understand it for decades without success until he realized Bion did not want people to agree, but instead to think about these questions with him. And the question, Ogden asserts, is not about memory or desire, but about the proper and overlooked role of intuition and the unconscious in the analytic process--which desire and memory can mask and distort. 

Ogden comes close to saying--but does not seem to do so--that the problem with memory and desire is that they are, as it were, a false floor. We might think we are grounded on them, but in reality they cover over a yet deeper level where the truth is more likely to be found (cf. pp.77-78). I catch glimpses of this in my own life when I can allow myself sometimes to try to get behind certain memories or desires to discover that they might not in fact mean what I have long thought they did. (We are, as Phillips might say, too easily satisfied literalists!) If Ogden is correct on this, then it is both a little alarming and a little liberating: alarming because it suggests our capacity for self-deception is much deeper and more thorough-going than first realized; but liberating in that we might not quite be prisoners of our desires after all. This will bear continued thinking about. 

We can circumvent memory and desire, he suggests, by dreaming in the session, by reverie, though to do so may require that "the analyst engage in an act of self-renunciation. By self-renunciation, I mean the act of allowing oneself to become less definitively oneself in order to create a psychological space in which analyst and patient may enter into a shared state of intuiting and being-at-one with a disturbing psychic reality that the patient, on his own, is unable to bear" (p.79). 

This passage immediately put me in mind of working with psychotic and borderline conditions, both of which I have found require that I become for a time something more or other than what I seem to be. I really do think Harold Searles (whom I discussed a bit here) was right that in working with such patients, you have to be willing to allow yourself to be a little bit psychotic--or at least be somewhat comfortably, if only for a time, in the neighborhood of your own psychotic elements. These patients are so split, so fragmented so much of the time, that trying to keep them all together, or to put them together, too soon does not, it seems to me, help them learn how to bear what they cannot bear right now. 

How can you do that--allow yourself to be a little bit psychotic? I doubt I could have even entertained the thought when I was younger. It is not easy, and it can be a little bit frightening. But now I rely heavily on a strong frame along with good supervision, supportive colleagues, and my own psychotherapy. I think having patience is also crucial: if you get in touch with those terrifying psychotic elements, you can do so more easily knowing that (as Christopher Bollas has suggested, among others) it is possible to dip into and out of "madness" without getting stuck in it, and the dark and difficult experiences will pass. (Here I really do believe Ophir's recent arguments that "madness" is on a continuum, and not some radically "other" state or "disease entity" that is totally separate from ordinary human experience). 

 Speaking of schizophrenia and psychotic disorders, I have a half-dozen new books to read over my Christmas break, so I suppose I will have to frustrate my desires to order some more Ogden until I get through at least part of that pile. Of course, my super-ego can sometimes be overpowered or ignored, so who knows. But I will certainly read more of him when I can (and also, come to think of it, write more about Phillips' two newest books).

Michael Garrett on Treating Psychotic Disorders: Part the First

Back in the early summer, outside the pressures of the academic year, I ordered a half-dozen books on psychosis and schizophrenia, thinking, in my slightly manic way, that I'd have abundant time and energy to "read, mark, and inwardly digest" each of them in great detail (to borrow one of Cranmer's genteel phrases from my Anglican childhood in Canada that doesn't quite describe how I often brutally ransack books like some kind of shameless Vandal), and perhaps even to re-read some of them. 

Well that didn't happen, but I did make steady, though much slower, progress on two of them, including Michael Garrett's Psychotherapy for Psychosis: Integrating Cognitive-Behavioral and Psychodynamic Treatment (Guilford, 2019). xiv+354pp. 

Part-way through the book, I learned on Twitter that Dr Garrett would be leading a 9-hour training workshop on Zoom discussing cases and techniques--both CBT and psychodynamic--for treating patients with psychotic disorders, whom he has had some considerable success in treating over the decades. So I signed up, and just completed it with him in early November. It was very useful in all sorts of ways, and in fact the week after the first session, I had occasion to meet with a heavily delusional patient and the "peripheral questioning" technique Garrett described in both the book and the seminar were extremely useful in beginning to chip away slowly at the delusional thinking. 

What follows, then, are my initial thoughts on the first third of the book (I won't have time profitably and deeply to read the rest until my Christmas break) farced with some comments and examples of his from the training, and my thoughts in response to that.

Garrett endeared himself to me in the first paragraph of the first page of the book in which he said (with no false modesty evident here or in person in our seminar) that "I make no claim to have invented a new therapy." To which let all the masses say: Amen! Alleluia! Blessing and Glory and Thanksgiving Be to Our Author! Later, at the end of ch.1, he will further outline a second important caveat that "I make no claim that the approach outlined in this book will be useful with all patients" (p.26). 

Instead of attempting to invent something de novo, he says his approach in the book will be to "fix two existing therapies together" (p.1). This he does by drawing in a careful and respectful way on longstanding training in both CBT and psychoanalytic methods. For those who are immediately nervous about such an approach, which has been attempted in the past by some apologists for therapy "integration," and often seems to end up trying to jam (one is tempted to write repress) dynamic ideas and practices into a Procrustean CBT bed, rest assured this is most certainly not Garrett's approach. He is, after all, first trained psychoanalytically long before he did CBT training. And second, he's married to the incomparable Nancy McWilliams (to whom he dedicates this book), arguably one of the great psychoanalytic psychotherapists practicing today in the anglophone world, whose praises I sang here. 

Aware that pulling two traditions together, especially in service of psychotic disorders, may seem a tall order, Garrett rightly says that "psychotherapy for psychosis should be ambitious" (p.1, his emphasis), and a little later on notes that the lack of ambition means many, perhaps most, patients are drugged and given little beyond that to help. Their suffering is relatively unabated by clinicians who are not ambitious enough on their behalf, seeking little more than symptom control via neuroleptics.

Garrett's approach is, as noted, twofold, and in the book and seminar he noted that it is usually important to begin with CBT methods in the first phase of treatment to try to "examine the literal falsity of delusional ideas" before trying, via psychodynamic methods and theory (especially that of object relations) to "examine the figurative truth (specific personal meaning) contained in psychotic symptoms" (p.2). Garrett thus takes his place alongside others we have noted on here who believe that "psychotic symptoms are a symbolic expression of the psychotic person's mental life" (p.3). 

In putting CBT and dynamic practices together, he will later argue in the book that there are "many differences of terminology rather than substance" (p.24). His one caution about integrating them is again the timing, noting that a weakness of dynamic therapists is to interpret the unconscious meaning of symptoms too early in the treatment. Doing so before a well-established foundation of trust is laid means that the therapist is likely to fail to help for the simple reason that "it isn't a clever point of logic that proves the delusion wrong and wins the therapeutic day; rather it is the patient's trust in the therapist" (p.25). 

Also in the introduction Garrett notes that as a prescriber he is not opposed to neuroleptics, but he rightly insists we should be aware of at least two things: first, that "the longitudinal data indicate that in the majority of patients long-term neuroleptics do not restore premorbid functional capacity" and second that "some individuals can recover without medication" (p.4). If treatment should be ambitious, then it should be open to using drugs where necessary, but even more it should be committed to long-term intensive psychotherapy for the latter lacks the notoriously nasty side-effects of neuroleptics. 

To argue for such intensive therapy requires that we counter the "discrediting myths about psychotherapy for psychosis," which he does very smartly and without polemics or fireworks in the the last half of the introduction to the book. I will not repeat those arguments here for I am utterly convinced by them and would regard their demonstration as tedious. But for those who are less convinced (e.g., most of mainstream psychiatry it seems), this is important reading.  

The first chapter begins with challenging head-on another excuse for avoiding psychotherapy with psychosis: that it is too difficult. Au contraire, he says: "it is doable and is often no more difficult than psychotherapy with people who have severe personality disorders" (p.17). I would second this based on my limited clinical experience. I find psychotic disorders more straightforward than the histrionic and borderline conditions I have attempted, with little success so far, to treat.

The chapter ends with Garrett saying something that I find so refreshing about work with psychotic patients: their directness and earnestness. "When a psychotic person talks in earnest with a clinician, there is no idle chit-chat...[or] half-truths and social niceties....The conversation is densely meaningful" (p.26). I find this very true, which is why I find myself greatly looking forward to seeing my psychotic patients.

Ch.2: "Biological and Psychological Models of Psychosis" does not pretend to be exhaustive, but it is wide-ranging and fair-minded enough to give readers with little background a good introduction to various theories. Like other authors, he notes that psychosis often begins with a prodromal period in which things begin somehow to feel 'off.' (This put me in mind of Christopher Bollas' image of When the Sun Bursts which I discussed here.) 

The prodromal phase may, he told us in the seminar, be brought back to mind in taking a history by asking such questions as "have you noticed any changes in the way your thoughts come to you lately?" Often, he says, patients "hear" their thoughts more than think them per se. Often, too, this phase is marked by a more intense awareness of the environment--its colours are more intense, or its suns and planets (cf. Bollas) more prominent in odd ways. 

In putting this chapter together, Garrett ranges widely, back to Harry Stack Sullivan and Karl Jaspers. An important sign of this prodromal phase, Garrett says, may be found in patients who report no longer thinking their thoughts, but instead "perceiving their thoughts." This, to put it into Fonagy's terms, could be described as a collapse of any ability to mentalize. Or to put it in Lysaker's terms--with which Garrett shows some familiarity at several points in the book--we see the inability to engage in any sort of metacognition. (One of these days, dear longsuffering reader, I will get around to writing about Lysaker's very rich and dense book, which I read nearly a year ago now.) 

As for the question of how to define psychosis--is it a 'disease' that is 'other' than or radically breaks with, common human experience, or is it on a continuum (Ophir's book examines these issues with great skill), Garrett reviews the evidence that "roughly 20% of the general population report transient psychotic experiences of some sort, which indicates that psychotic states exist along a continuum with ordinary mental life" (p.46). I like to scandalize my students by following Bion and altering Freud's famous phrase to say to them that the dream is the royal road to the psychotic mind, and to the extent we all dream, we all experience our own 'psychotic' minds. If nothing else, this claim of mine usually momentarily rouses the sleepers and Instagramers in the back of the room to raise their heads to lodge some desultory protest ("Whaddya mean we're all psychotic?") I laugh at with a little bit of smug sadism. 

Ch.3 advances Garrett's argument that psychosis is "an autobiographical play staged in the real world" (p.58). As compelling as I found this metaphor upon initially hearing it, I challenged him (in an amicus curiae sort of way) in our seminar, saying that I found Bion's argument about "Attacks on Linking" very powerful, and to just that extent wondered how a psychotic patient could link together his or her life in such a way as to mount a play that an audience could follow with some coherence and facility. In our exchange, which was very helpful and cordial, he was able to 'rescue' the metaphor, as it were, by suggesting that the play might make sense and cohere, more or less, to the patient, but of course would do so far less to the 'audience' (clinician, etc.). The job of the clinician, then, is partly to help the patient recover the ability to make sense not just to himself but especially to others, thus overcoming much of the profound isolation that so often marks psychotic disorders. In other words, the recondite meaning of the psychotic play needs, via psychotherapy, to become gradually more and more apparent and understandable to others. 

Also in this chapter Garrett advances his argument that delusions of grandeur exist in part to "fend off self-hatred and shore up self-esteem" (p.68). Thus, instead of rolling your eyes (as Garrett of course rightly said in our seminar a good psychotherapist should not do) at a patient who reports being a messenger of the divine, or perhaps even God himself, we can instead see this as valuable material, testifying to how little self-regard the patient has for him/herself: the more grandiose the delusion, perhaps the more depleted the sense of self.

Following the same logic, MG later in this chapter says that command delusions point to ambivalence in the patient: if they are uncertain about about a course of action, the delusion might resolve this for them in a kind of 'absolutist' way that you can decipher to find the uncertainty behind it. In other words, the more demanding the delusion, the more there might lurk ambivalence and confusion behind it in inverse proportion. 

On the topic of delusions, our seminar noted that one key hallmark here is the background becoming foreground, and things usually not noticed in daily life (e.g., the particular colour of cars in a parking lot) become hyper-salient details, perhaps revealing hidden meaning (apophenia). In addition, any sense of self disappears into the background and thoughts are no longer something I have, but malignant and persecutory outsiders that come to me unwanted and unbidden. 

Finally for this chapter, MG notes that any thespian metaphors are time-limited and prone to instability: "clinicians should not regard psychosis as essentially a static mistaken idea or cognitive bias. Psychosis is more like an ongoing improvisational drama, with unexpected twists and turns in the plot and an expanding cast of characters" (p.82). 

In Ch.4 MG notes that an important thing to keep in mind is that figurative language is almost always replaced by very concrete language and metaphors. We will return to this point later.

Well, that's it for now. I hope to finish the book in December and post the next part then.

On Sexualized Defenses, Transferences, and Counter-Transferences

Though I can remember almost none of my undergraduate professors at the University of Ottawa from the early 1990s, I have never forgotten Dr Arthur Blank, for both salutary and unsavory reasons. The salutary: I got to write a research paper in his Family Psychology class on what happens to families (such as mine) with a child who is chronically ill and then dies, and it was a profoundly revealing and helpful experience which earned me an A (not a grade I was anywhere near in my psychometrics or neurobiology classes that semester!), and gave me new and more sympathetic insights into what my parents faced and the choices they made to concentrate on my sister in the last six years of her life to the inevitable and unavoidable neglect of me and my younger sisters for most of our late childhood and nearly entire adolescence. 

The unsavory: a few months after class ended, he was in the papers on a regular basis being sued by former patients whom he had sexually abused in his private practice, including a woman who went into therapy with him to deal with having been sexually abused while growing up. He would be struck off the register of psychologists in Ontario and have to pay hundreds of thousands in damages to his ex-patients. I read the newspaper accounts with horror that a man could do such a thing to vulnerable patients. 

This coincided with living with a roommate, whom I knew slightly from my church (which very much encouraged his moving in), who had all kinds of issues with boundaries; we ended up having to ask him to leave. And it also coincided a few months later with my starting analysis and the great pains my analyst took to coax me onto the couch, which I was more than a little frightened of for the vulnerable position it places one in. ("What's she thinking back there watching me? What if she reaches around and touches me before I can see what she's up to and leap out of the way?")

Boundaries, then, have long been prominent in my mind. A few weeks back, I had occasion to read Glen Gabbard, "Lessons to be Learned from the Study of Sexual Boundary Violations" last week (American Journal of Psychotherapy 50, Summer 1996: pp.311-322). I posted insights from that on Twitter. He offers clear and concrete guidelines for avoiding boundary violations based on his work with more than 100 such cases. 

As important as his work in this essay is, he does not reflect on what might be useful in erotic transferences and counter-transferences and how to handle them in a profitable way that does not lead to disastrous outcomes. That crucial task falls to Andrea Celenza, Erotic Revelations: Clinical Applications and Perverse Scenarios (Routledge, 2014), who breaks the ice on these discussions (for me at least). As she notes, much of the clinical literature and likely almost all supervisory contexts avoid the topic because of the understandable fear and even shame such things evoke. 

I was not familiar with her work until Adam Rodriguez on Twitter mentioned how important her work is, and how she should be required reading in training programs. Having taken at least one lesson from her already, and used it in my own supervision, I would agree: she offers insights that begin a long overdue discussion, and we should be introducing that discussion to our students and supervisees. 

What do I mean by that? My take-away from her many insights is that there is a necessary difference between erotic attraction and sexual enactment, and that to feel and discuss the former without shame is not to necessarily risk the latter. Indeed, to put the point more strongly: perhaps the extent to which we feel more free to discuss erotic elements in the transference and counter-transference we may deprive them of the power of secrecy which so often masks and precedes boundary violations. Reading her book has in fact moved me along into feeling more comfortable discussing these things with my own supervisor, who has himself published on problems of sexual boundaries with certain populations, and discusses these with grace and good humour (not unlike Celenza's own supervisor as recounted in an hilarious anecdote on p. 69). 

The other crucial insight she offers is that sexual desire between patient and psychotherapist is always complex and complicated. Though Celenza is not so blunt on this point, I take her to be reminding therapists that if you think your patient really wants to just have sex with you in some straightforward manner, then you are deluded and have indulged in a self-serving and grossly reductionistic attempt to focus on only one thing: your desire. In this monomaniacal pursuit, you not only take your eye off the patient and his or her welfare, but you also fail to recognize that the patient's putative desire for you is highly ambivalent and complicated by many factors, and most certainly does not mean what you want it to. 

She puts it more elegantly and less compactly throughout the book, noting, first, that "being multiple selves is the human condition, and being multiple others to our patients is the analytic condition" (p.62). This multiplicity of self-states comes up several times in the book, and puts me in mind of a wonderful essay by Phillip Bromberg, "Standing in the Spaces," that I read recently and profitably. 

She continues in this vein, arguing, second, that "the gender that the analyst is...is not necessarily the only gender the analyst can be in the erotic transference" (ibid). I found this very revealing, opening up a new way of trying to understand same-sex erotic transference which baffled me in one particular case.

So the patient--whether male or female--could be responding erotically to us in a more maternal or masculine, or paternal or feminine role, or mixtures thereof; they could be responding from a younger and more childish part of the self, or (in our counter-transference) we to them from such multiple and entangled and ambiguous self-states of our own. Thus we see that the erotic response of patient to analyst, and therapist to patient, is not at all clear or straightforward, and responding as though it is will always invite disaster. (Celenza notes in an offhand passage something that Gabbard goes into in more detail: sexualized boundary crossings often happen when the therapist is engaged in "defensive efforts to manage our self-neglect" [p.67, with a reference to her 2007 book on the topic].)

Third, she states a little later that "the wish to know the analyst sexually is invariably complicated and usually highly conflicted. And if it is not, it should be, given the inherent power imbalances" in the therapeutic relationship (p.79). This theme of power imbalance is one she threads throughout much of the book, noting that it is inevitable no matter how much some misguided efforts might be made to flatten things and to insist patient and clinician meet on equal terms. We do not, and never will. 

I remember almost nothing else from one of my first supervisors, but he made damn sure to pound into my head one crucial point: We are not and never will be friends with our patients. A fortiori, we are never going to be lovers, either. As Adam Phillips says in one of his many wonderful books, psychoanalysis welcomes exploration of any and all topics no matter how emotionally and erotically laden and we can do this only because we agree never to have sex with each other.

On the question of sexual desires and their conflicts, I think the crucial passage in the entire book is this:

What do our patients want? They say they want our love, or more pointedly, to have sex--but do they really want that? We are many things to our patients simultaneously and equally important: analyst, woman, person, mother, father, sibling, and child....At any one time a plea for love or sex is a plea from within only one of those dimensions....The man may want a kiss, but the child does not. 

From this she follows up even more directly, insisting that "our patients do not really want us to gratify their erotic wishes, despite their vociferous protests to the contrary. But they do not want us to simply maintain our professional role either" (p.68-69). 

How, then, ought we to handle such things if it seems we are caught on the horns of a most serious dilemma? I confess I was gratified to read of her approach, which I stumbled upon myself before I had heard of this book. Celenza notes that if we cannot indulge patient desires, nor shut them down in a brutally "professional" way (for both responses harm patients in different ways), what is needed of us? Patients need us to respond to them as human beings, and so she said that sometimes a response like "I would if I could!" or "In another time or place" are just the sorts of responses "we need to convey to our patients" (p.69). (Quoted in this way, it may sound like Celenza is a bit flippant about such matters, but the force of her cogent book is quite to the contrary: she has clearly thought about such matters in depth and has hard-won wisdom abundantly displayed throughout the book.) 

I do not want to suggest this book is only devoted to these issues. Its other riches include good discussions in ch.1 especially on overly restrictive ideas of gender and on the uses of sexuality as a defense mechanism. Ironically, sexualized defenses and behaviors can often be used to stave off intimacy--a theme she devotes the entire second part of the book to in her focus on sadomasochistic and perverse habits and enactments. 

That final section, on sadomasochism, explicitly draws on a book I have half-finished right now: Robert Stoller's Perversion: The Erotic Form of Hatred. Celenza picks up where Stoller (whose work was published in 1975 but still has valuable insights for me at least in clinical work with sex offenders) leaves off and gives us a nuanced and balanced assessment before concluding that in her view sadomasochistic enactments are problematic insofar as they may be attempts to destroy any "tolerance of dependency, vulnerability, and self-revelation" (p.114) and may participate in "dehumanization of the other" (p.109). She notes that too often sadomasochistic habits may exist as a "closed feedback loop in which repetition and sameness is substituted for creativity and growth" (p.100). She gives an encouraging case study of one such patient who was finally able, after intensive analysis, to move into a much freer and more loving relationship with a woman who became his wife.