"THE THAW" (24 Essays in Psychotherapy) by Paul Genova, M.D.

Dorrance Publishing Co., Inc., Pittsburgh, Pennsylvania. $13.

Many psychiatric readers might remember the essays by Paul Genova in the last decade of the 20th century in Psychiatric Times, a free, monthly, "throwaway" journal. Paul was the main reason I did not throw away the issue until I had at least scanned his essay. Detailed reading was always a treat. His essays also appeared in "Voices," the journal of the American Academy of Psychotherapists, in which he is now an editor.

I was glad when I learned that many of his best essays were collected in one volume, giving me the opportunity to read, re-read and study them at leisure, a process which has been edifying and gratifying. There was many a time I found myself thinking--- I wish I had said that! At my venerable age, I thought at first that he was nothing more than another precocious whipper-snapper, but as time went by I could only wonder how he got so much wisdom so early in his professional development. He was one of those whiz-kids from Harvard College who graduated from Dartmouth Medical School. He obviously had good training and supervision, he knows how to write, and is an original thinker. His clinical experience is synthesized in a unique way.

His dedication gives a clue to the title of the book:

"For the two therapists that I paid...

And the two I didn't: Margart Nichols and Darrell Dawson.

The goose is frozen in the lake.

I'm going to thaw it out.

The goose was hurt in the wings.

The ice came fast.

The others left without it.

The ice came fast.

I'll build a small fire

by the goose.

Frightened look in its eyes.

See, its neck is stretching

the way the others went.

It's got the south

in its neck,

stretching that way.

But the wings kept it here.

The broken wings.

I'm going to thaw it out.

Told by Isaac Greys (Otter Lake, Manitoba)

translated from the Cree by Howard Norman."

The metaphor of 'the thaw' will make a lot of sense to those therapists who see their work as liberating the individual from stifling and rigid characterologic defenses. It also presages his down-to-earth and poetical style, which, like the best poetry, has the uncanny ring of truth.

The first part of his book includes a number of clinical cases:

In his first case, entitled, "Dream Rebuts Therapist," Genova writes: "This case illustrates how the simple recognition of the dreamer's Unconscious as a radically separate Other, a third voice in the therapy process, can sometimes save the day."

Further, "The general psychiatrist avoids dreams at the patient's peril, as well as his or her own. To adapt to the old saw about war and generals, dreams are too important to be left to the psychoanalysts--- or for that matter to fringe therapists and New Age bookstores. They are a vital, and temporarily substantial, part of our life process."

In his second case, entitled, "Catfish on the Bottom," Genova writes, "A companion piece to the last one, this is another instance of the dreamer's Unconscious supplying us with an opposing view to that of the patient herself--- one that I seized upon and insistently amplified for her. This patient's own extensive comments from five years later are the essay's high point."

In his third case, "The Permanent Trip," Genova writes, "Here is a situation where an experiential risk paid off. I have never seen the visual world in quite the same way since. One could say that the intervention here was primarily cognitive--- and I'm no snob about that--- but I would argue that it was equally important that I joined the patient in his isolated perceptual world as a companion."

The fourth case is "Lacan at Bonus Bagels." Genova writes, "Some of my regular readers from the "Psychiatric Times" found this piece to be "out of character" for me. I have often played the down-home country psychiatrist in my column there, and here I was spouting trendy Parisian theories in a somewhat different tone. In fact, this patient brought me directly to the tension within myself between the Ivy-educated intellectual and the provincial rustic. It took the appearance of a better integrated figure in his dream to lead both of us out of this hamstrung position.

Case five is called, "Living with Doubt." This case was a struggle during which he had to deal with the 'collective hysteria' in the country at the time about repressed memories of sexual abuse. This is a such a case, with which most of us have had to struggle, in which there are clues to repressed sexual abuse, but nothing convincing, not even after long years of searching buried memories of the past. Learning to live with doubt is a universal task of all serious psychotherapists. In this case, while the patient seemed to be falling apart, what happened was "... along with the patient's desperation and deteriorated functioning came a visible increase in vitality."

"This was a woman who needed me to throw away the books. Externally imposed truth, whether in the former of the then-contemporary …insistence on the "fact" of incest and on fusion or in the guise of today's short-term manuals, would not have served her well. She had to explore her inner world in her own way and time or not at all."

In the sixth case, "I'm Not Your Urban Renewal Project." Genova writes, "My good friend, the Atlanta psychologist Margaret Nichols, has observed that sometimes patients will arrive in her practice and she'll just want "to sit at their feet and learn." I don't necessarily recommend trusting one's spontaneous responses as a general rule, but there are some remarkable people one encounters for whom doing anything else seems wrong.

He writes further, "Nowhere have I witnessed thriving psychological health more clearly than in the life of an African-American woman, now in her thirties, whose therapist I happened to become...."

In case number seven, "The New Covenant," Genova writes, "The standard treatments sometimes fail. When this happens, a creative collaboration which enlists the unique interests and aptitudes of both therapist and patient is called for.

In his introduction to Part II, in which Genova describes some of his supervisory cases, as supervisor to his supervisees, he notes that the latter's exposure to the classical literature of psychotherapy has been minimal. He realizes that the analytical language in which most of it has been written is as remote to them as Elizabethan English. "Thus, one constant aim of my teaching has been to pass on as much as I can of the remarkable insights of some of the Old Masters--- Jung, Balint, Winnicott, Horney, Semrad (I'm sure Freud was a 'given')--- so these young clinicians will not have to reinvent the wheel when their training in today's standardized cognitive-behavioral techniques fails them.

"I wage an ongoing guerilla war against these new orthodoxies while trying simultaneously to remain open to the value and real innovation contained in some of them."

In helping a beginning resident deal with the fact that his patient has given him a 'gift,' a painting the patient himself had done, he tried to convey the need to be flexible about 'border crossings,' rather than be rigid about 'boundaries.' He states that, ..."nine times out of ten there is no "right" thing to do, and even be thankful for that fact. Therapy is a series of more or less controlled mistakes, and if there are no mistakes there can be no therapy--- only a sterile procedure in which patients learn to successively approximate an unerring authority figure and are thus sealed into implicit inferiority. This may help them adapt, but please, let's call it something else."

Further essays comment on the perils of step-parents, illustrated by an analysis of "Snow White," and one called "Raffaela's Hug," in which Raffaela is non other than Genova's own Italian grandmother. It is a gentle tract about unconditional love and "open-hearted" therapy. It deals with our desire for personal contact, the lack of which can result in "burnout."

In "I Just Keep Playing the Same Note," Genova, an amateur musician, playing the guitar, dreams of jamming with the greats, including Miles Davis. In the dream, Genova asks Miles how he does it. First Miles says I don't know; then, thinking further about it he says, "I just keep playng the same note until it turns into all the other notes." Genova says that these have been his watchwords ever since. Transposed onto psychotherapy, he says he tries to be a rhythm player.

"The lead part is for the patients, and if you try to teach them to play like you, they will blow it. When they find the dominant note of themselves, help them to hammer on it. If they are struggling to be smart, pretty, insightful, "genuine," successful, the best this or that--- it's always on someone else's terms. If instead they just keep hitting that one note, they'll be the one and uniquely best [fill in name here] the world will ever know, and all the other notes will follow."

Part III is called "The Psychiatric Persuasion." It deals with some of the bitter realities of the current practice of psychiatry, the use of drugs and dealing with the underclass. In "Why I Love Lewiston," Genova relates some hair-raising tales of doing 20 minute 'med-checks' in a small clinic in a hardscrabble town in Maine, not found on most maps. A dedicated group of mental health workers, including old-line psychiatrists doing some longterm therapy grinds away passing out human and chemical soporifics to severely, chronically disturbed and poor patients, down on their luck. Sometimes they help, sometimes not, but they try to alleviate suffering and maintain hope like true doctors of medicine. In the process, Genova learns much about life and the other side of the tracks. He quotes Lao Tzu: "Trust the trustworthy... and trust the untrustworthy."

He notes the heavy reliance on religion in that town, reminding him of his past. "No one is dismayed if I pause to cross myself and quietly recite a Hail Mary that echoes down from childhood. People in Lewiston are not above praying. One of the photographs in the book is of his grandmother, Raffaela. Another is of the Bathtub Madonna in Lewiston, Maine. He says it's a favorite local custom to half bury a bathtub on end and place a diminutive statue of the Madonna within it, resulting in an arched shelter. He speculates on a Jungian analysis of this symbol of transformation.

This addition to the genre of psychotherapy cases is quite different from Lindner's "Fifty Minute Hour," in which each case is a dramatic short story. "The Jet-Propelled Couch" is infamous and a classic, and who would not be interested in the psychotherapy of a Nazi war criminal by a Jewish shrink? Genova's cases are ones we know and have lived with, giving us new perspectives on many of our old cases.

Yalom's "Every Day Gets a Little Closer" was tainted from the start by a pre-arranged agreement with a writer for each of them to take notes on the therapy sessions, and to share these notes and discuss them periodically, with the aim in mind to possibly eventually use them to write a book together. This was an interesting experiment, but hardly a case of psychotherapy.

Freud's five classic cases, although dissected and challenged over time from every conceivable angle are the prototypes for these case histories, but what has followed hardly compare, in terms of deft writing and penetrating insights.

I have quoted liberally from "The Thaw." Genova's writing style may not be everyone's cup of tea, but if this kind of writing and these kinds of ideas and formulations happen to be intriguing to you, you will spend many luminous hours reading them.

Victor Bloom MD is Clinical Associate Professor of Psychiatry in Wayne State University's School of Medicine. He is in private practice in Grosse Pointe Park, Michigan and on the editorial board of the Wayne County Medical Society.