The Daily Novel

Patrick Casement’s latest book, ‘Learning from Life‘ (Routledge £20) is primarily written for a readership of psychotherapists, like his three other books, ‘On Learning from the Patient‘, Further Learning from the Patient and ‘Learning from our Mistakes‘. The last of those won the Gradiva prize for its contribution to psychoanalysis. The new book is different in kind to the other three, because Casement has decided to come out from behind the couch and reveal what goes on in his own head.

It is an autobiographical memoir in which he reveals the relevant details of his own personal life which led him to train as a psychoanalyst in the first place. He then goes on to discuss some of his own case histories, choosing those which changed his own thinking about what is the best clinical practice, and which also changed his own personal beliefs. One of the refreshing things about this section is that he relates in detail cases in which the patient was not cured. In the final chapters he deals with some events in his life, which he finds it difficult to explain, either by the theories of psychoanalysis or by what science has discovered about how the human mind works.

The back cover has a quote from Professor Andrew Cooper of the Tavistock Clinic and the University of East London, which asserts that the book has much to offer ‘anyone who works with mental pain in a professional capacity’. I would go even further and say that it is a book which ought to be read also by policy makers in government and managers in the national health service. And, for reasons explained later, journalists.

The dominant form of treatment of mental health problems in the national health service is still drugs administered by psychiatrists, not psychotherapists. There has been a breakthrough in the past year when, thanks to the Layard report, the government has decided to allocate some millions of pounds to the talking treatment. But they have chosen to funnel this money to cognitive behavioural therapists, who don’t learn any more about psychotherapy than the psychiatrists do.

Anyone reading this book is likely to want to question this decision and ask why the money should not be diverted to psychotherapy, which has a much longer history and has practioners far more experienced in dealing with mental health problems. This is not because Casement is propagandising. On the contrary he tells the story of his life straight, of how he stumbled into his ultimate trade, and of how he gradually learnt to do the job properly, after making many mistakes. Most of the book does not require a detailed knowledge of psychotherapy. The exceptions are the two or three chapters in the middle which are reprints of scholarly articles in the journals. They should not have been there in any case, because the experts have probably read them already.

One of them, about why Samuel Beckett had to learn another language (French) and write in it, before he could found the voice which made him a great playwright, annoyed me intensely. It was full of the jargon of the trade. Casement could have done something much better by revisiting this subject from the perspective he writes from in for most of the rest of this book. There his voice is that of the human being reflecting on how he has lived his life, rather than the lecturer addressing the students.

Back to Casement’s life story. He was born into a British upper middle class family which is distantly related to Sir Roger Casement. His grandfather was an Admiral and all the male members of his family on the paternal side had been in the Royal Navy. He felt that he was expected to follow in their footsteps but he was a difficult child who did not want to conform. His father was away from home a lot and he was sent to boarding school at Winchester, where he found substitute father figures who were thinkers rather than fighters.

During his last year in Winchester he came under the influence of a group of evangelical Christians. At the time, he thought he was rebelling, but he sees it from today’s perspective as ‘a flirtation with certainty’. When he went back home to his parents, who were in fact regular attenders at the local church, he urged them to recognise the error of their ways and join him on his evangelical crusade. He felt that he might have a vocation to be a priest. His family was not impressed: ‘What career prospects are there in that?’ said one.

By the time he got to Trinity College, Cambridge, after doing his national service in the navy, he was in a state of confusion. He had got a place to read economics, but had no interest in it. His tutor told him he could change and together they went through the whole range of subjects on offer. Casement had no enthusiasm for any of them. His tutor suggested he study anthropology, because he seemed to dislike that least. Patrick agreed when he discovered that anthropology was the ’study of Man – embracing women.’

What he learnt in his first year became the central issue of the particular style of psycho-analysis he was to develop years later; ‘the essential discipline of maintaining an open mind, especially when trying to understand how others live their lives, and how societies different from our own are structured and maintained.’ In Freud speak he was beginning to learn about ‘the otherness of others’. He now has regrets that he did not continue. Instead he switched to theology, partly to test his possible priestly vocation and partly because it meant being taught by Trinity’s Dean of Chapel, who was one of the most inspiring minds in Cambridge.

He left Cambridge with a degree but no clear idea of what he wanted to do with it. He thought he probably would not become a priest but he decided to enlist on an innovative training programme for priests which started with six months working as a bricklayer’s mate in a steel factory. This brought him face to face with the ‘otherness’ of the British working classes. It also led him to opt for a career in the Probation Service. This meant he had to gain a diploma in Social Studies first, which he did at Barnet House, Oxford.

It was in that year that he suffered a serious breakdown. The trigger event was that he was dumped by his girl friend. She told him that she could not marry him because she suffering from a terminal illness and wanted to stop seeing him. Some time later he learnt that she was going to marry a friend of his. Casement writes: ‘Not only had I lost her, but I felt I had lost the only way I could imagine for coping with her dying: being with her at the end.’

Casement was referred by his GP to the local mental hospital, where they decided to offer him assisted sleep treatment, which was fashionable at the time. Casement describes his treatment there in detail. Below is his summary paragraph.

‘I left the hospital feeling that a successful suicide would be what they all deserved. What had they done except to make my life almost unbearable? But I also began to think that there must be better ways of treating patients. In the 17 weeks I had been an inpatient I had been allowed a total of 15 minutes alone with a doctor: ten minutes when I arrived and five at my discharge. For the rest of the time I was spoken to by the medical director only when he came on his ward rounds, always in the company of his junior doctors. The notion that anyone desperate enough to attempt suicide could be discharged without further discussion or enquiry seemed extraordinary. I became determined to find something better than that.’

But before he could change the world he had to find a way to earn his living. And because he had been in the bin the Home Office required him to be vetted by a consultant before he could resume his probation service training. By co-incidence the consultant who was appointed to decide his fate was also a Jungian analyst. After listening carefully he told Casement that he preferred to believe his account of what had happened rather than the report from the hospital.

Casement spent several years in probation work. Many of his clients were suffering from mental health problems as well as getting themselves in trouble with the law. He often had to see them in their own homes and with other members of the family so that he learnt something of the dynamics of the family in relation to mental health. This period also helped him to understand people from working class backgrounds.

I found it impossible to find two or three quotes which would convey the key insights he obtained from his practice as a psycho-analyst. But I will attempt to summarise them.

The core is how the analyst handles the interview process. The analyst not only has to clear of his mind of all the theory he has learnt, he has to ‘forget’ the ways of behaving he has learnt in his training. He also has to ‘forget’ what he has decided about this patient already. He must treat the patient coming through the door as if they were a new person. He must not only give them a chance to tell him what has happened and to express their powerful feelings about their lives and about how they feel about the analyst, he must resist the impulse to jump in too soon with an interpretation.

While doing all this the analyst has to stay in touch with his own emotions and particularly with what happens inside him when he is verbally attacked with huge anger or moved to incredible sadness. Casement found in his clinical practice that when he was moved to sadness the tears started to stream down his face. Since he often faces patients, in a chair, these tears were visible to the patient. Casement has found that such expressions of his own emotion helps the healing process, whereas an interpretation or expression of his own opinions at such critical moments, causes the patient to clam up and adopt his usual compliant behaviour, burying the real problem.

This example would be misleading if I did not also say that Casement gives other examples where it is necessary to confront the patient.

Another key core issue is the fact that success or failure in therapy depends not on uncovering traumas in the past, which have created the problems, it depends on how these revelations are dealt with in the analytical situation. It is what happens in the present that is important. Theory and training can help but in the instant the analyst has to make a judgement and then act decisively. That is always a risk, because the analyst can never be quite sure he is right.

At this point I can use an example from the book. He notes that in Sanskrit the word for uncertainty is the same for the word for freedom. Then he writes: ‘I see non-certainty as very different from uncertainty. Non-certainty is not about indecision, nor is it about ignorance. Rather we can make a positive choice to remain, for the time being non-certain. This can help to keep us open to meaning that we have not yet arrived at. I also try to return to a position of non-certainty when I notice I am beginning to claim too much sureness in relation to others, because anyone who is too sure can quickly become someone who is sure that those who disagree must be in the wrong.’

This paragraph is worth thinking about in relation to the journalistic interview. The journalist, like the analyst, has to choose, in the instant, whether to adopt a questioning/confronting style or a listening/drawing out style. The dilemma for the radio and television journalist is that the confronting style can cause listeners and viewers to think that the interviewer is one of those people who thinks that those who don’t agree with him are wrong. Why does Jeremy Paxman not give Michael Howard or Tony Blair have a chance to say what they want to say?

There is not much that the journalist can do to avoid giving this impression, because he does not have time to demonstrate that his style is chosen, not from ignorance or prejudice, but because journalists actually know that the minister is concealing things, although they don’t have the proof. So it is absolutely imperative to challenge ministers on matters such as the existence of weapons of mass destruction, even if it is months before the full facts become generally available.

Jeremy Paxman, in fact, finds out much of what he knows, by using the listening/drawing out style of interviewing. I know that because I have met him several times, and noticed how he cocks an ear and listens to what other people are saying, and then draws them out. The public perception of his dominant style arises from what he does on Newsnight. I think it a pity that the BBC management did not give him the Desert Island Discs job which would have given the public a chance to see him operating in quite a different way. (The format used, and the style of interviewing adopted on Desert Island, is frequently extremely revealing of the person being interviewed, and on matters far beyond their choice of records.)

Journalism students, in my experience, find it easier to develop the confronting style, than they do to develop the drawing out/listening style. Because of their need to ask the questions to get a particular story. And because it really is difficult to learn how to temporarily suspend your own beliefs, assumptions and prejudices and draw out what the ‘other’ knows.

To round off on mental health. My own view is that mental hospitals have not changed that much since Casement was inside about fifty years ago. Individual psycho-therapy is not on offer. And the medical teams which treat patients are dominated by the psychiatrists, who are taught no more about psychotherapy than when I was at university. The few clinical psychologists, have often studied psychotherapy but they have mostly not been trained in it.

The psycho-analysts, on the other hand, have changed significantly. One reason is that they have to satisfy the market. In order to make a living comparable to that of other middle class professionals, like university teachers, they need to persuade the well-off clients who want the classic five day a week treatment to fork out £10,000 a year. (Nearly all of them spend part of their time treating people who can only afford a fraction of that.) There are also a large number of psychotherapists, trained in theory and practice, who work for lower fees and manage to achieve results with sessions of two or three times a week.

Rich people do not usually throw their money away on something that does not work. But I realise that I should not conclude this article without addressing the readers of this blog who know nothing of psychotherapy except that some research studies have shown that psychotherapy does no better statistically with patients who suffer breakdowns of various kinds, than some who recover with no treatment at all.

There are all sorts of theoretical reasons why it is very difficult to design a research study which would prove scientifically that psychotherapy works, or does not work. I do not have time today to discuss them, but may return to it in some future blog. The important thing I want to ram home now is that the no-one has proved satisfactorily the negative case that it does not work

But Casement’s books (and no doubt many others that I have not read) do offer a different kind of proof that the treatment does work. They also show that it does not work in every case. One reason for this is that unlike the drug, which is made to a uniform standard and given to the patient, therapy varies as to the personality, training and skills of each individual therapist. One of the paradoxes of therapy is that the theory has a full explanation for why it sometimes does not work. That is because the critical points in the therapy are often when the patients’ anger or depression is at its peak. Theory demands that these feelings are projected on to the therapist. But sometimes the patient cannot face doing that so he breaks off the therapy, believing instead that the therapist is no good at his job.

What the therapist is seeking to do is something different in kind to what the doctor is doing in administering a drug. He is seeking to bring the patient to the point when he can take command of his own therapy and avoid future breakdowns. This is an educational approach rather than a medical approach.

One useful way of regarding therapy is that it is a tutorial in the emotions. As far as the patient is concerned what matters is not whether they are ‘cured’ but whether they have learnt enough to enable them to cope with their lives better.

This long blog has not dealt with the other subject in Casement’s book – religion. He moved in life away from the evangelical Christianity that nearly ensnared him when he was 21 and made a quite conscious decision to become a Freudian analyst. He spent the whole of his career maintaining an agnostic position. And worked in a world where anyone who believed in God was regarded as someone who needed further analysis. In his retirement he has started to go to church again, not from a revival of evangelical fervou,r but from an intellectual commitment to his non-certainty principle. There are several things he has experienced in his life which are not explained by science or any psychological theory. And so he now feels: ‘Just possibly there is something that lies entirely beyond us that will always defy definition, that cannot be grasped or owned. I have therefore come to believe that there is still a place for bowing before mystery.’

I will blog tomorrow on the events which brought Casement to this position. Meanwhile the book is published by Routledge. I wanted to quote the Amazon price, but, guess what, the web site says, ’service unavailable’.