Robert M. Young Online Writings
BETWEEN NOSOLOGY AND NARRATIVEvWHERE SHOULD WE BE?
When for some reason I acknowledge that I am getting old a part of me wants to look behind uncomprehendingly and see who I am taking about. It can’t be me, since I am twenty-seven inside, frequently a lot younger than that. It is undeniable, however, that I was twenty when I was first led to think about psychiatric nosology. I was working as a psychiatric aide in the admissions ward of Arizona State Hospital. We were taught how to recognise the four types of schizophrenia (paranoid, hebephrenic, catatonic, simple), manic-depressive psychosis, psychotic depression, true paranoia, psychopathic personality disorder. In those days they also had priapism and nymphomania, but, as the daily news proves, times have changed, and one can now rise to high office with those symptoms. I sat in on diagnostic interviews and got quite good at classifying mental diseases. I even got a certificate of competence. I next worked as a research assistant to a psychoanalytic psychotherapist, John Dollard, who was attempting to classify and quantify the utterances of patients. I sat for many, many analytic hours behind a two-way mirror and recorded the sessions and checked the transcripts. When I got to medical school I memorised the nomenclature of psychoanalytic structural and topographic theories and learned definitions of the ego’s thirteen mechanisms of defence as if they were extensions of my studies in anatomy, pathology and immunology. So, you see, I had an apprenticeship in classification.
I did not think again about these matters until I was asked to give some lectures on psychopathology about a decade ago. My reaction was panic. I was sure I knew nothing about the subject and rushed out to buy the American Psychiatric Association’s Diagnostic and Statistical Manual, DSM-IIIR and an up-to-date psychiatric textbook. It struck me as very odd that I, a qualified clinician and the incumbent of a chair in psychoanalytic studies, felt so ignorant about what seemed appropriately central to what I do, and I gave as my first lecture some reflections on the concept of psychopathology. I have since written that out and put it on the web, so I won’t repeat it here. I will, however touch on a few pertinent points relevant to nosology. First, psychopathology is a discipline which depends for its legitimacy on some commonly assumed but highly dubious analogies to somatic pathology in medicine — to the medical model itself, to a sharp dichotomy between the normal and the pathological, and to the disease/syndrome concept. There are interesting philosophical reasons why we think of mind in analogies drawn from the physical, chemical and biological sciences, for example, forces, energies, structures, functions. Cartesian dualism left mind with no language of its own. Descartes defined mind negatively as that which does not pertain to body, so psychology is always playing host to analogical concepts.
I turn now to psychopathology per se. Its literal etymology is knowledge (logos) of the suffering (pathein) of the psyche. As David Levin puts it, it is all the ways of hiding, manifesting, communicating, sharing and, in brief, living out the mind's experience of worldly suffering (p. 2). The term came into English in 1847 as a transliteration of a German text (which I read in the early 60s) by Baron Ernest von Feuchsterleben. Such analogies were rife in the mid-nineteenth century and found their way into a number of books on ’mental pathology’, ’mental physiology’, etc. The task of psychopathology was seem as to provide a science of mental disease, while psychiatry was an applied discipline.
This brings us to the topic for today, a feature to put alongside the normal/pathological dichotomy, the analogy to the somatic and disease/syndrome model: classification - nosology - the search for a natural classification, the study of types, pigeon holes, lists, differential diagnoses. That's what DSM is, but it is an evolving one. Its introductory passages refer us to a first edition in 1952 and a 2nd edition which appeared in 1968 and was based on the 8th edition of the International Classification of Disease. The third edition appeared in 1980 and was revised in 1987.
There is an important story to be told about the historicity of DSM, and I will get to it in a moment. A coup occurred between DSM-II and DSM-III which I did not know about when I first pondered the book and the problems raised by the concept of psychopathology. I made my critique on the basis of my work as an historian and philosopher of the biomedical and human sciences, ignorant of the fact that an ideological change was responsible for a fundamental revolution in the approach taken by the editors of this compendium.
But first some remarks on classification. When we consider the philosophy of classification it is clear that some sorts of classifications come nearer to being natural kinds than others. The list of fundamental particles in physics becomes more and more esoteric, but we believe in it, as we do the Periodic Table of Elements in chemistry. Biological taxonomy is a less certain and open-ended discipline, but we do take its foundations for granted in many ways, even though taxonomists in biology continue to have extensive conceptual and philosophical debates about them. However, it is much more dubious to argue that a medical diagnosis, a medical syndrome, is a natural kind. It is something we can often, though by no means always, trace to natural causes and show the natural effects which cause the experienced symptoms. But it is only a ’kind’ in the sense that we decide to be interested in it, because it discomfits us. Angina, emphysema, arthritis and so on are just our terms for the consequences of certain natural processes. We focus on them because they make us suffer, something we dignify with the concepts of symptom and of disease. Indeed, there is a growing literature on the historicity of somatic disease categories — how they come and go in particular historical and cultural circumstances.
If that is true of somatic diseases, what are we to say of psychiatric and psychotherapeutic disorders? First, we are taken right back to the fundamental point I mentioned earlier — that discussion of the mind or inner world occurs by the use of analogies, and the main one here is the analogy between somatic and psychic pathology. (Berrios, 1991, 1996). ’Psychopathology’ is a simile, so psychopathologies are slippery and lie well inside the controverted domain of the historicity of classifications.
The history of DSM, as I hinted a moment ago, is most interesting. It is more like the history of encyclopaedias than the history of medical diagnoses. It might be thought that encyclopaedias chronicle the linear progress of knowledge, that they are cumulative. But that would only be a part of the story. Not only does the content of knowledge accumulate, but the frameworks, the terms of reference, the assumptions or paradigms of knowledge change. For example, I am a collector of successive editions of The Encyclopedia Britannica. As a Darwin scholar, I am particularly interested in the changes which occurred between the eighth and the ninth editions. The eighth finished being published just before Darwin’s theory of evolution by natural selection was made public, while the ninth was published in the 1870s, after Darwinian evolution had become the basis of many disciplines. The whole way of thinking changed. The long article on the Biblical ’Deluge’ in the eighth edition disappeared, while new and extensive ones on Evolution in biology and in psychology appeared de novo.
Something similar is true of DSM. In particular, the framers of DSM-I and DSM-II were sympathetic to psychodynamic formulations of mental disorders. However, the man who was asked to take charge of the editorial team of DSM-III said he would do so only on the condition that he would have a free hand, and what he would do with that hand was to purge DSM of psychodynamic and psychoanalytic concepts and analyses of disorders (A. Young, 1995, ch. 3, esp. p. 99). All descriptions of diseases were to be about behaviour, not about the inner worlds of patients. It was a palace revolution, a coup. As I’ve said, I did not know this, and I had not read DSM-I or DSM-II, but when I read DSM-III, I found myself, quite spontaneously, inclined to mount a critique of its terms of reference. It was only after I had written two chapters of a book on this matter that I happened to read about this revolution and the reconceptualisation of nosology in psychiatry which ensued. Classifications are made by real people who are not, as I have been arguing, in touch with that will o’ the wisp ’pure objectivity’. They are individuals inhabiting real subcultures, with strongly-held belief systems, and they seek to make those the reigning ideas.
Early in 1973, Walter Barton, Medical Director of the American Psychiatric Association, initiated a task force ’to revise DSM-II and prepare DSM-III within the next two years’ (quoted in Shorter, 1997, p. 301 sqq., which I am paraphrasing here). Melvin Sabshin, a Young Turk, then succeeded Barton as medical director. Sabshin realized that if the group who had designed DSM-II were to take on the revision, DSM-III would become just ’a minor variant’ of its predecessor. What was needed (as Monty Python would say) was ’something completely different’. In April 1974, Sabshin summoned Robert Spitzer and Theodore Millon, another Young Turk who was a PhD psychologist at the Neuropsychiatric Institute of the University of Illinois Medical Center in Chicago, for an all-day conference. Out of this conference came the leadership team that would drive forward DSM-III, which was published in 1980.
Spitzer headed the task force. He is also listed as Chair of the Work Group to revise DSM-III and as ’Special Adviser’ in DSM-IV. Also serving on the DSM-III task force were Clayton and Woodruff from the Guze group (a third of the task force had trained at Washington University); Donald Goodwin at the University of Kansas, who had studied with Guze, was on it, as was Z. J. (Bish) Lipowski, a specialist in delirium, an organic psychiatric condition. There was also Donald Klein, a psychopharmacologist and psychiatrist who was once in analysis but became sceptical about it, who in 1978 became professor of psychiatry at Columbia, as well as thirteen other members. Just as previous DSM task forces had been weighted in favor of psychoanalysis, this one was weighted against it and toward biological psychiatry, though the members did not use that then inflammatory term. As Spitzer later said, ’With its intellectual roots in St. Louis instead of Vienna, and with its intellectual inspiration derived from Kraepelin, not Freud, the task force was viewed from the outset as unsympathetic to the interests of those whose theory and practice derived from the psychoanalytic tradition’ (quoted in Shorter, 1997, pp. 301-2). Of course, if you are a student coming to these matters for the first time, you can easily be led to believe that the terms of reference of DSM-III or the newer DSM-IV are simply common sense reality and the only natural and appropriate way of thinking about psychiatry. QED.
I tell this story, complete with some of the relevant names, to make it clear to you that how we think about human suffering, how we conceptualise and classify it, is deeply ideological in the sense that all facts are theory-laden, all theories are value-laden and all values are instanced inside a value system, an ideology or world view. The person who became the tsar of DSM-III was a traditional, objectivist biological psychiatrist, deeply committed to purging psychiatry of intrapsychic concepts. When the opportunity to make his point of view a new orthodoxy arose, he did so quite ruthlessly and systematically, believing, I am sure, that he was promoting the advancing edge of objectivity. Of course, larger historical forces played a part in being invited to be in the role of co-ordinator of this important compendium in the Nixon/Reagan era. Indeed, there was a coalescence between the growth of biological approaches to human nature, on the one hand, and biological psychiatry, on the other, which has been chronicled by Donna Haraway as part of her magisterial book, Primate Visions, which analyses the history of ways of thinking in several of the human sciences and their links with primatology (Haraway, 1989; Young, 1992). The general point I am making is that the leading ideas of an epoch are the ideas of its ruling elites, and ideology becomes a material force in theory and practice by virtue of which individuals get the posts and who gets to write the textbooks and manuals and edit the journals which define the norms in a give field. Haraway traces this in detail.
By the way, the ideological determination of ways of thinking in the human sciences does not always militate toward conservatism. DSM-III was, as I have shown, dominated by a biological, objectivist approach at the expense of psychodynamic concepts concerned with the inner world. But there was also a very significant omission. Homosexuality, which featured as a mental disease in DSM-II, simply did not feature in DSM-III (Shorter, 1997, pp. 303-5). It did not completely vanish, since, if your homosexuality was not ’ego-syntonic’, you were still sick. Does this mean that new cases ceased to occur as happened with poliomyelitis? Not at all; it was de-pathologised as a result of the rise of the gay and lesbian movement for the rights of the homosexual. This is a striking example of how social and political forces change our concepts of who is ill and who is just different.
Turning once again to the concepts of normal and pathological which are the parents of the concept of psychopathology, I enthusiastically refer you to Georges Canguilhem’s classic study The Normal and the Pathological, in which he argues that the ideas of the normal and the pathological in medicine, ‘far from being scientifically or statistically determined, are rather concepts of value deeply imbued with political, economic and technological imperatives’ (q from cover blurb). German Berrios, who has written an exhaustive history of mental symptoms, subtitled ‘Descriptive Psychopathology since the Nineteenth Century’, tells us that the persistence of 'psychopathology' in British psychiatry can be attributed to the empiricist false consciousness seeking theory-neutral descriptions. The effort to describe and classify frees one from understanding process, dynamics, aetiology. Put more succinctly, pigeon-holing reifies. Thereby hangs the rest to my tale.
You may say that I have spent a long time on nosology and that this is odd, since my story began with my own bewilderment about the fact that in spite of my own trajectory and position as someone employed to think theoretically, I did not myself think in those terms. My defence of speaking at length about nosology and psychopathology, in addition any intrinsic interest my story may have, is, quite precisely, to draw your attention to the fact that most analysts and psychoanalytic therapists do not spend their time, except, I suppose, when filling out forms for funding agencies, thinking in those terms. The line between DSM-III and its successors, on the one hand, and what we do, on the other, is rightly drawn. They have decided not to think about the inner world, and we have decided to continue to do so. But in what terms do we think? My reading of the professional journals is that we decreasingly employ nosological terms, that our case reports use less of the terms drawn from analogies to physics, chemistry and biology — the terms of David Rapaport and Merton Gill’s attempt in 1959 and 1960 to systematise psychoanalysis. More and more, it seems to me, we tell stories. However, we do not just do that. Even the best psychoanalytic story-tellers, those least burdened with technical and metapsychological terms, e.g., Robert Lindner in the five gripping case studies in The Fifty-Minute Hour or Harold Searles’ dramatic tussles or Christopher Bollas’ well-told tales — even those enviable stylists employ psychoanalytic concepts in the telling of their case studies. I want to ask in the time remaining what role those concepts play in the space between a nosology of which we are rightly suspicious and forms of narrative which we would not want to call psychoanalytic.
I want to draw your attention to writings on the borderline between these two worlds. One volume which has intrigued me a lot is Silver and Rosenbleleuth’s Handbook of Borderline Disorders. It is a large collection of essays in which many hands reflect on the validity of the concept of Borderline Disorder, something for which, you’ll recall, DSM offers eight criteria:
(1) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of overidealization and devaluation
(2) impulsiveness in at least two areas that are potentially self-damaging, e. g., spending, sex, substance abuse, shoplifting, reckless driving, binge eating (Do not include suicidal or self-mutilating behavior covered in [5].)
(3) affective instability: marked shifts from baseline mood to depression, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days
(4) inappropriate, intense anger or lack of control of anger, e. g., frequent displays of temper, constant anger, recurrent physical fights
(5) recurrent suicidal threats, gestures, or behavior, or self-mutilating behavior
(6) marked and persistent identity disturbance manifested by uncertainty about at least two of the following: self-image, sexual orientation, long-term goals or career choice, type of friends desired, preferred values
(7) chronic feelings of emptiness or boredom
(8) frantic efforts to avoid real or imagined abandonment (Do not include suicidal or self-mutilating behavior covered in [5}.)’ (APA, 1987, p. 347).
Borderline Disorder comes pretty well out of the scrutiny of the contributors to the Silver and Rosenbleuth volume. In a fascinating chapter and in a separate article co-authored with L. Paul Chesterman and Alice M. Parshall, Alex Tarnopolsky, by whom it was my good fortune to be supervised, offers to explain these same phenomena in psychoanalytic terms under the banner of the Kleinian concept of Pathological Organization, a syndrome conceptualised in recent years by Henri Rey, Donald Meltzer, Herbert Rosenfeld,. Betty Joseph and others and most particularly by John Steiner, whose articles and subsequent book synthesize this idea, one which has been taken further by Michael Sinason. My purpose here is not to characterise this concept in detail but to draw your attention to the highly dramatic descriptions of the inner world which is involved. Rosenfeld, in particular, refers to a ‘gang in the mind’. He writes,
The destructive narcissism of these patients appears often highly organised, as if one were dealing with a powerful gang dominated by a leader, who controls all the members of the gang to see that they support one another in making the criminal destructive work more effective and powerful. However, the narcissistic organization not only increases the strength of the destructive narcissism, but it has a defensive purpose to keep itself in power and so maintain the status quo. The main aim seems to prevent the weakening of the organization and to control the members of the gang so that they will not desert the destructive organization and join the positive parts of the self or betray the secrets of the gang to the police, the protecting superego, standing for the helpful analyst, who might be able to save the patient. Frequently when a patient of this kind makes progress in the analysis and wants to change he dreams of being attacked by members of the Mafia or adolescent delinquents and a negative therapeutic reaction sets in. This narcissistic organization is in my experience not primarily directed against guilt and anxiety, but seems to have the purpose of maintaining the idealization and superior power of the destructive narcissism. To change, to receive help, implies weakness and is experienced as wrong or as failure by the destructive narcissistic organization which provides the patient with his sense of superiority. In cases of this kind there is a most determined chronic resistance to analysis and only the very detailed exposure of the system enables analysis to make some progress (Rosenfeld, 1971, reprinted in Spillius, 1988, vol. 1, p. 249).
That is one of my favourite passages in all of the analytic literature. I am attracted by its vivid evocation of the way things are, the atmosphere in the unconscious of the patient. Michael Sinason has taken this way of thinking further and has argued that in the mind of everyone there are two personae on the model of Dr Jekyl and Mr Hyde. In a gripping essay, ‘Who Is the Mad Voice Within?’ he advocates this model of the unconscious and its therapeutic consequences. I am not an acolyte of Sinason’s way of thinking, something he dislikes being called a theory or model, so sure is he of its being the literal truth. However, I am struck in his writings as I am in the writings of some others, by the way that technical psychoanalytic terms are there, but their place is background, not foreground. Tarnopolsky alludes to this feature when he says, ’An added problem for the North American reader is that the most classical psychoanalytical paradigms and metaphors, the structural model and the theory of instincts, have been relegated to an unobtrusive position by the British writers’ (Tarnopolsky, 1992, p. 178). I made this point in another way in a paper on ‘New Ideas about the Oedipus Complex’, but I did not then generalise it. I said,
I think it's a matter of background and foreground. This may appear at first glance a small matter, but I think it is of fundamental significance. At first I thought that developmental chronology and stages didn't matter at all for Klein. I thought the structural hypothesis of id, ego and superego didn't matter to her, either, but I was wrong. These concepts are there — all of them. So are oral, anal, phallic, genital, as well as the Oedipus complex, but they are not in the foreground. They are background. What is in the foreground is the interplay of positions and emotions. The fundamental dichotomy is between Eros and Thanatos; this creates the fundamental split between the depressive and paranoid-schizoid positions, which, in turn, give us paired emotions such as love and hate, gratitude and envy — all directed to whole-object and part-object relations.
I went on to outline a very helpful paper which characterises Kleinian writings:
In a very interesting paper in the International Journal of Psycho-Analysis Ruth Stein took 'A New Look at the Theory of Melanie Klein' (Stein, 1990). She argues that Klein's is fundamentally a theory of affect in which the focus is 'shifted from Freud's cathectic explanations to the concepts of objects and the feelings attached to them' (p. 500). 'Positions' become more important than structures, and these are 'built around different core feelings' (p. 504). There are basically two psychological configurations, corresponding to the two basic instincts. They 'differ fundamentally according to the capacity of the individual to tolerate unpleasant or conflictual feelings’ (p. 505). Psychic life is the regulation of feelings (p. 508). She concludes that 'Klein has no theory of the mental apparatus, and feelings are not placed in any such frame' (p. 509).
Where al this is leading is a way of thinking and of writing about patients in which the technical language of psychoanalytic mechanisms are in no way eschewed, but they become background. In the foreground we find a narrative of the vicissitudes of the life and the inner life of the patient, an alliance between the language of narrative and that of object relations. Theory becomes the base clef, as it were, while an appropriately dramatic story is told in the treble clef. A good example of this is Ronald Britton’s case material in his new book, Belief and Imagination, where in one chapter he is illustrating the moves as well as moving on in vacillations between the paranoid-schizoid and depressive positions and a psychic retreat.
Behind this apparently undramatic point about background and foreground is a model of the mind which is very different from the neo-Freudian one. My understanding of the ego’s mechanisms of defence, as outlined by Anna Freud, is that we strive for an increasingly conflict-free sphere of the ego where rationality predominates. The irrational is being kept at bay by defence mechanisms acting as safety-valves. The big difference between this model and the Kleinian one is that the role of the primitive is very differently conceived. In the Kleinian model the unconscious is rather more like a cauldron, always bubbling away, threatening from time to time to boil over or burst its container. Primitive, psychotic anxieties are at work all the time in the process of unconscious phantasy. Indeed, without them, according to Klein and Riviere and Isaacs, we have no mind. We are engaged in a perpetual, ongoing process of compromise formation whereby we move between one position in which splitting and projective identification, punitive guilt and part-object relations predominate, to another in which there are whole object relations, concern for the object, moderation depressive (i.e., non-punitive) guilt and reparation. There is no escape from this vacillation, only the hope that we will not be taken over by malignant or virulent splitting and projective identification. The inner process is always dramatic, and we are only ever relatively at peace with ourselves and our internal objects. The primitive is never transcended.
I have been very struck by two passages in the Kleinian literature. The first is Meltzer’s observation that, in spite of Klein’s protests, in calling the processes going on in children psychotic, she did not mean that the children are psychotic. Donald Meltzer dryly observes that it is difficult to draw any other conclusion. He then points out that her two key mental positions, ones which come to characterize the warp and woof of unconscious processes, began life as fixation points for adult psychoses then became developmental stages and ended up in her writings and even more so in Bion’s as absolutely routine basic mental stances in all of us all of the time. The other passage which struck me forcibly was one from Joan Riviere’s essay ‘On the Genesis of Psychic Conflict in Early Infancy’. According to Kleinian psychoanalysis, there is a warrant in Freud for considering primitive processes and distortions of experience which are usually considered to be psychotic as part of everyday experience. Riviere appeals to Freud's hypothesis that the psyche is always interpreting the reality of its experiences — 'or rather, misinterpreting them — in a subjective manner that increases its pleasure and preserves it from pain' (Riviere, 1952a, p. 41). She says that Freud calls this process
hallucination; and it forms the foundation of what we mean by phantasy-life. The phantasy-life of the individual is thus the form in which the real internal and external sensations and perceptions are interpreted and represented to himself in his mind under the influence of the pleasure-pain principle'.
Riviere adds that 'this primitive and elementary function of his psyche — to misinterpret his perceptions for his own satisfaction and to do so to a degree which it is appropriate to call hallucination — still retains the upper hand in the minds of the great majority of even civilised adults (p. 41).
This general function for phantasy is repeated in Susan Isaacs' definition. ’The "mental expression" of instinct is unconscious phantasy... There is no impulse, no instinctual urge or response which is not experienced as unconscious phantasy' (Isaacs, 1952, p. 83).
The first mental processes... are to be regarded as the earliest beginnings of phantasies. In the mental development of the infant, however, phantasy soon becomes also a means of defence against anxieties, a means of inhibiting and controlling instinctual urges and an expression of reparative wishes as well... All impulses, all feelings, all modes of defence are experienced in phantasies which give them mental life and show their direction and purpose (ibid.).
If this way of thinking about the mind is, as I believe, appropriate and more true to life — it is to my life, at any rate — than some others which posit greater benignity in our inner worlds, one consequence for how I think about my patients, my lovedones and my not-so-lovedones is that accounts of human thoughts and actions become more like drama, more vivid, less appropriately conveyed in language drawn by analogy from science and more appropriately told as a tale, what my grandfather used to call, a yarn. I do not want to take us into the murky waters of the new discipline of narratology, partly because I have not gone very far into them myself and partly because I want to assert the primacy of the tale over the theory of narrative, of prose over esoteric accounts of what it means to speak prose or to get on with the story. I am staking a claim for the communicable account at the expense of the esoteric one.
Of course I have my own preferred analytic concepts and use them. Of course when a patient comes into the room I am thinking in familial terms, pondering primitive anxieties, savouring the Oedipal, that which Freud insisted in a lovely footnote in 1920 is the shibboleth which separates psychoanalysis from other theories of human nature. I do not claim innocence of concepts or of orientation. My favoured list includes projective identification, ps÷d, the transitional, whole and part-objects, reparation, reverie, containment, detoxification. It is centred on the concept of projective identification and of countertransference as the basis of all communication and of countertransference as a species of projective identification. Having made a special study of it, I am satisfied that what we do is to interpret the countertransference, what the patient evokes in our unconscious. I well recall learning this through the seat of my pants. When I was, as I often was, floundering, Alex Tarnopolsky would always ask what I was feeling and then get me to analyse that feeling. His advice, the best I have had, was that when, in the session, I could not find myself, I should do nothing. He put it this way, ‘Sometimes the only thing to do is to hold on to the arms of your chair’.
Nosology and Narrative, like noumenon & phenomenon, are theoretical extremes: we live and do our work in the space between them. To the extent that we merely classify, we miss out the life of the inner world. To the extent that we remain purely in narrative, we bring to bear nothing which is usefully analytic or psychoanalytic and therefore usefully illuminating and potentially mutative. To paraphrase Immanuel Kant, theory without content is empty, and content without theory is blind. I have found myself moving more and more away from the security of nosology and nearer to the narrative pole, but it remains true that there is no pure narrative, any more than there is a neutral observation language. Just as I said earlier, in philosophy, where all facts are theory-laden, all theories are value laden and all values have meaning only within ideologies or world views, so in psychoanalytic work, all experiences are mediated by unconscious motivations and all stories are structured in the mind of the patient and the therapist through assumptive worlds. Even the least sophisticated consumer of stories knows that different story tellers have different styles and tell them for widely varying reasons. Patients’ stories have a quality of perseveration, of stuckness. The process of therapy, to the extent that it works, brings them to have a shared though not identical perception and altered areas of light and shade, changed feelings about what emotions belong to whom (i.e., to take back their more virulent projections) and changed ability to contain, to bear experience and to relate generously and reparatively toward others. It is hoped that by the end of the process the patient’s story will have more unconstrained space, more ’freedom to relate’, as Roger Kennedy recently put it in his book on the meaning of the concept of freedom in psychoanalysis.
Before closing I want to mention one other matter which doesn’t fit neatly into the plot of my paper, so I am putting it here. I do not want it to be thought that I have no time for traditional accounts of mental disorders, much less that I think that such disorders are not real. I have lived with some. I had a psychically depressed mother and a manic-depressive wife. I only want to be sure that our accounts of them stay in touch with the dialectic of experience. Here I find the accounts of Peter Barham in Schizophrenia and Human Value and the writings of Harold Searles particularly valuable. Nor am I uninterested in orthodox matters such as the ego’s mechanisms of defence, even if I would place them within a different larger framework than a contemporary Freudian would. In fact, I was fascinated by Joseph Sandler’s extensive interviews with Anna Freud in The Analysis of Defence: The Ego and the Mechanisms of Defence Revisited, in which they reflected at length on her classic monograph. They unravel each mechanism and make it clear just how far her list is from being definitive and provide a glimpse of its relationship with a more narrative-based account. I think there is important work to be done to rethink that list. I suggest that the mechanisms are not all of the same order and should be grouped. Briefly, I think projection and introjection are at the boundaries of relating and are the sine qua non of the very having of experience. Repression, regression, sublimation and conversion are the fundamental mechanisms for conducting the relationship between the conscious and the unconscious, what we can bear to allow ourselves to think. Denial and rationalisation are somewhat less fundamental but ubiquitous, while the rest — isolation of affect, undoing, reaction formation, turning against the self and reversal — strike me as occasional and less profound. Moreover, I suspect that the members of this group are all variations around the themes of denial and splitting. I think it would be worth reconceptualisng this list and asking if it is complete. Anna Freud and Joseph Sandler were quite open to extending it to up to, say, nineteen mechanisms.
One more penultimate point. My partner, Em Farrell, is a specialist in eating disorders and the author of a monograph on the psychoanalysis of anorexia and bulimia. She was recently asked to give a talk on her work at the Maudsley Hospital in London. After she had done so there was a case presentation, at the conclusion of which a senior staff member said definitively, ‘This is a typical case of unconscious masochism’. This authoritative pigeon-holing prestructured the discussion, because of her position. What followed was a discussion of diagnostics. The rest of the people present seemed to give up on whatever they might have said. When she read an early draft of this talk, Em’s comment was that we want a way of thinking which keeps people’s stories alive and helps them to be more so, where nosological concepts can so often militate against thinking and act as a defence against the therapist letting in the psychic distress which the patient (or in this case the presenting therapist) is projecting into them in the hope of getting it contained and detoxified and returned in a bearable form which can be thought about.
Now, to conclude. I have searched for a way of characterising my position, and I am not sure I can find one you won’t find unbearably folksy. I am a Kleinian but not an orthodox one. I draw on several approaches but do not believe myself to be an eclectic. The older and more clinically experienced and theoretically well-informed I become, the more I feel that I act in a way which is not, consciously, at least, guided by theory. It’s a bit like what is sometimes said about the difference between the Old and the New Testaments. Living according to the Laws as spelled out by the Old Testament, for example, the abominations of Leviticus, in its way admirable, but there is a different way: having internalised the spirit of the law, one can then act spontaneously, because one’s spontaneity is infused with that spirit.
As I was washing up on Christmas Eve and panicking about the prospect of giving this lecture, two analogies occurred to me. The first is about my tool bag. It is fairly capacious and made of strong khaki canvas. It has no compartments. The tools lie in it higgledy-piggledy, except for certain ones which are in sets, e.g., drill bits and socket wrenches. When I have a job to do I rummage round in it until I find the right tool. Sometimes I am not sure which will do, so I take several out, say wrenches with various gaps or an adjustable one. I have accumulated these tools over several decades; indeed, a few were my father’s. You might conclude that this really does convey an image of eclecticism, but everything in the bag was put there by me because I thought it would come in handy. I also have some power tools on the shelves in my tool cupboard, so we should probably think of the whole collection in that larger space, but it’s the bag which comes to mind when I think of my clinical work.
The second analogy is about plates and cutlery. I have two or three of this and that. My partner likes to eat off one of two yellow plates. I like (you won’t be amazed to hear) a larger deep blue one or a nice Italian pottery one. Then there are the flowered ones and a special dish for pasta which started life as the water reservoir at the base of a potted plant. I spent over two decades frequently eating in university dining halls, and I have found myself collecting that sort of cutlery in markets and second-hand shops. For some reason I am also always on the lookout for grapefruit spoons (My father made me ear grapefruit every morning. I rebelled for a long time. Now one of my great daily treats is a half of pink grapefruit, with the sections carved out by a particular — and often misplaced — grapefruit knife.) I could go on in this vein, but I hope I have said enough for you to get the idea about the idiosyncrasies of my crockery and cutlery.
For years while I was washing the dishes the thought occasionally came into my mind that with this motley collection I would not feel comfortable having Janine Chasseguet-Smirgel to dinner. I hasten to add that this is an unfair thought — pure projection — since she is a charming and unassuming person, and on the one occasion when I did entertain her (to launch Creativity and Perversion, which I edited and published), she was a gracious and appreciative guest of honour. In my fantasy, however, she represents Freudian orthodoxy and system. The truth is that we did not sit down for a formal meal, so I manage to sustain my insecure self image of scruffiness and of being an outsider, unorthodox, unworthy. Lately, however, as my sense of my clinical and theoretical identity has grown, I have decided that it might, after all, be okay.
That tool kit, that crockery, that cutlery are me and mine and I’ll stand by them. They work for me, for how I live and what I do. From time to time I add a new tool or plate or knife or mug. I hope I use them in the service of moderation, but, as you see, there is some evidence that I don’t. I am working on that, though. As Bob Dylan once said, ‘Everybody’s got a knife and fork, and they’ve got to cut somethin’. I’m trying to cut alienating and desiccated theoreticism.
This is the text a talk given to the Toronto Psychoanalytic Society, 8 January 1999.
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Copyright: The Author
Address for correspondence: 26 Freegrove Road, London N7 9RQ
robert@rmy1.demon.co.uk