An Argument for Psychoanalysis. Book Review: The Gossamer Thread, by John Marzillier

Fifty Abstract Paintings Which as Seen from Two Yards Change into Three Lenins Masquerading as Chinese and as Seen from Six Yards Appear as the Head of a Royal Bengal Tiger, by Dali
Fifty Abstract Paintings Which as Seen from Two Yards Change into Three Lenins Masquerading as Chinese and as Seen from Six Yards Appear as the Head of a Royal Bengal Tiger, by Dali

John Marzillier’s autobiographical account attempts to convey what the experience of therapy ‘is really like’. Rather than elucidating case histories, he has provided a fictionalised, novelistic memoir of cases spanning his four decade career. Marzillier began working as a behaviourist and became during practice a cognitive therapist, and finally a ‘psychodynamic narrative therapist’. The book’s title relates to the uniqueness and importance of the ‘real relationship’ (Duqette, 1993) between therapist and client.

The Gossamer Thread provides an insight into the experience of therapy for the psychotherapist. It does so without any attempt at objectivity or summation, rather it represents the particular and unique experience of one practitioner, deeply rooted in his own autobiography.

The author points out the liability and unreliability of his (and his clients) memory of events, arguing that this no obstacle to understanding the uniqueness of individual perspective. Perspective, the way in which we view our histories and positions in the world, is open to change, and it is this change Marzillier suggests is key in psychotherapy (Marzillier, 2010, pp8). Marzillier emphasises the contiguity between normality and disorder – the continuum along which anxiety and depression run, laid down by social norms and expert discourses. Marzillier himself utilised ‘electrical aversion therapy’ with gay clients (in the 1960’s). His experience as an influential participant in a rapidly changing discipline (clinical psychology), made him keenly aware of ambiguity and ethnocentricity of diagnosis and mental illness.

By ironically reflecting on his own imagined competence as a new behaviourist practitioner, Marzillier demonstrates the man behind the curtain of psychotherapy (Marzillier, 2010, pp29). This is especially pertinent given the popularity of behavioural approaches in the treatment of autistic spectrum disorders (Rosenwasser & Axelrod, 2001), and cognitive behavioural approaches to depression (Leichsenring, 2001) today.

It is noteworthy how much more of himself Marzillier required as a practitioner of psychoanalysis, and how much more emotionally challenging the process seemed (Marzillier, 2010, pp169). Marzillier also notes the higher requirements on the client in psychoanalysis, the ability to tolerate the pain of unconscious exploration, reflexivity, commitment to long term treatment, trust in the practitioner (Marzillier, 2010, pp135).

Too often in accounts of psychodynamic work, the duration disappears, the months of work without progress becomes dissolved by the relatively brief narrative description of the case. Marzillier bucks this trend, demonstrating the slow progress of re-parenting a closeted narcissistic client. Here he introduces an interesting concept from self psychology (Kohut, 2009) (a sect of psychoanalysis that seems to mirror object relations with different terminology) – ‘Selfobjects’, external ‘objects’ that the narcissist cannot separate from their internal function or perceive as separate to themselves, a defense against unbearable emptiness / disillusion (Marzillier, 2010, pp177).

Marzillier argues for the utility of brief psychodynamic therapy (Marzillier, 2010, pp200) – as a means of rapidly approaching insight for the prolonged grief of his patient (rather than the relief of suffering, as in CBT).

Having been educated right when ethology / behaviourism was being superseded by the cognitive revolution in psychology (Marzillier, 2010, pp69), and at a time when psychoanalysis was gaining popularity in Britain (despite its dismissal within academic psychology), Marzillier is in a unique position to highlight the arbitrary way in which intellectual fashions choose to focus on specific aspects of personality or cognitive function. This parallel’s my own experience, studying psychology at a time when cognitive science is being integrated (somewhat tortuously) with neuroimaging.

Marzillier argues for the need to shape psychotherapy to the individual client, and to continually critically evaluate the assumptions behind theory and practice and the origin and meaning of client distress. He also demonstrates the importance of relationship over methodology in addressing the needs of clients (which can vary significantly from their presenting problem) (Marzillier, 2010, pp24). I share Marzillier’s dislike of the value laden conception of personality disorder (and psychological disorder in general), rooted in a syndromal disease model that lack construct validity (Clark et al, 1997). I found Marzillier’s reference to the work of Jerome Frank on the ritual of psychotherapy (as more important than the technique / theory) fascinating, as it relates to Erving Goffman’s theories on the dramaturgical aspects of everyday life (Marzillier, 2010, pp25).

Despite his later disavowal of behaviourist treatment approaches, Marzillier describes a number of successes in treating phobias, anxiety disorders and the like with behavioural approaches (Marzillier, 2010, pp32), and later similar success with social phobias, teaching social skills with feedback (Marzillier, 2010, pp52). Given the irresolute nature of outcomes in psychodynamic psychotherapy, it’s hard not to find this attractive. Similarly, last year I studied ‘choice theory’ (Glasser, 1998), a cognitive approach to behavioural change rooted in needs and contemporary relationships; and I find it challenging not to apply any of these techniques to client work. However, as Marzillier goes on to demonstrate, clients differ enormously, and simple techniques are not necessarily universally applicable (Marzillier, 2010, pp44, pp57). Focusing too intently on specific symptoms or (frequently misapplied) diagnosis can professionalise the clients identified disorder (Marzillier, 2010, pp47), providing a (toxic) identity as well as a sense of learned helplessness. Marzillier argues for a therapeutic approach rooted in aspects of a variety of techniques – the anxiety / depression reduction of cognitive therapy, the use of transference and the working alliance of psychodynamic therapy (Marzillier, 2010, pp188)

Another issue which arose for Marzillier was his client’s reluctance to take ‘trained’ learning into the real world (Marzillier, 2010, pp60). This is an issue I’ve found myself as a client of therapy – it’s a great deal easier to come to an insight than to apply it in practice. There are several important take home messages here: One, for behavioural therapies to work they need to be as ecologically valid as possible, even taking place in the real world. Two, a great number of client’s core issues are disguised by their surface problems. Three, as I discovered during the course of my own undergraduate thesis, experimental power requires large, homogenous groups of participants (Marzillier, 2010, pp61).

Although Marzillier later disavowed simple behaviourism (Marzillier, 2010, pp75), his practical approach to the difficulties of clients – informed by cognitive and behavioural accounts – is appealing. For example with one client ‘Angie’, his focus on cognitive factors (‘vicarious traumatization’) helps to elucidate the origin of violent fantasies and ultimately remove their severity (through self monitoring and curtailing avoidance) (Marzillier, 2010, pp78). He’s never averse to trying to help a client resolve their difficulties, rather than to simply accept them or endlessly ruminate upon their origins.

I found a number of Marzillier’s reflections on the psychotherapeutic process enormously insightful; ‘avoidance prevents… anxiety from going away’ (Marzillier, 2010, pp77), ‘significant change always entails a significant loss’, (Marzillier, 2010, pp92), aggression can be expressed through gratitude (Marzillier, 2010, pp156), passionate love is ‘the archetypal narcissistic illusion’ – the projection of what’s missing in oneself into the other person (Marzillier, 2010, pp260), cognitive appraisal (negative thinking) affects how you feel (Marzillier, 2010, pp93) and negative feelings that persist become depressed mood. Never having studied CBT, I found the detailed description of a variety of cognitive distortions and schema underlying depression informative.

For Marzillier, work with a variety of clients demonstrated that core beliefs (schemas / metaphysical beliefs) were difficult to mollify with cognitive techniques (Marzillier, 2010, pp111), and more amenable to emotional challenge from within, from a place of safety in therapy. There’s an intrinsic issue with any kind of cognitive therapy – and it is that the most useful, cheering belief may not be true, and whether true or untrue may not be good for the individual to hold, or the community to be subjected to (as for example in the destructive behaviour of narcissists). Marzillier’s own issues with cognitive therapy arose as much out a disillusioning of his idealisation of his mentor, Aaron Beck, during an embarrassing tennis game, as through rigorous methodological critique (Marzillier, 2010, pp 127)! Problem solving is useful in some circumstances, the important thing is to tailor the treatment to the client’s needs (Marzillier, 2010, pp157).

Marzillier’s commentary on the normality of depression and disorder (even amongst practitioners) is heartening – like Jung’s concept of the wounded healer (Burns & Burns, 2009), it allows a place for our damaged humanity.

Marzillier notes the utility of illness – the function of disorder within the family dynamic, both as identity and escape (Marzillier, 2010, pp 47). I find this a useful adjunct to the idea of the ‘identified patient’ (Agazarian, 1999) – rooting disorder in the family and social system, rather than ignoring the environment in which suffering emerges. Specifically, the power of obsessive compulsive routines to control those around the client is something I’ve witnessed in group psychotherapy.

Marzillier’s difficulties in not offering practical help to his clients when he begins practicing psychoanalsysis (Marzillier, 2010, pp145), mirror my own. This links in with his frustration at the avoidance implicit in the orthodox Freudian analysis he receives as a client, which fails to penetrate a surface relationship and is allowed to become a cursory exercise (Marzillier, 2010, pp195).

The chapter on boundaries ‘getting too personal’, is informative in showing that boundary violations can be as much about wanting to do something to help the client (unconsciously treasuring their approval) as taking advantage of them (Marzillier, 2010, pp 239). In the subsequent chapter Marzillier focuses on ‘the unanswerable question’ of what drove one of his clients to suicide – highlighting impulsivity, life history of failure and conflict, and inescapable patterns of negative feeling and thinking. Again the theme of unwillingness to disappoint the client, to disillusion them, arises (Marzillier, 2010, pp251).

It’s useful to note that Marzillier takes three to four sessions to decide whether to see and how to treat a client (Marzillier, 2010, pp 242). After which he offers a written formulation (essentially a case study) to his client (both psychoanalytic and cognitive aspects) and discusses potential treatments. This emphasis on disclosure and informed consent has impacted on my psychotherapeutic practice.

Writing a book like this, so deeply rooted in subjective life experience, skipping forward and backward through memory is inarguably inexact and inscrutable. However, this kind of ‘romantic science’ (to use Oliver Sack’s phrase) (Wasserstein, 1988) has the capacity to include aspects of the lived experience of the practitioner that more rigid / theoretically driven accounts leave out.

It was fascinating reading about Marzillier’s encounter with the ‘desk drawer problem’ in scientific research – where studies that fail to find an effect (rather than serving to demonstrate the lack of one) rarely have an impact.Interesting too, was his experience of parallel process in the supervision relationship (Marzillier, 2010, pp158).

The books weakness is Marzillier’s relatively privileged clinical position – he generally doesn’t work with (or write about) about intellectually or physically disabled, extremely socially deprived or at risk clients, geriatric, children or adolescent clients: Essentially excluding most ‘front line’ clients of publically provided psychotherapy today.

Marzillier’s self deprecating description of a career in psychotherapy is deeply entertaining. His points about the arrogance of applying evidence based therapies regardless of the uniqueness of the client in question are well made. By charting his own course from behavioural to cognitive and finally psychoanalytic therapy, Marzillier makes a convincing case for developing a therapeutic practice that suits the individual practitioners style of relating; and finding value in a variety of techniques. Finding a way of working he could ‘identify with’ was most important in his development as a therapist (Marzillier, 2010, pp211). Marzillier rejects the systematisation of technique as costly and time consuming (Marzillier, 2010, pp99), and his own career reflects the truth that pioneers have the freedom to make mistakes, and hence the freedom to grow and develop. His experience evidences the importance of allowing therapists to learn ‘on the job’, in a scenario where their developing learning can be put into practice as they become ‘agentic’ practitioners (Bandura, 2001).

I share the author’s distrust of ‘doctrinal’ aspects of psychoanalytic orthodoxies (Marzillier, 2010, pp 212), and other rigid forms of therapy. Marzillier successfully argues for the importance and utility of finding meaning in suffering allied with change (Marzillier, 2010, pp213). The advantage of ‘time to listen’ (in long term, private therapy) provides Marzillier with an open ear to client’s evaluations of their own problems, and the underlying problems they sometimes conceal (Marzillier, 2010, pp217).

Marzillier has built a therapeutic methodology that seeks to combine the best elements of the various aspects of his training background. The book is convincing in its invocation to build a toolkit with which to as Marzillier puts it, citing Yalom, ‘create a new therapy for each patient’ (Marzillier, 2010, pp220); to operate from an unknowing place, but an empowering one – respectfully focusing on the avowed problem (Marzillier, 2010, pp223) without blinding oneself to deeper causation, providing containment (Marzillier, 2010, pp 248) without constriction. All this is demonstrated by Marzillier’s treatment of ‘Cordelia’, a client who presents with panic attacks, later revealed to be stemming from deeper problems (Marzillier, 2010, 227).

The book finishes by focusing on the importance of the personal factor in psychotherapy (Marzillier, 2010, pp260), of the personality and humanity of the practitioner; and the utility of providing a ‘secure base’ even when cure is impossible.

References

Agazarian. Y.M. (1999) Phases of Development in the Systems-Centered Psychotherapy Group. Vol. 30 no. 1 82-107.

E.I. Burns, L. Burns. (2009) Literature and therapy: A systematic view. Karnac Books: UK.

Bandura, A. (2001) Social cognitive theory: an agentic perspective. Annual Review of Psychology. 2001;52:1-26.

Clark, L.A., Livesley, W.J., Morey, L. (1997). Special Feature: Personality Disorder Assessment: The Challenge of Construct Validity. Journal of Personality Disorders: Vol. 11, No. 3, pp. 205-231.

Duquette, P. (1993) What Place Does the Real-Relationship Have in the Process of Therapeutic Character Change? Jefferson Journal Of Psychiatry. Vol 11, 2.

Falk, L. (2001). Comparative effects of short-term psychodynamic psychotherapy and cognitive-behavioral therapy in depression: A meta-analytic approach. Vol 21(3), 401-419.

Glasser, William. (1998) Choice Theory. USA: Harper Collins.

Kohut, H. (2009) The Analysis of the Self: A Systematic Approach to the Psychoanalytic Treatment of Narcissistic Personality Disorders. USA: University of Chicago.

Marzillier, J. (2010) The Gossamer Thread. Karnac Books: London

Rosenwasser, B., Axelrod, S. (2001). The Contributions of Applied Behavior Analysis to the Education of People With Autism. Behavior Modifaction. Vol: 25: 671-677.

Wasserstein, A.G. (1988) Toward a Romantic Science: The Work of Oliver Sacks. Annals of Internal Medicine. Vol 109(5):440-444.

Lets Pretend! Synchronicity, Suffering & Psychoanalysis

Girl with Death Mask (She Plays Alone), Frida Kahlo
Girl with Death Mask (She Plays Alone), Frida Kahlo

Can there be a more reliable indication of stupidity than the phrase ‘everything happens for a reason’? But if we play the game of presupposing a shape or interconnection to life, this play space connects us to the real – the shared experience of illusion. This game allows us to act as though our lives had weight, to act as though the universe possessed meaning in relation to us, to the you and I (and I in you) of this moment. This is the game of faith, not in the nebulous other, but the dreamlike meaningful coincidence that Jung called synchronicity.

Alan Watts used to ponder, when confronted with cruelty or stupidity, ‘Oh how interesting the form Buddha has taken for me today!’ The form Buddha has taken for me today is precisely the ‘third space’ of the transitional phenomena D.W Winnicott speaks of as the birth place of play, culture, and the emergence of self; the transition space between the inner world of drive, and the outer world of succor / dukkha. In other words, the real.

If the structure of phenomenological reality is what Robert A. Wilson called a ‘reality tunnel’, then merely being a client (of analysis, of CBT or whatever) can create an inner world mirroring the therapist’s theory. Demand characteristics in the fragile sciences, refer to the affect on experimental participants of experimenters unconsciously expressed desires. Elizabeth Loftus, that great pioneer of imagined memory, applied the idea to psychotherapy, demonstrating the epistemic metaconsensus of the encounter is shaped by the implicit communication (in psychodynamic terms, the suggestion) of the therapist.

The patient of psychoanalsysis becomes the parapraxic analysand, the subject of analytical psychology arrives at each session brimming with archetypal dreams and so on. All the players have their scripts in the dramaturgy of the therapy session. This being the case, we see that psychoanalysis (and indeed clinical psychology) isn’t archaeology of the mind so much as the construction of a creationist theme park. But if we play the game of presupposing it is not… Then we all become Lacanians.

Winnicott & Creativity

Emotions, Indifference, by Erte
Emotions, Indifference, by Erte

The psychoanalyst D.W. Winnicott was one of the pioneers of the ‘object relations’ school. Broadly object relations (an enormously diverse area, underlying modern approaches like family systems theory and transactional analysis) situates the primary parental bond as the source of the individual’s ability to contain threatening feelings, and understand themselves as a subjective participant in an ‘objective’ consensual reality. I’m not entirely convinced by object relations accounts of child development – which rely heavily on untestable assumptions about the infant experience. However, I do find Winnicott’s approach to play and creativity exciting.

Winnicott argues for the essentiality of ‘creative apperception’ to life, and the corresponding deathliness of ‘compliance’. For Winnicott, creativity is a universal faculty of life (not merely the domain of artistic creation) – a faculty which can be diminished (hidden) or damaged by illness or repression. To be creative is to retain the capacity to suffer – and it is those who are unable to sacrifice their own creativity who suffer most under tyranny. In common with Freud and Foucault, Winnicott claims that modernity made possible the individual – alienated from pure identification with community and nature, and hence capable of reflection and creativity. Creativity is embodied in ‘healthy looking’ and ‘deliberate doing’ – active engagement rather than passive participation in life. Thus Winnicott normalises and universalises ‘the creative impulse’, placing it at the heart of healthy life.

“Compliance carries with it a sense of futility for the individual and is associated with the idea that nothing matters and that life is not worth living”

Winnicott, Playing & Reality

[Note – the first time I wrote out that quote, I substituted the word ‘mothering’ for ‘nothing’, psychoanalytically inclined readers can go ahead and half a field day with that one]

Winnicott goes on to discuss the schizoid, to whom ‘reality remains to some extent a subjective phenomenon’. This is a state not sharply delineated from health – nor from schizophrenia, one in which a ‘fay’ individual is unable to fully connect with consensual reality. These individuals feel dissociated, detached from both the ‘real’ world, and the ‘dream’ symbolic universe.

Its worth noting here that labeling is a huge issue in mental health, and that personality disorders are syndromal – that is to say classified based only on underlying symptoms, rather than any understanding of ‘disease process’. It’s probably more meaningful to this of personality disorders as states / conditions, or even positions, rather than fundamental to the structure of self – since in many cases they can alter greatly over time, and are amenable to treatment.

Dead end, Ślepa uliczka
Dead end, Ślepa uliczka

According to Winnicott, to understand early breakdowns in the capacity for creativity (in Bionian terms –K learning) – we need to examine both the individual and their early environment (primarily their parenting). Hence Winnicott offers a space for the social in (traditionally individualist) psychoanalysis. The ‘graduated failure’ of the ‘good enough mother’ makes it possible for infants to tolerate the trauma of losing the illusion of their own omnipotence. Thus, a reliable infant environment is key to the development of trust that allows the creation of internal objects that match reality (‘subjective objects’) – and it’s absence can create the kind of schizoid dissociation, or incapacity for a real creative engagement with the world, we’ve been discussing.

Winnicott argues that searches for ‘self’ in creative work are doomed to failure (Winnicott, 1971, pp73), since the discovery of self requires ‘non-purposive’ activity. In practice this exhibited in his therapy sessions in a tolerance for ambling digression, without imposed interpretation (primarily given in response to client request).  He allowed sessions to overrun by hours, and his treatment room was full of toys and art supplies! Clients would physically wander round the treatment room, fall asleep or draw a picture. This can seem problematic to a modern reader – especially since Winnicott stretched sessions to fit client’s needs on request, and added sessions to compensate for missed sessions: violations of boundaries that seem inviolable today. Winnicott often let his clients without interpretation – allowing them their own creative space to act (prefiguring Patrick Casement’s emphasis on negative capability, and paralleling Carl Roger’s person centred approach) and crises to emerge and be communicated by impact. As with Irving Yalom and even Freud, we see an informality and humanity that has been (perhaps inevitably) lost as psychotherapy has professionalised and become more concerned with protecting clients from exploitation.

I’ll write more on the construct of ‘the schizoid personality’ in a future post.

Symbolism

Great article on symbolism at Dan Costigan’s new blog. Dan was responsible for one of the most popular talks at Open Learning Ireland‘s Learn Something; Share Something; Do Something Festival. With a bit of luck we’ll be making the prezi of Dan’s talk available soon. Snippet…

urlThe world is bad because young girls are murdered. The world is a better place because we can have coffee and donuts…. Food is basically affection, love or emotional nourishment. In one 1958 article written by a ‘Hamburger, M.D’,(I shit you not!), he discussed four different patients and their dreams of food within the context of this association. I, being damned to remember dreams night after night, can recall many dreams relating to food. Mostly they involve searching for food (love/ affection), finding better food behind lower quality food, hiding food, refusing food or finding the evidence of food like a stylish cooler bag but with no food.

I find this perspective facinating, as personally I’m symbol blind. Symbols seem arbitrary and totally intellectual to me. I wonder how much of Dan’s perspective is innate / deep self exploration, and how much a demand characteristic of reading all that psychoanalysis. Just how labile is our phenomenology? Check out the full article here.

Therapists Don’t Know Everything

Objects in Space, Arturo Souto
Objects in Space, Arturo Souto

Wilfred Bion used Keat’s term ‘negative capability’ to refer to the capacity to hold onto not knowing until something touches upon the truth, to allow new experiences be new (rather than reflections of past client experiences, or the work of other sessions). This is the subject of Patrick Casement’s book, ‘On Learning From The Patient’. Casement is the psychoanalyst best known for two ideas – 1) the value of recognising and owning your mistakes as a therapist, and 2) the necessity of being tentative with interpretations.

Casement outlines a number of ways of remaining in the experience of the client’s discourse, examining various interpretations of their primary process material, and previewing the impact of potential interpretations (through what he calls ‘trial identification’). This ‘negative capability’ allows the client’s individuality to emerge over the course of therapy, rather than being imposed by the therapist. As a client I have experienced the constraint and disappointment of being misunderstood and misinterpreted, and the damage this can have on the ‘real relationship’ at the core of growth and healing in the therapeutic encounter.

The therapeutic alliance requires collaboration, trust and commitment; and client’s dysfunctional development / family environments may have meant that they have never experienced having these things reliably provided by another person. Hence clients come into therapy armed with their learned patterns of anxiety, distrust, alienation and reactance. These emerge in the development (or obstruction) of the therapeutic alliance. Trust must be earned, through the provision of safe ‘containment’, which both support’s client’s catharsis and restrains client transference.

Casement illustrates this through the case of an obese and intensely manipulative client who had been sexually abused by both parents. His client had experienced an intense erotic transference relationship with her previous therapist, who (at least according to the client) had played into this by engaging in inappropriate touch in his own home. Similarly, while attending therapy with Casement, this client simultaneously attended another ‘behaviourist’ therapist, who also failed to provide healthy boundaries.  Casement reports that by firmly resisting his client’s boundary testing, from the very first session, he was ultimately able to model a healthy, trusting relationship, that became a collaboration enabling the client to separate herself from her enmeshed mother, and ultimately to employ healthy control over her weight and relationships (at least according to the therapist).

Making People Happy

The Happy Donor
The Happy Donor, by Rene Magritte

This is the second in a series of articles about contemporary mental health and psychotheraputic treatment, following an article focusing on meaning and society in mental illness.

Different models of psychotherapy not only offer distinct understandings of pathology and ‘ways of intervening’, but suggest wildly varying pictures of health or recovery. The integrative psychotherapist needs to evolve an approach that selectively combines often mutually incompatible seeming therapies, into a coherent, client directed treatment.

Choice Theory / Reality Therapy, takes a needs based approach, positing five basic needs which are individually variant (love & belonging, freedom, fun, power and survival). The idea of needs, whether viewed as libidinous impulses or aspects of personality, is valuable. However, Glasser’s specific taxonomy of needs seems arbitrary and ethnocentric. For Glasser, all fun and creativity is based on learning, while sex is not a need on its own, but rather serves a variety of other needs. This is starkly at odds with an evolutionarily perspective – situating our universal dimensions of personality and behaviour in the context of their utility in our environment of evolutionary adaptedness.

In keeping with Jungs idea of enantiodromia, Glasser’s needs could be refined by adding another dimension, perhaps entitled ‘avoidances’. Since it seems evident motivation is as much about the avoidance of unwanted / intolerable situations, states etc, as desire. Avoidances might be perceived as neurotic, however resolving or satisficing (SIC) them could be an important element of lifelong happiness. For example – jogging in the morning might help to fulfil my freedom need, however if my experience each afternoon is to suffer under the caprices of a tyrannical boss, my need-avoidance of domination may be a larger contribution to the happiness of my day.

Glasser also emphasises that all needs are met through present relationships – and here he has something to offer psychoanalysis. Fixating on past relationships and their discussion in the present can blind us to the value of real and potential relationships, in providing a healthy emotional environment and support for life challenges. While people certainly re-enact toxic (as well as positive) patterns of relating, whether in the psychotherapeutic encounter or with friends, partners and families; present relationships offer the field of current functioning, and can act to sustain or alleviate trauma, to heal and to wound afresh.

Psychoanalysis traditionally offered the catharsis of past trauma, and the development of insight as the ultimate routes to healing. Insight, combined with ‘corrective recapitulation‘ in the safety of the therapeutic encounter, allowed a ‘reverie’ to contain the clients suffering, and transform it into something which could be re-introjected – split off aspects of self becoming defrosted, feelings long disowned being assumed into the emotional vocabulary. While we need to be wary of re-traumatisation of clients; and equally of the construction of artificial memories previously ‘repressed’; the value of catharsis should not be understated. Simply being heard (and accepted through congruent empathic unconditional positive regard of Person Centred therapy) is a healing experience, which allows the self to obtain a measure of secure reality – which may have been absent developmentally. This is emphasised in contemporary object relations approaches, which focus on ‘reparenting’ (essentially healing attachment difficulties), through corrective emotional experiences in the ‘containment’ of the psychotherapeutic encounter. Through the therapeutic relationship the analyst provides the appropriate tolerance and nuanced emotional response lacking in the client’s developmental history. They ‘fail gradually’, allowing the client to assume responsibility and self direction.

Psychodynamic processes like projection, can provide more insight into a range of expressions of suffering than many current (and proposed) DSM criteria of syndromal mental illness. In the mental universe ‘symptoms’ are less important in their specificity than in their utility, their function in expressing or providing relief from intolerable pain. Allowing meaning into the understanding of illness, not only provides for a more hopeful outcome, and motivates a more genuine listening to client issues, but also more accurately reflects the experience of clients – that mental illness is frequently potentiated by trauma, in both its timing and mode of expression.

However, risk factors like neurological insults, developmental disorders and neurocognitive impairment contribute to vulnerability to mental illness; interfacing with resilience factors (like family health, access to educational resources etc) that ameliorate or even prevent mental illness. The support and resources a client receives outside of the therapy room (and the skills needed to acquire them), may in fact be much more important than the psychodynamic processes at work in their individual distress. Communications skills, social support and practical resources can provide the bulwark against illness that clients need.

Teaching clients how to acquire such resources, whether through CBT, or life skills training, can be a valuable aspect of psychotherapy: Although this very much conflicts with the Winnicotian idea that therapists must never ‘model health’ for the client, and need to move past being a ‘need fulfilling object’ – to avoid transference dependency. This kind of agentic approach has emerged as important in my own life, since my diagnosis with severe central and obstructive sleep apnea, a condition which leads to hypoxia, tiredness and dysphoria along with memory difficulties and other health risks. Treating my sleep apnea has enabled me to greatly increase my productivity, consistency, sense of competence and general mood. All of which might have been seen, by psychoanalysts and cognitive therapists alike, as related to motivation, disorder or personality type.

New research has called into question the famous ‘marshmallow test’, which demonstrated that children with better ability to resist the allure of immediate rewards went on to greater success in adulthood. It seems now that what the test was measuring was not simply an innate reward circuit, malfunctioning in some, but rather the predictability of the childhood environment. Kids raised in chaotic circumstances could not realistically expect to be rewarded for forbearance. This is important, because the kind of resilience demonstrated by patient kids can be taught. Teaching such ‘soft’ and ‘metacognitive’ skills, can be enormously beneficial in ameliorating the gap between healthy and dysfunctional family of origin. Similarly, providing clients with the tools to develop relationships that will support and encourage them, can be extremely productive.

The role of meaning is also important in lifelong emotional health. Meaning making has been examined by Viktor Frankl in his ‘logotherapy’, while modern research into Positive Psychology, statistically examines what makes people happy in general. Logotherapy posits that we can derive meaning a number of ways: through creative work or deed, through experience or encounter, or through our attitude to unavoidable suffering. For Frankl (a holocaust survivor), the existential vacuum accounts for much despair, addiction and power seeking. Individual meaning needs an individual process, and cannot be imposed.

Helping clients to find and develop the meaningful aspects of their lives and work, could be an important element of enabling them to find happiness.
Factors like community participation, ‘spirituality’, norms, values, education, creativity / self expression and continuing personal development – the top of Abraham Maslow’s hierarchy of needs – are elements of meaning making. Meaning making likely changes with life stage too, taking into account Erik Erikson’s conception of a variety of lifelong developmental stages. Although Erikson’s stages and stage crisis’s are somewhat arbitrary and culture bound; they can point us towards a far more helpful developmental model than the folk psychology concept of ‘maturity’ / degeneration.

Finally, psychological research indicates an enormously important role for the physiological and physical environment in emotional health. We are embodied creatures, our affect linked to what neuroscientist Antonio Domasio calls ‘somatic markers’, conditioned bodily responses / brain circuits, that mediate emotion (and, in the case of mirror neurons, empathy). Thus light, exercise, diet, and environmental stressors (like sitting down all day at work), can be important determinants of maintaining mood stability – particularly in those subject to mood dysfunction.

I’d go further than this, and suggest that the design and history of our buildings and neighbourhoods, can have an enormous impact on wellbeing; be it in reminding us of the hopelessness of our situation, or elevating us to new levels of self belief and trust.

As important to psychological health as the physical environment, is the family system. The stability, warmth and encouragement of the family in childhood; and the health and support provided by a client’s current friends, family and partner, are vital elements in determining well being. Similarly, a client’s current position within a dysfunctional family system may force them into the role of the ‘identified patient’, or may reinforce their predispositions toward unhealthy behaviours and addictions. Our place in the social strata is also an important determinant of stress, and a variety of life outcomes, and societies with a low ‘power distance’, have been found to be more happy and helpful.

In summary – not only the client’s traumatic history / object relations, but also their broader family and social system, their physiology and physical environment, their innate needs and learned avoidances, their resilience factors, and the meaning they find in their lives, may all be as or more important as the therapeutic relationship in a client’s happiness and overall life satisfaction. Perhaps there is a role for assessments of wellbeing (much broader than that offered by clinical psychological global assessment of functioning), prior to beginning therapy, and before ending it. A way of learning, with and from the client, how best to help them become happier, more fulfilled people.

Meaning and society in mental illness

Parable Of The Blind
Parabel of the Blind, by Bruegel

Last week I was involved in organising the first Open Learning Ireland week long education festival.

For the festival I prepared a talk on ‘Madness, Pyschotherapy & Medication’ (slides and notes). Delivering this talk, and discussing the issues raised with attendees, helped focus my mind on something I’ve been thinking about since college, the nature of meaning and mind in mental illness.

The medical model situates syndromal mental illness squarely in the individual (and more specifically the brain, subjected to stress and diagnosed with a psychiatric disorder): Extending a disease model analogy beyond it’s diagnostic, aetiologic and prognostic utility. While the psychoanalytic object relations model perceives pathological defences / illusions rooted in childhood trauma / attachment difficulties as a core element of pathology.

We are however social beings, and our emotional dysfunctions manifest in socially prescribed ways. Mental and emotional difficulties, like language exist at a meta-individual level. Viewing the individual alone, whether as the possessor of a dysfunctional brain, maladaptive cognitive schema or dysfunctional reality testing will never be sufficient for understanding the meaning of their ‘disorder’. Illusion (Winnicott’s term) is possibility, potential energy. It’s also social – symbols are perceptions generalised and shared, and culture can be viewed as the use of collective symbols and symbolic actions. Thus our contemporary ‘mental illnesses’ manifest as inevitable extremes or dysphoric projections of our schizoid visual culture / information society.

The psychologist Gottrschalk writes of telephrenia, believing oneself the subject of direct communication from the mass media – and this is a prototypic example of the blurred lines between metaphor and reality in relation to the cultural mediation of belief and mental health. Today’s delusions centre around feeling the subject of surveillance and conspiracy, or secret communication. Defences of paranoia / pronoia are employed by individuals with an uncertain sense of self, threatened by a lack of real recognition (coupled with a sense of being constantly seen). At a time when the panopticon is moving from metaphor to reality (online, from surveillance drones, CCTV and via the sousveillance of the ever present smartphone), the gap between delusion and metaphor can become thin indeed – especially when the deluded themselves become the subject of surveillance (due to their socially unacceptable behaviour). Are these delusions merely socially shaped, or are they socially derived, intrinsically linked not only in syndrome but causation with our collective alienation?

Two troublesome disorders in the DSM-IV-TR, conduct disorder and oppositional defiant disorder, centre around the individuals obedience to the collective. Here we see a direct line between conformity pressures and the diagnosis of pathology, little different from the traditional psychodynamic understanding of homosexuality / paraphilia as ‘inversion’. I don’t mean to suggest for a moment that mental illness is not real, or amenable to individual treatment – but I do want to question our ideas concerning the function and causes of illness (for the individual, their family and the culture at large). If prevention is the goal, the monistic alienation of consumerism needs to be addressed.

Heidegger differentiated between the nature of being, and the question of being as such. “The question is: Why is there any being at all and not rather Nothing?” (Heidegger, 1949). This elicits the unasked ‘why’ in mental illness, if being as such (the meaning of the symptom / sinpthone) is ignored – psychology becomes merely a taxonomic exercise (as in the DSM).

For more on the individual-cultural intersection in madness, check out Dan Costigan’s article ‘On Being Normal & Other Mental Illnesses‘. In my next couple of posts I will talk about some more socially and somatically grounded, multi-dimensional conceptions of the mind and mental illness that have emerged from the culture and health, and clinical psychology perspectives.