On Treating Obsessive Compulsive Personality Disorder

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

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

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

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

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

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

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

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

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

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

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

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

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

        Mirroring:     To be recognized

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Notes on Motivational Interviewing

Having here praised William R. Miller, whose book, co-authored with Theresa Moyers, was unexpectedly helpful, I realized I could now go back and read Miller's famous work on motivational interviewing. As so often seems to happen with me (a phenomenon first noted by Nina Coltart), current clinical work brings certain books back to mind and unconsciously nudges them up the priority list, on which reside, at any given moment, at least a dozen other works in various stages of being read, marked, and inwardly digested. So I found my copy of Motivational Interviewing and cracked it open again. 

Psychoanalytic snob that I have so often been, when I first heard that phrase years ago my eyes instinctively rolled so far back into my head they were able to watch old episodes of WKRP in Cincinnati. Herb Tarlek instantly came to mind--he who was always arrayed in a hideous jacket and had the oily demeanour of the salesman that he was. That is what I thought of "motivational interviewing": some smarmy technique devised by the more revolting apologists for "dollarland," Freud's acid nickname for America. 

But Adam Phillips taught me (this appears in many of his books, but perhaps most especially The Cure for Psychoanalysis) that ideological thinking is the antithesis of a psychoanalytic mind, and snobbery and defensiveness around it are both false to its promises and unnecessary to its survival (indeed, are fatal to its survival). 

My Canadian and Catholic instincts here further remind me that many differences are frequently exaggerated, and a careful work of "translation" will often reveal how similar things are. Though I have often thought the contemporary academy (especially in the humanities) is too enamoured of works of intellectual genealogy, they have their place, perhaps especially in the clinical sciences as we see just how much covert borrowing there is, especially by those (e.g., Aaron Beck, Marsha Linehan) who had analytic training but went to great pains to downplay or disown it in order to promote or tolerate the spread of myths of their own putative originality. 

Many concepts later "pioneered" (and trademarked and copyrighted) by others are demonstrably and indisputably analytic in origin. This is not noted smugly, but simply as a matter of honest intellectual history. Freud himself in several places notes how much he borrowed from others (Feuerbach, Schopenhauer), and I have myself noted his debts to monastic practices of late antiquity. There really is very little new underneath the sun. 

So if, in what follows--some selective, non-systematic notes on the second edition of Miller's Motivational Interviewing, bought years ago but left mostly unread--you find my taking particular pains to relate these to my analytic training, or to find psychoanalytic antecedents and analogues, you will understand why. (Others have done this with greater skill than I--Glen Gabbard for one, including in this article; see also Stanley Messer here; and perhaps most especially D. Westen's 1998 article--showing how often extremely similar techniques are to be found in differently labelled theories under different terms.) 

And the first note of significance comes at the start of the Acknowledgements page, where the authors note that "there is little that is truly original in motivational interviewing," referring to their debts to Carl Rogers in particular. 

It is an interesting exercise to return to this book after having read the more recent treatment of effective therapists. For much of that latter book is foreshadowed in Motivational Interviewing, as when they note already on p.6 that across different theories and types of treatment, common factors "frequently make a difference," and these factors are bound up with "certain characteristics of therapists." Therapists who consistently manifest empathy, avoid being high-handed, and do not infantilize their patients have better outcomes than those who view it as their mission to engage in "confrontation" and advice giving.  

I am also heartened that this book's second chapter is "Ambivalence: the Dilemma of Change." (Miller has a more recent book entirely on ambivalence.) Freud brought ambivalence to common awareness, though I sometimes fear it has largely disappeared from the clinical landscape, full as it often seems to be of much boosterish talk of techniques and tool boxes and work-sheets promising transformational change in 6 sessions or fewer (most of these barbaric self-promoters would write "less"). In any event, our authors note that ambivalence is universal and natural, and hectoring people who are ambivalent only serves to deepen the defenses and make change harder. 

Instead of that, you need to see what does motivate someone, for we are all motivated by something, and often several things. Discover what continues to motivate your patient even as they remain ambivalently attached to the thing they are trying to give up or alter. And while you're about it, do not--these authors strongly suggest--be a purist about this but a pragmatist: how much of the thing are they willing to give up? Go with that rather than pushing for total abstinence or complete change. (I am heartened to read this, because it seems to accord with something I've been calling "partial victories" with my patients who are inclined to totalized thinking.)

Developing Discrepancy: Our authors note that discrepancy is a good thing, and sometimes may actively need to be cultivated. Help the patient come to see the gap between where they claim to want to be, and where they are now. This then leads into what is called "change talk," which manifests itself in four ways:

1) Recognizing disadvantages of the status quo
2) Recognizing advantages of change
3) Hope for change
4) Intention to change.

This leads the authors to recognize the entire process of motivational interviewing is one led by the patient, and not an imposition on them--or a panacea either. It takes time and patience, and consists in the clinician giving space to talk through the ambivalence and bring patients to decide for themselves what they want to do. (That, of course, sounds very much like the kind of free and freeing environment that most of us try to create in psychodynamic treatment, which resists imposing our ideas upon, and thus infantilizing, the patient.) As they say a little later, the key here is "exploration more than exhortation" (p.34), and the exploration and decision-making sees the patient very much in the lead. 

All of this is premised upon something I have heard attributed to Rogers, and occasionally to Jung: "paradoxically, this kind of acceptance of people as they are seems to free them to change" (p.37). (So many people seem to come into my consulting room full of zeal for change which is motivated entirely by masses of self-loathing. They therefore find the idea of working from a place of self-acceptance utterly baffling.) Once people feel accepted as they are, and not forced prematurely into change by the therapist, then it is your next job with them to bring forward what they are already motivated by, and use that as a spring-board for action. Discovering a sense of self-motivation and self-efficacy will be key to everything that follows. 

At the outset of treatment the authors warn clinicians off the use of questions--closed are worse than open-ended, but both invite superficial and often defensive answers. (Other traps to avoid: labelling, instructing, playing the expert, taking sides, blaming, and going to fast--what a friend of mine calls a failure of pacing). 

At this stage, minimize the use of questions. Reflective listening and the use of statements are better. (In saying this, our authors remind me of Brodsky and Lichtenstein's useful article, "Don't Ask Questions.") Affirmation and elaboration are also useful techniques, particularly when the latter involves questions of values. Ambivalence can often be worked through if the desired change is in keeping with the patient's values.

Chapter 8: Responding to Resistance. I know that word has increasingly been avoided by some, but the authors note that no good alternatives have yet been found so they keep using it. Every time I hear it, I think of an example my first supervisor gave me. His besetting sin, he said, was getting too far out in front of the patient by moving too fast. He would look around and see how far behind him the patient was. Instead of chiding the patient for being a slow-poke, he realized he had gone too far too fast and had, he said, "humbly to walk back where they were and come along side them again." I think this example nicely illustrates Miller and Rolnick's ideas of resistance. Do not, they say, see this as something to blame the patient for: it is the fault of the clinician, just as my old supervisor recognized. 

So what do you do--how ought you to respond? You meet resistance with non-resistance. Shifting the focus (what I've heard called "lowering the anxiety temperature in the room" by changing the subject) is useful, along with exaggerated (but calm and sincere) reflection back are useful here. 

Ch.9: Enhancing Confidence: Not surprisingly, the authors recognize two traps at the outset to be avoided: one is to fall into the patient's totalized gloom-mongering and not have hope that things can change; the other is to be a mindless booster, offering cheap, soothing encouragement that is equally totalized and simplistic. You need to have and hold out hope for the patient, but it needs to be tempered and realistic hope. It also needs to be discerning enough that you know when to hope for change and when to gently bring the patient (as the Serenity Prayer reminds us) towards some reality-testing so they can see what is unlikely to change. 

Having found realistic hope, the process next moves on to actual planning of the change--lists of ideas, desires, hopes, obstacles, and strengths. At every stage this is led by the patient and your job as clinician is not to be the expert dispensing advice or telling them what and how to do something. This is repeated, along with many of the observations briefly noted above, throughout the first half of the book, which is easily twice as long as it needs to be. Overall, the summary of MI's "four general principles" occurs early in the book (p.36), thus:

1) Express empathy
2) Develop discrepancy
3) Roll with resistance
4) Support self-efficacy.

Part IV: Applications of Motivational Interviewing features nearly a dozen chapters by invited contributors focusing on specialized populations (groups, couples, adolescents, criminals et al) or issues. There are also chapters reviewing the evidence on the efficacy of MI and its application in medical and other contexts. 

Psychoanalysis and Christianity

Prologue:

A tedious bit of autobiography: since 1990, when I was in gr. 12 first reading Freud and Jung and trying to decide, first, what I was to study at university the following year (psychology? theology? history?) and, second, whether to pursue clinical and then analytic training in Montréal, or priestly ordination into the Anglican Church of Canada, I have lived my life at the intersection of theology and psychoanalysis. When I went on sabbatical in 2018, my project was to finally write the book I had been carrying around in my head for nearly thirty years at that point, then tentatively titled "Theology After Freud." (Events intervened and I turned my sabbatical project to writing Everything Hidden Shall Be Revealed: Ridding the Church of Abuses of Sex and Power, where Freud features very prominently and unapologetically throughout). 

I may yet write that book, though increasingly with a much different focus. Some of its materials have in the last decade worked their way into lectures on the relationship between theology (especially Orthodox and Catholic theology) and psychoanalysis that I have gladly given before academic and ecclesial audiences in England and Wales, Canada, and in several places across these United States. A version of that lecture is available here as a podcast.

The other development in 2018 that swayed me against writing my book on psychoanalysis was the appearance of the most powerful theological engagement of Freud I have ever read. The Spanish psychotherapist and Jesuit Carlos Dominguez-Morano (who has published many books in his native tongue, few, alas, having been translated into English) published Belief After Freud: Religious Faith Through the Crucible of Psychoanalysis. That book is, and remains, a stunning work of far-reaching criticism of the most prominent manifestations of the massive psychopathology at the heart of Catholic Christianity. I could only salute the author's penetrating insights and great courage in writing a much more forceful book than I would have attempted. If you read nothing else on this list, read, mark, and inwardly digest this book. The Catholic Church would be a far less objectively disordered and sadomasochistic institution if Dominguez-Morano's proposals were taken at all seriously, which they won't be. (I wrote a bit about him for the Jesuit periodical America, and in more detail at an old blog.) 

If you read Morano and then want to read more in this area, I have, over the last three decades, read as many books about religion and psychoanalysis as I can lay my hands on--with many more to read! What follows are a few notes on disastrous books to avoid, a few that are "good enough," and a rare few that our outstanding. 

Books Fit for Burning:

Previously I noted on here one book that, had it been edited and published properly, would have been a handy collection to have. But it was so shoddily produced it's not fit for reading and the publisher should be ashamed to have foisted such slop on us. 

The other book is one I can only think of as psychotic: by that I mean Bion's theory of psychosis as the severance of all meaning-making links and possibilities for rationality and reality-testing. I cannot in all honesty discern any sort of rational purpose to the book as it staggers around vomiting out incoherent statements unconnected to any sort of discernible purpose--or to each other. The Freud who features here, and the "arguments" made, bear no relationship to reality. There is of course no end of attacks on Freud, and almost all of them are at least generally coherent (see, e.g., Frederick Crews), but this book could not even manage to rise to the level of childish diatribe. 

Mediocre Treatments:

Beyond such egregious examples, there are plenty of books in which others might quite rightly find value but I found to be very thin gruel indeed. Most of them were written in too general a way, and often very poorly edited. Under this heading I include Christianity & Psychoanalysis: A New Conversation, eds. Earl D. Bland and Brad D. Strawn; and Marie Hoffman's sprawling Toward Mutual Recognition: Relational Psychoanalysis and the Christian Narrative. Her premise and methods were good but the execution very poor. Other books along these lines could be mentioned but need not detain us further. 

Good General Treatments:

If you are new to the area, then a 30,000-foot overview provided by one of the great scholar-clinicians and social critics of the last century, Erich Fromm, is a good place to start: Psychoanalysis and Religion was originally delivered as part of the Terry Lectures at Yale. Like all Fromm's books, it is written at a very general and accessible level. (I discuss Fromm in a bit more detail here but keep meaning to get back to him at some point.) 

A more advanced but still general treatment may be found in William Meissner, the Jesuit psychiatrist and psychoanalyst I wrote about in my America piece, who authored several decent books, including Psychoanalysis and Religious Experience.

Two other collections merit mention: Soul on the Couch: Spirituality, Religion, and Morality in Contemporary Psychoanalysis, eds. Charles Spezzano and Gerald Gargiulo is decent. Even better is Psychoanalysis and Religion in the 21st Century: Competitors or Collaborators? ed. David M. Black.

Ana-Maria Rizzuto's Works:

The Argentine-born but American-educated Catholic psychiatrist and psychoanalyst remains too little known, in my view, but deserves to be for her first book in 1979, The Birth of the Living God, which was based on fascinating and highly original research with psychiatric inpatients and their internalized God objects. 

Then her 1998 book Why Did Freud Reject God?, published by Yale, is the most careful and respectful such treatment yet published of a topic that almost always sees authors descend to the level of puerile polemics and "pseudo-mentalizing" (to borrow a phrase from Fonagy). 

Only recently has Rizzuto come in for some attention in this decent collection: Ana-María Rizzuto and the Psychoanalysis of Religion: The Road to the Living God, eds. Martha J. Reineke and David M. Goodman.

Winnicott and Religion:

Back when I taught undergraduates theology, I came across the works of the scholar and Jungian clinician Ann Ulanov, author of such books as Finding Space: Winnicott, God, and Psychic Reality as well as Primary Speech: A Psychology of Prayer (which my students loved). 

Stephen Parker has written an unexpectedly excellent monograph (I say "unexpectedly" because works like this are often ploddingly dull, having all the vices of a doctoral dissertation and none of its virtues), Winnicott and Religion, which is very much worth your time if you love Winnicott half as much as I do. Winnicott, as always, has a lovely and useful phrase to describe his own relationship to the Methodism and Anglicanism in which he was reared: traditions to "grow up out of." That phrase admits of wider application today if much research (e.g., Stephen Bullivant's important new book Nonverts: The Making of Ex-Christian America is to be believed on declining practices. 

Highly Specialized Scholarly Monographs:

Under this heading I put two dense but worthwhile works: Peter Tyler's The Pursuit of the Soul: Psychoanalysis, Soul-making and the Christian Tradition; and then Marcus Pound's Theology, Psychoanalysis and Trauma. Pound's book has the virtue of making some of Lacan accessible--a figure whom I otherwise find needlessly and vexatiously obscure so much of the time (though I did find something useful in him as I argued here). 

One of the best books I have read is Pia Sophia Chaudhari's Dynamis of Healing: Patristic Theology and the Psyche. I discussed its virtues and interviewed her about it here. 

Let me end with a new book I forgot to mention in a recent post on On Bare Attention: it is a book by Paul Marcus entitled Psychoanalysis as a Spiritual Discipline: In Dialogue with Martin Buber and Gabriel Marcel. The book is a bit choppy in execution, but it draws out useful material from its two named interlocutors. I read some of Marcel and Bueber in writing my M.A. in moral philosophy at the end of the 1990s (when I read rather a lot more of Alasdair MacIntyre and Emmanuel Levinas, whose "ethics of the face" and critique of abstraction I still teach to my students). 

Marcus seems to suggest in this book that for people who both find themselves "ecclesially homeless" (to use a phrase of Stanley Hauerwas) or "deconstructing" their faith, or otherwise alienated from religious institutions, and are clinicians or interested in psychoanalysis, then the analytic tradition offers both insights and "disciplines" similar to ascetical practices found in Judaism, Christianity, and Buddhism. This allows him to say that "psychoanalysis can reasonably be conceptualized as a spiritual/moral venture." As such, it has practices of "communion" (to borrow a term from Marcel) or what Marcus calls "the five essential elements of psychotherapeutic support--presence, holding, caring, challenging, and confirming."

 

Gabbard and Bejnamin on Love and Hate

Freud won the Goethe prize for his magnificent German prose. We do not seem to have comparable prizes (so far as I know) in English to award to psychoanalysts like the venerable Glen Gabbard, whose prose is cogent and crisp, and written in an accessible and admirably humble way. In a future world when justice is finally and permanently established, that is, when I am at last emperor of all I survey, I shall bestow a prize on him. Perhaps we might call it the BST Prize. 

Having, as you will see here and here, recently written of how profoundly helpful I have found Andrea Celenza on the challenges of erotic and loving transferences and counter-transferences, and the associated problems of boundaries, it is no surprise to find Gabbard, in Love and Hate in the Analytic Setting, to be equally valuable on precisely the same points. Indeed, Gabbard and Celenza have collaborated on these issues in previous publications.

What follows is less a systematic reflection on Gabbard (and, toward the end, Jessica Benjamin, whose The Bonds of Love: Psychoanalysis, Feminism, and the Problem of Domination I finished on the same weekend as Gabbard) and more a kind of "aphoristic plundering," as it were. I used to feel vaguely guilty about this method of reading (which I do not use all the time), but having been fortified by stiff doses of Winnicott, quoted lavishly by both Gabbard and Benjamin, I justify such a method to myself by saying I am "using up" both authors, consuming them as good objects, and they are manifestly able to survive this "destructive" consumption of mine. 

Gabbard on Love and its Limits:

Gabbard begins on a note that might seem commonplace to many but which, within the hidebound context of psychoanalytic schools-cum-ideologies, is startlingly rare to read: "No one theory had all the answers to the challenges we confront in clinical practice" (xi). With this one simple manumission, as it were, Gabbard frees himself to range widely and unapologetically over Freudian, object relational, intersubjective, Kohutian, and other analytic traditions, finding what is useful and leaving the rest behind--the very model of "plundering the Egyptians" (cf. Exodus 12:36) one expects, but infrequently finds, in scholars and clinicians alike. 

Chapters 1 and 2 went over well-trod territory (for me) in quoting Freud's famous line to Jung that "essentially, one might say, the cure is effected by love." Gabbard admires this but is also troubled by it, leading him, in the second chapter, to note that one common motive in choosing to follow a vocation to be a psychotherapist is that you wish to be loved and admired. This is fine, he seems to say, provided you come (as he will spend the bulk of the book doing) to grapple with how much "sadism and aggression are ubiquitous forces in love relationships" (p.43). 

You must, to be an effective clinician, not fall into the trap of assuming that love is all you need, for love never goes anywhere by itself: tagging along are always aggression and hatred, and your failure to recognize and deal with these can, at best, lead to stalemate in the treatment, and at worse destructive enactments of various sorts (up to and including sexual boundary violations, about which he has written definitively in several places, including here). 

Gabbard on Hate and its Purposes:

Hatred, Gabbard shows, has multiple functions. Inter alia, it can:

• organize the ego
• master rage and destructiveness to prevent them from getting out of hand
• "conceal longings for love and acceptance" (especially in the transference; p.47)

Why, we often ask, do we hate for so long? Why can we not adhere to the simple counsel, "let it go!"? Gabbard says that "to hate is to hold on to an internal object" which may have had some purpose, including maintaining some contact with that object which was and is better than no contact. Such contact cannot just be dropped by the patient alone: the ties that bind to the object, he argues, can only be undone via the transference. Once again, following Franz Alexander, we see that what we learn to hate in one relationship we can relearn to hate (less) in another, and perhaps even to love it (more). 

Gabbard sees"hatred as residing on a continuum." My crude attempt to illustrate his several points would look like this: on the mild end of the continuum we'd see attempts at control or "domination" (as Benjamin calls it); in the middle there would be preservation of the hated object, but with some sadistically inflicted suffering; and on the extreme end, we would find complete destruction of the object. 

Regardless of type, Gabbard repeatedly cautions the clinician against rushing in to change focus, or try to control the hatred, or urge the patient on to replace it quickly with "positive" thoughts or "happy" memories (or worksheets and breathing exercises one might add somewhat snippily). I have often felt the pressure to do so, but every time I have resisted such pressure it has turned out for the best. As he rightly reminds us, "with many patients the necessary depth of understanding is not reached until one has sat for a sustained period with searing hatred or painful longings" (p.65).

Gabbard reminds us throughout the book that we all have our own hatreds and propensity for aggression. We cannot, even as well analyzed clinicians, fool ourselves into thinking we are utterly incapable of such things. Thus, he seems to suggest, it should not be that hard for us to have empathy for the patient's hatred and aggression if they are relatively accessible within us. (He quotes Searles and often Winnicott on this point of having your own hatred and aggression close by.) If we do find those things hard to understand, then we have forgotten what Christopher Bollas said decades ago: "In order to find the patient we must look for him within ourselves."

No Collusion!

Gabbard reinforces an important lesson, especially relevant to work with teens or disaffected spouses, but in some ways to all of our patients and their diverse hatreds: do not collude in creating an extra-transferential object to hate together. A therapeutic alliance cannot be built upon having a shared person or movement or experience to hate. Remember: hatred and love always co-exist, and to indulge in one-sided and totalized hatred (of, say, your patient's spouse, boss, or parent) is to risk collapsing the analytic space, to destroy the therapeutic stage on which you need to be able to "play" with these things for the patient to move forward. 

How Special Am I?

At one point Gabbard says we must confront the tension inherent in this work: we can only be special to the patient by renouncing all other special relationships, including lover, mother/father, friend, etc.

I admit to finding this very helpful with certain cases from time to time which seem to evoke a very strong protective-paternal counter-transference (discussed weekly in supervision, I hasten to say!). Part of me wants to fill multiple roles for such patients, being special in a good 4 or 5 different roles they lack--but which I know I cannot play because doing so would actually be harmful. 

What I can do, instead, is make sure that this one role--that of psychotherapist--is done according to the best of my ability. Allen Frances, on one of his very valuable videos with Marvin Goldfried (some of which I have my students watch), says that at every session the therapist should ensure it is a memorable experience for the patient. Do not treat it as just an ordinary event because, he says, for some their appointment with you is the highlight of their week. Thus it is special for the patient even as I am not that special. 

Such tension is hard to maintain for some. Gabbard recognizes that the forbidden nature of the relationship can make it highly erotically charged. We might not even experience conscious erotic or sexual attraction to the person; but the fact that we operate inside the frame, with its restrictions on what and how we meet and work together, increases the desire some have for a deeper intimacy than is possible (or healthful). 

At the same time, however, erotic and sexual desires may not be the hardest to deal with. I admit I was rather stopped cold by Gabbard's claim that "Sexualization may also defend against feelings of love...,which are relatively more difficult for many analysts to acknowledge than lustful feelings" (p.91). I have never thought of that before, but in reflecting on it, especially in light of my own analytic therapy, I think I see the logic of this now.  

Gender Fluid Transferences:

Perhaps the most valuable thing I have learned, first in Celenza, and now in Gabbard, is that--as it were--the unconscious mind and its desires are not gendered in the ways we might consciously expect. Some of the transferences toward me have been baffling until reading these two authors who argue, as Gabbard does here, that "there is considerable gender fluidity in the roles played by both analyst and patient in the analytic drama, and if these are allowed to emerge without premature foreclosure, a variety of transferences may appear that involve both homosexual & heterosexual longings" (120). 

Thus, whether with male or female patients, and prescinding from their manifest gender and sexual identities, I can at times be mother, father, brother, lover, and many other objects in the transference. And my counter-transferences are not just what might be called "paternal" (this one seems the most obvious) but also (much less obviously) "maternal": on this latter point I am constantly reminded of how much the experience inside the consulting room is indeed a "holding environment" as Winnicott put it, a "container" as Bion called it, and how those contemporary-clinical experiences are not far removed from the primitive experience of being held and cradled as a child as one's upsets and unknown desires are contained by the soothing mother. 

Let me turn now from Gabbard to Jessica Benjamin. Her book The Bonds of Love is one I have found helpful in dealing with overly sadistic material in some patients. 

I will not go into the wonderful (I almost said masterful!) ways she spends the first part of the book going beyond the understanding of domination in Freud to bring in Winnicott and others. She very helpfully gets us past the rather narrow range within which Freud understood these concepts into a wider terrain from which we gain a broader perspective. 

Much of this is possible by returning to Winnicott on "The Use of an Object." There he famously outlined how objects can be used and are destroyed--but survive. Indeed, use and destruction are linked: they must be destroyed inside our minds in order to see that they can survive outside and beyond us. This is a necessary first testing of reality, and (unlike Winnicott) Benjamin says such a discovery of reality is not merely grim awareness, but can be joyful: the destroyed object has--I discover to my delight--survived after all. 

Benjamin says the utility of this experience lies in the fact it reminds us how interconnected we forever are to each other: "if we assume complete control over him and destroy his identity, then we will have negated ourselves as well. For then there is no one there to recognize us, no one there for us to desire" (39). In saying this, of course, what echoes loudly in the background is Winnicott's famous declaration "there's no such thing as a baby!" By that he meant that a baby is always and only an object-in-relation: to the mother, father, and others around it on whom it depends. 

This dynamic helps us understand relations between sadists and masochists. Both need each other to undergo but survive the experience. Both may arrive at love via the experience. 

For the sadist (and I must say Benjamin gives rather more attention to masochists: her attempt to understand sadists is much less developed), the "thrill of transgression and the sense of complete freedom" are tinged with "fear (guilt) that his aggression will annihilate her." Her survival, however, "creates for him the first condition of freedom." The survival of the masochist creates in and for the sadist a real feeling of "love." 

In turn, the masochist's "submission is ambiguous," Benjamin suggests. It is a "false self," that is a "compliant, adaptive self that has staved off chaos by accepting the other's direction and control, that has maintained connection to the object by renouncing exploration, aggression, separateness" (p.72). But in giving over to an experience of pain "in the presence of a trusted other who comprehends the suffering he inflicts," the masochist can find not just relief but also a form of love. 

There is something a bit too neat here, I must admit. But I have already inflicted my own form of suffering on the reader with this over-long reflection, so I shall rein in my sadism for now, recommending both Gabbard and Benjamin and their excellent books to those who are not familiar with them.

On Love, Eros, and the Perverse

Introduction:

Recently with my students, I began a discussion about transference and counter-transference in psychotherapy, including erotic transferences and counter-transferences. The class seemed to cleave into two: those who regarded the idea of any sort of erotic feelings arising, in either direction, as "gross"; and those who didn't see what the big deal was. I'm not sure by whose response I am more disconcerted. 

Part of the difficulty turns on the wide variety of meanings attached to the term "erotic." I tried, following the ancients, to expand upon it as something much wider and more vital than the merely sexual or, narrower still, the genital. I brought in Freud's notion of the libidinal and its close links in to the notion of both "life" and "love." This gained traction with the students and also frank relief among them. At last they seemed to find a notion they could relate to: the erotic as something that excites deep and wide interest, even "passion," as people often say today, without necessarily implicating them in some sordid desire for sexual intercourse with whatever/whomever this objet is. 

In talking with them, I was of course drawing on what I've written previously about what I have learned, and am still learning, from Andrea Celenza, especially in her vitally important book Erotic Revelations: Clinical Applications and Perverse Scenarios (Routledge, 2014). I drew on her work with my students in attempting to illustrate the polymorphous ways in which erotic desire can arise in treatment. As Celenza shows, such desire, far from being avoided as it almost universally seems to be today, can in fact be helpful--but it can also lead to disastrous outcomes if not handled well. 

On the strength of how much I had learned from that book, I recently bought another of hers: Transference, Love, Being: Essential Essays from the Field (Routledge, 2022). There are riches scattered throughout this collection, one of whose chief virtues is that almost every chapter is 3 or at most 4 pages in length. 

The collection begins by reflecting on the disappearance of the notion of love in psychotherapeutic practice. And that reflection itself begins by referring to Philip Bromberg's work, who really deserves (and will one day achieve) an essay of his own on here. When someone introduced me, last fall, to his essay "Standing in the Spaces," it effected a sea-change in how I conceive of my own mind and the notion of selfhood and psychic change. It also changed for the good how therapy was progressing with one particular long-term case that seemed to be bogged down. 

Since then, I have used excerpts from his essay in a number of classes, and in every case it has stirred up lengthy and fascinating discussion. 

Celenza says that the splits in the self, which Bromberg focuses on, can be helped by reconsidering and reintroducing the notion and practice of love, properly understood, in the therapeutic relationship. 

Disappearing Love and Hidden Sexuality:

Along with the disappearance of any notion of love in contemporary practice, Celenza, in this book and her other one, has pressed the case more relentlessly and compellingly than anyone else I have read about the disappearance of sexuality and the erotic, citing a word-count Fonagy did some years back showing that terms like 'relational' are all over the literature today, but 'sexual' and cognate terms have taken a nose-dive. This leads Celenza to claim that "there is an unmistakable desexualization that pervades psychoanalytic theorizing...., an erasure of the natural erotic and sensual aspects of intersubjectivity" (p.75).

Celenza, later in this chapter, speculates that perhaps this disappearance has someting to do with the fact that, understood classically, "Eros is described as the son of Chaos, the original primeval emptiness of the universe" (p.76). She does not elaborate the point but the suggestion seems to be that therapy is often difficult enough without (one imagines some bedraggled, overworked, underpaid clinician moaning) introducing further potentially destabilizing and presumably difficult elements such as the erotic.

But at what cost do we exclude such things? In later chapters, she returns indirectly to the theme saying that "we must have the full range of affectivity at our disposal" in order for us to "help our patients...experience the excitements and mysteries within themselves" (113). These excitements, she notes a page later, "include allowing sexual desire to be present in our countertransference." The point of doing so, she repeatedly notes throughout the book, is to serve the patient: "the more we can acknowledge what we feel at work with our patients, the better we do." (Her earlier book, Erotic Revelations, has helped me greatly in seeing that such feelings can be stirred up within us in ways that unconsciously and blithely ignore our cultured notions of "gender" and "sexual orientation.") 

The Perverse and Sadomasochistic:

The essays in the final section are the ones I gravitated towards the most for I have for some time been engaged in trying to understand manifestations of what she calls "the perverse," including sadomasochistic fantasies and actions of some patients.

Some interesting work has been attempted here over the years, but there seems to have been gaps in the literature. Robert Stoller's book Perversion: the Erotic Form of Hatred, from the mid 1970s, seems to have been one of the first major works in the area. The topic comes and goes across the decades. There was renewed interest in the late 90s on the "perverse," and I have to say that it was a great surprise to see my first analyst's work in this area cited in Celenza's chapters and notes. (See also this essay by Dr. Louise Carignan, whose winsome necrology is here.) 

Celenza brings much (not all) of this literature together in chapters 30 and 31, which I found the richest in the book. She begins, rightly, by trying to define terms, offering "a contemporary definition of perversion that reveals a form of psychic functioning as a quality of being toward others, toward one's body, or toward internal objects" (p.139). This differs, she says, from past definitions which were almost always entirely behavioral in nature. She continues: "I propose that a perverse internal psychic mode is one where affective embodied and pre-reflective self-experience is split off or dissociated." 

Chapter 31 is perhaps the longest and most helpfully detailed in the book, and continues on these themes. She explicitly reviews the past literature to see what she finds still useful, discarding the rest. She says that any new attempt at defining the perverse must abandon "phallocentric and heteronormative assumptions." 

What does perversion look like in action? She begins by arguing that "persons engaging in perverse scenarios are attempting to imagine a one-person universe" (142). The tracks closely with cases I have seen clinically.

From here she lays out seven "characteristics that define a perverse quality of being." These are:

• Constriction and Constraint
• Repetition
• Objectification
• Sexualization
• Desire to Harm
• Means/End Reversal
• Absence of Symbolization. 

Taken together, these are usually brought to bear in constructing scenarios and fantasies to manage anxiety, ward off danger, and maintain control. As Stoller put it, sadomasochistic fantasies are usually ones of triumph that at some level are thereby trying to reverse the traumas of the past. They have a dead and deadening, self-reinforcing nature to them; their objects are sexualized to turn threats into pleasure; and there is very little ability to play with them in a symbolic register. She very helpfully elaborates on all these points in some detail, and with clinical material--as she does in nearly every chapter. 

Overall, then, Transference, Love, Being is a rewarding collection and I continue to be grateful for having been led to Celenza's work.

On Bare Attention: Notes on Ascetical Practice in Psychotherapy

I'm trying to teach my students this semester what it is required of clinicians if you are to open yourself to a patient in psychotherapy and listen to them at depth and in a way nobody else does. Such listening has, of course, gone under a number of phrases, starting with Freud's "evenly hovering attention." He posits this as the equally demanding practice expected of the analyst to correspond with the "fundamental rule" of free association. Both are deceptively simple on paper, but fiendishly difficult to practice regularly. 

I've never forgotten the first time that phrase came back to mind as a life-preserver as it were. It was during my internship and I was listening to my first-ever patient to report childhood sexual abuse in the Catholic church. It was a horrifying tale of systematic gang rape in essence lasting many years. As detail after detail poured forth, I found myself fixating on each fresh revelation, trying to sustain an equal level of horror and compassion for every new item. But after about 15 minutes of this, I felt my mind (in what I now regard as a protective-defensive manoeuver to protect me from this demonic horror) starting to disbelieve the patient and think she must be joking. Horrified at this, I realized I had to pull back, as it were, and allow my attention evenly to hover over the entire story rather than immersing myself in the bloody and dark gore of each detail. This allowed me to listen with less inner perturbance and with a greater distance on the scene, which, of course, is what the patient needed for she already knew how horrifying it was, and my constatnly saying so added nothing useful. 

I felt twinges of guilt as I pulled back, as though not being constantly horrified at each detail was somewhow to fail at being compassionate. But I've learned over the years that you cannot be over-identified with your patients. That does not, in the end, help them. They need you to be more objective, to have greater distance, and to offer a perspective that differs from all others in their life. 

How do I know this? They tell me, very explicitly! People will note how their friends will rush to offer them heaps of support and unquestioned sympathy, but they themselves know they need more and other than that, which is why they present for therapy in the first place. 

From this one can derive a technical rule: Don't try to outdo their friends, thinking this is what "empathy" is! As my first supervisor pounded into my head, "The fact you get paid means you will never be friends with your patients!" Thus, I tell my students, you need to listen in ways that go well beyond what friends and family do. Listen for the gaps, the pauses, the inconsistencies, the contradictions; listen for the darker emotions their friends and family did not hear and could not handle. 

From this a second technical rule can be derived: do not collude, especially unconsciously, in hating the people your patient hates. You need to be free to see what might be good in the person (typically parents or spouses) they claim to hate, and how that hate is invariably closely bound up with more tender emotions, including those of love. Your colluding in hate will preemptively destroy any space for ambivalence to emerge and breathe. 

How can you do such things, avoiding such entanglements as over-identifying and hating? At this point I introduce to my students the concept of "bare attention," which is a Buddhist-inflected concept found in the works of Nina Coltart. What does that mean?

Fittingly, Coltart offers only a very minimal definition, saying that to practice bare attention requires that we "teach ourselves so continuously to observe, and watch, and listen, and feel, in silence that this kind of attention becomes--in the end--second nature to us." But what does that look like? She does offer two highly complex paragraphs (quoted here) trying to explain this, which I have my students "meditate" upon as it were. But for the time being I want to advance the thesis that "bare attention" and "evenly hovering attention" are both practices I can only describe using explicitly theological language: they are ascetical practices.

Now "ascetical," for those who remember their Greek, is not in fact theological in origin, but simply pertains to that form of "training" or, as the OED has it, "ἀσκεῖν to exercise." Thus listening with "bare attention" requires the same sort of exercise, training, or practice as you would expect Olympiads to put in to train for a marathon or comparable exercise. 

The sheer physicality of this training should not escape us. It means--as I have learned by trying to ignore some of these things--that you have to take seriously the following as inescapable components of your training:

Food: don't skip meals or hydration in order to see more patients. Your practice of "bare attention" will be severely weakened as you pay more attention to your growling stomach or fantasies of how large a steak you will grill for dinner. (I've learned to keep "good" snacks in my desk--fruit and nuts usually, but also dark chocolate, along with a large pot of tea.)

Exercise: Coltart learned to her great cost that years of sitting without exercise can bring on severe back pain. Do not stint on getting up and walking around between sessions, and working in as much physical movement as you can outside of your clinical schedule. (For me running 15 miles a week is the bare minimum I need to sustain my attention as well as clear my head of the "vicariously traumatic" details of my patients' lives.) 

Timing and Scheduling: Figure out what works for you. If late afternoon or early evening appointments mean you are very tired, but are wide awake for an 8am appointment, then adjust your schedule if you can. There's no attention--bare or otherwise--paid to your patients if you are nodding off! 

Furniture in your consulting room: Again, Coltart was a cautionary tale for me: crappy chairs for you to sit in (including a lack of the fabled ottoman!) will induce discomfort that make your practice of "bare attention" much more difficult. Don't stint here! 

Sleep: You can't pay attention to anything or anyone if you are exhausted all the time. Get good sleep and don't stint on this to work in a few extra appointments.  

Your own Psychotherapy: I think for me likely the single-biggest factor on this list is my own first full psychoanalysis and then ongoing analytic psychotherapy which has allowed me to feel sufficient "ego strength" as it were that I can open myself up to my patient in a self-denying way without feeling threatened or deprived. To put it in "oral" terms, their slaking their needs through me does not leave me starving and resentful. 

These practices require a commitment to training or physical exercise, a form of discipline, a type of "rule of life" known to monastics of antiquity. Observing these things requires a form of self-discipline, indeed of self-denial and self-emptying. 

Such language may make some uncomfortable. Perhaps they will be reassured by learning that no less a figure than Thomas Ogden, in his book Reclaiming Unlived Life, on which I reflected a bit here, calls for such self-denial: 

the analyst must 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.

Ogden does not make the point explicit, but I have to think he would be adamant here that none of this self-renunciation is to be done masochistically.

Here I think Ogden would gladly join hands with Karen Maroda who, echoing Emmanuel Ghent, has rightly called for  "distinguishing between emotional surrender and masochistic submission" (p.39) in the therapeutic dyad. If you are masochistically foregoing food or sleep or other basic needs in order to spend more time with your patients, perhaps you need to ask whether this is really helping you practice the "bare attention" they need and want from you? 

In the end, then, the paradox of self-renunciation is that it helps not just the patient but you as the psychotherapist. After all, which of us does not want to be well-fed, well-rested, decently mobile and fit, and reasonably comfortable in our consulting rooms? Perhaps in the end "self-renunciation" is a disguised synonym for that sometimes infelicitous phrase "self-care"?