From the Editors

Psychoanalytic Approaches to the Treatment of Psychosis

The original papers in this issue of JAPA spotlight Otto Kernberg’s work on personality disorders. In this section of the Review of Books, we extend the focus on severe psychopathology by introducing two books, each of which examines the psychodynamic treatment of psychosis from a unique angle.

Michael Garrett brings to his review of David Downing and Jon Mills’s edited volume, Outpatient Treatment of Psychosis, his own deep experience as both clinician and researcher, combining psychodynamic and cognitive behavior methods in his work with psychotic individuals. Garrett deeply appreciates the authors’ and editors’ contributions to this book, and also raises some important questions. Where do the boundaries between psychosis and nonpsychotic pathology lie? How might we translate across, and perhaps integrate, the various meanings of “psychotic” that arise in different schools of psychoanalytic thought (e.g., Freudian, Kleinian, Lacanian, Jungian)? And, crucially, how might psychoanalysts help to bring psychodynamic treatment to those suffering with entrenched psychosis, most of whom cannot hope to pay out of pocket for treatment?

In a review of Lacan on Psychosis: From Theory to Praxis, Gerald Perman’s ten-year study of Lacanian theory informs his close reading of another collection edited by Mills and Downing. Perman recommends this book to those interested in learning about Lacanian theory, with the caveat that while “this book will serve as a primer for some aspects of Lacanian theory,” nonetheless “parts of the book will be challenging even to the moderately advanced Lacanian clinician.” Perman reminds us of Lacan’s well-known notion that “language is meant to be misunderstood,” and he observes that some concepts throughout this book may confound Lacanian scholars and initiates alike. Psychotic states are best understood, Perman tells us, as “language deficits [that] result in problems in four areas: (1) social functioning, (2) body experience, (3) subjective feeling, and (4) externality in relation to manifestations in the unconscious.” Focused on the theoretical understanding, treatment, and clinical outcomes of patients with psychosis, Perman explores Lacan’s concept that rather than “cure” psychosis, a Lacanian might hope to see the successfully treated patient as “a well-functioning psychotic person.” Ultimately, Perman writes, “one of the things I like most about Lacan, and that Downing elaborates, is privileging the patient’s discourse above all else in the therapy”—a worthy reminder across the theoretical spectrum.

Mentalization: Keeping Our Theory in Mind

In this section of the Review, we explore the notion of mentalization, considering how to apply it both in our work with patients and in reflecting on our field as a whole. In his review of Elliot Jurist’s Minding Emotions: Cultivating Mentalization in Psychotherapy, Ralph Beaumont takes up Jurist’s view of mentalization as “a substantial reorganization and extension of many earlier part theories.” Beaumont highlights Jurist’s emphasis on the important role of mentalization in psychoanalytic work with patients. Mentalization, Beaumont writes, is a joint effort between analyst and patient. Over the course of a treatment, patient and analyst together use mentalization as a way to increasingly “identify,” “modulate,” and “regulate” emotions, eventually reaching “a joint comprehension of the patient’s theory of mind, or manner of spontaneously using mentalization.” Mentalization involves a shared experience of recognizing and tolerating that though the other’s views may differ from one’s own, they are nonetheless meaningful and worthy of empathic response. Beaumont explores important questions raised by Jurist’s excellent exploration of the notion of mentalization as a pathway to exploring the patient’s psychic truth. For Jurist, Beaumont writes, “the thrust of mentalization theory . . . is integrative,” with the aim of “bringing together science with the humanities, empirical research with clinical experience, and insights from a variety of psychoanalytic schools often seen as incompatible.”

Elliot Jurist, now in the role of reviewer, next considers Enrico Gnaulati’s Saving Talk Therapy: How Health Insurers, Big Pharma, and Slanted Science are Ruining Good Mental Health Care. Jurist directs our attention to the current climate of mental health care and the contemporary trends that shape the public’s understanding of the field. As he points out, we all have encountered patients who come to us for therapy yet, with little or no understanding of what we can offer, lean instead toward pharmacological or cognitive behavioral interventions, often viewing such approaches as the quickest and most efficient pathways to mental health. Jurist offers a rich perspective on Gnaulati’s view that health insurance, the pharmaceutical industry, and short-sighted evidence-based science have distorted the public’s understanding of what is truly beneficial about psychotherapy—that is, the central roles of empathy, analytic listening, and the therapeutic alliance. Jurist cautions, however, against the impulse in our field to throw out the scientific baby with the evidence-based bathwater: “It is counterproductive,” he argues, “to ignore that not all evidence-based approaches are the same, and that the impetus to know what works is not in itself problematic.” For Jurist, the work of psychoanalysis goes beyond Gnaulati’s view that a nurturing relationship is the key to a successful psychoanalytic treatment. Instead, Jurist reminds us—as he does in his own book on mentalization, reviewed in this issue by Ralph Beaumont—that “our aim is to restore, work on, and improve the capacity to communicate through the means of mentalizing.”

The Magic of Language in Psychoanalysis

Jean-Claude Rolland’s The Mind’s Eye and Vittorio Lingiardi’s Mindscapes illustrate a literary poetic style prominent in contemporary French and Italian psychoanalytic literature. These two authors use philosophical and literary references in an effort to grasp the immanent visual activity of the mind, which Rolland—borrowing an expression from Hamlet—calls “the mind’s eye.” Both authors take the liberty of bringing the psychoanalytic experience along on a poetic and creative journey.

In his meticulous review of The Mind’s Eye, Christian Seulin describes how Rolland draws a parallel between creative activity and psychoanalysis; both employ an imaging (imageant) activity that gives way to drive impulse. This primitive activity of the mind precedes the renunciation of the bodily experience that logos requires. Rolland uses literary examples—drawn from Ovid, Shakespeare, Baudelaire, Hölderlin, and others—to illustrate imaging experiences in psychoanalytic treatments that, in his view, words cannot easily grasp. These imaging experiences are fundamentally constitutive of individuality. They are where the infantile lies in each of us, and also where creative activity thrives.

In her rich description of Lingiardi’s Mindscapes, reviewer Angela Cappiello shows how this eminent psychoanalyst and writer explores the continuum between the mind and its natural environment. Lingiardi argues that landscapes have psychoanalytic, neuro-aesthetic, and poetic ties that cannot be ignored in our practice. In his view, images of landscapes are immersed in our psyche, participate in our development, and are part of our history. Thus, mindscapes are present in the consulting room as potential connections with patients, inciting our minds to wander, as Lingiardi’s book invites us to do.

Next Lewis Kirshner turns us back to an investigation of Lacan’s work, this time from the perspective of Lacan’s complex, literary views on language and psychoanalysis. Even among analysts who have not read him extensively, Jacques Lacan is known for his assertion that “the unconscious is structured like a language,” as well as for the difficult nature of his language (for some impenetrable, as noted in Perman’s review of Mills and Downing’s volume on Lacan). Here Kirshner—who has read Lacan extensively and published several articles on his work—reviews the first of three planned commentaries on Lacan’s oeuvre, Reading Lacan’s Écrits: From ‘Signification of the Phallus’ to ‘Metaphor of the Subject,’ edited by Stijn Vanheule, Derek Hook, and Calum Neill. Kirshner describes the Écrits as “a unique literary form, somewhere between writing and speech, . . . more like a primary process exercise in arcane allusions, puns, and jokes than a structured argument.” He recommends this volume for its value as a reference work “when reading contemporary Lacanian writings, which too often repeat the rhetoric without . . . deep reflections on meaning.”

Kerry Malawista offers a rich and appreciative review of Patrick Casement’s Learning along the Way: Further Reflections on Psychoanalysis and Psychotherapy. Here Casement has assembled in a single volume the wisdom and experience accumulated over his many years in practice. Its author now retired after recovering from a bout of lymphoma, the book represents the culmination of a well-respected career as both psychoanalyst and writer. Malawista underscores Casement’s passionate commitment to listening with an open heart and mind, learning to create space for the patient’s otherness, authentic voice, and creativity. She considers Casement’s work an invitation to “channel the poet in ourselves.” “Real change can happen in session with our patients,” Malawista reflects, “only if we are willing to be surprised, to value different viewpoints, to accept the limits of our open-mindedness, question our theoretical certainties, pose questions from a different vantage point, and at times disregard convention.”

Jeanine Vivona has written extensively about the nature of verbal development and its implications for psychoanalytic theory and technique, twice winning the JAPA Prize for original papers in this domain (in 2006 and 2012). Here she brings her expertise to a deeply thoughtful review of Donnel Stern’s The Infinity of the Unsaid: Unformulated Experience, Language, and the Nonverbal. Through Vivona’s review, we learn how—in his current thinking about unformulated experience—Stern “offers new ways to conceptualize the verbal and nonverbal forms of meaning that imbue interpersonal experience and fuel therapeutic action in psychoanalysis.” Vivona appreciates Stern’s approach to “vexing contemporary questions regarding the potentials and limits of language in psychoanalysis”—questions important to Vivona, and to most practicing analysts. Is there—as many contemporary theorists suggest, and as Stern seems here to agree—a stark cognitive separation between the “verbal” and the “nonverbal”? Vivona thinks not, and her effort to understand the difference between Stern’s view and her own leads her to ask what exactly we mean by “verbal.” Whether any aspect of human experience is, and must forever remain, beyond words is a matter of deep theoretical debate, with important implications for psychoanalytic technique. Vivona suggests that at the very least, “words allow us to articulate meaning with incredible efficiency; sometimes, a word is worth a thousand words. Importantly, any involvement of words can foster knowing and reflection, actions that are impossible in the absence of words.”