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Book Review: The Snake in the Clinic

28 Feb, 17 | by cquigley


Guy Dargert, The Snake in the Clinic: Psychotherapy’s Role in Medicine and Healing. London: Karnac, 2016


Reviewed by Dr Jane Slater


The best review of a book is unlikely to be written by an enthusiast, so I need to confess upfront that this book blew me away. The first time I read it, I entertained passersby with involuntary exclamations of “ Yes” and “ That’s SO true”, and even on one sublime paragraph, “ Go Guy”. Thus, my first task was to rein in my paeans of praise and attempt to be objective.

In titling the book The Snake in the Clinic, Dargert refers to the snake coiled around the staff of Aesclepius, the god of healing, a symbol used by the British Medical Association. The book reminds us that in the age of the serum rhubarb, scans for everything and a pill for every ill, we forget at our peril the crucial role of simply understanding what an illness is doing for us. The wisdom of the ancients deserves review and benefits our patients and ourselves, cutting through the fog of technology into which modern medicine risks becoming lost.

The Snake in the Clinic is an overview of the art of healing, bringing together strands of orthodox clinical medicine (p.45, illness being the opposite of health) with various psychotherapeutic philosophies, and interweaving them with ancient understanding of the purpose of illness (p.142, dancing with illness). Indeed, the whole premise of the book is to re-jig our concept of illness from something to be avoided and fought (p.40, the War on Cancer) to a gift: the illness itself can bring an opportunity to heal or make whole some broken area within us (p.46, Jung’s thoughts). Dargert even takes us to the ultimate with his question, “Can there be a healthy death?” (to which the  medic’ asked responded, “A young fit man in an RTA?”). Along with all GPs, I have been privileged to have seen many a ‘healthy death’ over the course of my career – patients wholly at peace with themselves at the end.

Dargert questions our very concept of illness and wellness, contrasting the WHO definition of health as an absence of disease with the idea of health as a state of equilibrium, a balance between so many factors in our lives that are at odds with one another: the pressure to conform and to live up to expectations versus the wild spirit wishing a different path. He gives numerous examples from patient encounters to illustrate his points, which was valuable in cementing my understanding of sometimes alien ideas.

Dargert draws on Taoist, Buddhist, tribal religions and the concept of the Daimon (so well realised by Phillip Pullman in his Northern Lights trilogy as the connection between the physical body, mind and spirit) to exemplify his holistic approach. There are also explorations of dream material as a bridge to the unconscious,  holding vital keys to those physical and psychological problems seeking solutions.

He is unafraid to quote his detractors, such as Susan Sontag’s rant against the use of psychotherapy in the treatment of cancer, though hers seemed a misplaced criticism of what psychotherapy could achieve: it seeks not to get rid of the disease or symptom, but to understand what it may offer, and through this understanding find an acceptance and an ability to fully live despite the condition. Whilst encouraging the use of all available therapies and not abjuring the more physical medical approach, Dargert rather seeks to balance and complete the process of achieving wellness by simultaneously exploring the effects of the dis-ease on the soul or psyche. If ever I were to need the aid of an oncologist, I hope to find a Guy Dargert character in the wings helping me to interpret and make sense of what it all means to me and my life. We’re around for so short a time, it behoves us all to be proactive in looking for meaning for ourselves and our patients before our little lights are snuffed  out.

To combine erudition with readability is a skill indeed, and Dargert displays both with humour and an infectious sense of questing which comes only from a therapist and pedagogue brimming with life. It is well researched, engagingly composed, and absorbing. I would love this book to be a set text for GP registrars, and indeed would commend it both to those in the business of healing and those requiring of the same.

My only criticism is that I couldn’t find it as an audio book – listening in the car between visits and clinics is one of the few “ breaks” one has these days. But it is a good bedtime read also.

Who knows what you might dream…

Book Review: Thinking in Cases

23 Jan, 17 | by cquigley


Thinking in Cases

by John Forrester. Published by Polity, 2016.

Reviewed by Dr Neil Vickers


John Forrester, who died in 2015, was the most original historian of the human sciences of his generation. His great love was the history of psychoanalysis – he was for 10 years the editor of the journal History and Psychoanalysis – and he published no fewer than 4 major books in that field, including the classic Freud’s Women (which he wrote with his wife, Lisa Appignanesi).

Thinking in Cases is the first of two books to be published posthumously, the second being the monumental Freud in Cambridge (co-authored with Laura Cameron), due out later this year. It comprises six essays written over the last two decades on what he memorably termed ‘case-based reasoning’. Forrester, along with many historians of science, believed that case-based reasoning had embedded itself in a variety of disciplines, in ways that experts were often reluctant to acknowledge. It might be thought that in the era of evidence-based medicine, medical education no longer needs the case. Yet, as Forrester argues in his classic essay, ‘If P, Then What? Thinking in Cases’ (1996), novice practitioners learn their science by absorbing a handful of standard experiments from scientific textbooks. These case studies – for that is what they are – serve not only to make the underlying principles more memorable, they also provide something like a shared professional memory.

Much of Forrester’s thinking on case-based reasoning was informed by his decades-long engagement with the work of Thomas Kuhn, with whom he studied in the early 1970s. The most brilliant essay in the book (‘On Kuhn’s Case’) treats the evolution of Kuhn’s thought as a case study in how the philosophy of science actually works at an individual level. Kuhn, it turns out, came from a family that was steeped in psychoanalysis. His grandmother had analysis in Cincinnati with Alfred Adler, sometime in the 1910s or early 1920s. His mother edited some of Karen Horney’s works. And most important of all, he twice underwent psychoanalysis himself, first (briefly) as a child, and again as an adult, between 1946 and 1948. The end of this second analysis coincided with two great changes in Kuhn’s life. He was admitted into the Society of Fellows at Harvard which enabled him to abandon his career as a theoretical physicist and to become a historian of science instead. And he embarked on a marriage that lasted 30 years. He decided to abandon physics for history when he read Aristotle’s Physics. At first he was baffled by the great man’s obtuseness. How could someone who had written so penetratingly on so many other subjects have got the laws of the physics so wrong? But one day it dawned on him that Aristotle was investing concepts like ‘motion’ with completely different meanings from the Newtonian ones he had learned as a boy, and that, once he had made allowances for this altered usage, Aristotle’s physics not only made sense but was far in advance of its time. This Gestalt shift in his own thinking was the first instance of the famous ‘paradigm shift’ which became the master idea of Kuhn’s book The Structure of Scientific Revolutions (1962). Forrester leaves us in no doubt that it was the result of analysis. In an interview published in 2000, Kuhn stated that it was while he was in analysis that he learned ‘to climb inside people’s heads’. He recognised that this ability was central to his work as a historian of science and that for this reason he owed psychoanalysis ‘a tremendous debt’, even though he didn’t much enjoy being a patient. The Aristotle epiphany occurred while he was in analysis. Forrester points out that Kuhn’s method was both individualistic and psychologistic. Kuhn called himself an internalist historian of science because of his overriding preoccupation with the problems his subjects were trying to solve. The historical contexts in which they tried to solve them were a secondary matter. But he was an internalist in the more informal sense that he worked by climbing into other people’s heads. In the same interview Kuhn recalled feeling he could ‘read texts, get inside the heads of the people who wrote them, better than anybody in the world’. These other people were encountered as auxiliary selves – extensions of himself. Forrester quotes several anecdotes Kuhn told about himself in which new selves – famous scientists all – would arise almost in the manner of out-of-body experiences.

The other highlights of the book for me were two pieces on the LA analyst, Robert J. Stoller (1924-99). The first puts forward an extended speculation concerning Stoller’s analysis of a woman on whom he conferred the pseudonym Belle. Belle is the protagonist of one of Stoller’s best books, Sexual Excitement: The Dynamics of Erotic Life (1986). The turning-point in Belle’s analysis occurred when she described a daydream she’d nurtured from childhood in which a figure called The Director instructed her to humiliate herself sexually before a group of adults (and sometimes animals). Stoller was bothered by what he took to be his patient’s seductive behaviour towards him. It was only in retrospect he realised she was pressing him into the role of the Director. (Belle’s mother was a famous Hollywood actress who took up with a number of Directors. The injunction to perform was everywhere in family life.) Forrester suggests it was from Belle that Stoller drew his controversial theory that sexual excitement ultimately depended on hostility. He suggests that the book detailing her case history, written years after her treatment ended, was an attempt to model a more benign form of watchfulness for her. Stoller consulted Belle over every draft of the book and gave her carte blanche to alter anything she didn’t agree with. It was sobering for them both to discover that they had very different views of what had been valuable in their work together. Forrester suggests that the writing of the book was the decisive part of the treatment for through it he showed her that he didn’t need to be entertained by her. ‘If he had not published his book,’ he writes, ‘her analysis would have been a failure.’

The second Stoller-related chapter (unpublished until now) is a paper on ‘Agnes’, one of the world’s first male-to-female transsexuals. Agnes’s case was first described in Harold Garfinkel’s Studies in Ethnomethodology (1967) but Garfinkel took Stoller on as a co-author as he was one of Agnes’s psychiatrists. Agnes claimed to have been born intersexed and, starting in the late 1950s, went through an arduous vetting procedure lasting many years in order to obtain surgical gender reassignment. Many years later she told Stoller that from the age of 12 she had in fact taken her mother’s hormone replacement medication which resulted in her acquiring female secondary sex characteristics. Garfinkel the sociologist thought that Agnes’s attempts to pass as female shed light on what maleness and femaleness were, as socially-credited qualities summoned up into being every moment of every day. Her deception about her history was just another instance of what she had to do to ‘pass’. Stoller on the other hand originated the concept of core gender identity on the basis of his treatment of Agnes. He met Agnes’s mother and discovered that she had regarded herself as male from the age of eight and that she had passed her own ambivalence about her gender identity on to her adored son, whose transformation into a woman she supported wholeheartedly.

Thinking in Cases is an ideal introduction to Forrester’s thought, containing some of his most important papers. He combined a scientist’s delight in devising new methods to understand recondite things with an exceptionally acute sense of the role of contingency in intellectual discovery. These strengths were central to his style of reasoning and, as these pages testify, made him one of a kind. Everyone with an interest in the medical case history and its wider ramifications should read this book.

Book review: Is Literature Healthy?

22 Nov, 16 | by cquigley




Is Literature Healthy?

by Josie Billington. Published by Oxford University Press, 2016.


Reviewed by Dr Neil Vickers


Many years ago, I blagged a ticket to an invitation-only symposium on the subject of medicine and narrative, held under the auspices of what was then the Arts and Humanities Research Board. The premise of the meeting was that humanities academics were sitting on a goldmine – something called narrative – but were too high-minded or obtuse to rate it at its true worth. There were a few big names in attendance but the star turn was a researcher from the hospital soap, Holby City. Here was someone who knew how to link medicine and narrative in a way millions approved of, on an almost weekly basis. We were also invited to read Jed Mercurio’s novel, Bodies, which was being adapted for television but hadn’t yet been broadcast. The organisers hoped that by studying ‘hard-hitting’ narratives of healthcare from a variety of disciplinary perspectives, we might stumble upon facts concerning medicine, or healthcare, that had eluded observation by other means. It was never explained why narrative would be better at picking these things up than other kinds of investigation. It was assumed that narrative was a good in its own right and that we would all find ways of making common cause through it. Needless to say, we didn’t. It was clear that narrative was as vexed a term as ‘literature’ and even though we were focusing on fictional texts some of those present – including your reviewer – felt that what would be found would depend on the quality of the sources. Rubbish in, rubbish out. The idea that narrative, merely by being narrative, would yield up untold secrets was a piece of magical thinking.

Josie Billington’s Is Literature Healthy, is, among other things, a compendium of everything I wish I’d said that day. Billington is a literary scholar who works at Liverpool University’s Centre for Research into Reading, Literature and Society (CRILS). Her book is a plea for literary reading but she starts from a premise that is seldom aired at meetings of literary scholars or medical humanists: that our culture has lost its literary edge. We no longer have an adequate metric for valuing literature because we have forgotten what makes literary experience distinctive. We think it has to do with narrative. For Billington, the problem isn’t that literature is missing from medical syllabuses or even university literature departments (though even there, it is missing). It is missing from life.

Chapter 1, ‘Healthy and Unhealthy Thoughts’, introduces the reader to the ideas of the British psychoanalyst Wilfred Ruprecht Bion (1897-1979), as set out in four fiendishly difficult works published between 1962 and 1970. Bion believed we have an inherited propensity to distance ourselves from meaning because it disturbs our mental balance. To become attuned to meaning we have to be willing to acknowledge the extent of what we do not know. We have to acknowledge our dependence on others. We also have to submit to experiences whose outcomes may be very threatening. Bion traces the development of our capacity to bear meaning to early infancy. If our anxieties have been ‘contained’ by a mother, say, we can set aside some of their physical impact and face them as mental entities. In this form they are not necessarily rational. They may appear as shards of thought disconnected from the rest of what goes on in our mind or as dream images; or they may exist as unconscious phantasies. Bion gives the name ‘alpha function’ to the process by which the psychobiological sources of anxiety are converted into forms of mental life of this way. He thought it was a lifelong process. Now most humanists, like most scientists, treat this zone of our lives with polite disdain. But Billington argues—very persuasively, in my view—that literary reading is profoundly enmeshed with alpha function. When a piece of literature moves us deeply, it is because it resonates with something in our history that carried a great weight of anxiety when we experienced it the first time around. The work of reading allows us to continue the processes by which we came to terms with it or failed to do so. If we feel more alive, it is because the most primitive stakes in our existence have been thrown into relief. An analogy from biology suggests itself. It used to be thought that DNA that didn’t code for a protein – i.e., at least 95 per cent of human DNA – was ‘junk’. We now know that so-called junk DNA provides the instruction manual for turning genes on and off.

It requires something like Bion’s alpha function to follow a character like Dorothea Brooke or Anna Karenina through their confusion. We must attune ourselves to their mental states, make these our own, before we can do anything with them. Literary reading begins when we strive to catch the primitive edge of experience which is a literary text’s true growing point. In Billington’s words, ‘the experience must not be used—only let be, in its words… a book can have thoughts that humans cannot have’ (44). In a reading designed to be provocative to medical humanists of Tolstoy’s The Death of Ivan Ilyich, Billington praises not the butler’s assistant Gerassim’s empathic witnessing of his master’s sufferings (the standard Med Hums reading), but Tolstoy’s depiction of what it is like to live completely beyond the reach of human care. I loved it.

The second chapter, ‘Telling a New Story’, does three things. It offers a broadly-brushed but incisive critique of narrative medicine. It explains why literature is not coterminous with narrative. And finally, with an eye to Billington’s own practice at CRILS, it explains why healthcare interventions that seek to use literature must go beyond narrative. Billington is fully alive to the humanistic aspirations underpinning narrative-based medicine. In particular she recognizes and approves of its concern to treat ‘the whole person’ and to vouchsafe patients a voice in any therapeutic process. But in cases of depression, for example, she thinks the whole person is absent to himself or herself. To be depressed often means not to have a story. The hero of this chapter is another psychoanalyst, Michael Balint (1896-1970), Sándor Ferenczi’s great pupil and literary executor. Balint is remembered in this country as the founder of ‘Balint groups’ which were designed to help GPs listen psychoanalytically to their patients’ complaints. Billington appears to think that the best kind of general practice will do just this. A good doctor, like a good literary reader, will know how to bear with his patient’s confusion and not substitute his own understanding for it prematurely. The limits of narrative-based medicine stem from its obsession with immediately-measurable variables and its conviction that story per se is empowering. It will often be easy for a clinician to give a narrative shape to their own or other people’s lives. It will not always go very deep. At this point, Billington appeals to what was once a commonplace of literary criticism. At the heart of poetic experience is something that lies beyond words. By virtue of its preoccupation with the ineffable parts of human experience, the parts whose importance we barely know how to articulate, the zone of Bion’s alpha function, the nineteenth-century realist novel is in fact a mode of poetry. It is only superficially a narrative form. Its power to move us is patterned after our experiences of poetry and the chapter concludes with a description of participants in reading groups run by Billington finding their own deepest selves mirrored in verse by, among others, Ben Jonson and Elizabeth Barrett Browning.

The third chapter, ‘Reading in Practice’ describes Billington’s work with her colleagues at CRILS and The Reader using reading aloud as a therapeutic intervention with patients with depression and chronic pain. The meetings were video-recorded and individual reactions noted. Billington is at pains to say that this intervention has nothing to do with bibliotherapy, where readings are often matched to conditions. The assumption is that the sufferer will be ‘found’ by the text ‘in a deep sense and at a deep level’ (105). It is his or her ‘inner life’ that she and her colleagues wish to engage. They believe it has a therapeutic effect arising from the ‘something deeper’ that literary reading provides. I think the time has come to test this claim experimentally. The final chapter puts forward an exemplary reading of John Berger’s masterpiece, A Fortunate Man, though, pace Billington, I think that book owes more to Marx than to Balint.

Underpinning this entire book is a compelling theory of literary reading which could be made more explicit. If I had to summarise it, it would go something like this. The reader of a great literary work such as Middlemarch gets to experience the process of containing the vicissitudes of Dorothea’s fate by rehearsing George Eliot’s words as if they were his or her own, allowing them ‘to be’, without attempting to put a construction on them, and simultaneously of being contained by the total process of getting through the book. It is this doubleness at the heart of literary experience that makes perseverance so rewarding. It is only superficially the same as telling a story or piecing one together. It is being acted upon by means of a story. A Kleinian, such as Bion once was, might see it as a benign species of projective identification. But all sorts of lexicons can capture it.

The medical humanities have become more complex and more theoretically savvy over the years. But we desperately need more books like Billington’s that address us quietly and clearly, about something very basic. Literature and the literary have lost their cachet in our field. If you want to know why it should be restored, read this book. The case could not be better made.

Book Review: Brett Kahr’s ‘Tea with Winnicott’

5 Jul, 16 | by cquigley



Tea with Winnicott

by Brett Kahr with illustrations by Alison Bechdel. Published by Karnac, 2016.


Reviewed by Dr Neil Vickers.


Brett Kahr’s Tea with Winnicott is the first volume to appear in Karnac’s new ‘Interviews With Icons’ series, in which contemporary psychoanalysts conduct imaginary interviews with major figures from the psychoanalytic pantheon. Brett Kahr, psychoanalyst, Winnicott scholar and Winnicott’s first biographer, is first up with a sequence of ten riveting interviews with Donald Woods Winnicott (1896-1971), the paediatrician turned psychoanalyst who played a vital part in the evacuation of children during the Second World War. Winnicott’s legacy is arguably the most influential of any psychoanalyst from the English-speaking world. As I write, his paper on ‘Transitional Objects and Transitional Phenomena: A Study of the First Not-Me Possession’ first published in 1953 is the most popular journal article in Psychoanalytic Electronic Publications Online, which contains a huge proportion of all psychoanalytic papers ever published (n > 45,000). Indeed four of the top 10 articles are by him. Kahr knows the Winnicott archive inside out, having enlarged it considerably through his friendship with Winnicott’s secretary, Joyce Coles, and many of the statements attributed to Winnicott in this book originate in the great man’s writings, published and unpublished.

Ernest Jones, the St. Paul of British psychoanalysis, called Winnicott the first male child psychoanalyst. Kahr observes that he was also ‘the first proper media psychologist in Great Britain’ (187). From the 1940s onwards, he made radio programmes aimed at mothers and fathers, on child development, play, and the meaning of delinquency and adolescence. Many of these programmes were produced or commissioned by Isa Benzie for the BBC, who was struck by a phrase Winnicott used casually in conversation with her, ‘the ordinary devoted mother’ (she made it the title of his first radio series). In the 1960s he moved across to television. A handful of his books were bestsellers, notably The Child, the Family and the Outside World (1957) and the posthumously-published case history of The Piggle (1980), a little girl he saw from the age of two years and four months until she was five. His reputation took something of a battering in 2001 when it was revealed that Masud Khan, his trainee, colleague and editor, had abused some of his patients terribly and was routinely cruel. Some of these had been referred to Khan for treatment by Winnicott. More recently, though, Winnicott has become an important figure in popular culture, in no small measure thanks to the cartoonist Alison Bechdel, the illustrator of Kahr’s book, and whose bestselling graphic memoir, Are You My Mother? (2012) foregrounds Winnicott by naming each chapter after one of his concepts. The most common complaint levied against Winnicott’s thought is that he appears to have little to say about sex. This very reticence may have secured him admirers among those who feel they’ve had a raw deal from psychoanalysis on grounds of sex and sexuality. It is not irrelevant to remark that Alison Bechdel is a gay icon. She writes a widely-syndicated strip on lesbian and gay life called Dykes to Watch Out For. And more recently Winnicott has been extolled in the poet Maggie Nelson’s analytic memoir The Argonauts (2015), a book celebrating, inter alia, transexualism and non-normative sexuality.

Although Kahr tells Winnicott a little about his posthumous reputation (and asks for his views on the Masud Khan scandal), his book’s chief focus is on how Winnicott himself saw his work in relation to his life. A remarkably coherent picture emerges. Winnicott took house jobs in children’s medicine and psychiatry and his analysis with James Strachey which he began at the age of 26 enabled him to unite the two. Unlike most of his analytic colleagues, Winnicott saw thousands of patients at Paddington Green Children’s Hospital and at the Queen’s Hospital for Children in Hackney, quite apart from his analytic consultancy. Analysis showed him that children’s illnesses were often rooted in the parent-infant relationship but he remained acutely aware that psychoanalysis wasn’t the only way of treating children or indeed adults psychotherapeutically. Winnicott was most at home playing with children. When he started out, his assumptions about play were very much in line with those set out by Melanie Klein. Klein thought that the primary function of play was to manage anxiety. When a child plays, he expresses the state of the figures in his internal world (his parents, siblings, playmates for the most part but also body parts and functions associated with these). Optimally, through play, we learn to bring the figures in our mind together creatively. Winnicott enlarged Klein’s view by suggesting that the value of play lay in its power to liberate us from object relationships as well as draw us deeper into them. It begins in what he once called ‘the area of formlessness’, meaning the zone between internal, psychic reality and the external world. The creativity of play and its potential independence from the world of objects is what makes it so important. In his biography of Winnicott, Kahr suggests that Winnicott’s love of play stemmed from his idyllic early childhood when he was doted upon not only by his mother, but also two sisters and a large staff of female servants. They, Kahr suggests, supplied the blueprint for the transitional experience that Winnicott described so powerfully in his great 1953 paper.

With the outbreak of the Second World War, Winnicott found he had no patients. Rather than fleeing to the countryside or joining the Royal Army Medical Corps, he took a post as a psychiatric consultant in Oxfordshire and the surrounding areas, caring for evacuated children. Oxfordshire was one of the most billeted areas in the country. Kahr reveals that Winnicott surreptitiously arranged to transfer his most disturbed patients from Paddington Green to hostels in the county where he would visit them once or twice a week and ‘talk to them, draw with them, [and] simply be with them’ (97). It was around this time that he developed an ambition to talk to large numbers of parents about children’s needs. One of the first things he tells Kahr over a fictional cup of tea is that he (Winnicott) grew up in a psychologically illiterate age. His wartime broadcasts and contributions to progressive magazines such as The New Era in Home and School attempted to offer the lay person the rudiments of psychoanalytically-informed psychological understanding. Anyone who reads The Child, the Family and the Outside World or the broadcasts collected in Home Is Where We Start From will recognise Winnicott’s formidable pedagogical gifts. He could make the most abstruse psychoanalytical ideas sound like common sense. Wartime enabled Winnicott to flourish in other ways too. He met his second wife, Clare Britton, a psychiatric social worker, afterwards an analyst and senior Home Office civil servant. It was with Clare that he began the work that culminated in his great paper, ‘Delinquency as a Sign of Hope’. He tells Kahr that ‘marriage to Clare enabled me to become the theoretician of play and creativity, rather than just a theoretician of madness and breakdown and misery’ (182).

It could easily have gone the other way. In 1949, he published one of his most celebrated papers, ‘Hate in the Counter-Transference’ in which he described his reactions in the analysis of a psychotic woman he’d been treating for nearly twenty years. Winnicott said in that paper that he’d had to ‘reach down into very primitive areas’ of himself in order to treat that woman and that he found himself developing something akin to psychotic symptoms in his dreams. The woman eventually committed suicide. He tells Kahr that although he hated her for being so ill, he also ‘loved her deeply, in many ways like a daughter… the closest that I ever had to having a daughter really’ (121). He thought that his experience of hatred for his patient must have mirrored her mother’s experience and that she had become schizophrenic because of ‘environmental failure’.

Kahr has written wonderfully about this case in a long article and is currently writing a whole book about it. He tells Winnicott that psychiatry has become very anti-psychoanalytic in recent decades and that the Winnicott’s ideas about schizophrenia (that it was caused by environmental failure) had not been well received. Personally I would like to send Dr Winnicott some better news by pointing out that few researchers in the field of schizophrenia research today discount the power of environmental factors. Robin Murray’s group at the Maudsley have published scores of studies on the effects of gene-environment interactions. Seymour Kety’s classic studies from the 1960s of Danish twins who had been separated at birth took place in Winnnicott’s own lifetime. Kety reported a 1% incidence of schizophrenia in the population as a whole. Being brought up by an adoptive parent with a diagnosis of schizophrenia increased the risk to 3%. Having a schizophrenic biological parent if you are brought up in an adoptive household with no schizophrenia you will gave a risk of 9%. Worst of all, having a biological schizophrenic parent and being adopted by a schizophrenic parent pushed the risk up to 17%. The bio, the psycho and the social produce synergisms that are not reducible to the bio. And epigenetic studies on attachment show the same thing. Early experience switches different parts of the genome on and off, with lasting effects. The biological is just as often an epiphenomenon of the psychosocial as the other way around. The holding environment has its role, even if that term hasn’t caught on outside psychoanalysis.

The eighth chapter of Kahr’s book, or ‘Cup 8’ as it’s called, is entitled ‘A Crash Course in Winnicottiana’ and is masterly. In it, the reader will find limpid discussions of the differences between holding, handling and object presenting and the importance of ‘good enough’ parenting (parenting that is neither so good that the infant need not develop as an individual at all, nor so bad that that he cannot). Kahr writes beautifully about Winnicott’s sensitivity to the interaction between mothers and babies. Apparently, Winnicott once told the bookseller and publisher, Harry Karnac, that babies’ minds are like blotting paper (146). They absorb everything that is put in their way. When the baby learns to use his parent, he finds that the parent acts as the blotting paper that makes the baby feel safer. ‘And then we have health’ (147).

The matter of Masud Khan is held over until the ninth cup. Understandably, Winnicott suggests he and his interviewer move on to sherry. Although he has published at least one major article on the Khan-Winnicott psychodrama, Kahr uses this chapter to articulate what he imagines Winnicott’s defence would have been. Khan’s descent into alcoholism and bouts of psychosis occurred after Winnnicott’s death. The charge sheet Kahr puts before Winnicott is very mild: ‘you had an extra-analytic relationship with him and, thus, a lack of clarity, some might argue, about the purpose of your relationship’ (173). Winnicott expresses deep sorrow in reply but says he ‘cannot offer a complete explanation of what really happened to Masud. Partly because I do not know… I knew about Masud’s difficulties – at least those that had occurred during my lifetime! And I kept meeting with him to try and work it through. He might have been much, much worse off if he had not had the analysis’ (176). Khan has been much written about so perhaps it is right that someone should attempt to look at the scandal surrounding him from Winnicott’s point of view. But I think Kahr should have put to Winnicott some of the more trenchant claims made against him. It has been said, for instance, that he was himself a serial boundary-crosser, bringing some of his most disturbed or deprived patients into his home to live with him for months on end, listening to radio programmes with analytic patients in their sessions, practising regression therapies, and that he perhaps encouraged his disciple to take a similar ‘active’, non-analytic, approach. It has also been suggested (not least by Kahr elsewhere) that Winnicott was too dependent on Khan as his ‘secretary’ to have been able to see him clearly. Kahr doesn’t disguise the extent of Winnicott’s boundary-crossing. He just doesn’t mention it in relation to Khan.

It would be hard to imagine a more congenial and convivial introduction to Winnicott’s life and work than this timely book which deserves great success, especially amongst the young who are discovering Winnicott in ever greater numbers. All his dimensions are brought out with great skill: in addition to the clinical theorist, we meet Winnicott the concert-goer, opera-lover and pianist, the painter of hand-painted Christmas cards, even the poet. One of Winnicott’s compositions contained the memorable line ‘Oh God, may I be alive when I die!’. His wish has been granted in all relevant ways in this delightful book.

The Reading Room: The Other Side of Silence

20 May, 16 | by cquigley


The Other Side of Silence_CMYK_cropped

The Other Side of Silence: A Psychiatrist’s Memoir of Depression by Linda Gask.

Vie Books, 2015

Reviewed by Dr Lilian Hickey

There is a shocking, but humane and tender poetry in George Eliot’s lines in Middlemarch which refer to the deafening ‘roar’ of life that might lie ‘on the other side of silence’ in our ordinary day-to-day emotional experiences –  if we only had ears to hear it (or the courage to bear it). We humans spare ourselves, Eliot says, by securely, routinely, tuning out from awareness of the more unmanageable aspects of life – for our sanity’s sake (‘wadding’ ourselves in ‘stupidity’).

Linda Gask takes some of these words of Eliot’s for the title of her memoir, which has a fierce, tenacious, calm and utterly generous sense of commitment in her remarkably frank account of that potentially overwhelming ‘roar’, both in her own life, but also in her accounts of many of her patients’ lives from her long career. Her book sets out to help others through her very personal account of a life beset by periods of severe depression, as well as by episodes of disabling anxiety, difficult obsessional ruminations and even paranoia. Her professional life as an esteemed psychiatrist, researcher and educator has been deeply, tacitly informed by her awareness of her own fragilities, which have included times of almost suicidal desperation, and her story is a compelling one of love, loss, betrayal, kindness, hope and dedication. (And also, tellingly, of some very kind and good doctoring and therapy, hers and others’, along the way)

The bedrock of her memoir rests, as most lives tend to, in the matrix of her childhood experiences, which she brings to life in simple, vivid, often unhappy, detail. Her labouring father always had oil-stained hands, from long and dangerous hours spent tending to the workings of a funfair ride…his determined and passionate nature has been passed down to his only daughter, who adored him.  She can see how she has become her father’s daughter, and benefited from his ambition for her. His later rages, sometimes violent in her adolescence, and his sudden death while she is in Edinburgh working as a house officer, are for a long time impossible for her to take in. It is years later with the help of her first therapist that she begins to make sense of her relationship with her father and what his loss has meant. (Though she says she can never be sure exactly how proud he might have been of her achievements, praise and pride were not in the family behavioural lexicon). Her relentlessly unhappy, critical, jealous mother is cold and ever-unappeasable, but in the book, the lack of warm maternal care seems especially hard to place – if not describe – in the origins and seams of her very real childhood, and then adult, distress. Perhaps the great tragedy of her family unhappiness however lay in the persistent, mostly silent, tormented obsessive compulsive illness of her younger brother, whose later apparently ineffective psychiatric care is described. The lack of any help or support for his childhood torment and its deeply devastating effect on family life,  seem to have been important factors in her later coming to find in psychiatry a place where she could become the sort of doctor who could bear to hear and think about the roaring of despair.

Gask’s childhood sensitivities to unspoken emotional weathers, and to the fears and distress of others, bring to her professional life a capacity for concern, clear sighted clinical observation and an ability to attend to, and be concerned about, troubled states of mind.  The book is also, amongst its chapters, a reminder of the stresses of undergraduate medical studies, the pressures of long hours as a junior doctor and of what it can be like to work in neglected, down-at-heels psychiatric facilities. The notion of asylum for those is distress is thought about, and often in her story seems much more in evidence in the kindness of professionals than in the tatty surroundings offered to the mentally ill.

The professionals who make a difference to Gask are described candidly – the kind, the solid, the unreliable, the awkward and the wise. We are reminded that the right psychiatrist or therapist can be an astonishing lifeline on the edge of a mental abyss, and over the years her medical and psychotherapeutic relationships have been essential aspects of her own soul-rescuing in times of dread or confusion.

The book reads both easily and uncontroversially because of the truths it elaborates with quiet honesty and rigour. Its exposition is simple, its creed straightforward – that there are different kinds of depression, that everyone’s experience of mental distress is uniquely theirs in its origins and setting, and that professional kindness and expert unflinching attention matter profoundly. There are different sorts of treatments and some have worked for Gask better than others. That things change – illness and the medical and psychological therapies which help, at different times in life – is a given.

The self and the coordinates of being are tested by depression, but this is a memoir of a life lived with, ultimately, very considerable personal and professional achievement. What is exceptional in this volume is the absolute sanity of its project. It is one of the least mad books on madness imaginable, and it most essentially promotes hopefulness inspite of its tales of real despair and disorientation. It will change the understanding of anyone who has heard the whisper of Eliot’s roar at any point in their lives. Which is, presumably, all of us.



Lilian Hickey

Consultant in Older Adult Mental Health

Fulbrook Centre

Churchill Hospital

Oxford OX3 7JU.

The Reading Room: Ronald Britton’s ‘Between Mind and Brain’

27 Jan, 16 | by cquigley


Between Mind and Brain: Models of the Mind and Models in the Mind

by Ronald Britton. Published by Karnac, 2015.


Reviewed by Dr Neil Vickers.


Ronald Britton is one of the most significant psychoanalytic theorists writing today. Now retired from clinical practice, though still active in training, he is perhaps best known for his contributions to Kleinian theory. His first book, Belief and Imagination: Explorations in Psychoanalysis (1998), asked questions such as ‘What is and where is the Imagination in any modern model of the Mind?’ and ‘How can we conceive of it in psychoanalytic terms?’ His second, Sex, Death and the Superego: Experiences in Psychoanalysis (2003), set out his thinking on three concepts that were important to psychoanalysis historically. Britton has always used literature as a kind of interlocutor for analytic theory. Belief and Imagination contains lengthy discussions of, and arguments with, Wordsworth and Coleridge, Blake, Milton and Rilke, as well as Freud, Klein and Bion; and Sex, Death and the Superego contains a compelling reading of the Book of Job and a fascinating extended speculation about the role that Wagner’s operas played in Jung’s correspondence with Sabina Spielrein. Britton is a medical humanist avant la lettre.


The theme of his new book, Between Mind and Brain: Models of the Mind and Models in the Mind, is that we think in models. Britton’s concern is more with the mind than the brain though the early chapters do make reference to contemporary neuroscience. In the first chapter Britton asks a question that once tormented Freud: would psychoanalysis and brain science ever arrive at a substantially overlapping account of mental experience? Britton’s answer is ‘probably not,’ though he thinks the reasons for this have changed since Freud’s time. The success of quantum biological models in neurology has resulted in a situation in which a mechanistic account of how the brain works has been replaced by one that is probabilistic (so outcomes can never fully be determined in advance), and full of complex, counterintuitive interaction (Patrick Haggard of Queen Square has demonstrated that, in a range of situations, the brain executes our intentions before these are consciously formulated in the mind). Freud originally hoped to ground concepts like repression in the workings of different types of neurones. Today, Britton suggests, convergence would have to be sought in other places, using different concepts borrowed from each discipline. At one point, he playfully suggests that the evaporating black holes of quantum mechanics might somehow dovetail with the psychic ‘black holes’ that psychoanalysts have described in very disturbed children. But the comparison remains at the level of play, because the two models aim to capture very different things. And models, along with their potential and limitations, are where Britton’s real interest lies.


For better or worse, psychoanalysis, like other psychotherapies, has to derive its models from directly-reported mental experience. Fantasies, conscious and unconscious, are models in Britton’s sense. But so too are theoretical constructs such as the Oedipus complex, the ‘depressive position’, or ‘basic assumptions’. Many people imagine that psychoanalysts apply these models dogmatically to their patients. On this view, patients are talked into seeing their difficulties as having an Oedipal origin, say. Britton takes this case apart at some length. The psychoanalyst, in his view, should aim as far as possible to set aside all models, especially those to which he is most attached. They will only distort what he sees. To understand another person, you have to tolerate not understanding him or her for a long time. Britton is on record as saying that he assumes he does not understand his patients for the first two years of four- or five-times-a-week analysis. Of course, psychoanalytic models are brought in, sceptically, but only gradually.


Occasionally, patients’ difficulties will be very well captured by a model. In Chapter 6, Britton gives the example of a man called Peter who entered psychoanalytic psychotherapy with a stammer. Peter led a very ordered life. He did not work. He had a celibate marriage. He avoided talking to his mother on the telephone, writing typed letters to her instead. And he appeared to have few friends. The model that seemed to fit Peter’s case was of a narcissistic organisation, as described by Herbert Rosenfeld. Patients in the grip of narcissistic organisations may want to make contact with others in the outside world but are prevented from doing so by an internal figure or group of figures who threatens terrible punishment. So it seemed with Peter who felt he had to isolate himself from his wife and mother and from the world of work for reasons that were unclear. Eventually he revealed that from the age of fourteen, ‘there had been a voice in his head that had ordered him not to speak and not to get close to anyone’ (53). Stammering was a way of obeying that voice. Peter also revealed he never stammered and could talk fluently when he was at home alone or when he was with children. Britton and Peter’s analyst took care not to introduce Rosenfeld’s model directly in Peter’s treatment until such time as he gave them cause to, which to their amazed delight he did. The model might otherwise have been a source of distortion and misunderstanding.


Analytic models can be useful only if they illuminate the analyst’s subjective experience of the patient’s subjective experience. But before such a point can be reached, analyst and patient have to learn to hear one another in as unprejudiced a manner as each can manage. It is to Britton’s credit that he does not minimise how difficult this can be for both parties. This stage of ‘building out into the dark’ as Freud called it, has its own micro-models too. Chief among these are the beliefs that the patient holds about himself and his analyst. ‘Believing,’ writes Britton, ‘is a form of object-relating. I think belief as an act is, in the realm of knowledge, what attachment is in the realm of love. The language of belief is clearly cast in the language of a relationship’ (82). For this reason, beliefs offer a point of entry into the patient’s internal world and the figures who inhabit it. They supply models of that world, seen from a certain point of view. At a more basic level still are the unmentalised psychophysical experiences that manifest themselves in the transference as ‘imageless expectations’ (19). These await transformation into the models constituted by fantasies, symbols and dream elements. These lower-level models form the bedrock of most patients’ and analysts’ analytic experience. The larger theoretical models such as the Oedipus complex or the ‘depressive position’ shimmer in and out of view but they must take their shape from this more detailed and theoretically open work. They have no substantial existence independently of it.


The systole and diastole of this process are transference and countertransference. Britton subscribes to the now widely-held but once heretical view that the analyst’s countertransference, far from being an obstacle to analytic progress, is a spur to it. The analyst has to be willing to receive the patient’s unconscious fantasies and to allow them to act on his unconscious mind. The hope is that the analyst will have enough self-understanding to distinguish what belongs to the patient from what he brings himself. Acting as the crucible for other people’s unconscious experience in this way is intellectually and emotionally demanding. As Britton observes, ‘Analytic neutrality does not mean freedom from emotion, it means unbiased observation of its play within ourselves’ (23). In his last book, Sex, Death and the Superego (2003), Britton went so far as to propose a new psychoanalytic nosography based on the kinds of countertransference experience that different sorts of patients evoke and some of that work is rehearsed again in chapter 7 of Between Mind and Brain.


Unsurprisingly, given his previous books, Britton thinks that literature and theology are rich sources of models of mental life. This volume contains interesting new material on myth as a model of mental life and on writing by Blake, Milton and Mary Shelley. Britton sees Milton as a man divided against himself. The theologian author of De Doctrina Christiana needed to secure himself against a suspicion that God might be a sadist (a line of inquiry which Stanley Fish argues runs through Paradise Lost). But the poet of Paradise Lost makes Satan the hero of his poem and depicts him as ‘a whole person experiencing conflict, remorse and dread’ (115). Satan (distinct from Milton) is a destructive narcissist in Herbert Rosenfeld’s terms and by engaging with him imaginatively, Milton defends himself against the depressive melancholia Britton thinks lay at the core of his theology. Britton has a vivid sense of what an achievement it is to live out ones conflicts in this way. In similar vein, Britton reads Blake’s Marriage of Heaven and Hell as an exploration of what is entailed in substituting one’s own ideal self for the superego. Most impressive of all is the chapter on Mary Shelley’s Frankenstein (‘What made Frankenstein’s creature into a monster?’). which Britton reads as a parable about the absolute horror of perinatal rejection for both mother and child’ (106).


I have given the barest indication of the many riches contained in this very fine book. I was left with only one puzzle. Britton says a great deal about Darwin the man in this book but very little about Darwinism’s implications for psychoanalysis. He complains at one point that the radicalism of Darwin’s theory of evolution has scarcely penetrated educated opinion. I think he’s wrong about that but what about Darwinian models of psychoanalysis: Bowlby’s, pre-eminently, but also the more modern version of attachment theory promulgated in this country by Peter Fonagy, Anthony Bateman and Mary Target and in the United States by figures such as Allan Schore? Neuropsychoanalysis is completely Darwinian in outlook. It would be good to have Britton’s opinion of these models, not least because they engage so many of his interests. The same thought was with me when it came to neuroscience, a field Britton holds in high regard. Neuroscience uses a thoroughly Darwinian framework when considering the structures of the brain: the basal ganglia making up the reptilian complex were the first to evolve; later came the limbic system, the seat of most of our emotional reactions; finally, the neocortex evolved, from which we humans derive so many of our cognitive advantages. These structures, which can be found in non-human animals too in different proportions, now supply the basis for a great deal of neuroscientific theory. Has psychoanalysis nothing to say about them?

These quibbles are based on a wish that the book had been longer. Coming away from it, my overall feeling was of gratitude for such an incisively-argued and powerful book.

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