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The passing of Arnold I. Goldberg, MD, on September 24, 2020 is a “for whom the bell tolls” moment. No doubt his family, students, friends, and colleagues feel the loss most acutely; however, the community is diminished, though in another sense irreversibly enriched by his contributions and innovations in expanding empathy.
Our loss is great, yet we breath easier thanks his lessons in empathy, which is oxygen to our souls.
Arnold I. Goldberg was an innovator in psychoanalysis and self psychology, a prolific author (really prolific!), an inspiring educator, and simply a wonderful human being.
My personal recollections are of Dr Goldberg inspiring my younger, graduate student self to pursue and complete a dissertation on empathy and interpretation at the
University of Chicago Philosophy Department. I fondly recall introducing Arnold to one of my dissertation advisors, Paul Ricoeur, over a wine-enriched dinner at the middle eastern restaurant that used to be on Diversey Avenue (the Kasbah?). I was also lucky enough to take a year long case conference at Rush Medical that he taught to the psychiatric residents as part of the Committee on Research and Special Projects sponsored by the Chicago Institute for Psychoanalysis. Notwithstanding a multiyear gap during which our paths diverged, I have known him and his wife Connie (herself a Self Psychology power) since I was a twenty-something; and I still have in my possession a couple of his hand written letters to me regarding hermeneutics that I used to good purpose when “roasting” him at a retirement event at Rush Medical. What a privilege: I experienced Arnie’s deep listening, incisive and penetrating wit, the humor, the humanity, the remarkable learning and even-handedness in disagreement, and above all – his empathy.
I choose to republish this book review from June 23, 2013 precisely because its provocative title best encapsulates the validity of Goldberg’s contribution to psychoanalysis and self psychology while subtly and humorously “sending up” some of his less flexible colleagues. Arnie, thank you for being you!
Read the complete review in the International Journal of Psychoanalytic Self Psychology: click here: GoldbergAnalyticFailureReview2014
The power of Arnold Goldberg’s approach in The Analysis of Failure: An Analysis of Failed Cases in Psychotherapy and Psychoanalysis (Routledge) is twofold. First, if a practice or method cannot fail, then can it really succeed? If a practice such as psychoanalysis or dynamic therapy can fail and confront and integrate its failures, then it can also succeed and flourish.
Such is the point of Karl Popper’s approach to the philosophy of science in Conjectures and Refutations. For those who have not heard of hermeneutics, narrative, and deconstruction, and who are still suffering from physics envy, the natural science have advanced most dramatically by formulating and disproving hypotheses. Natural science is avowedly finite, fallible, and subject to revision, advancing most spectacularly within the paradigm of hypothesis and refutation by failing and picking itself up and pulling itself forward.
The Analysis of failure is inspired by this lesson without engaging in most of the messy details of the history of science. Second, for a discipline such as psychoanalysis (and psychodynamic therapy) that prides itself on the courageous exploration of self-deceptions, blind spots, self-defeating behavior, and the partially analyzed grandiosity of its practitioners (and patients), the well worn but apt saying “physician heal thyself” comes to mind.
The professional ambivalence about taking a dose of one’s own medicine upfront is a central focus not only in psychoanalysis (in its many forms) but in related area of psychiatry, psychopharmacology, cognitive behavioral therapy (CBT), social work, clinical psychology, and so on. Goldberg’s openness to alternative conceptions and frameworks along with his exceptional knowledge of and commitment to psychoanalysis (and self psychology) is an obvious strong point.
As a former colleague of the late Heinz Kohut, Goldberg studiously avoids (and indeed fights against) adopting the paranoid position with respect to failed analytic and psychotherapy cases – what’s wrong here? When a therapy case fails (the determination of which is a substantial part of the work) a series of blame-oriented questions arise: What’s wrong with the patient? What’s wrong with the therapist? What’s wrong with the treatment method(s)? What’s wrong!? And, yes, these questions must be engaged; but, Goldberg demonstrates, they must be put in perspective and engaged in the context of a broader question What is missing the presence of which would have made a difference? The answer will often, but not exclusively, turn in the direction of a Kohut-inspired interpretation of sustained empathy.
This leads to the part of Goldberg’s argument that is explicitly humorous. Having announced a case conference on failure and invited all levels of colleagues, Goldberg reports the casual laughter of many colleagues as they announced that they had no failed cases and so could not be helpful. “One person agreed to present but the following day he yelled across a long hall that he could not and quickly walked away (p. 41).
The list of excuses goes on and on, producing a humorous narrative that is definitely a defense against just how confronting the whole issue really is. Less humorous and more problematic is what happens when a case comes to grief and the candidate reportedly does exactly what the supervisor recommends. How one would know what is the “exact recommendation” is hard to determine, but relations of power loom large in such a triangular dynamic. Even Isaac Newton acknowledged that the “three body problem” of the (gravitational) relations between any three bodies is theoretically computable but practically intractable. The number of variables changing simultaneously is such that we are dealing with expert judgment rather than algorithmic results.
For my part I cannot help but think of the process for airline pilot reporting of errors in procedures, operations, and maintenance. Yes, pilots are part of a complex system and “pilot error” does occur – pulling back on the stick to get lift rather than pushing down – yet they are usually given more training and rarely blamed or faulted, absent illegal or blatantly unethical conduct (e.g., drinking on the job).
Goldberg calls for an ongoing case conference inquiring into failed cases, and thereby implicitly calls for taking our thinking to a new level of professional rigor, encompassing scientific objectivity that is consistent with talk therapy being a hermeneutic discipline. One might call it looking at the entire system, but not in the sense of family therapy –rather in the sense of the total professional-cultural-scientific milieu.
However, Goldberg’s approach differs decisively from a Check List Manifesto (a distinction not in Goldberg (he does not need it) but abroad in the land and by a celebrity MD, Atul Gawande) in that individual chemistry looms large between the therapist and the patient. In analysis or therapy, the number of unknown variables in fitting a prospective patient to a prospective treatment (whether analysis, therapy, psychoparm, CBT, etc.) is so large as to be nearly intractable. These are areas where we simply lack the super-shrink who has mastered the basics of all these methods and can make an objective, upfront call of what just might have the best odds of a favorable outcome without the usual trial and error. For the foreseeable future, mental health professionals can be expected to continue to “sell what they got.” If a person knows Talk Therapy, then that is most often what is initially recommended. If that does not work, try CBT or medication – and vice versa.
This reviewer does not agree that the crashes in the mental health area are usually not so spectacular – and they do make the papers in the form of suicides and inexplicable violence – though the track record is no where near the five-nines (one error in a million) that characterizes the airline industry. Goldberg’s subtext for mental health professionals is that we are still learning to live with uncertainty even as we organize case conference, postmortems, and the equivalent of crash investigations that strive to look objectively at outcomes without blame and without omniscient rescue fantasies in the service of healing and professional (“scientific”) development.
In some thirty cases that were reviewed by Goldberg, using the method of expert evaluation and feedback by the participants in the local case conference, the definition of failure included cases that never get off the ground; cases that are interrupted and so felt to be unfinished by the therapist or analyst; cases that suddenly go bad, characterized by a negative eruption whereas previously therapy was perceived to be going well; cases that go on-and-on without improvement; cases that disappoint whether due to the initial goal not being attained or being modified and not attained or endless pondering of what might have been.
Since this is not a “soft ball” review, one category of failure that is conceivable but missing from The Analysis of Failure is the example where treatment arguably left the person worse off (other than in terms of wasted time and money, which itself is not trivial). What about someone who did not experience impotence, writer’s block, or (say) hysterical sneezing until they tried psychoanalysis (psychotherapy)? What about compliance and placating behavior, reportedly a significant risk in the case of candidates for analytic training? What about regression in service of treatment that was initiated within the empathic context of the therapeutic alliance, but something happened and the regression got out of control and a breakdown or fragmentation occurred? Work was required to contain the fragmentation that was minimally successful, prior to an untimely termination that was a flight from fragmentation, a flight into health or a statement that in effect said “Let me otta here for my own good!” To his credit, Goldberg identifies “a patient who was getting worse off” (p. 162), but leaves the matter unconnected to regression mishandled or any other psychodynamic explanation. It is possible that such a scenario is already encompassed in the category of “cases that go bad,” at least implicitly, but in an otherwise through review of possibilities, this one was conspicuous by its absence.
The book itself is Goldberg’s answer to the question, given that failure occurs, what do we do about it? We inquire, define our terms, organize the rich clinical data, identify candidate variables, take the risk of making judgments about possible, probable, and nearly certain reasons, causes, and learn from our failures, pulling ourselves up by our boot straps in an operation that seems impossible until it succeeds. The role of lack of sustained empathy, counter-transference, rescue fantasies, disappointments, uncontrolled hopes or fears, partially analyzed grandiosity (on the part of the therapist), lack of knowledge of alternative approaches to therapy, are towards the top of a long (and growing) list of issues to be engaged in the classification of causes for failure.
The turning point of Goldberg’s argument occurs in his chapter on “How Does Analysis Fail”? This is an obvious allusion to Kohut’s celebrated work on How Does Analysis Cure? Once again, failure is a deeply ambiguous term, and the ironic edge is that in contrast to an analysis gone bad where the patient leaves in a huff with symptoms unresolved, a successful self psychology analysis proceeds step-by-step by tactical, nontraumatic failures of empathy that are interpreted and used to promote the development of self structure. The short answer is that analysis cures through stepwise, incremental, nontraumatic breakdowns – i.e. failures – of empathy, which are interpreted in the analytic context and result in the restarting of the building and firming of psychic structure of the self. In turn, these transformations of the self promote integration of the self resulting in enhanced character traits such as creativity, humor, and expanded empathy in the analysand.
The entertaining and even heartwarming reflections on Goldberg’s relationships with his teachers Max Gitelson and Charles Kligerman, betrayed (at least to this reader) a significant critique of the “old guard,” resolutely defended against the possibility of any failure, thanks to a position that avoided any risk – analysis is about improving self-understanding. According to this position, the reduction of suffering and symptoms relief is a “nice to have” but not essential component. Analysis is a rite of passage into an exclusive club, where you are just plain different than the untransformed masses.
Though Goldberg does not emphasize the debunking approach, the reduction to absurdity of the description of the old guard makes psychoanalysis sound a tad like the est training from the late 1970s. You just “get it” or you don’t – in which case here is your money back and now go be miserable and unenlightened (only analysis does not give you your money back). In both cases failure is not an option, though not in the sense initially intended by the slogan, namely, that risk is analyzed and mitigated through interpretation. Failure is not an option because it is excluded by definition from the system of variables at the onset, thus, also excluding many meaningful forms of success. In short, many things are missing including sustained empathy, which, in turn, becomes the target of the analysis of failure in the remainder of the book
The net result of the compelling chapters on Empathy and Failure, Rethinking Empathy, and Self Psychology and Failure, is to challenge the analyst and psychotherapist to deploy sustained empathy in the service of structural transformation. While I personally believe that agreement and disagreement are over-valued in terms of creating authentic understanding, the section on Empathy and Agreement raises a significant distinction between the two terms. It is insufficiently appreciated by many clinicians how agreement becomes a smoke screen – and defense against – basic inquiry and exposure to the other’s affects in all their messiness and ambivalence. It remains unclear how sustained empathy undercuts agreement (or disagreement).For example, Dr. E. wants his analyst to agree with him that it is okay to sleep with his patient(s). For the sake of discussion, the analyst mouths the form of words, “Okay, given your marriage, okay, I agree.” But Dr. E. then asserts that he can tell the analyst does not really mean it (an accurate observation). So why not raise the question what is agreement doing here other than disguising Dr. E.’s own unacknowledged commitment to “being righteous and justified”. There is nothing wrong with being righteous, everyone does it. However, is it workable?
The resistance has to be engaged and interpreted at some point in order to make a difference in treatment. Agreement (or disagreement) remains a conversation with the superego, even in the mode of denying there is amoral issue. It may stop a tad short of moral justification, but it is on the slippery slope to it. There are many cases along a spectrum of engagements but the really tough one is empathizing with behaviors that are ethically and legally suspect such as doctors sleeping with their patients and other relations of power where one individual uses his or her position to dominate the other as a mere means not an end in him- or herself. This is a high bar in the case of empathizing with the child molester or Nazi who have used a form of empathy (arguably a deviant one) to increase his domination of the victim. This remains a challenge to our empathy as well as to our commitment to treating a spectrum of behavior disorders (where Goldberg has made a life-long contribution) that are significantly upsetting to large parts of the mental healthcare market. Keeping in mind the scriptures and the sayings of Jesus(the rabbi), which Goldberg does not mention but arguably is the subtext, we are still challenged to love the sinner but hate the sin.
In a concluding rhetorical flourish, Goldberg claims that the book is a failure. The prospective reader – a very wide audience as I am any judge of the matter – may see the many complimentary remarks that properly disagree with this rhetoric printed on the back cover (which this review endorses and agrees). In a further ironic and richly semantic double reverse in the title of the final chapter, failure has a great future. This is especially so when failure is scaled down from a global narcissistic blind-spot on the psyche of the therapist (where failure remains a valid research commitment) to an expanded tactical approach in the form of “optimal frustration … disappointment being real, tolerable, and structure building” (p. 200).
The concluding message is an admirably nuanced clarion cry for further study rather than condemnation, finger pointing, or blame of some particular therapeutic modality such as Talk Therapy versus CBT. The concluding message is a sustained reflection on de-idealization, the difficult process of taking responsibility for the inevitability of one’s parents’ lack of omnipotence. Failure is part of the development process in analysis and psychotherapy, and, by implication (and taken up a level), the study of failure in broad terms will be part of the development of the profession going forward. The analyst and therapist must give up the rescue fantasy, give up being right and justified, give up misplaced ambition, but also give up guilt, self-blame, disappointment, and embrace an approach that interpretation of the pathogenic situation of early childhood in which traumatic deidealization of the parent occurred, becomes inherently transformative. It reactivates the process of structure-building internalization. Learning to live within one’s limitations invites a process of risk taking that sometimes results in failure, sometimes results in success, and always results in – redefining one’s limitations outwards towards an endless horizon of progress in satisfaction and meaning making. Our thanks to Arnold Goldberg both for the journey and the end result.
Chicago Tribune Obit, Sept 29, 2020: https://www.legacy.com/obituaries/chicagotribune/obituary.aspx?n=arnold-i-goldberg&pid=196869091
(c) Lou Agosta, PhD and the Chicago Empathy Project
The genie is out of the bottle. The day that the first therapist invited his one-on-one client (who had an urgent need for a conversation but an inability to get to the office) to
put down the phone and dial into Skype, the genie escaped from the bottle.
The reader will recall that in the 1001 Arabian Nightsthe Genie was very powerful but a trickster and nearly impossible to control. Making wishes is tricky, and if one is not careful, the sausages end up stuck to one’s nose and one must waste the last wish to get them off. In this case, the Genie is Internet technology such as Skype and Google Groups and the emerging conveniences, affordances, complexities, entanglements, and even resistances that it offers.
In the Arabian Nights, the hero, Aladdin, had to trick the Genie to getting back in the bottle by appealing to his narcissism. “You are not all powerful,” Aladdin said. “A large creature like you could not possibly fit in that small bottle!” The Genie’s wounded narcissism caused him to prove that he can indeed fit back in the bottle. Aladdin puts the stopper back on – trapped! However, in the case of the Internet and online communication tools, do not look to be able to turn back the clock.
But there is good news. The human face is an emotional hot spot. It is rich in micro-expressions many of which are available and visible even though the “real estate” on the screen in less rich in detail than an in-person experience. Indeed it is not even clear that the face as presented online is “less rich.” It is the only thing being displayed, and the viewer is led to concentrate on it in detail. But here the trade-off of bodily presence versus the imaginary comes into the foreground.
The criticism fails that the online conversation between persons lacks the reality of the in-person encounter. But this criticism fails, in a surprising way. The criticism fails notbecause the online media is so real. Rather the criticism fails because the in-person psychotherapy encounter is shot through-and-through with the imaginary, with symbolism, the imaginary and irreality. The “irreal” includes the symbolic, the imagined, the fictional, the part of reality which is distinct from the real but includes the past and the future and the imaginary, which are not really present yet influence reality.
In psychotherapy, the in-person encounter is precisely about the symbolic and the imagined – the transference. The basic definition of “transference” is that the person relives emotionally the relationship to objects (persons) from the past, persons who are not physically present in the room (or in the virtual space online).
What we are calling the “virtuality” of the technology media adds an additional dimension of irreality to the symbolic and imagined transference relationship. Yes, the media is the message (as Marshall McLuhan famously wrote), but with the arrival of online therapy the media is first and foremost the transference. The message now occurs with a strike-through, message.The online technology itself becomes a source and target of transference.
The one thing that immediately occurred to me: Psychotherapy invokes a virtual reality all of its own – even without cyber space. This is especially the case with dynamic psychotherapy that activates forms of transference in which one relates to the therapist “as if” in conversation with a past or future person or reality, the latter not physical present. Indeed, with the exception of being careful not to step in front of a bus while crossing the street on the way to therapy, we are usually over-confident that we know the reality of how our relationships work or what people mean by their communications. This is less the case with certain forms of narrowly focused behavioral therapies, which are nevertheless still more ambiguous than is commonly recognized. Never was it truer that meaning – and emotions such as fear – are generated in the mind of the beholder.
While virtual reality (VR) goggles as such are not a part of any online therapy group process, VR goggles are currently being used in individual psychotherapy with clients who are dealing with phobias and related individual issues. [See www.psious.com– an engaging start up which is promoting the VR goggles for psychotherapists. The author (Lou Agosta) reports: I have no financial relationship with this company, and I wrote a blog post in 2016: “A Rumor of Empathy at Psious”: https://tinyurl.com/jyuxedq]
For example, it is much easier for someone with a fear of flying to put on a set of VR goggles in the therapist’s office and take a virtual trip to the airport, board an airplane (in VR), and be taxing down the run away (in VR), than it is to do this in the real world. The next step in a group process is to create an avatar that resembles one’s individual physical self, warts and all, and to join the other avatars in an online virtual reality group session. New possibilities are opened up by this form of therapy for dealing with all kinds of emotional and mental issues that are beyond the scope of this article.
Here the point is just to look at how virtual reality (“virtuality”) already lives in the in-person psychotherapy session even as it might have been conducted in 1905. There is a strong sense in which the conversation between a client and a psychodynamic therapist already engages a virtual reality, even when the only “technology” being used is a conversation is English or other natural language.
For example, when Sigmund Freud’s celebrated client, Little Hans, developed a phobia of horses, Freud’s interpretation to Hans’ father was that this symbolized Hans’ fear of the father’s dangerous masculinity in the face of Hans’ unacknowledged competitive hostility towards his much loved father. The open expression of hostility was unacceptable for so many reasons – Hans was dependent on his father to take care of him; Hans loved his father (though he “hated” him, too, in a way as a competitive for his mother’s affection); and Hans was afraid of being punished by his father for being naughty.
So Hans’ hostility was displaced onto a symbolic object, the horse. Hans’ symptoms (themselves a kind of indirect, “virtual reality” expression of suffering) actually gave Hans power, since the whole family was then literally running around trying to help him and consulting “The Professor” (Freud) about what was going on. In short, the virtual reality – now remove the quotes – made present in the case is that the horse is not only the horse but is a virtual stand-in for the father and aspects of the latter’s powerful masculinity.
So add one virtual reality of an imagined symbolic relatedness onto another virtual reality of a simulated visual reality (VR) scenario, the latter contained in a headset and a smart phone. Long before VR technology, therapists of all kinds, including behaviorists, used VR by activating the client’s imagination by asking him or her to imagine the getting on the feared airplane. One may try to escape virtual reality by not going online, but the virtuality follows as long as human beings continue to be symbolizing, imagining creatures.
This blog post is an excerpt from: Lou Agosta’s article “Empathy in Cyberspace: The Genie is Out of the Bottle” in Theory and Practice of Online Therapy: Internet-delivered Interventions for Individuals, Groups, Families, and Organizations edited by Haim Weinberg and Arnon Rolnick. London and New York: Routledge: To order the complete book, click here: Theory and Practice of Online Therapy [https://tinyurl.com/yyyp84zc]
(c) Lou Agosta, PhD and the Chicago Empathy Project
The Theory and Practice of Online Therapy: Internet-delivered Interventions for Individuals, Groups, Families, and Organizations, eds., Haim Weinberg and Arnon Rolnick, published by Routledge:
Table of Contents
Introduction to the book Haim Weinberg and Arnon Rolnick
Section 1 General considerations for online therapy edited by Haim Weinberg and Arnon Rolnick
Chapter 1 Intoduction to the general consideration section: principles of internet-based treatment Arnon Rolnick
Chapter 2 Interview with Lewis Aron and Galit Atlas
Chapter 3 Empathy in Cyberspace: the genie is out of the bottle Lou Agosta
Chapter 4 Sensorimotor psychotherapy from a distance: engaging the body, creating presence, and building relationship in videoconferencing Pat Ogden and Bonnie Goldstein
Chapter 5 The clinic offers no advantage over the screen, for relationship is everything: video psychotherapy and its dynamic Gily Agar
Chapter 6 Cybersupervision in psychotherapy Michael Pennington, Rikki Patton and Heather Katafiasz
Chapter 7 Practical considerations for online individual therapy Haim Weinberg and Arnon Rolnick
Secion 2 Online couple and family therapy edited by Shoshana Hellman and Arnon Rolnick
Chapter 8 Introduction to the online couple and family therapy section Shoshana Hellman and Arnon Rolnick
Chapter 9 Interview with Julie and John Gottman
Chapter 10 Internet-delivered therapy in couple and family work Katherine M. Hertlein and Ryan M. Earl
Chapter 11 Digital dialectics: navigating technology’s paradoxes in online treatment Leora Trub and Danielle Magaldi
Chapter 12 Practical considerations for online couple and family therapy Arnon Rolnick and Shoshana Hellman
Section 3 Online group therapy edited by Haim Weinberg
Chapter 13 Introduction to the online group therapy section Haim Weinberg
Chapter 14 Interview with Molyn Leszcz
Chapter 15 Oline group therapy: in search of a new theory? Haim Weinberg
Chapter 16 Transformations through the technological mirror Raúl Vaimberg and Lara Vaimberg
Chapter 17 Practical considerations for online group therapy Haim Weinberg
Section 4 Online organizational consultancy edited by Rakefet Keret-Karavani and Arnon Rolnick
Chapter 18 Introduction to the online organizational consultancy section Rakefet Keret-Karavani and Arnon Rolnick
Chapter 19 Interview with Ichak Kalderon Adizes
Chapter 20 All together, now: videoconferencing in organizational work Ivan Jensen and Donna Dennis
Chapter 21 A relexive account: group consultation via video conference Nuala Dent
Chapter 22 Practical considerations for online organizational consultancy Rakefet Keret-Karavani and Arnon Rolnick
Epilogue Arnon Rolnick and Haim Weinberg
This blog and blog post (c) Lou Agosta, PhD and the Chicago Empathy Project
Jamieson Webster writes like a combination of an Exocet missile and a feline feather tease. Webster has previously published on The Life and Death of Psychoanalysis (2012) and with Simon Critchley on Hamlet (Stay Illusion! The Hamlet Doctrine (2014)). Her latest contribution is Conversion Disorder: Listening to the Body in Psychoanalysis (Columbia University Press, 2019, 303 pp. ($33)).
Between Jacques Lacan, Giorgio Agamben, and Michel Foucault, Conversion Disorder is
a challenging read, though the effort will be rewarding for many. The audience for this book is largely academics engaged by the some version of psychoanalysis, drawing mainly on Lacan and Freud. Much is to be admired in this courageous work, but since this is not a softball review, I have some criticisms, too. Webster has given us a brilliant work, though a deeply flawed one.
After such a significant effort, I am going to have some fun with this one.
Webster exemplifies a kind of postmodern writing that assumes one has read everything and therefore context is not required. Ideas streak through the text like ciphers from the Oracle of Delphi, whereas the statements are just ideas of university graduate level complexity being quoted out of context. Summaries are sometimes provided at the end of arguments, resulting in a benefit to those who decide to read the text backwards. Nothing wrong with that as such, but the approach does seem to be limited to intellectual haunts in Southern Manhattan, The New School For Social Research, the academic suburbs of London, and comparative literature seminars at the more prestigious universities.
With any book on psychoanalysis, the recommendation is to read the Appendix and endnotes first. They are the equivalent of a literary slip of the tongue, a symptomatic action, a parapraxis, revealing the subtext. Reading the book backwards works well in this case.
Webster recognizes that her relationship with her own body is troubled – the work is acknowledged as an attempt at self-help. It takes courage to make oneself vulnerable by this manner of self-disclosure: Diets, Pilates, yoga, purges, mega-purges, and more purges. Within the realm of the fundamental unity of mind and body, psyche and soma, this self-treatment triggers a full-blown appendicitis in the author. Literally. What happened? A powerful demonstration of the inseparability of, yet tension between, psyche and soma?
The final three words of the book (p. 272) assert that the conversion disorder in question is “my conversion disorder” – i.e., Webster’s. The microcosm is the macrocosm. “Conversion” is writ large. Very large. Many other conversions and conversion disorders are engaged along the way.
Webster asserts that her work has aspects of a memoire, and the reader does eventually get to meet the parents (who had their own struggles to survive) in the last ten pages of the book. However, I was disappointed in that I got no sense of the “good parts” of the memoire – what the author had to survive or how she ended up becoming a psychoanalyst, which is surely a courageous project, and not an undertaking for the faint of heart.
Webster repeatedly calls out psychoanalysis as an “impossible” profession, notwithstanding the paradox that she credibly claims to practice it. Here Webster walks the semi-sacred ground mapped out by Janet Malcolm in a book of the same name (Psychoanalysis: The Impossible Profession, Alfred Knopf, 1977/1981). Webster might usefully have invoked Janet Malcolm and whether her (Webster’s) contribution is a debunking in the same or a different sense than Malcolm’s. How about a footnote? This is the sort of thing I would have expected the editor (Wendy Lochner) to catch, but editing is not what it used to be.
Another editorial pet peeve: The words “abjection” and “abject” are used as if they are clear to the reader. Context? Julia Kristeva is not in the references, though she is the one who gave “abjection” currency and a certain popularity. It is not otherwise defined. A criteria: If you do not already know what it means or are prepared to live with this uncertainty of not knowing, then this text is not for you. Once again I would have hoped that the editor would have intervened with guidance: “Please define one’s terms.” Once again, editing is not what is used to be.
Meanwhile, on how psychosomatic physical symptoms – migraines, lower back pain, headaches, which are notoriously difficult to diagnose – get “hijacked” by the emotions and become the source of substantial psychic suffering, there are more recent treatments, including Webster’s, but there is quite simply no better one than Arthur Kleinman’s The Illness Narratives (1988). An engagement with Kleinman will decisively change one’s listening – as, of course, will reading Lacan or being hit in the head with a rolled up newspaper – but Kleinman will also deepen one’s empathy, humanity, and toleration of uncertainty, which the former will not do.
Webster engages with biopolitics (key term: biopolitics) and the institutional dynamics around psychoanalysis. On the professional issues confronting psychoanalysis – and there are many self-inflicted wounds here – Kate Schechter’s The Illusion of a Future (2010) deserves honorable mention and more – and Schechter provides a far superior treatment of psychoanalytic gossip than Webster – very juicy indeed and funny in a satirical sort of way – albeit in the context of the Chicago Institute for Psychoanalysis. While Webster talks a lot about “courage” and she demonstrates much, noticeably absent is any trace of speaking truth to institutional power that might ruffle any feathers in the local establishment. Courage indeed.
My complaint? There is something fake about “I don’t want to be a psychoanalyst” – if one does not, okay, then stop and do something else – practice CBT, DBT, ACT, primal scream therapy (joke!) or take up water colors. At no point does the two ton elephant in the living room get noted – the dirty little secret: most of the psychoanalytic “patients” are behavioral health professionals (graduate students in psychology or psychiatric residents) aspiring to be enrolled in the pyramid. Nothing wrong with that. These good folks need help too. And it is a shame that psychoanalysis has fallen on such hard times as it can get results that no other intervention seems able to produce. But what does one have to do to get a piece of the action – a piece of the objet (petit) a? If one has doubts about the viability of psychoanalysis, this text will do little to dispel them.
Therefore, get ready for – biopolitics!? Webster follows Giorgio Agamben, who, in turn, follows Foucault off the biopolitical cliff into the abyss of – what? The objet (petit) a– we are now speaking French – which, according to Lacan, is not to be translated, the unattainable object, the part object (penis, breast, foot) – perhaps the Kantian thing in itself. Another cipher = x, that which is being converted in somatoform disorder?
If one wants to bring biopolitics into the vicinity of hysteria, then ditch the Agamben. Take a look at Arthur Miller’s The Crucible, which is a re-telling of the Salem Witch Trials using a lens from the 1950 McCarthy Hearings on House Un-American Activities. Politics and hysteria are front and center. Once the authorities agree to admit spectral evidence – not unlike fake news or alternative facts – including the hysterical utterances of over wrought pubertal girls, then the audience of The Crucible knows things are not going to go well for the adults. If one is going to make a deal with the devil, be sure to read the fine print. The pact with the devil results in a commotion – a literal witch-hunt – and a slaughter of innocents. The emotional anguish and suffering is wide spread and the audience is vicariously traumatized.
Webster has considerable “skin in the game.” Webster is suffering, too, though admittedly not to the degree of John Proctor (protagonist of The Crucible). Webster is engaging with conversion because she has a contribution to make in disentangling the complexities of the phenomena. What really interests her is how the [counter]transference of hysterical symptoms occurs from patient to analyst (e.g., p. 74). Webster is Exhibit A – and proud of it.
Webster tells the reader as much: “Who would want to make themselves the vessel for so many others in this way? To have them repeat their pain and unlived life in your flesh?” [P. 54.] This is her “day job.” Once again, there is nothing wrong but there is something missing – empathy.
The lack of well-regulated empathy leads to compassion fatigue, burn out, and empathic distress. Apparently it also leads to an appendicitis. Her own appendicitis (see the Appendix) is not a hysterical pregnancy, but then again her patient is confronted with one of those – and see Freud’s comments on Negation. (When the patient says “now that is not my mother,” then strike though the not: not. Who do you think it is?)
The word “empathy” plays no explicit role in the text, though I suggest empathy’s breakdown is the underlying mechanism is many examples of conversion. I am not saying Webster has too much empathy. I am not saying Webster lacks empathy. I am saying: expanding empathy is hard work. Webster is no natural empath, as near as I can see from here, but a committed professional – and a celebrity academic. She is on the path of bearing witness and self-disclosure, but something is off the rails. Webster suffers from a breakdown of empathy specifically in the regulation of empathic receptivity.
Webster “picks up” the patient’s somatization – whether it is mirror neurons, neuropeptides, the adrenal pituitary axis or simple muscle mimicry (which is not so simple). The emotional receptivity breaks down into an individual form of emotional contagion so the therapist suffers too. The educated guess is that, being all-too-human, some unprocessed sex and aggression lurks near by, but mostly unprocessed narcissism, a term conspicuous by its absence.
People seeking dynamic psychotherapy (and its extreme form in psychoanalysis) are suffering. Sometimes after much work and effort and self-overcoming these same people become therapists. All well and good. The process is daunting and not to be made light of. However, Webster is so overwhelmingly taken with the significance of the process that no room remains available to enjoy a lighter moment. In addition to expanded capacity to love and work, Heinz Kohut (dismissed by Webster in the closing pages) pointed out how a successful psychoanalysis of the self may expect to transform frozen narcissism into expanded humor, empathy, and even wisdom. Here the narcissism is ultimately untransformed – and unconverted?
Webster quotes the Diagnostic and Statistical Manual of Mental Disorders, Version 5 (2013), the deeply flawed but consensus-forming, boundary defining “bible” of the behavioral health world. Webster “gets it” that something essential is missing. “Hysteria” in the narrow sense of a signification (representation/symbolization) of an underlying sexual or aggressive content was removed from the manual several editions ago. Yet hysteria in the narrow sense lives on in Webster’s practice, in her transference, and (here is the courageous part) especially in her counter-transference.
In the DSM itself, mental and emotional disorders are described at the level of behavior and constellations of symptoms. It is a check list manifesto (with apologies to Atul Gawande) that enables the therapist (or prescribing psychiatrist) to map symptoms to treatments without having to unmask, go “under the hood,” or seek for hidden causes = x. Ideal for those prescribing psychotropic medications.
While Webster is a strong advocate for a close reading of Freud, this is precisely the area in which she is significantly at risk. The hazard of Jacque Lacan’s guidance of “getting back to Freud” is that what Lacan really means is “replacing Freud with Lacan.”
In a separate interview, the Webster notes: “When I read him [Lacan], it changes the way I listen.” Of course it does. So does being beaten about the head with a rolled up newspaper (once the ears stop ringing).
My concern? I believe that it is possible for one to read too much Lacan or Foucault – like sniffing too much glue – it does make one high, but after a certain point the consequences are irreversible. [See Webster’s interview with Cassandra Seltman (01/05/2019 https://blog.lareviewofbooks.org/interviews/cost-alone-cassandra-seltman-interviews-jamieson-webster/ )].
For Webster, “conversion” is not restricted to the somatization of psychic or emotional conflict into physical systems that present in a human body. “Conversation” also refers to religious transformation as might have interested William James or Giorgio Agamben or any radical discontinuity in experience that profoundly shifts the experience of the subject in a lasting and sustainable way. So it’s all fair game and whatever comes up, comes up. Quite a lot comes up.
“Conversion” is writ large, as noted, but I suspect most readers will require more guidance than is provided by Webster. For example, a person is under extreme stress. The person develops irritable bowel syndrome, lower back pain, or migraine headaches. That is direct somatization – conversion of the stress into a physical symptom (pain) – depending on whether one has a weak head, intestine, or lower back – depending on whether one has a disposition or microscopic, subclinical injury that is exacerbated by the stress.
Next comes extreme stress resulting in hypochondriasis – now called “illness anxiety” – where the person is not in pain but is literally worried sick, for example, believing the sebaceous cyst in his neck is incurable cancer or the headache means an inoperable brain tumor.
The third form (which is the one Freud engaged with most insightfully) is exemplified as the conversion disorder takes on an unmistakable symbolic expression. The patient’s
hand is neurasthenic – loses feeling and the patient is unable to control it. The paralysis ends at the wrist, which confirms that the paralysis does not map to standard neural anatomy. The patient’s leg is paralyzed, but in such a way that his paralysis does not map to standard neural anatomy. The patient is asked to free associate and her reflections go in the direction of her shame and conflict over masturbation – with the hand in question.
In a different example, Freud’s patient Frau Emma von N is accused by her late husband’s relatives of poisoning him (an accusation that is fake and self-serving). Emma develops a persisting burning on her face – on her cheek – as if she had been slapped!? Insulted? Trigeminal neuropathy? Freud after all was a neurologist. (Note this is Freud’s example, not Webster’s.) She talks about it with Freud, and it gets better.
For Freud when libido (desire) is directly transformed into bodily symptoms, the result is an “actual neurosis” (better translated as a “contemporary neurosis,” but, in any case, a technical term) – the body directly translates the psychic suffering as physical symptoms – paralysis, cramps, in extreme cases symptoms like epilepsy – except there is no anatomic lesion.
In some cases, these symptoms are painful; in other cases they are just disruptive of daily life – as when the patient loses consciousness. However, for Freud, when libido (desire) is unable to be directly expressed in bodily symptoms due to repression, then the desire (libido) gets expressed in bodily symptoms that enact sexual representations. Desire finds a way to become articulate, symbolizing forth what it has to express by means of bodily signifiers (i.e., symptoms).
For instance, the patient is conflicted over marrying her brother-in-law (once again Freud’s example, not Webster’s), the husband of her late sister (who has just died). The patient is free to remarry and (a crucial condition) such a thought is abhorrent to the patient. It has no where else to go to be expressed than to be translated into a bodily symbol.
Although I believe Webster gives examples of this third kind, to the best of my knowledge (and I have read every word), no where does she make the point that the symbolism expresses sexual or aggressive or a conflict-inspiring violations of conventional community standards – which is precisely what has fallen out of the latest editions of the DSM.
By the way, Ludwig Wittgenstein, who was a tortured soul for reasons completely unrelated to conversion disorder, wrote: “The human body is the best picture of the human soul” (Philosophical Investigations, 1950, tr E. Anscombe, p. 178e).
Perhaps it is so obvious to Webster that it does not require mentioning; yet unless one is steeped in these matters, this loss in the DSM is of the essence. In short, if one is looking for a book on conversion disorders that does for them what the late Oliver Sacks did for migraines, Tourette’s syndrome, music, or diverse anomalous neurological disorders (a high bar indeed!) that work has yet to be written.
American Psychiatric Association. 2013. Diagnostic and Statistical Manual of Mental Disorders. DSM-5, Fifth Edition. Arlington, VA: American Psychiatric Association.
© Lou Agosta, PhD and the Chicago Empathy Project