Psychoanalytic Psychotherapy
Blagys and Hilsenroth (2000) […] identified seven factors distinguishing psychodynamic from cognitive-behavioral treatments. The psychodynamic therapies were characterized by (1) focus on affect and the expression of emotion; (2) exploration of the patient's efforts to avoid certain topics or engage in activities that retard therapeutic progress (i.e., work with resistance); (3) identification of patterns in the patient's actions, thoughts, feelings, experiences, and relationships (object relations); )(4) emphasis on past experiences; (5) focus on interpersonal experiences; (6) emphasis on the therapeutic relationship (transference and the working alliance); and (7) explorations of wishes, dreams, and fantasies (intrapsychic dynamics).
When [Freud] was being simply reflective about the essence of the process, he was known to say that any line of investigation in which transference and resistance are addressed can legitimately call itself psychoanalysis. In a 1906 letter to Carl Jung, he made a serious comment—with which anyone who has experienced a transformative personal psychotherapy can resonate—that analytic treatment is essentially a cure through love.
Freud invited his patients to recline and relax and to speak as freely as possible, reporting every thought and feeling as it made its appearance in their consciousness. He tried to listen with a trance-like receptiveness ("evenly hovering attention") for the themes that emerged in their free associations, to interpret their meanings, and then to convey his understanding to the analysand (the analytic patient). He soon discovered that as people tried to do this, they struggled against inhibitions about saying everything on their minds and against impediments to acting on the basis of their new insights ("resistance"). He also learned that they persistently responded to him as if he were more like a past love object than he viewed himself as being ("transference").
The medicalization of psychoanalysis also tilted its language toward mechanization and objectification. It has been a loss, for example, to have Freud's "it," "I," and "I above" represented by the Latin terms "id," "ego," and "superego." Personal pronouns thus morphed into abstract agencies with little subjective resonance. As Jonathan Shedler once commented to me, it is easy for most of us to relate to the distinction between "I" and "it" in ordinary speech: "I did this" is a different experience from "It came over me." The conflictedness of human psychology, the insight that the mind is not unitary but multifaceted and divided against itself, is a profound yet simple idea.
While teaching recently in Istanbul, I was told that the Turkish language has two different words for science: belim, referring to the "scientific method" idealized by Western academic psychology, and elim, referring to the pursuit of understanding by a more observational, introspective, and associative means. Psychoanalytic scholarship is appreciated as within the domain of elim.
The sense of awe is usually associated with religious themes, with the numinous realm, the place of the spirit. It is intrinsically connected with humility, the acknowledgement that human beings are, as Mark Twain observed, "the fly-speck of the universe" and that each of us is impelled by countless forces outside our own awareness and control. Awe involves the willingness to feel very small in the presence of the vast and unknowable. It is receptive, open to being moved. It bears witness. It could not be more different from the instrumental, utilitarian mind-set of the technical problem solver or from the pragmatic, can-do optimism of the man who believes himself to be completely in charge of his life. It is not antiscientific, but it defines scientific activity in much broader ways than the logical positivist who breaks huge, complex issues down into small and simple ones so that concepts can be easily operationalized and variables readily controlled. Awe allows our experience to take our breath away; it invites each client to make a fresh imprint on the soul, the psyche, of the therapist.
"Overdetermination" refers to the observation that significant psychological problems or tendencies have more than one cause; in fact, most have a complex etiology. A symptom important enough to instigate a trip to the therapist has typically resulted from many different, interacting influences, including factors such as one's constitution, emotional makeup, developmental history, social context, identifications, reinforcement contingencies, personal values, and current stress. "Multiple function" refers to the fact that any significant psychological tendency fulfills more than one unconscious function, such as to reduce anxiety, to restore self-esteem, to express an attitude that is unwelcome in one's family, to avoid temptation, and to communicate something to others.
There is an implicit consensus in the analytic community that under the constitutional and situational conditions affecting the patient, the therapist would have become similarly symptomatic.
Very often, the kind of change that the client originally envisioned is not the kind that occurs, only because what does occur is something the client could not have initially imagined. To move into areas that are emotionally new, the client must proceed on a kind of borrowed faith. If the practitioner proceeds with integrity, the client will eventually feel trust in the therapist as a person; the therapist, meanwhile, exemplifies faith in the client, the partnership, and the process. […] The faith of the therapist is not attached to a particular expected outcome but to the conviction that if two people conscientiously put a certain effort in motion, a natural process of growth that has been arrested by the accidents of the patient's life thus far will be released to follow its own self-healing logic. This kind of faith assumes that the effort to pursue the truth of one's experience has intrinsic healing value.
It is my deep conviction that the attitudes I have discussed—curiosity and awe, a respect for complexity, the disposition to identify empathically, the valuing of subjectivity and affect, an appreciation of attachment, and a capacity for faith—are worth cherishing not only as components of a therapeutic sensibility but also as correctives to some of the more estranging and deadening aspects of contemporary life. Their opposites—intellectual passivity, opinionated reductionism, emotional distancing, objectification and apathy, personal isolation and social anomie, and existential dread—have often been lamented by scholars and social critics as the price we pay for our industrialized, consumer-oriented, and technologically sophisticated cultures. The cultivation of the more vital attitudes that undergird the psychoanalytic sensibility just might be good for the postmodern soul whatever one's orientation to psychotherapy.
No lasting harm comes from most errors made by therapists—at least if they are picked up quickly, and that is what supervisors are for. In fact, mistakes (or what clients experience as mistakes) are inevitable, no matter how experienced one is, and they can be addressed in a conversation that has considerably more therapeutic power than the (strictly hypothetical) "ideal" response would have had. And given that human beings have conflicting feelings about most important matters, there is often no response a therapist can make that is not frustrating to some part of the patient's wishes and needs. Conveying sincere effort to understand, even if one is getting things wrong, is much more therapeutic than conveying the belief—or even persuading the client—that one does understand.
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Artificiality and posturing have no place in analytic therapy, mainly because they are discordant with the effort to foster an unflinching emotional honest. It is natural to be anxious in a new role, and it is a common enough defense to cover anxiety with an adopted persona, but in the role of therapist, that defense is a handicap. Perhaps the best antidote to anxiety is the knowledge that psychoanalytic therapy does not require intellectual brilliance or sophisticated social skills or mastery of the literature on technique. Its most elemental ingredients are the therapist's genuine wish to help and nondefensive curiosity.
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Mark Hilsenroth tells his students that one of the best ways to help a supervisor give effective supervision is to ask, "What would be an example of how I might say (or do) that?" This effort to pursue the concrete is particularly useful when one is working with a person that makes vague pronouncements such as "You should have interpreted the resistance there" or "You have to make that symptom ego alien." Helping a supervisor to be more effective in his or her role is not entirely different from helping a patient to get better. It requires a willingness to give sincere feedback about the best qualities of the supervisor and tactful, timely attention to the worst.
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If I had to identify the most common failing of novice therapists, I would say it is the tendency to try to "do therapy" without first securing an alliance.
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With psychotic patients, who can be consumed with anxieties about fragmentation and annihilation, therapists may have to express an appreciation of their fears that professionals will harm them. Even well-medicated patients with psychotic tendencies harbor such fears. Bertram Karon begins an interview with a withdrawn patient with schizophrenia by announcing, "I want you to know that I will not kill you and that I will not allow other people to kill you."
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[…] I typically spend the first session with a new patient trying to get a sense of his or her presenting problem (including its history and the person's prior efforts to deal with it) and to establish myself as a potentially helpful presence. In the second meeting I take a detailed history. After that, I make a statement along the following lines:
"I think that's enough information for me to have a context for what you want to work on. From this point on, I'll follow your lead. If you can come in and talk as freely as possible about any aspect of this, or anything else that's on your mind, I'll try to listen for the more emotional side of it and see what I can say that might cast some new light on what you're talking about. For a while, I'll probably be pretty quiet, as I try to catch up with your own understanding of your problem. The most important thing for you to keep in mind is to try to be as open and honest as you can. Feel free to talk at any point about how you feel the process is going and whether you feel I'm being helpful or not."
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In contemporary Western cultures, respectful listening is rare enough to justify a decent remuneration; we tend to undervalue activities that are receptive rather than based on doing, producing, manufacturing, achieving, and so on.
As many practitioners have noted, money is a critical aspect of therapy. It is the means by which the two participants have a kind of moral equality, a genuine reciprocity. The therapist takes care of the patient emotionally; the patient takes care of the therapist financially. Because the therapist is getting paid by the patient, there is no other way in which the patient is expected to take care of the therapist.
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I have found that when I discuss limits, patients are much more willing to cooperate with my rules when I relate them to my own needs than when I make a speech about how the limit is really in their best interest.
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In this therapy one is required to cooperate in certain ways, but one does not have to pretend to like cooperating. Actions and feelings are separate things; some actions may be unacceptable, but no feeling is beyond the pale.
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Common defenses against frank verbalization include such mannerisms as talking in the second person (e.g. in response to "How did you feel?", "Well, you know, you feel bad when that happens"), talking in the third person ("I guess it's natural for people to feel bad in that situation"), dramatizing or demonstrating things that could be simply expressed ("I was SOOOOO angry!" with an exaggerated eye-roll that slightly ridicules the feeling it portrays), trying to bring the therapist into the experience ("Can you believe the bastard did that to me?"), avoiding the naming of affects and substituting a vague term ("How did you feel?", "Kinda weird, I guess"), changing the subject when feelings get too close, talking in baby talk or some other affected way about more intimate topics, and many other unconscious strategies to keep pain and shame at a distance.
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I have concluded over the years that when clinicians talk most passionately about an attitude or process that is "at the center of" or that is "the essence of" the healing process, they often prescribe a stance that either normalizes their own dispositions or compensates for the limitations of their character type. In either case, they seem to be trying to heal themselves.
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It is not uncommon for an individual coming to treatment to have exhausted friends, relatives, teachers, doctors, and spiritual counselors in an effort to solve some intractable psychological problem. And often, these failed sources of help have behaved with impeccable intelligence and concern, only to confront ultimate exasperation in the face of someone's incomprehensible resistance to change. Schlesinger astutely compares trying to make serious changes in someone's personality organization with trying to make significant reforms in an entrenched bureaucracy.
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Inquiries into how therapists deal with the question of their approaching death have revealed that denial seems to be the defense of choice for afflicted practitioners. […] The analytic requirement to be honest with oneself is no less stringent for therapists than for patients, and no matter how painful it is to acknowledge one's looming demise, it is a professional responsibility.
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When we encourage people to listen to their feelings, when we help them search inside themselves for their own answers, or when we conceptualize their suffering in a way that allows them to understand it better and embrace their own humanity, we do so on the assumption that we all have the potential for attaining a kind of wisdom about life, about who we are and what we seek, about what is possible and what is no, about what can be changed and what must be mourned.
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A related lesson that many of our clients learn in therapy is that diffuse and disturbing emotional states can be named and integrated smoothly into awareness. Sometimes when therapists see themselves as "uncovering" feelings that have been buried by a defense, they are in fact labeling an emotion for the first time in the client's memory. What the clinician may think of as mirroring may be taken in by the patient as new knowledge. That is, the therapist may assume that he or she is simply restating, with some accent on the feeling tone, what the client has just expressed, but the client's sense may be that a previously unformulated perception has now been given shape and color. The person's experience is not so much one of being "reflected" as of being organized by the power of words to give form to chaos.
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[…] I sometimes say to people who are exhausting themselves caring for a dying parent,
"It's my experience that no matter how devoted you are, no matter how much time you spend at the bedside, you'll probably find yourself feeling after the death that you should have done more. I doubt that heroic care-taking now will protect you from later self-criticism. That just seems to be an integral part of early grief. I've known people who were models of dedication, who were holding their loved one's hand at the moment of death, who still castigate themselves that they didn't say 'I love you' one more time.
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There is a continuing fascination for the practicing therapist, at the emotional as well as the intellectual level, in learning about the uniqueness of each person's internal, subjective world. This gratification begins right away. Psychoanalysis is not boring. Even when it feels boring, the therapist gets fascinated with why a sense of boredom is invading the therapeutic space right now. Every patient is different. Every patient opens up a new window on how a life can be lived. Every patient teaches us something about ourselves and our families, if only by providing a contrast with what we have always considered (consciously or not) "natural" or "normal." Thus, we learn more about ourselves as we learn more about each client.
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Fromm-Reichmann, who was reared as an orthodox Jew, was inspired in childhood by the writing of the great sixteenth-century rabbi Isaac Luria on tikkun, the collective task of rescuing the sparks of the divine that were scattered at creation. Luria taught that to help another human being is inherently redemptive. According to the principle of tikkun, "To redeem one person is to redeem the world." This kind of faith and the satisfactions of acting in accordance with it are fundamental to the commitment of most analytic therapists.
For the patient, one of the greatest satisfactions that emerges in a psychoanalytic therapy is the sense that he or she has been accepted, psychological warts and all. But the virtue of nurturing the true self applies to ourselves as well as to our clients, and it is inseparably bound up with our ability to do our job. Creating the right conditions for truths to emerge and become explicit is the essence of the psychoanalytic project.
