Learning From Experience: A Guidebook for Clinicians (Book Review)

Author:  Charles, Marilyn
Publisher: Hillsdale, NJ: The Analytic Press, 2004 [1
Reviewed By: Trevor R. Olson and Michael Wm. MacGregor, Fall 2005, pp. 64-65

Marilyn Charles’ book, [2] Learning from Experience: A Guidebook for Clinicians, is a wonderful introduction to psychodynamic psychotherapy for those in the early stages of their clinical career. Charles’ goal is to guide readers through an understanding of themselves as not only clinicians, but, more importantly, as human beings. She expertly achieves this by inviting the reader into her therapy sessions, and at times into her life. Charles’ empathy with her patients is conveyed throughout the book and captures her approach to therapy. By discussing how she connects with her patients, Charles helps the reader discover him- or herself and ultimately learn to become more connected in the therapeutic situation. Learning from Experience can be broken down into three sections: An introductory section where basic concepts are introduced, a section on various metaphors that aid in the understanding of ourselves and our patients, and a section integrating metaphors into psychodynamic concepts such as transference and countertransference.

The first section of Learning from Experience begins with a concept every novice therapist can identify with: Discomfort at being ‘the authority’ in the therapy room. This upfront discussion of what often feels like the deepest darkest secret of the training therapist effectively hooks the reader and sets the tone for the rest of the book. The reader is left feeling as though Charles is speaking directly to him or her. Immediately after Charles’ discussion of being uncomfortable with the idea that the therapist is the authority in the room she provides the reader with theory to act as scaffolding to support and catch the therapist when he or she stumbles. This scaffolding helps support the therapist and control the feelings of being overwhelmed and paralyzed by intense affect. It is here that Charles introduces us to the topic of metaphors, which she elaborates more fully in the next section. Metaphors, she argues, are a way of indexing and conceptualizing complex relationships in a simpler, more readily accessible manner.

The second section of the book expands on the metaphors Charles has introduced. The first metaphor Charles delves into is that of containment. This metaphor is applied not only to containment of the patient’s anxieties and fears, but also our own. Tying this metaphor back to her previous discussion of the anxiety inexperienced clinicians face at being ‘the authority’. Charles argues that if we can contain our anxiety over being ‘the authority’ we can then attend to the needs of our patient. This containment can be achieved, she argues, by coming to learn that not knowing the answers is not due to experience, but is in fact part of the process. It is at this point that Charles introduces the metaphor of saturation. Saturation is where our own ‘understanding’ of the patient is so ever-present, that we do not allow ourselves to view what is going on in the moment. Charles follows up the containment metaphor with a focus on the role of symptoms in treatment. Charles suggests that symptoms are indicative of underlying pain. If we only address symptoms then the underlying pain and distress will simply be exhibited elsewhere. She illustrates this with a clinical example involving substance use. Attending to affect and not to the overt symptoms, she argues, is the key to resolving the distress.

The second metaphor Charles introduces in this section of the book is that of the Paranoid-Schizoid and Depressive positions. As with the containment metaphor, Charles illustrates this with clinical examples. This concept is reified for the novice psychodynamic clinician with her discussion of ‘knowing the unknowable’. She applies the positions to the phenomenon of having something we thought was known between clinician and patient suddenly disappear from awareness of the patient. Understanding this phenomenon, and the omnipresent splitting of the patient in the Paranoid-Schizoid position, is a welcome and useful metaphor to help conceptualization of this issue. Charles also returns to the concept of containment and applies it to the Paranoid-Schizoid position. This joining of the two metaphors solidifies the reader’s understanding and aids in clinical utilization of the metaphors. Particularly enlightening is the comparison of being in the room with a patient in the Paranoid-Schizoid position to being caught in a Chinese Finger Trap. Struggling only leads to further entrapment, and only when you can contain your struggle and accept your position can you free yourself from your predicament. Charles helps the reader understanding of the Paranoid-Schizoid position, and how to best address it in session, with the concept of symbolic equation. She guides the reader through the importance of being able to be attacked without retaliating (by containing that reaction) and of allowing the patient to discover truths without preemptive interpretation. Finally, Charles leaves the reader with an understanding of how the use of metaphor in the session allows for the creation of space which in turn allows the patient to play with and explore concepts with a more tolerable level of anxiety.

The final Metaphor Charles focuses on in the second section of Learning from Experience is that of Projective Identification. Charles illustrates this metaphor through the clinical example of a patient depositing her distress in her therapist during one session and then returning to the following session seemingly calm. Charles writes that as clinicians we need to be able to recognize distress that has been projected onto us and the function it serves. Furthermore, we need to be able to separate projected distress from our own actual affect to accurately perceive the situation. In other words, we need to contain it. Charles uses this section to integrate the concepts of symbolic equation, transitional space, and the Paranoid-Schizoid and Depressive positions. She further argues that one must not treat projective identification as a hot potato, tossing it back at the patient as soon as it becomes uncomfortable. Instead, she argues that we must understand the function projective identification serves for the patient. Finally, Charles discusses distortions used by patients by examining truth and lies; or as she frames it, the difference between lies and false statements. She illustrates this difference, and its importance, brilliantly with the case example of David.

The last section of Learning from Experience integrates the metaphors and concepts that Charles has discussed into more traditional aspects of psychodynamic therapy such as recognizing patterns and working with transference and countertransference. Charles differentiates between the symmetrical logic of the unconscious and the asymmetrical but the more logic based processes of the conscious. She does this as a way for the training clinician to recognize and understand patterns that might otherwise be overlooked. Charles illustrates the importance of transference, and effective methods of conceptualizing and working with transference through a number of case examples. Particularly interesting is her application of transference and the Paranoid-Schizoid position to patient’s view of the therapist as all good, and the need to de-idealize and integrate the good and bad aspects. In applying metaphors to countertransference, Charles invites us to imagine our bodies as receptors, and to trust that they are attuned to aspects of the interaction that may be distorted by words. She argues that our intuition can be considered a composite indicator of all our previous experiences, and that these countertransference reactions should be considered and not dismissed as illogical reactions. The section ends with a reminder to not only the new clinician, but also to the more experienced one, that we must not saturate therapy with out own ‘understanding’ of the patient and must leave room for observing and playing with new concepts and possibilities.

Although applicable for clinicians with varying levels of experience, Charles book is particularly useful for the new clinician learning psychodynamic therapy. She integrates the works of various theorists, such as Bion, Klein, and Winnicott and provides her own clinical examples to help illustrate her ideas. In fact, the use of clinical examples is one of the most valuable components of the book. It is in these examples that we see Charles as a therapist and come to more fully understand her use of metaphors. Charles’ willingness to let us into her world and into her understanding of herself invites the reader to honestly look into him- or herself as a clinician and as human being. Examining her own reactions to those that remind her of her sister, and describing the containment of her embarrassment of being caught bored and sleepy in a session adds realism to the concepts Charles conveys. The use of metaphors is indeed a way of indexing and conceptualizing complex relationships in a simpler and more readily accessible manner.

Footnotes

1 By Marilyn Charles. Hillsdale, NJ: The Analytic Press, 2004, 128 + xii pages.
2 Marilyn Charles is a Training and Supervising Analyst with the Michigan Psychoanalytic Council and an Adjunct Professor of Clinical Psychology at Michigan State University.

Reviewer Note

Trevor R. Olson is a candidate in clinical psychology at the University of Saskatchewan. Michael Wm. MacGregor is Associate Professor, Department of Psychology, University of Saskatchewan. Correspondence can be sent to: Michael Wm. MacGregor, Ph.D., Department of Psychology, University of Saskatchewan, 9 Campus Drive, Saskatoon, Saskatchewan, S7N 5A5. Telephone: (306) 966-2525. Facsimile: (306) 966-6630. E-mail: michael.macgregor@usask.ca

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